Delayed ANCA positivity in pulmonary-renal syndrome.

A 57-year-old man was admitted due to rapidly progressive renal failure and pulmonary edema. Chest X-ray showed a bilateral lung infiltrate, while a normal myocardial contractility was reported by echocardiography. Though initially ANCA were absent, a necrotizing vasculitis with polymorphonuclear leukocyte infiltrate was observed in a kidney biopsy specimen. Renal histology was compatible with microscopic polyangiitis because of necrotizing lesions located at small vessels and at glomeruli that were not crescentic. Corticosteroids and immunosuppressive treatment was played with significant clinical improvement. Six months later, the patient died of a gastrointestinal hemorrhage due to bowel perforation by vasculitic lesion. This time high p-ANCA positivity was detected and at renal histology crescentic glomeruli were observed.

A case of Sweet's syndrome associated with monoclonal immunoglobulin of IgG-lambada type and p-ANCA positivity.

We report a case of Sweet's syndrome associated with monoclonal gammopathy of uncertain significance (MGUS) and positivity for perinuclear antineutrophil cytoplasmic antibodies (p-ANCA). A 65-year-old man patient came to our hospital complaining of remittent-intermittent fever, weight loss, associated with papules affecting all his body and without mucosal or ocular involvement. Histology of biopsy specimens of papules allowed the diagnosis of Sweet's syndrome. This is the first case of this rare syndrome associated both with MGUS and p-ANCA positivity. The monoclonal immunoglobulin, possibly directed to neutrophils like an antibody, may cause both their fragmentation and release of antigens responsible of p-ANCA appearance.

An unusual case, in Italy, of hepatocarcinoma characterized by portal hypertension and absence of cirrhosis.

We report a case of a 40-year-old man of Bantu origin, affected by both HBV infection and primitive hepatocarcinoma in the absence of cirrhosis. The fine-needle aspiration specimen reported a rare variant of liver cancer resembling an adenocarcinoma. The neoplasm was certainly a hepatic primitive carcinoma, because chest X-ray, cranial computed tomography, colonoscopy, and abdominal computed tomography did not detect neoplastic lesions and alpha-fetoprotein was > 1000 ng/mL. The present neoplasm, characterized by severe portal hypertension and absence of cirrhosis, is rare in Italy, but largely diffused in Bantu people in Africa.

Synchronous gastric adenocarcinoma and MALT lymphoma in a patient with H. pylori infection. Could the two neoplasms share a common pathogenesis?

Low-grade primary MALT (mucosa-associated lymphoid tissue) lymphoma of the stomach is a neoplasm with an indolent course and a good prognosis. Patients with this type of neoplasm seem to have a higher risk for other neoplasms. Of interest is the association of gastric MALT lymphoma with gastric adenocarcinoma of intestinal type. We report the case of a patient, with a history of H. pylori-related gastritis, in whom a diagnosis of synchronous gastric adenocarcinoma of intestinal type and low-grade MALT lymphoma, occurring as collision tumors, was made. The stage procedures confirmed the presence of a locally advanced gastric tumor staged as T3 N1. The patient underwent two cycles of neoadjuvant EEP (etoposide, epirubicin, cisplatin) chemotherapy. After 2 months, a R0 total gastrectomy with D2-lymphoadenectomy was successfully performed. The development of simultaneous primary gastric lymphoma and carcinoma is a rare event. The possible coexistence of both tumors should be kept in mind, especially in patients infected with H. pylori, since a possible etiopathogenetic role of this bacterium has been differently postulated for both disease.

An apparent idiopathic case of relapsing acute pancreatitis.

We describe a case of relapsing acute pancreatitis apparently idiopathic in a 55-year-old man. The patient did not smoke and was a modest and irregular drinker of wine. Endoscopic retrograde cholangiopancreatography showed an initial dilatation of secondary ducts like a chronic pancreatitis of class I of Cremer. Ultrasound and computed tomography resulted negative for pancreatic lesions. In the follow-up however, magnetic resonance cholangiopancreatography detected the presence of an intraductal mucin-hypersecreting neoplasm, a duct-ectatic mucinous cystic tumor of the pancreas, in the uncinate process. This is a benign lesion clearly recognized nowadays by magnetic resonance cholangiopancreatography, because this radiological technique shows the grape-like clusters of cystic lesions in secondary ducts communicating with the main duct on the same plane. The radiological picture above excludes a malignant lesion and a biopsy specimen is not required. Furthermore, an intraductal mucin-hypersecreting neoplasm of the pancreas does not require an immediate surgical resection because of its slow evolution and can be followed-up. Conversely cystoadenocarcinoma spreads in peripheral ducts and does not communicate with the Wirsung duct. It requires both surgical resection and a biopsy specimen for histological diagnosis. In the last episode of acute pancreatitis, a sphincterotomy was performed at endoscopic retrograde cholangiopancreatography and our patient had no more pain for one year.

[The nurse's role in the identification and management of alcohol abuser in the Emergency Department]. / Ruolo dell'infermiere nell'identificazione e gestione del paziente con abuso alcolico nel dipartimento di emergenza.

