[Necrotizing subcutaneous infection by Streptococcus agalactiae]

Necrotizing soft tissue infections constitute some of the most potentially threatening infections that may be acquired in the community or in the hospital milieu as they are associated with a high mortality rate. In most cases they are produced by Streptococcus pyogenes. We report a case of a necrotizing soft tissue infection caused by Streptococcus agalactiae (group B beta hemolytic streptococcus) that involved the leg of an elderly man with chronic lymphatic leukemia and diabetes mellitus. The lesions notably improved after initiating intravenous antibiotic treatment with amoxicillin-clavunate and clindamycin.

Siringoma condroide: revisión clínica e histológica de ocho casos

INTRODUCTION

Chondroid syringoma is a rare skin tumor that presents as a slow growing, indolent lesion, that is more frequent in male adults and is usually benign. It is treated surgically and its diagnosis is histological. It can be classified as eccrine and apocrine according to its pathological characteristics.

MATERIAL AND METHODS

Eight cases diagnosed of chondroid syringoma in our Department in the last eight years were reevaluated clinically and histologically and the epiluminiscence microscopy was used in one of them.

RESULTS

Most of the cases occurred as well-defined nodular lesions, whose presumptive clinical diagnosis was adnexal or cystic pathology. All were treated surgically. The epiluminiscence microscopy showed a pattern of homogenous whitish-blue coloring. All the cases had a myxoid matrix and most also had a chondroid one. Five of the eight cases were apocrine, one of them with follicular and sebaceous differentiation.

DISCUSSION

The chondroid syringoma is usually a small-sized skin tumor, frequently on the head and neck. The dermatoscopy does not seem to supply any specific trait to this lesion. The microscopic examination of these lesions reveals tubuloalveolar and glandular type structures positioned as islets within a fibroadipose, chondroid, myxoid or hyaline stroma. The final treatment of these tumors is surgical. As a general rule, it is a benign tumor. Some authors have proposed the term of atypical mixed tumor of the skin for those chondroid syringomas with histological traits of malignancy but without evidence of metastasis.

CD4+/CD56+ haematodermic neoplasm: a preculsor haematological neoplasm that frequently first presents in the skin

CD4+/CD56+ hematodermic neoplasm, formerly known as blastic NK cell lymphoma, is an aggressive and rare preculsor hematologic neoplasm recently recognized by the WHO-EORTC classification consensus for cutaneous lymphomas. The neoplasm tends to affect elderly patients, who usually present with skin lesions but often have a disseminated disease, including bone marrow involvement. Although the lesions are composed of cells with a lymphoblast-like morphology and an NK-cell phenotype, exhibiting a CD4+, CD56+ positive immunophenotype, recent studies support a relationship to plasmacytoid dendritic cells. Because of the rarity of this disease, we describe two patients suffering a CD4+/CD56+ hematodermic neoplasm.

Cutaneous plasmacytosis associated with lung and anal carcinomas

Cutaneous plasmacytosis is a rare disorder characterized by a benign proliferation of mature plasma cells that appears as multiple dark-brown to purplish skin lesions, often associated with polyclonal hypergammaglobulinaemia. We present the case of a 55-year-old Caucasian man who suffered from a cutaneous plasmacytosis associated with two different carcinomas. Cutaneous plasmacytosis seems to be a reactive process because most cases reported are not associated with any apparent underlying disease. Nevertheless, because few reported cases were associated with malignancies, screening of additional neoplasms would be justified.

[Neuropsychological impairment in patients with intracranial aneurysms: surgical versus endovascular treatment]

OBJECTIVES

To describe the neuropsychological status of patients with intracranial aneurysms and to compare the cognitive status of patients with intracranial aneurysm treated by surgical or endovascular methods.

MATERIAL AND METHODS

Ninety-three cases with intracranial aneurysms treated with surgery (n = 56) or embolization (n = 37) were included. A neuropsychological assessment was applied to both groups retrospectively, at least one year after treatment.

RESULTS

Neuropsychological impairment was found in both groups. 35.7% of the patients treated with surgery and 43.2%, of those treated with embolization did not show any cognitive impairment. Visual Memory and Cued Recall of verbal information are better in patients treated by embolization.

CONCLUSIONS

Our results show that a large proportion of patients with intracranial aneurysms have cognitive impairment after treatment. Endovascular management may cause less impairment in visual and verbal memory. However, bleeding may be the most important factor to explain these cognitive impairments.

Adal-1 bioadhesive for sutureless recession muscle surgery: a clinical trial

AIMS

To evaluate the efficacy and biotolerance of the Adal-1 adhesive for muscle sealing in strabismus surgery.

