Helical tomotherapy versus conventional radiation to deliver abdominopelvic radiation.

While whole abdominopelvic radiation (APRT) provided satisfactory radiation dosimetry for the treatment of cancers with peritoneal dissemination, APRT was abandoned due to unsatisfactory tumor control from necessary radiation shielding of vital organs. Our goal was to develop a helical tomotherapy (TOMO) abdominopelvic radiation technique improving target tissue coverage while dose-limiting vital organs, especially hematopoietic bone marrow. This study reports our clinical development of a TOMO abdominopelvic radiation technique for treatment of patients with advanced stage ovarian cancer. Novel chemoradiosensitizing agent clinical trials incorporating our TOMO abdominopelvic radiation technique for treatment of patients with recurrent ovarian cancer are under development.

Recurrent ovarian dysgerminoma after laparoscopy.

To our knowledge, recurrent dysgerminoma at the site of tumor removal by laparoscopy in a patient with stage IA disease has not been previously reported. A woman with ovarian dysgerminoma treated by laparoscopy and tumor removed through the cul-de-sac recurred the 17 months later at the site of tumor removal. She was successfully treated with etoposide, bleomycin, and cisplatin chemotherapy with complete response. This case illustrates the potential for surgical site implant of an ovarian dysgerminoma; surgeons should follow strict guidelines when performing laparoscopic procedures for ovarian malignancies in order to prevent this type of incident.

Motor cortex excitability in patients with cerebellar degeneration.

OBJECTIVES: To study motor cortex (M1) excitability and the effect of subthreshold transcranial magnetic stimulation (TMS) in patients with cerebellar degeneration and normals performing a reaction time (RT) task. METHODS: Time to wrist flexion after a visual go-signal was measured. TMS was always delivered at 90% of resting motor evoked potential (MEP) threshold. In one experiment, test TMS was delivered at various intervals after the go-signal. In half the trials priming TMS was also given with the go-signal. A second experiment examined the effect on RT of M1 and occipital priming stimulation alone. RESULTS: M1 excitability, measured as the likelihood of producing MEPs in the wrist flexor muscles, increased immediately after the go-signal in the patients and stayed high until movement. In controls, excitability rose gradually. This difference was largely eliminated by priming TMS. RT was longer in the patient group, but improved with priming TMS. Occipital priming produced less effect on RT than M1 stimulation in both controls (P=0.008) and patients (P=0.0004). CONCLUSIONS: M1 excitability prior to movement in an RT task increases abnormally early in cerebellar patients. This may reflect compensation for deficient thalamocortical drive. Subthreshold TMS can partially normalize the prolonged RT and abnormal excitability rise in cerebellar patients.

[Bartonella henselae infection in immunocompetent patients: cat scratch disease]. / Infección por Bartonella henselae en pacientes inmunocompetentes: enfermedad por arañazo de gato.

BACKGROUND: Cat scratch disease, whose etiologic agent is Bartonella henselae, is a benign disease in immunocompetent subjects, characterized by lymphadenopathy of prolonged course and occasional involvement of other organs such as liver, spleen, central nervous system, eye and lung. In immunocompromised patients, the infection is bacteremic and disseminated. AIM: To report Chilean cases of cat scratch disease. PATIENTS AND METHODS: Ten children (seven male, aged between 6 and 13 years old) with histologically or serologically confirmed cat scratch disease are reported. RESULTS: Lymphadenopathy location was pre auricular in four cases, axillary in two, inguinal in two and epitrochlear in two. Three children had fever over 39 degrees C and two had a parinaud syndrome. Nine children had a history of cat scratch and one of a cat byte. Six had an erythrocyte sedimentation rate over 40. Lymph node ultrasound examination was a useful diagnostic tool. Two patients had splenic granulomas. Lymph node biopsies were obtained in four cases, showing a suppurative granulomatous lymphadenitis in all and a positive Warthin-Starry stain in two. Serology, done in patients without histological confirmation was positive with titles ranging from 1:64 to 1:8192. All patients had a satisfactory outcome with regression of lymphadenopathy. CONCLUSIONS: Infections by Bartonella hemselae occur in the Chilean population and must be considered in the differential diagnosis of regional lymph node enlargement.

