Biomedical subjects
Publications and source records attributed to M Pirovino.
Abscesses of the spleen are rare and, if untreated, lead to death. The usual mode of development is by hematogenous spread of infection. Treatment options are splenectomy, percutaneous drainage and in selected cases an antibiotic therapy. We report a case of a splenic abscess due to Streptococcus bovis treated with antibiotics only.
Abuse of ecstasy is the second most frequent cause of acute liver failure in young adults less than 25 years of age. Typically, the disease has an acute onset and runs a severe course with jaundice, coagulopathy and a tendency to hypoglycemia. Transplantation of the liver may be required. The histological characteristics are not yet sufficiently known. We report the case of a 17-year-old patient with a clinically severe, protracted course, presenting a giant cell hepatitis in the liver biopsy.
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We present a patient with adult polycystic kidney disease, who developed a Budd-Chiari Syndrome due to compression of the hepatic venous outflow tract by liver cysts. In patients with adult polycystic kidney disease who present a fast ascites formation, it is of great importance to look for a Budd-Chiari Syndrome as a complication of liver cysts.
We present a carrier of the sickle cell trait who developed a serious splenic infarction. An antecedent hypoxaemic event and a blood coagulation disorder were ruled out. The observation shows that the sickle cell trait can represent a risk factor for a life-threatening thrombotic event, even in the absence of a predisposing condition.
Among 174 patients admitted for acute gastrointestinal bleeding the source of bleeding remained undetermined in 19 (10.9%) despite standard diagnostic workup. We show that an unknown source of acute gastrointestinal bleeding is not a risk factor with regard to the in-hospital outcome: there was no difference in the number of in-hospital days, of PRBC transfused or of surgical interventions; none of these patients died. While patient characteristics regarding mean age and sex distribution likewise did not differ, there was a significantly higher percentage of patients on NSAIDs or oral anticoagulants among those whose source of bleeding could not be found (80 vs 42%; p = 0.002). The clinical follow-up of the patients with undetermined source of bleeding reveals gastrointestinal pathology in a considerable proportion (18%); it calls for close follow-up of these patients after discharge.
BACKGROUND: Despite the benefits of thrombolytic therapy, there is evidence that not all suitable patients are receiving it. Early and accurate recognition of the ECG changes of myocardial infarction is a prerequisite for effective thrombolytic treatment. METHODS: During the Olten Heart Emergency Study we prospectively evaluated 951 consecutive patients with symptoms suggestive of myocardial infarction who were cared for by the emergency networks connected with Olten Cantonal Hospital. MAIN OUTCOME MEASURES: The final diagnosis was myocardial infarction in 173 patients (18.2%). Diagnostic ST-segment elevation was found in 48.6% and complete left bundle branch block in 13.9% of these patients, representing a total of 62.5% acute myocardial infarction patients eligible for thrombolysis based on the ECG findings. Using a time limit of 6 hours between onset of symptoms and hospital entry for small and medium-size myocardial infarctions and 12 hours for large infarctions, plus an age limit of 70 years for inferior and 75 years for anterior infarctions as exclusion criteria for thrombolysis, we found one or more contraindications for the use of thrombolytic therapy in 50.9% of these patients. The most prevalent contraindication was time delay in the prehospital phase in 38.2%, followed by advanced age in 34.5%. Medical contraindications to thrombolytic treatment were found to be present in only 10.9%. Extension of the prehospital time delay to 24 hours would have increased the candidates for thrombolytic treatment to 39.3%, and raising the upper age limit by 5 years would have increased them to 46.8%. CONCLUSIONS: Our figures for a theoretically adequate thrombolysis rate contrast with many previous studies and the clinical reality in different hospitals both in Switzerland and around the world. In view of the importance and socioeconomic consequences of thrombolytic treatment in myocardial infarction, studies focusing on possible reasons for discrepancies between guidelines for thrombolytic therapy and their implementation in hospital practice would appear to be a necessity in providing measures to improve patient care in this clinical setting.
The author reviews the history, symptoms and signs of acute hepatitis B and its differential diagnosis. Special emphasis is laid on its natural history and the discussion of uncomplicated acute hepatitis B, fulminant hepatitis and chronic HBV infection.
