Laryngeal Kaposi sarcoma: case report and literature review

PROBLEM/OBJECTIVE

Kaposi sarcoma is the most frequently-occurring neoplasm in AIDS patients. Laryngeal localization is infrequent. We discuss the management options for laryngeal Kaposi sarcoma based on a literature review.

CASE REPORT

A 42 year old, HIV-positive male receiving HAART therapy presented with mild hoarseness and sore throat. Fiberoptic laryngeal examination identified a small purple lesion in the right ventricular fold. He underwent biopsy under general anaesthesia. The lesion was histologically diagnosed as a Kaposi sarcoma. Systemic treatment was pursued, but 6 weeks later the patient developed severe dysphagia and acute airway obstruction when the lesion became glotto-supraglottic and obstruced the airway. Transoral tumour vaporization with a CO2 laser was performed in the emergency department. Post-operative chemotherapy was administered. Three months later, the patient was completely asymptomatic and the laryngeal examination was normal.

CONCLUSION

Transoral CO2 laser vaporization combined with chemotherapy is a valid option for managing obstructive laryngeal Kaposi sarcoma.

[Intra-uterine fetal death by knife: case report]

INTRODUCTION

Opened injuries by knife are rare in pregnant women and are responsible of foetal death in most cases.

OBSERVATION AND COMMENTARY

We report a case of a 27-years woman, in her 8th months of pregnancy, victim of three knife punchs in her right iliac fossa. An emmergent laparotomy revealed deep wounds in the uterus and its right vascular pedicles, and a right external iliac artery lesion. Hysterectomy was performed and the extracted fetus was dead. He had two wounds in skull and back. Foetal death is common in opened knife injuries especially at the end of pregnancy. On one hand, the fetus has an abdominal situation that expose him to penetrating lesions. On the other hand, the uterus is richly vascularized during this period of pregnancy, thus any uterine or pedicular wound could result in a maternal hemorrhagic shock and hence a poor foetal and maternal prognosis.

CONCLUSION

Knife injuries in pregnant women could compromise the foetal prognosis. Managmanent should be early and requires a close collaboration between resuscitators, obstetricians and vascular surgeons.

[Pregnancy in rudimentary uterine horn: diagnostic and therapeutic difficulties]

Ectopic pregnancy in a rudimentary uterine horn is extremely uncommon. Implantation of one embryo in the uterine cavity and of another in a rudimentary uterine horn is an extremely uncommon form of twin pregnancy. The authors report three cases of pregnancies in a rudimentary uterine horn. One was associated to a heterotopic pregnancy in the other eutrophic horn. Through these three cases, they report the risks incurred and the difficulties of the assumption of responsibility of this type of pathology, on the diagnostic as well as therapeutic level. But generally underline the interest of echography especially endovaginale and the coelioscopy in the early diagnosis of this type of uterine malformation.

[Severe neonatal myasthenia with arthrogryposis]

Maternal myasthenia gravis has been associated with the presence of neonatal myasthania and sometimes fetal congenital anomalies. The purpose of this paper is to present an infant with multiple deformations born to a mother with myasthenia gravis. The infant presented with arthrogryposis multiplex and pulmonary hypoplasia. The new born died within the first day of life. Twenty-seven other cases of neonatal myasthenia with arthrogryposis have been reported. Twenty-two of them were stillborn or died. The surviving children needed ventilatory assistance for a long period.

[Pelvic lymphocele: report of a case and review of the literature]

Lymphadenectomy for pelvic cancer can lead to complications, particularly lymphocele. We report a case of pelvic lymphocele, which occurred in a patient who underwent surgery for stage IIa cervical carcinoma after preoperative radiotherapy. The intervention consisted in colpohysterectomy, with lymphadenectomy without peritonisation. Five months later she developed dysuria and pelvic pain. Ultrasound and computed tomography showed a pelvic lymphocele complicated by renal insufficiency. Kidney function was re-established after intraperitoneal marsupialisation. One year later the patient was in good clinical condition with no disorder of kidney function.

