Clinical efficacy of the amplified Mycobacterium tuberculosis direct test for the diagnosis of pulmonary tuberculosis

The amplified Mycobacterium tuberculosis direct test (MTD) is a rapid diagnostic test based on a nucleic acid amplification technique, which can be used directly on processed clinical specimens. We evaluated the clinical utility of the MTD for diagnosing pulmonary tuberculosis by comparing the sensitivity and specificity of the test with acid-fast smear, mycobacterial culture, and clinical evaluation. The study included 844 respiratory tract specimens from 421 patients, which were submitted to the microbiology laboratory of our urban teaching hospital over a 6-mo period. Compared with culture, MTD had a sensitivity of 93.6% and specificity of 97.8%. MTD was more sensitive in detecting pulmonary tuberculosis in patients with previously undiagnosed disease (74.7%) than in those with established disease receiving chemotherapy (29.2%), and in smear-positive (95.5%) than in smear-negative (70.0%) disease. There were two false positive MTD results in patients with nontuberculous mycobacteria, for a specificity in this population of 97.3%. We conclude that MTD, when used in conjunction with routine smear and culture, is a useful rapid diagnostic test for suspected pulmonary tuberculosis.     

Retroperitoneal schwannoma: report of a clinical case and review of the literature

The retroperitoneal localization of a schwannoma or neurilemmoma undoubtedly represents an unusual occurrence (0.5-0.7% of all sites); this data, together with the absence of a typical clinical picture and the lack of peculiar instrumental signs, make a preoperative diagnosis of this lesion really hard to ascertain. In this paper, on the basis of a case report successfully treated, the Authors review the literature analysing current diagnostic and therapeutic work up, mainly emphasizing controversies in determining a proper preoperative diagnosis among all retroperitoneal tumours.     

Chylothorax: case report and review of literature

C57BL/6J-Min/+ mice, which are heterozygous for a non-sense mutation in the Apc gene, provide a model for both familial adenomatous polyposis and sporadic colon cancers. In our study, gut tumors and small intestine lymphoid nodules were counted in Min mice fed fiber-enriched diets for 6 weeks. Neither starch-free wheat bran nor resistant starch modified the number of tumors. However, short-chain fructo-oligosaccharides dramatically reduced the incidence of colon tumors and concomitantly developed gut-associated lymphoid tissue. Our experiment shows that short-chain fructo-oligosaccharides counteract advanced stages of colon carcinogenesis, possibly via stimulation of antitumoral immunity by modulation of the colonic ecosystem.     

Mesenteric panniculitis: case report and literature review

Mesenteric panniculitis is an extremely rare inflammatory condition of the adipose tissue of unknown etiology in which the mesentery is replaced with fibrosis. Knowledge of this rare syndrome should prevent any unwarranted aggressive therapy and help to use the clinical, radiological, and surgical sources to obtain the diagnosis. This paper is a review of symptomatology, pathology, treatment, and outcome of this disorder. A case report is described that presented with obstruction of the sigmoid colon.     

Kenny syndrome: case report and literature review

A 34-month-old girl presented with a clinical picture of Kenny syndrome. The clinical manisfestations included growth retardation, persistent open anterior fontanelle, prominent forehead, mid-facial dysplasia, hypocalcemic tetany and characteristic radiologic skeletal abnormalities. Serum levels of immunoreactive parathyroid hormone (PTH) remained inappropriately low during hypocalcemic episodes in the neonatal period; indicating that hypocalcemia was a consequence of the hypoparathyroid state. This is the first reported case of Kenny syndrome in Taiwan. The literature on the pathogenesis, etiology and genetic basis of this disorder is reviewed in this paper.     

