[Epidemic nephropathy. An important differential diagnosis of acute renal failure in Reutlingen, an endemic area]. / Die Nephropathia epidemica. Wichtige Differenzialdiagnose des akuten Nierenversagens im Endemiegebiet Reutlingen.

BACKGROUND AND OBJECTIVE: Hantavirus ("epidemic") nephropathy (HN), or hemorrhagic fever with renal syndrome (WHO nomenclature), is an infection caused by strains (e.g. Puumala) of Hantavirus, which is often accompanied by acute renal failure. Although its typical symptomatology has been fully reported, it is rarely included in the differential diagnosis of renal nephropathy. This study investigated whether, in the presence of typical symptoms, specific search for a certain constellation of laboratory values in association with a typical history can more often provide the diagnosis of HN. PATIENTS AND METHODS: 18 patients (4 females, 14 males; average age 41 years) fulfilled the following inclusion criteria: abnormal values for creatinine, LDH and C-reactive protein, proteinuria and hematuria, as well as thrombocytopenia in conjunction with fever, back- and headache. After the diagnosis had been confirmed by demonstrating antibodies against the Puumala strain of hantavirus, follow-up included laboratory tests and clinical observation. RESULTS: All patients fully recovered without any sequelae. There was a clearly increased frequency of cases at the Reutlingen Clinic compared with the previous years (maximally 7 cases per year in 1995-1999). The incidence in the Reutlingen region was probably at least 6.5/100 000 inhabitants. CONCLUSION: At least in endemic regions HN is one of the most common causes of acute renal failure. The increase of cases can, among other reasons, be explained by the described prospective diagnostic schema. But climatic factors with changes in the density of the vector (bank vole) cannot be excluded.

[Autoimmune pancreatitis (AIMP) - a clinical entity of its own?]. / Die autoimmune Pankreatitis (AIMP) - ein eigenständiges Krankheitsbild?

HISTORY AND ADMISSION FINDINGS: A 34-year-old man with chronic inflammation of both tear glands for 10 years was admitted because of severe upper abdominal pain and jaundice. INVESTIGATIONS: Transaminase and cholestasis parameters were raised, as were gamma-globulins on electrophoresis. Ultrasound revealed an echo-poor diffusely enlarged pancreas with hypervascularity on colour-Doppler. Endoscopic retrograde cholangiopancreatography (ERCP) indicated chronically changed pancreatic ducts of varying diameter and stenosis, as well as a filiform distal stenosis of the common bile duct. A pancreatic biopsy showed chronic sclerosing pancreatitis with broad periductal lymphocytic infiltration. TREATMENT AND COURSE: ERCP and a guide-wire papillotomy were performed, followed by placement of a nasobiliary catheter. All findings markedly improved on oral prednisone. CONCLUSION: This case supports the supposition that in idiopathic chronic pancreatitis autoimmune processes may be responsible for the changes in the pancreatic ducts. Immunosuppressive treatment is thus recommended in these cases.

[Puerperal sepsis caused by streptococcus group A with a severe form of progression like "toxic shock-like syndrome"]. / Puerperalsepis durch Streptokokken der Gruppe A mit schwerer Verlaufsform als "Toxic Shock-like Syndrome".

HISTORY AND CLINICAL FINDINGS: A previously healthy 32-year-old woman was admitted with shock symptoms 5 days after an uneventful home delivery. She developed a fever up to 39.5 degrees C during the days after delivery with sore throat, diarrhoea and muscle aches in all limbs. On physical examination there were swellings of the arms and lower legs as well as macular and vesicular erythrodermia, especially of the trunk. INVESTIGATIONS: Abnormal laboratory findings were thrombocytopenia (20,000/microliters), increased serum concentrations of fibrin breakdown products (102 mg/dl) and of C-reactive protein (> 200 mg/dl), increased creatine kinase (5700 U/l), transaminases (GOT 220 U/l, GPT 52 U/l), creatinine (2.0 mg/dl) and urea (114 mg/dl). Streptococcus pyogenes was grown on blood culture and from vaginal smear. Sonography, echocardiography and radiological examinations failed to demonstrate a septic focus. TREATMENT AND COURSE: Mechanical ventilation was required for 7 days because of respiratory failure and shock symptoms (toxic shock-like syndrome, TSLS). Penicillin G and tobramycin were given after the bacteriological diagnosis. Severe consumption coagulopathy was successfully treated with antithrombin III and platelet concentrates. After extubation she was found to have a flaccid tetraparesis, especially of the right and of the legs, due to soft-tissue necrosis and damage to peripheral nerves. An embolic occlusion of the right brachial artery 4 weeks after onset of the disease required upper-arm amputation. CONCLUSION: One of the decisive factors for the prognosis of TSLS is early antibiotic treatment. The prodromal symptoms in this case underline the necessity of early recognition and treatment to prevent a full-blown picture of the syndrome.