Disseminated fungal infection due to Saprochaete clavata in a kidney transplant recipient.

Saprochaete clavata and Saprochaete capitata are closely related fungal species (family Dipodascaceae, order Saccharomycetales) that are rarely involved in the etiology of systemic infections in humans. In recent years, these yeasts are emerging as cause of life-threatening infections in patients with severe neutropenia and haematological malignancies. Infections by these fungi have been reported mostly from Mediterranean countries. To the best of our knowledge, only 2 cases of infection due to S. capitata have been reported in solid organ transplant recipients and none due to S. clavata. Herein we report a fatal case of S. clavata disseminated infection occurring in a patient with recent kidney transplantation and severe neutropenia. Patient was receiving antifungal echinocandin prophylaxis and the yeast was isolated from the blood and multiple non contiguous sites. Saprochaete spp. should be considered in the differential diagnosis of invasive mycoses in transplant recipients, especially if they are neutropenic and living or travelling in Mediterranean countries.

Activated recombinant factor VII in orthotopic liver transplantation.

UNLABELLED: Orthotopic liver transplantation (OLT) is affected by important alterations of hemostasis. The aim of this study was to evaluate the efficacy of recombinant factor VII activated (rFVIIa) to reduce intraoperative bleeding during OLT. METHODS: Twenty OLT patients were assigned in double-blind way to a rFVIIa group or a control group. Inclusion criteria were hemoglobin > 8 g/dL: INR > 1,5 and fibrinogen > 100 mg/dL. We administered a single bouls of rFVIIa (40 microg/kg) or placebo. We determined INR, partial thromboplastin time, fibrinogen, ATIII, and blood cell counts. Blood products were administered as follows: 4 units of fresh frozen plasma when INR > 1.5, and 1 unit of RBC for Hb < 10 g/dL. The study ended 6 hours after the bolus. RESULTS: No thromboembolic events occurred. The INR was different between rFVIIa group and the controls at T0 (1.9 vs 1.6 P < .021) and during T1 (1.2 vs 1.6 P < .004). The total transfused red blood cells was 300 mL +/- 133 in rFVIIa group and 570 mL +/- 111 in control group (P < .017). The total fresh frozen plasma was 600 mL +/- 154 in rFVIIa group and 1400 mL +/- 187 in control group (P < .001). Total blood loss was greater in the control group than the rFVIIa group: 1140 mL +/- 112 vs 740 mL +/- 131 (P < .049). DISCUSSION: The use of rFVIIa during OLT can reduce the risk of bleeding during surgery. The literature has described cases who did not benefit from the treatment. An adequate cut-off of INR, allowed us to treat only patients at greater bleeding risk.

Modifications of intracranial pressure after molecular adsorbent recirculating system treatment in patients with acute liver failure: case reports.

UNLABELLED: Cerebral dysfunction may be fatal in patients with acute liver failure (ALF); intracranial pressure (ICP) monitoring may be mandatory to direct measures to prevent further cerebral edema. Recently the introduction of dialysis with the molecular adsorbent recirculating system (MARS) has improved the outcomes among patients with ALF. The aim of this study was to evaluate ICP changes after MARS treatment among patients with ALF. METHODS: Three patients -- 14, 18 and 16 years old -- were admitted to the ICU for acute liver failure induced by HBV in two cases and by acetaminophen in the other one. Because of Glasgow Coma Score (GCS) <8, they were intubated and ventilated to protect the airway and maintain moderate hypocapnia. Invasive monitoring of intracranial pressure MARS treatments were performed in all patients. RESULTS: The patients received MARS treatments every day after their admission to liver transplantation. After MARS therapy the ICP decreased on average from 21 to 7 mm Hg. Significant hemodynamic modifications were not observed and their neurological conditions improved. CONCLUSION: MARS treatment improved the clinical pictures of these patients increasing the available time to obtain an urgent liver graft.

Clinical effects of direct hemoperfusion using a polymyxin-B immobilized column in solid organ transplanted patients with signs of severe sepsis and septic shock. A pilot study.

