BRIEFCLINICALOBSERVATIONS DIASTOLICHYPERTENSIONIN AIDS PATIENTS WITH CRYPTOCOCCALMENINGITIS Recently, we observed a new onset of diastolic hypertension in several patients with acquired immunodeficiency syndrome (AIDS) and cryptococcal meningitis whose clinical course quickly terminated in death. Although the mortality of cryptococcal meningitis in patients with AIDS remains high despite antifungal therapy [l-3], the new onset of elevated diastolic pressure followed by death has not been observed. A case-control retrospective chart review of patients with AIDS from the last 24 months was performed to determine whether diastolic blood pressure elevation was unique to cryptococcal infection. Blood pressure readings were ob-

TABLE I Patient Demographicand Clinical Data Cryptococcal Meningitis Gender Male Female Age (mean ? SD) Race Black White Hispanic Median duration of HIV infection (y) Risk for HIV infection Intravenous drug use Fl~lwuality Opportunistic infections First episode of CM Recurrent CM Pneumocystis carinii Mycobactefium avium complex Extrapulmonary tuberculosis Cytomegalovirus retinitis Toxoplasma encephalitis

15 0 40 ? 8.5

Control

14 1 38.6 + 5.4

15

13

i

!

1.25

2.5

10 i

tained at least three times a day. A comparison of cryptococcal-infected patients versus patients with other opportunistic infections (control group) is shown in Table I. Logistic regression of the factors with outcome (death or no death) showed a good correlation of diastolic hypertension with impending death (p 0.07). All patients received amphotericin B therapy, and the diastolic hypertension was not temporally related to drug infusion. Only one patient had a history of hypertension prior to the diagnosis of meningitis. Ten of the 11 patients with diastolic hypertension died during the same hospitalization. The number of days to death after the onset of diastolic hypertension averaged 23. The exact mechanism for the new onset of elevated diastolic blood pressure in these patients with cryptococcal meningitis is unknown. Meanwhile, observed new diastolic hypertension may be considered a serious clinical sign and may require close monitoring of blood pressure. PATTYFAN-HAVARD,P~~~~.D. ELENA YAMAGUCHI,M.D. SHARONM.SMITH,P~.D. ROBERTH.K.ENG,M.D. Department

of Veterans Affairs Medical Center East Orange, New Jersey

1. Kovacs JA, Kovacs AA, Polis M, eta/. Cryptococcosis in the acquired immunodeficiency syndrome. Ann Intern Med 1985; 103: 533-8. 2. Eng RH. Bishburg E, Smith SM, Kapila R. Cryptococcal infections in patients with acquired immunodeficiency syndrome. Am J Med 1986; 81: 19-23. 3. Zuger A, Louie E. Holzman RS. Slimberkoff MS, Rahal JJ. Cryptococcal disease in patients with the acquired immunodeficiency syndrome. Ann Intern Med 1986; 104: 234-40. Submitted

January

29, 1992, and accepted

Figure

1. Further

progression

of patient’s

rash.

in revised form May 29, 1992

METASTATIC GLUCAGONOMA:CLINICAL RESPONSETO A COMBINATION OF SFLUOROURACILAND a-INTERFERON Glucagonomas arise from pancreatic alpha-2 islet cells and produce a characteristic syndrome of hyperglucagonemia, dermatitis, glucose intolerance or diabetes mellitus, hypoaminoacidemia, weight loss, and anemia. More than 75% of the tumors are malignant, and cytoreductive surgery of metastases may produce prolonged and significant palliation. Glucagonomas often respond to streptozotocin, dacarbazine, or 5-fluorouracil [l-3]; symptomatic relief has also been achieved with the somatostatin analogue octreotide acetate (SMS 201-995) [4]. Novel treatment strategies are needed for patients in whom all therapeutic options presently available have been exhausted. We report a patient with a glucagonoma who experienced a dramatic clinical improvement when treated with a combination of 5fluorouracil and a-interferon. Case Report. A 52-year-old man presented with a 2-year history of a progressive rash over his perineum and back, watery diarrhea (without steatorrhea, melena, or hematochezia), and a 11.4-kg weight loss. The diagnosis of glucagonoma syn348

September

1992

The American

Journal

of Medicine

Volume

Figure tory

93

2. Resolution hyperpigmentation.

of patient’s

rash

with

only

postinflamma-