Life-threatening hemorrhage due to cytomegalovirus infection of the gastrointestinal tract.

Cytomegalovirus infection of the gastrointestinal tract of normal hosts is very rare. On the other hand, this is a common cause of morbidity in immunocompromised hosts. Herein we describe the case of a 52-year-old male who underwent a gastrectomy due to a severe gastrointestinal hemorrhage. Histological examination showed the characteristic cytomegalovirus inclusion bodies. The diagnosis was confirmed with immunohistochemistry and his immune system revealed no abnormality. We believe that, although it is very rare, cytomegalovirus infection should be kept in mind for non-immunocompromised patients with upper gastrointestinal bleeding or multiple gastric ulcers.

Inflammation and Chlamydia pneumoniae infection correlate with the severity of peripheral arterial disease.

BACKGROUND: Our aim was to investigate the association of inflammation and Chlamydia pneumoniae infection with the presence and severity of peripheral arterial disease. METHODS: Twenty-eight patients whose initial claudication distance (ICD) in the traditional constant-load treadmill test was <200 m, underwent femoral endarterectomy as part of their interventional treatment (group A). Group B consisted of 23 patients whose ICD was >200 m and were put on medication and a daily exercise program. The control group consisted of 30 non-vascular patients of the Ophthalmology Department (group C). We measured the levels of C-reactive protein, fibrinogen, vascular cell adhesion molecule-1 and tumor necrosis factor-alpha, and the titers of IgA and IgG antibodies against C. pneumoniae in the serum of all the patients. Finally, the atheromas and vein segments of group A patients, were immunohistochemically (IHC) examined for the presence of C. pneumoniae. RESULTS: Peripheral arterial disease (PAD) patients, had significantly higher CRP (p=0.026) and anti-Cp IgA levels (p=0.001) when compared to control subjects, after a multiple linear regression analysis. The odds ratio for the prevalence of femoral atherosclerosis was 3.16 for IgA seropositive patients (CI 1.15-8.67). When comparing group A and group B patients, CRP (p=0.003) and IgA (p=0.011), were significantly correlated with severe PAD. Group A patients with positive immunohistochemical examination of the plaque, had higher anti-Cp IgA levels (p=0.023) and TNF-alpha values (p=0.031), compared to the IHC negative patients. C. pneumoniae was detected in 50% of the femoral atheromas, but in only 3.6% of the veins. CONCLUSION: This study supports the hypothesis that inflammation (CRP) and chronic C. pneumoniae infection (IgA seropositivity), have an important role in lower limb atherosclerosis and correlate with the severity of the disease.

Inflammation and atherosclerosis.

PURPOSE: The aim of this article is to discuss the role of inflammation in atherosclerosis. SUMMARY: An initial chemical, mechanical or immunological insult induces endothelial dysfunction. This triggers a cascade of inflammatory reactions, in which monocytes, macrophages, T lymphocytes and vascular smooth muscle cells participate. Leukocyte adhesion molecules, cytokines, growth factors and metalloproteinases participate in all stages of atherogenesis. Almost all of the traditional risk factors for atherosclerosis are associated with and participate in the inflammatory process. Many infectious agents, mainly Chlamydia pneumoniae, have been proposed as potential triggers of the cascade. The immune system has been implicated in plaque formation, through the activation of cellular and humoral immunity against innate or microbial heat shock protein 60. Methods of detection of systemic or local plaque inflammation have been developed and research is being conducted on the potential use of anti-inflammatory and antibiotic drugs in atherosclerosis.

Hemostatic function and carotid artery disease.

AIM: Since conventional risk factors predict less than one half of future cardiovascular events, other factors that contribute to atherogenesis need to be evaluated. The aim of this study was to investigate whether clotting factors are associated with carotid artery disease. Furthermore, we tried to determine whether clotting factors could be used to predict the risk of cerebrovascular events in patients with internal carotid artery stenosis. METHODS: Twenty-six patients with high-grade (>70%) internal carotid artery stenosis and 43 age-matched controls were evaluated for atherogenic risk factors and hemostatic function. Laboratory tests included plasma assays of fibrinogen, tissue plasminogen activator (TPA), D-dimer, plasminogen activator inhibitor 1 (PAI-1), plasminogen and factor VII:c. Nineteen (72%) patients had history of stroke or transient ischemic attack, while the remaining 7 (28%) were asymptomatic. Statistical analysis was performed using multiple linear regression analysis. RESULTS: Carotid artery stenosis was associated with high levels of TPA (p<0.001), D-dimer (p=0.019) and PAI-1 (p<0.001). No statistically significant correlation was found between the presence of carotid artery disease and the levels of fibrinogen (p=0.28), plasminogen (p=0.96) or factor VII:c (p=0.19). As regards the clinical manifestations, none of the studied clotting factors was correlated with the history of cerebrovascular events in the patients with carotid stenosis. CONCLUSION: The results of this study show that the hemostatic system may play a role in the development of carotid artery atherosclerotic disease, while it does not seem to affect the development of symptoms in patients with carotid stenosis.

