Wound botulism in heroin addiction]

Botulism is a rare disease which usually is caused by preformed botulinum toxin in food. However, this article describes a case of wound botulism in a 29-year-old male heroin addict who developed progressive diplopia, dysphagia and proximal weakness of skeletal limb muscles. He needed mechanical ventilation for two weeks. The clinical diagnosis of botulism was supported by neurophysiological tests. Assays for detection of botulinum toxin and Clostridium botulinum were negative. The patient had not eaten any contaminated food the last two weeks before symptoms appeared, but he had multiple contaminated skin wounds. After treatment with botulinum antitoxins and antibiotics he gradually recovered, and six weeks later he was discharged from hospital in good condition. To the best of our knowledge this is the first case of wound botulism reported in Norway.     

Does concurrent acute ethanol ingestion during omeprazole therapy affect pituitary gonadal axis in male subjects?

We describe a male infant with biopsy-confirmed interstitial lung disease (ILD) who responded to chloroquine, after he failed to improve on oral corticosteroids or cyclophosphamide. The infant presented at 8 days of age with respiratory distress and cyanosis. Lung biopsy at 8 weeks of age was consistent with desquamative interstitial pneumonitis (DIP). He was treated with corticosteroids at 2 weeks of age because of a family history of two siblings who died during infancy and who had DIP on postmortem examination. At 8.5 months, our patient was treated with cyclophosphamide because of lack of response to corticosteroids therapy. At 14 months of age, he began treatment with chloroquine in addition to corticosteroids and had a dramatic response within 3 weeks. The patient has been maintained successfully on continuous treatment with chloroquine alone for more than 9 years since this treatment was started.     

Abdominal pain, weight loss, tarry stools

A 65-year-old man had abdominal pain and night sweat for several weeks. He had lost weight and also reported black stools. Anemia of iron deficiency was found in laboratory tests. Further investigation revealed a stenosing process in the small intestine as source of bleeding. High grade non-Hodgkins' lymphoma was diagnosed histologically in the resected bowel segment and the mesenteric lymph nodes. Further staging did not reveal further manifestations of lymphoma. Polychemotherapy and subsequent irradiation were administered.     

A man with vague rheumatic complaints

A 52-year-old man presented with a four-month history of malaise, low-grade fever, decreased appetite, and a 20-pound weight loss. He complained of joint pain and swelling, proximal muscle weakness, exertional dyspnea, and a dry cough. He also noted that his fingers had turned white and then blue when chilled and red when rewarmed. He had not had pleuritic chest pain, dysphagia, dry eyes or mouth, rash, or skin photosensitivity.     

Acute myeloid leukaemia complicated by anergic tuberculosis

A case of acute myeloid leukaemia presenting as pyrexia of unknown origin and weight loss with pancytopenia is described. Initial investigations revealed trilineage myelodysplasia which evolved into acute myeloid leukaemia within 2 weeks of presentation. He was commenced on a standard induction regimen consisting of idarubicin, Ara-C and thioguanine. Throughout his hospital stay he remained febrile. In spite of exhaustive investigations no cause for the pyrexia was found nor did he respond to any form of treatment. He died after 9 weeks in hospital. His post-mortem examination revealed widespread disseminated tuberculosis without any reactive inflammatory tissue response or granuloma formation.     

Fracture of the tarsal navicular associated with calcaneonavicular coalition: a case report

Fracture of the navicular occurred in a 23-year-old male with unilateral cartilaginous calcaneonavicular coalition. Inversion sprain of the left foot caused the longitudinal navicular fracture next to the coalition. En bloc resection from the beak of the calcaneus to the fracture line of the navicular including the calcaneonavicular coalition was performed, and a short leg cast was applied for 10 days. Four weeks after surgery, he returned to his preinjury level of activity and job as a long-distance truck driver. Two years and 3 months after surgery, he was totally asymptomatic and had gained a full range of subtalar motion. He had no peroneal spasm or recurrence of the coalition.     

