Undetectable Blood Levels Research Articles

Analysis of a family with hypouricemia due to type Ⅰ xanthinuria

This article reports a patient presenting with"extremely low uric acid levels in blood and urine"clinically along with reviewing relevant literature to consider a diagnosis of xanthinuria. Peripheral blood samples of the patient and her family were further collected for xanthine dehydrogenase(XDH) gene sequencing, showing that the patient had compound heterozygous mutations in exon 19:c.1995_2006del12(p.His666_Gly669del) and exon 10:c.871G>T(p.Glu291*), however no mutations were found in the gene encoding MOCOS on chromosome 18, confirming the diagnosis of hereditary xanthinuria type Ⅰ.The patient's father, son and daughter carried heterozygous mutations in exon 19:c.1995_2006del12(p.His666_Gly669del), and the mother carried heterozygous mutations in exon 10:c.871G>T(p.Glu291*).Mutations in the XDH gene cause a lack of xanthine oxidoreductase function, which hinders the production of uric acid, leading to very low or undetectable levels in blood and urine. Patients present clinically with hematuria, renal colic, urolithiasis, and even acute renal failure. Through the diagnosis and treatment of this patient and literature review, the article aims to deepen the understanding of purine metabolism and uric acid production process, and improve the clinicians' diagnosis and treatment ability of hypouricemia.

Characterization of Moxidectin against Strongyloides ratti: In Vitro and In Vivo Activity and Pharmacokinetics in the Rat Model.

Strongyloides stercoralis is a soil-transmitted helminth affecting an estimated 30-100 million people. Since the infection may be severe and life-threatening, accessible and effective treatment is pivotal. Currently, ivermectin is the drug of choice but has limitations. Moxidectin, a veterinary anthelminthic approved for use in human onchocerciasis, is a promising drug alternative against strongyloidiasis. In this study, we evaluated the in vitro activity of moxidectin on Strongyloides ratti larvae (L3) and adult females and the activity as well as the pharmacokinetics of moxidectin in S. ratti infected rats. In vitro, moxidectin had an activity that was similar to that of ivermectin, with median lethal concentration values for L3 and adults in the range of 0.08-1.44μM, after 72 h of exposure. In vivo, doses of 250, 500, and 750 μg/kg of moxidectin resulted in a reduction of the worm burden ranging from 48.5 to 75%. At the highest dose (750 μg/kg) we observed a maximal blood concentration of 50.3 ng/mL and an area under the curve of 895.2 ng × h/mL. The half-life in rats was 9 h, and moxidectin was cleared to undetectable blood levels within 7 d (<10 ng/mL). No exposure-response relationship was observed. This work contributes to the characterization of moxidectin in the treatment of S. ratti as a model of Strongyloides spp. and, as such, supports moving moxidectin further along the drug development pipeline in the treatment of human strongyloidiasis.

Human Safety and Pharmacokinetics Study of Orally Administered Icariin: Randomized, Double-Blind, Placebo-Controlled Trial

Preclinical literature suggests that icariin, a flavonoid found in Epimedium, may have potential for medical and psychiatric conditions. The objective of this study was to examine the safety, tolerability, and pharmacokinetics of orally administered icariin at doses of 100 to 1,680 mg/day in 24 healthy adult participants. Cognition, mood, and side effects were assessed over 5 days. Multiple blood samples were obtained over 24 hours to assess bioavailability and pharmacokinetics. Data were analyzed using a Wilcoxon signed rank test and Mann-Whitney U test. At all doses, either very low or undetectable blood levels of icariin were observed, demonstrating the low bioavailability of the oral formulation and preventing a determination of pharmacokinetic properties. No significant between-group differences were observed on side effect scales, either by self-report, or on cognitive assessments. A statistically significant, but not clinically significant, increase in self-reported depressive symptom severity was observed with icariin relative to placebo. Tolerability of icariin was good except at the highest dose. Two participants receiving 1,680 mg of icariin discontinued the study drug due to gastrointestinal symptoms. Bioavailability of oral icariin appears to be low at all doses tested. Although icariin appears generally to have a favorable tolerability profile, the highest doses may be associated with gastrointestinal distress. Different drug formulation and delivery method may be needed to assess the pharmacokinetic profile of icariin adequately.

