[A very uncommon reason for chest pain]. / Thoraxschmerzen - eine sehr ungewöhnliche Ursache.

A 25-year old female immigrant from Kosovo living in Switzerland for three years complained of intermittent atypical chest pain and shortness of breath for three months. The patient was febrile (38.4 °C) and had a regular tachycardia of 120/min and a blood pressure of 105/65 mmHg. The ECG showed deep symmetric negative T-waves on the leads V1 - V6. The conventional chest X-ray revealed a small bulge of the left cardiac outline. Leucocytes and differential count were normal but the C-reactive protein was markedly elevated (118mg/L). Computed tomography of the chest revealed several pleural and paramediastinal cystic masses on the left side. One of these cystic lesions covered a small defect of the aortic wall appearing as a pseudoaneurysm at the beginning of the descending aorta. Echocardiography showed pericardial cysts on the left ventricle and a small pericardial effusion. Serological tests for Echinococcus granulosus were strongly positive. Thus, the patient was diagnosed with cystic echinococcosis with pericardial, pleural and mediastinal involvement with a pseudoaneurysm of the descending aorta.

[Unclear neurological condition and fever]. / Unklares neurologisches Zustandsbild und Fieber.

We report two cases of elderly patients who developed an unclear neurological condition with fever. The CSF findings showed a predominantly mononuclear pleocytosis, low glucose in relation to serum glucose and elevated protein. This liquor constellation led to the suspicion of tuberculous meningitis. PCR and finally CSF culture confirmed the diagnosis, which is often delayed because of nonspecific clinical findings. The characteristic CSF formula should lead to rapid antituberculous treatment, as mortality is high.

New possibilities of maximal revascularization of the foot as a limb salvage procedure in diabetics.

Diabetics and patients with chronic renal insufficiency often have severe peripheral arterial disease of the distal lower limbs with obstructions of crural and pedal arteries and the imminent risk of critical ischemia and major amputation. Neuroischemic foot ulcers have been shown to fail to heal even after successful arterial revascularization. We report on two diabetic patients with the neuroischemic diabetic foot syndrome and different clinical outcomes after percutaneous transluminal angioplasty of chronic occluded crural arteries and discuss, whether endovascular revascularisation of infrapopliteal and pedal arteries, if possible with complete plantar arch, could promote ulcer healing in neuroischemic diabetic foot ulcers.

[Young man with intermittent dysphagia]. / Rezidivierende Schluckbeschwerden bei einem jungen Mann.

Endoscopic findings of an 18-year old man with intermittent dysphagia showed widespread white exudations of the oesophagus. First misinterpreted as oesophageal candidiasis the mucosal biopsies revealed the histological features of a severe eosinophilic oesophagitis. Under treatment with topical steroids the symptoms dissolved. The control endoscopy showed a histological remission with absence of eosinophilic granulocytes, too. The eosinophilic oesophagitis is a rare allergy-like inflammation of the oesophagus especially seen in young men with increasing incidence. Without treatment the long-term risk of eosinophilic oesophagitis is the induction of severe oesophageal strictures.

[Epigastric pain and abnormal ECG]. / Epigastrische Schmerzen und pathologisches EKG.

We report on a 50-year old man who presented with upper abdominal pain and new T-wave inversions in the anterior leads of the electrocardiogramm. Since the patient additionally had cardiovascular risk factors (positive family history, smoking, hypercholesterinemia and hypertension) he was initially thought to have an acute coronary syndrome. Moreover, he had elevated serum levels of amylase and lipase, and together with typical findings of abdominal ultrasound he was diagnosed with acute pancreatitis responsible for the patient's pain. The ECG changes persisted during the hospital stay, but had fully normalised three weeks later. Further cardiologic evaluation yielded normal results. Thus, the ECG-abnormalities could be attributed to the acute pancreatitis, which can cause ECG-pathologies mimicking an acute coronary syndrome in up to 30%. Knowledge of there findings is important in order to prevent wrong therapeutic decisions.

Age and bioavailability of alcohol.

