Intrathoracic gossypiboma: radiographic and CT findings.

Intrathoracic gossypiboma, a retained surgical sponge in the thoracic cavity, is a rare but serious consequence following surgery. Because of its rare occurrence and non-specific clinical and radiographic presentations, the diagnosis is often missed. Herein we report a patient presenting with a chronic recurrent cough due to a retained surgical sponge in the pleural cavity. The patient has been misdiagnosed with bronchiectasis for 22 years. The characteristic spongiform appearance on CT and a history of previous thoracic surgery led to the diagnosis of a gossypiboma that was confirmed at surgery.

Fibromuscular dysplasia: a rare cause of cilioretinal artery occlusion in childhood.

OBJECTIVE: To report a case of cilioretinal artery occlusion with angiographic findings characteristic of the "string of beads" associated with renovascular hypertension secondary to fibromuscular dysplasia of the renal artery in a child. DESIGN: Case report. INTERVENTION: The patient underwent ex vivo renal artery reconstruction with saphenous vein graft and reimplantation. MAIN OUTCOME MEASURES: The main clinical outcomes were control of severe hypertension, reversible hypertensive retinopathy, and improvement of vision. RESULTS: Revascularization of the kidney improved renal function, and renovascular hypertension was clearly improved. Visual acuity improved to 20/200. CONCLUSIONS: A child with hypertensive retinopathy and arterial occlusion in the retina should undergo investigation to rule out a surgically curable hypertension. Magnetic resonance angiography of extrarenal vessels may reveal other sites of involvement of fibromuscular dysplasia. Evaluation and early diagnosis of renovascular hypertension will prevent severe end-organ damage.

Inhibition of atherosclerosis by dietary pectin in microswine with sustained hypercholesterolemia.

Sustained hypercholesterolemia is a known risk factor for development of atherosclerosis. In animal studies, grapefruit pectin fed concurrently with a high-lipid diet inhibits hypercholesterolemia and atherogenesis. The purpose of the present study was to determine if grapefruit pectin affects cholesterol levels and atherogenesis of animals with established hypercholesterolemia. Microswine were fed an atherogenic diet to establish hypercholesterolemia. Plasma cholesterol levels rose rapidly and for 360 days were sustained at levels 6- to 12-fold the normal level. Then, half the microswine, selected at random, were fed a diet in which 3% grapefruit pectin was substituted for cellulose, and the remaining animals received the original diet. Animals were killed 270 days later, and the extent of atherosclerosis was determined. In animals with established hypercholesterolemia, pectin did not lower their cholesterol levels. However, pectin reduced the extent of atherosclerosis in both the aorta and coronary arteries. The mean surface area covered by atherosclerosis in the aorta was 13.6% in the group that did not receive pectin compared with 5.3% in the group that did receive pectin. The mean coronary artery narrowing was 45% without pectin and 24% with pectin. We conclude that pectin may have a direct beneficial effect on atherosclerosis by a mechanism independent of cholesterol levels.

Origin of cells in the coronary intima during acute vascular rejection of the transplanted human heart.

Acute vascular rejection of the coronary arteries in human heart transplants is characterized by a lymphocytic infiltrate and a thickened intima that contains numerous highly vacuolated cells. The origin of the vacuolated cells has been controversial. In this immunocytochemical and electron microscopic study of four patients with acute vascular rejection, the predominant cells in the coronary artery intima were host-derived lymphocytes and highly vacuolated smooth muscle cells. Lymphocytic infiltrates were composed of T cells with variable numbers of B cells. Macrophages were infrequent. Smooth muscle cells were identified by their reactivity to muscle-specific actin and ultrastructural features of a peripherally displaced elongated nucleus associated with abundant myofibrils. In addition, the vacuolated cells did not react with endothelial factor 8-related antigen or Ulex europaeus agglutinin, as would be expected of endothelial cells. The cytoplasmic vacuoles present in the smooth muscle cells appear to be swollen endoplasmic reticulum containing watery fluid consistent with the hypothesis that they result from altered ion movement across the plasma membrane in response to cellular injury.

Endomyocardial biopsy: a review of its current role and usefulness.

Endomyocardial biopsy via transvascular technique is safe. It shows a wide range of clinical applications. The fresh endomyocardial tissue thus obtained is very helpful for further research in the field of cardiac pathology. It facilitates almost all sophisticated techniques that need fresh and viable cells. Results of the study are relevant and mostly clinically useful. However, application of this technique to the study of heart diseases in Thai people is still limited. This may be partly due to excessive patient fear according to the general belief that the heart is the utmost important part of life. Other possible explanations include the doubt about the safety of this procedure and the benefit that they will receive. Then, any misunderstanding should be corrected and this technique should be encouraged when clinically indicated.

Acute vascular rejection of the coronary arteries in human heart transplantation: pathology and correlations with immunosuppression and cytomegalovirus infection.

Prior studies of vascular rejection in transplanted human hearts have stressed the importance of accelerated coronary arteriosclerosis (chronic vascular rejection). We, however, have had four patients with sudden onset of acute heart failure within 90 days of transplantation who have died without significant myocardial interstitial rejection or the concentric intimal thickening with dense collagen that is typical of chronic vascular rejection. In contrast, the coronary arteries in our patients had a prominent lymphocytic infiltrate, a loosely organized intimal thickening composed of smooth muscle cells, and extensive endothelial injury. We believe that these changes define acute vascular rejection of the coronary artery. In 14 transplanted hearts obtained consecutively, at autopsy or at a second transplant procedure, graft failure was caused by acute coronary vascular rejection in six cases and by chronic coronary vascular rejection in one case. The remaining seven patients showed no evidence of vascular rejection and died primarily of sepsis. Cytomegalovirus (CMV) disease was present in 6 of 7 patients with vascular rejection, of which 43% were CMV-negative recipients of hearts from CMV-positive donors. The adoption of a triple-drug protocol, in which azathioprine was added to cyclosporine and prednisone, reduced the incidence of acute vascular rejection from 27% to 8%. We conclude that acute coronary vascular rejection may be initially seen as global cardiac ischemia in the absence of significant interstitial myocardial rejection. Further, acute vascular rejection should be pathologically distinguished from chronic vascular rejection, although both are probably stages in the natural history of immune-mediated vascular injury.

Human pythiosis associated with thalassemia hemoglobinopathy syndrome.

Pythium infection (pythiosis) in humans has not previously been described, even in areas endemic for animal pythiosis. We report five patients with a unique presentation of fungal arteritis. The medium- to large-sized arteries were involved, and in some cases this involvement led to gangrene of the limbs, aneurysm formation, and ultimately fatal arterial leakage. All five patients were farmers. All patients, with the possible exception of one who had hemoglobin typing performed after receiving a blood transfusion, had thalassemia hemoglobinopathy syndrome. Fungal isolation was difficult. Amphotericin B treatment seemed to be ineffective. Radical surgical removal of infected tissues and oral administration of a saturated solution of potassium iodide are proposed therapy. In the tropics, where Pythium is ubiquitous, one should actively look for this fungal infection in patients with unexplained arterial occlusion, especially in the case of patients with thalassemia hemoglobinopathy syndrome.