Showing papers in "Southern Medical Journal in 1979"

Tendon Rupture After Local Steroid Injection

Abstract: Thirteen patients who developed 15 ruptured tendons subsequent to injection of a depository steroid in or about the tendons are described. Eight were treated surgically. Ruptures were encountered in three Achilles tendons, two supraspinati, one lateral epicondylar attachment at the elbow, eight tendons of the long head of the biceps at the shoulder, and one anterior tibial tendon. Measures designed to lessen this complication are described. In most cases triamcinolone hexacetonide was used as the depository steroid, mixed with procaine or lidocaine. Patients with this complication who were not treated surgically were the older patients who had ruptures of the tendon of the long head of the biceps.

Secondary renal neoplasms: an autopsy study.

Abstract: The records of 11,328 autopsies performed on patients who died of malignant disease between March 1944 and August 1974 were reviewed, and 816 cases (7.2%) demonstrated renal metastases. The most common primary tumors in decreasing order of frequency were lung, breast, skin (melanoma), and tumors of

Methotrexate-induced diffuse interstitial pulmonary fibrosis.

Abstract: Three patients received respectively 190 mg, 175 mg, and 196 mg of methotrexate and developed bilateral pulmonary infiltrates without evidence of peripheral blood eosinophilia. Sputum in the three cases failed to reveal acid-fast bacilli, pathogenic fungi, or opportunistic organisms by cultures and appropriate stains. Despite discontinuance of the drug and/or institution of corticosteroid therapy, progressive respiratory failure led to death. In all three cases, autopsy revealed gross and microscopic features indistinguishable from those seen in the Hamman-Rich syndrome, and methotrexate hepatotoxicity was present in one. Pulmonary eosinophilia or granulomas, classically seen in previously reported cases of methotrexate pneumonitis, were not observed. It is suggested therefore that methotrexate be added to the list of agents capable of inducing diffuse interstitial pulmonary fibrosis. Conversely, diffuse interstitial pulmonary fibrosis should be considered in the differential diagnosis of patients receiving methotrexate who develop bilateral pulmonary infiltrates seen on chest roentgenograms.

Severe hypersensitivity reactions to allopurinol.

Abstract: The frequency of severe reactions to allopurinol has probably been underestimated. A retrospective study encompassing a five-year period has yielded 20 patients with severe hypersensitivity reactions to allopurinol. Patients with preexisting renal impairment or who were receiving concomitant thiazide diuretics appeared to be especially predisposed. Cutaneous reaction patterns included maculopapular eruptions, exfoliative dermatitis, and toxic epidermal necrolysis. eosinophilia was uncommon. Forty percent of the patients developed hepatic involvement and 45% had renal involvement. Hepatic and renal changes usually were reversible and were not unique to any one cutaneous reaction pattern. Three patients with renal involvement required prolonged administration of systemic steroids. Complications included sepsis, decubitus ulcers, and thromboembolism. Two patients required hyperalimentation. Sequelae included dry eyes, pigmentary disturbances, and keloids. Three patients died as a result of their reaction. It is concluded that allopurinol should be used only in select patients, and the dosage should be modified if renal disease exists.

Major venous anomalies complicating retroperitoneal surgery.

Abstract: Transposition of the inferior vena cava, duplication of the inferior vena cava, circumaortic renal collar, and retroaortic renal vein constitute the four most common major venous anomalies occurring in the retroperitoneum. Recent clinical cases are presented to review the embryogenesis, incidence, and clinical importance of these anomalies and to alert the unfamiliar surgeon to their possible existence. A high index of suspicion on the part of the surgeon is required to prevent inadvertent injury to these anomalous veins and to avoid significant hemorrhage during retroperitoneal surgery.

Left main coronary artery disease.

Abstract: Eighteen patients with significant stenosis of the left main coronary artery are reported and compared with 1,040 patients described in the ten largest published series. In comparison to previous reports, our patients have a higher incidence of congestive heart failure, previous myocardial infarction (especially inferior wall), poorer left ventricular function, and more advanced coronary artery disease. Despite this, there was no increased risk during catheterization and bypass surgery. This small group of patients reflects the modern experience that, with increasing awareness of this lesion, there need not necessarily be a higher risk during diagnostic studies and therapeutic intervention.

Cutaneous horns: a histopathologic study.

