'Low-dose' corticosteroid prophylaxis against fat embolism.

The effect of 'low-dose' corticosteroids (9 mg/kg methylprednisolone), given after skeletal trauma, on the incidence of the fat embolism syndrome and isolated arterial hypoxemia was studied in 42 controls and 40 steroid-treated subjects. Fat embolism occurred in ten controls (23.8%) and one steroid-treated subject (2.5%) (p = 0.01). A further 44 subjects developed isolated hypoxemia. This was severe (PaO2 less than 50 mm Hg) in seven of 32 controls (21.9%) and one of 39 steroid-treated subjects (2.6%) (p = 0.01). The overall incidence of hypoxemia was 67.1%, affecting 33 controls (78.6%) and 22 steroid-treated patients (55%) (p less than 0.05). The degree of hypoxemia was severe (PaO2 less than 50 mm Hg) in 12 controls (28.6%) and two (5%) of the steroid-treated subjects (p = 0.005). No control subject died or required mechanical ventilation. One steroid-treated subject without fat embolism died of a fulminant infection. Although methylprednisolone in a relatively low dose provides protection against fat embolism and pulmonary dysfunction after skeletal trauma, the safety of this therapy requires further evaluation.

Severe deficiency of alpha 1-antitrypsin associated with cutaneous vasculitis, rapidly progressive glomerulonephritis, and colitis.

The association of vasculitis with severe deficiency of alpha 1-antitrypsin is rare. This report describes a 44-year-old man with severe deficiency of alpha 1-antitrypsin associated with diffuse vasculitis involving skin, kidney (rapidly progressive glomerulonephritis), and colon (colitis). Colitis has not previously been reported in association with deficiency of alpha 1-antitrypsin. Other reported cases are reviewed and the possible immunologic mechanisms underlying the association are discussed.

Invasive pulmonary aspergillosis complicating influenza A pneumonia in a previously healthy patient.

A rare occurrence of invasive pulmonary aspergillosis complicates influenza pneumonia in a previously healthy adult. Five other similar cases are reported in the literature. Both transient depression of cell-mediated immunity and loss of ciliary function in the tracheobronchial tree occurs during acute influenzal illness and may predispose to fungal superinfection. Early diagnosis and treatment of opportunistic Aspergillus infection complicating influenza is mandatory in view of the high mortality associated with this complication.

Neurotoxicity due to the bite of the shield-nose snake (Aspidelaps scutatus). A case report.

The bite of the elapid snake Aspidelaps scutatus has previously been regarded as medically unimportant. We report a case in which its bite resulted in neurotoxicity.

Experience at an adolescent and adult cystic fibrosis clinic. An analysis and overview.

Cystic fibrosis (CF) is the most common serious genetic condition in the White population groups. Thirty-three White patients (mean age 20 years, range 14-32 years) seen at an adult CF clinic at the Johannesburg Hospital between January 1980 and January 1983 are reviewed. All had elevated sweat chloride levels. There was a family history of CF in 45,5% of the cases. Most were of normal height but significantly underweight. Chronic obstructive pulmonary disease was present in 94% of the patients. Pulmonary infections played a major role in both symptomatic exacerbations and progressive lung disease. Most frequently, mucoid Pseudomonas aeruginosa and/or Staphylococcus aureus were cultured from the sputum. The management of infective exacerbations is discussed. Other respiratory complications included cor pulmonale, haemoptysis, recurrent pneumothorax and sinusitis. Chest radiographs and pulmonary function tests are also analysed. Gastro-intestinal complications included pancreatic exocrine insufficiency (94%), intestinal obstruction, cholelithiasis, and liver disease. Insulin-dependent diabetes occurred in 9%. Five pregnancies were recorded in 4 patients. By January 1983 there had been 7 deaths (mean age 19,4 years). Most of the patients are highly motivated, with few psychological problems, and appear to be well-functioning and integrated members of society.

Treatment of acute post-infective polyneuropathy by means of plasma exchange.

