Biomedical subjects
Publications and source records attributed to A C White.
ARDS developed in association with tumor lysis syndrome (TLS) in a patient with non-Hodgkin's lymphoma. Although a number of life-threatening complications have been noted to occur following TLS, this appears to be the first report of ARDS developing in association with TLS.
Larval stages of Taenia species survive for prolonged periods in the tissues of their intermediate hosts. Other groups have demonstrated that host immunoglobulins are taken up by the cysticerci by adsorptive endocytosis, degraded, and the amino acids incorporated into parasite proteins. We have shown that a 43-kDa cysteine proteinase is the major parasite enzyme that degrades immunoglobulin in vitro. To localize this enzyme in situ, Taenia crassiceps cysticerci were incubated with the peptide substrate Z-Phe-Arg-methoxynaphthylamide. Free methoxynaphthylamide was coupled to p-rosanilin and osmium and visualized by transmission electron microscopy. Initial studies of cysticerci incubated without substrate confirmed the normal microanatomy and absence of significant host inflammation. In comparison to controls with no substrate, sections of cysticerci incubated with substrate revealed electron-dense deposits in round vesicles. The vesicles were found primarily within the tegumentary cytons and internuncial processes, a location similar to that described for vesicles associated with adsorptive endocytosis. There were proportionately more endocytotic vesicles and electron-dense vesicles in smaller cysticerci than larger ones. Formation of electron-dense deposits was inhibited by heat and partially inhibited by the cysteine proteinase inhibitor E-64. These data are consistent with localization of the cysteine proteinase activity to lysosome-like vesicles.
We have used a formal transplant protocol to select patients with alcoholic liver disease (ALD) for transplantation. We retrospectively analyzed all the patients with ALD who were referred specifically for transplantation to our Liver Unit between 1987 and 1994. Patients were selected for liver transplantation if they had end-stage liver disease and had remained abstinent from the time they were medically advised to stop alcohol intake. Of the 180 patients referred for transplantation, 43 (none of whom were transplanted) had case records insufficiently complete for full analysis; this may bias the analysis. Of the remaining 137 patients, 39 were transplanted and 4 were awaiting transplantation at the time of analysis. Of the patients who were not accepted for transplantation, 13 died during the assessment, 7 were considered to be unlikely to survive the procedure, 29 were found to be medically unsuitable, 16 psychologically unsuitable, 7 patients refused the offer of transplantation, and an additional 19 either showed clinical improvement or were considered too well for transplantation. Special investigations, such as brain computerized tomography (CT) scan and echocardiograph, changed the clinical decision to transplant in only a small number of cases (4% and 5%, respectively). Nine of the transplanted patients died and the remaining were followed up for a median of 25 (range, 7-63) months. One year actuarial survival for the transplanted patients was 79%, for those considered too sick was 0%, for medically unsuitable patients was 44%, for psychologically unsuitable patients was 65% and for those considered too well was 94%. Only 5 of the transplanted patients (13%) reverted to drinking. The observed actuarial survival of nontransplanted patients was compared with the expected survival calculated by 'the Beclere model.' The observed actuarial survival in the nontransplanted groups was much better than anticipated from the Beclere model, which therefore, is not applicable to our patients. The proportional hazards regression analysis of our nontransplanted patients identified serum bilirubin, serum albumin, blood urea, ascites, and spontaneous bacterial peritonitis as factors significantly predictive of their probability of survival. Using a model based on these parameters, the expected survival of our transplanted patients was calculated. Although we applied the model to a different population, the observed actuarial survival in the transplanted patients was found to be better than their expected survival (P < or = .001). Our protocol was useful in selecting suitable patients with ALD for liver transplantation, which resulted in significant survival advantage with low recidivism rate.
