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PubMed1998

The role of infarction-associated pericarditis on the occurrence of atrial fibrillation.

AIMS: Transient atrial fibrillation is a relatively common arrhythmia in the early phase of acute Q-wave myocardial infarction. However, the role of infarction-associated pericarditis on the genesis of atrial fibrillation is controversial. This study was designed to examine the relative importance of infarction-associated pericarditis among other clinical variables on the genesis of transient atrial fibrillation in patients with acute myocardial infarction. METHODS AND RESULTS: Three hundred and ninety-eight patients with acute Q-wave myocardial infarction were examined carefully by means of auscultation, ECG, two-dimensional echocardiography and haemodynamic measurements. The diagnosis of pericarditis was made on the basis of pericardial rub detected during the first 3 days after admission. At least 0.5 mm of PQ-segment depression from a TP segment lasting more than 24 h in both limb and precordial leads was considered diagnostic of PQ-segment depression. Atrial fibrillation was present in 76 patients (19%). Sixteen (42%) of 38 patients with PQ-segment depression had atrial fibrillation, whereas 23 (30%) of 77 patients with pericardial rub had atrial fibrillation. Based on ten clinical variables, multivariate analysis was performed to determine the important variables related to the occurrence of atrial fibrillation. PQ-segment depression (chi-square = 4.10, P < 0.05) was selected with age (chi-square = 10.52, P < 0.005), the number of left ventricular segments with advanced asynergy (chi-square = 7.73, P < 0.01) and pericardial effusion (chi-square = 7.95, P < 0.005) as important factors related to atrial fibrillation. Patients with PQ-segment depression had a significantly higher pulmonary capillary wedge pressure than those without it. CONCLUSION: Among patients with infarction-associated pericarditis, those with PQ-segment depression represent atrial involvement associated with extensive myocardial damage and hence, PQ-segment depression is one of the clinical signs related to the occurrence of atrial fibrillation in acute Q-wave myocardial infarction.

Aged↗
PubMed2004

Measurement and treatment of elevated blood pressure in the pediatric patient with chronic kidney disease.

Hypertension, as in adults, is a frequent complication found in children with chronic kidney disease (CKD). Indeed, hypertension has now become one of the most prevalent chronic diseases of childhood. The most recent data available (2003) indicate that at least 38% of children with CKD in the United States are receiving antihypertensive therapy. Only recently has it been shown in children that hypertension, traditionally considered a marker for disease severity in children, is additionally a significant and independent risk factor for accelerated deterioration of kidney function and progression of CKD and a significant risk factor for cardiovascular disease. The following review outlines the differences and similarities of childhood versus adult hypertension with respect to measurement, diagnosis, treatment, and consequence in CKD. The definition of hypertension changes continually as a child grows with or without CKD. Despite numerous guidelines, the diagnosis of childhood hypertension continues to be based on epidemiologic data rather than evidence. For children, the current definition includes 2 categories: high normal, which is blood pressure (BP) between the 90th and 95th percentile, and hypertensive, which is BP above the 95th percentile. The evaluation of all hypertensive children should include a complete assessment of end-organ damage, including eyes, cardiovascular system (including blood vessels), kidneys, and nervous system. For children with CKD and end-stage renal disease (ESRD), a high percentage have left ventricular hypertrophy (LVH). The finding of end-organ damage or comorbidity (CKD, diabetes) in any child is an absolute indication for immediate pharmacologic therapy, whereas the presence of hypertension above the 95th percentile in children without CKD warrants initial intervention such as life style modification. The guidelines for measurement of BP in children with CKD are similar to those in children without CKD and include casual BP measurement, self-measured BP, and ambulatory BP monitoring. The recommendation for BP measurement in children is, when permitted, by auscultative method with a well-calibrated mercury manometer. Most casual BP measurements are performed with an automated oscillometric device whose validation has not been confirmed in children with CKD. The ambulatory BP monitor (ABPM) has 2 advantages: it significantly correlates with the presence of end-organ damage, and it identifies abnormal BP patterns that are frequently present in CKD patients, such as hypertension during the sleep period. An abnormal ABPM pattern can also be predictive of the development of end-organ damage. Treatment of hypertension in children, with and without CKD, is based on 3 factors: degree of BP elevation, the presence of cardiovascular risk factors, and the presence of end-organ damage. Additionally, the initial antihypertensive agent may be selected on available and age-appropriate formulations (eg, suspension and dosage selection). A physician treating a hypertensive child with CKD faces multiple challenges. They include selecting the convenience of available automated devices and the ABPM versus traditional auscultatory techniques upon which all normative standards have been based. Current research initiatives propose to develop pharmacokinetic and pharmacodynamics properties of antihypertensive medications and to study the effect of early intervention on end-organ damage.

