Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study.

BACKGROUND: Traditionally, patients with pulmonary embolism (PE) are initially treated in the hospital with low molecular weight heparin (LMWH). The results of a few small non-randomized studies suggest that, in selected patients with proven PE, outpatient treatment is potentially feasible and safe. OBJECTIVE: To evaluate the efficacy and safety of outpatient treatment according to predefined criteria in patients with acute PE. PATIENTS AND METHODS: A prospective cohort study of patients with objectively proven acute PE was conducted in 12 hospitals in The Netherlands between 2008 and 2010. Patients with acute PE were triaged with the predefined criteria for eligibility for outpatient treatment, with LMWH (nadroparin) followed by vitamin K antagonists. All patients eligible for outpatient treatment were sent home either immediately or within 24 h after PE was objectively diagnosed. Outpatient treatment was evaluated with respect to recurrent venous thromboembolism (VTE), including PE or deep vein thrombosis (DVT), major hemorrhage and total mortality during 3 months of follow-up. RESULTS: Of 297 included patients, who all completed the follow-up, six (2.0%; 95% confidence interval [CI] 0.8-4.3) had recurrent VTE (five PE [1.7%] and one DVT [0.3%]). Three patients (1.0%, 95% CI 0.2-2.9) died during the 3 months of follow-up, none of fatal PE. Two patients had a major bleeding event, one of which was fatal intracranial bleeding (0.7%, 95% CI 0.08-2.4). CONCLUSION: Patients with PE selected for outpatient treatment with predefined criteria can be treated with anticoagulants on an outpatient basis. (Dutch Trial Register No 1319; http://www.trialregister.nl/trialreg/index.asp).

Pancreatitis associated with the use of itraconazole.

BACKGROUND: We call attention to the assumed association between itraconazole and pancreatitis by presentation of four Dutch case reports. METHODS AND RESULTS: The Netherlands Pharmacovigilance Centre Lareb received four reports of pancreatitis associated with the use of itraconazole, all reported by health professionals. The diagnosis of pancreatitis was confirmed by diagnostic tests. All four patients had been using relatively high doses of itraconazole. In two of these cases, recurrent use of itraconazole resulted in recurrent symptoms. We describe these four cases and discuss the possible mechanism. CONCLUSIONS: The presented cases suggest a causal relation between itraconazole and pancreatitis. Given the often mild indication for the use of itraconazole and the seriousness of this possible adverse drug reaction, it is essential that more data are obtained in order to strengthen the causality of this association. Physicians are invited to report their experiences on the subject.

C-reactive protein and D-dimer with clinical probability score in the exclusion of pulmonary embolism.

This study evaluated the diagnostic value of C-reactive protein (CRP) combined with a clinical decision rule in the exclusion of pulmonary embolism (PE) and compared this with D-dimer. In 363 consecutive outpatients CRP and D-dimer test were performed and clinical probability of PE was assessed. Patients with D-dimer levels<500 microg/l and clinical probability indicating 'PE unlikely' were followed for 3 months. Ventilation-perfusion scan or spiral computerized tomography was performed in patients with D-dimer levels>or=500 microg/l or clinical probability indicating 'PE likely'. The CRP had a sensitivity of 95.7% [95% confidence interval (CI): 90-100] and negative predictive value (NPV) of 98.4% (96-100). CRP<5 mg/l with clinical probability score indicating 'PE unlikely' (n=108, 30%), had a sensitivity of 96.7% (90-100), a specificity of 43.0% (37-49) and NPV of 99.1% (97-100). D-dimer<500 microg/l with clinical probability score indicating 'PE unlikely' (n=170, 51%), had a sensitivity of 96.7% (90-100), a specificity of 67.9% (62-74) and NPV of 99.4% (98-100). Based on retrospective data it was concluded that a standard CRP test can potentially be used to safely exclude PE, either as a sole test or combined with clinical probability assessment. Prospective studies are needed to confirm these findings.

[Intravascular lymphoma: a rare but curable cause of interstitial lung disease]. / Het intravasculair lymfoom; een zeldzame, maar curabele oorzaak van interstitiële longafwijkingen.

A 69-year-old man presented with dyspnoea, cough and diffuse interstitial changes and ground-glass effect on a CT-scan. After 5 months the patient was diagnosed with pulmonary intravascular lymphomatosis. A histologic diagnosis was made by a video-assisted thoracoscopic surgical biopsy. Treatment with combination chemotherapy, i.e. 8 cycles of cyclophosphamide-doxorubicin-vincristine-prednisone (CHOP), resulted in a complete remission and a disease-free survival of 5 years at the last follow-up. Intravascular lymphomatosis is a rare but curable cause of interstitial lung disease. Intravascular lymphomatosis is an uncommon type of non-Hodgkin's lymphoma, characterized by proliferation of neoplastic lymphoid cells within the lumen of small blood vessels, resulting in thrombotic and ischaemic complications in multiple organ systems. Primary pulmonary presentation is even more uncommon. It is important to consider intravascular lymphomatosis in the differential diagnosis of unexplained interstitial lung disease, since early diagnosis and treatment may lead to complete remission and long-term survival.

