[Liver failure in a 27 years old female patient]. / Leberversagen bei einer 27-jährigen Patientin.

We report about a 27-years old female patient with acute liver failure due to an acute Budd Chiari Syndrom (thrombosis of all three liver veins an vena cava inferior) with caval web, birth control pills and after long distance flight. After successfull aspiration of the caval thrombus and dilatation of caval web liver transplantation could be bypassed. Two weeks after intervention the patient was in a good healthy condition with normal laboratory values, normal liver size, normal perfusion of the V. cava inferior and signs of reperfusion of the middle liver vein.

[An uncommon cause of iron deficiency anemia]. / Eine nicht-alltägliche Ursache der Eisenmangel-Anämie.

A 55-year-old patient was diagnosed having a malignant melanoma metastatic to the small bowel as cause of an iron deficiency anemia. Although up to 60% of patients with metastatic melanoma are found to have intestinal metastases at autopsy, clinically apparent gastrointestinal involvement is rare during lifetime and often delayed after resection of the primary tumor. Diagnostic procedures include radiological imaging and endoscopic modalities. Early diagnosis is desirable for prognostic reason both in curative and palliative settings.

[Lymphogranuloma venereum. An old disease in a new dress]. / Lymphogranuloma venereum. Eine alte Krankheit in neuem Kleid.

Lymphogranuloma venereum is a sexually transmitted disease caused by Chlamydia trachomatis, serotypes L1, L2 and L3. The classical clinical manifestation is a painful inguinal lymphadenopathy, resulting without treatment in severe complications. Over the last years, however, the emergence of massive ulcerative proctitis has been observed, especially in men who have sex with men. Because the clinical symptoms are unspecific, Chlamydia trachomatis should actively be looked for. Reliable and rapid molecular tests have now been established to diagnose lymphogranuloma venereum. The therapeutic recommendation is tetracycline for 3 weeks. We present 5 cases to illustrate this disease.

[Seizure and non-cardiogenic pulmonary edema after intoxication]. / 35-jährige Patientin mit generalisiertem Krampfanfall und nicht-kardiogenem Lungenödem nach Intoxikation.

We report a case of severe intoxication with extended-release verapamil. In addition to cardiovascular toxicities with hypotension, atrioventricular block and bradycardia, the patient suffered from grand-mal seizure and pulmonary edema 13 and 48 hours respectively, after ingestion of 4.8 g of extended-release verapamil. Adverse reactions after intoxications with extended-release tablets appear delayed with prolonged manifestation of symptoms. Early and repetitive administration of activated charcoal and antegrade whole bowel lavage are crucial, even in primary asymptomatic patients.

[Diarrhea with sequelae]. / Diarrhoe mit Folgen.

We report on a twenty-three year old woman with shifting polyarthritis after an episode with gastroenteritis. Despite normalisation of stool we could detect campylobacter jejuni one month later. After therapy with macrolide antibiotics arthritis recovered.

[Weight loss and night sweats with unexpected tumor localization]. / Gewichtsverlust und Nachtschweiss mit unerwarteter Tumorlokalisation.

A 52-year-old patient presented himself with weight loss and night sweats. Laboratory analyses revealed a high sedimentation rate, elevated immunoglobulines and anaemia with sludge phenomenon. Differential diagnoses included Multiple Myeloma and Lymphoma. Having a risk constellation for HIV infection and just having recovered from oral thrush also made this diagnosis possible. Urinary analysis and chest x-ray were normal; however, CT-scan detected renal cell cancer with pulmonary metastases. Renal cell cancer is heterogeneous in presentation, symptoms are unspecific, therefore they are often discovered late when they have already metastasized. Paraneoplastic syndromes, e.g. hypercalcaemia or hypertension are not infrequent in renal cell cancer.

[Bronchitis, pregnancy test and hematuria--an atypical algorithm for diagnosis]. / Bronchitis, Schwangerschafts- test und Hämaturie--ein atypi- scher Algorithmus zur Diagnose. 42-jährige Hausfrau mit trockenem Husten.

A 42-year old housewife presented herself with flu symptoms and dry cough. Because of pregnancy test (chest x-ray) we accidentally detected a hematuria. Exact medical history revealed the presence of a known IgA-Nephropathy. Banal respiratory infections can exacerbate IgA Nephropathy. In addition, medical history and further investigations are important because of possible secondary IgA-Glomerulonephritis. Treatment of IgA glomerulopathy depends on blood pressure, renal function and degree of proteinuria. An acute renal insufficancy is uncommon (< 5%), but 25% patients develop during 20-25 years a terminal insufficandy.

