Burning-Feet Syndrome: Case Due to Malabsorption and Responding to Riboflavine

A woman with the burning-feet syndrome was found on investigation to have malabsorption. The syndrome responded rapidly to intramuscular injections of 6 mg. of riboflavine daily. It is suggested that deficiency of this substance, due to malabsorption and aggravated by a defective diet and repeated pregnancies, was responsible for the syndrome in this case.     

Is bile acid malabsorption underdiagnosed? An evaluation of accuracy of diagnosis by measurement of SeHCAT retention.

The cause of intractable chronic diarrhoea was found to be malabsorption of bile acid in five out of 42 patients thought to have the irritable bowel syndrome, six out of 29 patients with persistent diarrhoea after surgery for peptic ulcer, 23 who had undergone small bowel resection, and two others. Specific treatment brought symptomatic relief. The diagnosis was established by measuring the proportion of SeHCAT, a synthetic bile salt, retained one week after oral administration of a tracer dose of less than 100 micrograms of the compound labelled with 40 kBq (1 microCi) of selenium-75. These results indicate that malabsorption of bile acid is a more common cause of chronic diarrhoea than is generally appreciated. Measurement of retention of SeHCAT is a simple, accurate, and acceptable means of establishing the diagnosis of this debilitating but treatable condition.     

Successful salvage therapy with Daptomycin for osteomyelitis caused by methicillin-resistant Staphylococcus aureus in a renal transplant recipient with Fabry-Anderson disease

Paroxysmal nocturnal hemoglobinuria (PNH) is a clonal disorder that presents with hemolytic anemia, marrow failure and thrombophilia. During acute attacks, corticosteroid can alleviate the hemolytic paroxysm, but the prolonged administration induces serious toxicity including immunosuppression. So American thoracic society (ATS) for tuberculosis (TB) recommends prophylactic anti-TB medication in patients with a long-term steroid therapy. However, in the patient who was treated for active TB in the past, there are no guidelines of the test for determining patients who have latent TB infection (LTBI) and no recommendations of TB prophylaxis if there is no evidence of reactivation at present. A 40-year-old male patient presented with fever and aggravated weakness for a week. He was diagnosed with PNH a month ago and took corticosteroid for 3 weeks. In the past, he was diagnosed with pulmonary TB and completely cured after treatment. According to guideline, he was not indicated with TB prophylaxis. However, he caught miliary TB, progressed to acute respiratory distress syndrome. We experience this embarrassing case, and emphasize the need to investigate multicentral TB prevalence and to make the guidelines of anti-TB medication in subgroups of hematologic diseases including PNH.     

吸入维生素A和皮质激素对大鼠哮喘性肺炎的疗效及TSLP表达的影响

目的:观察胸腺与肺的胸腺基质淋巴细胞生成素(TSLP)和Th因子在病程发展中变化,分析吸入维生素A(VA)与皮质激素对哮喘性肺炎疗效。方法:卵蛋白激发大鼠哮喘4周后休息1周,VA与皮质激素吸入治疗1周,吸入90%乙醇液作为哮喘组。通过免疫荧光染色、组织化学染色等法检查胸腺与肺。结果:激发第4～5周后,哮喘组胸腺与肺TSLP阳性细胞、肺泡巨噬细胞(AM)较多,胸腺和脾增生,血Th2因子升高,肺部炎症逐渐加重;VA组第4周胸腺与肺TSLP和Th2因子表达均较低;第5周TSLP轻度增加,胸腺、脾T细胞区增生由强转弱,AM明显增多,肺炎症逐渐消退。激素组第4～5周胸腺和肺TSLP、Th2因子表达低,胸腺、脾增生渐强。AM数量少,肺炎症渐重。结论:激发哮喘期间TSLP表达增强伴有Th2类反应,VA和皮质激素均抑制TSLP与Th2因子表达,但VA促进T淋巴细胞增生与AM清除抗原功能,停药后肺炎症逐渐消退;皮质激素停药后炎症加重。     