Cervical lymph node metastatic patterns of squamous carcinomas in the upper aerodigestive tract

We report a patient with medial medullary infarction who showed deep sensory impairment as his prominent neurological manifestation. A 54-year-old man with a history of hypertension was admitted to our hospital with numbness of the bilateral upper and lower extremities, followed by dysarthria and right hemiparesis. Physical examination revealed no abnormalities except for high blood pressure. He hiccuped continuously. On neurological examination, he exhibited dysarthria, mild dysphagia and right hemiparesis without facial or lingual paresis. Sensitivity to light touch and pinprick was normal, but sensitivity to vibration and joint position was severely decreased in the bilateral upper and lower extremities, predominantly in the lower extremities and on the right side in the upper extremities. He had been treated with antiedema agents and thromboxane synthetase inhibitor. His hiccups stopped within two weeks, and his right hemiparesis gradually improved within one month. However, his deep sensory impairments remained prominent. Blood examinations disclosed positive lupus anticoagulant. MRI showed bilateral infarction at the medial portion of the upper medulla oblongata, extending to both pyramids, especially on the left. Somatosensory evoked potentials (SEP) after median nerve stimulation showed P14 and the later components with prolonged latency. No SEP were recorded after posterior tibial nerve stimulation. The latency of P14 was well correlated with the severity of deep sensory impairments in the upper extremities. Neurological manifestations of our patient are not typical of medial medullary infarction, and are informative about the functional anatomy of the deep sensory tract in the medulla oblongata. We discuss the relation of the intractable hiccups to the bilateral medial medullary lesions, and emphasize the importance of lupus anticoagulant as one of the risk factors in brainstem infarction.     

Double pyloroplasty and vagotomy for gastric ulcers

A group of 31 patients with a variety of gastric ulcers were treated by vagotomy, biopsy, oversewing of bleeding points and a wide double pyloroplasty. On patient, a quadriplegic with multiple stress ulcers, rebled and had to undergo resection. He died a month later of progressive respiratory problems. A second quadriplegic died a month after a bleeding episode from myelitis and encephalitis resulting from a gunshot wound of the neck. He had no rebleeding. A third patient died two years after a gastric operation as a result of bronchial carcinoma. He had no recurrence of the ulcer problem. The remaining 28 patients were observed from six months to five years, an average of two and one-half years. There were no recurrences and only minimal untoward symptoms. It would appear that, for this period of observation, vagotomy with double pyloroplasty offers good treatment for patients with benign gastric ulcers.     

Zinc therapy in otology

At a recent panel on Otology, I asked the audience for a show of hands of those using Zinc for delayed healing and granulations. It was surprising to note that not more than 4 physicians out of 100 had tried Zinc. The need to report our encouraging results was apparent. From 1971 to 1975, 544 tympanoplasties and 122 mastoidectomies were studied for delayed healing due to granulations. Forty-six patients were found to have resistant granulations. Thirty-three of these healed within two weeks of therapy, 10 more required a total of four weeks for healing, and three did not respond well. Sixteen patients had recurrence when the medication was terminated as soon as healing had occurred but responded well when the medication was continued for four weeks after healing was complete. Five patients had nausea, which subsided when the dosage was reduced from the usual 200 mg. of Zinc Sulfate, three times daily with meals to 100 mg., t.i.d. or b.i.d. One patient developed mild urticaria. Zinc therapy is apparently indicated in granulomata of the ear when healing does not occur with conventional therapy, especially in the post-operative patient; however, it will not suffice when there is massive involvement of the mastoid or middle ear, where surgical removal is indicated.     

Arterial embolism complicating implantable cardioverter defibrillator shocks with normal ventricular function

A 69-year-old man developed an embolus to his right femoral artery 24 h following the insertion of an implantable cardioverter defibrillator (ICD), with multiple shocks administered in the early postoperative period. He had nonobstructive hypertrophic cardiomyopathy with normal left ventricular function and no evidence of left atrial or ventricular thrombus seen on pre- or postoperative transthoracic echocardiography. There was no evidence of atrial fibrillation documented before or after implantation of the device. He had no other known risk factors for thromboembolic disease. Thromboembolic phenomena as a complication of ICD use have been described but arterial emboli believed related to ICD shocks have not been reported in patients without impaired systolic function.     

