Unrecognized malaria and its consequences--a case report of severe malaria with acute renal failure.

Severe malaria is a medical emergency that requires urgent recognition and treatment, because it may rapidly progress to serious complications and death. We report a case of imported severe malaria tropica in an adult traveller, with a parasitemia of 20%, complicated by acute renal failure. Patient was initially misdiagnosed by a physician unaware of the importance of patients travel history, as having a viral infection. Despite the treatment delay, the patient was successfully cured with parenteral artemether combined with peroral mefloquine and vigorous supportive measures including renal replacement therapy.

Tumor necrosis factor receptor-associated periodic fever syndrome in a 58-year-old man: caution not to discount TRAPS as a diagnosis in older patients.

Tumor necrosis factor receptor-associated periodic fever syndrome (TRAPS) is a rare systemic autoinflammatory disorder characterized by recurrent episodes of fever and localized inflammation of different organs. The disease is dominantly inherited, with an onset usually in early childhood. We describe a case of a 58-year-old patient with TRAPS caused by the low-penetrance R92Q mutation in TNFRSF1A gene. The patient responded well to anti-tumor necrosis factor α therapy. Although periodic fever syndromes, including TRAPS, mainly begin in early childhood, it is important to consider periodic fever syndrome also in patient presenting at an age older than the average reported case for TRAPS.

Isolated atherosclerotic aneurysm of the profunda femoris artery.

True aneurysms of the profunda femoris artery are extremely rare in comparison to pseudoaneurysms of the same artery. In most cases they are accompanied by aneurysms of the abdominal aorta or peripheral vessels. The most common reason for aneurysmic dilatation of vessels is a generalized vascular degenerative process. An isolated true aneurysm of the profunda femoris artery due to atherosclerosis is markedly unusual. These aneurysms have a high incidence of complication; therefore surgical management is mandatory for all diagnosed cases regardless of whether they are symptomatic or not. We describe a case of a 73-year-old man with a large isolated atherosclerotic aneurysm of the profunda femoris artery. He presented with an enlarging, progressively debilitating mass in his upper thigh. Ultrasound and computed tomography-angiography demonstrated a 15 x 14 cm large aneurysm of the profunda femoris artery. The patient was successfully treated by aneurysm neck ligation and sac decompression.

Cytomegalovirus reactivation after low-dose steroid treatment for hemolytic anemia in a patient with primary Epstein-Barr virus infection.

Cytomegalovirus reactivation is a well described event occurring after intensive therapeutic suppression of the immune function in patients with latent infection. Treatment protocols for suppression of the immune response often include high-dose steroids. However, it is not known whether even a low-dose steroid treatment can reactivate latent cytomegalovirus in otherwise healthy persons. We documented cytomegalovirus reactivation after low-dose steroid treatment for autoimmune hemolytic anemia as a complication of Epstein-Barr virus mononucleosis in an immunocompetent 21-year-old man.

The human cytomegalovirus UL78 gene is highly conserved among clinical isolates, but is dispensable for replication in fibroblasts and a renal artery organ-culture system.

The human cytomegalovirus (HCMV) UL78 ORF is considered to encode a seven-transmembrane receptor. However, neither the gene nor the UL78 protein has been characterized so far. The objective of this study was to investigate the UL78 gene and to clarify whether it is essential for replication. UL78 transcription was activated early after infection, was inhibited by cycloheximide but not by phosphonoacetic acid, and resulted in a 1.7 kb mRNA. Later in the replication cycle, a second mRNA of 4 kb evolved, comprising the UL77 and UL78 ORFs. The 5' end of the UL78 mRNA initiated 48 bp upstream of the translation start and the polyadenylated tail started 268 bp downstream of the UL78 translation stop codon within the UL79 ORF. By using bacterial artificial chromosome technology, a recombinant HCMV lacking most of the UL78 coding region was constructed. Successful reconstitution of the UL78-deficient virus proved that the gene was not essential for virus replication in fibroblasts. The deletion also did not reduce virus replication in ex vivo-cultured sections of human renal arteries. Analysis of viral proteins at different stages of the replication cycle confirmed these results. Among clinical HCMV isolates, the predicted UL78 protein was highly conserved. However, an accumulation of different single mutations could be found in the N-terminal region and at the very end of the C terminus. Due to the absence of an in vivo HCMV model, the role of UL78 in the pathogenesis of HCMV infection in humans remains unclear.

