Sarcoidlike manifestations of histoplasmosis.

We have evaluated 11 patients with sarcoidosis accompanied by laboratory evidence for histoplasmosis. Clinical findings were typical of those described in sarcoidosis. Eight patients were treated with corticosteroids and responded promptly without progression of histoplasmosis. One patient received a 35 mg/kg course of amphotericin B without clinical improvement, but responded appropriately to corticosteroid therapy. Another patient had positive sputum cultures for Histoplasma capsulatum 5 years after initial diagnosis of sarcoidosis, but showed no improvement in the pulmonary infiltrate after treatment with amphotericin B. Although histoplasmosis and sarcoidosis may be interrelated in several ways, we postulate that H capsulatum may have triggered a chronic inflammatory disease recognized as sarcoidosis in some of these patients, a hypothesis yet to be tested. Alternative explanations for the association of histoplasmosis and sarcoidosis include the coincidental occurrence of two separate illnesses in a "hyperendemic" area for histoplasmosis and false-positive serologic test results caused by the heightened humoral immune response observed in sarcoidosis.

Clinical and laboratory features of disseminated histoplasmosis during two large urban outbreaks.

Clinical and laboratory features have been reviewed in 66 episodes of disseminated histoplasmosis that occurred during two large urban outbreaks in Indianapolis. Immunosuppression, age greater than 54 years, and presence of other serious underlying illnesses predisposed to the disseminated form of the disease; only 21% of patients lacked one of these risk factors. Central nervous system findings, splenomegaly, hepatomegaly, and lymphopenia suggested disseminated disease but were present in only about one-third of patients. Miliary or diffuse pulmonary infiltrates also suggested dissemination and were noted in about one-third of patients, while mediastinal lymphadenopathy was present in only 17%. Histoplasmal serologic tests, positive in 90% of patients, provided useful diagnostic clues. The diagnosis could be confirmed by culture in 88% of patients, and special stains were positive in about two-thirds. Although 10% of patients recovered without treatment, 11 patients (17%) died because of failure to suspect the diagnosis and initiate therapy promptly. Amphotericin B was effective in all patients receiving at least 500 mg, but relapse occurred if the total dose was less than 30 mg/kg. Ketoconazole appeared effective in non-immunosuppressed patients but not in those with underlying immunosuppression; however, a controlled trial comparing ketoconazole and amphotericin B is required to establish the role of this new fungistatic oral agent.

Pericarditis as a manifestation of histoplasmosis during two large urban outbreaks.

During two histoplasmosis outbreaks in Indianapolis 45 patients presented with pericarditis. The pericarditis occurred as a late complication in individual patients and during the outbreak. Risk factors for this complication included young age, immunocompetence, and male sex in persons between 20 and 39 years old. Intrathoracic adenopathy was present in 66% of cases. Since cultures were uniformly negative, including pericardial fluid or tissue from nine patients, serologic studies provided the basis for diagnosis. Although the course was usually benign, nine patients presented with tamponade and another with constrictive pericarditis. Prompt response to antiinflammatory medications and failure to identify H. capsulatum in the pericardial fluid or tissue support a noninfectious, inflammatory mechanism for this complication. Of 20 patients reexamined 1 year later, none had evidence of constriction but three had pericardial thickening by echocardiography. Histoplasmosis should be considered in patients with pericarditis from endemic areas, particularly when associated with intrathoracic adenopathy.

Pitfalls in interpretation of computed tomography prior to second-look laparotomy in patients with ovarian cancer.

Fifty-seven patients with ovarian cancer were assessed with computed tomography (CT) prior to undergoing second-look laparotomy. All patients were clinically free of disease following chemotherapy. Patients were scanned from the top of the liver to the symphysis pubis using oral, rectal and intravenous contrast medium. Tumour was correctly identified on CT scan in nine of 25 patients who had visible evidence of cancer at laparotomy. However, in the remaining 16 patients peritoneal studding was present and was not detected. Tumours smaller than 1.5 cm in size were not found by CT scanning. Computed tomography showed abnormality in eight of 32 patients subsequently found to be free of disease. Fine-needle aspiration cytology, bolus contrast injection and repeat scanning with additional oral contrast medium could have assisted in these circumstances. As persistent disease is by definition, a contraindication to second-look laparotomy, aggressive pre-operative assessment will spare some patients unnecessary surgery. However, CT cannot detect the small nodules often present in ovarian cancer, and thus, normal scans cannot replace surgical restaging.

Subepithelial pyeloureteric lesions in patients with nephrostomy tubes.

Mural filling defects were identified in the renal pelves or ureters in five patients with nephrostomy tubes. In two patients, infection was documented. In the remaining patients, the urine was sterile. While typical ureteritis cystica associated with infection may be seen in patients with nephrostomy tubes, in some patients, other mechanisms are responsible for this appearance.

