Michael Rosenberg

Clinical and Immunologic Criteria for the Diagnosis of Allergic Bronchopulmonary Aspergillosis

Clinical and immunologic characteristics are reported in a series of 20 patients with allergic bronchopulmonary aspergillosis seen by physicians in one consulting service during a period of 9 years. Seventeen of these patients have been identified in the past 2 years, reflecting the increasing recognition of the entity. Fifteen of the 20 patients are believed to have proven diagnoses; the other five are strongly suspected. Asthma, pulmonary infiltrates, and eosinophilia are the usual presenting symptoms. Serum immunoglobulin E was markedly elevated in all patients, and serum immunoglobulin D was normal in four out of five patients sampled. Bronchograms were abnormal in all cases in which they could be done. Lymphocyte transformation may be present in some cases but is not a diagnostic feature. The average age at time of diagnosis was 25.5 years, and seven of the 15 proven patients were 20 or younger.

The assessment of immunologic and clinical changes occurring during corticosteroid therapy for allergic bronchopulmonary aspergillosis

Twenty-two patients with allergic bronchopulmonary aspergillosis have been treated and evaluated for a period ranging from two months to nine years. Twelve are available for periodic blood sampling. Data are presented suggesting the following: (1) Patients with allergic bronchopulmonary aspergillosis have high initial levels of total serum immunoglobulin E (IgE). These levels are significantly higher in those patients who had not been previously treated with prednisone for the control of asthma. (2) Treatment with alternate day prednisone (0.5 mg/kg given on alternate days) caused clinical and roentgenologic improvement as well as marked decreases in total serum IgE but does not necessarily prevent recurrence of the disease. (3) Total and specific IgE against Aspergillus antigen may increase prior to and during exacerbations of disease. (4) Specific IgG and IgE against Aspergillus antigen are increased in most patients with allergic bronchopulmonary aspergillosis and reflect disease activity as evidenced by x-ray and clinical exacerbations in some cases. (5) Lymphocyte transformation using Aspergillis antigen, as measured by the whole blood technic, is present in patients with allergic bronchopulmonary aspergillosis, but serial changes in lymphocyte transformation do not correlate with disease activity. (6) Precipitin reactions are present in patients with allergic bronchopulmonary aspergillosis, but presence or absence does not reflect disease activity in most cases.

The Spectrum of Radiologic Findings in Allergic Bronchopulmonary Aspergillosis

Early diagnosis of allergic bronchopulmonary aspergillosis (ABPA) is important. Initiation of corticosteroid therapy in ABPA is essential to prevent progressive destruction of lung parenchyma. The earliest radiographic manifestations of the disease may be present only on bronchograms. In addition to the classic radiographic findings (infiltrate, massive homogeneous consolidation, tram-line shadow, parallel line shadow, ring shadow, toothpaste shadow, glove-finger shadow), perihilar infiltrates simulating adenopathy (pseudohilar adenopathy) and air fluid levels were frequently demonstrated.

Administration of local anesthetics to patients with a history of prior adverse reaction

Abstract The clinical histories of 71 patients evaluated for suspected local anesthetic (LA) allergy were reviewed retrospectively. The clinical histories were classified into (1) immediate generalized reactions (15%), (2) localized swelling at the injection site (25%), (3) nonspecific systemic symptoms (42%), and (4) other histories (17%). Serial dilutional intradermal skin tests were performed with mepivacaine, lidocaine, and procaine in 59 patients. There were 5 skin test-positive patients found, and each had a positive reaction to an LA to which, by history, they had not reacted. In 50 patients, when an LA was subsequently required, a subcutaneous challenge was performed with an LA chosen for chemical nonsimilarity. No significant reactions were observed in this group. Three patients tolerated a challenge with an LA to which they were skin test-positive. These data indicate (1) the low incidence of reactions compatible with a systemic IgE-mediated mechanism by history in patients referred for evaluation of LA allergy, (2) the lack of specific and clinically relevant information provided by dilutional skin tests, and (3) the apparent safety and usefulness of careful challenge with an alternative LA.

