Spontaneous bacterial peritonitis in the cirrhotic patient

Spontaneous bacterial peritonitis in cirrhotic patients is a severe complication which frequently decompensate the underlying disease and which is associated, even in our days, to a 50% mortality. Hence, the relevance of an adequate exploration, as weil as an early treatment. The acknowledge of several variants, as are the concepts of bacterascites and neutrocytic ascites with negative culture required the use of updated diagnostic criteria. In addition to the already known clinical and bacteriological characteristics of the ascitic fluid infection, we have also intended to review new aspects of this entity referred to in the literature published in the past years, as are the followings; study of possible predictive factors of this complication and factors which have an influence on its mortality, in order to be able to implement the most adequate preventive its mortality, in order to be able to implement the most adequate preventive its mortality, in order to be able to implement the most adequate preventive and curative therapeutics.     

Spontaneous peritonitis in a cirrhotic patient with a cat: Pasteurella multocida infection of the ascitic fluid

Spontaneous peritonitis due to Pasteurella multocida is exceptional. As far as we know only 11 other cases have been reported. We describe a 45 year old patient who presented with a spontaneous Pasteurella multocida peritonitis as the first complication of a previously undiagnosed cirrhosis. The patient used to play with his pet cat, not recalling having ever sustained any injury. Cultures of the cat's mouth grew the same strain of Pasteurella multocida than was found in the patient's ascitic fluid. The clinical findings of the previous cases, most of which were also related to non traumatic exposure to domestic animals, are here described. Pasteurella multocida in one potential agent in the cirrhotic patient presenting with spontaneous peritonitis, especially if in close contact with animals, cats being the most often carriers.     

Spontaneous coronary dissection. Apropos of 2 cases

Spontaneous coronary dissection is a rare and still poorly understood pathological disease entity; the authors report two cases in which the diagnosis was reached in the context of incipient necrosis in young patients. A review of the literature reveals the main characteristics of this problem: the clinical aspect is generally that of acute coronary failure with the constitution of an infarction. The subjects are young with no risk factor but some cases of combination with a disease affecting the elastic tissue have been described. Female gender and the post-partum phase are promoting factors. Diagnosis was long established by means of autopsy but can now be based on coronary angiography. Histologically, the lesion is a hematoma which dissects the arterial wall between the internal two thirds and external third of the media. The main etiological hypothesis is acquired or congenital fragility of the media, which promotes the formation of a dissecting hematoma, however the triggering phenomenon remains poorly understood.     

Uninodular bronchioalveolar carcinoma. Apropos of 10 operated cases

The complete amino acid sequence of the porcine alpha subunit of the eighth component of complement (C8A) was determined by characterizing the full length cDNA clone isolated from a porcine liver cDNA library. Porcine C8A was found to be similar to human and rabbit C8A in length, leader sequence, conserved cysteine residues, cysteine-rich modules, and overall sequence. Differences in the amino acid sequence among the three species were detected in the proposed candidate site for CD59 recognition (amino acids 352-389). The porcine C8A gene was physically mapped to chromosome 6q33-35 by in situ hybridization using the porcine bacterial artificial chromosome (BAC) clone as a hybridization probe. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis of C8A was performed using the restriction enzyme Hha I. Distribution of the alleles was determined in pigs (n = 173) of several different breeds. Estimates of allele frequency of the 201 bp fragment were 0.22,.0.43,.0.04,.0.50,.0.58,.0.50,.0.98, and 0.91 in Landrace, Large White, Duroc, Berkshire, Jinhua, Crown Miniature Pig, wild boar, and Meishan, respectively.     

Spontaneous rupture of pheochromocytoma in a patient with polycystic kidneys. Apropos of a case

OBJECTIVE: To report a case of spontaneous rupture of adrenal pheochromocytoma. METHODS/RESULTS: A patient previously diagnosed as having arterial hypertension and chronic renal failure secondary to adult polycystic renal disease was admitted to the emergency services with abdominal pain, signs of peripheral vasoconstriction and syncope. A CT scan showed a large perirenal hematoma. The patient underwent an extended left radical nephrectomy and evacuation of the hematoma. The histopathological analysis showed a polycystic kidney and a ruptura adrenal pheochromocytoma. The clinical features, diagnosis and treatment of this condition are discussed.     

