Major Presenting Symptom Research Articles

Hypopituitarism in the Elderly: Multifaceted Clinical and Biochemical Presentation

Hypopituitarism (HYPO) is a rare and under-investigated pathology in the elderly. to review our case records of patients > or =65 yrs with first diagnosis of anterior global hypopituitarism, in order to evaluate presentation symptoms, etiology, biochemical and hormonal pictures, pituitary morphology, and efficacy of therapy. 15 patients (65-82 yrs) were studied: in 11 (73%) HYPO was secondary to pituitary macroadenoma (non-secreting in 10 and GH-secreting in 1); in 3 it was associated to empty sella, and in 1 to pituitary hypoplasia. major presenting symptoms were visual-field defects and asthenia (40%) but also memory and/or gait impairment and nausea (30%) and depression (20%) were significantly observed. Dyslipidemia (73%), anemia (20%) and severe hyponatremia (13%) were found. After starting substitutive therapy and clinical improvement, 10 patients with macroadenoma underwent uneventful neurosurgery, which improved visual alterations but not pituitary function. Immunohistochemistry showed positivity for FSH in one patient and for GH in one patient. Six out of the eight patients with a post-surgical tumor remnant required treatment (surgery/radiotherapy/somatostatin analogue treatment in the acromegalic patient). The diagnosis of HYPO is often delayed in the elderly, since symptoms may be ascribed to aging and associated comorbidities. In our series, most of the aspecific symptoms were retrospectively addressed to HYPO since their resolution/improvement with replacement therapy. The prevalent cause of HYPO remains non-functioning pituitary macroadenomas. Hyponatremia can be a life-threatening presenting symptom. Symptoms considered apparently aspecific in the elderly should be investigated in order to possibly diagnose an important treatable disorder as HYPO.

Breast‐feeding‐associated hypernatremia: Retrospective analysis of 169 term newborns

The aim of the present paper was to define the incidence, complications, morbidity and mortality of hypernatremic dehydration due to inadequate breast-feeding in a neonatal intensive care unit. A retrospective study was carried out between 2002 and 2005, to identify the term breast-fed neonates with serum sodium level > or =150 mEq/L at the Ministry of Health Ankara Diskapi Children's and Research Hospital. The incidence of hypernatremic dehydration secondary to inadequate breast-feeding was 4.1%, occurring in 169 term infants among 4136 hospitalized term neonates with the following characteristics: mean gestational age, 39.1 weeks (37-42 weeks); birthweight, 3352 g (2200-4500 g); mother's age, 26.1 years (17-38 years); weight loss, 15.9% (5.4-32.7%); proportion of spontaneous vaginal deliveries, 75.7%; and proportion of first-time mothers, 74.6%. Major presenting symptoms were neonatal jaundice (47.3%) and poor infant suck (29.6%). The median sodium; blood urea nitrogen (BUN); and creatinine levels on admission were 155 mmol/L (150-194 mmol/L), 35 mg/dL (7-253 mg/dL), and 0.9 mg/dL (0.2-10 mg/dL), respectively. Major complications were as follows: acute renal failure, 82.8%; elevated liver enzymes, 20.7%; disseminated intravascular coagulation, 6.5%; brain edema, 5.2%; intracranial hemorrhage, 3.6%; cavernous sinus thrombosis, 1.2%; and bilateral iliac artery thrombosis, 0.6%. Ten patients (5.9%) developed seizure within the first 24 h of rehydration therapy with a mean sodium decrease of 11.9 mmol/L per day (4-19 mmol/L per day). Two patients (1.2%) died. There were positive correlation between weight loss and serum sodium, BUN, bilirubin levels (P < 0.01); there was no correlation between weight loss and mothers' age, education level, delivery route, or first-born status (P > 0.05). Hypernatremic dehydration in neonates due to inadequate breast-feeding is a serious, potentially devastating and life-threatening disorder, and can damage the central nervous system. Follow up of infants for adequate breast-feeding is important. Pediatricians must maintain a high level of suspicion, especially in cases of pathologic infant weight loss after delivery.

