High risk of tuberculous infection in North Sulawesi Province of Indonesia.

SETTING: Of all the provinces in Indonesia, the highest tuberculosis (TB) case notification rates are reported from North Sulawesi Province. OBJECTIVE: To estimate the annual risk of tuberculous infection (ARTI) among schoolchildren in the 6-9 year age group. METHODS: A cross-sectional survey was carried out in 99 schools selected by a two-stage sampling process. Children attending grades 1-4 in the selected schools were administered intradermally with 2 tuberculin units (TUs) of purified protein derivative RT23 with Tween 80, and the maximum transverse diameter of induration was measured about 72 h later. A total of 6557 children in the 6-9 year age group were satisfactorily test-read, irrespective of their bacille Calmette-Guérin (BCG) vaccination status. RESULTS: Based on the frequency distribution of reaction sizes obtained among satisfactorily test-read children (without and with BCG scar), the estimated ARTI rates when estimated by different methods (anti-mode, mirror-image and mixture model) varied between 1.9% and 2.5%. BCG-induced tuberculin sensitivity was not found to influence the ARTI estimates, as the differences in estimates between children without and with BCG scar were not statistically significant. CONCLUSION: TB control efforts should be further intensified to reduce the risk of tuberculous infection.

Annual risks of tuberculous infection in East Nusa Tenggara and Central Java Provinces, Indonesia.

SETTING: East Nusa Tenggara (NTT) and Central Java Provinces, Indonesia. OBJECTIVE: To estimate the average annual risk of tuberculous infection (ARTI) among school children aged 6-9 years in each province. METHODS: Children attending Classes 1-4 in 65 schools in NTT and 79 in Central Java, selected by two-stage sampling, were intradermally administered 2 tuberculin units of purified protein derivative RT23 with Tween 80 on the mid-volar aspect of the left forearm. The maximum transverse diameter of induration was measured 72 h later. The analysis was carried out among 5479 satisfactorily test-read children in NTT and 6943 in Central Java. One hundred and fifty-five new sputum smear-positive pulmonary tuberculosis (PTB) cases (78 in NTT and 77 in Central Java) were also tuberculin tested. Based on the frequency distribution of reaction sizes among the children and PTB cases, the prevalence of infection was estimated by the mirror-image method using the modes of tuberculous reactions at 15 and 17 mm. RESULTS: Using the 15 mm mode, ARTI was estimated at 1% in NTT and 0.9% in Central Java. Using the 17 mm mode, ARTI was estimated at 0.5% in NTT and 0.4% in Central Java. CONCLUSION: Transmission of tuberculous infection may be further reduced by intensification of tuberculosis control efforts.

Annual risk of tuberculosis infection in West Sumatra Province, Indonesia.

OBJECTIVE: To estimate the annual risk of tuberculosis infection (ARTI) among children attending elementary school Classes I-III in West Sumatra Province, Indonesia. METHODS: The survey was designed to estimate ARTI among children, irrespective of BCG scar status. Fieldwork was carried out in 72 schools selected by two-stage sampling. Children were administered 2 TU of purified protein derivative RT23 with Tween 80 intradermally on the mid-anterior aspect of the left forearm. The maximum transverse diameter of induration was measured at about 72 h. Analysis was carried out among 5653 satisfactorily test-read children aged 6-9 years. RESULTS: The estimation by mirror-image method among all children (without and with BCG scar) revealed an ARTI of between 1% and 1.3%. The estimated ARTIs among children without and with BCG scar varied between 0.8-1.3% and 0.9-1.4%, respectively, using the mirror-image method, anti-mode method and mixture model. CONCLUSION: Tuberculosis control efforts need to be intensified to reduce the risk of transmission of infection.

[Multidisciplinary therapy of colorectal cancer]. / A colorectalis rák multidiszciplináris kezelése.

A multidisciplinary program for the treatment of colorectal cancer is described. The main objective of the authors has been to define uniform up to date guidelines based on recent progress in the treatment of colorectal cancer. Preoperative diagnostic procedures are summarized which advance determination of clinical stage and prognosis. These information essentially determine care. Sequences of surgical methods, preoperative and postoperative radiotherapy and medical treatments are discussed according to tumor stages. Guidelines for surveillance following active treatment and recommendation for the screening of population at high risk for colorectal cancer are presented.

45T-1, an established cell line with characteristics of Sertoli cells, forms organized aggregates in vitro after exposure to tumor necrosis factor alpha.

