Concomitant pulmonary tuberculosis and tuberculous appendicitis in a recipient of a renal transplant: a case report.

INTRODUCTION: Tuberculosis is still a serious infection among recipients of renal transplants. Although the ileocecal region is the most affected part in intestinal tuberculosis, acute tuberculous appendicitis is quite a rare entity. We report a case of concomitant pulmonary tuberculosis and tuberculous appendicitis in a recipient of a renal transplant. CASE PRESENTATION: A 27-year-old Iranian woman, who had been the recipient of a renal transplant five years earlier, presented with a two-week history of coughing, fever and weight loss. The cause of her end-stage renal disease was chronic pyelonephritis. There were fine crackles noted during a chest examination, and a plain chest radiography showed fine miliary nodules throughout her entire lung fields. Sputum and bronchial aspirate examination was positive for acid-fast bacilli, suggestive of Mycobacterium tuberculosis infection. A chest computed tomography scan revealed widespread miliary nodules, compatible with miliary tuberculosis. She developed severe abdominal pain and abdominal surgery disclosed a perforated appendicitis. Histopathological examination of the resected appendix revealed widespread caseating epithelioid granulomas, suggestive of tuberculosis. CONCLUSION: Our case report highlights a rare presentation of tuberculosis in a patient who has undergone renal transplant. Such unusual presentation of tuberculosis, particularly among patients receiving potent immunosuppressive protocols, should be considered by clinicians.

A testimony to the history of heart and lung transplantation: English translation of Demikhov's paper, "Transplantation of the Heart, Lungs and other Organs".

Vladimir Petrovich Demikhov, a Soviet physiologist and surgeon, made meticulous attempts at reviving heart and lung transplantation in the last century. Herein, we present an English translation of Demikhov's 1969 paper of Transplantation of the Heart, Lungs and other Organs (published in Eksperimental'naia Khirurgiia i Anesteziologiia), which represented a synopsis of his experiences with experimental transplantation. A brief account of Demikhov's life and contributions to transplant medicine is also given.

Transplant renal artery stenosis associated with acute cytomegalovirus infection: resolution following ganciclovir administration.

Cytomegalovirus has been implicated in the pathogenesis of transplant renal artery stenosis. However, the clinical course of this infection-associated transplant renal artery stenosis and its response to antiviral treatment is still unclear. We report a patient with transplant renal artery stenosis associated with an acute cytomegalovirus infection, which resolved following ganciclovir administration without the need for surgical or angiographic intervention. Serological testing revealed positive titers of anti- cytomegalovirus IgM and IgG antibodies. Renal allograft Doppler study findings were compatible with critical renal artery stenosis. Renal allograft angiography disclosed a critical circular stenosis. Following the intravenous ganciclovir administration, dramatically decreased Doppler ultrasound parameters along with the absence of parvus/tardus waveform pattern revealed the resolution of the stenosis. Moreover, the serological testing was negative for anti-cytomegalovirus IgM antibody, but anti-cytomegalovirus IgG antibody was positive. This report not only implies the causative possible relationship between acute cytomegalovirus infection and transplant renal artery stenosis, but it also highlights the importance of this complication when managing a renal transplant recipient with signs of allograft arterial stenosis.

Facial palsy and its management in the Kitab al-Hawi of Rhazes.

More than 1000 years ago, Rhazes practiced rudimentary neurology. This monumental physician wrote more than 200 books in his lifetime and died a blind pauper in the 10th century AD. His Kitab al-Hawi (Liber Continens) was one of the most famous and detailed medical texts of the ancient world. Here, we discuss the life of Rhazes and provide perhaps the first English translation of his writings dealing with facial palsy (Lagveh) and its treatment. It is the contributions of early clinicians/scholars such as Rhazes on which we base our current medical knowledge.

Outcome of renal transplant in hereditary gelsolin amyloidosis.

Amyloid nephropathy is an unusual manifestation of hereditary gelsolin amyloidosis and may present with proteinuria and progressive renal failure. We report the first case of renal transplantation in a patient with hereditary gelsolin amyloidosis complicated by end-stage renal disease. The patient was a 44-year-old man from the Northwest of Iran who had undergone hemodialysis for 1 year. He finally received a living, unrelated renal transplant. During a 6-year posttransplant period, the patient maintained stable allograft function without proteinuria. No significant infectious or cardiac complications were noted. Although a definite conclusion cannot be reached with a single case, this report may indicate that renal transplantation can be successfully attempted in patients with hereditary gelsolin amyloidosis and amyloid nephropathy. Renal transplantation has been performed in various hereditary, primary, and secondary amyloidoses. A brief review of this topic is presented.