Successful surgical treatment for fungal endocarditis involving the aortic valve: report of a case

A 50-year-old man who had undergone successful aortic valve replacement for fungal endocarditis was presented. He had been doing well until October 1993, when he suddenly developed shock with high fever. In two weeks he recovered from septic shock with vigorous medical treatment including intravenous administration of antibiotics. The infecting organism was not detected on repeated blood cultures. Four months later he was admitted to our hospital because of left heart failure. Although he was afebrile on admission, a two dimensional echocardiogram revealed vegetation on the aortic valve and massive aortic regurgitation. Inflammatory signs persisted and the vegetation increased in size, and therefore an aortic valve replacement was performed. A surgical specimen of the aortic valve revealed perforation in each of three cusps and vegetation on the non-coronary cusp. Pathological exploration revealed typical colonies of fungi. Following the diagnosis of fungal endocarditis, administration of an anti-fungal drug was started. His post-operative course was uneventful, and there was no evidence of recurrence with the anti-fungal medication for one year postoperatively.     

Regression of superficial gastric MALT lymphoma with unsuccessful eradication therapy for Helicobacter pylori infection

A 51-year-old man had a reddish flat granular lesion in the stomach on endoscopic examination. Histology of biopsied specimen confirmed the diagnosis of low-grade B-cell gastric lymphoma of mucosa-associated lymphoid tissue (gastric MALT lymphoma) and simultaneous infection with Helicobacter pylori. He was given antibiotic treatment. Five weeks later, endoscopy and histology of biopsied specimen showed eradication of H. pylori, and the tumor had regressed. Six months later, H. pylori reemerged, but the tumor had not recurred. After the second antibiotic therapy, H. pylori has been eradicated. The lymphoma has been in remission for 14 months.     

Dream interpretation can change beliefs about the past.

Forty-six nonclinical subjects reported on their childhood experiences on two occasions, separated by 3–4 weeks. between these sessions, some subjects were exposed to a 30-min therapy simulation in which their dream material was analyzed by a clinical psychologist. He suggested to subjects that their dreams were indicative of having experienced, before the age of three, certain critical experiences (e.g., being lost in a public place or feeling abandoned by parents). Subjects previously reported that these critical events had not occurred. The brief therapy simulation led them to dramatic shifts in belief that the experiences had occurred. These results show that brief therapy-like interactions can change people's beliefs about the past, and have implications for the power of clinical intervention. Dream interpretation, commonly practiced in psychotherapy to guide patient's understanding of themselves, may have unexpected side effects if it leads to beliefs about the past that may in fact be false. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Oakley Stern Ray (1931-2007).

Presents an obituary for Oakley Stern Ray. Ray was a teacher--whether in the role of professor, chief, or colleague. Late in his life, he described himself as having had four "day jobs," although he could not have accomplished so much if he had limited himself to daylight hours. He so completely inhabited each role that the colleagues he knew in one capacity were often unaware the others existed. These four careers were Veterans Administration (VA) psychologist, professor, author, and executive. He always had at least two of these careers going at the same time, usually three. During the 1970s and 1980s, he was productive in all four simultaneously. Oakley's 76th birthday was February 6, 2007; he died of leukemia on February 7, 2007. He is survived by his wife Kathy Ray, his sons Steve, Christian, and Tom Ray, his daughter Deb Scanlon, his grandchildren--and thousands of students. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cyclosporin for the treatment of severe ulcerative colitis

The effect of cyclosporin was evaluated in six patients with severe ulcerative colitis not responding to at least 8 days of standard therapy with intravenous corticosteroids. Cyclosporin (5-7.5 mg/kg/day intravenously) was added while steroid therapy was continued. Five of 6 patients responded after a mean of 7 days and colectomy was not necessary. After 4 weeks three patients achieved clinical remission or had mild symptoms and were weaned from cyclosporin and corticosteroids without exacerbation within the next 7-15 months. Two patients improved and they were put on oral cyclosporin. One of them relapsed after 2 weeks and then responded to high dose corticosteroids. This patient is doing well at 8 months of followup on azathioprine and steroids. One patient stopped oral cyclosporin after 3 months abruptly and then had a relapse. He subsequently improved while refusing any medical therapy. Side effects of cyclosporin occurred in 2 patients but were mild and self limited and did not necessitate discontinuation of the drug. Cyclosporin appears to be effective in a large portion of patients with severe ulcerative colitis who failed to improve on corticosteroids and in whom colectomy would otherwise be considered.     