In the testis TNF is produced by germinal cells. The putative role of tumor necrosis factor alpha (TNF) in development and differentiation was investigated in 45T-1 mouse cell cultures, a cell line with characteristic markers of Sertoli cells, established from transgenic mouse families expressing the polyoma large T antigen in their testes. Exposure to TNF elicited a gradual assembly of the cells of the monolayer into highly organized spheroids. The first morphological sign of the changes was detected one week after TNF treatment by anti-desmin immunostaining which showed the formation of foci in the culture consisting of several hundred cells connected by an increasing number of cell contacts. Between days 10-20 the cells formed large ovoid or vermiform aggregates covered by several layers of flat, elongated cells. These cells extended septae into the inner mass of the spheroids consisting of loosely arranged, large polygonal or palisadic cells. The spheroids were surrounded by radially arranged elongated cells covered by small blebs. TNF treatment upregulated laminin expression in 45T-1 cell cultures, which is known to induce formation of cord-like structures by Sertoli cells in vitro. Coculturing 45T-1 cells with immortalized germinal cells or TNF-producing HeLa cells also lead to the formation of spheroids. These observations suggest that TNF production of germinal cells might contribute to the organization/differentiation of Sertoli cells.

Polyneuropathy with endoneurial immune complex deposition as the first manifestation of systemic lupus erythematosus.

A 72-year-old male presented with progressive sensorimotor polyneuropathy. Later weight loss, proteinuria and deteriorating renal function were noted. The electrophysiological examinations revealed extensive, symmetrical demyelinating and axonal polyneuropathy. Frozen sections obtained from sural nerve biopsy sample showed the presence of immune complexes and complements in the walls of the epi- and endoneurial blood vessels, and perineurium suggestive of systemic lupus erythematous (SLE). IgG and Clq deposits were also present along the basement membranes of Schwann cells. The electron microscopy confirmed the presence of immune complex deposition. Diagnosis of SLE was proven by positive serology (anti-nuclear antibodies, anti-Sm, anti-RNP, anti-double-stranded DNA) and renal biopsy showing membranous lupus nephritis with extensive immune complex deposition in the tubular basement membranes. Despite combined immunosuppressive treatment for 10 months, the patient died of complications of generalized immune complex vasculitis. The manifestation of SLE in elderly patients, especially in males, is very rare. Moreover, the polyneuropathy is an unusual initial symptom of SLE. Immune complex deposition in Schwann cell basement membrane probably plays an important role in the pathomechanism of sensorimotor polyneuropathy in SLE.

Detection of cutaneous Leishmania infection in paraffin-embedded skin biopsies using the polymerase chain reaction.

In this study the polymerase chain reaction (PCR) with previously developed oligonucleotide primers was used to detect Leishmania aethiopica in paraffin-embedded skin biopsy specimens. The Leishmania-specific 120 base pair fragment of the kinetoplast deoxyribonucleic acid (kDNA) minicircles has been amplified from all parasitologically or histologically confirmed cases of cutaneous leishmaniasis (CL), as demonstrated by gel electrophoresis and hybridization with L. aethiopica kDNA. Control specimens from patients with skin diseases other than CL were all negative. Using PCR, Leishmania were demonstrated in the skin lesions of 7 cases in a group of 40 patients in whom the parasites could not be demonstrated by histopathology or culture in vitro although lesions were clinically suggestive of CL. These data indicate that PCR, carried out on DNA extracted from formalin-fixed and paraffin-embedded tissue specimens, is a valuable method for the diagnosis of CL, especially in chronic cases where the parasite load in the lesion is low.

Clinical meaning of DNA content in the long term behaviour of follicular thyroid tumours: a 12-year follow up.

OBJECTIVE: To find out if there was any correlation between the DNA aneuploidy in benign tumours and in malignant follicular tumours of the thyroid and the progression of either disease. DESIGN: Retrospective study. SETTING: University hospital. SUBJECTS: 71 of 75 patients who had had cytofluorimetric nuclear DNA analyses done on their follicular thyroid tumours during the period 1977-1980, and for whom clinical follow up data were available. MAIN OUTCOME MEASURES: Correlation between clinical course and finding of aneuploidy in original histological specimens. RESULTS: Aneuploidy was found in 6/40 follicular adenomas, 3/17 adenomatous goitres, and in 13/14 follicular carcinomas. The patients were examined after 12 years, when there had been no recurrences of the benign tumours. 5 of the patients with carcinoma had died of distant metastases, all of whom had aneuploid stemlines. There are, however, 8 patients with carcinomas and aneuploidy who are still alive with no recurrences or metastases. CONCLUSIONS: DNA aneuploidy indicates neither the invasiveness nor the metastatic potential of follicular thyroid tumours, and does not distinguish between the minimally invasive (encapsulated) and highly invasive carcinomas.

