Michael Thaler

Cardiovascular calcifications after radiation therapy for Hodgkin lymphoma: computed tomography detection and clinical correlation.

ObjectiveTo study cardiovascular calcifications, detected by computed tomography, in patients following mediastinal radiation for Hodgkin lymphoma, and correlate them with clinical findings. Materials and methodsFifteen patients, ≤55 years, with computed tomography detected cardiovascular calcifications after mediastinal radiotherapy for Hodgkin lymphoma were identified during a 10-year period. Calcifications were evaluated for site and extent and were correlated with clinical data including symptoms and signs of heart disease, angiographic and surgical findings. ResultsAccelerated calcifications were detected in the coronary arteries (n=11), in the aorta (n=11), and in the aortic valve and the mitral apparatus (n=8). Calcifications were more extensive when radiation was given at a young age. Clinical evidence of cardiovascular disease included coronary events in three patients, valvular dysfunction in two, pericarditis in two and complete atrioventricular block in one. Seven patients had no cardiac symptoms. ConclusionEarly cardiovascular calcifications can be radiation associated. Such calcifications may represent radiation-induced atherosclerosis and can be detected by computed tomography even in asymptomatic patients. The implication of our findings is that spiral computed tomography may serve as a non-invasive modality to detect accelerated cardiovascular calcifications in high-risk asymptomatic patients who survived Hodgkin lymphoma.

Peripartum cardiomyopathy occurring in a patient previously treated with doxorubicin.

We present a 28-year-old primigravida woman in whom congestive heart failure developed 3 months after delivery of a neonate. The patient underwent doxorubicin treatment 10 years previously. The combined cardiotoxicity of prior doxorubicin treatment and pregnancy is considered, and the importance of careful follow-up of cardiac function during pregnancy and postpartum in patients previously treated with doxorubicin is stressed.

Multiple Salmonella enteritidis leg abscesses in a patient with systemic lupus erythematosus.

We describe a 19 year old woman with systemic lupus erythematosus on corticosteroid therapy, who developed bilateral, multiple, gas-forming Salmonella enteritidis leg abscesses and osteomyelitis mimicking deep vein thrombosis. The infection was treated successfully by a combination of surgical drainage and intravenous ceftriaxone, followed by prolonged oral pefloxacin. This rare case of gas-producing S. enteritidis emphasizes the difficulty in diagnosing such complications in active systemic lupus erythematosus.

Nocardiosis: A 15-year experience in a tertiary medical center in Israel

OBJECTIVESnThe objective of this study is to characterize the common risk factors, clinical presentation, imaging findings, treatment and outcome of nocardial infection.nnnDESIGN AND SETTINGSnA retrospective cohort study. We reviewed the charts of all patients with nocardiosis in the Chaim Sheba Medical Center, a tertiary medical center in Israel, between the years 1996 and 2011.nnnRESULTSnA total of 39 patients who had positive culture of Nocardia were analyzed. The majority of our patients were immunocompromised (74.5%), mostly due to corticosteroid therapy. None had HIV/AIDS. The clinical presentation was either acute or a chronic smoldering illness. The three major clinical syndromes were pleuropulmonary, neurological and skin/soft tissue infection about 20.5% each. Pathology in the lungs was seen in most of the patients by CT scan; discrete nodules and wedge shaped pleural based consolidations were the most frequent findings. Brain lesions consistent with abscesses were detected in 10 patients by brain imaging. Some cases had relapsing disease in spite of antimicrobial treatment. 25% of examined isolates were resistant to trimethoprim/sulfamethoxazole. The duration of intravenous antimicrobial treatment ranged from one month to over a year in the severe cases. One year mortality rate was 32%.nnnCONCLUSIONnNocardiosis requires a high clinical index of suspicion in order to diagnose and treat promptly. Disease extent and bacterial susceptibility have important implications for prognosis and treatment.

Acute Respiratory Failure in a Patient with Sarcoidosis and Immunodeficiency—An Unusual Presentation and a Complicated Course

Pulmonary sarcoidosis is usually a chronic, insidious disease resulting from granuloma formation in the lung parenchyma. The epithelioid non-caseating granulomata of sarcoidosis are the result of a T-helper1-mediated immune reaction to an unknown self or foreign antigen. We describe the case of a patient with sarcoidosis and a coexistent common variable immunodeficiency who presented with rapidly progressive respiratory failure. This unusual presentation was followed by a complicated course with recurrent pneumoccocal infections, which could be explained by the coexistence of common variable immunodeficiency. Physicians should be alert to the possibility of sarcoidosis even when the clinical presentation is of acute respiratory distress syndrome (ARDS) since early treatment with steroids can be lifesaving. The detection of accompanying hypogammaglobulinemia is also crucial, as treatment with intravenous immunoglobulins (IVIG) together with steroids can improve the patient’s outcome.

Plasma cell dyscrasia with polyneuropathy--POEMS syndrome presenting with vasculitic skin lesions and responding to combination chemotherapy.