Wegener''s granulomatosis: case report and literature review

The columnar-cell variant of papillary carcinoma is a rare tumor of the thyroid, associated with aggressive behavior, early visceral metastasis, and a rapidly fatal course. In this report we present the fine-needle aspiration cytologic findings of two examples of this variant of papillary carcinoma with cytohistologic correlation. In the smears, clusters, monolayered sheets, and scattered papillary fronds of tumor cells were present. The tumor cells were columnar and exhibited overlapping and stratification of the nuclei. In the first case the tumoral cells showed round nuclei with finely granular chromatin pattern, small nucleoli and vacuolated-appearing cytoplasm. The malignant cells in the second case presented oval to elongated nuclei with stippled chromatin, inconspicuous nucleoli and indistinct cytoplasmic borders. It is important to distinguish this tumor from the common thyroid papillary carcinoma because of its much more aggressive behavior.     

Gestational psittacosis: case report and literature review

OBJECTIVE: To evaluate the safety, efficacy, and biocompatibility of icodextrin- and glucose-containing dialysis fluid during continuous cycling peritoneal dialysis (CCPD), patients were treated for 2 years with either icodextrin- or glucose-containing dialysis fluid for their daytime dwell (14-15 hours). Prior to entry into the study, all patients used a standard glucose solution (Dianeal 1.36%, 2.27%, or 3.86%, Baxter, Utrecht, The Netherlands). DESIGN: Open, randomized, prospective, two-center study. SETTING: University hospital and teaching hospital. PATIENTS: Both established and patients new to CCPD were included. A life expectancy of more than 2 years, a stable clinical condition, and written informed consent were necessary before entry. Patients aged under 18, those with peritonitis in the previous month, and women of childbearing potential, unless taking adequate contraceptive precautions, were excluded. Thirty-eight patients entered the study, and 25 (13 glucose, 12 icodextrin) had a follow-up period of 12 months or longer in December 1996. MAIN OUTCOME MEASURES: Serum icodextrin metabolites: one to five glucose units (G1-G5), a high molecular weight fraction (G > 10), and total carbohydrate level, as well as a biochemical profile were determined every 3 months in combination with all other study variables. RESULTS: In icodextrin-treated patients, serum disaccharide (maltose) concentrations increased from 0.05 +/- 0.01 (mean +/- SEM) at baseline, to an average concentration in the follow-up visits of 1.14 +/- 0.13 mg/mL (p < 0.001). All icodextrin metabolites increased significantly from baseline, as illustrated by the serum total carbohydrate minus glucose levels: from 0.42 +/- 0.05 mg/mL to an average concentration in the follow-up visits of 5.04 +/- 0.49 mg/mL (p < 0.001). At the same time, serum sodium levels decreased from 138.1 +/- 0.7 mmol/L to an average concentration in the follow-up visits of 135.4 +/- 0.8 mmol/L (p < 0.05). However, after 12 months the serum sodium concentration increased nonsignificantly (NS) from baseline to 136.6 +/- 0.9 mmol/L, after an initial decrease. Serum osmolality increased significantly from baseline in icodextrin users at 9 and 12 months, but did not differ significantly from glucose users in any visit. In icodextrin-treated patients, the calculated serum osmolal gap increased significantly from 4.1 +/- 1.4 mOsm/kg to an average of 11.8 +/- 1.7 mOsm/kg (p < 0.01). The sum of the serum icodextrin metabolites in millimoles/liter equaled the increase in osmolal gap. Body weight increased in icodextrin users (71.9 +/- 2.8 kg to 77.8 +/- 3.0 kg; NS). Clinical adverse effects did not accompany these findings. Residual renal function remained stable during follow-up. CONCLUSIONS: The serum icodextrin metabolite levels in the present study increased markedly and were the same as those found previously in continuous ambulatory peritoneal dialysis patients treated with icodextrin, despite the longer dwell time for CCPD patients (14-16 hr versus 8-12 hr). The initial decrease in serum sodium concentration was followed by an increase to a concentration not different from baseline at 12 months. The pathophysiology of this finding is speculated. Calculated osmolal gap in icodextrin patients increased significantly (p < 0.01) at every follow-up visit, and could be explained by the serum icodextrin metabolite increase. We encountered no clinical side effects of the observed levels of icodextrin metabolites.     