Aspergillosis of a dog genital tract-Case report

The information about aspergillosis locations in the reproductive organ is scarce. This short paper deals with aspergillosis in the dog genital tract with hyphae present in semen. There are two therapy schemes used in visceral mycoses, non-invasive treatment and surgical intervention. Considering the future reproductive career of the dog, we decided on antifungal drugs administration. Based on the microbiological results, we administered amoxycillin with clavulonate (Synulox 500mg, twice daily) orally. Itraconazole was used as an antimycological agent (Orungal, 100mg, twice daily) every other week. In 8th week of therapy no Aspergillus spp. growth was noted, yet slight Penicillium growth was observed. After 12 weeks of treatment, no fungus growth was present. Neither spores or hyphae were seen in the microscopic examination. Three months after the termination of the therapy, the dog mated with two females. In one case, unifetal pregnancy was diagnosed by ultrasound examination on day 42 after mating. Due to purulent discharge on day 45 after mating, the owner decided to terminate the pregnancy. In the other case, severe pyometra appeared 12 days after the second mating and the owner decided to put the female to sleep. The pathogen eradication from the ejaculates may be treated as a serious success, yet the lack of litters after mating calls for an explanation and consequences of Aspergillus spp. infection need to be considered.     

Prolonged pseudoaldosteronism induced by glycyrrhizin.

We describe the natural recovery from the aggravated hypertension, hypokalemia and suppression of the renin-aldosterone axis after the glycyrrhizin discontinuation in two mild hypertensive women aged 71 and 68 years, who had been administered 273 to 546 mg glycyrrhizin daily for 1.5 and 6 months, respectively, for the treatment of liver disease. About one month after the glycyrrhizin discontinuation, acceleration of hypertension, hypokalemia and suppression of the renin-aldosterone system still continued in both patients. At this stage, sodium restriction resulted in the normalization of blood pressure with weight loss and the subsequent sodium repletion produced a rapid increase in blood pressure to hypertensive levels observed before sodium restriction, with weight gain. Plasma renin activity and plasma aldosterone were low and did not respond to sodium restriction. Inappropriately excessive amounts of potassium were also excreted in the presence of hypokalemia. About one and a half months later, the improvements of aggravated hypertension, hypokalemia and suppressed renin-aldosterone system gradually occurred in both patients. Sodium restriction performed about three months later in case 2 no longer produced the changes in blood pressure and body weight. Plasma renin activity and plasma aldosterone responded subnormally to sodium restriction. These results demonstrate that both patients had a prolongation of the syndrome resembling primary aldosteronism except the low plasma aldosterone level about one month after the glycyrrhizin discontinuation. The possible mechanisms by which this prolongation was caused are discussed.     

Systemic lupus erythematosus

Imerslund-Gräsbeck syndrome (IGS) or selective vitamin B₁₂ (cobalamin) malabsorption with proteinuria is a rare autosomal recessive disorder characterized by vitamin B₁₂ deficiency commonly resulting in megaloblastic anemia, which is responsive to parenteral vitamin B₁₂ therapy and appears in childhood. Other manifestations include failure to thrive and grow, infections and neurological damage. Mild proteinuria (with no signs of kidney disease) is present in about half of the patients. Anatomical anomalies in the urinary tract were observed in some Norwegian patients. Vitamin B₁₂ absorption tests show low absorption, not corrected by administration of intrinsic factor. The symptoms appear from 4 months (not immediately after birth as in transcobalamin deficiency) up to several years after birth. The syndrome was first described in Finland and Norway where the prevalence is about 1:200,000. The cause is a defect in the receptor of the vitamin B₁₂-intrinsic factor complex of the ileal enterocyte. In most cases, the molecular basis of the selective malabsorption and proteinuria involves a mutation in one of two genes, cubilin (CUBN) on chromosome 10 or amnionless (AMN) on chromosome 14. Both proteins are components of the intestinal receptor for the vitamin B₁₂-intrinsic factor complex and the receptor mediating the tubular reabsorption of protein from the primary urine. Management includes life-long vitamin B₁₂ injections, and with this regimen, the patients stay healthy for decades. However, the proteinuria persists. In diagnosing this disease, it is important to be aware that cobalamin deficiency affects enterocyte function; therefore, all tests suggesting general and cobalamin malabsorption should be repeated after abolishment of the deficiency.     

