Spontaneous bacterial peritonitis following treatment for cervical carcinoma

Spontaneous bacterial peritonitis (SBP) is an acute bacterial infection usually associated with ascites and cirrhosis or is a complication of peritoneal dialysis. There are very few case reports of cancer patients who developed this disease. Furthermore, there have been no published case reports of successfully treated gynecological cancer patients who later developed SBP. We present a case involving a 41-year-old woman who was treated for cervical carcinoma in 1992. She underwent radical surgery and adjuvant chemoradiation therapy. Two years later, the patient presented with streptococcal group B cellulitis associated with left leg lymphedema. She recovered following antibiotic treatment but had recurrent episodes of streptococcal cellulitis in her leg over the past 10 years. In 2003, the patient was admitted to the hospital because of sepsis, acute renal failure, and SBP. She was treated and recovered following treatment. SBP is usually associated with cirrhosis. Although SBP is rarely seen in successfully treated gynecological cancer patients, oncologists should be aware of this clinical entity. Timely treatment is essential to maximize chances of survival.     

Endoscopic mucosal resection with a cap-fitted endoscope for early gastric carcinoma with focal submucosal invasion in a patient with decompensated liver cirrhosis.

Prognosis for patients with early gastric cancer who undergo gastric resection is far better than that for patients with advanced disease. However, patients with advanced liver cirrhosis may not be suitable for general anesthesia and major surgery. We used a less invasive endoscopic mucosal resection (EMR) with a cap-fitted endoscope to resect an early gastric cancer in a 58-year-old male with decompensated liver cirrhosis. Although postoperative pathology revealed that the tumor had focal invasion to the submucosa, the patient had an uneventful course and was well during 4 years' follow-up. This method may be effective for the treatment of early gastric cancer with focal submucosal invasion when patients are not suitable for major surgery.     

Liver cell adenoma with concomitant hepatocellular carcinoma: report of two cases.

Malignant transformation of liver cell adenoma and unequivocal hepatocellular carcinoma in resected liver cell adenomas are rare. We report two cases of liver cell adenoma with concomitant hepatocellular carcinoma. The first occurred in a 19-year-old male with an asymptomatic liver mass and was discovered incidentally. He had a history of nephrotic syndrome treated with oral prednisolone for 15 years. The second occurred in a 46-year-old female who was admitted due to right tubo-ovarian abscess. Computerized tomography scanning incidentally found a 10-cm liver mass in the right lobe. There was no history of oral contraceptive use. Both patients were negative for serum hepatitis B surface antigen and anti-hepatitis C virus antibody. Neither had cirrhosis. These two cases imply that malignant transformation of liver cell adenoma does occur, and that liver cell adenomas should be excised when malignant transformation is suspected.     

Abdominal nontuberculous mycobacterial infection in a university hospital in Taiwan from 1997 to 2003.

BACKGROUND/PURPOSE: Abdominal nontuberculous mycobacterial infection is a rare condition. Continuous ambulatory peritoneal dialysis (CAPD)-associated peritonitis is the most common manifestation of infection due to nontuberculous mycobacteria (NTM). There are limited data on the clinical manifestations of nontuberculous mycobacterial infection. This study investigated the diagnostic features, clinical presentation, mycobacteriology, treatment and outcome of all abdominal NTM infections treated over a 7-year period at a major teaching hospital in Taiwan. METHODS: The medical records of all patients with a diagnosis of abdominal NTM infection from January 1997 through to December 2003 were retrospectively reviewed. RESULTS: All 11 patients with abdominal NTM infections identified during the 7-year period were included. Among these patients, six were male and five were female, with a mean age of 64.5 years. The disease manifested as peritonitis (9 patients, 82%), splenic abscess (1, 9%), or perirenal abscess (1, 9%). Most patients (73%) had underlying malignancy, most often hepatoma (45%). Immunocompromised status (liver cirrhosis, malignancy, acquired immunodeficiency syndrome) was noted in 10 patients (91%). None of our patients who developed NTM peritonitis had received CAPD. The peritoneal fluid appearance varied considerably, with no particular predominance of clear, turbid, bloody, or chylous findings. Rapidly growing mycobacteria were the major etiology (46%) of abdominal NTM infection, and Mycobacterium abscessus played a major role (27%). Overall, eight patients died, and only one patient survived longer than 1 year. Seven patients (64%) died before diagnosis. CONCLUSION: Abdominal NTM infection is frequently overlooked because of its rarity and nonspecific symptoms, with consequent delays in diagnosis and treatment. In immunocompromised patients with ascites from any cause (liver cirrhosis, malignant ascites, etc.), NTM peritonitis should be considered early in the differential diagnosis of symptoms including fever, abdominal pain and weight loss. The poor prognosis of abdominal NTM infection appears to be related to the severity of underlying conditions, most often malignancy.     

