Improvement in gonadotropin secretion after corticosteroid therapy in a case of POEMS syndrome

We report a case of POEMS syndrome with various endocrine dysfunctions. A 49-year-old man was admitted to our hospital for pretibial edema and general fatigue. He had weakness of the lower extremities, hepatomegaly, monoclonal protein (IgG-lambda type), impotence, pigmentation and hypertrichosis. Endocrinological examination revealed impaired glucose tolerance, primary hypothyroidism and hypogonadotropic hypogonadism. After three months of treatment with corticosteroids, he showed an improvement in gonadotropin secretion, but no considerable change in the secretion of the other hormones. To our knowledge, this is the first case that showed an improvement in gonadotropin secretion as a result of corticosteroid therapy in POEMS syndrome.     

Allergic bronchopulmonary aspergillosis in a patient with no symptoms of asthma until after bronchial lavage

An asymptomatic 56-year-old man was admitted to our hospital because of an abnormal shadow on a chest X-ray film. Allergic bronchopulmonary aspergillosis was diagnosed on the basis of five findings: eosinophilia, immediate skin reactivity to Aspergillus antigen, the presence of precipitating antibodies against Aspergillus antigen, a high concentration of IgE in serum, and central bronchiectasis. He had no symptoms of asthma at the time of diagnosis, but did a few days after he underwent bronchial lavage. We speculate that the asthma attack was related to the bronchial Lavage as follows: First, drainage of mucus plugs by bronchial lavage may have exposed the bronchial epithelium, which had already been sensitized, to aspergillus antigens. Second, the scattered antigen may have dose-dependently stimulated the bronchi. Third, the infection may have increased bronchial responsiveness to the antigen. Symptoms of bronchial asthma are not necessary for the diagnosis of allergic bronchopulmonary aspergillosis.     

Comparative recovery from three nondepolarizing neuromuscular blockers in a patient before and after chronic anticonvulsant therapy: a case report

We describe a 51-year-old patient undergoing a second neurosurgical procedure after being prescribed anticonvulsant therapy. The patient had significant changes in the duration of action of identical doses of nondepolarizing muscle relaxants and we were able to compare the duration of action of neuromuscular blockers before and after the chronic administration of anticonvulsant therapy. A brief review of the possible mechanisms of action of the acceleration of the patient's recovery profile is also presented.     

Systemic vasculitis in a patient with small-cell neuroendocrine bronchial cancer

A 75-yr-old male hospitalized for vascular purpura with joint pain had a medical history of polymyalgia rheumatica. A generalized oedematous syndrome occurred and the patient also presented with haemoptysis and complained of transient paraesthesia of the hands and feet. Renal biopsy showed lesions of focal segmental proliferative glomerulonephritis associated with a few cellular crescents. Lung biopsy showed small-cell neuroendocrine carcinoma. After the first course of chemotherapy signs of vasculitis disappeared. Small-cell neuroendocrine carcinomas, which represent 25% of all lung cancers, have numerous paraneoplastic (especially neurological) extrapulmonary manifestations. Disseminated vasculitis has never been described with this type of cancer, whereas nonsmall-cell carcinomas are associated essentially with cutaneous vasculitis or purpura rheumatica. In the case reported here, anticancer chemotherapy allowed vasculitic manifestations to be treated.     

Pharmacokinetics of carboplatin in a patient with cervical cancer with ureteric obstruction before, during, and after hemodialysis

The pharmacokinetics of total and free (ultrafilterable) platinum were investigated in a patient with cervical cancer with ureteric obstruction who, at the time of carboplatin administration, appeared to have a mild renal impairment (i.e., creatinine clearance 1 mL/s), but developed an acute renal failure shortly thereafter, which required hemodialysis. The decline in the concentration of total or free Pt in plasma as function of time correlated well (P < 0.0098) with that of serum creatinine concentration. The elimination half-lives (t1/2) of total and free Pt in this patient were eight- and nine-fold longer than those observed earlier for patients with normal renal function, and the total body clearance was 12.4% and 18.4%, respectively. Although t1/2 of Pt during dialysis was two to three times (total Pt) and eight times (free Pt) shorter than those observed before and after dialysis, three sessions of hemodialysis removed only 5.6% of total Pt and 9.3% of free Pt. Because the pre- and post-dialysis t1/2 values were similar, hemodialysis apparently had no impact on the intrinsic elimination of Pt in this patient.     

