Unklare Gewichtszunahme bei einer 41-jährigen Frau

A 41-year-old female was admitted to our clinic due to weight gain and facial edema. The patient also reported hair loss, amenorrhea and the formation of striae. The laboratory diagnostics ensured the diagnosis of Cushing’s syndrome. Unfortunately, the patient was among the 5–10% of patients in whom neither laboratory testing nor imaging revealed the source of the cortisol excess. Due to the dramatic decrease of her general condition, and the appearance of hypertension and diabetes mellitus we chose to refer the patient to bilateral minimally invasive adrenalectomy. The advantage of this therapeutic approach is, that it is a definitive treatment that provides immediate control of hypercortisolism. As disadvantage, the resultant permanent hypoadrenalism requires a lifelong glucocorticoid and mineralocorticoid replacement therapy. Furthermore, given that the problem was caused by occult pituitary microadenoma, Nelson’s syndrome has to be considered. As only one adrenal could be excised due to technical reasons, the underlying pathology is thus not solved. In spite of this, the patient’s general condition improved dramatically without need for replacement therapy. As the mortality of patients with persistent moderate hypercortisolism is increased 3,8- to 5 fold, mainly due to cardiovascular reasons, thorough surveillance for signs of recurrence is mandatory to be ready for quick intervention.     

Akutes Nierenversagen bei einer 70-jährigen Frau

The case of a 70-year-old female patient is presented, who was admitted to hospital because of deterioration of the general condition, loss of appetite, and pain in the right foot. Clinical signs were disorientation. a dry gangrene on the foot and laboratory parameters typical for renal failure and rhabdomyolysis. Magnetic resonance tomography revealed muscle edema and a biopsy of the gastrocnemius muscle revealed signs of rhabdomyolysis, an artery closed by thrombosis with evidence of cholesterol crystal gaps and foreign body giant cells. The pathogenesis, clinical course and therapy of rhabdomyolysis and cholesterol embolism syndrome (CES) are presented with special reference to renal complications. The main lesson from the presented case is that in cases of rhabdomyolysis CES should always be taken into consideration.     

Fieber, Unterschenkelschwellung, Husten und linksseitige Oberbauchschmerzen bei einer 19-jährigen Patientin

Persistent fever and unspecific general symptoms need a complete and thorough medical history and search for infection. We report on a case of brucellosis (Malta fever) with involvement of organs in a 19-year-old woman. She had previously lived on a farm in Portugal for several weeks, where she had consumed self-produced goat cheese. After a latency period of several months, unspecific general symptoms, fever, monarthritis, an increase of transaminases, and a newly diagnosed cardiac murmur became apparent. After the serologic and cultural proof of brucellosis, the patient underwent an antibiotic combination therapy. Within 20 days she was free of symptoms and could be released.     

Fieber, Husten und Dyspnoe bei einer nierentransplantierten 38-j?hrigen Patientin

This article reports on a 38-year-old kidney transplant patient who presented with fever, coughing and dypnea. The patient was immunosuppressed with mycophenolate and prednisone. Due to the suspicion of community acquired pneumonia antibiotic treatment was initiated and the patient was admitted to the intensive care unit. Despite antibiotic treatment the condition did not improve and in the subsequently performed bronchioalveolar lavage parainfluenza virus was diagnosed. Infections with respiratory viruses can be fatal in immunosuppressed patients. Human parainfluenza virus is the third most common pathogen of viral pneumonia. Molecular genetic detection methods allow fast and sensitive diagnosis of respiratory materials. As the treatment options are limited for these infections prophylactic measurements are important.     

Hirsutismus und Struma multinodosa bei einer 40-jährigen Uhrmacherin

This article presents the case of a female patient with acromegaly caused by ectopic production of growth hormone-releasing hormone (GHRH) secretion. In the presence of typical clinical features of acromegaly but a lack of evidence for a pituitary adenoma the results of somatostatin receptor scintigraphy were indicative of a typical carcinoid of the lungs as the cause of the ectopic secretion of GHRH and the stimulation of pituitary gland growth hormone secretion resulting in acromegaly. Finally, the patient underwent curative surgical treatment.     

Große multizystische Leberraumforderung bei einer 19-jährigen Frau

A 19-year-old woman presented with liver capsule pain and a liver lesion on sonography, which contained microvesicular cystic, necrotic and solid fibrotic formations typical for alveolar echinococcosis (AE). The diagnosis was confirmed by serology and histopathology. This parasitic infection which is endemic in Germany is feared because of its malignant growth. The increasing expansion of E. multilocularis in Europe will lead to a higher incidence of AE with an occurrence of cases outside classical endemic regions.     

