Interstitial pneumonia preceding systemic sclerosis

Spontaneous intramural dissection of the oesophagus has been recognized as a separate clinical entity between a transmural oesophageal rupture (Boerhaave syndrome) and an oesophageal mucosal tear (Mallory-Weiss syndrome). It is important to differentiate this condition from myocardiac infarction, dissecting aneurysm and other acute surgical conditions. Conservative management is usually thought to be adequate. We report a case of spontaneous intramural oesophageal dissection, in which the symptom of dysphagia did not improve with the conservative management and an endoscopic incision of the septum between true and false lumens using a needle-type diathermy knife was done safely and effectively.     

A rare case of spontaneous esophageal rupture (Boerhaave's syndrome) associated with pulmonary rupture

Spontaneous esophageal rupture (Boerhaave's Syndrome) is a life-threatening condition that requires early diagnosis and effective treatment. The authors describe a rare case of spontaneous rupture of the esophagus associated with pulmonary rupture in a 54-year-old man. The anatomical basis for the occurrence of a spontaneous esophageal rupture associated with pulmonary rupture is discussed.     

Boerhaave''s syndrome and children: a rare and unexpected combination

Boerhaave's syndrome, or the spontaneous rupture of the esophagus, appears most commonly in males between the ages of 40 and 60. Severe vomiting followed by excruciating chest pain are the classic clinical signs, often in conjunction with a history of over indulgence in food and alcohol. The authors describe a case of Boerhaave's syndrome in a child, the result of missed appendicitis.     

Differential diagnosis in dementia

The results of an autopsy of a 78-year-old female patient with an occluded of the right internal carotid artery after a traffic accident are reported. She presented with consciousness disturbance, right conjugate deviation, left hemiparesis and left pathological reflex. Evidence of right skull and clavicular fractures seemed to suggest that severe hyperextension of her neck associated with contralateral lateral flexion had stretched her carotid artery. Although she was treated with antiplatelet therapy, her cerebral swelling due to right global infarction progressed and she died due to bilateral cerebral herniation three days after injury. The autopsy disclosed right dissecting carotid artery occlusion and subadventitial dissection was revealed histologically. When a hematoma dissect the media and adventitia of the carotid artery wall, the outer wall weakens and may dilate without narrowing the lumen of the carotid artery. In this case, the vessel occlusion was considered to be due to a primary intramural hematoma which developed and subsequently ruptured through the intima into the vessel lumen. Early diagnosis and treatment are necessary for improving the prognosis of this disease entity. A patient with poor colateral flow, such as in this case, will show a rapid progression of cerebral infarction. It is best to consider surgical treatment in this case if the other traumatic lesions are able to tolerate surgery.     

Splenic complications in malaria: case report and review

Clinicians are increasingly confronted with diagnosis and management of malarial complications. In nonfalciparum malaria, severe complications usually involve the spleen, most notably among them the condition termed spontaneous splenic rupture. A case of infection due to Plasmodium malariae resulting in a symptomatic splenic hematoma is presented. Malarial splenic enlargement and pathology are reviewed, as well as splenic complications such as spontaneous rupture, hematoma, hyperreactive malarial syndrome, hypersplenism, ectopic spleen, torsion, and formation of cysts. Also evaluated are the 11 reported cases of spontaneous splenic rupture in malaria in the English-language literature from 1960 to 1991. Most cases of spontaneous splenic rupture in malaria occur during acute infection and are associated with Plasmodium vivax. Lack of prior immunity to malaria appears to be a major predisposing factor. Increasingly, splenic complications are managed by supportive care and spleen-conserving procedures to avoid postoperative and asplenic morbidity.     

