Asymptomatic gastric perforation by a toothpick. A case report

BACKGROUND

Many cases of gastric perforation with peritonitis, pylephlebitis, hepatic abscesses, or lethal bleeding, caused by ingested long and sharp objects, are reported in the literature.

METHODS

During a right hepatectomy for a giant hemangioma, a wooden toothpick was found between the two layers of the hepatogastric ligament. It was not possible to find the passage of the foreign body through the gastric wall. The patient did not report any correlated symptoms.

RESULTS

There was no sign of inflammation around the toothpick, which was enveloped in thin scar tissue. The removal of the foreign body was performed without complications.

CONCLUSIONS

The peculiarity of our case is the total absence of symptoms during and after the perforation. Despite the benign evolution of our case, toothpicks must be considered as potentially dangerous, like other pointed objects, and, therefore, removed immediately.

Use of "Gore-Tex surgical membrane" to minimize surgical adhesions in multistaged extrathoracic esophageal elongation for esophageal atresia

The procedure of choice in the surgical correction of "long gap" esophageal atresia should, when possible, preserve the native esophagus. We present a modification of "the multistaged extrathoracic esophageal elongation method," designed to facilitate esophageal elongation and use of a Gore-Tex (W.L. Gore and Associates, Flagstaff, AZ) surgical membrane to minimize surgical adhesions. We used this technique to successfully treat a 1-kg infant, with type A esophageal atresia, associated aortic coartation, and severe necrotizing enterocolitis with multiple perforations. Multistaged extrathoracic esophageal elongation was begun at the age of 9 months and concluded at 17 months.

The role of 99mTc-tetrofosmin Pinhole-SPECT in breast cancer axillary lymph node staging

The number of metastatic axillary nodes represents one of the most important prognostic factors in preoperative breast cancer patients. 99mTc-Tetrofosmin high resolution Pinhole (P)-SPECT was employed in 112 patients, 100 with breast cancer and 12 with benign mammary lesions, to ascertain axillary lymph node involvement. Axillary P-SPECT images were acquired utilizing specific software connected to a circular high resolution, single-head gamma camera equipped with a pinhole collimator with aperture size of 4.45 mm, rotating 180 degrees around the involved axilla. At the same time, patients also underwent conventional SPECT and planar acquisitions. Per-patient sensitivity and specificity were 100% and 93.6% for P-SPECT, 96.2% and 93.6% for SPECT and 56.6% and 100% for planar imaging, respectively. Moreover, P-SPECT detected more than 51% of lesions ascertained by histology, whereas SPECT and planar detected 32.6% and 20.3%, respectively. Only P-SPECT succeeded in identifying the exact number of metastatic axillary lesions in patients with multiple nodes; this procedure was able to correctly differentiate 88.67% of patients with 3 or less nodes from those with more than 3, thus giving important prognostic information. These data suggest 99mTc-Tetrofosmin P-SPECT is a reliable imaging method both for staging and prognostic purposes in breast cancer, and its routine use is recommended.

Detection of same sized 4.3 Kb extrachromosomal DNA elements in weakly beta-haemolytic human intestinal spirochaetes and Serpulina pilosicoli of swine origin

Agarose gel electrophoresis of total DNA from Italian strains of weakly beta-haemolytic human intestinal spirochaetes (w beta HIS) and porcine Serpulina pilosicoli reference strain P43/6/78 showed an extrachromosomal band having the same size and migrating at 4.3 Kb. The same results were observed after agarose gel electrophoresis of DNA obtained from the supernatant fluids of the spirochaetal cultures analysed. Swine Serpulina hyodysenteriae reference strain P18A was comparatively analysed and a 6.5 Kb extrachromosomal DNA element was found, as expected. Furthermore, S. hyodysenteriae reference strain P18A differed from all the other spirochaetes tested and had a higher number of flagella (8-12) at each cell end and was strongly beta-haemolytic. To the best of our knowledge, this is the first report on the detection of a band of extrachromosomal DNA having the same size in w beta HIS and S. pilosicoli from swine origin.

