[A Rare Differential Diagnosis of Chronic Cough]. / Eine seltene Differenzialdiagnose von chronischem Husten.

History and admission findings We report on a 62-year-old male patient with dry cough for 3 months, constitutional symptoms and elevated inflammatory markers. Investigations Despite extensive diagnostics no infectious, malignant or rheumatologic disease could be found. Bronchoscopy with bronchoalveolar lavage showed lymphocytosis. 18-FDG-PET/CT demonstrated increased metabolic activity of the aorta and its primary branches. Diagnosis, treatment and course We diagnosed large vessel vasculitis consistent to a subtype of giant cell arteritis (GCA) without cranial manifestation. Immunosuppressive therapy resulted in prompt resolution of symptoms and normalizing of inflammatory markers. Conclusions Elderly patients with unexplained fever, cough and constitutional symptoms should be investigated for GCA, even when classic symptoms are absent. Respiratory symptoms occur in about 4 % as initial and only presenting manifestation of GCA and in about 9 % along with classical symptoms.In cases with unclear focus of inflammation 18-FDG-PET/CT is becoming more and more important as a diagnostic tool.

Influence of postmenopausal state, solar radiation, drugs and comorbidities on serum calcium and phosphate in 13,000 hospital admissions.

AIMS: Our goal was to determine the relative contributions of demographic variables, drugs, comorbidities, and weather conditions on serum calcium (Ca) and phosphate (Pi) in patients admitted to a tertiary referral center. METHODS: For 12,667 consecutive patients admitted to the Kantonsspital St. Gallen, drug history on admission, age, sex, body weight, ICD-10 diagnoses, and laboratory data were extracted from electronic medical records. Weather parameters prior to hospital admission were also integrated in a regression analysis. RESULTS: Serum Ca was normally distributed with a median (interquartile range) of 2.3 (2.2/2.4) mmol/L. In contrast Pi showed a right tailed distribution of 1.0 (0.9/1.2) mmol/L. Ca was increased in postmenopausal women. Solar radiation prior to admission was associated both with higher Ca and higher Pi. Lower blood pressure was associated with lower Ca and higher Pi. In addition Ca increased by 0.017 mmol/L per g/L increase of albumin (p < 0.0001). CONCLUSIONS: Serum Ca and Pi at hospital admission are highly dependent on patient characteristics, drugs, and comorbidities. In particular, we found higher Ca in postmenopausal women. The commonly applied albumin correction formula of Payne (0.025 mmol/L Ca per g/L albumin) may overestimate the effect of albumin; we propose using 0.017 mmol/L Ca per g/L albumin or measurement of free (ionized) Ca.

[Harmless bruises? Coagulopathy despite normal INR]. / Harmlose blaue Flecken? Gerinnungsstörung trotz normaler INR.

Acquired hemophilia is a rare but severe bleeding disorder caused by autoantibodies mostly against factor VIII. Clinically it mostly presents with soft tissue and muscular bleeding. Diagnostics include a prolonged aPTT, antibodies against FVIII and a reduced FVIII titre. Acute bleeding is controlled with recombinant factor VIIa (NovoSeven(®)) or activated prothrombin complex (FEIBA(®)), as both bypass FVIII in the coagulation pathway. Treatment to reduce the inhibitor consists of immunosuppression with corticosteroids, cyclophosphamid and can be extended with rituximab.

[A fever of finally known origin]. / FUO - alles in Butter?

We present the case of a 77 year old man with fever of unknown origin. Despite a thorough assessment in hospital the diagnosis could only be made after discharge when positive results for C. burnetii serology revealed acute Q-fever. However, retrospectively history and clinical findings matched well with acute Q-fever.

Influence of weather conditions, drugs and comorbidities on serum Na and Cl in 13000 hospital admissions: evidence for a subpopulation susceptible for SIADH.

OBJECTIVES: Considerable variation in serum sodium (Na) and chloride (Cl) is found in patients at hospital admission. Our goal was to quantify the respective impact of drugs, comorbidities, demographic factors and weather conditions on serum Na and Cl. DESIGN AND METHODS: For 13277 consecutive patients without terminal kidney disease admitted to the Department of Internal Medicine of the Kantonsspital St. Gallen drug history on admission, age, sex, body weight, ICD-10 diagnoses, and laboratory data were extracted from electronic medical records. Weather parameters prior to hospital admission were also integrated in a multivariate regression analysis. RESULTS: Both serum Na and Cl showed an asymmetric left-tailed distribution. Median (interquartile range) Na was 138 (136/140) and Cl 104 (101/106). The distribution of sodium in patients with one or more risk factors for SIADH was best explained by the presence of two populations: one population with a similar distribution as the unexposed patients and a smaller population (about 25%) shifted to lower sodium levels. Lower weight, lower blood pressure, kidney dysfunction, fever, and diabetes were associated with both lower Na and Cl. Higher ambient temperature and higher air humidity preceding admission were associated with both higher Na and Cl values. CONCLUSIONS: Na and Cl at hospital admission are highly influenced by ambient weather conditions, comorbidities and medication. The bimodal distribution of Na and Cl in persons exposed to risk factors for SIADH suggests that SIADH may only affect a genetically distinct vulnerable subpopulation.

