[Fever and cavitary infiltrate in a renal transplant recipient]. / Receptora de trasplante renal con fiebre y neumonía cavitada.

Aspergillus infection is a rare but devastating complication following organ transplantation with high mortality rate. Aspergillus fumigatus is the most common cause of invasive aspergillosis. This fungus is present in the environment worldwide. Aspergillus infection is mainly acquired by inhalation of spores and several nosocomial infections in transplant recipient have been associated with construction work at hospitals. Risk factors for invasive aspergillosis include administration of steroid boluses, history of cytomegalovirus infection, neutropenia and prolonged antibiotic use after transplantation. Successful treatment depends on three factors: early diagnosis, aggressive antifungal therapy and decrease or removal of immunosuppression. Amphotericin deoxycholate has been the standard treatment for many years but lipid preparations for amphotericin are now used due to their significantly fewer adverse effects. A number of new antifungal drugs are now being developed including new azoles such as voriconazol and echinocandin. Invasive aspergillosis has a high mortality rate more than 95% when cerebral dissemination is demonstrated. We report the case of a 47 years old woman who received a cadaveric renal graft and developed pulmonary aspergillosis with fulminant cerebral dissemination two months later. The diagnosis of pulmonary aspergillosis was by culture isolation obtained from bronchioalveolar lavage. Removal of immunosuppresive agents and liposomal amphotericin B therapy were started shortly after admission. Brain CT scan performed on the 12th day showed cerebral dissemination. The recipient died two days later. Our patient had several risk factors such as the administration of steroid boluses and cytomegalovirus infection. Invasive aspergillosis must be always included in the differential diagnosis of fever and pulmonary disease in the renal transplant recipient.

Receptora de trasplante renal con fiebre y neumonía cavitada / Fever and Cavitary infiltrate in renal transplant recipient

Las infecciones fúngicas constituyen una causa poco frecuente de infección en el trasplante renal pero con una elevada mortalidad. La aspergilosis invasiva representa la segunda causa de infección fúngica en estos pacientes. Se adquiere por inhalación de esporas, su incidencia está en estrecha relación con factores ambientales, constituye una infección nosocomial en el trasplante renal, y se asocia a obras hospitalarias y a contaminación por los sistemas de ventilación. Los factores de riesgo en el paciente trasplantado para el desarrollo de la infección incluyen la neutropenia prolongada, la coinfección por virus como el citomegalovirus y la administración de altas dosis de esteroides. El pronóstico es muy grave con una mortalidad que oscila entre el 75-95% según las diversas series, siendo incluso mayor del 95% si existe afectación cerebral. El éxito del tratamiento depende de la precocidad del diagnóstico, la agresividad del tratamiento y la reducción o retirada de la inmunosupresión. El antifúngico clásico utilizado es la anfotericina B, últimamente sustituida por su forma liposomal debido a la menor incidencia de efectos secundarios. Actualmente existen nuevos azoles, como la equinocandina y el voriconazol, que constituyen un tratamiento útil de forma primaria. Se presenta el caso de una mujer de 47 años que recibió un trasplante renal de cadáver dos meses antes y desarrolló una aspergilosis pulmonar con diseminación cerebral inmediata y fulminante. La paciente presentaba como factores de riesgo el haber recibido altas dosis de esteroides y una infección por citomegalovirus. La enferma recibió tratamiento con anfotericina B liposomal y retirada precoz de la inmunosupresión, pero falleció poco después del diagnóstico de su afectación cerebral. La aspergilosis invasiva debe incluirse en el diagnóstico diferencial de fiebre y afectación pulmonar en el paciente con trasplante renal (AU)

Aspergillus infection is a rare but devastating complication following organ transplantation with high mortality rate. Aspergillus fumigatus is the most common cause of invasive aspergillosis. This fungus is present in the enviroment worldwide. Aspergillus infection is mainly acquired by inhalation of spores and several nosocomial infections in transplant recipient have been associated with construction work at hospitals. Risk factors for invasive aspergillosis include administration of steroid boluses, history of cytomegalovirus infection, neutropenia and prolonged antibiotic use after transplantation. Successful treatment depends on three factors: early diagnosis, agressive antifungal therapy and decrease or removal of immunosuppression. Amphotericin deoxycholate has been the standard treatment for many years but lipid preparations for amphotericin are now used due to their significantly fewer adverse effects. A number of new antifungal drugs are now being developed including new azoles such as voriconazol and echinocandin. Invasive aspergillosis has a high mortality rate more than 95% when cerebral dissemination is demonstrated. We report the case of a 47 years old woman who received a cadaveric renal graft and developed pulmonary aspergillosis with fulminant cerebral dissemination two months later. The diagnosis of pulmonary aspergillosis was by culture isolation obtained from bronchioalveolar lavage. Removal of immunossupresive agents and liposomal amphotericin B therapy were started shortly after admission. Brain CT scan performed on the 12th day showed cerebral dissemination. The recipient died two days later. Our patient had several risk factors such as the administration of steroid boluses and cytomegalovirus infection. Invasive aspergillosis must be always included in the differential diagnosis of fever and pulmonary disease in the renal transplant recipient (AU)

The adult attachment interview: rating and classification problems posed by non-normative samples.

