[Extracellular matrix remodeling as a risk factor for the progression of cerebrovascular pathology]. / Remodelirovanie vnekletochnogo matriksa kak faktor riska progressirovaniya tserebrovaskulyarnoi patologii.

In recent years, attention of experts has been attracted to remodeling of the brains' extracellular matrix in connection with analysis of alterations' causes of the blood-brain barrier (BBB), development of neuroinflammation and neovasculogenesis, as well as the possibility of regeneration of nervous tissue in cerebrovascular pathology. The review discusses the molecular mechanisms of increasing BBB permeability in stroke associated with the interaction of structural elements of the capillary wall (endothelium and pericytes), glial cells and perivascular leukocytes. The role of brain extracellular matrix remodeling in the pathogenesis of neuroinflammation and participation of pericytes in this process are discussed. Management of remodeling process of structural elements in extracellular matrix may be a promising new technology in the treatment of patients with cerebrovascular pathology.

[Risks of progression of cerebrovascular pathology associated with the activity of the brain purinergic system]. / Riski progressirovaniya tserebrovaskulyarnoi patologii, svyazannye s aktivnost'yu purinergicheskoi sistemy mozga.

Until now, there is no understanding of the relationship between risk factors and the progression of cerebrovascular pathology. The review presents facts that confirm the involvement of various subtypes of purine P2 receptors in neuron activation, growth and myelination of axons, migration and microglia phagocytosis, astrogliosis, regulation of vascular tone, thrombosis and angiogenesis, neuroinflammation and immune responses. The data suggest the possibility of the activation of purinergic system of the brain during the development of main risk factors for cerebrovascular pathology (age, arterial hypertension, diabetes), as a stereotypical mechanism that can affect the homeostasis of the ensemble "neuron-glia-capillary". Purinergic P2 receptors may be a potential target for the development of pharmacological methods to limit the progression of cerebrovascular pathology.

Multicentre randomized clinical trial of inspiratory muscle training versus usual care before surgery for oesophageal cancer.

BACKGROUND: Up to 40 per cent of patients undergoing oesophagectomy develop pneumonia. The aim of this study was to assess whether preoperative inspiratory muscle training (IMT) reduces the rate of pneumonia after oesophagectomy. METHODS: Patients with oesophageal cancer were randomized to a home-based IMT programme before surgery or usual care. IMT included the use of a flow-resistive inspiratory loading device, and patients were instructed to train twice a day at high intensity (more than 60 per cent of maximum inspiratory muscle strength) for 2 weeks or longer until surgery. The primary outcome was postoperative pneumonia; secondary outcomes were inspiratory muscle function, lung function, postoperative complications, duration of mechanical ventilation, length of hospital stay and physical functioning. RESULTS: Postoperative pneumonia was diagnosed in 47 (39·2 per cent) of 120 patients in the IMT group and in 43 (35·5 per cent) of 121 patients in the control group (relative risk 1·10, 95 per cent c.i. 0·79 to 1·53; P = 0·561). There was no statistically significant difference in postoperative outcomes between the groups. Mean(s.d.) maximal inspiratory muscle strength increased from 76·2(26·4) to 89·0(29·4) cmH2 O (P < 0·001) in the intervention group and from 74·0(30·2) to 80·0(30·1) cmH2 O in the control group (P < 0·001). Preoperative inspiratory muscle endurance increased from 4 min 14 s to 7 min 17 s in the intervention group (P < 0·001) and from 4 min 20 s to 5 min 5 s in the control group (P = 0·007). The increases were highest in the intervention group (P < 0·050). CONCLUSION: Despite an increase in preoperative inspiratory muscle function, home-based preoperative IMT did not lead to a decreased rate of pneumonia after oesophagectomy. Registration number: NCT01893008 (https://www.clinicaltrials.gov).

Predictors of Physical Fitness among Southwestern Native American Adolescents at Risk for Diabetes.