Blood Pressure↗
PubMedDate not supplied

Detachable coils for occlusion of patent ductus arteriosus in 2 dogs.

OBJECTIVE: To describe the use of a detachable coil for transcatheter closure (TCC) of patent ductus arteriosus (PDA) in 2 dogs. STUDY DESIGN: Clinical study. ANIMALS: Two female Pembroke Welsh Corgi dogs with PDA. METHODS: Using fluoroscopic guidance, an 8-mm-diameter coil stent with 5 loops (detachable coils for PDA closure) was inserted via catheterization of the femoral artery. The catheter was passed through the PDA into the pulmonary artery. The coil was withdrawn so that 1.5 loops remained on the pulmonary side of the orifice of the ductus. The rest of the loops were pushed out from the catheter into the ductus. After confirming the correct placement of the coil and the effectiveness of the occlusion, the delivery wire was detached from the coil. RESULTS: Insertion of the coil was easily performed, even without previous experience. Immediate and marked decrease of the cardiac murmur was auscultated. Only slight residual flow was detected by angiography conducted 3 months' postoperatively. The dogs experienced quick and uneventful recovery after coil placement and required minimal postoperative care. Follow-up evaluation of the dogs showed no functional clinical signs of PDA, and no cardiac abnormalities were detected on electrocardiographic, phonocardiographic, and echocardiographic examination. In dog 1, the residual flow had disappeared on the color-flow Doppler echocardiographic examination at 18 months' postoperatively. CONCLUSION: TCC using a detachable coil was easy, safe, and effective in 2 dogs with PDA. The minimal residual shunting observed only by echocardiography seemed hemodynamically insignificant. CLINICAL RELEVANCE: This method can be used as an alternative to traditional surgical methods.

Animals↗
PubMed2000

The postpericardiotomy syndrome as a cause of pleurisy in rehabilitation patients.

Pleuritic chest pain in patients on a rehabilitation unit may be caused by several conditions. We report 2 cases of postpericardiotomy syndrome (PPS) as a cause of pleuritic pain. PPS occurs in 10% to 40% of patients who have coronary bypass or valve replacement surgery. The syndrome is characterized by fever, chest pain, and a pericardial or pleural friction rub. Its etiology is believed to be viral or immunologic. The syndrome can be a diagnostic challenge, and an increase in length of hospitalization because of it has been documented. Identified risk factors for PPS include age, use of prednisone, and a history of pericarditis. A higher incidence has been reported from May through July. Many patients undergo a battery of expensive procedures before PPS is diagnosed. The pain is sharp, associated with deep inspiration, and changes with position. Pleural effusions may be present and tend to occur bilaterally. Pericardial effusions are a documented complication. A pericardial or pleural rub may be present and is often transient. Serial auscultation is important. Laboratory work provides clues with a mild leukocytosis and an elevated erythrocyte sedimentation rate. However, this does not provide the definitive diagnosis. Cardiac enzymes are not reliably related to the syndrome. An electrocardiogram will show changes similar to those associated with pericarditis. The patient may have a fever, but it is rarely higher than 102.5 degrees F. Complications include pericardial effusions, arrhythmias, premature bypass graft closure, and cardiac tamponade. Treatment consists of a 10-day course of nonsteroidal anti-inflammatory drugs.