The main complications of chronic viral B infection are briefly reviewed. The balance between the immune system of the host and viral replication, the histological definition of chronic hepatitis and the incidence of cirrhosis and hepatocellular carcinome are delineated. Clinical manifestations of cirrhosis and the question of HBV infection in liver transplantation setting are briefly summarized.
A 23-year-old man experiencing three episodes of acute pancreatitis of undetermined etiology is described. Repeated questioning revealed that all three events had occurred after intake of the drug pyritinol. Controlled rechallenge with a single dose of the drug led to a fourth episode of acute pancreatitis. Skin testing was negative, but lymphocyte stimulation tests and double fluorescence analysis detected pyritinol-activated CD4 and CD8 lymphocytes. Together with the clinical observation that the intervals between drug intake and start of symptoms of acute pancreatitis became shorter with repeated exposure, the data are consistent with an immune-mediated origin of the pancreatitis. Pyritinol has to be added to the list of drugs capable of inducing acute pancreatitis.
Early reperfusion in acute myocardial infarction has been shown to reduce myocardial damage and to improve prognosis. The goals of this study, the Olten Cardiac Emergency Study, were to identify the factors, related to the patients or to the emergency medical services, which influenced pre-hospital delay in patients with symptoms suggestive of acute myocardial infarction. From November 1, 1992, to June 15, 1993, all the events occurring between symptom onset and hospital discharge where analyzed for 341 such patients who were cared for by the emergency networks connected with the Cantonal Hospital, Olten: in addition, follow-up at 3 months was obtained on all patients discharged alive. Of the 341 patients, 14 (4.1%) died out of the hospital. The final diagnoses of the 327 patients admitted to the emergency department were: acute myocardial infarction 18.3%; unstable angina 10.1%; stable angina 3.4%; non-ischemic cardiac diseases 29.4%; other non-cardiac diseases 38.8%. Mean delay between symptom onset and arrival at the hospital was 8 h 55 min (median delay 4 h 10 min); for patients with a final diagnosis of acute myocardial infarction, mean delay was 9 h 43 min (median delay 5 h 10 min). Patient delay was surprisingly long and represented 70.4% of the total pre-hospital delay; 56.6% of the patients did not realize that their symptoms were serious and only 47.1% (and 68.3% of the patients with acute myocardial infarction) came to the hospital by ambulance. These long pre-hospital delays were responsible for the low (13.3%) thrombolysis rate of patients with acute myocardial infarction. We conclude that pre-hospital delay was much too long in our population. Improvements can only be achieved through patient education and better efficiency of emergency networks. Our findings underline the need for public education campaigns on heart attacks.
A case of isolated right ventricular myocardial tuberculoma with pericardial effusion is presented. The diagnosis of myocardial tuberculoma was initially suggested by echocardiography and later by magnetic resonance imaging. The diagnosis of cardiac tuberculosis was confirmed by demonstration of tubercle bacilli in the pericardial fluid. This is a very rare condition which is usually diagnosed only by necropsy. Myocardial tuberculoma should figure on the list of intraparietal masses visualized at echocardiography.
Nonbacterial thrombotic endocarditis is rarely diagnosed before death. We report on 3 patients with nonbacterial thrombotic endocarditis to illustrate the clinical course of this disease that can cause severe systemic thromboembolism and may be the first manifestation of malignant disease. Nonbacterial thrombotic endocarditis must be considered in the differential diagnosis of culture-negative endocarditis.
Chronic liver diseases, especially due to chronic hepatitis B virus infection, are among the leading causes of late mortality in renal transplant recipients. We report on 4 HBsAg-positive patients observed over a period of 8 years, who were free of symptomatic liver disease for 7-19 years after renal transplantation and died within a few days of acute hepatic failure. The cases presented document the prognostic relevance of chronic hepatitis B virus infection in renal transplant recipients and illustrate that an asymptomatic HBsAg carrier state can evolve within a very short time to fatal liver disease.