BACKGROUND: Polymyxin B (PMX-B) is a polycationic antibiotic, known to bind the lipid A portion of endotoxin, a cell wall component found exclusively in gram negative bacteria (GNB). An extracorporeal hemoperfusion device (TORAYMYXIN) has been developed: PMX is covalently bound on the surface of an insoluble carrier material so that the endotoxin can be inactivated in the blood without exerting its toxicity on the brain and kidney. The aim of this study was to clarify the efficacy, safety and clinical effects of direct hemoperfusion with an immobilized polymyxin-B fiber column (DHP-PMX) in solid organ transplanted patients with severe sepsis or septic shock. METHODS: From June 2004 to May 2005, 15 patients (10 men and 5 women), mean age 55 years old (46-65 range), underwent kidney or liver transplantation and developed severe sepsis or septic shock, as defined by the Consensus Conference of American College Physicians/Society of Critical Care Medicine (ACCP/SCCM) criteria. GNB were detected in all the patients receiving conventional treatments including antibiotic therapy, vasopressive or inotropic agents, and ventilation support. The DHP-PMX treatment was performed three times in each patient. Hemodynamic and respiratory parameters, dosage of vasopressor/inotropic drugs were assessed at baseline and after each treatment. RESULTS: No adverse events occurred. From baseline to 3rd treatment, mean arterial pressure (MAP) was increased (from 63+/-5 to 83+/-4 mmHg), while the dosage of dobutamine (from 7.5+/-3 to 3+/-2 mcg/kg/min) and noradrenaline (from 1.3+/-0.45 to 0.05+/-0.02 mcg/kg/min) were reduced. The PaO2/FiO2 ratio increased (from 234+/-38.47 to 290+/-107.48 mmHg). CONCLUSION: The use of DHP-PMX in association with conventional therapy may be an important aid in patients with sepsis.

Extracorporeal circulation with low systemic heparinization during lung transplantation.

BACKGROUND: Some lung transplantation (LT) recipients suffer from pulmonary hypertension and right ventricular dysfunction or failure requiring extracorporeal circulation (ECC) to avoid catastrophic complications during surgery. The extracorporeal support usually requires systemic heparinization which is potentially associated with important side effects. We performed eight LT using preheparinized ECC circuits and an oxygenator associated with a lower level of systemic heparinization without evidence of perioperative complications. PATIENTS AND METHODS: From May 2002 to May 2005, 8 patients (5 men and 3 women) of mean age 22.5 +/- 9.5 years underwent bilateral sequential lung transplantation (BSLT) for cystic fibrosis (n = 6) or idiopathic pulmonary fibrosis (n = 2). All procedures were performed with ECC through a femoro-femoral veno-arterial bypass with preheparinized circuits and an oxygenator. RESULTS: No intraoperative mortality occurred. The mean ECC time was 147.8 +/- 31.3 minutes and the mean heparin administered was 3525 +/- 969.16 UI. No coagulopathy or thrombotic events were observed perioperatively. CONCLUSIONS: Our study confirmed the efficacy and safety of prehepanized circuits and oxygenator for femoro-femoral veno-arterial bypass during LT for patients with severe pulmonary hypertension requiring ECC.

Presurgical integrated MRI/SPECT localization of the sensorimotor cortex in a patient with a low-grade astrocytoma in the rolandic area.

We describe the case of a young man who, despite the presence of a tumour in the left sensorimotor cortex, exhibited no motor deficit. Integrated MRI/SPECT-CBF study during motor activation was aimed at determining which cerebral areas were involved in movement execution in this patient and their relationship with the tumour. CBF changes during motor activation were located in two motor areas: anteriorly and medially to the tumour in the left frontal lobe (+29%) and in the right medial frontal cortex (+43%). Integrated MRI/SPECT images provided both an anatomical and functional definition of the motor areas in a patient with a rolandic tumour and could prove useful in determining preoperatively an appropriate surgical strategy.

Recurrent chromosomal aberrations in peripheral T-cell lymphoma.

Histological, immunological, and cytogenetic analysis of the same neoplastic tissues have been performed on seven patients with peripheral T-cell lymphomas (PTCL). Clonal chromosomal abnormalities in five cases are reported. The most common chromosomal aberration, observed in four patients, is a rearrangement of chromosome 14 with a breakpoint in q11.2. Aberrations of chromosome 8 also occurred in four patients, three of whom had an extra 8q. The data indicate that breakpoints of malignant diseases affecting similar cell types might cluster to specific chromosomal regions, which can be helpful in recognition and classification of PTCL.

Cytogenetics of pediatric central nervous system tumors.

A cytogenetic analysis was performed on short-term cultures of 43 previously untreated childhood central nervous system neoplasms of various histology. The cells were obtained from pediatric patients, none of whom had received therapy before karyotypic evaluation. Successful chromosome studies were performed on 24 tumors. The most commonly detected structural abnormalities involved chromosomes 1 and 17. Other structural chromosome abnormalities involved chromosomes 3, 6, 8, 9, 11, 12, and 20.