Late, intermittent obstruction of a mitral prosthesis by chordal remnants

A 59 year old male was admitted 10 weeks following insertion of a Medtronic Hall mitral prosthesis. He suffered recurrent episodes of electromechanical dissociation (EMD). Transthoracic echocardiography demonstrated that during the times of haemodynamic compromise, the mitral prosthesis was intermittently obstructed. Emergency surgical intervention revealed that chordae tendineae had prolapsed through the lesser orifice, obstructing the valve mechanism. The mitral remnants were excised, and as the valve functioned normally, it was not replaced. Postoperatively, the patient made an uneventful recovery. This case illustrates the Doppler echocardiographic features associated with extrinsic obstruction of a mitral prosthesis, and demonstrates that this unusual complication can be responsible for late valve dysfunction.     

Aureobasidium pneumonia in a post liver transplant recipient: a case report

This is the first report of Aureobasidium (A.) pullulans as an opportunistic pulmonary infection in a liver transplant recipient. A 46-year-old caucasian man had an orthotopic liver transplant in 1988. His liver disease was primary sclerosing cholangitis. He required 2 subsequent liver re-transplants for primary graft non-function and acute rejection. The patient had been living in the California desert for two months prior to admission and presented with ventilator-dependent acute respiratory failure and hemodialysis-dependent acute renal failure. Imaging studies revealed severe bilateral infiltrates. His initial bronchoalveolar lavage (BAL) and brushings grew A. pullulans. Pancultures, including sputum and throat cultures, were negative for bacterial or other fungal organisms. The patient responded to pulmonary support and aggressive systemic antifungal agents while being maintained on cyclosporine and prednisone for immunosuppression. He was discharged to a skilled nursing facility 37 days after hospitalisation. Delay in discharge was primarily due to severe malnutrition and renal impairment. Opportunistic fungal infections continue to be a major problem in immunosuppressed patients including liver transplant recipients. Here we report a pulmonary infection with Coccidioides (C.) immitis and superinfection with A. pullulans. Opportunistic infections such as A. pullulans can be treated successfully with systemic fluconazole when amphotericin B is not well tolerated.     

Melkersson-Rosenthal syndrome in a diabetic boy

The Melkersson-Rosenthal syndrome (MRS) consists of recurrent edema of the lips, intermittent facial palsy and furrowed tongue. This is the classic triad which defines the syndrome, although it is accepted that the presence of two manifestations or one with a granulomatous cheilitis in the biopsy, are sufficient to make the diagnosis. The case of a 15 year-old diabetic boy is presented. He had a persistent edema of the upper lip of one-year duration, which started abruptly without any clear etiologic correlation. He was treated with antihistaminics and corticosteroids without improvement but with diabetic imbalance. The complementary examinations were normal and the biopsy was compatible with granulomatous cheilitis. Despite the low incidence and the fact that there is no specific treatment, MRS has to be considered as a diagnostic possibility in a patient with recurrent edema although not necessarily having the complete triad.     

Cast brace treatment of plateau and bicondylar fractures of the proximal tibia

Twenty-nine patients with 30 intraarticular proximal tibial fractures were treated with early application of a cast brace. All fractures united, knee motion was excellent or good in all but one patient. The fracture fragments did not lose position after cast brace application. Varus or valgus deformities could be corrected and maintained. Ninety per cent had no pain at follow-up. Hospital stay was as short as two days and generally under two weeks.     

Distinguishing recovery from remission in a cohort of bulimic women: how should asymptomatic periods be described?

BACKGROUND: Empirical definitions of remission and recovery from eating disorders are needed to understand outcome data and compare results across studies. METHOD: 106 treatment-seeking women with bulimia nervosa, who had abstained from binging and purging for at least 4 weeks, were followed prospectively. Relapse was defined as at least 4 consecutive weeks of either binging and purging weekly or binging two or more times per week, regardless of purging. Recovery was differentiated from remission based on the probability of relapse. The minimum number of weeks after which the risk of relapse leveled off was used as the cut-off to distinguish between the two outcomes. Kaplan-Meier methods were used to estimate the weekly probability of relapse. RESULTS: When defining remission as at least 4 weeks of being asymptomatic, a quarter of the women relapsed within 11 weeks. By 37 weeks, only 49% of the women remained asymptomatic (95% CI, 41-61). The probability of relapse was substantial for approximately a year after a woman ceased to binge and purge. CONCLUSION: Bulimia nervosa is an episodic disorder. As a conservative approach, periods of being asymptomatic that last less than 1 year should be labeled as remissions, not recoveries.