Non-normative samples can pose major procedural and coding challenges to interviewers and raters of the Adult Attachment Interview (AAI). With reference to interview transcripts drawn from a population of personality disordered offenders detained in a high-security hospital, specific difficulties are identified and discussed. These difficulties have their roots in three separate but overlapping areas: extreme attachment-related experience; interviewees' psychological or psychiatric state; and factors relating to the context in which the interview is conducted. They raise questions about whether and when the use of the interview should be restricted, the rating rules elaborated and/or the rating system expanded. Suggestions are made as to how some of the difficulties might be addressed.

Advanced cancer of the vulva treated by vulvectomy and proctectomy. Case report.

In 5 selected patients with squamous cell carcinoma of the vulva invading the anus, a vulvectomy in combination with proctectomy and in three cases bilateral groin dissection en bloc, was performed. All five patients had microscopically well differentiated tumors and no one showed evidence of distant metastases. All five patients are now alive and well with a mean observation time of 8 years. It is concluded that in selected patients, extensive surgery for invasive squamous cell carcinoma of the vulva can be very rewarding.

Micturition studies in hypospadiacs.

Micturition studies were performed pre-, inter- and postoperatively in a consecutive series comprising 148 unselected hypospadiacs, both short-term results (on average 1 3/12 years after the last operation) and long-term results (on average 6 3/12 years after the last operation) being recorded. The clinical material was subdivided into 6 age-groups and the results were compared with a control material comprising 176 males. Supernormal flow values were recorded preoperatively in 38% of hypospadiacs, normal values in 49% and subnormal in 13%. Interoperatively, after meatotomy had been performed in all hypospadiacs, normalization of the subnormal flow values was observed and supernormal values were recorded in 72% of the patients. Postoperatively, the supernormal flow values successively declined but the long-term results demonstrated supernormal values in 26% of the patients, while the remainder had normal maximum flow values. Preoperative micturition urethrocystography revealed pathological changes in 48/148: trabeculation in 29; trabeculation and diverticula in 5; and vesicoureteral reflux in 14. The highest incidence of changes was found in the age-group 4--10 years and the second highest in 2--4 years. Postoperative micturition urethrocystography revealed a successive regression of the pathological changes. The most marked regression was recorded when surgical treatment was started at the age of 2--4 years.

Morphology of hypospadias.

Morphological investigation was performed in a clinical series for prospective study comprising 220 unselected cases of hypospadias. The patients were followed up postoperatively for 8 to 12 years. The investigation comprised the external and internal genitals, including anomalies of the testes and disturbances in gonad differentiation, and simultaneous malformations in the upper urinary tract and extraurogenital malformations. At the preoperative examination the meatal caliber was judged to be inadequate in 91% of the patients with glandular hypospadias, the mildest and commonest form. Curvature was observed in 69% and torsion in 16%. Manifest penile hypoplasia was registered in 7/220, 3 of whom showed chromosomal aberrations. Among the congenital anomalies of the proximal urethra, undevelopment of the prostate was discovered in one perineal hypospadiac and absence of the internal sphincter mechanism in one glandular and one perineal hypospadiac among 142/220 who had reached fertile age. The anomaly in these three patients caused retrograde ejaculation.

Microscopic studies of curvature-causing structures in hypospadias.

Microscopical studies were performed in a consecutive series of 20 hypospadiacs (3 crypto-hypospadias; 9 glandular; 7 penile; and 1 perineal) with curvature, 3 of whom also exhibited torsion. Specimens for the investigation were dissected free at the first operation and it was found that the binding tissues on the ventral side of the penis reached about half of the circumference of the penile shaft, stretching longitudinally from the coronal sulcus, passing the original meatus and extending proximally on the shaft. The specimens from the 17 hypospadias with curvature only exhibited a symmetric pattern in the tissue plate, while in 3 hypospadias with curvature and torsion an asymmetry was found, with longer lateral tissue plates in the contralateral direction to the torsion. With two exceptions, the microscopical investigation showed the same principal lesions: proximally the urethra had a normal circular corpus spongiosum, but at varying distances distally the ventral parts of the corpus spongiosum were thinned out, and disappeared and the lateral parts were disorganized, penetrating out laterally in the plate of connective tissue. The dorsal part of the corpus spongiosum was thinned and was found to continue distally from the meatus to the coronal sulcus. In the 3 hypospadias with curvature and torsion the microscopical findings were principally the same as in the cases with curvature only, but with longer lateral penetration on the side contralateral to the direction of the torsion.