Non‐Hodgkin's lymphoma presenting as an endobronchial tumor: Report of eight cases and literature review

Non-Hodgkin's lymphoma (NHL) involving the endobronchial tree is uncommon, and the initial presentation of NHL as an endobronchial tumor is extremely rare. In a series of 441 patients with newly diagnosed non-Hodgkin's lymphoma over a 7-year period, we reviewed the clinical features of eight patients who presented with an endobronchial tumor. All patients had local pulmonary disease without extrathoracic involvement. The major presenting symptoms were dyspnea, chest pain, cough, and hoarseness. None of the patients had systemic symptoms. Radiographs revealed lobar collapse in all cases. Five patients had mediastinal masses and three had isolated endobronchial lesions. Although MALT lymphoma is the most common primary pulmonary lymphoma, it was present in only one of our patients, while seven patients had aggressive lymphoma. All patients received chemotherapy. Six of the eight patients responded favorably to treatment with complete remission. The prognosis of patients with isolated endobronchial lymphoma is not worse than other local presentations of lymphoma. Bronchoscopic examination with biopsy is essential to differentiate these lesions from primary bronchongenic carcinoma.

Clinical significance of Mycobacterium fortuitum isolated from respiratory specimens

Although Mycobacterium fortuitum is not an uncommon organism among the non-tuberculous mycobacteria isolated from respiratory specimens, its clinical significance had not been well studied. We identified all patients whose respiratory specimens were positive for M. fortuitum between January 2003 and December 2005. Among 182 patients whose specimens were positive for M. fortuitum, 26 were positive at least twice. We retrospectively reviewed their characteristics, and clinical courses. Of the 26 patients, 15 had two positive culture results for M. fortuitum; the other 11 had three or more. Sixteen patients were male and the median age was 61.5 years. Major presenting symptoms were cough (65%) and sputum (58%). Most patients had known underlying lung diseases, including prior tuberculosis (54%), lung cancer (15%), idiopathic pulmonary fibrosis (15%), and other mycobacterial lung disease (15%). The most common CT findings were bronchiectasis (80%). Only one patient received specific prolonged antibiotic therapy against M. fortuitum infection; the other 25 did not. No patients showed clinical aggravation during the follow-up period, although in five patients their underlying lung diseases continued to progress. The median follow-up duration was 12.5 months and none of the patients whose sputum specimens were available had persistent positive cultures for M. fortuitum. M. fortuitum usually causes colonization or transient infection in patients with underlying lung disease, such as prior tuberculosis or bronchiectasis. The majority of patients may not need to receive prolonged antibiotic therapy for M. fortuitum isolates.

Outcomes of Hepatectomy for Hepatolithiasis

Surgical and nonsurgical procedures for management of hepatolithiasis have been reported. The aim of this study was to evaluate immediate and long-term results of hepatectomy as treatment for hepatolithiasis. Immediate and long-term outcomes of 123 consecutive patients who underwent hepatectomy for hepatolithiasis at our institution from 2000 to 2005 were analyzed retrospectively. Acute cholangitis was the major presenting symptom (in 106 out of 123, 86.2% of cases). The immediate stone clearance rate was 92.7% (114 out of 123) and final stone clearance rate was 96% (118 out of 123) after subsequent T-tube route or endoscopic retrograde cholangiopancreatography (ERCP). Residual stones were identified in 5 patients (4%). The surgical morbidity and mortality rates were 33.3% (41 out of 123) and 1.6% (2 out of 123) respectively. Of the 123 patients, 3 (2.4%) had associated cholangiocarcinoma at the time of hepatectomy. With a median follow-up of 40.3 months (range 5-58), a recurrent stone developed in 7 patients (5.7%) and cholangiocarcinoma in 2 (1.6%). Ten patients died during the follow-up period, with 4 of them (out of 123, 3.2%) due to recurrent stone with sepsis. Hepatectomy is a safe and effective treatment for hepatolithiasis, with a high stone clearance rate and fair rate of surgical complications. Recurrent stone-induced sepsis and cholangiocarcinoma are the major factors compromising long-term survival in these patients.