Treatment of Streptococcus pneumoniae otitis media in a chinchilla model by transtympanic delivery of antibiotics.

Otits media (OM) is the most frequent indication for antimicrobial prescription to US children. Streptococcus pneumoniae (S. pneumoniae) remains one of the most common pathogens causing OM. Successful eradication of S. pneumoniae in the middle ear can be achieved by adhering to a 7-10 day regimen of oral antibiotics. However, oral drug administration is challenging for parents. Lack of adherence has been associated with treatment failure or early relapse. To overcome this challenge, we used a noninvasive formulation to achieve high transtympanic antibiotic flux and cured S. pneumoniae OM in chinchillas. The formulation consists of a thermosensitive in situ gelling hydrogel, chemical permeation enhancers, and an antibiotic. The direct transport of drugs into the middle ear produced high concentrations of ciprofloxacin (in the range of hundreds of micrograms per milliliter) within the first 24 hours of administration. Drug concentrations above the minimum inhibitory concentration (MIC) for S. pneumoniae were sustained throughout the 7-day treatment. S. pneumoniae OM in a chinchilla model was successfully eradicated, without causing tissue toxicity. Transtympanic delivery minimized systemic drug exposure, as evidenced by undetectable levels in blood, measured by high-performance liquid chromatography.

Trypanosome-induced Interferon-γ production in whole blood stimulation assays is associated with latent Trypanosoma brucei gambiense infections

Control of human African trypanosomiasis (HAT) is highly dependent on the ability to detect and treat infected individuals. However, a number of individuals exposed to Trypanosoma brucei gambiense are able to control infection to undetectable levels in blood. They are long-term potential reservoirs and thus a threat for control strategies. Cytokine responses in whole blood stimulation assays were quantified in individuals with contrasting HAT status. Trypanosome-induced IFN-γ production was only observed in “trypanotolerant” subjects suspected of harboring latent infections. This result contributes new insights into the immune responses associated with infection control and opens novel diagnosis perspectives regarding HAT elimination.

Persistent HIV-1 replication maintains the tissue reservoir during therapy.

Lymphoid tissue is a key reservoir established by HIV-1 during acute infection. It is a site of viral production, storage of viral particles in immune complexes, and viral persistence. Whilst combinations of antiretroviral drugs usually suppress viral replication and reduce viral RNA to undetectable levels in blood, it is unclear whether treatment fully suppresses viral replication in lymphoid tissue reservoirs. Here we show that virus evolution and trafficking between tissue compartments continues in patients with undetectable levels of virus in their bloodstream. A spatial dynamic model of persistent viral replication and spread explains why the development of drug resistance is not a foregone conclusion under conditions where drug concentrations are insufficient to completely block virus replication. These data provide fresh insights into the evolutionary and infection dynamics of the virus population within the host, revealing that HIV-1 can continue to replicate and refill the viral reservoir despite potent antiretroviral therapy.

Human exposures to bisphenol A: mismatches between data and assumptions

Human exposure to bisphenol A (BPA), a synthetic estrogen found in numerous consumer products, is widespread. However, scientific knowledge about the sources and routes of exposure remains incomplete. Although human biomonitoring studies report small amounts of bioactive BPA in the blood of most subjects, toxicokinetic models suggest that circulating levels should be undetectable. The conflict between reported data and toxicokinetic models has spurred considerable debate, with some suggesting that data from analyses of human blood should be dismissed in their entirety. This review addresses the assumptions used by previous risk assessment panels regarding the sources and routes of exposure to BPA (specifically, that BPA exposures occur solely via a few dietary sources) and how these assumptions have affected the interpretation of BPA studies. Given new experimental evidence that route of exposure influences BPA pharmacokinetics, we consider the implications of basing regulatory decisions on limited data that have provided incomplete information about the products that contain this chemical and how it enters the body. We also address evidence that challenges the assumption that humans metabolize BPA rapidly enough to result in undetectable levels in blood and therefore determine that there is a possibility of harm from current exposure levels. Our conclusions are consistent with the large number of hazards and adverse effects identified in laboratory animals exposed to low doses of BPA.