The prevalence of obesity is increasing among children nationally. Native American children from Zuni Pueblo appear to be at increased risk for obesity, which also increases the risk for the metabolic syndrome, diabetes, and cardiovascular disease. While exercise and physical fitness can prevent or forestall these developments, predictors of physical fitness in this population are unknown. Forty-seven Native American adolescents completed four aspects of the Presidential Fitness Challenge (push-ups, sit-ups, step-ups, and timed walking) during screening for another study, and fitness was empirically summarized with a Presidential Fitness Index. Correlative analyses were subsequently performed to elucidate predictors of fitness. Age was the only independent predictor of the Presidential Fitness Index. Other variables that were not found to be independent predictors included BMI percentile, waist circumference, fat free mass, total body fat, and HDL cholesterol. Among adolescent Southwest Native Americans, older children performed better on the Presidential Fitness Challenge. Additionally, BMI was not found to be an independent predictor of fitness.

Asymptomatic atrial fibrillation and risk of stroke.

The incidence of atrial fibrillation rises with advancing age. About 10% of patients over 80 years suffer from atrial fibrillation, but episodes are often not recognized. However, about 25% of cryptogenic strokes are caused by asymptomatic atrial fibrillation showing a significant risk of thromboembolism by this condition. New insertable cardiac monitors or wearable sensors offer the opportunity of continuous rhythm monitoring over wider time spans. Thereby, they enable detection of asymptomatic atrial fibrillation episodes. Several lines of evidence point towards an association between duration of asymptomatic episodes and thromboembolic risk. However, definite data on optimal risk stratification and therapy is missing in this collective. Currently, oral anticoagulation should be initiated according to the CHA2DS2VASc Score. Given the better safety profile of direct oral anticoagulants these substances should be preferred. In patients with high bleeding risk and asymptomatic atrial fibrillation, catheter-based left appendage occlusion may represent a valuable alternative to oral anticoagulation.

Respiratory syncytial virus in critically ill adult patients with community-acquired respiratory failure: a prospective observational study.

The incidence of respiratory syncytial virus (RSV) and influenza virus infection was determined during three RSV seasons in 158 adult patients consecutively admitted to the intensive care unit with community-acquired respiratory failure. Nasopharyngeal swabs were tested for the presence of RSV and influenza virus by real-time polymerase chain reaction. Six patients (4%) were positive for RSV and all recovered. This finding was in sharp contrast to influenza (23 (15%) patients, 4 (17%) deaths). In conclusion, even in the midst of the RSV season, RSV is an infrequent cause of respiratory failure in adults admitted to the intensive care unit.

Effects of oligosaccharides in a soybean meal-based diet on fermentative and immune responses in broiler chicks challenged with Eimeria acervulina.

Fermentable oligosaccharides, particularly those found in soybean meal (SBM), may modulate fermentation in the ceca, thus affecting intestinal immune responses to intestinal pathogens. We hypothesized that fermentable oligosaccharides found in SBM would positively affect cecal fermentation and intestinal immune status in chicks challenged with an acute coccidiosis (Eimeria acervulina) infection and fed either a SBM-based diet or a semi-purified soy protein isolate- (SPI) based diet. Using a completely randomized design, 1-d-old broiler chicks (n = 200; 5 replications/treatment; 5 chicks/replication) were assigned to 1 of 4 SBM- or SPI-based diets containing either dietary cellulose (4%) or a fermentable carbohydrate, galactoglucomannan oligosaccharide-arabinoxylan (GGMO-AX) complex (4%). On d 9 posthatch, an equal number of chicks on each diet were inoculated with either distilled water (sham control) or E. acervulina (1 × 10(6) oocysts) and then euthanized on d 7 postinoculation. Overall, body weight gain and feed intake were greater (P < 0.01) for SBM-fed chicks, regardless of infection status. Gain:feed ratio was greater (P ≤ 0.05) for SPI-fed chicks except during d 3-7 postinoculation. Infection status, but not fiber source, affected propionate, isobutyrate, isovalerate, and total branched-chain fatty acid concentrations (P ≤ 0.02). Soybean meal-based diets resulted in greater (P ≤ 0.04) short-chain fatty acid and branched-chain fatty acid concentrations than SPI-based diets. Messenger RNA fold changes relative to uninfected SBM-cellulose-fed chicks of all duodenal cytokines were greater (P ≤ 0.01) for infected chicks, and SBM-fed chicks had greater (P < 0.01) interferon-γ and interleukin-12ß expression compared with SPI-fed chicks. Cecal tonsil cytokine expression was also affected (P ≤ 0.02) by infection; however, protein source only affected (P < 0.01) interleukin-1ß expression in this tissue. Overall, a SBM-based diet, compared with a semi-purified SPI-based diet with a different ingredient composition, resulted in greater weight gain, feed intake, and short-chain fatty acid production regardless of infection status, and also greater duodenal cytokine expression in E. acervulina- infected chicks, which is hypothesized to be related to the nutrients and oligosaccharides found in SBM.