Efficacy of pefloxacin in the treatment of patients with acute infectious diarrhoea.

OBJECTIVE: To investigate the clinical and bacteriological efficacy of 5- and 7-day pefloxacin therapy in patients with acute infectious diarrhoea. PATIENTS AND STUDY DESIGN: Eighty-two adult patients with acute infectious diarrhoea were randomly divided into three groups: group 1 (n = 20) received 5 days of treatment with pefloxacin, group 2 (n = 27) was assigned to a 7-day pefloxacin protocol, and group 3 (n = 35) was treated symptomatically. The daily dose of pefloxacin was 400mg orally. Clinical and bacteriological response was analysed on the third, fifth and seventh days of treatment as well as 1 and 4 weeks after the end of treatment. The study was an open-labelled, prospective clinical trial. RESULTS: In the 47 patients (100%) of both pefloxacin groups a clinical improvement was noted on the third day compared with the control group, where this occurred on day 7. Bacteriological eradication was verified on the fifth day in 18 patients (90%) from group 1 and in 25 patients (93%) from group 2; they all had negative stool cultures 1 and 4 weeks after therapy was completed. Only 22 patients (63%) in the control group had negative stool cultures on the seventh day of treatment, but 4 weeks later all of them were negative. CONCLUSION: There was no difference in clinical (p = 0.232) and bacteriological (p = 0.972) efficacy between the 5- and 7-day pefloxacin treatment protocols. However, both protocols differed significantly in clinical improvement (p < 0.001) and bacteriological eradication (p = 0.017) from the control group.

Inflamed urachal cyst containing calculi in an adult.

The urachus is an embryonic structure that persists after birth in some individuals and can cause various problems. We report a case of an inflamed urachal cyst filled with a thick yellow fluid and several calculi in a woman with a 1-month history of dysuria. Physical examination revealed a fist-sized tumor located infraumbically in the midline. The patient's erythrocyte sedimentation rate was elevated; the results of all other routine laboratory studies were normal. Sonography showed a regularly shaped, ovoid, hypoechoic cystic area in the abdominal wall measuring 8 x 4 x 3 cm and containing several hyperechoic masses associated with acoustic shadowing. The wall of the cyst was inhomogeneous, and a thin hypoechoic linear tract linked the superior aspect of the mass to the umbilicus. The results of excretory urography, voiding cystography, and cystoscopy excluded an abnormality of the urinary system. A urachal cyst was diagnosed, and the mass was surgically removed. The surgical specimen was sent for histopathologic analysis, which confirmed the diagnosis.

Modified range of alanine aminotransferase is insufficient for screening of hepatitis C virus infection in hemodialysis patients.

OBJECTIVE: A moderate increase in serum alanine aminotransferase (ALT) has been reported to be a helpful, low-cost tool for predicting viremia in anti-hepatitis C virus (HCV)-positive hemodialysis (HD) patients. This study focused on evaluating the effectiveness of a lowered normal serum ALT value as a screening method for HCV infection in HD patients. MATERIAL AND METHODS: Serum ALT levels were compared with HCV virologic status in 125 patients on maintenance HD. RESULTS: The prevalence of HCV antibodies was 23%. A total of 3.7% of viremic HD patients did not have a detectable antibody response. Using the conventional upper limit of normal for ALT of 37 IU, there was no significant difference in the frequency of elevated ALT levels between HCV RNA-positive and-negative patients. However, if the upper limit of normal for ALT was lowered to 27 IU, the difference was significant. Nevertheless, 60% of viremic patients still fell within the normal range. CONCLUSION: Although inexpensive and widely available, the monitoring of serum ALT levels is not useful as a screening method for HCV infection in HD patients.