Endocarditis due to Salmonella.

We present a case of endocarditis caused by Salmonella in a patient with newly diagnosed diabetes and preexisting rheumatic heart disease. Despite sterilization of the blood with a fluoroquinolone and a third-generation cephalosporin, the patient required surgical intervention.

Prehospital actions by health-care providers and physicians.

Extensive worldwide experience and literature exist on the benefits of early intervention in patients with an acute myocardial infarction. To make these benefits available to as much of the population as possible a number of goals have to be accomplished. Patients and bystanders must be taught to recognize the significance of symptoms and call immediately for assistance. Local emergency medical service has to dispatch appropriate personnel and equipment to the scene expeditiously. Transport without unacceptable delays must occur to appropriate facilities along with rapid initiation of treatment. A program to achieve these goals would be expected to substantially reduce morbidity and mortality. Attention is directed to prehospital actions by health-care providers including dispatch of personnel and equipment to the scene, stabilization and treatment in the field, and triage and transport of the patient to the most appropriate medical facility.

Non 0-1 Vibrio cholerae septicemia and culture negative neutrocytic ascites in a patient with chronic liver disease.

Non 0-1 Vibrio cholerae infection is often associated with ingestion of contaminated seafood and its common presentation is gastroenteritis. Septicemia may be found in immunocompromised hosts resulting in mortality approaching 50%. A case is reported of non 0-1 Vibrio cholerae infection presenting with septicemia in a patient with neutrocytic ascites suggestive of spontaneous bacterial peritonitis.

Hodgkin's disease masquerading as sclerosing mediastinitis.

Cases in which fibrotic variants of Hodgkin's disease have been confused with sclerosing mediastinitis have rarely been reported. Sclerosing mediastinitis typically involves the superior/middle mediastinum and, in the United States, is most commonly due to histoplasmosis. We describe the case of a patient who came to us with fevers, a mixed anemia, and a posterior mediastinal mass that on pathologic examination appeared to be due to idiopathic sclerosing mediastinitis. Only inclusion of a biopsy specimen from a local celiac node, after a new porta hepatis mass was found, revealed the correct diagnosis of Hodgkin's disease of the nodular sclerosing type. With the correct diagnosis, early intervention and appropriate therapy resulted in clinical cure.

The Ides of March. The match 1993 in perspective.

BACKGROUND: The total number of US medical school graduates who selected categorical programs in internal medicine in this year's match fell by 7.9%. Consequently, the program fill rate for US graduates declined for the eighth consecutive year, from 55.9% to 53.1%. Preliminary positions and international graduates continue to increase, though questions remain whether these residents serve as good role models to encourage student interest in internal medicine. METHODS: We reviewed the 1993 National Resident Matching Program data and several curricular reforms implemented in our internal medicine clerkship and residency program to evaluate whether such reform might enhance interest in general internal medicine. RESULTS: Reform in our internal medicine clerkship curriculum included increased emphasis on problem-based learning and exposure to generalist role models. This resulted in substantial increases on the average miniboard examination and a 22% increase in the number of students pursuing residency in internal medicine from the previous year. Residency curricular reform centered around enhanced ambulatory care teaching along with improved exposure to generalist role models. This resulted in a gradual increase in the number of residency graduates who were staying in general internal medicine from 21% in 1991 to 40% in 1993. CONCLUSIONS: Innovative curricular changes in our internal medicine clerkship and residency programs have led to enhanced interest in general internal medicine. Although our results are preliminary, such change is necessary, not only to continue program excellence, but for simple survival.

Case report: the spectrum of autoimmune thyroid disease with urticaria.

Urticaria has many known etiologies. An association with autoimmune thyroid disease is described. One individual had the triad of urticaria, Hashimoto's thyroiditis, and rheumatoid arthritis, whereas the other individual had urticaria preceding Graves' disease by over 1 year.

Fluconazole in the treatment of hepatosplenic candidiasis.

Hepatosplenic candidiasis has increased in frequency among immunocompromised hosts. Risk factors include hematologic malignancy, intensive chemotherapy, prolonged neutropenia, and treatment with broad-spectrum antibiotics. Patients most commonly present with abdominal pain, persistent fevers despite antibiotic therapy, and an elevated alkaline phosphatase level that is out of proportion to other hepatic enzyme levels. Gastrointestinal mucosal damage secondary to intensive chemotherapy may allow colonization with Candida species and subsequent seeding of the portal vein. Treatment has consisted of prolonged courses of amphotericin B, with mortality rates approaching 50%. We report a case of hepatosplenic candidiasis in a patient with acute myelogenous leukemia who had clinical and radiographic improvement during fluconazole therapy. Fluconazole may be an efficacious and less toxic alternative to amphotericin B.

Alcohol withdrawal with an unusual presentation.

We have reported the case of a 36-year-old woman in the early stages of alcohol withdrawal. Her initial tachypnea and hyperglycemia were misdiagnosed by emergency personnel as being due to diabetic ketoacidosis. Careful analysis and understanding of the complex metabolic features of alcohol withdrawal will lead to the proper management of such patients and allow gradual resolution of the metabolic consequences without complication.

Symptomatic adult polycystic liver disease in a young woman.

Adult polycystic liver disease is an entity that is striking for the presence of extraordinary hepatomegaly. Very rarely do patients under 40 years of age experience problems and only a minority of middle-aged patients manifest symptoms due to organ compression or biliary tree obstruction. The clinical course is usually benign, and no specific therapy is required. The onset of right upper quadrant pain, back pain, and shortness of breath prompted evaluation of a 32-year-old woman with progressive hepatomegaly. CT scan revealed a massive cyst-riddled liver with posterior displacement of the spleen, compression of the pancreas, and renal cysts. Prothrombin time, albumin, and liver enzyme values were normal except for a mildly elevated gamma-glutamyl transpeptidase.

Retroperitoneal fibrosis accompanying immune thrombocytopenia.

Retroperitoneal fibrosis represents an idiopathic systemic fibrosing syndrome which leads to the development of progressive hydronephrosis and azotemia (Stewart and Friberg: Southern Medical Journal 77:1185-1187, 1984; Morad et al.: American Journal of Medicine 82:363-366, 1987). Evidence in the literature supports a hypothesis that retroperitoneal fibrosis represents a systemic autoimmune process (Lichon et al.: Journal of Rheumatology 11:373, 374, 1984; Lipman et al.: JAMA 196:204-206, 1966; Littlejohn and Keystone: Journal of Rheumatology 8:665-669, 1981; Katz et al.: American Journal of Clinical Pathology 67:436-439, 1977). We report a case of a patient with retroperitoneal fibrosis, immune thrombocytopenia, presence of antinuclear antibody, and direct Coombs positivity which provides further evidence that retroperitoneal fibrosis is an autoimmune process. Progressive obstructive uropathy related to his fibrosis led to bilateral hydronephrosis and significant renal function impairment. Also, he developed marked immune thrombocytopenia. Treatment with prednisone produced a dramatic response in both platelet count and renal function.

Hypercalcemia as a clinical prodrome to lymphoma.

A 73-year-old man was admitted for evaluation of unexplained hypercalcemia and was found to have a large-cell non-Hodgkin's lymphoma with stage IV disease. Treatment with cyclophosphamide, doxorubicin (Adriamycin), vincristine sulfate, and prednisone chemotherapy returned his calcium levels to normal. Hypercalcemia with lymphoma is rare, and persistent evaluation for malignancy is essential.