Tuberculous peritonitis in patients undergoing continuous ambulatory peritoneal dialysis: case report and review.

A case of tuberculous peritonitis complicating continuous ambulatory peritoneal dialysis (CAPD) in a 37-year-old man who presented with fever, abdominal pain, and a malfunctioning Tenckhoff catheter is reported. The patient was initially treated for presumed bacterial peritonitis but remained febrile and had persistent abdominal pain and peritoneal fluid pleocytosis, despite broad-spectrum antibiotic therapy. Mycobacterium tuberculosis was isolated in a culture of peritoneal fluid, and the patient responded promptly to antituberculous therapy. More than 50 cases of tuberculous peritonitis complicating CAPD that have been reported in the English-language literature since the initial case was reported in 1980 are reviewed. The most common symptoms are fever (78%), abdominal pain (92%), and cloudy dialysate (90%); 76% of cases had a predominance of polymorphonuclear cells in peritoneal fluid. A smear for acid-fast bacilli or a culture was positive in 73% of cases. The peritoneal dialysis catheter was removed in 53% of cases, although this was rarely considered necessary for cure of tuberculosis. The attributable mortality rate is 15%, with the most significant factor being treatment delay (mean time from presentation to initiation of treatment, 6.74 weeks). We conclude that tuberculosis is an important diagnostic consideration for CAPD patients with peritonitis that is refractory to broad-spectrum antibiotics.

Antiretroviral therapy, 1998.

In summary, during 1996 and 1997 important improvements occurred in HIV therapy. The introduction of new drugs benefited patients with access to these medications. The use of antiretrovirals remains complex and is rapidly evolving. This is an inspiring challenge for physicians and health workers caring for HIV-infected patients.

[Leukocyte migration during erythrocyte sedimentation]. / Leukocyták mozgása vörösvértest-süllyedés folyamán.

Sedimentation properties of leukocytes was measured with a new, simple and reproducible method. The increment of leukocyte concentration was determined in the upper 100 mm section of the sedimentation blood column after one hour gravity sedimentation of the whole blood. The result (leukocyte antisedimentation rate, LAR) was expressed in percentage of the original, presedimentation leukocyte concentration. Blood samples taken from 35 healthy adults were investigated and 12.5% and 17.4% increments were found in total leukocyte count and in granulocyte concentration respectively in the upper half of the sedimentation blood column. The mean coefficient of variation of LAR measurements was 3.2% LAR was found significantly higher in a mixed group of patients than in healthy controls. The sedimentation properties of leukocytes were in significant correlation with leukocyte adherence (p < 0.01), with whole blood viscosity, hematocrit, and erythrocyte sedimentation rate (each p < 0.05) when blood samples of healthy individuals and postoperative intensive care patients were analysed in combination. In vitro pre-treatment of patients' blood samples with prednisolone and lidocaine resulted in a significant diminishment of LAR in a concentration dependent manner.

The use of respiratory-tract cultures in the diagnosis of invasive pulmonary aspergillosis.

PURPOSE: To define the role of lower-respiratory-tract cultures in the diagnosis of invasive pulmonary aspergillosis (IPA) in immunocompromised hosts. METHODS: Immunocompromised patients with a positive, nonbiopsy, lower-respiratory-tract culture for Aspergillus species were classified as having definite, probable, indeterminate, or no IPA. Culture data, positive predictive values (PPVs), correlation with clinical and radiographic findings, and the relationship between the number of specimens submitted and the likelihood of recovering Aspergillus were assessed. RESULTS: Definite or probable IPA was diagnosed in 72% of episodes from patients with hematologic malignancy, granulocytopenia, or bone-marrow transplant; in 58% of those with solid-organ transplant or using corticosteroids; and in 14% of those with human immunodeficiency virus infection. The PPV of cultures ranged from 14% in the latter group to 72% in the first group (bone-marrow-transplantation subgroup, 82%). Fungal cultures were more often positive than were routine cultures (P < 0.001). Clinical and radiographic findings suggestive of IPA were present more frequently in infected than uninfected patients (59% versus 24%, P < 0.025); and 73% versus 6%, (P < 0.0001, respectively). Infected patients with > or = 1 positive node had more cultures submitted than a control group of patients with no positive cultures (5.8 +/- 4.7 versus 2.1 +/- 2.2 cultures, P < 0.001). CONCLUSION: Recovery of Aspergillus species from high-risk patients is associated with invasive infection. Clinical and radiographic correlations help to separate true- from false-positive cultures. At least 3 sputum specimens should be submitted for fungal culture whenever fungal infection is suspected.

