1/2858. pituitary apoplexy after cardiac surgery presenting as deep coma with dilated pupils.Acute clinical deterioration due to infarction or haemorrhage of an existing, often previously unrecognized, pituitary tumour is a rare but well-described complication. It can occur spontaneously or may be caused e.g. by mechanical ventilation, infection or surgical procedures. We report on a case of pituitary apoplexy occurring in a 64-year-old patient 3 weeks after cardiac surgery. The patient presented with deep coma and dilated pupils. magnetic resonance imaging revealed a haemorrhagic pituitary tumour. After prompt endocrinologic replacement therapy with levothyroxine and hydrocortisone the patient regained consciousness. Neurological examination revealed right oculomotor nerve palsy and bilateral cranial nerve VI palsy. Subsequent trans-sphenoidal removal of a nonfunctional macroadenoma with large necrotic areas was performed. The patient recovered completely. To our knowledge, pituitary tumours presenting with a combination of deep coma and dilated pupils must be considered exceedingly rare. Possible pathophysiologic mechanisms are discussed. As our case illustrates, even in severe cases complete recovery is possible if the diagnosis is suspected, and diagnostic and therapeutic measures are initiated in time.- - - - - - - - - - ranking = 1keywords = ill (Clic here for more details about this article) |
2/2858. akinetic mutism after fourth ventricle choroid plexus papilloma: treatment with a dopamine agonist.BACKGROUND: akinetic mutism is a behavioral state wherein a patient seems to be awake but does not move or speak. Several patients are reported to have developed mutism after posterior fossa surgery. We present a patient who developed akinetic mutism after total excision of a choroid plexus papilloma of the fourth ventricle, and who was treated with bromocriptine. CASE DESCRIPTION: An 18-year-old woman was admitted with akinetic mutism, which had developed 6 days after posterior fossa surgery. She had had no neurologic deficit in the first 5 days after surgery and could communicate with her family. Despite antioedematous therapy and daily lumbar punctures to drain cerebrospinal fluid, there was no clinical improvement after she entered the akinetic mute state. brain magnetic resonance revealed ventriculomegaly; brain single photon emission computed tomography revealed bilateral reduction of perfusion in the frontal region. Because daily lumbar drainage did not result in clinical improvement, shunt placement was not considered. bromocriptine therapy was begun at a dose of 2x2.5 mg; 24 hours later, the patient started to speak and move her upper extremities. Further improvement occurred over the following week when the dose was increased to 3x2.5 mg. bromocriptine was replaced with a placebo to determine whether the neurologic improvement was caused by the medicine. The patient's neurologic status deteriorated progressively; therefore, bromocriptine was restarted and she was discharged from the hospital. During the 6 months of follow-up, the patient has remained in good health. CONCLUSIONS: The etiology of akinetic mutism is not clear. Monoaminergic pathways, particularly dopaminergic cell groups, are most probably involved in this syndrome, because bromocriptine has a dramatic effect on these patients, as demonstrated in our case.- - - - - - - - - - ranking = 5keywords = ill (Clic here for more details about this article) |
3/2858. scedosporium apiospermum sinusitis after bone marrow transplantation: report of a case.A forty-year-old man underwent an allogeneic BMT from his HLA identical sister. GvHD prophylaxis was done with cyclosporine (CyA), methotrexate and prednisone (PDN). On day 90 extensive GvHD was noted and higher doses of immunosuppressive drugs alternating CyA with PDN were initiated. Patient's follow-up was complicated by intermittent episodes of leukopenia and monthly episodes of sinusitis or pneumonia. One year after BMT, the patient developed hoarseness and nasal voice. No etiologic agent could be identified on a biopsy sample of the vocal chord. Upon tapering the doses of immunosuppressive drugs, the patient had worsening of chronic GvHD and was reintroduced on high doses of cyclosporine alternating with prednisone on day 550. Three months later, GvHD remained out of control and the patient was started on azathioprine. On day 700, hoarseness and nasal voice recurred. Another biopsy of the left vocal chord failed to demonstrate infection. Episodes of sinusitis became more frequent and azathioprine was withheld 3 months after it was started. One month later, the patient had bloody nasal discharge and surgical drainage of maxillary sinuses was performed. Histopathology showed hyphae and cultures grew scedosporium apiospermum. itraconazole 800 mg/day was initiated. The patient developed progressive respiratory failure and died 15 days later.- - - - - - - - - - ranking = 1keywords = ill (Clic here for more details about this article) |
4/2858. Acoustic trauma from the bone cutting burr.The amplitudes of the stapes footplate movements were determined in human temporal bones when the ossicular chain was drilled with a cutting and a diamond burr. High movements result in comparison to physiological data. The frequency distribution resembles the dB (A) curve. The intensity compared to sound pressure levels on the ear drum is higher than I30 dB. The pressure is constant over the period of contact between the burr and the ossicle. Most likely these unphysiologic movements of the stapes footplate can cause inner ear damage as we had to admit in a case of facial nerve decompression.- - - - - - - - - - ranking = 1keywords = ill (Clic here for more details about this article) |
5/2858. Treatment for empyema with bronchopleural fistulas using endobronchial occlusion coils: report of a case.We report herein the case of a woman with bronchopleural fistulas treated with the endobronchial placement of vascular embolization coils. She was referred to our hospital to undergo lavage of a postoperative empyema. She had undergone an air plombage operation for pulmonary tuberculosis 9 years previously. However, bronchopleural fistulas occurred postoperatively and she had to continue the use of a chest drainage tube since then. Lavage of her empyema space with 5kE of OK-432 (picibanil: Chugai) plus 100 mg minocycline was performed once every 2 weeks for 3 months, and the purulent discharge from the empyema remarkably decreased. Thereafter, the bronchopleural fistulas were occluded endobronchially by the placement of vascular embolization coils. Soon after the procedure, air leakage from the fistulas was stopped and the drainage tube was removed 2 days later. The patient remains well without any additional treatment at 20 months after this treatment. As treatment for empyema with bronchopleural fistulas, it would be worth trying to lavage the empyema space with OK-432 until it is cleaned out and to plug the fistulas by the endobronchial placement of embolization coils, before such radical operations as thoracoplasty and space-filling of the empyema are considered.- - - - - - - - - - ranking = 1keywords = ill (Clic here for more details about this article) |
