Echinocytosis induced by haemodialysis

BACKGROUND: Haemodialysis, widely used to treat patients with renal failure, is not always well tolerated. Different mechanisms have been postulated for this. We analyzed the influence of haemodialysis on erythrocyte morphology and blood rheology. METHODS: Twenty-two haemodialysed patients were studied immediately before haemodialysis, after 30 min, and at the end of haemodialysis with biocompatible membranes. Haematological routine was measured, the erythrocyte morphology was assessed on glutaraldehyde-fixed cells and blood viscosity was determined. RESULTS: Erythrocytes underwent various degrees of echinocytic shape transformation after 30 min of haemodialysis, which was completely reversible at the end. In a repetition of the investigations during a subsequent haemodialysis other patients were affected. A plasmatic factor caused echinocytosis since the incubation of control erythrocytes in patients plasma induced a similar, even more marked shape transformation and, vice versa, patient echinocytes regained a discocytic shape when incubated in buffer. The degree of echinocytosis was related to an increased blood viscosity at high shear rates (r=0.800, P<0.01). Echinocytosis was not accompanied by obvious clinical reactions. CONCLUSIONS: Reversible echinocytosis and an increase in blood viscosity is often seen during haemodialysis, which may affect the circulation in patients at risk.     

Leucocytoclastic vasculitis in a patient with azathioprine hypersensitivity

We report the case of a 77-year-old man admitted nine days after being commenced on azathioprine with symptoms initially thought to be secondary to sepsis but in fact due to azathioprine hypersensitivity. He developed histologically proven cutaneous leucocytoclastic vasculitis following the re-introduction of azathioprine. We review the literature concerning adverse reactions to azathioprine and the problems of making the diagnosis as well as highlighting azathioprine as a novel cause of leucocytoclastic vasculitis.     

Bladder cancer in a patient on long-term haemodialysis

OBJECTIVE: The results of the first cohort of 60 cavity reconstructions with hydroxyapatite with a minimum follow-up period of 15 years were studied. STUDY DESIGN: The study design was a retrospective study. PATIENTS: A total of 60 patients had a follow-up period of >15 years. In four patients, not all data were available. Therefore, 56 patients were included in the study. They had a combination of cavity problems and hearing loss. INTERVENTION: The ear canal was reconstructed with a canal wall prosthesis of porous hydroxyapatite. The ossicular chain was reconstructed with an incus or incus-stapes prosthesis of dense hydroxyapatite. RESULTS: After 15 years, 42 patients (75%) had an intact reconstructed ear canal. The main problem for failure was the recurrent purulent middle ear infection and not cholesteatoma. The histology of the retrieved canal wall showed a good remodeling in living bone tissue. After 15 years, 34 patients had a normal ear canal and an ossicular chain. Of these patients, 7.05% had an air-bone gap closure within 20 dB. CONCLUSIONS: Long-term results of cavity reconstruction with hydroxyapatite are possible. The main problem is recurrent mucosal disease of the new middle ear-mastoid cleft.     

Drug resistant typhoid fever

BACKGROUND: Malignant schwannomas are rare malignant mesenchymal tumors often associated with neurofibromatosis. They occur less frequently in the head and neck than in other regions. PATIENT: A case history of a primary malignant schwannoma of the head and neck area in a 27-year-old man is reported. The tumor was located in the left submandibular region. The patient did not have any functional deficits. The tumor was totally removed. There have been no signs of either recurrence or metastasis within the two years following diagnosis and surgery. DISCUSSION: The microscopic and immunohistochemical findings are presented, and the importance and therapy of this very rare malignant tumor of the head and neck area are discussed. CONCLUSION: Malignant schwannoma in the head and neck region is rare. Radical resection is the treatment of choice.     

Acquired amylase production induced by radiotherapy in a myeloma patient

A 55-year-old patient with multiple myeloma (IgG-lambda) diagnosed in November 1988 was admitted because of bone pain throughout the body. After plasmapheresis and several courses of chemotherapy, a massive tumor of the left thoracic wall involving the rib appeared. Radiotherapy was performed to ameliorate the severe chest pain, after which myelomatous pleural effusion appeared on the left side. The serum, urine and pleural effusion revealed increased activity of amylase of the salivary type. Amylase activity was also detected in the supernatant of myeloma cells cultured from pleural effusion. We reviewed 12 cases of ectopic amylase-producing multiple myeloma. All the cases except one have been reported from Japan, and hyperamylasemia in these cases was detected at diagnosis or during course of the illness. Moreover, cytogenetic analysis of myeloma cells of previous reports revealed structural abnormalities including chromosome 1, near the amylase gene locus. This case also showed t (1; 10) (q 21?; q 26) by examination of 8 metaphase derived from bone marrow. These observations suggested that ectopic amylase production was induced by irradiation to the plasmacytoma of thoracic wall.     

