Phytobezoars and trichobezoars: a 10-year experience.

INTRODUCTION: Bezoars are retained concretions of animal or vegetable material in the gastrointestinal tract. Most bezoars reside in the stomach, but they may be encountered elsewhere. Previous gastric surgery, which has resulted in impaired gastric emptying and/or decreased acid production, is usually the cause of bezoars. Phytobezoars are more common, while trichobezoars are rare. Endoscopy and gastrografin swallow may aid in diagnosis. The treatment of bezoars can be either conservative or surgical. METHODS: After searching the computerized medical database, all files of hospitalized patients in the years 1992 to 2002 with the diagnoses "bezoars," "phytobezoars," and "tricobezoars" were evaluated. RESULTS: Eighteen patients had bezoars: 16 had phytobezoars and 2 patients were diagnosed as having trichobezoars. Eleven of the patients had previous gastric operation. All patients but one were treated surgically. Two unusual cases of trichobezoar are presented here. DISCUSSION: Thorough understanding of bezoars can allow the clinician to be especially alert when dealing with those patients most likely to develop them, and thus diagnose the condition at an early stage.

Thrombotic thrombocytopenic purpura due to alcohol binge drinking.

Binge alcohol drinking is a pattern of alcohol abuse that is common among young males worldwide. It has been found to be associated with an increased likelihood of injury as a cause of death. Chronic alcohol abuse is known to cause some common hematological manifestations such as macrocytosis, thrombocytopenia, sideroblastic anemia, global marrow suppression, and folic acid deficiency anemia. We present a rare case involving an unusual and severe hematological manifestation of binge alcohol drinking: thrombotic thrombocytopenic purpura (TTP). The patient we present had severe and prolonged TTP necessitating prolonged treatment with plasmapheresis and plasma exchange. We discuss the relevant medical literature and the possible physiopathology of this complication.

[Nosocomial infections in internal medicine departments].

BACKGROUND: Nosocomial infections are a major cause of morbidity and mortality among hospitalized patients. The use of new generation antibiotics of wide spectrum caused a higher rate of virulent infections. AIMS: a) To study the prevalence, pattern and etiology of nosocomial infections in patients hospitalized in departments of internal medicine. b) to determine the characteristics of high-risk patients, deserving special precautions. METHODS: All medical files of patients who were admitted to internal medicine departments during the years 1994-8 were reviewed. All patients with nosocomial infections were included according to specific criteria. RESULTS: Of 2789 medical files, 72 (2.6%) patients, randomly elected had 76 episodes of nosocomial infection. Urinary tract infection (40.8%), pneumonia (32.9%) and sepsis (9.2%) were the most frequent infections. Mortality was significantly higher in patients with nosocomial infections--48.6% compared to 5% in a control group (p < 0.001). E. Coli, Pseudomonas auroginosa, and Staphylococcus Aureus were the most frequent infecting bacteria. Empiric antibiotic therapy was used in 84.7% of the patients. Any bacterial isolation was found in 61.9% of the patients samples (including blood cultures, urine cultures etc). Old age, female gender, prolonged hospitalization, mechanical ventilation and indwelling urinary catheter were found as risk factors for nosocomial infections. CONCLUSIONS: 1. Nosocomial infections in internal medicine departments in Brazilai hospital were found to be less common than previously reported. 2. Five risk factors for nosocomial infections were correlated with a higher prevalence of the disease. 3. Mortality due to nosocomial infections is very common, probably due to inappropriate empiric treatment and high rate of bacterial resistance. 4. Simple preventive measures as well as immediate treatment of nosocomial infection with proper antibiotics are expected to decrease mortality.

[Human transmissible spongiform encephalopathies].

A new variant of Creutzfeldt-Jakob disease was discovered in 1996. This new variant was found to be related to encephalopathy. There are 5 known human transmissible spongiform encephalopathies, all created by prions. The prion, a pure protein, smaller than a virus is derived from a normal glycoprotein of human cells wall. The function of this protein is unknown but supposed to be connected with copper incorporation into superoxide dismutase. Creutzfeldt-Jakob disease is an early dementive disease with loss of neurons, accumulation of amyloid and spongiform degeneration of the brain. We discuss the epidemiology, diagnosis and therapy of Creutzfeldt-Jakob and its variant. The increased life expectancy will certainly cause these diseases to be more common, thereby having a definite affect on the economy in both developing and developed countries. Future therapy will concentrate on either preventing the creation of pathologic prions or extracting intracellular prions.

Recurrent pneumonia post-thymectomy as a manifestation of Good syndrome.

A 78-year-old woman presented with right lobar pneumonia. Six months before, the patient had undergone surgery due to a large mass that was found to be spindle cell thymoma. During the past 6 months, the patient had been admitted to the hospital several times with recurrent pneumonia in both lungs; this was treated successfully with antibiotics. Laboratory examinations revealed lymphopenia, eosinopenia, hypogammaglobulinemia, and a low count of CD4 T cells and an inverted CD4:CD8 T cell ratio, both on peripheral blood and bone marrow. History and laboratory findings were compatible with the diagnosis of the rare Good syndrome. This syndrome is discussed here.

Severe enoxaparin-induced thrombocytopenia complicated by pulmonary emboli.

Low molecular weight heparins (LMWH) have been widely used in the last decade, especially for prophylaxis of deep venous thrombophlebitis. Enoxaparin-induced thrombocytopenia is rarely encountered, in contrast to its high prevalence among patients treated with unfractionated heparin. We report a case of a patient who was admitted because of a pulmonary embolus due to proximal deep vein thrombophlebitis 2 weeks after surgery, despite prophylaxis with low-dose enoxaparin after prostatectomy. The patient's original normal platelet count (255,000/microl) dropped to 30,000/microl while on enoxaparin therapy. Testing for antibodies against heparin was positive. Warfarin was initiated and an inferior vena caval filter was inserted. Within a few days, platelet count increased to 100,000/microl, pulmonary status improved, and the patient was released in good clinical condition. Heparin-induced thrombocytopenia (HIT) is discussed, as are alternative treatments for unfractionated heparins and LMWH.

[Splenic abscess as an unusual manifestation of colonic carcinoma].

A patient was admitted to the Internal Medicine Department after suffering from fever for 4 days. A splenic abscess was found in an ultrasound examination and was confirmed by an abdominal computerized tomography and galium scan. Antibiotic treatment was successful, however barium enema was performed due to the lack of a predisposing factor for this unusual abscess. A polypoid mass was found in the splenic flexure of the colon. Colonoscopy and histologic examination confirmed the mass to be colonic adenocarcinoma. Either an endoscopic examination or barium enema are recommended to exclude colonic lesions in cases of splenic abscess without an obvious cause.