Pseudoepitheliomatous keratotic and micaceous balanitis treated with topical 5-fluorouracil and liquid nitrogen.

Pseudoepitheliomatous keratotic and micaceous balanitis (PKMB) is an uncommon premalignant condition involving the glans penis. We report the case of an 86-year-old man who presented with phimosis and pain on retracting his foreskin. He had previously undergone circumcision, which revealed a hyperkeratotic plaque with thin mica-like scales involving his glans penis. Histology of the lesion showed hyperkeratosis, parakeratosis, epidermal acanthosis and papillomatosis with no evidence of dysplasia. Immunohistochemistry for human papillomavirus was negative. The patient was treated with topical 5-fluorouracil and liquid nitrogen with clinical improvement. He is now under long-term surveillance for verrucous carcinoma and squamous cell carcinoma.

Manganese does not alter the severe neurotoxicity of MPTP.

We utilized a mice model of Parkinsonism: (1) to evaluate 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-induced neurotoxicity; and (2) to evaluate whether manganese (Mn) exposure can affect MPTP-induced neurotoxicity. A 2 x 3 experimental design (MPTP x+/- Mn) was as follows: SS, MPTP(-) x Mn(-); SLMn, MPTP(-) x low Mn(+); SHMn, MPTP(-) x high Mn(+); MpS, MPTP(+) x Mn(-); MpLMn, MPTP(+) x low Mn(+); MpHMn, MPTP(+) x high Mn(+). We administered MPTP (30 mg/kg per day) to male C57BL/6 mice intraperitoneally, once a day for 5 days. Subsequently, mice were treated with either 2 or 8 mg/kg of MnCl(2).4H(2)O intraperitoneally, once a day for 3 weeks. Blood and striatal Mn levels were elevated in the Mnexposed groups. The number of tyrosine hydroxylase (TH)-immunoreactive (ir) neurons in the substantia nigra pars compacta were decreased significantly in the MPTP-exposed groups. The densities of TH-ir axon terminals in caudate-putamen (CPU) were significantly decreased in the MPTP-treated groups. However, Mn treatment did not affect MPTP neurotoxicity. The densities of glial fibrillary acidic protein (GFAP)-ir astrocytes in the CPU or globus pallidus were significantly increased in the MPTP-treated groups. Concentrations of dopamine in the striatum were decreased significantly in the MPTP-exposed groups only, but Mn had no effect.

Non-steroidal anti-inflammatory drugs, Helicobacter pylori and bleeding gastric ulcer.

BACKGROUND: Helicobacter pylori infection and NSAID usage are considered to be independent risk factors for gastric ulcer (GU). Whether they interact to influence the risk of bleeding in GU is unclear. AIM: To determine the prevalence of H. pylori infection and NSAID ingestion in a group of patients with GU and determine their roles in bleeding and non-bleeding GU. METHODS AND RESULTS: From January 1993 to June 1996, a total of 217 GU patients (150 male, 67 female, median age 61 years, range 26-94) were eligible for the study. Eighty-five per cent were H. pylori-positive and 15% were H. pylori-negative. NSAID usage within 4 weeks prior to endoscopy was present in 30%, more in the H. pylori-negative than H. pylori-positive patients (59% vs. 25% P = 0.0002). Aspirin was most commonly used (43%). One hundred patients bled from GU (69 male, 31 female, mean age 67 years, range 26-94) and 117 did not (81 male, 36 female, mean age 57 years, range 28-86). Univariate logistic regression showed that advanced age (>/= 65 years) and NSAID usage carried an increased risk of bleeding GU (odds ratio 3.4 and 6.8, respectively) while H. pylori infection alone was not associated with additional risk (OR = 0.8). However, when three variables were considered jointly in a multiple logistic regression, the OR associated with H. pylori infection increased to 2.4, suggesting that in the presence of NSAIDs and advanced age, H. pylori also increases the risk of bleeding GU, indicating an interaction between the variables. CONCLUSION: NSAID usage and advanced age are risk factors for bleeding GU, whereas H. pylori infection by itself is not. In the presence of NSAIDs and advanced age, an increased risk of bleeding GU with H. pylori is observed, indicating the possibility of an interaction between these factors.

