Malka Attali

Acute renal embolism. Forty-four cases of renal infarction in patients with atrial fibrillation.

Abstract: Acute renal embolus is rarely reported in the medical literature; thus, accurate data regarding presentation, laboratory tests, diagnostic techniques, and treatment are lacking. To better define this condition, we examined the medical records of all patients admitted to Kaplan Medical Center and Sheba Medical Center in central Israel from 1984 to 2002 who had a diagnosis of renal infarction and atrial fibrillation. We noted demographic, clinical, and laboratory parameters; method of diagnosis; treatment received; and patient outcome. We identified 44 cases of renal embolus: 23 females and 21 males, with an average age of 69.5 ± 12.6 years. Thirty (68%) patients had abdominal pain, and 6 (14%) had a previous embolic event. Nine patients were being treated with warfarin on admission, 6 (66%) of whom had an international normalized ratio (INR) <1.8. Hematuria was present in 21/39 (54%), and 41 (93%) patients had a serum lactate dehydrogenase (LDH) level >400 U/dL. The mean LDH was 1100 ± 985 U/dL. Diagnostic techniques included renal isotope scan, which was abnormal in 36/37 cases (97%); contrast-enhanced computed tomography (CT) scan, which was diagnostic in 12/15 cases (80%); and ultrasound, which was positive in only 3/27 cases (11%). Angiography was positive in 10/10 cases (100%). Twenty-three (61%) of 38 patients had normal renal function on follow-up. The 30-day mortality was 11.4%. Renal embolus was diagnosed mainly in patients aged more than 60 years, some of whom had a previous embolic event. Most of those receiving anticoagulant therapy had a subtherapeutic INR. Abdominal pain was common, as well as hematuria and an elevated LDH. These patients are at risk of subsequent embolic events to other organs. The most sensitive diagnostic technique in this population is a renal isotope scan, but contrast-enhanced CT scan requires further assessment.

Acute hepatitis E virus infection presenting as a prolonged cholestatic jaundice.

Hepatitis E virus (HEV) is an enteric virus that usually causes a self-resolving hepatitis; although, it may be fatal, especially in pregnant women. Although HEV is endemic in Israel, there have been no recent local outbreaks. We report the case of a 70-year-old man who presented with painless jaundice. Ultrasound and abdominal computed tomography scan revealed gallstones, with no evidence of cholecystitis and no dilatation of the intra-or extrahepatic bile ducts. An open cholecystectomy was performed with intraoperative cholangiography. There was no evidence of choledocholithiasis. A subsequent endoscopic retrograde cholangiopancreatography was normal. His bilirubin level subsequently increased to a maximum of 25 mg/dL, and his gamma-glutamyl-transferase level reached 1,400 U/L. There was no evidence of any autoimmune or metabolic disease, and routine viral serology was normal except for immunoglobulin G to hepatitis A virus. A liver biopsy revealed an acute cholestatic picture. The jaundice resolved slowly after a period of 6 months. Hepatitis E virus RNA was isolated from the acute-phase serum and was not detectable in the convalescent serum. This case is a unique example of chronic cholestatic jaundice that we think is caused by acute HEV infection.

Fatal heart block following treatment with botulinum toxin for achalasia

CCS diagnosis category 139) versusregional enteritis and ulcerative colitis (IBD, single-level CCS diagnosis category 144) based on age, sex, income, location, and region, while using the same query for all hospital stays as controls. These two diagnoses were chosen because of the known lower socioeconomic status and later onset of ulcer patients (epidemiology ofHelicobacter pylori ) and anticipated inverse trends for IBD. All hospital stays (discharges) were used as controls to ascertain that socioeconomic differences between the two diseases are not just due to lower socioeconomics of the first, but also to the higher than average socioeconomic status of patients with IBD. Abbreviated results are shown in Table 1 (while the reader is invited to run detailed queries on HCUPnet). As anticipated, IBD is characterized by earlier onset/need for hospitalization, and does affect a higher socioeconomic group. Regional differences (Northeast vs South) may also be a function of socioeconomic differences. Sex distribution in both diagnosis was very similar (not shown)—about 43% male and 57% female, and closely approximated all hospital stays.

Spontaneous bacterial arthritis in a cirrhotic patient.

Septic arthritis is usually of hematogenous origin and is increasingly being reported in elderly patients, who often have underlying medical conditions such as diabetes or alcoholism. We report a 62-year-old patient with alcoholic liver disease who presented with Escherichia coli bacteremia and septic arthritis in a previously fractured ankle. There are scarce reports of infectious arthritis in cirrhotic patients, but this is the first report of arthritis after a primary enteric bacteremia. We believe that the patient described here developed E. coli bacteremia as a result of bacterial overgrowth and translocation related to alcoholic liver disease and cirrhosis. The resulting bacteremia resulted in the development of infection in the left ankle, which had preexisting disease and was thus vulnerable. This case provides further evidence for the mode of infection being bacteremia in cirrhotic patients. In patients with cirrhosis and fever, a high index of suspicion is required for joint infection as a potential cause of fever or deterioration in the cirrhotics patient general condition.

Case Report: Three Cases of Chronic Mesenteric Ischemia Presenting as Abdominal Pain and Helicobacter pylori-negative Gastric Ulcer

Mesenteric ischemia is well described as a cause of chronic abdominal pain (1). The classic complaint is of postprandial abdominal pain. The pain steadily increases in severity before reaching a plateau and resolves during the next 1 to 2 hr. The pain appears in the epigastrium and may radiate through to the back. The severity of the pain is greater after large meals or meals with a high fat content (2). These complaints are, of course, not specific and raise the possibility of peptic ulcer disease. Chronic Helicobacter pylori infection is the major cause of peptic ulcer disease, and use of nonsteroidal antiinflammatory drugs (NSAIDs) accounts for the majority of the remainder (3). Non-NSAID, non-H. pylori gastric ulcers are constituting a greater proportion of diagnosed ulcers as the prevalence of H. pylori decreases (3). We report here three cases of chronic mesenteric ischemia where an H. pylori-negative gastric ulcer unassociated with the use of NSAIDs was detected in the initial evaluation. the patients’ complaints ultimately responded to revascularization therapy, with resolution of their non-NSAID, nonH. pylori gastric ulcers.

Real-time PCR for Strongyloides stercoralis–associated meningitis

Four immunocompromised patients, immigrants from Ethiopia, presented with diverse clinical manifestations of meningitis associated with Strongyloides stercoralis dissemination as determined by identification of intestinal larvae. The cerebrospinal fluid of 3 patients was tested by a validated (for stool) real-time PCR for S. stercoralis and was found positive, establishing this association.