Diarrhea complicating enteral feeding after liver transplantation.

In this case report we present in detail the complex nature of enteral feeding, diarrhea, hypoalbuminemia, and edema in a critically ill patient. We also discuss the use of a peptide-elemental formula in this patient, who suffered continuous diarrhea for 15 weeks after liver transplantation. Use of this formula was associated with cessation of the diarrhea and permitted adequate nutritional delivery. After 26 weeks of mechanical pulmonary ventilation, extubation was possible. This case illustrates the ineffectiveness of parenteral albumin infusions for treatment of enteral edema and demonstrates the restoration of normal intestinal absorptive capacity when ultrafiltration was instituted and the patient's generalized edematous state was corrected.

Treatment of acid maltase deficiency with a diet high in branched-chain amino acids.

Acid maltase deficiency in adults is associated with progressive muscle weakness and may effect respiratory muscles resulting in respiratory failure. The biochemical and clinical manifestations of acid maltase deficiency arise from a marked deficiency of the lysosomal enzyme alpha-glucosidase (acid maltase), which normally degrades glycogen to free glucose. In the past few years, high-protein diets have provided an alternative energy source for these patients and resulted in improved muscle strength. Recently, we treated a ventilator-dependent acid maltase-deficient patient with a general diet supplemented with branched-chain amino acids. Branched-chain amino acids are the principal amino acids involved in muscle protein synthesis and utilization. While on this diet, the patient had improvement of respiratory function and muscle strength and was able to be weaned from the ventilator during the day. In addition to his nutritional status, levels of serum branched-chain amino acids, showed improvement within 2 months after the diet started. This diet shows potential advantages over a high-protein diet without supplemented branched-chain amino acids for the treatment of acid maltase deficiency. These include theoretical sparing of amino acids required for muscle protein synthesis by providing higher concentrations of postprandial branched-chain amino acids in the circulation. Also, the liquid formula would be better tolerated by a ventilator-dependent or debilitated patient rather than a high-protein general diet. Further experience with branched-chain amino acid formulas will be needed to substantiate their efficacy in the treatment of acid maltase deficiency.

Study of amplitude frequency spectra of the compound action potentials recorded from normal and M. leprae infected mice using Fourier series analysis.

Compound action potentials recorded from normal and M. leprae infected mice sciatic nerves were analysed in frequency domain using Fourier Series Analysis. Changes in myelinated fibre potentials were detected as early as 2nd post-inoculation month. This technique could be further developed to aid in early diagnosis of leprosy.

Renal lesions in leprosy amongst north Indian patients.

Sixty consecutive patients with leprosy were investigated for renal involvement. Clinically overt renal disease was present in 4 patients; 3 presented with a nephrotic state and one patient with progressive renal failure. Urinalysis showed daily protein loss ranging from 0.4 to 8.9 g in 8 patients and microscopic haematuria in 4 cases. Elevated levels of blood urea and creatinine were seen only in one patient with diffuse proliferative glomerulonephritis. Of the 36 patients in whom distal tubular functions were evaluated, concentration and/or acidification defects were detected in 9 patients (25%). Renal histology revealed no abnormality in any of these patients. Serum C3 levels were decreased in 5 patients with lepromatous leprosy and 3 patients with borderline leprosy. Histological evidence of renal involvement was detected in 9 patients (15%). Amyloid deposits were seen in 3 (5%) patients of whom 2 had lepromatous leprosy and one had tuberculoid leprosy with chronic trophic ulcers. Mesangial proliferative lesions were seen in 5 (8.3%) and diffuse proliferative lesions (with crescents in more than 70% of glomeruli) in one patient. All of them had lepromatous leprosy. Three of the 5 patients with mesangial proliferative glomerulonephritis had erythema nodosum leprosum at the time of biopsy. Immunofluorescence studies revealed granular deposits of IgA, IgM and C3 in one patient with mesangial proliferation and IgA/IgM with or without C3 in 3 more patients in whom renal histology was normal. Glomerulonephritis associated with leprosy appears to be immune mediated but confirmation requires identification of lepra antigen in the glomerular immune complex deposits.

A study of the sciatic nerve compound action potential in vitro in normal and M. leprae infected mice.

A study of the sciatic nerve compound action potential was carried out, in normal and non-immunosuppressed swiss mice (white) inoculated with 5000 M. leprae in each hind foot pad, from 1st to 7th post-inoculation month. In normal mice, the threshold for stimulation, maximum amplitude, duration and conduction velocity of all the three components of the compound action potential were measured. Progressive changes were noted in amplitude and the threshold for stimulations of the unmyelinated fibre ('C' fibres) potentials. These changes were compared with the changes observed in the myelinated fibre potentials.

Disease due to Mycobacterium intracellulare: its possible association with human leukocyte antigens.

