Pneumoperitoneum recurring concomitantly with asthmatic exacerbation

We report a patient with pneumoperitoneum that recurred concomitantly with asthmatic exacerbation. The patient was a 71-year-old man with a medical history of bronchial asthma. Chest X-rays obtained during asthmatic exacerbation showed intra-abdominal air beneath his diaphragm. Subsequently, a computed tomography scan of his chest confirmed mediastinal emphysema and intra-abdominal air beneath his diaphragm. The intra-abdominal air disappeared after his asthmatic exacerbation was relieved by treatment. The patient showed recurrent pneumoperitoneum concomitant with asthmatic exacerbation. The cause of his pneumoperitoneum was conjectured to be the movement of air from the mediastinum to the peritoneal cavity through the sternocostal triangle.     

A case of cat scratch disease with encephalopathy

We report an atypical case of cat scratch disease (CSD), accompanied with encephalopathy that is a rare complication of CSD. A 17-year old man consulted a doctor for his right axillary lymphadenopathy. The history of his contact with cats and the sign of lymphnode swelling and fever suggested a suspect of cat scratch disease. Administration of ampicillin improved his clinical symptoms, but a few days later he suddenly fell into coma after an episode of convulsion. The CT scan of the brain and laboratory tests showed no significant findings except the slightly elevated cell counts and concentration of protein in his cerebrospinal fluid. He was referred to our hospital on the next day for further examinations and treatments for his coma of unknown cause. The physical examination on admission revealed slight neck stiffening and hypertonicity of his right lower limb, but radiological and laboratory tests showed no significant findings. He gradually recovered from his coma without apparent sequelae in three weeks. Indirect fluorescence antibody titers for CSD in his serum showed a significant elevation to 1:160 of IgM and 1:512 of IgG, and his clinical features were compatible to these of CSD with complications of the central nervous system.     

Probing the dynamics of Münchausen's syndrome. Detailed analysis of a case

During a 10-week period we made in-depth observations of a patient with Münchausen's syndrome who had chronic myelogenous leukemia. Probably because he perceived that his life expectancy was brief, he disclosed his wanderings and regularly used methods of deception. These methods were usually based on his knowledge of pathophysiology. He exploited the desire of medical personnel to be helpful. Through interviews with the patient, family members, and previous physicians and review of 14 kg of medical records, we attempted to reconstruct his life to gain insight into his conscious and unconscious motivations. Most features of Münchausen's syndrome appear to be explainable by the patient's attempts to have control over his immediate environment.     

A case of bronchiolitis obliterans: auscultation leading to accurate diagnosis]

This is a case of a 31-year-old man with a history of common cold. He had been suffering from productive cough and dyspnea on exertion. Squawks were heard through auscultation, and hyperinflation was also observed in his chest radiograph. Bronchiolitis was first suspected as a result of HRCT and TBLB. He was then treated with CAM for six months, but his symptoms showed little improvement. So we evaluated his squawks objectively by phonopneumograph, performed video assisted thoracoscopic surgery and diagnosed his illness as constrictive bronchiolitis. Based on the examinations, PSL therapy was applied to his case, which contributed improving his condition remarkably. The significance of this case is that proper auscultation led to the accurate diagnosis.     

An idiopathic skin eruption resembling a butterfly rash in a septic patient with disseminated intravascular coagulation following bone marrow transplantation.

A 31-year-old man who underwent chemotherapy and bone marrow transplantation to treat acute myeloblastic leukemia was admitted to our department complaining of high fever and hypotension. His physical examination revealed warm shock state, eruptions resembling that seen in systemic lupus erythematosus on his face and cyanosis in his fingers. We diagnosed septic shock and idiopathic skin eruption on his face. Following treatment with blood transfusion, anticoagulant, antibiotics, respirator and continuous arteriovenous hemofiltration and dialysis, the patient's condition gradually improved. The eruptions on his face first observed at admission progressed with a worsening of his disseminated intravascular coagulation (DIC), and subsided with an improvement in his DIC. A biopsy of the eruption was taken and pathological findings of the eruption revealed multiple micro-fibrin depositions of the dermis. The skin necrosis in purpura fulminans often begins in the distal extremities. But our patient developed this uncommon skin eruption on his face. Patients with an idiopathic skin eruption resembling a butterfly rash in a septic patient should be considered to complicate DIC as in the present case.     

