Mediastinitis due to cryptococcal infection: a new clinical entity in the HAART era.

OBJECTIVES: Highly active antiretroviral therapy (HAART) produces a rapid decline in plasma HIV-1 RNA levels with concomitant immune reconstitution. Probably due to the enhanced immune function, shortly after starting HAART, some latent opportunistic infections precipitated. The aim of this study was to illustrate the results of a survey on Cryptococcus associated mediastinitis occurring after HAART introduction, carried out at a referral centre of Infectious Diseases in the north-east of Italy, between October 1999 and October 2000. METHODS: All consecutive HIV-positive patients, naive to HIV-protease inhibitor therapy, and diagnosed with culture-proven cryptococcal infection were included in the study. Clinical and immuno-virological parameters before HAART and subsequently for 12 months were evaluated. RESULTS: Three of five patients were diagnosed with cryptococcal mediastinitis within a median time of 90 days (range, 60-150) after commencing HAART and fluconazole prophylaxis. Diagnosis was established by lymph node biopsy alone. Clinical improvement was documented when systemic anti-fungal therapy was combined with surgical drainage of the suppurative lesions. The role of immune restoration was confirmed by the significant increase in CD4 cell count, the reduction of HIV-RNA to undetectable levels and the prominent inflammatory reactions of lymph nodes. CONCLUSIONS: Our report suggests that HIV-positive patients with prior cryptococcal systemic infection may present a re-exacerbation of atypical cryptococcosis as a manifestation of immune restoration, even when fluconazole prophylaxis is ongoing.

[Treatment of hot thyroid nodule with percutaneous ethanol injection: indications, complications, and prognostic factors]. / La cura del nodulo caldo della tiroide con alcolizzazione percutanea: indicazioni, complicanze e fattori prognostici.

Percutaneous ethanol injection (PEI) has recently been proposed as an alternative therapy for toxic thyroid adenomas, instead of conventional treatments (pharmacological, surgical and radiometabolic therapies). The aim of this study was to investigate efficacy, complications and prognostic factors of PEI treatment in a group of 74 patients, 14 men and 60 women, treated from May, 1991, to December, 1994. Twenty-seven patients had nontoxic (pre-toxic) nodules (normal T3 and T4 and undetectable TSH serum levels) and 47 toxic nodules (high serum levels of thyroid hormones). A mean of 1.6 ml ethanol/cc of nodule volume was injected in 3-14 sessions (mean = 6). Ten subjects were treated twice, and 2 patients three times. Results were defined as: 1) complete cure: normalization of T3, T4 and TSH levels and appearance of extranodular thyroid tissue at scintigraphy; 2) partial cure: reduction in thyroid hormones within the normal range but still undetectable TSH levels and still suppressed extranodular thyroid tissue at scintigraphy; 3) failure. Complete cure was obtained in 96% of nontoxic (pretoxic) nodules and 65% of toxic ones. Moreover, partial cure was seen in 27.5% more toxic nodules and failure in 7.5%. The most significant complications were a case of transient dysphonia and two cases of common jugular vein thrombosis, both resolved spontaneously. The most important prognostic factor was the degree of hyperthyroidism (as FT4 and T3 serum levels), while nodule volume was rather useless to predict the final result. In conclusion, PEI can be an alternative, effective and low-cost treatment for autonomous thyroid nodules, without any severe complication and well tolerated by the patients.

Retained surgical gauzes: acute and chronic CT and US findings.

Surgical sponges retained after laparotomy represent a diagnostic problem if they cannot be identified by radiopaque markers on standard radiographs. We report on 9 patients from different hospitals with an abdominal gossypiboma 7 days to 21 years after the surgical procedure. Plain radiographs may suggest the diagnosis if a textile foreign body is calcified, that is, is equipped with radiopaque marker, or when a characteristic "whirl-like" pattern is present. CT and US are necessary procedures in chronic cases, since the lesion may mimic a mass; US shows specific echogenic areas with acoustic shadow; CT usually reveals a hypodense mass with a thick peripheral rim.

[Traumatic hematomas of the adrenal glands: CT and US findings in 3 cases]. / Gli ematomi traumatici del surrene. Rilievi TC e US in tre casi.

Traumatic hematomas of the adrenal gland are but little known; they are but seldom discussed in literature, and can be demonstrated only by US and CT due to their small size. These lesions are mostly located on the right side, probably following a direct trauma of the adrenal parenchyma against vertebral bodies, or as a result of the rupture of medullary sinusoids for a sharp rise in pressure into the inferior vena cava, during trauma. Bilateral traumatic hematomas can cause severe adrenal failure, and the healing is slow, without calcifications, and takes several months. Three new cases are reported, unilateral on the right adrenal bed. In 2 patients CT demonstrated a slight parenchymal enlargement after thoraco-abdominal traumas; the patients were young and healthy, and the lesions completely disappeared in some years. US detected a third hematoma in a young woman with suspected metastasis from ovarian carcinoma: CT confirmed the parenchymal swelling, and a percutaneous transhepatic biopsy clarified the diagnosis. Adrenal hematomas are to be reported in order to avoid confusing them with neoplastic lesions, even though only percutaneous biopsy allows a quick and reliable diagnosis.

Subcutaneous and visceral fat distribution according to sex, age, and overweight, evaluated by computed tomography.

Subcutaneous and visceral fat distribution as related to sex, age, and overweight was studied in 130 subjects and 10 women with Cushing's disease. Fat depots were evaluated by computed tomography at one thoracic and one abdominal level. Adipose tissue (density range - 50 to 250 Hansfield units) was highlighted and the fat areas were measured by a laser planimeter. The ratio between subcutaneous and visceral fat areas (S:V ratio) was assumed as an index. Ratios of both nonobese and obese groups were significantly higher in females than in males. Ratios decreased markedly over age 60. There was a significant inverse correlation between age and S:V ratios in females (r = 0.65; p less than 0.001) and in males (r = 0.61; p less than 0.001). Statistically significant correlations were found between S:V ratios at thoracic and abdominal levels. In Cushing's patients, the S:V ratio at the abdominal level was significantly lower than in controls matched for age, sex, and body mass index.