Prognosis of the so-called "diffuse" cerebellar astrocytoma.

The term "diffuse cerebellar astrocytoma" was originally introduced by Russell and Rubinstein to describe that minority of cerebellar tumors microscopically similar to the cerebral hemispheric astrocytoma. The aim of this study was to verify some recent reports warning against the less favorable long term prognosis of the "diffuse" form of the cerebellar astrocytoma. We reviewed our series of cerebellar astrocytomas in children and collected 49 cases operated on before 1966 (i.e., with a follow-up ranging from a minimum of 15 years to 29 years). In addition, we reexamined all recurrent cerebellar astrocytomas observed during a 30-year period, looking for the eventual occurrence of the "diffuse" form. In the first group, 10 cases (20%) were classified as "diffuse" and 39 cases (80%) were classified as "classic". However, in 3 cases largely featuring a diffuse pattern, we also noted some areas of the classic type. These two subgroups showed no significant differences in patient sex and age, the incidence of macrocysts, the surgical technique used, the eventual x-ray therapy, and the long term functional results (P greater than 0.05). When we studied recurrent tumors that were reoperated on, we did not find any case showing histologically the "diffuse" pattern. To conclude, we cannot agree with the pessimism about the ominous long term prognosis of the diffuse cerebellar astrocytoma. In our opinion, the so-called diffuse cerebellar astrocytoma does not exist as a separate clinicopathological entity.

Congenital extradural cyst of the orbital optic nerve: case report.

A rare congenital arachnoid cyst of the orbital optic nerve affecting a 5-year-old boy is described and the relevant literature is reviewed. On the basis of the macro- and microscopic features of the reported case, an analogy is suggested between the observed optic nerve cyst and the extradural arachnoid cyst of the spinal canal. Moreover, the hypotheses put forward to explain the pathogenesis of spinal extradural arachnoid cysts may also account for the exceptional appearance of a similar cyst in the orbital portion of the optic nerve.

Supratentorial ependymomas of the first two decades of life. Long-term follow-up of 20 cases (including two subependymomas).

In order to better elucidate the lesser known aspects of the biological behavior and prognosis of supratentorial ependymomas in children and young adults, we studied a series of 20 patients, ages 1 to 20 years. The tumor site was extraventricular in 14 cases and intraventricular in 6 (including one third ventricle tumor). Histologically, according to World Health Organization criteria, there were 12 ependymomas (E), 2 subependymomas (SE), and 6 malignant ependymomas (ME). Of the 18 patients surviving surgery, 12 (66.6%) are alive and disease free 63 to 252 months (mean, 146 mo) after the operation; 9 harbored an E, 2 had an SE and 1 had an ME. Four patients are now out of risk of recurrence according to Collin's law. Six of the long-term survivors (50%), four E and two SE, did not receive postoperative radiotherapy. However, two patients with E, initially treated by surgery alone, had a recurrence and one subsequently died. Two ME patients showed signs of spinal metastases after subsequent operation for recurrence and shortly before death. Considering the partially good results as well as failures after surgery alone in our and in other series and the risks of irradiating the child's brain, we tried to elucidate in what cases radiotherapy could be reasonably withheld, or alternatively, when prophylactic craniospinal irradiation should be prescribed. The main conclusions of our study are the following: 1) Radical surgery alone is a reasonable option as the initial treatment for lateral ventricle tumors and for solid extraventricular tumors located far from eloquent brain areas, provided the histology is benign, especially if of the SE type.(ABSTRACT TRUNCATED AT 250 WORDS)

Histologically benign recurrent meningioma metastasizing to the parotid gland: case report and review of the literature.

This report presents a very rare case of metastatic meningioma of the parotid gland from a recurring intracranial lesion. The primary tumor, intracranial residues, and parotid metastasis were histologically benign. Meningiomas rarely metastasize; even rarer are cases in which both the primary and the secondary tumors have benign histological characteristics. The 11 cases reported in the literature have been critically reviewed. The case we present is noteworthy also for the exceptional localization of the metastasis in the parotid gland.

Aphasia in polyglots: report of two cases and analysis of the literature.