Aged↗
PubMed2000

Bupivacaine-induced myocardial depression and pulmonary edema: a case report.

Central nervous system and cardiovascular toxicity are well-known side effects of bupivacaine. We report a case of bupivacaine-induced myocardial depression and cardiogenic pulmonary edema. A previously healthy woman developed soon after bupivacaine epidural injection of 5 mL 0.5% (25 mg) cardiogenic shock complicated with pulmonary edema. There were pronounced rales on auscultation with a butterfly sign on chest radiograph. A cardiac ultrasound showed reduced myocardial contractility, diffuse hypokinesia, left ventricular ejection fraction (LVEF) 25%, mitral and pulmonary insufficiency. Right heart catheterization showed increased pulmonary artery wedge pressure (34 mm Hg) and a pulmonary artery pressure of 48 over 33 mm Hg. These findings suggest myocardial depression owing to bupivacaine sodium channel blocking of myocardial nerve and tissue and subsequent reduction of myocardial contractility. The patient completely recovered with normalization of clinical, roentenographic, ultrasound, and hemodynamic findings and discharged 10 days later in good condition.

Adult↗
PubMed1977

[The frequency of the combination of arterial occlusive disease in supraaortic and leg range. An analysis in the patient population of a vascular surgical department (author's transl)].

Among 337 male patients who were hospitalized because of chronic ischemia of the leg, 103 (=30.6%) were shown to suffer from concomitant occlusive vascular disease of supraaortic branches. This was evaluated by simple examination like auscultation, bilateral blood pressure measurements, and palpation of pulses. In 52% the patients history revealed dizziness, hemiparesis and transient ischemic attacks (TIA). Arteriell hypertension promotes supraaortic vascular diseases as is shown by a relative frequency of 0.52 in contrast to 0.39. Combined occlusions of the iliac and femoropopliteal arteries are accompanied by supraaortic vascular disease in 40%, in femoropopliteal occlusion alone in only 20%. If the basic diagnostic approach is improved by directional ultra-sonic examinations of the carotid arteries, approximately 20% of all patients with advanced vascular disease of the iliac and femoropopliteal arteries have to be operated on for cerebrovascular disease.

Aged↗
PubMed1975

[Ruptured aneurysm of the aortic sinus of Valsalva (author's transl)].

Three cases of ruptured aneurysm of the aortic sinus of Valsalva (one each into the right atrium, right ventricle and pulmonary artery) are reported and clinical as well as haemodynamic features described. It is pointed out that the right sinus is most frequently involved, the non-coronary one only rarely, and the left one only quite exceptionally. The clinical findings depend on the size, site and direction of the rupture and its haemodynamic consequences. Rupture occurs most frequently into the right attrium or ventricle, much more rarely into the pulmonary artery or left ventricle. Cardinal clinical signs are retrosternal pain, marked shock with dyspnoea and tachycardia or rapidly progressive cardiac failure. Auscultation reveals either a continuous systolic-diastolic murmur or a holosystolic crescendo-decrescendo murmur followed by a high-frequency diastolic murmur, maximal parasternally in the second to fourth left intercostal spaces. As effective surgical treatment is available, early diagnosis is essential.

Adult↗
PubMed2000

Efficacy and tolerability of myrtol standardized in acute bronchitis. A multi-centre, randomised, double-blind, placebo-controlled parallel group clinical trial vs. cefuroxime and ambroxol.