6/2858. Unaccountable severe hypercalcemia in a patient treated for hypoparathyroidism with dihydrotachysterol.This report describes a forty-seven-year-old female patient with a complex medical history. She was suffering from an unspecified interstitial lung disease, papillary thyroid carcinoma which had been treated, hypoparathyroidism after thyroidectomy for which she was receiving dihydrotachysterol and calcium, and atrial fibrillation and congestive heart failure as a result of mitral stenosis. Shortly after mitral valve replacement she developed a severe hypercalcemia (serum calcium 5.95 mmol/l) during a febrile illness. At that time anti-tuberculous agents were also being administered for presumed tuberculosis. The possible mechanisms for this severe elevation of the calcium level are discussed. immobilization, while Paget's bone disease was present, and perhaps enhanced activation of dihydrotachysterol by rifampicin, could have led to increased calcium-release into the circulation. Continuous supplecation of calcium and vitamin d, provoked dehydration and the mechanism of the milk-alkali syndrome also contributed to this extremely high calcium level. It is concluded that hypoparathyroid patients being treated with vitamin d and calcium should be carefully monitored in the case of an intercurrent illness or a change in medication.- - - - - - - - - - ranking = 5.2780687860652keywords = ill, illness (Clic here for more details about this article) |
7/2858. cardiomyoplasty and implantable cardioverter defibrillator: efficacy and safety of concomitant device implantation: sudden death and cardiomyoplasty.Sudden death represents a common event in the natural history of patients affected by chronic heart failure. Such an outcome also has been shown to characterize the follow-up of the cardiomyoplasty procedure. We report two cases of patients who had cardiomyoplasty and experienced witnessed episodes of ventricular arrhythmia at variable times after surgery (2 years and 2 months, respectively). In the first case, an implantable cardioverter defibrillator (ICD) was implanted subsequent to the arrhythmic episode, whereas the second patient had a combined cardiomyoplasty and ICD implantation procedure. In particular, this patient underwent a modified wrapping technique, herein described, because of a large left ventricular dilatation. In both cases, ventricular defibrillation did not affect the correct functioning of the implanted cardiomyostimulator. Our article confirms that ventricular arrhythmia is common in cardiomyoplasty patients. The combined use of a skeletal muscle stimulator and implantable defibrillator may therefore be effective in preventing arrhythmia-related sudden death without any concurrent effect on the correct functioning of the wrapped muscle/heart circuit, with likely benefit on long-term cardiomyoplasty patient survival.- - - - - - - - - - ranking = 7keywords = ill (Clic here for more details about this article) |
8/2858. Donor-to-recipient transmission of bacteria as an unusual cause of mediastinitis in a heart transplant recipient.We present a 54-year-old male heart transplant recipient who developed mediastinitis caused by klebsiella oxytoca and veillonella species. culture of the donor's bronchus also grew K. oxytoca and a veillonella species. Pulsed-field gel electrophoresis revealed that the K. oxytoca isolates had identical banding patterns. This case illustrates transmission of pathogenic bacteria via a contaminated organ.- - - - - - - - - - ranking = 3keywords = ill (Clic here for more details about this article) |
9/2858. Vascularized fibular graft after excision of giant cell tumor of the distal radius. A case report.Although hemiarthroplasty of the wrist using vascularized proximal fibula has been described often, long term results with documentation of results are insufficient. A case of giant cell tumor of the distal radius with remarkable extraskeletal extension is reported. Vascularized fibula including its proximal head was used to replace the defect created after en bloc resection of the tumor. There was no deterioration in radiographic findings or function of the new joint at the time of the 10-year followup. Satisfactory range of motion of the wrist and the forearm was maintained. There was no instability in the joint, and grip strength measured 65% of the opposite side. Postoperative magnetic resonance imaging showed survival of the whole graft, including the subchondral portion. In addition to thorough revascularization of the graft, appropriate soft tissue reconstruction using dynamic tendon transfer contributed to the success. When these requirements are fulfilled, the graft can provide a functional and durable result. Although this is a single experience, the authors recommend wrist arthroplasty, rather than arthrodesis, in carefully selected patients.- - - - - - - - - - ranking = 1keywords = ill (Clic here for more details about this article) |
10/2858. Atypical mycobacterium infection with dermatological manifestation in a renal transplant recipient.In April 1997, a 58-year-old renal transplant recipient presented with abscess-like nodules in his left calf and on his right foot. Furuncular disease was suspected and the patient was treated with flucloxacillin. However, the lesions increased in size and became ulcerative. In the following 3 months, cultures of punctuated material, blood, and urine remained negative and gram stains did not reveal micro-organisms. In June 1997, acid-fast stains were positive. A diagnosis of a nontuberculous mycobacterium (NTM) infection was made and empirical antimycobacterial therapy was started. The combination of relatively minor symptoms with enlarged purulent lesions, causing severe morbidity, raises the possibility of NTM infection in the immunocompromised patient.- - - - - - - - - - ranking = 1keywords = ill (Clic here for more details about this article) |
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