A resolving sign of acute subdural hematoma: from report of two cases

A 7-year-old-boy (Case 1) and a 60-year-old-man (Case 2) presented with rare spontaneous resolution of acute subdural hematoma (ASDH). They were admitted with consciousness disturbance, drowsy in Case 1 and sleepy in Case 2. Initial CT showed ASDH associated with a low density band between the hematoma and the inner wall of the skull base, combined with right parietal contusion in Case 2. Repeat CT showed that the hematoma had resolved spontaneously after a few hours, and the patients regained clear consciousness next day in Case 1 within a few days in Case 2 without surgical treatment. The mechanism of spontaneous resolution of ASDH was thought to involve pulsatile flow of cerebrospinal fluid (CSF) through the tear in the arachnoid membrane, resulting in redistribution and dispersal of the hematoma, and retrograde flow into the subarachnoid space. The characteristic feature of the CT findings, the low density band between the hematoma and the inner wall of the skull bone, probably shows this process. Spontaneous resolution of ASDH requires that the brain compensatory function maintains the normal outflow of CSF, and controls the intracranial pressure by CSF buffering, blood outflow via the venous system, and brain elasticity. The low density band may be a useful finding to distinguish cases with good and bad prognosis.     

Delayed onset of hand tremor related to cerebellar hemorrhage

Spontaneous hematomas are rare and can present with acute or chronic symptoms. Our patient presented with deep vein thrombosis of the lower extremity associated with a spontaneous pelvic hematoma. This lesion was radiologically and clinically indistinguishable from a soft-tissue neoplasm. The case of a spontaneous pelvic neoplasm in an otherwise healthy young man is presented and the literature reviewed regarding issues of differential diagnosis and clinical management.     

Reproducibility of bone height measurements made on serial radiographs

A seventy-three-year-old woman had symptoms of aortic dissection. Initial computed tomographic (CT) scan and angiography showed an extensive intramural hematoma (IMH) of the aortic segment from the ascending aorta to the bulk of the descending aorta without intimal tear or false lumen. Two weeks later the patient's symptoms recurred. A repeat CT demonstrated a classic type A aortic dissection with a false lumen and an intimal defect. The patient underwent a successful hemiarch repair with use of selective cerebral perfusion under profound hypothermic circulatory arrest. This case suggests extensive IMH as an important underlying pathology of the aortic dissection.     

Ruptured thymic cysts with mediastinal hemorrhage and hemothorax--a case report and reviews of the literature

We report a rare case with rupture of thymic cyst including mediastinal hemorrhage and hemothorax. A 68-year-old man was referred to our hospital for the treatment of right hemothorax. A chest roentgenogram following thoracentesis demonstrated a widened mediastinum. Chest computed tomograms revealed a large anterior mediastinal mass extending to the right pleural cavity and bilateral pleural effusion. Digital subtraction angiography showed a normal aorta and great vessels. A median stenotomy revealed a large encysted hematoma along the thymic cyst extending from the right anterior mediastinum into the right pleural cavity and ending with rupture. Pathological examination demonstrated that the largest thymic cyst was continued to the hematoma resulting from partial destruction of its epithelial lining. To our knowledge, only five cases including our's with ruptured thymic tumors were reported, and this is the first report of ruptured thymic cyst resulting in mediastinal hemorrhage and hemothorax.     

Spontaneous rupture of the oesophagus (author's transl)

During the last 4 years three so-called spontaneous perforations of the oesophagus were treated, twice by surgical intervention 12 anys after the rupture. Two patients survived. The classical history of retching or vomiting and retrosternal splitting pain is indicative, wht medium, amidotrizoate sodium (Gastrografin), from the oesophagus. Prognosis depends decisively on the time of operation after the rupture. Direct suture of the rupture with plastic coverage of the defect by sewing on of the gastric fundus or by plication of the fundus have proved valuable.     

Comparative efficacy of chloroquine plus chlorpheniramine and halofantrine in acute uncomplicated falciparum malaria in Nigerian children

