Caroli's Disease Associated with a Gastric Diverticulum

Caroli's disease or communicating ectasia of the intrahepatic biliary tree is a rare disease with unknown aetiology. The coexistence of this along with the uncommon condition of a gastric diverticulum has never been reported before. A deficiency in the fibromuscular matrix of both the bile ducts and the gastric wall may explain why these two pathologies may coexist in a single patient.

Caroli's Disease Associated with a Gastric Diverticulum

Caroli's disease or communicating ectasia of the intrahepatic biliary tree is a rare disease with unknown aetiology. The coexistence of this along with the uncommon condition of a gastric diverticulum has never been reported before. A deficiency in the fibromuscular matrix of both the bile ducts and the gastric wall may explain why these two pathologies may coexist in a single patient. (AU)

Rectus versus linea alba: a biomechanical study

The comparative differences in pullout suture strength between rectus muscle and sheath and linea alba were studied in cadaveric models. A suture simulating the rectus repair procedure and one using just linea alba were used. Forces were measured on a tensiometer. Mean rectus force was found to account for over 59 percent variability. Both force uniformly decrease towards the symphysis pubis. This suggests that the rectus, when used for incisional hernia repair, may contributed significantly to wound strength. Additionally, our findings may help to elucidate the observance that incisional hernias are commonly subumbilical and occur mostly in females.(AU)

Dengue haemorrhagic fever/dengue shock syndrome: an unwelcome arrival in Trinidad

This is the first report of dengue haemorrhagic fever and dengue shock syndrome in Trinidad. Dengue infection was confirmed serologically or by viral isolation in five patients, aged 15 to 33 years, who presented with fever, thrombocytopenia and haemoconcentration. Three patients developed dengue shock syndrome, which was fatal; although there was no haemorrhagic tendency among these patients, bleeding occurred shortly before death in one of them. Two patients who had dengue haemorrhagic fever survived. The co-circulation of dengue virus serotypes 1, 2 and 4 in the Caribbean facilitates the development of dengue shock syndrome (DSS) or dengue haemorrhagic fever (DHF). Clinicans should therefore be aware of their clinical features, laboratory diagnosis and clinical management. Appropriate public health interventions and improved surveillance should be implemented to reduce the risk of DHS/DSS associated mortality in Trinidad and Tobago.

Dengue haemorrhagic fever/dengue shock syndrome: an unwelcome arrival in Trinidad

This is the first report of dengue haemorrhagic fever and dengue shock syndrome in Trinidad. Dengue infection was confirmed serologically or by viral isolation in five patients, aged 15 to 33 years, who presented with fever, thrombocytopenia and haemoconcentration. Three patients developed dengue shock syndrome, which was fatal; although there was no haemorrhagic tendency among these patients, bleeding occurred shortly before death in one of them. Two patients who had dengue haemorrhagic fever survived. The co-circulation of dengue virus serotypes 1, 2 and 4 in the Caribbean facilitates the development of dengue shock syndrome (DSS) or dengue haemorrhagic fever (DHF). Clinicans should therefore be aware of their clinical features, laboratory diagnosis and clinical management. Appropriate public health interventions and improved surveillance should be implemented to reduce the risk of DHS/DSS associated mortality in Trinidad and Tobago.(AU)

A Cervical smear review in women developing cervical carcinoma with particular reference to age, false negative cytology, and the histologic type of the carcinoma - abstract

