A case of disseminated tuberculosis mimicking metastatic cancer.

BACKGROUND: Disseminated tuberculosis (TB) or miliary TB is defined as lymphohematogenous dissemination of Mycobacterium tuberculosis bacilli, which may then affect virtually any organ system. The multiple organ involvement in disseminated TB can mimic metastatic cancer and can make the diagnosis challenging. False negatives are common therefore repeating microbiologic and histologic samples is essential. CASE REPORT: We report the case of a young immunocompetent patient presenting with multiple atypical extra-pulmonary TB involvement. The patient presented with pulmonary, pleural, bilateral testicular and multiple bone involvement including calcanerium abscesses. These lesions were initially described as metastasis by the radiologist. Therefore lymphoma and metastatic testicular cancer as well as TB were high on the differential in this young foreign-born male. Pleural, broncho-alveolar lavage, bone marrow and cerebrospinal fluid acid-fast bacilli smear and microbiologic culture were all negative. However the histologic examination of the trans-bronchial biopsy and pleural biopsy showed necrotizing granuloma and helped to narrow down the diagnosis. The patient improved with RIPE therapy. CONCLUSION: This case illustrates the diagnostic difficulty of disseminated TB with atypical organ involvement. Culture is the gold standard for diagnosing TB but is a long process and with 23% of culture negative TB in the United-States, the diagnosis sometimes relies on thoroughly ruling-out differential diagnosis and histologic examination.

New oral anticoagulants vs. warfarin treatment: no need for pharmacogenomics?

For patients requiring long-term anticoagulation, oral vitamin K antagonists (VKAs) such as warfarin have overwhelming efficacy data and present significant challenges. In addition to the potential exposure to numerous drug-drug and drug-food interactions, patients receiving warfarin require frequent monitoring. It had been hoped that the integration of pharmacogenomic with clinical information would improve anticoagulation control with warfarin, but trials have not supported this aim. Novel oral anticoagulants (NOACs) offer both advantages and disadvantages and deserve consideration in appropriate patients.

Two-dimensional, electrostatic finite element study of tip-substrate interactions in electric force microscopy of high density interconnect structures.

Two-dimensional electrostatic finite element modeling is used to estimate the variation of tip force as a function of potential, dielectric film thickness, and tip-substrate spacing when imaging using electric force microscopy. Blanket dielectric films and approximately 1000 nm thick interconnect structures were studied. We conclude that sidewall damage regions can be detected but will require special processing to make an unambiguous measurement.

A prospective randomized trial of urokinase as an adjuvant in the treatment of proven Hickman catheter sepsis.

BACKGROUND/PURPOSE: Chronic vascular access catheters have become an important adjunct to the treatment of children with complex medical diseases, particularly malignancy. One of the major complications of chronic venous access devices is bacterial infection of the catheter site and bloodstream. Infusion of systemic antibiotics directly into the catheter has been the standard initial therapy with failure leading to catheter removal and replacement. It has been suggested by a number of investigators that the addition of urokinase as a thrombolytic agent to lyse any accumulated thrombus or fibrin would increase the successful catheter clearance by antibiotics. This study was designed as a prospective, randomized trial to compare treatment of children with positive catheter blood cultures with either antibiotics alone or in combination with urokinase 5,000 U boluses 12 and 24 hours after study entry. METHODS: A total of 63 patients were entered in the study. Thirty-three received antibiotics and urokinase, and 30 received antibiotics alone. RESULTS: A total of 45 catheters (71%) were cleared of infection and salvaged. Treatment failures leading to catheter removal occurred in 9 of 33 in the experimental group and 9 of 30 in the control population (no significant difference). CONCLUSIONS: Urokinase could not be shown to act as an adjuvant in the clearance of infection from chronic central venous access catheters that had no evidence of clot or thrombus. This study required the performance of a dye study and excluded any patient with a known thrombus. This conclusion must therefore be limited to patients with no evidence of a clot or fibrin sheath.

Overcoming a kinked peel-away sheath during central line implantation.

In pediatric patients, central line implantation via the subclavian vein can be complicated by the presence of a kink in the peel-away sheath. A technique is described, which has been used on 62 occasions to overcome this problem. Reinserting the catheter through the kinked peel-away sheath in concert with a guidewire that extends 3 to 4 cm beyond the catheter tip can ensure successful placement.

Management of pulmonary blastoma in children.

Pulmonary blastoma is a rare neoplasm, accounting for 0.5 per cent of all primary malignant pulmonary tumors. The clinical features, radiologic findings, and management of five children with pulmonary blastoma are described. The female/male ratio was 4:1. Mean age at presentation was 34 months, with a mean duration of symptoms of 1.8 months. Fever and cough were the most common symptoms. Opacification of the right lung field with mediastinal shift to the left was the predominant roentgenologic feature. The tumor involved the right chest in all patients. Thoracotomy was performed in all patients to establish the diagnosis. Two patients underwent complete resection at the initial operation, an incomplete resection was performed in one patient. Delayed complete resection was performed in another patient. All the patients received combination chemotherapy and one patient also received radiotherapy for primary disease. Two patients with histologic and immunohistochemical evidence of striated muscle differentiation were treated as rhabdomyosarcomas. Both these patients have survived for 24 and 67 months after diagnosis. The tumor recurred in three patients. Recurrence was treated with a combination of surgery, chemotherapy, and radiotherapy. Overall disease-free survival rate was 40 per cent. Long-term follow-up and additional patients are required to provide prognostic information.