A 47-year-old woman on long-term hemodialysis due to a chronic isolated abdominal aortic dissection was admitted to our department with severe abdominal pain. She had not suffered any hematemesis or melena. An emergency laparotomy revealed an abdominal aortic aneurysm with a diameter of 60mm, densely adhered to the ileum. An aortoenteric fistula manifesting as intramural rupture into the ileum was found after infrarenal abdominal aortic and bilateral common iliac cross-clamping. The fistula on the ileac side was nontransmural, but that on the aortic side communicated with the pseudolumen of the abdominal aorta, and contained mural thrombus. The infrarenal abdominal aorta and bilateral common iliac arteries were replaced with a collagen-sealed woven Dacron bifurcated graft. Histological examination of the ileum in this portion showed intramural bleeding and xanthomatous granulation with foam cell infiltration in the thickened subserosa. While it is difficult to diagnose nonpenetrating aortoenteric fistula preoperatively, such a fistula must be considered in a patient with severe abdominal pain, for whom previous abdominal aortic surgery has been performed or when an abdominal aneurysm is observed. To our knowledge, no other case of an aortoenteric fistula presenting as an intramural rupture into the ileum in an isolated abdominal aortic dissection has ever been reported.     

Spontaneous intramural hematoma of the esophagus. Apropos of a case

The authors report a case of spontaneous intramural haematoma of the oesophagus. This is a rare observation which usually occurs in association with oesophageal hyperpressure and sometimes with impaired haemostasis. The strategy for diagnosis is based on tomodensitography and also endosonography and magnetic resonance imagery.     

Spontaneous rectus sheath hematoma during pregnancy mimicking abruptio placenta

Sudden disruption of a deep epigastric vessel may result in an abdominal wall hematoma, which, depending upon its location and size, can produce symptoms and clinical findings compatible with a variety of acute intra-abdominal conditions. The literature has noted a predominance of pregnant patients among those affected with this malady. Such hematomas are infrequently encountered and early accurate diagnosis could prevent surgical intervention. Unfortunately, the clinical manifestations of rectus muscle hematoma are sometimes so dramatic that laparotomy is performed under the belief that intra-abdominal pathology is present. We present a case of a suspected abruptio placenta misdiagnosed by clinical and ultrasound examination that was subsequently discovered to be a rectus sheath hematoma at the time of surgery.     

Ultrastructural alterations in pigs with naturally occurring hypertrophic cardiomyopathy

Naturally occurring hypertrophic cardiomyopathy (HCM) in pigs in generally characterized by unexplained cardiac hypertrophy with abnormal histological features (Liu et al., 1994; Dai et al., 1995). The histological alterations in HCM-affected hearts are characteristic, and can be used to diagnose the disease (Dai et al., 1995). Briefly, these are marked disorientation of cardiac muscle cells, thickening of the intramural coronary arterial wall with a narrowing of the lumen, endocardial and myocardial fibrosis. A high incidence of HCM in a population of pigs strongly suggests a hereditary basis and the Pig Research Institute, Taiwan has, therefore, endeavoured to produce a specific strain of HCM pigs. The purpose of the present study was to determine the ultrastructural changes occurring in pigs with naturally occurring HCM.     

Intramural hematoma of the thoracic aorta: precursor sign to thoracic aortic dissection

A 60-year-old man was admitted at his local hospital for persistent chest pain and suspicion of aortic dissection. No evidence of aortic dissection or intimal disruption was noted by means of computed tomography and transesophageal echocardiography. A localized intramural hematoma of the ascending aorta was found. He was first treated medically and remained asymptomatic for 8 days when he developed a new episode of chest pain. He was found to have an acute type A dissection by computed tomography. He underwent graft replacement of the ascending aorta and had an uneventful post-operative course. This case report describes the development of true aortic dissection in a patient who previously had a localized intramural hematoma.     

Spontaneous abdominal hematoma in dermatomyositis

Dermatomyositis is associated with a number of systemic manifestations and diseases. We present 2 patients with dermatomyositis, aged 11 and 50 years, who developed acute abdominal pain, both a result of spontaneous hemorrhage. Hemorrhage was detectable by physical examination in one and on computed tomography scan of the abdomen in the other. Both patients made a full recovery with supportive treatment. While the cause of the hemorrhage was uncertain, in 1 patient massive calcinosis of the abdominal wall was present, and trauma may have been the precipitant. Spontaneous abdominal hematoma is a cause of acute abdominal pain in patients with dermatomyositis, and surgery may be avoided if the diagnosis is recognized.     