Ingestion of a novel galactoglucomannan oligosaccharide-arabinoxylan (GGMO-AX) complex affected growth performance and fermentative and immunological characteristics of broiler chicks challenged with Salmonella typhimurium.

Fermentable carbohydrates may enhance the ability of the gastrointestinal tract to defend against a pathogenic infection. We hypothesized that a galactoglucomannan oligosaccharide-arabinoxylan (GGMO-AX) complex would positively affect immune status and prevent colonization and shedding in Salmonella typhimurium-infected chicks. Using a completely randomized design, 1-d-old commercial broiler chicks (n = 240 chicks; 4 replications/treatment; 5 chicks/replication) were assigned to 1 of 6 dietary treatments differing in concentration of GGMO-AX (0, 1, 2, or 4%) or containing 2% Safmannan or 2% short-chain fructooligosaccharides. Cellulose was used to make diets iso-total dietary fiber. On d 10 posthatch, an equal number of chicks on each diet were inoculated with either phosphate-buffered saline (sham control) or Salmonella typhimurium (1 × 10(8) cfu). All birds were euthanized on d 10 postinoculation (PI) for collection of intestinal contents and select tissues. Body weight gain and feed intake of chicks were greater (P < 0.05) in infected chicks PI for all time periods, except for weight gain on d 0 to 3 PI. Gain:feed was affected (P < 0.05) by diet, with Safmannan-fed chicks having the highest G:F and 1% GGMO-AX-fed chicks having the lowest. The GGMO-AX substrate demonstrated effects similar to a prebiotic substrate as indicated by increased cecal short-chain fatty acid concentrations, decreased cecal pH, and increased populations of Lactobacillus spp. and Bifidobacteria spp. as dietary GGMO-AX concentration increased. Excreta Salmonella typhimurium populations on d 5 and 10 PI, and ileal and cecal Salmonella typhimurium populations, tended to be affected (P < 0.10) by the main effect of diet. Messenger RNA expression of IFN-γ in the cecal tonsils was the only cytokine independently affected by infection and diet (P < 0.01). Chicks fed 2 and 4% GGMO-AX had similar expressions of IFN-γ and IL-1ß, regardless of infection, suggesting that Salmonella typhimurium virulence was suppressed. Dietary supplementation with GGMO-AX resulted in prebiotic-like effects but did not limit Salmonella typhimurium intestinal colonization or shedding, but possibly decreased the virulence of Salmonella typhimurium within the digestive tract.

The effects of a galactoglucomannan oligosaccharide-arabinoxylan (GGMO-AX) complex in broiler chicks challenged with Eimeria acervulina.