The evolution of the study of anatomy in Japan.

The following review focuses on how the study of anatomy in Japan has evolved throughout the centuries; specifically, we investigate anatomical knowledge during the primitive, ancient, feudal, and early modern periods of Japanese history. Early vague and mythical anatomical concepts derived from China prevailed for many centuries in Japan. Kajiwara wrote one of the earliest anatomical works in 1302. As a science, anatomy was the first basic science to be established in Japan, beginning simplistically during the 1600s and flourishing more recently with the onset of Meiji Restoration. As a result, Japan has produced several of the most influential anatomists of the 20th century, including Buntaro Adachi, who added detail to our knowledge of the vascular system and its variations; and Sunao Tawara, who discovered the atrioventricular node. Herein, we discuss the ways in which Japan has added to and promoted the anatomical sciences.

Marie-François Xavier Bichat (1771-1802) and his contributions to the foundations of pathological anatomy and modern medicine.

Marie-François Xavier Bichat (1771-1802) was a prominent French anatomist during a time of revolution and one of the founders of French scientific medicine. He conducted several experimental studies, which laid the foundation for modern physiology. Based on autopsy findings, Bichat introduced 21 tissues as the basic elements of organs. His name is carried on by several eponyms in anatomy and histology; Bichat's fossa (pterygopalatine fossa), Bichat's protuberance (buccal fat pad), Bichat's foramen (cistern of the vena magna of Galen), Bichat's ligament (lower fasciculus of the posterior sacroiliac ligament), Bichat's fissure (transverse fissure of the brain) and Bichat's tunic (tunica intima vasorum). This paper deals with the life and works of this early pioneer in anatomy and physiology.

Parvovirus B19 microepidemic in renal transplant recipients with thrombotic microangiopathy and allograft vasculitis.

Parvovirus B-19 (B-19) can lead to various clinical scenarios in renal transplant recipients. Here, we report a B-19 microepidemic that occurred between January and March 2007, involving renal transplant recipients from a single center in Tabriz, Iran. We observed 6 patients in whom there was a temporal association between active B-19 infection and thrombotic microangiopathy and intrarenal small and medium-sized vessel vasculitis. Patients typically presented with deteriorating renal allograft function and anemia, and laboratory findings revealed thrombotic microangiopathy. Ultimately, extensive endothelial injury and renal allograft vasculitis that mimicked a vascular rejection ensued. In conclusion, B-19-related thrombotic microangiopathy may precede allograft vasculitis in renal transplant recipients. A high index of suspicion is required for early diagnosis and treatment of B-19 infection. To the best of our knowledge, this series represents the first report of B-19-related renal allograft vasculitis in the English literature.

Asymptomatic bilateral ureteropelvic junction obstruction due to supernumerary renal arteries.

A supernumerary renal artery is a common arterial variation, which warrants considerations in a variety of urologic and retroperitoneal operations. Supernumerary renal arteries can be associated with other uro-vascular variations and anomalies such as duplicated renal veins and ureters, aberrant origin of the gonadal arteries, persistence of fetal renal lobulation, and kidney malrotation. The role of crossing supernumerary renal arteries in ureteropelvic junction obstruction (UPJO) is controversial. We report a healthy potential renal transplant donor with bilateral UPJO, which appeared to be secondary to supernumerary renal (inferior polar) arteries. We believe that the bilateral occurrence of asymptomatic UPJO associated with supernumerary renal arteries has not been previously reported.

The relationship between the internal jugular vein and common carotid artery in the carotid sheath: the effects of age, gender and side.

The internal jugular vein is often used for central venous catheter placement. The variations in the location of this vein along the major neck vessels (in the carotid sheath) may account for unsuccessful cannulations or iatrogenic arterial injuries. The aim of this study was to delineate the relation of the internal jugular vein and common carotid artery in the lower neck, and to assess the effects of age, gender and side on these anatomical structures. Two-dimensional ultrasonographic examinations of the right and left supraclavicular triangle were performed in 219 adult individuals who had no history of neck surgery or known pathology. The location of the internal jugular vein in relation to the common carotid artery was recorded. An anterolateral location of the internal jugular vein was the most common configuration observed on both sides (84% right side and 91.8% left side) followed by the lateral (14.2% right and 6.4% left) and anterior (1.4% right and 1.8% left) locations. A single case of a medial internal jugular vein was observed on the right side (0.23% of both sides). Subjects with a laterally located internal jugular vein were older than those with an anterolateral configuration (P<0.01). No gender differences were found with regard to these two configurations (P=0.867). The laterally located internal jugular vein was more frequent on right sides (P=0.007). Such information may be potentially useful for clinicians who are managing critically ill patients or patients undergoing hemodialysis.

