[Malignant struma ovarii]. / Maligne struma ovarii.

A 46-year-old patient underwent exploratory laparotomy due to indications of ovarian malignancy. Bilateral salpingooophorectomy, total abdominal hysterectomy, omentectomy and lymphadenectomy were performed, but no residual tumour was seen. Histopathological examination of postoperative specimens revealed malignant struma ovarii, a very rare condition. The patient had a low risk of disease progression (T1>1cmN0M0). Management consisted of initial conservative follow-up, which included administration of thyroid-stimulating hormone (TSH) suppression therapy with levothyroxine.

A bleeding disorder caused by a cardiac tumor: case report.

A 22-year-old female developed symptomatic thrombocytopenia. On physical examination, apart from ecchymoses, a loud holosystolic murmur was heard. Echocardiography revealed a cardiac tumor. The thrombocytopenia did not respond to corticosteroids, but after surgical removal of the intracardiac tumor, a papillary fibroelastoma, the platelet count normalised. There are no similar case reports in the literature. Our case report illustrates that thrombocytopenia may be associated with a cardiac tumor and that complete physical examination is essential in every patient presenting with easy bruising.

Pulmonary hypertension with limited cutaneous scleroderma (CREST syndrome).

A patient is described with a typical manifestation of pulmonary hypertension associated with limited cutaneous scleroderma, also known as CREST syndrome. The patient was treated with a calcium antagonist, oral anticoagulation and, because of evidence for parenchymal inflammation of the lung, with low-dose prednisone and cyclophosphamide. This treatment resulted in initial improvement of diffusion capacity and exercise tolerance, however, 1 year after diagnosis the patient died of progressive pulmonary hypertension.

Evolution of the clinical manifestations of infection during the course of febrile neutropenia in patients with malignancy.

The impact of a standardized set of diagnostic interventions on the further management of 968 episodes of fever in neutropenic cancer patients who did not respond to initial therapy was assessed prospectively. At the onset of fever, 65% of patients had no additional signs of infection, whereas skin and soft tissue infections were present in 12%, and clinical sepsis and gastrointestinal infections in 8% each. After 72 h, 41% of the fevers still remained unexplained. New foci of infection emerged in 11% of the cases involving mainly the lungs, skin and soft tissues, and urinary tract. The presence of a lower respiratory tract infection or a microbiologically defined infection of any sort was associated with higher mortality than other types of infection were. Changes in initial antibiotic therapy were based on the results of the diagnostic measures specified in the protocol in only 15% of the cases.

Serial monitoring of Aspergillus antigen in the early diagnosis of invasive aspergillosis. Preliminary investigations with two examples.

A recently developed sandwich ELISA, which detects Aspergillus galactomannan, was tested retrospectively in serial serum samples from an allogeneic bone marrow transplant recipient with proven invasive aspergillosis (patient 1) and another with suspected disease (patient 2). Galactomannan was detected in the serum 4 and 28 days, respectively, before pulmonary infiltrates suggestive of fungal infection first became apparent on the chest X-ray. Aspergillus was detected by ELISA and PCR in BAL fluid samples from both patients, and in CSF from patient 1. The diagnosis was confirmed at autopsy for patient 1 by histopathology and the recovery of Aspergillus fumigatus from the lung and brain. Furthermore, in both patients the course of the antigen titer in the serum during antifungal treatment corresponded with the clinical outcome. These results confirm that the sandwich ELISA appears to be useful for the early diagnosis of invasive aspergillosis. The value of the test for monitoring the response to antifungal treatment remains to be established in prospective trials.

Early identification of neutropenic patients at risk of grampositive bacteraemia and the impact of empirical administration of vancomycin.

The aim of this multicentre randomised trial was to determine whether it was possible to predict grampositive bacteraemia, and whether the empirical use of vancomycin would lead to reduced morbidity and mortality. 35 of 113 patients (31%; confidence interval, CI 8.5), who presented with a skin or soft tissue infection and had received empirical vancomycin in addition to either ceftazidime or piperacillin-tobramycin, had initial bacteraemia with a single gram-positive bacterium compared with 135 of the 784 (17%; CI 2.6), who presented with another infection and who had been given ceftazidime or piperacillin-tobramycin without vancomycin (P < 0.001). Empirical vancomycin resulted in a higher rate of eradication (P = 0.033, relative risk 1.2), but not a better clinical outcome and was associated with more toxicity (P = 0.042, relative risk 1.6). Irrespective of the initial treatment regimen, fever lasted an average of 8 days, the empirical regimen was modified in more than 50% of cases and mortality attributed to gram-positive infection was less than 2%. Incorporating vancomycin in the initial empirical antibiotic regimen for febrile neutropenic patients does not appear necessary, even for skin and soft tissue infections associated with gram-positive bacteraemia.

