Haemophilus influenzae serotype f endocarditis and septic arthritis.

Haemophilus influenzae represents gram-negative coccobacilli which can cause endocarditis, meningitis, septicemia, pneumonia, septic arthritis. H.influenzae exists as encapsulated and unencapsulated (non-typeable) strains. Non-typeable H.influenzae are emerging pathogens especially in elderly population. We report a case of a 73 year old woman with bacteremia, endocarditis and septic arthritis due to H.influenzae serotype f. This case emphasizes the clinical features and the key elements of diagnosis and management of infections caused by non-typeable strains of H.influenzae.

Two Cases of Rhabdomyolysis (Haff Disease) After Eating Carp Fish.

Unexplained rhabdomyolysis after eating fish is a rare condition caused by an unidentified toxin. Most of the incidences in the United States have been linked to consuming buffalo fish or crawfish. We present 2 cases of Haff disease in which the patients consumed grass carp as opposed to the usual suspects of buffalo fish or crawfish.

Do Cardiovascular Risk Factors and Severity and Complexity of Coronary Atherosclerosis Predict Aortic Pulse Pressure during Cardiac Catheterization?

Pulse pressure (PP), estimated from the peripheral blood pressure measurements, has been linked with adverse cardiovascular events. But, the association of PP and coronary artery disease is not well studied. There is a lack of data on the association of invasively measured aortic PP and cardiovascular risk factors and severity of coronary atherosclerosis. We determined the predictive factors of aortic PP during cardiac catheterization. Electronic medical records from 2010 to 2013 were retrospectively reviewed. A total of 368 patients were eligible. The data on demographics, cardiovascular risk factors, coronary lesion characteristics, and medication use was collected. On multivariable regression analysis, aging (ß = 0.34, p = 0.001, 95% confidence interval [CI] 0.14-0.53) and prior aspirin use (ß = 5.09, p = 0.015, 95% CI 0.99-9.18) were associated with higher aortic PP. Increasing estimated glomerular filtration rate (ß = - 0.52, p = 0.040, 95% CI -0.90 to -0.23) was associated with lower aortic PP. Severity and complexity of coronary lesions, SYNTAX score, and number of obstructed vessels were not associated with aortic PP. Aging, prior aspirin use, and declining renal function were associated with an increase in aortic PP. Aortic PP may not predict the severity and complexity of coronary atherosclerosis. Therefore, the risk of adverse cardiovascular events associated with an elevated aortic PP may not be mediated by the severity of coronary atherosclerosis.

Intimal (spindle cell) sarcoma of the left atrium presenting with abnormal neurological examination.

A 43-year-old man with an unremarkable medical history presented to our hospital with 2 weeks of headaches, ataxia and confusion. CT of the head revealed a large haemorrhagic cystic lesion. A subsequent chest CT revealed a large left atrial mass. The mass was subsequently biopsied with positive immunohistochemistry staining for MDM2, FLI1 and vimentin. Real-time PCR revealed MDM2 amplification, confirming the diagnosis of intimal sarcoma. The patient underwent surgical resection and reconstruction of the atrium with subsequent discharge to short-term rehabilitation, but his symptoms continued to progress. A repeat CT of the head revealed a new cerebellar mass. He underwent a second resection, but continued to experience worsening symptoms. He was diagnosed with stage IV intimal sarcoma and referred to hospice. The patient died 5 months after initial presentation. Autopsy was performed and revealed the cause of death as pneumonia. There was no involvement of the pulmonic or aortic vessels.

Elevated lactic acid is a negative prognostic factor in metastatic lung cancer.

BACKGROUND: Hyperlactatemia with or without type B lactic acidosis is a rare complication of cancer, previously observed most often in hematological malignancies. The aim of this study was to assess the prognostic value of lactic acid (LA) in patients with metastatic lung cancer. METHODS: Patients diagnosed with stage IV non-small cell lung cancer (NSCLC) and extensive stage small cell lung cancer (SCLC), were included in this single center retrospective study. Arterial and venous LA level, anion gap (AG), serum LDH and presence of urine ketones were recorded for each patient and their associations with demographic and clinical data and overall survival (OS) were examined. RESULTS: Eighty-five patients (43 males, median age 74, range 45-96 years) were studied. The maximal levels of arterial or venous LA were significantly associated with presence of ≥ 2 metastatic sites (p= 0.001), ICU admission or transfer (p= 0.016), intubation (p= 0.029), elevated serum anion gap (p< 0.001) and LDH levels (p< 0.001). Hyperlactatemia (≥ 1.4 mmol/L) was associated with shorter OS (log-rank p< 0.001). In a multivariate model including LA, ICU, intubation, AG as well as other known prognostic factors of NSCLC and SCLC, including age, sex, smoking status, number and location of metastases, histologic type, performance status (PS), chemotherapy and LDH, LA retained its prognostic value (OR: 1.3; 95%CI: 1.082-1.561; p= 0.005), along with PS (p= 0.039) and chemotherapy (p= 0.039). CONCLUSIONS: The results of the study suggest that a high lactic acid level (≥ 1.4 mmol/L) is associated with significantly shorter overall survival in patients with metastatic non-small cell lung cancer and extensive stage small cell lung cancer. Hyperlactatemia is an independent predictor of poor survival in metastatic lung cancer patients.

