Cases reported "Chronic Disease"

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1/123. Disseminated nocardiosis in a bone marrow transplant recipient with chronic GVHD.

    We describe a case of disseminated nocardiosis in a 53-year-old male allogeneic marrow recipient with chronic GVHD, 15 years post BMT. Six months prior to admission he was treated for recurrent chronic GVHD with corticosteroids with a good response. He deteriorated subsequently while still on steroids requiring admission for fever, anorexia, weight loss, productive cough and progressive dyspnoea. On admission he had multiple nodular lesions on chest roentgenogram and subsequently grew nocardia farcinica in blood culture. N. farcinica is rare post BMT, has a high mortality, is resistant to various antibiotics and needs prolonged antimicrobial therapy. We report the successful management of our patient with single agent trimethoprim-sulphamethoxazole.
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2/123. Observations on the treatment of dissection of the aorta.

    The results are presented of treatment in twenty-three patients with dissection of the thoracic aorta, in four of whom it was acute (less than 14 days' duration), and in nineteen chronic (more than 14 days' duration). Sixteen patients had Type I and II dissection (involving the ascending aorta) and five Type III (descending aorta at or distal to the origin of the left subclavian artery); in two, dissection complicated coarctation of the aorta in the usual site. Thirteen patients had aortic regurgitation. Three of the patients with acute dissection were treated medically; two, both with Type I dissection, died, and the third, with Type III, survived. The remaining acute patient was treated surgically and also died. Of the patients with chronic dissection, eight were treated medically and eleven surgically. None of the medical group died in hospital; three died between 3 months and 1 year, and five have survived from periods of 12-72 months. Eleven patients with chronic dissection were treated surgically; four died in hospital at or shortly after operation; and the remaining seven lived for periods of 12-84 months. The presentation, indications for surgical treatment and results are discussed. It is concluded that surgical treatment of chronic dissection may carry a higher initial mortality than medical, but that there may be slightly better overall long term results in the former. As this series was not selected randomly, because patients with complications were selected for surgery, and there are only a few patients in each group, the results do not permit firm conclusion regarding the relative merits of medical and surgical treatment. It is suggested that all patients should initially be treated medically but that surgical treatment should be considered if the dissection continues, if aortic regurgitation is severe, if an aneurysm develops or enlarges, if cardiac tamponade develops or there is evidence of progressive involvement of the branches of the aorta. attention is drawn to the important syndrome of chronic dissecting aneurysm of the ascending aorta with severe aortic regurgitation which requires definitive surgical treatment and aortic valve replacement. The importance of adequate visualization of the origin and extent of the dissection as a preliminary to surgical treatment is stressed.
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3/123. Acute hemorrhage into the peritoneal cavity--a complication of chronic pancreatitis with pseudocyst: a case report from clinical practice.

    Acute hemorrhage due to a pseudocyst of the pancreas is a dangerous complication of chronic pancreatitis (CP). Without operative treatment, mortality is as high as 90%. Immediate recognition of this complication as well as urgent operative treatment allowing the survival of 70% of patients is imperative. Described is the case of a patient with CP and pseudocyst in which hyperamylasemia and unclarified anemia developed following sudden abdominal pain. The suspicion of hemorrhage into the peritoneal cavity was confirmed by selective visceral angiography showing hemorrhage from the splenic artery in the region of the hilus of the spleen. Operative treatment was successful. During the procedure, a ligature was applied to the hemorrhaging splenic artery and a splenectomy was carried out with 2500 ml of bloody contents being removed from the abdominal cavity. Acute hemorrhage into the peritoneal cavity as a complication of chronic pancreatitis with pseudocyst (CPP) requires immediate identification, confirmation by visceral angiography, and urgent operative treatment.
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4/123. Use of topical recombinant human platelet-derived growth factor-BB (becaplermin) in healing of chronic mixed arteriovenous lower extremity diabetic ulcers.

    lower extremity ulcers cause significant morbidity and mortality in patients with diabetes. The primary factors that contribute to the development of this type of ulcer are peripheral neuropathy and peripheral vascular disease, which are often accompanied by infection. lower extremity diabetic ulcers are chronic and difficult to treat, in part due to underlying pathologic conditions in individuals with diabetes that can contribute to impaired wound healing. This article reports the author's experience with treatment of chronic lower extremity ulcers of mixed etiologies with recombinant human platelet-derived growth factor--BB [rhPDGF-BB, REGRANEX (becaplermin) Gel 0.01%] in a patient with multiple risk factors including long-standing insulin-dependent type 2 diabetes.
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5/123. aged budd-chiari syndrome attributed to chronic deep venous thrombosis with alcoholic liver cirrhosis.

    budd-chiari syndrome is a rare disease, but there are many known causes. Recent studies showed that it can be an acquired lesion resulting from thrombosis in some elderly patients. We report a 74-year-old man with budd-chiari syndrome attributed to chronic deep venous thrombosis and alcoholic liver cirrhosis. When he was aged 45 years, stasis ulcers of the lower extremities appeared. cerebral infarction and left hemiparesis occurred at age 71. ultrasonography, venacavography, and three-dimensional-magnetic resonance imaging on admission demonstrated total obstruction of the inferior vena cava with several massive thrombi and developed collateral vessels. Although the etiology of the thrombosis remained obscure, we made some speculative assumptions that chronic disseminated intravascular coagulation (which is frequently observed in cirrhosis) or hereditary coagulopathy could be involved, from his familial history of thrombotic phenomena and a severe deficiency of clotting inhibitors. Despite the high mortality of untreated budd-chiari syndrome reported in previous studies, this patient had been alive for about 30 years from the suspected onset.
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6/123. Long-term benefits of stellate ganglion block in severe chronic refractory angina.