Changes of the infrarenal aortic segment after conventional abdominal aortic aneurysm repair.

OBJECTIVES: to delineate the natural history of the residual infrarenal aortic segment after conventional abdominal aortic aneurysm (AAA) repair. DESIGN: open prospective study. PATIENTS AND METHODS: between 1990 and 1997, 100 patients, who underwent conventional infrarenal AAA repair at our department, were followed annually by means of colour duplex ultrasonography. Data from 76 patients who had at least 3 scans were analysed. RESULTS: mean duration of follow-up was 4.7 years (range: 3-8 years). The residual infrarenal aorta dilated a mean of 0.57 mm annually. No patient required reoperation. There was no significant correlation between dilatation and any of the recorded risk factors except for the initial neck diameter (p=0.03). CONCLUSIONS: conventional AAA surgery is durable so that surveillance, during the first 5 postoperative years, is not justified in terms of cost-effectiveness. The impact of such a dilatation on endovascular AAA repair requires further investigation.

Ampullary carcinoid and jejunal stromal tumour associated with von Recklinghausen's disease presenting as gastrointestinal bleeding and jaundice.

We report a very rare case of a 36-year-old woman with von Recklinghausen's disease, synchronous carcinoid of the ampulla of Vater and stromal tumour of the jejunum, who presented with gastrointestinal bleeding and jaundice.

Internal carotid artery stenosis: rate of progression.

OBJECTIVES: to assess the incidence and the rate of progression of internal carotid artery (ICA) stenosis and to determine the related risk factors. DESIGN: open prospective study. MATERIALS AND METHODS: between 1988-1997, 442 carotid arteries with various degrees of stenosis were followed using colour duplex ultrasonography every 6 months. Of these arteries, 290 (66%) were asymptomatic, 62 (14%) had caused transient ischaemic attack and 90 (20%) a stroke. In 145 cases (33%), there was concomitant coronary artery disease (CAD), in 134 (30%) diabetes mellitus, in 248 (56%) hypertension, in 139 (31%) hypercholesterolaemia and in 370 (84%) history of smoking. Of the plaques, 44 (10%) were uniformly echolucent, 19 (4%) haemorrhagic, 136 (31%) predominantly echolucent, 146 (33%) predominantly echogenic and 97 (22%) uniformly echogenic. RESULTS: significant progression of stenosis occurred in 82 cases (19%). The mean progression rate in these cases was 15% annually (range: 5-50%). There was no statistically significant correlation between the progression of the ICA stenosis and initial neurological status, age, gender, diabetes mellitus, hypertension, hypercholesterolaemia and smoking habit. Stenosis progression was correlated only with CAD and the ultrasonographic characteristics of the plaques. Patients with CAD as well as those with uniformly echolucent plaques presented a higher incidence and rate of stenosis progression (p<0.05). CONCLUSIONS: progression of internal carotid artery stenosis occurred in 19% of cases. The mean progression rate in these patients was 15% annually and was correlated with CAD and the ultrasonographic characteristics of the plaque.

Aneurysms of the distal branches of the external carotid artery.

Aneurysms of the distal branches of the external carotid artery are rare and usually traumatic in origin. We present two cases which were treated in our clinic. The first case is about a traumatic aneurysm of the left superficial temporal artery (STA) in a young boy 8 years old. The young patient developed a pulsatile mass above his left eyebrow ten days after a bite by a boy of the same age. The second case is referred in a 36-year old woman with a pulsatile mass behind the right ear, which was an aneurysm of the posterior auricular artery. The treatment was ligation and resection under local anesthesia in the first case and under general anesthesia in the latter. Surgeons' familiarity with this entity is important for diagnosis and treatment.