Venous thrombosis in immunocompetent patients with acute cytomegalovirus infection: a complication that may be underestimated

In the present study, we retrospectively studied clinical and laboratory findings associated with cytomegalovirus (CMV) infection in immunocompetent patients. We focused on severe CMV infection. Among 38 patients, five had a severe form of infection: one had meningitis, one had symptomatic thrombocytopenia and three had venous thromboses with pulmonary embolism, a rarely described complication. CMV-induced thrombosis has been reported in immunocompromised patients such as transplant recipients and patients with AIDS. Recent case reports have also described thrombotic phenomena in immunocompetent patients with CMV infection. Our study suggests that venous thrombosis during acute CMV infection is an underestimated complication.     

Association of blood group A with early-onset ovarian hyperstimulation syndrome

Purpose of the studyOvarian hyperstimulation syndrome is a potentially life-threatening complication during controlled ovarian stimulation for fertility treatment. Since no association of this condition with ABO blood groups was known, we compared ABO antigens with severity and onset of symptoms in a case-control study.Patients and methodsOne hundred and twenty-one patients, mainly Caucasians, were hospitalized because of ovarian hyperstimulation syndrome after receiving in vitro fertilisation, in the period from January 2000 to February 2007. Severity of symptoms, pregnancy rate and ABO blood group were collated. The ABO blood group distribution was compared to four independent control groups.ResultsBlood group A was markedly more frequent and blood group O less frequent in patients with ovarian hyperstimulation syndrome compared to the blood group distribution in all control cohorts. The odds ratio for patients undergoing controlled ovarian stimulation with blood group A versus O to develop the early-onset form of this condition was 2.171 (p-value 0.002). No association for late-onset form could be found. The overall pregnancy rate was 50.4% and three times higher in the group of late-onset ovarian hyperstimulation syndrome compared to the early-onset form. Four patients developed thromboses in the jugular or subclavian vein, none of whom had blood group O.ConclusionBlood group A may be associated with early-onset ovarian hyperstimulation syndrome in Caucasians. Depending on further studies, this possible association may be considered for an individualized hormone dosing in controlled ovarian stimulation.     

Massives Ovarialödem bei einem 13-jährigen Mädchen

Massive ovarian edema is a rare tumor-like condition found in young women resulting from accumulation of fluid mostly due to partial or intermittent torsion of the ovary or secondary, to a preexisting ovarian lesion. We report a case of a 13-year-old girl presenting with an ovarian mass measuring 16 cm. CA-12-5 levels were slightly elevated. Concerns regarding underlying malignancy led to salpingo-oophorectomy. Pathological evaluation revealed a massive ovarian edema and multiple thromboses of ovarian veins. Differentiating massive ovarian edema from malignant ovarian tumor is crucial to prevent patients from undergoing unnecessary surgery.     

Histological Hashimoto''s disease in a benign cystic ovarian teratoma

A case of Hashimoto's disease of the thyroid component of a benign cystic ovarian teratoma is reported, unassociated with previous neck surgery. Three hundred and fifteen cases of ovarian teratomata were reviewed to determine the incidence of this complication.     

Laparoscopic treatment of polycystic ovarian disease

There has been a recent surge of interest in laparoscopic treatmentof polycystic ovarian disease (PCOD) that is unresponsive tofirst-line ovulation-inducing agents. Laparoscopic treatmentoptions include multiple ovarian punch biopsy, ovarian electrocauterizationand laser vaporization or photo-coagulation. These proceduresare relatively easy to perform, devoid of major complications,and yield satisfactory ovulation and conception rates. Adhesionformation, however, is a potential complication following suchprocedures. Furthermore, women subjected to laparoscopic destructiveovarian procedures also need to be critically assessed regardingother long-term risks, such as premature ovarian failure. Laparoscopictreatment of PCOD, at present, should be viewed as experimentalawaiting further trials assessing its long-term safety     

Endocrinology: Ovarian hyperstimulation syndrome associated with spontaneous pregnancy

A case of ovarian hyperstimulation syndrome (OHSS) associatedwith a spontaneous pregnancy is reported with the hope of facilitatingearlier recognition of this condition. Although OHSS is usuallyan iatrogenic complication, it can also occur spontaneouslywithout any evidence of endocrinological disorder. Surgery wasperformed and induced a very rapid resolution of ovarian hyperstimulation.     

