Diagnosis Of Acute Exacerbation Research Articles

Serum heme oxygenase-1 as a prognostic biomarker in patients with acute exacerbation of interstitial lung disease

Serum heme oxygenase (HO)-1 level has been reported as a clinically reliable diagnostic biomarker for acute exacerbation of interstitial lung disease (ILD); however, its utility for predicting mortality among these patients is unclear. Serum HO-1 levels of patients newly diagnosed with acute exacerbation of ILD were measured at the time of initiating steroid pulse therapy. The relationship between serum HO-1 and various other serum biomarkers, change in HRCT findings, and disease prognosis at 12 weeks after diagnosis of acute exacerbation was evaluated in 51 patients, of whom 17 (33%) had idiopathic pulmonary fibrosis (IPF). Serum HO-1 was higher in patients with acute exacerbation of IPF than in patients with acute exacerbation of other ILDs. Serum HO-1 levels were higher in patients who died within these 12 weeks than in survivors. Among age, sex, comorbidities, IPF diagnosis, HRCT findings, and blood biomarkers, serum HO-1 was a primary predictor of 12-week mortality. In 41 patients who underwent repeat HRCT, serum HO-1 was higher in patients with honeycomb progression than in those without. Serum HO-1 measurement could be useful for evaluating disease mortality and morbidity of patients with acute exacerbation of ILDs.

＜Editors' Choice＞ Comparison of clinical features between patients with acute exacerbation of idiopathic interstitial pneumonia and collagen vascular disease-associated interstitial pneumonia.

Acute exacerbation (AE) of interstitial pneumonia (IP) shows poor prognosis, due to the typical histological pattern of diffuse alveolar damage superimposed upon lung fibrosis. The previous reports comparing clinical features between AE of idiopathic interstitial pneumonias (IIPs) and those of IPs with known etiology are limited. We retrospectively compared clinical parameters including age, sex, Charlson Comorbidity Index score (CCIS), blood biomarkers at diagnosis of AE, treatment, and 3-month mortality between patients with AE of IIPs and collagen vascular disease-associated interstitial pneumonia (CVD-IP). We assessed 85 patients, comprising 66 patients with AE of IIPs (78%) and 19 patients with AE of CVD-IP (22%). The least absolute shrinkage and selection operator regression selected CCIS (hazard ratio, 1.281; 95% confidence interval, 1.055-1.556; P = 0.012) and log serum lactate dehydrogenase (LDH) (hazard ratio, 6.267; 95% confidence interval, 2.172-18.085; P < 0.001) as significant predictors of 3-month mortality among these patients. Also, the adjusted survival curves using sex, CCIS, and serum LDH showed no significant differences between these two groups. In conclusion, among AE patients, CCIS and serum LDH level may be more important prognostic factors for 3-month mortality rather than two classification of IP subtypes: IIPs and CVD-IP.

Comparison of Clinical Features between the High and Low Serum KL-6 Patients with Acute Exacerbation of Interstitial Lung Diseases.

Background Serum Krebs von den Lungen-6 (KL-6) measurement is widely used to assess disease activity or prognosis in patients with interstitial lung diseases (ILDs). However, the clinical differences between high and low serum KL-6 levels at the time of acute exacerbation (AE) of ILD are not well known. Methods Clinical parameters including age, sex, Charlson Comorbidity Index score (CCIS), blood biomarkers, high-resolution CT findings, and disease mortality were retrospectively compared between high and low KL-6 (cutoff value: 1000 U/mL) patients at the time of diagnosis of AE of ILDs. Results Thirty-eight high serum KL-6 and 57 low serum KL-6 patients were included. There was no significant difference in 6-month mortality between them (P = 0.685), whereas serum lactate dehydrogenase was a significant predictor of 6-month mortality in the high serum KL-6 patients (odds ratio (OR): 1.006; 95% confidence interval (CI): 1.003–1.009; P < 0.001), and CCIS (OR: 1.502; 95% CI: 1.242–1.838; P < 0.001) and sex (OR: 5.751; 95% CI: 1.121–105.163; P = 0.033) were significant predictors in low serum KL-6 patients. In addition, the incidences of congestive heart failure, symptomatic chronic pulmonary disease, cerebrovascular disease, and second metastatic solid tumours were significantly higher in nonsurvivors with low serum KL-6 than in other groups (P < 0.05). Conclusions The clinical features in patients with AEs of ILDs may differ depending on the serum KL-6 level, and clinicopathological examination according to this subtyping guided by the serum KL-6 level is essential.

