Total serum thyroxine (T4), free thyroxine index (FTI), thyroxine binding globulin (TBG) binding capacity, serum albumin, alpha-globulins and urinary protein excretion were measured in 50 patients with chronic renal failure, but without nephrotic syndrome. 25 patients were undergoing chronic hemodialysis. T4 was within the normal range in most patients. There was a tendency to lower T4 values as compared to an age and sex-matched control group, but this did not reach statistical significance. TBG was normal in most patients. 4 patients showed elevated TBG concomitant with elevation of other alpha-globulins. Serum albumin was significantly decreased. No correlation existed between daily protein excretion and TBG or alpha-globulins, but the correlation between serum albumin and proteinuria was highly significant. T4 and proteinuria correlated with borderline significance. A highly significant correlation between T4 and TBG-albumin values was found. No correlation existed between FTI and TBG-albumin levels. The data suggest that T4 and TBG are normal in most patients with renal failure, even in the presence of significant proteinuria. Low T4 values, when found in renal insufficiency, may be secondary to low serum albumin and possibly prealbumin.
Healthy volunteers of ideal weight (12 men and 12 women) were fasted for 6 days, and obese but otherwise healthy subjects (20 men, 28 women) for 6--28 days. In all groups studied a significant increase in urinary nitrogen loss from day 1 to day 3 of fasting was followed by a steady decrease. The early rise in urinary nitrogen excretion coincided with a rise in plasma glucagon levels, suggesting a relation of the latter to increased gluconeogenesis from amino acids. At equal weight greater nitrogen losses were found in men than in women, in both normal and obese subjects. In spite of much higher weight and larger energy expenditure and nitrogen loss in obese subjects however was not higher than in normal ones. Mean daily nitrogen losses varied from 14.5 g (normal and obese men early in starvation) to 3.0 g (obese women after a 4-weeks fast). Calculating the amount of calories derived from body protien (urinary nitrogen X 6.25 X 4.1)and taking total energy expenditure from tabular metabolic values, the contribution of protein to total calorie output was found to vary from 15% (normal men 6 day fast) to 5(obese women, 4th week of fasting). The clinical significance of nitrogen loss during therapeutic fasting is discussed.
Report is given on a 68-year-old man who suffered primarily from progressive weight loss and repeated episodes of fever and arthralgia. Later, liver dysfunction and renal insufficiency developed. Liver and kidney biopsies disclosed granulomatous hepatitis and nephritis. Because of the morphologic and clinical findings, the diagnosis of Boeck's disease was made. Shortly before death, diarrhea developed. Autopsy revealed a massive systemic involvement in Whipple's disease proven by light and electron microscopy and immunofluorescence. Tuberculoid and epitheloid cell granulomas and isolated giant cells were found in addition to the biopsy findings in skeleton muscles, the small intestine, lymphnodes and bronchi. At autopsy, the kidney showed chronic interstitial nephritis. The literature of kidney involvement in Whipple's disease is reviewed. This is the first case with granulomatous interstitial nephritis and chronic renal insufficiency in an inadequately treated Whipple's disease.
The right abducens nerve palsy gradually improved. Six weeks after discharge lateral movement of the right eye was apparently full but the diplopia persisted and he complained of blurring in the left eye. Prednisolone was then given, but a week later vision in the right eye became blurred. The left carotid and the left radial pulses were absent and the right carotid pulse was weak. A short, soft systolic bruit was audible over the right carotid artery. Visual impairment was believed to be due to retinal ischaemia.Three months after discharge the patient still had headache and intermittent blurring of vision. The left auriculotemporal arterial pulsation was absent. Nicotinic acid added to the treatment gave no benefit. Four months after dischage he developed another crop of papulonecrotic eruptions over the back, buttocks, arms, legs, and face. The headache was intense and there was polyarthralgia involving the wrists, ankles, and knees. These symptoms persisted for over a month despite prednisolone in doses of up to 60 mg/day. Prednisolone was stopped and cyclophosphamide by mouth 150 mg/day gradually reducing to 100 mg/day was given instead. The headache became less frequent and less severe.Aortography nine months later showed the state of the extracranial cerebral vessels to be unchanged. CommentThe unilateral abducens palsy in this case might be attributed to a reduced blood supply to the nucleus of the nerve in the pons. The lack of any other evidence of brain-stem lesion, however, was against that explanation. Isolated oculomotor palsy associated with various causes of arteriopathy such as diabetes mellitus and syphilis is well known, but, unlike those disorders, the lesions in Takayasu's (1908) disease are confined to the large arteries.The onset and course of the abducens palsy in our patient were similar to those of a palsy due to infarction of the nerve trunk resulting from occlusion of the vasa nervorum, and the view that this could have been the nature of the lesion in our case is supported by the presence of widespread cutaneous microangiitis, manifested as papulonecrotic, tuberculidelike eruptions. Alternatively, the nerve may have been directly affected by a granulomatous process as in cranial neuritis, or polyneuritis cranialis-a condition that seems to be highly prevalent in some countries in the Far East, including Thailand (Steele and Vasuvat, 1970).
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