Thrombotic microangiopathy as a complication of medicinal leech therapy.

Medicinal leeches (hirudo medicinalis) are increasingly used as a useful therapeutic option in various medical and surgical settings. The potential complications associated with this therapy include infections with Aeromonas species, bleeding, anemia, and allergic reactions. We describe a patient who developed thrombotic microangiopathy and acute renal failure following leech therapy. It is proposed that the series of nonhuman proteins within leech saliva may be capable of injuring the endothelium.

Hypophosphatemic encephalopathy in a CAPD patient.

Severe refeeding hypophosphatemia has been reported in infants and adults on continuous ambulatory peritoneal dialysis. We report an episode of transient encephalopathy and cardiac suppression in a diabetic, malnourished end-stage renal disease patient undergoing peritoneal dialysis with a glucose-based solution, which was associated with severe hypophosphatemia. Further investigation revealed an adynamic bone disease. The potential factors precipitating this episode of hypophosphatemia are discussed.

Contributions of the fourth spinal nerve to the brachial plexus without prefixation.

OBJECT: The intradural contributions of the C-4 nerve rootlets have not been previously evaluated for their connections to the brachial plexus. The authors undertook a cadaveric study to evaluate the C-4 contributions to the upper trunk of the brachial plexus. METHODS: The posterior cervical triangles from 60 adult cadavers were dissected. All specimens that were found to have extradural C-4 contributions to the upper trunk of the brachial plexus were excluded from further study. In specimens found to have no extradural C-4 contributions to the brachial plexus a C1-T1 laminectomy was performed. Observations were made of any neural communications between adjacent spinal rootlets, specifically between C-4 and C-5. RESULTS: Nine (15%) of the 60 sides were found to have extradural C-4 contributions to the upper trunk of the brachial plexus. These sides were excluded from further study. No specimen was found to have a postfixed brachial plexus. Of the remaining 51 sides, 11 (21.6%) were found to have intradural neural connections between C-4 and C-5 dorsal rootlets and 1 (1.96%) had a connection between the ventral roots of C-4 and C-5. Communications between these 2 adjacent dorsal cervical cord levels were of 3 types. Type I was a vertical communication between the more horizontally traveling dorsal roots. Type II was a forked communication between adjacent C-4 and C-5 dorsal rootlets. The Type III designation was applied to connections between ventral rootlets. Although communications were slightly more frequent on left sides, this did not reach statistical significance. CONCLUSIONS: In approximately 20% of normally composed brachial plexuses (those with extradural contributions from only C5-T1) we found intradural C4-5 neural connections. Such variations may lead to misinterpretation of spinal levels in pathological conditions of the spinal axis and should be considered in surgical procedures of this region, such as rhizotomy.

Hindbrain herniation: A review of embryological theories.

Herniation of the hindbrain outside of the setting of intracranial hypertension, trauma, and brain tumors is an uncommon phenomenon with estimated incidence of less than 1%. In the late 1890's, Hans Chiari, a German pathologist, classified hindbrain herniation into three forms. This classification was then extended to include six types. We reviewed the current literature for the proposed embryological theories as well as the potential genetic mutations/syndromes associated with the hindbrain herniation or Chiari malformation. The review is illustrated by a unique cadaver with Chiari type I malformation (i.e. herniation of the cerebellar tonsils through the foramen magnum). Finally, it seems that no single theory could explain all forms of the Chiari malformation, and that this malformation might be a heterogeneous entity.

Lateral lakes of Trolard: anatomy, quantitation, and surgical landmarks. Laboratory investigation.

