[Atypical gout tophi for differential diagnosis of head and neck tumors : case report and review of the literature]. / Atypische Gichttophi als Differenzialdiagnose von HNO-Tumoren : Fallbericht und Literaturübersicht.

Gout is a mostly hereditary metabolic disease and is considered a disease of affluence. The disease is promoted by a purine-rich diet and shows an intermittent course of inflammatory joint manifestations and periods free of symptoms. The pathognomonic sign of the disease is an acute and very painful monarthritis with typical local deposits of uric acid, so-called gout tophi. No or inadequate treatment leads to the chronic form of gouty arthritis characterized more by joint destruction than by persistent pain. In head and neck gout tophi are seen as nodular lesions along the outer helical edges of the auricle. A case report of gout manifestation in the infratemporal fossa, deriving from the temporomandibular joint, with arrosion of the bony skull base demonstrates gout as a relevant disease for the ENT clinician. Potential diagnostic difficulties as well as recommendations for a therapeutic regimen of gouty lesions in such critical localizations will be reviewed.

[Granulocytic sarcoma of the tonsils associated with myelodysplastic syndrome]. / Granulozytisches Tonsillensarkom bei myelodysplastischem Syndrom.

HISTORY AND ADMISSION FINDINGS: A 60-year-old man with anaemia was found to have a myelodysplastic syndrome (MDS) which was classified as refractory anemia with ringsideroblasts (RAEB). Because of severe fever the patient was hospitalized. Waldeyer's throat ring revealed signs of acute inflammation. LABORATORY FINDINGS: Indicated severe anemia and thrombocytopenia. Leucocytes were 8000/ml with a pathological shift to the left (1920/ml blasts). CRP (4.7 g/dl) and BSG (59/91mm) were abnormal. An axial CT of the neck showed a left sided paratonsillar abscess. DIAGNOSIS AND THERAPY: The tonsillitis was treated with antibiotics. Persistent fever up to 39.8 degrees C suggested resistance to therapy. After three weeks the patient developed septicemia and died. Autopsy revealed MDS with excess of blasts in transformation (RAEBT-t). Granulocytic sarcoma was found in the throating where there was no paratonsillar abscess. Generalized miliary tuberculosis was proved at autopsy, explaining the continuous fever resistant to antibiotic treatment. CONCLUSION: Granulocytic sarcoma is rarely associated with myelodysplastic syndrome. Deficiency in the immune system may facilitate the occurrence of miliary tuberculosis.

Pulmonary nodules: detection with low-dose vs conventional-dose spiral CT.

The purpose of the study was the evaluation of low-dose spiral CT in the detection and assessment of contours of pulmonary nodules. In a prospective investigation 71 consecutive chest CT examinations were acquired both at 30 and 200 mA. Films were interpreted independently by two radiologists. According to the size, nodules were divided into four categories: 10 mm; nodule shape was registered. With both protocols, 240 nodules were detected. The correlation coefficient for both methods was 0.89. Discrepancies were found most frequently in nodules near to pulmonary vessels. Nodule size estimation did not differ more than one size category. Eight spiculated nodules were identified by both techniques. Low-dose spiral CT of the chest has a high sensitivity in the detection of pulmonary nodules. If clinical circumstances require dose minimization, low-dose spiral CT may be advocated as an alternative screening method to conventional dose spiral CT.

[Clinical relevance of thoracic CT in intensive care and emergency medicine]. / Klinische Relevanz der Thorax-CT in Intensiv- und Notfallmedizin.

PURPOSE: Evaluation of the impact, indications, and therapeutic efficiency of chest CT in intensive-care and emergency patients. MATERIALS AND METHODS: Retrospective assessment of 741 consecutive chest CT, or which 74% were acquired in the spiral technique, in intensive-care and emergency patients. Chest CT scans and respective clinical data were compared. RESULTS: 16% of all examinations were indicated to resolve questions arising from the chest radiogram, 10% to confirm or exclude pulmonary embolisms and 10% to confirm or exclude aortic dissection. In 10% a focus of infection was sought. 57% of all CT examinations had an impact on therapy, in 7% further diagnostic tests were prompted. Among a total of 588 clinical decisions based upon chest CT, the most frequent therapeutic conclusions consisted in: minimally invasive CT guided interventions in 17%. A new drug was administered in 13%, surgical intervention was performed in 13%, bed-side interventions such as insertion of a drainage tube in 13%, and a given pharmacological therapy was continued in 11%. CONCLUSION: Chest CT has a strong impact on patient management in emergency and critical-care medicine. CT guided interventions are frequently used in critically-ill patients. The introduction of the spiral technique has led to important new CT indications in the field of non-invasive vascular diagnosis, namely the assessment of pulmonary embolism and aortic dissection.

[Pathogenesis, diagnosis, clinical and therapeutic aspects of ataxia telangiectasia]. / Pathogenese, Diagnostik, Klinik und therapeutische Aspekte der Ataxia teleangiektatika.

