Jochen Riehl

Successful Treatment of Pulmonary Mycobacterium xenopi Infection in a Natural Killer Cell—Deficient Patient with Clarithromycin, Rifabutin, and Sparfloxacin

Isolation of Mycobacterium xenopi from the respiratory tract may indicate pneumonia, often clinically indistinguishable from tuberculosis. Resistance to the classic antituberculous drugs renders the treatment of these infections problematic. We report on a case of cavernous pneumonia caused by M. xenopi in a 36-year-old male with natural killer cell deficiency but without severe immunodeficiency. He was successfully treated with a novel triple-drug combination comprising clarithromycin, sparfloxacin, and rifabutin. An impressive subsequent regression of pathological pulmonary changes was observed, and mycobacteria could no longer be detected. The therapeutic potential of clarithromycin and sparfloxacin in the treatment of M. xenopi infections is discussed.

Bedside ultrasound in decision making for emergency surgery: Its role in medical intensive care patients

During an 18-month period the authors followed 1,024 patients referred to a general medical intensive care unit. A total of 7% of these patients underwent emergency surgery at some point during their admission. The role of abdominal ultrasound in the decision-making process for these emergency surgical interventions was evaluated and the patients were identified for whom the pathologic result of sonography was regarded sufficient to operate without any additional imaging procedures. Of 71 patients with unexpected surgical emergencies, abdominal ultrasound provided a definite diagnosis for 18 patients (25%), and the decision to operate could be made without delaying for further or more invasive diagnostic techniques. In all cases the sonographic diagnosis was confirmed during the operation. The critical care patients most likely to benefit from bedside ultrasound in a surgical emergency were those with hemorrhage of unknown origin (44%) or septicemia from an undetected focus (39%). The most frequent site of operation where ultrasound was considered diagnostic was the urinary tract (56%), particularly in emergencies following renal transplantation.

Sonographic changes of the pancreas in chronic renal failure.

Several abnormalities regarding pancreatic morphology and function have been reported in patients with chronic renal failure (CRF) with an incidence as high as 72%. In a prospective study we investigated 96 outpatients from our chronic ambulatory hemodialysis program by abdominal ultrasound. Of the patients with CRF, 20.6% were found to have morphologic alterations of the pancreas compared to 4.7% of controls. Although pathologic sonograms of the pancreas correlated with biliary disease, hyperparathyroidism and years of hemodialysis, the most obvious etiologic factor appeared to be the duration of CRF. Possible pathogenetic mechanisms are discussed and screening abdominal ultrasound examinations in patients with long-standing CRF are recommended.

Renal Oncocytoma of the Native Kidney after Renal Transplantation

Patients with acquired cystic kidney disease (ACKD) are at an increased risk of renal neoplasms. Frequent tumors are adenomas and renal cell carcinomas. However, renal oncocytomas may occur in patients with ACKD. Little is known about oncocytomas of the native kidney following renal transplantation. By means of B scan ultrasonography, a solid and echo-inhomogeneous renal mass was incidentically observed in the right native kidney of a 28-year-old female patient with ACKD 4 years following renal transplantation. A nephrectomy was performed. The histological examination revealed a renal oncocytoma. The increased prevalence of neoplasms in the case of ACKD and following renal transplantation requires careful monitoring of the patients concerned. In very rare cases a renal oncocytoma may develop in the native kidney after renal transplantation.

Skeletal scintigraphy in acquired adult Fanconi syndrome

Tc-99m dicarboxypropane diphosphonate (DPD) bone scintigraphy in a 74-year-old patient with a 1-year history of generalized bone pain revealed multiple foci of increased tracer accumulation. Laboratory tests showed hypophosphatemia and an elevated alkaline phosphatase level. Fanconi syndrome was diagnosed with combined tubular reabsorption defects for phosphate, glucose, amino acids, and bicarbonate. Immuno-electrophoresis and bone marrow aspiration revealed monoclonal gammopathy of the immunoglobulin G kappa type and Bence-Jones proteinuria. Iliac crest biopsy revealed severe osteomalacia. Based on these findings, the diagnosis of monoclonal gammopathy and secondary Fanconi syndrome with subsequent hypophosphatemic osteomalacia was established. Clinical signs and symptoms improved gradually with phosphate substitution. Finally, overt multiple myeloma developed.