Rhinosinusitis: Clinical Features Seen In Sagamu, Nigeria

A retrospective evaluation of the clinical features of rhinosinusitis seen in Olabisi Onabanjo University Teaching Hospital, Sagamu Nigeria over a five-year period between January 2002 and December 2006. 131 cases of rhinosinusitis were analysed with M: F=1:1.05. The mean age was 36.7years. The three major presenting symptoms were mucoid nasal discharge 90(68.7%), nasal obstruction/congestion 80 (61.1%) and excessive sneezing 61(46.6%). 75.6% of the patients presented after three months of onset of symptoms. Oedematous nasal mucosa 94 (71.8%), engorged nasal turbinates 93(71.0%), mucopurulent anterior rhinorrhoea 37(28.2%) and polypoidal nasal growth 21(16.0%) were the common nasal examination findings. 69.5% of the patients had abnormalities on plain X-rays, most of which were in the maxillary sinuses. 27.5% of the patients had other associated nasal diseases or complications while the two common individual nasal diseases diagnosed were allergic rhinosinusitis (40.5%) and infective rhinosinusitis (29.8%). Better health education of our patients and need for early specialist referrals were emphasized.

Neurocysticercosis: Current knowledge and advances

Neurocysticercosis is the most common cause of acquired seizures worldwide. Most cases of this larval stage infection of the pork tapeworm Taenia solium occur in the developing world, although increasing numbers of cases are being recognized in the United States, particularly among Hispanic immigrants. The ability of the pathogen to persist for years within the host is the subject of immunologic and biochemical investigation. The major presenting symptom is seizures, although symptoms of obstructive hydrocephalus occur if cysts are located near the ventricles or in the subarachnoid spaces. Diagnosis is dependent on clinical, radiologic, and serologic data. Therapy with antiparasitic agents, especially albendazole, is effective in large burden disease or disease within sensitive neuraxis sites (the ventricles, the subarachnoid spaces). When patients with radiologically enhancing disease are given cysticidal therapy, there appears to be a reduction in seizure recurrences. Surgery is indicated for disease in selected anatomic sites. Long-term prevention requires attention to pork husbandry and general sanitation, including the potential use of mass human chemotherapy and porcine vaccination.

Specialized Stromal Tumors of the Prostate: A Clinicopathologic Study of 50 Cases

Specialized stromal tumors of the prostate encompass stromal sarcoma and stromal tumors of uncertain malignant potential (STUMP). As a result of their relative rarity and lack of long-term follow-up, the prognosis of STUMP is unclear. We studied 50 cases of STUMP and stromal sarcoma with regard to their clinical presentation and follow-up. Patients ranged in age from 27 to 83 years (mean 58 years). The major presenting signs and symptoms were urinary obstructive symptoms (n=25), abnormal digital rectal exam (n=15), hematuria (n=7), hematospermia (n=1), and rectal dysfunction/fullness (n=3). An elevated prostate-specific antigen was either the sole or a compounding rationale for initial urologic examination and prostate biopsy in a subgroup of patients (n=11). The histology in the 36 cases of STUMP not associated with sarcoma were as follows: 25 composed of stroma with scattered cytologically atypical cells associated with benign glands; 8 resembling glandular-stromal hyperplasia but with hypercellular stroma; 6 with extensive myxoid stroma; and 1 with phyllodes pattern. Four of these cases had mixed patterns. Seven cases of STUMP were associated with sarcoma, either concurrently or subsequently. In another 7 cases, pure sarcomas were encountered: 3 low grade (LG) and 4 high grade (HG). In 19 STUMPs, the location of the lesion was determinable: 10 cases arose in the peripheral zone, 7 cases were located in the transition zone, and 2 cases seemed to involve both zones. In 3 of these cases, tumors were adherent to the rectum at the time of resection. There was no evidence of progression of disease for 14 STUMPs after biopsy, TUR, or enucleation where follow-up ranged from 0.3 to 14 years (mean 4.9 years). Five cases of STUMP showed local tumor growth: 1 case increased in size from 6 to 7.5 cm in 3 years and 4 cases recurred frequently necessitating multiple TURs of the prostate (n=2, n=3, n=3, n=3) over 1.1, 2, 7, and 8 years, respectively. Fourteen patients with STUMP underwent radical prostatectomy (RP) soon after diagnosis; of these, 12 were organ confined where the tumor size ranged from 0.7 to 7.5 cm (mean 2.7 cm); 2 cases with a history of a 28 g TUR and a 275 g enucleation showed no residual tumor in the RP specimen. Three cases were lost to follow-up. The histologic subtypes of STUMP did not correlate with the clinical behavior or likelihood of being associated with sarcoma. Two of the LG sarcomas locally invaded around the seminal vesicle, yet all of the LG sarcomas with follow-up were free of disease at 3, 13, 24, 25, 30, and 36 months. Of the 6 HG sarcomas with follow-up, 3 were free of disease at 3, 17, and 72 months. One man was alive with metastasis to the lung 10 months after RP, 1 man was alive at 280 months with multiple metastases, and another died of disease at 115 months. STUMPs can recur frequently, occur at a young age, often involve the peripheral zone where they can be adherent to the rectum requiring its removal, and can be associated with stromal sarcoma. Although STUMPs can be histologically misdiagnosed as nodular hyperplasia, it is important to recognize that these are neoplasms with unique local morbidity and malignant potential. Whereas LG stromal sarcomas can locally invade, HG sarcomas can metastasize and lead to death.

