Fibrotic disorders associated with methysergide therapy for headache

The radiographic findings of fibrosing mediastinitis

We retrospectively reviewed the radiographic findings of fibrosing mediastinitis (FM) in 33 patients. Imaging studies included chest radiographs, computed tomographic scans, magnetic resonance imaging examinations, esophograms, ventilation perfusion scans, angiograms, and venograms. Findings include bronchial narrowing in 11 patients (33 percent), pulmonary artery obstruction/narrowing in 6 patients (18 percent), esophageal narrowing in 3 patients (9 percent), and superior vena cava obstruction/narrowing in 13 patients (39 percent). Two distinctly different radiographic patterns were identified: a localized pattern seen in 27 patients (82 percent) that frequently contained calcification and a diffuse pattern seen in 6 patients (18 percent) that did not contain calcification. The localized pattern is most likely due to histoplasmosis and does not show radiographic evidence of improvement with steroid therapy. The diffuse pattern may more likely be truly idiopathic or of a noninfectious etiology. Several patients with the diffuse pattern showed radiographic evidence of improvement with steroid therapy.

Beethoven's renal disease based on his autopsy: a case of papillary necrosis

The autopsy report of Ludwig van Beethoven written by Dr Johann Wagner in 1827 reveals that he had renal calculi that had not been diagnosed during his lifetime, together with perirenal fibrosis. The most comprehensive interpretation of this autopsy finding is that the regular calcareous deposits in every one of his renal calices represented calcified necrotic papillae. Severe urinary obstruction or diabetes as possible causes of papillary necrosis were not present. Analgesic abuse because of headaches, back pain, and attacks of rheumatism or gout may be presumed on the basis of Beethoven's uncontrolled way of taking medication. Salicin, a commonly used analgesic substance of that time (dried and powdered willow bark), is able to cause papillary necrosis. Perirenal fibrosis may be due to chronic infection or drug intake. Beethoven's other well-known diseases are deafness caused by otosclerosis of the inner ear, relapsing attacks of diarrhea as the symptoms of irritable bowel syndrome, and liver cirrhosis following viral hepatitis and chronic alcohol consumption. Liver cirrhosis also may cause papillary necrosis. In Beethoven's case, renal papillary necrosis was most probably the consequence of analgesic abuse together with decompensated liver cirrhosis. The autopsy report of Beethoven is the first case of papillary necrosis recorded in the literature.

Inflammatory pseudotumor of the heart with vasculitis and venous thrombosis

Inflammatory pseudotumor (IPT) is a tumor-like reactive lesion of unknown etiology. An unusual case of intracardiac IPT with multisystemic involvement, including leukocytoclastic vasculitis, polyarthritis, and inferior vena cava thrombosis in a 17-year-old boy is reported. This unique combination may suggest that immune/autoimmune factors are important in the pathogenesis of IPT.

Xanthofibroma of the adrenal gland

The authors report on a 43-year-old woman who had undergone unilateral adrenalectomy for a right suprarenal mass. The removed specimen was histopathologically defined as xanthofibroma, a hitherto unpublished adrenal tumour. The connective tissue protein of this rare tumour contained great amounts of collagen, non-collagenous protein and elastin. The significance of such abnormal proliferation of fibrous tissue and the conventional sonographic and CT features of this neoplasm are discussed.

Pleuropulmonary disease associated with dopamine agonist therapy

Artificial dopamine agonists are widely employed for the treatment of idiopathic parkinsonism. Pleuropulmonary disease has previously been reported to occur with the use of bromocriptine and mesulergine. We report similar adverse effects induced by the newer agonists lisuride and cabergoline. All these agents are tetracyclic ergot derivatives. This suggests a causal link between ergot-derived dopamine agonists and pleuropulmonary disease.

Verapamil and migraine prophylaxis: mechanisms and efficacy

Calcium channel blockers have demonstrated efficacy in investigative use for prophylaxis of migraine and cluster headaches. In particular, verapamil, with its low side-effect profile, appears to be a promising alternative to the currently available agents for prophylactic treatment of chronic recurring headaches. Although its exact mechanisms of action in this application are unknown, verapamil exerts a vasodilatory effect on cerebral arteries and interacts with serotonergic systems involved in migraine pathogenesis. A review of studies from the past decade indicates that verapamil may be as effective as traditional therapies as prophylaxis for the major types of chronic recurring headache.