Deep venous thrombosis in a patient with superficial thrombophlebitis. Apropos of 2 cases]

Many schools refer children who have sustained an injury, directly to the local Accident & Emergency (A&E) department. This prospective study monitored these referrals for one school term (08.01.96-31.03.96). During this time 200 children under the age of 14 years presented from school to the A&E department of the Royal Aberdeen Childrens Hospital (RACH). The majority presented with trivial or mild injuries and 45% of parents felt that attending A&E was inappropriate. Half the accidents happened to unsupervised children. Rural children and children of working parents were less likely to attend A&E. In Grampian Region school referrals to A&E generate a significant workload for the A&E department with resultant cost implications. It would appear that a large number of these attendances are medically unnecessary and result from a desire by the school to avoid any complaint or litigation.     

Spontaneous intramural hematoma of the esophagus. Apropos of a case

The authors report a case of spontaneous intramural haematoma of the oesophagus. This is a rare observation which usually occurs in association with oesophageal hyperpressure and sometimes with impaired haemostasis. The strategy for diagnosis is based on tomodensitography and also endosonography and magnetic resonance imagery.     

Spontaneous bacterial peritonitis in liver failure

Cirrhosis of the liver results from a variety of mechanisms that cause progressive hepatic injury. It is the sixth leading cause of death in all patients between the ages of 35 and 55. This study attempts to correlate the morbidity and mortality of spontaneous bacterial peritonitis in liver failure patients to numerous etiologic and clinical variables. A retrospective review of 26 patients with spontaneous bacterial peritonitis associated with chronic liver disease was performed in a university hospital. Demographics (age and gender), clinical variables (etiology of liver failure, Child's classification, prior history of ascites, fever, abdominal pain, encephalopathy, and upper gastrointestinal hemorrhage), and laboratory variables (ascitic polymorphonuclearcyte count and cultures, serum albumin, bilirubin, creatinine, and prothrombin time) were studied. All of the patients had Child's C liver disease. Mortality rate was 46 per cent. Alcohol (46%) and hepatitis (30%) were the most common etiologies. Escherichia coli and Klebsiella pneumoniae were the most common culture isolates. All of the infections were monomicrobial. The only significant predictor of mortality (P < 0.05) in this study was the peritoneal fluid polymorphonuclear (PMN) cell count. PMN count >1000 PMN/mm3 was associated with a mortality of 88 per cent. Few patients with spontaneous bacterial peritonitis are ultimately transplanted.     

Cholesteatoma in children. Apropos of 110 cases

It has been considered that thromboxane A2 (TXA2) is involved in the development of bronchial hyperresponsiveness (BHR), a characteristic feature of asthma. To ensure the involvement of TXA2 in BHR of asthma, effects of a 1-week treatment with two orally active TXA2 antagonists, BAY u 3405 and S-1452, on BHR were examined in 10 and 13 patients with stable asthma, respectively, in two consecutive double-blinded, randomized, placebo-controlled, two-phase crossover studies. Provocative concentration of methacholine causing a 20% fall in FEV1 (PC20-FEV1) with BAY u 3405 (0.78 (GSEM, 1.50) mg/ml) was significantly greater than the value with placebo (0.65 (GSEM, 1.46) mg/ml) (ratio 1.23 times, 95% CI 1.01 to 1.46: P = 0.0401). PC20-FEV1 was also significantly increased with S-1452 (0.43 (GSEM, 1.39) mg/ml) compared with placebo (0.29 (GSEM, 1.27) mg/ml) (ratio 1.75 times, 95% CI 1.05 to 2.45: P = 0.0189). Baseline pulmonary function was not altered by these treatments. These results may ensure that TXA2 is significantly involved in the BHR of asthma while the degree of contribution may be small.     

Urogenital tuberculosis. Apropos of 40 cases

The authors report a series of 40 cases of genitourinary tuberculosis diagnosed and treated in the department of urology "B" of Avicenne hospital over a 7-year period. The objective of this study is to define the various diagnostic and therapeutic aspects of this disease. The patients were predominantly males (62.5%) with a mean age of 40 years. 25% of cases reported a history of extra-urinary tuberculosis. The very polymorphous clinical presentation is dominated by signs of cystitis (45%). Intravenous urography is frequently suggestive of the diagnosis based on the appearance and multiplicity of the lesions. The radiological lesions most frequently encountered were silent kidney (19 cases) and small tuberculous bladder (11 cases). The definitive diagnosis was established by pathological examination in 38 cases (biopsies, operative specimens, prostatic resection chips) and/or by demonstration of AFB in 2 cases (urine, pus). Tuberculostatic treatment was administered to all patients, either alone (5 cases) or, more usually, in combination with surgical and/or endo-urological treatment (35 cases), reflecting the magnitude and severity of the destructive and scar lesions.     

