Anaphylaxis caused by helminths: review of the literature.

BACKGROUND: Anaphylaxis is a severe, life-threatening, generalized or systemic hypersensitivity reaction. In many individuals with anaphylaxis a pivotal role is played by IgE and the high-affinity IgE receptor on mast cells or basophils. Less commonly, it is triggered through other immunologic mechanisms, or through nonimmunologic mechanisms. The human immune response to helminth infections is associated with elevated levels of IgE, tissue eosinophilia and mastocytosis, and the presence of CD4+ T cells that preferentially produce IL-4, IL-5, and IL-13. Individuals exposed to helminth infections may have allergic inflammatory responses to parasites and parasite antigens. AIM: To summarize the evidences about the role of helmiths in triggering anaphylaxis. MATERIALS AND METHODS: PubMed search was performed by combining the terms (anaphylaxis, anaphylactic, anaphylactoid) with each one of the etiological agents of human helminthiasis for the period January 1950 to September 2012. RESULTS: < The PubMed search identified 609 papers. Only four genera of helminths were associated with anaphylaxis. (Echinococcus spp, 302 papers; Anisakis spp, 73 papers; Taenia solium cysticercosis, 7 papers; and Ascaris spp., 243 papers). CONCLUSIONS: The risk of anaphylaxis in patients with helminthiasis can vary according to the pathogens, occurring more frequently during echinococcosis of after anisakis infestation and being extremely rare after other helminth infestations. However, physicians, allergist and parasitologist in particular, should be aware of a potential anaphylaxis caused by helminths.

Secondary hemophagocytic lymphohistiocytosis in zoonoses. A systematic review.

BACKGROUND: Hemophagocytic lymphohistiocytosis (HLH) is a rare syndrome that is often fatal despite treatment. It is caused by a dysregulation in natural killer T-cell function, resulting in activation and proliferation of histiocytes with uncontrolled hemophagocytosis and cytokines overproduction. The syndrome is characterized by fever, hepatosplenomegaly, cytopenias, liver dysfunction, and hyperferritinemia. HLH can be either primary, with a genetic aetiology, or secondary, associated with malignancies, autoimmune diseases, or infections. AIM: To focus on secondary HLH complicating zoonotic diseases. MATERIALS AND METHODS: PubMed search of human cases of HLH occurring during zoonotic diseases was performed combining the terms (haemophagocytic or haemophagocytosis or hemophagocytosis or hemophagocytic or erythrophagocytosis or macrophage activation syndrome) with each one of the etiological agents of zoonoses. RESULTS: Among bacterial diseases, most papers reported cases occurring during brucellosis, rickettsial diseases and Q fever. Regarding viral diseases, most of the cases were reported in patients with avian influenza A subtype H5N1. Among the protozoan zoonoses, most of the cases were reported in patients with visceral leishmaniasis. Regarding zoonotic fungi, most of the cases were reported in AIDS patient with histoplasmosis. No cases of secondary HLH were reported in patient with zoonotic helminthes. CONCLUSIONS: Zoonotic diseases are an important cause of HLH. Secondary HLH can delay the correct diagnosis of the zoonotic disease, and can contribute to an adverse outcome.

Management of true splenic artery aneurysms. Two case reports and review of the literature.

Few series of splenic artery aneurysms (SAA) have been reported, but today asymptomatic SAA are detected with increasing frequency. Their importance lies from their potentially fatal consequences as life-threatening hemorrhage. SAA management still remains controversial as reported in this review. Our 2 patients treated with resection of the aneurysms, both located in the middle third of the splenic artery. Some authors demonstrated that when splenic artery has been ligated (or embolized) and the patients remain anatomically splenic, they may not retain any splenic function. Laparoscopic SAA ligation repair appears to be optimal and useful for aneurysms protruding from the pancreas and it is gaining interest because clinical recovery is rapid with a poor morbidity and economic and cosmetic advantages. Transcatheter embolization too offers a temporary control in urgency to stop hemorrhage and go back at later date to make much better elective operation. Endovascular interventions as percutaneous embolization has recently gained popularity: it offers a safe alternative or adjunctive therapy to traditional surgery. We hope in the future instrumentation will likely improve so that this procedure can be done percutaneously by development of prosthetic devices in the 21th century.

Raltitrexed plus oxaliplatin as first-line chemotherapy in metastatic colorectal carcinoma: a multicentric phase II trial.

