Procalcitonin in hemodialysis patients presenting with fever or chills to the emergency department

We sought to assess the role of procalcitonin in discriminating severe bacterial infections requiring antibiotic treatment from non-bacterial causes of fever or chills in chronic dialysis patients. Chronic hemodialysis patients who were admitted to the emergency room due to fever and/or chills were recruited to the study. The presence or absence of bacterial infection was defined after recruitment conclusion by an infectious disease specialist who was blinded to procalcitonin results. Procalcitonin levels were compared between infected and non-infected patients. Out of 54 patients recruited, 22 (41%) patients eventually diagnosed with infection. Mean (± SD) procalcitonin values were 4.3 (± 5.5) ng/ml among cases, 1.0 (± 2.0) ng/ml among controls with no infection (p = 0.02). A cutoff PCT value of 1 ng/ml or higher had 77% sensitivity and 59% specificity for the diagnosis of severe infection. Procalcitonin cannot usefully identify hemodialysis patient with bacterial infection.

A novel system to study adenovirus tropism to normal and malignant colon tissues

We describe here a new organ culture system for the evaluation of viral tropism to colon carcinomas and normal colon tissues. Organ cultures of mouse and human colon retained viability for several days and thus facilitated studies of viral tropism. Two adenoviral vectors (AD) were compared in the study: AD5, that utilizes the CAR receptor, demonstrated poor infectivity to both normal and carcinoma tissues, while a capsid-modified-AD, recognizing haparan-sulfate receptor, demonstrated efficient infectivity of both tissues. Immunohistochemistry analysis demonstrated different viral tropism; while AD5 infected only the colon epithelia, the capsid-modified-adeno infected both the epithelia and mesothelial layers. To investigate other determinants in the tissue that influence viral tropism, human cancer tissues were pretreated with collagenase and infected with the AD viruses. Increased infectivity and altered tropism were noted in the treated tumor tissue. Taken together, this ex vivo system indicated that receptor utilization and extracellular-matrix components influence AD viral tropism in solid tissues.

Fibrin microbeads (FMB) as a 3D platform for kidney gene and cell therapy

Cell and gene therapy may alter the outcome of renal diseases, such as hereditary nephropathies, acute and chronic glomerulonephritis and allograft nephropathy. However, owing to blockade of many viral and cellular vehicles by the complex glomerular architecture, the exact nature of gene and cell delivery into specific renal compartments remains currently unknown. To study the interaction of viral vectors with a variety of renal cells and mesenchymal stem cells (MSCs), we employed a novel biological three-dimensional (3D) matrix comprised of fibrin microbeads (FMB) in comparison to monolayer cell culture. Our studies showed that renal cells of both established and primary lines can grow efficiently on FMB and differentiate into epithelial structures, as shown by electron microscopy. Gene delivery into renal cells in 3D was observed for several viral vectors and growth in 3D on FMB conferred resistance to renal cancer cells in the context of oncolytic adenoviruses. Finally, MSCs from various rodent species attached to FMB, grew robustly, survived for several weeks and could efficiently be transduced on FMB. Thus, on the basis of growth, differentiation and transduction of renal cells in 3D, FMB emerge as a novel 3D cellular microenvironment that differs substantially from monolayer cell cultures.

Heparin-induced recurrent anaphylaxis

BACKGROUND

Heparin-related immediate-type hypersensitivity reactions like urticaria, angio-oedema or bronchospasm are very rare, and only a few cases of anaphylaxis-like responses because of heparin have been described. However, the mechanisms underlying these reactions and the role of mast cells in their pathogenesis have not been elucidated.

OBJECTIVES

We report a patient with end-stage renal disease who presented with recurrent anaphylaxis after receiving heparin during haemodialysis. The underlying aetiology was obscured by the initiation of haemodialysis with its known anaphylactic-like side-effects. The diagnosis of hypersensitivity to heparin was confirmed by the clinical picture, positive skin tests and elevated serum tryptase levels.

MATERIALS AND METHODS

We performed prick and intradermal skin tests with heparin, enoxaparin and danaparoid heparinoid. Total and mature tryptase levels were measured in serum by ELISAs at 1, 24 and 36 h following the reaction.

