Laparoscopic closure of esophageal perforation following pneumatic dilatation for achalasia. Report of two cases

Esophageal perforation following pneumatic dilation of the esophagus is normally recognized shortly after the event. Two patients with esophageal perforation were repaired utilizing a transabdominal laparoscopic technique with suture closure of the perforation, contralateral Heller myotomy, and Toupet posterior partial fundoplication. Patients recovered excellently, were started on liquids within 3 days of surgery, and were discharged shortly thereafter. Details of the procedure are presented. This minimally invasive approach is well tolerated and appropriate in selected patients.     

Salmonella colitis. Report of two cases and literature review (author''s transl)

Uterine activity was measured for a 30-minute preinjection period and a 30-minute postinjection period for six drugs commonly used in labor. Uterine activity was quantitated by measuring the area below the uterine pressure curve with an on-line technic utilizing a voltage control oscillator. Uterine activity readings were obtained every 2.5 minutes and reported in uterine activity units (UAU). Unmedicated labor demonstrated a relatively static increase in UAU per unit of time in labor. On comparing total UAU before and after injection, only magnesium sulfate was noted to cause a decrease in total UAU. Utilizing 10-minute summations of UAU, the pre- and postinjection periods were compared to the calculated expected UAU for the 30 minutes following the preinjection period (assuming no drug had been used). For each of the other drugs, the positive slope of the calculated expected UAU shifted to a negative slope of the actual observed UAU following drug administration.     

Breast hamartoma with invasive ductal carcinoma. Report of two cases and review of the literature

Two cases of well-defined masses also containing clinical and radiographical abnormalities suggestive of malignancy, subsequently found to be invasive ductal carcinomas in breast hamartomas are described. The patients were 53 and 78 years old. Both presented with a generally soft palpable breast lump, containing a firm area which in one case invaded and ulcerated the skin. Mammography demonstrated two typical hamartomas: one containing a spiculated opacity, the other irregular opacities with suspicious calcifications, suggesting the presence of carcinomas in these benign lesions. The cut surface of these well-circumscribed masses measured 5 cm and 7 cm. The microscopic appearance was characteristic of breast hamartoma (sharp circumscribed "pseudocapsule" surrounding breast fibrocystic changes with variable amounts of adipose tissue) with the firm area in each case corresponding to invasive ductal carcinoma. In one case the invasive ductal carcinoma was confined to the hamartoma, whereas in the other malignant tumor, cells extended beyond the surrounding breast tissue and infiltrated the skin. These findings raise the question of secondary involvement of a hamartoma by invasive carcinoma. Breast hamartomas are probably underrecognized lesions. In our view, these findings do not justify a more aggressive approach towards the management of breast hamartomas.     

Association between inflammatory bowel disease and sarcoidosis. Report of two cases and review of the literature

BACKGROUND: Common etiopathogenic factors may explain the association of systemic sarcoidosis with inflammatory bowel disease. METHODS: We report two cases of such an association: one of sarcoidosis that developed 2 years after proctocolectomy for ulcerative colitis and one of sarcoidosis and Crohn's colitis. Factors like increased cellular immunity or circulating immunocomplexes or autoantibodies may have a role. Exogenous agents or familiarity may also be involved. CONCLUSIONS: It is postulated that the association between sarcoidosis and inflammatory bowel disease (both ulcerative colitis and Crohn's disease) does not occur by chance alone and that the two conditions may share some genetic or immunologic alterations. The two diseases, however, follow an independent clinical course.     

Calcification of the basal ganglia and Fahr disease. Report of two clinical cases and review of the literature

gamma-Aminobutyric acidA (GABAA) receptors are linked to ion channels which mediate many aspects of neural inhibition. Although the effects of phosphorylation on GABAA receptor function have been widely studied, the actual role of phosphorylation in the regulation of these receptors still remains controversial. In recent reports, we have described the effects of phosphorylating/dephosphorylating enzymes on the regulation of GABAA receptors in a rat cortical slice preparation (Shaw et al., Mol. Neuropharmacol., 2 (1992) 297-302; Shaw and Lanius, Dev. Brain Res., 70 (1992) 153-161; Pasqualotto et al., Neuroreport, 4 (1993) 447-450) and predicted that ionic co-factors are involved in mediating the regulation of GABAA receptors by kinases and phosphatases. In the present report, the effects of chloride, sodium, potassium, and calcium were examined alone and in the presence of cAMP-dependent protein kinase (protein kinase A) or alkaline phosphatase. The results showed a decrease in [3H]SR 95531 (GABAA receptor antagonist) binding after incubation with chloride alone; this decrease was further enhanced in the presence of protein kinase A. Both effects could be blocked by a protein kinase A inhibitor. Conversely, an increase in [3H]SR 95531 binding was observed after incubation with sodium alone; this increase was further enhanced in the presence of alkaline phosphatase. In both cases these increases in binding could be blocked by sodium orthovanadate, a phosphatase inhibitor. Potassium was ineffective under all conditions; calcium showed enzyme-independent effects at low concentrations only. These results suggest the existence of a novel chloride-dependent protein kinase which may have significant sequence homology to protein kinase A, and a novel sodium-dependent phosphatase.(ABSTRACT TRUNCATED AT 250 WORDS)     

