Akute fieberhafte Erkrankung mit Splenomegalie und Panzytopenie

We report on a 66-year-old patient originating from Greece and living in Germany with a prosthetic mitral valve because of a combined vitium following juvenile rheumatic fever. The patient fell ill with acute fever, splenomegaly, and pancytopenia. After unsuccessful antibiotic therapy because of presumed endocarditis or sepsis with unknown focus, visceral leishmaniasis was suspected because of recent travel to Greece. Subsequently, this diagnosis was confirmed by serology. Considering thrombocytopenia and concurrent anticoagulation after prosthetic mitral valve replacement, we avoided a bone marrow biopsy usually required for definite proof of leishmania infection. Instead, infection with Leishmania infantum was diagnosed by PCR of a peripheral blood sample. After treatment with liposomal amphotericin B the patient recovered fully.     

HIV-positiver Patient mit Panzytopenie und massiver Splenomegalie

A 30-year-old homosexual man presented with anemia and a several months history of recurrent fever, night sweats and weakness. His travel history included several stays in mediterranean countries during the recent years. Abdominal ultrasound showed massive splenomegaly, hepatomegaly and abdominal lymphadenopathy. A bone marrow aspirate revealed the presence of numerous Leishmania amastigotes, and bone marrow culture and polymerase chain reaction were also positive for Leishmania. In this case report epidemiological, immunological, diagnostic and therapeutic aspects of HIV-Leishmania coinfection are discussed with special emphasis on the impact of liposomal amphotericin B and highly active antiretroviral therapy on the treatment of HIV-leishmania-coinfection.     

Panzytopenie unter kombinierter Behandlung mit Azathioprin und Allopurinol

Azathioprine has been used in rheumatology for more than twenty years. Indications are collagen diseases with multiorgan involvement, where co-medications are frequently necessary. We describe a patient suffering from pancytopenia following a combination therapy of azathioprine and allopurinol because of lupus erythematodes and diabetic nephropathy with hyperuricemia.     

Lymphknotenschwellung in der Leiste

Zusammenfassung Eine 65 Jahre alte Patientin wurde mit unspezifischen Symptomen unter dem Verdacht auf ein malignes Lymphom in der rechten Leiste stationär aufgenommen. Histologisch stellte sich jedoch ein follikulärer dendritischer Retikulumzelltumor (FDC-Tumor) heraus. Da es für diese Art von Tumoren keine etablierte Therapie gibt, jedoch auch durchaus sehr aggressive Verläufe berichtet wurden, entschlossen wir uns nach der chirurgischen Tumorresektion zu einer zusätzlichen kombinierten Radio-Chemotherapie. Trotz dieser Maßnahmen kam es 16 Monate nach der Erstdiagnose zu einem neu aufgetretenen Prozess in der Lunge, welcher sich als Filia des follikulären dendritischen Retikulumzelltumors herausstellte. Dieser wurde reseziert. Nach wie vor ist unklar, welches die optimale Therapie für diese Tumoren ist.     

Rezidivierende hypokalz?mische Tetanien, generalisierte Anf?lle und geh?ufte bronchopulmonale Infekte bei einem 18-j?hrigen Patienten

Ein 18-j?hriger Patient wurde wegen eines generalisierten Anfalls station?r eingewiesen. In der Vorgeschichte traten seit der Kindheit rezidivierende hypokalz?mische Tetanien und insgesamt 3 generalisierte Anf?lle auf. Ebenfalls waren anamnestisch geh?ufte Atemwegsinfektionen eruierbar. Auff?llig waren pathologische Befunde des Kalziumhaushaltes mit einer Hypokalz?mie und einem Hypoparathyreoidismus sowie ein gest?rtes zellul?res Immunsystem mit einer selektiven Verminderung sowie einem Funktionsdefizit der T-Helferzellen. Unter der Verdachtsdiagnose eines kombinierten famili?ren Fehlbildungssyndroms der Nebenschilddrüsen und des Thymus wurde eine Fluoreszenz-in-situ-Hybridisierung durchgeführt, in der eine heterozygote Mikrodeletion im Bereich des Chromosoms 22q11 gesichert werden konnte.     

