Markéta Nová

Letter: telmisartan-associated enteropathy – is there any class effect?

*2nd Department of Internal Medicine – Gastroenterology, Charles University in Prague, Faculty of Medicine in Hradec Kralove, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic. Department of Infectious diseases, Charles University in Prague, Faculty of Medicine in Hradec Kralove, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic. Fingerland Department of Pathology, Charles University in Prague, Faculty of Medicine in Hradec Kralove, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic. E-mail: jiri.cyrany@fnhk.cz

Fatal Intraventricular Hemorrhage After the Extracranial Carotid Artery Angioplasty and Stent Placement

We report on a 72-year-old female with an unusual intracranial bleeding complication after an extracranial carotid artery stenting procedure performed for a tight left ICA stenosis associated with contralateral carotid occlusion. Two hours after the procedure, the initial signs of intracranial bleeding appeared that led to the patient’s demise 5 days later. A brain CT showed and autopsy proved massive intraventricular bleeding. To our knowledge, our case is only the second report of isolated reperfusion intraventricular hemorrhage post-CAS.

Impact of Hashimoto's thyroiditis, TSH levels, and anti-thyroid antibody positivity on differentiated thyroid carcinoma incidence.

INTRODUCTION The relationship between Hashimotos thyroiditis (HT) and thyroid cancer (TC) is controversial. While most surgical studies report a high incidence of malignancy among patients with HT, cytological studies do not. The role of autoantibodies in the incidence of malignancy is unclear. MATERIAL AND METHODS A single-centre retrospective observational study was conducted in patients evaluated for thyroid nodules by US-guided fine-needle aspiration cytology (FNAC) and, if indicated, by surgery. The levels of thyroid-stimulating hormone (TSH) and anti-thyroid antibodies were measured at the time of FNAC. RESULTS Of 4947 patients, 599 (12.1%) were diagnosed with HT. A malignant/suspicious cytological result was found in 14.2% of the patients with HT and in 15.2% of the others. The odds ratio (OR) for malignancy in HT was 0.921 (0.716-1.183, p = 0.51). Of 1603 patients who underwent surgery, differentiated thyroid carcinoma was found in 29.5% of the HT patients and in 15.2% of the others (OR 2.33, 95% confidence interval CI, 1.403-3.854, p < 0,001). Low TSH (< 0.4 mIU/L) decreased the malignancy rate in the entire patient population, both when considering the cytological results and the surgical results. This was not confirmed in the subgroup diagnosed with HT. No relationship was observed between autoantibodies against thyroid peroxidase (ATP) or thyroglobulin (ATG) and malignancy rate. CONCLUSIONS No association between HT and thyroid cancer was observed cytologically; a positive relationship in histological series was caused by selection bias. Low TSH levels decreased the risk of TC in patients with nodular goitre, but this has not been proven in patients with HT.

Thyroid transcription factor 1 expression is associated with outcome of patients with non-squamous non-small cell lung cancer treated with pemetrexed-based chemotherapy

Pemetrexed is an antifolate cytostatic agent targeting several folate-dependent enzymatic pathways, widely used in the treatment of locally advanced or metastatic stage non-small cell lung cancer. Aside from the non-squamous histology, there is still no available molecular biomarker predicting treatment efficacy of pemetrexed-based chemotherapy. The aim of our retrospective study was to evaluate the association of thyroid transcription factor 1 expression with outcome of a large cohort of patients with non-squamous non-small cell lung cancer treated with pemetrexed. We retrospectively analysed clinical data of 463 patients with advanced-stage non-small cell lung cancer (IIIB or IV) treated with pemetrexed-based chemotherapy. Thyroid transcription factor 1 expression was assessed using indirect immunohistochemical detection in formalin-fixed paraffin-embedded tumour tissue at the time of diagnosis. Thyroid transcription factor 1 expression was detected in the tumour tissue from 76.0% of patients, and tumours from 24.0% of patients were thyroid transcription factor 1 negative. The median progression-free survival and overall survival for patients with thyroid transcription factor 1 positive tumours were 4.8 and 11.8 months compared to 2.8 and 8.3 months for those with thyroid transcription factor 1 negative tumours (p = 0.001 and p < 0.001). The multivariable Cox proportional hazards model revealed that thyroid transcription factor 1 expression was significantly associated with progression-free survival (hazard ratio = 1.57, p < 0.001) and also with overall survival (hazard ratio = 1.73, p < 0.001). In conclusion, the results of the conducted retrospective study suggest that the thyroid transcription factor 1 expression was independently associated with progression-free survival and overall survival in patients with advanced-stage non-squamous non-small cell lung cancer treated with pemetrexed-based chemotherapy.

Case 3-2011: Invasive mucormycosis (zygomycosis) after bone marrow transplantation in a 26-year-old man with relapsing acute myeloid leukaemia.