Pulmonary cryptococcosis: manifestations in the era of acquired immunodeficiency syndrome.

To examine the clinical manifestations, treatment, and outcome of pulmonary cryptococcosis, we reviewed the medical records of all patients treated for Cryptococcus neoformans infection at our hospital from January 1988 through September 1998. Sixty-three patients were included in the analysis, 10 (16%) of whom had acquired immunodeficiency syndrome (AIDS). Thirty-four of the 53 non-AIDS patients, including 19 men and 15 women had pulmonary cryptococcosis, including 31 with isolated pulmonary cryptococcosis and three with disseminated disease. Of the 10 AIDS patients, seven presented with disseminated cryptococcosis (including one patient with lung involvement) and one had isolated cryptococcal lung disease. The age (mean +/- SD) of the 34 non-AIDS patients with pulmonary cryptococcosis was 52.1 +/- 15.2 years (range, 19-75 yr). Cough was the most common symptom (58%). Diabetes mellitus (12%) and malignancy (12%) were two major underlying diseases. Nodules and masses were the predominant manifestations of pulmonary cryptococcosis in non-AIDS patients (79%). The most frequently used diagnostic modality for pulmonary cryptococcosis was biopsy with/without aspiration under ultrasound guidance (56%). Antifungal therapy (20/34) was the most common treatment for non-AIDS patients, followed by surgical resections with antifungal therapy (9), surgical resections alone (3), and no treatment (2). Antifungal therapy and/or resection yielded excellent outcomes (total recovery, 27; improvement, 4). Of the 18 patients who underwent lumbar puncture, only two had positive cerebrospinal fluid (CSF) cultures for C. neoformans, both had symptoms and signs of increased intracranial pressure. There was no clinical evidence of meningitis in the other 32 patients. Our findings indicate that pulmonary cryptococcosis in non-AIDS patients tends to be a more localized and benign process than in AIDS patients. Ultrasound-guided lung biopsy or aspiration is an effective tool for diagnosis. CSF examination may not be mandatory as an initial routine procedure for pulmonary cryptococcosis in non-AIDS patients.     

Childhood mixed connective tissue disease.

Two girls with mixed connective tissue disease (MCTD) were treated in our hospital in the past 5 years. Patient 1, a 10-year-old girl presenting with migratory arthralgia, had an initial diagnosis of juvenile rheumatoid arthritis. Muscle weakness with elevated levels of creatine kinase and liver enzymes, sclerodactyly, Raynaud's phenomenon and heliotrope sign developed subsequently in the following 3 years. Patient 2, a 13-year-old girl, had been treated for suspected systemic lupus erythematosus since 9 years of age. She presented with lymphadenopathy, arthralgia, pericardial effusion, and paralytic ileus. The symptoms waxed and waned. Sclerodactyly, Raynaud's phenomenon, proteinuria, and hypertension were also noted. Both patients had high serum titers of antinuclear antibody (speckled pattern, 1:5120) and were seropositive for antiribonuclear protein antibody. Intravenous immunoglobulin, prednisolone, cyclosporine A, and nonsteroidal anti-inflammatory drugs (NSAIDs) were given to patient 1. Patient 2 received cyclosporine A, prednisolone, and methylprednisolone pulse therapy. The disease has been well controlled for 2 years by low-dose immunosuppressants and NSAIDs. MCTD is a rare juvenile rheumatic disease: early identification and appropriate treatment can improve the disease outcome.     