Epidemiological trend of human leptospirosis in Italy between 1994 and 1996

In the three-year period 1994 1996, 222 reports on human cases of leptospirosis were received by the Italian Ministry of Health. The average annual number of reports was 29.2% lower than in the preceding eight years. In all cases but two the infections were thought to have been acquired in Italy. As in previous years, the majority of cases was observed in the northern regions of the country (83.8%), mostly in males (88.9%). Cases occurred in all age groups, but were more common in the working-age population (15-64 years). There was no common-source outbreaks. The typical leptospiral seasonal course, with a peak in August, was observed. During 1994, leptospirosis was the reported cause of death in 19 patients. Mortality was higher among males than females. The overall fatality rate was 22.6%. During the study period, a total of 126 cases of leptospirosis were confirmed by the National Centre for Leptospirosis or one of the 12 Regional Leptospira Laboratories. Of the 103 patients for whom information on place of residence, contact with animals, occupational and recreational activities was available, 98 (95.1%) were people who live in rural areas or devote themselves to occupational or recreational activities at risk. The likely source of infection and the mode of exposure were known for 55 patients. Forty-five patients (81.8%) were likely infected by contaminating water (43 cases) or soil (2 cases), ten (18.2%) by direct contact with animals or animal urine. Both running (51.2%) and stagnant water (27.9%) have been reported as a source of infection. Rodents were implicated in 50.0% of the 10 cases involving animals. In comparison with the preceding eight-year period, the risk of contracting leptospirosis was found to have increased for recreational activities (from 34.7 to 38.2%) and decreased for occupational activities (from 45.8 to 32.7%). A large number of infections, however, was ascribed to accidental events (25.5%). As in the previous period, besides fever, the involvement of the liver was the most frequent clinical manifestation (70.8%). Influenza-like symptoms were the only signs of illness in 15.1% of cases. Infections by 9 different serogroups were detected. The most frequent antibodies were those against serovars icterohaemorrhagiae, poi, copenhageni and brattislava. The presence of co-agglutinins against serovars belonging to different serogroups prevented the identification of the presumptive infecting serogroup in 19.8% of subjects.

Aggressive congenital fibromatosis of the small intestine in the newborn. Report of a case and review of the literature

A case of so-called congenital fibro(leio)myosarcoma of the small intestine in a 18-day-old female baby, treated only with surgical resection, was studied by immunohistochemistry and electron microscopy in order to investigate the proliferating cell type. The tumour cells showed positivity only for vimentin and CD 34 and were negative for smooth muscle actin, desmin, alpha-sarcomeric actin, factor VIIIR: Ag and S-100 protein. Ultrastructural findings showed oval nuclei with prominent nucleoli, rare intracytoplasmic mitochondria and well developed rough endoplasmic reticulum. According to histoimmunological and electron microscopy findings the proliferating cells were likely to be of fibroblastic origin. A 7-year follow-up showed a favourable clinical evolution thus confirming that surgical resection can be a sufficient therapeutic approach. The morphological findings and clinical behaviour suggest that more appropriate terminology for this tumour would be "aggressive congenital fibromatosis" which better highlights its local progressive invasion without metastases.

Detection of Mycobacterium bovis in bovine tissue samples by the Abbott LCx Mycobacterium tuberculosis assay and comparison with culture methods

A ligase chain reaction (LCR) DNA amplification method for the molecular diagnosis of Mycobacterium tuberculosis complex (Abbott LCx MTB) was evaluated in comparison with solid (Lowenstein Jensen), liquid (7H12, Bactec 460 system) phase culture and microscopic examination (ME) on 86 tissue samples collected from 86 intradermal tuberculin positive cattle and one pool from 4 guinea pigs experimentally infected with M. bovis. Overall, 48 samples (58.81%) were culturally positive for mycobacteria, and on the basis of biochemical characters, all the isolates were identified as M. bovis. Sensitivity was 83.92% for LCx, 53.57% for LJ, 85.71% for Bactec and 41.07% for ME. In 3 out of 25 "no visible lesion" tissue samples, M. bovis was detected only by LCx and Bactec but not by LJ and ME. The concordance in the determination of positives and negatives among the methods observed in pairs was calculated according to Cohen's K concordance coefficient and showed 81.1% of concordance of LCx vs Bactec, 68.8% LCx vs LJ, 72.2% LCx vs ME, 80.0% Bactec vs LJ, 66.7% Bactec vs ME, 85.5% LJ vs ME. Despite a certain variability in concordance rates, both Cohen's K concordance coefficients or standardized (Zk) values were statistically significant. Both LCx and Bactec appear not alternative but subsidiary to the other methods traditionally applied for direct diagnosis of bovine tuberculosis on tissue samples from cattle reacting to intradermal tuberculin test.

