A rare cause of acute pancreatitis: ischemia caused by free-floating intraluminal aortic thrombus.

BACKGROUND/AIM: Acute pancreatitis is a common gastrointestinal condition worldwide with variable severity and complications. Alcohol and gallstones are the leading causes of acute pancreatitis, while pancreatic ischemia is uncommon. Although venous thrombosis, especially adjacent to the inflamed pancreas, is a common complication of acute pancreatitis, arterial thrombosis secondary to pancreatitis has rarely been described. On the other hand, arterial thromboembolic events, secondary to cardiovascular diseases, are a rare cause of pancreatic ischemia. Herein, we present an interesting case of acute ischemic pancreatitis secondary to aortic atheromatosis complicated with multi-organ infarcts. DESCRIPTION OF THE CASE: An 80-year-old male patient presented with nausea, abdominal pain, and vomiting accompanied by peripheral edema and ascites. Clinical, laboratory, and imaging investigation showed acute moderate to severe pancreatitis with multiple splenic and renal infarcts. An intraluminal free-floating aortic thrombus, secondary to atheromatosis of the descending aorta, was the cause of the complications. A conservative approach was successfully implemented, including supportive measures, antiplatelets, and vasodilators. CONCLUSION: Identification of acute pancreatitis' cause, especially in the setting of a systemic disease like atheromatosis, is a challenging task and of great importance, given the implications on treatment decision-making and prevention of recurrent episodes. HIPPOKRATIA 2021, 25 (3):138-140.

Upper extremity pleomorphic dermal sarcoma in a patient with chronic myelomonocytic leukemia.

BACKGROUND: Pleomorphic dermal sarcoma is a potentially high-grade cutaneous spindle cell tumor that closely resembles atypical fibroxanthoma in the superficial, dermal aspects but with adverse pathological features. Chronic inflammation, as several autoimmune disorders are co-associated with chronic myelomonocytic leukemia. CASE DESCRIPTION: We report here an 84-year-old male patient with swelling lump on the upper third of the left arm. Previously he suffered from a type I chronic myelomonocytic leukemia. Based on the initial ultrasound-guided biopsy of the lesion, the histopathological examination revealed an atypical fibroxanthoma. A wide local excision was performed and the diagnosis was revised to pleomorphic dermal sarcoma by the pathologist, based on the currently accepted criteria. Adjuvant radiotherapy was performed. CONCLUSION: Differentiating between atypical fibroxanthoma and pleomorphic dermal sarcoma is pivotal. A partial sampling of the skin lesion poses a significant pitfall, as important diagnostic features cannot be assessed. Immunosuppression seems to be involved in the pathogenesis of chronic myelomonocytic leukemia and pleomorphic dermal sarcomas, because of the advanced patient age. HIPPOKRATIA 2019, 23(4): 181-185.

Symptomatic abdominal simple cysts: is percutaneous sclerotherapy with hypertonic saline and bleomycin a treatment option?

Aim. To evaluate the feasibility of percutaneous sclerotherapy of symptomatic simple abdominal cysts, using hypertonic saline and bleomycin, as an alternative to surgery. Materials and Methods. This study involved fourteen consecutive patients (ten women, four men, mean age: 59.2 y) with nineteen symptomatic simple cysts (liver n = 14, kidney n = 3, and adrenal n = 2) treated percutaneously using a modified method. Initially CT-guided drainage was performed; the next day the integrity of the cyst/exclusion of extravasation or communications was evaluated under fluoroscopy, followed by two injections/reabsorptions of the same quantity of hypertonic NaCl 15% solution and three-time repetition of the same procedure with the addition of bleomycin. The catheter was then removed; the patients were hospitalized for 12 hours and underwent follow-ups on 1st, 3rd, 6th, and 12th months. Cyst's volumes and the reduction rate (%) were calculated in each evaluation. Results. No pain or complications were noted. A significant cyst's volume reduction was documented over time (P < 0.001). On the 12th month 17 cysts disappeared and two displayed a 98.7% and 68.9% reduction, respectively. Conclusion. This percutaneous approach constitutes a very promising nonsurgical alternative for patients with symptomatic simple cyst, without complications under proper precautions, leading to eliminating the majority of cysts.

Body fat distribution by anthropometric and MRI-based techniques in relation to insulin secretion and action in men with diabetes.

