Dilek Soysal

Adrenocortical oncocytic neoplasm presenting with Cushing's syndrome: a case report

IntroductionOncocytic neoplasms occur in several organs and are most commonly found in the thyroid, kidneys and salivary glands. Oncocytic neoplasms of the adrenal cortex are extremely rare and are usually non-functioning.Case presentationWe report the case of an adrenocortical oncocytic neoplasm with uncertain malignant potential in a 31-year-old man with Cushings syndrome. The patient had been operated on following diagnosis of a 7 cm adrenal mass. Following surgery, the Cushings syndrome resolved. The patient is still alive with no metastases one year after the surgery.ConclusionAdrenocortical oncocytic neoplasms must be considered in the differential diagnosis of both functioning and non-functioning adrenal masses.

Evaluation of transient hyperglycemia in non-diabetic patients with febrile neutropenia

BACKGROUND We aimed to examine the effect of transient hyperglycemia in non-diabetic patients with febrile neutropenia. METHODS A total of 86 patients with febrile neutropenia were evaluated between June 2006 and December 2009. After measuring random blood glucose level at admission, cases with stress hyperglycemia were included in the study. Stress hyperglycemia was defined as documented random blood glucose level of 140 mg/dl and above without known diabetes mellitus, impaired glucose tolerance and impaired fasting glucose. A Multinational Association for Supportive Care in Cancer (MASCC) scoring system was used for the prediction of low and high risk patients according to medical complications at the onset of the febrile episode. RESULTS There were more patients with stress hyperglycemia than the patients with normoglycemia in the high risk group (p = 0.001). The growth of gram negative bacteria and fungi was higher in patients with stress hyperglycemia than with normoglycemia (p = 0.001). The patients receiving antifungal therapy had a higher rate of stress hyperglycemia than the patients without receiving antifungal therapy (p = 0.009). The patients with stress hyperglycemia had higher mortality rates than the patients with normoglycemia (p = 0.007). According to the MASCC risk-index, stress hyperglycemia increased 3.35 fold in the high risk patients compared to the low risk patients (p = 0.046) and 4.14 fold in the patients treated with antibacterial and antifungal agents compared to the patients treated with only antibacterial agents (p = 0.038). CONCLUSION Patients with stress hyperglycemia had more adverse clinical outcomes than patients with normoglycemia. We think further studies are needed to evaluate the relationship between stress hyperglycemia and febrile neutropenia.