Ataxia-telangiectasia (AT) is an autosomal recessively inherited disease (one case in 40,000 to one case in 100,000 live births) whose principal features are oculocutaneous telangiectasia, progressive cerebellar ataxia, B- and T-cell immunodeficiency with recurrent sinopulmonary infections, sensitivity to ionizing radiation and cancer predisposition. The AT-gene (ATM) was recently identified by positional cloning on chromosome 11q22-23. In this paper the diagnostic, clinical and therapeutic problems of 9 AT-patients treated in our clinic are discussed in context with the current literature. Although all patients had discrete signs of cerebellar ataxia at infancy, there was a significant delay of definitive diagnosis (median 4, range 1.5-6.5). Elevated alpha fetoprotein levels clearly distinguish AT from other ataxias and immunodeficiency syndromes.

[Goodpasture syndrome: treatment initiation with plasmapheresis before histologic diagnostic verification]. / Goodpasture-Syndrom (GPS): Behandlungsbeginn mit Plasmapherese vor histologischer Diagnosesicherung.

A 28 years old male patient presented, after a history of previous recurrent hemoptysis, with diffuse bilateral air space consolidation at chest radiography (CXR). Within 48 hours, partial respiratory insufficiency developed and required intubation. On a clinical and roentgenographic basis, the diagnosis of a Goodpasture syndrome was suspected. Plasmapheresis and immunosuppressive therapy with prednisone and cyclophosphamide were started immediately. Three days after admission, macrohematuria developed and serum creatinine began to rise to a maximum of 3.9 mg/dl. Totally, 13 plasmaphereses were performed within 27 days. Clinical, laboratory and radiological findings improved markedly. 30 days after admission, the patient was discharged and followed on an outpatient basis. Serum creatinine eventually decreased to 1.1 mg/dl. Initially, circulating antibodies against glomerular basement membrane (GBM) were positive, controls remained negative. Renal biopsy was performed after the acute phase and showed glomerulonephritis and linear immunoglobulin deposition along the GBM. Radiologic findings at CXR and high resolution computed tomography are demonstrated.

[Infarct of the lower renal artery segment: diagnosis with CT-angiography and 3-dimensional spatial representation]. / Infarkt des unteren Nierenarteriensegmentes: Diagnose mittels CT-Angiographie und dreidimensionaler Raumformatierung.

The case of a CT-angiographically diagnosed partial renal infarction is presented. The infarction was diagnosed during a postoperative CT-control of the arteries after implantation of an aorto-biliac dacron graft. Reformatting of the axial spiral scans data was elaborated with surface rendering, maximum intensity projection, and volume rendering for comparison. Each of the reformatting modalities was able to re-present the renal infarction, elaboration time is short and a clear presentation of the spatial relationship can be obtained.

[Aspiration-induced lung complications following emergency endoscopy in upper gastrointestinal hemorrhage: incidence and localization by thoracic radiography]. / Aspirationsbedingte Lungen-komplikationen nach Notfallendoskopie bei oberer Gastrointestinalblutung: Inzidenz und Lokalisation im Röntgen-Thorax.

PURPOSE: Determination of incidence and mortality of pulmonary pathologies arising after gastroscopy for acute bleeding, of left to right ratio of pulmonary findings in postgastroscopic chest films, and determination of a possible relationship between bleeding activity and frequency of aspiration. METHODS: 174 patients with emergency gastroscopies for upper gastrointestinal haemorrhage with pre-/postendoscopy chest films, retrospective analysis. Of the pulmonary findings, infiltrates and atelectases were considered. RESULTS: After emergency gastroscopy, 16% of patients had infiltrates or atelectases at chest radiography. Mortality within 30 days in the study group was 18%, and 39% among the subgroup with radiologically proven pulmonary complications. The distribution of chest findings between left and right side was 1:1,3. In the subgroup with gastroscopic signs of bleeding the share of postgastroscopic pulmonary findings was slightly superior to that of patients without direct signs of bleeding; however, the difference was statistically not significant. CONCLUSION: Endoscopy-related aspirations do not seem to account for an increased rate of pulmonary complications after emergency gastroscopy.

[Current aspects of lymph node tuberculosis of the neck]. / Aktuelle Aspekte der Halslymphknotentuberkulose.

In 1994, the incidence of tuberculosis (Tb) in Germany is 16/ 100,000, and the incidence of extrapulmonary Tb is 2,3/100,000. The peripheral lymph nodes represent with 41% the most commonly involved extrapulmonary organ system. At present, cervical lymph node Tb is of clinical relevance on one hand in patients from endemic areas of Tb in the developing countries and on the other hand in immunocompromised patients, particularly in course of HIV infection. Diagnostic methods are discussed with special attention to fine needle biopsy; modalities and indications of imaging methods are described. The microbiological examination allows the definitive diagnostic clarification. Cervical lymph node Tb responds well to antituberculous chemotherapy. Regimens of drug combination and the duration of treatment are discussed; generally chemotherapy should be continued for at least 9 months. Indications to surgical intervention are explained. The different aspects of adenopathies caused by atypical mycobacteria are considered.