UNLABELLED: It has been shown that advanced age results in a decreased first pass metabolism (FPM) of ethanol with elevated serum ethanol concentrations (SECs). It is still unknown if this is due to age by itself or to other factors like for example atrophic gastritis with decreased activity of alcohol dehydrogenase (ADH). To study the effect of age on SECs and on bioavailability of ethanol, 15 volunteers with a mean age of 71 +/- 1 year (8males and 7 females) and 16 volunteers with a mean age of 37 +/- 2 years (8males and 8 females) showing normal gastric histology received ethanol (0.225 g/kg b. w.) intravenously (iv.) and orally. RESULTS: The difference between the SEC time curves after iv. and oral ethanol administration (so called FPM of ethanol) was significantly increased in elderly subjects (54 +/- 6 vs. 12 +/- 9 %, p < 0.001). The SEC time curves after iv. ethanol application were significantly increased in the elderly (p < 0.001), whereas SECs following oral alcohol administration were significantly lower in elderly as compared to younger individuals (p < 0.02). Peak SECs following iv. application was also significantly elevated with age (52 +/- 4 vs. 31 +/- 1 mg/100 ml, p < 0.001) and occurrence of peak SECs following oral ethanol intake was significantly delayed (47 +/- 4 vs. 28 +/- 4 min, p < 0.001). No gender effect at all was observed. CONCLUSION: FPM of ethanol is inexpectedly increased in elderly with normal gastric morphology compared to young people. The elevation of SECs after iv. ethanol administration in the elderly could be explained by the reduction of the water distribution space with age, whereas the increased FPM of ethanol in elderly subjects with normal gastric morphology is probably due to a deceleration of the speed of gastric emptying leading to an increased contact time of alcohol with gastric alcohol dehydrogenase (ADH). Our data do not confirm results from other research groups showing increased SECs in the elderly after alcohol consumption. Increased SECs are therefore not due to age by itself, but are probably caused by other factors as for example atrophic gastritis which is frequently found in the elderly people and which decreases FPM of ethanol.

[General AL-amyloidosis: a rare complication in Waldenstrom macroglobulinemia]. / Generalisierte AL-Amyloidose: Eine seltene Komplikation bei Makroglobulinämie Waldenström.

Waldenström's macroglobulinemia (W.M.) is a paraproteinemic disorder similar to multiple myeloma expressing a monoclonal IgM paraprotein. The course of W.M. is milder and the occurrence of renal disease is less frequent than in multiple myeloma. Amyloidosis occurs in less than 5% of patients with monoclonal IgM. We report a 65 year old patient with an asymptomatic long-term survival whose W.M. remained without any therapy. Amyloidosis developed twenty-one years after the initial diagnosis presenting with the nephrotic syndrome, renal and heart failure. W.M. combined with amyloidosis is a rare association. The deposition of amyloid causes progressive organ damage and indicates a bad prognosis. Most commonly nephrotic syndrome or heart failure are signs of amyloidosis. The development of amyloidosis does not seem to be influenced by the duration of W.M. disease or the paraprotein level. It is not known whether the amyloidosis can be prevented by an early chemotherapy.

[Recurrent severe lower gastrointestinal hemorrhage. Acute recurrent diverticulum hemorrhage in the cecum]. / Rezidivierende schwere untere Gastrointestinalblutung. Akute rezidivierende Divertikelblutung im Coecum.

This 83-year-old patient was admitted to the emergency room after a sudden and abundant rectal bleeding without any other abdominal symptoms. The physical examination showed normal abdominal findings. However, digital rectal examination revealed dark red blood. Upper and lower endoscopic examination did not show an active bleeding source. A diagnosis of an acute lower gastrointestinal bleeding probably originating from a diverticulum was made. The patient was dismissed two days later without any signs of further bleeding. However, the same day he was readmitted again because of acute rebleeding. Emergency colonoscopy was not conclusive because of massive hemorrhage. Angiography of the abdominal arteries was performed which showed marked active bleeding in the coecal region. Ileocoecal resection was performed and histopathological examination showed a solitary coecal diverticulum.

[Acute myocardial infarction: time delay from onset of pain to hospital presentation and thrombolysis]. / Akuter Myokardinfarkt: zeitliche Verzögerung von Schmerzbeginn bis Spitaleintritt und Thrombolyse.

