Münchhausen syndrome in otorhinolaryngology

A 66-year-old man was treated by graft replacement for a thoracic aortic aneurysm. Chylothorax occurred on postoperative day 2. In spite of cessation of oral intake and IVH management, chest tube drainage did not decrease, the patient became malnourished. A chest X-ray and CT scan revealed the massive pleural effusion. Reoperation assisted with a thoracoscopy was carried out for chylothorax on postoperative day 27. Because we were unable to find the thoracic duct and the leakage point, the fibrin glue and absorbent mesh was applied to parietal and mediastinal pleura. Four days after reoperation, the chest tube was removed. This method is useful for this type of a chylothorax and lymphorrhea.     

CT reconstruction of an unusual chronic posttraumatic aneurysm of the thoracic aorta

Chronic traumatic aneurysm of the thoracic aorta is an unusual occurrence. Previously, arteriography was performed on all patients seen in our institution with this entity to allow confirmation of the diagnosis and anatomic delineation for operation. A case of chronic traumatic aneurysm of the distal descending aorta discovered on a routine chest roentgenogram and evaluated with chest computed tomographic scanning with three-dimensional reconstruction is presented. It is our belief that not all thoracic aneurysms require arteriography, and improved methods of computed tomographic scanning allow adequate diagnosis and anatomic delineation with decreased morbidity and cost.     

Subclavian mycotic aneurysm presenting as mediastinal abscess

A 60-year-old man was admitted to a hospital for evaluation of intermittent fever, dysphagia, hoarseness, and general chest discomfort. Great vessel mycotic aneurysm was suspected when antibiotic trials failed and chest X-ray showed paraaortic mass with pleural effusion mimicking mediastinitis. Although the correct diagnosis of mycotic aneurysm of innominate artery was made thereafter and vigorous treatment was initiated immediately, this patient succumbed to overwhelming sepsis, probably due to a 2-week delay in another hospital. This case is reported to remind readers of the possibility of this unusual location of mycotic aneurysm. A high index of suspicion should be maintained to make an earlier diagnosis and obtain better prognosis. Computed tomography and 3D magnetic resonance angiography also significantly improve the diagnosis when mycotic aneurysm location is unusual and presentation is equivocal.     

Hemangioma of the rib: a rare diagnosis

Hemangioma of the rib is an exceedingly rare tumor with less than ten cases reported in the literature. Wide local resection without preoperative needle biopsy is the preferred treatment. The case of a 76-year-old man with a right chest mass that was discovered on chest X-ray obtained for asbestos exposure is reported to demonstrate the presentation, diagnosis, and treatment of this distinctly uncommon tumor.     

Behcet's disease with pulmonary vessel involvement

The case of systemic vasculitis with involvement of pulmonary vessels was described. 36-years white woman with cerebral vasculitis and recurrent uveitis 5 and 3 years ago, now was admitted to hospital because of the mouth ulceration and lesions in the chest x-ray. After lung cancer exclusion, aneurysm of pulmonary artery branch was confirmed by dynamic tomocomputer examination All mentioned above manifestations were diagnosed as Behcet disease. Patient was treated with prednison, cyclophosphamide and cyclosporine. Clinical effect was observed after corticotherapy, but no improvement in chest X-ray picture was obtained also after immunosuppression. Patient died because of pulmonary haemorrhage 7 years after first symptoms of vasculitis and 2 years after first massive haemorrhage.     

A case of type A dissecting aneurysm who are complicated by paraplegia at the 4th day after emergent operation

The 62-year-old man was admitted to our hospital with chief complaints of chest and back pain. He was diagnosed type A acute dissecting aneurysm by chest computed tomography, and underwent urgent operation, replacement of the ascending aorta and resuspension of the aortic valve. He was recovered without any neurologic complications. However, he was complicated by paraplegia at the 4th postoperative day. We suspect that is due to early thrombotic occlusion of the false lumen where the anterior spinal arteries branch by the operation.     

Large right atrial aneurysm: rare cause of recurrent pulmonary embolism]

Case report on a 72 year old female patient presenting with collapse and progressive dyspnea. X-ray of the chest showed a marked enlargement of the heart extending to the right. Echocardiography revealed an impressive displacement of the heart chambers to the left caused by a large aneurysm (11 x 5 x 5 cm) located anteriorly and medially from the right heart communicating with the right atrium. Pronounced compression of the basal part of the right ventricle was present. Within the aneurysmatic cavity several highly mobile thrombi and extensive spontaneous echo contrast were demonstrated. On magnetic resonance imaging and right heart angiocardiography the aneurysm was visualized as well. Coronary angiography revealed a marked curved displacement of the right coronary artery to the left side. Perfusion lung scanning suggested bilateral segmental pulmonary embolism proven by digital substraction angiography. With long-term oral anticoagulation the patient remained symptom-free during follow-up of now more than four years.     