Traumatic rupture of duodenal diverticulum. Report of a case and literature review

Duodenal diverticulum is a common anatomic abnormality. Its inflammatory perforation is a rare complication, with less than 100 cases reported in the available literature. Traumatic perforation is exceedingly rare (only 3 cases reported). In this report one more case of traumatic perforation is presented, and the literature is reviewed focusing on the pathogenic, diagnostic and therapeutic aspects of this severe disease.     

Amyloid goiter. Report of two cases

Congenital pedicle abnormalities are rare. Unilateral aplastic and hypoplastic lumbar pedicles have been reported, but these were usually discovered incidentally and did not need surgical treatment. We present a case of absence of both pedicles and the neural arch of L2, with associated kyphoscoliosis with neurological involvement, that needed a two-stage corrective surgery. An L1-L4 fusion was achieved with relief of the symptoms.     

Vascular injury during lumbar disc surgery. Report of two cases; a review of the literature

Iatrogenic vascular injuries are unusual complications of lumbar disc surgery. The incidence of such injuries is very low but probably underestimated because clinical manifestations may be extremely variable depending on the extension of trauma. Diagnosis is suspected when early signs of retroperitoneal haemorrhage appear, but may often be delayed for weeks or years due to formation of a pseudoaneurysm or an arteriovenous fistula which may be of gradual onset and produce initially only a few symptoms. Prompt diagnosis and aggressive treatment can improve the current mortality rate of more than 50%. Two cases are described that illustrate the full spectrum of acute and chronic manifestations of such injuries. One case of acute haemorrhage due to arterial trauma was immediately detected and the other case with arteriovenous fistula was recognized several years post-operatively.     

Non-alcoholic steatohepatitis. Report of five cases and review of the literature

We describe three men and two women, aged 18-50, with an occasional finding of increased aspartate and alanine aminotransferase and gamma-glutamyl transpeptidase levels in the absence of any drug treatment and past or current alcohol abuse. Two patients were overweight (body mass index 29 and 32, respectively) and physical examination was normal in all but one case. Tests for hepatitis A, B and C, Epstein-Barr virus, cytomegalovirus, toxoplasma and autoimmune hepatitis were negative and metabolic diseases (Wilson's disease, haemochromatosis, alpha-l-antitrypsin deficiency) were excluded by specific tests. Ultrasound liver scan revealed massive steatosis in all patients. Liver histology showed diffuse steatosis and parenchymal inflammation in all cases, with concomitant fibrosis and Mallory bodies in three of them. Findings were consistent with non-alcoholic steatohepatitis, a rare condition with potential progression to cirrhosis in a minority of cases. This disease, for which no treatment is currently available, must be considered in all subjects with elevated aminotransferases, in the absence of known causes of liver damage.     

Nocardia bacteremia. Report of 4 cases and review of the literature

Laparoscopic colon surgery is gaining acceptance for benign conditions, but cannot yet be considered an established procedure for malignancy. The main reported benefit of the technique is the reduction in length of hospital stay. Other potential benefits such as cosmesis, improvement in quality of life, physiologic and immunologic advantages, as well as reduced complication rates have not been clearly demonstrated. Concerns about laparoscopic colon surgery for cancer including the possibility of inadequate resection, tumor staging, and altered tumor spread due to pneumoperitoneum have only been partially addressed by retrospective and experimental studies and require a prospective randomized trial for definitive resolution. Details of the trial currently underway sponsored by the National Institutes of Health are described. Although innovations in clinical practice and increased familiarity account for the expanding popularity of laparoscopic colon surgery, results from this and similar worldwide trials are needed before this approach can be recommended for cancer.     

