[A Rare Cause for B Symptoms]

A Rare Cause for B Symptoms Abstract. The 78-year-old patient was referred by her general practitioner for a tumor search after a 3-month deterioration of her general condition, B-symptomatology, persistently elevated inflammation values, progressive anemia and renal insufficiency. Given the previously discovered pulmonary nodules and microhematuria, we suspected vasculitis proven by elevated MPO-ANCA levels and a kidney biopsy. Therapy with steroids and cyclophosphamide effected remission.

[Just Anorexia?]

Just Anorexia? Abstract. We report the case of a 30-year-old woman presenting with fatigue, loss of weight, nausea, emesis and hyponatremia. The evaluation proved Addison's disease due to an autoimmune polyendocrine syndrome type 2 with Hashimoto thyreoiditis. Under substitution with hydrocortisone and fludrocortisone all the symptoms subsided completely.

[The Sour Patient]

The Sour Patient Abstract. We report the case of a 75-year-old woman presenting with an elevated anion gap metabolic acidosis. The evaluation proved a 5-oxoprolin acidosis due to acetaminophen in therapeutic dose and concomitant risk factors such as malnutrition, chronic alcohol abuse, renal insufficiency, hepatopathy, and female sex. After stopping paracetamol medication and admission of bicarbonate and N-acetylcysteine, there was a rapid improvement in clinical symptoms and blood analysis.

[Not Available]

Zusammenfassung. Wir berichten über einen 79-jährigen Patienten mit einer generalisierten Muskelschwäche. Als Ursache fand sich eine bioptisch und durch anti-HMGCR-Antikörper gesicherte Statin-induzierte immunmediierte nekrotisierende Myopathie. Erst die Behandlung mit Rituximab in Kombination mit Steroiden und Azathioprin führte zu einer Besserung der Muskelschwäche.

[Community-acquired pneumonia in the elderly]

We report the case of a 88 years old patient with cough and new onset confusion. Delirium was caused by a necrotizing Methicillin-sensible staphylococcus aureus pneumonia with bacteremia. Despite antibiotic therapy for several weeks and fall of inflammatory markers the patient died from consequences of delirium.

[A rare cause of heart failure]

We report the case of a 52 years old patient with dilated cardiomyopathy. Ischemic heart disease was excluded by coronary angiography. However, bilateral hilar lymphadenopathy was present on plain chest radiography. Transbronchial biopsy showed non-necrotizing, epitheloid cell granulomas and thus sarcoidosis was diagnosed. A MRI of the heart confirmed the cardiac involvement by the sarcoidosis with corresponding structural changes.

[Therapy-resistant pneumonia]

We report the case of a 72 year old patient with B-symptoms and a persistent pulmonary infiltrate despite an antibiotic therapy. Buds of granulation tissue were found by transbronchial biopsy proving an organizing pneumonia. B-Symptoms and pulmonary infiltrate were improved immediately by a therapy with steroids. Even though there were reasons for a secondary organizing pneumonia due to a known chronic lymphocytic leukemia and a pneumonia treated four months before, we consider a cryptogenic organizing pneumonia as most probable.

[Hyperammonemic encephalopathy in multiple myeloma]

HISTORY AND CLINICAL FINDINGS

A 54-year old man had suffered from advanced multiple myeloma for two years. After initially good response the myeloma was refractrory to treatment with dexamethasone, cyclophosphamide, bortezomibe, zoledronate and additionally doxorubicine. The patient then complained of dyspnea without clinical signs of cardiopulmonary disease.

INVESTIGATIONS

Arterial blood gas analysis showed hyperventilation with respiratory alkalosis and normal alveolo-arterial gradient as the reason for the dyspnea. With a normal MRI of the brain and lumbal puncture, a neurological disease could be excluded. Serum calcium, creatinine and serum viscosity were normal. Eventually, serum ammonia levels were found to be substantially elevated (144 µmol/l) and hyperammonemic encephalopathy was diagnosed.

TREATMENT AND COURSE

Therapy with bortezomib and high dose dexamethason was repeated, and the patient also received bendamustin. Despite this treatment, he lost consciousness and died after two weeks because of aspiration pneumonia.

CONCLUSION

The existence of respiratory alkalosis and multiple myeloma should prompt a search for hyperammonemia.