[Pancreatitis ascribed to the use of itraconazole]. / Pancreatitis toegeschreven aan het gebruik van itraconazol.

A 50-year-old woman was treated intermittently with itraconazole (Trisporal) due to onychomycosis. After the initial period of 7 days and after the first 9 days of the second period she experienced abdominal complaints. In the second episode, pancreatitis was diagnosed. No known risk factors for acute pancreatitis were present. The pancreatitis may have arisen due to the use of itraconazole. As far as we know, this side effect of itraconazole or other triazole derivatives has not previously been reported in the literature. It seems to be a rare side effect, for which the pathogenesis has yet to be elucidated.

[High levels of carcinoembryonic antigen in a woman with hypothyroidism]. / Hoge concentratie van carcino-embryonaal antigeen bij een vrouw met hypothyreoïdie.

A 53-year-old woman was referred to the outpatient clinic for Internal Medicine, due to an elevated serum concentration of carcinoembryonic antigen (CEA). Hypothyroidism was diagnosed. Following replacement therapy with levothyroxin, the serum concentrations of thyroid stimulating hormone (TSH) and CEA decreased to near-normal levels. No malignancy was found during the remainder of the treatment period. A decreased hepatic clearance of CEA seemed to be the most likely explanation for the observed high CEA concentration in this patient with hypothyroidism. An increased CEA concentration may occur in association with certain malignancies, as well as with non-neoplastic disorders, such as hypothyroidism. As CEA has a low tumour specificity, routine assessment of CEA is not advocated for diagnostic evaluation.

Echocardiographic follow-up of Chlamydia psittaci myocarditis.

Chlamydia psittaci myocarditis has been infrequently reported. A case of serologically confirmed C psittaci myocarditis with dilated left ventricle and severely impaired left ventricular function is described. Serial echocardiograms demonstrated complete recovery after therapy. An early diagnosis has important prognostic implications.

Wilkie's syndrome, a rare cause of vomiting and weight loss: diagnosis and therapy.

Wilkie's syndrome is a rare disease that should be considered in the differential diagnosis of upper abdominal discomfort and weight loss. Compression of the inferior part of the horizontal duodenum by the superior mesenteric artery may result in high intestinal obstruction with postprandial or positional discomfort, vomiting and weight loss. The diagnosis is based on clinical presentation and confirmed by radiographic studies during a symptomatic period. Therapy of first choice is conservative. Nevertheless, surgical intervention with duodenojejunostomy is often required.

Bilateral brachial plexus neuritis following parvovirus B19 and cytomegalovirus infection.

A man, 23 years of age, had a typical erythema infectiosum, complicated by a severe bilateral brachial plexus neuritis. Motor function recovered slowly and only partially after 6 months. An infection by human parvovirus B19 was demonstrated, with strongly positive and gradually declining IgM antibodies and viral DNA detectable in serum for more than 3 months. There was also clear evidence of a recent infection by cytomegalovirus. The interaction between these two viruses could be responsible for this rare and severe complication of common infections in this patient.

[Hepatitis attributed to the use of terbinafine]. / Hepatitis toegeschreven aan het gebruik van terbinafine.

A 71-year-old woman was admitted to our hospital with jaundice after she had been using terbinafine for a few weeks. The liver function tests showed a mixed cholestatic-hepatocellular pattern. A liver biopsy revealed large amounts of intracellular bile pigment. Causes of the liver disorder other than the use of the aforementioned antimycotic drug were excluded. Ten months after cessation of the drug the patient had recovered completely. The Netherlands Inspectorate for Health Care received 20 reports of liver enzyme elevations due to terbinafine in 1991-1994.

Acute thyroiditis caused by Moraxella nonliquefaciens.

A 43-year-old woman presented with thyroiditis caused by Moraxella nonliquefaciens. Antibiotic therapy resulted in complete recovery. The literature on M. nonliquefaciens and acute bacterial thyroiditis is reviewed. This is the first documented case of a thyroiditis caused by M. nonliquefaciens.

[Accessory spleens as a cause of recurrent idiopathic thrombopenia]. / Bijmilten als oorzaak van een recidief van idiopathische trombopenie.

A female aged 62 yr developed a recurrence of chronic idiopathic thrombocytopenia 7 years after splenectomy. Two accessory spleens were identified and removed surgically. An increase in platelet count was seen. An analysis of the literature shows that extirpation of accessory spleens was successful in over 60% of the patients (32/52) with recurring idiopathic thrombocytopenia after splenectomy.