Congenital carotid-jugular fistula in an elderly patient

Carotid-jugular arteriovenous fistulas (AVF) are extremely rare with only 20 cases reported in the literature up to December 1996. The case of a 74-year-old man (the oldest reported in the literature) with abnormal communications between the external carotid artery and the internal jugular vein is reported. The condition was treated by platinum coil embolization via catheterization and by repeated operations to ligate the branches of the external carotid artery, besides removal of the tissue containing the fistula and ligation of the external carotid at its origin. The result was incomplete because about 6 months after the last operation the patient showed the same symptoms, although in a milder form. Until standard treatment is established, the appropriate technique should be decided on a patient-to-patient basis.

Detection of extrachromosomal DNA in Italian isolates of weakly beta-haemolytic human intestinal spirochaetes

Weakly beta-haemolytic human intestinal spirochaetes (w beta HIS) isolated in Italy showed an extrachromosomal band migrating at 4.3 kb after agarose gel electrophoresis of total DNA. The band was observed within 4 strains (HRM2, HRM4, HRM7 and HRM14) among the 7 w beta HIS analysed and was resistant to proteinase K and RNase treatment, whereas after purification it was completely digested by incubation with DNaseI. The origin, the structure and the significance of this extrachromosomal DNA are at present unknown. In addition to w beta HIS, the reference strain P18A of Serpulina hyodysenteriae was comparatively analysed and a 6.5 Kb extrachromosomal DNA element was found, as expected. This finding proves that the experimental conditions we used while searching for extrachromosomal DNA within w beta HIS were appropriate. To the best of our knowledge, this is the first report on the detection of extrachromosomal DNA from w beta HIS.

Tardive presentation of congenital cystic adenomatoid malformation of the lung

Congenital cystic adenomatoid malformation (CCAM) of the lung is a neonatal disease not often found after the first year of life and extremely rare in adults. Three cases of CCAM, one in a ten-year-old girl and two in adults, are reported. An understanding of this disease is important because, although relatively rare, it is one of the most frequent causes of neonatal respiratory distress. Greater awareness of the condition and its early detection would also reduce the number of cases found at a later age.

Cooperative haemolysis between weakly-beta haemolytic human intestinal spirochaetes and Clostridium perfringens

Interactions between human intestinal spirochaetes (HIS) related to intestinal spirochaetosis and intestinal pathogenic anaerobic bacteria were investigated by searching for the presence of cooperative haemolysis among 39 strains of weakly beta-haemolytic human intestinal spirochaetes and Clostridium perfringens alpha-toxin producers on plates carrying six different sheep blood agar media. An area of intense cooperative haemolysis (about 3-10 mm) was observed between all tested spirochaetal strains and C. perfringens where the clostridial alpha-toxin diffused toward the colonies of the spirochaetes overlapping part of their growth zone. The cooperative haemolysis was a potentiation of the haemolysis due to the single cultivation of human intestinal spirochaetes and C. perfringens and was observed after anaerobic incubation for 24-48 hours when both bacteria at a concentration range of 10(8)-10(3) CFU/ml were streaked at a distance of 3-10 mm to each other. A cooperative haemolysis was also observed between C. perfringens and weakly beta-haemolytic spirochaetes related to porcine and avian intestinal spirochaetosis and the spirochaete causing swine dysentery. The present study indicated that the damage produced in vitro by the clostridial alpha-toxin was enhanced only on the red blood cells which were in proximity to the HIS colonies causing the complete lysis of the erythrocytes. It is hence possible that the potentiation of the damage to red blood cells observed in vitro mimics an in vivo damage on the membranes of enterocytes to which HIS are attached when intestinal spirochaetosis occurs and when cytolysins similar to the alpha-toxin are available in the intestine of the host.

