Meningitis due to Listeria monocytogenes as a complication of infliximab therapy

A 41-year-old woman was admitted to the hospital with meningitis caused by Listeria monocytogenes. Because of her Crohn's disease she used prednisolone and azathioprine. Two weeks before presenting with meningitis, infliximab had been given as the other immunosuppressant drugs had no effect. This tumour necrosis factor alpha (TNF alpha) blocking agent is known to increase the risk of opportunistic infections. This is the first Dutch patient described with meningitis caused by L. monocytogenes after treatment with infliximab. She recovered after antibiotic therapy. When antibiotic treatment is chosen, the possibility of opportunistic infections in patients who use infliximab concurrently with other immunosuppressant drugs should be taken into account.     

Hypersensitivity Pneumonitis (extrinsic allergic alveolitis)

Farmer's lung was first described in 1932. We can define hypersensitivity pneumonitis as a pulmonary and systemic disease that is accompanied by dyspnoea and coughing; it is caused by an immunological type of inflammation of the alveolar walls and the terminal airways and it is secondary to the repeated inhalation of a variety of antigens by a susceptible host. It can be said that it is an underdiagnosed disease and only a high degree of clinical manifestations and a detailed history of exposure can lead to an early diagnosis and satisfactory treatment. A combination among clinical-radiological, functional, cytological or pathological findings leads in some cases to a diagnosis. Treatment is based on avoiding further exposure to the causal agent and in the more serious cases the administration of systemic corticoid treatment.     

Pneumothorax as a complication of recompression therapy for cerebral arterial gas embolism.

The danger from pneumothorax in patients who undergo compression chamber treatment for cerebral arterial gas embolism (CAGE) following pulmonary barotrauma is frequently emphasized. Two cases of CAGE treated by recompression after submarine escape tank training (SETT) accidents are described. Both were complicated by bilateral pneumothoraces but the first case, treated on an air table, required thoracentesis in the chamber, whereas the second case, treated on an oxygen table, escaped the need for in-chamber thoracentesis despite large pneumothoraces. Review of similar Royal Navy and United States Navy SETT accidents suggests that the danger from pneumothorax during recompression treatment of CAGE victims may be overstated. Modern management on oxygen-based therapeutic recompression tables may significantly reduce the risk. Thoracentesis while under pressure should be reserved for cases developing symptoms or signs of tension pneumothorax. Treatment options for these cases are discussed and a decision algorithm is proposed.     

Experience with cytostatic therapy of stomach cancer

The authors have been working on the cytostatic treatment of gastric cancer since 1982. The patients were divided into two groups. Group 1.: Patients who had been operated radically on gastric cancer. Group 2.: Patients who had advanced gastric cancer. The following cytostatic drugs were administrated: Cyclophosphamide, Vincristine, Ftorafur. The patients who had been operated on radically were given adjuvant cytostatic treatment for 3 months according to their own protocol. The patients advanced gastric cancer got life long systemic cytostatic treatment. Between 1982 and 1989, 36 histologically proven gastric carcinoma patients were treated. The effectiveness of the therapy was measured by the survival time from the beginning of the cytostatic treatment. The control group 67 patients consisted of radically or palliative operated patients of the surgical department of those who had not got chemotherapeutic treatment. According to the experiences of the authors, the survival time was prolonged considerably by cytostatic treatment in the group of palliative operated or inoperable patients.     

Deep vein thrombosis as a complication of megestrol acetate therapy among nursing home residents

OBJECTIVES: To describe a cluster of cases of proximal deep vein thrombosis among nursing home residents treated with megestrol acetate, to identify other risk factors for deep vein thrombosis development among these patients, and to alert physicians to this potential complication of megestrol acetate therapy. DESIGN: Retrospective review. SETTING: A 129-bed Maryland nursing home. PARTICIPANTS: Nineteen residents prescribed megestrol acetate between November 1997 July 1998, identified by computerized pharmacy records. MEASUREMENTS: Demographic data (including identification of known risk factors for deep vein thrombosis development) were collected along with information on the indications for megestrol acetate therapy and its duration, diagnostic studies related to detection of deep vein thrombosis and their results, and patient outcomes following diagnosis of deep vein thrombosis. RESULTS: Megestrol acetate was prescribed for 18 nutritionally at-risk patients and one with uterine cancer. Six (32%) patients developed deep vein thrombosis signs and symptoms, and all diagnoses were confirmed as proximal deep vein thromboses with Doppler studies. (No diagnosis of deep vein thrombosis were made among any nursing home patients not being treated with megestrol acetate during the observation period.) All patients diagnosed with deep vein thrombosis were hospitalized and anticoagulated, but none were diagnosed with pulmonary embolus or died. The length [median (range)] of megestrol acetate treatment was similar regardless of whether deep vein thrombosis developed [117 (57-244) versus 143 (2-294) days, respectively, P = 0.83]. Stratification by length of treatment in 50-day increments revealed that most patients who developed deep vein thrombosis did so after 50 days of treatment (P = 0.046). CONCLUSION: A high incidence of deep vein thrombosis was identified among nursing home residents treated with megestrol acetate, even among ambulatory individuals with no other known risk factors. Because the efficacy of megestrol acetate treatment in nursing home residents with weight loss is unproven, the risk of deep vein thrombosis must be considered when prescribing megestrol acetate, and its use to treat nutritionally at-risk nursing home residents should be limited.