Thyroid hormones in diabetic ketoacidosis before and after therapy

Fifteen IDDM patients were evaluated for thyroid hormone abnormalities before and after control of diabetes mellitus/ketoacidosis. Blood sugar mean +/- SEM mg/dl on admission was 430 +/- 20.3 and after therapy fasting and post prandial blood sugar values were 120 +/- 14.5 and 150 +/- 20.2 respectively. GHb mean +/- SEM % on admission was 15.2 +/- 0.36. Serum T3 mean +/- SEM ng/dl of 0.36 +/- 0.04 was in hypothyroid range and rT3 mean +/- SEM ng/ml 0.40 +/- 0.6 was significantly raised (P < 0.001) before therapy. After metabolic control both T3 and rT3 became normal. T4 concentration mean +/- SEM meg/dl of 5.5 +/- 0.7 was well within normal range before therapy and rose to mean +/- SEM mcg/dl 8.8 +/- 0.5 after therapy (P < 0.01). TSH response to TRH was blunted in uncontrolled state. It is concluded that peripheral changes in T3, T4 and rT3 (low T3, high rT3 and low or normal T4) occurred in uncontrolled diabetic state during ketoacidosis. TSH response to TRH was blunted due to suppression of hypothalamic pituitary thyroid axis which takes more than a week for complete recovery.     

Acute tumor lysis syndrome due to mono-therapy with a corticosteroid in a patient with non-Hodgkin lymphoma

A 20-year-old man was hospitalised because he nearly suffocated when lying on his back. After bronchoscopy which revealed severe external compression of the airways, suddenly respiratory insufficiency developed. Because a malignant lymphoma was suspected chemotherapy was started, using monotherapy with prednisolone as the risk of acute tumour lysis syndrome (ATLS) is high with polychemotherapy of bulky tumours. Nevertheless ATLS developed, for which haemodialysis had to be applied. The tumour, a T-cell lymphoblastic non-Hodgkin lymphoma with high grade malignancy, was treated successfully with cyclophosphamide, doxorubicin, vincristine en prednisone. ATLS is characterized by hyperkalaemia, hyperuricaemia, hyperphosphataemia, hypocalcaemia, lactate acidosis and acute renal failure. It can occur in the course of aggressive cytoreductive therapy in rapidly growing lymphoproliferative malignancies with large tumour size, due to massive tumour cel lysis. Corticosteroid monotherapy is a very rare cause of ATLS.     

Coronary artery spasm during anesthetic induction in a patient with bronchial asthma

A 68-year-old man was scheduled for subtotal gastrectomy. He had bronchial asthma, but had no history of ischemic heart disease and showed normal ECG. He stopped taking antiasthmatic drugs after the admission. His operation had been postponed for 10 days for an attack of bronchial asthma. The asthmatic attack was suppressed by infusing aminophilline. Before the operation, general anesthesia combined with epidural anesthesia (mepivacaine; 60 mg) was induced. At the time of the insertion of a stomach tube, bradycardia (48 bpm) and hypotension (48/30 mmHg) with an elevation of ST-segment in ECG were observed. We administrated 10 mg of isosorbide dinitrate followed by continuous intravenous injection (0.5 mg.kg-1.min-1) of dopamine (6 mg.kg-1.min-1). After 20 minutes, increases of both blood pressure (82/49 mmHg) and heart rate (89 bpm) were achieved and ST-segment in ECG was reversed. The operation was postponed again. Although the patient had refused to take coronary angiogram, the episode was explained by coronary artery spasm. Pathogenesis of the spasm was likely to be 1) elevation of endogenous cathecolamine due to asthma, 2) inhibition of cardiac sympathetic system by epidural anesthesia and 3) stimulation of vagal system by the insertion of a stomach tube.