[Spondylodiscitis without fever: a diagnostic challenge]

HISTORY AND CLINICAL FINDINGS

Three patients with different forms of vertebral osteomyelitis are presented, two with hematogenous infections caused by Streptococcus pneumoniae and Staphylococcus aureus and one with postsurgical infection after excision of a vertebral disc caused by coagulase-negative staphylococci. None of the patients was initially febrile, but all had localized back pain and a restricted range of movement of the vertebral column. EXAMINATIONS, DIAGNOSIS: In all three patients the MRI of the affected vertebral column was consistent with vertebral osteomyelitis. Microbiological diagnosis was made by bone biopsy in all patients and by blood cultures in two of them.

TREATMENT AND COURSE

Antibiotics were administered for 4-6 weeks. At follow-up two patients were without symptoms, but the third patient had persistent back pain without radiological signs of vertebral osteomyelitis.

CONCLUSION

In patients with localized back pain vertebral osteomyelitis should be included in the differential diagnosis, even if there is no fever and no increase in white cell count, the erythrocyte sedimentation rate or C-reactive protein level and radiography is normal. Specific bacterial diagnosis should be made by multiple bone biopsy or blood cultures, before starting appropriate antibiotics.

[Angiosarcoma]

Angiosarcomas are rare tumors accounting for 1-2% of all soft tissue sarcomas. Nonetheless a dermatologist needs to be knowledgeable about this tumor because the prognosis is particularly poor. Angiosarcoma favors superficial soft tissues and skin (60%) with a clear predilection for the head and neck region. The average age of the patients presenting with cutaneous angiosarcomas is around 70 years with a peak incidence in the 8th decade. However, some subtypes may occur in children and adolescents. Secondary angiosarcoma after tissue-conserving radiation therapy for carcinoma of the breast represents an increasing problem, both the differentiation between atypical vascular lesions and true aggressive angiosarcoma and the therapy are challenging. The prognosis for angiosarcoma patients is gloomy despite all therapeutic efforts. Only early therapy seems to influence the outcome at all. There are some established guidelines for the primary and palliative therapy. Interesting new options of biomodulatory and molecularly targeted therapy can be envisioned.

Somatic FGFR3 and PIK3CA mutations are present in familial seborrhoeic keratoses

BACKGROUND

Seborrhoeic keratosis (SK) represents one of the most common benign skin tumours. Familial occurrence of multiple SKs has been reported, but the genetic basis of these SKs has not been investigated so far. We present a German family with at least seven affected members in two generations and occurrence of high numbers of SKs at an unusually young age, suggesting a hereditary background.

OBJECTIVES

Because FGFR3 and PIK3CA mutations have been reported to be involved in the pathogenesis of sporadic SK, we analysed five SKs of an affected family member for hotspot mutations of these genes.

METHODS

A SNaPshot multiplex assay was used for analysis of 11 previously described FGFR3 hotspot mutations. In addition, exon 9 of PIK3CA was directly sequenced and the H1047R hotspot mutation in exon 20 was analysed by a SNaPshot assay.

RESULTS

FGFR3 mutations were present in three of five SKs. One SK with a FGFR3 mutation additionally showed a hotspot PIK3CA mutation. None of these mutations was present in the germline.

CONCLUSIONS

The results show that this case of familial SK reveals the same mutational spectrum as sporadic SK. Because FGFR3 and PIK3CA germline mutations can be excluded as an underlying genetic basis, alternative mechanisms have to contribute to familial SK such as inherited susceptibility factors predisposing to the acquisition of somatic FGFR3 and PIK3CA mutations in skin, or increased exposure of the family members to yet unknown environmental risk factors causing these mutations.

Evaluation of the autonomic nervous system using the FAN device -- range of normal and examples of abnormal

Different components of the autonomic nervous system may be affected by different disorders to varying degrees. The aim of this study is to report first experiences with a new device (FAN®, Schwarzer, Germany) which measures heart rate variability (HRV), sympathetic skin responses (SSR) and the pulse wave transit time (PTT). We examined 190 healthy volunteers (102 men, 88 women) and in 89 subjects (46 men, 43 women) PTT during VM was investigated. In a subset of 24 subjects PTT was compared to conventional blood pressure recording. Thereafter, normal data were compared to patients with polyneuropathy (PNP) and Parkinson syndromes. All parameters of HRV decreased with age. 6 parameters for HRV at rest, during deep respiration and the valsalva ratio were reclassified into three age categories: under 40 (n=96), 40 – 60 (n=71) and 60 or older (n=23). Applying the lower limits of normal (5%-tile) subjects did not have more than 2 of these 6 parameters in the pathological range PTT reduction during phase IV of the valsalva manoeuvre was greater than 7.7 ms (5%-tile) but not age dependent. Patients with PNP had reduced HRV and SSR, Parkinson patients had more frequently impaired blood pressure regulation according to PTT assessment. Our investigation shows that the FAN® might be useful for clinicians to detect autonomic disorders.