Neurotoxicity evoked by N-methyl-D-aspartate in the organotypic static slice cultures of rat cerebral cortices: effect of GABA(A) receptor activation

BACKGROUND: von Recklinghausen's neurofibromatosis is a hereditary disease that may affect any organ or system of the body primarily or secondarily, including the vascular system. Among the rare cerebrovascular abnormalities, the most common is stenosis or occlusion of the cerebral artery. Intracranial aneurysms are uncommon. CASE DESCRIPTION: A case of an intracranial cerebral aneurysm associated with von Recklinghausen's neurofibromatosis is reported. A 55-year-old woman presented with a history of intermittent headache for 2 months and right oculomotor nerve palsy for 1 month. Widespread cutaneous neurofibromas and angiomas were found over her trunk and limbs with prominent cafe-au-lait spots. X-ray showed that her left lung was compressed by a large mass in the left chest with rib defects and lateral spinal curvature. Right internal carotid angiography revealed a saccular aneurysm between C1 and C2. Craniotomy to clip the aneurysm could not be performed because the mass in her chest made intubation for general anaesthesia almost impossible. CONCLUSION: The clinical features of this case are discussed together with a review of 15 similar cases in the literature. There are different theories about this disorder. We agree that the malformations are derived not only from ectodermal, but also from mesodermal pathology. In terms of our case, we consider the progression of this disease to be slow.     

Human papillomavirus-specific serologic response in vulvar neoplasia

We describe a case of positional dyspnea due to compression of the tracheobronchial tree by an extensive thoracic aneurysm. In a 77-year-old woman with long-standing systemic hypertension, intermittent anterior chest pain gradually developed over several years. She had no history of asthma or thoracic trauma. She was admitted to our hospital because of sudden, severe shortness of breath. The breathlessness was markedly worse when she lay on her back or on her right side. On physical examination, she was in acute respiratory distress with cyanosis, severe hypertension (180/110 mmHg), tachycardia, and inspiratory stridor. A chest X-ray film showed loss of volume and nearly complete radiopacity of the left hemithorax. Arterial blood gas analysis revealed an arterial oxygen partial pressure of 54.8 mmHg, a carbon dioxide partial pressure of 39.8 mmHg, and an oxygen saturation of 84.5 percent on room air. Computed tomographic examination of the thorax showed dilation of the aortic arch and descending aorta, and marked compression of the trachea and the left main bronchus. Examination with a fiberoptic bronchoscope revealed extrinsic compression of the trachea just proximal to the carina. The patient's symptoms stabilized. However, she did not undergo surgery because of her age and because of the size of the aneurysm. She died due to rupture of the aneurysm.     

Idiopathic pulmonary artery aneurysm

The purpose of this article is to report two cases of pulmonary artery (PA) aneurysm in patients who had no evidence of left-to-right intracardiac shunting or other known relevant etiologies. One patient, a 52-year-old woman, was admitted to the hospital due to exertional palpitation, while the other patient, a 73-year-old woman, came to the hospital because of fever and cough. In both women, chest radiographic findings of a hugely dilated PA were confirmed by computed tomography (CT). In both cases, a ventriculogram showed fusiform dilatation of the main PA without evidence of pulmonary valve stenosis. The results of chest radiography, two-dimensional echocardiography, CT of the thorax, including pulmonary angiography in one patient, were compatible with the diagnosis of PA aneurysm. No specific drug regimen was administered nor was any surgical intervention performed in either patient. Both patients were asymptomatic as of the last telephone follow-up. Idiopathic PA aneurysm is a benign condition with better survival than PA aneurysms of other etiologies, because of the absence of left-to-right intracardiac shunting and significant pulmonary hypertension. PA aneurysm must be considered as part of the differential diagnosis in an enlarged pulmonary trunk seen on chest radiogram, and two-dimensional echocardiography should be performed initially.     

Rupture of the aortic arch due to bacterial aortitis--a case report of a patient undergoing successful surgical therapy

A 59-year-old man came to our hospital because of hoarseness and chest pain. On initial examination, a chest roentgenogram showed no abnormality. Three weeks later, while the patient was waiting to undergo a computed tomographic (CT) scan, shock suddenly developed. A chest roentgenogram revealed an extremely wide mediastinal shadow. A CT scan revealed rupture of the aortic arch near the base of the left subclavian artery, although there was no aneurysm. An emergency operation was performed. The ruptured aortic arch was replaced with an artificial graft during cardiopulmonary bypass with selective cerebral perfusion. A diagnosis of infectious aortitis was not made until a pathologist discovered colonies of gram-positive cocci in the resected specimen of the aortic arch. Postoperatively, antibiotics were administered for only four days. The patient is well about two years after the operation. Infectious aortitis had a very low prevalence and rarely involves the thoracic aorta. However, we should be aware of that it may cause aortic rupture even in the absence of aneurysmal dilatation.     