Fermentable carbohydrates may enhance the ability of the gastrointestinal tract to defend against pathogenic infection. We hypothesized that a mannose-rich, galactoglucomannan oligosaccharide-arabinoxylan (GGMO-AX) complex would positively impact immune status and prevent weight loss resulting from acute coccidiosis (Eimeria acervulina) infection of chicks. Using a completely randomized design, 1-d-old commercial broiler chicks (n = 160; 4 replications/treatment; 5 chicks/replication) were assigned to one of 4 corn-soybean meal-based diets containing supplemental GGMO-AX (0, 1, 2, or 4%) that replaced dietary cellulose. On d 9 posthatch, an equal number of chicks on each diet were inoculated with either distilled water (sham control) or E. acervulina (1 × 10(6) oocysts). All birds were euthanized on d 7 postinoculation (PI) for collection of cecal contents and duodenal tissue. Overall, BW gain of chicks was not affected by diet PI, whereas infection decreased (P < 0.01) weight gain on d 0 to 7 PI. Feed intake was not affected by dietary treatment, but infection decreased (P < 0.01) feed intake on d 0 to 7 PI. Overall, infection, but not diet, decreased (P < 0.01) G:F on d 0 to 7 PI. Cecal propionate concentrations were independently affected by infection and diet, while butyrate concentrations were affected only by infection (P = 0.02). Cecal Bifidobacterium spp. populations were affected (P < 0.01) by diet, with the 2% GGMO-AX resulting in the highest cfu/g of cecal contents (on a DM basis). Messenger RNA expression of all duodenal cytokines evaluated was affected by infection status (P ≤ 0.02) but not by dietary treatment alone. Supplementing 4% GGMO-AX consistently resulted in the greatest fold change in proinflammatory cytokine expression, while inhibiting antiinflammatory cytokine expression, which indicates a more robust innate immune response. Despite decreasing performance, 4% dietary GGMO-AX improved select fermentation indices and the innate intestinal immune response to an acute E. acervulina infection.

Activated macrophages containing tumor marker in colon carcinoma: immunohistochemical proof of a concept.

The presence of carcinoembryonic antigen (CEA)-containing activated macrophages has been demonstrated in peripheral blood from patients with colorectal carcinoma. Macrophages migrate from the circulation into the tissue, phagocytose debris, and return to the bloodstream. Hence it seems likely that activated macrophages containing tumor debris, i.e., tumor marker, are present in the stroma of colorectal carcinoma. After phagocytosis, they could follow a hematogenic or lymphogenic route to the peripheral blood. The aim of this study is to assess the presence of tumor marker-containing activated macrophages in the stroma of colon carcinoma and in regional lymph nodes. From 10 cases of colon carcinoma, samples of tumor tissue and metastasis-free lymph nodes were cut in serial sections and stained for CD68 to identify macrophages and for CEA, cytokeratin, or M30 presence. Slides were digitalised and visually inspected using two monitors, comparing the CD68 stain to the tumor marker stain to evaluate the presence of tumor marker-positive macrophages. Macrophages containing tumor marker could be identified in tumor stroma and in metastasis-free regional lymph nodes. The distribution varied for the different markers, CEA-positive macrophages being most abundant. The presence of macrophages containing tumor marker in the tumor stroma and lymph nodes from patients with colon carcinoma could be confirmed in this series using serial immunohistochemistry. This finding supports the concept of activated macrophages, after phagocytosing cell debris, being transported or migrating through the lymphatic system. These results support the potential of tumor marker-containing macrophages to serve as a marker for diagnosis and follow-up of colon cancer patients.

Galactoglucomannan oligosaccharide supplementation affects nutrient digestibility, fermentation end-product production, and large bowel microbiota of the dog.

