A case of delayed oxaliplatin-induced pseudo-obstruction: an atypical presentation of oxaliplatin neurotoxicity.

Chemotherapy-induced neurotoxicity is a serious complication of cancer treatment. Oxaliplatin, a third-generation platinum drug, has become one of the first-line therapies used in the treatment of metastatic colorectal cancer. Peripheral neuropathy is a common complication of platinum-based chemotherapy. Most commonly a sensory neuropathy occurs with cold-triggered symptoms in the acute phase and numbness and painful paresthesias as a late presentation. Autonomic neurotoxicity and late presentation, months after cessation of the therapy, has rarely been described. We report a patient who clinically presented with a pseudo-obstruction months after treatment with oxaliplatin for metastatic colorectal cancer. Intestinal adhesions and relapsing malignancy were carefully excluded. By exclusion the pseudo-obstruction was attributed to a toxic oxaliplatin-induced autonomic neuropathy which slowly improved during months of follow-up.

Hepatic adenomatosis: MR imaging features.

Hepatocellular adenomas are rare benign liver neoplasms that commonly occur in women with a history of oral contraceptives intake for more than 2 years. Hepatic adenomatosis is characterized by the presence of multiple adenomas, arbitrarily > than 10, involving both lobes of the liver, without any history of steroid therapy or glycogen storage disease. Although the adenomas in liver adenomatosis are histologically similar to other adenomas, liver adenomatosis appears to be a separate clinical entity. Adenomas in hepatic adenomatosis may be of the inflammatory, hepatocyte nuclear factor 1alpha-mutated, or beta-catenin-mutated subtype, and accordingly show variable imaging appearances. Hepatic adenomatosis carries the risk of impaired liver function, hemorrhage and malignant degeneration. We report a case with the inflammatory subtype of hepatic adenomatosis in a 39-year-old woman with liver steatosis. The magnetic resonance imaging features using extracellular gadolinium chelates and hepatocyte-targeted contrast agents are described.

Acute intestinal anisakiasis: CT findings.

Small bowel anisakiasis is a relatively uncommon disease that results from consumption of raw or insufficiently pickled, salted, smoked, or cooked wild marine fish infected with Anisakis larvae. We report a case of intestinal anisakiasis in a 63-year-old woman presenting with acute onset of abdominal complaints one day after ingestion of raw wild-caught herring from the Northsea. Computed tomography (CT) scanning demonstrated thickening of the distal small bowel wall, mucosa with hyperenhancement, mural stratification, fluid accumulation within dilated small-bowel loops and hyperemia of mesenteric vessels. In patients with a recent history of eating raw marine fish presenting with acute onset of abdominal complaints and CT features of acute small bowel inflammation the possibility of anisakiasis should be considered in the differential diagnosis of acute abdominal syndromes.

Incidental radiological finding of a renal tumour leading to the diagnosis of Birt-Hogg-Dube syndrome.

Birt-Hogg-Dubé (BHD) syndrome is a rare autosomal dominant condition characterised by benign tumours of the hair follicle, renal cancer, pulmonary cysts and spontaneous pneumothorax. We report the diagnosis of a BHD syndrome achieved after incidental radiological finding of a renal tumour in a 24-year old man. The patient also displayed recurrent pneumothoraces and showed to have cysts in the basis of both lungs. The association of recurrent pneumothoraces and renal neoplastic disease should alert for the possible presence of this syndrome.

Neurobehavioural changes and persistence of complaints in workers exposed to styrene in a polyester boat building plant: influence of exposure characteristics and microsomal epoxide hydrolase phenotype.

OBJECTIVES: To investigate neurobehavioural effects and the persistence of complaints in workers exposed to styrene relative to exposure characteristics and the enzyme microsomal epoxide hydrolase (mEH) activity. METHODS: A cross sectional study was performed in a retrospective cohort of workers of a polyester boat building plant 3 years after the main activity shut down in 1989. Workers still currently exposed to a much lower concentration of styrene in air than before (n=27) and formerly exposed workers (n=90) were compared with matched control workers (n=64). Currently and formerly exposed workers laminated 4700 and 3610 hours on average at mean exposure to styrene concentrations of 148 and 157 mg/m(3) respectively. A structured neurological anamnesis into former and present complaints, the NSC-60 questionnaire, and computer assisted neurobehavioural tests (NES) were administered. The mEH phenotype activity was measured in lymphocytes with a novel gas chromatography-mass spectroscopy (GC-MS) method. RESULTS: For the period before 1989, currently and formerly exposed workers reported more complaints than control workers which related well with the mean exposure to airborn styrene concentration (p=0.03). Most complaints disappeared after the end of exposure, although the chest, equilibrium, and somatic category scores of NSC-60 and the number of workers reporting diminished sense of smell remained increased in formerly exposed workers (p

Giant cell (temporal) arteritis diagnosed following upper limb claudication.