Abstract: We report a series of 230 cutaneous horns, of which fewer than one fourth were frankly malignant Actinic keratoses were the lesions most commonly found underlying cutaneous horns (3739%) Cutaneous horns overlying a benign lichenoid keratosis, epidermolytic hyperkeratosis, trichilemmoma, an epider

Primary lymphomas of the gastrointestinal tract.

Abstract: An institutional experience with primary gastrointestinal lymphoma (PGL) is reviewed. Included are 46 cases involving the stomach, 11 involving the small bowel, and two, the large bowel. The clinical, pathologic, and therapeutic aspects of PGL are discussed.

Paecilomyces cellulitis in a renal transplant patient: successful treatment with intravenous miconazole.

Abstract: We report an immunosuppressed host with an unusual fungal infection which resolved during intravenous therapy with a new antifungal agent. This agent, miconazole, appears to have minimal side effects and a broad antifungal spectrum, and it deserves consideration for treatment of susceptible organisms.

Cholesterol embolism: the great masquerader.

Abstract: Embolization of cholesterol crystals from ulcerated atheromatous lesions can produce distinct syndromes that mimic more common disease processes. Cholesterol emboli can present as renal failure, hypertension, spells of numbness, abdominal pain, and myocardial infarction, or as a multisystem disease that closely approximates the presentation, clinical course, and even biopsy picture of polymyositis or periarteritis nodosa. A review of this problem with particular attention to the clinical presentations should help in the early diagnosis and treatment of cholesterol emboli and avoid unnecessary and inappropriate therapies.

Gastric, intestinal, and gallbladder varices: hemodynamic and therapeutic considerations.

Abstract: Atypically located varices are frequently overlooked in the differential diagnosis of gastrointestinal bleeding in patients with portal hypertension. The circulatory changes associated with these lesions are described and their relation to diagnosis and treatment emphasized.

Arthrography in acute shoulder dislocations.

Abstract: Arthrography of the shoulder was performed on 50 patients with acute traumatic shoulder dislocations. The mean interval between injury and arthrogram was 2.3 days, with a median interval of one day. Anterior dislocations occurred in 96% of patients, and posterior dislocations in 4%. Initial dislocations were present in 74%, and recurrent dislocations in 26%. The most frequent abnormality identified or arthrograms was an enlarged but intact shoulder capsule (58%), most commonly seen in shoulders subject to recurrent dislocations (77%). Shoulder joint capsular tears or disruptions were seen in 48% of the patients. The next most common lesion was fracture (52%), identified on standard roentgenograms. These included Hill-Sachs lesions (28%), greater tuberosity fractures (22%), and coracoid fractures (2%). Ruptures of the rotator cuff, present in 28% of the cases (14 patients), occurred more frequently in initial dislocations (62%) than in recurrent ones (36%). The high frequency of enlarged intact shoulder capsules, even after an acute initial joint dislocation (58%), suggests that the humeral head does not routinely rupture the capsule during dislocation, but rather tears the glenoid labrum at its bony attachment and dislocates subperiosteally, dissecting a false pouch below the periosteum and under the subscapularis.

Traumatic rupture of the thoracic aorta.

Abstract: :Aortic transection secondary to blunt trauma is not an uncommon injury. Prompt recognition and treatment of the injury is required to salvage patients with this type of injury. Ten patients with transection of the thoracic aorta at the isthmus have been treated in the past two years at our

Fungus balls of the urinary tract

Abstract: Fungus balls of the urinary tract are rare and usually associated with infection by Candid albicans. Since 1968 five patients seen at the Medical College of Virginia Hospitals presented with this peculiar manifestation of candidiasis. Summaries of their epidemiologic clinical, pathologic, and mycologic data are presented. All Candida fungus balls involved the upper collecting system and were detected by radiography and confirmed by culture and/or pathologic section. Two of the five patients completely recovered. Three patients were treated with flucytosine and/or local irrigation with a polyene antifungal agent. Two recovered and the third died of probable bacterial sepsis. One patient was treated successfully with surgical removal of the fungus ball and a brief period of local irrigation with amphotericin B (AMB). The fifth patient recovered after 28 days of parenteral AMB. Predisposing factors and pathogenetic mechanisms are discussed, and a rational approach to therapy is outlined.