Evaluation of the Abbott LCx Mycobacterium tuberculosis assay in comparison with culture methods in selected Italian patients

A ligase chain reaction (LCR) DNA amplification method for the molecular diagnosis of Mycobacterium tuberculosis (Abbott LCx MTB) was evaluated in comparison with solid and liquid phase culture on 622 selected samples collected in two large Italian hospitals, of which 310 obtained from HIV-1 positive patients and 312 from HIV-negative individuals. The overall prevalence of mycobacteria by culture was 22% (137/622), and the apparent sensitivity and specificity of LCx vs. culture were 87.6% and 98.2%. Of the 26 culture positive/LCx negative samples, 22 were positive for MOTT and 4 for M. tuberculosis. All 9 samples positive by LCx and negative by culture were classified as true positive by clinical criteria. The final values of sensitivity, specificity, positive predictive value and negative predictive value for LCx rose to 96.8%, 100%, 100% and 99.2%, respectively. The adjusted sensitivity of culture methods was 89.5% for solid phase and 92.7% for Bactec. In view of the high sensitivity on both smear-positive (100%) and smear-negative (92.4%) samples and of the high negative predictive value, the LCR-based amplification method appears suitable as a routine screening method for the rapid diagnosis of M. tuberculosis in high-risk patients.

Role of reoperation in recurrence of adrenal cortical carcinoma: results from 188 cases collected in the Italian National Registry for Adrenal Cortical Carcinoma

BACKGROUND

Recurrence of adrenal cortical carcinoma (ACC) after radical surgery is a common finding. Although successful reoperations have been reported with encouraging results, most published experiences are anecdotal and based on few cases. We report the results of surgical treatment for recurrent ACC in a multiinstitutional series.

METHODS

One hundred eighty-eight cases of ACC were collected in a national registry. A complete follow-up was obtained in 179 cases. At initial diagnosis 92 patients had local disease (stage I or II). One hundred seventy patients underwent surgical treatment, considered radical in 140; in this group, recurrent disease was observed in 52 cases (37%) after a mean disease-free interval of 21.7 months.

RESULTS

Adjuvant chemotherapy was ineffective in ameliorating the prognosis. The mean survival in 20 patients who underwent reoperation was significantly higher (15.85 +/- 14.9 months) than in nonreoperated cases (3.2 +/- 2.9 months). Five-year actuarial survival in reoperated patients is significantly better than in nonreoperated patients (49.7% versus 8.3%, respectively).

CONCLUSIONS

Although the prognosis of this tumor is still poor, surgery is the only effective therapy; reoperation allows survival comparable to that observed in patients without recurrent disease. An aggressive strategy for recurrent ACC is advisable until prospective studies demonstrate a real effectiveness for chemotherapy.

Cooperative haemolysis between weakly beta-haemolytic human intestinal spirochaetes and Staphylococcus aureus

Weakly beta-haemolytic spirochaetes related to human intestinal spirochaetosis produced a cooperative haemolysis together with S. aureus consisting of an enhanced haemolysis in the zone of the spirochaetal growth which was overlapped by the zone of activity of the staphylococcal beta-haemolysin. The cooperative haemolysis was observed in sheep blood agar media when the concentration of spirochaetes ranged from 1.5 x 10(3) to 1.5 x 10(8) CFU/ml and the concentration of S. aureus from 4 x 10(3) to 4 x 10(8) CFU/ml. With the increase of the distance between the streaks of the spirochaetes and S. aureus from 3 to 10 mm, the period of incubation needed to observe the cooperative haemolysis also increased from 18 to 72 hours. When the spirochaetes and S. aureus were streaked at the same time and when S. aureus was streaked earlier than the spirochaetes, the phenomenon was observed after anaerobic incubation of the plates for 24-72 hours but not after incubation in 10% CO2 under atmospheric conditions. A cooperative haemolysis was also observed between S. aureus and spirochaetes related to the porcine and avian intestinal spirochaetosis and the spirochaete causing swine dysentery when the same experimental conditions were used which allowed an observation of the phenomenon involving human spirochaetes and S. aureus.

Videothoracoscopic removal of a mediastinal teratoma

We describe a case of a mature mediastinal teratoma resected by videothoracoscopy. This new procedure, now widely adopted for many intrathoracic conditions, has proved to be easy, safe, and advantageous also in the treatment of rare tumors, such as mature mediastinal teratomas. We recommend its use in all cases like the one described.

Biliary, anorectal and esophageal atresia: a new entity?

