Myocarditis in Whipple's disease: an unsuspected cause of symptoms and sudden death.

Whipple's disease (WD) is an uncommonly diagnosed infection caused by the recently characterized bacillus, Tropheryma whippelii. The association of WD with pericarditis and endocarditis is widely recognized, although less attention has been paid to the myocardium as a site of disease. Although the disease was uniformly fatal before antibiotic therapy, current treatment usually results in cure. We report two patients whose deaths were directly related to cardiac involvement by WD and whose underlying disease escaped diagnosis for years. The first, a 60-year-old white woman, suffered a cardiovascular collapse, and lymphocytic myocarditis was demonstrated at autopsy. The second, a 48-year-old black man, had a lengthy history of progressive cardiac failure that terminated in arrhythmia. Extensive myocardial fibrosis, with lymphocytic and granulomatous inflammation, was demonstrated at autopsy. The presence of T. whippelii was confirmed by electron microscopic examination in both cases and by polymerase chain reaction in one. Patients with WD might harbor an undiagnosed lymphocytic or granulomatous myocarditis, and this diagnosis should be considered in the evaluation of cardiac failure.

A study of clinicians' responses to abnormal laboratory data as a function of diagnostic related group and test classification by College of American Pathologists criteria.

This study reports the frequency of new clinical orders, diagnoses, or testing after initial abnormal results of selected serum chemistry tests in 122 hospitalized patients at a Veterans' Administration Hospital. This study also reports the frequency of new orders, diagnoses, or testing after initial abnormal test results in relation to the test's classification as basic, common, less common, or unlisted in the workup and management of patients belonging to 24 common diagnostic related groups as classified by the College of American Pathologists. By chart review, initial abnormalities of serum potassium, creatinine, or blood urea nitrogen were most frequently followed by changes in treatment. For tests categorized as basic, abnormal creatinine and potassium were always followed by changes in treatment. Results were similar for tests categorized as common. Few abnormalities were found in tests categorized as less common.

Hemorrhagic adrenal adenoma simulating myelolipoma: CT evaluation.

We present a hemorrhagic adrenal adenoma surrounding and encompassing adjacent retroperitoneal fat to simulate the appearance of a myelolipoma by CT. A well-defined fibrous capsule, punctate calcification, and several macroscopic foci of fat within the mass led to an erroneous preoperative diagnosis. Lesions displaying large amounts of soft tissue attenuation material in addition to fat preclude a confident diagnosis of myelolipoma and should undergo directed percutaneous needle biopsy or surgery.

Death from renal cyst.

Simple renal retention cysts are the most common masses of the kidney, but rarely cause any clinical difficulty, are usually without attendant symptoms, generally posing only a differential diagnostic problem when discovered. However, renal cysts can predispose to hemorrhage, particularly in a setting of anticoagulation therapy. In this case, the patient died of massive hemorrhage from a small renal cyst while under anticoagulation treatment.

Recurrent arteriotracheal fistula.

A 28-year-old man with a tracheostomy had two episodes of hemorrhage from an arteriotracheal fistula secondary to erosion of the cannula tip into the right subclavian and the right common carotid arteries. Arteriotracheal fistual formation is associated with high pressure cuffs, low tracheostomies, excessively long or curved tracheostomy tubes, mediastinal infections, and superiorly placed anatomic variants of the innominate artery. Repeat fistula formation can be anticipated until the underlying factor is eradicated.

Primary amyloidosis, pure red cell aplasia, and Kaposi's sarcoma in a single patient.

A patient who developed primary amyloidosis, pure red cell aplasia, and Kaposi's sarcoma is described. This is the second reported coincidence of Kaposi's sarcoma and pure red cell aplasia and the first coincidence of Kaposi's sarcoma and primary amyloid, thus enlarging the spectrum of plasma cell and immunoglobulin abnormalities seen in Kaposi's sarcoma. Because immunologic abnormalities have been described in all these diseases, it is felt that some primary immune dysfunction is the underlying cause of the three diseases in this patient.

Concentration of Tc-99m methylenediphosphonate in hepatic metastases from squamous cell carcinoma.

A case is described in which Tc-99m methylene diphosphonate concentrated in a hepatic metastasis from esophageal squamous cell carcinoma. We observed radiopharmaceutical concentration in the hepatic metastases, which was probably related to the presence of necrosis with calcification.

Ulcer occurring in Zenker's diverticulum.

The radiographic and pathologic findings of a Zenker's-type diverticulum containing multiple ulcers are described. This rare complication probably represented peptic ulceration of the diverticular mucosa resulting from reflux of the gastric content.

Serum enzyme alterations in hypothyroidism before and after treatment.

Recognition of a pattern of elevations in commonly measured serum enzymes [creatine phosphokinase (CPK), lactic dehydrogenase (LDH), and glutamate oxalacetate transaminase (SGOT)] can facilitate the diagnosis of hypothyroidism, especially when muscle weakness is a symptom. Elevated levels of serum cholesterol, total protein, and albumin further contribute to a chemical profile of hypothyroidism, which can be observed in a routine chemistry screening test such as that obtained with the SMA 12/60 AutoAnalyzer. An illustrative case concerns a 50-year-old man who presented with angina pectoris and leg weakness. Subsequently he was found to have severe hypothyroidism. Special attention is given to the serum enzyme values which initially were elevated and fell to normal levels during thyroid replacement therapy. Isoenzyme fractionation of LDH and CPK indicated skeletal muscle as the source of the elevated enzyme activity. The literature on enzyme abnormalities in hypothyroidism is reviewed, with special reference to hypothyroid myopathy.