[Bilateral pneumothorax following acupuncture]. / Bilateraler Pneumothorax nach Akupunktur.

Acupuncture, a subsection of traditional Chinese medicine, plays an important role as an alternative healing method. Even though there is little proof of its efficacy, acupuncture is becoming more and more popular in the Western world, especially because it is considered almost free of side effects. However, severe complications may occur and have previously been described.We will present a patient who suffered from bilateral pneumothoraces after acupuncture into the paravertebral area. This complication was not considered as a differential diagnosis thus even worsening the patient's life-threatening condition.

[Pitfalls and difficulties in interpretation of bone densitometry]. / Fehlermöglichkeiten und Interpretationsprobleme der Osteodensitometrie.

The clinical relevance of osteoporosis as a frequent systemic skeletal disease is to be found in fractures and their consequences. For prevention of these disease manifestations great importance must be attached to a safest possible diagnosis even before the occurrence of the first fracture and osteodensitometry is a well established technique for this purpose. Among the different measurement procedures DXA (dual-energy X-ray absorptiometry) has become the gold standard worldwide. This method is seen as very reliable and adequately precise. Prerequisites for these characteristics are the correct interpretation of the measurement data obtained by taking into consideration all potential influencing factors which can either false positively or false negatively influence a single value as well as the calculated mean value and the T and Z scores. Thus, exact knowledge of potential sources of error is of crucial importance. The present study shows important sources of error and difficulties in interpretation as well as a discussion of the options for their prevention. For the clinical practice osteodensitometry is to be seen as an important diagnostic component, which can only been interpreted meaningfully with respect to the clinical data.

Treatment of invasive pulmonary aspergillosis in neutropenic patients by additional bronchoscopic amphotericin B instillation.

BACKGROUND: Invasive pulmonary aspergillosis (IPA) remains a life-threatening condition despite systemic antifungal therapy. OBJECTIVES: This retrospective analysis investigated whether additional bronchoscopic instillation of amphotericin B (amB) would improve efficacy of antifungal treatment in patients with haematological malignancies suffering from IPA. METHODS: Twenty patients (40.6 +/- 14.2 years, 14 male) with preceding chemotherapy, bone marrow or stem cell transplantation complicated by severe IPA who did not respond sufficiently to systemic antifungal therapy were additionally treated by repeated bronchoscopic instillations of amB solution (91 instillations, on average 4.6 +/- 2.2 instillations per patient over a period of 24.1 +/- 21.0 days). Therapeutic response to this combined treatment regimen was monitored by chest X-ray and CT scan. RESULTS: The mean infiltration sizes during systemic antifungal therapy alone (mean duration 11.9 +/- 9.9 days) did not change significantly. However, after additional bronchoscopic instillation of amB solution infiltration sizes were reduced significantly (p < 0.05). A total resolution of infiltrates was seen in 3 and a partial reduction in 13 of 20 patients. Mean duration of total antifungal treatment was 50.1 +/- 24.0 days. The mean follow-up period was 34.1 +/- 31.2 months. The IPA-related mortality rate was 18.8% (3 of 16 patients). CONCLUSIONS: Additional bronchoscopic instillation of amB may improve the efficacy of systemic antifungal therapy in patients with haematological malignancies complicated by severe IPA. Bronchoscopic instillation of amB should be considered as an additional treatment option in cases with IPA unresponsive to systemic therapy.

[Osteodensitometry in children and adolescents with inflammatory bowel disease]. / Osteodensitometrie bei Kindern und Jugendlichen mit chronisch entzündlichen Darmerkrankungen.

PURPOSE: To evaluate the quantity and severity of bone disorders in children and adolescents with inflammatory bowel diseases (IBD) and to examine the correlation to whole body growth. MATERIALS AND METHODS: In this study 89 bone mineral density measurements were performed and retrospectively analyzed. RESULTS: Under consideration of growth retardation, over 65.2 % of the patients with Cohn's disease showed a reduced bone mineral density. Osteopenia/Osteoporosis is seldom seen in patients with ulcerative colitis, i. e., only 34.8 % showed a reduction in bone mineral density. Growth retardation and reduced bone mineral density are correlated. Patients with Cohn's disease and a body length below the 25th height percentile showed a reduced bone mineral density in 78.1 % of the cases. Patients with a body length below the 10th height percentile had a reduced bone mineral density in 83.3 % of the cases. CONCLUSION: These results demonstrate the value of osteodensitometric measurements in patients with chronic diseases, especially in children and adolescents with inflammatory bowel disease.

