[Imported malaria in Emergency Department]. / La malaria d'importazione nel Dipartimento di Emergenza-urgenza.

It occasionally happens that patients don't suspect to have malaria and diagnosis becomes difficult for the Emergency Department physicians. Since September 1995 to February 1999, 8 cases of malaria have been diagnosed in our first aid station; 5 occurred in european and 3 in extraeuropean immigrants. Incidence of imported malaria was greater after holiday period for european, and equally distributed along the year for immigrants. Patients' provenience was sub-Saharian Africa and Asia. Standard blood examination and thick and thin blood smears were performed showing P. falciparum and P. malariae infection. All patients were successfully treated with mefloquine as recommended. The aspecificity of the symptoms and signs makes diagnosis difficult if malaria is not suspected, in presence of fever in people returning from the tropics. Even in presence of symptoms and abnormal laboratory examinations, diagnosis is possible only with microscopic blood examination.

Transient global amnesia or subarachnoid haemorrhage? Clinical and laboratory findings in a particular type of acute global amnesia.

Acute global amnesia may be due to several causes, such as transient global amnesia (TGA), acute drug-related confusional state, toxic substances, metabolic abnormalities, infective diseases, cerebral tumours, cerebrovascular accidents, subarachnoid haemorrhage and epilepsy. In particular both TGA and subarachnoid haemorrhage may be precipitated by sexual activity; by contrast the two diseases are quite different in prognosis and treatment. Ten subjects were admitted in the period 1997-99 to our emergency department for acute global amnesia related to sexual activity. They represented 18% of total acute global amnesias observed in the same period. All patients were males, aged between 41 and 64 years. TGA was found in nine cases, while one patient had subarachnoid haemorrhage, due to rupture of an aneurysm of the right middle cerebral artery. The patient with subarachnoid haemorrhage showed neurologic defects (second-degree nystagmus and retropulsion), while no major neurologic abnormalities were found in TGA. Likewise computerized tomography (CT) scan was positive only in the case of subarachnoid haemorrhage. Patients and relatives in most cases left out sexual activity as a trigger factor. This experience indicates that acute global amnesia related to sexual activity is mostly due to TGA. Major neurologic signs are suggestive of subarachnoid haemorrhage and an immediate CT scan is recommended. Targeted questions are needed to identify the cause of the event.

Food allergy in children: results of a standardized protocol for oral desensitization.

BACKGROUND/AIMS: Food allergy in children is still an unresolved problem that merits investigation, particularly when the food is fundamental for the child's growth. Reports in the literature that deal with the possibility of a desensitizing treatment are sporadic and often inconsistent, and no standardized protocols are yet available. In this paper we propose a standardized oral desensitization program for food allergy in children. METHODOLOGY: The treatment was carried out in 14 cases with allergy to food (milk in 6 cases, egg in 5, fish in 2 and apple in 1 case). The control group consisted of 10 age and sex matched allergic subjects (5 to milk, 4 to egg and 1 to fish), who underwent a strict elimination diet regimen. RESULTS: Compliance to treatment was satisfactory, since 12 out of the 14 treated cases (85.7%) completed the program. Treatment was successful in 100% of the cases that completed the program: all the treated patients are now able to tolerate any food with no untoward effects or need for preventive drugs. CONCLUSIONS: The proposed standardized oral desensitization treatment may represent a safe and convenient alternative in the management of food-allergic subjects.

[A case of arterial hypertension after use of oral contraceptives]. / Un caso di ipertensione arteriosa dopo uso di contraccettivo orale.

It is known that oral contraceptives may induce high blood pressure that usually returns to normal values a few weeks after interruption of the drugs, and without any specific treatment. The precise mechanism by which oral contraceptives cause hypertension is not clear. A severe hypertension and mild heart failure in a young woman using oral contraceptives has been observed in the case described. The patient needed a careful and prolonged therapy to maintain a normal blood pressure.

Oral hyposensitization to nickel allergy: preliminary clinical results.

Fifty-one patients presenting a dermatological allergy (erythema, urticaria, angioedema, contact dermatitis) to nickel were treated over 3 years with oral doses of 0.1 ng nickel sulfate per day, following a low-nickel diet. Diagnostic tests comprised patch and oral provocation tests. In 7 cases, the treatment was interrupted because of symptom reactivation, and in 14 cases for other reasons. Among the 30 cases who went through the whole follow-up, symptomatology totally disappeared in 29 cases, and a partial alleviation was achieved in 1 case after 1 year of treatment. Oral provocation tests with these 30 patients showed an overall increase of tolerance. Patch tests showed no variation in 20 cases, a diminution in 5, and were negative in 5. Although the study was not conducted double blind, the results of this attempt to cure nickel allergy are statistically significant.

Rush desensitization in heparin hypersensitivity: a case report.