Indikationen und Ergebnisse der Kypho- und Vertebroplastie

The best currently available evidence based treatment reduces vertebral fracture risk but does not totally prevent osteoporotic and malignant follow-up fractures. Kyphoplasty and vertebroplasty are options of a causal treatment to reduce pain by internal stabilization of fractured vertebrae. The indication for these minimal invasive procedures requires an interdisciplinary discussion of the individual case to guarantee technical feasibility, to increase the likelihood that these procedures will indeed reduce pain and to embed these procedures into the long term therapeutic concept of every single patient. In addition to internal stabilization of a painfully fractured vertebra kyphoplasty also seeks to restore lost vertebral height which appears promising in acute vertebral fractures. Due to the procedure there are more cement leakages after vertebroplasty. Available controlled prospective studies demonstrate only for kyphoplasty a long-term benefit for the patient in terms of pain reduction, increased mobility and improved quality of life.     

Ionenkanäle und Nieren- und Hochdruckerkrankungen

Renal function is essentially determined by ion channels and ion transporters. Several outstanding discoveries have been made in the past 10 years in the field of research on ion channels. These insights have shed new light on ion channelopathies, i.e., disorders due to dysfunction of individual ion channels, and at the same time pinpointed the pathophysiological significance of ion channels for multifactorial diseases. This development also applies particularly to the area of nephrological research where studies on ion channels have not only led to progress in understanding physiological renal function but have also aided in elucidating the pathomechanisms of specific kidney diseases. Illustrated on the basis of five renal and hypertensive diseases, the manner in which ion channels can cause disease is described.     

Hepatitis-B- und -C-Reinfektion: Prophylaxe und Therapie

Orthotopic liver transplants (OLT) have fundamentally changed the treatment of terminal liver failure and the 10-year survival rates are now approximately 70%. The long-term results for patients with OLT due to cirrhosis caused by hepatitis B and C are mostly influenced by the danger of recurrence. This article gives a review of the current strategies and perspectives for the management of recurrent viral hepatitis. In addition monitoring before and after OLT will be discussed (routinely taken biopsies following transplantation even when transaminase levels do not increase, vaccination strategies, problems of resistance development and antiviral therapy, such as modifying therapy by lack of or non-persisting viral response and modification by mycophenolatmofetil), even before transplantation. According to our investigations the effective synergistic antiviral therapy is the most important factor for avoidance of transplant loss due to hepatitis-associated re-infection.     

Klinik und Diagnostik der Osteoporose und Osteomalazie

Osteoporosis and osteomalacia are systemic metabolic bone diseases characterized by an impaired composition, architecture, and quality of bone. In light of the demographic development and the recent use of sensitive tests, both diseases are increasingly diagnosed. Subjects at high risk include elderly, chronically hospitalized patients, and nursing home residents. Patients with gastrointestinal, rheumatologic and endocrine disorders are also at risk for the development of osteoporosis or osteomalacia. In this review, we will discuss practical aspects of the clinical presentation and the diagnosis of osteoporosis and osteomalacia.     

Ethik und Palliativmedizin in Intensiv- und Beatmungsmedizin

Ethics and palliative care have a growing impact at the present time. This is true not only in oncology but also increasingly more for intensive care medicine and home mechanical ventilation. In particular, the large number of invasively ventilated patients with weaning failure has led to a clear focus on this both life-sustaining and possibly undesired life-prolonging treatment. In addition to what is technically feasible, the perspectives of patients and their families are coming more into focus. Palliative care skills are needed to elicit and adequately react to the patient’s wishes, even if that leads to therapy withdrawal or withholding treatment. Changing the aim of the treatment is becoming increasingly more important. In the non-clinical area of home mechanical ventilation the establishment of palliative care structures for chronically critically ill patients mainly suffering from dyspnea are crucially needed. Early intervention in and counseling of patients with chronic diseases is helpful in avoiding futile long-term invasive mechanical ventilation.     

Physiotherapie und Bewegung bei Osteoporose und Folgeerkrankungen

Osteoporosis is defined by decreased bone strength and increased susceptibility to fracture. Fractures and their consequences are the clinical manifestation of osteoporosis. Acute and chronic pain, functional limitations including permanent impairment and the need for long-term care may be caused by osteoporotic fractures. The aim of osteoporosis treatment is to prevent fractures by bone strengthening. The aims of rehabilitation in patients with osteoporosis are to reduce pain, maximize the level of musculoskeletal function, particularly following fractures, decrease risk of falls and optimize quality of life and independence. Certain sports and exercises greatly promote skeletal development in children and adolescents and augment bone strength in adults. Physiotherapy and therapeutic exercise may relieve pain, increase musculoskeletal function and form an important part of fall management.     