RESULTS

An elevated mature tryptase level was found at 1 h, which returned to normal levels at 24 and 36 h. A high total tryptase level was detected at 1 h, but remained somewhat elevated at 24 h. Prick tests were negative with the three compounds. Intradermal skin tests with heparin and enoxaparin were both positive, while with danaparoid negative. Following negative skin test results, danaparoid was used as an anticoagulant during dialysis for the next 3 years without any adverse effects.

CONCLUSIONS

In conclusion, we report the first case of heparin-induced anaphylaxis confirmed by an elevated level of mature tryptase in serum. Following skin tests, the patient was treated with danaparoid during haemodialysis sessions three times a week without any adverse effects. Because of increasing use of heparin in daily medical practice, physicians should be aware of possible immediate hypersensitivity reactions to this medication and know how to diagnose and treat them.

Shortening and migration of Wallstents after stenting of central venous stenoses in hemodialysis patients

PURPOSE

To report our results for the placement of central venous stents in patients undergoing hemodialysis.

METHODS

Ten Wallstents (Schneider, Bülach, Switzerland) were placed in 10 patients with shunt thrombosis, shunt dysfunction or arm swelling associated with central vein stenosis or occlusion. Technical success, patency and complications were evaluated.

RESULTS

Stent deployment was successful in all cases. In seven cases (70%) there was significant delayed stent shortening. In two of these cases there was also stent migration. All these cases required additional stents. Primary patency rates at 6, 12 and 24 months were 66%, 25% and 0. Twenty-three additional procedures (percutaneous transluminal angioplasty or stenting) were required to achieve secondary patency rates at 6, 12 and 24 months of 100%, 75% and 57%.

CONCLUSION

Stent placement in the central veins of dialysis patients has a high technical success rate resulting in symptomatic relief and preservation of access. Repeat interventions are required to maintain patency. Significant delayed shortening of the Wallstent occurred in 70% of patients which may have affected the patency rates. Strategies are suggested to avoid this problem.

The common mutations C677T and A1298C in the human methylenetetrahydrofolate reductase gene are associated with hyperhomocysteinemia and cardiovascular disease in hemodialysis patients

BACKGROUND

Plasma total homocysteine (tHcy) level might be an important risk factor for the development of cardiovascular disease (CVD) in dialysis patients. While both renal failure and mutations of the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene may result in hyperhomocysteinemia and CVD, the distinct roles of the thermolabile MTHFR mutation at nucleotide C677T and the more recently described mutation at nucleotide A1298C have not been evaluated concurrently in patients on hemodialysis.

METHODS

A cross-sectional study was performed in 120 maintenance HD patients to determine the prevalence of MTHFR C677T and A1298C mutations and their relative association to hyperhomocysteinemia and CVD.

RESULTS

Both mutations, the C677T and the A1298C, were highly prevalent in HD patients with allele frequencies of 0.41 and 0.27, respectively. The prevalence of CVD in HD patients was 55% and its significant risk factors included, in descending order, hyperhomocysteinemia, MTHFR C677T mutation, low serum folate levels, diabetes mellitus, hypertension, and double heterozygote state for both MTHFR mutations (677CT/1298AC). MTHFR A1298C mutation alone and gender were not associated with either hyperhomocysteinemia or increased CVD risk, but the HD patients with homozygotes 1298CC and wild alleles 677CC (677CC/1298CC) have significant increase of tHcy (37.7 +/- 12) and high prevalence of CVD.

CONCLUSIONS

Hyperhomocysteinemia, serum folate levels and both C677T and A1298C MTHFR mutations are associated with CVD in HD patients.

Conditional gene targeting for cancer gene therapy

Current treatment of solid tumors is limited by severe adverse effects, resulting in a narrow therapeutic index. Therefore, cancer gene therapy has emerged as a targeted approach that would significantly reduce undesired side effects in normal tissues. This approach requires a clear understanding of the molecular biology of both the malignant clone and the biological vectors that serve as vehicles to target cancer cells. In this review we discuss novel approaches for conditional gene expression in cancer cells. Targeting transgene expression to malignant tissues requires the use of specific regulatory elements including promoters based on tumor biology, tissue-specific promoters and inducible regulatory elements. We also discuss the regulation of both replication and transgene expression by conditionally-replicative viruses. These approaches have the potential to restrict the expression of transgenes exclusively to tissues of interest and thereby to increase the therapeutic index of future vectors for cancer gene therapy.