Use of anti-thrombotic agents during chemotherapy for epithelial ovarian cancer

The association between malignancy and venous thrombotic events is well established. However, arterial thrombosis among cancer patients is extremely rarely reported. There are several mechanisms of arterial thrombosis or embolism in malignancy. Important mechanisms in arterial thrombogenesis are shear stress-induced platelet aggregation and platelet-derived microparticles. Both of these are induced by major abdominal surgery. A major abdominopelvic surgery followed by adjuvant platinum-based combined chemotherapy is routinely performed for epithelial ovarian cancer which is the leading cause of death among all gynecologic malignancies. These patients have a greater risk of arterial thrombosis at the postoperative period. If the affected arteries are relatively larger, clinical findings will be evident due to limb ischemia or fatal organ infarctions. However, thrombosis of the small arteries disturbs the tissue circulation which is extremely important for the chemotherapeutic agents to reach the residual tumor cells. When the thrombosis of small arteries is prevented, these drugs will reach all of the residual macroscopic or microscopic tumoral tissues and so the prognosis of the patients may be improved. Therefore, we hypothesize that anti-platelet therapy with aspirin is needed to be initiated during the postoperative period of epithelial ovarian cancer patients and be continued as long as chemotherapy goes on. Such an approach might have a role in optimizing the oncological prognosis of these patients via increasing the effectiveness of cytotoxic therapy since some of the recurrences may be caused by some microscopic tumor foci which were not affected by cytotoxic drugs because of subclinical small arterial thromboses.     

Unilateral hydrothorax as a sole and recurrent manifestation of ovarian hyperstimulation syndrome following in-vitro fertilization

Acute unilateral hydrothorax may appear as the sole extra-ovarian expression of severe ovarian hyperstimulation syndrome (OHSS). This case report describes two such cases, in one of which the patient developed this rare complication in two consecutive ovarian stimulation cycles. Awareness is needed for the timely and appropriate diagnosis of this rare complication that occurs 9-14 days following human chorionic gonadotrophin (HCG) administration and may recur in consecutive stimulation cycles. Thoracocentesis and fluid balance maintenance are efficient modes of therapy resulting in good outcome.      

Clinical experiences of fetal ovarian cyst: diagnosis and consequence

Ovarian cysts are the most frequent, prenatally diagnosed intra-abdominal cysts. Fetal ovarian cyst often presents complication such as torsion and seems to be an indication for surgical intervention. In this study, we reviewed pre- and post-natal medical records and ultrasonography of 17 fetuses that were diagnosed with ovarian cysts. In a total of 17 cases, postnatal surgery was performed in 7 infants. Of these cases, four cases of ovarian cyst torsion were confirmed. In the remaining 10 fetuses, one case regressed completely during pregnancy, and the other nine cases including two complex cysts resolve spontaneously after birth. Postnatal symptomatic cysts or cysts with a diameter greater than 5 cm that do not regress or enlarge should be treated, but uncomplicated asymptomatic cysts less than 5 cm in diameter should only be observed and reassessed by serial ultrasonography. If they regress spontaneously, no surgical intervention is necessary independent of their sonographic findings.     

Epidemiology and prevention of ovarian hyperstimulation syndrome (OHSS): a review

Ovarian hyperstimulation syndrome (OHSS) is a rare iatrogenic complication of ovarian stimulation occurring during the luteal phase or during early pregnancy. Fortunately, the reported prevalence of the severe form of OHSS is small, ranging from 0.5 to 5%. Nevertheless, as this is an iatrogenic complication of a non-vital treatment with a potentially fatal outcome, the syndrome remains a serious problem for specialists dealing with infertility. The aim of this literature review was to determine whether it is possible to identify patients at risk, and which preventive method should be applied when an exaggerated ovarian response occurs. Data pertaining to the epidemiology and prevention of OHSS in women were searched using Medline, Current Contents and PubMed, and are summarized. Preventive strategies attempt either to limit the dose or concentration of hCG or to find a way to induce luteolysis without inducing a detrimental effect on endometrial and oocyte quality. The following particular preventive strategies were reviewed: cancelling the cycle; coasting; early unilateral ovarian follicular aspiration (EUFA); modifying the methods of ovulation triggering; administration of glucocorticoids, macromolecules and progesterone; cryopreservation of all embryos; and electrocautery or laser vaporization of one or both ovaries.     

