A Comparative Assessment of Cardiovascular Autonomic Reflex Testing and Cardiac 123I-Metaiodobenzylguanidine Imaging in Patients with Type 1 Diabetes Mellitus without Complications or Cardiovascular Risk Factors.

AIM: To compare the cardiovascular autonomic reflex tests (CARTs) with cardiac sympathetic innervation imaging with 123I-metaiodobenzylguanidine (MIBG) in patients with type 1 diabetes mellitus (T1DM). PATIENTS AND METHODS: Forty-nine patients (29 males, mean age 36 ± 10 years, mean T1DM duration 19 ± 6 years) without cardiovascular risk factors were prospectively enrolled. Participants were evaluated for autonomic dysfunction by assessing the mean circular resultant (MCR), Valsalva maneuver (Vals), postural index (PI), and orthostatic hypotension (OH). Within one month from the performance of these tests, patients underwent cardiac MIBG imaging and the ratio of the heart to upper mediastinum count density (H/M) at 4 hours postinjection was calculated (abnormal values, H/M < 1.80). RESULTS: Twenty-nine patients (59%) had abnormal CARTs, and 37 (76%) patients had an H/M_4 < 1.80 (p = 0.456). MCR, PI, Vals, and OH were abnormal in 29 (59%), 8 (16%), 5 (10%), and 11 (22%) patients, respectively. When using H/M_4 < 1.80 as the reference standard, a cutoff point of ≥2 abnormal CARTs had a sensitivity of 100% but a specificity of only 33% for determining CAN. CONCLUSIONS: CARTs are not closely associated with 123I-MIBG measurements, which can detect autonomic dysfunction more efficiently than the former. In comparison to semiquantitative cardiac MIBG assessment, the recommended threshold of ≥2 abnormal CARTs to define cardiovascular autonomic dysfunction is highly sensitive but of limited specificity and is independently determined by the duration of T1DM.

Reactivation of resolved hepatitis B virus infection after immunosuppression: is it time to adopt pre-emptive therapy?

New therapeutic options like monoclonal antibodies (anti-CD20/rituximab) and hematopoietic stem cell transplantation (HSCT) have increased both the effectiveness of therapies and the risk for reactivation of Hepatitis B virus (HBV). We describe two cases with serological evidence of resolved HBV infection (hepatitis B surface antigen (HBsAg) negative/antibody to hepatitis B core antigen (anti-HBc) and antibody to hepatitis B surface antigen (anti-HBs) positive), who developed reverse seroconversion (clearance of HBsAb/appearance of HBsAg) with active HBV infection after treatment with combination of conventional chemotherapy, rituximab and autologous HSCT for hematological malignancies. Review of the literature highlights the increasing incidence of HBV reactivation in patients with resolved infection and raises concerns as to whether current guidelines for pre-chemotherapy screening with sensitive HBV-DNA assays and serial monitoring for anti-HBs titres should be implemented also for patients with resolved infection. Future studies should aim at clarifying the cost-benefit from administration of nucleoside analogues in these patients.

Hematogenous spinal infection in central Greece.

STUDY DESIGN: We retrospectively analyzed spinal infection (SpI), in a teaching Hospital, in Central Greece. OBJECTIVE: To study presentation, etiology, and outcome of SpI in Central Greece. SUMMARY OF BACKGROUND DATA: SpI most frequently involves the intervertebral disc and adjacent vertebral bodies and can cause neurologic impairment. METHODS: Thirty three patients (23 men; age [mean +/- standard deviation], 60.6 +/- 11.3 years; disease duration, 44.5 [+/-54.7] days) hospitalized with SpI between January 2000 and December 2007 were included in the study. All patients had magnetic resonance imaging of the spine. RESULTS: Nineteen patients had pyogenic SpI (57.6%) and 14 patients had granulomatous SpI, 11 due to Brucella spp (34.4%), 3 due to Mycobacterium tuberculosis (9.4%). Staphylococcus aureus was the most frequent cause of pyogenic SpI, and spondylodiscitis (SpD) was the most frequent localization. Epidural entension was found in 8 of 17 pyogenic SpD and in 2 of 11 brucellar SpD patients. Subdural extension was detected in 3 patients with pyogenic SpD. Blood cultures were positive in 17 of 19 patients with pyogenic SpI. Two patients had concomitant endocarditis (staphylococcal 1, enterococcal 1). The most common associated disease was diabetes mellitus. All but 2 patients received medical treatment alone. Two patients died of uncontrollable sepsis. CONCLUSION: Back pain in presence of fever, constitutional symptoms, and/or high inflammation markers should alert physicians for spinal infection. In endemic areas, Brucella is a frequent cause of SpI.

Immunological features of visceral leishmaniasis may mimic systemic lupus erythematosus.

OBJECTIVE: Visceral leishmaniasis (VL), caused by the intracellular parasite Leishmania, can present with fever, splenomegaly, pancytopenias, hypergammaglobulinemia, and autoantibody production. These features may mimic systemic lupus erythematosus (SLE). The objective was to study features of VL that shared with and differed from SLE. DESIGN AND METHODS: A small retrospective study of six patients with VL diagnosed in a University Hospital between 2001 and 2007. RESULTS: All patients had cytopenias, firm splenomegaly, high acute phase reactants, and activation of the coagulation cascade. Hypergammaglobulinemia was detected in five patients. Direct Coombs test was positive in all patients, anti-nuclear antibodies were detected in five patients, anti-smooth muscle antibodies (ASMA) in four patients, and IgM rheumatoid factor (RF) in four patients. Anti-dsDNA antibodies were detected in one patient and IgM anti-cardiolipin antibodies were detected in one patient. CONCLUSION: Autoantibodies are frequently detected in VL and may mimic SLE, but massive firm splenomegaly, very high acute phase reactants, and activation of coagulation system with high D-dimers point toward infection.

Two episodes of hemoperitoneum from luteal cysts rupture in a patient with congenital factor X deficiency.

The clinical manifestation of two episodes of hemoperitoneum from ruptured corpus luteum cysts, during the luteal phase of the cycle in a young patient with the rare congenital factor X deficiency, is reported for the first time in literature. The correct diagnosis of the underlying disorder, the gynecological management and the regular follow-up can minimize the risks of this potentially life-threatening hematological disorder.