Scleroderma, fasciitis, and eosinophilia associated with the ingestion of tryptophan

An association between the ingestion tryptophan and a syndrome characterized by scleroderma-like skin abnormalities, fasciitis, and eosinophilia has recently been recognized in the United States. We report the clinical and histopathological findings in nine patients and the results of biochemical analyses of tryptophan metabolism in seven patients with this syndrome. Edema of the extremities, frequently accompanied by pruritus, paresthesia, and myalgia, developed in the nine patients (six women and three men; age range, 30 to 66 years) 1 to 18 months after the start of therapy with tryptophan (1.5 to 3.0 g daily) for insomnia, depression, or obesity. Five patients were taking drugs (benzodiazepines) known to inhibit hypothalamic-pituitary-adrenal function, and one had adrenal insufficiency. All had blood eosinophilia in the acute phase of their illness (mean eosinophil count [+/- SD], 3.62 +/- 2.87 X 10(9) cells per liter). All had histopathological changes in the dermis and subcutaneous tissue typical of scleroderma, and seven patients had eosinophils. The fascia was inflamed and fibrotic, and adjacent skeletal muscle often showed perifascicular inflammation. Tryptophan was discontinued in all patients, and eight received prednisone. The cutaneous symptoms improved, but only two patients had complete resolution of their illness. The patients had plasma levels of tryptophan before and after an oral dose of tryptophan that were similar to those in normal subjects. Plasma levels of L-kynurenine and quinolinic acid, which are metabolites of tryptophan, were significantly higher in four patients with active disease than in three patients studied after eosinophilia had resolved or in five normal subjects (P less than 0.001)--findings consistent with the activation of the enzyme indoleamine-2,3-dioxygenase. This illness resembles eosinophilic fasciitis and probably represents one aspect of the recently reported eosinophilia-myalgia syndrome. The development of the syndrome may result from a confluence of several factors, including the ingestion of tryptophan, exposure to agents that activate indoleamine-2,3-dioxygenase, and possibly, impaired function of the hypothalamic-pituitary-adrenal axis.

Hydralazine, hydrochlorothiazide and ampicillin associated with retroperitoneal fibrosis: case report

A case of retroperitoneal fibrosis possibly associated with hydralazine, hydrochlorothiazide and ampicillin therapy is reported.

Morphea after bromocriptine therapy

A 57-year-old man developed morphea while taking bromocriptine. This drug is a semisynthetic ergot alkaloid, one of a class of drugs that is associated with fibrotic disorders. Other agents known for such association are serotonin (5-hydroxytryptamine) and beta-adrenergic blockers. A common pathogenesis to link these agents to fibrosis remains uncertain.

Ileal carcinoid tumor complicated by retroperitoneal fibrosis and a prolactinoma

A patient with mid-gut carcinoid tumor and the unusual complication of retroperitoneal fibrosis was also found to have a prolactinoma. This case brings the number of reported mid-gut carcinoid tumors complicated by a second endocrine neoplasm to five. Three of the second tumors were parathyroid in origin, and the fourth was an insulinoma. In view of the rarity of second tumors and in the absence of documented familial occurrence, it is inappropriate to exhaustively study each person with mid-gut carcinoid tumor, or their families, for a second endocrine neoplasm; however, physicians caring for patients with mid-gut carcinoid should be aware that second tumors are possible. Retroperitoneal fibrosis is also a rare complication of carcinoid, but can be associated with renal failure that can be prevented by surgical intervention. Thus, physicians caring for patients with the carcinoid syndrome should also be aware of this complication.

A comparison of cytoplasmic immunoglobulins in retroperitoneal fibrosis and abdominal aortic aneurysms

Retroperitoneal fibrosis is associated with Riedel's thyroiditis, in which an unexpectedly high proportion of the plasma cells have been reported to contain IgA and lambda light chains. It has been suggested that retroperitoneal fibrosis and the inflammation and fibrosis in thick-walled abdominal aortic aneurysms are caused by a hypersensitivity reaction to antigens leaked from aortic atheroma. We examined cases of retroperitoneal fibrosis and aortic aneurysms in order to quantify the types of heavy and light chains in the plasma cells. A mean of 44% of the plasma cells contained IgA and 52% contained lambda light chain. These results provide further evidence of the pathological relationship between retroperitoneal fibrosis and Riedel's thyroiditis. It is suggested that a cross-reaction between antigens in mucosal surfaces and in the thyroid or retroperitoneum may be implicated, possibly involving vessel walls. Of the total plasma cells in the wall of the aortic aneurysms 24% contained IgA and 40% lambda, although there was a significant trend towards a higher proportion of IgA with increasing thickness of the wall. No definite support for a relationship between atheroma and retroperitoneal fibrosis is provided by this study.

Mediastinal and retroperitoneal fibrosis with fibrotic pulmonary nodules: a case report

We report a patient with a long history of pan-hypopituitarism treated with pituitary snuff who developed superior mediastinal fibrosis involving the visceral pericardium, retroperitoneal fibrosis, and a peculiar widespread nodular fibrosis of the lungs.

Simulation of acute myopericarditis by constrictive pericardial disease with endomyocardial fibrosis due to methysergide therapy

Methysergide ( Sansert ) has been associated with numerous fibrotic disorders. In particular, multiple cardiac lesions have been described in cases where methysergide was thought to have played a causative role. A patient is described who presented with cardiac findings suggestive of acute myopericarditis . An inflammatory myocarditis was subsequently excluded by endomyocardial biopsy. Hemodynamic findings suggested the presence of constrictive pericarditis or restrictive cardiomyopathy, or both. Radiographic evidence of constrictive pericarditis and biopsy evidence of endocardial fibrosis were documented in this patient with a long history of interrupted methysergide therapy.

