Correction to: Voriconazole-induced periostitis deformans: serial imaging in a patient with ANCA vasculitis.

The original version of this paper unfortunately contained mistakes in the affiliations for all authors.

Voriconazole-induced periostitis deformans: serial imaging in a patient with ANCA vasculitis.

OBJECTIVES: A 61-year-old with acute granulomatosis and polyangiitis developed Aspergillus fumigatus pneumonia after admission to the intensive care unit with a small bowel perforation. This occurred after immunosuppression (intravenous methylprednisolone, intravenous cyclophosphamide, and plasmapheresis) for his initial presentation with stage 3 acute kidney injury. MATERIALS AND METHODS: The mycologist recommended long-term treatment with voriconazole after initial recovery. RESULTS: After 7 months of treatment, the patient complained of joint pain and swelling in his hands. Radiographs, computed tomography, and single-photon emission computed tomography appearances were consistent with periostitis. A diagnosis of Voriconazole-induced periostitis deformans was made and the voriconazole was stopped. Plasma fluoride level was 278 µg/L (normal range < 50 µg/L). Discontinuation of voriconazole led to clinical improvement. CONCLUSIONS: Periostitis deformans due to fluorosis is a rare complication of voriconazole treatment. The imaging in our case is unusually dramatic. We were able to track the evolution of periosteal reactions over serial imaging.

CT and MRI of primary and metastatic fibrolamellar carcinoma: a case series of 37 patients.

OBJECTIVE: Fibrolamellar carcinoma (FLC) is a rare disease, with limited radiographic reported information. We assessed the imaging patterns of primary and metastatic FLC. METHODS: CT and MR examinations of patients with FLC were retrospectively reviewed. Imaging features were assessed for primary and recurrent liver tumours, including dimension, enhancement characteristics, and presence or absence of central scars. Locations of nodal and extranodal metastases were also recorded. RESULTS: Of 37 patients (18 males and 19 females; average age, 23.5 years) with FLC, 24 had imaging of their primary tumour; 13 had metastases at presentation and 7 developed metastases on follow-up. The remaining 13 patients had follow-up imaging of metastatic disease. Primary FLC had a mean diameter >11 cm, with central scars in ten (46%) patients. Most tumours enhanced heterogeneously (96%) and showed arterial enhancement (81%). On MRI, 62% of FLCs were hypointense on T1 weighted imaging and 54% were hyperintense on T2 weighted imaging. 13 patients (54%) had nodal metastases at presentation, mostly in the upper abdomen (92%) and commonly in the chest (38%). Extrahepatic metastases were most frequently pulmonary or peritoneal. Predominantly small and homogeneous intrahepatic recurrences were detected on follow-up in 15 patients. CONCLUSION: FLC often presents as a large hepatic tumour with nodal and distant metastases. Thoracic adenopathy and lung metastases were frequently found in our series, suggesting the need for pre-operative and follow-up chest imaging. ADVANCES IN KNOWLEDGE: Thoracic nodal and lung metastases are common in FLC; therefore, dedicated chest imaging should be part of the evaluation of a patient with FLC.

Case report. Glioblastoma multiforme presenting as a haemorrhagic minimally enhancing mass of the trigone.

Tumours of the trigone are rare, representing less than 2.5% of all intracranial tumours. The most common cause in adults is a meningioma. Glioblastoma multiforme of the trigone is extremely rare, with only six cases reported in the literature. We present a case of a glioblastoma multiforme of the trigone presenting in a 57-year-old man with temporal lobe seizures. Imaging revealed a haemorrhagic minimally enhancing mass of the trigone. Histology showed a high-grade malignant glial-derived neoplasm of World Health Organization Grade IV.

Efficacy and safety of the angioseal vascular closure device post antegrade puncture.

In this study, the efficacy and safety of the Angioseal vascular closure device post antegrade puncture of the common femoral artery (CFA) for lower limb vascular interventional procedures are evaluated. A retrospective analysis of the medical records of 60 consecutive patients who were referred for interventional procedures in the superficial femoral artery (SFA) or popliteal artery (popl. art.) was performed. Antegrade puncture was successfully performed in 58 of 60 patients (96.6%). Indications included right SFA angioplasty (n = 35), left SFA angioplasty (n = 17), right popl. art. angioplasty (n = 5), and left popl. art. angioplasty (n = 1). Hemostasis was achieved by, on an intention-to-treat basis, the Angioseal vascular closure device in 46 patients and manual compression in 12 patients. Manual compression was used instead of Angioseal because of severe calcified arterial wall plaques (n = 7), failed deployment of the Angioseal (n = 4), and left SFA dissection (n = 1). There were no major recorded complications in the Angioseal group despite the use of antiplatelet or anticoagulant medications. Twenty-three (50%) of the patients in the Angioseal group were discharged within 24 h. Thirty-seven of the 46 patients who received an Angioseal device had undergone a previous ipsilateral CFA puncture (time range, 2 days to 56 months; mean, 6.2 months). Nine of these patients had undergone ipsilateral Angioseal deployment in the previous 3 months. We conclude that the Angioseal vascular closure device is a safe and efficient means of achieving hemostasis post antegrade puncture.

