Lege Artis Medicinae



DECEMBER 20, 2004

Lege Artis Medicinae - 2004;14(12)

[INTRODUCTION - Gallstone ileus is a rare disorder among elderly population. The gallstone coming through a bilioenteral fistula into the gastrointestinal tract is stuck into the duodenal lumen causing ileus in approximately 0,5% of all cases. The syndrome is named after Bouveret, the first describer. CASE REPORT - Author present the case of 72 year old female patient with known cholelithiasis. Investigations proved existing cholelithiasis causing the patient abdominal pain one year before admission but she gave no consent to surgical intervention. An emergency admission to our department occurred after four days of abdominal pain and vomiting. The clinical status of the patient and abdominal X-ray examination suggested stomach evacuation disturbance. Double contrast barium swallow test and gastroscopy proved bowel obstruction caused by a gallstone. During surgery gastrotomy and the removal of gallstone was carried out. There were no postoperative complications and the patient was discharged home. CONCLUSION - Cholelithiasis should be resolved at any chosen time well before complications may occur. The simultaneous appearance of stomach evacuation problems and cholelithiasis should draw attention to this rare disease.]



Further articles in this publication

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BÉLY Miklós, APÁTHY Ágnes

[INTRODUCTION - The lethal septic infection was studied in a randomized (non-selected) autopsy population of 234 in-patients with rheumatoid arthritis. The patients died at the National Institute of Rheumatology between 1970 and 1999. PATIENTS AND METHOD - The aims of this study were to determine the prevalence of lethal septic infection with or without purulent arthritis in rheumatoid arthritis; the relationship between purulent arthritis and lethal septic infection; the clinically missed diagnosis of lethal septic infection and purulent arthritis; the influence of the main complications and associated diseases on lethal septic infection with and without purulent arthritis; the pathogens in lethal septic infection; and the clinico-laboratory parameters associated with lethal septic infection in rheumatoid arthritis. RESULTS - Lethal septic infection was found in 31 (13.24%) of 234 rheumatoid arthritis patients. Purulent arthritis complicated lethal septic infection in 15 (6.4%) of 31 patients. There was a significant association between lethal septic infection and purulent arthritis. Sepsis was detected clinically in 17 of 31 lethal cases and purulent arthritis was detected 9 of 15 septic infection complicated with suppurative articular processes. The coexistent complications (systemic vasculitis, AA amyloidosis), and associated diseases (tuberculosis with or without miliary dissemination, malignant tumors, diabetes mellitus) did not influence the prevalence of septic infection. The most frequent pathogenic agents were: Staphylococcus aureus, Escherichia coli, Proteus mirabilis, Pseudomonas aeruginosa, Klebsiella species, Streptococcus species. The patients with septic infection had significantly lower levels of beta-globulin, and higher values of Waaler-Rose or latex fixation test in comparison to patients without septic infection or without complications. CONCLUSION - Lethal septic infection may exist in rheumatoid arthritis without the classical clinical symptoms of sepsis, and clinically latent suppurative processes may be found at autopsy. The missed clinical diagnosis of a fatal complication is explained by the weak immune response and atypical clinical symptoms of elderly patients mainly treated with steroids and immunosuppressive drugs.]

Lege Artis Medicinae

[A new medical field is born - The first world congress of immuno-genomics, Budapest]

PÓS Zoltán, WIENER Zoltán

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[INTRODUCTION - In this article we analyze the relationships between behavior problems of adolescents and depressed mood of their parents based on literature review and on our own questionnaire surveys. METHODS - We present the data from two surveys conducted among Hungarian adolescents. The first survey was conducted among 1604 young women students, aged of 15-19 years. The second survey included 502 high school students in Budapest. Both surveys were aimed at the lifestyle, health behavior, risk behavior, and emotional state, as well as the social-economic status and family background of the adolescents. Data of both surveys were analyzed using the SPSS 8.0 statistical program package. The association between the mood category of mothers and fathers and the risk factors and emotional state indicators of their children were tested with χ2 tests, as well as the indicators of students whose parents were not treated for depression. RESULTS - Data from both surveys suggest that there are close relationships between the negative mood states of the parents and the behavior problems of their children, especially between the mood of mothers and the behavioral and emotional state of daughters. CONCLUSIONS - Our research data call attention to the phenomenon that girls react explicitly and quite sensitively to the mood state of their mothers while the boys’ behavioral and emotional states are less responsive to their parents’ mood. On the other hand, boys react more intensively to the emotional instability of their fathers than to the instability of their mothers.]