Most of the population of the United States is exposed to Mycobacterium intracellulare, but only a few persons develop disease due to this organism. This fact suggests that certain host factors may predispose an individual to this disease. To investigate the possibility that susceptibility to disease due to M. intracellulare may be determined by genetic factors, as evidenced in profiles of human leukocyte antigens (HLAs), we examined 41 consecutive patients with use of tissue typing for HLA-A and HLA-B loci. The association in individuals between disease and frequency of HLAs was analyzed and compared with control data of HLA frequencies in the caucasian American population. The observed frequencies of many HLAs were different from those expected, but none of the individual differences were significant statistically. However, the frequency of the haplotype A2-B12 was found to be significantly higher than the expected frequency (P less than 0.05). While the population of patients studied was small, the observed increase in the haplotype frequency may indicate a possible predisposing genetic factor in this disease.

Dynamic aspects of the activity of clofazimine against Mycobacterium intracellulare.

The interaction of clofazimine with M. intracellulare was studied using the in vitro dialysis model and the membrane filtration technique. With the in vitro model, clofazimine when it was inside the bag at 3 micrograms/ml or more exerted a bactericidal action within 6 days. On the other hand, when the drug concentration in the outside medium was gradually raised from 1 microgram/ml to 3 micrograms/ml over a period of 5 days, it produced only a bacteriostatic effect. Using the membrane filter technique, exposure of M. intracellulare to 1 microgram/ml of clofazimine for 24 and 48 hours induced lag periods of 24 and 168 hours respectively.

Antituberculosis activity of 6 cyclo-octylamino-5,8-quinolinequinone (CQQ).

A new compound, 6 cyclo-octylamino-5,8-quinolinequinone (CQQ), a dual analogue of vitamin K and coenzyme Q, was effective against several drug-susceptible and drug-resistant strains of Mycobacterium tuberculosis. In vitro studies indicated the bactericidal nature of its action at 1 microgram/ml. Pulse exposure studies using M. tuberculosis H37Rv showed that a growth lag period of 96 hours resulted with exposure to 1 microgram/ml for 24 hours or longer.

Immune complexes and antibodies to BCG in sera from patients with mycobacterial infections.

We have examined the prevalence of circulating immune complexes in sera from patients with mycobacterial infections. Sera from 68 percent of patients with active M. tuberculosis and 58 percent of patients with M. intracellulare infections had significantly elevated Clq binding activity (Clq-BA). In general there was a fall in Clq-BA with treatment. Only 15 percent of M. tuberculosis patient with a bacteriological cure, 22 percent of non-tubercular patients with chronic obstructive pulmonary disease, and 3 percent of normal individuals had an elevated Clq-BA. Antibodies to a BCG-derived antigen were demonstrated in most of the individuals studied in all groups but, significantly elevated levels were seen only in patients with mycobacterial infections. In certain patients there appeared to be an inverse relationship between Clq-BA and BCG binding, suggesting that perhaps BCG-related antigens participated in the immune complexes found. Other possible antigen-antibody complexes are discussed.

Inhibition of Mycobacterium intracellulare by some vitamin K and coenzyme Q analogues.

Because vitamin K is present in several species of mycobacteria, and because coenzyme Q has been found to stimulate the growth of Mycobacterium tuberculosis and atypical mycobacteria, 8 quinones that can be considered to be dual analogues of vitamin K and coenzyme Q were tested for their activity against Mycobacterium intracellulare. One compound, 6-cyclo-octylamino-5,8-quinolinequinone (CQQ) exhibited considerable activity in vitro against several strains of Mycobacterium intracellulare at a concentration of 8 micrograms per ml. It has also shown evidence of bactericidal activity against growing cultures of Mycobacterium intracellulare. Time exposure studies indicated that a minimal contact period of 24 hours with a concentration of 8 micrograms of CQQ per ml is necessary for permanent inhibitory action against Mycobacterium intracellulare. At a concentration of 1 microgram per ml, CQQ inhibited Mycobacterium tuberculosis, including the rifampin-resistant strains. The drug has no activity against rapidly growing mycobacteria or organisms that are not acid-fast.

Antimycobacterial activity of some potential chemotherapeutic compounds.

Fourteen compounds were tested in vitro for activity against Mycobacterium intracellulare and other pathogenic mycobacteria. Only clofazimine and chaulmoogric acid showed significant activity against M. intracellulare. In view of known minimal side effects of clofazimine further studies are warranted for this drug in chemotherapy of M. intracellulare infections.

Flavobacterium meningosepticum as an opportunist.

Flavobacterium meningosepticum was isolated from the cerebrospinal fluid of an adult immunodeficient female. In spite of prompt therapy the patient succumbed to the infection. The opportunistic role of the organism is discussed.