Thyroid metastasis from gastric carcinoma: report of a case

Thyroid metastasis from gastric carcinoma is rare. In this report, we describe the case of a patient in whom a rapidly growing thyroid metastasis was found 3 months after an operation for gastric carcinoma.

Intra-abdominal gallstone spillage detected during umbilical trocar site hernia repair after laparoscopic cholecystectomy: report of a case

It is well known that spilled gallstones may occur as a complication during laparoscopic cholecystectomy. We present herein the case of a patient in whom intra-abdominal gallstone spillage was found during repair of an incisional hernia at the umbilical trocar port site 3 months after a laparoscopic cholecystectomy. We describe this case and present a review of the recent literature to stress the importance of preventing stone spillage and retrieving any stones that are spilled into the abdomen.

Drug-induced acute interstitial nephritis and vasculitis or vasculary rejection in renal allografts

We describe a patient who sought treatment for acute renal allograft dysfunction 2 weeks after renal transplantation. Renal allograft biopsy (RAB) showed intimal arteritis, severe interstitial infiltration with a few eosinophils, and severe tubulitis. Pathologic diagnosis was acute rejection (grade 2b- Banff 93); however, another clinical diagnosis, drug-induced acute interstitial nephritis (AIN), was not excluded. Before the RAB, his trimethaprim-sulfamethoxazole (TMP-SMZ) treatment was discontinued. Renal function began to improve on biopsy day without antirejection therapy. Recovery of renal function without antirejection treatment and discontinuation of TMP-SMZ shows that renal pathology might be related to drug-induced dysfunction and drug-induced AIN and vasculitis. After 5 years, the patient and his renal allograft function are both well.

[Traumatic splenic injuries]

Splenectomy is the frequently used surgical method for the treatment of traumatic splenic injuries. In this study, the patients who had traumatic splenic injuries were investigated and the results of surgical treatments were evaluated. There were 225 patients with traumatic splenic injuries, which contains 55 (24%) female and 170 (76%) male. The mean age was 29 (range 16-71) years. Severity of splenic injury was classified according to Moore organ injury scaling and there were 23 (10%) patients in grade 1, 96 (43%) in grade II, 75 (33%) in grade III, 24 (11%) in grade IV and 7 (3%) in grade V. Splenectomy was performed in 203 (90%) patients, splenoraphy in 18 (8%) and partial splenectomy in 4 (2%) patients. The overall mortality was 12%. A positive correlation was estimated between the combined trauma and the mortality (Fisher's Chi-Square test; chi 2 = 9,538, p < 0.002). In conclusion, non-operative treatment methods may prevent unnecessary splenectomies, especially in grade I and II blunt or penetrating splenic injuries. Combined injuries are the major factor increasing the mortality.

Solitary subcutaneous hydatid cyst: a case report

In the absence of hepatic and pulmonary involvement, hydatid disease of other organs is extremely rare. In this paper, we report on a patient who had a solitary subcutaneous hydatid cyst in the submandibular region.

Clinicopathological features of rapidly progressive hepatitis C virus infection in HCV antibody negative renal transplant recipients

BACKGROUND

Hepatitis C virus (HCV) infection acquired during dialysis treatment generally shows a relatively benign course after renal transplantation (RTx). However, less is known about the course of HCV infection acquired during or after RTx.

METHODS

Clinical and histopathological assessment of 15 renal transplant recipients who acquired HCV infection during or after RTx.

RESULTS

Alanine aminotransferase levels rose for the first time 1-19 weeks after RTx. HCV RNA was found positive in all patients, but anti-HCV became positive in only nine of them. During a mean follow-up of 21 +/- 12 months, jaundice appeared in 12 patients while ascites and/or hepatic encephalopathy occurred in six. Azathioprine was stopped in all patients. Cyclosporin was also stopped in four patients and in two of them prednisolone was also interrupted for a period of 3-7 weeks. Following this, ascites, hepatic encephalopathy and biochemical disturbances improved, while no deterioration was seen in graft function. Nine of the 15 patients had undergone two consecutive liver biopsies (LB). The first LB revealed cirrhosis in three and chronic hepatitis in six patients; the second LB showed cirrhosis in seven patients. The histological activity index (Knodell's score) progressed from 11.8 +/- 3.5 to 13.8 +/- 3.8.

CONCLUSIONS

The results suggest that HCV infection acquired during or after RTx may run an unusual and rapidly progressive clinical and histopathological course at least in some of these patients. Decrease or withdrawal of immunosuppressive drugs may improve early hepatic failure without detrimental effect on graft function during that period.