A galactoglucomannan oligosaccharide (GGMO) obtained from fiberboard production was evaluated as a dietary supplement for dogs. The GGMO substrate contained increased concentrations of oligosaccharides containing mannose, xylose, and glucose, with the mannose component accounting for 35% of DM. Adult dogs assigned to a 6 × 6 Latin square design were fed 6 diets, each containing a different concentration of supplemental GGMO (0, 0.5, 1, 2, 4, and 8%) that replaced dietary cellulose. Total tract DM and OM apparent digestibilities increased (P < 0.001) linearly, whereas total tract CP apparent digestibility decreased (P < 0.001) linearly as dietary GGMO substrate concentration increased. Fecal concentrations of acetate, propionate, and total short-chain fatty acids increased (P ≤ 0.001) linearly, whereas butyrate concentration decreased (P ≤ 0.001) linearly with increasing dietary concentrations of GGMO. Fecal pH decreased (P ≤ 0.001) linearly as dietary GGMO substrate concentration increased, whereas fecal score increased quadratically (P ≤ 0.001). Fecal phenol (P ≤ 0.05) and indole (P ≤ 0.01) concentrations decreased linearly with GGMO supplementation. Fecal biogenic amine concentrations were not different among treatments except for phenylethylamine, which decreased (P < 0.001) linearly as dietary GGMO substrate concentration increased. Fecal microbial concentrations of Escherichia coli, Lactobacillus spp., and Clostridium perfringens were not different among treatments. A quadratic increase (P ≤ 0.01) was noted for Bifidobacterium spp. as dietary GGMO substrate concentration increased. The data suggest positive nutritional properties of supplemental GGMO when incorporated in a good-quality dog food.

Protein digestibility evaluations of meat and fish substrates using laboratory, avian, and ileally cannulated dog assays.

Meat and fish serve as important protein sources in the companion animal diet; however, limited protein digestibility data are available for assessing protein digestibility differences among good-quality protein sources. Beef loin, pork loin, chicken breast, pollock fillet, and salmon fillet were evaluated for composition, protein digestibility, and AA bioavailability using the immobilized digestive enzyme assay, cecectomized rooster assay, and ileally cannulated dog assay. Pollock contained the greatest amount of CP, total essential AA (TEAA), and total nonessential AA (TNEAA; DM basis; 96.9, 38.6, and 50.3%, respectively). Salmon contained the next greatest amounts (92.8, 36.4, and 44.6%), followed by chicken (90.3, 36.1, 43.2%). Beef had the least CP content (82.7%), but had slightly greater TEAA and TNEAA concentrations (33.9, 42.0%) compared with pork (86.2, 33.6, 41.3%). Immobilized digestive enzyme assay values were greatest for pollock fillet (0.71) and least for chicken breast (0.52). Beef loin, pork loin, and salmon fillet were similar (0.63, 0.62, and 0.64, respectively). Standardized TEAA and TNEAA digestibility coefficients, evaluated using the cecectomized rooster assay, were greatest (P < 0.05) for pollock fillet (90.4 and 89.8%, respectively) and least (P < 0.05) for chicken breast (86.6 and 85.9%, respectively) and salmon fillet (87.8 and 86.4%, respectively). Dogs assigned to a 5 x 5 Latin square design were fed 5 diets, with each test substrate as the major protein source. No significant differences (P > 0.05) were found in ileal digestibility of protein. Values ranged from 88.9% for chicken to 90.5% for pork loin and pollock fillet. Ileal TEAA and TNEAA coefficients were not different among test substrates, with values between 91.7 and 92.7%, and 88.8 and 90.4%, respectively. Total tract CP apparent digestibility values ranged from 94.4 to 94.8%, with no differences noted among treatments. Despite marked differences in composition and predicted and standardized digestibility values, when the protein sources were added to diets at a concentration of approximately 30% (25% of total energy intake), no differences in test protein substrates were noted in either ileal or total tract nutrient digestibility.

Motion correction of PET brain images through deconvolution: II. Practical implementation and algorithm optimization.

Image quality is significantly degraded even by small amounts of patient motion in very high-resolution PET scanners. When patient motion is known, deconvolution methods can be used to correct the reconstructed image and reduce motion blur. This paper describes the implementation and optimization of an iterative deconvolution method that uses an ordered subset approach to make it practical and clinically viable. We performed ten separate FDG PET scans using the Hoffman brain phantom and simultaneously measured its motion using the Polaris Vicra tracking system (Northern Digital Inc., Ontario, Canada). The feasibility and effectiveness of the technique was studied by performing scans with different motion and deconvolution parameters. Deconvolution resulted in visually better images and significant improvement as quantified by the Universal Quality Index (UQI) and contrast measures. Finally, the technique was applied to human studies to demonstrate marked improvement. Thus, the deconvolution technique presented here appears promising as a valid alternative to existing motion correction methods for PET. It has the potential for deblurring an image from any modality if the causative motion is known and its effect can be represented in a system matrix.