The Extent of Honeycombing on Computed Tomography Cannot Predict the Treatment Outcome of Patients with Acute Exacerbations of Interstitial Lung Disease.

Background The purpose of this retrospective study was to clarify whether the presence of honeycombing on computed tomography (CT) can affect the prognosis of patients with acute exacerbations (AEs) of interstitial lung diseases (ILDs). Methods Clinical parameters including age, sex, Charlson Comorbidity Index Score (CCIS), blood biomarkers, and 3-month mortality were retrospectively compared between the CT honeycombing present and absent groups at the diagnosis of AEs of ILDs. Results Ninety-five patients who were on corticosteroid pulse therapy were assessed. Though log-rank tests showed that Kaplan–Meier survival curves of the high and low ground-glass opacity (GGO) score groups differed significantly in 3-month mortality in patients with AEs of idiopathic ILDs (P = 0.007) and overall patients (P = 0.045), there was no significant difference between the CT honeycombing present and absent groups in patients with AEs of idiopathic ILDs (P = 0.472) and AEs of secondary ILDs (P = 0.905), as well as of overall patients (P = 0.600). In addition, whereas CCIS (OR, 1.436; 95% CI, 1.156–1.842; P < 0.001) was a significant predictor of 3-month mortality in the CT honeycombing absent group, serum LDH (OR, 1.005; 95% CI, 1.002–1.007; P = 0.001) was a significant predictor in the CT honeycombing present group. Conclusions The clinical features of patients with or without honeycombing may differ due to the difference in prognostic factors, but these groups were found to have similar prognoses 3 months after AE onset, and clinicopathological examinations according to these groups are essential.

STUDY OF DECAF SCORE FOR IN - HOSPITAL MORTALITY PREDICTION OF ACUTE EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Background: COPD is one of the leading causes of death. The lack of an accurate prognostic tool that can accurately predict in-hospital mortality and help clinicians triage patients to the appropriate level of care is still challenging. This study aims to: 1/ To evaluate the parameters of DECAF Score, 2/ To assess the prognosis for in-hospital mortality of acute exacerbation of COPD. Materials and methods: 68 male patients with the diagnosis of acute exacerbation of COPD admitted to the hospital. Admission clinical data and inhospital death rates were recorded. The prognostic value of DECAF score were assessed by the area under the receiver operator characteristic (AUROC) curve. Results: DECAF score included 5 factors: eosinopenia (26.5%), consolidation (10.3%), acidemia (14.7%), atrial fibrilation (5.9%), eMRCD 5a (10.3%), eMRCD 5b (2.9%). The DECAF AUROC curve for in-hospital mortality was 0.884 (95%CI: 0.783 - 0.949) with sensitivity 77.8% (95%CI: 40.1 - 96.5) and specificity 93.2% (95%CI: 83.5 - 98.1). Conclusion: DECAF is a simple but powerful predictor of in-hospital mortality for acute exacerbation of COPD. Key words: DECAF score, acute exacerbation of COPD, mortality, prognostic value

Redundant medication use during acute exacerbation of chronic obstructive pulmonary disease in hospitalized patients.

Background Few clinical studies have evaluated redundant therapy during an exacerbation of chronic obstructive pulmonary disease in hospitalized patients, but clinical practice guidelines endorse this practice. Objective The aim of this study is to measure the frequency of redundant therapy and explore its association with clinical outcomes, adverse effects, and cost among adults hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Setting Six hospitals within an academic health system in the United States. Method A retrospective cohort study of adults with a principal diagnosis of acute exacerbation of chronic obstructive pulmonary disease between January 1, 2016 and March 31, 2016 was performed. Main outcome measure The primary outcome was the proportion of patients who received redundant therapy during inpatient management of acute exacerbation of chronic obstructive pulmonary disease. Results Overall, 137 patients were included and 99 (72.7%) received redundant medication therapy. Redundant therapy was not associated with significant differences in clinical outcomes such as median hospital length of stay, 30-day readmission, tachycardia, thrush, psychiatric symptoms or urinary retention in the univariate or multivariate analyses. The median medication acquisition cost per patient was nearly 11-fold higher among those receiving redundant medication therapy [$135.14 (49.21) vs 12.50 (17.02); p < 0.001]. After controlling for confounding variables using multivariate linear regression, the cost of redundant medication therapy was $50.20 higher on average (p < 0.001). Conclusion Redundant inhaled therapy for acute exacerbation of chronic obstructive pulmonary disease in the hospital setting was not associated with improved clinical outcomes or more adverse effects but did significantly increase medication cost. The findings of this study should be considered exploratory.