Halsschmerzen und Weichteilemphysem bei einer 71-jährigen Patientin

A 71-year-old woman was admitted to our emergency department due to sore throat and swelling of the neck and face. She had a history of chronic obstructive pulmonary disease grade 4 based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Clinical examination revealed subcutaneous emphysema of the neck and face. CT scan of the thorax and abdomen showed air in the retroperitoneum, ascending through the mediastinum into the neck and face. Laparotomy confirmed the diagnosis of a retroperitoneal colon perforation due to colon diverticulitis. The colon was partially removed followed by a surgical debridement and Hartmann’s procedure. The postoperative course was without complications, the clinical symptoms resolved rapidly.     

Pharyngitis, Sturzsenkung und Hyperthyreose bei einer 71-jährigen Patientin

Zusammenfassung Eine 71-jährige Patientin leidet für mehrere Wochen an Halsschmerzen mit zunehmender äußerer, einseitig betonter Schwellung, Schluckbeschwerden, subfebrilen Temperaturen und einer allgemeinen Abgeschlagenheit ohne Zeichen einer klinisch manifesten Hyperthyreose, obwohl diese laborchemisch nachgewiesen werden kann. Hier zeigt sich weiterhin eine massive Beschleunigung der BSG. In Kombination mit der im Sonogramm inhomogenen echoarmen Schilddrüse und dem im Szintigramm verminderten Technetium-Uptake lässt sich die Diagnose einer akut/subakuten Thyreoiditis de Quervain stellen. Unter Therapie mit Prednison kommt es zur raschen Besserung, innerhalb von 2 Wochen entwickelt sich jedoch eine zunächst asymptomatische Hypothyreose, die eine Thyroxinsubstitution erforderlich macht. Wir diskutieren hier das Krankheitsbild der akut/subakuten Thyreoiditis de Quervain sowie die Differenzialdiagnose der entzündlichen Schilddrüsenerkrankungen.     

Kopfschmerzen und passagere Aphasie bei einer 35-jährigen Patientin

We describe the case of a 35-year-old female patient who suffered from fulminant tick-borne encephalitis and subsequently died. Remarkable about this case was that the woman was not living in an endemic area and that the disease occurred outside the usual season. Furthermore, this indicates that an increase in transmission of tick-borne encephalitis can be expected outside the classical endemic areas in higher altitudes, possibly as a consequence of climate changes.     

Hyperthyreose und akute Tonsillitis bei einer 23-jährigen Patientin

A 23-year-old woman with preexisting Graves’ disease who received thiamazole treatment presented with fever, dysphagia, hyperthyroidism and leukopenia. With suspicion of thyreotoxicosis accompanied by drug-induced agranulocytosis she was successfully managed by plasmapheresis, G?CSF administration and inhibition of periphereal conversion of thyroid hormones. In due course she underwent thyroidectomy. Thiamazole is frequently associated with drug-induced agranulocytosis. Long-term therapy with thiamazole requires critical evaluation and alternatives should be considered early. Plasmapheresis is an adequate treatment option to achieve normal thyroid hormonal status.     

Chylothorax bei einer 87-jährigen Patientin

An 87-year-old woman presented with a left-sided pleural effusion. The milky aspirate fulfilled the criteria of a chylothorax. Thorax computed tomography (CT) showed characteristic multiple cysts and consequently the rare diagnosis of post-menopausal pulmonary lymphangioleiomyomatosis was made. In the diagnostic work-up of pleural effusion the determination of triglycerides should be considered to confirm the diagnosis of chylothorax. In the presence of a chylothorax the differential diagnosis of lymphangioleiomyomatosis should be included even in advanced age.     

ST-Hebungsinfarkt bei einer 18-jährigen Patientin

Isolated left ventricular non-compaction cardiomyopathy (LVNC) is classified as a rare form of cardiomyopathy and is characterized by prominent trabeculae and deep recesses which appear as thickened myocardium with two layers. Thereby one layer dominates as non-compacted and one as compacted myocardium. Echocardiography is the clinical standard method for LVNC, while several diagnostic criteria exist. In challenging cases cardiac magnetic resonance imaging (MRI) is helpful due to its excellent native contrast between blood and myocardium. Most patients are symptomatic due to chronic heart failure and thromboembolic events and arrhythmia are often noticed during follow-up. No causal therapy is available, hence therapeutic approaches are limited to the management of heart failure and the prevention of thromboembolic events.     

Erstmanifestation einer Epilepsie bei einer 17-jährigen?