    angina pectoris that is refractory to optimal medication and revascularization is becoming an increasingly common clinical problem. Recently the US food and Drug Administration (FDA) approved transmyocardial laser revascularization (TMLR) for use in this group of patients and a large numbers of patients have already undergone this therapy. Unfortunately TMLR has is associated with an unacceptably high perioperative mortality (Cooley DA, Frazier OH, Kadipasaoglu KA, Lindenmeir MH, Pehlivanoglu S, KoIff JW, Wilansky S, Moore WH. Transmyocardiai laser revascularisation: clinical experience with twelve-month follow-up. J Thorac Cardiovasc Surg 1996;111:791-799; Horvath KA, Cohn LH, Cooley DA, Crew JR, Frazier GH, Griffith BP, Kadipasaoglu K, Lansing A, Mannting F, March R, Mirhoseini MR, Smith C. Transmyocardial laser revascularisation: results of a multi-centre transmyocardial laser revascularisation used as sole therapy for end-stage coronary artery disease. J Thorac Cardiovasc Surg 1997;113:645-654; Schofield PM, Sharples LD, Caine N, burns S, Tait S, Wistow T, Buxton M, Wallwork J. Transmyocardial laser revascularisation in patients with refractory angina: a randomised controlled trial. Lancet 1999;353:519-524), and recurrent refractory angina is common (Allen KB, Dowling RD, Fudge TL, Schoettle GP, Selinger SL, Gangahar OM, Angell WW, Petracek MR, Shaar CJ, O'Neill WW. Comparison of transmyocardial revascularization with medical therapy in patients with refractory angina. N Engl J Med 1999;341:1021-1028; Frazier OH, March RJ, Horvath KA, for the Transmyocardial carbon dioxide Laser Revascularization Study Group. Transmyocardial revascularization with a carbon dioxide laser in patients with end-stage coronary artery disease. N Engl J Med 1999;341:1021-1028). Temporary sympathectomy by stellate ganglion block (SGB) is in widespread use in a variety of chronic pain conditions and has long history of use in the management of angina (Moore DC. stellate ganglion block. Springfield, IL: CC Thomas, 1954; Wiener L, Cox JW. Influence of stellate ganglion blockade on angina pectoris and the post exercise electrocardiogram. Am J Med Sci 1966;252:289-295). Here we describe a patient with end stage coronary artery disease and chronic refractory angina whose has been successfully treated with repeated unilateral left SGBs following multiple bypass operations, angioplasty procedures and laser therapy. This case report details his progress over a 34 month follow-up period.
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7/123. A giant parietal wall hematoma: unusual complication of laparoscopic appendectomy.

    Laparoscopic appendectomy is an established procedure in the treatment of appendicitis. Complications of the procedure are related to the Veress needle and trocar insertions or pertain to actual operative procedures. Trocar-elated major bleeding is rare, and, if it occurs, is detected on the table or during the immediate postoperative period. Delay in recognition may lead to significant morbidity and mortality. We report a case of giant parietal wall hematoma in a 34-year-old female, presenting one week after discharge from the hospital. The hematoma was completely evacuated by exploration through paramedian incision, followed by an uneventful recovery.
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8/123. Hibernating myocardium, stunning, ischemic preconditioning: clinical relevance.

    hibernation is a chronic condition that can be due to either chronic low perfusion or repetitive stunning. When oxygen demands increase, prolonged periods of ischemia occur, resulting in multiple episodes of stunning. Because hibernation may play a significant role in refractory failure, the diagnosis of hibernation followed by reperfusion can be life saving. myocardium that has sustained a transient sublethal injury but has the potential for recovery with time is referred to as stunned myocardium. myocardial stunning is commonly seen after coronary artery bypass surgery: variable periods of myocardial ischemia are sustained during coronary artery bypass graft surgery, and when these patients return to the intensive care unit, their ventricular function is severely impaired because of the prolonged anoxia during bypass. With the support of artificial assist devices, counterpulsation or temporary use of catecholamines, these patients improve and have a favorable prognosis. Similarly, recovery occurs with time in stunning that follows AMI or cardiac transplantation because in either case the heart had been temporarily anoxic. Clinical observations of ischemic preconditioning include the following: (1) first-effort angina or "warm-up phenomenon," i.e., angina with exercise early, but similar or greater effort the rest of the day does not cause any angina and (2) mortality of AMI is lower in patients with a history of angina preceding AMI. Angina 1 to 2 hours before AMI is the most effective time window for ischemic preconditioning. A less potent "second window" is observed when angina occurs during the second to fourth day before AMI. adenosine possesses marked cardioprotective properties and has been used to pharmacologically induce ischemic preconditioning with some success. work is still in progress.
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9/123. Perinephric abscess presenting as chronic diarrhea.

    Perinephric abscess is an uncommon diagnosis with a variable presentation and high mortality. We report an unusual case of a patient with a perinephric abscess who presented with chronic diarrhea and weight loss.
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10/123. panniculitis and arthritis as the presenting manifestation of chronic pancreatitis.

    Although rare, panniculitis and polyarthritis can be the presenting manifestations of pancreatitis. Early recognition of this triad is critical because of the high mortality rate from pancreatic disease when the diagnosis is delayed. We report a patient with chronic alcohol intake whose sole presentation was severe polyarthritis and skin lesions secondary to chronic pancreatitis associated with extra pancreatic pseudocyst. Both arthritis and skin lesions disappeared after partial pancreatectomy and pancreatic stent insertion for a pancreatic duct stricture.
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