Human immunodeficiency virus type 1-mediated syncytium formation is compatible with adenovirus replication and facilitates efficient dispersion of viral gene products and de novo-synthesized virus particles

Conditionally replicative adenovirus (CRAd) vectors are designed for specific oncolytic replication in tumor tissues with concomitant sparing of normal cells. As such, CRAds offer an unprecedented level of anticancer potential for malignancies that have been refractory to previous cancer gene therapy interventions. CRAd efficacy may, however, be compromised by inefficient dispersion of the replicating vector within the tumor tissue. To address this issue, we evaluated the utility of a fusogenic membrane glycoprotein (FMG), which induces the fusion of neighboring cellular membranes to form multinucleated syncytia. We hypothesized that the FMG-mediated syncytia would facilitate dispersion of the adenovirus (Ad) gene products and viral progeny. To test this, human immunodeficiency virus type 1 (HIV-1) envelope glycoproteins, which induce syncytia in the presence of CD4+ target cells, were expressed by an Ad (Ad5HIVenv) in permissive (CD4-positive) and nonpermissive (CD4-negative) cell lines. After validating this Ad-FMG model, the efficiency of Ad replication in the presence or absence of syncytia was evaluated. The results demonstrated that syncytium formation was compatible with Ad replication and dramatically increased the dispersion of virus gene products within the cytoplasm of the syncytia as well as viral particles in the nuclei of the syncytial mass. Moreover, progeny virions were released more efficiently from syncytia compared with nonsyncytial cells. These data demonstrate the utility of FMGs as a dispersion agent and suggest that FMGs can improve the efficacy of CRAd gene therapy.

Heat shock and heat shock protein 70i enhance the oncolytic effect of replicative adenovirus

Replication-competent viruses are currently being evaluated for their cancer cell-killing properties. These vectors are designed to induce tumor regression after selective viral propagation within the tumor. However, replication-competent viruses have not resulted heretofore in complete tumor eradication in the clinical setting. Recently, heat shock has been reported to partially alleviate replication restriction on an avian adenovirus (Ad) in a human lung cancer cell line. Therefore, we hypothesized that heat shock and overexpression of heat shock protein (hsp) would support the oncolytic effect of a replication-competent human Ad. To this end, we tested the oncolytic and burst kinetics of a replication-competent Ad after exposure to heat shock or to inducible hsp 70 overexpression by a replication-deficient Ad (Adhsp 70i). Heat-shock resulted in augmentation of Ad burst and oncolysis while decreasing total intracellular Ad DNA. Overexpression of hsp 70i also enhanced Ad-mediated oncolysis but did not decrease intracellular Ad DNA levels. We conclude that heat shock and Adhsp 70i enhance the Ad cell-killing potential via distinct mechanisms. A potential therapeutic implication would be the use of local hyperthermia to augment oncolysis by increasing the burst of replication-competent Ad. The role of hsp in Ad-mediated oncolysis should be additionally explored.

Late-onset downregulation of NaPi-2 in experimental Fanconi syndrome

The pathogenesis of renal phosphate (Pi) leak in Fanconi syndrome is unknown. Disorders of apical membrane transporters, leaky apical membrane, depleted cellular Pi and ATP, and impaired sodium (Na) pumps have been proposed as underlying defects. The present study examined the role of type II Na-Pi cotransport system (NaPi-2) in experimental Fanconi syndrome in rats. Following a single injection of maleic acid (MA), 75 mg/kg body weight i.p., rats were sacrificed after 90 min, 4 h, and 24 h. Renal cortical expression of NaPi-2 mRNA was determined by Northern blotting, and brush border membrane (BBM) NaPi-2 protein by Western blotting. Increased urinary excretion of phosphate was demonstrated as soon as 90 min after MA injection, and was sustained at 4 and 24 h, NaPi-2 mRNA expression and NaPi-2 protein were not decreased after 90 min. NaPi-2 mRNA decreased after 4 h, while NaPi-2 protein decreased only at 24 h. Hence, the immediate phosphaturia in experimental Fanconi syndrome may be independent of NaPi-2 downregulation, possibly resulting from energy depletion or membrane dysfunction. The decrease in NaPi-2 mRNA expression and the subsequent NaPi-2 protein decrease may account for the second-phase phosphaturia.

