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A 29-year-old man was seen in an outpatient clinic because of abdominal pain, fever, and weight loss. Testing for HIV antibodies was positive, and the CD4 T-lymphocyte count was 10 per cubic millimeter. Chest imaging revealed tiny nodules in both lungs.

Live pentavalent human-bovine reassortant rotavirus vaccine is recommended in the United States for routine immunization of infants. We describe three infants, two with failure to thrive, who had dehydration and diarrhea within 1 month after their first or second rotavirus immunization and subsequently received a diagnosis of severe combined immunodeficiency. Rotavirus was detected, by means of reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay, in stool specimens obtained from all three infants, and gene-sequence analysis revealed the presence of vaccine rotavirus. These infections raise concerns regarding the safety of rotavirus vaccine in severely immunocompromised patients.

We sought to identify determinants of health-related quality of life after primary treatment of prostate cancer and to measure the effects of such determinants on satisfaction with the outcome of treatment in patients and their spouses or partners.We prospectively measured outcomes reported by 1201 patients and 625 spouses or partners at multiple centers before and after radical prostatectomy, brachytherapy, or external-beam radiotherapy. We evaluated factors that were associated with changes in quality of life within study groups and determined the effects on satisfaction with the treatment outcome.Adjuvant hormone therapy was associated with worse outcomes across multiple quality-of-life domains among patients receiving brachytherapy or radiotherapy. Patients in the brachytherapy group reported having long-lasting urinary irritation, bowel and sexual symptoms, and transient problems with vitality or hormonal function. Adverse effects of prostatectomy on sexual function were mitigated by nerve-sparing procedures. After prostatectomy, urinary incontinence was observed, but urinary irritation and obstruction improved, particularly in patients with large prostates. No treatment-related deaths occurred; serious adverse events were rare. Treatment-related symptoms were exacerbated by obesity, a large prostate size, a high prostate-specific antigen score, and older age. Black patients reported lower satisfaction with the degree of overall treatment outcomes. Changes in quality of life were significantly associated with the degree of outcome satisfaction among patients and their spouses or partners.Each prostate-cancer treatment was associated with a distinct pattern of change in quality-of-life domains related to urinary, sexual, bowel, and hormonal function. These changes influenced satisfaction with treatment outcomes among patients and their spouses or partners.

A 73-year-old man was admitted to the hospital because of three days of fever and pain and weakness in his leg muscles that caused difficulty walking. He had begun taking atorvastatin several months earlier and had recently traveled to Cape Cod and South Carolina. There was mild leukopenia and thrombocytopenia, with elevated levels of creatine kinase. A diagnostic procedure was performed.

A red eye is the most common ocular disorder that primary care physicians encounter. Most cases are relatively benign. Some, however, herald a vision-threatening or even life-threatening disorder. A detailed description of the full differential diagnosis of a red eye is available elsewhere.1 This overview does not assume that the examiner has access to a slit lamp or has been trained to use it. Subconjunctival Hemorrhage A subconjunctival hemorrhage (Figure 1) is often the cause of acute ocular redness. The diagnosis is based on simple observation of the characteristic features of such a hemorrhage: the redness, which is unilateral, is . . .

Complete deficiency of adenosine deaminase causes severe combined immunodeficiency that is inherited as an autosomal recessive trait. The patients present in infancy with recurrent infections, lymphopenia, defective proliferative responses to mitogens, hypogammaglobulinemia, and an inability to mount specific antibody responses. Patients with a low level of residual adenosine deaminase activity have a later onset of clinical disease owing to a slower and sometimes less complete loss of immune function.1–3 Unlike other primary immunodeficiencies caused by defects in lymphocyte signaling pathways,4 adenosine deaminase deficiency is a systemic metabolic disorder. The enzymatic defect is expressed in all cells, and therefore the . . .

Presentation of Case A 28-year-old man was evaluated at the hospital because of the acquired immunodeficiency syndrome (AIDS), pancytopenia, and lymphoma. The patient had been well until 38 months earlier, when he was first examined at this hospital because of generalized lymphadenopathy, and a test for antibodies to human immunodeficiency virus (HIV) was positive. He was raised in Ohio and had traveled throughout the United States. He was a phlebotomist at another medical facility, where he wore rubber gloves when working; he had received two transfusions after a motor vehicle accident nine years earlier and had no other risk factors . . .