Resection of the manubrium

Direct exposure of the superior mediastinum is essential when resecting subglottic tumours of the larynx, neoplasms of the cervical trachea or cervical oesophagus. This facilitates low resection of the trachea and clearance of the paratracheal nodes. This may best be carried out by removal of most of the manubrium sterni and both sternoclavicular joints and this operation has been performed in 22 patients with minimal morbidity or long term disability.     

Macroscopic and pathohistological investigation of endarterial plaque after intraoperative balloon dilatation of the carotid artery during carotid endarterectomy

Twelve patients associated with stenosis of the extracranial carotid artery underwent intraluminal balloon dilatation during carotid endarterectomy (CEA). There were 11 men and 1 woman, and age ranged from 56 to 73 years old. The rate of stenosis, shown by angiography, in each patient was from 60 to 85% in width. After securing carotid blood flow by a T-shaped shunt tube, a balloon catheter was inserted from the exposed common carotid artery into the internal carotid artery. The balloon was inflated three or four times with 2.5-3.5 atm. for 30-40 seconds. Immediately after balloon dilatation, endoscopic investigation was performed (Wolf; hard type endoscope, 2.7 mm diameter). Then CEA was performed using the usual procedure. The removed endarterial plaque was investigated pathohistologically. In macroscopic and endoscopic findings, there were 6 patients with mural thrombosis, 4 patients with laceration of the intima, and one patient with outflow of atheroma from the intima. Only 3 patients had increase in lumen after balloon dilatation. In pathohistological appearance, all patients had a moderate degree of fibrosis, calcification, and atheroma in the cross section of the plaque. Ten patients had intramural hemorrhage. Three typical patients were revealed by the use of angiographical, ultrasonographical, endoscopic, and pathohistological presentation. Case 10 showed laceration of the intima by balloon dilatation, and had moderate increase in lumen size macroscopically and endoscopically. There were moderate cases of fibrosis, calcification, atheroma, and intramural hemorrhage. Dilatation of the lumen seemed to be accomplished by a decrease in thickness of the atheroma and intramural hemorrhage. Case 8 demonstrated an increase in lumen size, but also laceration of the intima and outflow of atheroma from the arterial wall. There were much atheroma and large intramural hemorrhage in the intima, which might become a source of enbolism. Case 7 revealed no laceration of the intima and no increase in lumen size. Preoperative ultrasonography showed hyperechoic finding and postoperative pathohistological findings showed severe fibrosis and calcification, which were thought to have interrupted balloon dilatation. There have been small numbers of reports about pathohistological presentation after percutaneous transluminal angioplasty (PTA), because it is very difficult to take a specimen after PTA. In this report we were able to present the necessity of preoperative investigations by angiography, ultrasonography, and 3D-CT.     

Naloxone potentiates the anxiolytic but not the amnestic action of chlordiazepoxide in C57BL/6 mice

There are some cases in which conservatively treated acute subdural hematoma (ASDH) does not disappear naturally and progresses to chronic subdural hematoma-like hematoma (CSDH) (hematoma with capsule formation). The objective of the present study was to identify factors which can be used to predict this unfavorable course during the early phase after the onset of the lesion. During the past 13 years, 10 of 96 cases of mild, conservatively treated ASDH (excluding suckling infants) progressed to CSDH, and those 10 patients showed the following background characteristics. There were 7 males and 3 females, and the mean age was 63.1 years. Five of the patients had a history of alcohol consumption, and one case each had a history of cerebral infarction, cerebral hemorrhage and a VP shunt. Acute-phase computerized tomography (CT) at the time of ASDH showed, in all 10 cases, an expansive-type lesion with a low density area in the hematoma, with expansion of the hematoma into the interhemispheric fissure. The hematoma was observed to undergo transient natural shrinkage in the acute phase. The period for progression to CSDH was indicated to be a mean of 20.5 days after the onset of the lesion, and its cure was possible with trepanation. In consideration of these results, it was surmised that ASDH patients with the following characteristics have a high risk of progression to CSDH during the subacute and chronic phases when conservative therapy is administered during the acute phase of the lesion: (1) old age, (2) a history indicative of brain atrophy, (3) an expansive-type image of ASDH on acute-phase CT, and (4) acute-phase CT indicative of cerebrospinal fluid mixing in the hematoma.