[Purulent lymphadenitis after peritonsillar abscess under immunosuppression. An often forgotten differential diagnosis]. / Eitrige Lymphadenitis nach Abszesstonsillektomie bei Immunsuppression. Eine oft vergessene Differenzialdiagnose.

In the present case study, a 75-year-old, immunosuppressed man presented with recurrent cervical abscesses after a peritonsillar abscess. In the cervical region, an ulcer developed with persistent wound healing deficit. Subsequently, the patient's general condition deteriorated, showing symptoms of a Landouzy sepsis. In the course of the examination, Mycobacteria tuberculosis was detected in the cervical ulcer. He suffered from latent tuberculosis, which was reactivated by a combination of his disease, immunosuppressive therapy and the preceding peritonsillar abscess. Upon treatment with tuberculostatics, the patient fully recovered.

[A 17-year-old student with therapy-resistant pneumonia]. / Siebzehnjährige Schülerin mit therapieresistenter Pneumonie.

If empiric antibiotic treatment is not successful in a case of suspected pneumonia further investigations are required. We present a case where originally an intralobar, bronchopulmonary sequestration could clearly be diagnosed by a thoracic CT scan. A 3D reconstruction revealed the pathognomonic arterial supply from the thoracic aorta and the venous drainage via pulmonary vein to the left atrium. Therefore, elective resection of the sequestration was indicated.

Long-term experience in percutaneous transluminal dilatation of renal artery stenosis.

Percutaneous transluminal dilatation was attempted in 65 patients with renovascular hypertension. In five cases (8 percent), percutaneous transluminal dilatation could not be performed for technical reasons. In the remaining 60 patients (35 with atherosclerotic stenosis and 25 with fibromuscular dysplasia), both mean systolic and diastolic pressure fell immediately after percutaneous transluminal dilatation and remained significantly lower for a period of up to five years. Cure rates after a mean control period of 21.6 months were higher in patients with fibromuscular dysplasia (50 percent) than in those with atherosclerotic stenosis (29 percent). Improvement of blood pressure was observed in 32 percent of patients with fibromuscular dysplasia and in 48 percent of patients with atherosclerotic stenosis. Follow-up angiography in 33 cases showed occlusion of the dilated artery in two patients and recurrence of slight renal artery stenosis in nine patients. Successful redilatation could be performed in five of these cases. Furthermore, renal vein renin determinations were only of limited diagnostic or prognostic value. These results document the good long-term effect of percutaneous transluminal dilatation in patients with renal artery stenosis. Percutaneous transluminal dilatation should, therefore, be the favored procedure in patients with renovascular hypertension.

Problem cases in renovascular hypertension.

The clinical course and response to therapy of 16 patients with various complex forms of renovascular hypertension were investigated. Reconstructive surgery and/or transluminal dilatation was either ineffective (n = 5) or could not be performed for technical reasons (n = 11). The group contained 7 patients with multilocular fibromuscular disease involving both renal arteries, two cases with multiple arteriosclerotic vascular occlusions, 3 patients with branch renal artery aneurysms, 3 with renal artery stenosis in a solitary kidney and one patient with renal artery stenosis and contraction of the contralateral kidney due to a non-vascular cause. With antihypertensive treatment, particularly with the angiotensin converting enzyme inhibitor captopril (n = 7), blood pressure could be reduced from 214 +/- 40/124 +/- 23 mm Hg to 145 +/- 23/88 +/- 9 mm Hg (P less than 0.001). In 11 of the 16 patients (69%) the values decreased to less than 160/95 mm Hg. These results suggest that, in complex forms of renovascular hypertension, antihypertensive treatment may be a potent therapeutic alternative if surgery and/or transluminal dilatation can not be performed or seem to have too high a risk.

Renal venous renin activity in various forms of curable renal hypertension.

The diagnostic and predictive value of renal venous renin determinations was investigated in 73 patients who had various forms of hypertension associated with unilateral renal disease and who were operated upon. Patients with fibromuscular hyperplasia showed a markedly higher cure rate than cases with arteriosclerotic renal artery stenosis (64% vs. 25%) and were less frequently not improved (4% vs. 12%). Patients with unilateral (non-vascular) small kidney and patients with unilateral hydronephrosis showed comparable high cure rates (53% and 50%, respectively), whereas in no patient with a unilateral renal cyst did postoperative blood pressure return to normal. In the present study no statistically significant correlation was found between postoperative pressure reduction and PRA-ratios in either the whole group of patients or in the various subgroups. A negative PRA-ratio (less than or equal to 1.4) was found in 36% of all cured patients. In particular, cured patients with fibromuscular hyperplasia showed a high percentage (38%) of falsely negative tests. As expected, characteristic differences were observed in simple clinical data between cured and improved patients. Patients with normal postoperative blood pressure were significantly young (34.7 +/- 13.6 years) than improved cases (47.3 +/- 10.8 years; P less than 0.001) and cured patients showed lower preoperative blood pressure values (192 +/- 29/119 +/- 15) than improved ones (214 +/- 31/126 +/-117 mm Hg). Thus our results document a limited prognostic value of renal venous renin determination in patients with hypertension due to unilateral renal disease.