Nodular skin tuberculosis with lymphatic spread--a case report.

An unusual case of tuberculosis paronychia with skin infection of the big toe was recently seen in a patient returning from Kalimantan. This was complicated by inguinal lymphadenitis and tuberculosis abscess formation. The diagnosis was made on culture of the pus from the abscess and upon biopsy and histological examination of the skin lesion from the toe. The patient responded to surgical treatment and chemotherapy with ethambutol, rifampicin and isoniazid.

Autogenous osteochondral morselised grafts for full thickness osteochondral defects in the knee joints of pigs.

The aim of this study is to firstly ascertain the survival of autogenously grafted morselised cartilage for full thickness osteochondral defects in knee joints of pigs. Secondly, it is to determine the quality of the grafted cartilage that survives and to score to it based on a recognised and tested system of indices and thirdly, to recognise, if any, the potential for reconstitution of the osteochondral junction. Two groups of five pigs were followed up for six and 12 weeks. Similar osteochondral defects were created in the medial condyles of both knees with the right medial femoral condyle defect filled with graft and the left used as control and filled with gel foam. At the end of the study period, an independent pathologist assessed the defects macroscopically and microscopically with an accepted and comparable histological scoring system. Macroscopically, there was better filling of the defect and restoration of bony contour in the grafted group compared to the control. Microscopically, at six weeks, filling of the defect, nature of predominant tissue, matrix staining and nature of cells all showed significantly better histological score than the control using the Mann-Whitney U test at the level of significance of p<0.05. At 12 weeks, in addition to the above, the reconstitution of osteochondral junction also showed a significantly better score. Comparing the test groups at six and 12 weeks, the reconstitution of the osteochondral junction was significantly better at 12 weeks. In conclusion, the autogenous osteochondral morselised graft persisted as mature hyaline cartilage with good histological score at six weeks with significantly better reconstitution of osteochondral junction occurring at 12 weeks. The use of morselised graft allows for the inclusion of bone graft which possibly allows for larger amounts of donor tissue and thus the possibility of treating larger defects. In the human model the donor site would be the non-weight bearing surfaces of the knee such as the intercondylar notch as described by Walgenbach A and Stone KR at the 1997 Annual Meeting of the American Academy of Orthopaedic Surgeons in San Francisco.

A case of cavitating pneumonia in AIDS.

Tuberculosis is a common cause of cavitating pneumonia in Singapore. In patients with the human immunodeficiency virus (HIV), cavitary pneumonias mimicking tuberculosis can mislead the clinician, delaying diagnosis, resulting in increased morbidity. We describe a HIV seropositive patient with cavitating pneumonia in whom the diagnosis of Pneumocystis carinii pneumonia (PCP) was ultimately established only on bronchoscopy.