[Vesico-uterine fistula of obstetrical origin. Report of 3 cases]

Vesico-uterine fistulae (VUF) lead to an abnormal breech between the bladder and the womb. They are responsible for urinary incontinence and/or cyclic hematuria. They are rare and, in most cases, lead to complications following caesarean deliveries. We report observations of 3 vesico-uterine fistulae treated over a 5 years period at university maternity based at Casablanca, Morocco; they all occurred following caesarean deliveries. These patients were consulted for urinary leakage occurring few weeks up to many years following surgical traumatism. Diagnosis was evoked clinically in all cases and confirmed by intravenous urography and/or hysterography. These VUF were successfully treated by simple breech suture at laparotomy. Treatment is very simple and efficient when the diagnosis is made early and fistula simple. Surgery is recommended after medical treatment failure aiming at fistula drainage.

[Prevalence of urinary incontinence in Moroccan women. Report of 1,000 cases]

An inquiry concerning the prevalence of urinary incontinence for the moroccan women has been archived about 1000 women aged more than 18 years to study prevalence, epidemiology and risk factors of urinary incontinence. 271 women among the 1000 women said that they had suffered from the mictional disorder at least one time during the last month, let 27.1%; 48.7% of the incontinent women are from 30 to 60 years; 22.5% are less than 30 years old, and 8.85% are more than 75 years old. Among these 271 women, 49.44% suffered from leakage after making an effort; 42.80% an imperiosity, and 7.76% spontaneous leakage. Seventy per cent among these women had level of study at least medium; 85.97% among these women suffered the discomfort; but 8.48% of them had been consulted for this disorder, 78.96% are able to consult a medical and to have a clinical or paraclinical exams. The elements who are responsible of this disorder are: menopause, parity, the use of forceps, the weight of first child birth over 3.5 kg, the perineal tearing. Among the medical antecedents we find: chronic bronchitis, urinary infections, chronic constipation, diabetes, and in the other way among surgical antecedents are: hysterectomy and prolapsus cure.

[Current profile of obstetrical vesicovaginal fistulas at the maternity unit of the University of Casablanca]

Obstetrical vesicovaginal fistulas are secondary to dystocia. Late and inappropriate treatment are still a health public problem in under development countries. In five years (1993-1997), twelve vesicovaginal fistulas were repertored in the department of obstetrics and gynaecology of Casablanca (Morocco) with a frequency of 0.33@1000 deliveries and 2.4 new cases a year. 80% of the cases occurred after a long labour without efficient obstetrical care. Most of the cases (75%) were simple with an easy surgical treatment. All the fistulas were resolved after one or two surgical procedures realised by vaginal route in eight cases (2/3). During these last decades, with the efforts in obstetrical care in our country, we are assisting in a diminution of the frequency of this pathology and specially the number of complicated fistulas.

[Mammary tuberculosis: a series of 14 cases]

OBJECTIVES

We examined cases of mammary tuberculosis in order to determine the different modes of presentation and analyze diagnostic difficulties.

METHODS

Retrospective analysis of 14 cases of mammary tuberculosis treated at the Ibn Rochd University Hospital in Casablanca over a 16 year period.

RESULTS

Patient age ranged from 16 to 65 years. Contact with a contaminated person was recognized in 2 cases. The predominant clinical presentation was a tumor formation (12 cases) which sometimes simulated cancer. Axillary nodes were observed in 10 cases with 1 case of fistulization. Mammography suggested cancer in 3 cases. The diagnosis of mammary tuberculosis was based on pathology findings in 14 cases (2 biopsies, 12 peroperative specimens) and isolation of bacilli from pus in one case. Medical treatment was given. Surgery was associated as needed (abscess drainage, residual lesions). Except for one death due to tuberculous meningoencephalitis, clinical course was favorable with ad integrun breast recovery.

DISCUSSION

Mammary tuberculosis is uncommon and often produces a pseudoneoplastic presentation. Pathology confirmation is required for diagnosis.

