Pulmonary thromboembolism secondary to left spermatic vein thrombosis: a case report

Spermatic vein thrombosis is a particularly rare entity which can be difficult to diagnose. Pulmonary embolism associated with spermatic vein thrombosis is rarely seen. We report the diagnosis and management of a case at our institution and recommend spermatic vein ligation as the definite treatment for thrombosed spermatic veins associated with pulmonary thromboembolism. We prefer laparoscopy as a minimally invasive approach because of its clear advantages over open surgery.     

Laparoscopy-assisted ureter interposition by ileum

PURPOSE: To report our experience with the laparoscopic approach to managing ileal ureter substitution for extensive ureteral stenosis. PATIENTS AND METHODS: Two patients, one man and one woman, ages 38 and 51 years, respectively, underwent laparoscopic ileal substitution between March 2004 and December 2005 because of extensive ureteral stenosis after stone disease management. A three-port technique was used. The ileal segment was managed extracorporeally through a McBurney incision. Pyeloileal or ileoureteral anastomosis was performed intracorporeally. Follow-up included clinical evaluation, nuclear renography, intravenous urography. and serum chemistry analysis. RESULTS: There were no complications, and there was minimal blood loss. Mean operative time was 195 minutes (range 180-210 min). Both patients remain without any symptoms or complaints at a median of 18.5 months follow-up (range 8-29 months). Postoperative pyelography verified adequate excretion from the renal unit. Nuclear renography showed no evidence of loss of renal function. No evident variations of preoperative and postoperative serum chemistry values were noted. None of the patients had any complaint or symptoms of urinary-tract infection or urolithiasis. CONCLUSIONS: The laparoscopic approach appears to be a safe and effective alternative to open surgery for ileal ureter substitution. Extracorporeal management of the ileal segment would appear advantageous because it reduces operative time and morbidity.     

Laparoscopic resection of an extra-adrenal pheochromocytoma

Extra-adrenal pheochromocytomas are of rare occurrence. Since first reported laparoscopic adrenalectomy has become the gold standard in the treatment of adrenal tumors, the feasibility of laparoscopic adrenalectomy in the setting of pheochromocytoma has also been established given a careful preoperative planning. Literature on the laparoscopic treatment of extra-adrenal pheochromocytomas is lacking. We report a hypertensive 54-year-old male patient (body mass index, 26.2) with elevated urinary catecholamines and a 6-cm solid mass under the right renal hilum diagnosed after a magnetic resonance. The patient underwent complete transperitoneal laparoscopic excision of the tumor. Recovery was uneventful and final histopathologic examination showed an extra-adrenal pheochromocytoma. We believe that transperitoneal laparoscopic excision of extra-adrenal pheochromocytoma is a feasible and reproducible technique that allows for complete removal of tumoral tissue with low morbidity, shorter hospital stay, and minimal convalescence.     

Periodontal disease immunology: ‘double indemnity’ in protecting the host

During the last two to three decades our understanding of the immunobiology of periodontal disease has increased exponentially, both with respect to the microbial agents triggering the disease process and the molecular mechanisms of the host engagement maintaining homeostasis or leading to collateral tissue damage. These foundational scientific findings have laid the groundwork for translating cell phenotype, receptor engagement, intracellular signaling pathways and effector functions into a ‘picture’ of the periodontium as the host responds to the ‘danger signals’ of the microbial ecology to maintain homeostasis or succumb to a disease process. These findings implicate the chronicity of the local response in attempting to manage the microbial challenge, creating a ‘Double Indemnity’ in some patients that does not ‘insure’ health for the periodontium. As importantly, in reflecting the title of this volume of Periodontology 2000, this review attempts to inform the community of how the science of periodontal immunology gestated, how continual probing of the biology of the disease has led to an evolution in our knowledge base and how more recent studies in the postgenomic era are revolutionizing our understanding of disease initiation, progression and resolution. Thus, there has been substantial progress in our understanding of the molecular mechanisms of host–bacteria interactions that result in the clinical presentation and outcomes of destructive periodontitis. The science has embarked from observations of variations in responses related to disease expression with a focus for utilization of the responses in diagnosis and therapeutic outcomes, to current investigations using cutting‐edge fundamental biological processes to attempt to model the initiation and progression of soft‐ and hard‐tissue destruction of the periodontium. As importantly, the next era in the immunobiology of periodontal disease will need to engage more sophisticated experimental designs for clinical studies to enable robust translation of basic biologic processes that are in action early in the transition from health to disease, those which stimulate microenvironmental changes that select for a more pathogenic microbial ecology and those that represent a rebalancing of the complex host responses and a resolution of inflammatory tissue destruction.     