Pharmacological management of pain in chronic pancreatitis

Pain is the major presenting symptom of chronic pancreatitis. Patients with chronic pancreatitis experience substantial impairments in health-related quality of life. Pain may be considered as the most important factor affecting the quality of life. The pathogenesis of pancreatic pain is poorly understood. The cause of pain in chronic pancreatitis is probably multifactorial. This article discusses the various hypotheses that have been suggested to underlie pain. Special attention is paid to the concept of autonomous central sensitisation and hyperalgesia as a cause of pain. Strict abstinence from alcohol is the first step of chronic pancreatic pain management. As a second step, it is important to exclude treatable complications of chronic pancreatitis, such as pseudocysts. Symptomatic treatment with analgesics is often unavoidable in patients with chronic pancreatitis. Acetaminophen, non-steroidal anti-inflammatory drugs and eventually opioids are suitable. Several trials have been performed with pancreatic enzymes, but a meta-analysis demonstrated no significant benefit in terms of pain relief. The treatment of chronic pancreatic pain requires a multidisciplinary approach that tailors the various therapeutic options to meet the need of the individual patient.

Paranasal Sinus Pathologies in Patients Presenting with Headache as the Primary Symptom

Headache is a frequent symptom of lesions in the paranasal sinuses. Although some inflammatory symptoms are suggestive of pathologies of the paranasal sinuses, occasional headache is sometimes the major presenting symptom. In a retrospective study, we examined the chart histories of 36 patients presenting for treatment at our hospital from 1 January 1992 to 30 June 2001 who were diagnosed as having pathologies of the paranasal sinuses with the primary symptom being headache. All patients had been evaluated with complete otolaryngological and neurological examinations, diagnostic nasal endoscopy, and sinus computed tomographic (CT) scans. Sinus surgery was arranged after failure in performing appropriate medical treatment. Among the 36 patients, 33 showed significant improvement after sinus operation (92%). A paranasal sinus aetiology of headache is an important factor in the differential diagnosis of chronic headache. Those patients who are clinically suspected of having headaches arising from paranasal sinus pathology should receive comprehensive otorhinolaryngological examination and evaluation. Nasal endoscopy and sinus CT scans are good diagnostic tools. Surgical management may be beneficial in those for whom medical treatment fails to resolve the problem.

