Subacute meningitis caused by Candida albicans was confirmed by culture and immunoserologically in a 19-year-old girl. Combined administration of amphotericin B and flucytosine only slowly affected the course of the disease despite impressive improvement in clinical symptoms. Pleocytosis (1000/mm3) in cerebrospinal fluid persisted. Falling Candida antibody titre in serum and CSF, however, pointed to an improvement in the acute infection. Treatment had to be discontinued after 42 days because of side-effects such as rigor, fever and polyuria with low concentration. Under serial clinical observations with occasional CSF punctures complete cure occurred with normal CSF findings. There was an additional and unusual neurological-otological condition of intermittent inner-ear deafness, left more than right, before treatment. Recording of early auditory evoked potentials pointed to an involvement of the cranial nerves as part of the inflammatory process.

We report three patients with CNS involvement in thrombotic thrombocytopenic purpura (TTP). The first two cases presented with fluctuating levels of consciousness and lateralized neurologic deficits. Repeated brain CT scans were normal in case 1, and showed small parietal lucencies in case 2. Both patients recovered to only minor residues after combined treatment of plasma exchange, corticosteroids, immunoglobulins, vincristine (case 1), and cyclophosphamide (case 2), respectively. Case 3 with multiple infarctions in brain CT died of heart failure. Autopsy showed myocardial infarction and multiple hemorrhages in various organs including cerebral cortex. Excess deposition of von Willebrand factor antigen within hyaline thrombi in small and medium‐sized arteries of the cerebral cortex is shown for the first time immunohistologically.

A case of adult Still's disease is described which, in addition to the more common manifestations, also included abdominal discomfort. Upon laparoscopy, peritonitis was disclosed; a biopsy showed massive granulocytic infiltration of the spleen which could not be attributed to an infectious disease. The patient did not improve on conventional therapeutic modalities but required intensive combination therapy consisting of high dose acetylsalicylic acid, prednisone, and slow-reacting substances before entering remission.

To evaluate, wether a new non-ionic contrast medium decreases the complication rate of endoscopic retrograde cholangiopancreaticography (ERCP), we performed a prospective randomized study in 46 indoor patients with suspected pancreatic or bile duct related disease. The low-osmolar low-viscosity non-ionic Iopromid (Ultravist, n = 15), the low-viscosity high-osmolar Ioglicinate (Rayvist, n = 18), and the conventional dissociable high-viscosity Ioxaglinate (Heaxbrix, n = 13), each presenting a iodine content of 300-320 mg/ml were compared. All three contrast solutions gave excellent imaging of pancreatic and bile ducts. No complications, particularly no pancreatitis were observed. Hexabrix caused significant elevations of gamma-GT from 126 U/l to 178 U/l and mof lipase from 144 U/l to 418 U/l (p less than 0.01), respectively. Following Rayvist or Ultravist injections, no significant changes of the leucocytes, SGOT, SGPT, gamma-GT, AP, lipase and amylase were observed. We conclude that ERCP performed by skilled investigators is a low risk procedure. Selection of suitable contrast media may diminish hepatotoxic and pancreatotoxic side effects. According to our results, we recommend low-viscosity contrast media (Rayvist, Ultravist). The presumed benefit of the non-ionic solution (Ultravist) could not be demonstrated.

The present knowledge of the inflammatory reaction occurring in situ during hepatitis B favors a T cell-dependent MHC-restricted immune response. However, the reports in the literature are primarily based on the application of monoclonal antibodies directed at different lymphocyte subsets which discern only lymphocytic phenotypes and do not reflect the actual situation adequately. Therefore, we investigated the liver biopsies of patients with hepatitis B (28 patients) and non-A, non-B (21 patients) by immunoelectron microscopy with monoclonal antibodies directed at lymphocyte subtypes (pan-B, pan-T, T8, T4 and NKH1) and at activation epitopes (IL-2 receptor, TA1 and T11/3) as well, in order to determine the phenotype in association with the activation status of the lymphocytes that are in close contact with hepatocytes; thus, establishing an effector-target cell relationship on the ultrastructural level. We were able to confirm the central role of T8 lymphocytes being the predominant type of lymphocytes in close contact with liver cells in the space of Disse. A certain percentage of these cells expressed “activation” markers as IL-2 receptor, TA1 and T11/3. In acute hepatitis, the NK lymphocytes made up a fifth of all lymphocytes, whereas their number dropped below 10% in the chronic stage. There was a vague correlation between the inflammatory activity of the disease and the expression of HLA antigens (both classes I and II) on inflammatory cells and also on hepatocytes. The results did not show significant differences between hepatitis B and non-A, non-B. Our findings underline the significance of a T lymphocyte-dependent, MHC-restricted immune response in chronic hepatitis B and non-A, non-B as the decisive mechanism which seems to be flanked by NK cell activity in the acute phase. The expression of the T11/3 antigen on many lymphocytes indicates that a certain proportion of the T lymphocytes may be activated by an antigen-independent alternative pathway.

Endoskopische retrograde Cholangiopankreatikographie (ERCP) und endoskopische Papillometrie (EPT) sind wesentliche Säulen der Diagnostik und Therapie der akuten biliären Pankreatitis. Patienten mit Pankreatitis sowie klinischen und laborchemischen Hinweisen auf eine extrahepatische Cholestase sollten unbedingt endoskopiert werden.

Cellular immune responses in vitro were studied in 24 patients on chronic hemodialysis and 16 healthy volunteers with normal kidney function. Patients on maintenance hemodialysis had lymphopenia with diminished numbers of both T4+ and T8+ T-lymphocytes. The T4/T8 ratios were within the normal range. Peripheral blood lymphocytes (PBL) showed a diminished proliferative response upon stimulation with concanavalin A, phytohemagglutinin and pokeweed mitogen. When cell surface antigens were used for stimulation (mixed lymphocyte culture) uremic lymphocytes also showed a lower proliferation rate. Although without statistical conformation, there was a tendency by uremic PBL to produce less IL-2 as compared to healthy controls. Moreover, in a PWM driven system, peripheral blood lymphocytes from uremics produced significantly less IgG than PBL from normals. These results support the notion that a profound defect in lymphocyte function accounts at least, in part, for the observed immunodeficiency of uremic patients.