[A gynaecological cause of upper abdominal pain: Fitz-Hugh-Curtis syndrome]. / Een gynaecologische oorzaak van bovenbuikpijn: Het Fitz-Hugh-Curtis-syndroom.

A 19-year-old woman was admitted to our hospital because of unexplained pain in the right upper abdomen and fever. Her medical history noted a recent uncomplicated pregnancy and birth of a healthy child. Our differential diagnosis included pyelonephritis, pulmonary embolism, pneumonia causing pleural pain, a gastrointestinal cause, or a subphrenic abscess. A vaginal culture was taken as part of a second opinion by a gynaecologist. However, after a few days PCR on the vaginal sample was positive for Chlamydia trachomatis, indicating a case of Fitz-Hugh-Curtis syndrome. This syndrome is a complication of pelvic inflammatory disease caused by a bacterial infection, most frequently Gonococcal or Chlamydia species. The patient was treated with doxycycline and recovered quickly. As a result of ignoring a possible gynaecological cause in this patient, the time to diagnosis and treatment was delayed. Left untreated, this disease might result in infertility and in complications in the newborn. A broad differential diagnosis is therefore important.

Evaluation of a panel of expert pathologists: review of the diagnosis and histological classification of Hodgkin and non-Hodgkin lymphomas in a population-based cancer registry.

Abstract Correct histological classification of malignant lymphomas is important but has always been a difficult challenge. Since 2001 the World Health Organization (WHO) classification has been used, which should make it easier to define distinct disease entities. The purpose of this study was to evaluate the usefulness of a panel of expert hematopathologists in reviewing the diagnosis of malignant lymphomas and to examine whether the discordance between primary and panel diagnoses has declined throughout the years. All patients with a primary malignant lymphoma diagnosed between 2000-2001 and 2005-2006 were identified through the population based cancer registry. All diagnoses were reviewed by a panel of three expert pathologists. In 2000-2001, 344 patients were included, and in 2005-2006, 370 patients. The overall discordance rate decreased from 14% in 2000-2001 to 9% in 2005-2006 (p = 0.06). We were able to identify lymphoma subgroups with the highest discordance rates and lowest discordance rates (mantle cell lymphoma and classical Hodgkin lymphoma), which remained unchanged throughout the years. Based on these results we would propose to review all cases of malignant lymphoma with the exception of mantle cell lymphoma and classical Hodgkin lymphoma, when the initial pathologist has no doubt about the diagnosis.

[A woman with a disappearing breast]. / Een vrouw met een verdwenen borst.

A 76-year-old woman presented with dyspnea. She had received breast conserving therapy for cancer in her left breast 26 years earlier. During physical examination a redness of the skin on the left side of the torso and neck, as well as disappearance of the left breast and shift of the left nipple was noted. This proved to be a metastatic recurrence of the breast cancer. Despite over 20 years of follow-up consisting of mammography, the complete shrinkage of the breast as an expression of locally recurrent disease was missed because no physical examination was performed. This underlines the importance of physical examination in addition to mammography in the follow-up of breast cancer patients.

[Pathophysiology of one warm foot. Anatomy of the autonomic nervous system]. / Pathofysiologie van één warme voet. De anatomie van het autonome zenuwstelsel.

A 50-year-old man presented with a persistently warm left foot, which did not perspire. What initially seemed to be an innocent disorder turned out to be a retroperitoneal germ cell tumour situated at Liii-Liv. In most people this location is the site of the lumbar paravertebral ganglia (an important part of the sympathetic nervous system). The fact that these ganglia were affected by the tumour explained the autonomic dysfunction in this case. The patient received curative chemotherapy. Exploration of the symptoms with respect to the pathophysiology and anatomy of the autonomous nervous system might have led to an earlier diagnosis.

[Interstitial pneumonitis as a side effect of rituximab]. / Interstitiële pneumonitis als bijwerking van rituximab.

A 42-year-old man with large B-cell non-Hodgkin lymphoma was admitted to hospital after eight chemotherapy cycles of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone (R-CHOP). He had high fever, non-productive cough, dyspnoea, and on chest X-ray, interstitial infiltrations. Extensive microbiological investigation excluded any infection, including opportunistic infection. Positron emission tomography (PET) scan was negative at previous lymphoma sites, but showed diffuse fluorodeoxyglucose uptake in both lungs. Pulmonary function testing demonstrated a restrictive pattern and a diffusion deficit. Review of the literature showed that this clinical picture closely corresponded with that of rituximab-induced interstitial pneumonitis. Treatment with prednisolone, 40 mg/day, resulted in a fast and complete recovery. Physicians administering rituximab should be aware of rituximab-induced interstitial pneumonitis, since according to recent literature this condition occurs in 9-14% of patients. It can run a mild course, but can also be fatal. Besides stopping rituximab, most patients need corticosteroid therapy.