Meningeal involvement in B-cell chronic lymphocytic leukemia: report of two cases.

Symptomatic central nervous system (CNS) involvement in chronic lymphocytic leukemia (CLL) or its variants is rare. We report two cases of CLL with leptomeningeal involvement. Patient one was an 81-year-old male who had CLL stage C (IV) at diagnosis and developed meningeal disease 29 months later. Patient 2 was a 42-year-old male with a diagnosis of CLL stage A (II) that evolved into mixed-cell CLL/prolymphocytic leukemia (PLL) 1.5 years later, with leptomeningeal infiltration of prolymphocytes developing 26 months after initial diagnosis. Meningeal leukemia was diagnosed by cerebrospinal fluid examination, with flow cytometry showing the same immunophenotypic findings of lambda-light chain restriction as the lymphocytes in bone marrow in one patient, and with morphologic characteristics exhibiting exclusively prolymphocytes in the other patient. The CNS disease of both patients responded effectively to intrathecal chemotherapy and cranial irradiation. However, both patients died of infection, a major cause of morbidity and mortality in patients with CLL. The clinicopathologic features of these two patients indicate that, despite the rarity of CNS involvement in CLL patients, any neurologic manifestation in CLL patients should arouse suspicion of meningeal leukemia and patients should be examined and managed accordingly.     

Cryptococcal infection presenting with lumbosacral polyradiculopathy: report of a case.

Cryptococcal infection presenting primarily as lumbosacral polyradiculopathy is rare. We report on a 57-year-old man with lumbosacral polyradiculopathy, and in which a culture from the cerebrospinal fluid grew Cryptococcus neoformans. A serum cryptococcal antigen study showed a positive reaction. Biopsy specimens from the spinal nerve rootlet showed evidence of arachnoiditis and direct involvement of the nerve root by Cryptococcus neoformans. It is important to remember that localized lumbosacral polyradiculopathy can be the sole initial manifestation of cryptococcosis.     

Transplacental transmission of Cryptococcus neoformans to an HIV-exposed premature neonate

Cryptococcosis during pregnancy is well documented, but transmission of infection to the fetus is rare. We describe a premature neonate born to a mother with congenitally acquired human immunodeficiency virus (HIV) and active cryptococcosis. Histological examination of the placenta revealed Cryptococcus neoformans within the maternal intervillous space with focal invasion into the chorionic villi. A positive serum cryptococcal antigen (1:2) was detected on days 1 and 5 of life. The neonate had no evidence of central nervous system disease and was treated with fluconazole with resolution of antigenemia. This case highlights both the potential for transplacental transmission of C. neoformans infection and the complexities of caring for pregnant mothers who themselves are congenitally infected with HIV.     

Cellulitis and bacteremia caused by Bergeyella zoohelcum.

Bergeyella zoohelcum is a rod-shaped, aerobic, Gram-negative, non-motile and non-saccharolytic bacterium. It is frequently isolated from the upper respiratory tract of dogs, cats and other mammals. Clinically, B. zoohelcum has been known to cause cellulitis, leg abscess, tenosynovitis, septicemia, pneumonia and meningitis, and is associated with animal bites. In addition, food-borne transmission was considered in a recent case report. We report a 73-year-old man with liver cirrhosis who had no history of dog bite but had dog exposure, who developed cellulitis of the left lower leg and B. zoohelcum was isolated from blood culture. This patient, without evidence of polymicrobial infection, was treated with cefazolin and gentamicin with a good outcome. B. zoohelcum is a zoonotic pathogen that may cause bacteremia in patients with underlying disease such as liver cirrhosis; it can be treated with a beta-lactam or quinolone.     