OBJECT: There is scant and conflicting information in the literature regarding the lateral lacunae, or lateral lakes of Trolard. As these venous structures can be encountered surgically, this study aimed at further elucidating their anatomy, identifying surgical landmarks, and associated quantitation. METHODS: Thirty-five adult cadavers were dissected of lateral lacunae. Following quantitation of the lacunae, these structures were measured, as were the distances from them to the coronal and sagittal sutures. RESULTS: A mean of 1.9 lacunae were identified on the right sides and 1.4 lacunae on the left sides. Although there tended to be slightly more lacunae on the right sides, this difference did not reach statistical significance (p > 0.05). The average lengths of the lacunae were 3.2 and 2.0 cm for the right and left sides, respectively. The mean widths of these venous lakes were 1.5 cm for the right sides and 0.8 cm for the left sides. Lacunae were variably positioned but tended to cluster near the vertex of the skull. None were identified posterior to the lambdoid sutures, and only 5 were found to lie anterior to the coronal suture, with 4 of these located on right sides (p < 0.05). When lacunae were identified anterior to the coronal suture, they were generally 5-6 cm from this structure. The majority of lacunae could be identified between the coronal and lambdoid sutures and within 3 cm of the midline. CONCLUSIONS: Although the situation varies, lateral lacunae are concentrated posterior to the coronal suture and anterior to the lambdoid sutures. They are most often found within 3 cm of the sagittal suture. These previously unreported data could be useful to the neurosurgeon in planning surgical procedures that traverse the calvaria.

Hepatitis C virus genotypes in patients with end-stage renal disease in East Azerbaijan, Iran.

Information about the genotypes and associated risk factors in hepatitis C virus (HCV) infected patients in Iran is limited. The aim of this study was to identify the HCV genotypes and associated risk factors in a group of HCV infected patients on dialysis therapy in Iran. The sera of 753 patients with chronic renal failure from fifteen dialysis units in East Azerbaijan Province were screened for anti-HCV antibodies as well as HCV RNA; viral RNA was extracted for the genotype specific primer approach. Patients were questioned concerning documented risk factors. Genotyping analysis was performed in 55 patients with positive anti-HCV and HCV-RNA. Genotypes 1 and 3 were found in 46 (83.7%) and three (5.5%) patients, respectively. The most frequent HCV subtype was 1a (76.4%), followed by 3a and 1b and 1b (5.5% each) while one patient was infected with both 1a and 1b. There was no statistically significant difference between the risk factors analyzed and the acquisition of HCV infection. This study gives added evidence of the predominant HCV genotypes in Iran, which is different than reports from other Arab countries and similar with the pattern of genotype in both Europe and United States.

Costanzo Varolio (Constantius Varolius 1543-1575) and the Pons Varolli.

COSTANZO VAROLIO (CONSTANTIUS Varolius) (1543-1575) was born in Bologna and died in Rome. This professor of anatomy and papal physician was the first to examine the brain from its base up, in contrast with previous dissections of this organ performed from the top down. Varolio was the first to describe many structures, including the pons, which is still known today as the pons Varolli. Varolio was a pupil to the well-known anatomist Aranzio, who was in turn a pupil of Vesalius. Our current understanding of the nervous system is based on the early anatomic descriptions and depictions by such individuals as Varolio.

Peri-hilar branching patterns and morphologies of the renal artery: a review and anatomical study.

The peri-hilar (extra-parenchymal) branching pattern of the renal artery is important for surgeons to know prior to kidney transplantation. The aim of this study was to identify the variations in peri-hilar branching pattern and morphology of the main renal artery. Arteriograms of 81 kidneys were examined. After marking the renal shadow, the main renal artery was traced laterally from its origin. Morphologically, the arterial branching patterns were classified into ladder (with sequential branching points) and fork (with a common branching point) types. The latter was either duplicated or triplicated. The peri-hilar morphology of the main renal artery was then categorized according to its primary and secondary divisions and their patterns. If a single category encompassed at least 5% of the observed figures, it was recorded as a "cardinal" peri-hilar arterial morphology. Otherwise, it was counted within the category of "infrequent" morphologies. At the level of the main artery, a fork pattern was observed in 92.6% (n = 75) (80.2% duplicated (n = 65) and 12.4% triplicated (n = 10)) and a ladder pattern in 7.4% (n = 6) of kidneys. Of 160 primary branches off the fork-type main artery, a secondary division was found in 68.8%. Only one further division (4.4%) was noted from the ladder-type primary arteries. Eight "cardinal" peri-hilar renal arterial morphologies were identified and represented 82.7% of all cases. At least ten "infrequent" morphologies were also found. These patterns showed some alteration with the presence of a supernumerary renal artery. We concluded that the peri-hilar branching of main renal artery is highly variable, though this may follow certain patterns. We believe that the results may be useful to surgeons operating at the renal hilum especially during kidney transplantation.