Transdermal methanol intoxication: a case report

Sir, We report a 51-year-old woman with coma and high-anion-gap metabolic acidosis following a supposed transdermal methanol intoxication. She had a 7-year history of epilepsy. The patient was admitted to the emergency service with an episode of tonic–clonic convulsions similar to previous attacks. Cranial computed tomography showed no abnormalities. She was discharged from hospital. Eighteen hours later, she was brought to the emergency service again with a Glasgow coma scale score of 3. The patient’s vital signs included a heart rate of 105 beats/min, blood pressure of 80/60 mmHg and body temperature of 36.7 8C. Her pupils were dilated with an absent light reflex. Laboratory examinations showed the following results: serum sodium, 138 mmol/l; potassium, 4.5 mmol/l; chloride, 105 mmol/l; creatinine, 1 mg/dl; blood urea nitrogen, 20 mg/dl; glucose, 138 mg/dl. The arterial blood gases were as follows: pH 7.10; Po21⁄4 159mmHg (21.2 kPa); Pco2 1⁄4 17.9 mmHg (2.4 kPa); HCO3 1⁄4 9.1 mmol/l, with an anion gap of 28 mmol/l. The lactate level was 3.7 mmol/l. Urinary ketones were negative. She was mechanically ventilated and intravenous sodium bicarbonate infusion was given to correct the acidosis. Despite bicarbonate infusion, the acidosis could not be corrected; therefore, a period of haemodialysis was performed on the third day. Salicylate and methanol analyses could not be performed in our hospital. Therefore, samples were sent to another hospital, revealing a normal S-salicylate level and an S-methanol value of 3.3 mg/dl. The patient’s relatives denied oral intake of cologne, spirit or ethanol, but the patient had suffered from headache on the days prior to hospitalization, and used spirit to massage her head on several occasions. One more period of dialysis was performed. The high-anion-gap acidosis resolved, but the neurological status did not improve. She died on the fourth day of hospitalization. Fatal methanol poisoning can result from many sources and routes. Although almost all reported cases in the literature have occurred after oral ingestion, absorption via the transdermal route may lead to intoxication (1, 2). It may be difficult to make a diagnosis of methanol poisoning if no history of ingestion has been obtained. In this patient, the absence of a history of ingestion resulted in a delay in diagnosis. As the patient had a history of epilepsy, the possibility of a metabolic condition precipitating the convulsions was not considered. Various factors complicate the correlation of serum methanol concentrations with clinical effects, including differences in sampling time, individual variation in methanol metabolism, concentration of toxic metabolites and the concomitant ingestion of ethanol (3). The low serum methanol concentration in this patient can be correlated with the sampling time of 3 days after admission and the increase in elimination as a result of dialysis. In the absence of S-methanol analyses, the use of osmolal and anion gaps to establish an early diagnosis is crucial (4). In this patient, a suspicion of methanol intoxication was reached on the basis of the high-anion-gap metabolic acidosis and coma after differential diagnosis with lactic acidosis, diabetic ketoacidosis, uraemia, salicylates, alcohol, paraldehyde and ethylene glycol. The site of application and individual variability of the skin have a significant effect on the transdermal absorption of methanol (5). The skin of the scalp contains hair, numerous sebaceous glands, a thin stratum corneum and a rich vascular and lymphatic supply. Therefore, we hypothesize that methanol may be absorbed more easily through the skin of the scalp than on other parts of the body. Given the fatal course of this patient, however, a large amount of methanol must have been applied, and additional oral intake cannot be excluded. Methanol intoxication must be considered in patients with high-anion-gap metabolic acidosis. Exposure via transdermal and inhalational routes must be kept in mind in patients who have no history of oral methanol ingestion in order to ensure prompt diagnosis and management.

A rare case of systemic lupus erythematosus with chylous ascites and chylothorax.

During the course of the disease a patient with systemic lupus erythematosus (SLE) may develop inflammation of one or more serous membranes, resulting in pleural, peritoneal, or pericardial effusion. Chylous ascites and chylothorax have rarely been described in patients with SLE. Therefore, in parallel with the analysis of blood samples, detailed analysis of the effusions should be carried out. Supportive measures are often needed to relieve the symptoms of chylothorax or chylous ascites together with the treatment of the primary disease. The available literature had reported just 4 cases of chylous ascites and/or chylothorax in association with SLE, and this patient presented here is one of the rare cases apart from the reported ones.

Management of health-care waste in Izmir, Turkey

The aim of this study was to evaluate health-care waste in the 18 districts of metropolitan municipality of the third biggest city in Turkey. This cross-sectional study was carried out with 825 health institutions established in the 18 districts of Izmir metropolitan municipality, in 2007. The total amount of health-care waste collected was 4841 tons and 621 kilograms per patients bed in 2007. Most of the medical wastes were collected from Konak, Karsiyaka and Bornova districts and were 2308, 272 and 1020 tons, respectively. Regarding to overpopulation, the number of health institutions in these districts are more than the number of health institutions in the other administrative districts. There was a statistically significant, positive correlation between the amount of health-care waste collected and population of the 18 districts (r = 0.79, p < 0.001), and number of beds/patients (r = 0.83, p < 0.001). To provide a safe health-care waste management metropolitan municipality must provide hazardous waste separation in health institutions, establish sterilization units for infectious waste, and provide the last storage of medical waste in completely different, safe and special areas apart from the municipal waste storage areas.