[Maternal complications of cesarean section: retrospective analysis of 3,231 interventions at the Casablanca University Hospital, Morocco]

We carried out a retrospective analysis of 3,231 cases of cesarean section between 1994 and 1997, to assess the maternal mortality and morbidity associated with this intervention. The frequency of cesarean delivery was 12.4%. The indications for cesarean section were of three types: elective indications (627 cases, 19.4%), emergency indications (454 cases, 14.1%), failure of normal labor (2,150 cases, 66.5%). Nine maternal deaths were noted (2.8 per thousand), one of which was directly linked to surgery. The peroperative complications were primarily major hemorrhagia (39 cases, 1.2%), visceral lesions such as bladder rupture (3 cases, 0.1%) and intestinal lesions (3 cases, 0.1%). Postoperative morbidity was predominated by infectious complications, particularly endometritis (5.1%). Thromboembolism was reported in 7 cases (0.2%). Cesarean section is used to preserve the life of both the mother and the child. However, maternal morbidity and mortality rates are higher with cesarean section than with vaginal delivery and therefore its indications must be justified.

[Delivery of large baby after cesarean section: role of trial of labor. Apropos of 355 cases]

OBJECTIVE

Our goal is to determine whether a trial of labor in women with suspected fetal macrosomia would be a valuable alternative to elective repeat cesarean.

MATERIAL

and methods: Based on retrospective analysis of 355 women with previous cesarean section who delivered macrosomic infants (> or =4,000g), we tried to determine the impact of fetal weight on a trial of labor. The outcomes of trial of labor with fetal macrosomia were compared on the one hand to those of elective repeat cesarean and on the other hand to those of trial of labor with normal birth weight (<4,000g).

RESULTS

The trial of labor was conducted in 297 cases (83,7%), and had led to vaginal birth in 189 cases (63,6%). There were 4 uterine ruptures (1,3%) and 8 uterine dehiscences (2,7%) among the women who underwent a trial of labor. In this group, there were 4 perinatal deaths (1,3%) related in one case to uterine rupture, and 2 brachial plexus injuries related to shoulder dystocia after vaginal birth. Perinatal and maternal outcomes of trial of labor were similar to those of elective repeat cesarean. A trial of labor was more associated with scar separations and lower success rate if the infant weighed 4,000g or more.

CONCLUSIONS

It appears that the use of trial of labor for delivery of large baby with prior cesarean section was associated with lower success rate and the maternal and fetal risks could be increased. However, carefully others controlled studies are necessary to establish the appropriate management in this setting.

[Induction of labor by misoprostol, an analog of PGE1. A prospective study of 200 cases]

We carried out a prospective study of 200 pregnant women who required induction of labor at full term, at the Lalla Meryem maternity unit of the Ibn Rochd University Hospital, Casablanca, between January 1st 1996 and June 30th 1997. The aim of this study was to evaluate the efficacy, tolerance and acceptance of misoprostol (Cytotec) as a drug for inducing labor in unfavorable conditions (Bishop < 5). Misoprostol (a PGE1 analog) was administered to the women via the vagina, with a dose of 1/4 tb (50 mg) given every 6 hours, and a maximum of 3 doses (150 mg). If labor had not begun 18 h after the start of the protocol, misoprostol induction was considered to have failed. We found that misoprostol failed to induce labor in 5% of cases, Syntocinon was required in 40% of cases and the interval between misoprostol insertion and vaginal delivery was 13.3 + 11.1 h. The rate of delivery by cesarean section was 22% and the mean amount of misoprostol required was 1.3 doses (66 mg). The mean cost of labor induction was 0.6 FF, the frequency of uterine hyperstimulation was 3.5% and maternal, fetal and neonatal tolerance was good. Our results confirm that intravaginal misoprostol is very effective and well tolerated for the induction of labor in pregnant women at full term, in unfavorable obstetric conditions.

[Use of gracilis musculocutaneous flap in tissue loss caused by Fournier's gangrene. Apropos of 4 cases]

The gracilis myo-cutaneous flap was used in 4 patients to cover soft tissue defects of the perineal, scrotal, penile and inguinal regions after Fournier's gangrene. This is a simple technique, which allows a simultaneous reconstruction of the perineoscrotal region. Very satisfactory esthetic and functional results were obtained in the recipient and donor sites.