Cutaneous lymphomas showing prominent granulomatous component: clinicopathological features in a series of 16 cases

Background  The presence of a prominent granulomatous tissue reaction in skin biopsies from primary cutaneous or systemic malignant lymphomas with secondary cutaneous involvement is a rare but well-known phenomenon.
Objective  This paper aims to characterize and study a series of cutaneous lymphomas showing a prominent granulomatous component.
Patients and methods  The clinical, histopathological and evolutive features of granulomatous variants of mycosis fungoides (5 patients, 2 of them associating 'granulomatous slack skin' features), Sézary syndrome (1 patient), CD30⁺ cutaneous T-cell lymphoma (2 patients), CD4⁺ small/medium pleomorphic cutaneous T-cell lymphoma (1 patient), primary cutaneous B-cell lymphoma (3 patients) and peripheral T-cell lymphoma with secondary epithelioid granulomatous cutaneous involvement (4 patients) were reviewed.
Results  The observed features were clinically non-distinctive. Only those cases presenting with granulomatous slack skin features were clinically suspected (2 patients). Non-necrotizing granulomata (11 patients) and granuloma annulare-like (4 patients) were the most frequently observed histopathological patterns. In five cases, no diagnostic lymphomatous involvement was initially observed. From our series, no definite conclusions regarding prognosis could be established.
Conclusion  The diagnosis of cutaneous lymphoma may be difficult when a prominent cutaneous granulomatous inflammatory infiltrate obscures the true neoplastic nature of the condition. However, the presence of concomitant lymphoid atypia may help to suspect the diagnosis. In doubtful cases, the clinical evolution and the demonstration of a monoclonal lymphoid B- or T-cell population may lead to a definite diagnosis.

Conflicts of interest

None declared.     

In vitro activity of voriconazole against Mexican oral yeast isolates

Oral candidiasis is the most prevalent complication in HIV‐infected and AIDS patients. Topical antifungal treatment is useful for the initial episodes of oral candidiasis, but most patients suffer more than one episode and fluconazole or itraconazole can help in the management, and voriconazole may represent a useful alternative agent for the treatment of recalcitrant oral and oesophageal candidiasis. The aim of this research was to study the in vitro activity of voriconazole and fluconazole against Mexican oral isolates of clinically relevant yeast. The in vitro susceptibility of 187 oral yeast isolates from HIV‐infected and healthy Mexicans was determined for fluconazole and voriconazole by the M44‐A disc diffusion method. At 24 h, fluconazole was active against 179 of 187 isolates (95.7 %). Moreover, a 100% susceptibility to voriconazole was observed. Voriconazole and fluconazole are highly active in vitro against oral yeast isolates. This study provides baseline data on susceptibilities to both antifungal agents in Mexico.     