Giant cell arteritis or temporal arteritis occurs almost exclusively in people over 50 years of age. It classically presents with new onset temporal headache, scalp tenderness and jaw claudication. Proximal muscle pain and stiffness is often present because of frequent association with polymyalgia rheumatica. In most cases, the erythrocyte sedimentation rate is markedly elevated. Uncommon presentations include systemic symptoms and symptoms related to large artery involvement. We report a case of giant cell arteritis without symptoms related to the temporal artery, diagnosed angiographically following upper limb claudication and confirmed by temporal artery biopsy.

Comparison of ethylene, propylene and styrene 7,8-oxide in vitro adduct formation on N-terminal valine in human haemoglobin and on N-7-guanine in human DNA.

Epoxides react at various nucleophilic sites in macromolecules such as haemoglobin and DNA. To study the reaction rate constants of ethylene oxide (EO), propylene oxide (PO) and styrene 7,8-oxide (SO) towards two of these positions, i.e., the N-terminal valine in haemoglobin and N-7-guanine in DNA was the central aim of this investigation. These two reactive sites are the most studied haemoglobin and DNA adducts, respectively. Further attention, therefore, was also paid to the applicability in vivo of the in vitro determined reaction constants. The determination of the second-order rate constants between EO and PO and N-terminal valine in Hb [2.7 l (mol Hb h)-1 and 1.0 l (mol Hb h)-1, respectively] were consistent with the literature values. The constants for the reaction with N-7-guanine [16x10(-3) l (mol DNA nucleotide h)-1 and 7. 7x10(-3) l (mol DNA nucleotide h)-1, respectively] were lower than previously published values, probably due to differences in the methodology used. The use of the in vitro obtained values to model the in vivo situation lead to a consistent picture for EO and PO. In contrast, for SO the in vitro ratio between the adduct formation on N-terminal valine [1.5 l (mol Hb h)-1] and N-7-guanine [0.71x10(-3) l (mol DNA nucleotide h)-1] was about two orders of magnitude greater than for the in vivo situation. This was probably due to a lower than expected reactivity of SO towards N-terminal valine in vivo. Further research is needed to elucidate whether the use of SO in vitro, contrasting with the in vivo experiments in which SO was metabolically formed from styrene, could entail an explanation for this discrepancy. Concerning the methodological part, the use of dipeptide standards to replace the alkylated globins as standard lead to an improvement of the method. Especially the commercial availability of the standards, their stability and accurately known adduct content will make them to the standards of choice in the future.

Comparison of styrene-7,8-oxide adducts formed via reaction with cysteine, N-terminal valine and carboxylic acid residues in human, mouse and rat hemoglobin.

The reactive metabolite of styrene, styrene-7,8-oxide (SO), reacts with a variety of nucleophilic sites in hemoglobin (Hb) to form SO-Hb adducts. Following the in vitro incubation of SO with blood from humans, NMRI mice and Sprague-Dawley rats, the second-order reaction rate constants were determined for the reaction of SO with cysteine (through both the alpha- and beta-carbons of SO), N-terminal valine (through the beta-carbon of SO), and carboxylic acid (presumably through both the alpha- and beta-carbons of SO) residues in Hb. The rate constants for cysteine adducts vary dramatically between species [2.04, 10.7, 133 L (mol Hb)-1 h-1 (alpha binding) for humans, mice and rats, respectively] and [0.078, 2.16, 20.4 L (mol Hb)-1 h-1 (beta binding), respectively]. The considerably higher rate of reaction with cysteine in rat Hb probably reflects the presence of an additional cysteine residue at position beta 125. Although the rate constants for valine adducts (1.82, 0.80, 0.29 L (mol Hb)-1 h-1, respectively) and COOH adducts (3.55, 1.94, 2.37 L (mol Hb)-1 h-1, respectively) are much more consistent, the inter-species differences are statistically significant for the reaction of SO with the N-terminal valine of Hb. Following the i.p. administration of styrene to mice and styrene and SO to rats, the levels of adducts at each of these sites were used in conjunction with the calculated rate constants to predict the integrated blood doses of SO. While the SO doses predicted from cysteine and valine adducts were very similar, that based upon COOH-binding was significantly different, presumably due to the instability of SO-COOH adducts. This research affirms the use of both cysteine and valine adducts, but not carboxylic acid adducts, as biomarkers of exposure to styrene and SO.

Ring test for the determination of N-terminal valine adducts of styrene 7,8-oxide with haemoglobin by the modified Edman degradation technique.