Common hepatic duct stricture: are lithiasis and negative brush cytology enough to rule out Klatskin tumor?

In this case report, the experience of treating a patient with clinical suspicion of hilar cholangiocarcinoma is shared and key points in differentiating from coexistent lithiasis are discussed.

Vitamin status as a determinant of serum homocysteine concentration in type 2 diabetic retinopathy.

We investigated the association of serum homocysteine levels and vitamin status with type 2 diabetic retinopathy. This study included 65 patients with and 75 patients without diabetic retinopathy. Patients with diabetic retinopathy had significantly higher serum homocysteine levels (P < 0.001), higher prevalence of hyperhomocysteinemia (P < 0.001), lower serum folic acid (P < 0.001), and vitamin B12 (P = 0.014) levels than those without diabetic retinopathy. Regression analysis revealed that homocysteine was an independent risk factor for diabetic retinopathy and there was a threshold in its serum level (13.7 µ mol/L), above which the risk of diabetic retinopathy greatly increases (OR = 1.66, P = 0.001). Folic acid was associated with decreased odds for diabetic retinopathy (OR = 0.73, P < 0.001). There was a threshold in serum vitamin B12 level (248.4 pg/mL), below which serum homocysteine concentration significantly increases with decreasing serum vitamin B12 (P = 0.003). Our findings suggest that hyperhomocysteinemia is an independent risk factor for the development and progression of diabetic retinopathy. Decreased serum levels of folic acid and vitamin B12, through raising serum homocysteine concentrations, may also affect the diabetic retinopathy risk.

Increased expression levels of apolipoprotein J/clusterin during primary osteoarthritis.

Osteoarthritis (OA) is a slowly progressive degenerative joint disease that is associated with joint space narrowing, osteophyte formation and subchondral sclerosis. Despite extensive effort actual breakthroughs in the field of genetic or biochemical biomarkers of OA are limited. As secretory apolipoprotein J/clusterin (sCLU) has been implicated in both inflammatory and apoptotic molecular processes which contribute to the OA phenotype, the sCLU concentration in human serum and synovial fluid during advanced primary knee and hip OA was analysed. Elevated sCLU protein levels were shown in these two biological fluids. sCLU mRNA expression was also studied in normal cartilage and in advanced primary knee and hip OA samples. A significant up-regulation of sCLU mRNA expression (~25-fold) was found in samples collected from the tibial bone that was osteotomized during total knee arthroplasty in patients with primary knee OA, as compared to healthy tissue samples collected from the femoral head of macroscopically normal cartilage during the surgical treatment of subcapital fractures. By studying sCLU mRNA expression levels in samples collected during total hip arthroplasty in patients with advanced primary hip OA, an additional up-regulation of the sCLU mRNA expression (~4-fold), as compared to advanced primary knee OA, was found. Taken together, these observations indicate that the sCLU protein or mRNA expression level may be of a significant diagnostic and/or prognostic value during OA progression.

Thrombotic risk factors and liver histologic lesions in non-alcoholic fatty liver disease.

BACKGROUND/AIMS: The pathogenetic mechanisms of development of non-alcoholic steatohepatitis (NASH) and fibrosis are not clear, although thrombosis of small intrahepatic veins has been suggested to trigger liver tissue remodelling and thrombotic risk factors have been associated with more advanced fibrosis in chronic viral hepatitis (CVH). We evaluated the prevalence of thrombotic risk factors (RFs) in non-alcoholic fatty liver disease (NAFLD) and their possible association with fatty liver or NASH. METHODS: We included 60 patients with histologically documented NAFLD and a historical cohort of 90 patients with chronic hepatitis B (n=39) or C (n=51). Thrombophilic factors were evaluated on the day of the liver biopsy. RESULTS: One or more thrombotic RFs were detected in 37% of NAFLD patients, and >or= 2 RFs were detected in 12% of NAFLD patients, being less frequently present than in CVH patients (37% and 68%, respectively; P