Successful pregnancy after D-penicillamine therapy in a patient with Wilson's disease.

Infertility and amenorrhea are reported in most cases of Wilson's disease. In this report, we describe a case of Wilson's disease with pancytopenia and liver cirrhosis for over 4 years, without any specific treatment. After 2 years of D-penicillamine therapy, the patient became pregnant and delivered a liver mature female baby with a body weight of 2,800 g. Both before the pregnancy and after delivery, brainstem auditory evoked potential studies showed similar bilaterally abnormal prolongation in the III-V and I-V intervals. In visual evoked potentials, the P 100 latency was delayed bilaterally. Although serial evoked potential studies failed to show any improvement, a successful pregnancy was proven to be possible in a patient with Wilson's disease who had received regular D-penicillamine treatment.     

Primary hepatic pregnancy

A case of primary hepatic pregnancy in a 31-year-old woman is reported. She underwent laparotomy due to abdominal symptoms suggesting peritonitis. A 2 x 2 cm large bleeding lesion was found on the upper side of the right lobe of the liver. Microscopic examination of the excised lesion showed chorionic villi and trophoblast cells. The patient made an uneventful recovery.     

Successful treatment of intractable hemothorax with recombinant factor VIIa in a nonhemophilic patient.

Recombinant factor VIIa (rFVIIa) was developed for the treatment of bleeding in hemophilic patients with inhibitors. It has also been used to stop bleeding in nonhemophilic patients who fail to respond to conventional treatment. We report a case of catastrophic hemothorax in which bleeding was stopped by administration of rFVIIa. A 68-year-old woman with chronic hepatitis C-related liver cirrhosis was admitted due to pneumonia and parapneumonic effusion. The patient developed hemothorax and hypovolemic shock after thoracentesis. Conventional therapies including tube thoracostomy and transarterial embolization failed to stop the life-threatening bleeding. The bleeding stopped after administration of rFVIIa 100 microg/kg/BW at 2-hour intervals for a total of two doses on the 3rd day of hospitalization. Despite intensive care, however, the patient died due to nosocomial infection and multiple organ failure on the 12th day of hospitalization. Hemothorax in a nonhemophilic patient can be successfully treated with rFVIIa.     

Peritonitis caused by Chryseobacterium meningosepticum in a patient undergoing continuous ambulatory peritoneal dialysis.

Chryseobacterium meningosepticum is rarely encountered as a pathogen causing peritonitis in adults. A 54-year-old woman who underwent continuous ambulatory peritoneal dialysis for 8 years developed peritonitis due to C. meningosepticum. Although she received intravenous antibiotics with good in vitro activity against the organism, the fever and signs of peritonitis persisted. The Tenckhoff catheter was finally removed on the 25th day of hospitalization and the fever subsided. Four isolates of C. meningosepticum recovered from 4 ascites samples drawn on the third, 13th, 18th, and 23rd hospitalization days had identical antibiograms and random amplified DNA polymorphism patterns generated by an arbitrarily primed polymerase chain reaction. Early removal of Tenckhoff catheter and appropriate antimicrobial therapy are crucial to the successful treatment of peritonitis due to C. meningosepticum.     

The myofibroblastic inflammatory tumours: A fortuitous association or an unknown postpartum complication

The inflammatory myofibroblastic tumour has clinical, biological or histological features sometimes misleading with a septic condition. Presenting symptoms are variable and arising circumstances remain obscure. We report three cases occurring in a postpartum context. The first patient, a 28-year-old female, had left psoitis with a sepsis the first day postpartum in relation with an inflammatory myofibroblastic tumour of the meso-ovary. The second patient, a 40-year-old woman, had a hepatic inflammatory myofibroblastic tumour revealed by a ruptured sub-capsular haematoma of the liver in the forth day postpartum. The third patient, a 32-year-old woman, had a pulmonary inflammatory myofibroblastic tumour, diagnosed 5 months after a delivery and which recurred 10 years after surgical treatment. These cases illustrate the difficulty to diagnose inflammatory myofibroblastic tumour, particularly in postpartum.     

