Extensive necrotizing soft tissue infection of the perineum.

Synergistic necrotizing fasciitis of the penis and scrotum was first described by Fournier, and remains a rare, but life-threatening disease. The reported mortality rates in different series range between 22 and 60%. We present a study of 20 patients treated over a 9 year period by early aggressive excision. Four of the treated patients (20%) died. A high index of suspicion, combined with early radical surgical intervention, is the key to effective treatment. Delayed diagnosis and treatment were the primary factors responsible for death.

Adrenal cortical adenoma with extensive fat cell metaplasia.

This report describes a large adrenal cortical tumor with a significant component of mature adipose tissue in a 40 year old woman. No bone marrow elements were identified in multiple sections. This lesion, representing most likely an adrenal cortical adenoma with extensive fat cell metaplasia, has not been previously reported and must be differentiated from adrenal myelolipoma.

[A case of self-circumcision].

A 29-year-old bachelor had immigrated from Uzbekistan to Israel 2 years before to improve his economic situation. He began drinking at the age of 20, and increased to 1-1.5 bottles of vodka a day. He was unable to keep a job more than a few months. When called up for limited military service, he thought that the army might be a solution for his employment problem. However, he felt that he would not be able to integrate into the army, and later into Israeli society, unless he was circumcised. The Ministry of Religion deferred his request for a religious circumcision because they did not consider him Jewish. Since he could not afford to pay for the operation, he read up on the procedure, drank a bottle of vodka as premedication, and tried to circumcise himself with a razor blade. Since he was unable to control bleeding, he applied to the hospital emergency room half an hour later, where the circumcision was completed and sutured. The psychiatric diagnosis was an unspecified personality disorder with psychopathic but not psychotic features.

[Retrograde ejaculation as a side-effect of clozapine].

3 chronic paranoid schizophrenic men, aged 29, 30 and 37 years, respectively, developed retrograde ejaculation, a rare side-effect of clozapine. It disappeared after the dose was lowered in 1 of the patients and after stopping the drug in the other 2. On rechallenging with the drug, retrograde ejaculation recurred.

[Intracavernous auto-injection of prostaglandin E1 for diagnosis and treatment of erectile dysfunction].

34 impotent patients were offered auto-injection therapy and all except 2 began treatment. Prostaglandin E1 (PGE) was used regularly for a mean of 8.6 months (range 1-17). The onset of erection was 5-30 min (mean 11.4) after injection and it lasted at least 30 min (mean 106.2 min). An erection of more than 6 hrs was observed in only 2 patients. There have been no instances of cavernous fibrosis, chemical priapism or systemic reactions. The most common adverse effect was penile pain after injection. It was mild to moderate in 4 patients (11.7%), and in only 1 was it severe enough to require stopping treatment. Overall, intracavernous injection of PGE appears to be safe, effective treatment for impotence without side-effects other than pain after injection in a few.

[Primary tuberculosis of the glans penis].

Primary tuberculosis of the glans penis is extremely rare. We report a case in a 70-year-old man who presented with a deep ulceration of the ventral surface of the glans which mimicked malignancy. The diagnosis of tuberculosis was confirmed by biopsy, culture, and response to antituberculous chemotherapy. There was no coexisting tuberculous infection elsewhere.

[Brucella infection of the testis mimicking malignancy].

A testicular mass is a diagnostic challenge, as it may include both benign and malignant processes. Due to the difficulty in diagnosis and the need to prevent complications, it is sometimes necessary to perform orchiectomy. We present an unusual case of brucellosis in which the presenting features were persistent cough for 6 months and a right testicular mass. The clinical picture and ultrasound findings suggested malignancy. Orchiectomy and medical treatment resulted in rapid resolution of symptoms.

Cardiomyopathy and multiple myeloma. Complications of scleredema adultorum.

Multiple myeloma and congestive heart failure developed in a patient with long-standing scleredema adultorum. Staining of the myocardium, performed after her death, was positive for acid mucopolysaccharide and negative for amyloid. To the best of our knowledge, this is the first case in which acid mucopolysaccharide has been demonstrated in the myocardium, thus explaining the cardiomyopathy of scleredema adultorum. Review of the world literature enabled us to identify a statistically significant increased prevalence of plasma cell dyscrasia among patients with protracted scleredema. In all patients, plasma cell dyscrasia appeared years after the onset of scleredema. Immunofluorescent studies were negative for immunoglobulin deposition. We assume, therefore, that the plasma cell dyscrasia was secondary to scleredema.

Preoperative evaluation of localized prostatic carcinoma by transrectal ultrasonography.

We evaluated 31 patients with clinically localized prostatic carcinoma by transrectal ultrasonography before radical prostatectomy. Results of ultrasonography were reviewed without previous knowledge of the extent of the disease and were compared to the pathological staging obtained by step section of the prostate. Preoperative transrectal ultrasonography was sensitive in detecting capsular and seminal vesicle involvement (89 and 100 per cent, respectively). However, the specificity of the method was low for capsular involvement (50 per cent), probably owing to the inability of this method to detect microscopic disease. This method is a valuable tool in the preoperative evaluation of patients with clinically localized prostatic carcinoma.

Multilocular cyst of the kidney: a case report.

A 69-year-old female was referred to Roswell Park Memorial Institute for management of a right kidney tumor. Her evaluation included excretory urography, ultrasound, computerized axial tomography (CT scan), and selective renal angiography. Fine needle aspiration cytology was felt to be consistent with primary renal cell carcinoma. In spite of the radiological appearance of a benign lesion, a right radical nephrectomy was performed because of the positive cytology on fine needle aspiration. The pathological diagnosis was a solitary multilocular cyst of the kidney.

Radical cystectomy at Roswell Park Memorial Institute. Preoperative and post operative observations.

Between January 1979 and March 1983, 63 consecutive patients underwent cystectomy and urinary diversion for primary carcinoma of the bladder at Roswell Park Memorial Institute (RPMI). Fifty-five patients had transitional cell carcinoma, 6 squamous cell carcinoma and 2 adenocarcinoma of the bladder. Twelve patients with bladder cancer were found to have adenocarcinoma of the prostate on the pathological specimen. Preoperative radiation was given to 41 patients. Thirty-six patients received 4000 rads preoperatively followed by radical cystectomy, 5 patients received 2000 rads. Thirteen patients received 6000 rads as curative treatment and underwent salvage cystectomy and colon conduit because of failure. There was no operative mortality. Severe complications in the early postoperative period occurred in 19 instances, some patients having more than one complication. Late complications necessitating surgical correction occurred in 5 patients. Although radical cystectomy is effective in controlling the local disease, most patients still died of metastatic transitional cell carcinoma.