Aminosidine and its combination with sodium stibogluconate in the treatment of diffuse cutaneous leishmaniasis caused by Leishmania aethiopica.

Treatment of diffuse cutaneous leishmaniasis (DCL) caused by Leishmania aethiopica remains unsatisfactory as the parasite is relatively insensitive to antimonial compounds. Reports of the clinical effectiveness of aminosidine sulphate, especially in combination with sodium stibogluconate, in visceral leishmaniasis and the finding that this antibiotic is potent against L. aethiopica in vitro, prompted us to evaluate its usefulness in DCL. Two patients with long-standing, active DCL were treated for 60 d with aminosidine sulphate, 14 mg/kg/d parenterally. The skin lesions resolved completely in both patients although they relapsed subsequently. Synergism between aminosidine and stibogluconate was demonstrated in vitro against parasites isolated from the patients. This led us to administer combined therapy, aminosidine sulphate 14 mg/kg/d and sodium stibogluconate 10 mg/kg/d, to the 2 patients in relapse and to another, third patient. Treatment was continued for 2 months beyond parasitological cure. Side effects were minimal. Following treatment, a return of specific cell-mediated immunity occurred, as expressed by a moderate infiltration of lymphocytes into the lesions and by lymphocyte proliferation in vitro in the presence of live Leishmania antigen, with synthesis of interleukin-2 and interferon gamma with one patient and interleukin 4 with the other. During follow-up periods of 2 to 21 months after treatment, no sign of relapse was seen.

Histological methods for assessing myelin sheaths and axons in human nerve trunks.

Although there are many histological techniques for assessing myelin sheaths and axons in paraffin embedded or frozen sections of the peripheral nervous system, modern approaches usually use plastic embedded material. Although plastic embedding is superior for small cutaneous branches, this method has limited value for histological assessment of nerve trunks. We report three methods which together yield a comprehensive approach for thorough and detailed investigation of human nerve trunks. The rapid osmication method permitted assessment of myelinated nerve fibers from frozen sections at operation, thus providing the surgeon with guidance on the extent of nerve resection. The modification presented here resulted in permanent slides, allowing comparison of results with those of the other two procedures. The new osmium-hematoxylin technique could be performed on paraffin embedded nerves. Paraffin, unlike plastic, permitted the study of the whole cross sectional area of the nerve in single sections. Moreover, the sharp image of the myelin permitted computerized morphometry. The significantly modified axonal silver impregnation technique was performed on frozen sections mounted on glass slides, as opposed to the time-consuming impregnation of free-floating sections. The latter technique had a high success rate and permitted semiquantitative assessment of axons in nerve trunks. These methods can be performed in any routine histology laboratory and resulted in greater accuracy compared to conventional methods.

Regeneration at the predilective damage sites of nerve trunks in treated leprosy.

Superficially located large and medium sized mixed peripheral limb nerves in active leprosy have previously been shown to have well-recognized fusiform swellings. It is generally agreed that these are the sites of predilective nerve involvement where the severest degeneration and fibrosis occur. A semiquantitative histopathological study on one of these sites, the flexor retinaculum region of the posterior tibial nerve, has been carried out on 14 treated leprosy patients who suffered from total sensory loss to the foot for between 2 and 40 years. The following observations were made: (1) large-scale nerve regeneration was present as characterized by numerous Schwann cells and unmyelinated axons which formed regeneration clusters; (2) thick myelinated axons were either absent or present only in very low numbers; (3) the intraneural fibrosis was usually not severe; (4) the presence of active inflammation probably interfered with nerve regeneration; (5) it appeared that this regeneration started shortly after the onset of therapy and persisted for decades; (6) lepromatous cases were characterized by evenly distributed pathology, whereas borderline tuberculoid cases had an unevenly distributed pathology; (7) the massive nerve regeneration observed was functionally ineffective--these findings indicate that the total nerve damage may affect the more peripheral nerve branches.

Damage and regeneration of peripheral nerves in advanced treated leprosy.