For advanced colorectal carcinoma, two new drugs, raltitrexed (TOM) and oxaliplatin (L-OHP), have recently shown interesting results. Preclinical and clinical studies suggest that this combination, because of its favorable toxicity profile, high response rate and convenient schedule of administration, can be administered successfully in this disease. In our phase II study, 37 non pre-treated patients with metastatic colorectal carcinoma were treated with TOM (3 mg/m(2)) and L-OHP (130 mg/m(2)) every 3 weeks. In total, 222 cycles were administered; all patients received at least 2 cycles (median 6, range 2-8). There were two complete and 14 partial responses for an overall response rate of 43% (95% CI 27-69%). The median time to response was 2.5 months (range 2-4) and the median duration was 10.3 months (range 5-18). Twelve of the 23 (52%) patients with symptomatic colorectal cancer were classified as clinical benefit responders for at least 4 weeks during the study period. Treatment was well tolerated, and both acute, essentially hematologic, and cumulative hepatic and neurologic toxicities were manageable and reversible. Response rate and toxic effects observed during this study warrant additional studies comparing this TOM-L-OHP regimen with CPT-11 and/or capacitebine-containing regimens in metastatic colorectal carcinoma.

Early and late (ten years) experience with circular stapler hemorrhoidectomy.

PURPOSE: We present a retrospective clinical study concerning the preliminary experience with the circular stapler in the treatment of hemorrhoids. Early results, complications, and long-term follow-up are revisited. METHODS: Fifty-six consecutive patients with second-, third-, and fourth-degree hemorrhoids were included in the study. Data about operation, early postoperative results, and follow-up at one, two, and four weeks were collected. Patients were also contacted by phone after a long-term follow-up (mean, 33 (range, 5-120) months). RESULTS: Every operation attempted was successfully terminated. The length of the operation was less than 15 minutes. No major bleeding or anastomotic disruption occurred. Six patients (13 percent) who underwent spinal or epidural anesthesia had urinary retention. One patient (1.7 percent) had minor bleeding, and four patients (7.1 percent) experienced transient edema of the anastomotic ring after the operation. None needed further treatments. The mean analgesic requirement was 1.4 (range, zero to eight) ketorolac 30-mg injections; 23 patients (41 percent) received no analgesics, and seven patients (12 percent) required a single extra dose of opiates (10 mg morphine cloridrate). Length of hospital stay was between 0 and 11 (mean, 2.7) days, but 20 patients (35 percent) received an additional operation for coexisting surgical disease. At one week, almost all patients experienced little pain at digital inspection and little bleeding after defecations. No anastomotic leakage, wound infection, or healing delay was found. Three patients (5.3 percent) experienced wound edema and pain during defecation. Two weeks later, one patient (1.7 percent) suffered from painful defecation and ten patients (17 percent) reported minor bleeding, but all returned to normal activities. No pain during defecation, bleeding, stenosis, soiling, incontinence, or other anal symptoms were found at one month after the operation, and all patients were well. All patients were contacted by phone 5 to 120 (mean, 33) months later, and all were pleased with the results of this procedure. There were no symptomatic recurrences. DISCUSSION: Our study confirms the feasibility of circular stapler hemorrhoidectomy in the treatment of hemorrhoids. Complications and postoperative pain were minimal. There were no recurrences during long-term follow-up. CONCLUSION: Mechanical hemorrhoidectomy is a promising new option in the treatment of all patients eligible for a surgical approach.

Expression of nm23 gene in gastric cancer is associated with a poor 5-year survival.

The nm23 gene is thought to play a role as an inhibitor of metastatic progression in several human cancers and its down-regulation has been associated with increased metastasis and reduced survival in some studies, though not in others. To better investigate the role of nm23 in gastric cancer (GC), the expression and prognostic impact of this gene was examined in 107 radically operated GC patients in a high risk area. The expression of nm23 was determined immunohistochemically by using the rabbit antibody anti-human nm23 protein. The expression of nm23 was detected in 40.2% (n = 43) of 107 gastric tumours and correlated with a poorer clinical outcome. In a survival analysis at 5 years, patients with nm23-positive tumours had significantly worse prognosis than patients (n = 64) with nm23-negative tumours (p < 0.05). The prognostic significance of nm23 expression was confirmed by multivariate analysis including terms for tumour stage and lymph node involvement. Our results suggest that the expression of the nm23 gene in gastric carcinoma is significantly related to tumour progression and poor prognosis at 5 years.