Association of anticardiolipin antibodies with vascular access occlusion in hemodialysis patients: cause or effect?

BACKGROUND

Uremic patients on hemodialysis (HD) often display occlusive disorders despite their uremic thromboasthenia. The role of anticardiolipin antibodies (aCL) and the recently identified anti-beta2-glycoprotein I antibodies (abetaGPI) in these phenomena is unknown.

METHODS

The prevalence of IgG and IgM aCL and abetaGPI was documented in 54 HD patients and 19 nondialyzed patients with chronic renal failure (CRF). The HD patients were further divided into arteriovenous (AV) access occluders and nonoccluders.

RESULTS

HD patients had a higher mean IgG aCL level than CRF patients (14.68 +/- 3 vs. 2.96 +/- 1 IU/ml, respectively, p < 0.0007). IgM aCL did not differ significantly. AV access occluders had a higher mean IgG and IgM aCL levels than nonoccluders (24.47 and 8.39 IU/ml in occluders vs. 8.45 and 3.59 IU/ml in nonoccluders, p < 0.0226 and p < 0.05, respectively). IgM and IgG abetaGPI antibody levels were below the cutoff point and did not differ significantly between the various groups. Cardiovascular episodes were not correlated with the titer of aCL or abetaGPI.

CONCLUSION

These results indicate that HD, especially in patients with recurrent access occlusion episodes, is associated with elevated levels of IgG aCL, and that IgG aCL level may predict the occlusive status of HD patients.

End-stage renal interstitial fibrosis in an adult ten years after ifosfamide therapy

A 33-year-old male presented with end-stage renal failure. Renal biopsy showed severe interstitial fibrosis without glomerulopathy or vasculopathy. More than 10 years previously the patient had been successfully treated for recurrent rhabdomyosarcoma. The treatment included ifosfamide, a drug known to cause acute tubular dysfunction. Though a possible synergistic effect of previous radiation which was well within accepted tolerance limits cannot be excluded, it would appear that ifosfamide was almost certainly the major cause of the late onset chronic renal disease.

Pseudo-normal osmolal and anion gaps following simultaneous ethanol and methanol ingestion

Methanol, ethylene glycol, and isopropyl alcohol are associated with acute intoxication. The diagnosis is dependent upon high anion-gap metabolic acidosis, and an osmolal gap between the calculated and the measured osmolality. Normal anion gap has been reported in some cases of concomitant methanol and ethanol ingestion, where the high serum levels of ethanol inhibited the metabolism of methanol by alcohol dehydrogenase. The osmolal gap in these cases was higher than expected for methanol, and served as a constant marker for a metabolic derangement. Herewith, we present a patient who presented with normal osmolal and anion gaps 36 h after ethanol and methanol ingestion, yet progressively developing ocular toxicity. Normal anion and osmolal gaps should not rule out earlier methanol poisoning.

Pancreatitis following hepatitis A vaccination

We describe a 23-year-old male patient who presented with epigastric abdominal pain, 8 days following vaccination with inactivated hepatitis A virus (Haverix(R)). Clinical and laboratory data confirmed the diagnosis of pancreatitis. Repeat polymerase chain reaction (PCR) for hepatitis A replication was negative. A comprehensive evaluation ruled out other etiologies for pancreatitis. IgM Hepatitis A antibodies did not develop even after 3 months. Pancreatitis following Hepatitis A is a well-known complication of the viremia, but the exact mechanism is controversial. We suggest that the pancreatitis may have been a cellular immunlogical reaction to one of the antigens of hepatitis A virus vaccine, or it might have been caused by the release of mediators of anaphylaxis such as histamine and leucotriens, induced by HAV antigens, resulting in pancreatitis without development of humoral immunization.

