Life-threatening Pneumocystis jiroveci pneumonia following treatment of severe Cushing's syndrome.

We describe two patients with a severe Cushing's syndrome due to ectopic production of ACTH. Both patients developed a life-threatening Pneumocystis jiroveci pneumonia (PCP) shortly after treatment of the hypercortisolism was started by means of inhibition of production of glucocorticoids and glucocorticoid receptor blockade. We presume that the restored immune response elicited the clinical symptoms of the opportunistic, previously subclinical Pneumocystis jiroveci infection. The immunocompromised state and the delicate glucocorticoid balance in patients with a severe Cushing's syndrome necessitate a specific diagnostic and therapeutic approach.

Functional outcome in patients with thoracolumbar burst fractures treated with dorsal instrumentation and transpedicular cancellous bone grafting.

The aim of the study was to develop an insight into the impairments in spinal fracture patients, operatively treated with an internal fixator, and also into their ability to participate in daily living, return to work and quality of life as defined by the World Health Organization. Nineteen patients operated for a type A fracture of the thoracolumbar spine (T9-L4) between 1993 and 1998 in the University Hospital Groningen, the Netherlands, aged between 18 and 60 years, without neurological deficit were included in the study. Operative treatment consisted of fracture reduction and internal fixation using the Universal Spine System, combined with transpedicular cancellous bone grafting and dorsal spondylodesis. No ventral fusion operations, laminectomies or discectomies were done. Restrictions in body function and structure were measured on radiographs and in functional capacity tests, such as lifting tests and ergometry. Restrictions in activities were studied with the Visual Analogue Scale (VAS) Spine Score and the Roland Morris Disability Questionnaire (RMDQ). Restrictions in participation/quality of life were analysed with the Short Form 36 (SF36) and described in the return to work status. The radiological results are comparable to the literature. The reduction of the anterior wedge angle was followed by a gradual partial loss of intervertebral angle and regional angle. The maximum oxygen uptake (VO2-max) was reduced in only 8.3% of the patients. Arm and trunk lift was within the normal range in 87% and 80% of the patients respectively, but only 53% of the patients were able to perform a leg lift within the normal range. A mean RMDQ score of 4.0 positive items (SD 6.0) was found, and the mean VAS Spinal Score was 79.4 (SD 25.0), both better than in other series. No significant differences compared to the values of a comparable (healthy) age group could be identified in any variable of the SF36. A high correlation was seen between RMDQ, VAS Spine Score and the SF36 categories. No correlation was found between the anterior wedge angle and the regional angle on the one hand, and functional capacity tests or questionnaire scores on the other. Of the patients in paid employment before the trauma, 87% had returned to work at follow-up. About 50% of the patients had been obliged to change the intensity of their work or the kind of work they performed after the injury and treatment. In this matter, leg (muscle) performance seems a more important factor than overall condition (VO2-max). The results of the study indicate that patients with thoracolumbar spinal fractures without neurological deficit, treated with dorsal instrumentation, perform like healthy people 3-8 years after injury, according to the RMDQ, VAS Spine Score and SF36 results. Physical capacity tests reveal that leg (muscle) performance seems a more important factor in impairment than arm lift or overall condition.