[Diagnosis of floating venous thrombi by spiral CT phlebography]. / Diagnose flottierender venöser Thromben mittels Phlebo-Spiral-CT.

PURPOSE: Evaluation by means of spiral CT as to whether or not a thrombus in a proximal deep vein of the leg is floating or adherent to the vessel wall. METHODS: Local application of contrast agent into an ipsilateral dorsal foot vein and spiral CT were used to examine 16 consecutive cases with deep venous thrombosis proven at conventional venography; in addition, colour Doppler flow imaging was performed. RESULTS: At conventional venography, 8/16 thrombi appeared to be floating and the remaining 8/16 were adherent to the vessel wall. Spiral-CT showed 15/16 thrombi to be adherent to the vessel wall; the floating thrombus correlated with findings in conventional venography. At colour Doppler flow imaging 3/16 thrombi were considered floating, one of them was discordant to conventional venography. The comparison of conventional venography to spiral-CT demonstrates complete agreement for adherence to vessel wall seen in conventional venography (p = 1,0) and significant discordance in cases with free-floating appearance in conventional venography (p = 0,0002). CONCLUSION: Adherence of thrombi to the wall of the vessel at conventional venography is in agreement with computed tomography. Conventional venography probably overestimates the prevalence of free floating thrombi.

[Radiological thorax monitoring in ventilated intensive-care patients]. / Radiologisches Thoraxmonitoring bei beatmeten Intensivpatienten.

PURPOSE: At many institutions chest x-rays (CXR) are routinely performed on mechanically ventilated patients on a daily basis. Among the aims of this study was the assessment of a) frequency of clinically relevant findings from routine CXR in surgical patients under mechanical ventilation, b) comparison of expectations of clinically important CXR findings with estimation of clinical relevance of findings once films were obtained, c) indications and clinical consequences of findings from CXR requested in addition to routine films. METHODS: Prospective study, 40 patients with 741 CXR. Standardised film reporting. Daily recording of clinical data by means of an evaluation score. Interview of intensive-care physicians for assessment of: what information was expected from any routine CXR? did CXR offer helpful information for further treatment planning? RESULTS: 26% of routine CXR had a considerable therapeutical impact. 43% of all routine CXR were expected to have an influence on patient management, 57% were not. 16% of those CXR that had been expected not to offer essential information, disclosed relevant findings. Of the additionally obtained CXR, 53% were performed to check position of endotracheal tube and catheters and 47% related to other indications. CONCLUSION: Critically ill surgical patients under mechanical ventilation should have daily CXR follow-up, as one-fourth of these films has an impact on the patient's management.

[CT and HR-CT in the diagnosis of pulmonary complications of bone marrow transplantation]. / CT und HR-CT in der Diagnostik pulmonaler Komplikationen bei Knochenmarktransplantation.

The aim of this prospective study was to compare conventional and high resolution CT for demonstrating pulmonary complications. 23 patients treated by bone marrow transplantation were included in the study between December 1990 and August 1991. These patients were examined radiologically at regular intervals following the transplants. In 9 patients lung changes were detected by CT: there were pneumonic infiltrates, including one CMV pneumonia, two cases of mild parenchymal fibrosis, two cases of extensive lung fibrosis and one of miliary tuberculosis. The advantages and disadvantages of conventional and high resolution techniques are discussed in relation to our findings.

[Daily "routine chest x-ray" in ventilated surgical intensive care patients]. / Der tägliche "Routine-Röntgenthorax" beim beatmeten chirurgischen Intensivpatienten.

We investigated the relevance of daily routine chest x-ray in intensive care for therapeutical decision. A special emphasis was put on clinical laboratory parameters according to the APACHE-II-score. Within a prospective study we investigated 40 intubated patients of our surgical intensive care unit with a total of 609 x-ray films. 26% of all pictures gained influence on therapeutical procedure. Analysis of different patient subgroups showed only between those under 50 and those above 70 years of age an important discrepancy quote of relevant films (19 vs. 31%).

[Asbestosis accompanied by primary peritoneal mesothelioma]. / Asbestose mit primär peritonealem Mesotheliom.

Diffuse, continuous abdominal pain and weight loss of 10 kg in 3 months were observed in a 57-year-old female patient. A CT examination of the abdomen was requested to rule out a malignant gynecological tumor. The CT study, however, showed a small amount of ascites and a thick sheet-like mass covering the internal anterior abdominal wall. On the basis of these CT findings, a peritoneal mesothelioma was suspected, which was confirmed by diagnostic laparotomy. The patient's history revealed exposure to asbestos at work from 21 to 24 years of age. The following signs of asbestosis and asbestos-related pleural disease were observed in the chest X-ray film: small opacities in the lower zones of both lungs, diffuse pleural thickening, a plaque on the right diaphragm, and small bilateral pleural effusions. In cases of suspected occupational illness such as that presented here, each physician concerned including the radiologist involved in the diagnosis, is required to advise the social insurance institution responsible.