METHODS

27 eyes were included in the study: 17 in the control group and 10 in the study group. Surgery was performed on the recession of the horizontal rectus muscles. In the control group the muscle was joined to the sclera by a Vicryl 7/0 suture. In the study group, the Adal-1 adhesive was used instead. The efficacy of the sealing of the muscle to the sclera and the biotolerance of the surrounding tissues were evaluated.

RESULTS

The muscular recession in the control group was 8.17 (SD 2.38) with displacement of the sealing point of 0.02 (1.7) mm. In the group sealed with adhesive, the muscular recession was 9.09 (3.08) and the displacement was 0.15 (1.56) mm, with no significant differences between the techniques (p<0.05). The inflammation of the surrounding tissues in the immediate postoperative period was greater with the suture technique (p>0.05), but there were no differences in the other postoperative periods (Mann-Whitney U test).

CONCLUSION

Adal-1 was an effective and safe alternative to sutures in muscle recession for strabismus surgery in this study.

Clinico-pathological analysis of the cutaneous lesions of a patient with type I pseudohypoaldosteronism

The autosomal recessive form of type I pseudohypoaldosteronism (PHA-I) is an unusual disorder characterized by aldosterone resistance at the target organs, which leads to an excessive loss of sodium chloride through urine, sweat and saliva, among other secretions. Such a high concentration of salt in the sweat during the depletive crises directly causes inflammation and damage in the eccrine structures, with cutaneous lesions similar to those appearing in miliaria rubra. We report an autosomal recessive PHA-I in a 4-year-old girl, with cutaneous lesions mimicking miliaria rubra, that improved after treatment with astringent solutions and avoidance of profuse sweating.

Clinicopathological and immunohistochemical analysis of 20 cases of Merkel cell carcinoma in search of prognostic markers

AIMS

To evaluate the clinicopathological and immunohistochemical characteristics of Merkel cell carcinoma (MCC) in an attempt to find new, potentially significant, prognostic markers.

METHODS AND RESULTS

Clinical data and follow-up, histopathological features (pattern, cell size, thickness, mitoses, vascular invasion, lymphocytic infiltration) and immunohistochemical detection [CK20, thyroid transcription factor (TTF-1), chromogranin A, synaptophysin, p53, Ki67, Fli-1, CD99, c-Kit] were evaluated in 20 cases of MCC. Fli-1 and CD99 were detected in 90% and 55% of cases, respectively. Tumour size>30 mm, stage II, 'absent' lymphocytic infiltration, and the presence of>50% of Ki67+ tumour cells, were found to be prognostic indicators of disease-free interval (DFI), but only 'absent' lymphocytic infiltration constituted an independent prognostic factor of DFI after multivariate analysis. For overall survival, the same variables, together with local recurrence and lymph node involvement, had prognostic significance, with only local recurrence as an independent prognostic factor after multivariate analysis.

CONCLUSIONS

Absence of lymphocytic infiltration and Ki67 immunoreactivity in more than 50% of tumour cells should be evaluated in conjunction with other well-known prognostic markers in MCC. Furthermore, recognizing that Fli-1 and CD99 expression is commonly found in MCC by immunohistochemistry may avoid misinterpretation in the differential diagnosis of MCC with other small round cell tumours.

An amalgam tattoo on the oral mucosa related to a dental prosthesis

A 60-year-old woman presented with a pigmented lesion on the upper left gingival mucosa of 2 years duration. The lesion was in an area where a dental metallic prosthesis had been inserted into a nearby tooth several years earlier. A biopsy of the affected mucosa showed aggregates of pigmented granules varying in size in the dermis, extracellular matrix and within macrophages; these did not stain with melanin stains. The diagnosis was consistent with an amalgam tattoo.

[Factor V Leiden mutation as a cause of venous thrombosis]

INTRODUCTION

Venous thrombosis is infrequent in paediatrics. A lot of prothrombotic risk factors have been described. Disturbances of coagulation are present in more than half of children with stroke. Leiden V factor mutation is emphasized as one of the most common genetic cause of deep venous thrombosis in Caucasian children and adults, which represents 20-25%, depending on series.

CASE REPORT

Two years-old girl with hypoxic-ischemic disease and West syndrome, which presents a deep venous thrombosis in both legs. This evolved to gangrene, requiring surgical exceresis of scar and amputation of 2nd, 3rd and 4th fingers of left foot. She also presented a right frontoparietal intraparenchima haemorrhagic stroke with tetraventricular bleeding and hydrocephalus. It required an external ventricular derivation and later a Ventricular-peritoneal valve.