[Frequency and histopathologic features of chronic gastritis in 300 patients without endoscopic lesions]. / Frecuencia y caracteres histopatológicos de gastritis crónica en 300 pacientes sin lesiones endoscópicas.

Three gastric mucosal biopsies were obtained from 300 patients showing a normal upper digestive tract endoscopy. Histologically, in 9% of the patients the biopsies were normal: in 87%, showed a common-type chronic gastritis, and in 4% showed a reactive (chemical or reflux-type) gastritis. Helicobacter pylori was present in 25.9% of the patients without gastritis, in 33.3% of the patients with reactive gastritis, and in 87.7% of those with common-type gastritis. In 19.9% of the patients with common-type chronic gastritis there was intestinal metaplasia, consisting of type I metaplasia in 14.1%, type II in 3.1% and type III metaplasia in 2.3%. The association of type III intestinal metaplasia with the other forms of metaplasia, its lower frequency and its tendency to be present in older patients supports the hypothesis that type III incomplete colonic metaplasia represents a more advanced stage than complete and incomplete small bowed metaplasia of the gastric mucosa.

Responses to paired transcranial magnetic stimuli in resting, active, and recently activated muscles.

Transcranial magnetic stimulation (TMS) causes the corticospinal system to become refractory to subsequent stimuli for up to 200 ms. We examined the phenomenon of paired pulse inhibition with TMS under conditions of rest, ongoing voluntary activation (isometric force generation), and at variable delays following activation (postactivation) of the wrist extensors of seven normal subjects. Paired stimuli were delivered to the motor cortex with a circular coil at 1.1 times motor evoked potential (MEP) threshold, with various interstimulus intervals. Voluntary activation caused a marked decrease in the variability of the ratio of the amplitude of the MEP evoked by the test pulse to that of the MEP evoked by the conditioning pulse. Marked inhibition of the MEP evoked by the test pulse was still present. Postactivation, however, caused a dramatic reversal of the inhibitory effect of the conditioning pulse in all subjects at interstimulus intervals ranging from 40 to 120 ms. This effect lasted for up to 10 s following the cessation of activation. MEPs to transcranial electrical stimulation were also inhibited by conditioning TMS, but postactivation did not reverse this inhibition, indicating that the reversal of paired pulse inhibition is intracortical. We conjecture that paired pulse inhibition reflects activity of inhibitory interneurons or inhibitory connections between cortical output cells that are inactivated in the postactivation state.

[Disseminated nocardiosis in 3 immunocompetent patients]. / Nocardiosis diseminada en tres pacientes inmunocompetentes.

Nocardia asteroide infections, an aerobic actinomycete, have several forms and lungs, skin and brain are the organs most frequently involved. When the infection suspected, special staining methods must be ordered to identify the agent. We report three immunocompetent patients with disseminated nocardiosis, two presenting with nodular lesions of skin and lungs and one presenting with pulmonary involvement and brain abscesses. The importance of clinical suspicion and early diagnosis of nocardiosis is emphasized.

[Pneumonia caused by Pneumocystis carinii in immunodepressed patients: clinical picture, treatment, and prognosis]. / Neumonia por Pneumocystis carinii en inmunodeprimidos: cuadro, clínico, tratamiento y pronostico.

Pneumocystis carinii pneumonia is frequent in patients with cellular immunity impairments, specially those with AIDS. We communicate our experience in 20 patients (15 with AIDS) with Pneumocystis carinii pneumonia confirmed by the finding of trophozoites or cysts. Clinical manifestations were cough in 75% of cases, dyspnea in 70% and fever in 65%. Eighty five percent of cases had diffuse reticular and nodular radiological densities. Nineteen patients had an increased alveolar-arterial O2 gradient. Nineteen patients were treated with trimethropim-sulphamethoxazole (TMP-SMX) and 4 with pentamidine isethionate (1 due to previous allergy and 3 due to poor response to TMP-SMX). Three patients died during the acute episode. Of the survivors, 13 died within 2 to 44 months later (14.5 +/- 12 months). It is concluded that AIDS is the most frequent underlying condition in patients with Pneumocysts carinii pneumonia and that long term survival is low.

