Aortitis as a manifestation of myelodysplastic syndrome.

Aortitis is the inflammation of the wall of the aorta and can occur from an infection or autoimmune disease. Myelodysplastic syndrome (MDS) is characterised by abnormal haematopoiesis and a dysfunctional immune system. Autoimmune manifestations have been described in MDS. Here a case of a patient with aortitis and MDS is presented and discussed. All possible aetiologies were ruled out. The patient's symptoms resolved after she received steroids.

Splenosis presenting as occult gastrointestinal bleeding.

A 48-year-old man presented with recurrent gastrointestinal bleeding and anemia. Routine endoscopic evaluation was nondiagnostic. Angiography demonstrated multiple apparent arteriovenous malformations. Exploratory laparotomy revealed numerous splenic implants along the small and large bowels, some of which had apparently eroded through the bowel mucosa and bled. Excision of these penetrating lesions prevented further bleeding. An incidentally noted renal cell cancer was also resected. The patient's splenosis was the result of childhood trauma that caused splenic rupture and precipitated splenectomy. Splenosis develops frequently following traumatic splenic rupture. Experimental evidence suggests that the presence of an intact spleen suppresses the growth and development of splenic implants. Following splenectomy, splenules may replace some of the "housekeeping" and immunologic functions of the spleen, but even patients with documented splenosis should be considered functionally hyposplenic. While in most cases splenules cause no symptoms, splenosis must be considered in the differential diagnosis of previously splenectomized patients who present with unexplained masses or occult bleeding.

Atrial fibrillation and tumor emboli as manifestations of metastatic leiomyosarcoma to the heart and lung.

Leiomyosarcoma is a malignant tumor of the smooth muscle that rarely occurs in the gastrointestinal tract. High-grade leiomyosarcomas of the rectosigmoid usually metastasize to the liver and lungs. Although it is unusual, metastases to the heart have been reported. When this occurs, the metastatic tumor usually seeds in the right atrium and pulmonary artery. We report on and discuss a patient who had atrial fibrillation, peripheral emboli, and thrombocytopenia resulting from a low-grade rectosigmoid leiomyosarcoma metastatic to the pulmonary vein and left atrium. Atrial fibrillation is not a common manifestation of malignant neoplasms that have spread to the heart. Surgical removal of the tumor terminated the arrhythmia and thrombocytopenia.

Persistent parvovirus B19 related anemia of seven years' duration in an HIV-infected patient: complete remission associated with highly active antiretroviral therapy.

A human immunodeficiency virus (HIV)-infected individual was first diagnosed with red blood cell aplasia due to B19 parvovirus infection in late 1989. Over the subsequent seven-year period, he received a total of 119 units of red blood cells (RBCs) and intravenous immunoglobulin every 2-3 weeks. In 1996 combination antiretroviral treatment with a protease inhibitor was initiated. He received four more units during the following two months and then required no more transfusions for the subsequent 24 months of follow-up. His CD4 count progressively increased and DNA polymerase chain reaction for parvovirus B19 became undetectable. Aggressive antiretroviral treatment may effectively diminish transfusion requirements among HIV-infected individuals with pure RBC aplasia resulting from parvovirus B19 infection.

Splenic rupture: an unusual complication of colonoscopy.

Splenic rupture is an uncommon complication of colonoscopy. A high index of suspicion is a crucial factor in the prompt diagnosis of this rare but potentially fatal complication. We report a case of splenic rupture diagnosed 3 days after a colonoscopy and requiring splenectomy. We also reviewed 17 reported cases of splenic rupture after colonoscopy, including our case. The presumed mechanisms of splenic rupture during colonoscopy are direct trauma to the spleen, excessive splenocolic ligament traction, and decrease in the relative mobility between the spleen and the colon. Of the 17 cases reviewed, 10 had polypectomy and/or biopsy performed during colonoscopy. Other probable risk factors are identified and tabulated. The hemodynamic status of the patient is the primary factor used to determine the therapeutic option. Computed tomographic (CT) scan of the abdomen reliably demonstrates well-contained splenic laceration and subcapsular hematoma, and differentiates these splenic complications from perisplenic clot and hemoperitoneum. Thus, CT scan may help decide which patients may be managed operatively or nonoperatively. Splenectomy is the operative procedure of choice for splenic rupture after colonoscopy. Conservative management includes broad spectrum antibiotics, intravenous fluids, blood transfusion, and close hemodynamic monitoring. The factors mandating further evaluation of persistent abdominal pain after colonoscopy are hemodynamic instability, clinical features of acute abdomen, leukocytosis, and/or acute anemia. The onset of abdominal pain associated with one or more of these critical factors is usually within 24 h after colonoscopy. An emergent CT scan of the abdomen is the modality of choice to further evaluate these clinical features, but intestinal perforation and external bleeding must first be excluded.

Determinants of case selection at morning report.

