[Pericardial empyema as a rare complication of pneumococcal pneumonia]. / Das Perikardempyem als seltene Komplikation der Pneumokokken-Pneumonie.

The case histories of 3 patients hospitalised for severe pneumococcal pneumonia are reported. Electrocardiography showed generalized ST-segment elevations and echocardiography revealed pericardial effusion. Pericardiocentesis was performed and analysis of the punctate fluid was consistent with empyema. The pericardial empyema was removed by percutaneous drainage in one patient and by thoracoscopy in 2. During the course of the disease, 2 patients developed constrictive pericarditis after 4 to 6 weeks, necessitating epi- and pericardectomy in one. When patients with pleuropneumonia present generalised ST-segment elevations in the ECG, the possibility of pericardial involvement should be evaluated by echocardiography. The pericardial empyema must be removed as soon as possible, ideally by thoracoscopic drainage. Percutaneous drainage often fails to evacuate the empyema completely and does not prevent recurrent effusions. Constrictive pericarditis occurs early in the course of the disease and is a serious complication. When a patient suffering from constrictive pericarditis remains symptomatic despite optimal conservative therapy, pericardectomy should be performed. However, as only one of our three patients required the procedure, it should not be routinely performed.

[Morphine poisoning in chronic kidney failure. Morphine-6-glucuronide as a pharmacologically active morphine metabolite]. / Morphin-Intoxikation bei chronischer Niereninsuffizienz. Morphin-6-Glucuronid als pharmakologisch aktiver Morphin-Metabolit.

HISTORY AND ADMISSION FINDINGS: A 57-year-old woman with metastasizing ovarian cancer and chronic renal failure was admitted for morphine treatment of an acute lumbospinal pain syndrome, ambulant treatment with analgesics having failed provide adequate pain relief. On admission due to pain the conscious patient presented with reduced general condition and lumbal pain sensitive to tapping. Lasègue's sign was positive on both sides, no other disturbed neurological functions were found. TREATMENT AND COURSE: On the 7th day of morphine administration she became somnolent and breathing became markedly depressed, indicating overdosage, metabolic and intracranial causes having been excluded. Naloxone, an opioid antagonist, was given i.v. and the breathing pattern improved. But drowsiness continued for another 48 hours and only regressed after repeated doses of naloxone. CONCLUSIONS: Morphine-6-glucuronide (M6G), formed from morphine in the liver, accumulates in blood and penetrates the blood-brain barrier, binding with strong affinity to opiate receptors and exerts a strong analgesic effect. As M6G is excreted by the kidney, its concentration rises in renal failure and can lead to severe intoxication. Morphine dosage must therefore be carefully controlled in patients with renal failure.

[Chronic cholestatic liver disease and grand mal seizures]. / Chronische cholestatische Hepatopathie und Grand-mal-Anfall.

HISTORY AND CLINICAL FINDINGS: A 48-year-old woman was hospitalised because of grand-mal seizures. 3 years previously a malignant melanoma had been resected from the skin of the back. She was also known to have chronic cholestasis of unknown cause. On physical examination there were postictal signs, but no neurological abnormalities and no jaundice. INVESTIGATIONS: Biochemical tests demonstrated greatly increased alkaline phosphatase (576U/I). gamma-GT (1556U/I) and leucine aminopeptidase (258U/I). The transaminases were only slightly raised (GOT 113U/I, GPT 82U/I). Magnetic resonance imaging of the brain revealed a single intracerebral space-occupying lesion, compatible with a melanoma metastasis. Endoscopic retrograde cholangiopancreatography discovered a filiform, short stenosis in the choledochal duct, histologically an adenocarcinoma. TREATMENT AND COURSE: The cerebral metastasis was removed stereotactically without complications. A Whipple-type gastroduodenopancreatectomy was performed 2 months later. Histology of an intraoperative liver biopsy revealed Caroli's syndrome (focal intrahepatic biliary dilatation) with congenital hepatic fibrosis. Cholestasis persisted after the operation and was treated with ursodeoxycholic acid. The patient has now been free of symptoms for 3 years. CONCLUSIONS: Caroli's syndrome should be included in the differential diagnosis of chronic cholestasis of unknown cause. The case also demonstrates the justification, under certain conditions, of aggressive treatment even when there are two different malignancies.

[ARDS caused by military zinc fumes exposure]. / ARDS durch militärische Zinknebelexposition.

A previously healthy 19-year-old male was exposed to concentrated hexite smoke (ZnCl2) for several minutes during military training. The initial symptoms (vomiting, cough, dyspnea) disappeared after a few hours. After 48 hours the patient developed acute respiratory distress syndrome requiring tracheal intubation and mechanical ventilation for 8 days. He left hospital 10 days after extubation. Spirometry at this time revealed a restrictive defect (vital capacity 50% predicted). Four months after the accident the patient had returned to work without symptoms of respiratory insufficiency. Lung function tests had normalized with the exception of a slight reduction in carbon monoxide diffusion. This case illustrates the typical course of inhalative intoxication with hexite. It underlines the importance of prolonged clinical surveillance in view of the latency between the initial symptoms of hexite intoxication and possible later development of ARDS.

[Long-term follow-up of a patient with accidental phosphor 32 overdose]. / Langzeitbeobachtung einer Patientin mit akzidenteller Phosphor-32-Uberdosierung.

The follow-up of a 93-year-old-patient with polycythaemia vera (PV) diagnosed in 1977 is presented. The patient accidentally received a ten-fold overdose of radioactive P32 due to an incorrectly labelled vial. 14 days after the administration of the overdose of P32, the patient was admitted to the University Hospital of Zurich with bone marrow aplasia. She recovered from the aplasia within 6 weeks. During the following 15 years she has suffered no relapse nor developed leukemia as a secondary complication.