Hypoglycemia in patients with renal failure

Of a total of 1545 admissions of end stage renal failure (ESRD) patients, fifty-six (3.6%) were admitted during a ten-year period with hypoglycemia. Thirty-eight of them were diabetic while the others were non-diabetic patients. The most common etiology found to be drug-induced hypoglycemia in 26 (46%) patients. In 22 (39%) cases, sepsis was the contributing cause of hypoglycemia. Severe malnutrition caused 7% of hypoglycemic episodes. Of the patients, 18 (32%) with ESRD eventually died, none of them were from the drug induced group. However, mortality rate in the sepsis induced hypoglycemia group was 66%, and of the malnutrition group 17% of the deaths. Thus, hypoglycemia is frequent in ESRD patients, and is fatal if associated with either sepsis or malnutrition.

The renal effect of low-dose dopamine in high-risk patients undergoing coronary angiography

OBJECTIVES

The purpose of the study was to examine the potential renal protective effect of low-dose dopamine in high-risk patients undergoing coronary angiography.

BACKGROUND

Contrast nephropathy is prevalent in patients with chronic renal failure (CRF) and/or diabetes mellitus (DM). Decreased renal blood flow due to vasoconstriction was suggested as a contributory mechanism. Low-dose dopamine has a dilatory effect on the renal vasculature.

METHODS

Sixty-six patients with mild or moderate CRF and/or DM undergoing coronary angiography were prospectively double-blindedly randomized, to either 120 ml/day of 0.9% saline plus dopamine 2 microg/kg/min (Dopamine group) or saline alone (Control group) for 48 h.

RESULTS

Thirty-three Dopamine-treated (30 diabetics and 6 with CRF) and 33 Control (28 diabetics and 5 with CRF) patients were compared. Plasma creatinine (Cr) level increased in the Control group from 100.6+/-5.2 before to 112.3+/-8.0 micromol/liter within five days after angiography (p = 0.003), and in the Dopamine group from 100.3+/-5.4 before to 117.5+/-8.8 micromol/liter after angiography (p = 0.0001), respectively. There was no significant difference in the change of Cr level (deltaCr) between the two groups. However, in a subgroup of patients with peripheral vascular disease (PVD), deltaCr was -2.4+/-2.3 in the Control group and 30.0+/-12.0 micromol/liter in the Dopamine group (p = 0.01). No significant difference occurred in deltaCr between Control and Dopamine in subgroups of patients with preangiographic CRF or DM.

CONCLUSIONS

Contrast material caused a small but significant increase in Cr blood level in high-risk patients. There is no advantage of dopamine over adequate hydration in patients with mild to moderate renal failure or DM undergoing coronary angiography. Dopamine should be avoided in patients with PVD exposed to contrast medium.

Acute hyperphosphatemia caused by sodium phosphate enema in a patient with liver dysfunction and chronic renal failure

We report a case of acute hyperphosphatemia secondary to rectal administration of sodium phosphate and sodium biphosphate (Fleet enema). Parathyroid hormone and calcitonin levels were measured along with phosphate clearance and the tubular reabsorption of phosphate.

A rapidly progressive cataract in a patient with autoimmune hypoparathyroidism and acute liver and renal failure

Cataract is a well-known complication of hypoparathyroidism, albeit the mechanism is obscure. The progression of cataract is typically slow in patients with idiopathic hypoparathyroidism. We describe a case of an extremely rapid evolution of typical hypocalcemic cataracts in a patient with familial autoimmune hypoparathyroidism during acute idiopathic hepatic and renal failure, while serum calcium and phosphorus were unbalanced. Physicians and ophthalmologists must be aware of cataracts developing rapidly in the setting of such metabolic derangements.

[Neurological manifestations of non A-G viral hepatitis]

Guillain-Barre and other neurologic syndromes rarely occur as complications of viral hepatitis (A, B and C). Other neurologic syndromes have also been reported in serologically defined viral hepatitis, including mononeuritis, auditory neuritis, and seizures. Chronic hepatitis B and mononeuritis multiplex are found together in 31-54% of patients with periarteritis nodosa. The mechanisms of these associations are unknown, but may include direct cytotoxicity of the virus or immune-mediated damage. Vasculitis of the vasa nervorum plays an intermediate role, at least in some cases. We describe a 36-year-old man with acute non A-G hepatitis complicated by Guillain-Barre syndrome. The neurological manifestation resolved completely without specific therapy within 6 days, as the hepatitis resolved.