Systemic vasculitis associated with seronegative spondylarthropathy (Reiter's syndrome).

A first case of Reiter's syndrome developing a severe systemic necrotising vasculitis is reported. After a disease course with major complications, aggressive consistent immuno-suppressive treatment was successful.

The neglected time factor and antihypertensive therapy. A pitfall in evaluating side effects in a cross-over study.

The aim of this study was to examine the influence of a time factor that may lead to inaccurate interpretation of data on the incidence of side effects in a double-blind study with drug cross-over. After a washout period, 58 patients with essential hypertension received either 20 mg of enalapril or 50 mg of atenolol. After two weeks, the dosage was doubled (to 40 mg of enalapril and 100 mg of atenolol) in those patients with diastolic blood pressure higher than 95 mm Hg. After four weeks of active treatment and a second two-week washout period, patients received the alternative antihypertensive agent under the same procedure and time schedule as in the first treatment phase. Four patients dropped out. Side effects were evaluated by questionnaire at weeks 2, 4, 8, and 10. In the 54 patients who completed the study, enalapril and atenolol led to almost identical blood pressure reduction in both treatment phases, indicating that pooling these data is a sound method. However, incidence of side effects was twice as high in phase 1 as in phase 2 and markedly decreased in each treatment phase, with no differences being observed between enalapril and atenolol. These results clearly demonstrate that pooling side effects data from a cross-over study may lead to quite wrong interpretations.

[Febrile state, headache and arthralgia]. / Status febrilis, Kopf- und Gliederschmerzen.

A 38-year-old man was admitted to the hospital with complaints of persistent fever up to 40 degrees C, arthralgias, headache and a nonproductive cough. The white-cell count was within the normal range but was markedly shifted to the left and demonstrated toxic granulations. Sonographic examination of the abdomen revealed a slight enlargement of the spleen. A nonspecific reactive hepatitis which was clinically asymptomatic was detected by laboratory evaluation. Diagnosis of an acute Q fever was made by demonstration of antibodies against C. burnetii. Following therapy with doxycycline, the patient became afebrile within 48 hours.

[Development of dementia]. / Dementielle Entwicklung.

A 67-year old male patient was admitted to our clinic because of slowly developing dementia. Severe dysfunction of memory, confusional states and urinary incontinence were observed. A diagnosis of general paresis was made by positive serology for syphilis and CSF examination. The patient's condition improved markedly after high-dose penicillin G treatment.

[Thoracic pain]. / Thoraxschmerz.

A 28-year-old male patient was admitted to our outpatient clinic because of severe chest pain. Past history, ECG and laboratory findings revealed an anterior myocardial infarction and rhabdomyolysis after cocaine consumption. Coronary arteriography performed six days after the infarction showed no significant stenoses. In view of these findings a coronary vasospasm due to cocaine was postulated. Cocaine effects are discussed.

[Diminished vision, loss of libido, headache]. / Visuseinschränkung, Libidoverlust, Kopfschmerzen.

A 34-year old patient was diagnosed to suffer from a carcinoma of the pituitary gland. A developing panhypopituitarism was seen first and the complete extirpation of a chromophobe, non-secreting adenoma of the pituitary gland was preliminary not successful. During half a year the patient relapsed clinically and morphologically by scanning methods and the progression of the malignancy of the tumor from WHO grad (adenoma) to WHO grad III (carcinoma) was histologically confirmed.

[Maculopapular rash, pruritus, upper abdominal pain, attacks of dizziness]. / Makulopapulöse Effloreszenzen, Pruritus, Oberbauchschmerzen, Schwindelattacken.

A 48 year old male patient presented with maculopapular rash, pruritus, peptic ulcer disease and attacks of headache and vertigo. Rubbing of the cutaneous lesions led to urticarial whealing which is indicative of abnormal mast cell proliferation in the cutis. Histologic evidence of abnormal mast cell proliferation in biopsy specimens of skin and bone marrow led to the diagnosis of systemic mastocytosis. Treatment with H1 and H2 receptor antagonists was started.

[Fish oil: clinical application possibilities]. / Fischöl: klinische Anwendungsmöglichkeiten.