Gunther Tulip retrievable inferior vena caval filters: indications, efficacy, retrieval, and complications.

PURPOSE: We evaluated the Gunther Tulip (GT) retrievable inferior vena cava (IVC) filter with regard to indications, filtration efficacy, complications, retrieval window, and use of anticoagulation. METHOD: A retrospective study was performed of 147 patients (64 men, 83 women; mean age 58.8 years) who underwent retrievable GT filter insertion between 2001 and 2005. The indications for placement included a diagnosis of pulmonary embolism or deep venous thrombosis with a contraindication to anticoagulation (n = 68), pulmonary embolism or deep venous thrombosis while on anticoagulation (n = 49), prophylactic filter placement for high-risk surgical patients with a past history of pulmonary embolism or deep venous thrombosis (n = 20), and a high risk of pulmonary embolism or deep venous thrombosis (n = 10). Forty-nine of the 147 patients did not receive anticoagulation (33.7%) while 96 of 147 patients did, 82 of these receiving warfarin (56.5%), 11 receiving low-molecular weight heparins (7.58%), and 3 receiving antiplatelet agents alone (2.06%). RESULTS: Filter placement was successful in 147 patients (100%). Two patients had two filters inserted. Of the 147 patients, filter deployment was on a permanent basis in 102 and with an intention to retrieve in 45 patients. There were 36 (80%) successful retrievals and 9 (20%) failed retrievals. The mean time to retrieval was 33.6 days. The reasons for failed retrieval included filter struts tightly adherent to the IVC wall (5/9), extreme filter tilt (2/9), and extensive filter thrombus (2/9). Complications included pneumothorax (n = 4), failure of filter expansion (n = 1), and breakthrough pulmonary embolism (n = 1). No IVC thrombotic episodes were recorded. DISCUSSION: The Gunther Tulip retrievable filter can be used as a permanent or a retrievable filter. It is safe and efficacious. GT filters can be safely retrieved at a mean time interval of 33.6 days. The newly developed Celect filter may extend the retrieval interval.

The importance of microbiological investigations, medications and artificial feeding in diarrhoea evaluation.

BACKGROUND: Diarrhoea in hospitalised patients is usually attributed to medications especially antibiotics, enteral tube feeding or enteropathogenic bacteria particularly Clostridium difficile. AIMS: The aim of this study was to evaluate the investigations performed on patients who developed diarrhoea during their stay in an acute general hospital. METHOD: Over 18 working days, an unselected group of adult inpatients who developed diarrhoea following their admission to hospital were reviewed. Symptoms, medications, nutritional support and any investigations performed were assessed. RESULTS: Eighty-one patients developed diarrhoea. Forty-nine (60%) were receiving antibiotics prior to the development of symptoms, 30 (37%) were being enterally tube fed, 14 (17%) had positive stool for Clostridium difficile A and B toxin and 3 (4%) had salmonella species positive stool. CONCLUSION: The majority of cases of diarrhoea were related to medications and enteral tube feeding. A small but significant number did develop bacterial infections. In contrast to some suggested guidelines, when investigating hospital acquired diarrhoea, it is considered worthwhile to perform microbiological stool examinations.

Cannonball metastases with favourable prognosis.

BACKGROUND: Secondary 'cannonball' metastases to the lung are frequent and usually associated with disseminated malignancy and poor prognosis. AIM: To report the case of a patient with metastatic pulmonary endometrial stromal sarcoma who had a previous hysterectomy for benign uterine fibroids and no past history of malignancy. RESULT: A 70-year-old female presented with cannonball metastases in her lung. Four years previously she had a hysterectomy for 'fibroids'. Review of the original histology revealed endometrial stromal sarcoma, similar to the lung metastasis. She currently has a good prognosis. CONCLUSION: A patient with 'cannonball' metastases can have a favourable prognosis. A female patient with a previous hysterectomy for uterine fibroids, should be considered to have metastatic sarcoma until proven otherwise.

Improved detection of Duchenne muscular dystrophy heterozygotes using discriminant analysis of creatine kinase levels.

We have assessed the sensitivity and specificity of tests to detect carriers of Duchenne muscular dystrophy by use of three serum enzymes (creatine kinase, pyruvate kinase, and aldolase) and discriminant analysis in 21 obligate heterozygotes and 28 normal controls. We found no significant age effects on enzyme levels. Each enzyme level considered separately was significantly higher in heterozygotes. Use of logs improved discrimination, and log CK was sufficient by itself as a discriminant (that is, addition of other enzymes did not significantly improve discrimination). We present procedures to generate posteriori probabilities for genetic counselling that incorporate prior probabilities and enzyme levels. Our results show both improved sensitivity (90%) and specificity (86%).