[Phyllodes tumors of the breast. Forty one cases]

Phyllode tumors of the breast are fibroepithelial tumors similar to fibroadenomas but with a predominant conjunctive tissue component. The aim of this work was to determine the specific diagnostic, therapeutic and prognostic features of this tumor. A retrospective series of 41 cases was collected in the gynecology-obstetrics ward from 1980 to 1991. The analysis of this series showed the following characteristics: incidence of phyllode tumors was 0.46% of all breast tumors. Mean age at diagnosis was 30 years, in 75.6% of the women were in a period of reproductive activity. Mean delay between the first clinical signs and diagnosis was 20 months. Mean size was 12 cm Diagnosis was confirmed at pathology examination in all cases. The tumor was classed grade 1 and 2 in 65.9% of the cases, grade 3 in 9.8%, grade 4 in 17.1%. Surgical treatment alone was used in all cases with large tumorectomy (48%), simple mastectomy (30%), and total mastectomy with node dissection (22%). After a follow-up of 1 to 7 years, there were 3 deaths and 11 local recurrences requiring reoperation. In the remaining cases, the outcome was favorable without recurrence or metastasis. These results together with those reported in the literature show that histological confirmation is required for the diagnosis of phyllode tumors. Surgical treatment alone is required with wide exeresis because of the voluminous tumor formation the age of the patient and the histological grade. Finally, prognosis depends on the histological characteristics of the conjunctive tissue component of the tumors.

[Meadows syndrome: puerperal cardiomyopathy]

This retrospective study concerns six cases of gravido-puerperal cardiomyopathy. These six cases account for 18% of all cases of non-obstructive cardiomyopathy (NOCM) affecting women in general and 67% of NOCM in women of childbearing age. Mean age was 28.5 with a range of 18 to 39. Reported risk factors include poor socio-economic conditions, multiparity, twin pregnancies and anemia. The clinical picture is that of cardiac failure, most often congestive (83.3%), with a systolic murmur of functional mitral incompetence (50%) and atypical chest pain (50%). The ECG is invariably abnormal, without specific signs. The high incidence of repolarisation disturbances is a fairly special feature. Echocardiography is the technique of choice, enabling detection, diagnosis and study of ventricular function, which is an important factor in prognostic evaluation. Medical treatment is based upon a combination of rest, salt-free diet, diuretics, digitalis and vasodilators. The etiology remains unknown and the prognosis is severe despite cases of complete recovery.

Partitioning of work of breathing in mechanically ventilated COPD patients

In 10 sedated paralyzed mechanically ventilated chronic obstructive pulmonary disease (COPD) patients, we measured the inspiratory mechanical work done per breath on the respiratory system (WI,rs). We measured the tracheal and esophageal pressures to assess the lung (L) and chest wall (W) components of WI and used the technique of rapid airway occlusion during constant-flow inflation to partition WI into static work [Wst, including work due to intrinsic positive end-expiratory pressure (WPEEPi)], dynamic work due to airway resistance, and the additional resistance offered by the respiratory tissues. Although the patients were hyperinflated, the slope of the static volume-pressure relationships of the lung did not decrease with inflation volume up to 0.8 liter. WI,W was similar in COPD patients and normal subjects. All components of WI,L were higher in COPD patients. The increase in Wst,rs was due entirely to WPEEPi. Our data suggest that, during spontaneous breathing, COPD patients would probably develop inspiratory muscle fatigue, unless continuous positive airway pressure were applied to reduce WPEEPi.

[Acute pancreatitis and pregnancy]

Acute pancreatitis during pregnancy is a serious condition and diagnosis is often difficult. The authors report the case of a 32-year-old woman in the 32nd week of her fifth pregnancy, in which the outcome was fatal for both mother and child. The cause of pancreatitis during pregnancy has been attributed to many factors, chiefly cholelithiasis. A number of recent studies have shown the relationship existing between the role played by pregnancy in predisposing to gallbladder disease with lithiasis. Many diagnosis errors are made in this condition. Thus modern treatment methods have improved the prognosis in acute pancreatitis but, when it occurs during pregnancy, diagnostic delays often lead to a gloomy outlook.

