High-dose intravenous immunoglobulin and rituximab treatment for antibody-mediated rejection after kidney transplantation: a cost analysis.

Antibody-mediated rejection (AMR) generally occurs in highly sensitized patients. A pilot study was performed on 7 consecutive patients with AMR to assess the efficacy of high-dose intravenous immunoglobulin (IVIG; 2 g/kg) + rituximab (RTX; 375 mg/m(2)) without plasmapheresis. After a 24-month follow-up, 1- and 2-year allograft survivals were 86% and 58%, respectively. C4d became negative in 1 patient posttreatment. Donor-specific antibody (DSA) titers decreased to less than 1:4 in 2 cases. There were 4 infectious complications and 1 case of aseptic meningitis followed by cranial nerve VI palsy. The average hospital charge for 1 administration of IVIG + RTX, including hospital stay and renal biopsy expenses, was approximately $49,000. A combination of IVIG + RTX in late AMR may be beneficial but is an expensive treatment approach for selected renal transplant patients.

Prevalence and cellular reservoir of latent human herpesvirus 6 in tonsillar lymphoid tissue.

There are few studies that examine prevalence, quantity, and cellular proclivity of latent human herpesvirus 6 (HHV-6) in healthy populations. We examined 69 tonsils with paired blood specimens from children without evidence of acute infection. By polymerase chain reaction (PCR), HHV-6 was detected at low levels in 100% of tonsils and 39% of blood samples (n = 27), suggesting that prevalence of latent HHV-6 infection is high in children and may be underestimated by PCR analysis of blood. Although HHV-6A and HHV-6B were detected, HHV-6B predominated, being found in 97% of samples (n = 67). Tonsil sections from 7 cases were examined by in situ hybridization using 2 HHV-6 probes and immunohistochemical analysis. Using both in situ hybridization and immunohistochemical analysis, all tissues revealed marked HHV-6-specific staining in the squamous epithelium of the tonsillar crypts and rare positive lymphocytes. We conclude that HHV-6 is present universally in tonsils of children, and tonsillar epithelium may be an important viral reservoir in latent infection.

High cardiac output state in patients with multiple myeloma: case report and review of the literature.

A high cardiac output state, with or without congestive heart failure, has recently been recognized in patients with multiple myeloma. This case report deals with a 62-year-old man with multiple myeloma refractory to treatment, a high cardiac output state, and life-threatening pulmonary edema. In addition, a brief review of the literature is presented.

Differentiation of convulsive syncope and epilepsy with head-up tilt testing.

OBJECTIVE: To evaluate the usefulness of head-upright tilt table testing in the differential diagnosis of convulsive syncope from epileptic seizures in patients with recurrent idiopathic seizure-like episodes. DESIGN: Prospective, nonrandomized study. SETTING: Electrophysiology laboratory of a university hospital. PATIENTS: Fifteen patients (8 men and 7 women patients; mean age, 29 +/- 20 years) with recurrent unexplained seizure-like episodes, unresponsive to antiseizure medication. MEASUREMENTS: Head-upright tilt table testing with or without isoproterenol infusion. Five patients who were initially tilt positive had a second tilt test with continuous electroencephalographic (EEG) recording. MAIN RESULTS: Syncope associated with tonic-clonic seizure-like activity occurred in six patients (40%) during the baseline tilt and in four patients (27%) during isoproterenol infusion (total positive tests, 67%). The EEG showed diffuse brain wave slowing (not typical of epileptic seizures) in five of five patients during the convulsive episode. All patients who had positive test results eventually become tilt table negative after therapy, and over a mean follow-up period of 21 +/- 2 months, no further seizure-like episodes have occurred. CONCLUSION: Upright tilt table testing combined with isoproterenol infusion may be useful to distinguish convulsive syncope from epileptic seizures.

Cerebral vasoconstriction during head-upright tilt-induced vasovagal syncope. A paradoxic and unexpected response.

BACKGROUND: To determine the effect of vasovagally mediated syncope on the cerebral circulation, transcranial Doppler sonography was used to assess changes in cerebral blood flow velocity during head-upright tilt-induced syncope. METHODS AND RESULTS: Thirty patients (17 men and 13 women; mean age, 43 +/- 22 years) with recurrent unexplained syncope were evaluated by use of an upright tilt-table test for 30 minutes, with or without an infusion of intravenous isoproterenol (1-4 micrograms/min), in an attempt to provoke bradycardia, hypotension, or both. Transcranial Doppler sonography was used to assess middle cerebral artery systolic velocity (Vs), diastolic velocity (Vd), ratio of systolic to diastolic velocities, pulsatility index (PI = Vs-Vd/Vmean), and resistance index (RI = Vs-Vd/Vs) before, during, and after tilt. Syncope occurred in six patients (20%) during the baseline tilt and 14 (46%) during isoproterenol infusion (total positives, 66%). In the tilt-positive patients, concomitant with the development of hypotension and bradycardia, transcranial Doppler sonography showed a 75 +/- 17% decrease in diastolic velocity, unchanged systolic velocity, a 46 +/- 17% decrease in mean velocity, a 295 +/- 227% increase in pulsatility index, and a 73 +/- 34% increase in resistance index. CONCLUSIONS: These findings reflect increased cerebrovascular resistance secondary to arteriolar vasoconstriction distal to the insonation point of the middle cerebral artery. This is paradoxic because the expected response of the cerebral circulation to hypotension is vasodilation. We conclude that abnormal baroreceptor responses triggered during vasovagal syncope result in a derangement of cerebral autoregulation with paradoxic vasoconstriction in the face of increasing hypotension.

Rupture of a pulmonary artery mycotic aneurysm associated with candidal endocarditis.

Candidal endocarditis can develop if candidemia occurs during Swan-Ganz catheterization. Candida endocarditis may persist for many months and is fatal unless the infected valve is resected. Herein is reported the first case of rupture of a mycotic pulmonary artery aneurysm caused by chronic candidal endocarditis. The endocarditis followed Swan-Ganz catheterization and aneurysm progressed despite appropriate medical and surgical therapy.