Motion correction of PET brain images through deconvolution: I. Theoretical development and analysis in software simulations.

Image quality is significantly degraded even by small amounts of patient motion in very high-resolution PET scanners. Existing correction methods that use known patient motion obtained from tracking devices either require multi-frame acquisitions, detailed knowledge of the scanner, or specialized reconstruction algorithms. A deconvolution algorithm has been developed that alleviates these drawbacks by using the reconstructed image to estimate the original non-blurred image using maximum likelihood estimation maximization (MLEM) techniques. A high-resolution digital phantom was created by shape-based interpolation of the digital Hoffman brain phantom. Three different sets of 20 movements were applied to the phantom. For each frame of the motion, sinograms with attenuation and three levels of noise were simulated and then reconstructed using filtered backprojection. The average of the 20 frames was considered the motion blurred image, which was restored with the deconvolution algorithm. After correction, contrast increased from a mean of 2.0, 1.8 and 1.4 in the motion blurred images, for the three increasing amounts of movement, to a mean of 2.5, 2.4 and 2.2. Mean error was reduced by an average of 55% with motion correction. In conclusion, deconvolution can be used for correction of motion blur when subject motion is known.

[Acute intoxication with isopropanol]. / Akute Intoxikation mit Isopropanol.

Isopropanol is an ingredient of commonly used industrial and household agents. Intoxication can occur unintentionally, in suicide attempts or by alcohol abusers when used as a substitute for ethanol. Symptoms involve the gastrointestinal tract, the central nervous system, and the cardiovascular system at higher doses. Mortality is especially high in patients with deep coma and marked hypotension. This report describes a case of life-threatening isopropanol intoxication of a prison inmate successfully treated by haemodialysis.

[Reversible complete heart block by re-infection with Borrelia burgdorferi with negative IgM-antibodies]. / Reversibler totaler AV-Block durch Reinfektion mit Borrelien bei negativen IgM-Titern.

UNLABELLED: PAST HISTORY AND PHYSICAL EXAMINATION: A 38-year-old farmer presented at his general practitioner with dizziness. Physical examination was notable for a heart rate of 35 beats/min. The electrocardiogram (ECG) showed a complete (third degree) heart block with a bradycardic ventricular escape rhythm. The patient reported having had an rash on his right lower leg six weeks previously. After spreading centrifugally it had turned pale in its centre, then regressed and finally disappeared. After having been supplied with a temporary pacemaker in a county hospital the patient was transferred to our hospital. ADMISSION FINDINGS: The ECG showed pacemaker stimulation of the ventricle at about 60 beats/min. Without this stimulation the complete atrioventricular block persisted. Coronary heart disease was excluded by angiography and levocardiography revealed normal systolic left ventricular function. Serological findings were a positive titre of IgG-antibodies against Borrelia while the IgM titre was negative. THERAPY AND COURSE: The heart block disappeared under antibiotic therapy with ceftriaxon within eight days, after first changing to transitory second and first-degree atrioventricular block, and the pacemaker was removed. The patient did not develop any neurological symptoms. CONCLUSION: Cardiac involvement in Lyme disease can be the only manifestation of borreliosis. Possible reversibility under antibiotic therapy is an important aspect of diagnosis. In spite of atypical serology the combination of history, symptoms and serological findings will lead to the diagnosis Lyme disease.

Oral myiasis in a child by the reindeer warble fly larva Hypoderma tarandi.