UNLABELLED: Myrtol standardized (Gelomyrtol forte) is a phytotherapeutic extract (distillate) consisting mainly of three monoterpenes: (+)alpha-pinene, d-limonene and 1,8-cineole. OBJECTIVE: This study describes and compares the efficacy, safety and tolerability of a 2-week treatment with myrtol stand. (4 x 300 mg, day 1-14), cefuroxime (CAS 55268-75-2) (2 x 250 mg daily for day 1-6), ambroxol (CAS 18683-91-5) (3 x 30 mg for day 1-3, 2 x 30 mg for days 4-14) and matched placebo in acute bronchitis. PATIENTS: 676 male and female outpatients, aged > or = 18 years, with acute bronchitis of recent onset (within last 5 days), with an FEV1 > 75% of the normal EGKS-value and without evidence or suspicion of chronic pulmonary disease or any further confounding illness were included in the study. INTERVENTION: Patients were randomly assigned to a 2-week treatment course with either myrtol stand. (N = 170), cefuroxime (N = 171), ambroxol (N = 163) or placebo (N = 172) in a double-blind, placebo-matched, parallel-group fashion. Evaluations were at baseline (visit 1), after 1 and 2 weeks of treatment (visits 2 and 3) and at 2 weeks after conclusion of the treatments (visit 4). CRITERIA: Responder- and non-responder rates (primary), signs (abnormal auscultation), symptoms (daily diary data on nightly cough, coughing fits during the day, sputum consistence and general well-being; visit data on bronchial hyperreactivity and absence/presence of associated symptoms), FEV1, overall efficacy, absence of relapse, safety and tolerability (adverse events, laboratory screens, vital signs and physical examination). Criteria were evaluated for the intention-to-treat data-set (ITT) and the 'efficacy evaluable' sample (EAP), i.e. excluding patients with missing values (incl. discontinued non-responders and drop-outs for other reasons) at the time of assessment. RESULTS: The signs and symptoms of acute bronchitis regressed readily in all treatment groups, but regression was slower and less complete in the patients treated with placebo. In patients treated with placebo, the acute bronchitis was considered to have deteriorated to such an extent that discontinuation was indicated ('non-responder') in 36 patients (ITT: 20.9%, 95% CI: 15.1 to 27.8% and EAP: 21.3%, CI: 15.4 to 28.3%) after 1 week (visit 2) and in 19 further patients (ITT: 11.0%, CI: 6.8 to 16.7%; EAP: 14.8%, CI: 9.2 to 22.2%) after 1 further week (visit 3). In contrast, in the group of patients treated with myrtol stand. the non-responder rates at visits 2 and 3 were only 5.3% (ITT, CI: 2.4 to 9.8%; EAP: 5.4%, CI: 2.5 to 10.0%) and 1.2% (ITT, CI: 0.1 to 4.2%; EAP: 1.3%, CI: 0.2 to 4.7%); the responder rates at visit 2 were statistically significantly higher (p < 0.001) for myrtol stand. (ITT: 92.9%, CI: 88.0 to 96.3) compared to placebo (ITT: 77.3%, CI: 70.3 to 83.4), and similar to those for cefuroxime (ITT: 92.4%, CI: 87.4 to 95.9) and ambroxol (ITT: 89.6%, CI: 83.8 to 93.8%). The superiority of the active treatments vs. placebo with little difference among the treatments was confirmed for all further criteria of evaluation. There was no evidence of bronchoconstriction or relapse in any treatment group for the patients continuing treatment (i.e. for those who were not discontinued because of non-response). The treatments were safe and comparably well tolerated. CONCLUSION: Compared to placebo, treatment with myrtol stand. was well tolerated but evidently superior in terms of efficacy, resulting in a more rapid and more complete recovery; although well comparable with the other active treatments, myrtol stand. tended to be superior to cefuroxime and ambroxol for several ancillary criteria. Myrtol stand. is a well-evidenced alternative to antibiotics for acute bronchitis without specified infective agent, without the risk to promote the development of bacterial resistance.

Acute Disease↗
PubMed2000

[Aortic rupture in idiopathic Gsell-Erdheim medial necrosis].

