[A 52 year-old woman with fever, cough and dyspnoea]

A 52 year-old woman with gastric cancer treated with surgery and chemotherapy, is admitted in our Internal Medicine Department because of the presence of fever (max 41.2 degrees C), dyspnoea, non-productive cough and mental confusion. The anamnesis and the physical examination address to the diagnosis of CAP (Community-Acquired Pneumonia); in particular the alteration of consciousness and the onset of symptoms after the insertion of a nose-gastric tube let us to consider the diagnosis of aspiration pneumonia. The clinical presentation and radiological imaging (Rx and CT of thorax) suggest the pattern of bronchiolitis obliterans with organizing pneumonia (BOOP). BOOP is not a disease, but a non specific pattern of answer to a lung injury. It can be either idiopathic or associated with a variety of causes, such as infections, drugs, radiations and connective tissue diseases. Besides the clinical course is complicated by the onset of an ARDS (Adult Respiratory Distress Syndrome). The gold standard for the diagnosis is represented by lung biopsy with hystopathologic confirmation but, if it cannot be done, it's necessary to start immediately steroid therapy because BOOP may be fatal. The patient received antibiotic and steroid therapy with success.

[Multiple cerebral tuberculomas resistant to conventional therapy in an immunocompromised subject]

A 33 years old immunocompromised woman was admitted for a fever of unknown origin during the last five months. She referred a body temperature up to 38.3 degrees C, headache, weakness. The physical examination revealed right homonymous hemianopia, hyperreflexia and Babinski on her right side. A TC scan and a following bioptic specimen showed multiple cerebral tuberculomas. A conventional therapy was started but no significative improvement was observed. She was finally treated with interferon gamma and GM-CSF in addition to the therapy with an important regression of the lesions and significative improvement of the fever and neurological findings.

What is vertigo?

Vertigo is one of the types of dizziness with dysequilibrium, presyncope and lightheadedness. But what does vertigo mean? Vertigo indicates a sensation of false movement (generally described like a rotation) but sometimes the patient can describe it like a sensation of tilt. Instead, the word dizziness indicates a sensation of disturbed relation to surrounding objects in space with feelings of rotation or whirling characteristic of vertigo as well as non-rotatory swaying, weakness, faintness and unsteadiness characteristic of giddiness. In our review we describe, after brief considerations about functional anatomy of the vestibular system, the most important cause of vertigo considering the duration of the symptom; moreover we underline the importance of anamnesis and of the objective examination for a correct differential diagnosis of a dizzy patient. As to objective examination we describe the most important characteristics of nystagmus, that is the only objective sign in vertigo, of central and peripheral origin. At last we consider the most efficacious therapies, like as medications (specific and aspecific), surgery (conservative and destructive) and rehabilitation, in relation the characteristics and the causes of vertigo.

Benign paroxysmal positional vertigo: a comparative prospective study on the efficacy of Semont's maneuver and no treatment strategy

PURPOSE

The present study investigates the efficacy of Semont's repositioning liberatory maneuver by comparing it with no-treatment in a population of patients with benign paroxysmal positional vertigo (BPPV).

MATERIALS AND METHODS

In this randomised, controlled, 6-month efficacy trial, 40 patients affected by BPPV were treated with Semont's maneuver. Outcomes were measured subjectively by patients about their Activities of Daily Living (ADL) and quality of life, based on the "Vestibular Disorders Activities of Daily Living Scale". Results were compared to those obtained in 40 non-treated BPPV patients.

RESULTS

During the first month of the study, 92.5% of patients of Semont's group resolved their symptoms. Cure rates with Semont's maneuver were significantly higher than those obtained with no-therapy (92.5% versus 37.5%). Within a six month follow-up, relapse rates were lower among patients treated with Semont's maneuver than among the no-treated ones (5% versus 60%). All patients with a resolution of symptoms and a negative Dix-Hallpike's test presented a great improvement in daily activities and quality of life.