A ring-test was organised between three laboratories using different versions of the modified Edman degradation technique for the gas chromatographic-mass spectrometric determination of N-terminal valine adducts of styrene 7,8-oxide. The analyses were performed on a sample of human haemoglobin reacted in vitro with styrene 7,8-oxide and on a set of five haemoglobin samples from mice dosed by i.p. injection of styrene. Strong correlations between the haemoglobin adduct determinations of the different laboratories were observed. However, covariance analysis revealed different slopes for the dose-response curves, indicating differences for the calibration of the reference globin or reference peptide.

Adduct formation on DNA and haemoglobin in mice intraperitoneally administered with styrene.

Styrene-specific N-7- and O6-guanine DNA adducts and N-terminal valine adducts were determined in mice tissues after the intraperitoneal administration of styrene. Blood, liver, lungs and spleen were collected 3 h after administration of various doses (from 0 to 4.35 mmol/kg b.w.) of styrene. DNA adducts were analysed by the modified 32P-postlabelling assay and N-terminal valine adducts were detected by GC-MS according to the modified Edman degradation technique. In the dose-range studied, for all adducts a clear dose-response relationship was observed. 7-Alkylguanines and O6-styrene guanine adducts were most abundant in lungs, approximately 30% more than in liver and spleen. In all analysed tissues 7-alkylguanines were more abundant than O6-styrene guanine adducts. We found a considerably lower rate of N-terminal valine adduct formation as compared with both DNA adducts. The ratio between 7-alkylguanines and O6-guanine adducts was 1.9, 1.6 and 7.8 in liver, lung and spleen, respectively. In vitro determination of both DNA adducts by 32P-postlabelling resulted also in a lower ratio than that reported earlier using an HPLC analysis. All correlation's between dose, haemoglobin and DNA adducts were very high and significant. However, at the highest injected doses the adduct formation showed a levelling off. To explain this phenomenon a model simulation was performed revealing that 3 h after the injection of the higher doses styrene was not completely converted into styrene-7,8-oxide.

Urinary mandelic acid and hemoglobin adducts in fiberglass-reinforced plastics workers exposed to styrene.

OBJECTIVES: A field study was undertaken to investigate the effects of occupational styrene exposure on mandelic acid excretion and the formation of styrene-7,8-oxide hemoglobin adducts. Especially the sensitivity of a gas chromatography-mass spectrometry method for determining hemoglobin adducts was evaluated. METHODS: Over a four-week period, each individual of a group of 52 fiberglass-reinforced plastics workers was monitored once a week by the simultaneous measurement of styrene in the air and urinary postshift mandelic acid. In addition mandelic acid and hemoglobin adducts were monitored in a group of 24 unexposed referents. At the end of the monitoring period styrene-7,8-oxide adduct formation on N-terminal valine in hemoglobin was examined by gas chromatography-mass spectrometry according to the modified Edman degradation technique. RESULTS: Personal air samples showed an average styrene exposure of 31 mg.m-3. The average postshift mandelic acid was 98 mg.g creatinine-1. For workers not wearing respirators and not showing breath ethanol, the correlation coefficient between styrene and mandelic acid was 0.78. The blood samples were analyzed for styrene-7,8-oxide adducts on hemoglobin. With a detection limit of 10 pmol.g-1, no styrene-7,8-oxide adducts were found under these exposure conditions. CONCLUSION: Adduct formation in humans is less effective than in mice. In comparison with ethylene, styrene is at least 70 times less effective in forming hemoglobin adducts. Investigating adduct formation in humans at or below the exposure levels reported in this study would require a detection limit of about one order of magnitude better.

Cytogenetic analysis of lymphocytes from fiberglass-reinforced plastics workers occupationally exposed to styrene.

In this study a group of 52 workers employed in a plant manufacturing fiberglass-reinforced plastic (FRP) pipes and cisterns, and therefore daily exposed to styrene, were monitored. As a control group 24 non-exposed workers from another factory producing and repairing pallets volunteered to participate. The airborne styrene during the monitoring ranged from 2.2 to 110.1 mg/m3. As a metabolic marker for styrene exposure mandelic acid was measured in the urine and ranged from 11 to 649 mg/g creatinine. From 43 exposed and 15 control workers sister-chromatid exchanges (SCE) and high frequency cell (HFC) data and from 49 exposed and 23 control workers micronucleus (MN) data from peripheral lymphocytes are reported. Although the two groups of workers could clearly be distinguished on the basis of the airborne styrene concentrations and urinary mandelic acid concentrations no differences in any of the cytogenetic markers were found. Correlations between the cytogenetic data and the level of airborne styrene concentrations or urinary mandelic acid levels could also not be demonstrated. Otherwise, smoking increased the SCE frequency. Grouping the workers according to smoking habits showed a statistically significant difference in SCE. Moreover, levels of urinary thiocyanate (SCN), which can be used as a metabolic marker for smoking, showed a significant positive correlation with the number of SCE. This indicates that SCE is a sensitive biomarker and might still be useful in biomonitoring. However, only chronic exposures over a long period would probably be detectable. In this study, where exposure was rather low and the number of working years was small (mean of 2.9 years), cytogenetic effects are probably too low or rare to be detectable with any assay.