[<<Sterile>> spondylodiscitis]

We report the case of a 81 year old women presenting with fever and back pain. Infectious spondylodiscitis was first supposed due to the imaging of the spine although no pathogenic agent could be proved. Antibiotic therapy was initiated. Because of the persistence of the symptoms biopsy was repeated, this time done by a surgeon. Eventually spinal gout was diagnosed. Symptomatic therapy alone removed the discomfort.

[Sudden onset of abdominal distension...]

We report the case of a 39 years old patient with sudden onset of abdominal distension and icterus. Occlusion of the liver veins discovered by doppler ultrasound caused the portal hypertension and liver disease. Given the erythrocytosis the detection of JAK 2-mutation proved polycythemia vera as underlying disease for the Budd Chiari syndrome. The implantation of a TIPS wasn't successful because of an early thrombotic occlusion. Therefore a surgical mesocaval shunt was done. At the moment the patient is therapied with oral anticoagulation and hydroxycarbamide and is fully capable of work again.

[Polyps of the gallbladder]

Gallbladder polyps are a common incidental finding in ultrasound. They may be clinically significant, because adenomas have a malignant potential, in contrast to the benign cholesterol polyps occuring more frequently. As non-neoplastic polyps and neoplastic polyps cannot be morphologically discriminated in ultrasound, maximal diameter of a polyp has proven to be the best predictor for malignancy. Cholecystectomy is widely accepted as the treatment of choice for patients with polyps >1 cm. Patients with polyps <1 cm should have a follow-up check for a longer period of time (with the exception of very small polyps).

[Persistent fever in the elderly]

We report the case of a 68 year old immuncompetent woman with persisting fever. Symptomatic acute CMV infection with a partial thrombosis of the left portal vein branch was diagnosed.

[Spontaneous hematomas and isolated prolongation of aPTT]

We report a case of a 64 year old woman with spontaneous hematomas. A prior history of bleeding disorder was not known up to now. The result of investigation of coagulation was an isolated prolonged aPTT that was caused by an inhibitor of factor VIII without underlying disease (idiopathic acquired hemophilia A). Therapy with steroids and cyclophosphamid resulted in partial remission.

[Persistent neutropenia]

We report the case of a 72-old patient with persistent neutropenia diagnosed during investigation of sialadenitis. Further examination led to the diagnosis of immune neutropenia and systemic lupus erythematosus. Anamnesis and the clinical course made initial diagnosis of drug-induced lupus erythematosus implausible. Steroid trial was done, followed by maintenance therapy, with good control of symptoms.

[Fever and dysphagia of a young woman]

We report the case of a 39-year old patient with septicemia treated for pharyngitis with antibiotics since a few days. She wasn't able to swallow her antibiotics anymore because of dysphagia. Radiologic examination revealed pulmonary infiltrates and Vena iugularis interna-thrombosis. These findings and anamnesis led to the diagnosis of Lemierre syndrome inspite of lacking detection of bacteria. After changing the antibiotic therapy and start of anticoagulation further course of illness was favorable. The long duration of hospitalization was indepted to high morbidity typically seen in Lemierre syndrome.

[Right-sided lower abdominal pain and diarrhea of a young diabetic woman]

We report the case of a 24-years old diabetic women hospitalised because of right-sided lower abdominal pain and diarrhea. She fulminantly developed shock before appendectomy could be performed and was transferred to intensive care unit. Hypotension remained and laparoscopy revealed primary peritonitis and toxic shock syndrome by Group A Streptococcus which was cultivated in blood and ascites. Therapy with penicilline and clindamycine resolved symptoms. During hospitalisation Clostridium difficile colitis occurred. This complication leaded to prolonged hospitalisation.

[Lymphadenopathy and diabetes insipidus - association]

We report the case of a 62 year old women with chronic idiopathic myelofibrosis who developed acute lymphadenopathy. At the same time diabetes insipidus, osteolytic bone lesions and exanthema of the skin were diagnosed. Suspected Langerhans cell histiocytosis could be proven by repeated biopsies of affected organs. Therapy was started in accordance with the recommendations of the Histiocyte Society.

[Odynophagia of a young mother]

We report the case of a 34-year old mother presenting in the emergency unit because of fever and odynophagia. Herpetic esophagitis with Herpes simplex virus primoinfection in a immunocompetent patient was diagnosed. The virus was transmitted by her own child which came to be hospitalised because of herpetic stomatitis. In the blood chemistry pancreas enzymes were elevated which we interpreted as herpetic pancreatitis because of coincidence with herpetic esophagitis.