PIP: In February 1991, a 30-year old single, Chinese male, who had not has sexual intercourse with another man but did have it with a woman while in another country 12 months earlier, sought medical care at Tan Tock Seng Hospital in Singapore. He had a productive cough for 3 months, lost 5 kg over 4 months, and had been gasping for breath for 3 days. Upon admission, he had a low grade fever and breathed very rapidly while resting. The apical segment of the right lower lobe of the lung had a 3 x 2 cm cavity which was filling with exudate. A sputum smear did not indicate acid fast bacilli in 2 of 3 samples and blood cultures did not yield aerobic or anaerobic bacteria. The Western blot test revealed HIV antibodies. The absolute CD4 lymphocyte count stood at 80/cu mm compared with more than 500/cm mm in healthy individuals. Physicians used a bronchoscope to do bronchoalveolar lavage (BAL) and transbronchial lung biopsy (TBLB), both of which disclosed cysts of Pneumocystis carinii. Treatment first consisted of trimethoprim/sulfamethoxazole for 7 days and antituberculosis chemotherapy for 2 weeks until the physicians realized he had Pneumocystis carinii. They switched the treatment to iv pentamidine isethionate because he still had a fever after 7 days. This treatment was successful. Physicians then administered Zidovudine (AZT) and aerosolized pentamidine each month. As of mid-1992 he was still healthy. In addition to the BAL/TBLB results indicating Pneumocystis carinii and excluding tuberculosis, other features excluding tuberculosis were a Mantoux reading of O, absence of hilar and/or mediastinal lymphadenopathy, response to pentamidine isethionate, and sputum and blood cultures that did not indicate Mycobacterium species.

A case of Bizarre Parosteal Osteochondromatous Proliferation of the hand.

We report a case of Bizarre Parosteal Osteochondromatous Proliferation (BPOP) of the hand that was initially misdiagnosed as an osteochondroma. BPOP, although a benign lesion, behaves aggressively with rapid growth and high risk of local recurrence after local resection. The distinguishing features of BPOP as opposed to an osteochondroma are discussed.

Recurrence of Helicobacter pylori infection and duodenal ulcer relapse, following successful eradication in an urban east Asian population.

We aimed to determine the rate of Helicobacter pylori (HP) recurrence and duodenal ulcer relapse in patients of a hospital in Singapore over a period of at least one year from the time of eradication. Ninety-six consecutive duodenal ulcer patients with biopsy-proven HP eradication and healed ulcer were seen at 3-month intervals, and follow-up endoscopy was performed when dyspepsia recurred, at the end of one year after eradication, or at the time of recall if the patient had been lost to follow-up. HP status was determined by antral and corpus biopsies and by antral cultures. Sixty-five had been given triple therapy, and 31 received dual therapy with omeprazole + amoxycillin or clarythromycin. Median time to follow-up endoscopy was 12 months. Six patients (6.25%) were positive for HP infection after eradication. Recurrence of HP infection was detected at 9 and 10 months after confirmation of HP eradication in two patients, and at between 13 and 20 months in the remaining four. Two of these had recurrent duodenal ulcer; all but one had erosive duodenitis. Two other patients had recurrent duodenal ulcer despite absence of HP reinfection; they admitted to taking low-dose aspirin. It was concluded that the recurrence of HP infection is low at the end of one year after successful eradication therapy in this urban East Asian population. Ulcer relapse occurred in 4.17% (4/96) of patients, and was associated with recurrent HP infection or NSAID exposure.

Massive bleeding per rectum from a caecal pregnancy.

An unusual case of massive bleeding per rectum caused by erosion into the caecum of placental tissue from an ectopic pregnancy is presented. Despite its rarity, abdominal pregnancies may have to be considered in sexually active fertile women presenting with difficult torrential bleeding from the lower gastrointestinal tract.

Two case reports of metastases from colon carcinoma to the thyroid.

INTRODUCTION: Secondary malignancy of the thyroid gland is uncommon, but it is a problem requiring ongoing recognition. As it is more common than primary thyroid malignancy, metastatic disease involving the thyroid gland should be actively excluded in a patient with enlarging or abnormal thyroid gland and a previously known primary tumour. CLINICAL PICTURE: We report 2 cases of primary colon carcinoma with metastasis to the thyroid gland that mimicked thyroid anaplastic carcinoma. In both cases, airway compromise was evident. TREATMENT AND OUTCOME: Emergency tracheostomy was necessary in the first case with subsequent oxaliplatin-based chemotherapy providing palliation of symptom of breathlessness, with significant reduction in size of thyroidal metastasis. Palliative thyroidectomy relieved airway compromise in the second case. CONCLUSION: Our case report highlights the importance of early recognition of thyroidal metastases from a colonic primary as life-threatening airway compromise may otherwise rapidly ensue.