[Analysis of costs of drug therapy in patients with acute respiratory insufficiency]. / Az akut légzési elégtelenség kezelésének gyógyszerköltség-elemzése.

In a retrospective study, the authors analysed the clinical data of 38 patients who were admitted to a surgical intensive care unit (SICU) for mechanical ventilation lasted for at least 72 hours. The APACHE III score was calculated on the basis of clinical data documented during the first 24 hour of the treatment and the cost of drug administrations per patients per day was also determined by analysing all the drugs prescribed on the first 5 days of intensive care. The patients admitted to SICU with polytrauma or with abdominal septic focus required significantly higher cost of drug treatment than the patients after cardiopulmonary resuscitation or with bronchial asthma or pneumonia. The APACHE III score of the patients died at the SICU was significantly higher compared to the survivors who needed more expensive drug therapy than the non-survivors required. Antibiotic treatment, blood transfusions, and human plasma proteins caused the highest drug expenditure. There was no significant correlation between the APACHE III score and the cost of drug treatment.

Does the age-related change in CD44-defined T-cell subsets have functional significance for cytotoxic T lymphocyte generation?

CD44 or Pgp-1 is a transmembrane leukocyte adhesion-related glycoprotein which is often expressed in greater density on the membranes of memory T lymphocytes (CD44hi) compared to naive T cells (CD44lo). The proportion of Pgphi or CD44hi cells among T cells is increased with advancing age. We examined the relevance of this alteration for the age-related decrease in the generation of allospecific CTL activity. The findings confirm the age-related increase in the frequency of CD44hi cells in spleens of aged mice of several strains, but also show interstrain variability in the magnitude of the increase (bm1 > C57BL/6 > BALB/c). In contrast, we found that after allo-stimulation, the proportion of cells bearing the memory phenotype is decreased in cells from aged mice, particularly within the CD8+ T cell subset. To determine if these observations reflected an alteration in the frequency or responsiveness of naive T cells, enriched populations of spleen cells depleted of CD44hi cells were prepared from spleen cells of young and aged mice, and stimulated in mixed lymphocyte culture. Enrichment for cells expressing the naive phenotype did not restore the ability of T cells from aged mice to generate allospecific CTL. Together, these findings suggest that (1) the age-related increase in frequency of splenic T cells expressing memory phenotype and concordant decrease in phenotypically naive cells, does not explain the age-related decrease in the ability to generate primary allo-CTL, and (2) naive cells from aged mice exhibit intrinsically compromised ability to generate CTL in response to primary alloantigenic stimulation.

Assessment of alloreactive T cell subpopulations of aged mice in vivo. CD4+ but not CD8+ T cell-mediated rejection response declines with advanced age.

The present investigation explored age-related alterations in T cell populations mediating allospecific responses in vivo. Healthy aged and young H-2b and H-2bxH-2k mice were engrafted with major histocompatibility complex (MHC) class II-disparate bm12 skin, rejection of which requires CD8+ T cells, and MHC class I-disparate bm1 skin, rejection of which requires CD8+ T cells. Aged mice of both genders exhibited prolonged survival of bm12 skin grafts relative to their young counterparts but rejected bm1 skin grafts at a rate equivalent to that of young mice. Consistent with prolonged survival of bm12 skin grafts, markedly diminished levels of Iabm12 CTL activity were elicited from T cells of aged mice in vitro. However, no such decline was observed in the level of Kbm1 CTL from T cells of aged mice. The alterations in Iabm12 allospecific responses were not attributable to quantitative changes in CD4+ T cells of aged mice, and addition of soluble T cell helper factors to response cultures of aged mice did not augment Iabm12 cytotoxic T lymphocytes activity. These data demonstrate that aging fundamentally affects CD4+ T cell-mediated allospecific responses particularly in vivo, and that deficient generation of soluble T cell helper factors alone cannot explain this deficit.