Spontaneous bacterial peritonitis (SBP) is a frequent complication of cirrhosis with ascites. As clinical symptoms are often mild or lacking, the condition may not be perceived in otherwise severely ill patients. This study focuses on diagnostic and prognostic aspects in 25 patients with 26 episodes of SBP. A microbiological diagnosis was established in 18 patients by positive culture of ascitic fluid or positive gram stain. In 8 episodes the diagnosis was presumed on the basis of an elevated polymorphonuclear leukocyte (PMN) count in the ascitic fluid (> 250 PMN/microliters). The mean (+/- SD) age of the 11 women and 14 men was 55 +/- 14 years; 16 were attributed to Child grade C, 9 to Child grade B liver dysfunction. In 19 cases, cirrhosis was confirmed histologically. The underlying liver disease was Laennec's cirrhosis in 13 cases, hepatitis-B virus associated chronic liver disease in 7 cases and primary biliary cirrhosis in 2 cases. At the time of diagnosis, 6 of 25 patients had no fever, 13 of 25 patients had no abdominal pain, 10 of 24 patients showed no abdominal tenderness upon palpation and 5 of 26 patients had no fever or abdominal pain. 17 of 26 patients showed signs of portosystemic encephalopathy. The total white blood cell count in the ascitic fluid was 3627 +/- 3978/microliters with 71 +/- 29% polymorphonuclear cells in the group with microbiologically proven peritonitis and 5105 +/- 2860 cells/microliters (80 +/- 13%) in the group with negative ascitic fluid culture, respectively. Gram stains were positive in 8 cases and culture in 16 of 25 patients. E. coli was cultured in 8 episodes and Str. pneumoniae in two. In-hospital mortality was 61% in the group with microbiologically proven peritonitis and 14% in the group with negative ascitic fluid culture (p = 0.062); 6-month mortality rate was 78% and 86% respectively (p = 0.91). Prognosis was worse in patients Child grade C (p = 0.027), in patients lacking symptoms or signs of peritoneal irritation (p = 0.017), in patients with septic shock (p = 0.018) and in patients with elevated serum-creatinin levels at the time of diagnosis (p = 0.05). SBP is a treatable complication with high mortality of advanced liver disease. Clinical manifestations may be non-specific or absent. We recommend that diagnostic paracentesis be performed in all patients with cirrhosis and ascites if their clinical condition is rapidly worsening.
Among the local complications following the intramuscular injection of therapeutic drugs, the syndrome of 'embolia cutis medicamentosa' deserves special attention. Shortly after the intramuscular injection, the patients notice severe pain and an erythematous discoloration of the skin at the injection site, followed by central demarcation and a sharply circumscribed skin necrosis with or without damage to peripheral nerves. We report about three patients, two of which had to be hospitalized. The drugs injected were combinations of analgesics of the phenylbutazone-type, corticosteroids, local anesthetics and cyanocobalamin. The observation that this severe complication may be associated with technically proper ventrogluteal injection of a wide array of therapeutic drugs shows that intramuscular injections require valid indications.
We report on two siblings with giant cell arteritis (GCA) and polymyalgia rheumatica (PMR). Temporal artery biopsies revealed GCA in three cases, and sclerosis of the wall of the temporal artery in one case. The HLA haplotype was identical in the first pair, and in the second pair HLA-A2, HLA-B39 and HLA-DR53 were identical. In three patients HLA-DR4 was demonstrated. Cases of familial aggregation of GCA have been reported in the literature. In several reports an increased prevalence of HLA-DR4 was described (about 40% of patients with GCA, compared with about 13% in the European population). HLA-DR4 was observed in three of our four patients and a haploidentity was found in one pair. Based on our observation and the results published in the literature, it seems probable that giant cell arteritis--a typical disease of advanced age--has at least partially a genetic basis.
In two patients, mother and daughter, with breast cancer a paraneoplastic syndrome of probably autoimmune pathogenesis developed in the course of the neoplastic disease. In the mother the cancer occurred when she was aged 51, first in the left and then, 4 years later, in the right breast. A local recurrence 18 years later caused a pericardial effusion and further tumour recurrences were associated with symptoms like those in Sjögren's syndrome, as well as bullous pemphigoid and polyneuropathy. Antinuclear antibodies, extractable nuclear antigen antibodies and rheuma factors were demonstrated in serum. Both symptoms and antibody titres regressed under treatment with tamoxifen and various cytostatic drugs. The patient died aged 74 years.--The daughter underwent a lumpectomy for breast cancer when aged 39 years, followed by mastectomy for local recurrence after 2 years. A further 2 years later she was found to be anaemic with a positive Coombs test (1:1024) and antibodies against IgG and complement. Metastases developed later. In her case, too, clinical and serological findings clearly regressed under treatment with tamoxifen and chemotherapy. She died, aged 45 years, from the consequences of further metastases.