A muscle mass in a patient with polymyalgia rheumatica.

We report the extremely uncommon case of a 77-year-old woman in whom a tumor found to be a melanotic schwannoma, arising from the right rectus abdominis muscle, was detected during investigation for a rheumatic disorder, finally identified as polymyalgia rheumatica (PMR). Tumors of this type most commonly occur in spinal nerve roots, and their clinical behavior is very difficult to predict. As far as we are aware, this is the first reported case affecting the aforementioned site. The challenging issue in this case concerns the possible link between the 2 clinical conditions, in particular the development of PMR as a paraneoplastic syndrome. Although such an association has not been reported, PMR is included among the rheumatic disorders reported to be associated with malignancies and occasionally with benign tumors. However, given that tumor resection did not result in remission of PMR and symptoms improved rapidly with prednisone, it seems likely that the above disorders might simply coexist.

Recurrent syncopal episodes of neurocardiogenic origin in a patient suffering from cardiac syndrome-X.

We describe the case of a 44-year-old man, with a history of recurrent syncopal episodes and effort angina, the latter attributed to cardiac syndrome-X, who was admitted to our department because of a syncopal episode. During his hospitalization laboratory investigations including haematologic and blood chemical findings, head C/T scan, electroencephalogram, 48-hour Holter monitoring, electrophysiologic testing and echocardiographic study disclosed no abnormalities. On the contrary, a passive upright tilt testing was found to be positive, resulting, approximately, in a 10-seconds time interval of asystole accompanied by syncope. The association in the same patient of cardiac syndrome-X and neurocardiogenic syncope, although never described before, might be explained by a similar pathophysiological mechanism, which is a sympathovagal imbalance.

Apical hypokinesis in a patient with hypertrophic cardiomyopathy and myocardial bridging: reversal with beta-blockade--a case report.

A 42-year-old man presented with effort angina pectoris of 20 minutes' duration. Hypertrophic obstructive cardiomyopathy, severe myocardial bridging involving the midleft anterior descending coronary artery, and apical hypokinesis were identified. Regional wall motion normalized following the initiation of beta blockade.

Thirty one-year durability of a Starr-Edwards aortic prosthesis.

We report the case of a 57-year old man who was admitted to our department because of worsening dyspnea - orthopnea and whose aortic valve had been replaced 31 years previously, with a Starr-Edwards caged-ball prosthesis. His symptoms' deterioration was due to a recent myocardial infarction which in combination with the chronic mitral regurgitation of rheumatic origin led to heart failure. As assessed by echocardiography the mechanical prosthesis did not show signs of significant dysfunction and except for mild regurgitation, it had a good performance. Despite some valve related complications, such as the recurrent thromboembolic events that our patient had, his Starr Edwards aortic prosthesis demonstrated an excellent long term durability and reliability.

Nuclear morphometry of the myocardial cells as a diagnostic tool in cases of sudden death due to coronary thrombosis.

Sudden cardiac death due to underlying coronary artery thrombosis is one of the leading causes of death. However, in a significant percentage of individuals who died suddenly, no indication of myocardial infarction is found during post-mortem examination, especially when the time interval between appearance of symptoms and death is short. In the present study, we have evaluated certain nuclear morphometric parameters, such as, minimum, maximum, mean and standard deviation of perimeter and area in 20 individuals who died of coronary artery thrombosis, within 1 h from symptoms onset. Furthermore, the above parameters were compared with those of a control population of 20 individuals whose sudden death was caused by traffic accidents. Statistical elaboration of the results by means of t-test, Mann-Whitney (U-test) and analysis of covariance (adjusting for age), showed a statistically significant difference for all variables except for the minimum area. With stepwise discriminant analysis method, the mean perimeter was selected as the best predictor of cardiac death. Mean perimeter achieved a correct reclassification percentage (based on Fisher's linear discriminant function) of 92.5% (85% and 100% for cases and controls, respectively). Moreover, by applying the cut-off of 172 microns, we could identify the individuals who died suddenly because of coronary artery thrombosis with a specificity of 100% (sensitivity 85%, P < 0.001). Our results show that nuclear morphometry of the myocardial cells is a reliable diagnostic tool for the diagnosis of coronary thrombosis based lesion in cases of sudden death, even when methods trying to verify the presence of infarction fail to do so.

Comparison of endothelin-1 levels at rest and during exercise between patients with cardiac syndrome-X and healthy people.

Several previous studies have shown that endothelin-1 (ET 1) plasma levels are raised in cases of endothelial abnormality and microvascular dysfunction. Syndrome-X constitutes an important clinical entity characterized by angina-like pain and normal coronary arteries which is believed to reflect microvascular dysfunction. The aim of the present study was to investigate the role of ET 1 in the pathophysiology of the above syndrome. For that purpose the plasma ET 1 concentrations, measured by radioimmunoassay, between 28 X-syndrome patients (group A) and 10 age-matched normal control subjects (group B) at rest and at the peak of the exercise testing were compared. We specify that all individuals of group A were referred to our Department for effort angina and were found to have normal coronary arteriograms, negative ergonovine and hyperventilation test and positive exercise test. Our results showed that while at rest ET 1 plasma concentrations did not differ significantly between the two groups, at the peak of the exercise test its levels were found to be significantly higher in syndrome-X patients as compared with those of normal subjects (p< 0.001). In addition, in healthy control subjects ET 1 levels decreased during exercise as compared with the baseline values and that difference was found to be statistically significant (p approximately 0.01). The above finding suggests opposite kinetics during exercise of ET 1 between the two groups studied, which could explain effort angina onset in patients with syndrome-X.

Amineptine induced liver injury. Report of two cases and brief review of the literature.

Two cases of amineptine induced liver injury in patients treated with the drug for 18 and 15 days respectively, are reported. Hepatic reaction lasted 60 days in the first case and 120 days in the second one, with the latter considered unusually prolonged. The patients history, the course of the reaction and the histologic findings were compatible with the diagnosis of drug induced liver disease in both cases. Furthermore, every other possible origin of hepatobiliary injury such as disorders of bile ducts, ongoing viral hepatitis and autoimmune hepatitis were excluded. The mechanism of amineptine induced liver injury and the influence of a possible genetic predisposition to amineptine hepatotoxicity are also discussed.

Terbinafine-induced cholestatic liver disease.

Hepatobiliary disorders associated with orally administered terbinafine have rarely been reported. We describe a case of prolonged terbinafine-induced cholestatic liver disease. Extrahepatic cholestasis, viral hepatitis and autoimmune liver disorders were excluded. The histological findings of marked cholestasis without evidence of extrahepatic biliary obstruction or acute hepatitis were compatible with the diagnosis of drug-induced liver disease. Biochemical parameters of liver cell damage returned to normal levels 6 months later.