Sigmoid endometriosis and ovarian stimulation

In-vitro fertilization (IVF) and ovarian stimulation are frequently performed in patients with endometriosis. Although endometriosis is a hormone-dependent disease, the rate of IVF complications related to endometriosis is low. We report four cases of severe digestive complications due to the rapid growth of sigmoid endometriosis under ovarian stimulation. In three patients, sigmoid endometriosis was diagnosed at laparoscopy for sterility. Because of the absence of digestive symptoms or repercussion on the bowel, no bowel resection was performed before ovarian stimulation. All patients experienced severe digestive symptoms during ovarian stimulation, and a segmental sigmoid resection had to be performed. Analysis of endoscopic and radiological data demonstrated that bowel lesions of small size may rapidly enlarge and become highly symptomatic under ovarian stimulation. At immunohistochemistry, these infiltrating lesions displayed high populations of steroid receptors and a high proliferative index (Ki-67 activity), suggesting a strong dependence on circulating ovarian hormones and a potential for rapid growth under supraphysiological oestrogen concentrations. Clinicians should be aware of this rare but severe digestive complication of ovarian stimulation. The early diagnosis of such lesions may help the patients to avoid months of morbidity falsely attributed to ovarian stimulation side effects. Further experience is necessary to determine the optimal attitude when diagnosing a small and asymptomatic endometriotic bowel lesion before ovarian stimulation.     

Plaque rupture and consequent thromboses probably do not cause acute coronary syndromes

The objective of this communication is to provide evidence that the spasm of resistance vessel (S-RV) concept of ischemic heart disease (IHD) and other ischemic disorders provides a more consistent set of explanations for acute coronary syndromes than the accepted mechanism of plaque rupture and consequent thromboses. The concept avers that S-RV directly induces symptoms in the various syndromes of IHD, including acute coronary syndromes. The S-RV concept is considered to be an alternate paradigm to explain IHD, and interest only develops in such models when there is significant doubt about the validity of the accepted paradigm.This report is an update of a study reported in this Journal in 1999 and has 2 changes; evidence will be evaluated by formal verification/falsification (pass/fail) methods - the method used to evaluate paradigms, and this report focuses on the mechanism of acute coronary syndromes because of the importance of these syndromes.It is well accepted that acute coronary syndromes are due directly to plaque rupture/thromboses, and there is considerable evidence to support this obvious mechanism. In spite of the obviousness of this mechanism, the S-RV concept asserts that S-RV is a more rational mechanism to explain acute coronary syndromes. Consistent with this position, the results of the study favor the S-RV concept. The standard position was given 8 passes, 2 passes with associated possible limited failures, and 2 possible failures. In contrast, the S-RV concept was given 12 passes, and no failures. Hopefully, the results of this study, and other available information about the S-RV concept, will prompt interest in the concept - such as independent testing of its premises.     

Spontaneous ovarian hyperstimulation syndrome and deep vein thrombosis in pregnancy: case report.

This report describes a case of spontaneous ovarian hyperstimulation syndrome (OHSS) occurring in a pregnant woman carrying the factor V Leiden mutation. Even though prophylactic treatment for thrombo-embolism was adopted by administering low molecular weight heparin, the pregnancy was complicated by thromboses of the left subclavian, axillary, humeral and internal jugular veins during the second trimester of gestation. The pregnancy was managed conservatively and a healthy newborn was delivered at term. In order to avoid unnecessary laparotomy, we emphasize the importance of careful diagnosis in order to differentiate spontaneous OHSS from ovarian carcinoma, as well as the necessity to look for the presence of coagulation disorders in women affected by OHSS.     

A case of cerebral infarct in combined antiphospholipid antibody and ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome is a serious complication of ovulation induction and has a diverse clinical spectrum from edema to thromboembolism. Antiphospholipid antibody syndrome, one of the well known hypercoagulable states, can be also manifested as an arterial or venous thrombosis and recurrent spontaneous abortion. Sometimes a patient with antiphospholipid antibodies might not notice a miscarriage and seek for assisted reproduction treatment, which harbors a chance of developing ovarian hyperstimulation syndrome. If this happens, the ovarian hyperstimulation syndrome can exacerbate the thrombotic complication of underlying antiphospholipid antibody syndrome, resulting in a catastrophic vascular event. The authors experienced a case of middle cerebral artery infarct, which developed during ovarian hyperstimulation syndrome in a 33-yr-old woman with a previous history of fetal loss. An elevated titer of anticardiolipin antibodies was noticed and persisted thereafter. The authors suggest screening tests for the presence of antiphospholipid antibodies before controlled ovarian hyperstimulation.     

articles

Thromboembolic events are serious but rare complications followingovarian stimulation for in-vitro fertilization (IVF). We reporta case of severe ovarian hyperstimulation syndrome (OHSS), presentingin a second IVF cycle with a late complication of right internaljugular vein thrombosis despite mini-dose heparin prophylaxis.Thrombosis and thromboembolism as late complications of OHSShave been reported by others but not after prophylactic heparinization.The patient was successfully treated with heparin and the twinpregnancy is ongoing. In pregnant patients with severe OHSSconsideration should be given to treatment with low dose heparinthroughout the first trimester to prevent the serious complicationsof thrombosis and thromboembolism.     

