Medizinische Klinik最新文献

Case report: A 73-year-old male patient presented with upper gastrointestinal bleeding. The reason was an arterial hemorrhage from a duodenal tumor that could only be stopped by an angiographic intervention. In the further staging, there was evidence for a neuroendocrine carcinoma of the pancreatic head with infiltration of the duodenum and hepatic metastases. Due to good differentiation (G1) a systemic biotherapy with octreotide LAR was induced. After recurrent bleeding with arrosion of a branch of the superior mesenteric artery, a duodenum-preserving pancreatic head resection was performed. Afterwards, the systemic therapy was changed to a palliative chemotherapy with streptozotocin and 5-fluorouracil due to local progression of the disease and a Ki-67 index of 4% in the primary tumor.

Conclusion: In about 0.7% of patients with neuroendocrine tumors, the lesion is located in the pancreas. At this site these entities are very heterogeneous. The majority are nonfunctional tumors without secretion of bioactive substances and the associated symptoms. About 60% of the patients present with advanced metastasized disease. The therapy depends on the local spread and histological grading as well as symptoms of the patient. The only curative option represents surgical resection. However, even in a palliative situation, there can be benefit for the patient in case of a tumor mass reduction of > 90%. Alternative therapies in the palliative situation are somatostatin analogs, a classic systemic chemotherapy, or locoregional interventional procedures.

Case report: The case of a 46-year-old male with progressive dyspnea on exertion and severe headache while having the head lowered is described. Clinically, the patient showed left-sided pleural effusion, jugular venous distension, and a congested liver. During cardiologic work-up, echocardiography, combined left/right heart catherization and magnetic resonance imaging established the diagnosis of constrictive pericarditis. Under conservative medical treatment, the patient again developed cardiac decompensation and, therefore, a pericardectomy was performed. Immediately after surgery, symptoms diminished and exercise tolerance increased. The patient is currently in cardiac rehabilitation.

Conclusion: Constrictive pericarditis is a rare differential diagnosis of right heart failure. Especially in patients with congested inferior vena cava, but normal systolic left ventricular function and normal function of the cardiac valves, constrictive pericarditis should be considered as a differential diagnosis.

Background: In patients with a history of pancreatic surgery, chronic diarrhea is mainly caused by exocrine pancreatic insufficiency. The authors report, for the first time, a case of jejunocolic fistulae as a cause of diarrhea and weight loss after pancreatic head resection.

Case report: A 55-year-old patient presented with chronic diarrhea and cachexia. He had undergone pylorus-preserving pancreatic head resection for chronic pancreatitis 8 years earlier. A recent colonoscopy showed an uncommon anatomy of the colon. Gastroscopy and computed tomography revealed several jejunocolic fistulae as the cause of chronic diarrhea. The patient underwent surgery and the fistula-carrying parts of jejunum and colon were resected. After surgery, his clinical status improved and he gained weight.

Conclusion: Interenteric fistulae after pylorus-preserving pancreatic head resection have not been reported so far. Impaired synchronization of gastric emptying and bile secretion could be a possible cause of autodigestion in the anastomosis region.

Case report: A 52-year-old female patient was admitted to hospital because of progressive thrombosis despite therapeutic anticoagulation as well as leukocytosis with eosinophilia and thrombocytopenia. On examination, the patient presented with dyspnea and swelling oft her left leg and arm. The laboratory findings revealed leukocytosis (31,000/microl) with eosinophilia (54%), thrombocytopenia (58,000/microl), together with an increased C-reactive protein of 247 mg/dl (reference range < 5 mg/dl). Initial computed tomography scans showed pulmonary embolism and a slightly enlarged left inguinal lymph node. Histological examination of the lymph node biopsy revealed in part an epitheloid and spindle cell-like tumorous lesion with slightly increased tissue eosinophilia consistent with an inflammatory myofibroblastic tumor (IMT). Resection of the left inguinal lymph node resulted in an immediate regression of the paraneoplastic eosinophilia and thrombocytopenia. Anti-inflammatory medication with ibuprofen was subsequently initiated. Imaging and clinical examination at 3 months after discharge revealed no relapse and no signs of a paraneoplastic syndrome.

Conclusion: The IMT is a rare soft-tissue tumor of intermediate dignity with a low tendency to metastasize. It is consistently accompanied by paraneoplastic syndromes. Therapy of choice is complete resection of the tumor. In nonresectable cases, corticosteroids and nonsteroidal antirheumatics have been shown to be effective. Because of the variable clinical course ranging from spontaneous regression to metastasis, IMTs might be separated into different entities (autoimmune, inflammatory, neoplastic subtype) which thus far cannot be classified on a histopathologic basis. A clinical assessment of the dignity is therefore important until further subclassifications of this rare disease become available.