Studies in animals indicate that methylprednisolone and naloxone are both potentially beneficial in acute spinal-cord injury, but whether any treatment is clinically effective remains uncertain. We evaluated the efficacy and safety of methylprednisolone and naloxone in a multicenter randomized, double-blind, placebo-controlled trial in patients with acute spinal-cord injury, 95 percent of whom were treated within 14 hours of injury. Methylprednisolone was given to 162 patients as a bolus of 30 mg per kilogram of body weight, followed by infusion at 5.4 mg per kilogram per hour for 23 hours. Naloxone was given to 154 patients as a bolus of 5.4 mg per kilogram, followed by infusion at 4.0 mg per kilogram per hour for 23 hours. Placebos were given to 171 patients by bolus and infusion. Motor and sensory functions were assessed by systematic neurological examination on admission and six weeks and six months after injury. After six months the patients who were treated with methylprednisolone within eight hours of their injury had significant improvement as compared with those given placebo in motor function (neurologic change scores of 16.0 and 11.2, respectively; P = 0.03) and sensation to pinprick (change scores of 11.4 and 6.6; P = 0.02) and touch (change scores, 8.9 and 4.3; P = 0.03). Benefit from methylprednisolone was seen in patients whose injuries were initially evaluated as neurologically complete, as well as in those believed to have incomplete lesions. The patients treated with naloxone, or with methylprednisolone more than eight hours after their injury, did not differ in their neurologic outcomes from those given placebo. Mortality and major morbidity were similar in all three groups. We conclude that in patients with acute spinal-cord injury, treatment with methylprednisolone in the dose used in this study improves neurologic recovery when the medication is given in the first eight hours. We also conclude that treatment with naloxone in the dose used in this study does not improve neurologic recovery after acute spinal-cord injury.

PNEUMOCYSTIS CARINII is a well-known pulmonary pathogen that has been increasingly identified in extrapulmonary sites in patients with the acquired immunodeficiency syndrome (AIDS).1 2 3 4 5 6 7 We describe a case of pneumocystis osteomyelitis that occurred in a patient with common variable immunodeficiency. It was striking that the patient appeared to have normal cell-mediated immunity, including a blastogenic response to pneumocystis antigen. Case Report A 27-year-old black woman with common variable immunodeficiency presented with a one-month history of increasing pain in the left buttock. Common variable immunodeficiency had been diagnosed five years earlier after an evaluation for recurrent infections of the upper and lower . . .

Studies in animals indicate that methylprednisolone and naloxone are both potentially beneficial in acute spinal-cord injury, but whether any treatment is clinically effective remains uncertain. We evaluated the efficacy and safety of methylprednisolone and naloxone in a multicenter randomized, double-blind, placebo-controlled trial in patients with acute spinal-cord injury, 95 percent of whom were treated within 14 hours of injury. Methylprednisolone was given to 162 patients as a bolus of 30 mg per kilogram of body weight, followed by infusion at 5.4 mg per kilogram per hour for 23 hours. Naloxone was given to 154 patients as a bolus of 5.4 mg per kilogram, followed by infusion at 4.0 mg per kilogram per hour for 23 hours. Placebos were given to 171 patients by bolus and infusion. Motor and sensory functions were assessed by systematic neurologic examination on admission and six weeks and six months after injury. After six months the patients who were treated with methylprednisolone within eigh...

Presentation of Case A 78-year-old woman was admitted to the hospital because of bilateral renal masses. She was in a stable state of health until three months earlier, when nausea, vomiting, and fever developed. She was examined by a physician, who found no abnormality. An x-ray film of the abdomen showed a large mass in the left kidney. An intravenous urographic examination, with nephrotomograms, revealed a mass, 11 by 16 cm, in the lower pole of the left kidney and another mass, 7 by 7 cm, in the lower pole of the right kidney. The masses appeared solid and hypervascular. . . .