Hypospadias. A review of 299 cases operated 1957-69.

A review of 299 unselected primary cases of hypospadias of all types treated during the period 1957 to 1969 is presented. The same indications for operation and the same surgical principles were applied in all cases. The surgical treatment was performed in two stages: meatotomy or meatotomy combined with straightening in the first stage and urethral construction according to Denis Browne's method in the second stage. Complications occurred after the urethral construction in 11/289 cases (separation of the skin flaps in 5/289 and fistulas in 6/289). All 11 patients were reoperated with fully satisfactory results. The long-term results were followed up in a series of 220/299 cases. This series was used to study different problems affecting hypospadias. The mean age at the first operation was 8.5 years and the median age 4.4. The mean age at the latest control was 15.1 years and the median age 18.4. At the latest control no relapses with regard to curvature were observed during erection in the 151/220 cases in which straightening was performed. The meatus was adequate in all cases and the urinary flow, measured with a uroflowmeter, was normal.

On aetiological factors in hypospadias.

An analysis of genetic and non-genetic factors which might be of importance for the aetiology of hypospadias was performed in a clinical and in a registered material comprising altogether 893 hypospadiacs. Of 213 index patients in the clinical material, the probable aetiology was known in 11: in 3 patients chromosomal aberrations, in 2 well-defined syndromes with a known genetic background, in one maternal diabetes, in 2 maternal rubella, and 2 of the hypospadiacs were born after the mothers' use of anticonvulsant drugs and one after the mother's use of thalidomide. Other hypospadiacs were identified in 28 of the families of the remaining 202 index patients. As regards inheritance, 10 cases of hypospadias associated with clinodactyly were found in one family and this suggests an autosomal dominant gene as the cause of hypospadias. In the great majority (174/213) of index patients neither genetic nor non-genetic factors could be demonstrated but a significant cyclic trend for the month of birth and the month of the last menstrual period was found.

The development of puberty, the sexual début and sexual function in hypospadiacs.

The development of puberty, the sexual debut and the sexual function were investigated in a longitudinal study of an unselected material of 220 primary cases of hypospadiacs, treated during the period 1965 to 1969 and followed-up during the period 1965 to 1974. The development of puberty in hypospadiacs strongly resembled that in a normal male population. Out of 121 hypospadiacs between 13 and 30 years of age 66 had had sexual intercourse. The median age for the sexual debut was 16.9 years compared to 16.6 years in a normal male population. Thirty out of 55 hypospadiacs without experience of sexual intercourse were in the age-group 13-16. Hypospadiacs with experience of sexual intercourse continued their sexual function was normal. Forty-one out of 66 were married and 24 out of 41 had children. In order to study the influence of the surgical treatment on the sexual debut and sexual function the 121 hypospadiacs were divided into two groups: those in whom treatment was completed before or at the age of 12 years, and those in whom treatment was completed at 13 years of age or later. The median age for the sexual debut was 15.5 years in the former group and 17.6 in the later group. An interesting finding was that almost half of the hypospadiacs in whom treatment was complted at 13 years of age or later had had a preoperative sexual debut despite the presence of curvature in all cases, and despite the fact that all types of hypospadias were represented. The median age for the sexual debut in this group was 17.1 years.

The incidence of hypospadias in Sweden.

In a study of the incidence of hypospadias the source material consisted of cases of hypospadias continuously reported to two central registers during the years 1965 to 1968. The material was then extended by the addition of hypospadiacs aged 5 to 9 years and admitted to departments of plastic and pediatric surgery, and in a few cases to departments of urology or surgery, who were not reported to either of the registers. During the years 1965 to 1968, 666 live male infants with hypospadias were identified among a total of 480 607 live births of both sexes in Sweden. The incidence of hypospadias was 13.9 per 10 000 of both sexes. 13.1 of these were single and 0.8 multiple malformations. A systematic grading of hypospadias showed that the mildest, glandular form was present in 62%. Early neonatal deaths with identified hypospadias was 7.