Psoriasis und Psoriasisarthritis im Kindes- und Jugendalter

There are about 1.2–1.6 million psoriasis sufferers in Germany. In about a third of these, the disease manifests before the age of 20. A classic complication of psoriasis is psoriasis arthritis (PsA), which, from the latest figures, effects about 20% of all psoriasis patients. PsA also starts in childhood and is included under the term juvenile idiopathic arthritis (JIA). The expert round table discussion which took place in 2006 in Wörlitz elaborated the recommendations for the classification, comprehensive diagnostics and therapy of effected children and adolescents. As controlled studies are lacking, the treatment of PsA has been empirically based and carried out in analogy with the treatment of other forms of JIA. The use of methotrexate (MTX) shows a good success rate. In 2004, about a third of the patients found in the core documentation, including over 80% of children and adolescents undergoing a primary therapy, were treated with MTX, a quarter in combination with other medication. A total of 7% of all and 16% of those undergoing primary therapy were treated with etanercept, most (>80%) in combination with basis medication, usually MTX. Consensus opinion indicated that an early, and intensive local skin therapy should be applied in order to reduce inflammatory activity. If PsA is present, the early use of non-steroid anti-inflammatories as well as local therapy of the joints with the intra-articular application of glucocorticosteroids is recommended. The primary medication should preferentially be MTX, if necessary combined with other therapies. In cases of a severe, episodic progression as well as high inflammatory activity, systemic glucocorticosteroids should be considered. Further studies addressing both the clinical course of jPsA compared to the adult manifestation as well as optimal therapeutic procedures should be initiated in the near future.     

Diagnose und Therapie von Kopf- und Gesichtsschmerzen

The symptom headache is very frequent. Most frequently headache is the leading symptom of a primary headache syndrome such as migraine or tension-type headache. Sometimes it is caused by another disease. In everyday clinical practice it is important to diagnose and treat primary headaches properly. It is even more important not to miss a secondary headache, which is rare, but if misdiagnosed could conceal life-threatening conditions. This review provides an overview of the clinical picture, diagnostic procedures and treatment strategies of frequent headache syndromes such as migraine, tension-type headache, medication overuse headache, trigeminal autonomic cephalgias and trigeminal neuralgia. This is followed by a brief summary on symptomatic headache caused by non-neurological diseases as well as on diagnostic procedures and management of headache in the emergency situation.     

Vater und Sohn mit Muskelschmerzen und Kraftlosigkeit

Zusammenfassung Bei einem 48j?hrigen Patienten wurde ein periorbitales ?dem als Begleitsymptom einer r?ntgenologisch gesicherten schweren Sinusitis maxillaris et ethmoidalis interpretiert. Trotz Antibiose und kompletter Rückbildung des periorbitalen ?dems entwickelte der Patient ein schweres Krankheitsbild mit heftigsten disseminierten Myalgien, Kraftlosigkeit, Fieber und Eosinophilie im Blutbild. Eine Muskelbiopsie des M. deltoideus ergab zun?chst nur den Befund einer unspezifischen Myositis. Erst nach Untersuchung der Pr?parate in Serienschnitten zeigten sich Larven von Trichinella spiralis; somit war die Diagnose einer akuten Trichinose gesichert. Beim Sohn des Patienten bestanden ebenfalls Myalgien und Kraftlosigkeit, jedoch in deutlich milderer Form. Die Muskelbiopsie best?tigte auch bei ihm eine Trichinose. Retrospektiv war zu eruieren, da? Vater und Sohn ca. 2 Wochen vor Beginn ihrer Symptomatik unvollst?ndig durchgebratene Schweinefilets verzehrt hatten. Beide erhielten eine antihelminthische Therapie mit Mebendazol. W?hrend der Sohn beschwerdefrei ist, klagt der Vater auch 3 Jahre nach der Infektion immer noch über persistierende Myalgien und Kraftlosigkeit. Die Trichinose mu? unver?ndert in die Differentialdiagnose verschiedenster Erkrankungen einbezogen werden.