Abdominal placement of tube thoracostomy due to lack of recognition of paralysis of hemidiaphragm.

Tube thoracostomy is an invasive procedure that carries a risk of complications. We report a patient with liver cirrhosis, ascites and large left-sided pleural effusion, in whom a trocar type chest tube was inserted at the seventh left intercostal space in the midaxillary line. Chest roentgenogram revealed that the drainage tube was placed into the abdominal cavity because of a misrecognized elevation of the left hemidiaphragm. This case demonstrates that the placement of a tube thoracostomy requires caution in the identification of possible abnormalities which can lead to dangerous complications.

[Still's disease in adults: diagnostic problems]. / Malattia di Still dell'adulto: problemi diagnostici.

Still's disease is a seronegative arthritis of children which, in a limited number of cases, can affect adults. The diagnosis of adult-onset Still's disease is characterized by high fever, arthritis and negative serologic tests for rheumatoid factor and antinuclear antibodies and by at least two minor symptoms (leukocytosis, evanescent rash, serositis, hepato- or splenomegaly, and lympho-adenopathy). Since many diseases present analogous manifestations and the adult-onset Still's disease is generally diagnosed by exclusion, we report two patients, aged 26 and 39, with Still's disease, the former with a classic clinical feature, the latter with a clinical feature characterized by severe hepatic abnormalities. The determination of histocompatibility antigens can be useful because some of them (HLA-DR4 in case 1 and HLA-DRw6 in case 2) are frequently associated with the adult-onset Still's disease. The role of anti-inflammatory therapy (acetylsalicylic acid, indomethacin, steroids) must be emphasized, whose efficacy can constitute the pathognomonic element on which the diagnosis of adult-onset Still's disease can be based in a proper clinical pattern.

[Naloxone and naltrexone in the therapy of advanced COPD]. / Naloxone e naltrexone nella terapia della BPCO in fase avanzata.

We report a patient with COPD and bullous emphysema treated with narcotic antagonists (naloxone and naltrexone) for severe respiratory failure, with hypoxemia and hypercapnia, non responding to traditional medical therapy. According to previous reports, this treatment was started while waiting for lung transplantation, and it improved clinical pattern and arterial blood gas levels. Though the patient died for left ventricular failure fifteen days after the beginning of therapy, we think that narcotic antagonists can be successfully administered in some patients with advanced stage COPD.

[EDTA-induced pseudothrombocytopenia]. / Pseudotrombocitopenia da EDTA.

EDTA-induced pseudothrombocytopenia is a laboratory artifact caused in vitro by platelet aggregation, due to IgG or IgM class antibodies reacting with antigenic binding site of the GP IIb glycoprotein. Pseudothrombocytopenia is rarely found (about 1% of platelets counts), but must be considered in the differential diagnosis of thrombocytopenia, since it could lead to useless investigations and therapies. We report three patients with pseudothrombocytopenia, one of whom underwent bone marrow biopsy and danazol treatment, before establishing the correct diagnosis. The absence of hemorrhagic manifestations with persisting low platelets counts led to a re-examination of peripheral blood smear and to the diagnosis of pseudothrombocytopenia. Therefore a morphological platelets evaluation and their count on citrate-anticoagulated blood must be performed in every patient under assessment for thrombocytopenia.

Chylous pleural effusion in tuberous sclerosis.

We report on a male patient with tuberous sclerosis (adenoma sebaceum and digital fibromas, renal angiomyolipomas and subependymal brain calcifications), who presented with chylothorax. Chest CT scan did not show pulmonary parenchymal alterations, but only a moderate enlargement of the paracaval mediastinal lymph nodes. Tuberous sclerosis with lung involvement presents clinical, radiologic and pathologic manifestations similar to those of lymphangioleiomyomatosis. The pulmonary manifestations of tuberous sclerosis and lymphangioleiomyomatosis have been observed almost exclusively in women, and it has been suggested that they represent opposite ends of a spectrum of presentations of the same entity. Based on these considerations the formation of a chylothorax in a male with tuberous sclerosis constitutes an extremely rare finding.

Central diabetes insipidus due to acute monocytic leukemia: case report and review of the literature.

We describe a 69-year-old man who presented with a four-month history of polyuria and polydipsia. Plasma vasopressin levels were undetectable, and a dehydration test was abnormal. Based on these findings, a diagnosis of central diabetes insipidus has been established. Hematologic studies showed acute monocytic leukemia. A relationship between the hematologic and endocrine disturbance has been hypothesized, and histological examination at autopsy showed leukemic infiltration of the pituitary stalk. This patient represents the third case in the world literature of central diabetes insipidus associated with acute monocytic leukemia.