[Purulent lymphadenitis after peritonsillar abscess under immunosuppression. An often forgotten differential diagnosis]. / Eitrige Lymphadenitis nach Abszesstonsillektomie bei Immunsuppression. Eine oft vergessene Differenzialdiagnose.

In the present case study, a 75-year-old, immunosuppressed man presented with recurrent cervical abscesses after a peritonsillar abscess. In the cervical region, an ulcer developed with persistent wound healing deficit. Subsequently, the patient's general condition deteriorated, showing symptoms of a Landouzy sepsis. In the course of the examination, Mycobacteria tuberculosis was detected in the cervical ulcer. He suffered from latent tuberculosis, which was reactivated by a combination of his disease, immunosuppressive therapy and the preceding peritonsillar abscess. Upon treatment with tuberculostatics, the patient fully recovered.

[A 17-year-old student with therapy-resistant pneumonia]. / Siebzehnjährige Schülerin mit therapieresistenter Pneumonie.

If empiric antibiotic treatment is not successful in a case of suspected pneumonia further investigations are required. We present a case where originally an intralobar, bronchopulmonary sequestration could clearly be diagnosed by a thoracic CT scan. A 3D reconstruction revealed the pathognomonic arterial supply from the thoracic aorta and the venous drainage via pulmonary vein to the left atrium. Therefore, elective resection of the sequestration was indicated.

Secondary adrenal insufficiency due to opiate therapy - another differential diagnosis worth consideration.

We report on a 64-year-old patient in whom fentanyl therapy was found to be responsible for the induction of secondary adrenal insufficiency as clearly demonstrated by re-exposure. We conclude that given the widespread use of opiates in chronic pain management physicians should raise their level of awareness for adrenal insufficiency and look for it generously. Opiates should be added to the list of differential diagnoses to be considered routinely in patients with newly diagnosed secondary adrenal insufficiency.

[Muscle weakness]. / Muskelschwäche.

A 31-year old cook suffered from episodes with muscular weakness since 3 weeks. These episodes resolved, at times, spontaneously and completely after a few hours. The weakness affected mainly the muscles of trunk and proximal extremities. Investigation of the patient revealed flaccid tetraparesis with diminished tendon reflexes, however, cranial muscles were not affected. Mental function and sensibility were intact. These findings were consistent with hypopotassemic periodic paralysis rather than a neurological or psychiatric disease. Serum potassium was determined as 1.8 mmol/l. Moreover, the patient suffered from atrial fibrillation. Grave's disease could be identified as the underlying cause of hypopotasemic periodic paralysis and atrial fibrillation. Further manifestations of primary hyperthyroidism were nervousness, diarrhea and weight loss of 5 kg observed during the previous months. The symptoms resolved under treatment with potassium, betablocker and thyrostatic agents. The patient was treated with warfarin because of atrial fibrillation and finally underwent electroconversion.

[Rational diagnostic approach in hypertension]. / Rationale Diagnostik der Hypertonie.

The list of causes of hypertension is quite long. However, the diagnostic procedure for detection of such forms should take in account the fact that the cause of nearly 95% of the cases with high blood pressure is unknown, i.e. primary or essential. The most often form of secondary hypertension is seen in patients with chronic renal disease, whereas renovascular, endocrine, cardiovascular or neurologic disorders all show a prevalence of less than 1%. Careful anamnestic evaluation and clinical examination combined with few simple laboratory tests allow the detection of most cases with secondary hypertension. Diagnosis of renovascular hypertension may require a more expended work up which, however, should only be performed in case of clinical suspect. Furthermore, the procedure in case of suspected endocrine disorders is of high clinical relevance, since hormonal analysis and/or radiologic examinations may be very expensive.

[Syncope]. / Synkope.

Syncope may be due to cardiac, vascular or cerebral disease. The cause of syncope is not established in up to 50-60% of cases. Where a diagnosis is possible, the patient's history, physical examination, ECG and prolonged ECG monitoring serve to establish the underlying disease in most cases. Additional diagnostic tests should only be performed in patients with possible cardiac syncope, since these cases show a higher mortality rate during follow-up than patients with non-cardiac syncope. Finally, newer therapeutical approaches, including permanent cardiac pacing in recurrent vasovagal syncope, are discussed.

[Cholestatic jaundice and pruritus]. / Cholestatischer Ikterus und Pruritus.

The 38 year old male patient was admitted to our clinic with jaundice and invalidating pruritus of unknown origin. The primary evaluation made by the practitioner of the patient and the initial examinations performed in the clinic revealed no diagnosis. In particular, an infectious liver disease could be excluded. Reevaluation of anamnestic data revealed then the in-take of Dianabol, an often used anabolic steroid as the most possible reason for the cholestatic hepatopathy.

[22-year-old patient with left groin pain]. / 22-jähriger Patient mit Leistenschmerzen links.