Early effects of radium therapy on natural killer (NK) activity in patients with gynaecological malignancies

The effect of radium therapy on NK activity in patients with gynecological cancer is presented. Patients were tested before treatment, immediately after treatment and at 1 week intervals for 2 weeks. NK activity in patients before treatment was not statistically different from the normal controls. There was a statistically significant decrease of NK activity after treatment compared to pretreatment value (p less than 0.001). After 1 week NK activity reached pretreatment value and did not change a week later. Radium therapy does not result in a long lasting depression of NK activity, the important host defense mechanism.     

Delayed small-intestinal transit in tropical malabsorption.

The time of breath hydrogen appearance (T) after oral lactulose was determined in 98 patients in London who had been to the tropics. Fifty-six controls from three different ethnic groups had no evidence of gastrointestinal disease; 23 had tropical malabsorption, which was severe in 10; and 19 had chronic diarrhoea without malabsorption. Mean T was significantly delayed in patients with tropical malabsorption compared with controls, indicating that their mouth-caecum transit rate was abnormally slow. In six patients with tropical malabsorption who were reinvestigated after treatment a fall in the value for T seemed to parallel clinical improvement. Three patients with diarrhoea due to chronic colonic disease had delayed T. Patients with tropical malabsorption have bacterial colonisation of the small intestine, which is important in the pathogenesis of the disease. Bacterial overgrowth, which sometimes occurs after infective diarrhoea in the tropics and gives rise to tropical sprue, is a result of stasis.     

儿童激素耐药型肾病综合征合并星形诺卡菌脑脓肿1例

本文报道1例激素耐药型肾病综合征儿童合并星形诺卡菌(Nocardia asteroides,N.asteroides)脑脓肿。患儿,男性,8岁,临床诊断为原发性肾病综合征(激素耐药型),病理诊断为局灶节段性肾小球硬化症(经典型)。肾穿后第4天患儿出现持续高热、抽搐,时有头痛,抗感染、抗凝治疗效果不佳。复查颅脑磁共振成像(magnetic resonance imaging,MRI)提示多发脑脓肿。头颅脓肿液经穿刺后培养显示为星形诺卡菌感染。予以多种抗生素联合糖皮质激素等治疗2个月,患儿体温正常,头痛缓解,脑脓肿范围明显缩小。因此,肾病综合征患儿在应用激素及免疫抑制剂治疗过程中如出现化脓性炎症,常规抗生素疗效差,应积极寻找病原,高度警惕诺卡菌病及其他机会性感染的可能。     

Changes in vaginal microbiocenosis in patients with chronic pelvic inflammatory diseases following antibiotic therapy

The species composition of the vaginal microorganisms in healthy women and in patients with chronic pelvic inflammatory diseases before and after treatment in a gynecological hospital was studied. The study revealed that antibiotic therapy did not lead to complete clinical convalescence. During bacteriological investigation of patients changes in vaginal microbiocenosis, manifested by a decreased number of microbial species, an increased proportion of Escherichia coli, the occurrence of Staphylococcus aureus, a decreased number of Lactobacillus ssp., were observed. Antibiotic therapy aggravated the dysbiotic microbial picture of the vagina.     

Can prefrontal theta cordance differentiate between depression recovery and dissimulation?

We present a case report of a 37-year old woman diagnosed with depressive disorder, first episode, who was admitted into a psychiatric hospital after a failed suicidal attempt. She responded to antidepressant therapy, as evidenced by a >50% reduction in MADRS total score. She was discharged after 4 weeks of treatment, denying any suicidal ideations. The following day the patient committed suicide; she burned herself to death. It is very likely that the patient dissimulated her symptoms and ideations. Subsequently, her quantitative EEG records were retrospectively analyzed. An increase of prefrontal theta cordance value after the first week of mirtazapine therapy was found. Recently three small studies have revealed that decrease of prefrontal theta cordance after 1 week of antidepressant administration can predict clinical response in patients with unipolar depression. In our previous study the absence of a decreased theta prefrontal cordance was associated with lack of treatment response with NPV 1.0 (Bares et al., 2007). Thus, we hypothesize that prefrontal theta cordance could become an objective marker of change of depressive symptoms, independent of patients' compliance and symptom dissimulation, more precise than objective and self-rated depression rating scales.     