HISTORY AND CLINICAL FINDINGS: A 75-year-old man was admitted with increasing dyspnoea and recurrent left-sided chest pain, at first during exercise and later at rest. No cardiovascular risk factors could be found. His past medical history revealed mastectomy and radiotherapy for breast cancer and an operation for benign prostate hyperplasia. At admission the patient was in very poor conditions with marked orthopnoea. Bilateral moist rales were heard over both lungs with a 3/6 diastolic murmur an cardiac auscultation. INVESTIGATIONS: Anterolateral ST segment depression in the ECG and signs of pulmonary oedema in chest X-ray were also noted. Echocardiography discovered global reduced left ventricular contractility with aortic insufficiency (II degree) in mild aortic valve sclerosis. Coronary angiography demonstrated marked dilatation of the coronary arteries without stenosis. The ascending aorta was dilated without angiographic signs of a dissection. DIAGNOSIS, TREATMENT AND COURSE: After medical treatment and a short period without symptoms the patient had to be resuscitated and died after a intense attack of dyspnoea and chest pain. The autopsy revealed a focal dissection of the ascending aorta with a small aortic rupture caused by idiopathic Erdheim's medial necrosis. CONCLUSION: Erdheim's medical necrosis is an important cause of aortic dissection and aortic rupture. If symptoms of acute severe chest pain are present and a coronary syndrome can be excluded, possible disease of the aorta should be investigated. The reported case demonstrates the short time window between onset of symptoms and the necessary treatment.

Aged↗
PubMed2000

[Superior vena cava thrombosis after in vitro fertilization].

HISTORY AND CLINICAL FINDINGS: A 29-year-old female was admitted with the diagnosis of multiple deep vein thrombosis of the upper limbs and neck and pneumonia secondary to pulmonary embolism on the right side. Medical history revealed that in vitro fertilization with hormone stimulation had been carried out 5 weeks before. For ten days the patient had noticed a growing, painful swelling on the right side of her neck accompanied by difficulties in swallowing. Since this time she had experienced episodes of shortness of breath without chest pain. Clinical findings showed a soft and slightly painful swelling of the right side of the neck without dyspnoea or cyanosis at rest. Breath sounds were decreased over the right lower lung on auscultation. INVESTIGATIONS: Magnetic resonance imaging (MRI) confirmed complete obstruction of the subclavian and brachiocephalic vein on the right side and clots in the superior vena cava, left subclavian vein, bilateral internal jugular veins and the right axillar vein. Chest x-ray showed pleural effusion on the right side. TREATMENT AND COURSE: As the seven-week pregnancy was found not to be viable anymore, fibinolysis with streptokinase was started under protection of a temporary cava filter. During the following hours the patient developed serious bleeding as a complication of this therapy and fibrinolysis had to be discontinued after 16 hours. In subsequent examinations the obstruction of the left internal jugular vein was unchanged but collaterals around the obstruction were noticed. The other veins affected were open, some with reduced flow. Several risk factors were found in the history of the patient such as smoking, immobilization, a positive family history, protein S deficiency and APC resistance. After 3 weeks of hospital therapy the patient was discharged under oral anticoagulation with coumarin. CONCLUSION: In vitro fertilization with hormonal stimulation may cause serious complications in patients with unknown coagulation disorders or with an ovarian hyperstimulation syndrome. Risk factors for thromboembolism need to be ruled out carefully before starting the procedure.

Abortion, Spontaneous↗
PubMed2000

A comparison of the indirect estimate of mean arterial pressure calculated by the conventional equation and calculated to compensate for a change in heart rate.