A review of all available cervical smears from 96 consecutive women diagnosed as having invasive cervical carcinoma during 1985 - 1991 was undertaken. The purpose of the study was to determine the incidence of confirmed negative smears prior to the histologic diagnosis of carcinoma and to investigate the relationship between the duration and grade of smear abnormality, the patient's age and the histological types of cervical carcinoma. The slides of the smears were mixed and examined "blind" by at least two pathologists separately. The degree of concordance was 95 percent. Thirty-four patients had microinvasive disease and 62 had invasive carcinoma. Review of 54 smears initially reported as "negative" revealed that 44 (81 percent) were assessed as abnormal; 42 ( 44 percent) of the 96 patients in this study had abnormal cytology reported correctly at varying time intervals prior to diagnosis of carcinoma and there was inadequate clinical follow-up of 16/42 (38 percent) of these women with knowm abnormality. The review revealed that 43 (70 percent) of the 61 younger (< 40 years) women had significant or high grade abnormality in smears (or histology) taken > 1 year before diagnosis of carcinoma. This study revealed that 81 percent of the reviewed smears were falsely reported as negative. There is evidence to suggest that the preinvasive phase of cervical cancer may be shorter in younger women and the less common types of cervical cancer occur more frequently in this group. The combination of inadequate clinical follow-up and false negative cytology may have allowed a significant proportion of these women to develop invasive cervical carcinoma (AU)

Dengue haemorrhagic fever/dengue shock syndrome: an unwelcome arrival in Trinidad - abstract

Dengue is endemic throughout most of the Caribbean, and increased activity has been noted within recent times. The co-circulation of dengue virus serotypes 1, 2 and 4 has been a cause of concern regarding the development of dengue shock syndrome/dengue haemorrhagic fever. The clinical presentation, investigate findings and confirmatory evidence for dengue infection in four patients are described. In all cases, there were fever, marked thrombocytopenia and haemoconcentration. The youngest patient was 15 years old and the oldest was 53 years. In two cases, there was no haemorrhagic tendency but profound shock ensued. Bleeding occurred preterminally in one of these. Both patients with dengue shock syndrome died but the two cases of dengue haemorrhagic fever survived. Dengue infection was confirmed serologically in three cases and by viral isolation in the other. This, to our knowledge, is the first report of dengue haemorrhagic fever/dengue shock syndrome in Trinidad, and clinicians should be aware of the clinical features and management. It is also crucial that public health measures be put in place to minimize dengue virus-associated mortality in Trinidad (AU)

Thyroid surgery without drainage: 15 years of clinical experience

Drainage in thyroid surgery has been a routine but empirical practice with no scientific evidence to support its benifit. The largest series to date of nondrainage in thyroid surgery is presented, comprising 260 patients over a 15-year perios. No case selection for non-drainage was employed. Two hundred and fifty-nine cases were not drained and included toxic goitres, and bilateral and redo procedures. There was one thyroid storm and two cases of subcantaneous fluid collection, treated by needle aspiration. No cases of recurrent laryngeal nerve injury, airway obstruction or death were recorded. This study strongly demonstrates the safety of non-drainage in routine thyroid surgery (AU)

Acute renal failure following multiple stings by africanized bees - abstract

From 1979 to October 1990, Africanized bees have stung 3,955 humans with 10 deaths and 1,071 animals with 715 deaths in Trinidad and Tobago. The medical records of all patients seen at the General Hospital, Port-of-Spain, who developed acute renal failure following stings by Africanized bees were included in the study. Of the 5 patients in the study, 4 were males and 1 was female. One patient was stung by just over 500 bees while the rest were stung by over 1,000 bees. All patients had grossly elevated muscle enzymes. Two of the 5 patients died within 48 hours and causes of death were acute pancreatitis with acute renal failure, and acute pulmonary failure with acute renal failure. Two of the three patients who survived were desperately ill and had to be dialyzed. Renal function in these survivors did not return to normal under 50 days. It is likely that other islands of the Caribbean will soon be presented with this syndrome (AU)

Human papilloma virus infections and other risk factors as determinants of cervical intraepithelial neoplasia in Trinidad and Tobago - abstract