Clinical features and outcome of acute exacerbation in connective tissue disease‐associated interstitial lung disease: A single‐center study from India

Acute exacerbation (AE) of idiopathic pulmonary fibrosis (IPF) is associated with high mortality, but there is limited clinical data on AE of interstitial lung disease (ILD) in connective tissue disease-associated ILD (CTD ILD). The present study was conducted to provide prevalence and clinical features of AE, as well as various risk factors associated with mortality among AE CTD ILD patients. Between May 2013 and April 2018, 15 patients who developed AE among 105 consecutive patients with CTD with chronic ILD were included. AE was defined using the criteria recently proposed by the IPF net, with slight modification for adaptation to CVD-IP6 (collagen vascular disease-associated interstitial pneumonia), and patients having CTD with AE met all the criteria. Fifteen patients with mean age of 45.8±13.9years developed AE; the most common subgroup (n=5, 33%) was systemic sclerosis. The mean duration (months) between diagnosis of ILD and AE was 56.5±38.0 with mean follow-up duration of 24±18.1months. The baseline arterial oxygen pressure (PaO2 ) was 81.7±8.1mmHg and mean forced vital capacity (%) was 57.9±8.9. Five patients requiring mechanical ventilation died. Patients with shorter duration (months) of disease between onset of ILD to AE had higher mortality, 40.4±45.1 vs 64.6±33.6. Those who had significantly lower baseline PaO2 (mean±SD), 72.6±3.4 vs 86.2±5.3mmHg (P=.002) had higher mortality. In our study, the majority of patients with AE CTD ILD had systemic sclerosis. Patients with lower baseline PaO2 and those requiring mechanical ventilation had higher mortality.

Eosinophilic Cationic Protein as a Biomarker in Diagnosis of Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Eosinophilic Cationic Protein as a Biomarker in Diagnosis of Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Pulmonary artery enlargement predicts poor outcome during acute exacerbations of fibrotic interstitial lung disease.

In fibrotic interstitial lung disease (f-ILD), pulmonary artery diameter to ascending aorta diameter ratio (PA/A) ≥ 1 during the stable stage is associated with worse outcomes; however, the effect of acute exacerbation (AE) on the PA/A is unknown. Patients with a diagnosis of AE of f-ILD and with a computed tomography (CT) scan performed during stable period to confirm background fibrosis, as well as a CT scan at admission, were included. The pulmonary arterial diameter, ascending aortic diameter and PA/A were measured using CT during AE and CT prior to AE, when available, to evaluate the changes. Demographic data, co-morbidities and clinical outcome (90-day mortality) were analysed. Of the 123 patients included, 45 had a PA/A ≥ 1 during AE and compared to the PA/A < 1 group, they were younger, had lower % vital capacity (VC) and % forced vital capacity (FVC), required more long-term oxygen therapy and other treatments, and had lower PaO2 /FiO2 (P/F) ratios. During AE, the PA/A increased from that during stable periods (P < 0.001), and a PA/A ≥ 1 was significantly associated with 90-day mortality both before and after adjustment for age, the P/F ratio at admission, long-term oxygen therapy usage and the type of background f-ILD (P = 0.018 and 0.025). To the best of our knowledge, this is the first longitudinal examination of the PA/A ratio and evaluation during AE of f-ILD. Our data show that a PA/A ≥ 1 during AE predicted poor survival outcome in f-ILD.

Expanded acceptance of acute exacerbation of nonspecific interstitial pneumonia, including 7 additional cases with detailed clinical pathologic correlation.