Tissue Says Blood Is Misleading, Confusing HIV Cure Efforts

A recent meeting provided fresh insights into why HIV is so difficult to eliminate from the body: Even when antiretroviral drugs knock down HIV to undetectable levels in blood, the virus remains active in tissues.

Overcoming the effect of rifampin on the tacrolimus metabolism by itraconazole administration in an allogeneic hematopoietic stem cell transplant recipient

Rifampin, one of the first-line agents for tuberculosis, has a great potential to induce the activity of the cytochrome P450 (CYP) enzyme, CYP 3A4, and lowers the concentration of calcineurin inhibitors such as tacrolimus and cyclosporine A (CsA). When calcineurin inhibitors and rifampin are coadministered, increasing the dose of calcineurin inhibitors is essential in maintaining therapeutic blood levels, but this often fails and results in the induction of graft-versus-host disease (GVHD) after allogeneic hematopoietic stem cell transplantation (HSCT) or graft rejection after solid organ transplantation [1–6]. Another option is the administration of agents which could compete with the activity of rifampin upon CYP 3A4. We here present a case in which rifampin was coadministered with tacrolimus after allogeneic HSCT, and administration of oral-solution itraconazole successfully offset the effect of rifampin on the tacrolimus metabolism, resulting in the achievement of a therapeutic blood level of tacrolimus. A 50-year-old woman with myelodysplastic syndrome underwent bone marrow transplantation from an unrelated donor. Tacrolimus and short-term methotrexate were given for the prophylaxis of GVHD. Tacrolimus was given at an initial dose of 0.03 mg/kg by continuous intravenous infusion from day -1, and its dose was adjusted to maintain its blood level at 15–20 ng/ml during the first 4 weeks, followed by oral administration to maintain the blood level at 5–10 ng/ml. She developed acute GVHD of the skin on day 33 post-transplant, which was successfully treated with prednisolone. Prednisolone was given at a dose of 1 mg/kg for 7 days, then tapered, and discontinued on day 96 posttransplant. During prednisolone therapy, voriconazole at dose of 400 mg/day was orally given for the prophylaxis of fungal infection. Antifungal agents were not given thereafter. Around day 150 post-transplant, when tacrolimus was still being orally administered (3 mg/day) and its whole-blood trough level was around 5.5 ng/mL, pulmonary tuberculosis was diagnosed. Anti-tuberculosis chemotherapy consisting of rifampin (300 mg/day), isoniazid (300 mg/day), ethambutol (750 mg/day), and pyrazinamide (1200 mg/day) was initiated. Shortly after initiating this combination therapy, the trough level of tacrolimus became undetectable by automated microparticle enzyme immunoassay (minimum detectable level: 3.0 ng/ mL). Doubling the dose of tacrolimus to 6 mg/day failed to achieve a detectable level of tacrolimus. Oral-solution itraconazole was then initiated at a dose of 200 mg/day for the prophylaxis of fungal infection. The trough level of tacrolimus began to rise, and reached 5.7 ng/ml with 3 mg/ day of oral tacrolimus in 8 days after initiating itraconazole. The patient did not develop GVHD during or after the period of undetectable blood levels of tacrolimus, and fungal infection throughout the clinical course. The combination antituberculosis therapy was effective, and the pulmonary tuberculosis was cured after the 12-month therapy. Coadministration of oral-solution intraconazole with tacrolimus, rifampin, and three other anti-tuberculosis agents caused no clinically significant adverse events. As seen in the present case, rifampin has a great impact on the pharmacokinetics of calcineurin inhibitors, and markedly increases the dose requirement of calcineurin inhibitors to maintain a therapeutic blood level during rifampin therapy [1]. Increasing the dose of calcineurin inhibitors is not always effective, and the reduced levels T. Mori (&) Y. Aisa J. Kato Y. Nakamura T. Shimizu S. Okamoto Division of Hematology, Department of Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan e-mail: tmori@sc.itc.keio.ac.jp

RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY OF MALARONE FOR MALARIA PROPHYLAXIS IN NON-IMMUNE COLOMBIAN SOLDIERS

Malarone was compared with placebo in a double-blind, randomized, placebo-controlled trial of prophylaxis of malaria in predominately Plasmodium vivax areas of Colombia. The study population consisted of 180 completely non-immune Colombian soldiers, male, average age 19 years, and average weight 63 kg. Twenty-four subjects were considered unevaluable because of compliance issues, including one Malarone subject (with no detectable drug levels) who became infected with P. vivax. Of the 97 evaluable subjects who received Malarone (250 mg atovaquone plus 100 mg proguanil hydrochloride) daily from 1 day before entering the endemic area to 7 days after leaving the endemic area, none became parasitemic. Of the 46 evaluable placebo subjects, 11 became infected with P. vivax and 2 became infected with Plasmodium falciparum. The protective efficacy of Malarone for all malaria and for P. vivax malaria was 100% (LL 95% CI = 63%) and 100% (LL 95% CI = 58%), respectively, and was 96% if the one case with undetectable blood levels was included. Malarone has high protective efficacy for P. vivax in Colombia.

Fetal Loss Associated With Excess Thyroid Hormone Exposure

ContextMaternal hypothyroidism and hyperthyroidism have deleterious effects on the outcome of pregnancy. While the effects of thyroid hormone (TH) deprivation on the fetus, independently from that on the mother, can be studied in infants with congenital hypothyroidism, this is not the case in those with fetal thyrotoxicosis.ObjectiveTo study the effects of TH excess on fetuses carried by mothers with resistance to TH (RTH) who are euthyroid despite high TH levels but who may carry normal fetuses that are exposed to high maternal hormone levels.Design, Setting, and ParticipantsRetrospective study of 167 members of an Azorean family with RTH. Affected individuals had the RTH phenotype (high serum concentration of free thyroxine and triiodothyronine without suppressed thyrotropin) confirmed by genotyping to identify the Arg243→Gln mutation in the TH receptor β gene.Main Outcome MeasuresPregnancy outcome of affected mothers vs that of unaffected mothers carrying fetuses conceived by affected fathers, as well as that of unaffected first-degree relatives and outcomes from the general island population. Comparison of birth weights and blood concentrations of thyrotropin (TSH) obtained during routine neonatal screening of infants born to these 3 groups.ResultsThirty-six couples with complete information belonged to 1 of 3 groups: affected mothers (n = 9), affected fathers (n = 9), and unaffected relatives (n = 18). Mean miscarriage rates were 22.9%, 2.0%, and 4.4%, respectively (χ2 = 8.66, P = .01). Affected mothers had an increased rate of miscarriage (z = 3.10, P = .002, by Wilcoxon rank-sum test). They had marginally higher than expected numbers of affected offspring, ie, 20 affected and 11 unaffected children (P = .07), while affected fathers had 15 affected and 12 unaffected children (P = .35). Unaffected infants born to affected mothers were significantly smaller than affected infants, having a mean SD score for gestational age of –1.79 (SD, 0.86) vs −0.06 (SD, 1.11) to –0.22 (SD, 0.70) for all other groups (P<.001). Only unaffected infants born to affected mothers had undetectable blood levels of TSH.ConclusionThere was a higher rate of miscarriage in mothers affected by RTH that may have involved predominantly unaffected fetuses. The lower birth weight and suppressed levels of TSH in unaffected infants born to affected mothers indicates that the high maternal TH levels produce fetal thyrotoxicosis. These data indicate a direct toxic effect of TH excess on the fetus.

Fetal loss associated with excess thyroid hormone exposure.