Human Papilloma Viruses (HPV) are considered to play a key role in the induction of malignant neoplasms of the cervix uteri but there have been no published reports on the prevalence of genital HPV infections among women in this region where the incidence of cervical cancer is high. The objectives of this study were to assess the overall and type-specific prevalence of HPV infections of the uterine cervix in a sample of urban and rural women with and without cytologically or histologically defined cervical intraepithelial neoplasia (CIN) in this population of non-hysterectomized, non-pregnant females aged 18 - 60 years. One hundred and sixty-nine urban women, roughly half of whom had abnormal cytological diagnoses and 159 rural women were examined colposcopically and directed cervical biopsies performed. Cases and controls were identified on the basis of results of examinations of these specimens. Z-tests, kappa statistic, chi-square, odds ratio and confidence limits and multivariate logistic techniques were used where appropriate. Overall prevalence of HPV infection was 6.7 per cent, HPV DNA was detected in 5.6 per cent of controls and only 6.3 per cent of cases. HPV type 16 was the commonest isolate (54.5 per cent). HPV positivity was not an independent predictor of the risk of CIN. Early coital onset, high parity, multiple sexual partners and high gravidity were the most significant, independent predictors of the risk of CIN (AU)

Primary idiopathic cutaneous amyloidosis: can coconut oil be a contributing factor? - abstract

Twenty patients who presented clinically with either macular or lichen amyloidosis at clinics at the Port of Spain General Hospital or the St. Joseph Health Centre had skin biopsies done. Two control groups of male and female patients were randomly selected. They presented with other unrelated skin conditions and either used coconut oil only occasionally or used other types of oil. Skin biopsies were stained with haematoxylin and eosin and congo red/methyl violet. The study group were all female Indo-Trinidadians who had daily applied coconut oil to the arms, legs and hair for an average period of 31 years (range 4 months - 40 years). In 15 patients, there was histological confirmation of amyloid. Seven patients had at least 1 family member with a similar skin condition. Papular and macular skin lesions were seen on the anterior aspect of the leg and the extensor aspect of the arm and scapular region. It is proposed that the common practice among female Indo-Trinidadians of daily application of coconut oil to arms, legs and hair is a risk factor in the development of primary cutaneous amyloidosis and that genetic and familial factors are also involved in this condition (AU)

Cutaneous histoplasmosis in the acquired immune deficiency syndrome: a report of three cases from Trinidad

Three cases are reported of patients with the acquired immune deficiency syndrome (AIDS) and cutaneous histoplasmosis. Their initial presentation was that of a generalised malculopapular rash. Two patients were bisexual males and the third was an unmarried female. The range of opportunistic infections seen in AIDS patients in Trinidad is mentioned and clinicians are alerted to the fact that in areas endemic for histoplasma capsulatum maculopapular rash in patients with AIDS may suggest disseminated histoplasmosis. The value of skin biopsy is mentioned. (AU)

Behcet's syndrome with unusual manifestations

A patient with two uncommon manifestations of Behcet's Syndrome, oesophageal ulceration, and glomerular disease is presented. In both systems, as in all others affected by Behcet's Syndrome, there was vasculitis principally involving veins, venules, and capillaries. Response to conventional management was not successful. (AU)

Skin biopsy and cutaneous histoplasmosis in the acquired immune deficiency syndrome in Trinidad - abstract

Eighteen patients with the acquired-immunodeficiency syndrome (AIDS) presented with primary skin manifestations at the Port-of-Spain General Hospital in 1986. The lesions included local (3) and generalised (4) dermatitis, pustules, plaques (2), crateriform ulcers (2), erythematous lesions (4) and maculo-papular rashes (7). Some patients had a mixture of lesions. The maculo-papular rashes were commonest. Full-thickness skin biopsies were stained with periodic acid-Schiff and methamanine silver; yeast forms of Histoplasma capsulatum were found in 11 cases. Three of these cases had a post-mortem examination; this revealed the presence of the fungus in all the tissues sampled which included brain, liver, spleen and lymph nodes. The skin lesions were the only presenting clinical manifestations of disseminated histoplasmosis in these patients. Histoplasmosis capsulatum is endemic in Trinidad and Tobago but clinical infection was extremely rare before the advent of the AIDS epidemic. In areas endemic for H. capsulatum, clinicians should be alerted to the fact that cutaneous lesions in patients with AIDS may suggest histoplasmosis. Given the facts that cultures may be negative and unnecessarily delay treatment, that the histoplasmin skin test is of doubtful value and that serological titres are unreliable in the immunocompromised, we advocate full-thickness skin biopsy to diagnose histoplasmosis in AIDS patients (AU)