The standard equation used to calculate mean arterial pressure (MAP) assumes that diastole persists for 2/3 and systole for 1/3 of each cardiac cycle. This ratio is altered when heart rate increases, and therefore we investigated the efficacy of predicting MAP during exercise using non-invasive indirect methods. Eight subjects exercised on a cycle ergometer for 3 minute intervals to elicit heart rates between 100-110, 120-130, 140-150, 160-170, and 180-190 beats/min. In the last minute of each 3 min interval an ECG recording was taken and systolic (SP) and diastolic (DP) blood pressure was measured by manual auscultation. MAP was calculated for each heart rate interval by: MAP=DP+1/3(SP-DP) (method A), and MAP= DP + Fs(SP- DP) (method B), where Fs is the fraction of the cardiac cycle comprising systole, measured from the ECG. Fs increased from 0.35+/-0.049 at rest to 0.47+/-0.039 at a heart rate of 180-190 beats/min. MAP measured by method B was consistently greater than MAP calculated by method A at all heart rates greater than resting heart rate (p<0.01). The error incurred when using the standard MAP equation (method A) to derive MAP during exercise (measured as the percentage difference between method A and B) increased linearly with heart rate (r=0.98). The standard MAP equation should not be applied during exercise, as it does not account for the change in the systolic: diastolic period ratio as heart rate increases.

Adult↗
PubMed2000

[Unclear pulmonary infiltrates with eosinophilia, a problem of differential diagnosis]

Unclear pulmonary infiltrates with eosinophilia, a problem of differential diagnosis. HISTORY AND ADMISSION FINDINGS: A 60-year-old woman was admitted for the diagnosis of pulmonary infiltrates. A year before she had been exposed to tuberculosis when working as a doctor in Manila, the Philippines. Ten days before admission she had spent 10 days in Sao Paulo, Brazil. On admission she complained of fatigue, dry cough and nocturnal sweating. Her body temperature was 37.8; C. At auscultation of the chest fine rales were heard with diminished percussion sounds over both lungs. INVESTIGATIONS: The chest radiogram showed bilateral apical infiltrates. Blood count indicated normal white and red cells, but platelets were raised to 606 x 10 9/l. The differential blood count revealed an eosinophilia of 30%, ESR was raised at 91 mm/h and C-reactive protein increased to 103 mg/l. Angiotensin-converting enzyme, IgG, IgA, IgM, IgE, C3 and C4, paraproteins, antinuclear antibodies and double-strand DNA antibodies were all within normal limits. There was no direct or indirect evidence of tuberculosis and no parasites were found in sputum, stool, urine and blood. DIAGNOSIS, TREATMENT AND COURSE: After bronchoscopy with bronchial biopsy had failed to establish a diagnosis, an open lung biopsy with partial lung resection was performed. This revealed histologically an eosinophilic pneumonia with intra-alveolar protein precipitation and multinucleated giant cells, as well as interstitial fibroblast proliferation without demonstrable mincroorganisms. Under cortisone administration there was striking improvement of symptoms within a few days, and C-reactive proteins fell to 3 mg/l, ESR to 25 mm/h and the eosino-philia to 2%. CONCLUSION: Eosinophilic pneumonia should be included in the differential diagnosis of unclear pulmonary infiltrations with eosinophilia, once parasitological and malignant diseases, tuberculosis and allergic pulmonary aspergillosis have been excluded.

Journal Article↗
PubMed2002

[A hemodynamically active type II atrial septal defect in a 78-year-old patient. Indications for interventional catheter occlusion?].

HISTORY AND ADMISSION FINDINGS: A 78-year-old woman presented with a first episode of syncope. She reported increasing fatigue and dyspnoea upon exertion over a period of 20 years and chest pain 2 months prior to admission. Auscultation revealed fixed doubling of the second heart sound. INVESTIGATIONS: Laboratory tests showed increased troponin I. Transaminases were moderately elevated. Chest X-ray showed an enlarged right heart and a dilated pulmonary artery (2 cm). Echocardiography discovered a large secundum atrial septal defect with a diameter of 3 cm but no right to left shunt (no Eisenmenger reaction). Cardiac catheterization revealed a stenosis of the right coronary artery and severe systolic pulmonary hypertension of 80 mmHg. DIAGNOSIS, TREATMENT AND COURSE: A significant stenosis of the right coronary artery was successfully dilated. The ASD was closed by interventional implantation of a commercial closure device (Amplatzer). One month later, echocardiography indicated in an estimated systolic pulmonary pressure of 30 mmHg. The patient's condition improved considerably. CONCLUSION: This case is remarkable in that a very large ASD was asymptomatic up into old age and without the development of an Eisenmenger reaction. Also, large ASD can be by catheterization with the appropriate closure device. Fixed pulmonary hypertension is not obligatory. Non-invasive closure is a good alternative of surgery in elderly patients with risk factors.

