Harry N. Hoffman

Zinc-Induced Copper Deficiency

Copper deficiency was found in an adult patient who had received excessive daily oral zinc for 10 mo. The deficiency was characterized by hypochromic-microcytic anemia, leukopenia, and neutropenia. Although initially thought to be caused by iron deficiency, the anemia did not respond to oral or intravenous iron. Cessation of zinc tablets and ingestion of an oral copper preparation daily for 2 mo failed to correct the anemia or leukopenia. It was not until shortly after intravenous administration of a cupric chloride solution during a 5-day period, at a total dose of 10 mg, that serum copper and ceruloplasmin levels increased and the anemia, leukopenia, and neutropenia resolved. These data suggest that the elimination of excess zinc is slow and that, until such elimination occurs, the intestinal absorption of copper is blocked.

THE PLASMA REMOVAL OF INDOCYANINE GREEN AND SULFOBROMOPHTHALEIN: EFFECT OF DOSAGE AND BLOCKING AGENTS

In 1950 Brauer and Pessotti (1) observed that the concentration of sulfobromophthalein in bile reached maximal values which were not influenced by further increments in infusion rate. In 1956 Combes, Wheeler, Childs and Bradley (2) introduced the concept of maximal biliary transport capacity for sulfobromophthalein. It is now generally held that when sulfobromophthalein is infused at a rate that exceeds the maximal biliary transport capacity, the biliary excretion of the dye remains relatively constant. The effect of the initial dosage or infusion rate of sulfobromophthalein on the various parameters measuring hepatic uptake is not so uniformly agreed upon, due in part to confusion about the meaning of the parameters themselves. These include: 1) hepatic extraction-the percentage of dye removed in one passage through the liver; 2) clearance rate-the milliliters of plasma comipletely cleared of dye in 1 minute; and 3) disappearance rate or removal rate-herein defined as the percentage of remaining dye removed each minute. Unless specified, removal rate will not be used to express the number of milligrams removed per minute. Casselman and Rappaport (3), Andrews, Maegraith and Richards (4) and Combes and associates (2) have suggested that hepatic extraction is constant or nearly constant, regardless of dosage or infusion rate. Myers (5) and Cook, Lawler, Calvin and Green (6) observed the exact converse; that is, that extraction became less efficient with increasing dose. Lavers and colleagues (7) found that variation in the initial single dose did not affect the rate of removal of sulfobromophthalein from the plasma. Again, the converse has been reported: Fauvert (8) stated that increasing the initial dose decreased the plasma disappearance rate of the dye. Wheeler and associates (9, 10) recently described the hepatic uptake of sulfobromophthalein under special circumstances in which a constant infusion of dye is in excess of the maximal biliary transport capacity. Under these circumstances a portion of plasma removal of the dye is accounted for by bile excretion; this is a constant. The remainder of the dye taken up by the liver from the plasma is stored in the hepatic cells. These authors have shown that hepatic storage is directly proportional to plasma concentration. Consequently, the higher the plasma concentration, the more milligrams of dye can be stored. Limitations were not observed for any potential maximal capacity for this removal mechanism, but it should be noted that the phenomenon is not rate limited. This description does not apply to the mechanics of removal of a single injection of dye, however, because the storage compartment is empty at the outset and, obviously, no constant proportional relationship between storage and plasma concentration would be possible. Several authors (1, 11-13) reported that sodium dehydrocholate will slow the removal of sulfobromophthalein from the plasma and will delay its excretion in the bile. Cantarow, Wirts, Snape and Miller (14) and Fauvert (8) suggested that competition for hepatic uptake exists between bilirubin and sulfobromophthalein, the latter being selectively removed. Brauer and Pessotti (1) observed that rose bengal slowed the excretion of sulf-obromophthalein in bile, but Popper and Schaffner (15) and Fauvert (8) pointed out that sulfobromophthalein is selectively taken up by the liver when administered simultaneously with rose bengal. Wheeler, Cranston and Meltzer (16) reported that the hepatic uptake of sulfobromophthalein was faster than that of indocyanine green; Cherrick, Stein, Leevy and Davidson (17) reported the converse. However, the last two reports were done on different species with different dosage relationships, and the dyes were not administered simutltaneously.

Untreated gastric pseudolymphoma.

SummaryGastric pseudolymphoma is an inflammatory process that may simulate malignancy. In most reported cases, the initial diagnosis has been malignant lymphoma and treatment has been applied accordingly.We report a case of gastric pseudolymphoma wherein the diagnosis was made from multiple surgical biopsies, and follow-up now exceeds 11 years. To our knowledge, no other case of untreated gastric pseudolymphoma has been reported. This case may more closely represent the biologic nature of this presumably benign condition.

Nonoperative retrieval of an impacted long intestinal tube

SummaryA patient with recurrent intestinal obstruction and jejunocutaneous fistula was referred for treatment of the latter condition. Management with total parenteral nutrition was complicated by bacteremia. Subsequently, a double-lumen tube was passed via an existing gastrostomy for purposes of aspirating above the level of the fistula and infusing approapriate nutrients and fluids distally. A period of marked clinical improvement was followed by increased fistula output and evidence of intestinal obstruction secondary to gaseous distention of a sealed latex terminal balloon which was retrieved only after percutaneous puncture. The unusual complication of prolonged intestinal intubation is discussed with special reference to this nonsurgical method of managing the impacted balloon and tube. Factors affecting balloon distention are discussed and the necessity of venting intestinal balloons reemphasized.

Current Concepts of Bilirubin Metabolism in Jaundice

Studies of the metabolism of bilirubin have shown that bilirubin may be added to the already-known metabolites and exogenous substances which are excreted by the liver as glucuronides.From experiments in animals, it seems likely that bilirubin undergoes conjugation to pigment I (monoglucuronide) outside the liver or to pigment I and then to pigment II (diglucuronide) within the liver. The transformation of lipid-soluble bilirubin to water-soluble pigments is thought to be responsible for the chemical and physiologic differences between indirect and direct bilirubin in various forms of jaundice.