Human neurocysticercosis, due to infestation of the central nervous system with Taenia cysts, is a common cause of neurologic disease in endemic areas and is being increasingly recognized in the United States. Previous studies have suggested that Taenia cysts bind host IgG via Fc-like receptors and that bound IgG is degraded by the parasite, perhaps as a source of nutrients or a means of immune evasion. We now demonstrate that IgG degradation is thiol dependent and is inhibited by the cysteine proteinase inhibitor, E-64. The cysteine proteinase activity from Taenia crassiceps cysts was purified 682-fold by acid extraction, gel filtration chromatography, and anion-exchange FPLC. The cysteine proteinase appeared as a 43 kDa band on silver-stained gels. Its isoelectric point was 5.27. The purified enzyme was inhibited by cysteine proteinase inhibitors and also by chloromethyl ketone inhibitors, but not significantly by other inhibitors of serine, aspartic, or metallo-proteinases. Substrate studies showed pronounced cleavage of Z-Phe-Arg-7-amino-4-trifluoromethylcoumarin (Z-Phe-Arg-AFC), but not of substrates with neutral or positively charged amino acids in the P2 position. Km for Z-Phe-Arg-AFC was 1.0 x 10(-7) M, Kcat 58 s-1, and Kcat/Km 5.8 x 10(8) mol-1s-1. Amino acid sequencing of the amino terminus revealed a single cysteine residue with surrounding residues suggestive suggestive of a cysteine proteinase active site. The sequence, however, did not contain the conserved active site associated with enzymes of known cysteine proteinase families. This cysteine proteinase may play an important role in the interaction of Taenia cysts and host immunoglobulin and is a potential target for antiparasitic chemotherapy.
Antimicrobial control programs are widely used to decrease drug expenditures, but effects on antimicrobial resistance and outcomes for patients are unknown. When a requirement for prior authorization for selected parenteral antimicrobial agents was initiated at our urban, county teaching hospital, total parenteral antimicrobial expenditures decreased by 32%. Susceptibilities to all beta-lactam and quinolone antibiotics increased, with dramatic increased susceptibilities in isolates recovered in intensive care units, increased susceptibilities in isolates recovered in other inpatient sites, and little change in susceptibilities in isolates recovered in outpatient sites despite no change in infection control practices. For patients with bacteremia due to gram-negative organisms, overall survival did not change with restrictions. No differences occurred in the median time from initial positive blood culture to receipt of an appropriate antibiotic or in the median time from positive blood culture to discharge from the hospital. Thus, requiring preapproval for selected parenteral agents can decrease antimicrobial expenditures and improve susceptibilities to antibiotics without compromising patient outcomes or length of hospital stay.
Explore the source record for details and available documents.
Cryptosporidiosis is an important cause of diarrhea. We identified 95 patients with cryptosporidiosis over a 6-year period in our county hospital system, including 9 children and 86 adults infected with the human immunodeficiency virus (HIV). Risk factors included male-to-male sexual practices and Hispanic race. Diarrhea, weight loss, and gastrointestinal complaints were the most common symptoms at presentation. Among the HIV-infected adults, 20 (23%) developed biliary tract disease. Biliary involvement was associated with low CD4 counts. Treatment with paromomycin and antimotility agents was effective in reducing diarrheal symptoms in 54 of 70 (77%) patients with the acquired immunodeficiency syndrome (AIDS), although there was a high rate of relapse. Paromomycin did not prevent the development of biliary disease. Biliary disease responded to cholecystectomy or sphincterotomy with stent placement. Though often a cause of morbidity, cryptosporidiosis was only rarely the cause of death, even among patients with HIV. Cryptosporidiosis continues to be an important medical problem even in developed-countries. Current methods of prevention and treatment are suboptimal.