Acute exacerbation is uncommonly diagnosed in patients with nonspecific interstitial pneumonia (NSIP) and its pathologic features have received relatively little attention compared to idiopathic pulmonary fibrosis. We retrospectively studied 14 consecutive cases of histopathologically proven NSIP by surgical lung biopsy. The diagnosis of acute exacerbation was confirmed clinically. We analyzed whether four reported pathologic features, including organizing pneumonia lesion, alveolar hemorrhage, many fibroblastic foci, and focal hyaline membranes were present and suggestive of acute exacerbation of NSIP or not. Acute exacerbation in patients with NSIP was diagnosed in 8 cases, while the remaining 6 cases were diagnosed as clinically stable. Seven cases of organizing pneumonia lesion, 7 of alveolar hemorrhage, 6 of many fibroblastic foci, and 3 of focal hyaline membranes were identified as the main pathologic components in patients with acute exacerbation. Organizing pneumonia lesion and many fibroblastic foci were identified in 2 and 3 stable cases, respectively. Having more than two components was significantly associated with acute exacerbation. Evaluation of lung biopsies with NSIP for organizing pneumonia lesions, alveolar hemorrhage, many fibroblastic foci, and focal hyaline membranes may be useful to predict the possibility of acute exacerbation.

The Predictive Role of Neutrophil to Lymphocyte ratio in Chronic Obstructive Pulmonary Disease

Objective:Recently neutrophil-to-lymphocyte ratio (NLR) -the level of neutrophil reflecting the severity of inflammation and lymphocyte occurring after physiological stress has been gaining popularity, which was, along with other inflammatory markers, commonly accepted as an accurate marker of the inflammatory status.In this multi-centered study, an early, rapid, and low-cost diagnosis method was investigated. To this end, the correlation between chronic obstructive pulmonary disease and inflammation was planned to be utilized and whether neutrophil-to-lymphocyte ratio can be used as a valid tool in the diagnosis of acute exacerbations of chronic obstructive pulmonary disease was investigated.Method:We retrospectively enrolled the 467 patients. Control group included sex and age-matched healthy people.C-Reactive protein, forced expiratory volume-1, forced vital capacity, complete blood count and clinical data A receiver-operating characteristic curve analysis was performed to determine the best cut-off value of N/L ratio and C-Reaktif protein to predict the exacerbation. Two-sided p values <0.05 were considered statistically significant.Results:By spearman analysis, there was a strong correlation between.C-Reactive protein and N/L ratio in both stable group (r=0.436, p<0.001) and exacerbation group (r=0.534, p=0.001).Conclusion:Neutrophil/lymphocyte ratio may bea useful predictor of inflammation in chronic obstructive pulmonary disease and acute exacarbation of chronic obstructive pulmonary disease patients.

Prognostic factors associated with poor outcomes among multiethnic patients with acute exacerbation of chronic obstructive pulmonary disease

Background: Acute exacerbation is the most common cause of hospitalization for patients with chronic obstructive pulmonary disease (COPD). Objectives: To investigate prognostic factors associated with poor outcomes after acute exacerbation of COPD. Methods: A retrospective study of patients with a diagnosis of acute exacerbation of COPD (AECOPD) admitted to hospital in Penang over 5-year periods between January 2007 and December 2011 were conducted. We analyzed survival data using a Kaplan–Meier curves, and Cox regression was used to identify prognostic factors for mortality and readmission. Results: The study included 259 patients with a median age of 70 years (interquartile range = 59.7–76.7 years), and men comprised 92.7% of the cohort. Mortality after 1, 3, and 5 years was 26.3%, 49.8%, and 59.5% respectively. Older age (hazard ratio (HR), 2.53; 95% confidence interval (CI), 1.29–4.92) and long-term oxygen therapy (LTOT) at discharge (HR, 2.78; 95% CI, 1.54–5.02) were identified as independent prognostic factors associated with a higher risk of mortality after discharge. The risk of hospital readmission was 34% for 1 year, 43.2% for 3 years, and 48.6% for 5 years. Older age (HR, 1.78; 95% CI, 1.12–2.85), LTOT at discharge (HR, 3.63; 95% CI, 1.89–6.95), frequency of admissions in the previous year (HR, 2.92; 95% CI, 1.47–5.80), and being ventilated (HR, 0.19; 95% CI, 0.08–0.47) were identified as prognostic factors associated with readmission. Conclusions: Patients surviving AECOPD were prone to poor outcomes. Older patients and those discharged with LTOT were at higher risk of mortality and readmission at any time. Keywords: COPD, exacerbation, mortality, patient readmission, prognosis

Kronik Akciğer Hastalığı Olan, Akut Alevlenme ve Pnömoni Tanısı ile Başvuran Çocuklarda Streptococcus pneumoniae Serotip Dağılımı ve Antimikrobiyal Duyarlılıkları

