Video-mediastinoscopic resection of a long bronchial stump and reclosure of bronchial insufficiency after pneumonectomy

Bronchial stump insufficiency after pneumonectomy is a severe problem and there is still debate about the appropriate method (transthoracic or transsternal) for reclosure. Access through a sterile operative field for a successful redo-procedure seems to be important so an alternative to the open methods could be the video-mediastinoscopy as it allows approaching the bronchial stump via the mediastinum. Previously in 1996 Azorin performed the first mediastinoscopic reclosure by stapling an early insufficiency after left pneumonectomy. We report the first case to our knowledge of resection and reclosure in bronchial stump insufficiency via mediastinoscopy. An HIV-positive man presented with late bronchial stump insufficiency after left pneumonectomy for lung cancer. The cause was a long bronchial stump and there was no sign of tumour recurrence. Decision was made for a video-mediastinoscopy and resection and reclosure successfully performed by using an endostapler device. Postoperative bronchoscopy at six months revealed a well-healed stump and two years postoperatively the patient is doing well. The mediastinoscopic approach is a novel option in highly selected patients. It warrants minimal surgical trauma; however, one has to be prepared to convert to an open technique immediately.     

Saving the red baby: Successful allogeneic cord blood transplantation in Omenn syndrome

Haematopoietic stem cell transplantation is the treatment of choice for severe primary immunodeficiencies, but only has moderate prognosis in Omenn syndrome as it is complicated by highly activated Omenn T-cells resulting in delayed T-cell engraftment and a high rate of graft failure. A 6 1/2 months old patient with a previously unknown compound heterozygous defect within the RAG1 gene (R474C; R975W) underwent 8/10 HLA-matched cord blood transplantation after myeloablative conditioning. Immune reconstitution was impressive with T-, B- and NK-cells reaching the median of age-dependent reference values within twelve, four and two months respectively. With a continuous decrease of activated Omenn T-cells there was a steady increase of naive, probably thymus-derived T-cells. Polyclonal B-cell activation and hypergammaglobulinaemia disappeared with B-cell engraftment. This case emphasizes that, despite their naive status and HLA-barriers, cord blood T-cells were apparently able to achieve T-effector function resulting in the elimination of all activated Omenn T-cells.     

Skin: major target organ of allergic reactions to small molecular weight compounds

Skin is a major target organ for allergic reactions to small molecular weight compounds. Drug allergic reactions may be life-threatening such as in the case of anaphylactic reactions or bullous drug reactions and occur in about 5% of all hospitalized patients. Allergic contact dermatitis has an enormous influence on the social life of the patient because it is the most frequent reason for occupational skin diseases and the treatment and prevention of this disease cost approximately euro 3 billion per year in Germany. The different proposed pathophysiological pathways leading to a drug eruption are discussed in this paper. All major enzymes which are involved in the metabolism of xenobiotica were shown to be present in skin. Evidence supporting the role of metabolism in the development of drug allergy and allergic contact dermatitis is demonstrated in the example of sulphonamides and fragrances.     

Allergisches Kontaktekzem

Summary: An increased knowledge about proinflammatory and immunemodulating cytokines and other factors improved our understanding of the pathophysiology of the allergic contact dermatitis. This knowledge led to the development of several new in‐vitro‐techniques to assess the risk of sensitization by old and new chemical compounds.
In addition new options for an immunotherapy of this kind of sensitization were developed at least in the mouse model of delayed allergic reaction. In particular recent investigations of the sensitization to nickelsulfate, fragrances, and
p‐phenylendiamine are discussed, showing that individual risk factors (T‐cell‐receptor expression in the case of nickelsulfate, oxidation of eugenol and isoeugenol by polymorphically expressed cytochrome P450 or acetylation of p‐phenylenediamine by polymorphically expressed
N‐acetyltransferase) may exist, which allow a risk assesssment by the application of toxicogenomic‐techniques in future.     

Arzneimittelallergien

Cutaneous adverse drug reactions (ADR) are common and encompass a broad clinical spectrum. Since the skin acts as a signaling organ for ADR, the dermatologist plays a key role in their diagnosis. Only a minor part of cutaneous ADR are due to underlying allergic mechanisms. Among these, delayed-type reactions such as maculopapular exanthems and immediate-type reactions such as urticaria and angioedema predominate. Risk factors for the development of cutaneous allergic ADR may be related to the patient (e.g. certain HLA-types), the drug (e.g. its reactivity), and underlying conditions (e.g. viral infections). Antibiotics, non-steroidal anti-inflammatory agents and anticonvulsive medications are most often reported to be causally related.