[Ultrasound guided transthoracic biopsy - safety and efficaces]. / Ultraschall gestützte Biopsie mit Durchleuchtungskontrolle zur Diagnostik thoraxwandnaher Raumforderungen - sicher und diagnostisch effektiv.

BACKGROUND: The biopsy of pulmonary neoplasms localized in close proximity of the thoracic wall and the histological examination of the specimens represent an important diagonstic tool in the work up of benign and malign pulmonary tumours. The biopsy techniques differ with respect to the guiding imaging method, the devices used and the quantity of specimen. This study investigates efficacy and safety of the ultrasound guided transthoracic biopsy. PATIENTS: 46 consecutive patients (n = 37 male; n = 9 female) with a mean age of 64.4 years were included in this analysis. 13 patients suffered from COPD with a mean residual volume in per cent of total lung capacity of 61.9 +/- 12.6 %. 43 pulmonary or pleural and 3 mediastinal neoplasms were investigated. The neoplasm reached the pleura in 41 cases. The mean tumours sizes was 59.1 +/- 30.6 mm. METHOD: The target structure was localized by ultrasound. The ultrasound probe and in its orientation to the target structure was fluoroscopically visualized. Local anaesthesia and sampling were performed in the same orientation under fluoroscopic control. Using the BioPince device (Medical Device Technologies, Inc.; Florida, USA; length 150 mm; Gauge: 18) two to five biopsy cylinders were taken. Chest X-ray was performed within some hours to rule out pneumothorax. RESULTS: The histological examination provided the diagnosis in 44 of 46 cases (95.6 %): lung cancer n = 29, other malign tumours n = 9; benign tumours n = 6). Complications were observed in three patients: haemoptysis, cutaneous emphysema (without need for intervention), pneumothorax with consecutive chest tube placement (one case each). CONCLUSION: The ultrasound guided transthoracic biopsy may be regarded as a safe diagnostic procedure. Complications, even in patients with structural lung disease are in the range of comparable techniques.

[The future of bedside chest radiography: Comparative study of mobile flat-panels and needle-image plate storage phosphor systems]. / Die Zukunft der Thoraxbettaufnahme: Vergleichende Untersuchung von mobilen Flachdetektoren und Speicherfoliensystemen mit Nadelkristalldetektoren.

BACKGROUND: Chest radiography is the most common diagnostic modality in intensive care units with new mobile flat-panels gaining more attention and availability in addition to the already used storage phosphor plates. PURPOSE: Comparison of the image quality of mobile flat-panels and needle-image plate storage phosphor system in terms of bedside chest radiography. MATERIALS AND METHODS: Retrospective analysis of 84 bedside chest radiographs of 42 intensive care patients (20 women, 22 men, average age: 65 years). All images were acquired during daily routine. For each patient, two images were analyzed, one from each system mentioned above. Two blinded radiologists evaluated the image quality based on ten criteria (e.g., diaphragm, heart contour, tracheal bifurcation, thoracic spine, lung structure, consolidations, foreign material, and overall impression) using a 5-point visibility scale (1 = excellent, 5 = not usable). RESULTS: There was no significant difference between the image quality of the two systems (p < 0.05). Overall some anatomical structures such as the diaphragm, heart, pulmonary consolidations and foreign material were considered of higher diagnostic quality compared to others, e.g., tracheal bifurcation and thoracic spine. CONCLUSIONS: Mobile flat-panels achieve an image quality which is as good as those of needle-image plate storage phosphor systems. In addition, they allow immediate evaluation of the image quality but in return are much more expensive in terms of purchase and maintenance.

Pulmonary nocardiosis with cutaneous involvement mimicking a metastasizing lung carcinoma in a patient with chronic myelogenous leukaemia.

We report a unique case of a man suffering from chronic myelogenous leukaemia who presented with clinical symptoms, X-ray, and bronchoscopical findings consistant with a bronchopulmonary space-occupying process which was suspected to be a central lung carcinoma as a secondary de novo malignancy. In addition, the patient developed several subcutaneous nodular livid red lesions on the left forearm which were considered to be cutaneous metastases of the presumptive lung malignancy. Treatment was started with percutaneous radiation of the mediastinum over a period of ten days with a total dose of 25 Gray. The patient died from circulatory and respiratory failure. Only post mortem pathological examination was indicative of a nocardiosis of the lungs with haematological spread to eosophagus, pleura, and subcutaneous skin of the left forearm. Unfortunately, diagnosis of nocardiosis could not finally proven by culture or molecular biological methods. A lung carcinoma or an infiltrate of residual or relapsing chronic myelogenous leukemia in the lung could be definitely ruled out.

