Cardiovascular and metabolic manifestations of heat stroke and severe heat exhaustion.

We prospectively studied the clinical, biochemical (including creatine phosphokinase (CPK) isoenzymes) and electrocardiographic features of exertional heat stroke in 13 patients (group 1) and severe heat exhaustion in 14 patients (group 2). Despite initial presentations with severe hyperthermia, tachycardia and hypotension, only one patient with heat stroke had myocardial ischemia. The CPK isoenzymes were not indicative of myocardial damage in any patient. The patients with heat stroke were somewhat more dehydrated than those with heat exhaustion as measured by differences in serum creatinine, sodium and osmolality, and the former (group 1) had a significantly lower initial glucose level (P less than 0.05). Although significant differences in potassium were not observed in the pretreatment samples, at 12 hours the serum potassium was significantly lower in group 1 (P less than 0.05). This suggests that this group may have been more potassium-depleted at the time of heat stroke. Prompt recognition and vigorous therapy were successful in rapidly lowering high temperatures and in preventing serious complications.     

Occult dental infection as a cause of fever of obscure origin.

Three patients with prolonged unexplained fevers were ultimately found to have deep-seated dental infection. After initial examination failed to elicit symptoms or signs of dental infection, and extensive in-hospital evaluation was nonproductive, dental consultation with roentgenograms provided the diagnosis. All three patients underwent dental extractions with periapical or peridontal debridement; following a brief postoperative febrile period, all three responded with defervescence, without subsequent recurrence of fever. These cases emphasize the importance of periapical and peridontal infection as causes of fever of obscure origin. The pathogenesis, characteristics and bacteriology of periapical abscess are discussed.     

Pulmonary hypertension as a presentation of hepatocarcinoma. Report of a case and brief review of the literature

A case, unique in the literature, is reported in which a primary carcinoma of the liver presented a right-sided heart failure and pulmonary hypertension. The diagnosis of hepatocarcinoma was established by needle biopsy of the liver. Later, postmortem examination demonstrated that the pulmonary arterial tree was severely compromised by multiple tumor microemboli, despite the persistent lack of characteristic roentgenographic abnormality in our patient. In reviewing the literature, we found rare cases of occult renal cell carcinoma, choriocarcinoma and one of occult hepatocarcinoma, which presented as pulmonary embolism. These were diagnosed by pulmonary embolectomy, human chorionic gonadotrophin levels or autopsy, respectively. In another small group of reported cases of known carcinoma (gastric, breast, colonic) the patients had a clinical picture of "idiopathic" pulmonary hypertension or of pulmonary hypertension with pulmonary metastases. Pulmonary hypertension in these cases resulted from carcinomatous lymphangitis and/or tumor microembolization, as in our case. We report this case to emphasize the necessity of including occult carcinoma in the differential diagnosis of pulmonary hypertension and right ventricular failure.     

A case of lymphoproliferative disease presenting as juvenile rheumatoid arthritis. Diagnosis by synovial fluid examination

Lymphoproliferative disease can present as arthritis, most commonly mimicking acute rheumatic fever. The finding of arthritis rarely leads to the correct diagnosis, in fact, it frequently suggests inflammatory rheumatic diseases. We present a case closely resembling juvenile rheumatoid arthritis in which the diagnosis was made by demonstration of malignant cells In the synovial fluid at a time they were absent from the peripheral blood and initial bone marrow specimen. Closed synovial and bone biopsy specimens, the latter of an osteopenic area, revealed the infiltrative character of this disorder.     

Resting U wave inversion as a marker of stenosis of the left anterior descending coronary artery

Resting 12-lead electrocardiographic records from 849 patients who underwent coronary cineangiographic studies were reviewed for U wave negativity without knowledge of the clinical data or angiographic results. In order to evaluate U wave negativity as an independent electrocardiographic sign, patients with significant Q waves in the anterior leads were excluded from the final data analysis leaving 760 patients. Twenty-seven patients had U wave negativity in leads I, a VL or V₄ through V₆. For the study population, the prevalence of coronary artery disease was 64 percent (484 of 760); the prevalence of significant left anterior descending or left main coronary artery stenosis was 46 percent (350 of 760); and the prevalence of angiographic left ventricular dysfunction was 41 percent (309 of 754). Among 27 patients with resting U wave negativity the prevalence of coronary artery disease was 89 percent (24 of 27); the prevalence of left anterior descending or left main disease was 89 percent (24 of 27); and the prevalence of angiographic left ventricular dysfunction was 80 percent (20 of 25). Among patients selected for coronary cineangiographic study, U wave negativity was a significant predictor (p <0.001) of ?75 percent stenosis of the left anterior descending or left main coronary artery and of left ventricular dysfunction (p <0.001).     

Acute pancreatitis with hyperlipemia. Evidence for a persistent defect in lipid metabolism

Hyperlipemia has been recognized with increasing frequency in patients with acute pancreatitis. The significance of this association is unknown. Twenty-two such patients were electively readmitted to a metabolic ward for study of their lipid metabolism during a quiescent period. Persistent fasting hypertriglyceridemia was found in 16 and abnormal lipoprotein electrophoretic patterns in 17. In addition, response to a lipid load was abnormal; in 20 of the 22 patients triglyceride levels rose over 500 mg/100 ml, and in 10 over 1,000 mg/100 ml. It is concluded that the lipid abnormalities detected during the acute attack of pancreatitis were not secondary but persisted long after the patient had recovered. Such underlying lipid abnormalities may play an intermediary role in the pathogenesis of pancreatitis.