CONCLUSIONS

BPPV is easy to solve with a successful repositioning maneuver. Since BPPV is a very common cause of vertigo and can represent a medical emergency, we believe that it is of interest for every general practitioner to be able to promptly recognize this frequent balance disorder and to be able to treat a patient affected by BPPV with a safe repositioning maneuver.

Myiasis of a perineal fistula

We report a case of myiasis of a rectocutaneous fistula in a subject suffering from bone metastases after surgical resection of a neoplastic bladder. The fistula was infested by maggots identified as third-instar larvae of flies belonging to the family Sarcophagidae, genus Sarcophaga. The infestation was neither intestinal nor pseudointestinal; it was probably caused by a fly ovipositing on the fistula of the patient while having wound care at home, even though the possibility that the infestation might have occurred during hospitalization cannot be ruled out.

[A 74-year-old woman with macrocytic anemia]

A seventy-four years old woman is assessed for asthenia, fatigue, non ulcerous dyspepsia with macrocytic anemia. The patient's medical history taking in Binswanger disease--diagnosed 5 aa before-, epilepsy-2 aa before- and a previous episode of TVP of the left leg, suggested the hypothesis that a B12 deficiency, by a chronic gastritis, would involve an increase of homocysteine cause of the clinical manifestations of megaloblastic anemia, Binswanger disease, tardive epilepsy and previous TVP. The fisic and blood and instrumental exams confirmed the clinical diagnosis. The patient is having vitamin B12.

A rare anorectal malformation: a very large H-type fistula

A very large H-type rectovaginal fistula was observed in a 9-year-old girl. The diameter of the abnormal opening was about 15 mm. The fistulous tract originated from the stenotic segment 1 cm above the pectinate line of the anus and was connected to the back wall of the vagina. The patient underwent posterior sagittal transrectal surgery with a protecting colostomy. At present, she has good bowel function and sphincter control without recurrence of the fistula.

Association between multiple intestinal atresia and omphalocele: a case report

Multiple intestinal atresia is a rare disorder with vascular or hereditary etiology. So far, the occurrence of this malformation along with omphalocele has not been reported. We describe a boy born from a nonconsanguineous gypsy couple with intrauterine growth retardation, omphalocele, and multiple intestinal atresia from the pylorus to the rectum. The microscopic examination of the intestine shows multiple small lumina with a sieve-like appearance. This is characteristic of the hereditary atresias and suggests development of a defect in (re)canalization during embryogenesis. The association with omphalocele indicates a common developmental defect may be present.

Liver focal lesions and hepatocellular carcinoma in cirrhotic patients: from screening to diagnosis

This short review aims at pointing out the role of ultrasonography (US) as a valuable means for an early detection of liver focal lesions in cirrhotic patients. Among these lesions which may be benign and malignant, hepatocellular carcinoma (HCC) finds its place with an incidence in cirrhotic patients becoming higher as the time passes from the onset of cirrhosis. US is of fundamental importance in the regular screening of subjects with viral cirrhosis because of its sensitivity in evaluating focal lesions (79-82%); however, it is not yet the most valuable method for the diagnosis of HCC for which other diagnostic techniques are needed such as CT (Computerized Tomography), MR (Magnetic Resonance) and the US-guided fine-needle biopsy. In fact, the echo-structure of HCC varies with its dimensions and may mimic that of one of many other liver focal lesions. Lately, some new sonographic techniques have become available that can allow a more accurate investigation of HCC. Among them, the "Tissue Harmonic" and the "Pulse Inversion Imaging" techniques provide a better definition of the grey-scale image thus improving the conspicuity of focal lesions. Color and Power Doppler techniques, while allowing an accurate observation of the lesion vascularization, integrate the sonographic appearance of HCC. The enhancement of the US color Doppler signal obtainable by using echographic contrast agents, represents a further progress for a detailed observation of the focal lesions' micro-vascularization and, thus, for the HCC identification. Further advancements in terms of improvement of the image quality and characterization of the focal lesion are to be expected from the use of "Tissue Harmonic" and "Pulse Inversion Imaging" techniques associated with echographic contrast agents. However, the diagnosis of HCC still rests on the incontrovertible histological evidence obtained by echo-guided fine-needle biopsy.