Neurocysticercosis, caused by Taenia solium, is one of the most common causes of seizures worldwide. The symptoms result from granulomatous inflammation associated with dying cyst forms of the parasite. Although the invasive larvae can be killed by immune serum plus complement, immunity to the cyst stage depends on a cellular response. This dichotomous immune response is reminiscent of the extremes of the immune response associated with T helper 1 (Th1) and Th2 cytokine profiles. To characterize the cytokine response in cysticercosis, granulomas were removed from the peritoneal cavity of mice infected with Taenia crassiceps cysts and examined for cytokine message by in situ hybridization using 35S-labeled RNA probes. The granulomas were staged based on histologic appearance of the degenerating parasite. Message for gamma interferon (IFN-gamma) was identified by light microscopy in 11 of the 12 granulomas, and interleukin-2 (IL-2) message was identified in 9 of the 12. By laser scanning confocal microscopy, significantly increased IFN-gamma and IL-2 pixel intensity was identified in nearly all of the granulomas from early histologic stages. Message for IL-4 was seen in 6 of the 12 granulomas. Only granulomas with complete destruction of the parasite architecture displayed more than minimal amounts of IL-4 message by light microscopy, and only 2 of 12 granulomas had IL-4 pixel intensity significantly above background. Only minimal amounts of IL-10 message were detected in 4 of 11 granulomas. Thus, early granulomas in cysticercosis are predominantly associated with a Th1 response, whereas later granulomas, in which parasite destruction is complete, have a mixture of Th1 and IL-4. The Th1 response appears to play an important role both in the pathogenesis of disease as well as in the clearing of the parasites, with IL-4 involved in downregulation of the initial response.
We have previously observed that transforming growth factor beta 1 (TGF beta 1) produces a pro-oxidant effect and decreases cellular glutathione (GSH) levels of cultured bovine pulmonary artery endothelial cells (BPAEC) (White A. C., S. K. Das, and B. L. Fanburg. Am. J. Respir. Cell Mol. Biol. 6:364-368, 1992). In the present studies we demonstrate that 2 ng/ml TGF beta 1 reduces the uptake of two GSH precursor amino acids (cystine and glutamate) by 50% (cystine; control 359.35 +/- 100, TGF beta 1 187.7 +/- 26 pmol/10 min/10(6) cells, p < 0.05; glutamate; control 215.15 +/- 18, TGF beta 1 110.2 +/- 16 pmol/10 min/10(6) cells, p < 0.001). The inhibitory effect of TGF beta 1 on the uptake of GSH precursor amino acids persisted in the presence of buthionine sulfoximine (inhibits gamma-glutamyl cysteine synthetase, the rate limiting step in GSH synthesis) or acivicin (inhibits gamma-glutamyl transpeptidase). The uptake of leucine, an amino acid that does not serve as a precursor for GSH, was unaffected by TGF beta 1. In additional experiments TGF beta 1 decreased the levels of cellular and medium GSH-indicating that TGF beta 1 did not increase efflux of GSH from BPAEC. We propose from these observations that TGF beta 1 decreases cellular glutathione, at least in part, through down regulation of precursor amino acid transport and, thereby, its rate of synthesis.
We retrospectively reviewed the medical records of all infants and children (< 18 years of age) with the discharge diagnosis of malaria who were admitted to the four major pediatric teaching hospitals in Houston, Texas from January 1988 through December 1993. Thirty-four cases of pediatric malaria were identified in three newborns, 22 travelers, and nine recent immigrants. The travel destination was West Africa in 68%, Central America in 14%, India in 14%, and unknown in 4%. The location of the child's and parents' birthplace was available in 77% of the travel-related cases and in all cases the destination of travel was the parents' country of origin. The peak incident of the travel-related cases was late summer and early January corresponding to return from summer or Christmas vacation. Sixteen (75%) of the 22 travel-related cases had received either no prophylaxis (12 of 22) or inadequate (4 of 22) chemoprophylaxis. Half of the patients who were given appropriate chemoprophylaxis admitted to poor compliance. The clinical presentation was usually nonspecific. Fever was the most common symptom (97%) and was paroxysmal in one-third. Splenomegaly was the most common physical finding (68%). The malaria species identified included Plasmodium falciparum (56%), P. vivax (23%), P. malariae (3%), and unidentified (18%). Moderate anemia (hemoglobin level = 7.0-10 g/dL) occurred in 38% and severe anemia (hemoglobin level < 7.0 g/dL) in 29%. Three patients required transfusion. There were no end-organ complications. In summary, pediatric malaria in Houston was primarily seen in immigrants or children of immigrants who returned to their native country. Education and preventive strategies should target these families and should be part of the routine well child care of these children.