Despite the rapidly falling prevalence of leprosy, the disability and handicap resulting from loss of protective sensation, due to irreversible nerve damage, will remain a huge medical problem for many years. To elucidate the location and consequences of permanent nerve damage in treated leprosy, a prospective study involving nine patients who underwent leg amputation was conducted. Full-length nerves dissected from amputated legs were studied with histological and immunohistochemical methods. Our main findings were that: in both lepromatous and tuberculoid leprosy nerve damage increased distally, culminating in total destruction of dermal nerves and sensory nerve endings; after the therapy-related decrease of inflammation large-scale nerve regeneration took place; and that regenerating axons persisted for decades and in tuberculoid leprosy they might reach the subcutaneous fat of the plantar skin. We conclude that nerve regeneration was blocked by fibrous replacement of the distal-most nerves and nerve endings, and that the theoretical basis of nerve grafting in leprosy is in need of further clarification. In some patients, autologous transplantation of skin flaps, probably irrespective of the duration of loss of sensation, might help in regaining protective sensation.

In leprosy the presence of mycobacteria in the nerve is an essential factor in the cycle and spectrum of Mycobacterium leprae infection.

A total of 220 untreated leprosy patients who underwent parallel skin and nerve biopsies are included in this study, which is intended to evaluate the extent of previously reported differences in bacillary load between skin and nerve lesions in leprosy and to describe the response of peripheral blood lymphocytes to Mycobacterium leprae antigens in such patients. In 161 patients out of the 220, the skin and nerve biopsies were diagnostic for leprosy. When patients were grouped according their skin and nerve lesions, the 3 groups observed were (1) paucibacillary skin and nerve lesions; (2) multibacillary skin and nerve lesions, and (3) paucibacillary skin and multibacillary nerve lesions. There was no observation of a group of patients with multibacillary skin and paucibacillary nerve lesions. In all patients with multibacillary nerve lesions, regardless of the type of skin lesions, a low response of peripheral blood lymphocytes to M. leprae was consistently noted. These results suggest that the bacillary load in the nerve is certainly one of the factors determining the immunological spectrum observed in leprosy.

Mycobacteria contain two groEL genes: the second Mycobacterium leprae groEL gene is arranged in an operon with groES.

In contrast to other bacterial species, mycobacteria were thus far considered to contain groEL and groES genes that are present on separate loci on their chromosomes, Here, by screening a Mycobacterium leprae lambda gt11 expression library with serum from an Ethiopian lepromatous leprosy patient, two DNA clones were isolated that contain a groEL gene arranged in an operon with a groES gene. The complete DNA sequence of this groESL operon was determined. The predicted amino acid sequences of the GroES and GroEL proteins encoded by this operon are 85-90% and 59-61% homologous to the sequences from previously characterized mycobacterial GroES and GroEL proteins. Southern blotting analyses with M. leprae groES- and groEL-specific probes demonstrate that similar groESL homologous DNA is present in the genomes of other mycobacteria, including Mycobacterium tuberculosis. This strongly suggests that mycobacteria contain a groESL operon in addition to a separately arranged second groEL gene. Using five T-cell clones from two leprosy patients as probes, expression of the M. leprae GroES protein in Escherichia coli after heat shock was demonstrated. Four of these clones recognized the same M. leprae-specific GroES-derived peptide in a DR2-restricted fashion. No expression of the groEL gene from this operon was detected in E. coli after heat shock, as tested with a panel of T-cell clones and monoclonal antibodies reactive to previously described GroEL proteins of mycobacteria.

[Fatal thrombotic microangiopathy in the mother and fetus]. / Az anya és a magzat halálához vezetö thrombotikus microangiopathia.

The appearance of thrombotic microangiopathy (thrombotic thrombocytopenic purpura, haemolytic uraemic syndrome) could have been documented in a 23 years old pregnant woman, who had been treated previously for immune-thrombocytolytic purpura. The disturbing anamnestic data caused significant delay in correct diagnosis and in starting of fresh-frozen plasma therapy, so the woman and her fetus (in utero) had been died. The specific histological microangiopathic lesions could have been well documented by the autopsy of the mother, however no such alterations could have been detected in the fetus and placenta. This latter intriguing observation might be remarkable in the evaluation of several concepts dealing with the aetiopathogenesis of thrombotic microangiopathy. The short review of literature of thrombotic microangiopathy in pregnancy and puerperial period is also given.