Emergency surgery for generalized peritonitis caused by cytomegalovirus colitis in a patient with AIDS.

Cytomegalovirus infection of the colon is a late and severe complication in human immunodeficiency virus patients. Despite availability of medical treatment, occasional life-saving emergency surgery must be performed. The controversial surgical aspects of treatment are discussed based upon an unusual case of aseptic generalized peritonitis without perforation. The feasibility and value of limited resection are emphasized.

Changing patterns of autopsy findings among persons with acquired immunodeficiency syndrome in an inner-city population. A 12-year retrospective study.

OBJECTIVE: To determine patterns of autopsy findings among persons with acquired immunodeficiency syndrome (AIDS) during a 12-year period. DESIGN AND SETTING: All 168 autopsies performed on adult AIDS patients at the Bronx-Lebanon Hospital Center in New York City between 1982 and 1993 were analyzed. The Center is a 725-bed, acute-care facility in the south Bronx, which serves a population of approximately half a million people. High poverty levels, tuberculosis and AIDS incidence, and intravenous drug abuse are common in this population. Subjects were predominantly Hispanic and black. MAIN OUTCOME MEASURES: Changes in the frequency of single and multiple opportunistic infections in general and frequencies of specific infections during the 12-year period. RESULTS: Through 1986, 75% of AIDS autopsies demonstrated single infections, particularly Pneumocystis carinii pneumonia. Since 1987, 72% of autopsies demonstrated multiple infections related to P carinii pneumonia, mycobacteriosis, cytomegalovirus, and various fungi. During the last 3 years, the prevalence of mycobacterial infections was higher than in the previous 9 years combined. In contrast, P carinii pneumonia decreased from 52% in 1988 to 14% in 1993. CONCLUSIONS: We note the recent emergence of multiple infections by multiple organisms, a significant decrease in the prevalence of P carinii pneumonia, and a slight increase in mycobacterial tuberculosis. Awareness of these changing patterns of infection may be useful in treating persons with AIDS.

Fatal Hemoptysis during Coronary Thrombolysis.

Cerebral hemorrhage is the most dreaded complication of coronary thrombolysis. Significant bleeding has also been described from catheter-entry sites, the retroperitoneum, and the gastrointestinal and genitourinary tracts. However, hemoptysis induced by thrombolysis has rarely been described in the literature. We present a 66-year-old male who received front-loaded tissue plasminogen activator (tPA) for acute transmural anterior wall myocardial infarction and developed massive hemoptysis from preexisting cavitary lung disease. The patient died within 5 hours. We believe this is the first case report of fatal hemoptysis induced by coronary thrombolysis. A history of cavitary lung disease may be a risk factor for life-threatening hemoptysis in patients receiving thrombolytic therapy.

Sarcoidosis presenting as obstructive jaundice.

Sarcoidosis is an uncommon disorder characterized by a multi-systemic granulomatous disease of undetermined etiology and pathogenesis. The diagnosis is established by the presence of a compatible clinical illness and by histologic demonstration of noncaseating epithelioid cell granulomas in the affected organs. Accurate diagnosis requires a thorough evaluation to exclude infectious and neoplastic diseases that can mimic sarcoidosis. Although all organs and systems can be affected, the lungs and intrathoracic lymph glands are the most common sites of involvement. We describe an unusual case of extrapulmonary sarcoidosis presenting as obstructive jaundice.

Comparison of five methods of assessment of intestinal viability.

A strain gauge device called the electronic contractility meter (ECM) was designed to measure quantitatively intestinal ischemic damage by delivering electrical stimuli to the intestine. Threshold stimulus level (TSL) was the minimum stimulus in milliamps necessary to produce a smooth muscle contractile response. TSL scale ranged from zero to 100 milliamps. Resection and anastomosis in ischemic intestinal segments was carried out in 30 dogs to compare TSL, intestinal color, peristalsis, Doppler ultrasound and resection margin histology with survival. There were five fatal anastomotic leaks, all resulting from intestinal necrosis. Doppler pulse in the marginal artery (MA) was absent at four of the five anastomoses that leaked versus eight of the 25 that healed (p less than or equal to 0.01). Mean TSL at the resection site was 38 +/- 7 milliamps in surviving dogs versus 51 +/- 4 milliamps in nonsurvivors (p less than or equal to 0.001). Mean TSL of normal intestine was 22 +/- 2 milliamps. Both TSL and Doppler ultrasound also correlated with resection margin histology (p less than or equal to 0.02 and p less than or equal to 0.005, respectively). Presence of peristalsis did not correlate with histologic grade or survival rate. Intestinal color correlated with resection margin histology (p less than or equal to 0.001) but not survival. The ECM and Doppler ultrasound were both superior to gross visual assessment in predicting intestinal survival. The ECM quantitatively measures tissue damage, a potential advantage over Doppler ultrasound, which provides only an estimate of local arterial blood flow.