A unique case of newborn biliary atresia associated with esophageal atresia and tracheoesophageal fistula, ano-rectal atresia, Reovirus type 3 infection and an early switch of fetal into adult hemoglobin is reported. At birth, the infant, who had only one umbilical artery, was operated on by primary anastomosis of the esophagous, and descending colostomy. At six weeks of age the baby underwent a "Kasai hepatic portoenterostomy-Type I" for a EHBA Type III, Subtype C2, Subgroup O ("aplasia" of all extrahepatic biliary ducts, including the gallbladder). The absence of an artery branch for the left lobe of the liver was observed. Histologically, the liver showed a hyperplasia of the intrahepatic bile ducts due to persistence of an excess of embryologic bile ducts in "ductal plate malformation" (DPM). Specific Reovirus type 3 antibodies were found in both the mother's and baby's sera. In the postoperative period the infant developed rapid and severe liver failure and underwent a successful liver transplantation. Although in most cases EHBA appears to be a perinatal event due to a necro-inflammatory process of unknown etiology, cases associated with complex extrahepatic anomalies, may be due to different pathogenetic mechanisms supported by different causative agents operating very early in the fetal period. Viral infection seems to be the most reliable etiology.

Evaluation of the in vitro activity of seven selected antimicrobial agents to be used for the isolation of human intestinal spirochaetes

This study aimed at making a comparative assessment of the growth of pure cultures of Human Intestinal Spirochaetes (HIS) in a control medium without antibiotics and in media including antibiotics (spectinomycin, rifampin, colistin, polymyxin B, amphotericin B, vancomycin, spiramycin) whose use had been indicated in the literature in connection with the isolation of HIS or animal intestinal spirochaetes. All the strains of HIS tested grew in media to which appropriate concentrations of those drugs had been added giving a final number of CFU/ml +/- 10 times the number of CFU/ml observed in the control medium. These results indicate that a selective medium to be used for the isolation of HIS may include appropriate concentrations of one or more of the following antibiotics: spectinomycin (100-1,000 micrograms/ml), rifampin (10-30 micrograms/ml), vancomycin (6.25 micrograms/ml), colistin (6.25 micrograms/ml), polymyxin B (5 micrograms/ml), spiramycin (1-10 micrograms/ml) and amphotericin B (0.05-35 micrograms/ml).

Comparative growth of pure cultures of human intestinal spirochaetes on six selective media

The growth of pure cultures of 24 human intestinal spirochaetes (HIS) was analysed comparatively in six selective media with antibiotics and in a control medium without antibiotics. The selective media SR and SP were the only two media among the six tested which allowed the growth of all the strains studied. These media contained spectinomycin (400 micrograms/ml) and rifampin (30 micrograms/ml) (SR), and spectinomycin (400 micrograms/ml) and polymyxin B (5 micrograms/ml) (SP), respectively. Moreover, most of the strains tested showed in these two media a number of CFU/ml equal to, or, for a few strains, not more than ten-fold lower than that observed in the control medium. The other four selective media tested were: SRVC (spectinomycin 200 micrograms/ml; rifampin 12.5 micrograms/ml; vancomycin 6.25 micrograms/ml; colistin 6.25 micrograms/ml), CSp (colistin 6.25 micrograms/ml; spiramycin 25 micrograms/ml), SRSp (spectinomycin 200 micrograms/ml; rifampin 12.5 micrograms/ml; spiramycin 25 micrograms/ml) and SRVCSp (spectinomycin 200 micrograms/ml; rifampin 12.5 micrograms/ml; vancomycin 6.25 micrograms/ml; colistin 6.25 micrograms/ml; spiramycin 25 micrograms/ml). The growth of most of the spirochaetes was strongly reduced in the media SRVC, CSp, SRSp and SRVCSp. Furthermore, several of the 24 HIS examined did not grow in the medium SRVC (3 spirochaetes, 11%), CSp (15 spirochaetes, 62%), SRSp (17 spirochaetes, 70%), SRVCSp (19 spirochaetes, 79%). The results reported in this paper indicate that the media SR and SP, of the six selective media tested, may profitably be used in the isolation of HIS as they did not significantly affect the growth of the HIS tested.