A case of atrial tachycardia sensitive to increased caffeine intake

A 33-year-old Japanese man with atrial tachycardia visited our clinic. He regularly consumed daily alcohol with cola, one cup of regular coffee, and a candy containing 0.7 mg of caffeine per tablet. After stopping his caffeine intake, his arrhythmia ameliorated. Since caffeine might be associated with his arrhythmia, a caffeine load test (equivalent to his daily intake of caffeine) was performed for 4 days. Atrial tachycardia time from a Holter recording was 44.2 minute/day before the caffeine load, compared with 215.2 minute/day during the caffeine load. Plasma caffeine concentration before and during caffeine loading was 3.1 mg/dL and 5.4 mg/dL, respectively. Caffeine use seemed to be an important factor for his atrial tachycardia, since his arrhythmia became worse during caffeine load testing and was ameliorated after the cessation of caffeine.     

Recurrent leg ulcers and arterial thrombosis in a 33-year-old homozygous variant of antithrombin

We report here a homozygous variant case of antithrombin (AT) associated with arterial thrombosis and recurrent leg ulcers. The deep vein thrombosis was recognized by the venogram of his pelvic veins. His leg ulcers were scattered around his left ankle and accompanied by lipodermatosclerosis, which was evident in venous insufficiency. The propositus had developed cerebral infarction 12 years prior to his leg ulcers. Coagulation study showed low heparin cofactor activity of his AT with a normal level of immunoreactive AT. Nucleotide sequence analysis of the exon 2 of his AT gene showed Arg47-Cys mutation, leading to the lack of affinity of AT for heparin. The propositus is a homozygote for this abnormality.     

Q Fever Presenting As Recurrent, Culture-negative Endocarditis with Aortic Prosthetic Valve Failure: A Case Report and Review of the Literature.

The present report describes a case of recurrent, culture-negative endocarditis presenting with aortic prosthetic valve dysfunction in a 62-year-old man who required four valve replacement surgeries. On each occasion, he presented with valve failure. Fever was only documented during his first presentation. Furthermore, no vegetations were detectable on his aortic valve at transesophageal echocardiography. On the occasion of his most recent presentation, a detailed history of animal exposure - including hunting and skinning deer, moose and other large animals with his bare hands - was the only clue to his diagnosis. Serum antibodies against Coxiella burnetii were strongly positive, and C burnetii DNA was detected by polymerase chain reaction from his resected aortic valve tissue. Q fever is a worldwide zoonotic infection with diverse reservoirs. This diagnosis should be considered when evaluating unexplained prosthetic valve dysfunction, particularly in the setting of animal exposure.     

Goya's Lost Hearing: A Twenty-First Century Perspective on Its Cause,Effects and Possible Treatment

Francisco Goya produced over 1,800 works during his long career, which earned him a reputation as one of the greatest artists of modern times. When he was 47, he developed a mysterious illness that destroyed his hearing, and for the next 35 years left him “deaf as a stump.” Of the diagnoses proposed to date, Susac syndrome is the one most consistent with what little we do know of the character of that illness. If he were alive today, given the severity of his hearing loss, Goya would be treated with a cochlear implant, which might restore his ability to communicate in spoken language, though probably not to the level preceding his 1793 illness.     

Ernest Kurtz: The Historian as Storyteller and Healer

Ernest Kurtz has made significant contributions to the addictions field through his classic treatise on the history of Alcoholics Anonymous, his writings on spirituality, his collaboration on studies of addiction recovery, and his prolonged service as teacher and mentor. This article profiles the life and thought of Ernest Kurtz, with a particular focus on the themes that permeate his written work and professional presentations.     

Rectal complications of inflammatory disease of the small and large bowel

Summary In general, rectal complications of inflammatory diseases of the small and large bowel offer the proctologist a large field of interest and usefulness. If he uses to the full his medical knowledge and his diagnostic acumen, as well as his well-timed surgical skill, his efforts should be rewarded with success.     

Nonocclusive coronary disease after chronic exposure to nitrates: Evidence for physiologic nitrate dependence

A 38-year-old man, exposed to nitroglycerin in his work as an explosives expert, developed non-occlusive ischemic heart disease after with-drawal of exposure to organic nitrates. Despite the severity of his symptoms and the documented spasm of his right coronary artery, his electrocardiogram was at all times normal, as were results of a wide panel of laboratory tests. Sublingual nitroglycerin ameliorated the symptoms which have decreased with time.     

