Asymptomatic primary biliary cirrhosis. A progress report on long-term follow-up and natural history.

Thirty-six patients presenting with asymptomatic primary biliary cirrhosis have been followed for a median period of 11.4 yr, extending by 5 yr a previously reported median follow-up study of 6 yr. Life table survival analysis indicates that the overall survival of this subgroup of patients with primary biliary cirrhosis continues to remain similar to that of the general population (p = 0.91). Over this period, 15 patients developed symptoms and 8 patients died, 6 from liver disease; 21 patients remained in an asymptomatic state. Portal granulomas on initial liver biopsy were the only finding that correlated with a normal survival and a continued asymptomatic state (p = 0.03). In contrast, associated autoimmune disorders (thyroiditis, sicca syndrome, CRST syndrome, Raynaud's phenomenon) correlated with decreased survival (p = 0.01). No other clinical, laboratory, or histologic features correlated with survival or the development of symptoms. This extended follow-up study (median 11.4 yr) indicates that many patients with asymptomatic primary biliary cirrhosis have a benign outcome. Although 42% developed signs or symptoms of progressive disease at variable times up to 14 yr from presentation, the group survival remained similar to the general population.

Cavitary pulmonary sarcoidosis.

A 25-year-old woman was initially seen with hilar adenopathy and bilateral cavitary lesions. No cause for these roentgenographic abnormalities other than sarcoidosis could be determined. In contrast to what is usually found in acute sarcoidosis, the bronchoalveolar lavage fluid from this patient contained a normal number of lymphocytes and an increased number of multinucleated giant cells. These findings raise the possibility that patients with acute sarcoidosis and cavitation have an atypical form of this disease. Even though cavitation in acute sarcoidosis is rare, this disorder must be considered in making the differential diagnosis of cavitary lung disease.

Rebound rib: stress-induced first rib fracture.

Reported are two cases of stress-induced fracture of the first rib in young, healthy basketball players. Presumably the fractures resulted from violent contraction of the scalene musculature. This is the usual method of production of stress-induced first rib fracture, but basketball-related cases have not been reported previously. This entity probably is underdiagnosed, and is amenable to conservative outpatient management in most cases.

Bilateral scapular fractures from low-voltage electrical injury.

Bilateral, characteristically distributed fractures of the scapula occur from low-voltage electrical injury due to tetanic muscle contraction involving the upper extremities and shoulder girdles. We present the case of a 43-year-old man who sustained bilateral scapular fractures after exposure to a 440-volt, 60 cycle-per-second current passing briefly through his upper extremities. Conservative management, consisting of shoulder immobilization, analgesia, and progressively physical therapy, led to healing of the fractures over six weeks with essentially normal shoulder function after a follow-up period of six months. The absence of an associated fall or other direct trauma should not dissuade the physician from the diagnosis of scapular fractures in electrical injury.