Gulf War illnesses: causes and controversies.

Numerous studies investigating Gulf War illnesses have documented that, while Gulf War veterans are no more likely to die or be hospitalized, they complain of more symptoms than their non-Gulf War counterparts and are more likely to seek medical treatment and disability retirement. Proposed causes include exposure to chemical and microbiological agents and psychological factors. No definitive evidence has emerged to link chemical exposures to these illnesses, although epidemiological studies and animal research suggest possible synergistic effects to multiple exposures. Microbiological agents are unlikely to be etiologic. Psychological and cultural factors undoubtedly contribute to a number of illnesses, but their exact role requires further study. Based on a review of the scientific and popular literature, it is reasonable to conclude that Gulf War illnesses remain a poorly defined group of symptom clusters. Well-controlled research from independent groups is required to answer the numerous questions that have arisen from this illness outbreak.

Mycobacterium marinum arthritis.

Mycobacterium marinum is an atypical acid-fast organism that is rarely associated with septic arthritis. Most often this is seen in patients with monarticular synovitis of the hands or wrists, especially in association with a history of periarticular trauma or exposure to marine environments. From tissue obtained by aspiration or synovectomy, Mycobacterium marinum can be identified by Ziehl-Nielson stain and has optimal growth in Lowenstein-Jenson medium. Therapy should consist of at least two antimycobacterial agents for a minimum 6 months. Surgical debridement also may be beneficial. The clinician must have a high index of suspicion that exposure to Mycobacterium marinum has occurred so appropriate stains and cultures can be obtained and antimycobacterial therapy initiated.

Serum lipid and fat-soluble vitamin levels in primary sclerosing cholangitis.

We reviewed the initial lipid and fat-soluble vitamin levels in 56 patients with primary sclerosing cholangitis (PSC) enrolled in a randomized, placebo-controlled trial evaluating ursodeoxycholic acid. We also evaluated lipid and vitamin levels in a group of 87 patients with advanced PSC being evaluated for liver transplantation. Of the patients entering the therapeutic trial, 41% had total serum cholesterol levels greater than the 95th percentile, whereas only 20% had high-density lipoprotein cholesterol levels above normal, and only one (2%) had an elevated triglyceride level. Total cholesterol levels were correlated with serum bilirubin levels and were lower in early versus later histologic stages (206 +/- 61 vs. 248 +/- 79, p = 0.04). Of the 87 pretransplant patients, 29% had elevated serum cholesterol levels and 17% had elevated serum triglyceride levels. Total serum cholesterol levels correlated inversely with total serum bilirubin levels in this group. In patients in the therapeutic trial, vitamin A deficiency was seen in 40%, vitamin D deficiency in 14%, and vitamin E deficiency in 2% of those tested. More prominent deficiencies of fat-soluble vitamins occurred in the pretransplant group of patients, with 82% deficient in vitamin A, 57% deficient in vitamin D, and 43% deficient in vitamin E. We conclude that hypercholesterolemia and fat-soluble vitamin deficiencies are frequent in patients with PSC and are more common with more severe disease. Patients with PSC, especially with advanced liver disease, should be screened for fat-soluble vitamin deficiencies and supplemented accordingly.

From mercury to malaria to penicillin: the history of the treatment of syphilis at the Mayo Clinic--1916-1955.

Between 1916 and 1955 the Mayo Clinic became recognized as one of the premier institutions specializing in the treatment of syphilis. First under the direction of John H. Stokes (1916-1924) and later Paul A. O'Leary (1924-1953), its Department of Dermatology and Syphilology, together with the members of the Clinical Cooperative Study Group, oversaw the establishment of standardized methods for the administration of the existing arsenicals and the introduction of new therapies. Malaria therapy, heat therapy, penicillin, and oxytetracycline each represented important advances in the treatment of syphilis and were extensively evaluated. Two important ancillary benefits of syphilis treatment were the development of routine intravenous techniques, which would later prove invaluable for the administration of antibiotics and cancer drugs, and the establishment of large cooperative clinical trials, the first of their kind. Under the leadership of Stokes and O'Leary the department produced a stream of pivotal clinical research that contributed to the effective management of syphilis in the United States.

A case of Aspergillus fumigatus peritonitis complicating liver transplantation.

A 55-year-old male underwent orthotopic liver transplantation for sub-fulminant hepatitis B/delta infection superimposed on probable genetic hemochromatosis with early cirrhosis. Pre-operatively, he demonstrated serologic evidence of cytomegalovirus reactivation and developed cytomegalovirus viremia when ganciclovir was discontinued post-operatively. His post-operative course was complicated by chronic ductopenic rejection, biliary anastomotic leak, and persistent confusion and malaise. At the time of laparotomy for repair of the bile leak, nodular peritoneal lesions were noted, with biopsy and culture showing angioinvasive Aspergillus fumigatus. Despite administration of amphotericin B, the patient continued to have culture-confirmed evidence of infection at follow-up peritoneoscopy. Oral itraconazole was begun, but the patient died of liver failure secondary to progressive ductolpenic rejection. At autopsy, Aspergillus organisms were seen in histologic sections taken from the small bowel; there was no evidence of disseminated disease.

Infectious diseases during the Civil War: the triumph of the "Third Army".

The American Civil War represents a landmark in military and medical history as the last large-scale conflict fought without knowledge of the germ theory of disease. Unsound hygiene, dietary deficiencies, and battle wounds set the stage for epidemic infection, while inadequate information about disease causation greatly hampered disease prevention, diagnosis, and treatment. Pneumonia, typhoid, diarrhea/dysentery, and malaria were the predominant illnesses. Altogether, two-thirds of the approximately 660,000 deaths of soldiers were caused by uncontrolled infectious diseases, and epidemics played a major role in halting several major campaigns. These delays, coming at a crucial point early in the war, prolonged the fighting by as much as 2 years.

Granulomatous hepatitis: a retrospective review of 88 cases at the Mayo Clinic.

Although several studies have shown that sarcoidosis and tuberculosis are the most common causes of granulomatous hepatitis (GH), these studies were biased because results of unselected liver biopsies and autopsy reports were included. We reviewed the medical records of patients diagnosed with GH at the Mayo Clinic between September 1976 and October 1985 for the current study. Our study group consisted of 45 women and 43 men (mean age, 54.2 years). Overall, 65 patients (74%) were symptomatic; the rest had only liver enzyme abnormalities. The mean duration of symptoms was 19.1 months. Assessment of these patients and a comprehensive workup for infectious agents or other causes revealed idiopathic GH confined to the liver in 50%, sarcoidosis with confirmed extrahepatic disease in 22%, drug-related GH in 6%, tuberculosis in 3%, and other causes in 19%. Our study found a much higher frequency of idiopathic GH than previously published reports, and it represents the largest number of cases of idiopathic liver granulomas reported in a single series.