Johanan E. Naschitz

Arterial occlusive disease in occult cancer

Thromboembolism frequently complicates advanced cancer. The incidence of TE as one of the initial manifestations of occult cancer and the diagnostic value of TE as a signal of a possible unrecognized tumor were the subjects of recent studies. TE may precede the diagnosis of cancer by several months or years. The polymorphism of manifestations of paraneoplastic TE has been described previously. An accelerated course of intermittent claudication and of ischemic heart disease has been described in patients with cancer and probably represents additional variants of Trousseaus syndrome. Recently, clues for the presence of occult neoplasms in patients with TE have been proposed. Their value in the stratification of patients needs to be established in prospective studies. That cancer may be responsible for a precipitated course of coronary or peripheral arterial disease raises the question of whether work-up is recommended to uncover a silent malignancy in a patient who has been referred for treatment of these severe ischemic syndromes.

The patient with supine hypertension and orthostatic hypotension: a clinical dilemma.

Coexistent supine hypertension and orthostatic hypotension (SH-OH) pose a particular therapeutic dilemma, as treatment of one aspect of the condition may worsen the other. Studies of SH-OH are to be found by and large on patients with autonomic nervous disorders as well as patients with chronic arterial hypertension. In medical practice, however, the aetiologies and clinical presentation of the syndrome seem to be more varied. In the most typical cases the diagnosis is straightforward and the responsible mechanism evident. In those patients with mild or non-specific symptoms, the diagnosis is more demanding and the investigation may benefit from results of the tilt test, bedside autonomic tests as well as haemodynamic assessment. Discrete patterns of SH-OH may be recognisable. This review focuses on the management of the patient with coexistent SH-OH.

The Fasciitis-Panniculitis Syndrome: Clinical Spectrum and Response to Cimetidine

The term fasciitis-panniculitis syndrome (FPS) is proposed as a novel compilation encompassing several disorders, common to which is subcutaneous induration caused by cicatrizing fasciitis as well as septal and lobular panniculitis and perimysial fibrosis. Included herein are Shulmans eosinophilic fasciitis, morphea profunda, lupus profundus, venous lipodermatosclerosis, toxic oil syndrome, altered tryptophane-related eosinophilic myositis, graft-versus-host reaction, and fasciitis reactive to subjacent basal cell carcinoma. FPS should be differentiated from scleroderma, which primarily affects the dermal structures and in which arterioles are injured. In contrast, vasculopathy of the subcutaneous medium-sized veins accompanies the hypodermal lesions of FPS. The importance of recognizing and grouping these disorders lies in their different histopathology, characterization as reactive phenomena, enhanced responsiveness to treatment, and better prognosis than scleroderma. In view of the excellent prognosis of FPS, steroid treatment is not warranted. Long-term therapy with cimetidine appears to benefit the majority of patients.

Intermittent Claudication: Predictors and Outcome:

The authors reviewed 460 patients with intermittent claudication. With primarily conservative management, these patients were followed for an average of 4.1 years (one to ten years). The mean age was 71.7 years, ranging from thirty-six to eighty-four years; 55.9% were males. The subsequent follow-up study revealed that the status of 44.1% of the patients with underlying arterial insufficiency deteriorated. Eventually, they underwent vascular surgery for limb-threatening ischemia. From this study, the analysis of the parameters could predict the clinical outcome of intermittent claudication at the time of initial and follow-up evaluation. During initial evaluation, when the ankle brachial index (ABI) was higher than 0.7 or when follow-up evaluation did not show a decrease of ABI by 0.15, the chance of favorable outcome was increased by 2.4 and 1.6 times respectively. When the ABI was less than 0.5 at the initial evaluation and decreased 0.15 or more during follow-up studies, the risk of requiring vascular surgery for limb salvage increased by 3.8 and 1.9 times, respectively. The onset of major vascular events in other areas appeared to influence the time of significant deterioration in the lower limb arterial disease, indicating multifactorial and systemic contribution in the natural history of intermittent claudication. In this homogeneous patient population with arterial insufficiency referred to the vascular surgeon, conservative management with strong supervision for smoking cessation, exercise, diet control, body weight reduction, and medical regimen can modify the natural course of intermittent claudication and associated vascular problems.

Intrathoracic Amyloid Lymphadenopathy

2 patients with intrathoracic lymph node enlargement as their presenting symptom, were found to have amyloid lymphadenopathy. Both also had peripheral involved lymph nodes. The demonstration of amyloid deposits in the peripheral lymph nodes did not suffice to deduce that the intrathoracic nodes were of the same nature. A biopsy of the intrathoracic nodes was needed for final diagnosis. An additional 11 cases of intrathoracic amyloid lymphadenopathy from the literature are reviewed.

Midodrine treatment for chronic fatigue syndrome

The long term results of midodrine treatment in a patient having debilitating chronic fatigue syndrome (CFS) are reported. Midodrine treatment, directed at the autonomic nervous system, resulted in correction of the dysautonomia followed by improvement of fatigue. This finding is consistent with the hypothesis that dysautonomia plays a major part in the pathophysiology of CFS and that therapies directed at the autonomic nervous system may be effective in the treatment of CFS.

Clinical Significance of Paraneoplastic Syndrome

The prevalence, clinical presentations, and diagnostic significance of the paraneoplastic syndrome (PNS) in the setting of a department of internal medicine in a community hospital was studied. During a 7-year period (1979-1985) a total of 167 patients among 11,000 hospitalized patients were diagnosed as having a malignant neoplasia previously unknown. From this group we selected all cases who presented with one or more of the known clinical PNSs. Forty-two cases, i.e., 25% fulfilled the selection criteria. Their prevalence in our population was higher than usually found in the literature. Sixteen different categories of PNS were observed. They occurred 55 times, since more than one PNS was present in 9 cases. No significant correlation was observed between any type of PNS and any particular class of malignant neoplasia. At the time of initial evaluation, PNSs were associated with stage I malignancy in 15 cases, with stages II and III in 8 and 3 cases, respectively, and with stage IV in 22 cases. PNSs were the leading symptom or sign in 56% of the patients. In these patients the PNS determined the direction of work-up in the search for a malignant tumor. However, PNSs were essential for suspecting cancer in stage I of the disease in 6 cases only, i.e., 14%. We stress that awareness of the clinical implications of these syndromes may permit an earlier diagnosis of malignancy.

Spontaneous colosplenic fistula complicating immunoblastic lymphoma

Immunoblastic lymphoma of the colon, complicated by colosplenic fistulization, is reported. It is suggested that ulceration and extensive coagulative necrosis of a bulky large cell lymphoma in the absence of a desmoplastic reaction are the prerequisites for fistula formation.

Reversible diminished insulin requirement during acute renal failure.

Very little is known concerning insulin requirements in diabetic patients who develop acute renal failure, although decrease in daily insulin requirement in patients with chronic renal failure is recognized. A 46-year-old diabetic patient is described, whose daily insulin requirement decreased from 56 to 8 units per day during an episode of acute post-streptococcal glomerulonephritis causing acute reversible renal failure. The insulin requirement returned to its previous level after the patient recovered.

Downslope Claudication in Eosinophilic Fasciitis: A Fourth Type of Claudication—Case Presentations

Two patients who presented with discomfort in the calves while walking down a slope were diagnosed as suffering from eosinophilic fasciitis of the lower limbs. Following therapy of the underlying disease, this peculiar discomfort remitted concomitantly with the disappearance of the subcutaneous abnormalities. The authors posit that downslope claudication of the calves in eosinophilic fasciitis constitutes an additional variant of claudication of the lower limbs.