[Livid facial erythema: marker lesion of a multi-facet systemic illness]. / Livides Gesichtserythem: Markerläsion einer Systemkrankheit mit vielen Facetten.

We present a 53 year old woman with a progressive violaceous erythema (heliotrop rash) of the face with periorbital oedema. A clinical diagnosis of dermatomyositis was proposed. Except for the cutaneous manifestation there was no further clinical evidence of systemic disease and specifically of muscle involvement. The lesions developed about six months earlier and an amyopathic dermatomyositis was diagnosed. The patient was treated with hydroxychloroquine. The risk of malignant disease is increased in primary idiopathic and amyopathic adult onset dermatomyositis. Therefore an adequate work-up is mandatory.

[Dyspnea on exertion and bihilar space occupying lesion in intravenous cocaine/heroin abuse]. / Belastungsdyspnoe und bihiläre Raumforderung bei i.v.-Kokain/Heroinabusus.

We report about a 44 year old man with intravenous cocaine/heroin abuse with shortness of breath (NYHA III) and prominent bilateral hila. We documented a severe pulmonary hypertension with bilateral dilated pulmonary vessels. Differential diagnosis is broad and further diagnostic evaluation is needed. Therapy includes anticoagulation, diuretics, if necessary oxygen supply and specific inhalative and perorale drugs.

[Delayed upper abdominal pain and tarry stool after transjugular liver biopsy. A 24-old man with hemophilia]. / Verzögerte Oberbauchbeschwerden und Teerstuhl nach transjugulärer Leberbiopsie. 24-jähriger Mann mit Hämophilie.

A 24-year old patient with severe haemophilia A and chronic hepatitis C developed two weeks after transjugular liver biopsy (TJLB) haemobilia with colicky upper abdominal pain, coffee ground emesis, melaena and anaemia. Abdominal ultrasound and endoscopic retrograde cholangiogram confirmed the diagnosis. After adequate factor VIII substitution and revision with a balloon catheter the patient became asymptomatic. Haemobilia is a uncommon complication after liver biopsy. This complication should be kept in mind even if the occurrence is delayed after intervention. TJLB is an established and safe method to obtain liver specimen in patients with coagulation disorders.

[Status febrilis and unconsciousness]. / Status febrilis mit Bewusstlosigkeit.

Cerebral malaria with Plasmodium vivax is uncommon. Normally Plasmodium falciparum is the cause of cerebral malaria. We report about a 18 year old patient from Pakistan with a history of intermittent fever for several months. The patient recovered within a few days; however prognosis can be severe when cerebral malaria is complicating the course of Plasmodium vivax infection.

[Pancreatic and biliary tract tumors--diagnosis: ultrasonic diagnosis--endosonography]. / Pankreas- und Gallenwegstumoren--Diagnostik: Ultraschall--Endosonographie.

Pancreaticobiliary tumors are mostly adenocarcinomas with a poor 5-year survival of less than 2%. Early diagnosis of resectable tumors improves outcome. Conventional ultrasound (US) is non-invasive and is the first modality employed on suspicion of these tumors. With adequate skills and equipment, pancreatic tumors from 1.5 cm in diameter can be detected. By contrast, US is less sensitive in the detection of lymph node involvement and infiltration of blood vessels. Depending on the location tumors of the biliary tract appear as a mass lesion intrahepatically or within the gallbladder. Perihilar and extrahepatic bile duct carcinomas cause proximal duct dilatation which is readily detected by US. Again, sensitivity in the detection of lymph node metastases or portal vein invasion is limited. Endoscopic ultrasound (EUS) has emerged as the method of choice in detecting small pancreatic tumors (e.g. < 2 cm in diameter). An accuracy of over 90% in T-staging and blood vessel infiltration can be achieved whereas lymph node metastases are correctly diagnosed in only 67% of cases. EUS-guided biopsy is readily performed using a curved array scanner. This technique enables neurolysis of the coeliac plexus in patients with heavy pain. EUS adds valuable information in cases of distal extrahepatic bile duct cancer. The role of EUS is limited in perihilar and intrahepatic cholangiocarcinoma. Staging and palliative therapy of perihilar carcinoma is still a domain of endoscopic retrograde cholangiography. Intraductal EUS is restricted to specialized centers and plays no role for routine purposes.