Flow resistance in mechanically ventilated patients with severe neurological injury

In 5 mechanically ventilated patients with severe neurological injury (SNI), we measured the respiratory system's flow resistance (Rrs) over a range of inspiratory flows between 0.2 to 2 L/s, at inflation volumes (delta V) ranging from 0.1 to 1 L. Under baseline ventilatory conditions (V = 1 L/s; delta V = 0.95 L), we also partitioned Rrs into airway resistance (Raw) and the additional resistance offered by the tissues of the lung and chest wall (delta Rrs). At all inflation volumes, Rrs decreased hyperbolically with increasing flow but was higher than in normal anesthetized paralyzed subjects (N). At V of 1 L/s and delta V of 0.5 L, Rrs was significantly greater in SNI than in N (7.7 +/- 1.5 v 4.2 +/- 0.5 cm H2O/L/s; P < .01). This discrepancy was due to higher Raw in SNI. Indeed, at V of 1 L/s, Raw (mean +/- SEM) was significantly higher in SNI than in N (4.0 +/- 0.9 v 2.4 +/- 0.2 cm H2O/L/s; P < .001), whereas delta Rrs did not differ significantly. The increased Raw in SNI was due to the fact that these patients were therapeutically hyperventilated (PaCO2 = 30.4 +/- 4.2 mm Hg) and as a result their airways were bronchoconstricted. We conclude that in the intensive care unit setting, hyperventilated patients with severe neurological injury can not be considered to be adequate controls in terms of Rrs and Raw, because hypocapnia induces an increase of Raw and consequently also in Rrs (= Raw+delta Rrs).

Lung and chest wall mechanics in mechanically ventilated COPD patients

By use of the technique of rapid airway occlusion, the effects of inspiratory flow, volume, and time on lung and chest wall mechanics were investigated in 10 chronic obstructive pulmonary disease (COPD) patients mechanically ventilated for acute respiratory failure. We measured the interrupter resistance (Rint), which in humans reflects airway resistance; the additional resistances due to time constant inequality and viscoelastic pressure dissipations within the lungs (delta RL) and the chest wall; and the static and dynamic elastances of lung and chest wall. We observed that 1) static elastances of lung and chest wall in COPD patients were similar to those of normal subjects; 2) Rint of the lung was markedly increased and flow dependent in COPD patients, whereas Rint of the chest wall was negligible as in normal subjects; and 3) in COPD patients, delta RL was markedly increased at all inflation flows and volumes, reflecting increased time constant inequalities within the lungs and/or altered viscoelastic behavior. The results imply increased dynamic work due to Rint and delta RL and marked time dependency of pulmonary resistance and elastance in COPD patients.

Bilateral pneumothoraces hasten mortality in AIDS patients receiving secondary prophylaxis with aerosolized pentamidine. Association with a lower Dco prior to receiving aerosolized pentamidine

We have administered aerosolized pentamidine (AP) to 48 AIDS patients for secondary prophylaxis of Pneumocystis carinii pneumonia (PCP). Pentamidine 60 mg was administered by ultrasonic nebulization (Fisoneb) five times during the first two weeks and then every two weeks. The mean follow-up was 343 +/- 22 days. PCP recurred in ten patients, 297 +/- 33 days after starting AP therapy. All responded to anti-Pneumocystis therapy but two patients died of unrelated reasons (20 percent mortality). Five patients developed bilateral pneumothoraces 260 +/- 35 days after starting AP therapy. Recurrence of PCP could be documented in only one patient. All died 66 +/- 27 days after the onset of the first pneumothorax. Only 5 of 33 patients without recurrence of pneumonia or pneumothorax died during the study period (15 percent mortality). No association was found between the development of pneumothorax and age, smoking, previous respiratory or infectious problems, time from last PCP and the initiation of AP therapy, and treatment duration of last PCP. Patients with pneumothoraces had a significantly lower Dco (58.6 +/- 2.6 percent predicted) prior to AP therapy than patients with recurrence of PCP without pneumothoraces (81.1 +/- 2.1 percent predicted) or patients with no recurrence of PCP (67 +/- 2.5 percent predicted) (p less than 0.05, ANOVA). In conclusion, bilateral pneumothoraces are associated with a hastened mortality in patients receiving AP for secondary prophylaxis of PCP. Low Dco before AP therapy is associated with an increased risk of bilateral pneumothoraces in patients treated with AP for secondary prophylaxis of PCP.