Perirenal pancreatic pseudocysts: diagnostic management.

Three cases of pancreatic pseudocysts involving the kidney are presented in which clinical findings or diagnostic imaging favored intrinsic renal disease. Correct diagnosis was established in all cases by sonographically guided cyst aspiration with amylase determinations on the cyst fluid. In addition, laboratory studies ruled out infection, a well known complication of pancreatic pseudocysts. The findings were instrumental in guiding clinical management and insuring correctly timed and properly guided surgical intervention. It is concluded that any patient with a fluid collection in the kidney region may have a pancreatic pseudocyst even without a clear-cut history of pancreatitis or trauma. Fine-needle aspiration is safe and efficacious, and laboratory analysis of cyst fluid should always include amylase determination, in addition to bacteriologic and cytologic evaluation, even if serum amylase is normal.

Unequal doses of ioversol versus diatrizoate for urography.

A randomized, double-blind clinical trial was performed to compare a higher dose of conventional ionic contrast media (diatrizoate) with a lower dose of a new, nonionic contrast material (ioversol) for excretory urography (EU). One hundred twenty patients were randomized to receive either 100 ml of diatrizoate (Renografin-60) or 75 ml of ioversol (Optiray-320). Despite the lower iodine dose, the use of ioversol resulted in significantly better opacification of the calyces, renal pelves, and ureters. There was no significant difference in renal parenchymal opacification, opacification of the urinary bladder, or distention of the collecting system. We conclude that high-quality EU can be performed with a lower iodine dose using ioversol.

Intravenous cholangiography with helical CT: comparison with endoscopic retrograde cholangiography.

PURPOSE: To determine whether helical computed tomography (CT) performed during intravenous cholangiography can provide useful images of the biliary tree and to compare this technique with endoscopic retrograde cholangiography (ERC). MATERIALS AND METHODS: Eighteen adult patients with clinically suspected biliary disease who were referred for ERC were first examined with helical CT cholangiography performed 75 minutes after intravenous infusion of 100 mL of 10.3% iodipamide meglumine. RESULTS: Helical CT cholangiography revealed good opacification of the biliary tree in 13 of 14 patients with serum bilirubin levels less than 2 mg/dL (34 mumol/L) and poor opacification in three of four patients with levels greater than 2 mg/dL. In six of seven patients with choledocholithiasis, the diagnosis was made by means of helical CT cholangiography. CONCLUSION: Helical CT cholangiography may be a clinically useful method for visualization of the biliary tree in some patients with suspected biliary disease with normal bilirubin levels and in patients in whom attempts at ERC fail.

Parapelvic lymph cyst in a renal allograft mimicking hydronephrosis: CT diagnosis.

Lymphoceles are common complications of renal transplantation and usually arise between the bladder and the transplant kidney. A rare case of a parapelvic lymphocyst in a renal allograft is presented that sonographically mimicked hydronephrosis but was correctly diagnosed by CT.

Anatomic changes in the pelvis after uncomplicated vaginal delivery: a CT study on 14 women.

We analyzed CT scans of the pelvis made within 24 hr of an uncomplicated term vaginal delivery in 14 women to document the anatomic changes that occur in the immediate postpartum period. Scans were interpreted by three radiologists, and the results were compared with those from pelvic CT scans made from normal, age-matched, nonpregnant women. In addition to soft-tissue windows, bone windows also were obtained to assess the pubic symphysis and sacroiliac joints in both the postpartum women and the control subjects. The mean uterine length, transverse width, and anteroposterior diameter in the postpartum women (14 +/- 1.4, 12 +/- 1.5, and 9 +/- 1.6 cm, respectively) were significantly larger than in the nonpregnant women (7 +/- 1.4, 5 +/- 0.8, and 4 +/- 0.9 cm) (p less than .0001). CT scans showed intrauterine blood in nine of the postpartum women (64%), and three (21%) had intrauterine gas. There was widening of the sacroiliac joint in one (7%) of the postpartum women compared with none of the control subjects. Widening of the pubic symphysis was present in six (42%) of the postpartum women and in none of the control subjects. Six (42%) of the postpartum women had gas in the sacroiliac joints, 33% of which occurred bilaterally; gas in the pubic symphysis was seen in four (28%) of the postpartum scans. In one patient, an asymptomatic muscle hematoma was discovered. We conclude that normal changes in the pelvis after uncomplicated term vaginal delivery include enlargement of the uterus, intrauterine blood, widening of the symphysis and sacroiliac joints, and gas in the sacroiliac joints.

Spiral CT with ionic and nonionic contrast material: evaluation of patient motion and scan quality.