A 22 year old man from Ethiopia suffered from progressive left inguinal pain and weight loss for ten months. The pain aggravated with leg movement, in particular with flexion of the left hip. ESR and CRP were slightly elevated, and a PPD was strongly positive. Abdominal ultrasound was normal but CT-scan revealed a left sided psoas abscess. Pott's disease was suspected and tuberculostatic therapy with INH, PZA, ETH, RIF was initiated immediately. A MRI of the spine excluded spondylodiscitis. Primary Tb psoas abscess was diagnosed. Treatment response after 5 weeks was clinically insufficient and CT-scan showed enlargement of the abscess. Treatment adherence was verified by drug prescriptions and INH urinary stix testing. M. tuberculosis, suspected microscopically in the puncture fluid, grew in culture and was fully drug sensitive. After 12 weeks, surgical abscess debridement had to be performed due to disease progression. The patient's health state improved considerably the first two postoperative months, inflammatory markers normalized, although a small residual abscess was still visible on CT. Subsequently, three months after surgery, pain reemerged, CT showed abscess progression. The patient had to be reoperated. Tb psoas abscess was a frequently described complication of Tb spondylodiscitis (Pott's disease) the first half of the last century and became rare thereafter in the Western hemisphere. However, the last two decades, due to migration policies and a worldwide increase of Tb epidemic because of socioeconomic destabilization and spread of the HIV-pandemic, Tb reemerged in Western countries. Therefore, physicians should be aware of atypical manifestations of tuberculosis. Primary Tb psoas abscess is extremely rare. Only four cases are described in the literature. In analogy to Pott's disease, therapy consists of tuberculostatic treatment, supported by surgical debridement.

[Incidental finding: left sided solid adrenal mass]. / Zufallsbefund: Linksseitige solide adrenale Raumforderung.

In a 49 year old male patient diagnostic evaluation of pneumonia performed by computed tomography revealed a left sided adrenal mass. The results of laboratory examination and MR-imaging of the adrenal glands suggested a hormonal inactive adrenal adenoma. Two years later, due to an increase in size, a surgical procedure was performed which revealed a gastrointestinal stromal tumor of the posterior gastric wall, rather than the suspected adrenal mass. Radiologic evaluation of adrenal masses and the clinical and pathologic characteristics of stromal tumors are discussed.

[Incidental finding: left sided cystic adrenal mass]. / Zufallsbefund: Linksseitige zystische adrenale Raumforderung.

Because of the widespread use of imaging techniques the incidental diagnosis of an adrenal mass without clinical symptoms and pathologic laboratory values becomes more and more common. To avoid unnecessary therapeutic interventions an intensive evaluation should take place including blood and urine testing as well as radiologic examination. An accurate assessment is often helpful in making the diagnosis of a benign process to avoid an invasive procedure and to determine the frequency and intensity of further controls. Nevertheless, in some cases the invasive approach is necessary because of an unclear situation or because of influences caused by the patient. An advantage is the possibility of laparoscopic intervention because of the minimal morbidity and until now no reported mortality.

[Sudden left-sided vision loss. Occlusion of the left central retinal artery]. / Plötzlicher linksseitiger Visusverlust. Verschluss der linked A. centralis retinae.

A 77 year old female patient was admitted to our hospital because of a rapid onset left-sided visual loss. Occlusion of the left central retinal artery was confirmed by the consultant ophthalmologist. The patient was further evaluated to exclude a thromboembolic event. Chest x-ray was consistent with pulmonary hypertension. Doppler echocardiography revealed a secundum atrial septal defect with a bi-directional shunt. In this 77 year old patient, arterio-arterial embolism from atherosclerotic plaques is the most probable cause of her central retinal artery occlusion. Yet, paradoxical embolism might be another reason for acute visual loss in this setting, which, however, is difficult to confirm definitively.

[Sudden coma in a 20-year-old man]. / Plötzliches Koma bei einem 20-jährigen Mann.

A 20-year-old male patient was brought to the emergency department by Emergency Medical Services after having been found unconscious. Upon arrival the patient was comatose with a GCS of 3, his vital signs were stable (with blood pressure 100/54 mmHg, heart rate 48 per minute, respiration rate 12 per minute and oxygen saturation 98% on room air). Both pupils were 3 mm, symmetric, and only minimally responsive. Approximately 2 hours after arrival the patient awoke and admitted having taken three ampoules of GHB (gamma hydroxybutyrate). GHB is a synthetic analog of gamma-amino butyric acid (GABA), a centrally inhibitory neurotransmitter. While GHB produces euphoria in low doses, small overdosing can result in severe poisoning with coma. The combination with other CNS depressants such as alcohol, opioids, and other narcotics is particularly dangerous. Physicians should be alerted to the clinical effects of GHB since abuse has become more widespread in Switzerland within the last months. In patients with unexplained coma the differential diagnosis of GHB-intoxication should be taken into consideration.

Hyperthyroidism and pulmonary hypertension.