Patients with chronic pancreatitis are burdened with an increased risk of developing pancreatic cancer. Strategies or guidelines for the surveillance and early detection of pancreatic adenocarcinoma in patients with chronic pancreatitis are not established, because available clinical, serologic or imaging techniques are still of limited sensitivity and specificity. Despite these limitations do patients with chronic pancreatitis and suspected pancreatic cancer need a careful and sometimes repeated diagnostic work-up. A clear benefit of surveillance programs outside of clinical trials for the early detection of pancreatic cancer has not been demonstrated. A 51-year-old patient with chronic pancreatitis is reported who developed cancer of the pancreatic head while undergoing repeated imaging studies.

Background: The frequency of diagnosis of celiac disease has increased since the introduction of serologic testing. The number of patients in whom extraintestinal symptoms reflect the initial manifestation is rising. Common symptoms are changes in blood counts, which can arise from changes in all cell lineages. Among these, iron deficiency anemia is very common, but also thrombocytosis and thrombocytopenia have been reported to manifest themselves within the framework of celiac disease.

Case report: The authors report on a patient with malnutrition, macrocytic anemia, and pronounced thrombocytopenia. Based on changes of peripheral blood smear and endoscopic result, celiac disease was suspected that could be confirmed by histology of duodenal biopsies. The thrombocytopenia was reversible after initiation of gluten-free diet and folic acid substitution. In addition, clinical symptoms resolved and hematologic reconstitution could be observed.

Conclusion: Similar deficiencies have almost exclusively been observed in patients with increased folic acid requirements during pregnancy or intensive care. Celiac disease must be taken into consideration, if changes in blood counts occur associated with gastrointestinal symptoms.

Background: Secondary hypertension can rarely be caused by different disorders as shown in the present case with simultaneous occurrence of two possible causes.

Case report: Magnetic resonance imaging findings of a 58-year-old patient showed an eccentric left renal artery stenosis of 60-70% and an inhomogeneous tumor of the left adrenal gland. After percutaneous transluminal angioplasty, elevated plasma aldosterone concentrations persisted. Adrenal vein sampling in the authors' hospital confirmed a primary hyperaldosteronism due to unilateral adenoma. Subsequently, unilateral laparoscopic adrenalectomy was performed.

Conclusion: Atherosclerotic renal artery stenosis stimulates the renin-angiotensin system and thereby causes secondary hypertension. Furthermore, adrenal disorders that lead to abnormal aldosterone secretion, i.e., primary hyperaldosteronism, often result in secondary hypertension. Though the simultaneous occurrence of two potential causes of secondary hypertension is rare, it has to be considered for differential diagnosis and therapy. The presumed pathophysiological relevance should guide the order of therapeutic measures.

Case report: A 37-year-old patient with cephalgia and fever after his return from Mexico is reported. Due to persistently elevated transaminases, a liver biopsy was performed. Histological examination revealed hepatic involvement of a granulomatous disease. Serologic analyses detected anti-Brucella IgM. The suspected diagnosis was thus brucellosis taking the typical anamnesis into account. Treatment with rifampicin and doxycycline led to a complete convalescence of the patient.

Conclusion: Brucellosis is an anthropozoonosis that exists worldwide. Potential sources of infection are uncooked or unpasteurized milk and milk products of infected animals. Complete cure of most brucellosis-infected patients can be achieved by an early and adequate antibiotic treatment.

Tako-tsubo cardiomyopathy is characterized by a transient and reversible left ventricular dysfunction and shows clinical similarities with the acute coronary syndrome. Here, the authors report and discuss a case of a patient with tako-tsubo cardiomyopathy triggered by adrenaline injection after a wasp sting.

History and admission findings: A 73-year-old man with NSTEMI (non-ST segment elevation myocardial infarction) underwent coronary angiography and an in-stent restenosis and thrombosis in ramus circumflexus was found. A drug-eluting stent (DES) was implanted. 12 h after intervention during threefold platelet inhibition the patient presented a gastrointestinal bleeding with melena and the hemoglobin level dropped from 15.3 g/dl to 9.7 g/dl.

Investigations: Blood tests revealed a considerable elevation of cardiac enzymes, troponin I, leukocytes and C-reactive protein but normal hemoglobin. In coronary angiography, the stent in ramus circumflexus was found to be occluded. Therefore, a percutaneous coronary intervention with implantation of a DES (Taxus) was performed. In gastroscopy, a 2.5-cm necrotic formation resembling a tumor with an oozing bleeding was identified. The bleeding was stopped after injection of adrenaline. Histological evaluation showed no criteria of malignancy.

Treatment and course: With high-dose proton pump blocker therapy, calculated Helicobacter pylori eradication with amoxicillin and clarithromycin, and cessation of NSAID (nonsteroidal anti-inflammatory drugs), the hemoglobin level was stable with 9.7 g/dl. No blood transfusion and no interruption of the dual platelet inhibition were necessary. In control gastroscopy, the initial endoscopically malignancy-suspicious formation presented as a small, superficial, healing ulcer.

Conclusion: Bleeding complications after stent implantation create a dilemma situation. The risk of a hemorrhagic shock by continuing platelet inhibition therapy and the risk of an acute stent thrombosis with interruption of the platelet inhibition should be carefully calculated considering individual facts and the guidelines.