Immunosuppressive therapy for peripartum-type spontaneous coronary artery dissection: case report and review.

BACKGROUND: A 35-year-old postpartum woman presented with myocardial infarction (MI) due to spontaneous coronary artery dissection (SCAD). In addition to conventional medical therapy, she was treated with immunosuppressive agents (prednisone and cytoxan) because of five noncontiguous coronary dissections, surgical inoperability, and postinfarction angina. Repeat angiography 94 days later demonstrated angiographically normal vessels. METHODS: A literature review of 42 additional cases of peripartum SCAD was performed, and the results were compared with this patient. RESULTS: Mortality was 48.8% (21/43). Sudden cardiac death was the initial presentation in 27.9% (12/43) of cases. The left coronary artery was involved in 78.6% (44/56) of dissections with left main segment dissection in 10 cases. In women who survived > 24 h post infarction, recurrent MI, usually due to a second coronary dissection, occurred in 20.8% (5/24). Histopathologic studies have often shown periadventitial inflammation (80%, 16/20), in which eosinophils predominate (68.8%, 11/16), and may be linked to the medial degeneration often found in these cases. CONCLUSIONS: The common observation of eosinophilic periadventitial inflammation suggests a role in the pathophysiology of this rare, yet serious condition. Aggressive immunosuppressive therapy in this case of multivessel dissection resulted in spontaneous angiographic healing of all lesions.

Early lymphocyte transformation abnormalities in human immunodeficiency virus infection.

Two hundred twelve patients with enzyme immunoassay and Western blot confirmation of human immunodeficiency virus (HIV) infection were evaluated with anergy panel, lymphocyte cell surface phenotyping, lymphocyte transformation, and serum immunoglobulins. Mitogen responses were used to develop a lymphocyte transformation index (LTI) comparing the summation of each individual's response to its normal control. By multiple regression, anergy panel, absolute CD4 level, and LTI show a progressive decline and IgA shows a progressive increase when correlated with a worsening Walter Reed (WR) classification (R = 0.84). Lymphocyte transformation is first abnormal in WR class 1, absolute CD4 in WR class 3, and anergy and serum IgA in WR class 4. The above markers are useful to assess immunologic function in HIV infection. Lymphocyte transformation abnormalities precede other immunologic deficits in HIV positive patients. Serial evaluation of these markers may help define the immunologic response and natural history of HIV infection.

Goodpasture's syndrome associated with pulmonary eosinophilic vasculitis.

Lung hemorrhage and antiglomerular basement membrane (anti-GBM) antibody mediated nephritis define Goodpasture's syndrome. We present the case of a 19-year-old Caucasian woman with unique clinical findings of Goodpasture's syndrome. Our patient initially presented with leukocytoclastic vasculitis of the skin followed by the development of nephritis and lung hemorrhage. An open lung biopsy done prior to diagnosing anti-GBM antibody disease demonstrated an intense eosinophilic vasculitis. Skin vasculitis has only been rarely reported, and to our knowledge this is the first reported case of pulmonary eosinophilic vasculitis associated with Goodpasture's syndrome.

Pulmonary hypertension in systemic lupus erythematosus: effect of vasodilators on pulmonary hemodynamics.

Hemodynamic studies of the response of the pulmonary vasculature to vasodilator drugs were performed in 3 patients with systemic lupus and pulmonary hypertension. In one patient isoproterenol infusion produced a reduction in total pulmonary resistance, but increased pulmonary blood flow and pulmonary artery pressure. No significant change in pulmonary artery pressure or resistance was noted with nifedipine in any of the patients. One woman with associated pulmonary infiltrates improved symptomatically with high dose steroids.

Objective and subjective tremor responses to oral beta 2 agents on first exposure. A comparison of metaproterenol and terbutaline.

Objective and subjective postural tremor responses at 60 and 120 min after drug treatment were studied in 24 veterans with chronic obstructive pulmonary disease who received either 5 mg terbutaline, 20 mg metaproterenol, or a placebo in random order. Subjects were fasting, and had not taken theophylline for 15 to 24 h or any oral sympathomimetics for 2 wk. The mean tremor response to terbutaline and metaproterenol was equal at 60 min, but the 120-min response to metaproterenol was less. When the 60- and 120-min responses were averaged, tremor response to terbutaline was significantly greater than that to metaproterenol in a 5 : 4 ratio. Subjective awareness was also greater. These results are consistent with the difference in bronchodilatory potency of the two preparations. That the drug producing the greater tremor could usually be identified by the patient, even at low tremor intensities, is consistent with the hypothesis that perception of tremor is a function of relative rather than absolute increase over basal tremor unless the tremor becomes physically disabling. In general, the individual tremor response was proportional to the extent by which a patient's basal tremor exceeded the minimal basal tremor for the group as a whole. These results fit a model in which the postural tremor derives from beta-sensitive and beta-insensitive cardioballistic and skeletal muscle forces. Variability in tremor response resides principally at the peripheral skeletal beta 2-receptor and its control system.