[Leiomyosarcoma of the inferior vena cava. Presentation of 1 case of autopsy and review of the literature]. / Leiomiosarcoma de la vena cava inferior. Presentación de un caso de autopsia y revisión de la literatura.

This is a clinico-pathological report of a 30 years old male patient that presented with acute epigastric pain. Ultrasound examination showed a retroperitoneal tumor, thrombosis of the inferior vena cava and ascites. CAT scan disclosed thrombosis of hepatic vein and inferior vena cava with right atrium involvement. Necropsy showed a leiomyosarcoma of the inferior vena cava. There are seldom reports of this tumor in the last 5 years and an early diagnosis allows therapeutic interventions associating surgery, radiotherapy and chemotherapy.

[Cyto-histologic evaluation of parametrial involvement in cervico-uterine cancer using aspiration puncture guided by transvaginal echography]. / Evaluación cito-histologica del compromiso parametrial en cáncer cérvico-uterino mediante punción aspirativa guiada por ecografía transvaginal.

Vaginal tact is not sufficient for staging the extension of cervical Ca in its adnexal compromise. The use of transvaginal echography with a cytological hystological parametrial biopsy allow the diagnosis to be certified. In 23 cases studied, 21 epidermoid carcinoma and one adenocarcinoma related with of original cervical tumor were revealed. The clinical staging had a 8.3% error margin.

[Progressive multifocal leukoencephalopathy in a patient with acquired immunodeficiency syndrome]. / Leucoencefalopatía multifocal progresiva en un paciente con síndrome de inmunodeficiencia adquirida.

We report a 28 year old heterosexual male with AIDS that presented with progressive motor disturbances and malaise. Light and transmission electron microscopy of a stereotaxic brain biopsy demonstrated a progressive multifocal leukoencephalopathy. This is a demyelinating infectious cerebral disease attributed to JC virus and must be considered in the differential diagnosis of central nervous system disturbances in AIDS patients.

[Leiomyosarcoma of the saphenous vein]. / Leiomiosarcoma de vena safena.

A 48 years old male presenting with a painless tumor of the right thigh is reported. An initial surgical excision showed that the tumor was joint to the saphenous vein. The histopathological study showed that it was a venous vascular leiomyosarcoma of intermediate degree of malignancy. The patients was re-operated performing a resection of the abductor muscle and two weeks later was subjected to radiotherapy (50 Gray). The only postoperative sequel was a moderate lymphedema of the right limb. This is the first reported case in the Chilean literature.

Intestinal microsporidiosis in a Chilean patient with acquired immunodeficiency syndrome (AIDS).

A 24-year-old male patient with AIDS diagnosed in 1989, and with several episodes of pneumocystosis, was admitted because of a chronic diarrheic syndrome and severe epigastric pain. Endoscopy showed a granular duodenal mucosa. Light microscopy showed a moderate villous atrophy with round-cell inflammatory infiltration of the chorion. Giemsa, Ziehl-Neelsen, and Gram stains showed microsporidial spores measuring between 1.5 and 2 microns in the supranuclear cytoplasm of some enterocytes. Electron microscopy showed sporoblasts and spores consistent with Enterocytozoon bieneusi, with an apparently non-tubular, rather electron-dense polar filament showing up to 7 coils and also a microtubular internal structure with annular disposition, a finding which has not been adequately emphasized in the pertinent literature, probably representing a contractile property of the polar filament, rather than a mere duct for the parasitic sporoplasm to be inoculated.

Successful treatment of Trypanosoma cruzi encephalitis in a patient with hemophilia and AIDS.