Current interest in fish-oil stems in part from epidemiologic evidence gathered in eskimos. Due to a high proportion of fish in their diet eskimos have a low incidence in cardiovascular mortality. The active principle in fish-diet are n-3-fatty acids. These modulate prostaglandin and leukotriene metabolism. Numerous studies have been undertaken to demonstrate clinical usefulness. Current interests focus on lipid lowering, inhibition of hemostasis and antihypertensive actions. Furthermore antiinflammatory and immunologic effects as well as uses in oncology are discussed.

[Acute abdomen]. / Akutes Abdomen.

A 28-year-old turkish patient was admitted to hospital several times within the last years because of acute abdominal and thoracic pain. On each admission laboratory parameters indicative of an acute inflammatory process were initially found to be slightly increased; however, the cause for the complaints remained undetected. During a recent episode of acute abdominal pain a short increase of these laboratory parameters (particularly of CRP) could be documented, and since no other diagnostic sign indicative of an other disease was found, familial mediterranean fever was diagnosed. A basic therapy with colchicine was initiated, and since five months the patient remained mostly free of symptoms.

[Thoracic pain, dyspnea]. / Thoraxschmerzen, Dyspnoe.

A 54-year old patient was admitted to the hospital with chest pain, dyspnea and left-sided pleural effusion, which was confirmed by a radiograph of the chest. In view of an exposure to asbestosis a CT scan of the chest was performed, which showed pleural thickening. The suspected diagnosis of a malignant mesothelioma was confirmed by needle biopsy of a paraaortic lymph node. Because of the existence of metastases a palliative pleurectomy was performed. Histologically a malignant mesothelioma of the biphasic type was found. The patient died less than half a year later from local progression of the tumor.

[Effect of a follow-up action in diet instruction]. / Effekt einer Nachkontrollaktion in einer Diätsprechstunde.

Efficacy of diet-counseling was analyzed in 349 adipose patients, (140 men and 209 women.) The patients were guided in a specialized consultation service by diet-assistants. A daily caloric intake of 1200 calories was usually recommended. Mean observation time was 14.6 months in women, 15.4 months in men. After completion all patients were invited for a single check-up. 72.9% of the men and 81.4% of the women participated. Mean weight reduction during counseling amounted to 6.7 kg for men (n = 127) and 4.8 kg for women (n = 191). Blood pressure fell from 145/95 to 130/90 in men and from 140/92 to 135/88 in women. At the time of the follow-up visit a further reduction in body weight and blood pressure was noted in both sexes. Analysis of further factors disclosed a better performance of non-smokers vs. smokers and a higher frequency of consultations demanded by women. Treatment by diet-consulting is thus effective and its success persists after termination of the guidance by the diet assistant. A drop-out rate of 25% has to be accepted.

[Nutrition and hypertension: what are the goals?]. / Ernährung und Hypertonie: Was ist erreichbar?

The dependence of blood pressure on nutritional factors is reviewed in the light of possible therapeutic consequences. Salt restriction, increased administration of potassium, restriction of alcohol intake, weight loss and prescription of fish-oil are discussed by review of own and published data. All these measures may contribute to a reduction of hypertension although to a variable extent. They should be envisaged as therapeutic alternatives to drugs in mild hypertension.

[Visceral leishmaniasis as an opportunistic infection. Case report and literature review]. / Die viszerale Leishmaniose als opportunistische Infektion. Kasuistik und Literaturübersicht.

With increasing numbers of immunocompromised patients a rise in the incidence of visceral leishmaniasis has to be expected. Presenting a case of visceral leishmaniasis in an HIV-infected patient and reviewing the literature, we discuss general aspects of this parasitic disease and special features of it as an opportunistic infection.

[HIV infection, fever and cholestasis]. / HIV-Infektion, Fieber und Cholestase.

A 35-year-old Swiss woman with AIDS experienced fever, jaundice and cough. Laboratory evaluation revealed signs of an infection and cholestasis. The examination by ultrasound showed thickening of the intra- and extrahepatic bile ducts and gallbladder wall, without dilatation or stones. Endoscopic retrograde cholangiography demonstrated diffuse sclerosing cholangitis like lesions in the biliary tract and confirmed the diagnosis of a HIV related cholangiopathy. The cause was a cytomegalovirus infection as shown by liver biopsy with detection of cytomegalovirus early antigen. The treatment with ganciclovir was of some efficacy with improvement of jaundice.

[Leg pain, dyspnea]. / Beinschmerzen, Dyspnoe.

A 59 year old patient with leg pain and dyspnea was hospitalized for suspected deep venous thrombosis and pulmonary embolism. The clinical, scintigraphic and radiological findings confirmed the diagnosis. Immediate therapy with heparin and oral warfarin resulted in an improvement of pain and dyspnea within a few days. The strategy for diagnostic evaluation of patients with suspected pulmonary thromboembolism is discussed.