[Imaging of osteoarticular diseases of the anterior chest wall]

The purpose of this paper is to present a pictorial display of osseous and articular lesions of the anterior chest wall. The role of CT and MR imaging in such disorders is emphasized. Imaging of the anterior thoracic wall by plain films is particularly difficult. However numerous disorders may be encountered. They include inflammatory hyperostosis and sclerosis of the clavicle and the sternum, condensing osteitis and post-traumatic osteolysis of the clavicle, radiation osteitis of the sternum and the ribs, septic arthritis of the sternoclavicular joint, primary and secondary tumors of the sternum and the ribs. We illustrate a spectrum of such lesions in which CT and MR imaging provides acute evaluation of both soft tissue and bone details.

[Spontaneous intraperitoneal perforation of the urinary bladder--a rare cause of acute abdomen. 2 case reports]

In the last ten years we have seen two cases from which we can prove that the cause of the acute abdomen was an intraperitoneal urinary bladder perforation. One had previously undergone radiation treatment of the abdomen and the other had a total abdominal hysterectomy.

Hemodialysis and hemoperfusion for treatment of valproic acid and gabapentin poisoning

A 31-y-old epileptic man developed coma and shock after suicidally ingesting large amounts of valproic acid and gabapentin. His peak valproic acid, level was 1306.9 micrograms/mL (therapeutic range = 30-100 micrograms/mL). His peak gabapentin level was 60.0 micrograms/mL (therapeutic range = 2.0-8.0 micrograms/mL). His hypotension was refractory to crystalloid and pressor infusions, but resolved during concurrent hemoperfusion and hemodialysis to enhance elimination of valproic acid. Concurrent hemoperfusion and hemodialysis, in series, produced a maximum valproic acid plasma clearance of 55.4 mL/min versus a maximum reported intrinsic valproic acid plasma clearance of 10.6 mL/min. concurrent hemoperfusion and hemodialysis, in series, should be considered in hemodynamically unstable patients with valproic acid poisoning whose clinical condition is worsening in spite of aggressive supportive care.

Gabapentin, valproic acid, and ethanol intoxication: elevated blood levels with mild clinical effects

CASE REPORT

A suicidal, epileptic patient ingested ethanol, valproic acid, and gabapentin, a new antiepileptic drug. He did well clinically despite elevated blood gabapentin, valproic acid, and ethanol.

CONCLUSIONS

Preliminary data from this case and one previous report indicate relatively mild clinical signs and symptoms with gabapentin poisoning.

Marijuana and hyperthermia

BACKGROUND

Animal and human laboratory studies suggest marijuana may cause hyperthermia. However, there are no clinical case reports of life-threatening hyperthermia associated with use of marijuana alone.

CASE REPORT

We report a patient who developed severe hyperthermia after smoking a marijuana cigarette and jogging on a warm day. He presented with delirium; hot, red, dry skin; and a rectal temperature of 41.7 degrees C. Historical and laboratory data indicated he had used cannabinoids and no other drugs. This is the first report of life-threatening hyperthermia temporally associated with use of marijuana alone.

Two inequivalent folding isomers of the three-way DNA junction with unpaired bases: sequence-dependence of the folded conformation

The global structures of three-way helical junctions in DNA that contain two unpaired bases at the point of strand exchange have been studied. All such junctions examined undergo a folding in the presence of metal ions, to a structure in which there is coaxial stacking of two helices, with the third at an acute angle. However there are potentially two isomers of this structure possible, which are stereochemically inequivalent. We find that the majority of sequences studied by us fold into the isomer in which the polarity of the bulge-containing strand passing from the unstacked to the stacked helix is 5' to 3'. However, some sequences adopt the alternative stacking isomer, in which the polarity of the bulged strand is 3' to 5'. These isomeric differences are in complete agreement with the findings from two other studies by NMR. In addition to the isomeric differences, we find significant sequence-dependent differences within series of junctions that adopt the same isomeric form in the presence of ions. We conclude that the folding of bulged three-way DNA junctions is highly sequence-dependent.

Wound botulism

Wound botulism is a rare infectious and toxicologic complication of trauma and i.v. drug abuse. Only 39 cases have been reported in detail in the English literature. This case report describes a patient with wound botulism who presented to four medical facilities before receiving definitive diagnosis and treatment. Although his history and physical examination were consistent with wound botulism, diagnosis and therapy were delayed because this rare disease was not considered initially in the differential diagnosis. Wound botulism should be considered in trauma patients and i.v. drug abusers who present with cranial nerve palsies and descending paresis.