[Surgical treatment of thyroid microcarcinoma]. / Trattamento chirurgico dei microcarcinomi tiroidei.

Thyroid microcarcinoma is nowaday defined as a tumor of one centimeter or less in the maximum diameter. It occurs in less than five per cent of all thyroid carcinomas. In personal experience four thyroid microcarcinomas have been found in specimens from 121 thyroidectomies and have been retrospectively reviewed clinical data and the long term follow-up of the patients. Total thyroidectomies nor prophylactic lymphadenectomies were never performed. All patients at present are well. Our purpose was to focus on the current surgical treatment of microcarcinoma. Many hypotheses are done to explain pathogenesis and fairly good prognosis of thyroid microcarcinomas, without univocal conclusions. Almost all authors agree that microcarcinoma of the thyroid gland is a low-aggressive tumor, with good biological behaviour, but the therapeutic strategies are not codified yet. Particularly, doubt still exists about the choice between total thyroidectomy and more conservative procedure, and lymphadenectomy, especially when tumor is found in specimens after surgery for benign disease. In conclusion, in our opinion conservative management is the best choice, provided that the patient is included in a correct long-term follow-up.

[Bilateral Morgagni-Larrey hernia. Report of a clinical case]. / Ernia di Morgagni-Larrey bilaterale. Descrizione di un caso clinico.

A rare case of bilateral diaphragmatic hernia, containing a long segment of transverse colon in the left breach and most of the omentum and a short segment of colon in the right one, is described. Diaphragmatic hernia can occur at any age in both males and females and it is often asymptomatic and diagnosed by chance. The epidemiological, etiopathogenic, clinic, diagnostic and therapeutic aspects of the disease are discussed. The only treatment, which is advisable in asymptomatic patients too, is the closure of the hernial orifice. This closure can be done directly or through the insertion of prosthetic material. The conventional access can be thoracic or abdominal, but laparoscopy is going to replace both of them successfully in the future.

Bizarre leiomyoma of the epididymis. A case report.

A case of epididymal leiomyoma with bizarre nuclei is described. A 48-year-old man presented with a painless scrotal mass raising the suspicion of a testicular neoplasm. A seven-year follow-up revealed no evidence of local recurrence or distant metastasis. To personal knowledge, this is the first reported case of bizarre leiomyoma of the epididymis.

[The solitary rectal ulcer today. A review of the literature]. / L'ulcera solitaria del retto oggi. Revisione della letteratura.

The solitary rectal ulcer (SRU) is a benign lesion of adults of either sex, which presents with chronic constipation, peculiar defecatory disorders, rectal prolapse and smaller psychological abnormalities. The characteristic appearance of this disease is a "neither being always ulcerate, nor always solitary" lesion, but often with polypoid or granular feature, typically localized in anterior rectal wall, a few inches from anal channel. Distinctive histopathological specimens are localized mucosal distortion, hypertrophic proliferation of muscularis mucosae and obliteration of lamina propria by fibroblasts and muscle fibres from the muscularis mucosae. Very few intermittent or recurrent symptoms are rectal bleeding and mucous discharge with defecations, difficulty of a complete ampullar evacuation and sometimes pelvic or rectoperineal pain. Clinical picture and endoscopic biopsies led to diagnosis. Barium enema, defecography, transrectal ultrasound, manometry and electromyography have an additional role. Medical treatment is performed by high-fiber diet, but biofeedback training is very helpful. Surgical management is as an excisional surgery, as a rectopexy if there is prolapse. Fecal diversion and rectocolic resection are considered only for patients with obstinate and severe symptoms. Even in patients who seem to advocate a surgical approach it is important to heal a dyskinetic puborectalis muscle.

Adjuvant chemotherapy after gastric resection in node-positive cancer patients: a multicentre randomised study.