Regression of left ventricular hypertrophy in haemodialysis patients by ultrafiltration and reduced salt intake without antihypertensive drugs

BACKGROUND

Left ventricular hypertrophy (LVH) is very frequent in haemodialysis patients. Only few investigations have reported its regression, and only by the use of antihypertensive drugs. Because volume load is at least as important as pressure load, we investigated whether persistent strict volume control by ultrafiltration alone may be effective in improving LVH METHODS: Using blood pressure (BP) and cardiac dimensions as a guide, we treated all hypertensive patients in our dialysis unit during the 3 times weekly dialysis sessions for 4 h per session with as much ultrafiltration as they could stand. If they gained too much weight an extra isolated ultrafiltration (UF) session was applied. Special attention was given to dietary salt restriction. The study group of all 15 patients in whom echocardiographic assessment had been made at least 1.5 years previously was selected retrospectively, and we acknowledge that important confounding factors might not have been controlled for. Cardiothoracic index (CTI) was estimated on the chest X-ray. Diameters of left atrium (LA), left ventricle systolic (LVS) and diastolic (LVD), interventricular septum (IVS), posterior wall (PW), and left ventricular mass index (LVMI) were estimated by standard echocardiographic methods.

RESULTS

Mean arterial pressure of the study group had been lowered by UF before the first echocardiogram from predialysis 136+/-11 to 101+/-14 and from postdialysis 119+/-8 to 92+/-12 mmHg. During a mean follow-up period of 37+/-11 months LVMI decreased from 175+/-60 to 105+/-11 g/m2. CTI decreased further from 48+/-3 to 43+/-4%, while significant decreases of LA (22.5+/-3 to 19.9+/-4 mm/m2), LVS (18.7+/-4 to 15.9+/-3 mm/m2) and LVD (28.3+/-4 to 24.0+/-3 mm/m2) were seen in all patients. There also was a further decrease in both pre- and postdialysis BP to 116+/-12/73+/-7 and 105+/-7/65+/-3 mmHg respectively.

CONCLUSION

The results of this uncontrolled retrospective study suggest that good long-term BP control and a decrease of LVM can be achieved by continuous efforts to control hypervolaemia. The decrease in volume may be even more important than pressure reduction to achieve this goal.

Disappearance of mitral and tricuspid regurgitation in haemodialysis patients after ultrafiltration

BACKGROUND

Doppler echocardiography has recently revealed frequent occurrence of valvular (in particular mitral) regurgitation in dialysis (HD) patients. We hypothesized that this may be in part 'functional' and related to the cardiac dilatation which is also frequently present. Thus it would be possible to improve it by ultrafiltration.

METHODS

Mitral and tricuspid regurgitation was detected in 21 haemodialysis patients who had cardiomegaly but no manifest cardiac failure. They were treated by intensified ultrafiltration sessions, as much as they could tolerate, while all antihypertensive drugs were stopped. Doppler echocardiograms were then repeated.

RESULTS

Mitral regurgitation disappeared in 13 and tricuspid regurgitation in 14 patients, while lesser degrees of either of them persisted in seven. This was accompanied by decreases of body weight (5.4 +/- 2.7 kg) mean arterial pressure (125 +/- 15 to 95 +/- 11 mmHg), cardiothoracic index (from 0.57 to 0.47), and left atrial (28 +/- 4 to 22 +/- 3 mm/m2), left ventricular systolic (25 +/- 5 to 21 +/- 55 mm/m2) and left ventricular diastolic (31 +/- 5 to 27 +/- 5 mm/m2), and mitral annular diameters (19.4 +/- 2 to 16.6 +/- 2 mm/m2). Ejection fraction increased but remained below 50% in 11 patients.

CONCLUSION

Most of the mitral and tricuspid regurgitations seen in HD patients are partly or completely functional, due to dilatation of the mitral annulus which is related to volume overload. A more aggressive approach, while discontinuing antihypertensive drugs can correct or improve many of them and also ameliorate cardiac function.

The efficiency of fractionated parenteral iron treatment in CAPD patients

Some chronic renal failure patients respond poorly to recombinant human erythropoietin (rHuEPO). In continuous ambulatory peritoneal dialysis (CAPD) patients, such a poor response may indicate inadequate dialysis or low body iron stores. To correct iron deficiency, once-a-week intravenous iron supplementation is recommended. However, hemodialysis patients receive iron supplements three times a week. This study was designed to compare the efficacy of iron supplementation between once-weekly and twice-weekly regimens. In both groups, rHuEPO doses were similar. Seventeen CAPD patients were studied. All had hemoglobin levels less than 10 g/dL. Ten patients were given 100 mg intravenous iron once weekly, and 7 were given 50 mg intravenous iron twice weekly until a total iron dose of 600 mg was achieved (stage I). The patients were crossed over to receive another 600 mg iron (stage II). Hematocrit increased significantly in patients receiving twice-a-week iron supplementation (+3.8% and 6%) compared to those receiving once-a-week iron supplementation (+1.3% and 1.4%) during stages I and II. The ferritin levels were not different between the groups. In conclusion, rHuEPO is more effective when administered with intravenous iron.