妊娠期急性阑尾炎66例诊疗分析

目的：探讨妊娠期急性阑尾炎的诊断及治疗方法。方法：回顾性分析66例妊娠期急性阑尾炎的临床资料,29例患者不同意手术而接受保守治疗,其中12例感染不能控制,改手术治疗,另37例入院急诊外科手术治疗。结果：66例患者顺利出院;8例患者出院后要求行人工流产术;2例患者术后流产,1例患者术后10 d早产;无胎儿宫内窘迫、死胎及妊娠妇女死亡等严重并发症。结论：妊娠期急性阑尾炎的及时诊断和手术治疗,是保证临床效果及母婴安全的重要手段。但对感染症状轻、局部腹膜炎不明显、不同意手术的患者,可先予保守治疗,密切观察,治疗效果不明显时应立即手术。     

Successful pregnancy in a woman with secondary biliary cirrhosis with portal hypertension from recurrent pyogenic cholangitis. A case report.

BACKGROUND: Pregnancy in women with secondary biliary cirrhosis due to recurrent pyogenic cholangitis is extremely rare. Little information is available on the effect of pregnancy on the disease and vice versa. CASE: A patient who had secondary biliary cirrhosis due to recurrent pyogenic cholangitis complicated by splenomegaly and portal hypertension had a successful pregnancy. Although she had a history of esophageal variceal bleeding before this pregnancy, there was no such bleeding during pregnancy. She had an uneventful antenatal course except that her liver enzyme level fluctuated slightly. The serum bilirubin level increased during the third trimester of pregnancy but returned to the prepregnant level after delivery. CONCLUSION: Termination of pregnancy may not be the only option for management. The management protocol for patients with primary biliary cirrhosis complicating pregnancy, which includes regular fetal surveillance and monitoring of maternal liver function, should be considered for pregnant women with secondary biliary cirrhosis.     

Sigmoid volvulus in children: report of two cases.

Volvulus of the sigmoid colon is rare in children. An early, accurate diagnosis can avoid unnecessary surgery and reduce the risk of complications. This condition is mainly due to a redundant sigmoid colon with a narrow mesosigmoid attachment. We describe two cases of sigmoid volvulus, which showed different clinical severities and were treated with different methods. Patient 1, a 9-year-old boy, presented with acute abdominal pain and vomiting. Patient 2, an 11-year-old boy, presented with abdominal pain, abdominal distention, and bloody mucoid stool. Plain abdominal radiographs revealed a distended colonic loop extending upward from the pelvis in patient 1 and a typical "coffee bean" sign in patient 2. Barium enema examination was used to confirm the diagnosis in both cases. The volvulus was reduced by insertion of a rectal tube in patient 1 and surgically in patient 2. Sigmoid colon volvulus should be included in the differential diagnosis of childhood abdominal pain or distention. This report suggests that nonsurgical reduction should be attempted first for uncompromised sigmoid volvulus in children, unless bowel ischemia or perforation develops.     

Lymphokinetic monitoring of a liver transplant recipient treated with OKT3.

Orthotopic liver transplantation was performed on a 48-year-old female patient with end-stage liver disease due to primary biliary cirrhosis. A course of OKT3 (5 mg/kg intravenously for 14 days) was given as immunosuppressive therapy. Lymphocyte population, T lymphocyte subsets and the lymphokine level in the peripheral blood were serially measured. Total T cells disappeared in the peripheral circulation within 10 minutes after an injection of OKT3. Helper T cells and suppressor T cells were also suppressed during the course of treatment. The ratio of T4/T8 declined from 2.5 to around 1.3. The serum interleukin-2 and the interleukin-2 receptor did not change markedly during treatment. The serum neopterin level increased after discontinuation of OKT3. The anti-mouse OKT3 antibody increased after the ninth day of OKT3 treatment. OKT3 showed potent T cell suppressive activity.