BACKGROUND: The efficacy of thrombolytic therapy in patients with myocardial infarction depends largely on the delay to initiation of treatment. METHODS: From February 1996 to May 1997 we prospectively studied 175 patients hospitalised for acute chest pain and suspected coronary heart disease. We determined the delays between onset of pain and calling for medical help, hospital arrival and thrombolysis. RESULTS: The median delay until hospital presentation was 3.1 hours, with no difference between male and female or younger and older patients. 35% of the patients arrived at the hospital within 2 hours, 38% within 2-6 hours and 27% after more than 6 hours. Most of the delay was caused by the patients (median 2.0 hours). Emergency doctors contributed 35 minutes, and transport to the hospital took 31 minutes. 99 patients (57%) were diagnosed with acute myocardial infarction. 53 (54%) fulfilled the criteria for thrombolysis and were so treated. The median overall delay from onset of pain to thrombolysis was 2.9 hours. 77% received treatment within 6 hours, and 23% within 6-12 hours after onset of pain. The median delay inside the hospital (door to needle) was 40 minutes. CONCLUSIONS: 75% of patients with acute chest pain arrived at the hospital within 6 hours of onset of symptoms. Most of the delay was caused by the patients themselves, a factor which needs to be improved by better education. Moreover, optimising in-hospital processes should further shorten the delay to thrombolysis.

[From Hashimoto thyroiditis to B-cell lymphoma of the thyroid gland]. / Von der Hashimoto-Thyreoiditis zum B-Zell-Lymphom der Schilddrüse.

Lymphoma of the thyroid gland is an uncommon condition occurring primarily in older women. Most patients have a short history of an enlarging thyroid or a neck mass causing tracheal compression. There is also a strong association between thyroid lymphoma and Hashimoto's thyroiditis. The diagnosis is established by biopsy. The conventional approach to treatment is combination of radiation therapy with multi-agent chemotherapy, while there is no significant role for extirpative surgery in the management of thyroid lymphoma. The prognosis of localised tumours (stage IE, Ann Arbor classification) is excellent. Extrathyroidal involvement (stage IIE-IVE) reduces the 5-year survival rate to about 70%, provided that current therapy regimens are respected. In this case report, the different stages of development from Hashimoto's thyroiditis to thyroid lymphoma are demonstrated by histology. In a review of the literature we discuss the diagnostic procedure and the current approach to treatment.

[Pulmonary artery malformations]. / Pulmonale arteriovenöse Malformationen.

We report on two patients with pulmonary arteriovenous malformations (PAVM). An almost asymptomatic young man and an elderly woman with severe dyspnoea illustrate paradigmatically various aspects of the clinical manifestation, diagnostic approach and treatment of this rare disorder. New aspects with respect to genetics, diagnosis and therapy are discussed. PAVM are often manifestations of hereditary teleangiectasia, which also affect blood vessels of the skin, mucous membranes, brain and liver. Transcatheter embolotherapy is a safe, effective and minimally invasive treatment option, which seems to be replacing surgical resection as first-line therapy in many cases.

Once-weekly administration of dapsone/pyrimethamine vs. aerosolized pentamidine as combined prophylaxis for Pneumocystis carinii pneumonia and toxoplasmic encephalitis in human immunodeficiency virus-infected patients.

To evaluate combined prophylaxis for Pneumocystis carinii pneumonia (PCP) and toxoplasmic encephalitis, 533 patients with symptomatic human immunodeficiency virus infection and/or CD4 lymphocyte counts of < 200/microL were randomized to receive dapsone/pyrimethamine (200/75 mg once weekly) or aerosolized pentamidine (300 mg every 4 weeks). The median CD4 lymphocyte count was 110/microL; 47.5% were seropositive for toxoplasma antibodies. The median duration of follow-up was 483 days. In the intent-to-treat analysis, 12 cases of PCP and 14 of toxoplasmic encephalitis occurred in the dapsone/pyrimethamine group and 13 and 20 cases, respectively, in the aerosolized pentamidine group (adjusted relative risk for toxoplasmosis, 0.56; P = .10). However, only two of the 14 cases of toxoplasmic encephalitis in the dapsone/pyrimethamine group developed during actual treatment. The mortality among the two groups was similar. Dapsone/pyrimethamine was not tolerated by 30% of participants. A subanalysis of 240 matched, tolerant patients yielded a relative risk for toxoplasmosis of 0.21 (P = .014), a result favoring the use of dapsone/pyrimethamine. Dapsone/pyrimethamine was as effective as aerosolized pentamidine as prophylaxis for PCP and significantly reduced the incidence of toxoplasmic encephalitis among those participants who tolerated it.

Dapsone/pyrimethamine may prevent mycobacterial disease in immunosuppressed patients infected with the human immunodeficiency virus.