Pituitary function and the somatotrophic system in patients with idiopathic Parkinson's disease under chronic dopaminergic therapy

Idiopathic Parkinson's disease and dopaminergic medication may influence pituitary hormone secretion. The present study aimed to reveal any abnormalities of the somatotrophic system induced by the disease itself and/or the dopaminergic therapy. Investigations of other pituitary hormones under basal and stimulated conditions, as well as an analysis of body composition, were also performed. This was a controlled diagnostic study in which luteinising hormone-releasing hormone, thyroid-releasing hormone, corticotrophin-releasing hormone and arginine hydrochloride were administered to ten patients with idiopathic Parkinson's disease under dopaminergic medication. Basal and stimulated hormone concentrations and bioelectrical impedance analyses were compared with those of healthy, age-matched controls. Basal growth hormone (GH) at -30 and 0 min was higher in Parkinsonian patients (2.74 +/- 3.79 ng/ml versus 0.53 +/- 0.10 ng/ml and 2.12 +/- 2.44 ng/ml versus 0.51 +/- 0.03 ng/ml; P < 0.05). The area under the GH curve after stimulation was greater in Parkinsonian patients (502.4 +/- 202.6 ng x min/ml versus 312.0 +/- 98.5 ng x min/ml; P < 0.05), depending on higher basal GH levels, rather than a greater arginine response. No differences in insulin growth factor (IGF)-1 or IGF-BP3 concentrations were detected. There were no differences between the groups in basal and stimulated gonadotrophic, corticotrophic and thyrotrophic function, or body composition. Prolactin was below the detection limit in the patients during the course of the study. Parkinsonian patients experience marked hypoprolactinaemia and repeated stimulation of GH secretion during chronic dopaminergic therapy. Our findings suggest a peripheral GH resistance in these chronically-treated patients.

Diagnostik und Therapie des Karpaltunnelsyndroms

Evidence-based supradisciplinary guideline that deals with the epidemiology, pathogenesis, symptoms, clinical and electrophysiological diagnosis, supplementary imaging investigations, differential diagnosis, conservative and surgical treatments, prognosis and course along with complications and revision surgery. The recommendations on investigation and treatment are based on a comprehensive literature search with critical evaluation and two consensus methods (expert group and Delphi technique) within the participating specialist societies. Besides this long version, a short version and a patient version can be viewed through the AWMF platform. The development of the guideline and the methodological foundations are documented in a method report. MAIN STATEMENTS: Apart from an accurate history and clinical neurological examination (including clinical tests), electrophysiological investigations (distal motor latency and sensory neurography) are particularly important. Radiography, MRI, high-resolution ultrasonography can be regarded as optional supplementary investigations. Among conservative treatment methods, treatment with a nocturnal splint and local infiltration of a corticosteroid preparation are effective. Oral steroids, splinting and ultrasound showed only short-term benefit. Surgical treatment is clearly superior to all other methods. Open and endoscopic procedures (when the endoscopic surgeon has sufficient experience) are equivalent. A routine epineurotomy and interfascicular neurolysis cannot be recommended. Early functional treatment postoperatively is important.

Dose-intensified bi-weekly temozolomide in patients with asymptomatic brain metastases from malignant melanoma: a phase II DeCOG/ADO study

BACKGROUND

Temozolomide has shown some efficacy in metastatic melanoma and recently received extended approval to treat brain tumours. The purpose of this study was to test a dose-intensified regimen of temozolomide in melanoma patients with brain metastases in a prospective, open-label, multicentre phase II trial.

PATIENTS AND METHODS

Forty-five patients with asymptomatic brain metastases from melanoma were stratified into arm A (no prior chemotherapy; n = 21) and arm B (previous chemotherapy; n = 24). Patients received oral temozolomide either 150 mg/m(2)/day (arm A) or 125 mg/m(2)/day (arm B), days 1-7 and 15-21, every 28 days. The primary study end point was objective response, and secondary end points were overall survival and safety.

RESULTS

Two patients (4.4%) achieved a partial response (PR) in brain metastases (one in each arm), one of them (2.2%) also showing a PR in extracerebral disease. An additional five patients (11.1%; two in arm A, three in arm B) showed disease stabilisation (SD) in brain and other sites. However, 82% revealed progressive disease (PD) already evident 8 weeks after therapy initiation. Median survival time from therapy onset was 3.5 months (range 0.7-8.3; arm B) and 4.3 months (range 1.6-11.8; arm A), P = 0.43. Dose modifications and prolongations of therapy cycles due to toxicity were required in 20% of patients. Grade 3/4 toxicity was observed in one patient only (2.2%).

