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.     

Leg bone pain syndrome due to cyclosporine in a renal transplant patient

A leg bone pain syndrome of unclear etiology has been recently described in renal transplant patients receiving cyclosporine A. Herein we report a 54-year-old woman treated with cyclosporine A (CsA), corticosteroids and azathioprine who developed two months after renal transplantation severe symmetric pain with periarticular soft tissue swelling in the knees and metatarsophalangeal joints. Scintigraphy showed periarticular radionuclide activity. Clinical onset was associated with both the high dosage and with the plasma levels of CsA. Symptoms improved when the dosage of CsA was reduced and the plasma levels declined to less than 150 ng/ml.     

Osteomyelitis due to Mycobacterium haemophilum in a patient with AIDS

A case of osteomyelitis resulting from infection with Mycobacterium haemophilum in a patient with the Acquired Immunodeficiency Syndrome (AIDS) and Hodgkin's disease is described. The clinical features and response to therapy are examined and compared to previous reported cases. Mycobacterium haemophilum infection in immunocompromised patients usually results in cutaneous lesions but osteomyelitis may be the presenting feature. Tissue samples should be obtained early for microbiological examination and treatment should consist of surgical debridement and appropriate antimicrobial therapy.     

Failure to control the airway in a patient with Hunter''s syndrome

We report a 36-year-old man with proximal dominant muscle weakness, thymic tumor, diabetes mellitus, hypokalemia, and increased levels of plasma ACTH and cortisol. The diagnosis of carcinoid tumor was made on the basis of pathological findings in the biopsied specimen of the thymic tumor. The proximal muscle weakness was considered to be due to steroid myopathy resulting from the overproduction of cortisol from the adrenal glands induced by the ectopic ACTH secreted by the thymic carcinoid tumor. Although thymoma in frequently associated with myasthenia gravis, we should also consider carcinoid tumors in patients with a thymic tumor presenting with a proximal muscle weakness.     

Solitary pulmonary nodule due to Leishmania in a patient with AIDS

BACKGROUND: Nitric oxide is an endothelium-derived vasodilator. Cardiopulmonary bypass may induce transient pulmonary endothelial dysfunction with decreased nitric oxide release that contributes to postoperative pulmonary hypertension and lung injury. Exhaled nitric oxide levels may reflect, in part, endogenous production from the pulmonary vascular endothelium. METHODS: We measured exhaled nitric oxide levels before and 30 minutes after cardiopulmonary bypass in 30 children with acyanotic congenital heart disease and left-to-right intracardiac shunts undergoing repair. RESULTS: Exhaled nitric oxide levels decreased by 27.6%+/-5.6% from 7+/-0.8 to 4.4+/-0.5 ppb (p < 0.05) 30 minutes after cardiopulmonary bypass despite a reduction in hemoglobin concentration. CONCLUSIONS: The decrease in exhaled nitric oxide levels suggests reduced nitric oxide synthesis as a result of pulmonary vascular endothelial or lung epithelial injury. This may explain the efficacy of inhaled nitric oxide in the treatment of postoperative pulmonary hypertension. Furthermore, strategies aimed at minimizing endothelial dysfunction and augmenting nitric oxide production during cardiopulmonary bypass may decrease the incidence of postoperative pulmonary hypertension. Exhaled nitric oxide levels may be useful to monitor both cardiopulmonary bypass-induced endothelial injury and the effect of strategies aimed at minimizing such injury.     

Variation in response to dexamethasone of a patient with Cushing's syndrome

A patient with Cushing's syndrome due to a nonresectable chromophobe adenoma underwent external irradiation of the hypothalamic-pituitary area. The signs of Cushing's syndrome ameliorated subsequently but recurred eventually, necessitating bilateral adrenalectomy 30 months after initial presentation. Response to dexamethasone suppression testing on four occasions varied greatly. These results may reflect alterations in sensitivity of the tumour or the hypothalamic-pituitary axis to feedback inhibition by glucocorticoids.     