Bronchopulmonary dysplasia: correlation of radiographic and clinical findings

BACKGROUND AND PURPOSE: Abnormalities of the chest wall have been described in bronchopulmonary dysplasia (BPD). Clinical, radiographic and pulmonary function variables were evaluated in 1-year-old children ventilated because of neonatal lung disease in order to quantify these thoracic changes and to evaluate the lung disease. METHODS: The pulmonary status of 51 infants with neonatal lung disease requiring artificial ventilation was reevaluated clinically and radiographically at the age of 1 year. Twenty-two of these infants had developed BPD. Thoracic depth and width were measured clinically and on chest X-ray. The Toce score evaluated the presence of cardiomegaly, hyperinflation, emphysema and interstitial lung disease. Lung function was measured after sedation using previously reported methods. In BPD patients, Toce score and lung function were determined and compared at 1 month and at 1 year of age. RESULTS: In BPD patients, chest depth was significantly smaller when measured clinically as well as on chest radiograph (P < 0.05; Mann-Whitney U-test). There was a statistically significant correlation between chest depth measured clinically and on chest X-ray. Toce score was significantly higher in BPD patients (P < 0.05). In BPD patients intersitial abnormalities and decreased lung compliance were more frequent at the age of 1 month than at the age of 1 year. At the age of 1 year, hyperinflation was more frequent and at that time increased airway resistance was still noted. Thus the type of X-ray abnormality reflects the type of lung function disturbance. CONCLUSION: The flatness of the chest is most likely a consequence of the long-standing lung function abnormalities.     

Right atrial thrombosis with concomitant thrombus attached to a central venous catheter. Clinical case

A clinical case of a patient in whom a right atrial thrombosis was casually discovered by transthoracic echocardiography is described. The hypothesis that also the central venous catheter (CVC) could be seat of thrombosis was done, and was confirmed by chest X-ray with dye injection in the CVC. A thrombolytic therapy with plasminogen tissular activator and with heparin infusion was started. After 24 hours from the beginning of therapy instrumental control were performed (transesophageal echocardiography ECOTEE, chest X-ray with dye injection in CVC), showing the completely dissolution of the thrombus. It is observed that, when in a patient with CVC high degree of thrombogenic factors (age over 60 years, presence of cardiac arrhythmias with ventricular hypokinesis, polyglobulia due to chronic obstructive pulmonary disease, CVC, low levels of antithrombin III) are present, the usual prophylactic measures (subcutaneous heparin, hydrophylic catheter) couldn't be sufficient to avoid superior caval vein thrombosis. The conclusion is drawn that these patient should be studied with ECOTEE and eco Doppler. Chest tomography and superior caval venography are also useful its early diagnosis of superior caval thrombosis.     

Large-scale screening for factor V Leiden mutation in a north-eastern German population

A 37-year-old man was referred with thoracic pain after a deceleration trauma. He also had a cerebral contusion and a wrist fracture. There were no sings of hypovolemic shock. Computerized tomography (CT) of the chest and transoesophageal echocardiography (TEE) demonstrated a type B aortic dissection originating just distal to the left subclavian artery. There was a patent false lumen without rupture or distal ischaemia. Conservative treatment was given. A paralytic ileus developed and abdominal complaints persisted for several months. Angiography showed normal patency of mesenteric vessels. On follow-up, 3 years after the accident a slight aortic dilation was found on CT thorax without development of a post-dissection aneurysm. Blunt thoracic injury to the aorta usually gives rise to aortic rupture in the region of the isthmus, which can be complete or partial. In the latter case a false aneurysm may develop. An intimal tear after blunt trauma leading to type B aortic dissection rarely occurs. General principles regarding treatment of type B dissection also apply to this particular condition.     

Echocardiographic oscillating flap in aortic root dissecting aneurysm

A patient had a history, physical findings, and chest x-ray film suggesting type I aortic dissection. This diagnosis could not be confirmed angiographically. Echocardiographic studies predicted both the presence of dissection and the anatomic findings at surgery. A regularly oscillating echo corresponding to the intimal flap was found in the false lumen. This is suggested as a new echocardiographic finding in dissecting aneurysm.     

