Anaphylactic reaction to bovine serum albumin after embryo transfer.

OBJECTIVE: To increase the awareness of bovine serum albumin (BSA) sensitivity as a potentially lethal complication during ET. DESIGN: Case report. SETTING: Routine ET in university hospital. PATIENT(S): A 26-year-old woman who was undergoing her first ET. INTERVENTION(S): ET with BSA containing standard fluid medium. MAIN OUTCOME MEASURE(S): Specific immunoglobulin (Ig) E antibodies and skin tests. RESULT(S): The patient demonstrated increased levels of specific IgE antibodies to BSA and a clearly positive scratch test for BSA. CONCLUSION(S): Anaphylactic reactions to BSA can occur during ET. The risk can be reduced substantially if a detailed medical history is obtained.

[Subcutaneous infusion anesthesia with prilocaine diluted with Ringer's lactate]. / Subkutane Infusionsanästhesie (SIA) mit durch Ringer-Lösung verdünntem Prilocain.

BACKGROUND: Dermatologic surgery is usually possible under local anesthesia, even when large amounts of highly diluted anesthetic solutions are required (tumescent anesthesia). Although special pumps now render such large injections effortless, it is usually still necessary to hold and guide the injection cannula. We have overcome this handicap by injecting anesthetic solutions slowly with an infusomat, which allows slow painless automatic infusion into the subcutaneous layer. METHOD: The speed of infusion varied between 40 ml and 1500 ml per hour depending on location, size of the operation, and needle size. Volumes usually ranged from 1 ml to 500 ml but rose as high as 1000 ml if necessary. We found it easier to inject larger amounts than with the conventional method. We used 21-gauge to 30-gauge needles with a length of 1 to 10 cm. The anesthetic solution was prilocaine (Xylonest), and the dilution liquid was original Ringer's solution in 500 ml bottles with no additives. The concentration of the solution varied between 0.4% and 0.1%. After setting up the system, the physician even can leave the room. Especially for children and very anxious patients, this feature is calming. MATERIAL: We used this type of subcutaneous infusion anesthesia (SIA) in our department to treat 502 patients ranging in age from 3 to 92 years (mean age: 51 years). We performed all kinds of tumor operations (n = 213), dermabrasions (n = 5), scar revisions (n = 21), stripping of the long and short saphenous veins (n = 82), sentinel node dissection (n = 27), complete lymph node dissection of the axilla (n = 12) and groin (n = 17), and 125 other operations as well. RESULTS: There were no severe complications. Postoperative recovery was fast. 110 (91%) of 121 patients who had previously experienced other forms of anesthesia for the same kind of operation preferred SIA. CONCLUSIONS: SIA Ringer's solution diluted prilocaine is an economical, safe and comfortable technique for nearly all skin operations, even for children and very sensitive patients.

Slow infusion tumescent anesthesia.

BACKGROUND: Dermatologic surgery is usually possible under local anesthesia, even when large amounts of highly diluted anesthetic solution are required (tumescent anesthesia). Although special pumps now render such large injections effortless, it is usually still necessary to hold and guide the injection cannula. OBJECTIVE: We have found it possible to overcome this handicap by injecting anesthetic solutions slowly with a common infusomat, as in paravenous infusion, into the subcutaneous layer. METHODS: The method consists of slow, automated tumescent anesthesia by means of infusion. The speed of injection varies between 50 and 1500 mL per hour depending on the location, the size of the operation, and the needle size. Volumes usually range from 2 to 500 mL but may rise as high as 1000 mL if necessary (maximum, 12 mg/kg). We use 30- to 20-gauge needles with a length of 1.5-10 cm and butterfly infusion cannulas. We customarily use an anesthetic solution of prilocaine (Xylonest); the dilution liquid is original Ringer's solution with epinephrine (1:1,000,000) in 500-mL bottles. The concentration of the solution varies between 0.4% and 0.1%. After setting up the system during pulsoxymetry, the physician can usually leave the room. This is calming, especially for children and very anxious patients. We used the slow infusion tumescent anesthesia (SITA) in our department to treat 502 patients ranging in age from 3 to 92 years (mean age, 51 years). We performed all kinds of tumor operations (n = 213), dermabrasions (n = 5), scar revisions (n = 21), stripping of the long and short saphenous veins (n = 82), sentinel node dissection (n = 27), complete lymph node dissection of the axilla (n = 12) and groin (n = 17), and 125 minor operations as well. RESULTS: There were no severe complications. One hundred ten (91%) of 121 patients who had previously experienced general or regional anesthesia for the same kind of surgery and all who had previously had conventional syringe injection preferred SITA. CONCLUSIONS: SITA is an economical, safe, and comfortable technique for nearly all skin operations, even for children and very sensitive patients. Choosing the most suitable concentration, needle, needle position, flow ad volume requires some experience.