Wound botulism

All published cases of wound botulism were reviewed to describe the epidemiology, clinical manifestations, diagnosis, and treatment of this rare infection. The MEDLINE data base of English-language literature was searched from 1966 to 1992, using the keywords "wound botulism". Cases published during this period were identified, and the bibliographies of these articles were used to identify cases published before MEDLINE's search limit of 1966. Because of the limited number of published cases, all were reviewed. Data related to epidemiology, clinical manifestations, diagnosis and treatment were collected on each case. When possible, cross-references from case series or reviews were used to corroborate and supplement data for a given case. There were 40 cases identified as wound botulism. The case fatality rate was 10%. The 36 survivors had significant morbidity requiring prolonged medical care. Wound botulism is a rare life-threatening complication of trauma and i.v. drug abuse. The diagnosis should be considered in any patient with either of these risk factors who develop paresis of cranial nerves and a descending pattern of weakness. Treatment, including administration of antitoxin, should be initiated prior to definitive diagnosis by microbiologic laboratory tests.

Delayed toxic acetaminophen level after initial four hour nontoxic level

Antidotal therapy for acetaminophen poisoning is routinely based on a single acetaminophen level obtained four or more hours after ingestion. Some experts recommend additional acetaminophen levels if there are coingestants. This case report describes a 20-year-old woman who ingested acetaminophen 13 g, propoxyphene napsylate 2 g and naproxen sodium 3.75 g. A 4.5 h acetaminophen level was 83.5 mg/L (nontoxic). A 6.75 h acetaminophen level was 124.6 mg/L (toxic). The patient was treated with N-acetylcysteine and recovered without sequelae. This is the first published report of a delayed toxic acetaminophen level occurring after an initial nontoxic level. Although rare, the possibility of a delayed peak acetaminophen level merits consideration, particularly with coingestions that delay gastric emptying.

Amelioration of nifedipine poisoning associated with glucagon therapy

Glucagon relieves calcium channel blocker-induced hypotension in animal studies. There are no published case reports of glucagon relieving hypotension in patients with calcium channel blocker poisoning. We describe a patient who developed hypotension after ingestion of 900 mg nifedipine. Therapy with IV lactated Ringer's solution and calcium chloride alone did not relieve his hypotension. However, hypotension rapidly resolved after the addition of IV glucagon therapy. This is the first case report of glucagon therapy at least temporally associated with relief of hypotension in a patient with calcium channel blocker poisoning. More research is needed to determine the appropriate role for glucagon in treating patients with calcium channel blocker poisoning.

Iodoquinol associated seizures and radiopacity

This case report describes seizures and encephalopathy in a nine year-old boy treated with iodoquinol for amebiasis. The toxicity of iodoquinol and other 8-hydroxyquinolines is discussed. The radiopacity of this medication, used worldwide for the treatment of diarrheal illnesses and dermatitis, may be diagnostically useful.

Suppression of the growth and export defects of an Escherichia coli secA(Ts) mutant by a gene cloned from Bacillus subtilis

A gene library of Bacillus subtilis chromosomal DNA was screened for genes capable of reverting the growth defects of the Escherichia coli secA51(Ts) mutant at 42 degrees C. A B. subtilis gene, designated csaA, was found to phenotypically suppress not only the growth defects of the E. coli mutant, but also to relieve the detrimental accumulation of precursors of exported proteins. The csaA gene encoded a protein of 15 kDa (137 amino acids) and was likely to be the distalmost member of an operon. No similarity to csaA was found among DNA or protein sequences deposited in databases. In contrast to other homologous or heterologous suppressors of the E. coli secA51(Ts) mutation, the csaA gene did not exert pleiotropic effects on either the E. coli secY24(Ts) or lep9(Ts) mutations. However, it restored the ability of a SecB-deficient mutant to grow on complex medium. It is proposed that CsaA serves as a molecular chaperone for exported proteins or alternatively acts by stabilizing the SecA protein.

Urine sampling in ambulatory women: midstream clean-catch versus catheterization

We conducted a study to determine if there were any significant differences in urinalyses or urine cultures obtained by midstream clean-catch (MSCC) urine sampling in comparison with in-and-out catheterization (CATH). One hundred five women with symptoms suggestive of a urinary tract infection were studied prospectively. Each woman had a MSCC urine sample obtained initially, followed by a CATH sample. The MSCC and CATH urine samples were analyzed and compared for urine culture, leukocyte esterase, nitrites, microscopic bacteriuria, and pyuria. Of the 105 patients, 42 (40%) had a culture-proven urinary tract infection. The concordance rates between MSCC and CATH urine cultures, nitrites, leukocyte esterase, significant microscopic bacteriuria, and pyuria were 96%, 94%, 93%, 90%, and 90%, respectively. There were no statistically significant differences between MSCC and CATH sensitivities, specificities, or positive or negative predictive values for any urinalysis variable (leukocyte esterase, nitrites, significant microscopic bacteriuria, or pyuria). We conclude that if proper MSCC technique is used, the differences between MSCC and CATH urinalyses or urine cultures do not appear to be significant in the majority of ambulatory women without active vaginal bleeding who present with symptoms suggestive of a urinary tract infection.