Pleural malignant mesothelioma with osseous cartilaginous and rhabdomyogenic differentiation

A 63-year-old man, who was formerly an asbestos factory worker who had been followed due to asbestosis, and was admitted to our hospital with left chest pain and dyspnea on exertion. A chest X-ray and chest computed tomogram (CT) on admission revealed a large tumor in the left lung field. Percutaneous needle biopsy determined that the tumor was a sarcoma. No clinical response was obtained by systemic chemotherapy. The autopsy revealed diffuse malignant mesothelioma of sarcomatous type with osseous, cartilaginous and rhabdomyogenic differentiation. Osseous and cartilaginous differentiation in a malignant mesothelioma is rare, and the presence of a malignant rhabdomyogenic component is the first to be described in the Japanese literature.     

Substance P and related peptides in porcine cortex: whole tissue and nuclear localization

We experienced a case of a 60 year-old man with cardiac sympathetic denervation after aortic graft replacement of ascending aorta for a dissecting aneurysm (Debakey type II). Fourteen years after pheochromocytomectomy (paraganglioma), the patient developed a severe chest pain, and admitted to the hospital for the diagnosis of dissecting aneurysm. CT scan with contrast enhancement revealed thrombosed dissecting aneurysm in the region of ascending aorta to aortic arch. Graft replacement was undergone on the same day. 123I-MIBG imaging 20 days after the operation showed severely attenuated myocardial uptake (heart to mediastinum ratio 1.19), although the MIBG imaging before the operation showed normal myocardial uptake (heart to mediastinum ratio 1.55). Heart rate variability analysis in Holter ECG showed that the power of the low frequency (LF), that of the high frequency (HF) and L/H ratio were severely decreased. MIBG and heart rate variability analysis indicated that cardiac sympathetic and parasympathetic nerve were denervated. This is the first report of cardiac sympathetic denervation after aortic vascular surgery. Clinical significance of cardiac sympathetic denervation after aortic vascular surgery is uncertain, and further investigation will be required.     

Case report of miliary TB, with mediastinal TB involving the aorta, trachea and esophagus with death due to hemorrhage from perforation of aorta into the esophagus during treatment

A 32-year-old male was diagnosed as having miliary tuberculosis in May 1990. In spite of antituberculosis chemotherapy, he developed tuberculous meningitis and intracranial tuberculoma in September 1990. Miliary shadows on chest X-ray disappeared in December 1990. However, he developed left atelectasis, and bronchofiberscopy revealed soft tumor in the left main bronchus in January 1991. He suddenly vomited large amounts of blood and expired in February 1991. At autopsy, tuberculous lymphadenitis and cavitation were noted in the mediastinum, through which the left main bronchus, esophagus and descending aorta communicated. The patient died of massive bleeding which resulted from the rupture of tuberculous aortitis into the esophagus. This is a very rare case of tuberculous aortic aneurysm rupturing into both the bronchus and esophagus.     

Evaluation of routine postoperative chest X-rays in the management of the cardiac surgical patient

OBJECTIVES: To evaluate the role of routine chest X-rays in the management of patients post cardiac surgery. METHODS: 340 adult patients undergoing cardiac surgery were studied in three consecutive groups (A, B, C) of 100 patients each. Forty patients were excluded due to the intensive care stay greater than 36 h (n = 35), or early mortality within 36 h (n = 5). Routine chest X-rays were performed according to different protocols in Groups A and B. In group C there were no routine chest X-rays during the entire postoperative period [corrected]. In all three groups chest X-rays were performed where clinically indicated. Group A had three routine chest X-rays post-operation. Group B had one routine chest X-ray on day 4 post-operation. Group C had chest X-rays only when indicated. The X-rays were evaluated in terms of their assistance value and the resultant number of interventions. RESULTS: The three groups were similar preoperatively for age, sex, preoperative left ventricular function, presence of chronic obstructive airway disease and type of operation performed. The total number of chest X-rays in groups A, B and C were 304, 133 and 36, respectively. The number of chest X-rays leading to interventions were five, four and four in groups A, B and C, respectively. Chest X-rays that helped in management were 36, 28, and 28, respectively, in the same groups. There was no mortality or morbidity attributable to non-performance of routine chest X-ray. CONCLUSIONS: Routine chest X-rays post-cardiac surgery are of very little value and patients are adequately managed by performing chest X-rays only when clinically indicated. There was no increased mortality or morbidity attributed to lack of routine chest X-rays in any of these groups. We recommend performing chest X-rays only when clinically indicated in satisfactorily recovering adult cardiac surgical patients.     

Three-year follow-up of a posttraumatic right coronary aneurysm

Posttraumatic saccular aneurysm of the right coronary artery is a rare complication of nonpenetrating chest trauma. We observed a posttraumatic coronary aneurysm for 3 years and noted that the aneurysm has changed in shape, with partial obliteration of the aneurysm sac, and that its clinical course was uneventful with conservative treatment. Surgical removal of aneurysms has been advocated in the literature; however, conservative medical treatment and a wait-and-see policy can be considered as a treatment modality for posttraumatic coronary aneurysm.