[Diagnostic image (300). A man with progressive bilateral leg oedema]. / Diagnose in beeld (300). Een man met progressiefoedeem aan beide benen.

In a 76-year-old man bilateral leg oedema was caused by compression of the V. cava inferior by a large abdominal aortic aneurysm. The oedema resolved after an aortobiiliac prosthesis was placed.

Fatal combination of moclobemide overdose and whisky.

The antidepressant moclobemide (Aurorix) is a reversible inhibitor of monoamine oxidase-A. Pure moclobemide overdose is considered to be relatively safe. Mixed drug overdoses including moclobemide are potentially lethal, especially when serotonergical drugs are involved. So far, only one fatality due to moclobemide mono-overdose has been reported. We report here on a fatality following the ingestion of a moclobemide overdose in combination with half a bottle of whisky. Although dietary restrictions during moclobemide therapy are not considered necessary, the combination of large quantities of moclobemide and tyramine-containing products seems to be lethal, probably because monoamine oxidase-A selectivity is overwhelmed after massive overdoses. Since there is no specific antidote and treatment is only symptomatic, the severity of an overdose with moclobemide must not be underestimated.

Occurrence of esophageal granular cell tumors in The Netherlands between 1988 and 1994.

Granular cell tumors (GCT) of the esophagus are rare. The tumor is generally beleived to be of neurogenic origin and shows a malignant course in 2-4% of cases. No unanimity has been reached regarding the management of this tumor. A national survey was conducted on the incidence of GCT of the esophagus, related symptoms, management, and follow-up. A national survey was performed on all newly registered esophageal GCTs in the PALGA system (Dutch register of all pathology diagnoses) for seven consecutive years (1988-1994). Fifty-two new cases (17 men, 35 women; median age 46 years, range 22-77 years) were registered. In 44 cases clinical data could be obtained (survey response 85%). The majority of the GCTs were solitary (42/44) and localized in the distal esophagus (33/44). At endoscopy the size of the tumor was estimated at <5 mm in 50%, 5-10 mm in 25%, and 10-30 mm in 18%. Most patients (40/44) presented with nonspecific gastrointestinal symptoms, only four had dysphagia (tumor size >1 cm). No malignancies were reported. Management of the tumor included excisional biopsy (1/44), endoscopic polypectomy (3/44), and surgical excision (1/44). Endoscopic follow up (1-60 months) in 16 out of 17 patients left untreated showed either a stable tumor size or regression of the tumor. In one case with multiple GCT's a slight tumor growth was seen after a follow-up period of 48 months. Esophageal GCTs in the Netherlands are rare, and mostly diagnosed incidentally. Most patients suffer from nonspecific symptoms; dysphagia occurs only with tumors >1 cm. The usual clinical course of esophageal GCTs is benign. Patients without dysphagia probably do not require routine endoscopic follow-up, provided they are instructed to contact their physician, once dysphagia develops.

Aerosolized prostacyclin in acute respiratory distress syndrome caused by Chlamydiaceae spp. pneumonia.

Management of respiratory failure in acute respiratory distress syndrome (ARDS) typically requires ventilatory assistance. If traditional approaches to mechanical ventilation and adjunctive measures fail to succeed in achieving adequate oxygenation, alternative measures should be considered. We describe an ARDS patient with respiratory failure caused by a severe Chlamydiaceae species community-acquired pneumonia (CAP). Aerosolized prostacyclin (PGI(2)) treatment was successfully instituted for refractory hypoxemia.

Cholecystogastric fistula presenting with haematemesis: diagnosed by endoscopic retrograde cholangiography.

The case is reported of a 72-year-old woman suffering from morbid obesity, who presented with haematemesis while on anti-coagulant therapy. The source of the bleeding proved to be the gastric exit of a cholecystogastric fistula. Subsequent cholangitis was successfully treated by endoscopic retrograde cholangiography (ERC) and endoscopic sphincterotomy (ES) while simultaneously the extent of the fistula was established. Cholecystectomy and closure of the fistula was contraindicated because of her morbid obesity. She remained well for 6 months but then presented with a gallstone ileus while another stone was found to be escaping from the gastric fistula. Her morbid obesity resulted in surgical procrastination, which eventually proved fatal. This patient experienced both of the most common types of complication in cholecysto-enteral fistulation, cholangitis and gallstone ileus. Although cholecysto-enteral fistulas (CEF) are probably less common than several decades ago, they are now most likely to be diagnosed during ERC. Gastroenterologists therefore need to be aware of their potential to contribute to the diagnosis and treatment of this surgical condition.

Primary lymphoepithelioma-like carcinoma within an intralobular pulmonary sequestration.

A 31-yr-old Chinese female, a nonsmoker, presented with digital clubbing and coughing. Diagnostic evaluation revealed a pulmonary sequestration in the left lower lobe. During surgery a tumour was discovered, which turned out to be a lymphoepithelioma-like carcinoma. These tumours are mainly found in Asians, and are associated with the Epstein Barr virus and not with smoking. They are thought to have a better prognosis and to be more chemosensitive. The need for surgical treatment of pulmonary sequestration and the recognition of lymphoepithelioma-like carcinoma as a distinct clinicopathological entity is emphasized.

Methemoglobinemia as an uncommon cause of cyanosis.

Cyanosis is usually caused by decreased arterial oxygen saturation due to pulmonary or cardiac diseases. Methemoglobinemia is a rare cause, sometimes with lethal outcome. Two patients are described, both with an unremarkable cardiopulmonary history, presented with severe cyanosis due to aniline-induced methemoglobinemia that developed at work. The symptoms and the treatment of methemoglobinemia are discussed.

Occurrence of thyroid carcinoma in Dutch patients with familial adenomatous polyposis. An epidemiological study and report of new cases.

OBJECTIVES: To assess the occurrence of thyroid cancer in Dutch patients with familial adenomatous polyposis (FAP) and to discuss the value of surveillance. DESIGN: Retrospective analysis of medical records. SETTING: The data were collected from the Dutch FAP registry. PARTICIPANTS: 601 patients with FAP, 339 males and 262 females. RESULTS: The registry contained four female cases with a thyroid carcinoma. The mean age at diagnosis was 30 years (range: 16-46). In two patients it was the presenting symptom of FAP. None of the women died from their thyroid carcinoma during a mean follow-up of 13 years (range: 6-31). The histology revealed one papillary carcinoma, one follicular carcinoma and two mixed papillary/follicular carcinomas. The relative risk (RR) of developing thyroid carcinoma compared with the general Dutch population was 23 (95% confidence interval: 9-61). At the age of 60 years, the cumulative risk (CR) of thyroid carcinoma for female FAP patients was 2.8%. CONCLUSIONS: Young female FAP patients have a significantly increased RR to develop a thyroid carcinoma. It may even be the presenting symptom of FAP. As the CR of thyroid carcinoma is low and the prognosis seems to be good, we recommend only periodical physical examination of the thyroid.