THE EFFECTS OF BROMOCRIPTINE ON THE SEXUAL BEHAVIOUR OF HYPERPROLACTINAEMIC MAN: A CONTROLLED CASE STUDY

A 44-year old man presented with loss of sexual interest and erectile failure and together with his wife was treated successfully with sexual counselling. He was subsequently found to have been hyperprolactinaemic before and after sex therapy. Comparison of bromocriptine with placebo in two double blind studies showed a modest increase in sexual interest when his prolactin levels fell to normal. In this case, the principal effect of hyperprolactinaemia was on sexual interest. His main problems, erectile impotence and decline in sexual activity, resulted from his and his wife's psychological reaction to this modest hormonal effect. Hyperprolactinaemia appears to have a similar effect to testosterone deficiency in men.     

Treatment of Diabetic Gustatory Sweating with Topical Glycopyrrolate Cream

A 42-year-old insulin-dependent diabetic man presented with severe bilateral gustatory sweating associated with a deterioration in his glycaemic control. Conventional oral anti-muscarinic medication was contraindicated because of his cardiac insufficiency. Topical 0.5 % glycopyrrolate cream was tried and applied on alternate days to his face, which resulted in the complete cessation of his gustatory sweating without side-effects. Topical glycopyrrolate cream is an effective treatment of diabetic gustatory sweating without the adverse effects commonly found with oral anti-muscarinic medication.     

Unstable transpositions of his4 in yeast.

Unstable transpositions in yeast have been selected in which the his4C gene from chromosome III is inserted into chromosome XII. This event is associated with the generation of a recessive lethal mutation, resulting from the integration of his4C into an essential gene. Strains with these transpositions are viable as diploids or aneuploids for chromosome XII. The event that generates the transpositions does not lead reciprocally to a deletion on chromosome III, implying that synthesis of a new copy of his4C and subsequent transposition may have occurred. The his4C transpositions are unstable and give rise to C- segregants at a high frequency, as a result of either precise excision of the his4C gene (restoring function of the gene into which insertion had occurred) or chromosome loss.     

The gumma and the gonad: syphilitic orchitis, a rare presentation of testicular swelling

A 47-year-old man presented to his general practitioner (GP) with painful swelling of his right testis. He was diagnosed with epididymo-orchitis and a two-week course of erythromycin 500 mg four times daily was prescribed by his GP. Despite initial improvement, his symptoms persisted and he was referred to the local urology department. His sexual history revealed one lifetime sexual contact. A midstream urine sample grew non-lactose fermenting coliforms sensitive to ciprofloxacin and a two-week course of ciprofloxacin 500 mg two times daily was prescribed. Despite clinical improvement, a persistent suspicious abnormality on the ultrasound scan of his right testis prompted a right radical inguinal orchidectomy to exclude malignancy. Further diagnostic tests including histopathology excluded malignancy but confirmed tertiary syphilis. A comprehensive literature search revealed only 11 confirmed cases in the past 59 years.     

Impaired TCR signal transduction, but normal antigen presentation, in a patient with common variable immunodeficiency

Summary. We describe a 27-year-old white man with common variable immunodeficiency (CVID) who has two healthy histoidentical brothers and one IgA-deficient sister who shares one HLA haplotype with the patient. T cells from the patient with CVID showed an impaired response to recall antigens (tetanus toxoid, E. coli ), whereas his IgA-deficient sister and his two healthy histoidentical brothers responded normally. Cross-mixing experiments using isolated monocytes and T cells from the CVID patient and one histoidentical brother revealed that the patient's monocytes were fully functional in processing and presenting antigen to resting T cells of his brother, and provided normal accessory cell function for superantigen-induced activation of his brother's resting T cells. In contrast, the patient's T cells were unable to respond to antigen presented by the brother's monocytes and failed to respond with an increase in intracellular free Ca⁺⁺ to stimulation with superantigen, which is known to bind to the TCR Vβ-chain outside the antigen-binding groove. However, stimulation with a combination of PMA and IM, directly activating protein kinase C and increasing intracellular free Ca⁺⁺ by bypassing membrane receptors, induced normal Ca⁺⁺ flux. These data indicate that the patient with CVID has a defect in TCR-mediated signalling at the level of the T cells which is not present in his histoidentical healthy brothers or in his haploidentical IgA-deficient sister.