Zusammenfassung Epileptische Anf?lle geh?ren zu den h?ufigsten neurologischen Notf?llen im Kindes- und Jugendalter. Nach erstmaligem Auftreten eines Krampfanfalls ist eine rasche Kl?rung der zugrundeliegenden Ursache in Hinblick auf eine m?glichst frühe zielgerichtete Behandlung von gro?er Bedeutung. Als m?gliche Ursachen kommen Raumforderungen, Blutungen oder Traumen, infekti?se Erkrankungen des Zentralnervensystems, Stoffwechselerkrankungen, Elektrolytentgleisungen, Drogen- oder Alkoholabusus sowie Schlafentzug in Frage. In nur etwa 1% sind die Anf?lle Ausdruck einer Epilepsie.    Wir berichten den Fall einer bis dato immer gesund gewesenen 17-j?hrigen, die wegen eines erstmals aufgetretenen, generalisierten tonisch-klonischen Anfalls an unserer Abteilung aufgenommen wurde. In der Anamnese fanden sich seit zwei Tagen bestehende starke Kopfschmerzen, die erfolgreich analgetisch behandelt wurden. Im klinisch physikalischen Status war eine Adipositas auff?llig, im neurologischen Status, im Labor sowie in der craniellen Computertomographie zeigten sich keine pathologischen Befunde, sodass die Patientin prim?r unter der Verdachtsdiagnose einer idiopathischen Epilepsie mit Antiepileptika behandelt wurde. Unter Therapie kam es zu einer Gesichtsfeldeinschr?nkung und schlie?lich zu weiteren generalisierten Anf?llen. Eine erweiterte Diagnostik mit Lumbalpunktion, Bestimmung der Schilddrüsenhormone und einem Drogenscreening blieb ebenfalls ohne pathologischen Befund.    Schlie?lich lieferte eine gezielte Befragung und die Harnanalyse den entscheidenden Hinweis für die Ursache des Anfallgeschehens, welches nun doch als Symptom einer schweren Grunderkrankung zu werten war. Eingegangen: 20. Dezember 2000 Akzeptiert: 2. Januar 2001     

Visusverlust und akutes Nierenversagen bei einer 28-jährigen aktiven Reiterin

A 28-year old active sportswoman was admitted to hospital suffering from fever, menigeal irritation, acute myopia and progressive acute renal failure. Showing signs of polyserositis in combination with pulmonary granulomatous changes a collagenosis as well as an atypical pneumonia was excluded first. Due to the renal loss of function a renal biopsy was taken with the typical histological result of a hantavirus infection. This could be confirmed serologically in the following. With symptomatic treatment the patient had an uneventful complete recovery during the next four weeks.     

Progredientes Oberlappeninfiltrat bei einer 73-jährigen, beschwerdefreien Patientin

A 73-year old healthy woman presented for pacemaker replacement. Chest X-ray showed an right upper lobe consolidation. CT-scan and bronchoscopy with bronchoalveolar lavage could not yield a specific diagnosis. Due to progression of the consolidation in a CT scan after 10 weeks another bronchoscopy with transbronchial biopsy was performed and yielded bronchiolo-alveolar carcinoma. The patient underwent resection of the right upper lobe and middle lobe with curative intent.     

Septisches Krankheitsbild bei einer 33-jährigen Patientin

Zusammenfassung Eine 33-j?hrige Patientin wurde mit dem Bild eines septischen Schocks, disseminierter intravasaler Gerinnung und beginnendem Multiorganversagen eingeliefert. Das Auftreten der ersten Symptome w?hrend der Mens-truation und der Tampongebrauch lenkten den Verdacht auf ein Toxic Shock Syndrome. Das TSS ist ein septisches Krankheitsbild, das durch einen exotoxinproduzierenden Staphylococcus-aureus-Stamm verursacht wird. Zur Diagnose müssen 5 Kriterien erfüllt sein. Im Cervix-uteri-Abstrich gelingt der Nachweis von Staphylococcus aureus und Toxic-Shock-Syndrome-Toxin-1. Die Therapie umfasst die Gabe von Clindamycin sowie in schweren F?llen die Gabe von Immunglobulinen. Die Inzidenz des TSS liegt bei 1,0 auf 100.000 Frauen zwischen 15-44 Jahren, mit einer Letalit?t von 3,5%. Ungef?hr 60% der TSS-F?lle sind menstruationsassoziiert. Differenzialdiagnostisch ist v. a. an Infektionen mit Gruppe-A-Streptokokken zu denken.     

Chronischer Husten,atemabhängiger Thoraxschmerz und Nachtschweiß bei einer 45‑jährigen Raucherin

A 45-year-old woman presented with chronic cough, pleuritic chest pain, and night sweat. High-resolution computed tomography revealed multiple bilateral nodular lesions in a centrilobular distribution, primarily located in the upper and mid lung zones with relative sparing of the lung bases. No lymphadenopathy or pleural effusions were detected. Histological analysis confirmed the suspected diagnosis of pulmonary Langerhans cell histiocytosis. After smoking cessation the patient recovered completely.