Epidural abscess: case report and review of the literature

Spinal epidural abscess is an uncommon site of infection, resulting in back pain, fever, weakness and loss of sensibility. These signs should suggest the diagnosis, and quick confirmation by MRI should be performed. Immediate surgical decompression and antibiotherapy is necessary, because this is the base of a possible successful functional recovery. Empiric therapy consisting of high dose of penicillinase-resistant antibiotics is advised because most often an epidural abscess is caused by Staphylococcus aureus. However, because other bacteria can be involved, an aminoglycoside or a cephalosporin should be added to the empiric treatment, until the results of the cultures are known. When diagnosis and therapy are delayed, permanent paralysis and death are common.     

Intramedullary teratoma: case report and review of the literature

OBJECTIVES: Clinical and genetic characterisation of families in the west of Scotland with familial hemiplegic migraine. METHODS: Families with familial hemiplegic migraine were identified via probands attending the regional paediatric neurology and child development centre. All available family members were assessed clinically and genetic linkage studies for the known familial hemiplegic migraine gene locus on chromosome 19 were carried out on three families. RESULTS: Seven unrelated kindreds with familial hemiplegic migraine were identified. Clinical information was obtained on 138 family members, 27 of whom fulfilled the International Headache Society criteria for familial hemiplegic migraine. Whereas the severity, duration, frequency, and temporal progression of acute hemiplegic migrainous attacks showed pronounced variability within and between families, and even in the same individual over time, no true clinical heterogeneity of the condition was apparent. Genetic linkage analysis gave results consistent with linkage to the familial hemiplegic migraine gene locus on chromosome 19p in one family. In the other two families, evidence against linkage was obtained. There was no significant clinical difference between these three families. CONCLUSIONS: This study provides characterisation of the clinical features of familial hemiplegic migraine in a British population. Significant variability was found in the frequency and character of migraine attacks within and between families, and no true clinical heterogeneity was identified. On the other hand, further evidence for genetic heterogeneity of the condition was found.     

Antley-Bixler syndrome: case report and review of the literature

Five patients requiring dialysis for acute pulmonary edema and uremia from severe renal artery occlusive disease underwent surgical revascularization. Three patients with oliguria had excellent outcomes and remain dialysis-independent as long as twenty-four months following operation (mean serum creatinine 2.0 mg/dl). The two patients who were anuric both had technically successful operations but remained dialysis-dependent. Diagnostic evaluation of the azotemic patient suspected to have renal arterial occlusive disease should include a history and physical examination, urinalysis, renal ultrasound, and duplex scan of the renal arteries. In appropriate patients, arteriography should then be considered if other diagnoses appear unlikely. This algorithm may help identify those patients who might benefit from renal revascularization. It appears that oliguria rather than anuria and the angiographic demonstration of a patent distal vessel and nephrogram suggest a better functional outcome after revascularization. Unfortunately, the response to surgery cannot be reliably predicted and patient selection remains a challenge, but retrieval of renal function can be achieved in some cases even if patients are already being hemodialyzed.     

Malignant prolactinoma: case report and review of the literature

BACKGROUND: Malignant prolactinomas are rare events. To date, only 14 patients with metastases in- or outside the central nervous system have been reported. CASE DESCRIPTION: We present a patient who developed a metastasis to the cauda equina, which is the first case documented with MRI. A giant prolactinoma in this 51-year-old man was partially removed by a transcranial approach. After radiotherapy and treatment with bromocriptine, the patient had a remission for 3 years. Thereafter, a sacral intraspinal tumor was diagnosed. Because of increasing prolactin levels not responding to bromocriptine and a radiologically suspected intrasellar tumor, we operated transsphenoidally first and found only fibrous tissue. We performed a sacral laminectomy and almost totally removed an intradural tumor. Histopathology and immunohistochemistry confirmed the diagnosis of a prolactinoma metastasis. The patient received radiotherapy and bromocriptine and has no evidence of recurrent tumor or metastases after a follow-up of 38 months, thus being the second reported patient with long-term remission of the disease. DISCUSSION: We review the literature on this topic and try to establish common features of the course of this rare malignant disease and the efficacy of therapy in the cases reported hitherto.     