Pulmonale alveoläre Mikrolithiasis – eine seltene Ursache bilateraler ausgedehnter pulmonaler Infiltrate

ZusammenfassungHintergrund: Die pulmonale alveoläre Mikrolithiasis ist eine seltene Erkrankung, die durch die pulmonale Ablagerung von Calciumphosphatkonkrementen in den Alveolen charakterisiert ist. Diagnostisch richtungsweisend ist das Röntgenbild mit einer typischen “Sandsturm”artigen Verschattung des Lungengewebes. Fallbeschreibung: Ein 29-jähriger Marokkaner stellte sich erstmals 1988 wegen atypischer linkstorakaler Schmerzen vor. Anamnestisch waren eine Nephrokalzinose und eine Lungenerkrankung bekannt. Die körperliche Untersuchung und die Laborbefunde waren unauffällig. Im Röntgenbild des Thorax fielen ausgedehnte pulmonale Infiltrate beidseitig mit einem “Sandsturm”-artigen Aspekt auf. Sonographisch zeigte sich auf beiden Seiten eine medulläre Nephrokalzinose. Mittels transbronchialer Biopsie wurde die Diagnose einer pulmonalen alveolären Mikrolithiasis gesichert. Im Verlauf von 13 Jahren kam es zu einer leichten Zunahme der pulmonalen Infiltrate und zu beginnender restriktiver Ventilationsstörung bei subjektiv weitgehend beschwerdefreien Patienten. Schlussfolgerung: Bei ausgedehnten pulmonalen Infiltraten beidseitig mit Nachweis intrapulmonaler Verkalkungen sollte als Differentialdiagnose an die seltene pulmonale alveoläre Mikrolithiasis gedacht werden. Dies gilt insbesondere für Patienten aus Ländern mit hoher Sonnenlichtexposition. In seltenen Fällen findet man auch Verkalkungen in extrapulmonalen Organen.AbstractBackground: Pulmonary alveolar microlithiasis is a rare disease, which is characterized by pulmonary deposition of calcium phosphate microliths. The radiographic features can be pathognomonic wit a “sandstorm”-like opacification throughout the lungs. Case Report: A 29-year-old Moroccan presented for the first time 1988 with atypical chest pain. His history was characterized by nephrocalcinosis and pulmonary disease. Physical examination and laboratory values were unremarkable. Chest X-ray revealed extensive bilateral pulmonary infiltrates with “sandstorm”-like opacifications. Sonography showed medullary nephrocalcinosis. The diagnosis of pulmonary alveolar microlithiasis was confirmed ty transbronchial biopsy. Over the next 13 years there was only a moderate expansion of the pulmonary infiltrates and a beginning restrictive pattern, whereas the patient was almost symptom-free. Conclusion: Pulmonary alveolar microlithiasis is a rare cause of bilateral pulmonary infiltrates and should be considered in the differential diagnosis. In some cases there is also an association with calcifications of extrapulmonary organs.

[Renovascular hypertension--diagnosis and therapy].

ZusammenfassungDie atherosklerotische Nierenarterienstenose ist die häufigste Ursache der renovaskulären Hypertonie (RVH). Klinische Merkmale lenken den Verdacht auf das Vorliegen einer RVH. Bei betroffenen Patienten können durch eine nichtinvasive Diagnostik mit Duplexsonographie, CT- oder MR-Angiographie Hinweise auf eine Nierenarterienstenose gefunden werden. Durch die intraarterielle Angiographie erfolgt dann die endgültige morphologische Sicherung der Stenose. Bisher gelingt es mit diesen Methoden jedoch nicht, die Auswirkungen revaskularisierender Maßnahmen auf den postinterventionellen Verlauf der Hypertonie zu prognostizieren. Hypertensive Patienten mit signifikanter Nierenarterienstenose können medikamentös und/oder durch interventionelle Maßnahmen behandelt werden (Angioplastie der Nierenarterie mit/ohne Stentimplantation; chirurgische Revaskularisation). Randomisierte Studien, die eine invasive oder medikamentöse Therapie vergleichen, belegen keine Überlegenheit eines der Therapieverfahren zur Behandlung von Hypertonie oder renalem Funktionsverlust. Die Indikation zum invasiven Vorgehen muss daher sehr kritisch gestellt werden.AbstractAtherosclerotic renal artery stenosis accounts for most cases of renovascular hypertension (RVH). Hypertensive patients with clinical features suggesting RVH should be submitted to further noninvasive evaluation including duplex Doppler ultrasonography, CT- or MR angiography. Invasive evaluation by contrast-enhanced angiography confirms the diagnosis of renal artery stenosis. However, neither diagnostic test reliably predicts the course of hypertension after revascularisation. The therapeutic approach in hypertensive patients with hemodynamically important renal artery stenosis includes medical or invasive therapy (renal percutaneous transluminal angioplasty, PTRA; renal arterial stent placement, PTRAS; surgical revascularisation). Randomized trials comparing invasive and conservative approaches demonstrated no differences in blood pressure control or renal function. Only patients with clear clinical indications should be submitted to interventional procedures as PTRA, PTRAS and surgical vascular intervention.