Measles epidemic: impact on pediatric oncology patients.

Measles, a preventable disease, is again epidemic in the United States and is a threat to the immunocompromised pediatric oncology patient. In response to this latest epidemic, the Immunization Practices Advisory Committee has revised its recommendations for controlling an outbreak and has changed childhood immunization to a two-dose schedule. Full understanding of measles management is needed to effectively protect the pediatric oncology patient during the current epidemic. This article reviews the epidemiology, clinical presentation and management of measles, including recommendations for vaccinations, exposures, isolation, and patient and family education.

Dental care experience of HIV-positive patients.

Three studies were conducted to assess the experiences of persons with acquired immune deficiency syndrome (AIDS) or risk factors for the disease in seeking dental care in Los Angeles; San Francisco; Seattle; and Tacoma, WA. Given previous reports from surveys of dentists that they would be reluctant to provide care to people from these groups, widespread denial of care was expected. Our two surveys conducted in San Francisco, however, showed that only 1.3% and 10.8% had been denied care by a dentist. These data suggest that dentist reactions to people with AIDS are more favorable than has previously been suggested, although denial of care is still a problem to some extent.

Phase II trial of combination chemotherapy of colonic cancer with 5-fluorouracil, mitomycin C, and hexamethylmelamine.

HexMF consists of hexamethylmelamine 150 mg/m2 D2-15, mitomycin C (MMC) 10 mg/m2 D2 and 5-fluorouracil (5-FU) 30 mg/kg/day as a continuous infusion D1-5 in 4-5 week cycles. It was designed as an alternative to treating patients with standard single agents in sequence, thereby preventing the testing of new drugs as part of primary therapy. Median survival was 12+ months for patients with measurable and 18+ months for patients with nonmeasurable colorectal cancer. It was 9+ months from the onset of secondary chemotherapy. Toxicity included severe thrombocytopenia (50%), severe leukopenia (25%), and moderate stomatitis (50%). Only one instance of leukopenia was life-threatening. The MMC and 5-FU infusion skeleton provides an attractive strategy for testing new drugs as primary therapy. HexMF itself has a potentially broad antitumor spectrum and excellent acceptance by patients. It is suitable for additional phase II trials.

Phase II trial of combination chemotherapy for pancreatic cancer with 5-fluorouracil, mitomycin C, and hexamethylmelamine.

A combination consisting of hexamethylmelamine 150 mg/m2 D2-15, mitomycin C 10 mg/m2 D2 and 5-fluorouracil 30 mg/kg/day as a continuous infusion for 5 days, in 4-5 week cycles, underwent phase II trial as primary therapy for 21 patients with regional and metastatic cancer of the pancreas. Median survival from the onset of therapy was 43 weeks. There were 2 complete responses, 4 minor responses and 6 stable diseases for more than 6 months. Nonambulatory patients were among the responders. There was only 1 life-threatening toxicity (thrombocytopenia) and only 33% of patients had clinically silent severe hematological toxicity. The regimen is well tolerated, active and associated with excellent survival. This regimen is suitable for further confirmatory trials.

Onset of insomnia: role of life-stress events.

During the year their insomnia began, chronic insomniacs experienced a greater number of stressful life events compared with previous or subsequent years and compared with good sleepers. In addition, among the life event categories assessed, insomniacs reported a greater number of undesirable events, particularly events related to losses and to ill health. They also had lifelong histories of more illnesses and somatic complaints, beginning with more childhood illnesses and more childhood problems related to eating and sleeping. During childhood, insomniacs reported more frequent discontent with their families, and prior to the onset of insomnia, they had less satisfying relationships with their parents as well as problems in other interpersonal relations and in their self-concepts. Currently, insomniacs felt considerably less satisfied with their lives, had lower self-concepts, and had greater difficulty with interpersonal relationships. Thus, stressful life events, mediated by certain predisposing factors of personal vulnerability, were found to be closely related to the onset of chronic insomnia.

Anxiety and depression associated with caffeinism among psychiatric inpatients.

Among 83 hospitalized adult psychiatric patients, 22% reported being high caffeine consumers (750 mg or more per day); these patients scored significantly greater on the State-Trait Anxiety Index and the Beck Depression Scale than moderate and low consumers. High consumers described significantly more clinical symptoms, felt that their physical health was not as good, and reported greater use of sedative-hypnotics and minor tranquilizers. Since caffeine modifies catecholamine levels, inhibits phosphodiesterase breakdown of cyclic AMP, and sensitizes receptor sites, association of caffeinism with both anxiety and depressive symptoms is possible.