Among all the known drug intolerances, adverse reactions to heparin are not very common. No desensitization in patients with heparin hypersensitivity has ever been attempted. We report the case of a 55-year-old female patient with mitral stenosis and insufficiency, and tricuspid and aortic insufficiency. The patient underwent heparin treatment, and urticaria occurred with either s.c. calcium heparin or i.v. sodium heparin. Allergy testing (skin tests and patch tests) was negative. A pseudoallergic intolerance was diagnosed. Mitral valve replacement with the extracorporeal circulation method was necessary; therefore, heparin treatment was administered. A heparin rush desensitization together with antihistamine drugs (4 mg clorpheniramine maleate for 3 d) was started: 50 UI (0.5 mg) s.c. sodium heparin were first administered; within 4 d, 5000 UI (50 mg) sodium heparin was administered i.v. with no side-effects. A full-dosage heparin treatment was then administered and heart surgery was easily performed. During the postsurgical course, i.v. sodium heparin was smoothly replaced with s.c. calcium heparin (25,000 UI s.c. per day) and with oral anticoagulants (sodium warfarin).

Anaphylactic shock after skin test with phytohaemoagglutinin.

A young woman (26 years old), with gastrointestinal candidosis of 8 months duration, was hospitalized in our department to study her cell immunity. Five minutes after an id injection of PHA (bactophytohaemoagglutinin M, Difco, 1 mg), mix monilieae, mix tricophyton and PPD Berna, she showed an extensive wheal and flare reaction in the PHA injection area, eyelid oedema and respiratory distress. In spite of adrenaline, corticosteroid and antihistamine drug administration, the patient collapsed and was admitted to the resuscitation department, where she quickly recovered. In the following days, the patient underwent immune and allergy testing: 1) total Ige immuno-enzymatic assay: 72 KU/1; 2) specific IgE and IgE immuno-enzymatic assay for Candida: negative; 3) in vitro lymphocyte transformation test (thymidine 2-C14) with PHA Difco was positive. This finding and the positivity of the id injection with PHA could indicate an allergic type I immunoreaction, the description of which we have not found in the international literature (the presence of IgG STS cannot be totally excluded).

Intranasal treatment with lysine acetylsalicylate in patients with nasal polyposis.

Forty-three patients suffering from nasal polyposis underwent intranasal treatment with increasing doses of lysine acetylsalicylate (LAS) corresponding to 20, 200, and 2000 micrograms of aspirin (ASA), until a maximal dose of 2000 micrograms weekly was reached. The patients were divided in two groups: a group of 28 patients with ASA intolerance, including 20 with ASA triad, and a group of 15 patients without ASA intolerance. The local treatment was usually started 1 month after polypectomy and was well tolerated without side effects. A control group included 191 subjects with nasal polyposis, 130 of whom had ASA intolerance. After polypectomy the controls received no further medical treatment. Patients were examined every 3 months and radiographs of the paranasal sinuses were obtained every 6 months. After 24 months 34 of 43 patients (79.1%) treated with topical LAS had suffered no relapse of polyposis. Only 45 of 191 control patients (23.6%) failed to relapse after 24 months (P less than .0001). Nine of 28 (32.1%) ASA-intolerant patients treated with LAS and 105 of the 130 (80.77%) control subjects relapsed (P less than .0001). None of the 15 ASA-tolerant patients treated with LAS relapsed, but 41 of the 61 (67.21%) nontreated control subjects relapsed (P less than .00001). These data indicate topical LAS is effective in preventing recurrence of nasal polyps after polypectomy.

AFP, CEA, CA 19-9 and TPA in hepatocellular carcinoma.

The present study is based on the assay of four markers (AFP, CEA, TPA, Ca 19-9) using IRMA methods in 36 normal subjects, 44 cirrhosis and 66 HCC patients. Parametric and non parametric tests were used to test differences and correlations. ROC curves and discriminant functions were also elaborated. Normal 95% "cut-off" was determined by the "boostrap" method yielding: CEA 3.4 ng/ml; Ca 19-9 55 U/ml; TPA 58U/l and AFP 5.2 ng/ml. In HCC patients the values of the four markers were, on average, significantly different from those of normal subjects. However, only AFP and TPA exhibited high diagnostic accuracy (90%) for detection of the tumor. Higher than normal mean values for all markers were, also observed in cirrhotic patients. Only AFP yielded effective discrimination between HCC and cirrhosis. The positive prediction for the presence of the tumor on cirrhotic ground was 95% for AFP values higher than 18.5 ng/ml, with a 78% negative predictive value with a 6 ng/ml threshold. Association of AFP with TPA showed only a marginal diagnostic improvement. Results were not improved at all by combining CEA and Ca 19-9 with AFP and/or TPA. In conclusion, AFP is and remains the best marker for HCC and the only one effective in discriminating of HCC from cirrhosis. TPA may be considered a valid alternative if cirrhosis is not present. CEA and Ca19-9 are of no use.