Computed tomographic observations in periaortitis: a hypothesis

Eight patients with features of retroperitoneal fibrosis are presented. The computed tomographic findings in these patients demonstrate the different in vivo appearances which may be encountered. In all eight patients the fibrotic process was centred on the lower aorta and encompassed the common iliac arteries to a variable extent. In no patient was a predisposing cause found, although in two the aorta was aneurysmal. We believe that these appearances illustrate the range of a single condition, periaortitis, which may well be due to an immune reaction to atheromatous material.

Retroperitoneal fibrosis complicating Stage IB squamous cell carcinoma of the cervix

A patient with Stage IB squamous cell carcinoma of the cervix associated with benign retroperitoneal fibrosis and hydroureters is reported. It is suggested that staging laparotomy is indicated in such a case to assess whether hydroureters are related to benign fibrosis or cancer metastasis.

Multifocal fibrosclerosis associated with suprasellar and macular lesions

Multifocal fibrosclerosis is a term used to denote a combination of similar fibrous disorders occurring at different anatomical sites and including idiopathic mediastinal and retroperitoneal fibrosis, sclerosing cholangitis, Riedel's thyroiditis, and orbital pseudotumour. This paper reports a patient, known to have retroperitoneal and testicular fibrosis, who suffered visual loss resulting from marked changes in the macular region of one eye and suprasellar extension of a mass in the pituitary fossa. These lesions appear to represent very uncommon manifestations of multifocal fibrosclerosis.

Pleuropulmonary fibrosis associated with chronic and excessive intake of ergotamine

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Identification of adverse reactions to new drugs. II--How were 18 important adverse reactions discovered and with what delays?

The process of discovery of 18 important adverse drug reactions was reviewed. For each adverse reaction the dates were noted of the report which first alerted the medical profession to the suspected reaction, the report which resulted in verification of causality beyond reasonable doubt, and the first regulatory action or warning to the medical profession in Britain by the Committee on the Safety of Medicines.

The diagnosis and management of headaches in childhood

Chronic headaches are relatively common in children and adolescents. The majority of these are benign and do not reflect organic pathology. Diagnosis can usually be made by careful history and physical examination, and extensive laboratory investigations are rarely required. Most children can be managed with reassurance, simple analgesics, and mild sedation. For more severe cases, particularly of migraine, effective pharmacologic agents are available. The prognosis is favorable. Very few of these children go on to develop significant intracranial pathology, and the majority will remit spontaneously. A significant number, however, do have chronic headaches in adult life.

Recent advances in the treatment of Parkinson's disease: the role of bromocriptine

We have treated 102 Parkinson patients with bromocriptine for up to 6 years; most of these posed problems of management when referred to us. Forty-two continue to take bromocriptine, at a mean dose of 49 mg daily (range 10-160), in combination with some 50% of their previous optimal dose of levodopa (with or without a decarboxylase inhibitor). We consider the main indications for bromocriptine are severe dyskinesia, early morning dystonia, and "wearing off" reactions. Contraindications include hallucinations, delusions, substantial confusion, acute myocardial infarction, active peptic ulceration, and active pleuropulmonary disease.

Psychophysiological aspects of migraine headaches

So complex are migraine headaches that the interplay of both psychological and physiological components is needed to explain and relieve symptoms. The difficulties of defining and delimiting migraine attacks, etiological theories and treatment approaches were reviewed with emphasis on the psychosomatic aspects.

Orbital pseudotumour and lacrimal involvement developing in a patient with Riedel's struma receiving steroids

We present a patient with hypothyroidism secondary to Riedel's struma, treated with thyroxine and prednisolone, who developed clinical and radiological features of a unilateral orbital pseudotumour with lacrimal gland involvement; the histology of which was indistinguishable from that of the thyroid gland.

Retroperitoneal fibrosis and scleroderma

The association of retroperitoneal fibrosis and systemic sclerosis is reported from a patient positive for the HLA-B27 antigen. This appears to be the first report of such an association. Pathological features common to the 2 syndromes are discussed and the literature is reviewed.

Occult diverticulitis, a cause of retroperitoneal fibrosis

A case is reported in which extensive mesocolonic and retroperitoneal granulomatous and fibrotic disease were apparently due to occult diverticulitis. The patient later had a good result from aggressive but limited operation for obstructions of the ureter and colon.

[Toxic nephropathies (author's transl)]

Direct tubular damage, hypersensitivity reaction, metabolically mediated kidney disturbances, and chronic nephropathies are important sequelae of several drugs or their metabolites. In this review the drug-induced kidney disease is discussed from a clinical, histological, and pathogenetic point of view. The knowledge of possible nephrotoxic reactions and their underlying toxins are essential for prevention of this kidney disease.