We describe a case of human oral myiasis by a first-stage larva of the reindeer warble fly, Hypoderma (Oedemagena) tarandi (L.) (Diptera: Oestridae), in a 12-year-old girl. In September the patient complained of erythema, swelling and conjunctivitis of the right eyelid. Symptoms subsided spontaneously but re-occurred in October. In December she presented with acute swelling of the right corner of the mouth. Later that day a living larva protruded from this swelling. The patient had been on vacation in Norway during the previous summer months.

Stroke volume variation does not predict fluid responsiveness in patients with septic shock on pressure support ventilation.

BACKGROUND: Stroke volume variation (SVV)--as measured by the pulse contour cardiac output (PiCCO) system--predicts the cardiac output response to a fluid challenge in patients on controlled ventilation. Whether this applies to patients on pressure support ventilation is unknown. METHODS: Thirty consecutive patients with septic shock were included. All were on pressure support ventilation, monitored using the PiCCO system and receiving 500 ml of colloid on clinical indications. Arterial pulse contour SVV and the transpulmonary thermodilution cardiac index were measured before and after fluid challenge. RESULTS: Forty-seven per cent of the patients were defined as fluid responders by an observed increase of > 10% in the cardiac index after fluid. Prior to fluid challenge, the cardiac index was lower in responders compared with non-responders (mean +/- SD, 3.0 +/- 0.6 vs. 4.0 +/- 1.2 l/min/m2, P < 0.01). In contrast, pre-infusion values of SVV were similar between subsequent responders and non-responders (13 +/- 5 vs. 16 +/- 6%, P =0.26). The mean areas under the ROC curves were 0.77 (95% confidence interval, 0.60-0.94) and 0.52 (0.30-0.73) for pre-fluid cardiac index and SVV, respectively, indicating a predictive power of only the cardiac index. CONCLUSIONS: SVV did not predict the response in cardiac output to fluid challenge in patients with septic shock on pressure support ventilation.

[Subcutaneous nodules with malignant presentation, but caused by infection]. / Een subcutane zwelling met een maligne presentatie, maar met een infectieuze oorzaak.

Three patients, a woman aged 32, a boy aged 6.5 and a man aged 56 years, presented with a subcutaneous mass suggesting a malignancy: respectively a rubbery swelling, painful to the touch below the left scapula, a partly massive, partly soft swelling on the inside of the left upper leg, and a non-fluctuating mass near the right eighth rib, parasternally. Additional diagnostic investigation revealed an infectious cause: respectively Mycobacterium tuberculosis, Bartonella henselae and Salmonella typhi. Antimicrobial therapy was successful. Subcutaneous masses suspected of being a benign or malignant tumour are sometimes caused by an infection. The differential diagnosis is extensive. Sometimes the travel anamnesis yields helpful information. It is concluded that besides histopathological examination, microbiological investigation can play a major role in the evaluation of subcutaneous masses.

[Persistent fever of unknown origin in two young infants caused by the atypical form of Kawasaki disease]. / Aanhoudend onbegrepen koorts bij twee zuigelingen door de atypische vorm van de ziekte van Kawasaki.

Two previously healthy infants, a boy and a girl aged 3 and 4 months, respectively, were admitted for fever of unknown origin with laboratory results indicating an inflammation. The boy presented with vomiting, pyuria, anaemia, and thrombocytosis. The girl presented with irritability, erythema and diarrhoea. All viral and bacterial cultures remained negative and supplementary radiology was unable to detect a focus of infection. The fever had persisted for at least 12 days in both cases before the diagnosis 'atypical Kawasaki disease' was considered. Cardiac echograms showed dilatation of the coronary arteries in both patients and confirmed the diagnosis. Immediate therapy with intravenous immunoglobulins and acetylsalicylic acid was given, whereupon the fever subsided within 24 hours; the further clinical course was uneventful. These cases illustrate the fact that atypical Kawasaki disease is often a late consideration, especially when the symptoms of the classical form are absent. This condition should be considered in every infant presenting with long-lasting unexplained fever.