Differences between synchronous and metachronous bilateral breast cancer

Lump, nipple discharge and pain are the major presenting symptoms of breast disease. Around 60% of referrals are for a lump and less than 10% of these will be diagnosed to have breast cancer. Benign diagnoses are: fibroadenoma, a firm mobile lump considered as aberrations of normal development; breast cysts, which are discrete lumps accounting for 15% of all breast lumps; and nodularity, which is the most common cause for referral in all ages. All breast lumps need to undergo triple assessment. Around 8% of referrals are for nipple discharge. Physiological nipple discharge is usually bilateral, multi-duct and coloured white, yellow green or black. Duct ectasia is due to ductal involution and the change is often bilateral and associated with ‘slit-like’ nipple retraction. Increasing risk of significant pathology is associated with unilateral, single duct, serous and blood stained discharge, which needs to undergo triple assessment. Blood stained discharge may be due to duct ectasis, intra-duct papilloma, epithelial hyperplasia or malignancy. Breast pain is divided into cyclical and non-cyclical mastalgia (including chest wall pain), and 25% of breast clinic referrals will be for breast pain. Cyclical mastalgia is an exaggeration of normal cyclical changes and the patient can be reassured without investigation. If pain is severe treatment is with gamolenic acid, danazol or bromocriptine. Where pain is non-cyclical, unilateral and localized investigation with mammography is required. Chest wall pain is a common end diagnosis for referrals with breast pain and is treated simply with reassurance and simple analgesics or NSAIDs.

Ziprasidone- and Lithium-Induced Neuroleptic Malignant Syndrome

To report a case of ziprasidone- and lithium-induced neuroleptic malignant syndrome (NMS). A 47-year-old white male with a history of schizoaffective disorder was admitted to the hospital due to an exacerbation of severe mania. He had been taking lithium 450 mg twice daily and divalproex sodium 750 mg/day. On hospital day 2, ziprasidone 80 mg twice daily was added, and as-needed doses of intramuscular ziprasidone 20 mg and lorazepam 2 mg were used for agitation. On day 6, the patient developed hyperthermia (39.4 degrees C), elevated creatine kinase 26,000 units/L and white blood cell (WBC) count (20.7 x 10(3)/microL), myoglobinuria, hypotension (68/40 mm Hg), altered mental status, and tachypnea (28 breaths/min). This case is notable for the absence of muscle rigidity, which presents in greater than 90% of patients with NMS taking traditional antipsychotics. This case of ziprasidone- and lithium-induced NMS is of probable cause, as determined by the Naranjo probability scale. The patient presented with symptoms consistent with NMS 4 days after initiation of ziprasidone and lithium. The majority of NMS cases present with the core features of hyperthermia, muscle rigidity, and elevated CK levels. Other frequently seen symptoms include altered mental status, tachypnea, tachycardia, elevated WBC count, hypotension, diaphoresis, and myoglobinuria. Our patient presented with 2 of the core symptoms, but did not develop muscle rigidity at any time. NMS criteria include muscle rigidity as one of the major presenting symptoms. Recent literature suggests that perhaps NMS due to novel antipsychotics presents with less muscle rigidity than is seen with traditional agents due to their lower affinity for the dopamine D2 receptor. This case illustrates that NMS due to the novel antipsychotic ziprasidone may present with many of the core symptoms of the syndrome, but possibly less muscle rigidity than is seen with traditional agents.

Benign breast disease

Lump, nipple discharge and pain are the major presenting symptoms of breast disease. Around 60% of referrals are for a lump and less than 10% of these will be diagnosed to have breast cancer. Benign diagnoses are: fibroadenoma, a firm mobile lump considered as aberrations of normal development; breast cysts, which are discrete lumps accounting for 15% of all breast lumps; and nodularity, which is the most common cause for referral in all ages. All breast lumps need to undergo triple assessment. Around 8% of referrals are for nipple discharge. Physiological nipple discharge is usually bilateral, multi-duct and coloured white, yellow green or black. Duct ectasia is due to ductal involution and the change is often bilateral and associated with ‘slit-like’ nipple retraction. Increasing risk of significant pathology is associated with unilateral, single duct, serous and blood stained discharge, which needs to undergo triple assessment. Blood stained discharge may be due to duct ectasis, intra-duct papilloma, epithelial hyperplasia or malignancy. Breast pain is divided into cyclical and non-cyclical mastalgia (including chest wall pain), and 25% of breast clinic referrals will be for breast pain. Cyclical mastalgia is an exaggeration of normal cyclical changes and the patient can be reassured without investigation. If pain is severe treatment is with gamolenic acid, danazol or bromocriptine. Where pain is non-cyclical, unilateral and localized investigation with mammography is required. Chest wall pain is a common end diagnosis for referrals with breast pain and is treated simply with reassurance and simple analgesics or NSAIDs.