Breast abscess with lethal septicemia due to Pseudomonas aeruginosa in a patient with AIDS

OBJECTIVE: The incidence of Pseudomonas aeruginosa in HIV-infected patients has increased over the last years. We describe a case of pseudomonal breast abscess complicated with fatal septicemia in an AIDS patient. CASE REPORT: A 21-year-old woman was admitted for fever, chills, nausea, vomiting and pain in the breast. She had a swelling in the right breast of 3 days duration. HIV infection had been confirmed 6 years earlier. CD4 count was 2/mm3. Surgical drainage produced a blue-green purulent discharge which grew Pseudomonas aeruginosa on culture. Despite cloxacilin, then ceftazidime and amikacin, initial improvement was followed 2 weeks later by nodular pulmonary infiltration with cavitation. P. aeruginosa was recovered from sputum and blood cultures, but stepwise resistance developed and the patient died 3 months after admission. DISCUSSION: Breast abscesses are infrequent in nonlactating women. P. aeruginosa is rarely involved, even in HIV patients. Due to the risk of resistance, prompt administration of appropriate antibiotics is required.     

Hemoperitoneum due to splenic rupture in a CAPD patient with chronic myelogenous leukemia

BACKGROUND: Due to the expression of urease, Helicobacter pylori is able to establish itself in the human stomach under acidic conditions. A novel host defence mechanism was recently proposed, suggesting that the formation of salivary nitrite in symbiosis with facultative anaerobic bacteria in the oropharynx, is aimed at enhancing the antimicrobial activity of gastric juice. AIMS: To investigate whether the addition of nitrite in physiological concentrations influences the resistance of H pylori to acid. METHODS: H pylori cultured from fresh gastric Biopsy specimens was exposed for 30 minutes to normal saline and to HCl/KCl buffer (0.2M) at pH 2 with urea (5 mM) added. The influence of potassium nitrite (50-1000 mumol/l) on bacterial survival was determined. RESULTS: Addition of nitrite (1 mM) to acidic solutions (pH 2) resulted in complete kill of H pylori within 30 minutes exposure time whereas acid alone allowed the organism to survive (p < 0.001). The antimicrobial effect of nitrite at pH 2 against H pylori was dose dependent and complete kill of organisms occurred at concentrations > or = 500 mumol/l. CONCLUSION: Acidified nitrite has anti-bacterial activity against H pylori. This should prompt further research into the effect of salivary nitrite on the survival of H pylori in the human stomach.     

Azathioprine-induced myelosuppression due to thiopurine methyltransferase deficiency in a patient with autoimmune hepatitis

Azathioprine can cause severe myelosuppression. The inherited activity of the enzyme thiopurine methyltransferase has been recently recognised as a major factor in the susceptibility to myelosuppression. Thiopurine methyltransferase deficiency occurs at a frequency of one in 300 and is associated with profound myelosuppression after a short course of azathioprine. Very low thiopurine methyltransferase activity represents the TPMTL/TPMTL genotype, and can be detected before therapy with azathioprine is started. We describe the first documented case of azathioprine-induced severe myelosuppression due to thiopurine methyltransferase deficiency in autoimmune liver disease. The azathioprine dose was low (1 mg/kg) and pancytopenia occurred after 56 days therapy. It would be advisable to measure thiopurine methyltransferase activity before patients with autoimmune hepatitis are exposed to azathioprine.     

Epinephrine-induced ventricular premature complexes due to early afterdepolarizations and effects of verapamil and propranolol in a patient with congenital long QT syndrome

We report a patient with congenital long QT syndrome in whom early afterdepolarizations (EADs) were demonstrated on monophasic action potential (MAP) recordings in the left ventricular mid-base inferior wall. Epinephrine infusion at 5 micrograms/min increased the amplitude of the EADs and the late component of the T(U) wave. Epinephrine also induced ventricular premature complexes (VPCs) with right bundle branch block morphology and left-axis deviation that occurred from the peak of the EADs. Verapamil injection (5 mg) during continuous epinephrine infusion abolished all VPCs with a slight reduction in the amplitude of the EADs. Propranolol injection (5 mg) in addition to verapamil further reduced the amplitude of the EADs and the late component of the T(U) wave. These findings suggest that the epinephrine-induced VPCs were closely related to triggered rhythm arising from the EADs, and that both verapamil and propranolol were effective for the suppression of VPCs and EADs.