Monoballism Associated with Newly Onset Ketotic Hyperglycemia

Movement disorders as the initial symptoms of diabetes mellitus are rare. Here, we describe one of these rare manifestations of primary diabetes: a case of newly diagnosed diabetes mellitus in an old-age female patient with transient monoballismus during an episode of ketotic hyperglycemia.

C-reactive protein in unstable angina pectoris and its relation to coronary angiographic severity and diffusion scores of coronary lesions.

OBJECTIVE We aimed to assess the relationship between C-reactive protein (CRP) and the severity and diffusion of coronary artery lesions in patients with unstable angina pectoris (UAP) and the independent association of CRP with this clinical situation. METHODS This cross-sectional, observational study included 50 patients. Classification by Braunwald was used for UAP. The severity and diffusion of angiographic coronary disease were graded according to Reardons modified scoring system. Plasma CRP levels were quantified by immunoturbidimetry. Nonparametric tests were used for comparison of CRP and other risk factors, and logistic regression analysis for evaluation of independent association between CRP and unstable angina pectoris. RESULTS The severity score was 46±18 points in class IIB1 UAP, 36±20 points in class IIB2 and 53±18 points in class IIIB2 (p=0.017, class IIIB2 vs IIB2). Respectively, CRP levels were 6.6 mg/L, 3.8 mg/L and 4.8 mg/L (p=0.371, class IIB1 vs IIB2 vs IIIB2). Lesions with diffusion score 4 revealed higher CRP values than lesions with diffusion score 1 (11.1 mg/L vs 3.1 mg/L, p=0.048). Adjusting age, sex and smoking, assessment of partial correlation analysis showed a positive, moderately powerful and significant association between CRP levels and the severity and diffusion scores of the coronary lesions (r=0.30; p=0.034 and r=0.31; p=0.030, respectively) in the whole study group. Multiple logistic regression analysis showed no appreciable independent association between CRP and UAP (OR: 1.63, 95%CI: 0.90-5.63, p=0.093). CONCLUSION Although, CRP was correlated with the severity and diffusion of angiographic coronary disease in patients with UAP, there was no independent association between CRP and clinical severity of UAP.

Necrotizing Cutaneous Vasculitis in a Patient with Infective Endocarditis and Severe Rheumatoid Arthritis

A 68-year-old woman with fever, chills, asthenia, night sweats, arthralgia, weight loss, and necrotizing skin ulcers on the body and lower extremities was admitted to our department. She had been followed for rheumatoid arthritis (RA) for over 20 years, and her rheumatoid factor (RF) level was very high at admission. A month ago, a temporary pacemaker was applied to the patient due to druginduced bradyarrhytmia, but the pacemaker’s lead fractured and remained inside the right ventricle while it was removed. Revealing the vegetations on the fractured lead and tricuspid valve by echocardiography and methicillinresistant coagulase-negative Staphylococcus aureus in separate blood cultures, the two major criteria for the diagnosis of infective endocarditis (IE) was confirmed to commence treatment of IE. The biopsy specimen from the skin ulcers revealed cutaneous vasculitis. Vasculitis is a serious complication of rheumatoid arthritis (RA) that develops in a minority of patients with this disease, and it is not uncommon in patients with IE. The diagnosis of rheumatoid vasculitis was confirmed by the history, clinical and laboratory findings of our patient. Methylprednisolon 500 mg intravenous bolus followed by 40 mg PO daily was administered. In spite of all taken measures the patient died of severe sepsis on the 50th day of her admission. In this case the differential diagnosis of cutaneous vasculitis in a patient with IE and severe RA is emphasized.

The metabolic syndrome prevalence and associated social and economic factors in a population of age between 30 and 69years: from the ongoing trial of Balcova Heart Study.