We report a 61-year-old male patient who presented with severe sensorimotor neuropathy, leg edema and skin lesions with M-paraprotein and 50% plasma cells in the bone marrow. The POEMS (Crow-Fukase) syndrome was diagnosed and the skin lesions were compatible with vasculitis according to the histopathology. The patient was treated with aggressive combined chemotherapy, which induced improvement in both the clinical and laboratory parameters of his disease. To the best of our knowledge this is the first report of a vasculitic process underlying the skin changes in the POEMS syndrome. Our findings may shed light on the unknown pathogenesis of this syndrome and the successful results of treatment support the adoption of an aggressive therapeutic approach in symptomatic patients.

Renal effects of L-DOPA in heart failure.

We examined whether low-dose L-DOPA treatment induces natriuresis and diuresis in patients with congestive heart failure who have cardiac decompensation despite treatment with digoxin, a diuretic, and an angiotensin-converting enzyme inhibitor and who respond acutely to intravenously infused dopamine. In a randomized, double-blind, placebo-controlled crossover study, 11 patients with severe congestive heart failure received L-DOPA (0.10 g, p.o., t.i.d., for 1 day and then 0.25 g, p.o., t.i.d., for 2 days after a washout period of > or = 1 day), with assessments of plasma and urinary levels of catechols, urinary volume, and sodium content, and clinical and laboratory measures of improvement of congestive heart failure. L-DOPA elicited short-term, dose-related increases in urinary volume and sodium excretion. At the 0.10-g dose, L-DOPA increased plasma L-DOPA levels and urinary L-DOPA excretion by about fivefold, whereas at the 0.25-g dose, L-DOPA increased plasma and urinary L-DOPA by >50-fold. Twenty-four-hour urinary dopamine excretion increased by about fivefold after the low dose of L-DOPA and approximately 50-fold after the high dose. The results demonstrate that oral L-DOPA treatment can produce beneficial natriuretic and diuretic effects in selected patients with congestive heart failure. The bioavailability of oral L-DOPA appears to vary with the dose. These results support findings from previous studies about beneficial cardiac functional effects of L-DOPA in patients with refractory heart failure.

Oral contraceptive-induced chorea

A case history of a patient with (OC) oral contraceptive-induced chorea is described. An 18 year old woman experienced involuntary movements of both upper extremities; she had received OCs 2 months prior to the onset of those symptoms. In addition to these choreoathetoid movements the patient exhibited grimaces exacerbated by stress. All laboratory procedures were normal as were electrocardiogram and electroencephalogram. OCs were discontinued and propranolol (4 times/day) was administered in an attempt to suppress choreiform movement. This was unsuccessful; however 1 month after OC discontinuance reduction in these movements was noted and grimaces disappeared. Within 10 weeks complete resolution was observed. Although the etiology of OC-induced chorea is not known clinicians should be aware of this potential side effect as chorea can be eliminated by stopping the drug.

Skin lesions in a patient with hairy cell leukaemia.

Accepted 10 May 1996 A 62-year-old woman was diagnosed as suffering from hairy cell leukaemia, on the basis of bone marrow biopsy results and a positive tartrate-resistant acid phosphatase stain. A single course of 2-chlorodeoxyadenosine was administered as a continuous intravenous infusion over seven days. During the following weeks her complete blood count reached almost normal values except for a lymphopenia of 0.51.0 x 109/1 which persisted during the following months and was attributed to the lympholytic effects of 2-chlorodeoxyadenosine. Bone marrow biopsy six months after treatment showed complete remission of the haematologic disease. Three months later the patient presented with two new erythaematous nodules, approximately 2 x 2 cm each, overlying the dorsal aspect of her right hand (figure 1). Otherwise the physical examination was normal. At that time the complete blood count was normal except for lymphopenia of 0.6 x 109/l with an abnormal CD4/CD8 ratio of less than 1.0. The absolute CD4+ count was 224/ul (normal range 3651600/,l) and absolute CD8+ count 275/,il (normal range 2702400/,il). Histology of the skin biopsies taken from both lesions is shown in figure 2. The immunohistochemical stain with a monoclonal anti-human hairy cell leukaemia antibody (clone DBA.44) was negative. Cultures were obtained from both lesions. While the microbiological test results were pending, the patient was treated for a week with clarithromycin for an incidental upper respiratory tract infection. A significant regression in the size of both skin lesions was noted.

Atrial natriuretic peptide in pulmonary emboli

Abstract The potent stimulation of ANP release by alveolar hypoxia raises the possibility that it might be an indicator of pulmonary emboli, a condition which is frequently not diagnosed. ANP was examined in hospitalized patients with pulmonary emboli evidenced by perfusion and ventilation scans, and in two control groups of patients with deep vein thrombosis or anginal syndrome. ANP was measured on days 1, 3, and 5 of hospitalization, while the patients were given heparin, and determined by double antibody radioimmunoassay. The level of ANP was 5 times higher in the pulmonary emboli group than in either of the control groups on day 1, and 3.5–4 times higher than the control groups on day 5. The ANP level remained low in the two control groups throughout the study. We suggest that ANP may serve as an indicator of the presence of pulmonary emboli, facilitating diagnosis of the condition.