This study aimed to investigate serotype distribution and antimicrobial resistance of Streptococcus pneumoniae isolates obtained from children with chronic respiratory diseases admitted to hospital with a diagnosis of acute exacerbations between 2008-2010 at Marmara University Hospital, Istanbul, Turkey. Sixty one S.pneumoniae strains isolated from the respiratory samples of patients were studied for erythromycin, clindamycin, tetracyline, trimethoprim-sulphametoxazole (TMP-SMX), vancomycin, levofloxacin susceptibilities by disk diffusion method; MIC values of penicillin and ceftriaxone were determined by E-test (AB Biodisk, Sweden). Results were evaluated according to the CLSI standards. The erythromycin-clindamycin double disc method was applied for the detection of macrolide resistance phenotypes. The presence of macrolide resistance genes, ermB, mef(A)/(E), ermTR were determined by PCR using specific primers for each gene. The serotypes were determined by multiplex PCR using specific primers for 40 different serotypes. According to CLSI criteria, penicillin resistance in S.pneumoniae isolates were found to be 8.2% (5/61) and intermediate resistance rate was 54% (33/61) for oral penicillin. Penicillin resistance were found to be only 1.6% (1/61) for parenteral penicillin. Resistance rates of erythromycin, clindamycin, tetracyline, TMP-SMX were detected as 55.8%, 46%, 47.5% and 67.2%; respectively. No resistance was detected to vancomycin and levofloxacin. Constitutive macrolide-lincosamide-streptogramin B (cMLSB) phenotype and M phenotype were observed in 82.4% (n= 28) and 17.6% (n= 6) of the macrolide resistant isolates, respectively. Inducible macrolide-lincosamide-streptogramin B (iMLSB) phenotype was not detected. The macrolid resistance genotypes, ermB, mef(A)/(E), were positive 50% and 14.7%; respectively. Both ermB and mef(A)/(E) genes were detected 35.3% of the macrolid resistant isolates. None of the isolates were positive for ermTR gene. The most common S.pneumoniae serotypes were determined as serotype 19F, 23F and 6, furthermore penicillin (34%, 15.7% and 18.4%, respectively) and macrolide (38.2%, 20.6% and 14.7%, respectively) resistance rates of those serotypes were found relatively high. Serotype covarage of 7-, 10-, 13-valent conjugated pneumococcal vaccines and 23-valent pneumococcal vaccine were 65%, 67%, 69%, and 78.6%, respectively. In our country, use of the vaccines with these coverage rates has been observed to be effective in children exposed to intensive use of antibiotics with chronic lung disease.

The diagnosis of COPD

Lung function testing (spirometry) is crucial for the diagnosis of COPD, as irreversible airway obstruction is the main feature of chronic airway inflammation. Spirometry not only is essential in making the diagnosis but also in grading the disease according to FEV1 measurements. Therapeutic interventions and prognostic evaluations are made according to the grading of the disease. Diagnostic procedures aim to evaluate symptoms and disability in the course of COPD. The most important influence on the course of the disease are acute exacerbations. The diagnosis of acute exacerbations is based on clinical observations of sputum production, cough and dyspnoea. Grading of exacerbations according to the severity of symptoms is important for the treatment and in particular for the need of hospitalisation. Exclusion of other lung diseases with similar symptoms necessitates a number of other examinations. Optimal treatment of COPD needs clinical and objective documentation of the course of the disease. Not only spirometry but also quantification of clinical symptoms and exercise capacity measurements are appropriate approaches to follow this chronic disease.

A prospective cohort study of the effectiveness of clinical pathways for the in-patient management of acute exacerbation of chronic obstructive pulmonary disease (COPD)

The aim of this study was to compare the clinical and functional outcomes of patients with an acute exacerbation of chronic obstructive pulmonary disease (COPD) treated with standard care to those treated with a clinical pathway at a regional Victorian university teaching hospital. An eighteen-month prospective cohort study was conducted comprising 178 patients admitted via the emergency department with a primary diagnosis of acute exacerbation of COPD. Of these, 90 were treated with standard care and 88 using a coordinated multidisciplinary clinical pathway. Clinical outcome measures included: oxygen saturation, subjective dyspnoea and anxiety levels, length of stay, complication rates and readmission within 28 days. Results indicated that there was no significant difference between the groups on length of stay, clinical and functional outcome apart from significantly reduced anxiety levels in the pathway group. Pathway patients had a 0.89-day (13.2%) shorter length of stay than standard care patients did and numerically less complications and readmissions. We conclude that patients cared for under a clinical pathway for COPD in this study did not experience worse clinical outcomes compared to those receiving standard care.