OBJECTIVES: To identify patients with hyperthyroidism and coincidental pulmonary hypertension and to document reversibility of pulmonary hypertension after treatment of hyperthyroidism. DESIGN: Patients with hyperthyroidism referred for transthoracal echocardiography for any reason that showed elevated pulmonary arterial pressures were collected. After therapy for the thyreotoxic state with documented normalization of thyroid hormone (IT4), pulmonary arterial pressure was measured again noninvasively. SETTING: An out-patient tertiary referral centre. SUBJECTS: The medical records were used to identify, retrospectively, patients with hyperthyroidism and pulmonary hypertension over a three-year period (April 1993 to April 1996). INTERVENTIONS AND MAIN OUTCOME MEASURES: Systolic pulmonary artery pressure (PAPs) was determined by adding up right ventricular systolic pressure (RVSP) and mean right atrial pressure (RAP) measured by continuous-wave Doppler echocardiography according to standard techniques. All patients were treated for hyperthyroidism to normal IT4 levels. After successful therapy. Doppler echocardiography was repeated. RESULTS: Four patients with pulmonary hypertension showing elevated PAPs of 40 +/- 11 mmHg were identified. After therapy. PAPs decreased in all patients to a mean of 25 +/- 6 mmHg. CONCLUSION: The observation of four patients with pulmonary hypertension and hyperthyroidism is striking and suggests a possible pathogenetic link of these disorders.

[Fever and dry cough in a construction worker from Portugal]. / Fieber und trockener Husten bei einem Bauarbeiter aus Portugal.

A 33-year-old Portugese worker presented with a one-week history of nonproductive cough and fever. A presumptive diagnosis "viral infection of the respiratory tract" was made. However, because of persisting cough and fever further investigations were necessary, and finally Brucella melitensis was isolated in blood cultures. Three months before admission to the hospital the man was dressing the carcasses of a goat in Portugal and consumpted fresh goats milk cheese. Antibiotic therapy with Rifampicin and Trimethoprim/Sulfamethoxazol over 6 weeks improved the signs and symptoms of the infection.

[The clinical spectrum of potassium-sparing diuretics]. / Das klinische Spektrum kaliumsparender Diuretika.

The role of potassium-sparing diuretics in the treatment of hypertension is discussed. The results of two newer case-control studies showing both an increased risk for sudden cardiac death in patients receiving non-potassium-sparing diuretics compared to those receiving potassium-sparing diuretics are presented. As a consequence of these studies thiazides should be given only at a low dose or in combination with a potassium-sparing agent. Data from several large intervention trials in elderly patients with hypertension show that treatment of high blood pressure with potassium-sparing diuretics is clearly beneficial since cerebral and cardiac events are both significantly reduced. Finally, potassium-sparing diuretics, especially spironolactone, play an important role in controlling high blood pressure in patients with primary aldosteronism. The presentation of a case report demonstrates, that development of resistance toward medical treatment may be due to elevated aldosterone levels and suppressed plasma renin activity and that the addition of spironolactone efficiently reduces elevated blood pressure values in this condition.

[Significance of diuretics in the treatment of hypertension]. / Die Bedeutung der Diuretika in der Behandlung der Hypertonie.

Due to new therapeutic substances the use of diuretics in the treatment of hypertension is decreasing slowly over the last few years. Nevertheless diuretics still represent one important cornerstone in the therapy of most forms of high blood pressure. Metabolic side effects of diuretics are often used as an argument against their clinical use. Indeed the diuretic therapy may lead as a function of the dosage and the duration of the therapy to an increase of total cholesterol and an impairment of the glucose tolerance. Spironolactone and other potassium sparing diuretics are "lipid-neutral". These metabolic side effects of the diuretics can be counterbalanced by the implementation of non-pharmacological means of blood pressure therapy. Body weight control seems to be of central importance. Therapy resistant forms of hypertension may be caused by many different pathogenetic mechanisms. Besides other reasons (such as secondary hypertension, non compliance ect) volume overload may represent one of the most important reasons of resistant forms of hypertension. Diuretics, especially also the aldosterone antagonists, play a central role in the control of most situations associated with volume overload in the setting of essential hypertension.

Systemic vasculitis associated with seronegative spondylarthropathy (Reiter's syndrome).

A first case of Reiter's syndrome developing a severe systemic necrotising vasculitis is reported. After a disease course with major complications, aggressive consistent immuno-suppressive treatment was successful.

[Therapy of hypertension in the elderly: Fosinopril in Old Patients Study (FOPS)]. / Therapie der Altershypertonie: Fosinopril in Old Patients Study (FOPS).

The necessity for a persistent antihypertensive treatment in elderly persons has not been proven until the beginning nineties. An adequate reduction of blood pressure is required also in high age for prevention of cardiovascular accidents. A study is presented which investigates efficacy and tolerance of the ACE-inhibitor fosinopril in an unselected cohort of hypertensive outpatients older than 60 years over 12 weeks. Diastolic hypertension (DBP > or = 96-110 mm Hg) and isolated systolic hypertension (SBP > or = 160-219 mm Hg, DBP 80-94 mm Hg) were analyzed separately. Blood pressure values in both groups were normalized in more than 80% of the patients. In the case of insufficient response an additional dose of 12.5 mg hydrochlorochiazide was somewhat more effective than doubling the dose of the ACE-inhibitor. Efficacy and side effects of the antihypertensive treatment with fosinopril in this study were not dependent on the degree of impaired renal function.