Hemoptysis and hematemesis due to a broncholith: granulomatous mediastinitis.

A 40-year-old man had new onset of hemoptysis and hematemesis. Bronchoscopy revealed red, inflamed mucosa with apparent rich blood supply in the left primary bronchus. Computed tomography revealed calcified subcarinal lymph nodes with a small extension into the left primary bronchus. Shortly after admission, the patient had an episode of gastrointestinal bleeding. Esophagogastroduodenoscopy showed a lesion in the posterior wall of the esophagus, 12 cm from the upper incisors. During exploratory thoracotomy, a single piece of irregular-shaped tan tissue measuring 3.5 x 2.5 x 2.0 cm and engulfing the esophagus, carina, and left primary bronchus was dissected. A single stonelike mass, or broncholith, was found to involve both the trachea and the esophagus. Microscopic examination showed multiple caseating granulomas with surrounding lymphoid tissue and germinal centers. During 12 months of follow-up, the patient has remained asymptomatic. The chronic inflammation in this case suggested granulomatous mediastinitis, a rare disease whose mass-like effects may contribute to structural compression. The trachea and esophagus are rarely involved. Tuberculosis and histoplasmosis are thought to be the two most common causes of granulomatous mediastinitis. Chronic inflammation leading to calcification and broncholith may invade bronchial lumen or esophageal wall, causing life-threatening hemorrhage and necessitating prompt surgical intervention.

Synergistic anti-nociceptive effect of L-NG-nitro arginine methyl ester (L-NAME) and flurbiprofen in the mouse.

1. L-NG-nitro arginine methyl ester (L-NAME) administered i.p. produces anti-nociception in the mouse assessed by the formalin-induced paw licking and acetic acid-induced abdominal constriction models. The non-steroidal anti-inflammatory drug (NSAID), flurbiprofen, was similarly anti-nociceptive in both models. 2. Combination of a sub-threshold dose of L-NAME (10 mg kg-1) with increasing doses of flurbiprofen (25- 75 mg kg-1) or a sub-threshold dose of flurbiprofen (50 mg kg-1) with increasing doses of L-NAME (10- 100 mg kg-1) resulted in potentiated anti-nociception in the formalin model. Combined therapy with sub-threshold doses of L-NAME (10 mg kg-1) and indomethacin (10 mg kg-1) also resulted in significant anti-nociception. In addition, combining sub-threshold doses of L-NAME (12.5 mg kg-1) and flurbiprofen (2 mg kg-1) significantly reduced acetic acid-induced abdominal constriction. 3. L-NAME (10 mg kg-1) administered i.p. caused a significant (approximately 35%) increase in MAP in the urethane-anaesthetized mouse. Flurbiprofen (50 mg kg-1) was inactive. Combination treatment with L-NAME (10 mg kg-1) and flurbiprofen (50 mg kg-1) failed to elevate MAP above that observed with L-NAME alone. Neither L-NAME (10 mg kg-1) nor flurbiprofen (50 mg kg-1) either alone or in combination significantly altered mouse locomotor activity. 4. These results suggest that L-NAME and flurbiprofen/indomethacin act synergistically in their anti-nociceptive action in the mouse. Combination therapy with L-NAME and flurbiprofen and a similar NSAID may provide an alternative to the clinical control of pain in man.

White clot syndrome.

Heparin therapy is currently a vital component in the medical management of thromboembolic events. Despite its widespread use, it is associated with relatively few complications, and these are usually minor and quickly reversible. Recently a much more dramatic and serious complication of heparin therapy has been identified. In heparin-induced thrombocytopenia with associated thrombosis or "white clot syndrome," patients have paradoxic thromboembolic events while receiving heparin. These events are of acute onset and of major consequence, often resulting in limb loss or death. This paper describes our own experience with ten patients in whom the white clot syndrome occurred during heparin therapy for thrombotic or embolic events. Both porcine and bovine heparin preparations were being given through various routes. In the three cases in which platelet aggregation testing was completed, results were positive. Our ten patients ultimately had a 20% major limb amputation rate and an overall 50% mortality.