A case of cardiogenic shock caused by capecitabine treatment.

BACKGROUND: A 52-year-old woman underwent successful resection of stage IIB primary mucinous adenocarcinoma of the appendix and was started on capecitabine chemotherapy. Five days into the first course, after initially experiencing diarrhea, nausea, vomiting and a transient episode of retrosternal chest pain radiating to the left scapula, she presented to the emergency department with cardiogenic shock. INVESTIGATIONS: Electrocardiography, transthoracic echocardiography, laboratory investigation of cardiac biomarkers, coronary angiography and endomyocardial biopsy. DIAGNOSIS: Capecitabine-induced cardiogenic shock. MANAGEMENT: Supportive treatment with dopamine, milrinone, norepinephrine (noradrenaline) and levosimendan.

A clinicopathological review of 34 cases of inflammatory breast disease showing an association between corynebacteria infection and granulomatous mastitis.

AIM: Granulomatous mastitis is a rare condition of unknown aetiology. The great majority of cases has not been associated with bacterial pathogens if women with mammary tuberculosis are excluded. We noted that some women in Auckland with a histological diagnosis of granulomatous mastitis had both microbiological and histological evidence of corynebacteria infection and aimed to study this further. METHODS: Thirty-four women were reviewed who presented with inflammatory breast disease and had microbiological specimens from which corynebacteria were isolated and/or histological specimens containing coryneform bacteria. These 34 cases were compared with 28 controls with similar histology but no evidence of corynebacteria infection. RESULTS: Twenty-seven (79%) of the cases and 21 (75%) of the controls had histological and/or cytological evidence of suppurative granulomas. Fourteen of the 34 cases also had Gram-positive bacilli (GPB), recognisable as coryneform bacteria, in histological sections. In all cases the bacilli were confined to empty spaces, consistent with dissolved lipid, and were surrounded by neutrophils and, frequently, suppurative granulomas. Corynebacterium species were isolated from 52 of 116 microbiological specimens taken from the 34 cases. Forty of these 52 cultures were pure. Twenty-four of the cultures were further classified biochemically and using 16S rRNA gene sequencing. Twenty of the 24 were lipophilic Corynebacterium species and 14 were identified as Corynebacterium kroppenstedtii. The cases were more likely to present with fever or neutrophilia and more often formed sinuses than the controls but other clinical features were similar. Maori and Pacific Islanders accounted for 77% of the women across both groups. CONCLUSION: We suggest granulomatous mastitis can be associated with corynebacteria infection, particularly infection by C. kroppenstedtii. The significance of this finding, which has previously been described in only a single case report, is discussed.

Cardiac sarcoidosis: an elusive diagnosis.

The diagnosis of sarcoidosis of the heart can be elusive, and is seldom established in life. We report the case of a 43-year-old man who underwent heart transplantation for presumed idiopathic dilated cardiomyopathy. Endomyocardial biopsy before transplantation showed only a mild infiltrate of lymphocytes. Histology of his explanted heart revealed extensive noncaseating granulomas and scarring, typical of sarcoidosis. A diagnosis of sarcoidosis had been made several years before by mediastinoscopic biopsy, after routine chest X-ray revealed mediastinal lymphadenopathy. Aside from the cardiac manifestations, the patient had no other symptoms of this disease. We discuss the inherent difficulties in the diagnosis of this rare but important condition, its varying presentations relating to the underlying pathology, as well as treatment options, including the role of transplantation.