[Low-grade MALT-type non-Hodgkin lymphoma of the stomach with local recurrence 14 years following resection. Demonstration of clonal identity using polymerase-chain-reaction (PCR)]. / Niedrig malignes Non-Hodgkin-Lymphom vom MALT-Typ im Magen mit Lokalrezidiv 14 Jahre nach Resektion. Demonstration der klonalen Identität mittels Polymerase-Kettenreaktion (PCR).

So-called low grade B-cell lymphomas of MALT type occurring mainly in the gastrointestinal tract but also in the salivary glands, the thyroid and the lungs are indolent neoplasms with a prolonged clinical course and persistent localized disease at the site of origin. This behaviour sets them apart from their nodal counterparts, which are frequently generalized from onset. Their recognition within and their separation from accompanying reactive processes (e.g. chronic gastritis) is important but may be difficult on morphology alone. In the immediate past there have been reports on regression of gastric MALT type lymphomas after eradication of Helicobacter pylori. We observed a 68-year-old male patient who underwent partial gastric resection for persistent ulcer disease in 1979. A histological diagnosis of pseudolymphoma was established at that time. In 1993 he again had gastrointestinal bleeding. Endoscopy revealed ulcerations at the anastomosis. Biopsies showed a monoclonal infiltrate of centrocytoid B-cells with typical lymphoepithelial lesions, suggesting the diagnosis of low grade B-cell lymphoma of MALT type which was seen focally in multiple biopsies randomly taken from the gastric remnant. Review of the 1979 specimen revealed identical lesions. Polymerase chain reaction (PCR) on both specimens demonstrated identical products of rearranged Ig-heavy chain genes, thus confirming the monoclonality and establishing the clonal relationship of both lesions. Staging revealed no extragastric disease. Two courses of chemotherapy did not affect the mucosal infiltrates. Although the patient had been under antacid medication and the presence of Helicobacter pylori could not be demonstrated, antimicrobial treatment was given, after which follow-up biopsies were free of tumor and bacteria after 4 months.(ABSTRACT TRUNCATED AT 250 WORDS)

[Bronchobiliary fistula in carcinoma of the hepatic duct bifurcation]. / Biliobronchiale Fistel bei Hepaticusgabelkarzinom.

Carcinoma of the hepatic duct bifurcation was diagnosed in a 67-year-old women with obstructive jaundice. As metastatic spread could not be demonstrated the carcinoma was removed with a view of achieving a cure (hemihepatectomy, resection of the hepatic duct and the bifurcation, cholecystectomy and hepatojejunostomy). Histological examination indicated adenocarcinoma of the biliary tract. Seven months postoperatively the patient was found to be cachectic and cough up greenish liquid sputum. Bilirubin concentration in sputum was 500 mumol/l. There was no jaundice and total bilirubin concentration was 33 mumol/l. Alkaline phosphatase was 508 U/l, but GOT and GPT were normal (23 U/l and 21 U/l). Computed tomography confirmed the clinical diagnosis of a biliobronchial fistula. The patient died 9 days after renewed hospitalization of tumour cachexia. The biliobronchial fistula was found at necropsy.

[A villous adenoma of the duodenum]. / Das villöse Adenom des Duodenums.

X-ray contrast examination of the upper gastrointestinal tract in a 73-year-old man with nocturnal heartburn demonstrated a constant filling defect in the duodenum. Gastroduodenoscopy revealed a 4 x 3 cm polypoid mucosal change of the duodenal wall adjacent to the pancreas. Histological examination of an endoscopically obtained biopsy showed a tubulovillous adenoma with severe mucosal dysplasia. The affected segment of duodenum was resected. Serial sections showed extensive focal carcinomatous degeneration of an adenoma. The postoperative course was unremarkable. At endoscopy 30 months later, when the patient was free of any symptoms, there was no macroscopic or microscopic evidence of recurrence. Experience so far indicates that villous adenoma of the duodenum should be treated by radical surgery.

[Intravenous high-dose short-term fibrinolysis in myocardial infarct. Experiences with 60 patients]. / Intravenöse, hochdosierte Kurzzeitfibrinolyse bei Herzinfarkt. Erfahrungen mit 60 Patienten.

Sixty patients with suspected myocardial infarction were treated in an open study with intravenous high-dose streptokinase (1.5 million U in 70 min). The average delay between onset of pain and fibrinolysis was 270 min. Reperfusion parameters were fast resolution of pain, rapid decline of ST elevation, arrhythmias and early CK peak. 27 patients were judged on the basis of these criteria as successfully reperfused, 13 as questionable and 20 as failures. Adverse events were 6 hypotensive episodes, 3 hypertensive phases, 2 interruptions due to flush, 1 chill, and 7 minor bleeding episodes. During follow-up there were 2 early deaths from cardiogenic shock. 58 patients were followed for 6-41 months, during which 4 died, 17 had a coronary angiogram and 6 were treated by bypass operation. 35 patients were able to work full-time and 7 half-time. Intravenous high-dose fibrinolysis is harmless and can be done in community hospitals.

[Early diagnosis of stomach cancer: reality or illusion?]. / Magenkarzinom-Frühdiagnose: Realität oder Illusion?

Cancer of the stomach is, in Switzerland, the fourth most common malignant tumor in both sexes. The five year survival rate is between 10 and 20% in Europe; where the cancer is diagnosed early, however, the patients have a survival rate of 85-95%. Of the 305 cases diagnosed in the last 5 years, 51.5% were operatively curable. In 29.5% of the cases palliative surgery was possible and 19% were inoperable. The rate of early cancer is 12% and thereby constitutes the largest portion of the total five year survival rate. Improvement of prognosis is only realizable through early detection, but even today this prospect is largely illusory. Practicable ways of obtaining optimum results are demonstrated.