The emergency department (ED) nurse plays a major role both in recognizing and in the management of the patients affected by alcohol related problems, such-as acute alcohol intoxication (AAI), alcohol withdrawal (AW), traumatic or spontaneous illness due to acute or chronic effects of alcohol abuse. Here are described both the clinical problems and the diagnostic instruments that nurse can use in ED to increase diagnostic sensibility. Furthermore both clinical features of AAI in relation with blood alcohol concentration (BAC), diagnostic criteria and test to evaluate AW severity are reported in this review. Even diagnostic instruments to identify alcohol abuse also in trauma are reported: the alcohol breath test, BAC and laboratory test. Even the Alcohol Use Disorders Identification Test (A.U.D.I.T.) questionnaire is reported to recognize the alcohol abuser. In conclusion acquiring a specific training, nurse can play a major role in the complex intervention net of alcoholics rehabilitation.

Hypertension in early alcohol withdrawal in chronic alcoholics.

AIMS: Hypertension is an established risk factor in chronic alcoholics, but little is known about the relationship between blood pressure (BP), severity of their alcohol abuse, and severity of alcohol withdrawal syndrome (AWS). METHOD: BP was assessed daily for 18 days in a series of chronic alcoholics on early alcohol withdrawal (AW), while also assessing the severity of their AWS on the CIWA-Ar scale. RESULTS: A sharp and sustained decrease in BP was observed after AW; at T0, BP had increased in 55% of patients, and at T18 in 21%. The variation of BP is partially explained by years of at-risk drinking and AWS severity, but other factors may play a role in hypertension in alcoholics, as a large amount of BP variation was not explained by the alcohol-abuse-related parameters that we studied. BP values were not correlated with cigarette smoking, anxiety, or depression. Hypertension found in 'detoxified' alcoholics (approximately 20%) may be related to alcohol-independent hypertension or to a long-lasting alcohol-induced derangement of the BP regulating mechanisms. Further research is needed in these patients to elucidate the mechanisms of persistent hypertension and to set up a treatment protocol. At present, careful monitoring is advisable, as well as pharmacological treatment for moderate or severe hypertension; often a modification of life-style is needed which includes physical activity and possibly sodium (Na) restriction, since hypertension in detoxified alcoholics seems to be Na sensitive. CONCLUSION: Complete alcohol abstinence must be recommended to all hypertensive alcoholics, as AW-induced transient hypertension was found to be harmless in all our subjects, and abstinence leads to a complete recovery from hypertension in most cases.

Resolution of syndrome X after eradication of virulent CagA-positive Helicobacter pylori.

A 42-year-old man with chest pain was found to have ST depression in leads V1 through V4. The coronary arteries appeared normal on angiography. Positive results of ventricular pacing and acetylcholine test led to a diagnosis of syndrome X. Other studies revealed gastritis due to CagA-positive Helicobacter pylori. Classic therapy for angina did not resolve chest pain, but eradication of H. pylori led to disappearance of symptoms and negative test results.

No evidence of Helicobacter pylori sequences in pancreatic juices of patients affected by chronic pancreatitis.

BACKGROUND: The course of chronic pancreatitis is often unpredictable and many factors are likely to be involved in the progression of the disease. In physiological condition, pancreatic juice exerts significant antibacterial activity, which is impaired in patients with chronic pancreatitis. AIM: Hypothesizing that Helicobacter pylori could, in these conditions, lead to an ascending infection, we aimed to assess the presence of H. pylori sequences in pancreatic juices of patients with chronic pancreatitis. METHODS: 40 patients (mean age 52+/-3 yr) with alcoholic chronic pancreatitis and H. pylori infection were examined. Pancreatic juices were collected during endoscopic retrograde cholangiopancreatography. Using polymerase chain reaction (PCR) with two primers homologous to a portion of urease-C gene, H. pylori DNA was detected. Gastric biopsies, microscopically positive to H. pylori were used as positive controls. RESULTS: All gastric biopsies produced H. pylori-specific DNA products. Conversely, no H. pylori urease-C gene sequences have been detected in any of the pancreatic juices. CONCLUSION: Our data suggest that the impaired antibacterial activity of pancreatic juices in patients affected by chronic pancreatitis does not have a permissive role for a superimposing H. pylori infection in the pancreas. The possibility that Helicobacter species other than pylori may be involved in a superimposing infection requires further investigation.

A case of severe hypertension caused by ACTH-independent macronodular adrenal hyperplasia.

This report describes a rare case of ACTH-independent macronodular adrenal hyperplasia (AIMAH) arisen with symptomatic severe hypertension and hypokaliemia. A 55-year-old man was admitted to hospital with a clinical picture characterized by several episodes of transient ischemic attacks (TIA) and right hemiplegia, related to severe arterial hypertension. Laboratory tests showed urinary levels of catecholamines, metanephrines and vanillylmandelic acid (VMA) in normal range; high urinary free cortisol excretion, elevated serum cortisol with loss of the circadian rhythm and low ACTH plasma levels. ACTH failed to respond to CRH administration. Serum cortisol levels were not modified after high doses of dexamethasone. MRI showed bilateral macronodular hyperplasia of adrenal glands, whereas pituitary-MRI did not show tumoral lesions. Therefore, ACTH-independent macronodular hyperplasia was suspected. Though obese, the patient had no typical Cushing habit, and symptomatic hypertension with hypokaliemia was the only clinical evidence for this rare kind of Cushing's syndrome. After obtaining a satisfactory control of blood pressure, the patient was successfully submitted to laparoscopic bilateral adrenalectomy and underwent complete clinical remission. The histology showed adrenal macronodular hyperplasia. During the twenty-four month follow-up, the patient had no further transient ischemic attacks or need of glucocorticoid replacement therapy and withdrew the antihypertensive drugs.