Delayed puberty in an 18-year-old female patient with late diagnosis of celiac disease

A case of a 18-year female patient is presented. The patient suffered from certain symptoms of malabsorption syndrome. She was also retarded sexually. Celiac disease was diagnosed according to ESPGAN criteria. Gluten -free diet produced body weight increase, pain relief, improved well-being and normal menstruation.     

Dissociation of LH and FSH Responses to LHRH during estrogen therapy of patients with ovarian failure

This study examines the effect of oral estrogen treatment on gonadotropin secretion in three young women with gonadal failure. Each subject was treated with 0.1 mg BID of ethinyl estradiol for four weeks, and the LH and FSH responses to 200 microgram of intravenously administered LHRH were measured basally and weekly during therapy. Significant reduction of basal levels of FSH occurred within one week of treatment, with obliteration of LHRH-mediated FSH responsiveness within two weeks. By contrast, basal levels of LH were significantly reduced by the end of the second week of treatment, and LHRH-mediated LH levels were sustained for three weeks. In one subject an LHRH test was performed every other day for two weeks after cessation of therapy. Return of FSH responsiveness was delayed one week beyond that of LH, which occurred within three days of discontinuation of estrogen. These results indicate that during the early phase of oral estrogen replacement therapy, FSH secretion may be selectively blunted; after discontinuation of treatment, recovery of FSH secretion lags behind recovery of LH.     

Toxic shock syndrome after suction lipectomy

We present a case of toxic shock syndrome with necrotizing fasciitis after suction lipectomy. The patient underwent aesthetic suction lipectomy of the abdomen, buttocks, and thighs during an office procedure by a cosmetic surgeon. On postoperative day 2, the patient was referred to the emergency department of our hospital because of pain. On admission, the patient was in toxic shock. She required intensive medical treatment for about 1 month, along with psychiatric help to adapt after the illness. Although toxic shock syndrome is a rare postoperative complication, every plastic surgeon should be acquainted with it. A combination of early recognition, diagnosis, and aggressive supportive therapy is the only successful treatment.     

Impact of furazolidone-based quadruple therapy for eradication of Helicobacter pylori after previous treatment failures

Background. One week of quadruple therapy including metronidazole is recommended for Helicobacter pylori treatment failures after first line therapy regardless of resistance status. This study investigated whether a quadruple regimen containing furazolidone could be effective as a third‐line (salvage) therapy. Methods. All patients with previous H. pylori treatment failure after a clarithromycin‐metronidazole ± amoxicillin combination plus acid suppression were given lansoprazole 30 mg twice a day (bid), tripotassiumdicitratobismuthate 240 mg bid, tetracycline 1 g bid, metronidazole 400 mg (PPI‐B‐T‐M) three times a day (tid) for 1 week. In the case of treatment failure with this second‐line therapy, the same regimen was applied for 1 week except for using furazolidone 200 mg bid (PPI‐B‐T‐F) instead of metronidazole (sequential study design). Results. Eighteen consecutive patients were treated with PPI‐B‐T‐M. Eleven of those 18 remained H. pylori positive (38.9% cured). Pretherapeutic metronidazole resistance was associated with a lower probability of eradication success (10% vs. 75%, p= .04). Ten of these 11 patients agreed to be retreated by PPI‐B‐T‐F. Final cure of H. pylori with PPI‐B‐T‐F was achieved in 9/10 patients (90%) nonresponsive to PPI‐B‐T‐M. Conclusions. In the presence of metronidazole resistance, PPI‐B‐T‐M as a recommended second‐line therapy by the Maastricht consensus conference achieved unacceptable low cure rates in our metronidazole pretreated population. In this population, metronidazole based second‐line quadruple therapy may be best suited in case of a metronidazole‐free first line‐regimen (e.g. PPI‐clarithromycin‐amoxicillin) or a low prevalence of metronidazole resistance. Furazolidone in the PPI‐B‐T‐F combination does not have a cross‐resistance potential to metronidazole and is a promising salvage option after a failed PPI‐B‐T‐M regimen.     