Comparison of Non-Ulcer Dyspepsia with H. pylori and H. pylori Infection in an Urban Cohort in Pakistan

Purpose: To determine the proportion of our patients with dyspepsia associated with and without H. pylori. Methods: One hundred twenty-four consecutive patients presenting with dyspepsia at first visit to gastroenterology outpatient of Aga Khan Hospital from January 2005- April 2005 were enrolled. Clinical symptoms at presentation were noted. All patients were endoscoped and antral biopsy specimens collected for the rapid urease test and histopathology. Dyspepsia was defined as intermittent or persistent discomfort in the upper abdomen or other symptoms related to the upper gastrointestinal tract. A diagnosis of H. pylori infection was made when either rapid urease test or histology was positive. A diagnosis of nonulcer dyspepsia associated with H. pylori was made when intermittent or persistent symptoms related to the upper gastrointestinal tract were associated with normal endoscopy and positive rapid urease or histopathology. Results: These are the preliminary results of an ongoing study. A total of 124 patients, 82 males were studied. Sixty-nine (56%) was H. pylori positive. 49/82 (60%) males and 20/42(48%) females were H. pylori positive. The major presenting symptoms of nonulcer dyspepsia associated with H. pylori and without were abdominal pain /discomfort 45/69 (65%) and bloating 17/69 (25%) compared to 38/55 (69%) and 9/55 (16%) with odds ratio (OR) 0.8 95% C.I (0.4 – 1.8) and OR 1.7 95% C.I (0.7 – 4.1) respectively. Endoscopy revealed minimal changes in nonulcer dyspepsia associated with H. pylori positive 21/33 (64%) compared to 12/33 (36%) with H. pylori infection. In 2/30 (7%) moderate antral gastritis was revealed in nonulcer dyspepsia with H. pylori compared to 28/30 (93%) with H. pylori infection alone. On histopathology, mildly active H. pylori associated antral gastritis was noted in 20/23 (87%) in nonulcer dyspepsia with H. pylori and 3/23 (13%) with H. pylori infection while moderately active H. pylori associated antral gastritis in 4/46 (9%) with nonulcer dyspepsia with H. pylori compared to 42/46 (91%) with H. pylori infection. Conclusions: The presenting symptoms of nonulcer dyspepsia with and without H. pylori infection are similar. There are minimal endoscopic and histopathology changes in nonulcer dyspepsia associated with H. pylori compared to H. pylori related diseases.

Delayed Discovery of Diaphragmatic Injury After Blunt Trauma: Report of Three Cases

Blunt diaphragmatic injury is an increasingly common occurrence, frequently associated with considerable comorbidity. This injury is often missed at the time of the initial event, but may present some time later. We report three cases of diaphragmatic injury diagnosed 3 weeks, 6 months, and 12 years after the original diaphragmatic injury, respectively. Two of the injuries resulted from side-impact road traffic accidents and one followed a fall from a height. Gastrointestinal obstruction and respiratory compromise were the major presenting symptoms. All three patients were managed with a thoracotomy and the defect was closed without the need for prosthetic mesh. They all recovered uneventfully and have remained well since.

Long-Term Follow-Up of Ureteral Stump Tumors after Nephrectomy for Benign Renal Disease

The occurrence of primary carcinoma of the ureteral stump after nephrectomy is rare. In this study, we evaluated the clinical characteristics of ureteral stump tumors after nephrectomy for benign renal disease. During a 16-year period, 318 consecutive patients underwent simple nephrectomy for benign renal disease (216 cases) or for donation (102 cases). Eight of these 318 patients diagnosed as having an ureteral stump tumor were treated by ipsilateral ureterectomy with cuff excision of the bladder. Pathologic findings, tumor stages, and clinical characteristics were analyzed. The eight ureteral stump tumors comprised; 6 transitional cell carcinomas (TCCs) and 2 squamous cell carcinomas (SCCs). The mean interval between nephrectomy and ureteral stump tumor diagnosis was 76.5 months. Six of the 8 patients had pyonephrosis and two renal tuberculosis as original renal diseases. Four of the 6 TCCs were stage T1 and 2 stage T2. There was no concomitant bladder tumor at stump tumor diagnosis. Hematuria was the major presenting symptom in 3 of the 8 patients and 4 patients were diagnosed by follow-up imaging study. Two of the 6 ureteral stump TCC patients developed bladder TCC during follow-up. The 5-year survival rate of patients with ureteral stump tumor was 37.5%. T1G1 TCC was associated with a better survival than T2 or G2 TCC. No ureteral stump tumor occurred in cases of donor nephrectomy. This study demonstrate, that long-term closed observation is needed to detect ureteral stump tumor, particularly in patients that have undergo nephrectomy for a long-standing inflammatory renal disease such as pyonephrosis or tuberculosis. Hematuria is a major presenting symptom of ureteral stump tumor. However, a follow-up imaging study is also important for ureteral stump tumor detection. The prognosis is poor in cases developing ureteral stump SCC, bladder tumor recurrence, or a high-grade ureteral tumor.