Two cases of aphasia in polyglot patients who experienced different symptoms in each of the languages they knew are reported. The authors discuss the problem and analyze the available literature in an attempt to formulate a pathogenetic hypothesis of the different involvement of the known idioms sometimes observed in aphasic polyglots. In particular, when time has elapsed between the learning of the mother tongue and other languages, and all the known languages are, consequently, functionally independent, it is possible that the two or more known idioms have distinct anatomical representations, probably localized separately in the two hemispheres. This could explain why, in some polyglots, aphasia affects one of the known languages preferentially. In subjects in whom the different known idioms were learned during early childhood, the anatomical representation of the languages is similar, which explains why, in this kind of polyglot, all the known languages can be equally affected by cerebral damage that causes aphasia.

Cerebral oligodendroglioma: prognostic factors and life history.

The records of 137 patients with supratentorial oligodendroglioma treated surgically between 1953 and 1986 were reviewed. The tumors were rated histologically benign or malignant. In the 105 patients followed up with a minimum observation time of 5 years to December 1991, the mean postoperative survival was 90.2 months (standard error, 9), the median 64 months (standard error, 9.6), the 5-year survival rate 52.4%, and the 10-year survival rate 24%. Sixteen possible prognostic factors, broken down into two or more variables each, were considered in the survival study on univariate methods (5-year survival rate, survival curves, and Cox's hazard function) and on multivariate analysis according to Cox's stepwise proportional hazards model. The latter showed that variables correlated positively with survival were benign histological findings (P, 0.000), postoperative radiation therapy (P, 0.004), and time of operation from 1977 to 1986 (P, 0.044) in 105 patients of the whole series, and period of surgery from 1977 to 1986 (P, 0.000), subtotal or total surgical resection of the tumor (P, 0.001), and radiation therapy (P, 0.005) in the subgroup of 79 patients operated on for benign tumors. However, the most interesting point to emerge from the study was the relevance of admission clinical status to the survival of patients who did not receive radiation therapy and to the prognostic response of those who did. Of the 40 patients with seizures and negative neurological status--Clinical Syndrome A--the 10 who did not receive radiation therapy had survived as long as the 30 who did (5-year survival rate, 80 versus 67%; P, not significant; median survival, 122 versus 85 months; Breslow and Mantel-Cox P, not significant), whereas of the 65 patients with intracranial hypertension and/or neurological deficits--Clinical Syndrome non-A--the 18 who did not receive radiation therapy had short survival times, and the 47 who did fared significantly better (5-year survival rate, 11 versus 53%; P, 0.002; median survival, 32 versus 64 months; Breslow and Mantel-Cox P, 0.000). These findings were not significantly affected by the exclusion of malignant neoplasms and in the group of benign tumors, in which the histological characteristics have not been found to be significantly different between those with A and those with non-A clinical syndrome, did not depend on different frequencies of subtotal or total tumor removal.(ABSTRACT TRUNCATED AT 400 WORDS)

Intradural extramedullary cavernous angioma: case report.

Cavernous angiomas represent 5 to 12% of spinal vascular malformations and usually are located at the vertebral body level with possible extension into the extradural space. The intradural intramedullary cavernoma occurs in about 3% of cases, whereas extramedullary localization is extremely rare. A new case of an intradural extramedullary cavernous angioma is reported, and the clinical, diagnostic, and therapeutic aspects of this rare malformation are analyzed.

Suprasellar epithelial cyst. Case report.

This case report describes an epithelial cyst lying above the diaphragma sellae and causing hypopituitarism and chiasmal compression in a 17-year-old girl. The epithelial lining of the cyst showed similarities with enteric epithelium rather than with "classic" Rathke's cleft. The problem of the true origin of Rathke's cleft, and of cysts so labeled, and the possible role played by neuroepithelium are discussed briefly.

Pituitary adenomas with onset during puberty. Features and treatment.

From a series of 207 patients with pituitary adenoma operated on by microsurgical technique from 1973 to February, 1982, the cases of nine young people whose symptoms had appeared between the ages of 11 and 15 years are presented. The most important data are that all the children were pubertal and that in seven the tumor was, or later became, invasive. By contrast, the tumor was enclosed in eight of nine other patients whose symptoms manifested between the ages of 16 and 20 years, and in 152 of the remaining 189 patients whose symptoms appeared after the age of 20 years. Considering the gravity of the disease treated, the results in this series may be termed encouraging. The treatment was multidisciplinary: starting with surgery, followed by radiotherapy, endocrine replacement therapy, and, in adenomas secreting prolactin and/or growth hormone, medical therapy with bromocriptine. The divergence between authors on the subject of childhood adenomas, especially as to whether they are more often invasive or enclosed, could be overcome, at least in part, if the term "pediatric age" were unequivocally defined and if there were an agreed distinction between puberty and childhood on the one hand and puberty and adolescence on the other.