AIM: Differences in fat accumulation and distribution might be responsible for the greater insulin resistance (IR) in type 2 diabetes. The study aims at examining the relationship between fat accumulation and distribution, and insulin secretion and action, by multilevel methodological approach. METHODS: Thirty-three diabetic men (D), and 28 sex, age and BMI-matched controls (C) were studied for glucose and insulin during OGTT, insulin resistance and sensitivity, employing HOMA and Matsuda index respectively, and, fat accumulation and distribution by anthropometrics, Bioimpendance Analysis (BIA), and multiple slices MRI of abdomen and hip. RESULTS: D exhibited higher HOMA compared to C (P<0.001), and lower Matsuda index (P=0.062). No differences in fat distribution by anthropometric or MRI measurements were observed; however, fat accumulation by BIA was higher in D (P=0.035). HOMA correlated to basal, AUC, and peak insulin in both groups (all P<0.001); with weight (r=0.415, P=0.031), hip circumference (HC) (r=0.482, P=0.011), %fat (r=0.400, P<0.05) in C; and with weight, BMI, total and %fat, and waist and HC when all subjects were considered as a group. Matsuda inversely correlated with basal, AUC, and peak insulin (all P<0.001), and HC (r=-0.406, P=0.032) in C. HOMA strongest correlated with L3-L4 subcutaneous (r=0.551, P=0.003) in C, and with L3-L4 visceral (r=0.456, P=0.022) in D. CONCLUSION: The greater IR in diabetic patients may not be interpreted by differences in fat distribution. IR correlates with different fat compartments in healthy and diabetic subjects of comparable fat distribution, suggesting differences in fat function.

A study on the age dependency of gustatory states: low-frequency spectral component in the resting-state MEG.

Magnetoencephalography (MEG) recordings were evaluated for 25 healthy female volunteers, in five different gustatory states: normal, sweet, bitter, sour and salty. The study population was divided in two groups according to age: group A (10-19 years old) and group B (20-30 years old). There was a higher count of low frequencies (2 Hz) and a lower count of high frequencies (7 Hz) with increasing age, in all studied states. We compared each state for the frequencies of 2 Hz and 7 Hz between the two groups. Statistically significant differences were found in the normal and sweet states for the frequencies of 2 Hz and 7 Hz and in the salty taste in the frequency of 7 Hz. We also intra-compared the five states in group A and the five states in group B for the 2 Hz and 7 Hz frequencies. The results were not statistically significant. A differentiation in the distribution of the frequencies with increasing age may provide new insights into the age-dependence of taste quality brain centers.

Docetaxel plus gemcitabine in combination with capecitabine as treatment for inoperable pancreatic cancer: a phase II study.

PURPOSE: To evaluate the activity and tolerance of gemcitabine in combination with docetaxel and capecitabine in previously untreated patients with advanced pancreatic cancer. PATIENTS AND METHODS: Chemotherapy-naïve patients with locally advanced or metastatic pancreatic cancer were treated with gemcitabine (1,500 mg/m(2) on days 1 and 15), docetaxel (50 mg/m(2) on days 1 and 15) and capecitabine (2,250 mg/m(2), orally in two daily divided doses, on days 1-7 and 15-21). All three drugs were administered in 4-week cycles, in an initial prospective plan of six cycles. The primary end-point was response rate. RESULTS: Forty patients were enrolled in the study. At the time of enrollment, 40% of patients had locally advanced and 60% metastatic disease. All patients were evaluable for response and toxicity. On an intent-to-treat analysis, the overall response and disease control rates were 40 and 80%, respectively. The median progression-free survival was 6.0 months, and the median overall survival was 9.0 months. Major grade 3/4 toxicities were neutropenia (17.5%), diarrhea (10%) and hand-foot syndrome (7.5%). There was no treatment-related death. CONCLUSION: The combination of gemcitabine with docetaxel and capecitabine is feasible and exhibits satisfactory degree of activity in patients with advanced pancreatic cancer, deserving further exploration.

Extracranial venous hemodynamics in multiple sclerosis: a case-control study.