Paralytic pontine exotropia A sign of acute unilateral pontine gaze palsy and internuclear ophthalmoplegia

Paralytic external deviation of one eye with horizontal immobility of the fellow eye specifies an acute brainstem lesion involving the paramedian pontine reticular formation and the medial longitudinal fasciculus on the side opposite the deviated eye. This paralytic pontine exotropia is distinguished from other exotropias. The deviated (exotropic) eye shows abduction nystagmus during attempts to move it further laterally, and extreme slowness of adduction saccades. Normal midbrain ocular motor functions are evidenced by intact vertical gaze, convergence, and pupillary constrictor reflex activity.

Evidence that Aspergillus fumigatus growing in the airway of man can be a potent stimulus of specific and nonspecific IgE formation.

Serum IgE levels in patients with allergic bronchopulmonary aspergillosis are elevated but the degree of elevation varies markedly. Serum IgE levels in patients with aspergillomas may be strikingly elevated or normal. Absorption of serums with antigens of Aspergillus fumigatus combined with a solid phase radioimmunoassay technic demonstrated that both immunoglobulin E (IgE) and immunoglobulin G (IgG) antibody activity against A. fumigatus were markedly reduced without a parallel reduction in serum total IgE. These results indicate that the very high levels of serum IgE found in allergic bronchopulmonary aspergillosis and aspergilloma are not all specific IgE. These results are similar to those observed in rats infested with Nippostrongylus brasiliensis. An explanation for the elevations of IgE levels in infestations with A. fumigatus may be analogous to the postulate that parasite-produced materials may result in T cell stimulatory factors for IgE-producing cells. Alternatively, A. fumigatus organisms may produce materials that inhibit T suppressor lymphocytes.

Gaze-evoked tinnitus.

Two patients developed gaze-evoked tinnitus in the year following removal of a cerebellopontine angle mass. The eighth nerve was transected in both cases. The noise was present with saccades, pursuit, and vestibuloocular eye movements. We postulate the tinnitus was due to an abnormal interaction between the vestibular nucleus and the cochlear nucleus, possibly secondary to neural sprouting.

Optic Nerve Involvement Associated with the multiple Evanescent White-dot Syndrome

Five patients presenting with signs and symptoms of primary optic nerve disease were, after careful examination, diagnosed as having the multiple evanescent white-dot syndrome. Optic nerve findings in these patients included disc edema, central visual loss, enlarged blind spots, and other optic nerve field defects. The subtlety of the white spots in some cases made the diagnosis difficult. Multiple evanescent white-dot syndrome should be considered in the differential diagnosis of young, healthy patients who present with unilateral or bilateral optic nerve dysfunction.

Predictive formula for calculating the probability of LASIK enhancement

Purpose: To develop a formula to predict a patients need for laser in situ keratomileusis (LASIK) enhancement. Setting: Northwestern Laser Vision Center, Department of Ophthalmology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA. Methods: In this retrospective study, charts of patients who received LASIK with the Visx Star excimer laser for myopia and myopic astigmatism were reviewed. Laser in situ keratomileusis enhancement was performed in 130 of 720 eyes. Variables such as age, keratometry, spherical power, power and axis of astigmatism, and surgeon factor were compared in patients who required retreatment and those who did not. Multivariate logistic regression analysis was used to determine a formula for the probability of enhancement surgery. Results: Age (P<.0001), preoperative cycloplegic sphere (P<.0001), and surgeon (P<.0001) were the statistically significant factors for predicting retreatment. The predictive formula derived from these factors had a sensitivity of 79%, a specificity of 61%, and positive and negative predictive values of 31% and 93%, respectively. Conclusions: Older age, higher preoperative cycloplegic sphere, and surgeon significantly influenced a patients likelihood for LASIK retreatment. A formula based on these predisposing factors helps to more accurately predict the need for retreatment.

Microindentation device for in situ study of pressure-induced phase transformations

In situ microscopic and spectroscopic studies of samples allow us to understand the mechanisms and measure kinetics of phase transformations in materials. We use a light microscope and a Raman microspectrometer to study phase transformations induced by contact loading. Many interesting phenomena occur in materials during indentation that can only be analyzed during indentation, in situ. By analyzing what occurs to ceramics and semiconductors in situ we can gain valuable insight into the mechanisms and kinetics of phase transformation. A microindentation device has been designed and fabricated to achieve these objectives. The microindentation device can provide the means to study pressure-induced phase transformations in real time. The basic design of the device is adaptable to several configurations, so that the device may be used in a wide variety of applications. The device consists of a piezoelectric actuator (piezoelectric translator), load cell, linear microscrew stage, translation stage containing t...