After curative resection for gastric adenocarcinoma, 103 patients, all with positive nodes, were randomised so that 48 received adjuvant chemotherapy of epidoxorubicin (EPI) 75 mg m-2 on day 1, leucovorin (LV) 200 mg m-2 on days 1-3 and 5-fluorouracil (5-FU) 450 mg m-2 on days 1-3, every 21 days for 7 months, whereas the remaining 55 did not. During the first year of observation, 21 control patients (38%) and five treated patients had recurrences. After a follow-up period of 36 months, 12 of the treated patients (25%) and only seven controls (13%) were still alive. At that point, the median survival was 13.6 months for the 55 untreated patients and 20.4 months for the 48 treated patients, a significant difference. We found a survival advantage for patients treated with the EPI-LV-5-FU regimen and a consistent delay in the appearance of recurrent or metastatic cancer. Acute toxicity was mild and treatment was well accepted by all patients. There was no long-term toxicity or any cardiac toxicity. We conclude that this particular chemotherapy, administered shortly after gastric resection, improves survival rate in node-positive gastric cancer patients, even although final assessment of this particular adjuvant approach must await completion of the trial.

[The Angelchik prosthesis. A computed tomography study]. / La protesi di Angelchik. Studio mediante Tomografia Computerizzata.

The Angelchik prosthesis is used in the surgical treatment of gastroesophageal reflux. Operated patients are primarily examined with imaging techniques, but manometric and acidometric techniques are also used. Although the conventional esophagogram still maintains its diagnostic significance, computed tomography (CT) has become the first-choice imaging modality. CT allows the correct evaluation of both the state of the prosthesis and its relationship to the esophagus and the gastric fundus. The possible postoperative complications following an incorrect placement of the prosthesis can be accurately diagnosed too. The authors report their experience in the study of 5 patients examined with both conventional radiology and CT.

Intragastric pH continuously monitored in health and in gastric diseases: chronobiologic assessment.

Some gastric diseases clinically show ultradian, circadian, and circannual periodicities. We continuously monitored, during a single 24-hr span, with a fully electronic, solid-state portable recorder, endoluminal gastric pH in five healthy subjects, in some patients with gastric diseases including duodenal ulcer and gastric cancer, and in high-risk persons prone to develop duodenal ulcer and gastric cancer. The daily schedule and the timing of standardized meals for each subject were strictly verified. All stored data (300 time points/subject) were decoded, read, and analyzed by an inferential statistical method to estimate the rhythm parameters. The intragastric dense pH samples showed highly significant circadian and ultradian (8-hr) rhythms in all investigated subjects, but rhythm parameters differed in pre- and in overt pathology.

Anorectal continence and bladder function. Effects of major sacral resection.

The effect of sacral resection up to S-2 has been investigated in two patients with "chordomas," surgical division of the spinal roots was unilateral and bilateral, respectively. Anal manometry, electromyography of the sphincters, and the ascertaining of tactile, thermic, and painful stimuli perception in the perineum and anal canal were executed to determine the effects of denervation on anorectal continence. Vesical function was tested by vesical manometry. Results differ strongly between the two patients: the first, with unilateral loss of S-2, has perfect anorectal continence. The second, with bilateral loss of S-2, is incontinent and unable to discriminate rectal contents. It is sufficient to retain only one S-2 root for the maintenance of physiologic continence, including distinction between different types of bowel contents (gaseous or solid) passing through the anal canal. The same is true concerning bladder function.

[The problem of fecal and urinary incontinence after extensive resection of the sacrum and 2d metamere]. / Le problème de l'incontinence fécale et urinaire après résection étendue du sacrum au second métamère.

Sacral resection was carried out in two patients presenting chordoma. Clinical and laboratory results are reported, with particular reference to preservation of anal and vesical continence. In the first case, double continence was virtually unaltered after unilateral resection of S2. In the second, continence was markedly perturbed by bilateral resection of S2.

[Gastroesophageal reflux of mixed type]. / Il reflusso gastro-esofageo di tipo misto.

Gastroesophageal reflux has been showed both clinically and experimentally to be especially damaging esophageal mucosal layer when the elements which make up reflux are gastric content and bilio-pancreatic juice.

[Histopathology of reflux esophagitis at an early phase. Study and significance of intraepithelial eosinophilia]. / L'istopatologia dell'esofagite da reflusso in fase precoce. Ricerca e significato dell'eosinofilia intraepiteliale.

The diagnosis of reflux esophagitis in the early stage is not easy because endoscopy rarely shows evident findings and histology of biopsy specimens still appears unclear and doubtful. Usual histopathological findings are reported and most available diagnostic criteria are discussed, on the basis of the literature and personal experience. Intraepithelial eosinophils are a possible marker of early reflux esophagitis: its diagnostic usefulness is outlined.