PURPOSE: To assess the effect of rapidly injected ionic or nonionic contrast material on patient motion and scan quality in spiral computed tomography (CT). MATERIALS AND METHODS: One hundred nine patients were prospectively, randomly chosen to receive ionic or nonionic contrast material. An acrylic rod was attached to the anterior abdomen with tape, which allowed an objective measurement of motion. Abdominal spiral CT was performed after intravenous injection of contrast material at a rate of 0.9 g of iodine per second. Scans were evaluated subjectively and objectively for motion and subjectively for quality. Complete data were available in 98 patients (47 in the ionic and 51 in the nonionic group). RESULTS: The acrylic rod moved an average of 0.44 mm per section in the nonionic group and 0.71 mm per section in the ionic group. Both subjective and objective measurements showed a statistically significant difference in patient motion. Use of nonionic contrast material resulted in less patient motion. Scan quality was better with nonionic contrast material. CONCLUSION: Less patient motion occurs and scan quality improves when spiral CT is performed with nonionic contrast material.

A comparison of findings at second-look laparotomy with preoperative computed tomography in patients with ovarian cancer.

Prior to undergoing second-look laparotomy, 57 patients with ovarian cancer were evaluated with computed axial tomography (CT). All patients were clinically free of disease following chemotherapy. At laparotomy, 25 patients had visible evidence of disease, 9 had microscopic disease only, and 23 were free of cancer. Tumor was correctly identified on CT in 9 of the 25 patients (36%) with macroscopic disease. Tumors smaller than 2 cm in size were not detected by CT. CT suggested disease in 8 of the 32 patients (25%) who were free of macroscopic disease. CT provides useful information when it is abnormal. Fine needle aspiration of suspicious areas can spare some patients laparotomy. However, CT has a significant false-negative rate due to its inability to detect small volume disease. Patients with negative CT will continue to require reexploration and tissue confirmation to assess the need for further therapy.

Objective measurement of motion in patients undergoing spiral CT examinations.

PURPOSE: To develop and evaluate an objective measurement of patient motion during spiral computed tomography (CT). MATERIALS AND METHODS: An acrylic rod was attached along the length of the torso in 109 patients (56 women, 53 men; age range, 21-79 years; mean age, 51 years) who underwent abdominal spiral CT examinations. Subjective evaluation of motion was graded on a five-point scale by two radiologists. Objective measurements of motion were determined by means of computer reconstruction of the rod in three dimensions and calculation of the deviation of the rod from its estimated position in the motionless state with time. RESULTS: Complete data were available in 98 patients. Subjective and objective measurements of patient motion showed a moderately high Spearman correlation coefficient of .49 (P < .001). The correlation between either observer and objective measurements was similar to the correlation between one observer and the other. CONCLUSION: This objective technique for assessing patient motion correlated well with subjective methods and may be useful in evaluating scanning parameters that may affect patient motion and hence scan quality.

Color Doppler flow imaging for deep venous thrombosis screening in patients undergoing pelvic lymphadenectomy and radical retropubic prostatectomy for prostatic carcinoma.

Patients undergoing pelvic lymphadenectomy and radical retropubic prostatectomy are traditionally considered to be at high risk for postoperative venous thromboembolic complications. A prospective deep venous thrombosis screening regimen was initiated at our medical center in 1990 following 2 cases of fatal pulmonary embolism that occurred after hospital discharge. During a 3-year period 245 consecutive patients undergoing radical retropubic prostatectomy for prostate cancer were screened postoperatively for lower extremity deep venous thrombosis using ultrasound duplex scanning with color Doppler flow imaging. The results were correlated only with the development of clinical deep venous thrombosis. No additional diagnostic modalities were used to confirm a normal venous system in asymptomatic patients. Venous thromboembolic complications were encountered in 9 of the 245 patients (3.6%). In 2 patients deep venous thrombosis was associated with nonfatal pulmonary embolism. Only 2 of the 9 cases of deep venous thrombosis were detected by color Doppler flow imaging screening. The striking decrease in the incidence of deep venous thrombosis following radical prostatectomy in the last decade and the low yield of screening at a single point in time may warrant reconsideration of the need for deep venous thrombosis screening among patients undergoing pelvic lymphadenectomy and radical retropubic prostatectomy for prostate cancer.

Osseous metastases from renal cell carcinoma: embolization and surgery for restoration of function. Work in progress.

Five patients underwent preoperative embolization of osseous metastases from renal cell carcinoma. The group consisted of four men and one woman who ranged in age from 46 to 79 years. The lesions were located in the pubic ramus and acetabulum, proximal femur, femoral midshaft, proximal humerus, and proximal tibia. All embolizations were performed within 24 hours of surgery. The internal fixation and tumor curettage was accomplished with estimated perioperative blood loss ranging from 10 ml to 1,250 ml. All patients had significant restoration of function following surgery. We suggest that preoperative embolization is an important and efficacious adjunct in the management of hypervascular renal cell osseous metastases.