Taenia parasites have developed elaborate mechanisms of interacting with their intermediate hosts. The oncospheres which invade the intermediate host are susceptible to antibody and complement. However, by the time the host has generated an antibody response, the parasites have begun to transform to the more resistant metacestode. The metacestodes have elaborate means of evading complement-mediated destruction, including paramyosin which inhibits C1q, taeniaestatin which inhibits both classical and alternate pathways, and sulfated polysaccharides which activate complement away from the parasite. Similarly, antibody does not seem to be able to kill the mature metacestode. In fact, the parasites may even stimulate the host to produce antibody, which could be bound via Fc receptors and used as a source of protein. Finally, taeniaestatin and other poorly defined factors may interfere with lymphocyte proliferation and macrophage function, thus paralyzing the cellular immune response. Since the symptoms of NCC are typically associated with a brisk inflammatory response, we hypothesize that disease is primarily caused by injured or dying parasites. This hypothesis raises important questions in assessing the role of chemotherapy in the management of NCC, as well as in the evaluation of clinical trials, most of which were uncontrolled.
BACKGROUND: Azithromycin is active in treating Mycobacterium avium complex disease, but it has not been evaluated as primary prophylaxis in patients with human immunodeficiency virus (HIV) infection. Because the drug is concentrated in macrophages and has a long half-life in tissue, there is a rationale for once-weekly dosing. METHODS: We compared three prophylactic regimens in a multicenter, double-blind, randomized trial involving 693 HIV-infected patients with fewer than 100 CD4 cells per cubic millimeter. The patients were assigned to receive rifabutin (300 mg daily), azithromycin (1200 mg weekly), or both drugs. They were monitored monthly with blood cultures for M. avium complex. RESULTS: In an intention-to-treat analysis, the incidence of disseminated M. avium complex infection at one year was 15.3 percent with rifabutin, 7.6 percent with azithromycin, and 2.8 percent with both drugs. The risk of the infection in the azithromycin group was half that in the rifabutin group (hazard ratio, 0.53; P = 0.008). The risk was even lower when two-drug prophylaxis was compared with rifabutin alone (hazard ratio, 0.28; P<0.001) or azithromycin alone (hazard ratio, 0.53; P = 0.03). Among the patients in whom azithromycin prophylaxis was not successful, 11 percent of M. avium complex isolates were resistant to azithromycin. Dose-limiting toxic effects were more common with the two-drug combination than with azithromycin alone (hazard ratio, 1.67; P=0.03). Survival was similar in all three groups. CONCLUSIONS: For protection against disseminated M. avium complex infection, once-weekly azithromycin is more effective than daily rifabutin and infrequently selects for resistant isolates. Rifabutin plus azithromycin is even more effective but is not as well tolerated.
Explore the source record for details and available documents.
Subcutaneous implantation of Taenia solium metacestodes in mice induces an inflammatory reaction made up mainly of neutrophils and eosinophils after 12 days. Administration of a small RNA-peptide (metacestode factor, MF) purified from T. solium metacestodes significantly reduces the inflammatory site in both size and composition, yielding a very low number of eosinophils. The metacestodes implanted in control mice were completely destroyed and their remnants were surrounded by an intense inflammation predominantly made up of neutrophils and eosinophils. In contrast, metacestodes implanted in mice treated with MF showed apparently intact suckers, rostellum, hooks, and tegument. Inhibition of inflammation around the parasites was also observed in mice immunized with T. solium metacestode antigens and inoculated simultaneously with MF. Mice immunized only with T. solium metacestode antigens produced a granulomatous process around metacestodes that destroyed most of the large metacestode structures: suckers, rostellum, hooks, and tegument-wall tissues. Furthermore, treatment of mice with MF or implanted metacestodes decreased the antibody (P < 0.05) and cellular responses (P < 0.05) to metacestode antigens. The antibody responses was even lower when both of these treatments were given simultaneously. These findings support the idea that MF plays a key role in the down-regulation of the host immune response, contributing to the parasite's survival.
