An aggressive and lethal course of Churg–Strauss syndrome with alveolar hemorrhage,intestinal perforation,cardiac failure and peripheral neuropathy

Churg–Strauss syndrome (CSS) is a rare type of necrotizing vasculitis affecting small to medium-sized vessels typically characterized by asthma, lung infiltrates, necrotizing granulomas and hypereosinophilia. Herein, we describe a case of CSS presenting severe and aggressive course. A 35-year-old male patient with weight loss, dyspepsia, dyspnea and hemoptysis was admitted. The laboratory analyses indicated a remarkable eosinophilia, elevated levels of serum total IgE and positive cANCA. Thorax CT findings were suggestive of alveolar hemorrhage. Bronchoalveolar lavage revealed alveolar hemorrhage with eosinophilia and transbronchial lung biopsy showed eosinophilic vasculitis. Cardiac enzymes were increased and murmurs were audible revealing cardiomyopathy proven by echocardiography. Pulse cyclophosphamide and methyl prednisolone was immediately started. On the 21st day, intestinal perforation developed and urgent surgery was performed. During a follow-up, although a radiological improvement was observed in the chest X-ray, cardiac failure, peripheral neuropathy and skin lesions developed and high-dose intravenous immunoglobulin and anti-TNF therapy (adalimumab) were applied. Despite the therapy, he died from heart failure and septicemia at 68th day of therapy.     

Acute massıve pulmonary embolism assocıated wıth olanzapıne

Treatment with low-potency anti-psychotic agents is an important risk factor in the development of pulmonary embolism (PE). We report a case of 74 years old female patient receiving olanzapine for psychotic depression admitted to the emergency service with the complaints of chest pain and shortness of breath. She had tachypnea, hypotension and tachycardia. Arterial blood gas analysis showed hypoxemia-hypocapnia and D-dimer level was high. Computed tomographic pulmonary angiography (CTPA) demonstrated pulmonary embolism in both main pulmonary arteries, through lobar and segmental branches. Tissue plasminogen activator (t-PA) was administered in intensive care unit. As the only possible risk factor for PE was olanzapine, olanzapine treatment was terminated with pyschiatry consultation. During the 12-month follow-up of the patient; malignancy was not observed. Diagnosis and prevention of PE are the important goals to reduce morbidity and mortality in subjects receiving olanzapine.     

Noninvasive central venous pressure measurement by controlled compression sonography at the forearm.

OBJECTIVES: We sought to validate a new noninvasive technique to determine central venous pressure (CVP) using high-resolution compression sonography. BACKGROUND: Information concerning CVP is crucial in clinical situations, including cardiac failure, volume overload, and sepsis. The measurement of CVP, however, requires puncture of a vein with attendant risk of complication. METHODS: After a proof-of-concept study in healthy subjects, a prospective blinded evaluation was performed comparing CVP measurement using a central venous catheter with measurement using compression sonography in critically ill (intensive care unit) patients. RESULTS: In healthy subjects with experimentally induced venous hypertension with a wide range of pressure values, a strong correlation (r = 0.95; p < 0.001) between noninvasive and invasive peripheral venous pressure at the forearm was shown. High interobserver agreement with an intraclass correlation coefficient of 0.988 shows excellent reliability of the system. Noninvasive peripheral venous pressure measurement at the forearm showed a good correlation with CVP in 50 intensive care unit patients with the forearm positioned both below heart level (r = 0.84; p < 0.001) and at heart level (r = 0.85; p < 0.001). The mean difference between invasive and noninvasive measurement was negligible (-0.1 +/- 3.5 cm H2O and -0.7 +/- 3.4 cm H2O, respectively). CONCLUSIONS: Controlled-compression sonography is a valuable tool for measuring venous pressure in peripheral veins and allows reliable indirect assessment of CVP without intravenous catheterization.     

Reactive oxygen species and chemokines： Are they elevated in the esophageal mucosa of children with gastroesophageal reflux disease？

AIM： To determine the role of inflammatory cytokines and reactive oxygen species （ROS） in childhood reflux esophagitis. METHODS： A total of 59 subjects who had complaints suggesting GERD underwent esophagogastroduoden oscopy. Endoscopic and histopathologic diagnosis of reflux esophagitis was established by Savary-Miller and Vandenplas grading systems, respectively. Esophageal biopsy specimens were taken from the esophagus 20% proximal above the esophagogastric junction for conventional histopathological examination and the measurements of ROS and cytokine levels. ROS were measured by chemiluminescence, whereas IL-8 and MCP-1 levels were determined with quantitative immunometric ELISA on esophageal tissue. Esophageal tissue ROS, IL-8 and MCP-1 levels were compared among groups with and without endoscopic/histo- pathologic esophagitis. RESULTS： Of 59 patients 28 （47.5%） had normal esophagus whereas 31 （52.5%） had endoscopic esophagitis. In histopathological evaluation, almost 73% of the cases had mild and 6.8% had moderate degree of esophagitis. When ROS and chemokine levels were compared among groups with and without endoscopic esophagitis, statistical difference could not be found between patients with and without esophagitis. Although the levels of ROS, IL-8 and MCP-1 were found to be higher in the group with histopathological reflux esophagitis, this difference was not statistically significant. CONCLUSION： These results suggest that the grade of esophagitis is usually mild or moderate during childhood and factors apart from ROS, IL-8 and MCP-1 may be involved in the pathogenesis of reflux esophagitis in children.     