Systemic scleroderma. Multicenter trial of 1 year of treatment with recombinant interferon gamma.

OBJECTIVE: To confirm significant improvement of the skin score in systemic sclerosis by treatment with interferon gamma in a larger group of patients and to investigate on a molecular level the influence of interferon gamma on collagen type I messenger RNA expression. DESIGN: Open, noncontrolled multicenter study. SETTING: Five outpatient clinics specializing in the care of systemic scleroderma. PATIENTS: Thirty-two patients suffering from the diffuse or limited form of systemic sclerosis and progressive disease were recruited; 20 patients finished the study. INTERVENTION: Each patient received interferon gamma, 50 micrograms subcutaneously 3 times a week for 1 year. MAIN OUTCOME MEASURE: Skin score, collagen type I messenger RNA in skin biopsy specimens. RESULTS: The patients who completed the study showed an unchanged median skin score after 1 year of therapy. In addition, similar collagen type I messenger RNA levels were detected in skin biopsy specimens taken from involved skin before and after therapy in these patients. CONCLUSIONS: Treatment of systemic scleroderma with interferon gamma is associated with stabilization of the skin score and lack of worsening of visceral involvement.

Double-blind, placebo-controlled study of intralesional interferon gamma for the treatment of localized scleroderma.

BACKGROUND: Localized scleroderma is characterized by circumscribed fibrotic plaques and may progress to widespread skin involvement and fibrosis. Interferon gamma (IFN-gamma) has been shown to be a potent inhibitor of collagen synthesis and of the migration and proliferation of dermal fibroblasts. OBJECTIVE: Our purpose was to determine whether IFN-gamma is effective in the treatment of localized scleroderma. METHODS: A double-blind, randomized, placebo-controlled, multicenter study was conducted. Twenty-four patients with progressive lesions received 100 micrograms of IFN-gamma or placebo subcutaneously on 5 consecutive days for 2 weeks followed by 100 micrograms of IFN-gamma or placebo once weekly for 4 weeks. Thereafter patients were observed for 18 weeks. To determine whether improvement could be related to an altered level of collagen messenger RNA (mRNA), biopsy specimens were taken from uninvolved and involved skin before and after therapy. RESULTS: The patients treated with IFN-gamma or placebo showed no significant difference in size or fibrosis of lesions or collagen type I mRNA synthesis. However, a reduction in the number of new lesions was observed in the IFN-gamma-treated group. The biopsy specimens obtained from involved skin showed a moderate increase of type I collagen and a significant decrease in the small proteoglycan decorin mRNA levels. CONCLUSIONS: The results indicate that IFN-gamma is ineffective in the treatment of localized scleroderma, but may inhibit the development of new lesions.

[Extensive rodent ulcer (type: solid basal cell carcinoma)]. / Ausgedehntes Ulcus terebrans (Typ: solides Basalzellkarzinom).

A 52 year old female had a large destructive basal cell carcinoma of the back measuring 27 cm in diameter. There was destruction of the vertebral bodies, envelopment of the medullary cone, early spinal compression and soft tissue spread into the retroperitoneum. Early neurological defects were present. The tumor was excised, covered with two large rotation flaps and post operatively irradiated. The patients quality of life has improved, the tumor has not progressed and there is no sign of paraplegia.

[Bullous pemphigoid as a paraneoplastic syndrome. A case report in renal-cell carcinoma]. / Bullöses Pemphigoid als paraneoplastisches Syndrom. Eine Falldarstellung bei einem Nierenzellkarzinom.

Paraneoplastic markers in tumor patients may occur at various stages of the disease. While some disorders almost invariably herald an underlying malignancy (obligative marker), most only occasionally do so (facultative marker). The association of bullous pemphigoid with malignancy is controversial. There are only a few reports of bullous pemphigoid associated with a renal cell carcinoma. We diagnosed a renal cell carcinoma in a 74 year old female patient, admitted to the hospital because of bullous pemphigoid. Multiple metastases were found in her lymph nodes, liver, lung and skeleton. The patient died eleven weeks after the first symptoms of bullous pemphigoid appeared.

[Exacerbation of pustular psoriasis in mercury poisoning]. / Exazerbation einer Psoriasis pustulosa bei Quecksilber-Intoxikation.

A patient suffering from long-standing pustular psoriasis of the palms was treated for 3 weeks with a mercury-containing drug. Exacerbation into generalized pustular psoriasis developed. Mercury levels in blood and urine were increased. After withdrawal of the mercury preparation, therapy with DMPA (2,3-Dimercapto-1-propane-sulfonic acid), a mercury antidote, was initiated, together with short-term treatment with aromatic retinoids and PUVA. Within a few days mercury levels decreased significantly and the skin lesions practically disappeared.