Long-term prognosis for atypical and malignant meningiomas: a study of 71 surgical cases.

To contribute to a better understanding of the prognostic differences between atypical and malignant meningiomas as defined by the World Health Organization (WHO) and the influence of the grade of initial surgical excision on postoperative course, 42 cases of atypical and 29 of malignant meningioma were studied, along with long-term follow up. The two groups were compared with respect to long-term survival, recurrence-free survival, and median time to recurrence. The prognostic significance of the Simpson grade of surgical resection and tumor location was also considered. Survival at 5 and 10 years was recorded in 95% and 79%, respectively, of patients with atypical meningioma and in 64.3% and 34.5% of patients with malignant meningioma (p = 0.001). Recurrence-free survival and median time to recurrence were also significantly longer in patients with atypical than in those with malignant meningiomas: 11.9 versus 2 years (p = 0.001) and 5 versus 2 years (p < 0.0041), respectively. Six (26%) of the 23 recurring atypical meningiomas became malignant. Simpson Grade I resection and location in the cerebral convexity, which were closely related, were found to be associated with a significantly better clinical course in the entire series (p < or = 0.0016). Patients with atypical meningiomas fared better than those with malignant meningiomas after incomplete surgical excision (Simpson Grades II-III), but the difference was not statistically significant. Multivariate analysis using the Cox model indicated that radical extirpation (Simpson Grade I vs. II-III) and histological findings (atypical meningioma vs. malignant meningioma) were significantly related to prolonged survival (p < 0.0003 and p < 0.0388, respectively). In conclusion, the current study shows that for most patients with atypical meningioma the prognosis was less severe than for those with malignant meningioma, but the risk of a downhill course resulting from malignancy after incomplete resection and recurrence was not negligible (26%). In addition, the WHO classification was found to be inadequate for a minority of the atypical meningioma cases, which currently have the same unfavorable course as cases of malignant meningioma. The results also indicate that objective Simpson Grade I extirpation of convexity meningiomas can be successful despite histological findings of malignancy.

Combined cardiac cinefluoroscopy, exercise testing and ambulatory ST-segment monitoring in the diagnosis of coronary artery disease; a report of 104 symptomatic patients.

To enhance diagnostic accuracy in coronary artery disease, cardiac cinefluoroscopy for the detection of coronary artery calcification was combined with exercise test and ambulatory ST-segment monitoring in 104 symptomatic patients before they underwent coronary angiography. In 44 patients with typical angina the combination of the three noninvasive tests and the exercise test alone both detected 92% of subjects with clinically important coronary artery disease. In 60 patients with atypical angina, the combination of the three noninvasive tests screened 77% of the subjects with clinically important coronary artery disease versus 43% after exercise test only (P less than 0.001). The exercise electrocardiogram was false negative in a substantial number of patients with atypical angina due to the presence of a good coronary reserve or to a daily circadian variation in the tone of the coronary arteries. Under these circumstances, cardiac cinefluoroscopy gave additional anatomic information to the physiological assessment of ischemia provided by the exercise test and ambulatory ST-segment monitoring. Our study suggests that the combination of cardiac cinefluoroscopy with other noninvasive tests may be particularly useful in screening atypically symptomatic populations.

Recurrence of spinal ependymoma. Risk factors and long-term survival.

STUDY DESIGN: A study was conducted on 78 patients with spinal ependymoma. The authors divided the patients in two groups. OBJECTIVES: The aim was to elicit the risk factors for recurrence and the fate of patients who underwent second operations. SUMMARY OF BACKGROUND DATA: Group A is made up of 59 patients with no signs of recurrence at follow-up (median 14 years), and group B is made up of 19 patients who had undergone second operations because of relapses (follow-up median 12 years). METHODS: The clinical and therapeutic characteristics and survival of the two groups were compared statistically. RESULT: Analysis of the series shows that the most important points in predicting recurrence are length of clinical history (P < 0.05), gross appearance of the tumor at first operation (P < 0.05), and type of excision (P < 0.001). CONCLUSION: These factors proved to be closely interrelated. In the event of recurrence, spinal ependymoma has an adverse prognosis.