Kikuchi''s disease: a benign cause of pyrexia of unknown origin with lymphadenopathy

Varicose veins are a major and increasing burden on the health service with waiting lists growing in the majority of units. Most successive Governments have funded waiting list initiatives to deal with this problem. We report the results of a one year varicose vein waiting list initiative which dealt with a total of 1104 patients. A standard triage regime was established. Two hundred and eighty five patients were removed from the waiting list due to failure to attend, surgery performed elsewhere, medically unfit or no longer wishing to have surgery. There were 63 late cancellations and 23 operations were cancelled following admission due to unrelated medical complications. Planned operating lists worked well and complications were uncommon. Several important lessons were learnt during this initiative and recommendations are made with regard to the optimal method of dealing with the problem of varicose veins.     

Localising the cause of an undiagnosed fever

Prenatal diagnosis of tyrosinaemia type I can be achieved in cultured amniotic cells and in chorionic villus material by testing the activity of fumarylacetoacetate hydrolase and by DNA analysis, and in amniotic fluid by succinylacetone measurement. This specific metabolite can be measured either by gas chromatography-mass spectrometry or by delta-aminolevulinate dehydratase inhibition assay. In a series of 65 at-risk cases tested with the enzyme inhibition assay, one case out of the 18 with the disease had a normal level of succinylacetone. This case is presented.     

Bartonella clarridgeiae, a newly recognized zoonotic pathogen causing inoculation papules, fever, and lymphadenopathy (cat scratch disease)

Shortly after adopting a 6-week-old cat, a veterinarian was bitten on the left index finger. Within 3 weeks, he developed headache, fever, and left axillary lymphadenopathy. Initial blood cultures from the cat and veterinarian were sterile. Repeat cultures from the cat grew Bartonella-like organisms with lophotrichous flagella. Sera from the veterinarian were not reactive against Bartonella henselae, B. quintana, or B. elizabethae antigens but were seroreactive (reciprocal titer, 1,024) against the feline isolate. Sequential serum samples from the cat were reactive against antigens of B. henselae (titer, 1,024), B. quintana (titer, 128), and the feline isolate (titer, 2,048). Phenotypic and genotypic characterization of this and six additional feline isolates, including microscopic evaluation, biochemical analysis, 16S rRNA gene sequencing, DNA-DNA hybridization, and PCR-restriction fragment length polymorphism of the 16S gene, 16S-23S intergenic spacer region, and citrate synthase gene identified the isolates as B. clarridgeiae. This is the first report of cat scratch disease associated with B. clarridgeiae.     

Cat-scratch disease as a diagnostic problem of lymphadenopathy

Remarkable progress has been made in the treatment of osteosarcoma in the past two decades as a result of the development of effective adjuvant chemotherapy. However, the prognosis is poor in patients with early lung metastases. We review the lactate dehydrogenase release prognostic factor in the development of early lung metastases. This is a retrospective study. Eighteen patients with osteosarcoma were divided in two groups: Group A, patients with normal lactate dehydrogenase and Group B, patients with elevated lactate dehydrogenase. A univaried analysis was established. Ten patients (55%) had elevated levels of lactate dehydrogenase at diagnosis; nine of these patients developed lung metastases in the first twelve months. The difference in patients with normal levels of lactate dehydrogenase was significant (p: 0.02). The value of lactate dehydrogenase as an isolated single factor is limited. It is necessary to consider the tumoral volume, the patient's age and the histologic subtype in the prognosis of these patients, to predict the early development of pulmonary metastatic disease.     

Hemophagocytic syndrome: an underestimated cause of the syndrome of non-infectious fever?]