Dapsone exhibits activity against Mycobacterium tuberculosis and Mycobacterium avium complex (MAC) in vitro. We retrospectively examined the incidence of mycobacterial diseases within a randomized prospective trial of prophylaxis for Pneumocystis carinii pneumonia and toxoplasmosis. Of 501 participants who had not previously had a mycobacterial disease, 274 received dapsone/pyrimethamine (200/75 mg once weekly) and 227 received aerosolized pentamidine (300 mg once every 4 weeks). The median CD4 lymphocyte count was 113/microL, and the median duration of treatment was 369 days. Six cases of tuberculosis, 22 of MAC infection, and 3 of Mycobacterium genavense disease occurred during treatment. Stratified by basement CD4 lymphocyte counts, the annual product-limit incidence of mycobacterial disease was 5% during treatment with dapsone/pyrimethamine vs. 12% during treatment with aerosolized pentamidine for patients whose counts were 0-24/microL, 0 vs. 12% for those whose counts were 25-49/microL, and 7% vs. 9% for those whose counts were 50-99/microL. Adjusted for CD4 lymphocyte counts at start of treatment, the relative risk for patients receiving dapsone/pyrimethamine was 0.47 (95% confidence interval, 0.19-1.16; P = .10). This inexpensive and simple regimen may prevent mycobacterial diseases and warrants further investigation as a means of prophylaxis for multiple opportunistic diseases.

The integration of alternative treatment modalities in HIV infection--the patient's perspective.

The relationship between professionals representing conventional treatment (CT) and professionals representing non-conventional therapies (alternative therapy (AT) and/or psychotherapy (PT)) is usually characterized by mutual scepticism and mistrust, the overriding fear being that either side will evoke unjustified hopes or will provide false treatment. We investigated whether patients with HIV infection had unrealistic hopes in non-conventional treatment (non-CT), to what extent they use non-CT, and whether perceived benefit and harm differ between the two modes of treatment. We examined a sample of 100 patients with documented HIV-infection in the out-patient department using a self-developed questionnaire, the Hospital Anxiety and Depression Scale (HAD) and data concerning the HIV status. Fifty-six patients used AT and/or PT. Severity of HIV disease did not differ between users and non-users of non-CT. The most important reasons for the use of AT were 'strengthening the body and resistance; supplementing conventional therapy'. Users of non-CT rated the competence of CT lower than non-users in solving medical problems (VAS-scores 0-100: 65.5 +/- 17.6 vs 76.3 +/- 17.7; p = 0.003) and in solving emotional problems (VAS scores 0-100: 35.8 +/- 21.2 vs 48.2 +/- 28.9; p = 0.02). Users of non-CT were significantly more anxious 8.4 +/- 4.8 vs 5.5 +/- 4.6; p = 0.004) and more depressive (5.7 +/- 4.5 vs 3.7 +/- 4.5; p = 0.03) than non-users. Expectations and hopes did not differ between users of AT and non-users: main hopes were a delay of disease progression (76% vs 71%) and an alleviation of symptoms (78% vs 66%).(ABSTRACT TRUNCATED AT 250 WORDS)

Usefulness of routine urine analysis in medical outpatients.

OBJECTIVE: To investigate prospectively the value of routine urine analysis in a university based, medical outpatient clinic providing primary (> 90%) and referral care (< 10%) in general internal medicine, as determined by whether it led to a new diagnosis requiring a change in medical management (new treatment; advice to patient; further follow up appointment). METHODS: A dipstick urine analysis was performed in 610 consecutive patients (mean (SD) age 41 (16) years) making their first clinic visit. A urinary sediment of the same specimen was examined in those patients with abnormal results for haemoglobin, leucocytes, or protein. A urine analysis was defined as routine when it was not considered indicated for diagnostic or management purposes by the resident in charge at the patients' initial clinic visit. The main outcome measures were the number and nature of new diagnoses leading to a change in patient management. RESULTS: In 183 patients (30%, 95% confidence interval (CI) 27% to 34%) the urine analysis was performed as an indicated test and in 427 (70%; 95% CI 64% to 73%) as a routine test. Urine analysis was abnormal in 71 of the 427 patients (17%) in whom it had been performed as a routine test. Abnormal findings led to a change in management in three patients only (0.7%; 95% CI 0.2% to 2.2%). Critical assessment makes the value of routine urine analysis debatable even in these three patients. CONCLUSIONS: In a middle aged medical outpatient group of a university based, teaching clinic providing predominantly primary care, urine analysis can be restricted to patients in whom it is clinically indicated.