Although the frequency of infection with the human immunodeficiency virus (HIV) is increasing dramatically in areas where Trypanosoma cruzi is endemic, trypanosomiasis has been rarely reported in persons with HIV infection or AIDS. Persons with hemophilia who receive multiple blood product transfusions from blood banks with little or no screening for infectious agents are at particularly high risk for infections with both HIV and T. cruzi. We describe the case of a person with hemophilia who was infected by blood transfusion with HIV and T. cruzi and in whom a multifocal, necrotic trypanosomal encephalitis was demonstrated by brain biopsy and electron microscopy. Treatment with benznidazole followed by that with itraconazole and fluconazole was associated with significant clinical and radiographic improvement.

[Disseminated histoplasmosis in a patient with acquired immunodeficiency syndrome]. / Histoplasmosis diseminada en pacientes con síndrome de inmunodeficiencia adquirida.

A twenty nine year old male homosexual presented with malaise, weight loss, fever and profuse sweating. An ill defined abdominal mass was found during physical examination in the right lower quadrant and chest X rays disclosed a pleural effusion. HIV antibodies and hepatitis B surface antigen were positive and immunological parameters were altered. Light and electron microscopic examination of operative biopsies of the abdominal mass revealed the presence of Histoplasma capsulatum. Treatment with Amphotericin B was started with a favorable response and the patient was discharged. He was readmitted with a septic shock and died. Necropsy showed pulmonary histoplasmosis. This is the first case of disseminated histoplasmosis in a patient with AIDS described in Chile.

[Acalculous acute cholecystitis caused by Cryptosporidium in a patient with AIDS]. / Colecistitis aguda alitiásica por Cryptosporidium en un paciente con SIDA.

We report a patient with the acquired immunodeficiency syndrome who developed acute cholecystitis. Removal of the gallbladder revealed infection by Cryptosporidium spp. The clinical course after cholecystectomy was favourable. The pathogenesis and therapy of this complication in patients with AIDS is discussed.

[Chagas disease with the acquired immunodeficiency syndrome. Clinical cases]. / Enfermeedad de Chagas en el sindrome de inmunodeficiencia adquirida. Casos clinicos.

We report 2 patients with AIDS who developed Chagas infection, one with encephalitis, the other with acute myocarditis. The implications of immune depression for the manifestations and course of Chagas disease are discussed. Chagas disease should be considered in patients with AIDS who live in endemic zones and who develop cerebral or cardiac manifestations.

Acute Chagas' disease (Trypanosomiasis americana) in acquired immunodeficiency syndrome: report of two cases.

Two heterosexual men, aged 31 and 40 years, with the acquired immunodeficiency syndrome and presenting with the acute form of Chagas' disease are reported. The first patient, a carrier of hemophilia A, was treated for 20 years with Chilean and Brazilian cryoprecipitates. This patient acquired both diseases through this medium. The second patient, an inhabitant of northern Chile (fourth region), was allegedly bitten by Triatoma infestans and was an intravenous drug addict. The hemophilic patient presented with a neurologic syndrome; a brain biopsy showed a necrotizing encephalitis with an obliterative angiitis and abundant macrophages. The second patient developed intractable congestive heart failure; necropsy showed a dilated myocarditis with rupture of myofibers and an inflammatory infiltrate rich in plasma cells, lymphocytes, and macrophages. Using light and electron microscopy, abundant amastigotes of Trypanosoma cruzi were seen in brain tissue, especially in the cytoplasm of macrophages, as well as in some myocardial fibers. In both cases, determination of anti-T cruzi antibodies (indirect hemagglutination technique) and xenodiagnosis were positive.

[Probable pulmonary damage caused by bleomycin. Communication of 4 cases]. / Probable daño pulmonar por bleomicina. Comunication de 4 casos.

Four patients with advanced germinal cell testicular tumors were treated with cisplatinum, vinblastine and bleomycin. Histopathologic studies revealed pulmonary damage and various degrees of respiratory insufficiency developed in all patients, one of whom died. There was no instance of opportunistic infections in any patient. The pathophysiology relating pulmonary damage to the action of bleomycin is discussed.