OBJECTIVES: A chronic state of impaired cerebral and cervical venous drainage, termed chronic cerebrospinal venous insufficiency (CCSVI), has recently been implicated in the pathogenesis of multiple sclerosis (MS). We performed a color-coded Doppler sonography case-control study to externally validate the CCSVI criteria. METHODS: We prospectively evaluated consecutive patients with clinically definite MS and healthy volunteers using extracranial and transcranial color-coded Doppler sonography. The recently developed neurosonology criteria for CCSVI detection were used for interpretation of ultrasound assessments. The presence of venous reflux in cervical veins was assessed both in the sitting and upright position during a short period of apnea and after Valsalva maneuver. RESULTS: We recruited 42 patients with MS (mean age 39 ± 11 years, 17 men) and 43 control individuals (mean age 38 ± 12 years, 16 men). Very good/excellent intrarater and interrater agreement (κ values 0.82-1.00) was documented in 3 out of 5 CCSVI criteria. There was no evidence of stenosis or nondetectable Doppler flow in cervical veins in patients and controls. Reflux in internal jugular vein (IJV) was documented in 1 patient (2%) and 1 control subject (2%), both in sitting and supine posture during apnea. After performing Valsalva maneuver, we documented the presence of IJV valve incompetence in 3 patients with MS (7%) and 4 healthy volunteers (9%; p > 0.999). CONCLUSIONS: With established reproducibility of venous ultrasound testing, our data argue against CCSVI as the underlying mechanism of MS. Without further independent validation of CCSVI, potentially dangerous endovascular procedures, proposed as novel therapy for MS, should not be performed outside controlled clinical trials.

MEG evaluation of taste by gender difference.

Magnetoencephalographic recordings were evaluated in five different states: normal condition, sweet, bitter, sour, and salt taste. Twenty-eight healthy volunteers, 14 male and 14 female, ranging from 12 to 50 years of age, were included in the study. The results showed that, in the normal condition, as well as in the sweet and the bitter taste, the male volunteers exhibited a higher count of low-frequency than high-frequency channels compared to the femal ones; in the case of the sour taste, there was no clear differentiation between the genders; with the salt taste, the female volunteers exhibited a higher count of low-frequency channels whereas there was no clear differentiation in the number of high frequencies between the gender. A discrimination in the spatial distribution of the frequencies provides novel insights into the identification of gender-related taste sensation.

Biweekly vinorelbine and gemcitabine as second-line treatment and beyond in non-small cell lung cancer.

BACKGROUND: To evaluate the activity and tolerance of gemcitabine (GEM) in combination with vinorelbine (VRL) in pretreated patients with advanced non-small cell lung cancer (NSCLC). PATIENTS AND METHODS: Fifteen patients with advanced NSCLC who had disease progression after a cisplatin- or taxane-based front-line regimen were enrolled into a 2-stage design trial and were treated with VRL 30 mg/m² i.v. for 10 min followed by GEM 1,200 mg/m² i.v. for 30 min on days 1 and 15 of each 28-day cycle. Chemotherapy was given for 6 cycles unless disease progression or unacceptable toxicity was seen. The patients' median age was 64 years and the performance status (WHO) was 0 (n = 7), 1 (n = 5), and 2 (n = 3). The treatment was second line for 10 (67%) and third line or more for 5 (33%) patients. RESULTS: No complete or partial responses were observed. Stable disease was seen in 4 (27%) patients and progressive disease in 11 (73%). The median time to tumor progression was 3 months (range 1-12) and the median survival was 4 months (range 2-31). Severe myelotoxicity was infrequent. Grade 2 neutropenia was observed in 2 (13%) patients, grade 2 thrombocytopenia in 1 (7%), and grade 2 anemia in 3 (20%). Nonhematologic toxicities were very mild and easily manageable. CONCLUSION: The GEM plus VRL combination at the present doses and schedule is a safe but ineffective regimen; therefore, it is not recommended as second-line treatment in patients with advanced NSCLC.

Magnetoencephalographic findings in two cases of juvenile myoclonus epilepsy.

The aim of this study is to investigate the electromagnetic sources of epileptic activity in two patients with juvenile myoclonus epilepsy (JME). The first patient was a 22-year old female with JME diagnosis by the age of 17 years old. Her initial EEG recording showed characteristic paroxysmal generalized activity with polyspike-wave complexes. She was on remission for 9 months. The second patient was a 29-year old male with JME diagnosis by the age 18 of years old. He showed an EEG recording with generalized spike-wave complexes of 3.5-4 Hz and presented a great improvement after therapeutic treatment. The MRI examinations for both patients did not disclose any focal lesions or areas of abnormal signal intensity or enhancement by contrast media. Magnetoencephalography (MEG) was recorded with a 122-channel whole-head system, 5 years after the disease onset for the first patient and 11 years for the second patient. For the first patient dipolar sources of MEG paroxysmal activity were localised at the vermis with extension up to the occipital region, whereas, for the second patient dipolar sources of MEG paroxysmal activity were localised at the cerebellar area (vermis and hemisphere). Implication of the cerebellum in JME, as suggested by MEG data in this study, is in accordance with previous reports employing functional MRI or cerebral blood flow evaluation in JME.