Adenocarcinoma associated with chronic anal fistula.

Adenocarcinoma in association with chronic anal fistula is a rare disease entity with a male preponderence in most reported series. The patient typically presents with a long history of perianal disease. Diagnosis is often delayed because of failure to obtain biopsy evidence of the condition. A chronic anal fistula may become malignant. However, despite delay in diagnosis, complete removal which usually entails abdominoperineal resections with wide excision of perianal skin and ischiorectal fossa is necessary to achieve good results. We relate our experience with two such rare cases and a literature review on the current views on the relationship between adenocarcinoma and the occurrence of anal fistula is presented.

Non-functioning cyst of the adrenal gland--a case report.

Adrenal cysts are a rare entity. Only about 300 cases have been reported throughout the world. A case of an asymptomatic, benign, non-functioning adrenal cyst of the left adrenal gland is presented. Pre-operative diagnosis is usually by incidental imaging findings as the majority of adrenal cysts are asymptomatic. The adrenal cyst in this case was detected on an abdominal ultrasound for the investigation of jaundice, and confirmed by a CT scan examination. Selective biochemical studies are needed to assess adrenal function, and here they were normal. Simple surgical enucleation of the cyst, with preservation of remaining adrenal tissue is the treatment of choice.

Gastric ulceration with acute bleeding from tuberculosis of the stomach--a case report.

Tuberculosis of the stomach is a rarity. Its diagnosis is difficult as it is often unsuspected or unrecognised. This is a case report of an elderly man who presented with active upper gastrointestinal tract bleeding. The diagnosis was made postoperatively following gastrectomy for bleeding gastric ulcers. The histological specimens showed caseating epithelioid granulomas with Langerhan's giant cells centrally. The authors reviewed the recent literature on tuberculosis of the stomach, and suggest ways to identify the patients at risk.

Calcifying epithelioma of Malherbe--a case report of a large preauricular tumour.

Calcifying epithelioma of Malherbe (pilomatrixoma) is a relatively uncommon benign skin tumour of hair follicle origin. It usually presents in the face and upper extremities of young adults as an asymptomatic subcutaneous or dermal tumour. Treatment is surgical excision. This paper presents a case of a large tumour in the preauricular region with difficulty in diagnosis preoperatively and required a superficial parotidectomy to clear the tumour from the facial nerve.

Systemic lupus erythematosus with erythema multiforme-like lesions and histiocytic necrotizing lymphadenitis--a case report.

A 9-year-old Chinese girl with systemic lupus erythematosus presented initially with persistent cervical lymphadenopathy without any constitutional symptoms. The histology of the involved lymph node showed histiocytic necrotizing lymphadenitis and the initial clinical diagnosis of Kikuchi-Fujimoto disease was made. The patient subsequently developed fever, oral ulcerations, epistaxis, generalised myalgia and erythema multiforme-like skin lesions over the face and upper arms. Investigations showed anaemia, leucopenia, hypocomplementemia, a positive antinuclear antibody and a positive anti-double-stranded DNA antibody test. The clinical diagnosis was revised to systemic lupus erythematosus. The histological picture of histiocytic necrotizing lymphadenitis can occur in systemic lupus erythematosus and may be indistinguishable from that seen in Kikuchi-Fujimoto disease. The diagnosis of Kikuchi-Fujimoto disease should be confined to a benign clinical subset of histiocytic necrotizing lymphadenitis which resolves spontaneously without treatment. The occurrence of erythema multiforme-like lesions in lupus erythematosus is unusual and together with the characteristic serologic abnormalities, fits Rowell's syndrome.

Actinomycosis of the brain.