A new approach to the problem of surgical wound infections in clean operations

A study was made of the risk factors causing a high incidence of surgical wound infections in clean operations. Identification of these factors in the preoperative stage allows the patients to be divided into two categories: a high risk (about 10% of patients for surgery) and low risk. By giving antibiotic prophylaxis only to patients at high risk, the incidence of postoperative infections can be reduced, decreasing the number of extra days in hospital and consequently lowering costs. This is a new approach to the problem of surgical wound infections since not only is it based on the usual classification of operations into clean, clean-contaminated, contaminated and dirty, but it also takes into account the defensive capacity of the target of the infection: the patient.

Asymptomatic carriage of intestinal Cryptosporidium in immunocompetent and immunodeficient children: a prospective study

Little information is available on asymptomatic carriage of Cryptosporidium in immunocompetent and immunodeficient children. We prospectively studied a group of asymptomatic children, 78 immunocompetent and 50 immunodeficient, to document the incidence of asymptomatic carriage of cryptosporidiosis in such a population. We also investigated whether the treatment of children who carried asymptomatic cryptosporidiosis could help in reducing their risk of gastrointestinal symptoms as well as the shedding of infectious oocysts. The occurrence of multiple infections with common intestinal pathogens including Giardia lamblia was also investigated. Asymptomatic cryptosporidiosis was documented in 6.4% of immunocompetent and 22% of immunodeficient children. In a control symptomatic population Cryptosporidium was found in 4.4% of immunocompetent and 4.8% of immunodeficient children. Asymptomatic carriage of Cryptosporidium was documented in 2 human immunodeficiency virus-infected children, one of whom also carried Giardia asymptomatically. Treatment with spiramycin (100 mg/kg daily for 14 days) reduced significantly the duration of the shedding of potentially infectious oocysts. Finally no gastrointestinal symptoms developed in children treated for asymptomatic infection with Cryptosporidium, whereas children who were not treated developed gastrointestinal symptoms.

Labial mucosa and combined labial/bladder mucosa free graft for urethral reconstruction

One-stage urethral reconstruction was performed using a free graft of labial mucosa and combined labial/bladder mucosa. We present the results of this technique in 12 cases that had a minimum follow-up period of 3 years. Eleven patients had medium penile or posterior hypospadias and one had chordee penis without hypospadias. Urethroplasty with labial mucosa was performed by two techniques: labial mucosa used alone or combined with bladder mucosa. The labial mucosa was harvested from the inner surface of the upper and/or lower lip, depending on which method was used. Seven patients, six with medium penile or posterior hypospadias and 1 with chordee without hypospadias, were given a labial mucosa graft alone; the urethral gap was 3.5 to 6 cm. The other five cases, all with posterior hypospadias, were treated by combined labial/bladder mucosa graft urethroplasty: the urethral gap was 6 to 13 cm. Follow-up (at 3 to 4 1/2 years) showed no complications apart from a urethral fistula in one patient and mild stenosis on the anastomosis in four cases, which required urethral dilatations in the first month after surgery.

Prevalence of anti-Toxoplasma gondii antibodies in the population of the area of Parma (Italy)

Between 1987 and 1991, the prevalence of IgG antibodies to Toxoplasma gondii was determined by ELISA in 28,247 serum samples belonging to 19,432 subjects of the area of Parma (Italy). The overall prevalence was 48.5%. The correlation of infection with age, performed on 420 sera, showed a significant increase of positivity until 30-40 approximately years. In consecutive sera obtained from 172 subjects, the IgG and IgM production was analyzed for about 8 months, and four different patterns were delineated which were comprehensive of the wide range of immunological responses to Toxoplasma gondii exposure observed. Among pregnant females the prevalence of anti-Toxoplasma gondii antibodies was 48.7%, and 5 cases of seroconversion during the pregnancy were observed (0.27%) from which two cases of congenital toxoplasmosis originated.

[Mammary secretion: retrospective study of diagnostic and therapeutic problems]

Nipple secretion is an important clinical symptom in the context of breast pathology second only, in terms of incidence and diagnostic role, to the presence of a mammary nodule. Its importance derives from its possible association with cancer (from 3% to 47%) of which it may be the earliest sign, even if it is most often in relation to a benign pathology. The authors report their experience from 1988 to the present in 60 cases of mammary secretion out of 1200 patients attending the clinic.