[Cholestatic jaundice caused by amoxicillin-clavulanic acid in 4 patients]. / Cholestatische icterus door amoxicilline-clavulaanzuur bij 4 patiënten.

In four patients, two men and two women aged 73, 68, 84 and 72 years respectively, reversible cholestatic liver injury was seen 28-35 days after the start of treatment with amoxycillin-clavulanic acid (Augmentin). This rare complication of amoxycillin-clavulanic acid treatment is characterized by a relatively long latent period before the onset of symptoms or biochemical abnormalities, which makes early recognition difficult. The mechanism responsible for this idiosyncratic cholestasis is unknown.

Sulfasalazine-associated encephalopathy in a patient with Crohn's disease.

We report a case of acute encephalopathy in a patient with Crohn's disease who had taken sulfasalazine for 1 month. The development of toxic hepatitis and dermatitis prompted interruption of the drug. Four days later, neurologic symptoms became evident. These included acute monoparesis of the left arm, the development of stupor and coma, with endorotation of both arms, and a left Babinski sign. CT and MR imaging revealed multiple lesions in the white and gray brain matter, suggesting diffuse cerebral microangiitis. All cerebrospinal fluid examinations were negative. Methylprednisolone was given intravenously. Complete clinical normalization followed. Neurotoxicity secondary to sulfasalazine has seldom been reported in the literature. We found certain similarities with two previous case reports suggesting a hypersensitivity reaction to sulfasalazine or one of its metabolites. For ethical reasons, no rechallenge was performed.

Sulfasalazine-associated encephalopathy in a patient with Crohn's disease.

We report a case of acute encephalopathy in a patient with Crohn's disease who had taken sulfasalazine for 1 month. The development of a toxic hepatitis and dermatitis prompted interruption of the drug. Four days later, neurological symptoms became evident. These included acute monoparesis of the left arm, the development of stupor and coma, with endorotation of both arms and a left Babinski sign. CT and magnetic resonance imaging revealed multiple lesions in the white and gray brain matter, suggesting diffuse cerebral microangiitis. All cerebrospinal fluid examinations were negative. Methylprednisolone was given intravenously. Complete clinical normalization followed. Neurotoxicity secondary to sulfasalazine has seldom been reported in the literature. We found certain similarities between this case and two previous case reports suggesting a hypersensitivity reaction to sulfasalazine or one of its metabolites. For ethical reasons, no rechallenge was performed.

Results of extracorporeal shock wave lithotripsy of gall bladder stones in 693 patients: a plea for restriction to solitary radiolucent stones.

During a period of 24 months 693 consecutive patients with symptomatic gall bladder stones (526 males, 167 females; mean age 51 years, range 18-89) were treated by extracorporeal shock wave lithotripsy with a Piezolith 2300. The procedure was carried out on an out-patient basis without analgesics or sedatives. Concomitant chemolitholytic treatment (ursodeoxycholic and chenodeoxycholic acid 7.5 mg/kg/day each) was administered until three months after total fragment clearance for a maximum therapy period of 1.5 years. In 601 patients with radiolucent stones complete clearance of all fragments was obtained after three, six, 12, and 18 months in respectively 20, 41, 64, and 78%. Actuarial analysis of the subgroups according to the stone mass (size and number) selected an ideal patient population with solitary stones less than 20 mm diameter (84% stone free after one year). The results are significantly less good when the greater the number of stones or their maximal diameter increases. Treatment was interrupted in 3.6% of the patients. In 90 sludge or fragments remain present. Twenty five patients were lost to follow up for non-biliary reasons. Stone recurrence was 5.7% at one year and was observed both in patients with solitary and multiple stones. A cost effectiveness analysis suggests that laparoscopic cholecystectomy is the most effective and economic solution, although extracorporeal shock wave lithotripsy for solitary radiolucent stones less than 2 cm is cheaper than conventional cholecystectomy. Extracorporeal shock wave lithotripsy for multiple stones is the most expensive and least effective option.

Ultrasound measurement of the subarachnoid space in infants.

An original non-invasive method for easy and reproducible measurement of the subarachnoid space width in infants is described. Preliminary results of normal values during the neonatal period are presented as well as of the validity of the ultrasound method for abnormal values obtained by available computed tomography scanning.