We have developed a flexible reverse transcription (RT) coupled quantitative polymerase chain reaction (PCR) assay for transforming growth factor beta-1 (TGF-b) mRNA. A deletion mutant cDNA internal standard was prepared from the wild type cDNA and used to normalize intersample PCR efficiency differences. The assay is compatible with samples from cow and other species. Using RT-PCR, we determined that TGF-b mRNA in bovine pulmonary artery endothelial cells is increased by TGF-b 7.5-fold within 6h and remains 4-fold above baseline after 12h. In addition, unlike TGF-b bioactivity, mRNA levels in endothelial cells are not decreased upon exposure of the cells to either glutathione (reduced or oxidized), cysteine, or N-acetylcysteine for 24h.
Malaria was endemic in the United States before World War II. However, locally acquired malaria was thought to have been eradicated. Since the mid-1980s, cases of locally acquired malaria have been described. We report the case of a 62-year-old man who came to the Houston Veterans Affairs Medical Center with fever, malaise, and weakness and was found to have Plasmodium vivax infection on peripheral blood smear. He had not left the country for 37 years and had no previous history of malaria. On specific questioning, he mentioned heavy exposure to mosquitoes. Thus, malaria was presumably transmitted locally by mosquitoes. Subsequently, two other cases of apparently locally acquired, mosquito-transmitted malaria were identified in Houston. Symptoms, signs, and general laboratory test results do not typically suggest a specific diagnosis. Therefore, malaria should be considered in all patients with febrile illnesses, even those without a history of travel.
There have been sporadic reports in the literature of an association between bullous disease of the lung and lung cancer; however, we believe that this clinical association is not well recognized. We present six cases in which bullous disease of the lung and lung cancer coexisted, and review the available literature on the topic. Five of the patients were males, the mean age of presentation was 42 yr (range: 32 to 62 yr), and all of the patients were smokers. Histologically the tumors in all six patients were non-small-cell carcinomas. The significantly younger age of these patients with lung cancer and bullous disease as compared with those reported in the literature with lung cancer but without bullous disease suggests that the association between these two processes is more than just coincidental. The utility of plain radiography and computerized tomography (CT) of the chest in screening patients with bullous disease for lung cancer is discussed.
To identify oncosphere excretory/secretory peptidases, Taenia saginata adult worms were collected from 3 patients. Eggs were hatched and activated in vitro and oncospheres cultured in vitro. The culture medium from the oncospheres was assayed with peptide substrates coupled to 7-amino-4-trifluoromethyl coumarin (AFC), and free AFC was detected fluorometrically. The endopeptidase substrates Z-Phe-Arg-AFC and Z-Arg-AFC as well as the aminopeptidase substrate Arg-AFC were hydrolyzed when incubated with spent media from the oncospheres compared to control culture medium removed prior to incubation. Hydrolysis of Z-Phe-Arg-AFC was inhibited 78% by preincubation of the medium with the serine proteinase inhibitor Phenylmethylsulfonyl fluoride. Endopeptidase activity was partially enhanced in the presence of exogenous thiols and partially inhibited with the cysteine proteinase inhibitor E-64, suggesting the presence of both serine and cysteine endopeptidases. No significant inhibition was noted with pepstatin or phenanthroline. The peptidase activities detected with Z-Phe-Arg-AFC and Arg-AFC were separated by gel-filtration fast protein liquid chromatography and eluted at volumes corresponding to molecular weights of 18 and 30 kDa, respectively. These data demonstrate that T. saginata oncospheres produce excretory/secretory peptidases, including serine and cysteine endopeptidases and an aminopeptidase. These enzymes may play a role in invasion of the intestinal mucosa of the intermediate host.