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1/17. Scopulariopsosis and hypersensitivity pneumonitis in an addict.

    Granulomatosis caused by fungal spores of a soil saprophyte is a newly recognized pulmonary complication of intravenous drug addiction. Brown, non-budding spores were histologically identified in necrotic tissue, inside giant cells of sarcoidlike granulomata, and in the vicinity of focal angiitic lesions. The fungus was identified by culture as the dematiaceous scopulariopsis brumptii. Cultural and histopathologic studies of lung biopsy specimens established the diagnosis. We showed precipitating antibodies to fungal antigen in the serum, prepared from the patient's isolate. Similar granulomatous pulmonary lesions were experimentally produced in mice by a single intravenous injection of spores of S. brumptii. The spores remained viable but did not show evidence of growth in the animal's tissue. Precipitating antibodies to fungal antigen and immediate wheal and late necrotizing type of skin reactions were shown in the challenged mice. The studies support the notion that pulmonary hypersensitivity to fungal spores was mediated by an Arthus'-type phenomenon.
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2/17. Novel cases: malingering by animal proxy.

    malingering to obtain medications of abuse is well documented in the general medical setting. However, we have found no cases previously reported of such malingering in a veterinary setting. We report five cases submitted by veterinarians in which clients (pet owners) are strongly suspected or confirmed to have been engaging in malingering to obtain controlled medications for their personal use. Cases bear a striking resemblance to malingering in the general medical setting for drugs to abuse. We propose that veterinarians, like their medical counterparts, are potential targets of malingering by their clients for drugs of abuse. Because of their familiarity with this condition, psychiatrists may have a role in training veterinarians to recognize malingering on the part of their human clients. In addition, psychiatrists may benefit from familiarizing themselves with novel forms of malingering, such as are presented in this case series.
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3/17. acute coronary syndrome and crystal methamphetamine use: a case series.

    "Ice" is a form of methamphetamine commonly used as a recreational drug in hawaii and the philippines, but seldom encountered in the continental united states. It differs in appearance from methamphetamine tablets, but otherwise has exactly the same molecules, only arranged in a crystalline structure. A sizeable body of in vitro, animal, and autopsy data suggest a linkage between methamphetamine use and myocardial pathology. In this report, we describe a series of eight patients who developed unstable angina or acute myocardial infarction in association with smoking crystal methamphetamine. The findings, to a large extent, resemble those with cocaine-associated acute coronary syndromes. Given the widespread abuse of methamphetamine among young age groups, the recognition and primary prevention of cardiovascular toxic effects is of mounting socioeconomic importance.
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4/17. Case report: rhodococcus equi pneumonia in a patient infected by the human immunodeficiency virus.

    rhodococcus equi, a facultative intracellular bacterium, is a common cause of pulmonary infection in farm animals, especially foals. Pulmonary and disseminated infection caused by this organism is occasionally seen in humans, especially in patients whose cell-mediated immunity has been altered by glucocorticoids or cytotoxic chemotherapy. Not surprisingly, the organism may cause serious disease in human immunodeficiency virus (hiv)-infected humans whose T cell-dependent immune system has been profoundly suppressed. This report describes an hiv infected patient with rhodococcus equi pneumonia and reviews nine additional hiv-infected patients. Treatment in humans is not standardized. Studies in foals indicate that erythromycin and rifampin together are the treatment of choice. The patient in this report responded to this treatment briefly before relapsing and dying of the infection.
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5/17. Lasting neuropsychiatric sequelae of ( -)methylenedioxymethamphetamine ('ecstasy') in recreational users.

    Two persons are described who demonstrated prolonged neuropsychiatric syndromes after the ingestion of large doses of ( -)-3,4-methylenedioxymethamphetamine (MDMA), a recreationally used amphetamine analog. These cases suggest that MDMA, known to be neurotoxic to serotonin neurons in several experimental animals, may also produce untoward effects in humans. In addition, they provide evidence that ingestion of large doses of MDMA can produce lasting adverse functional consequences in vulnerable persons.
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6/17. naltrexone-induced hypothermia in the rat.