Cellular and molecular mechanisms of the IL-12-induced increase in allospecific murine cytolytic T cell activity. Implications for the age-related decline in CTL.

The mechanism(s) by which IL-12 augments CTL generation and the potential for IL-12 to alter the age-related decline in CTL activity were assessed using primary CTL stimulated by allogeneic cells. IL-12 at 2 U/ml enhanced the generation of allospecific CTL response in young adult mice by 1.5- to 5-fold, and optimal augmentation was achieved and maintained with as low as 0.1 U/ml IL-12. In contrast to the enhancement of MHC-unrestricted lytic activity, which was most efficient when IL-12 was added near the end of the 5 day culture period, nearly equivalent augmentation of Ag-specific CTL was induced when IL-12 was added from 1 to 5 days before harvest. The augmentation of CTL by IL-12 was not associated with increased incorporation of [3H]TdR. Increased IFN-gamma production was not required for IL-12 to augment CTL activity because when three different Abs against mouse IFN-gamma were each included in the MLC at concentrations abolishing recoverable IFN-gamma protein, they did not inhibit the IL-12 effect but, under some conditions, further increased CTL activity. Ab to IL-2 also did not alter the IL-12 effect. Depletion of ASGM1+ cells from the responding population before stimulation did not significantly alter the response to IL-12. However, depletion of CD8+ T cells from effector cells obtained after stimulation substantially reduced the IL-12-induced augmentation of CTL. Thus, the results suggested that IL-12 augments CTL activity primarily through an effect on T cells, and the augmentation was associated with an approximate doubling of perforin levels, which was not caused by a significantly increased proportion of CD8+ cells. Finally, IL-12 was effective for moderating the age-related decrease in CTL activity, suggesting a potential role for immunomodulation by IL-12.

Pore-forming protein in individual cytotoxic T lymphocytes: the effect of senescence provides a probe for understanding the lytic mechanism.

The senescent decline of cytolytic T lymphocyte (CTL) activity was examined (a) to learn more about the effect of aging on the immune system, and (b) to probe the mechanism of cell-mediated cytolysis. The effect of age on the generation of pore-forming protein (Pfp) was examined at the cellular level in a murine model using CTL stimulated in allogeneic mixed lymphocyte culture (MLC). Pfp expression was analyzed by immunocytochemistry and enzyme-linked immunosorbent assay (ELISA). Immunocytochemical analyses of Pfp in MLC-stimulated splenic T cells from a large number of mice revealed that although stimulated cells from aged mice exhibited fewer Pfp-producing cells than those from young, the diminution in the proportion of Pfp+ cells was small compared to the age-related decrease in lytic activities (approximately 2-fold vs. approximately 7.4-fold, respectively). Time-course analysis disclosed similar kinetics for the generation of Pfp+ cells among responding cells from young and aged mice. No significant age-related difference in the proportion of Pfp+ cells was observed in MLC-stimulated lymph node cells despite a large and significant difference in lytic activity (approximately 6.5-fold). Purified CD8+ T cells demonstrated a large age-related difference in CTL activity (approximately 3-11-fold) and accounted for virtually all the Pfp. Although little difference in the proportion of Pfp+ CD8+ T cells could be detected between age groups, stimulated CD8+ cells or whole splenic T cells from old mice consistently exhibited a striking reduction in both the intensity of Pfp staining and the apparent numbers of granules per cell. This difference in Pfp was examined by ELISA and total Pfp levels were found to be approximately 12-fold greater in CTL generated from splenic T cells of young compared to aged mice. The results demonstrate that Pfp levels are reduced in CTL from aged compared to young mice at the level of the individual cells and suggest the possibility that a threshold level of Pfp may be required for potency of effector cell function.

[Traumatic fat embolism syndrome]. / Traumás "zsírembólia syndroma".

After a short literary review authors analyse the clinical and pathological process of the traumatic fat embolism. They call attention to the difficult diagnosis of the syndrome and to its frequency. The demonstration of the fat globuli from the peripheric blood is suggested by the authors who perform this as a screening for an easier diagnosis--if characteristic clinical symptoms are also joined to the microscopic finding.