A longitudinal study of blood folate levels and depressive symptoms among young women in the Southampton Women's Survey

BACKGROUND

Lower blood folate levels have been associated with depression in cross-sectional surveys, but no studies have examined the relationship prospectively to determine whether the relationship is causal. A follow-up study was designed to examine whether lower blood folate levels predict incident depressive symptoms.

METHOD

Women aged 20-34 years registered in general practices in Southampton, UK, were asked to participate. Baseline assessment included the general health questionnaire (GHQ-12) measure of anxiety and depression, and socioeconomic factors, diet, smoking and alcohol intake. Two years later, participants' general practice (GP) records were examined for evidence of incident symptoms of depression.

RESULTS

At baseline, 5051 women completed the GHQ-12 and had red cell folate levels measured, of whom 1588 (31.4%) scored above the threshold for case level symptoms of anxiety and depression on the GHQ-12. Two years later, GP records for 3996 (79.1%) were examined, but 1264 with baseline evidence of depression were excluded from follow-up analysis. Incident depressive symptoms were recorded for 307 (11.2%) of the remaining 2732. Lower red cell folate levels were associated with caseness on the GHQ-12 (adjusted prevalence ratio 0.99 per 100 nmol/l red cell folate, 95% CI 0.98 to 1.00). No relationship was found between red cell folate levels and incident depressive symptoms over 2 years (adjusted hazard ratio 1.00, 95% CI 0.97 to 1.03).

CONCLUSIONS

Low folate levels were not associated with subsequent depressive symptoms. This suggests that lower blood folate levels may be a consequence rather than a cause of depressive symptoms.

[Hermaphroditos in Greek mythology--DSD in moderne medicine]

We report a case of 34 year old woman how has been hospitalized at the age of 6 month with persistent vomitus. The vomitus was found to be caused by adrenal insufficiency with lack of all hormones of steroidobiosynthesis. The phenotypical femal child was diagnosed to have congenital lipoid adrenal hyperplasia with 46,XY DSD. 24 years later a homozygote mutation in the StAR-gene (L260P), which was first described in Switzerland, has been identified.

[Scepticism is warranted or when the CT scan reveals to be a pitfall]

We report the case of a 72-year old woman with known metastatic breast cancer who presented to the emergency department with progressive dyspnea on exertion and chest pain. The diagnosis of pulmonary embolism could be established by pulmonary scintigraphy after computed tomography and ultrasound of the lower extremities had been negative in spite of a moderate clinical pretest probability (Wells score). This case shows that even if we manage suspected pulmonary embolism using algorithms combining clinical probability, computed tomography and ultrasound we must remain aware of eventually missing the diagnosis and carry on investigating cases with elevated clinical probability.

Effects of histamine and activators of the cyclic AMP system on protein synthesis in and release of high molecular weight glycoproteins from isolated gastric non-parietal cells

1. Glycoprotein and protein synthesis in and release from pig isolated, enriched gastric mucous cells were measured by the incorporation of N-acetyl-[14C]-D-glucosamine and [3H]-L-leucine, respectively, into cellular and released acid precipitable material. 2. Histamine and activators of the adenosine 3':5'-cyclic monophosphate (cyclic AMP) system maximally stimulated total protein and glycoprotein synthesis in and release from the cells at concentrations of histamine (10 microM), forskolin (10-100 microM), 3-isobutyl-1-methylxanthine (100 microM), and dibutyryl cyclic AMP (1-3 mM), respectively. In the presence of 3-isobutyl-1-methylxanthine (30 microM) histamine stimulation was enhanced. 3. As shown by gel chromatography, stimulation by histamine (100 microM), forskolin (10 microM), 3-isobutyl-1-methylxanthine (100 microM) and dibutyryl cyclic AMP (1 mM) resulted in a release of high molecular weight (approximately 2 x 10(6) daltons) glycoproteins from the cells. The histamine H2-receptor antagonist, ranitidine (100 microM), blocked the effect of histamine. 4. We conclude that cyclic AMP-dependent processes are involved in the regulation of protein and glycoprotein synthesis in and the release of high molecular weight (mucous) glycoproteins from pig gastric non-parietal cells and that histamine may be a physiological activator of this system.