A Chryseobacterium meningosepticum outbreak observed in 3 clusters involving both neonatal and non-neonatal pediatric patients

Three clusters of Chryseobacterium meningosepticum infections in a tertiary health center in July 2006 and January 2007 involving 8 newborns and 5 older children were investigated. The index patient was from the neonatal intensive care unit, and the older patients were from other pediatric wards. Cultures were obtained from the environment and from health care workers' hands as part of an outbreak investigation. C meningosepticum was isolated from hand cultures obtained from a senior resident and from environmental cultures obtained from powdered infant formula, an electrical button, a computer keyboard, phone, a doorknob, and an Ambu bag. Antibiogram typing and enterobacterial repetitive intergenic consensus sequence polymerase chain reaction indicated that all of the isolates were epidemiologically related. Nine patients improved on antimicrobial treatment, and 4 premature infants died after the infection. C meningosepticum is a well-known etiologic agent for nosocomial infections involving newborns and immunocompromised patients. Wet and dry environmental surfaces and equipment may act as a source or play a role in disseminating the microorganism. Outbreaks may be controlled with strong emphasis on infection control measures.     

Can possible toxic effect of ultraviolet-A after corneal cross-linking be prevented? In vitro transmittance study of contact lenses at 370 nm wavelength

Context: Corneal collagen cross linking (CCL) with ultraviolet A (UVA) has been proposed as a treatment for the progression of corneal ectasia associated with keratoconus and post-laser-assisted in situ keratomileusis (LASIK) ectasia. Despite the reports about safety of procedure, we consider that UVA of sunlight can effect riboflavin saturated and de-epitelizated cornea early after CCL.

Objectives: To evaluate the UVA blockage capability of 11 different silicone hydrogel contact lenses which are widely used after CCL treatment.

Methods: Eleven different silicone hydrogel and daily disposable contact lenses were evaluated. The UVA light at 365?nm wavelength for UVA source and UV light meter to measure UVA radiation were used. 3, 9 and 18?mW/cm² power of UV radiance was applied centrally to the each type of contact lenses. The power of UVA transmittance for each radiance and percentage of blockage were evaluated for each brand. Also, protection factor (PF) was calculated.

Results: The senofilcon A and narafilcon A had the highest blockage and lowest transmittance (p?=?0.02). PF was significantly higher in the senofilcon A and narafilcon A at 3, 9 and 18?mW/cm² (p?=?0.0001). And also, the hilafilcon B, filcon IV, nelfilcon A, enfilcon A, lotrafilcon A and lotrafilcon B had the highest UVA transmittance.

Conclusion: The narafilcon A and the senofilcon A may be a good options for epithelial healing after CCL procedure to protect the cornea from UVA of sunlight. And also, the hilafilcon B, filcon IV, nelfilcon A, enfilcon A, lotrafilcon A and lotrafilcon B contact lenses that have high-UVA transmittance feature can be a treatment choice for contact lens-assisted CCL technique in thin corneas.     

A multicenter retrospective study defining the clinical and hematological manifestations of brucellosis and pancytopenia in a large series: Hematological malignancies, the unusual cause of pancytopenia in patients with brucellosis

The aim of the study is to review the clinical manifestations and the hematological findings of brucellosis and pancytopenia, with or without hematological malignancies. The records of 202 patients with brucellosis were evaluated retrospectively. Among these cases of brucellosis seen in a 6 year period between April 1999 and June 2005, 30 patients with pancytopenia were identified. The most common manifestation was fever, followed by weight loss, anorexia, malaise, arthralgia, and hepatosplenomegaly. Bone marrow biopsies revealed hypercellularity or normocellularity. The most common findings in the bone marrow evaluation were histiocytic hemophagocytosis and granulomas. Among all cases, we diagnosed 5 hematological malignancies (1 acute myelogenous leukemia, 2 acute lymphoblastic leukemia, and 2 multiple myeloma) concurrently with brucellosis. The clinical symptoms and findings were similar in patients with and without malignancies. In cases with malignancies, the bone marrow biopsy revealed predominant primary disease involvement. Significant increases in ESR and CRP, severe anemia and thrombocytopenia were observed in patients with malignancies. Peripheral blood counts in patients without malignancies returned to normal after antibiotic treatment for brucellosis. However, pancytopenia in two patients with malignancies did not recover because of primary resistant disease. We conclude that while histiocytic hemophagocytosis may be considered as a major cause of pancytopenia, leukemic infiltration can also be an extreme and unusual cause of pancytopenia in patients in whom brucellosis was concurrently diagnosed with hematological malignancies.