The term ‘socioeconomic status’ covers a wide range of measures, including education, income, occupation, living conditions, income inequality, and many other aspects of life [1]. Little is known on the association between social and economic factors and the metabolic syndrome, considered as a distinct clinical entity, specially addressing gender effects in the social patterning of the disease [2]. In this community-based cross-sectional study, prevalence of the metabolic syndrome and associated socioeconomic status was assessed among the 30–69 year old residents of an administrative quarter in Izmir, in 2008. At the time of the study, the population of the quarter in this age group was 3754. Data were collected in two stages. Firstly, detailed information was provided to the individuals who agreed to participate in the study during household visits, and every participant completed a questionnaire by face-to-face interview with trained surveyors at home. The questionnaire was defined by Boratavs [3] classification of social inequalities for the urban areas and included questions on the demographic and socioeconomic status of the participants. Education, household income and social class were considered to be the major inequalities in the study. Secondly, anthropometric measures and blood samples of the participants were collected at the community center. The study period included 30 days. After excluding participants who did not attend the first or the second visit and with missing or incorrect data in the main variables, a total of 1883 subject were included in the study with a 50.2% of response rate. Participation among women was higher than men, because, most of the men were working during office hours and failed to attend to the second visits at the community center. The mean age of the excluded subjects was 48.1±8.3 years with a male to female ratio of 2.4. To define the metabolic syndrome according to the NCEP ATP III guidelines [4], three out of five risk factor components are required, and the definition does not specify that any particular component be present. Based on the International Standard Classification of Education, illiterate, primary and secondary schools were pooled as the low educated class (LEC) [5]. Household income was assessed by self report according to the minimum wage in Turkey. Participants with missing substantial data (55 women and 11 men) were excluded from income analysis. Social classes and income were defined according to Boratav as presented in Table 1 [3]. Univariate analyses were performed to evaluate the statistical significance of the prevalence rates of the social inequalities in women and men with the metabolic syndrome. Binary logistic regression analysiswas used formen andwomen to assess the association between social inequalities and the metabolic syndrome. Covariates in the final model included level of education, household income and occupation with the presence of the metabolic syndrome as a dependent variable.

Anti-pankreatik antikor, anti-nötrofil sitoplazmik antikor ve antiSaccharomyces cerevisiae antikorlarının inflamatuvar barsak hastalıklarındaki tanısal değeri ve hastalık aktivitesi ile ilişkilerinin değerlendirilmesi

Background and Aims:Although many serological markers associated with inflammatory bowel disease have been defined, the evidence that interacts with clinical results is limited. We aimed to evaluate the relevance of anti-pancreatic antibody, p-ANCA and ASCA in the differential diagnosis of inflammatory bowel disease and their correlation with disease activity. Materials and Methods:The presence of antipancreatic antibody, p-ANCA and ASCA was determined in indirect immunofluorescence assay of serum samples from 95 patients with inflammatory bowel disease (63 ulcerative colitis, 29 Crohns disease, 3 indeterminate colitis) and 65 healthy controls. Results:Anti-pancreatic antibody was present in 6,9% (2/29) in Crohns disease and 3,2% (2/63) in ulcerative colitis. Anti-pancreatic antibody was not detected in the indeterminate colitis and control groups. No statistical difference was found between ulcerative colitis and Crohns disease in terms of anti-pancreatic antibody incidence. p-ANCA was detected in 46% (29/63) in ulcerative colitis, 13,8% (4/29) in Crohns disease, 66,6% (2/3) in indeterminate colitis, and 4,6% (3/65) in the control group. pANCA was statistically higher in ulcerative colitis compared to Crohns disease. ASCA was present in 34,5% (10/29) in Crohns disease, 7,9% (5/63) in ulcerative colitis and 3,1% (2/65) in the control group. ASCA was not detected in the patients with indeterminate colitis. ASCA was statistically higher in Crohns disease compared to ulcerative colitis. It was found that anti-pancreatic antibody, p-ANCA and ASCA were not associated with disease activity in inflammatory bowel disease. Conclusions:We may conclude that anti-pancreatic antibody can be associated with inflammatory bowel disease, but it is not sufficient by itself for the differential diagnosis of inflammatory bowel disease. ASCA and p-ANCA may be helpful tools in the differential diagnosis of inflammatory bowel disease, but more studies are warranted for antipancreatic antibody