[Femoral osteolytic lesions with soft tissue tumors and hypercalcemia as presentation form of a B-cell lymphoma]

Hypercalcemia associated with haematological neoplasms account for 15 to 20% of hipercalcemia in malignancy, and occurs usually in patients with multiple myeloma. However, its incidence in patients with linfoma is low, and it is observed usually in T-cell linfomas. Bone affectation is also uncommon in patients with non-Hodgkin linfoma. It usually is seen as a late manifestation of the disease, and its occurrence as the form of presentation is exceptional. We hereby report a patient with a B-cell non-Hodgkin linfoma presenting with hypercalcemia and femoral osteolytic lesions.

Endocarditis due to Acinetobacter lwoffi on native mitral valve

Endocarditis due to Acinetobacter is a rare pathology with high mortality, reported mainly in hospitalized patients with predisposing risk factors. This is the second case of endocarditis due to Acinetobacter reported in our country in the last 10 years.

[Normative data for the neuropsychological evaluation of intravenous drug users]

BACKGROUND

There are many recent epidemiological studies that find that intravenous drug users' (IDU's) performance in several measures of neuropsychological function are not the same than that of the general population, whether they are seropositive to HIV-1 infection or not. Consequently, it has been stated the need to establish appropriate norms for this population. The purpose of this study is to provide normative data on a battery of neuropsychological tests from a IDU group.

SUBJECTS AND METHODS

This report provide normative data from a group of 116 IDU, on a battery of neuropsychological tests stratified by age group (mean = 30.9; SD = 4.5), and educational level (mean = 8; SD = 2.4). Comparisons between the means of the different groups according to age and education, and also with respect to sex are made. The analysis includes estimation of partial correlations between neuropsychological test scores and age and education.

RESULTS

The analysis demonstrates that education is an important determinant of performance for most of these tests, while there are no differences in performance between the two age-groups. With respect to sex, females out-performed men on a measure of motor speed and coordination.

CONCLUSIONS

This report provides norms that may be of use as a reference for clinical evaluation and research in drug user populations. It also emphasizes the need to establish normative data controlling for variables like educational level, from a population with special characteristics such as IDU population.

[Fever of unknown origin as the clinical presentation of malignant peritoneal mesothelioma]

Malignant peritoneal mesothelioma is a rare disease. The most frequent initial symptoms are abdominal pain, anorexia, marked weight loss and ascites. Clinical presentation as fever of unknown origin is exceptional. We report three cases diagnosed over a period of twenty years, two cases as fever of unknown origin and the third as prolonged fever. Three patients died within two months after diagnosis and prolonged fever was the clinical manifestation at the onset of the disease. It is important to take malignant peritoneal mesothelioma in the differential diagnosis of fever unknown origin.

[Changes in bone mass in hepatic cirrhosis, chronic obstructive pulmonary disease, insulin-dependent diabetes, and primary hyperparathyroidism]

BACKGROUND

Liver cirrhosis, chronic obstructive pulmonary disease (COPD), insulin-dependent diabetes mellitus and primary hyperparathyroidism are frequent diseases which are considered as risk factors for the development of osteoporosis. However, review of the literature has shown that the studies published on the aforementioned are far from conclusive.

METHODS

By double energy X-ray absorptiometry the bone mineral density (BMD) of the lumbar spine and neck of the femur were determined in 29 patients with liver cirrhosis, 92 with chronic obstructive pulmonary disease (59 treated with corticoids), 81 with insulin-dependent diabetes mellitus and 30 primary hyperparathyroidism (7 operated).

RESULTS

Cirrhotic patients had a normal BMD in both localizations. In patients with COPD, without corticoids, a decrease of 6% was found in the spine and or 13.5% in the neck of the femur while in patients with COPD with corticoids the decrease was of 12% and 7% respectively. Diabetic patients had normal BMD in the spine and a decrease of 6% in the neck of the femur and in patients with hyperparathyroidism a decrease of 6% and normality were found, respectively.

CONCLUSIONS

The repercussion of cirrhosis, insulin-dependent diabetes, and primary hyperparathyroidism on bone mineral density is nul or slight. In patients with chronic obstructive pulmonary disease treated with corticoids decrease in density of the spine is approximately that of a standard deviation. In patients with the latter not treated with corticoids a similar decrease is found in the neck of the femur.

[Phosphocalcium metabolism disorders in patients with active pulmonary tuberculosis]

Several parameters of phosphocalcic metabolism were evaluated in 21 patients with active pulmonary tuberculosis. The serum levels of total calcium, ionic calcium, phosphorus, albumin, magnesium and alkaline phosphatase, and calciuria and calcium/creatinine ratio in 24-hour urine were normal and not change during therapy. The patients with tuberculosis showed a significant reduction in the 250HD concentrations (8.8 +/- 5.2 ng/ml vs 19.2 +/- 10.7 ng/ml; p = 0.002), 1.25(OH)2D (25 +/- 8 pg/ml vs 34 +/- 9 pg/ml; p = 0.002) and parathyroid hormone (intact molecule) (1.9 +/- 0.9 pmol/l vs 5.9 +/- 2.0 pmol/l; p = 0.0001). By contrast, the levels of calcitonin (65 +/- 30 pg/ml vs 36 +/- 17 pg/ml; p = 0.001) and tartrate-resistant acid phosphatase (17.3 +/- 2.3 U/l vs 11.8 +/- 1.8 U/l; p = 0.0001) were increased. There also was a mild increase of vitamin D carrier protein (532 +/- 109 mg/l vs 480 +/- 37 mg/l; p = 0.04). These data are consistent with a partial inhibition of parathyroid hormone, associated with vitamin D deficiency. The inhibition of the axis of parathyroid hormone--1.125(OH)2D resulting from calcium release from the bone is advanced as an explanation. This release might be due to the action on the bone of cytokines produced within the inflammatory process itself. The reduction in 250HD could presumably be related with the lower exposure to sun, which is common in sick persons.