    naltrexone, in relatively high doses, has been reported to cause a fall in body temperature in human ex-heroin addicts who had been abstinent for at least 6 weeks. The underlying mechanism of this hypothermic effect has been investigated in rats. The first consideration was that the temperature change was a reflection of delayed withdrawal but rats implanted with a morphine pellet 45 days earlier showed no significant change in temperature after a dose of naltrexone that caused marked withdrawal hypothermia in dependent rats implanted 3 days previously. A fall in core temperature was only induced in rats after doses of 80 and 160 mg/kg i.p. of naltrexone. Behavioral thermoregulatory studies revealed that the animals correct the falling body temperature by increased exposure to a radiant heat source indicating that the central thermostats had not been significantly affected by the drug. These data suggest that the major component in the hypothermic effect of naltrexone is activation of efferent heat loss pathways or peripheral heat loss mechanisms. Due to current suggestions that opiate receptors might represent the receptors for an endogenous transmitter the results are discussed in relation to this consideration. When compared to the sites and mechanism of action of opiates on thermoregulation the results with naltrexone lend little support to the hypothesis that the fall in temperature is due to displacement of an endogenous substance from central opiate receptors.
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7/17. Cerebral CT findings in drug abuse: clinical and experimental observations.

    Computed tomographic changes compatible with cerebral atrophy have been observed clinically and in experimental drug abuse animals. Most of the patients were thought to be polydrug users, but amphetamines and alcohol were two of the more commonly misused drugs. In the experimental animals, the effects of amphetamine, secobarbital, and marijuana were studied. brain damage was present in the animals that received intravenous amphetamine.
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8/17. Use of contingency contracts in specialty clinics for cocaine abuse.

    Animal research reveals that cocaine is a highly reinforcing drug, and patients describe it as "compelling"; the drug maintains vigorous self-administration behavior in animals and humans despite its clear adverse effects. This suggests that the drug is very difficult for experienced users to give up. It further suggests a need for vigorous treatment to produce and maintain abstinence, thus permitting patients to relearn drug-free behaviors which are alternative to continued cocaine use. This 12-month pilot study aimed to determine 1) whether cocaine abusers would enter and remain in treatment, and 2) whether contingency contracts appear to complement standard clinical treatment in initiating and maintaining abstinence. We established cocaine clinics in Denver and Aspen. Of the first 67 patients admitted into those clinics, 32 (48 percent) elected to utilize contingency contracts. Thirty-one of those completely abstained from cocaine use during the treatment. Of the 35 patients who did not elect to use contingency contracts, no one remained abstinent and in treatment for more than four weeks. The results indicate that cocaine abusers will enter treatment, and that contingency contracting may contribute to a favorable outcome.
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9/17. delirium and stereotypy from anticholinergic antiparkinson drugs.

    1. This report describes two cases of psychotic syndrome from benztropine (Cogentin), which was used to treat haloperidol-induced extrapyramidal side effects. The patients' symptomatology meets DSM III criteria for delirium. Both patients displayed repetitive motor automatisms (stereotypy). 2. Symptomatology appeared one-to-two days after the start of benztropine 2 mg b.i.d. and subsided one-to-several days after benztropine was stopped. Treatment consisted of administration of sedative hypnotic drugs. 3. The literature on anticholinergic-induced psychotic syndromes is surveyed. Particular attention is drawn to the occurrence of stereotypy. 4. It is proposed, on the basis of a review of animal and clinical data, that stereotypies in delirious patients are related to muscarinic blockade in the central nervous system. This model is used to explain repetitive motor automatisms which are seen in Alzheimer's disease. 5. The paper concludes with brief guidelines for the management of anticholinergic delirium.
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10/17. Reinforcing subjective effects of ( /-) 3,4-methylenedioxymethamphetamine ("ecstasy") may be separable from its neurotoxic actions: clinical evidence.

    ( /-)3,4-Methylenedioxymethamphetamine (MDMA), a synthetic amphetamine derivative used recreationally by humans, damages brain serotonin neurons in experimental animals. In preclinical studies, serotonin reuptake inhibitors block MDMA-induced serotonin release; they also block MDMA neurotoxicity. Whether serotonin reuptake inhibitors also block MDMA's psychoactive effects in humans has not been established. Reported herein are four individuals who describe their experiences after ingesting fluoxetine, a potent and selective serotonin reuptake inhibitor, before MDMA ingestion. Their reports indicate that fluoxetine does not block MDMA's reinforcing subjective effects and raise the possibility that MDMA's psychoactive effects may be separable from its neurotoxic actions.
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