Treatment of cholelithiasis in patients with sickle cell anemia

Abstract: The incidence of cholelithiasis and surgical risk of cholecystectomy in patients with sickle cell anemia is reviewed. Records of all patients with sickle cell disease currently attending the Medical University of South Carolina Hematology Clinic were reviewed. An oral cholecystogram has been part of the initial evaluation for the past year. The records of 16 patients having cholecystectomy from 1968 to 1977 were reviewed with regard to diagnostic studies, preoperative preparation, morbidity, and mortality. When the status of the gallbladder is known, the incidence of cholelithiasis is 67%. The morbidity of elective cholecystectomy was high (37%); there was one death. Cholecystectomy is not recommended for the discovery of asymptomatic gallstones because of the relatively poor surgical risk and short life expectancy of these patients.

Pemphigus vulgaris and lymphoma in a patient with scleroderma.

Abstract: The coexistence of scleroderma and malignancy is well documented. The case presented here is unique, however, as it is the first report of the occurrence of diffuse histiocytic lymphoma and pemphigus vulgaris in a patient with scleroderma. Because of this unusual triad of diseases, the possibility of a common pathogenetic basis was examined. A review of the literature confirms that each disorder does have immunologic abnormalities. It is suggested that an aberrant immune response, specifically impaired T-cell function, is responsible for the emergence of disease of this patient.

Response to influenza A vaccine among high-risk patients.

Abstract: In recent years, it has been recommended that "high-risk" patients receive influenza immunizations annually. During the 1976 National Influenza Immunization Program, a higher priority was given to these patients than to the general population. The present study was undertaken to compare the antibody response of high-risk patients with that of a group of individuals with no underlying disease after immunization with 0.5 ml of bivalent, split-virus vaccine containing 200 CCA units each of influenza A/New Jersey/76 and A/Victoria/75. Sera were obtained before and after immunization from 41 "healthy" volunteers and from 57 cariology, 31 hematology, 13 hemodialysis, and 16 renal transplant patients. The control, cardiology, and hemodialysis groups responded equally well to A/Victoria/75 antigen, but the hematology and renal transplant groups did not respond as well (P less than .05). Only the hematology patients responded at a significantly lower level (P less than .05) than the control group to A/New Jersey/76. The control and renal transplant groups had a significantly greater response to A/New Jersey/76 antigen than to A/Victoria/75 antigen (P less than .002). Although the same pattern was demonstrated by the other patient groups, the differences were not significant. Because hematology and renal transplant patients responded relatively poorly to influenza immunization, prophylactic administration of amantadine during influenza outbreaks should be considered in patients with renal function adequate to excrete this drug.

Metabolic alkalosis complicating weaning from mechanical ventilation.

Abstract: Metabolic alkalosis was identified and confirmed as a precipitator of acute hypercapnea. As a result, weaning from mechanical ventilator therapy was delayed. Correction of alkalosis followed by reduction of PCO2 confirmed the compensatory mechanism during alkalosis, and weaning from intermittent mandatory ventilation then proceeded at an appropriate rate.

Relationship of Neonatal Pneumonia to Maternal Urinary and Neonatal Isolates of Group B Streptococci

Abstract: Of 1,500 consecutive deliveries, there were 41 term infants with suspected sepsis in association with a positive culture for group B streptococci (GBS) from either the infant soon after birth, or the mother's urine routinely collected three days postpartum. A statistically higher incidence of pneumonia was found in these infants as compared to matched controls. Infants born to mothers with GBS in the urine had a high incidence of suspected sepsis (43.6%) as well as a high incidence of pneumonia (38.6%). We conclude that term infants colonized at birth with GBS or born to mothers with GBS isolated from their urine are at high risk of having pneumonia.

Penetrating keratoplasty using McCarey-Kaufman preserved corneal tissue.

Abstract: Two hundred consecutive penetrating keratoplasties, using suitable donor corneas stored in modified tissue culture medium (M-K medium), were performed by a single surgeon over a 21-month period. Two hundred consecutive cultures of the donor corneosclearl rims for aerobic and anaerobic bacteria and fungi, done immediately after surgery, yielded 25 positive cultures for aerobic and anerobic bacteria and three for fungi. No clinical infections nor primary donor failures were encountered with patients after one to 21 months of follow-up. Preservation of excised corneas by trained technicians, under rigidly sterile, laminar-flow, tissue culture conditions appears to be a convenient, safe, and effective method of corneal preservation which permits elective keratoplasty.