Antibiotic strategy after the empiric phase in patients treated for a hematological malignancy.

Empiric broad-spectrum antibiotic therapy has become a generally accepted strategy in the treatment of febrile neutropenic patients. Particularly in patients with prolonged neutropenia, subsequent adaptation of such a regimen will be the rule rather than exception. Since there are no uniformly accepted guidelines for the modification of antibiotic therapy during the post-empiric phase, we assessed the impact of a set of rules that evolved during the first randomized trials. Evaluation of the clinician's compliance with these rules in 1951 febrile neutropenic episodes was the subject of the present analysis. Treatment was modified in 761 (39%) cases, and these changes were made according to the rules in 76%. For 75% of the alterations in treatment during the evening and night shifts, no reasonable explanation was established, while 93% of the modifications during the normal working hours were made for objective reasons. The empiric regimen was more frequently changed in patients with a clinical focus of infection at the onset of fever than in patients who showed fever as the only symptom of a possible infection. The perceived need for modification amounted to 69% in pulmonary infections, to 51% in skin and soft-tissue infections, to 44% in patients with abdominal complaints, and to 37% in upper respiratory tract infections. Glycopeptides constituted 22% of modifications, particularly in patients with a central venous catheter, and systemically active antifungals were administered in 16% of cases. Especially inexperienced clinicians tend to adjust antibiotic therapy, in spite of the fact that persistence of fever alone seldom reflects inadequate treatment when the clinical condition of the patient is stable or improving. On the other hand, the development of subsequent infectious events emphasizes that a genuine need for modification does frequently exist.

Pre-emptive administration of corticosteroids prevents the development of ARDS associated with Streptococcus mitis bacteremia following chemotherapy with high-dose cytarabine.

Adult respiratory distress syndrome (ARDS) complicating Streptococcus mitis bacteremia is a major cause of mortality in patients undergoing therapy for leukemia. In order to try to prevent the development of ARDS in 11 patients with S. mitis bacteremia following chemotherapy including cytarabine, high doses of corticosteroids were administered pre-emptively. None of these patients developed ARDS. In a historical control group of 21 comparable patients who had not been given corticosteroids, the incidence of ARDS was high (38%), with a death rate of 14%. Preemptive administration of high-dose corticosteroids appeared to be highly effective in suppressing the mechanisms that induce ARDS in patients with S. mitis bacteremia after cytarabine treatment. The results suggest that ARDS complicating S. mitis bacteremia is not merely a microbiological problem but may, at least in part, represent an immunologically mediated phenomenon.

Assessment of pinacidil in patients with primary Raynaud's phenomenon.

In fourteen patients with primary Raynaud's phenomenon we performed a double-blind, controlled study, comparing single doses of 12.5 and 25 mg of the potassium channel opener pinacidil with placebo and the active control nifedipine in randomised order. The main response criterium was the area under the curve (AUC) of the photoelectric plethysmography (PEP) during cooling and rewarming, performed 2-3 hours after administration of the study medication. Single doses of 12.5 and 25 mg pinacidil were shown not to be superior to placebo in respect of the AUC of PEP. Nifedipine, on the contrary, was significantly better than placebo. We conclude that no efficacy can be expected from the potassium channel opener pinacidil in the treatment of primary Raynaud's phenomenon. The efficacy of nifedipine cannot be explained from central rheological effects, as total blood viscosity was the same after pinacidil, nifedipine and placebo.

Transcutaneous electrical nerve stimulation (TENS) in Raynaud's phenomenon.

Transcutaneous nerve stimulation (TENS) has been described as resulting in vasodilatation. The effect of 2 Hz TENS of the right hand during forty-five minutes on skin temperature and plethysmography of the third digit of both hands and feet and on transcutaneous oxygen tension (TcpO2) of the right hand was compared with that of a control study using indifferent stimulation of the iliopsoas region in 8 patients with primary Raynaud's phenomenon. After TENS a slight increase in skin temperature of both hands was found, while plethysmographic amplitude was increased in the contralateral hand only. No changes in TcpO2 occurred. The authors conclude that the observed small effects of TENS are of no clinical value in primary Raynaud's phenomenon.

Familial increased serum intestinal alkaline phosphatase: a new variant associated with Gilbert's syndrome.

Investigation of mild, inherited increased serum alkaline phosphatase activity partially combined with Gilbert's syndrome in one family showed, apart from a normal liver fraction, an intestinal isoenzyme pattern and an extra band in the agar electrophoresis. Analysis by agarose electrophoresis before and after incubation of neuraminidase showed that the extra fraction was an intestinal variant isoenzyme. The precise genetic background of the two disorders in this family could not be determined from the available data. Abnormal activities of (regular) intestinal alkaline phosphatase isoenzyme caused the increase in serum alkaline phosphatase in the absence of disease.