[Achilles heel of COPD]. / Atemnot und gehunfähigkeit.

We report the case of a 73 year old patient with a COPD. A severe exazerbation was treated with glucocorticoids and Quinolones. A few days later both ankles were tender and painful. Ultrasound examination showed bilateral Achilles tendon ruptures. Diagnostics, etiology and therapeutic options are discussed.

A pulmonary mass caused by Rhodococcus equi infection in a renal transplant recipient.

BACKGROUND: A 62-year-old male kidney transplant recipient was admitted to hospital with a 14-day history of fever, hemoptysis and left-sided pleuritic chest pain. He had suffered malaise, weight loss, night sweats and exertional dyspnea over the previous 3 months. Imaging studies of the patient's chest revealed a noncavitated mass measuring 5 x 8 cm in the anterior segment of the left upper lobe of the lung and a left-sided pleural effusion with septa, and bacterial cultures revealed the presence of Rhodococcus equi. INVESTIGATIONS: Physical examination, laboratory tests, chest X-ray, CT scan of the chest, bronchoscopy, and bacterial culture of blood, sputum, bronchoalveolar lavage fluid and pleural fluid. DIAGNOSIS: R. equi infection with bacteremic pleuropneumonia and pseudotumor. A secondary myopathy occurred 6 months after diagnosis of the infection as a result of a drug interaction between clarithromycin and simvastatin. MANAGEMENT: Long-term combination antibiotic therapy (ciprofloxacin plus vancomycin or clarithromycin), resection of the inflammatory pseudotumor, and reduction of immunosuppressive therapy. Following the diagnosis of myopathy, simvastatin was discontinued.

Cytologically malignant lymphoid pericardial effusion with benign clinical outcome.

BACKGROUND: Isolated malignant pericardial effusion is a manifestation of primary cardiac lymphoma (PCL) and primary effusion lymphoma (PEL), rare types of non-Hodgkin's lymphoma (NHL). The diagnosis is based on different cytological methods and analyses including DNA-image cytometry (ICM-DNA). DNA-aneuploidy has been reported to be highly specific for malignancy. CASE DESCRIPTIONS AND RESULTS: A 75-year-old man and a 66-year-old woman underwent urgent pericardiocentesis for cardiac tamponade due to large pericardial effusion. In both patients pericardial fluid analysis showed highly atypical blastic lymphoid cells expressing CD45 (both patients) and CD20 (assessed only in one patient), and ICM-DNA revealed significant DNA-aneuploidy (2c deviation index 9.22 and 10.73 respectively, 75% and 60% respectively of the target nuclei in aneuploid areas). Extensive staging examinations did not identify any other tumour manifestation. Although in neither of the two patients systemic chemotherapy was administered, both were free of cancer after a follow-up of ten and nine years respectively. CONCLUSIONS: Despite the highly atypical cytomorphology including unequivocal DNA aneuploidy, long-term survival in both patients strongly suggests that pronounced reactive lymphocytic changes are probably due to viral pericarditis rather than PCL or PEL as underlying conditions. It seems that DNA-aneuploidy may be not absolutely specific for the detection of malignant lymphoid cells in pericardial fluid.

Elevation of B-type natriuretic peptide levels in acute respiratory distress syndrome.

BACKGROUND: B-type natriuretic peptide (BNP) has been proven to be a biochemical marker of severity of congestive heart failure. We are aware of only few papers reporting the association of BNP elevation and pulmonary hypertension (primary, thromboembolic, or as a consequence of chronic obstructive pulmonary disease). Less is known about BNP in patients with acute respiratory distress syndrome (ARDS). CASE DESCRIPTION AND RESULTS: We present the case of a previously healthy 27-year-old man with parapneumonic ARDS and an extraordinarily increased BNP level. The ventricular systolic ejection fraction assessed echocardiographically was normal with no evidence of left ventricular diastolic dysfunction. However, a peak BNP level of >1300 pg/mL (normal <100 pg/mL) was recorded. Repeated BNP values were obtained on nine separate days over a period of 3 weeks of mechanical ventilation. With the respiratory improvement following the inhalation of nitric oxide BNP levels decreased to 113 pg/mL. The possible pathophysiological mechanisms of BNP release are discussed. CONCLUSION: There is evidence for BNP elevation in the absence left ventricular dysfunction. This case is an example of impressively high BNP levels associated with ARDS, probably attributable to right ventricular overload due to increased pulmonary vascular resistance.