Cryptococcosis as an opportunistic infection in immunodeficiency secondary to paracoccidioidomycosis

We describe the case reports of two patients with immunodeficiency secondary to paracoccidioidomycosis (PCM) and opportunistic Cryptococcus neoformans infections. Secondary immunodeficiency likely occurred as a consequence of the intestinal loss of proteins and lymphocytes associated with malabsorption syndrome due to obstructed lymphatic drainage. Both patients had had severe abdominal involvement during the acute PCM disease. Immunological evaluation showed cellular and humoral immunity impairment. Cryptococcosis manifested as relatively well circumscribed lesions: osteolytic lesions of the skull in one patient, and pulmonary nodules in the other. The latter was treated surgically and with amphotericin B, whereas the other was treated with the combination amphotericin-B and flucytosine. Both patients had a good response to treatment with complete regression of the lesions. They have now 2 and 4 years of follow-up with maintenance therapy and no indication of reactivation of the infection. PCM also did not reactivate. The clinical and immunological characteristics of these patients are discussed and compared to the opportunistic C. neoformans infections of AIDS and transplant patients.     

Successful use of olanzapine in adolescent monozygotic twins with catatonic schizophrenia resistant to electroconvulsive therapy: case report

We describe a case of monozygotic (MZ) male twins (14.6 years old) who suffered from a severe form of catatonic schizophrenia. On admission, the principal symptoms of the brothers were stupor, mutism, catatonic posturing, rigidity, negativism, and refusal of food and liquids. They were treated with electroconvulsive therapy (ECT) with no effect (twin A) and almost no effect (twin B). Both twins improved with initiation of olanzapine therapy. Twin B showed a marked improvement by week 2 on a dose of 10 mg daily (qd). Improvement in twin A was seen by week 4 on a dose of 15 mg qd. Twin B was discharged after 8 weeks and twin A after 11 weeks of olanzapine treatment. This appears to be the first report on concordant positive responses to olanzapine in MZ twins with catatonic schizophrenia, as well as, the first report on concordant resistance to ECT.     

Efficacy of 2-week, second-line Helicobacter pylori eradication therapy using rabeprazole, amoxicillin, and metronidazole for the Japanese population

Background: Following the failure of first‐line Helicobacter pylori eradication therapy using a proton pump inhibitor, amoxicillin, and clarithromycin, second‐line therapy is conducted for 1 week using metronidazole instead of clarithromycin in Japan. Recent studies indicate that metronidazole‐containing therapy has a higher eradication rate with prolonged treatment duration, even with metronidazole resistance. The aim of this study was to reveal the efficacy of 2‐week metronidazole‐containing second‐line therapy. Methods: Eighty‐two consecutive outpatients who had failed in the first‐line eradication therapy were enrolled and second‐line therapy was initiated with 10 mg rabeprazole, 750 mg amoxicillin, and 250 mg metronidazole twice daily. After they had been screened by hematological examination 1 week after initiation, the treatment was continued for 2 weeks after initiation in patients without hematological abnormality. Cure was essentially confirmed by the urea breath test. Results: After one patient was lost, hematological examination showed elevated serum aminotransferase in 14 of 81 patients. Although it was mild without clinical issues, they were ethically excluded from this study. In the remaining 67 patients and the lost patient, the eradication rate with 2‐week therapy was 65/68 (96%, 95% confidence interval: 88–98%) by intention to treat analysis and 65/65 (100%, 94–100%) by per protocol analysis. The main adverse event was soft stools (39%), and no serious adverse event was observed. Conclusion: This 2‐week metronidazole‐containing second‐line therapy provides high efficacy in Japan where metronidazole resistance is rare.     

The influence of experimentally induced pathological states on the flow and composition of central lymph in the rat

The flow of central lymph in the rat was examined and its concentration of total proteins was determined. Experiments were performed both on healthy animals and on animals with experimentally induced pathological states. The following results were obtained: The flow of the lymph is increased in chronic liver damage, acute kidney damage and the malabsorption syndrome. On the other hand, lymph flow is decreased in fasting animals, and it is unaffected by acute liver damage. Total protein concentration was increased in fasting rats and in the group with acute liver damage, and on the contrary, it was decreased in the group with chronic damage, acute kidney damage, and malabsorption syndrome. The lymph flow or total protein concentration are not sex-dependent.