Iliopsoas abscess in the neonate

Iliopsoas abscess (IPA) is rare, especially in the neonatal period. The major presenting symptoms of IPA are leg or groin swelling, limitation of leg motion, and pain. The etiologies of IPA in many cases remain unknown, and the etiologic agent in many cases is Staphylococcus aureus. Ultrasonography and computed tomography are useful in diagnosing this disease. Antibiotics therapy and appropriate drainage are effective, and the prognosis is good. The authors present a neonatal case of IPA and discuss clinical symptoms, etiologic agents, methods of diagnosis and therapy, and prognosis.

Human cytomegalovirus infection of the gastrointestinal tract in apparently immunocompetent patients

Human cytomegalovirus (HCMV) infection is usually reported in immunocompromised patients. This study reports 11 cases of HCMV infection of the gastrointestinal (GI) tract diagnosed in apparently immunocompetent hosts. The median age of the patients studied was 76 years, and the major presenting symptoms were diarrhea, epigastric pain, and abdominal discomfort. The large intestine was involved in 6 cases, the stomach in 4 cases, and the lower esophagus in 1 case. Endoscopy revealed ulcers or hypertrophic folds in the GI tract and single ulcers or erosions in the colon and rectum. Light microscopy showed chronic inflammatory infiltrate in the lamina propria in all cases. The diagnosis of HCMV infection was based on the histological and immunohistochemical identification of HCMV inclusion bodies in different cell types, including epithelial, endothelial, stromal, and smooth muscle cells. Both “classical” inclusions, characterized by an “owl’s eye” appearance, and atypical inclusions were found. For all patients, no apparent causes of immunodeficiency were detected at the time of diagnosis of HCMV infection. At follow-up, however, 4 patients were found to harbor a malignant tumor (ie, pancreas, lung, Vater’s papilla, and extrahepatic bile duct) at an interval of 2 to 5 months after the diagnosis of HCMV infection. Especially in elderly patients, HCMV infection of the GI tract might be an early clue to the presence of immunologic defects induced by an underlying neoplasia.

Recent advances in the treatment of rhinitis and rhinosinusitis

Current rhinitis treatment is unsatisfactory for many patients, possibly because monotherapy is employed, without regard to the major presenting symptom. Recognition of the impact of rhinitis on quality of life and on associated disorders such as asthma has led to the development of guidelines, use of which has been shown to improve symptom control and quality of life compared to unguided therapy. The role of antihistamines, topical corticosteroids and anti-leukotrienes is discussed.

A Clinical Guide to Inherited Metabolic Diseases, 2nd edition. Joe T.R. Clarke. Cambridge: Cambridge University Press, 2002, 306 pp., $40.00, softcover. ISBN 0-521-89076-4.

Although many textbooks are available on inherited metabolic diseases, they are usually big in size and unapproachable. Dr. Clarke has done an amazing task in providing this handy guide of approximately 300 pages on how to diagnose inherited metabolic diseases. Just as tourists need a travel guide when visiting new places, pediatricians and laboratorians will use this clinical guide, which shows them the way to arrive at a diagnosis. This book begins with a chapter on general principles of genetics, which serves as a quick review of basic medical sciences for clinicians. The next six chapters describe six groups of major presenting symptoms in inherited metabolic diseases—neurologic, acidosis, …