The effects of two ethanol doses (2 and 3 g/kg) on colonic temperature and levels of norepinephrine (NE) and uncoupling protein (UCP) mRNA in the interscapular brown adipose tissue (IBAT) were examined in rats exposed to 20 degrees C or 4 degrees C for 2 h. The controls received 0.9% NaCl solution. Ethanol produced a significant hypothermic effect versus saline at both temperature conditions. The dose at 3 g/kg reduced colonic temperature more in the cold than at room temperature (p < 0.01), whereas the ambient temperature did not affect the decrease in rats that received ethanol 2 g/kg. At room temperature ethanol did not significantly change the levels of NE or UCP mRNA, whereas after cold exposure (4 degrees C) NE levels in the ethanol-treated rats were significantly lower than in the controls (p < 0.001). Ethanol did not prevent a cold-induced increase in the UCP mRNA levels, although it reduced an increase. The magnitude of the reduction in increase was dependent on the dose, being significant at the dose of 3 g/kg (p < 0.05). The results show that the ethanol-induced drop in body temperature is not necessarily related to IBAT thermogenesis, as indicated by the levels of NE and UCP mRNA.     

Fat necrosis after trauma: a benign cause of palpable lumps in children

OBJECTIVE: Our objective is to describe the clinical entity and MR imaging appearance of fat necrosis after trauma, a benign cause of palpable soft-tissue lesions in children. A related objective is to establish MR imaging criteria that can be used reliably to differentiate this entity from other more serious causes of soft-tissue masses. CONCLUSION: Fat necrosis after trauma is a common cause of palpable lumps in children and has a benign course on long-term follow-up. When characteristic MR imaging findings are seen, conservative therapy is appropriate.     

Pancreaticoduodenectomy for benign disease

BACKGROUND: Surgeons are often called upon to perform pancreaticoduodenectomy for either suspicion of malignancy or symptoms due to benign disease. Perioperative morbidity and mortality following pancreaticoduodenectomy have decreased markedly over the last 2 decades. In response, many surgical centers advocate expanding the indications for pancreaticoduodenectomy to include lesions other than periampullary carcinoma. PATIENTS AND METHODS: A retrospective review of medical records for 108 patients undergoing pancreaticoduodenectomy for benign disease at The Johns Hopkins Medical Institutions over 100 months was completed. The subset of patients with a histopathologic diagnosis of chronic pancreatitis was identified and compared with patients undergoing pancreaticoduodenectomy for other benign conditions. RESULTS: The mortality rate for the present series was less than 1%. Perioperative complications, the majority of which were self-limited, occurred in 51% of patients. The most common complication was delayed gastric emptying. Pancreatic anastamotic leak occurred in 18% of patients and developed significantly more frequently in patients with benign diseases other than chronic pancreatitis (31% versus 8%, P < 0.05). CONCLUSION: Among appropriately selected patients, the rates of perioperative mortality and serious morbidity are low, and concerns about mortality and morbidity should not prevent an aggressive approach to surgical resection in patients with benign disease.     

Viral hemorrhagic fever--Ebola hemorrhagic fever, Marburg disease and Lassa fever

Viral hemorrhagic fevers include Ebola hemorrhagic fever, Marburg disease and Lassa fever. The etiologic agents of the diseases, Ebola virus, Marburg virus and Lassa virus, respectively, are categorized as viruses with biosafety level 4, because of their high mortality, high transmissibility and the lack of effective vaccines and therapeutic measures. Ebola and Marburg viruses are members of the Filoviridae family and easily distinguishable from viruses of other families by the characteristic morphology of the virion. The natural reservoir(s) of Ebola and Marburg viruses remain unknown. On the other hand, Lassa virus is a member of the Arenaviridae family and its natural reservoir is a kind of rodent of the Mastomys species, which are asymptomtically infected with the virus and continue to excrete the virus throughout their lifetime. Ebola, Marburg and Lassa viruses exist almost exclusively in Africa, with a minor fraction of Ebola virus being present in southeast Asia and possibly other tropical areas. However, these viruses can be imported to any part of the world industrialized countries. When attending patients with viral hemorrhagic fevers, "barrier nursing" using face shields (or goggles), masks, rubber gloves, etc., is recommended to avoid direct contact with blood and other body fluids of the patients.     