Patient J.S., 26-year-old man, was first seen by his general practitioner because of chest pain, dyspnoea, weakness, vomiting, headache, dizzines and recent fever on January 29th 2010. Blood samples were taken and revealed leukocytosis 149 × 109/L. His previous medical history was unremarkable. He was immediately referred to our University Hospital with suspicion of acute leukaemia. On admission in the evening of the same day, his leukocyte blood count was already 248 × 109/L and mild anaemia and thrombocytopenia was present. The diagnosis of acute myeloid leukaemia (myelomonocytic according to WHO classification) was made. There also was a severe syndrome of leukostasis on admission, and the patient developed acute myocardial infarction and respiratory insufficiency. Immediate leukoreduction with leukapheresis and hydroxyurea was started. When leukocyte count was reduced below 50 × 109/L chemotherapy with intermediate dose cytarabine (total dose 24 g) and idarubicin (total dose 70 mg) was started. Despite drastic leukoreduction our patient developed systemic inflammatory response syndrome (SIRS) with multiorgan failure reflecting tumor lysis syndrome following chemotherapy. He received artificial ventilation for respiratory failure caused by diffuse alveolar haemorrhage, and continuous renal replacement therapy for renal failure was started. The course of his disease was further complicated by shock, disseminated intravascular coagulation and liver failure. With full supportive care and corticosteroids patient was stabilised and eventually, after 5 days, he was successfully extubated and his renal and liver function recovered. Unfortunately, the induction chemotherapy did not lead to remission of the leukaemia. Patient received reinduction chemotherapy with FLAG IDA regimen (fludarabine, cytarabine, idarubicin, G-CSF) on March 6th. The remission was not achieved once again and another reinduction with HAM chemotherapy (cytarabine, mitoxantrone) was instituted on April 18th. Finally, there was a complete remission on bone marrow examination on May 27th. Patient obtained consolidation treatment (again HAM chemotherapy) and was scheduled for allogeneic stem cell transplantation. On August 18th he was admitted for allogeneic peripheral blood stem cell transplantation. His donor was unrelated woman with 3 mismatches (7/10). Unfortunately, before transplantation his bone marrow examination revealed a relapse of acute leukemia, and we decided to proceed to fully ablative approach enforced with cytarabine and mitoxantrone. The remission with 96% donor chimerism was achieved on September 29th. After transplantation he developed grade 3 skin acute graft versus host disease and BK virus hemorrhagic cystitis. Graft versus host disease resolved with corticosteroids treatment and hemorrhagic cystitis with reduced immunosupression. On November 11th, second relapse of the disease was diagnosed. The patient received chemotherapy and again developed multiorgan failure with respiratory failure and was artificially ventilated. He recovered and still cytopenic he refused further hospital stay and was discharged. Voriconazol was used as a prophylaxis during neutropenia. He was admitted shortly afterwards with the clinical signs of sepsis. Physical examination and X-ray revealed left side pneumonia and pericarditis. On pulmonary high resolution CT scan (HRCT), there was bilateral pneumonia with atypical pattern (Fig. 1). He also complained of vision disturbance, and an ischemic lesion in the occipital area on brain CT scan was found (Fig. 2). Lumbar puncture did not reveal any pathogen. Immediate treatment with antibiotics (meropenem and amikacin) and amphotericin B in combination was started. The patient died within 2 days (November

CT-guided biopsy of the mediastinal masses. Can anatomical relationships predict complications?

AIM To retrospectively evaluate the technical features, feasibility, efficacy, accuracy and appropriate complications of CT-guided biopsies of mediastinal masses and correlate them with anatomical relationships in the mediastinum. METHODS Over the course of ten years, 81 percutaneous biopsy procedures in 78 patients for tumors sizes 27 - 189 mm in diameter (median length 57.5 mm) were performed using only local anesthesia. These interventions were done under the guidance of computed tomography. The patients were men in 30 cases and women in 48 cases, aged 19 to 90 years. RESULTS In 78 cases (96.3%) results were either true positive or true negative; in only 3 cases (3.7%, 3 biopsies of 2 tumors in 2 patients) were histological findings false negative. In 2.3% of the patients, complications were revealed in the anterior part of the mediastinum, 43.7% occurred in the middle region, and 14.3% in the posterior region of the mediastinum. Statistical data analysis verified there was a 3.74 times chance of an increase in complications in the middle mediastinal section in correlation with other anatomical localizations. In only one case was therapeutic intervention for complication necessary. For all other cases, a conservative approach was suitable. CONCLUSION Percutaneous CT guided biopsies of the mediastinal tumors has a high accuracy rate in establishing the correct diagnosis. Masses in the middle mediastinum are associated with statistically higher incidences of postprocedural complications, which are not serious.

Case 2-2012: a 57-year-old woman with post-transplant lymphoproliferative disorder after allogeneic stem cell transplantation for primary myelofibrosis.

allogeneic haematopoietic stem cell transplantation (hsCt) has become a major life sustaining treatment for haematopoietic disorders, and it is the preferred treatment option for selected patients with idiopathic myelofibrosis. Still, it may be accompanied by various complications. here, we present a case of epstein-Barr virus (eBv) – associated post-transplant lymphoproliferative disorder (Ptld), i.e. an infection-induced malignant proliferation following hsCt.