Squamous cell carcinoma arising in endometriosis of the ovary.

Squamous cell carcinoma arising in ovarian endometriosis is extremely rare, but a case is reported in a 62 year old woman. If such an ovarian tumour is discovered evidence of teratoma, Brenner tumour, or endometriosis should be sought. Extensive sampling is mandatory as the developing tumour often overgrows the foci of endometriosis, thus obliterating evidence of its origin.     

Ovarian angioleiomyoma: a case report

Angioleiomyoma (ALM) is a rare and painful, benign neoplasm that is referred to an uncommon type of leiomyoma originating from smooth muscle cells of arterial and venous walls. ALM is very rarely found in the female genital organs such as uterus or ovary. Herein, we present the case of a huge primary ovarian ALM in a 35 year-old woman, clinically and radiologically mimicking an ovarian fibroma, which histologically has diffuse myxoid degeneration. This is the third case of ovarian ALM and the first case of ovarian ALM with diffuse degeneration reported in English literatures, to the best of our knowledge.     

Review of clinical course and treatment of ovarian hyperstimulation syndrome (OHSS)

The ovarian hyperstimulation syndrome (OHSS) is a rare iatrogenic complication of ovarian stimulation occurring during the luteal phase or during early pregnancy. This complication is unusual as it is not the consequence of a treatment which is vital or mandatory for the patient's health. Nevertheless, it can be accompanied by severe morbidity and may even be fatal. Data pertaining to the clinical course and consequences of OHSS in women and its treatment were searched using Medline, Current Contents and PubMed. To date, only a few studies have collected a large number of cases of OHSS. The clinical course of OHSS may involve, according to its severity and the occurrence of pregnancy, electrolytic imbalance, neurohormonal and haemodynamic changes, pulmonary manifestations, liver dysfunction, hypoglobulinaemia, febrile morbidity, thromboembolic phenomena, neurological manifestations and adnexal torsion. Treatment of the acute phase relies only on an empirical and symptomatic approach. The general approach will be adapted to the levels of severity. Specific approaches such as paracentesis, pleural puncture, surgical approach of OHSS and specific medication during OHSS were evaluated sporadically. More adequate treatment methods would require a better understanding of the underlying pathophysiological mechanisms, to promote an aetiological therapeutic approach. Properly conducted studies, including large numbers of patients are required in order to determine the best method of prevention and management.     

A case of autoimmune hemolytic anemia associated with an ovarian teratoma

Autoimmune hemolytic anemia associated with an ovarian teratoma is a very rare disease. However, treating teratoma is the only method to cure the hemolytic anemia, so it is necessary to include ovarian teratoma in the differential diagnosis of autoimmune hemolytic anemia. We report herein on a case of a young adult patient who had severe autoimmune hemolytic anemia that was induced by an ovarian teratoma. A 25-yr-old woman complained of general weakness and dizziness for 1 week. The hemoglobin level was 4.2 g/dL, and the direct and indirect antiglobulin tests were all positive. The abdominal computed tomography scan revealed a huge left ovarian mass, and this indicated a teratoma. She was refractory to corticosteroid therapy; however, after surgical resection of the ovarian mass, the hemoglobin level and the reticulocyte count were gradually normalized. The mass was well encapsulated and contained hair and teeth. She was diagnosed as having autoimmune hemolytic anemia associated with an ovarian teratoma. To the best of our knowledge, this is the first such a case to be reported in Korea.     

Primary urinary bladder adenosquamous carcinoma complicated with lower limb deep venous thromboses: a case report

Primary urinary bladder adenosquamous carcinoma is extremely rare and only a few cases have been reported in English literatures. Its biological behavior remains unclear. Here we reported a 60-year-old male patient with lower limb deep venous thromboses associated with primary urinary bladder adenosquamous carcinoma. A color ultrasonography showed right stock total venous thrombosis and right great saphenous vein thrombosis of lower limb. Contrast-enhanced computed tomography (CT) scan confirmed a 3.17 × 3.33 × 3.84 cm enhancing mass within the urinary bladder along the right lateral and posterior wall. Histopathological examination revealed adenosquamous carcinoma of urinary bladder, with extensive infiltration of the muscle layer. To the best of our knowledge, this is the first report of primary urinary bladder adenosquamous carcinoma complicated with deep venous thromboses in lower limb.