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A helpful diagnostic feature is the presence of antibodies to nuclear cytoplasmic antigens (c-ANCA), which are present in some cases, as they are in a number of other vasculitic and granulomatous processes A few of our own patients have also had adrenal or renal enlargement; presumably due to in ltration of the vessels of these organs by the neoplasm The spinal uid has a variable lymphocytic pleocytosis and protein elevation, but malignant cells are not found The sedimentation rate and serum LDH are said to be elevated in most patients, but this has not been so in our experience Like demyelinating and lymphomatous lesions, these abnormalities may recede temporarily in response to treatment with corticosteroids, and some clinical improvement occurs The course tends to be indolent and relapsing over months or years, although one of our patients died within weeks despite treatment.

The phenomenon of irritability, or an irritable mood, must be familiar to almost everyone, exposed as we are to all of the noise, niggling inconveniences, and annoyances of daily life It is, nevertheless, a dif cult symptom to interpret in the context of psychopathology Freud used the term Reisbarkeit in a restricted sense to denote an undue sensitivity to noise and considered it a manifestation of anxiety, but obviously this symptom has a much broader connotation and signi cance For one thing, some people are by nature irritable throughout life Also, irritability is an almost expected reaction in overworked, overwrought individuals, who become irritable by force of circumstances An irritable mood or feeling may be present without observed manifestations (inward irritability), or there may be an overt loss of control of temper, with irascible verbal and behavioral outbursts, provoked by trivial but frustrating events.

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Irritability in the foregoing circumstances can hardly be considered a departure from normal However, when it becomes a recurrent event in a person of normally placid temperament, it assumes signi cance, for it may then signify an ongoing anxiety state or depression Irritability is also a common symptom of obsessional neurosis Here the irritability tends to be directed inward, indicating perhaps a sense of frustration with personal disability (Snaith and Taylor) Depressed patients are frequently irritable; as a corollary, this symptom should always be sought in patients suspected of being depressed, since it is so readily recognized by both patients and their families The days preceding menses and the mother s common postnatal mood disorder are characterized by high levels of outwardly directed irritability Short-temperedness and irritability are also common features of the manic state.

The most extreme degrees of irritability, exempli ed by repeated quarrelsome and assaultive behavior (irritable aggression), are rarely observed in anxiety neurosis and endogenous depression but are usually the mark of sociopathy and brain disease Such irritable aggression is also observed in some patients with Alzheimer disease and other types of dementia and following traumatic contusions of the temporal and frontal lobes..

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and prosper. Or, looking at another kind of crisis, when a corporation faces a crisis of public confidence in its products or practices, such as the Tylenol poisonings back in the 1980s or the Firestone tire recalls in 2000, the company simply has to be at the top of its game. It has to think clearly, move quickly and effectively, put out the fire, and stay in the game.

In a few cases, whole-brain irradiation has been successful in prolonging survival, but the outlook in most instances is poor An uncertain number of these patients have AIDS (none in our group) The illness must be distinguished from multiple sclerosis, brain lymphoma, gliomatosis cerebri, and a process that simulates it closely, sarcoidosis (which produces brain and lung lesions) as well as from the cerebral vasculitides and Behcet disease,.

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