Asthma update. Part I. Mechanisms, pathophysiology, and diagnosis

Asthma, the diagnosis of which is increasing in children, is an area of intensive study by basic scientists and clinicians. New knowledge regarding mechanisms of asthma is changing the approaches to diagnosis and management. Part I of this asthma update reviews current knowledge of the scope of the problem and pathophysiology of asthma. The knowledge is then applied to the diagnosis of asthma in children, with emphasis on early recognition of an asthma problem and diagnosis of acute exacerbations. With application of current knowledge of the scope of the problem, mechanisms, pathophysiology, and newer treatment modalities, health care providers can assure better diagnosis and optimal care of children with asthma. Such recognition and intervention will prevent increases in mortality and may influence the development of chronic lung disease as the child reaches adulthood.

Lipodystrophia progressiva and temporary hydronephrosis.

If the association of two diseases in a patient is not fortuitous their relationship to each other may throw light on the aetiology of one or both diseases. Law rence's (1946) study of a woman with lipodystrophia progressiva and insulin-resistant diabetes supports the concept of two types of diabetes mellitus and suggests the simple explanation that the elderly obese person develops diabetes because she is unable to convert any more carbohydrate into fat. In this paper the association of temporary hydro nephrosis with lipodystrophia progressiva is reported and the renal disorders which have been described with this disease are reviewed. It is suggested that in some of the case reports the renal changes may have been similar to those present in the patient described here. Gross can develop in a week and dis appear completely if the obstruction is removed early enough, and the term temporary hydronephrosis has been used to describe these transient changes (Fowler and Frankel, 1947). Ellis (1951), writing about lipodystrophia progressiva, mentions the association of this condition with renal disease. He makes a brief reference to the occurrence of oliguria in Gerhartz's case (1916). The daily urinary output of this patient was 400-1,100 ml., and it is difficult to believe that this is a significant oliguria. Klien (1921) reports on a patient with lipodystrophy and mentions polyuria. Recently a patient with this disease was shown at the Royal Society of Medicine (Tizard, 1954), and the summary of the case included the information that she is said to drink and void excessive quantities of fluid. The glucose-tolerance test in this patient was normal, but full urinary investigations including a pyelo gram had not been done. Following the paper by Law rence (1946) on the association of lipodystrophy and diabetes, any patient with lipodystrophy complaining of thirst and polyuria may be examined for further evidence of diabetes mellitus only, as happened to our patient, when studied for a short period at another hospital. In 1932 two cases were reported in which lipo dystrophia progressiva and uraemia occurred in the same patient. They were both thought to have had chronic nephritis, but in neither did the diagnosis appear likely, nor was it confirmed. They both had unusual clinical features in common with the patient described in the present paper. Horton and Emmett (1932) report the case of a woman of 61 with a history of increasing nausea for one year with occasional attacks of vomiting. The patient was alert, and physical examination was essentially nega tive except for lipodystrophy affecting the legs. There were no symptoms or signs suggesting uraemia. On admission the blood urea was 400 mg. per 100 ml. After five weeks on a diet containing 25 g. of protein and 3-4 litres of fluid daily, the blood urea fell to 60 mg. per 100 ml. It was stated that pus cells, grade III, were present in the urine, l;ut no mention of urine culture was made. The renal lession was diagnosed as chronic diffuse glomerulonephritis after the possibility of poly cystic kidneys had been considered and dismissed, as no enlargement of the kidneys could be found on abdo minal palpation. Berger (1932) reported the case of a woman aged 26 who developed lipodystrophy at the age of 3years. Pyelitis occurred at 6 and another attack a year later. At the age of 19 the blood pressure was found to be raised and albumin was present in the urine. A diag nosis of acute exacerbation of chronic nephritis was made. Following a severe reaction to vaccination, the patient for a short time passed into uraemic coma. During the next seven years she remained well, and clinical examination at the end of this period was essen tially negative except for the lipodystrophy. The blood urea was then 21 mg. per 100 ml. Igersheimer (1948) described the case of a patient who had lipodystrophia progressiva, bilateral with aberrant renal arteries, and other congenital abnor malities.