[Bone turnover markers in tumor pathology with bone involvement]

We evaluated the serum osteocalcin and alkaline phosphatase levels and the urinary hydroxyproline excretion in patients with blastic, lithic or mixed metastases, humoral malignant hypercalcemia (HMH) and myeloma. In patients with metastasis of any type osteocalcin did not reach a significant increase although in blastic metastases an increase approaching signification was observed. However, the sensitivities of alkaline phosphatase or hydroxyproline were much higher. In HMH hydroxyproline increased to levels similar to those found in primary hyperparathyroidism. By contrast, although osteocalcin had a significant increase, its values were much lower than in parathyroid disease. The changes in alkaline phosphatase were nonevaluable. In myeloma none of the three markers changed. The major conclusion of the present study is that osteocalcin has little practical usefulness for the investigation of neoplastic patients.

[Response of vitamin D metabolites to calcium restriction in hypercalciuric renal lithiasis]

A group of patients with hypercalciuric renal lithiasis and a group of controls underwent dietary calcium restriction, reinforced by cellulose phosphate, during two weeks. Before and after that intervention, serum levels of 25 OH D, 1.25(OH)2D and PTH, and urinary excretion of cAMP and hydroxyproline were measured. Although the baseline 1.25(OH)2D level was higher in patients with stones, it did not increase with diet as it was the case with controls. Also, the urinary excretion of cAMP was increased in controls but not in patients. 25 OH D, PTH and hydroxyproline were not changed. We conclude that dietary calcium restriction in patients with hypercalciuric renal lithiasis does not appear to induce hormonal changes potentially damaging for the bone.

[Effect of active metabolites of vitamin D on manifestations of primary hyperparathyroidism]

We have evaluated the serum levels of 25-hydroxyvitamin D (25-OHD) and 1,25-dihydroxyvitamin D (1.25-OHD) in 33 patients with primary hyperparathyroidism and normal renal function, relating them with the clinical expression of the disease and other biochemical parameters. The level of 1.25-OHD of the patients was significantly higher than in healthy controls [51 +/- 18 vs 36 +/- 10 pg/ml (122 +/- 43 vs 86 +/- 24 pmol/l), p less than 0.001], although it was higher than the upper limit of the normal range in only 36% of patients. By contrast, the level of 25-OHD was diminished [11.0 +/- 6.3 ng/ml (27.5 +/- 15.7 nmol/l) in the patients and 19.9 +/- 10.5 ng/ml (49.7 +/- 26.2 nmol/l) in the controls, p less than 0.01]. A positive correlation was found between PTH and 1.25-OHD (r = 0.40, p less than 0.05) and a negative one between PTH and 25-OHD (r = -0.40, p less than 0.05). Calcemia was correlated with PTH (r = 0.77, less than p 0.001) but not with 1.25-OHD (partial r = 0.22). There was no correlation between vitamin D metabolites and calciuria, nor between the former and the biochemical indexes of bone remodelling. There were no significant biochemical differences between patients with renal calculi and those without them. It was concluded that PTH level appears as the major determinant factor of 1.25-OHD serum level. The serum level of vitamin D metabolites does not seem to clearly influence calcemia, calciuria, bone remodelling or the development of calculi.

[Tumoral hypocalcemia]

Hypocalcemia is a rare and not well understood paraneoplasic manifestation. We report the clinical case of a patient with hypocalcemia due to extensive osteoblastic metastasis. The corrected serum calcium levels for albumin was 7.2 mg/dl. Calciuria was less than 10 mg/24 h. Magnesium, phosphate and 25-hydroxyvitamin D levels were normal. PTH and 1,25-dihydroxyvitamin D levels were increased. The pathogenesis of this disorder is possibly related to the massive calcium flow toward metastatic areas, that can not be compensated for by the activity of the PTH-vitamin D axis.

Aortobronchial fistula: an uncommon cause of haemoptysis

A 16 year old patient who presented with haemoptysis as the main manifestation of the infection of an aortic patch graft is reported. The importance of being alert about the possibility of an aortobronchial fistula in patients with haemoptysis who have been previously subjected to cardiovascular surgery is emphasized.

Vertebral compression fractures and mineral metabolism in chronic obstructive lung disease

Chronic obstructive lung disease has been reported as a cause of osteoporosis, though whether this association is due to the disease itself or to corticosteroid treatment has not been elucidated. We studied 44 male patients with chronic obstructive lung disease (mean (SD) FEV1 39% (14%) of predicted normal) who were not having long term corticosteroids. No differences in a vertebral deformity score or in metacarpal index were found between them and a control group of similar age. Indices of bone formation (serum osteocalcin) and bone resorption (urinary hydroxyproline) were normal and parathyroid hormone and 1,25-dihydroxyvitamin D were also normal. Serum 25-hydroxyvitamin D was decreased, indicating depleted vitamin D. Calcitonin concentrations were higher in the patient than in the control group of the same age. There was no increase in the prevalence of osteoporosis in patients with chronic obstructive lung disease who had not received long term corticosteroid treatment. Increased concentrations of calcitonin may protect the skeleton from the detrimental effect of hypovitaminosis D.