Aged↗
PubMed2002

[Henoch-Schoenlein syndrome in an 80-year-old patient].

HISTORY AND CLINICAL FINDINGS: An 80-year old female patient, hospitalised with pneumonia and myocardial infarction, suddenly developed fever, dyspnoea, malaise, arthralgia and crampy abdominal pain. On the following day, she developed a petechial rash and on the 6 (th) day, macroscopic haematuria. On physical examination, the patient presented with a temperature of 40 degrees C, tachypnoea, tachycardia, and on auscultation coarse crepitations at the left lower base. The abdomen was tender upon deep palpation but bowel sounds were normal. Initially the petechial rash was located at the trunk, later progressing towards the extremities. INVESTIGATIONS: Chest X-ray and laboratory tests were consistent with left lower lobe pneumonia. The clinical picture was not consistent with any haematological causes, coagulopathy or any medication the patient was taking. Rheumatological blood tests (involving ANA, ANCA, rheumatoid factors) were basically negative. A skin biopsy revealed microvessel necrosis and IgA deposits, verifying Henoch-Schoenlein Purpura. An immune electrophoresis revealed a selective IgG-deficiency, which may explain the cause for the patient's recurrent pneumonias. COURSE: The patient recovered well under antibiotic treatment and skin lesions healed without sequelae. CONCLUSION: We present an unusual case of Henoch Schoenlein purpura associated with strictly petechial rash in an 80 year old female.

Aged↗
PubMed2004

[Alternating electric heart axis in a patient with small cell lung cancer].

HISTORY AND ADMISSION FINDINGS: A 62-year-old man was admitted because of recurrent abdominal pain 18 months after small cell lung cancer (SCLC) had been diagnosed and remission achieved with chemotherapy and radiotherapy. The abdomen was soft on palpation, but pressure on the epigastric region was painful. Symptomatic treatment brought improvement, but 16 hours after admission the patient complained of severe diffuse abdominal pain. Abdominal findings were unchanged. He was pale and in a cold sweat. Heart sounds were decreased, while auscultation and percussion of the lung were unremarkable. INVESTIGATION: Lactate dehydrogenase and aspartate-aminotransferase concentrations were markedly raised and the serum creatinine was increased, while the Quick value was decreased. The electrocardiogram (ECG) showed low voltage and alternating electrical heart axis. Chest radiogram demonstrated a double-contour cardiac silhouette suggesting a large pericardial effusion, confirmed on echocardiography, which also showed a pendulum-like cardiac motion. The needle aspirate of the pericardial fluid contained malignant cells. DIAGNOSIS: These findings indicated malignant, hemodynamically significant pericardial effusion due to a recurrence of SCLC, with pronounced abdominal symptoms and advanced right heart failure. TREATMENT AND COURSE: Pericardiocentesis brought about marked improvement. 30 mg cisplatin was injected into the pericardial sac and chemotherapy resumed. The ECG became normal. There was no tumor progression over the following 4 months when the pericardial effusion recurred, chemotherapy (4 cycles of carboplatin and etoposide) was restarted and another infusion of cisplatin undertaken. CONCLUSION: This case report illustrates a not uncommon manifestation of lung cancer, malignant pericardial effusion, first becoming symptomatic as severe abdominal pain. Characteristic changes in the chest radiogram and the ECG provided the diagnosis, confirmed histologically.

