Acute hepatitis due to fluoxetine therapy.

Fluoxetine-induced hepatotoxicity is generally considered of minimal clinical importance and is not well recognized. Asymptomatic increases in liver enzyme values have been observed in 0.5% of patients who take long-term fluoxetine therapy. This report details 2 cases of acute hepatitis believed to be caused by fluoxetine. Three cases of acute hepatitis caused by fluoxetine have been reported previously. The mechanism of fluoxetine-induced hepatotoxicity is unknown. Although routine monitoring of liver function may not be cost-effective, physicians should be alert to the possibility of fluoxetine-associated hepatitis and consider early discontinuation of the drug if this condition is suspected.

Patterns of reproduction among the Fang of Nsork (Equatorial Guinea): pregnancies, abortions and child spacing.

Fang women are known to practice virtually no contraception but for them induced abortion is not an acceptable option. Their reproductive behaviour consequently is governed by the ability to conceive, spontaneous intrauterine mortality and child spacing (due to prolonged breast-feeding and sexual abstinence). In a sample of 587 women from one hospital and one clinic in Nsork, there was a positive correlation between maternal age and the number of pregnancies, resulting in a mean of 5.52 pregnancies per female and one child born every 2.5 years. The reported spontaneous abortion rate was 28.6%.

PIP: Data were collected in the only hospital built in the Nsork district of Equatorial Guinea. Group A comprised deliveries at Nsork Hospital from March 1988 to July 1990 (29 months). Maternal age, number of previous pregnancies, and number of fetal losses from the fourth month of pregnancy were recorded. The total sample comprised 157 women aged 15-40 years who had a total of 555 pregnancies. Group B data were collected from May 1987 to December 1988 (20 months) from the prenatal clinic at a primary health post from a total of 430 pregnant women aged 14-45 years. Group A women represented 15.6% of all women in the district between 15 and 39 years of age; Group B, 36.5% between 15 and 44 years of age. There was a high level of prenatal attendances in Group B; however, only 20.2% of clinic visitors gave birth at the hospital. In Group A, the number of reported pregnancies continued to rise in direct relation to the woman's age (correlation coefficient r = .91). The reproductive age range of this population was 15 to 40 years with a mean of 5.52 pregnancies. The average number of reported abortions per female was .48 for each age group (p .05). The total incidence of fetal loss was 28.3%, 23.9% of which was reported by women with one abortion and 4.4% by women with at least two abortions. Group A had effective child spacing, achieved by a combination of sexual abstinence and prolonged breast feeding. Sexual abstinence was practiced after the seventh month of pregnancy until breast feeding ceased, and breast feeding was continued until the newborn was aged 16-21 months. The pattern of child spacing calculated from the regression between mean number of conceptions per woman and maternal age (r = .91, p .05) was around one pregnancy every 30 months. The data represented a population with close to natural fertility, since their reproduction was not deliberately controlled and there was no cessation of reproduction once the desired family size had been attained.

Barium enema versus colonoscopy for patients with polyps found during flexible sigmoidoscopy.

This prospective study compares the accuracy of barium enema examination performed by experienced radiologists to colonoscopy performed by experienced gastroenterologists blinded to the radiographic findings to detect proximal, synchronous lesions in patients with polyps detected during fiberoptic sigmoidoscopy. Three thousand six patients were examined, of whom 147 (5%) had polyps larger than 0.5 cm in diameter. Of 114 patients who completed the protocol, 46 patients (40%) had synchronous, proximal colonic lesions. There were no radiographic false positives, but the single-contrast barium enema missed polyps in 13 while detecting polyps in 2 patients (sensitivity = 13%). The double-contrast barium enema missed proximal polyps in 23 patients while detecting them in 8 (sensitivity = 26%). We conclude that patients with neoplastic polyps found during fiberoptic sigmoidoscopy should have colonoscopy without barium enema. If the entire colon cannot be examined at colonoscopy, we advise double-contrast barium enema.

Cholangitis due to Blastomyces dermatitidis.

A 70-yr-old woman presented with nonspecific complaints and had findings of a cholestatic liver enzyme pattern and a dilated left intrahepatic ductal system by radiographic imaging. Endoscopic retrograde cholangiopancreatography revealed multiple irregular flat stones and a fixed filling defect of the left hepatic duct. At the time of surgery a stonelike lesion of this ductal orifice was found along with a miliary pattern of infection of the left liver lobe. Histologic and microbiologic studies confirmed an infection by Blastomyces dermatitidis. Therapy with amphotericin B resulted in eradication of this infection. Despite their rarity, fungal infections of the biliary tree need to be considered in the differential diagnosis of biliary tract disease in the elderly and immunocompromised patient.

The significance of diminutive colonic polyps found at flexible sigmoidoscopy.

In order to determine the importance of identification and follow-up of diminutive colonic polyps (DCPs) (i.e., those less than or equal to 5 mm in diameter), we studied 3006 patients undergoing flexible sigmoidoscopy. DCPs were found in 315 patients (10.5%). Biopsy of these lesions showed them to be nonneoplastic in 187 patients (59.4%) and neoplastic in 128 (40.6%). Overall, 35% of all DCPs found were neoplastic. Gross appearance of the lesions was found to be an unreliable means of predicting their histologic makeup. Of the 128 patients with neoplastic DCPs, 73 underwent further examination with barium enema and colonoscopy. Synchronous lesions were found in 57.5%. In 10 patients, synchronous lesions were of significance, including carcinomas, adenomas greater than or equal to 8 mm in diameter, or severely dysplastic adenomas. We conclude that all DCPs discovered at sigmoidoscopy should be biopsied and in patients in whom DCPs are found to be neoplastic, colonoscopy should be undertaken to search for proximal synchronous lesions.

Primary hepatic leiomyosarcoma.

We describe a case of primary hepatic leiomyosarcoma and review the previous reports on this entity. We stress the histologic differentiation of this tumor from similar neoplasms and point out the need for aggressive resection in operable cases.

Hepatotoxicity associated with ticrynafen--a uricosuric diuretic.

Herein, we describe a patient who had ticrynafen-associated acute hepatitis. This complication has been reported in 57 patients (52 to the manufacturer, four to the Food and Drug Administration, and the current patient) in this country. The mechanism of hepatocellular injury is not known, but from the data to date it seems most likely to result from a hypersensitivity reaction rather than a direct hepatotoxic effect. The histopathological findings are difficult to differentiate from acute viral hepatitis. Removal of this drug from the market resulted from the prompt action of physicians in reporting the complications to the manufacturer and the rapid response of the pharmaceutical firm once the risks became known.

Granulomas and cholestatic--hepatocellular injury associated with phenylbutazone. Report of two cases.

A combined cholestatic-hepatocellular injury and noncaseating granulomas occurred in two patients 1 and 4 weeks after phenylbutazone therapy. Both patients were jaundiced, one had a macular rash, and both had peripheral blood eosinophilia. Symptoms and signs subsided, and abnormal findings from tests of hepatic function rapidly returned to normal following withdrawal of the drug. Sections of liver biopsy specimens 6 months later showed no granulomas or other pathologic changes. Previously reported cases are reviewed.