Post-traumatic flank hernias. Report of two cases

Dissecting aneurysms of the hepatic artery are extremely rare. We report herein the case of a 51-year-old man with massive hepatic metastases from rectal carcinoma, who was found incidentally to have a left hepatic artery aneurysm by a preoperative angiography. After replacing the left hepatic artery with a 2-cm segment of long saphenous vein, an extended right lobectomy with partial resection of the left lateral segment for multiple metastases was successfully performed. To prevent thrombus formation at the anastomosis, the Pringle maneuver was not used during dissection of the hepatic parenchyma. Histological examination of the resected specimen showed a dissecting aneurysm of the left hepatic artery, but there were no findings to suggest the etiology of this disease. The patient is currently alive 13 months after his operation without any evidence of further recurrence of the carcinoma. To the best our knowledge, 12 case reports of this anomaly have been documented, but only one of these describes a successful operation. The clinical features and etiology of the hepatic artery aneurysm that develops independent of other vascular diseases are discussed following this case report.     

Giant-cell arteritis of the uterus. Report of two cases

Two cases of giant-cell arteritis of uterus were found incidentally in association with uterine prolapse. One similar case has been reported in the literature. Microscopic examination disclosed fragmentation of the elastic laminae of the myometrial arteries with a giant-cell and mononuclear infiltrate. The relationship between giant-cell arteritis of the uterus, temporal arteritis, and polymyalgia rheumatica is discussed in view of similar cases reported in the literature.     

Inflammatory pseudotumor of the liver. Report of two cases

Hypersensitivity reactions from trimethoprim/sulfamethoxazole are likely caused by a reactive nitroso intermediate formed from sulfamethoxazole hydroxylamine. This pilot study tested whether cimetidine inhibits the urinary excretion of sulfamethoxazole hydroxylamine. Ten outpatients infected with human immunodeficiency virus (HIV) and currently receiving trimethoprim/sulfamethoxazole prophylaxis were randomly selected from 59 eligible patients. Five received cimetidine 800 mg twice daily for 1 week and five served as controls. Two spot urine samples one week apart were obtained after a trimethoprim/sulfamethoxazole dose for all patients. Patients taking cimetidine had a significant decrease in excretion of sulfamethoxazole hydroxylamine relative to total excreted drug in the two urine samples compared with control patients. Cimetidine likely caused this decrease in sulfamethoxazole hydroxylamine excretion through inhibition of CYP3A4. Because of potential differences between HIV-infected patients and healthy subjects in oxidative metabolism, future studies of inhibitors of sulfamethoxazole hydroxylamine formation should be conducted in the HIV population.     

Metastatic carcinoma to the mandible. Report of two cases

Two cases of rare metastases from malignant neoplasms to the posterior mandible in young adults are reported. Multiple imaging modalities were necessary to identify the many metastases and, in one case, the suspected primary site. Many of the radiographic images are presented for that case.     

Carotid sinus syndrome. Report of five cases and review of the literature

Five cases of carotid sinus syndrome are presented. The syndrome is defined by spontaneous attacks of dizziness and fainting which can be reproduced by graded pressure on one carotid sinus. Three forms of the clinical syndrome, cardioinhibitory, vasodepressor, and cerebral, are discussed. The hyperactive carotid sinsu reflex, in which there is ventricular asystole lasting at least 3 seconds or a decrease of more than 50 mm Hg in systolic and diastolic blood pressure, should be differentiated from this syndrome. Treatment modalities include reassurance, drugs, radiotherapy, cardiac pacemakers, and surgical approaches. Carotid sinus syndrome should be considered in the differential diagnosis of unexplained syncope, arteriovenous block, or inappropriate sinus bradycardia.     

Male genitourinary tuberculosis. Report of 12 cases and review of the literature

The incidence of genitourinary tuberculosis is constant in western countries, despite dramatically falling prevalence of pulmonary tuberculosis. The kidney is especially involved in urinary tuberculosis, and genital tuberculosis mostly affects the epididymis in males and the fallopian tubes in females. Twelve cases of male genitourinary tuberculosis are presented and the literature is briefly reviewed.     

Typical and atypical fractures of the odontoid process in young children. Report of two cases and a review of the literature

The most common injury to the odontoid process in children under the age of seven years is a fracture through the synchondrosis with or without anterior displacement of the odontoid process, but this is not the only type of fracture of the odontoid process in this age-group. Fractures above and below the synchondrosis and fractures with posterior displacement were described. Typical clinical features of these fractures are: (1) major and blunt trauma, (2) neck pain and resistance to active and passive head movements; and (3) no or only slight neurological deficits. Conservative treatment had excellent results in the majority of cases. Nevertheless, there are a few specific indications for surgery.