CONCLUSIONS

The coagulation study confirmed the Leiden V factor mutation in our patient. Later studies showed the same mutation in the father. The risk of recurrence and the severity of venous thrombosis indicate life antiaggregant treatment, currently maintained with aspirin.

Linear accelerator radiosurgery in treatment of central neurocytomas

OBJECTIVES

The purpose of this report was to review our experience with stereotactic radiosurgery in the management of patients with residual neurocytomas after initial surgery.

METHODS

Between October 1996 and December 2001, four patients with central neurocytoma were treated by surgery and subsequently underwent linear accelerator (LINAC) radiosurgery.

RESULTS

Two of the patients were cured, one exhibited a significant reduction in tumour size and the fourth remains stable. All four patients are alive and well.

CONCLUSIONS

In cases of small residual tumours or recurrences radiosurgery allows open surgery to be avoided and is a safe and potentially effective approach.

Mucinous eccrine nevus: an unusual lesion in a child

Mucinous eccrine nevus has been described as a variant of eccrine nevus. Only one instance of this variant, diagnosed in a 47-year-old woman, has been reported. We report a 2-year-old girl who had two 1 cm, asymptomatic, brownish nodules. Histologic analysis revealed a dermal lobulated proliferation of eccrine structures surrounded by a prominent mucinous stroma. This is thus, to the best of our knowledge, the first case of this extremely rare entity in a child.

An exploratory multivariate approach to drug consumption patterns in young people based on primary socialization theory

Drug consumption patterns and their psychosocial conditioning factors are explored on the basis of Primary Socialization Theory (PST), through the application of a questionnaire to a representative sample (N= 650) of the young population (age 15 to 29 years) in the Madrid Region. Cluster analysis identifies five consumption groups. Discriminant analysis, including indicators about subject's integration in primary socialization environments, beliefs about the effects of drugs, indicators of psychosocial wellbeing, and variables related to leisure time, allows 67.45% of correct consumption group prediction. Complex associations between drug use, socialization environments and psychosocial wellbeing are found, calling into question approaches establishing cumulative or unidimensional relationships between posited "risk factors" and drug consumption.

Organ donation and family decision-making within the Spanish donation system

This study analyses the variables associated with the decisions made by families of potential organ donors to give or deny consent for the extraction of organs. Different indicators were recorded in 68 cases of family interview for petition of consent carried out in 13 Spanish hospitals. Those variables showing the strongest relation with family decision (donation/refusal of consent) are knowledge shown by the family about the deceased's wishes with regard to donation (p<0.001), family relationship climate (p<0.01), expression of family's satisfaction level with medical attention received (p<0.01) and number of relatives present at the consent request interview (p<0.01). Logistic regression on family decision with considered variables correctly predicted relatives' final choice in 98.4% of cases. In turn, multivariate exploratory analysis highlights a potential association between the expression of the deceased's wishes and several concurrent variables in the process (satisfaction with personal treatment and medical attention received, emotional reactions in the interviews of notification of death and consent request). It also shows that patterns of reaction and family participation in this process may vary according to the sex of the deceased relative. Results suggest that both educational efforts devoted to promoting a positive attitude toward donation in the general population and the training of health professionals involved in the generation of organs may be key factors in reducing organ shortage.

Neurobehavioural and cognitive profile of traumatic brain injury patients at risk for depression and suicide

The possibility that patients who have suffered a traumatic brain injury will commit suicide is high, and in many cases clinicians tend to underestimate this possibility. In this study, 39 consecutive patients are studied through a Rorschach technique more than 1.5 years after their hospital discharge. The data show that 48.6% of the patients fulfil the criteria that classifies them as depressive, and, of these, 65% are at clinical risk to commit suicide (33.3% of the total of TBI patients); 25.6% have not met the criteria of depression or suicidal tendencies, and another 25.6% show very low suicide tendency scores. Only 15.6% of the total patients presented only depression without risk of suicide. The neurobehavioural and cognitive profile of the TBI suicide-prone patient shows an emotional person with cognitive difficulties in how they interpret reality, the person tries to understand what is happening around them, but is unable to cope. They show concrete thoughts, although they have difficulties solving problems and have few intellectual resources to cope with their surroundings. They do not know how to distance themselves from the emotional aspects of situations.

[Melanocytic schwannoma. A case report and review of the literature]

INTRODUCTION AND CLINICAL CASE

We report a new unusual case of a patient without known familiar history of melanocytic schwannoma or Carney complex with multiple melanocytic schwannoma in the spinal canal. Histologically, the tumor was composed of irregular interlacing spindle-shaped cells with pigments. The diagnosis is made by immunohistochemical techniques and electron microscopy findings.