CONCLUSIONS

Oral administration of temozolomide given bi-weekly is well-tolerated in melanoma patients with cerebral involvement. However, the efficacy is limited, with lower than 5% objective responses observed in brain and extracerebral metastases.

Safety data on adjuvant treatment of cutaneous melanoma patients with interferon-alpha2b and pegylated interferon-alpha2b: An interim analysis of 285 patients treated in Germany

8561

Background: A multicenter, prospective randomized, phase III trial (EADO 2002/CMII) evaluating efficacy of interferon-a2b (IFNa) and of pegylated interferon-a2b (PEGIFNa) was carried out in cutaneous melanoma patients. Patients were eligible for this trial after local excision of an intermediate risk cutaneous melanoma (tumor thickness >1,5mm) & the absence of regional nodal macrometastases). Methods: Interferon-a2b (IFNa) for 18 months (3x3MIU sc/week), and pegylated interferon-a2b (PEGIFNa) for 36 months (100 μg sc/week) were evaluated in 285 patients treated in Germany; 141 pts treated with PEGIFNa and 144 pts with IFNa. Safety data was analyzed and adverse events of the IFN-a treatment were monitored. Results: All relevant AEs appeared within the first year of treatment. The leading clinical adverse events observed in both arms were fatigue (27.7%) & myalgia (19.7%) (NCI-CTC2–3). There were no significant differences between both treatment arms in frequency and intensity for depression, fever, weight loss, erythema at injection site, nausea, constipation, hair loss, pain, cardiovascular function, pulmonal & nervous status (NCI-CTC2–3). There were no significant differences in terms of anemia, thrombocytopenia, bilirubinaemia, SGOT, SGPT, BUN & proteinaemia (NCI-CTC3). Leukocytopenia (NCI-CTC3) occurred in 2.4% of all cases, and was observed more frequently in the PEGIFNa arm (3.1% vs. 0.8%; p=0.09). Granulocytopenia (NCI-CTC3) was present in 6.7% of all treated patients, appearing more frequent in the PEGIFNa arm (11.0% vs. 2.3%; p=0.05), also. One patient in the PEGIFNa arm developed a grade 4 leuko- and granulocytopenia. In another case in the IFNa arm a grade 4 increase of the SGPT was observed. In 23.7% of all treated patients a dose reduction was performed. Conclusions: Both PEGIFNa and IFNa are well tolerated using these regimens for these treatment durations. There were few differences in the tolerability between PEGIFNa 100 μg sc/week and IFNa 3x3MIU sc/week. Only an increased myelosuppressive effects such as leuko- and granulocytopenia have been observed. A prolongation of PEGIFNa treatment to 3 years was not associated with an increase in AEs.

No significant financial relationships to disclose.

Cutaneous pseudolymphoma induced by Cimicifuga racemosa

We report a 56-year-old female patient who presented with asymptomatic, localized erythematous plaques on arms and legs. Histologically, the diagnosis of pseudolymphoma (PL) was confirmed. Because of menopausal complaints, the patient had been taking Remifemin(R), a phytotherapeutical agent containing a standardized extract of black cohosh (Cimicifuga racemosa) rhizome for 1 year. Six months after initial administration of this herbal drug, first skin lesions appeared which continuously increased. Withdrawal of Remifemin resulted in regression and complete remission of the lesions within 12 weeks. To the best of our knowledge, this is the first report on cutaneous PL induced by a standardized extract of C. racemosa rhizoma. Thus, though claimed to be poor in adverse effects, the potency of phytotherapeutical agents to induce uncommon cutaneous eruptions needs to be taken into careful reconsideration since the course of cutaneous PL tends to be chronic and indolent if the causative agent is not discontinued.

Atom-molecule collisions in an optically trapped gas

Cold inelastic collisions between confined cesium (Cs) atoms and Cs2 molecules are investigated inside a CO2 laser dipole trap. Inelastic atom-molecule collisions can be observed and measured with a rate coefficient of approximately 2.6 x 10(-11) cm3 s(-1), mainly independent of the molecular rovibrational state populated. Lifetimes of purely atomic and molecular samples are essentially limited by rest gas collisions. The pure molecular trap lifetime ranges 0.3-1 s, 4 times smaller than the atomic one, as is also observed in a pure magnetic trap. We give an estimation of the inelastic molecule-molecule collision rate to be approximately 10(-11) cm3 s(-1).