Breast cancer in Trinidad - abstract

Breast cancer is one of the commonest malignancies in the Trinidadian woman. A 7-year study of breast biopsies from 2,642 women shows that 20 per cent of the lesions biopsied were malignant. Patients with cancer were from 23 to 92 yrs, with a peak prevalence in the 45-60 yr. age group. The age-specific rate increased steadily with age. Most patients were multiparous; 92 per cent of them had breast-fed their children. Fifty-one per cent had stage 1 disease; 76 per cent had infiltrating duct carcinoma; 7.0 per cent scirrous, 2.7 per cent medullary, 1.6 per cent mucoid and 1.3 per cent Paget's Disease of the nipple; other less common carcinomas accounted for the remainder. The high rates of multiparity and breastfeeding in our patients with breast cancer are unusual associations with this disease. Our high incidence of infiltrating duct carcinoma is consistent with many studies; this type is usually linked to a poor prognosis. Education of the public on breast and its associated epidemiological factors could result in more patients presenting with stage 1 disease (AU)

Significant proteinuria: the Port-of-Spain General Hospital experience - abstract

Sixty-nine patients who had renal biopsies because of proteinuria of > 1 gm per day, oedema and normal sized kidneys were investigated. There were 58 adults and 11 children. Of the adults, 26 were male, and 32 female; of the 11 children, there were 10 males and 1 female. The modal age of the patients was 15 - 19 years. The majority of the patients (67 percent) had primary glomerular disease. The two most common histological patterns were minimal change and mesangio-capillary glomerulo-nephritis. Minimal-change nephritis was observed in 73 percent of children's kidney biopsies. The pattern was unlike that seen in tropical Africa. Mesangial-proliferative disease did not contribute remarkably (11 percent) to significant proteinuria. Membranous nephropathy, which usually accounts for the majority of idiopathic adult nephrotics in the developed countries, was rare in our Trinidadian series. Systemic lupus erythematous comprised the majority of patients (83 percent) who had secondary proteinuria. This may reflect a bias in the selection of patients for renal biopsy. Even though the incidence of the sickle-cell gene is high in Trinidad, sickle-cell disease did not contribute to the presence of nephropathy. The prognosis for patients with primary glomerular disease (21 percent mortality) was better than for thos with systemic disease (79 percent mortality). Our observations suggest that the pattern of proteinuria in Trinidad does not resemble that seen in tropical Africa but is some what similar to that observed in Jamaica (AU)

Immunopathological studies in a mixture of pemphigus and pemphigoid - abstract

This is the first report from the Commonwealth Caribbean of a mixture of two rare forms of vesiculobullous diseases. A mixture of both bullous pemphigoid and pemphigus vulgaris was present in a 61 year-old East Indian man. He presented at the Dermatology Clinic of the Port-of-Spain Hospital with vesiculobullous lesions of both the tense and flaccid types extending throughout his trunk, limbs and face. Skin biopsies showed both immunoglobulin and complement at the intercellular spaces of the epidermis of the flaccid bulla and at the basement membrane zone (BMZ) from the tense bulla supporting the existence of both pemphigus and pemphigoid but the fourth confirmed the above findings. This patient gave a favourable clinical response to corticosteroid therapy with the disappearance of pemphigus antibodies but the anti-BMZ antibodies (typical of pemphigoid) persisted, as expected. It is clear from these findings that immunopathological investigations are not only essential in the early diagnosis of these rare bullous forms but also in prognosis (AU)