[Invasive pulmonary aspergillosis--CT findings in context with the clinical course]. / Invasive Pulmonale Aspergillose--CT-Befunde im Kontext des klinischen Verlaufes.

PURPOSE: To investigate the impact of chest radiographs and CT in patients suffering from invasive pulmonary aspergillosis (IPA) compared to the clinical course. PATIENTS AND METHODS: Twenty-three patients with confirmed diagnosis of IPA between January 1996 and September 1999 were included in this study. Signs of inflammatory infiltrates on chest radiographs and CT were retrospectively evaluated in relation to the onset of the clinical symptoms. Infiltrates on CT were analyzed in detail with respect to number, morphology, and localization. RESULTS: Seventy-six infiltrates were found on the CT of 22 patients; one patient had diffuse areas of lung infiltrates. Both lungs were affected by infiltrates in 14 patients. Pleural effusions were confirmed in 12 patients. Twelve patients had typically round foci with halo and nine patients crescent air signs. The preferred localization of lung infiltrates was segment 6. The median interval between the onset of clinical symptoms and the first radiographic changes was 5.5 days, with an additional interval of 4.5 days until confirmation by CT. Localization, number of infiltrates, and clinical course were not related. CONCLUSION: In immune-compromised patients with fever, a CT of the chest should be carried out as soon as possible to detect signs indicative of IPA. Morphological changes on CT like a round focus with halo and crescent air sign support the diagnosis of IPA. In this context, special attention should be directed to pulmonary segment 6.

[Diagnosis, prophylaxis and therapy of osteoporosis in juvenile idiopathic arthritis: consensus statement of the German Association for Pediatric Rheumatology]. / Diagnose, Prophylaxe und Therapie der Osteoporose bei juveniler idiopathischer Arthritis: Konsensusstatement der Gesellschaft für Kinder- und Jugendrheumatologie.

In all subgroups of juvenile idiopathic arthritis (JIA), a pathologic loss of bone or the lack of increase in bone mass has been described in a high percentage of cases, even with new therapeutic approaches. The decrease in bone mass is correlated with the duration of active disease and the number of affected joints (cytokines, inactivity). In several studies, muscle mass was the strongest predictor of bone mass. A standardized diagnostic approach to the musculoskeletal system including measures of prophylaxis and therapy therefore seems to be mandatory for all children with JIA who do not achieve rapid remission. In this review, the diagnostic and therapeutic options are described and summarized in an algorithm.

[A 32-year-old patient with diarrhoea and acute kidney failure]. / 32-jähriger Patient mit Durchfall und akutem Nierenversagen.

A 32-year-old male patient presented in the emergency department of our hospital with acute vomiting and diarrhoea. He reported occasional non-severe diarrhoea over several years in the past. Furthermore, at the time of presentation the patient had had anuria for several days. A prerenal and postrenal origin of the renal failure was excluded. A renal biopsy was performed and histopathological examination displayed findings consistent with a haemolytic-uraemic syndrome but no signs of glomerulonephritis. MRI examination of the small bowel revealed inflammatory alterations typical for Crohn's disease, even without histological verification. We describe haemolytic-waemic syndrome as manifestation of Crohn's disease for the first time.

Central diabetes insipidus in a patient with malaria tropica.

Up to 21% of severe cases of malaria tropica are associated with polyuria and are life-threatening. We describe a 39-yr-old man with malaria tropica who developed disseminated intravascular coagulation, polyuria, and a pituitary lesion. Empiric treatment with vasopressin improved the polyuria. This is the first case of malaria tropica in which central diabetes insipidus has been documented.

[Life and places of activity of Julius Cohnheim]. / Leben und Wirkungsstätten von Julius Cohnheim.

This paper gives an account of the life of Cohnheim (1839-1884) beginning in Berlin where for seven years he was one of the most able pupils of Virchow, to the professorial chairs in Kiel (1868), Breslau (1872) and finally Leipzig (1878) where he headed the Pathological Institute until his premature death in 1884. In his scientific work Cohnheim devoted his attention to four great themes. These were the study of inflammation and the pathology of circulation, the causes and development of tumours as well as the problem of tumour metastasis and the aetiology of tuberculosis. The sum of his experience in all these central problems of pathology has been brought together in his "Lectures on general pathology". His worldwide reputation rests especially on his research into the causes of inflammation, in which he experimentally confirmed the outward migration of leucocytes through the blood vessel wall. Cohnheim fully recognized the importance which experiments have for pathology and made fundamental contributions to the perfection of experimental pathological techniques.

[Recurrent lower gastro-intestinal bleeding in a 38-year-old patient]. / Rezidivierende untere gastrointestinale Blutung bei einem 38-jährigen Patienten.