Maternal hypothyroidism and hyperthyroidism have deleterious effects on the outcome of pregnancy. While the effects of thyroid hormone (TH) deprivation on the fetus, independently from that on the mother, can be studied in infants with congenital hypothyroidism, this is not the case in those with fetal thyrotoxicosis. To study the effects of TH excess on fetuses carried by mothers with resistance to TH (RTH) who are euthyroid despite high TH levels but who may carry normal fetuses that are exposed to high maternal hormone levels. Retrospective study of 167 members of an Azorean family with RTH. Affected individuals had the RTH phenotype (high serum concentration of free thyroxine and triiodothyronine without suppressed thyrotropin) confirmed by genotyping to identify the Arg243-->Gln mutation in the TH receptor beta gene. Pregnancy outcome of affected mothers vs that of unaffected mothers carrying fetuses conceived by affected fathers, as well as that of unaffected first-degree relatives and outcomes from the general island population. Comparison of birth weights and blood concentrations of thyrotropin (TSH) obtained during routine neonatal screening of infants born to these 3 groups. Thirty-six couples with complete information belonged to 1 of 3 groups: affected mothers (n = 9), affected fathers (n = 9), and unaffected relatives (n = 18). Mean miscarriage rates were 22.9%, 2.0%, and 4.4%, respectively (chi2 = 8.66, P =.01). Affected mothers had an increased rate of miscarriage (z = 3.10, P =.002, by Wilcoxon rank-sum test). They had marginally higher than expected numbers of affected offspring, ie, 20 affected and 11 unaffected children (P =.07), while affected fathers had 15 affected and 12 unaffected children (P =.35). Unaffected infants born to affected mothers were significantly smaller than affected infants, having a mean SD score for gestational age of -1.79 (SD, 0.86) vs -0.06 (SD, 1.11) to -0.22 (SD, 0.70) for all other groups (P<.001). Only unaffected infants born to affected mothers had undetectable blood levels of TSH. There was a higher rate of miscarriage in mothers affected by RTH that may have involved predominantly unaffected fetuses. The lower birth weight and suppressed levels of TSH in unaffected infants born to affected mothers indicates that the high maternal TH levels produce fetal thyrotoxicosis. These data indicate a direct toxic effect of TH excess on the fetus.

A Macrolactam Inhibitor of T Helper Type 1 and T Helper Type 2 Cytokine Biosynthesis for Topical Treatment of Inflammatory Skin Diseases

T lymphocytes play a critical part in inflammatory skin diseases but are targeted by available therapies that have only partial efficacy, significant side-effects, or both. Because psoriasis, atopic dermatitis, and allergic contact hypersensitivity are associated with T helper type 1 (Th1), T helper type 2 (Th2), or mixed Th1-Th2 cell subsets and cytokine types, respectively, there is a need for a better broad-based inhibitor. The macrolactam ascomycin analog, ABT-281, was found to inhibit potently T cell function across species and to inhibit expression of multiple cytokines in human peripheral blood leukocytes which have been found in human skin disease cells and tissues. These included immunoregulatory Th1 (interleukin-2 and interferon-gamma) and Th2 (interleukin-4 and interleukin-5) cytokines. ABT-281 was shown to have potent topical activity (ED50 = 0.6% in acetone/olive oil) in a stringent swine model of allergic contact hypersensitivity, but its potency was markedly reduced compared with ascomycin when administered systemically due to more rapid clearance. Topical application of 3% ABT-281 in acetone/olive oil over 25% of the body surface in swine resulted in undetectable blood levels. Compared with a wide potency range of topical corticosteroids in clinical formulations, 0.3% and 1% ABT-281 ointments profoundly inhibited dinitrochlorobenzene-induced contact hypersensitivity in the pig by 78% and 90%, respectively, whereas super-potent steroids such as clobetasol propionate only inhibited in the 50% range and mild to moderate potency steroids such as fluocinolone acetonide were inactive. The potent topical activity of ABT-281 in swine, its superior efficacy, its rapid systemic clearance following uptake into the bloodstream, and its ability to inhibit cytokine biosynthesis of both Th1 and Th2 cell subsets, suggests that it will have a broad therapeutic value in inflammatory skin diseases, including psoriasis, atopic dermatitis, and allergic contact dermatitis.