Hyperthyroidism: an underappreciated cause of diffuse bone disease

A case of a solitary pulmonary nodule due to Scedosporium apiospermum (Pseudallescheria boydii) is related. A review of the pertinent literature was done and, in addition, similar lesions caused by other opportunistic fungi are commented.     

Delayed diagnosis of acute rheumatic fever in adults: a forgotten cause of febrile polyarthritis

Acute rheumatic fever is a nonsuppurative sequela of upper respiratory tract infection with group A streptococci. We describe our recent experience with the diagnosis and management of 3 cases of acute rheumatic fever to highlight the delays that may arise in the diagnosis of this condition. In adults, febrile polyarthritis is the most common presentation of acute rheumatic fever. Increased awareness on the part of the physician is necessary to ensure both prompt and accurate diagnosis of this cause of febrile polyarthritis.     

Immunogenetics and the cause of autoimmune disease

Up until recently, neurology was dominated by localisatory thinking. Language and other so-called "centers" were considered to be centers of command controlling the respective functions. Today, there is general agreement that, instead, for every brain function numerous brain regions must act together. For the exploration of these manifold topographic cooperations produced by cognitive tasks, coherence of long-term EEG periods proved to be a proficient parameter for the representation of functionally essential connections. Because of the unequivocal meaningfulness of absolute coherence values, instead, only the signs of significant differences between coherence values during cognitive tasks and periods of EEG at rest before and after the task were considered for all possible electrode pairings and charted on schematic maps of the brain. In addition, the signs of significant changes of amplitude were entered. This procedure was performed for each of 6 frequency bands and for the 19 electrodes of the 10/20 system, thus yielding 171 possible plus or minus values for coherence and 19 for amplitude, respectively. The positions of the electrodes were marked by an MRI contrast medium. After the EEG, MRI examination was performed. The MRI data were segmented and the cortex was mapped onto a plane using a method similar to cartography. The exact electrode positions are registered from a similarly obtained map of the scalp and the electrode position pattern is used as basis for the coherence graphs. A detailed map of the cortex based on the segmented MRI data with the electrode positions marked is provided as a reference enabling allocation of the electrodes to the cortical structures. The usefulness of this procedure is demonstrated with a single subject by means of different cognitive tasks including musical thinking.     

Danazol for benign breast disease

Three groups of women with benign breast disease were treated with danazol for 3 to 6 months. Doses of 100 mg per day were given to 40 patients, 200 mg to 55, and 400 mg to 35. The age range of the patients was 20 to 48 years. The patients were rechecked at 6-month intervals over a period of 48 months. Most of them were seen four or more times after completion of therapy. Elimination of nodularity occurred in about two thirds; three experienced no improvement, and partial resolution was obtained in the remainder. Untoward effects were minimal or trivial. Danazol proved to be an excellent hormonal agent in the management of fibrocystic disease of the breast.     

Controversies in benign breast disease

Breast health means more than breast cancer. At least 50% of patients seen at a multidisciplinary breast center have benign conditions. Pain, nipple discharge, and a question of a mass are the usual chief complaints. This article provides contemporary information and management guidelines for the common breast conditions associated with these complaints.     

Epidemiologic characteristics of benign breast disease

To see if the risk factors associated with fibroadenoma and cystic disease were similar to those reported for breast cancer, a retrospective study of benign breast tumor in a general population was conducted in Washington County, Maryland. The study population consisted of 320 white women 20 to 49 years of age who had had benign breast disease and 320 age-matched controls. More cystic disease cases than controls had the following characteristics, which had been reported to have been associated with breast cancer in other studies: higher socioeconomic status; fewer pregnancies; and a lack of association with lactation patterns. Nulliparity, late natural menopause and a maternal history of breast cancer were also more common among cystic cases than controls, although these differences could have occurred by chance. Cystic disease cases and controls did not differ with respect to other factors associated with breast cancer, such as early age at menarche, late age at first pregnancy, and negative history of artificial menopause. In contrast to cystic breast disease, fibroadenoma was not associated with most of the risk factors of breast cancer.