An unusual case of coccidioidomycosis.

Dissemination of coccidioidomycosis is rare. The skin, musculoskeletal system, and central nervous system have been described as the most common sites of extrapulmonary disease. We present a case of an asymptomatic patient in whom the diagnosis of coccidioidomycosis was made on a lymph node biopsy. The biopsy was performed because of an abnormal mammogram and physical findings suggestive of malignancy.

O6-methylguanine-DNA methyltransferase in normal and malignant tissue of the breast.

An important component of high-dose chemotherapy/autologous bone marrow support regimens for adjuvant treatment of breast cancer is carmustine. Preclinical studies have shown that the level of the DNA repair protein O6-methylguanine-DNA methyltransferase is correlated with the resistance of cultured human tumor cells to this drug, but little is known about transferase levels of breast tissue in vivo. We measured the DNA repair activity in 80 tissue samples from 65 patients, including normal, abnormal, benign, and malignant specimens. Wide interindividual variations was observed and average transferase levels were similar in normal and benign tissue. However, transferase levels were significantly elevated in stage I-IV disease. In addition, the frequency of samples with no detectable transferase was greatly reduced in this malignant group, and transferase was positively correlated with the presence of positive nodes, a marker for disease progression. In contrast, transferase levels were not correlated with age or estrogen receptor status, and the levels in normal tissue did not vary between patients with benign or malignant disease. These results suggest that this DNA repair activity may be increased in breast cancer relative to normal tissue and encourage further study of the predictive value of transferase measurements in high-dose chemotherapy/autologous bone marrow transplant for breast cancer.

Peritoneovenous shunting for cirrhotic versus malignant ascites.

The use of the peritoneovenous shunt in patients with cirrhosis is associated with a significantly higher complication rate than in patients with malignant ascites. Since many patients subsequently died due to the complications of shunt placement and the efficacy has never been clearly established by a randomized trial, it is difficult to recommend a procedure which may shorten the already brief life expectancy of the patient. We conclude that for the patients with ascites due to cirrhosis, the peritoneovenous shunt should be reserved for a carefully selected group, such as those patients with pending rupture of a hernia. However, for the patient with malignant ascites, the relatively low complication rate of peritoneovenous shunt placement and the lack of an adverse effect on survival time indicates that use of this successful palliative technique seems warranted in selected patients.

Duodenojejunostomy and stapled occlusion for distal duodenal perforation from malignant retroperitoneal tumors.

Three patients with unresectable malignant retroperitoneal tumors that invaded and perforated the distal duodenum presented with sepsis unresponsive to antibiotics. A technique of proximal side-to-side duodenojejunostomy with stapled occlusion of the distal duodenum resulted in successful diversion and immediate resolution of sepsis.