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[The organization, the budget and the practical delivery of modern healthcare are all based upon the sum of available evidences. However, in the individualized drug therapeutic decisions beside the external evidences the personal experience of the treating physician as well as the preferences and expectations of the patients must be represented with equal emphasis. Without the interaction of these three modern, patient oriented medicine is not conceivable. Evidenced based drug application is primarily based upon the results of prospective, randomized, controlled clinical trials. The individual experiences and the systematic observations represent the lowest level of the evidence hierarchy. The results of the clinical studies are expressed as the absolute difference of the results of the treated and control groups and as relative values relating the outcome of the experimental group to the control, respectively. In practice the easily interpretable term "number needed to treat" is widely used. It shows how many patients have to be treated relative to the control group in order to observe the expected therapeutic outcome in one case. The wealth of evidences cannot be efficiently used without systematization in the daily practice. Therefore, the data collected from the independent publications containing the primary evidences are subjected to a joint statistical evaluation. Thereafter, the results are combined in systematic reviews by independent experts following thorough weighting without prejudice. Then short summaries, more easily and rapidly digested by practicing physicians are made according to the same principle. They are restricted to the presentation of the problem, the tabulation of the summarized data and the conclusion. It is expected that in the future systems combining the electronically stored patient's data with external evidences making possible the patient oriented presentation of the sum and hierarchy of evidences will be extensively used.]

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[In our current understanding sepsis is a systemic inflammatory response syndrome to infections mediated by cytokines, an uncontrolled progression which may result in multiorgan failure and in the final stage septic shock. There are no pathognomic clinical signs or laboratory parameters in the early stage of sepsis and the diagnosis can be easily missed if the possibility is overlooked. One of the crucial points of therapy is early diagnosis: the mortality rate of severe sepsis is about 20% and that of septic shock is about 40-50%. The cornerstones of the therapy are the eradication of the focus of sepsis (surgical intervention and antimicrobial treatment), standard intensive care and the intervention in the pathophysiological process of sepsis. For successful treatment a multidisciplinary approach is required: only the early diagnosis and the teamwork of different specialists can decrease the mortality rate that is higher in Hungary than the international average.]

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Related contents

Hungarian Radiology

[The role of ultrasonography and X-ray examinations in the diagnosis of gallstone ileus in preoperative stage]

FARKAS József, KÁNYA László, LUDVIG Zsuzsanna, BENDE Sándor

[INTRODUCTION - Gallstone ileus develops in elderly patients as a result of complication of cholelithiasis and causes 1-3% of mechanical ileus. Due to its variable presentation and in many cases insidious and intermittent symptoms it is difficult to establish the diagnosis which is often delayed. The mortality rate is high and early diagnosis is essential. The role of X-ray, abdominal ultrasound and recently CT has been emphasized. The role of imaging studies was evaluated in the preoperative diagnosis of gallstone ileus based on their surgically proven cases. PATIENTS AND METHODS - From 1st January 1988 to 30th June 2004 nineteen operations were performed on seventeen patients suffering from gallstone ileus. The average age of the patients was 74.2 years, male/female ratio was 4/13. Ultrasound examination was performed in all cases before the operation. Plane X-ray examination also was carried out except in two cases. CT study was not performed preoperatively. The calculi were removed through an enterotomy whole. In four cases gall bladder were also removed and the biliary fistula was closed. The disease was diagnosed on the basis of symptoms described by Rigler. If two signs from the three was present the diagnosis was established. RESULTS - 17 cases out of 19 mechanical ileus were diagnosed, in one case acute cholecystitis and in one incarcerated abdominal wall hernia was suspected before surgery. Small bowel obstruction was found in all cases (jejunum in six cases, ileum in 13). In five cases multiple calculi were seen in the bowels. Two patients had to undergo surgery twice because of gallstone ileus. It is noted that in eight cases (42.1% of total operations) gallstone ileus was diagnosed before the operation. In seven cases ultrasound played a crucial role in establishing diagnosis. In one case gas was detected in the biliary tract and in six, gallstone was directly seen in the small bowel with ultrasound. CONCLUSIONS - In the preoperative diagnosis of gallstone ileus more and more is expected from appropriate radiological examinations. If diagnosis is primarily based on the physical examination, an illusion of clinical improvement can be created, and the delay of surgical treatment can lead to decompensation of elderly patients with increased mortality rate. A thorough radiological examination can show the stone in the bowel lumen, and observation of the indirect signs together with clinical state can considerably improve the results. The rate of correct diagnosis of gallstone ileus before sugery in our patients can be considered an average and similar to the published data in medical literature.]