Cysts of the prostate. Apropos of 2 cases

An unusual case of nodular fasciitis, arising from the splenius muscle, is presented. This uncommon lesion is always benign, but a local spread in the surrounding muscular tissue is possible. Through a Literature review, the main pathological, clinical and therapeutic features are discussed.     

Parapharyngeal tumors. Apropos of 6 cases

Natural infections with the lancet fluke (Dicrocoelium dendriticum) were detected in a group of seven diseased or dead/euthanized South American Camelids (five Llamas, two Alpacas) from Switzerland and Southern Germany. Clinical findings in almost all the animals revealed an acute decline of general condition followed by recumbency, decreased body temperature and a varying degree of anaemia. Concurrently, all animals showed an average to poor nutritional status. All liver enzyme activities analysed in serum biochemistry conformed to the reference values and therefore offered no diagnostic clues for this disease. Necropsy however, disclosed major alterations in the liver in the form of cirrhosis, abscesses, granulomas, and a massive infestation with D. dendriticum. The coprological investigations performed at the outset of the examinations revealed eggs of the lancet fluke in only two animals. This suggests that clinical findings alone permit at best only a provisional diagnosis. Repeated coprologic follow-ups showed that the presence of eggs of D. dendriticum can be diagnosed accurately and that clinical signs appear with an excretion rate above 1000 eggs per gram faeces (EpG). In these cases, praziquantel in a single dose of 50 mg/kg per os was given. This treatment was well tolerated and achieved a quite acceptable 90% reduction of eggs in the faeces.     

Ankylosing gout. Apropos of 2 cases

The Miles assay for vascular permeability has high intra- and interassay coefficients of variation (CVs). Quantification, usually by dye extraction and spectrophotometry, is time consuming. In this study, quantification by this means was compared with image analysis using the Olympus CUE-2 Image Analyzer (version 4). The test substance was recombinant human vascular permeability factor (rhVPF). The quantification process took approximately 10 min with image analysis. Formamide extraction and spectrophotometry required 1 hr of preparation, 4-6 days of incubation, and 1 hr for filtration and spectrophotometry. Between assay CVs ranged from 0 to 30% for spectrophotometry, but were all < 10% for image analysis. The sensitivity (2SD above the negative control mean) of the image analysis approach was 64 +/- 25 ng/mL, whereas for spectrophotometry it was 65 +/- 29 ng/mL. Interanimal CVs for rhVPF at 200 and 1000 ng/mL were 15% and 26% when assessed by spectrophotometry and 7% and 22%, respectively, by image analysis. The R2 value for the correlation of image analysis with spectrophotometry was 81.4%. Test substances injected close to the spine evoked a greater permeability response than those injected laterally: at 200 ng/mL p = 0.005, at 1000 ng/mL p = 0.1 (unpaired t tests).     

Spinal osteonecrosis in adults. Apropos of 4 cases

The authors report on 4 cases of aseptic osteonecrosis of the vertebral matter in adult. The relatively rare localisation is the lot of elderly patients. It may follow cobalt therapy or corticotherapy and seems to be brought about by osteoporosis, hypertriglyceridemia and, perhaps, malignant lymphoidal proliferation. Histological confirmation of osteonecrosis was available in one case. The radiological aspect is characterised by settling, with heterogenic osteo-condensation and gaseous dissection of the vertebral matter. A double vertebral localisation is possible, and scintigraphical hyperfixation is common. The course is slowly favourable, with a symptomatic treatment.     

Urethral diverticula in women. Apropos of 15 cases

Urethral diverticulum is a rare disease, arising in the urethrovaginal septum and communicating with the urethra through an orifice. Characterised by clinical polymorphism, it is diagnosed by urethrocystography and transvaginal ultrasound. We report a series of 15 cases of urethral diverticulum over a 10-year period. The mean age of the patients was post-voiding was 36 years (range 24-50). The symptoms were recurrent urinary tract infections (66%), post-voiding urethral leakage (22%), vaginal pain (22%). Clinical examination found a vaginal mass in all patients. Retrograde urethrocystography showed the diverticulum in every cases, while IVP confirmed the diagnosis in only 62% of cases. Treatment is surgical and consists of removing the diverticulum via a vaginal approach. Short and long-term course is favourable. All patients were asymptomatic and the follow-up urethrocystography showed no diverticular recurrence.