Abdominal Pain↗
PubMed2004

[Thoracic neuroblastoma in a young adult].

HISTORY AND CLINICAL FINDINGS: A 21-year-old patient was admitted to the hospital because of massively enlarged cervical lymph nodes. Additionally, a left-sided facial and brachial edema was visible. Auscultation of the left lung was remarkable for diminished breath sounds. EXAMINATIONS: Diagnostic imaging showed an extensive thoracic tumor and enlarged mediastinal and cervical lymph nodes. The diagnosis of neuroblastoma was established by biopsy. TREATMENT AND CLINICAL COURSE: The patient was treated with a polychemotherapy protocol according to the pediatric neuroblastoma study NB97. Subsequently, the patient underwent partial tumor resection, received two further chemotherapy courses and irradiation of the remaining tumor. Because of residual vital tumor cells, a second surgical tumour reduction followed by high-dose chemotherapy with autologous stem-cell support was performed. Two cycles of high-dose retinoic acid followed. Six months after the end of therapy, the patient is in a good condition despite of the presence of residual tumor. CONCLUSION: Neuroblastoma is a very rare tumor in adult patients. Therapy is multimodal and should follow pediatric guidelines for neuroblastoma treatment.

Adult↗
PubMed2005

[Bacterial pericarditis].

HISTORY AND CLINICAL FINDINGS: A 65-year-old previously healthy man was referred because of high fever, progressive dyspnea and retrosternal pain for 2 days. On admission, the patient was already in a reduced general condition, blood pressure was 120/70 mmHg, heart rate irregular at 75/min and temperature at 39.7 degrees C. Auscultation of the heart revealed distant heart sounds, murmurs were not present, but mild rales were heard over both lung bases. Jugular veins were congested. INVESTIGATIONS: ECG showed a generalized ST-segment elevation with preserved R-waves, slightly depressed PR-segment and atrial bigemini. Chest X-ray revealed an enlarged cardiac silhouette with signs of a pneumopericardium. Transthoracic echocardiography showed a circular pericardial effusion and haemodynamic impairment. Percutaneous pericardiocentesis revealed a purulent effusion with microbiological proof of pneumococci. The primary infectious focus was a maxillary sinusitis caused by pneumococci. DIAGNOSIS: Bacterial pericarditis due to by haematogenous spread of pneumococci. TREATMENT AND COURSE: Antibiotic therapy consisted of intravenous ceftriaxon and gentamicin. To rinse the pericardial space and drain the thick, purulent effusion subxiphoidal, pericardiocentesis and insertion of a drainage tube were done. Physiological saline was put into the pericardial space several times a day, drained and analysed microbiologically. In the meantime rinsing of the infected maxillary sinus was performed. Transthoracic echocardiography was done repeatedly to rule out complications of bacterial pericarditis, especially constrictive pericarditis. The pericardial tube was removed after proof of a sterile drainage 9 days after insertion. The patient was discharged after 4 weeks of hospitalization without clinical or echocardiographic signs of diastolic dysfunction. CONCLUSION: Suspected bacterial pericarditis must be treated as an emergency and confirmed or ruled out by percutaneous pericardiocentesis.

Aged↗
PubMed2005

[Nocturnal long-term recording of breath sounds in patients with bronchial asthma -- a reasonable diagnostic option?].

Alterations in normal breath sounds are an important indication of pathophysiological processes in the bronchial system and the lung. In the presence of non-specific symptoms like dyspnea, wheezing or cough while sleeping it seems reasonable to make a nocturnal long-term recording of breath sounds. Thus specific auscultation phenomena can be recorded qualitative and particularly quantitative in the course. A mobile recording system provides a non-invasive monitoring at home which is independent of vigilance. Furthermore it can be used for follow-up examinations of medical interventions.

Asthma↗