Fatal upper gastrointestinal bleed arising from duodenal varices secondary to undiagnosed portal hypertension.

Duodenal varices are an unexpected source of upper gastrointestinal haemorrhage associated with high mortality. The prevalence of ectopic variceal bleeding accounts for 2-5% of all variceal bleeding; of this, only 17% occurs in the duodenum. Diagnosis is difficult, and insufficient evidence exists to demonstrate the best treatment option when haemorrhage occurs. We report the case of a 69-year-old man with a history of chronic alcoholism who presented to the emergency department (ED) with nausea, vomiting and several episodes of haematochezia. Diagnostic workup in the ED included CT with multiplanar reconstruction, which revealed a network of large tortuous blood vessels running near the second portion of the duodenum between the inferior vena cava and portal vein. The patient was emergently treated with endoscopic therapy and clipping of the vessel. This failed, and he was subsequently taken to the operating room for suture ligation of the bleeding duodenal varices.

Pancreatic extra-gastrointestinal stromal tumour masquerading as a bleeding duodenal mass.

We describe a 55-year-old man presenting to our institution with a gastrointestinal bleed. He was found to have a 5 cm pancreatic extra-gastrointestinal stromal tumours (EGISTs) eroding into the duodenum and ampulla of Vater. Pancreaticoduodenectomy was performed and the tumour was noted to be positive for CD117 and CD34 with six mitotic figures per 50/high-powered field. At 5 months postoperatively he is receiving treatment with imatinib and doing well. To the best of our knowledge, our patient is only the 18th case reported in the literature to date.

Case report of hantavirus pulmonary syndrome and review.

A previously healthy 29-year-old male presented to the emergency department with pleuritic chest pain, nonproductive cough, and dyspnea. He was treated empirically for community acquired pneumonia and discharged to home. Two days later, the patient presented with respiratory distress along with neutrophilia, thrombocytopenia, elevated liver function tests, and hemoconcentration. Radiographs of his chest showed bilateral lung infiltrates and pleural effusions. He was admitted to the hospital and developed cardiopulmonary failure and died the following day. Serologic tests for hantavirus pulmonary syndrome confirmed the diagnosis.

Outbreak of dengue fever in Palau, Western Pacific: risk factors for infection.

Between January and June 1995, an outbreak of dengue fever occurred in Palau, an island nation of 32,000 inhabitants in the Western Pacific. To determine the magnitude of this outbreak and to determine modifiable risk factors to guide control strategies, we established active surveillance at the national hospital and private clinics, reviewed available clinical records, and conducted serologic and entomologic surveys. Between January 1 and July 1, 1995, 817 case-patients with acute febrile illness with body or joint aches and one of the following: headache, rash, nausea, vomiting, or hemorrhagic manifestations presented to health facilities in Palau. The epidemic peaked in the second week of April 1995. Of 338 case-patients tested, 254 (75%) had positive serologic results by an IgM capture enzyme-linked immunosorbent assay. Dengue 4 virus was isolated from 78 (51%) of 154 serum samples tested. Blood samples collected during a cross-sectional survey were tested for IgM antibody and yielded an attack ratio of 27% (95% confidence interval = 23-31%). Potential vectors included the introduced species Aedes aegypti and Ae. albopictus, and the native species Ae. hensilli. Significant risk factors (P < or = 0.05) for infection included age < 20 years, the presence of food or water pans for animals on the property, taro farming, the presence of Ae. aegypti on the property, and presence of Ae. scutellaris group mosquitoes (Ae. Hensilli, Ae. albopictus, and a native species). This was the first outbreak of dengue 4 virus in the Western Pacific, and the first documented epidemic of dengue in Palau since 1988.