Actinomyces species are rare but treatable causes of central nervous system infection. A case of actinomycotic cerebral abscess is reported. The primary source of infection was probably the lung based on radiological findings although culture of the bronchial brushings was negative. The patient had surgical excision and repeated drainage with two prolonged causes of antibiotic therapy. At follow-up examination 36 months later, the patient was well except for a residual left hemiplegia. Diagnosis of cerebral actinomycosis can be made by anaerobic culture of the appropriate specimens or on histologic grounds. Optimal management combines adequate surgical drainage and prolonged antibiotic therapy.

A retrospective study of melanocytic naevi at the National Skin Centre.

INTRODUCTION: A retrospective study of melanocytic naevi was undertaken to assess the degree of clinico-pathological correlation and incidence of histological atypia. MATERIALS AND METHODS: The case records from January to March 1996 of all patients with histologically diagnosed melanocytic naevi at the National Skin Centre were analysed. RESULTS: Of the 240 lesions removed from 167 patients, the majority being women (111/167 patients), it was found that 55% (132/240) were correctly diagnosed. Fourteen per cent were mistaken for non-melanocytic lesions, namely skin tag, neurofibroma, syringoma cylindroma, epidermal naevus, naevus sebaceous and basal cell carcinoma. Most of the lesions were located on the cheeks and eyelids. Junctional naevi, followed by compound naevi were often missed. Histological dysplasia were seen in 7 naevi; 6 compound and 1 congenital naevi. There was a lack of clinico-pathological concordance in dysplastic naevi. CONCLUSIONS: The clinico-pathological concordance of melanocytic naevi was high, with low incidence of atypia on histology.

Chondrosarcoma of the spine--report of two cases.

Chondrosarcoma arising from the spine is a rare malignant tumour, associated with a poor outlook due to inadequate excision in the majority of the cases. We report two cases arising from the cervical and the thoracic spine. Both survived 15 and eight years respectively. This condition carries with it a grave prognosis because of its proximity to the vital structures, making complete extirpation of the tumour frequently difficult if not impossible. Recent developments and progress in adjuvant radiation therapy has improved the prognosis significantly.

Paraganglioma with pulmonary metastases: a case report.

Distant metastases due to paraganglioma are a rare occurrence. We report a case of paraganglioma with pulmonary metastases and review the literature on paragangliomas. A 29-year-old female presented with cervical lymphadenopathy, excision biopsy of which confirmed the diagnosis of paraganglioma. She subsequently underwent tumour embolisation and received a course of radiotherapy. Seven years later, she was investigated for multiple pulmonary nodules noted on her chest roentgenogram. Histology of the wedge excision of the lung showed metastatic paraganglioma. Increased catecholamine production was documented; this was however not associated with symptoms of catecholamine excess. Reports concerning the treatment of paragangliomas with pulmonary metastases are few, given their rarity.

The results of autogenous tibial periosteal transplants for full thickness cartilage defects in the knee joints of pigs.

An experimental study was conducted to demonstrate macroscopic and microscopic healing of full thickness cartilage defects with mature stable hyaline cartilage after autogenous tibial periosteal transplants in the knee joints of pigs. Similar full thickness osteochondral defects were created in the medial femoral condyles of both knees in 10 healthy young adult pigs. Periosteal transplants were performed on the left knees and the right knees used as controls. The pigs were sacrified in two groups at 6 weeks and 3 months. The knees were inspected for healing and stability of the graft. Microscopic sections were taken and evaluated using a histological score developed by O'Driscoll. Macroscopically, almost all defects with periosteal grafts healed with a translucent bluish-white colour indicating articular cartilage formation. There was good restoration of the bony contour and filling of the defects were superior to controls. Histologically, we were able to demonstrate immature hyaline cartilage which matured at 3 months. The newly formed tissue was stable and well-incorporated. It had almost complete bonding to the adjacent articular margin, good reconstitution of the osteochondral junction and a well maintained structural integrity. We concluded that periosteal transplants in the knee of a pig model healed with mature stable hyaline cartilage.