Effects of PGE2, carbenoxolone, cholecystokinin, and the thromboxane-mimetic U46619 on protein and glycoprotein production by isolated pig gastric mucosal cells

We studied the effects of prostaglandin (PG) E2, carbenoxolone, cholecystokinin-octapeptide (CCK-OP), and the thromboxane-mimetic U46619, all known to stimulate gastric mucus secretion in vivo, on protein and glycoprotein synthesis in and release from isolated and enriched pig gastric mucous cells, as measured by the incorporation of [3H]L-leucine and N-acetyl-[14C]D-glucosamine respectively into cellular and released acid insoluble material. PGE2 stimulated glycoprotein and protein synthesis (EC50 7 and 30 nmol/L, respectively) and release (EC50 50 and 140 nmol/L, respectively) in a concentration-dependent manner, whereas carbenoxolone, CCK-OP and U46619 failed to enhance the incorporation of the tracers. We conclude that stimulation of mucus secretion by PGE2 is related to direct effects on protein and glycoprotein production of gastric non-parietal cells, whereas indirect effects may be involved in the stimulation by carbenoxolone, CCK-OP, and U46619.

Stimulation of glycoprotein and protein synthesis in isolated pig gastric mucosal cells by prostaglandins

The purpose of this study is to evaluate the effects of different prostaglandin derivatives on protein and glycoprotein synthesis and secretion in isolated and enriched pig gastric mucous cells, as measured by the incorporation of [3H]L-leucine and N-acetyl-[14C]D-glucosamine respectively into acid insoluble macromolecules (AIM). PGE2 and 16,16-dimethyl-PGE2 enhanced the incorporation of the amino sugar into cellular (EC50 8 and 75 nmol/l) and secreted (EC50 30 and 270 nmol/l) AIM in a concentration dependent manner during a 20 hours incubation. After incubation for eight hours or more they also stimulated the incorporation of [3H]L-leucine into cellular AIM. PGF2 alpha was considerably less potent (EC50 greater than 1 mumol/l) than the E-type prostaglandins. Iloprost, a stable prostacyclin analogue, was ineffective.

Effects of histamine on protein and glycoprotein production of isolated pig gastric mucosal cells

The production of glycoprotein and protein by isolated pig gastric non-parietal cells was measured by incorporation of N-acetyl-[14C]-D-glucosamine [( 14C]GlcNAc) and [3H]-L-leucine [( 3H]Leu), respectively, into acid insoluble material (AIM). Histamine enhanced incorporation of the tracers into cellular and released AIM in a concentration-dependent manner. The H2 receptor antagonist ranitidine completely blocked the effects of histamine (100 mumol/l) on [3H]Leu incorporation into cellular and released AIM (IC50 37 and 32 mumol/l, respectively) but had no inhibitory effect on the 16,16-dimethylprostaglandin-E2 - and forskolin-stimulated tracer incorporation. The H1 receptor antagonist mepyramine did not inhibit the histamine effect. We conclude that histamine is a stimulant of protein, via H2 receptors, and glycoprotein production of isolated pig gastric non-parietal cells.

Incorporation of N-acetyl-[14C]D-glucosamine and [3H]L-leucine by isolated pig gastric mucosal cells

Glycoprotein and protein production of isolated pig gastric mucosal cells were determined by the incorporation of N-acetyl-[14C]D-glucosamine ([14C]GlcNAc) and [3H]L-leucine ([3H]Leu) into acid-insoluble macromolecules (AIM). In four cell fractions (F1-F4), obtained by counterflow centrifugation, specific [14C]GlcNAc incorporation was greatest in the mucous cell-enriched F2. Tracer incorporation by F2 cells, proceeded linearly up to 20 h, was inhibited by cycloheximide or incubation at 0 degree C, and enhanced by PGE2 1 mumol/l. Gel chromatography of released AIM revealed that PGE2-stimulated [14C]GlcNAc incorporation was predominantly directed into high molecular weight (2 X 10(6) daltons) glycoproteins, whereas [3H]Leu incorporation was mainly related to proteins of albumin-like molecular weight. We conclude that incorporation of [14C]GlcNAc by enriched pig gastric mucous cells (F2), further analyzed by gel chromatography, is a suitable probe to study the production of high molecular weight gastric mucous glycoproteins in vitro.