HISTORY AND CLINICAL FINDINGS: A 38-year-old patient with a history of recurrent gastrointestinal bleeding for more than 15 years was transferred for the treatment of a new onset of hematochezia and anemia. His general condition was clearly reduced. EXAMINATIONS: Laboratory results showed a distinct microcytic hypochromic anemia; ferrum, ferritin, albumin, and protein were also diminished. Colonoscopy and transrectal ultrasound uncovered large hemangiomatous structures in the rectum. Digital substraction angiography of the bilateral internal iliac artery, superior and inferior mesenteric arteries including its branches showed a perirectal polypoid tumour with a discrete angiomatous structural shadow in the capillary phase. MRI of the pelvis revealed angiomatous blood vessels in the whole pararectal space and to a minor extension in the gluteal muscles. DIAGNOSIS, TREATMENT AND COURSE: The diagnosis of cavernous hemangioma of the rectum was made and a distal mesorectal resection of the rectum including a coloanal anastomosis and double-running ileostomy was performed. 3 months later the ileostomy was reversed. There was no further bleeding and the rectal continence was normal. CONCLUSION: In case of unclear recurrent lower gastrointestinal bleeding, with onset in the early childhood and impressive rectal varices, one has to think about the rare diagnosis of cavernous hemangioma.

[Pneumatosis cystoides intestinalis, a rare complication of mixed connective tissue disease]. / Pneumatosis cystoides intestinalis - Eine seltene Komplikation bei mixed connective tissue disease.

HISTORY AND ADMISSION FINDINGS: A 77-year-old woman presented with diarrhoea and increasing malaise. The patient reported a weight loss of 30 kilogram over the past 12 months due to recurrent episodes of diarrhoea. During previous hospitalisations the diagnosis of a mixed connective tissue disease had been established, and the patient was treated with azathioprine and prednisolone. Clinical findings at presentation included diffuse oedema of the hands, Raynaud's and Sicca syndrome, dysphagia and a distended abdomen and pain on palpation of the left lower abdomen. INVESTIGATIONS: A chest X-ray revealed pneumoperitoneum. Contrast medium radiography of gastro-intestinal passage and an abdominal CT with contrast medium confirmed the existence of pneumoperitoneum and showed, in addition, intramural gas in the wall of the dilated jejunum. No contrast medium leakage as an indicator of an open perforation was detectable. DIAGNOSIS, TREATMENT AND CLINICAL COURSE: Due to suspected encapsulated perforation a laparotomy was performed. In situ, multiple gas bubbles were found both in the bowel walls and in the mesentery. The small intestine was severely distended, atonic but without evidence for a stenosis. In the absence of an open perforation, the diagnosis of pneumatosis cystoides intestinalis (PCI) was established as the underlying cause of the pneumoperitoneum. Treatment with metronidazole was initiated and the diarrhoea resolved over the following 3 weeks. CONCLUSION: PCI is a rare condition, to be considered if pneumoperitoneum is present. One possible underlying cause is an intestinal manifestation of a mixed connective tissue disease.

[Bone metabolism in 53 children and adolescents with chronic inflammatory bowel disease]. / Knochenstoffwechsel bei 53 Kindern und Jugendlichen mit chronisch entzündlichen Darmerkrankungen.

BACKGROUND: Osteopathy is a common clinical feature of chronic inflammatory bowel disease (IBD) in children and young adults at the time of primary diagnosis. The aim of the following study was to address the question of prevalance of a decreased bone density or increased bone metabolism in children with IBD. PATIENTS: We examined 63 patients (mean age 13 years; 5 - 18 years): 36 Crohn's disease (MC) patients, 16 colitis ulcerosa (CU) patient and one patient with colitis indeterminata (CID). 10 children who had been referred to the gastroenterological outpatient department due to suspected IBD symptoms were later found not to suffer from IBD. These 10 patients therefore were included in the study as controls. RESULTS: 8 of 10 CU patients and 18 of 28 MC patients showed a pathological bone density and abnormalities in bone metabolism. Repetitive bone density measurement was performed in 18 patients. In MC patients a - 0.39 SDS decrease of bone mineral density was found, without a simultaneous deterioration of clinical stage and inspite of a decreased cumulative prednisolon dosage. However in CU patients a + 0.06 SDS increase of bone mineral density was detected. These patients had a lower cumulative prednisolon dosage and a stable clinical course. CONCLUSIONS: In conclusion, pediatric IBD patients often show abnormalities in bone metabolism and decreased bone density. There is a need for multicentre, prospective randomised control trials to further identify therapeutic tools on the basis of the multifactorial etiology of bone disease in pediatric IBD patients.