Gangrenous cystitis: case report and review of the literature

A case of gangrenous cystitis in a 67-year-old woman is reported. Associated etiological factors include invasive recurrent carcinoma of the cervix, radiotherapy and atherosclerosis. Primary infection was not a feature. The patient was treated with antibiotics, bladder drainage and total cystectomy with complete recovery. The etiology and management of this unusual condition are discussed.     

Serotonin syndrome: case report and review of the literature

We present the case of a 35-year-old woman who developed serotonin syndrome after receiving a single dose of the cyclic antidepressant imipramine (Tofranil). She was already being treated for depression with paroxetine (Paxil), a selective serotonin reuptake inhibitor. Two hours after receiving imipramine, the patient developed tachycardia, delirium, bizarre movements, and myoclonus, all classic findings of serotonin syndrome. Her antidepressants were discontinued and she was treated with intravenous fluids, sedation, and a short course of cyproheptadine, a serotonin receptor antagonist. All symptoms resolved completely within 24 hours. In this case report, we review the drug interactions that can precipitate serotonin syndrome, and give recommendations for the diagnosis and treatment of this potentially fatal disorder.     

Intrasellar meningioma: case report and review of the literature

BACKGROUND: Intrasellar meningioma is a rare clinical entity, and surgical resection may be difficult when it is hypervascularized. METHODS: A case of subdiaphragmatic hypervascular intrasellar meningioma with attachment to the dura of the anterior wall of the sella turcica is described. Literature review of 18 cases with operatively confirmed intrasellar meningioma discloses unexpected intraoperative bleeding and relatively low resectability of the tumor are also described. RESULTS: We used preoperative endovascular embolization of feeding arteries, and resected a hypervascular intrasellar meningioma by a combined transsphenoidal-transcranial approach safely and without massive bleeding. CONCLUSIONS: Preoperative endovascular embolization of feeding arteries and combined transsphenoidal-transcranial approach are useful for the surgical resection of hypervascular intrasellar meningiomas.     

Wegener's granulomatosis: case report and review of the literature

The clinical manifestations of Wegener's granulomatosis (WG) may be varied and easily overlooked. Awareness of distinguishing signs and symptoms allows early recognition and appropriate management. The body of literature dealing with the various facets of this disorder has grown in the past few years. Development of new diagnostic markers and successful therapies has rekindled interest in this disease. To assure early diagnosis and optimal prognosis the physician must maintain a high index of suspicion for WG. Although introduction of immunosuppressive therapy has dramatically improved the course of this disorder, treatment-related morbidity is often profound.     

Leiomyosarcoma of the auricle: case report and literature review

We present a case of a patient with achalasia who developed symptomatic gastroparesis after botulinum toxin injection therapy. Symptoms responded to prokinetics. Pathophysiology of gastric motility disturbances in patients with achalasia is discussed.     

Primary fetal hydrothorax: A literature review and proposed antenatal clinical strategy

OBJECTIVE: To investigate the prognostic factors for primitive fetal hydrothorax (PFHT) and propose a clinical strategy based on systematic literature review. METHODS: We reviewed 64 articles describing 204 cases of PFHT. For each case we focused on 11 criteria. We investigated prognostic factors in the 89 cases where no in utero treatment was undertaken. We also studied the impact of different in utero treatments on the evolution of PFHT. RESULTS: We have found 4 factors correlated with the course of PFHT: the presence of hydrops, gestational age at time of birth, the unilateral or bilateral nature of the effusion, and the occurrence of spontaneous resolution. With multivariate analysis, only hydrops remained determinant as a prognostic factor. CONCLUSIONS: Studies such as ours, reviewing case reports or series, are subject to the biases of literature underreporting of therapeutic failures or nonintervention. However (with the best available data) we propose a clinical approach to PFHT discovered in utero.