The usefulness of the application of nonlinear dynamics in the analysis of electrocardiograms in Chagas' disease patients]

INTRODUCTION AND OBJECTIVES: The application of nonlinear techniques allows the definition of early risk markers in patients with Chagas infection and without any evidence of cardiac involvement evaluated by standard diagnostic test. Nonlinear modeling techniques have proved to be effective in cardiac rhythm analysis, thereby justifying its use in Chagas' disease. PATIENTS AND METHOD: The routine noninvasive test and heart rate variability analysis were performed in Chagas' disease patients and in a group of healthy subjects. In a second phase we used nonlinear analysis in the evaluation of patients with Chagas infection and no evidence of heart disease, Chagasic patients with minimal electrocardiographic abnormalities and healthy controls. RESULTS: Twenty-four-hour electrocardiographic ambulatory monitoring and heart rate variability allowed us to establish differences between the healthy subjects and patients with Chagas infection without evidence of cardiac disease (p c 0.05 and p <0.005). In sharp contrast nonlinear analysis characterized 4 subgroups in Chagasic patients without cardiac involvement (sensitivity and specificity of 1 00%). CONCLUSIONS: Our findings suggest that nonlinear modeling techniques have a high sensitivity and specificity in the early detection of cardiac involvement and very early autonomic disturbance. We recommend that these techniques be applied to patients with high risk of cardiac disease other than Chagasic myocarditis. Our findings should be corroborated with studies in larger populations. We are currently developing a prospective study to this end.     

Evaluation of serological tests to identify Trypanosoma cruzi infection in humans and determine cross-reactivity with Trypanosoma rangeli and Leishmania spp

Five commercially available enzyme-linked immunosorbent assays (ELISAs), one in-house ELISA, and two hemagglutination assays were evaluated to determine their diagnostic accuracy for Chagas' disease in two studies. In study 1, ELISA kits showed 100% sensitivity, but specificities ranged from 82.84% to 100% when leishmaniasis cases were included and from 95.57% to 100% when leishmaniasis cases were excluded. Kits using recombinant antigens or synthetic peptides are more specific than those using crude extracts from Trypanosoma cruzi epimastigote forms. Kits evaluated in Panama, in study 2, showed 75% to 100% sensitivity and 97.12% to 100% specificity. These data were obtained by using a Western blot assay with T. cruzi trypomastigote excreted-secreted antigens as a reference test to confirm T. cruzi infection.     

Evaluation of a real-time PCR assay based on the repetitive B1 gene for the detection of <Emphasis Type="Italic">Toxoplasma gondii</Emphasis> in human peripheral blood

In this paper, we examined the diagnostic value of a real-time polymerase chain reaction (PCR) using fluorescence resonance energy transfer (TaqMan assay) with a new set of primers and probe targeting the B1 gene to reproducibly detect and quantify Toxoplasma gondii in human blood. A total of 183 buffy coat samples from patients serologically classified as recent toxoplasmosis (immunoglobulin M (IgM)+, n = 35) or chronic infection (IgM- and immunoglobulin G (IgG)+, n = 110), and seronegative individuals (n = 38) was investigated. Of the IgM seropositive patients, 17:35 (48.6%) presented parasitaemia, whereas 3.6% positivity was achieved in those individuals that theoretically corresponded to chronic infection (4:110). In the seronegative group, the assay provided 7.9% (3/38) of positive results. Interestingly, one of them was confirmed as positive in a conventional PCR targeting the Toxoplasma B1 gene after hybridization with an internal probe. Real-time PCR was able to accurately quantify the parasite load when concentrations of T. gondii DNA are low, revealing a parasite burden ranged from 9.92 x 10(-3) to 8.73 x 10(-1) tachyzoites genome per milliliter of blood. The chance of an IgM+ patient to present parasitemia detected by the TaqMan procedure was 19.02 times greater than in IgM- individuals (P < 0.05). It was observed a positive association between the optical density values of the IgM serological tests and the number of circulating parasites in the acute patients (P < 0.0001). The specificity of the molecular test was 95.3% when calculated using IgM+ patients as disease group and IgM- as nondisease group. The low sensitivity observed in the IgM seropositive group (48.6%) could be due to the use of buffy coat as clinical material for DNA extraction. An amplification control based on the human beta-actin gene was used in parallel to monitor PCR inhibition and to control for DNA integrity.