15 patients with acute post-infective polyneuropathy of the Guillain-Barré type have been treated by means of plasma exchange. The clinical course and outcome of these patients is compared to that in a retrospectively matched control series who were treated with supportive therapy only. All patients had severe rapidly evolving muscle weakness and approximately half the patients in each group required ventilatory assistance. Both the duration of muscle weakness and the hospitalisation time was significantly shorter in the patients treated by means of plasma exchange. These results suggest that plasma exchange is of significant benefit in the treatment of patients with the Guillain-Barré syndrome.

Life-threatening hypotension associated with azathioprine therapy. A case report.

We report a case of azathioprine sensitivity manifesting with severe hypotension and diarrhoea. This sequence of events occurred on two separate occasions after administration of the drug.

Survival following massive overdose of adrenergic blocking agents (acebutolol and labetalol).

Massive overdosage of adrenergic blocking drugs is associated with severe morbidity and a high mortality rate. We report the case of a 24-year-old medical intern who ingested 9.6 g acebutolol, 7.2 g labetalol and 0.625 g trimipramine in an attempted suicide. Blood samples drawn on admission were shown to contain markedly elevated plasma levels of acebutolol and its major metabolite and of labetalol. The patient was deeply comatose on admission. The heart rate was 60 min-1 (sinus rhythm) and the blood pressure was clinically unrecordable. Atropine, isoproterenol and dopamine initially had no effect on either heart rate or blood pressure. Only following the administration of inordinately large doses of isoproterenol and dopamine, together with glucagon was a clinical response obtained. The patient remained haemodynamically dependent on dopamine for 12 h and isoproterenol for 65 h. The total dose of isoproterenol administered was 260 mg, two thirds of this during the first 12 h. The patient left hospital well after 7 days but was readmitted after 26 days because of intestinal obstruction due to ischemic bowel necrosis.

Otolaryngologic complications of acute porphyria.

The porphyrias are a group of diseases which may be complicated by acute neurological crises having serious morbidity and a high rate of mortality. We report a case of acute porphyria in which an acute neurological crisis, resulting in loss of laryngeal function, precipitated life-threatening aspiration pneumonia.

Experience with neuromuscular respiratory failure in an intensive care unit.

Between 1976 and 1980, 32 patients with respiratory failure primarily due to neuromuscular disease were admitted on 34 occasions to the Respiratory Intensive Care Unit of the Johannesburg Hospital. Ninety-four per cent of patients admitted survived and were discharged from hospital. Ninety per cent of the survivors are fully rehabilitated and another 6.7% continue to improve. Despite a frequently prolonged illness, these patients have an excellent prognosis. Early diagnosis and management of respiratory failure in an intensive care unit are essential if their survival is to be ensured.

Hyperkalaemia in prolymphocytic leukaemia--a sometimes spurious result. A case report.

A patient suffering from prolymphocytic leukaemia was found to have extremely high serum potassium levels. The mechanism of the apparent biochemical change was investigated and was found to be a spurious abnormality related to in vitro lysis of the large mass of lymphocytes. This in vitro observation has been termed pseudohyperkalaemia and should not be mistaken for genuine disturbances that need treatment.

Adult respiratory distress syndrome in Leptospira canicola infection.

A man was admitted to the Johannesburg Hospital with a history of fever, diarrhoea, and dry cough for four days. He began to produce bloodstained sputum and was found to have severe arterial hypoxaemia. Radiography showed widespread opacification over both lung fields, and the clinical and haemodynamic features were consistent with the adult respiratory distress syndrome. Serology for Leptospira canicola was positive. Despite antibiotics, supportive therapy, and ventilation the patient died. Necropsy excluded cardiac disease. This case shows that leptospirosis may cause the adult respiratory distress syndrome.

Tamoxifen and hypercalcaemia. A case report.

A patient is reported in whom hypercalcaemia developed when adjuvant hormonal treatment with tamoxifen (Nolvadex) was instituted. The response to withdrawal of the drug and the recurrence of hypercalcaemia on rechallenge with tamoxifen make a causal relationship between hypercalcaemia and tamoxifen therapy probable. Some of the mechanisms of development of hypercalcaemia in cases of breast carcinoma are discussed, and the literature on hypercalcaemia and tamoxifen therapy is reviewed.