OBJECTIVE: To determine why residents present certain cases and not others at morning report (MR) in an institution that permits residents the free choice of cases. DESIGN/PARTICIPANTS: Prospective survey of 10 second- and third-year residents assigned to the medical service. SETTING: A 241-bed teaching hospital with 55 categorical internal medicine residents. MEASUREMENTS AND MAIN RESULTS: Over a 4-week period, there were 194 admissions to the medical service on 18 call days preceding MR. Of these admissions, 30 (15%) were presented at MR. Cases were more likely to be presented if they were considered unusual or rare in presentation or incidence (P = .001), involved significant management issues (p = .001), or were associated with remarkable imaging studies or other visual material (p = .006). Residents were more likely to present cases in which they disagreed with attending physicians on management plans (p = .005). Overall, residents rated few admissions as having notable physical examination findings (29/194) or ethical or cost issues (6/194). Of the seven most common admitting diagnoses, representing 44% of admissions, residents did not present cases involving four of these diagnoses. CONCLUSIONS: Residents presented cases at MR that they felt were unique or rare in presentation or incidence for purposes of discussing management issues. Complete resident freedom in choosing MR cases may narrow the scope of MR and exclude common diagnoses and other issues of import such as medical ethics or economics.

Acute epiglottitis. An 18-year experience in Rhode Island.

OBJECTIVE: To assess the incidence, clinical characteristics, management, and outcome of epiglottitis in a defined population over an 18-year period. DESIGN: Case series. SETTING: The state of Rhode Island, 1975 through 1992. PATIENTS OR OTHER PARTICIPANTS: Cases who met predetermined criteria for acute epiglottitis identified from hospital discharges and the State Medical Examiner's log of prehospitalization deaths. MAIN OUTCOME MEASURES: Incidence by year and age, clinical presentation, results of diagnostic evaluations, management, and outcome. RESULTS: Four hundred seven cases were identified, 134 in children and 273 in adults. Incidence in children dropped from 38 cases in the first 3 years of the study to 1 case in the last 3 years (p < 0.001). Adult cases increased from 17 in the first 3 years to 69 in the last 3 years (p < 0.001). Seventy-nine percent of adults and 32% of children were treated without an artificial airway. Factors associated with airway obstruction included symptomatic respiratory difficulty, stridor, drooling, shorter duration of symptoms, enlarged epiglottis on radiograph, and Haemophilus influenzae bacteremia (p < 0.001 for each). Twelve patients died (3 children and 9 adults), with all cases of fatal respiratory obstruction occurring within 12 h of presentation. CONCLUSIONS: There have been significant changes in the clinical epidemiology of epiglottitis, which now occurs almost exclusively in adults, often with less severe symptoms and a lower incidence of H influenzae infection. While careful observation is indicated for all patients, the data suggest that those with certain clinical characteristics can be treated safely without an immediate artificial airway.

Management of persistent B19 parvovirus infection in AIDS.

An HIV+ 26-year-old white man with a CD4 count of 0.06 x 10(9)/l was found to have red blood cell aplasia secondary to B19 parvovirus infection. Regular infusions of intravenous immunoglobulin (IVIG) were begun and resulted in marked reticulocytosis and correction of anaemia. The patient has been followed for over 4 years and has become anaemic and reticulocytopenic whenever IVIG was interrupted. Serial dot blot analysis of the patient's sera for B19 parvovirus DNA showed absence of DNA immediately following IVIG treatments but reappearance within 3-6 weeks. Regular IVIG was effective in controlling but not eradicating B19 parvovirus infection in this HIV+ patient.

Rush hemolysis. A 'bite-cell' hemolytic anemia associated with volatile liquid nitrite use.

Volatile nitrites are illegally marketed compounds that have been inhaled by persons who believe that they cause sexual arousal. These substances have been associated with significant hemolysis of red blood cells in patients with decreased or normal glucose-6-phosphate dehydrogenase levels because such nitrites act as cell-membrane oxidants. We report herein a case of hemolysis in a patient with an underlying glucose-6-phosphate dehydrogenase deficiency associated with the use of volatile nitrites, and we also review the literature of volatile nitrite-induced hemolytic anemia.

Beguiled by the gallium. Thymic rebound in an adult after chemotherapy for Hodgkin's disease.

An 18-year-old woman was diagnosed as having Hodgkin's disease involving the mediastinal lymph nodes and lung parenchyma. A pretreatment gallium 67 scan showed increased uptake in the mediastinum. Chest radiograph and chest computed tomographic (CT) scans after chemotherapy demonstrated resolution of disease, and a repeated gallium scan was normal. Four months later, a surveillance gallium scan showed increased activity in the mediastinal and hilar regions with corresponding chest CT and magnetic resonance imaging (MRI) showing a retrosternal mass. Prior to committing the patient to aggressive treatment for presumed disease relapse, a biopsy of the mass was performed and a specimen showed normal thymus tissue. The patient has continued in remission without further therapy 3 years after her initial treatment, with subsequent normal gallium scans and a stable mass on CT and MRI. Thymic enlargement following chemotherapy can occur with Hodgkin's disease in young adults, and interpretation of imaging studies, including gallium scanning, must be made with this consideration in mind.