Achilles tendon volume in type 2 diabetic patients with or without peripheral neuropathy: MRI study.

The aim of this study was to evaluate Achilles tendon (AT) in type 2 diabetic patients with vs. without peripheral neuropathy using Magnetic Resonance Imaging (MRI). The study included 19 patients (group A, mean age 63.9+/-7.4 years) with peripheral neuropathy and 19 patients (group B, mean age 63.6+/-6.1 years) without peripheral neuropathy, as well as 16 healthy controls (group C, mean age 61.6+/-8.4 years). Neuropathy was diagnosed by the Diabetic Neuropathy Index (DNI). The maximum AT thickness and AT volume were measured on sagittal T (1) weighted MRI images. AT volume was calculated by the sum of the tendon surface area of all contiguous sections multiplied by the slice thickness. Diabetic patients had significantly (p<0.001) greater AT volume than controls (9742.0+/-2034.9 mm(3) vs. 7323.8+/-1918.2 mm(3)). This difference was observed both in men (p=0.030) and in women (p<0.001). AT volume was significantly greater in group A vs. C (p=0.003) and in group B vs. C (p<0.001), but there was no difference between groups A and B (p=0.469). Finally, in group A increased AT volume was significantly (p=0.041) associated with clinical severity of neuropathy. CONCLUSIONS Type 2 diabetic patients have increased AT volume as compared to controls. There is no difference in AT volume between patients with and without neuropathy. However, in neuropathic patients increased AT volume is associated with severity of neuropathy.

A tumor-like manifestation of extrapulmonary tuberculosis in a hemodialysis patient.

Though pulmonary tuberculosis (TBC) remains the commonest clinical presentation, extrapulmonary TBC is an increasingly important clinical problem. Among the extrapulmonary sites, primary liver tuberculosis seems to be an extremely rare location. Fewer than 100 cases of TBC hepatic abscesses have been reported whereas most of them have been originated from other sites, usually the lung and the gastrointestinal track. Therefore, in the absence of any particular symptom this infrequent location may lead to a delayed or missing diagnosis. The present study reports the difficulties in early diagnosis of an extrapulmonary TBC case, as it happened to a 53-year-old man with diabetic nephropathy who started on regular hemodialysis for 5 months. In such "atypical presentations" the clinicians should bear in their mind the possibility of the TBC occurrence, which usually responds well to the conventional antituberculous therapy.

Groove pancreatitis: a diagnostic challenge.

Groove pancreatitis is a distinct form of chronic pancreatitis characterized by inflammation and fibrous tissue formation, affecting the groove area between the head of the pancreas, the duodenum and the common bile duct. It is manifested on imaging by a sheet-like mass in the groove area near the minor papilla. Thickening of the duodenal wall and cystic transformation in the duodenal wall also represent common imaging features. Pathogenesis is still unclear, and clinical presentation is not specific. Endoscopic ultrasonography (EUS), computed tomography (CT) and magnetic resonance imaging (MRI) demonstrate imaging findings consistent with the disease in typical cases, but specific diagnosis is challenging in a number of patients where biopsy is required. The disease may mimic pancreatic, common bile duct or duodenal wall cancer that requires prompt and excessive surgical intervention, as opposed to groove pancreatitis where initial conservative treatment is suggested. The clinical, histopathological and radiological features on cross-sectional imaging of this entity are discussed in this review, and differential diagnostic clues are given.

Aggressive leptomeningeal hemangioblastomatosis of the central nervous system in a patient with von Hippel-Lindau disease.

Hemangioblastomas of the central nervous system are the most common tumors seen in patients with von Hippel-Lindau (VHL) disease. A very rare case of diffuse leptomeningeal hemangioblastomatosis obliterating large areas of the subarachnoid space, both intracranial and within the spinal canal, which developed during a relatively short period, in a patient with VHL disease is presented.