Four previously healthy homosexual men contracted Pneumocystis carinii pneumonia, extensive mucosal candidiasis, and multiple viral infections. In three of the patients these infections followed prolonged fevers of unknown origin. In all four cytomegalovirus was recovered from secretions. Kaposi's sarcoma developed in one patient eight months after he presented with esophageal candidiasis. All patients were anergic and lymphopenic; they had no lymphocyte proliferative responses to soluble antigens, and their responses to phytohemagglutinin were markedly reduced. Monoclonal-antibody analysis of peripheral-blood T-cell subpopulations revealed virtual elimination of the Leu-3 / helper/inducer subset, an increased percentage of the Leu-2 + suppressor/cytoxic subset, and an increased percentage of cells bearing the thymocyte-associated antigen T10. The inversion of the T/ helper to suppressor/cytotoxic ratio suggested that cytomegalovirus infection was an important factor in the pathogenesis of the immunodeficient state. A high level of exposure of male homosexuals to cytomegalovirus-infected secretions may account for the occurrence of this immune deficiency.

DURING the past decade, the focus of mammalian molecular biology has evolved from the characterization of gene structure to the regulation of gene expression. In parallel, the ability to manipulate...

Presentation of Case A 28-year-old woman was admitted to the hospital because of jaundice. She was well until two months earlier, when an epigastric ache developed, with radiation to the back. Pain...

We measured salivary beta2 microglobulin concentrations in 49 patients evaluated for Sjögren's syndrome with a labial salivary-gland biopsy. The salivary concentration was elevated and a significant correlation (P less than 0.001) was found between the concentration and the degree of inflammation seen in the biopsy. Serum concentrations were increased in 135 patients with Sjögren's syndrome. Striking elevations were seen in patients with associated renal or lymphoproliferative complications. Three patients have an increase in serum beta2 microglobulin concentration in association with exacerbation of their disease, and six a decrease after clinically efficacious therapy. These data indicate that determination of beta2 microglobulin in saiva may provide a simple, noninvasive technic for estimation of the degree of local inflammation in autoimmune disease.

Although the risk of Down's syndrome increases with maternal age, women under 35 bear about 80 percent of the infants born with this condition. We prospectively investigated the utility of measuring maternal serum alpha-fetoprotein during the second trimester in women under 35 in order to identify pregnancies in which the fetus was affected with Down's syndrome. Over a two-year period, 34,354 women in this age group were screened. Amniocentesis was offered when the risk of Down's syndrome, calculated as a function of maternal age and maternal serum alpha-fetoprotein concentration adjusted for maternal weight and race, was 1:270 or higher, the risk for a 35-year-old woman. This threshold was exceeded in 1451 women in whom gestational age was confirmed by ultrasound; 9 women in this group had a fetus with the syndrome. In three women whose fetuses had trisomy 18 and one whose fetus had trisomy 13, the calculated risk of Down's syndrome was 1:270 or higher. Thus, among women in whom the risk exceeded our cutoff point, 1 in 161 were found to have a pregnancy in which the fetus was affected with Down's syndrome; the figure was 1 in 112 for all autosomal trisomies. Eighteen pregnancies involving Down's syndrome, three involving trisomy 18, and two involving trisomy 13 were not associated with a calculated risk above the cutoff point. The available data indicate that in our population, using a cutoff for risk at which 5 percent of women under 35 are offered amniocentesis, we will detect one quarter to one third of pregnancies in which the fetus has Down's syndrome.

MOST persons use tools whose functions are clear to them, but whose construction is beyond their understanding. On the simple side, I strike a safety match to light my cigar without the slightest i...

ALTHOUGH siderophilin (transferrin) is present in the urine of nephrotic patients1 and is often in low concentration in the serum of these patients,1 , 2 the quantitative aspects of siderophilinuria in renal disease have not been extensively investigated. Urinary siderophilin loss is reported here in 2 patients with the nephrotic syndrome, and in 1 of these cases the influence of a steroid-induced remission upon this loss is described. In this case, the urinary excretion of siderophilin in a twenty-four-hour period was found to exceed the total circulating quantity of this specific iron-binding serum globulin. Methods Samples of serum for iron and siderophilin . . .