Cushing''s syndrome induced by megestrol acetate in a patient with AIDS

This study indicated that a variety of survey techniques resulted in a modest return rate (66%) in a national survey of 455 exercise professionals. A $1.00 bill incentive was significantly more effective than no incentive in improving returns, and the rate of double responses in this anonymous mail survey was extremely low (< 1%).     

The patient with a clotted PTFE graft developing fever

Haemodialysis access graft infection is easily recognizable when local symptoms (warmth, swelling, pain, or drainage) predominate, and endocarditis is a well established complication of infected grafts. We report a case of bacterial endocarditis complicating silent infection in clotted haemodialysis access graft. It is suggested that, clotted non-functioning grafts may be the harbingers of silent infection, and should be suspected as the source of infection in every haemodialysis patient that presents with fever, even in the absence of clinical signs of graft site infection.     

Shock syndrome induced by bromocriptine test in a patient with prolactinoma--case report

A 72-year-old male developed shock syndrome after a single dose of bromocriptine. He had undergone uncomplicated subtotal removal of an invasive prolactinoma in our department. The patient had normal ranges of pituitary hormones apart from hyperprolactinemia (167.7 ng/ml) after surgery. An acute suppression test with bromocriptine (2.5 mg per os) was done in the supine position 6 days following surgery. Three and a half hours after bromocriptine administration, he suddenly complained of anterior chest discomfort in bed. Cyanosis and profuse diaphoresis were noted. His blood pressure was 80/60 mmHg. Electrocardiography revealed sporadic premature contractions and slight depression in the ST segments. He recovered in about 10 hours after a rapid infusion of corticosteroid and lactic Ringer solution, and was discharged without sequelae. This is a very rare complication of bromocriptine, but the cardiovascular function of patients taking bromocriptine for therapeutic and diagnostic purpose should be monitored carefully.     

Lichenoid skin lesions as a sign of beta 2-microglobulin-induced amyloidosis in a long-term haemodialysis patient

We report a case of beta 2-microglobulin-induced amyloidosis. The patient was a 40-year-old man suffering from non-amyloid nephropathy, who had been treated by haemodialysis for 20 years. Lichenoid skin lesions, consisting of groups of pin-head-sized shiny papules, were present on the arms and trunk. On histological examination, amyloid deposits were present, principally in the dermal papillae, but also around the sweat ducts and hair follicles. The amyloid displayed potassium-permanganate-resistant Congo red affinity, and green birefringence under polarized light. Immunohistochemically, beta 2-microglobulin was demonstrated in the lesions, confirming that they were a manifestation of beta 2-microglobulin-associated amyloidosis. Skin lesions of this type have not been reported previously in beta 2-microglobulin-associated amyloidosis.     

Sinus bradycardia induced by talipexole hydrochloride in a patient with Parkinson disease

The aim of this study was to evaluate the accuracy of the 14C-urea breath test by comparing the results to those obtained by endoscopy with mucosal biopsy. We also examined the value of the breath test result obtained prior to endoscopy in predicting peptic ulcer disease. Forty-two individuals underwent the 14C-urea breath test. Collections of expired C02 were analysed using a liquid scintillation counter. All individuals then underwent endoscopy with biopsy. Biopsy material was evaluated by the rapid urease method and by histology for the presence of H. pylori. Our results demonstrated that the 14C-urea breath test was 100% sensitive and specific when compared to the rapid urease test as the 'gold standard' for the detection of H. pylori. In comparison to pathology, the sensitivity remained 100% and the specificity was 89%. The results of the 14C-urea breath test had a poor predictive value for the determination of peptic ulcer disease. We conclude that the 14C-urea breath test can be easily performed at any medical facility equipped with a liquid scintillation counter and can accurately detect H. pylori. A negative breath test result could not exclude the presence of peptic ulcer disease.     

Drug misuse in a special clinic patient population in Glasgow

Defibrination with ancrod in nephrotoxic nephritis in rabbits. In rabbits with nephrotoxic nephritis, defibrination with ancrod provided protection when administered during the autologous phase, after extensive glomerular fibrin deposition had occurred and crescents and renal failure were developing. When further glomerular fibrin deposition was prevented by defibrination, deposited fibrin was rapidly removed, indicating that glomerular fibrin-clearing mechanisms are retained in crescentic nephritis. Defibrination had no effect on the extent of glomerular C3 deposition or on the amount of proteinuria.     

Drug induced impotence

Medication induced impotence has been reported in the some papers. However, it is unusual to talk about the sexual history in a general clinical interview and there are few reports to show the possible mechanisms of induced sexual dysfunction in Japan. Recently, the average life span of the Japanese population has gradually increased, so now we have a chance to evaluate the sexual history from older people. Some drugs, such as diuretics, antiarrtythmic and antihypertensive drugs, were reported to induce impotence, however, there was not a detailed study in Japan. We studied the effect of cardiovascular medicine to sexual dysfunction in 1,000 patients. Almost all medication did not always reduce sexual activities, however, sexual activities in old people might decrease because of medications or sickness. It is important for the general physician to ask the patients about general conditions including sexual history while on medications.