Second degree atrio-ventricular block and cardiotoxicity secondary to envenomation by the scorpion Leiurus quinquestriatus ('yellow scorpion')--an indication for serotherapy?

Tachyarrhythmia following scorpion envenomation might be an indication for anti venin therapy. We present a case of an unusual cardiotoxic response to Leiurus quinquestriatus ('yellow scorpion') venom-second degree atrio-ventricular block (Mobitz type 1). We review the biological activities of L. quinquestriatus' venom and the arrhythmia's possible pathophysiology. The question arising from this case is the therapeutic approach to cardiotoxicity and bradyarrhythmias induced by scorpion envenomation-mainly, the indication for anti serum therapy.

Normotensive scleroderma renal crisis: case report and review of the literature

A 58 year old man presented with skin manifestations of scleroderma without systemic involvement. Within few weeks of oral corticosteroids and penicillamine therapy, rapidly progressive systemic sclerosis developed. The deterioration manifested by skin lesions, diffuse interstitial restrictive lung disease, acute renal failure with normal blood pressure values, and microangiopathic hemolytic anemia compatible with hemolytic uremic syndrome. Chronic renal failure developed and was treated by dialysis, but the patient died due to sepsis. The course of renal involvement was normotensive; antihypertensive therapy was not prescribed even once. The association of scleroderma renal crisis with normal blood pressure is probably a rare and ominous combination.

The ontogeny of the expression of K+ channel-like gene (CHIF) in the rat kidney papilla

Recently, an IsK-like potassium (K+) channel corticosteroid-induced gene (CHIF) was cloned. A high-K+ diet enhances, while a low-K+ diet decreases the expression of this gene. The major expression of CHIF in the adult rat kidney is in the papilla, where it is constitutive, in contrast to its inducibility by corticosteroids and a low-salt diet in the rat colon. In order to further understand the ontogeny of K+ clearance, we studied the presence of CHIF in the kidney papilla in different stages of rat development. Total RNA from rat kidney papillae of 1- to 3-day pre-labor unborn offspring, 2- to 3-day-old newborns, 10-day-old, 6-week-old, and 43-week-old rats underwent northern hybridization for CHIF and the alpha-subunit of the Na+-K+-ATPase mRNA. Minor expression of CHIF mRNA was found in fetal and newborn rat papillae, while older rats showed an age-related increase in gene expression. The expression of the alpha-sub unit of the Na+-K+-ATPase was not age related. We conclude that CHIF is present in the rat kidney papilla and the expression is related to age. The relative deficiency of CHIF in the newborn may be one of the factors responsible for the reduced K+ clearance in is period.

Increased serum CA 19-9 antibodies in Sjögren's syndrome

A 67-year-old woman with a history of thyroiditis presented with recent intermittent epigastric pain and nausea. Hyperamylasaemia, oedema of the pancreas, and high serum levels of lipase and CA 19-9 were found. Xerostomia and dry eyes developed later, accompanied by an abnormal Schirmer's test. The diagnosis of Sjögren's syndrome was confirmed by increased anti-Ro and anti-La antibodies and the histological findings of parotid gland biopsy. Two additional cases of Sjögren's syndrome with elevated serum CA 19-9 are also described. These observations of elevated serum lipase and serum CA 19-9 in Sjögren's syndrome without evidence of malignancy may reflect pancreatic involvement in this disorder.

Pituitary apoplexy manifested by sterile meningitis

Pituitary apoplexy is rare and underdiagnosed. It results from either infarction or hemorrhage into an adenoma of the pituitary gland. The clinical presentation comprises a rapid development of impaired consciousness, severe headache, and amblyopia or diplopia. Meningeal irritation signs are considered rare and have not been reported as presenting signs. We report a 64-year-old patient whose presentation with necrosis of a pituitary adenoma was clinically indistinguishable from infectious meningitis.

Idiopathic pulmonary fibrosis associated with rectal carcinoma--a paraneoplastic syndrome or coincidence?