Cryptosporidiosis and blastocystosis in renal transplant recipients

Some intestinal parasitic infections are frequently seen in renal transplant recipients. Parasites such as Cryptosporidium spp. and Blastocystis hominis are often asymptomatic or responsible for limited infections in normals, but may cause prolonged and heavy infections with gastrointestinal complaints, mainly diarrhea, in immunocompromised patients. Such infections can often not be detected by routine diagnostic procedures, but special concentration and staining methods are needed. We investigated 115 fecal specimens from 69 renal transplant recipients and 42 fecal specimens from 42 control cases. Of the 69 recipients, 27 (39.1%) had B. hominis and 13 (18.8%) had Cryptosporidium spp. in at least one fecal specimen. Prevalence of symptomatic Cryptosporidium infections was significantly higher in the renal transplant recipients, when compared with the control group (p < 0.05). Special parasitological procedures must be performed in immunocompromised patients with chronic gastrointestinal complaints. Disappearance of symptoms after antiparastic drugs in some of 16 symptomatic patients are described, suggesting that these infections are more pathogenic in transplant recipients.

Development of collaterals in intermittent and permanent ischemia of the liver

The ischemia caused by the hepatic dearterialization as therapy for hepatic malignancies is transient because of the rapid formation of collaterals. In order to prevent this transient repeated ischemia has been suggested. An experimental study was planned to compare the collateral occurrence in persistent ischemia and transient repeated ischemia of the liver. Fourteen dogs (seven persistent ischemia, seven transient repeated ischemia) were used in this study. Hepatic dearterialization were performed in both groups. In the first group (persistent ischemia), the hepatic artery was ligated proximal to the gastroduodenal artery. In the second group (transient repeated ischemia), the hepatic artery was occluded externally in the same region as the first group by means of a device modified from 8 guage Foley catheter and after occlusion for one hour it was reopened. Occlusions were repeated twice in a day. Five dogs in the first group and six dogs in the second group completed a three week ischemia period and angiography were then performed in all. The dogs were sacrificed after the angiography and examined for possible abscess formation, arterial thrombosis, peritoneal adhesions and liver necrosis. After angiography, the two groups were also examined for collateral occurrence. Only one collateral occurred in the transient repeated ischemia group, but in the persistent ischemia group, collaterals occurred in all dogs. This difference between two groups is statistically significant (Fischer Absolute Chi Square Test, p = 0.013). Transient repeated ischemia is superior to persistent ischemia because of fewer collaterals, but in practise, total dearterialization of the liver is impossible.

Comparison of the effects of enalapril and theophylline on polycythemia after renal transplantation

Posttransplant erythrocytosis (PTE) is a potentially serious complication for which (apart from phlebotomy) two alternative treatments have been proposed: theophylline (Theo) and angiotensin-converting enzyme inhibitors. We investigated 28 patients with PTE, who were assigned to 3 matched groups. Group 1 (10 patients) received 10 mg of Enalapril (Ena)/day. After 2 months, mean hematocrit (Ht) had dropped from 0.57 (range 0.52-0.62) to 0.45 (0.34-0.49). Ena was stopped and, after a period of 3.8 +/- 0.3 months, Ht had risen again to baseline values (0.56, range 0.52-0.61) in 8 of them. These 8 patients were then given 5 mg/day Ena. Ht decreased more slowly, and after 3 months reached a mean of 0.49 (0.44-0.54). Group 2 (9 patients) received 600 mg/day Theo in 2 doses. After 2 months, Ht had decreased from 0.56 (0.52-0.61) to 0.52 (0.46-0.63), but in 5 patients, Ht remained above 0.51. After 1 month discontinuation of treatment, PTE persisted in 7 patients. These patients were given 10 mg/day Ena, whereupon Ht decreased from 0.55 (0.52-0.64) to 0.46 (0.40-0.53) after 2 months and to 0.41 (0.33-0.47) after 3 months. Group 3 did not receive medical treatment. After 3 months, PTE persisted in 8 out of the 9 patients and remained unchanged during the following 3 months. Mean values for Ht were: baseline, 0.55 (0.52-0.58); after 3 months, 0.56 (0.53-0.59); and after 6 months, 0.55 (0.52-0.60). We conclude that Ena is superior to Theo in the treatment of PTE. There were no resistant patients, but individual sensitivity differs. Its effect is dose dependent, reversible, and reproducible. Excessive Ht decrease may occur; thus, doses should be titrated individually.