CONCLUSION

We review the literature, and the different theories on the origin of these tumors are discussed.

Sources of influence on medical practice

OBJECTIVES

To explore the opinion of general practitioners on the importance and legitimacy of sources of influence on medical practice.

METHODS

General practitioners (n=723) assigned to Primary Care Teams (PCTs) in two Spanish regions were randomly selected to participate in this study. A self administered questionnaire was sent by mail and collected by hand. The dependent variable collected the opinion on different sources that exert influence on medical practice. Importance was measured with a 9 item scale while legitimacy was evaluated with 16 items measured with a 1 to 7 point Likert scale.

RESULTS

The most important and legitimate sources of influence according to general practitioners were: training courses and scientific articles, designing self developed protocols and discussing with colleagues. The worst evaluated were: financial incentives and the role played by the pharmaceutical industry.

CONCLUSIONS

The development of medical practice is determined by many factors, grouped around three big areas: organisational setting, professional system and social setting. The medical professional system is the one considered as being the most important and legitimate by general practitioners. Other strategies of influence, considered to be very important by the predominant management culture (financial incentives), are not considered to be so by general practitioners. These results, however, are not completely reliable as regards the real network of influences existing in medical practice, which reflect instead different "value systems".

Immunohistochemical localisation of rabbit haemorrhagic disease virus VP-60 antigen in early infection of young and adult rabbits

This study evaluated the time course distribution of rabbit haemorrhagic disease virus (RHDV) structural protein VP60 in tissues from experimentally infected rabbits from three different age groups. Viral VP60 antigen could not be detected in tissue samples from animals under four weeks, and only a few hepatocytes (0.01 to 0.2 per cent) were stained in the 6-week-old animals. A 6-week-old rabbit euthanised at 72 hpi showed VP60-labelling in hepatocytes and macrophages close to areas of inflammation. Viral VP60 antigen was detected as early as 12 hpi in a few hepatocytes (0.03 per cent) from adult animals. Within this age group, the extent of hepatocyte labelling considerably increased at 18 (3.0 per cent), 24 (25.5 per cent), 36 (50 per cent) and 48 (60 per cent) hpi. Extrahepatic viral VP60 antigen was also detected at 36 and 48 hpi in spleen macrophages and lymphocytes from adult rabbits. These findings support the hypothesis that the hepatocyte is the only cell type in the liver able to support RHDV replication almost immediately after viral infection.

[Prevalence of hepatitis C virus genotypes: epidemiology and histologic characteristics]

OBJECTIVE

To analyse the prevalence of HCV genotypes among patients from Gran Canaria and the relation with the routes of viral transmission, date of primoinfection and severity of hepatic lesion.

PATIENTS AND METHODS

179 patients were studied. In 61 patients the date of exposure was determinate. Liver biopsies were obtained in 139 patients. Genotypes were determinate by reverse hybridisation using InnoLiPA genotyping kit (Innogenetics).

RESULTS

The distribution of genotypes was: 1b, 114 (63.7%), 1a, 30 (16.7%); 1, 17 (9.5%); 3a, 7 (3.9%); 4c/4d, 6 (3.3%); 2, 1 (0.5%); 2a/2c, 2 (1.1%), 3, 1 (0.5%) and 4f, 1 (0.5%). We did not find any case of coinfection with a second genotype. In univariable analysis, we found statistically differences in sex (78.9% of women infected with genotype 1b compared with 55.1% of men, p < 0.01 and 31.6% of men infected with 1a, 3a and 4c/4d compared with 15.7% of women, p < 0.01) and age (median age in genotype 1b 45 +/- 12 years vs 36 +/- 9 years in the other genotypes, p < 0.01). HCV subtypes 1a and 3a were predominant in patients IVDA (47.6% and 23.85% respectively) and 1b in blood transfusion receptors (71.2%) (p < 0.01). In 40.2% of the patients, the sources of infection were unknown. In the multivariable logistical regression analysis we found the only factor influencing the genotypes distribution was the transmission mechanism (p < 0.001) and sex and age are relationated with the transmission mode. The media infection duration in patients infected with 1b was 22 +/- 11 years vs 9 +/- 6 years in the other genotypes. We found differences in the liver histologic findings and the age of the patient, but not in the different genotypes.

CONCLUSIONS

Our study reflects the higher frequency of HCV subtype 1b in our area and a different prevalence of genotypes in relation to mode of transmission. Our results suggest that in our media the liver damage seems to be directly influenced by the age of the patient, but not influenced by HCV genotype.