The association between lung cancer and idiopathic pulmonary fibrosis (IPF) is well documented, complicating > or = 10% of cases involving IPF. This association is considered to be a result of neoplastic degeneration, rather than a paraneoplastic phenomenon. However, rectal carcinoma has only rarely been linked to paraneoplastic manifestations. We describe a young patient with IPF that preceded the appearance of rectal carcinoma by 6 mo. The possible association between the two disorders is discussed.

Primary non-Hodgkin's lymphoma of the lung presenting as bronchiolitis obliterans organizing pneumonia

A 44-year-old man presented with fever, dyspnea, and bilateral cavitary lung lesions. Following percutaneous transthoracic CT guided needle biopsy of the lung, a diagnosis of bronchiolitis obliterans organizing pneumonia (BOOP) was made and the patient was treated with corticosteroids. Despite a good initial response he developed new lung lesions within six months, associated with a lack of response to corticosteroids. Due to further deterioration and the development of Guillian-Barre' syndrome an open lung biopsy was performed and revealed T-cell rich, B-cell non Hodgkin's lymphoma with BOOP. We suggest that BOOP may be the presenting manifestation of primary lung lymphoma. We recommend that when BOOP has an atypical course or does not respond to corticosteroids open lung biopsy should be performed in order to exclude pulmonary lymphoma.

Resistance to activated protein C: arterial thrombosis associated with autoimmune features

A 27 year old woman presented with recurrent cerebrovascular strokes in the setting of an ill defined auto-immune disease responsive to corticosteroid therapy. Investigation for a hypercoagulable state revealed activated protein C resistance in the absence of protein C, protein S, or antithrombin III deficiency or anticardiolipin antibodies. Her parents and sibling did not demonstrate APC resistance. This case suggests that activated protein C resistance may be associated with arterial as well as venous thrombotic events and implies that resistance to activated protein C should also be considered in the evaluation of young adults with strokes.

CT-guided biopsy of peripheral lung lesions associated with BOOP

Diagnosis of Bronchitis Obliterans with Organizing Pneumonia (BOOP), has been carried out thus far by open lung biopsy, or by transbronchial biopsy. We report a patient who presented with fever, cough and dyspnea. A transthoracic CT-guided biopsy of a peripheral lesion resulted in the diagnosis of BOOP. The histological findings were also confirmed by a transbronchial biopsy. It is suggested that transthoracic CT-guided biopsy should be considered for the evaluation of peripheral lung lesion compatible with BOOP.

A late retroperitoneal hematoma mimicking acute appendicitis--an unusual complication of coronary angioplasty

Peripheral vascular complications following coronary angiography and angioplasty are well established. They consist of arterial bleeding, occlusion, false aneurysm, and a-v fistula. Bleeding and thrombosis are usually evident within the twelve hours after the procedure. A case of acute right lower quadrant abdominal pain five days following thrombolytic therapy and percutaneous transluminal coronary angioplasty is presented. A computerized tomography was compatible with a periappendiceal inflammation, and the patient underwent laparotomy. A large retroperitoneal hematoma was the only positive finding on operation. A late complication of coronary angioplasty, such as retroperitoneal hematoma, presenting as an acute abdomen, should be a part of the differential diagnosis in such cases.

"Black esophagus": a rare complication of shock

An 83-yr-old man was admitted to our hospital in a state of shock. Twenty four hours after his admission, he started to pass fresh blood from his nasogastric tube. Upper endoscopy revealed diffuse, confluent blackening of the esophageal mucosa. A repeated endoscopy, after hemodynamic stabilization, demonstrated a striking improvement with granulation tissue. Caustic injury and viral or fungal infections were ruled out by history, clinical features, and appropriate tests. We suggest that in this elderly patient, a state of shock resulted in ischemic infarction of the esophageal mucosa.

Talc granuloma of the uterus

A 40-year-old woman presented with acute obstructive lung disease. She was treated with steroids and achieved a good response. However, she had two previous pelvic operations with histological findings of uterine serosal caseating granulomas presenting in the latter operation. Antituberculosis (TB) prophylaxis was suggested due to the suspicion of TB reactivation under steroid management. Investigation for TB infection or exposure was negative while revision of the histological slides disclosed talc granulomas. Although talc granuloma is reported in starch powder gloves which should not contain talc, it is still very uncommon.