Clinical Neuroscience

Late simultaneous carcinomatous meningitis, temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting with mono-symptomatic vertigo – a clinico-pathological case reporT

JARABIN András János, KLIVÉNYI Péter, TISZLAVICZ László, MOLNÁR Anna Fiona, GION Katalin, FÖLDESI Imre, KISS Geza Jozsef, ROVÓ László, BELLA Zsolt

Although vertigo is one of the most common complaints, intracranial malignant tumors rarely cause sudden asymmetry between the tone of the vestibular peripheries masquerading as a peripheral-like disorder. Here we report a case of simultaneous temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting as acute unilateral vestibular syndrome, due to the reawakening of a primary gastric signet ring cell carcinoma. Purpose – Our objective was to identify those pathophysiological steps that may explain the complex process of tumor reawakening, dissemination. The possible causes of vestibular asymmetry were also traced. A 56-year-old male patient’s interdisciplinary medical data had been retrospectively analyzed. Original clinical and pathological results have been collected and thoroughly reevaluated, then new histological staining and immunohistochemistry methods have been added to the diagnostic pool. During the autopsy the cerebrum and cerebellum was edematous. The apex of the left petrous bone was infiltrated and destructed by a tumor mass of 2x2 cm in size. Histological reexamination of the original gastric resection specimen slides revealed focal submucosal tumorous infiltration with a vascular invasion. By immunohistochemistry mainly single infiltrating tumor cells were observed with Cytokeratin 7 and Vimentin positivity and partial loss of E-cadherin staining. The subsequent histological examination of necropsy tissue specimens confirmed the disseminated, multi-organ microscopic tumorous invasion. Discussion – It has been recently reported that the expression of Vimentin and the loss of E-cadherin is significantly associated with advanced stage, lymph node metastasis, vascular and neural invasion and undifferentiated type with p<0.05 significance. As our patient was middle aged and had no immune-deficiency, the promoting factor of the reawakening of the primary GC malignant disease after a 9-year-long period of dormancy remained undiscovered. The organ-specific tropism explained by the “seed and soil” theory was unexpected, due to rare occurrence of gastric cancer to metastasize in the meninges given that only a minority of these cells would be capable of crossing the blood brain barrier. Patients with past malignancies and new onset of neurological symptoms should alert the physician to central nervous system involvement, and the appropriate, targeted diagnostic and therapeutic work-up should be established immediately. Targeted staining with specific antibodies is recommended. Recent studies on cell lines indicate that metformin strongly inhibits epithelial-mesenchymal transition of gastric cancer cells. Therefore, further studies need to be performed on cases positive for epithelial-mesenchymal transition.

Clinical Neuroscience

A variant of Guillain-Barre syndrome after SARS-CoV-2 vaccination: AMSAN

TUTAR Kaya Nurhan, EYIGÜRBÜZ Tuğba, YILDIRIM Zerrin, KALE Nilufer

Introduction - Coronavirus disease 2019 (COVID-19) is a respiratory infection that has rapidly become a global pandemic and vaccines against SARS-CoV-2 have been developed with great success. In this article, we would like to present a patient who developed Guillain-Barré syndrome (GBS), which is a serious complication after receiving the inactive SARS-CoV-2 vaccine (CoronaVac). Case report – A 76-year-old male patient presented to the emergency department with nine days of progressive limb weakness. Two weeks prior to admission, he received the second dose of CoronaVac vaccine. Motor examination revealed decreased extremity strength with 3/5 in the lower extremities versus 4/5 in the upper extremities. Deep tendon reflexes were absent in all four extremities. Nerve conduction studies showed predominantly reduced amplitude in both motor and sensory nerves, consistent with AMSAN (acute motor and sensory axonal neuropathy). Conclusion - Clinicians should be aware of the neuro­logical complications or other side effects associated with COVID-19 vaccination so that early treatment can be an option.

Clinical Neuroscience

Acute transverse myelitis after inactivated COVID-19 vaccine

ERDEM Şimşek Nazan, DEMIRCI Seden, ÖZEL Tuğba , MAMADOVA Khalida, KARAALI Kamil , ÇELIK Tuğba Havva , USLU Ilgen Ferda, ÖZKAYNAK Sibel Sehür

Vaccines against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been rapidly developed to prevent coronavirus disease 2019 (COVID-19) pandemic. There is increasing safety concerns regarding COVID-19 vaccines. We report a 78-year old woman who was presented with tetraparesis, paresthesias of bilateral upper extremities, and urinary retention of one-day duration. Three weeks before these symptoms, she was vaccinated with CoronaVAC vaccine (Sinovac Life Sciences, China). Spine magnetic resonance imaging showed longitudinally extensive transverse myelitis (TM) from the C1 to the T3 spinal cord segment. An extensive diagnostic workup was performed to exclude other possible causes of TM. We suggest that longitudinally extensive TM may be associated with COVID-19 vaccination in this case. To the best of our knowledge, this is the first report of longitudinally extensive TM developing after CoronaVac vaccination. Clinicians should be aware of neurological symptoms after vaccination of COVID-19.