Concealed Locations of Lentiviruses in Caprine Arthritis Encephalitis System

Ultrastructural examinations of ovine and caprine tissue culture cell lines infected with a molecular sheep lentivirus clone KV72 revealed typical cytoplasmic A type retrovirus particles and budding particles from plasma cell membrane. Blood examinations of a heavily caprine arthritis encephalitis virus-afflicted herd revealed that three goats, which on previous blood examinations had showed a high level of infection, had become negative. Two of these goats underwent a necropsy. The main findings were the presence of typical intracytoplasmic A-type particles found only in neural tissue. No budding or extracellular retrovirus particles were seen in any of the neural tissue examined or in lymph nodes, spleen, or buffy coat cell samples of these animals. This concealed location may be in some analogy with the human immunodeficiency virus system. Despite undetectable blood levels of human immunodeficiency virus in patients after potent combination therapies, they may still harbor latent viruses in different loci.

Role of platelet-activating factor in the ovine heparin-protamine reaction.

Platelet-activating factor (PAF) infusion into sheep, as well as protamine reversal of heparin anticoagulation, causes thromboxane release into plasma, pulmonary hypertension, hypoxemia, and leukopenia. We investigated the possible role of PAF in the heparin-protamine reaction. Intravenous protamine was administered to neutralize heparin anticoagulation in five awake sheep and caused an increase of mean pulmonary arterial pressure from 16.6 +/- 1 (SE) mmHg at base-line to 47 +/- 9 mmHg at 1 min after protamine injection (P < 0.01) because of a 4.5-fold increase of pulmonary vascular resistance. This neutralization reaction induced a 25% reduction of circulating leukocyte count and arterial PO2. Undetectable blood levels of PAF were measured by bioassay and high-performance liquid chromatography during these heparin-protamine reactions. Infusion of BN 52021 (20 mg/kg), a PAF receptor antagonist, before rechallenging the same sheep with heparin and then protamine did not reduce the level of peak pulmonary hypertension or the degree of hypoxemia and leukopenia. We conclude that the leukopenia and thromboxane-mediated pulmonary vasoconstriction occurring after rapid intravascular formation of heparin-protamine complexes in sheep are not due to the release of PAF.

Medication Compliance, Antidepressant Blood Levels, and

A study of medication compliance, side effects, and clinical change with the use of antidepressants in 32 Southeast Asian refugee patients seen at an urban mental health center is reported. Patients met criteria for either major depressive episode, posttraumatic stress disorder, or both. Only five of the 32 patients who stated that they were taking their medications regularly had antidepressant blood levels in the therapeutic range. Another 10 patients had subtherapeutic levels and the remaining 17 had undetectable blood levels. Patients with therapeutic blood levels had fewer side effects (p = 0.049) than patients with undetectable blood levels. Blood levels tended (p = 0.070) to be correlated with clinical improvement. The authors discuss cultural attitudes of Southeast Asian refugee patients toward medication use and side effects that appear to influence medication compliance.

Presence of platelet-activating factor in blood from humans and experimental animals. Its absence in anephric individuals

Blood from humans and experimental animals was examined for the presence of platelet-activating factor. The procedure included a rapid extraction of the samples and a purification of the lipid content by thin layer chromatography. The chemical characterization was performed by phospholipases' treatment and high performance liquid chromatography. Rats contained the highest concentrations of platelet-activating factor and rabbits the lowest. Five anephric patients undergoing support hemodialysis had undetectable blood levels and the same finding was observed in six rats in which surgical nephrectomy was performed. Based on these data we suggest: 1) Low amounts of platelet-activating factor can be present in blood under normal conditions. 2) Kidney tissue seems to play a role in the formation of the platelet-activating factor that can be detected in blood under these conditions.