Gunshot Wounds to the Spinal Cord

Abstract: A series of 59 patients with gunshot wounds to the spinal cord is presented. Seventeen injuries were cervical, 30 were thoracic, 11 were lumbar, and one was sacral. Twenty-nine patients had immediate complete sensorimotor loss of function, 18 had sensory or motor sparing below the cord lesions, and 12 had injury of the cauda equina. Thirty-nine patients were treated with decompressive laminectomy, four with local wound debridement only, three with cervical traction and subsequent anterior cervical fusion; 13 had only conservative therapy. Eleven patients had return to normal function and 20 patients had some degree of improvement. There was no significant difference in the outcome between patients operated on and those treated conservatively. Language: en

Respiratory failure secondary to Mycoplasma pneumoniae infection.

Abstract: Three previously healthy patients presented with bilateral pulmonary infiltrates, hypoxemia, and respiratory failure associated with Mycoplasma pneumoniae infection. None had underlying pulmonary or immune deficiency diseases. One died with dense fibrotic reorganization of the lungs, and another sur

Gastric carcinoma in young adults.

Abstract: The clinical and pathologic characteristics of gastric carcinoma in patients younger than 30 are compared with those of patients 30 to 39 years of age. Patients in both age groups had similar symptoms, predominantly undifferentiated neoplasms, and poor prognoses. In both groups, there were significant delays in initiation of definitive treatment because of delays in diagnosis. In 80% of the patients, the malignancy extended beyond the stomach wall at diagnosis, adversely affecting their long-term survival. The 20% five year survival in both groups indicates the necessity of early diagnosis and aggressive treatment.

Inadvertent intracranial placement of a nasogastric tube through a basal skull fracture.

Abstract: Inadvertent intracranial placement of nasogastric tubes may occur during intubation of patients with severe maxillofacial trauma and basal skull fractures. Oral intubation, nasogastric intubation under fluoroscopy, or nasogastric intubation under direct vision will eliminate the possibility of this complication.

Hypoplasia of the abdominal aorta associated with rubella syndrome.

Abstract: Our patient, a 23-year-old white woman with congenital rubella syndrome, presented with claudication and upper extremity hypertension. To our knowledge this is the first patient with congenital rubella syndrome to present with an abdominal coarctation. Since 75% of the patients with abdominal coarctation are young women, this may be only a chance association.

Cystic lymphangioma of the spleen.

Abstract: Splenic cysts are uncommon, with fewer than 600 cases reported in the world literature. This report concerns a case of cystic lymphangioma of the spleen, consisting of a large splenic cyst with associated multiple, small, subcapsular cysts and lymphangiectasia. The cysts are lined by endothelium, and they conform to the characteristics of dilated lymphatic channels. Lymphangioma of the spleen is thought to arise from congenital obstruction of lymphatic flow, with subsequent dilatation of lymphatic channels. The diagnosis and treatment of splenic cysts are discussed and a new classification of splenic cysts is proposed.

Candida meningitis in the newborn.

Abstract: The incidence of Candida meningitis in the neonatal period is increasing, and 63% of reported patients have either died or are mentally retarded. We report a newborn with Candida meningitis and arthritis who did well after treatment with intravenous and intrathecal amphotericin B, along with oral flucytosine.

Caustic burns of the esophagus: ten-year results of aggressive care.

Abstract: In 1967, care of esophageal burns from caustic substances was altered to include immediate esophagoscopy, high doses of steroid, and follow-up dilatations plus cine-esophagograms as needed. Previously, this area averaged six repairs of esophageal stricutre each year. Since 1967, there have been no esophageal strictures in 100 patients.

Cervical cerclage: twenty years' experience.

Abstract: During a 20-year period, 40 pregnancies were managed in 32 patients with a diagnosis of an incompetent cervix, a ratio of 1:775 deliveries. Diagnosis before development of symptoms produced a 92% fetal salvage, with 68% reaching 36 weeks of gestation. Development of symptoms before cerclage resulted in only a 40% fetal salvage. Fetal salvage was reduced in cases where membranes bulged beyond the cervix, the cervix was more than 3 cm dilated, or the gestational age was greater than 26 weeks at the time of suture placement. No difference was noted between the Shirodkar and McDonald procedures. Major complications included uterine rupture in three patients and acute chorioamnionitis in two. Because of complications, treatment is contraindicated based on history alone or where close follow-up is not available.