Flow and volume dependence of respiratory system flow resistance in patients with adult respiratory distress syndrome

Using a simple and rapid technique, we studied the flow and volume dependence of the total resistance of the respiratory system (Rrs) in six patients with ARDS. At any given inflation volume, Rrs decreased progressively with increasing flow (V) according to the following hyperbolic function: Rrs = a/V + b, where a and b are constants. At any fixed inflation flow, Rrs increased progressively with increasing inflation volume. The observed flow and volume dependence of Rrs is probably mainly due to the viscoelastic properties of the pulmonary and chest wall tissues. The flow and volume dependence of Rrs found in the patients with ARDS is qualitatively similar to that previously observed in normal anesthetized paralyzed subjects. In ARDS, however, Rrs was considerably greater than in the normal subjects, indicating that besides a low respiratory compliance ARDS is characterized by a high flow resistance. This mainly reflects increased effective flow resistance of the pulmonary and chest wall tissues, although airway resistance is also higher than normal.

Effects of positive end-expiratory pressure on alveolar recruitment and gas exchange in patients with the adult respiratory distress syndrome

The effects of different levels of positive end-expiratory pressure (PEEP) (zero to 15 cm H2O) on the static inflation volume-pressure (V-P) curve of the respiratory system and on gas exchange were studied in eight patients with the adult respiratory distress syndrome (ARDS). Alveolar recruitment with PEEP was quantified in terms of recruited volume, i.e., as difference in lung volume between PEEP and zero end-expiratory pressure (ZEEP) for the same static inflation pressure (20 cm H2O) from the V-P curves obtained at the different PEEP levels. In addition, static compliance of the respiratory system at fixed tidal volume (0.7 L) was determined at the different PEEP levels. The results suggest that: (1) in some patients with ARDS the V-P curves determined on ZEEP exhibit an upward concavity reflecting progressive alveolar recruitment with increasing inflation volume, and PEEP results in alveolar recruitment (range of recruited volume at 15 cm H2O of PEEP: 0.11 to 0.36 L); (2) in other patients with ARDS the V-P curves on ZEEP are characterized by an upward convexity, and PEEP results in a volume displacement along this curve without alveolar recruitment and with enhanced risk of barotrauma; (3) the PEEP-induced increase in arterial oxygenation is significantly correlated to the recruited volume but not to the changes in static compliance. The shape of the static inflation V-P curves on ZEEP allows the prediction of alveolar recruitment with PEEP.

Flow resistance in patients with chronic obstructive pulmonary disease in acute respiratory failure. Effects of flow and volume

The flow and volume dependence of the total resistance of the respiratory system (Rrs) was investigated in six mechanically ventilated patients with chronic obstructive pulmonary disease (COPD) using a simple, rapid method. Isovolume Rrs-flow (V) relationships obtained at different inflation volumes (range 0.1 to 1 L) fitted (p less than 0.001) the following function: Rrs = a/V + b + cV, where a, b, and c are constants. The term "a/V" in this equation represents the hyperbolic decrease in thoracic tissue resistance with increasing flow; the term "cV" represents the linear increase in airway resistance with increasing flow. Rrs initially decreased with increasing V because at low flow the weight of the a/V was greater than that of the cV. At higher flow, however, cV became predominant and hence Rrs tended to increase. At an inflation volume of 0.5 L, minimum Rrs occurred at average inflation flow of 1.28 L/s. At low flow, Rrs increased progressively with increasing inflation volume; at inflation V greater than 1 L/s, the highest values of Rrs were obtained at low inflation volumes. The flow and volume dependence of Rrs implies that, for comparative purposes, measurements of Rrs should be standardized to a fixed inflation flow and volume.