Lege Artis Medicinae

[SIMULTANEOUS PRESENCE OF GIST AND MALT-LYMPHOMA OF THE STOMACH IN A HELICOBACTER PYLORI NEGATIVE PATIENT]

KOVÁCS Ferenc1, GYÖKERES Tibor1, TAKÁCS Imre Géza2, PADÁNYI István3, FEKETE Csaba3, OROSZ Zsolt4, PAP Ákos1

OCTOBER 18, 2006

Lege Artis Medicinae - 2006;16(10)

[INTRODUCTION - The simultaneous presence of gastric mucosa-associated lymphoid tissue lymphoma (MALT) and a gastrointestinal stromal tumor (GIST) is an extremely rare finding that has not been published until now. CASE REPORT - The authors report on a 78- year-old man who was referred to their department with an emergency upper gastrointestinal bleeding. Urgent gastroscopy revealed a bleeding ulcer in the middle third of the stomach. On the follow-up endoscopy 6 weeks later, an umbilicated polypoid lesion was found proximal to the healed ulcer, which was subsequently removed by elective surgery. Histology and immunohistochemical staining of the specimen for c-Kit confirmed the diagnosis of gastrointestinal stromal tumour. A few weeks later the patient was readmitted because of haematemesis. Upon detailed histological examination of the biopsy specimens taken from the multiple superficial ulcers found near the previous lesion, MALT-lymphoma was diagnosed. The absence of Helicobacter pylori was confirmed by repeated histological examinations, serology and urea breath test. CONCLUSION - This is the first report on a patient with simultaneous presence of a gastrointestinal stromal tumour and gastric mucosaassociated lymphoid tissue lymphoma with H. pylori negativity. Several observations suggest that the development of malignant tumours of the stomach is also associated with H. pylori infection. In view of the reported case, the possibility of a common aetiology of these two neoplasms other than H. pylori infection is discussed.]

AFFILIATIONS

  1. MÁV Kórház és Központi Rendelôintézet, Gasztroenterológiai Osztály
  2. MÁV Kórház és Központi Rendelôintézet, Patológiai Osztály
  3. MÁV Kórház és Központi Rendelôintézet, II. Sz. Sebészeti Osztály
  4. Országos Onkológiai Intézet, Patológiai Osztály

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Lege Artis Medicinae

[EPITHELIAL CYST OF THE SPLEEN COMBINED WITH HAEMANGIOMA]

LÉVAY Bernadett, SZELECZKY Márton, MAKAI Gábor, HIDVÉGI Judit, TAMÁS Róbert, GAMAL E. Mohamed

[INTRODUCTION - The most common symptom of spleen diseases is splenomegaly of various extent, which may be accompanied by pain in the upper left quadrant of the abdomen, as well as by fever, jaundice, haemorrhages. CASE REPORT - A 24-year-old woman with an abdominal mass that could not be determined by imaging was operated on and an epithelial cyst of unusually large size was identified in the spleen. CONCLUSION - The pathological background, diagnostic possibilities, and treatment options are discussed for this rare disease.]

Lege Artis Medicinae

[STUDY OF PARAOXONASE ACTIVITY IN MIXED CONNECTIVE TISSUE DISEASE]

BODOLAY Edit, SERES Ildikó, JAKAB Zsanett, CSÍPŐ István, SZILÁGYI Anna, SZEGEDI Gyula, PARAGH György

[INTRODUCTION - Mixed connective tissue disease (MCTD) is an inflammatory autoimmune disease with multiple organ involvement. Immune- inflammatory processes play a crucial role in the pathogenesis of atherosclerosis. The connection between inflammatory parameters and atherosclerosis in MCTD has not yet been studied. Lipid abnormality is an important risk factor of atherosclerosis. Among the lipids, HDL is protective, which is in part due to the antioxidant effect of paraoxonase. In this paper, the lipid profiles and paraoxonase activities of MCTD patients were studied and the factors causing abnormalities were investigated. PATIENTS AND METHODS - Thirty-seven patients with MCTD, who had not taken any lipid lowering drugs in the past 2 months, were enrolled in the study. Thirty healthy individuals served as controls. At the time of the study the mean age of the MCTD patients was 51.2 ± 9.5 years, and the mean disease duration was 11.0 ± 7.2 years. Paraoxonase activity was determined by spectrophotometry, lipid profiles were determined by a Cobas Integra 700 Analyser, the von Willebrand factor antigen (vWFAg) was measured by turbidimetry in platelet-poor plasma and the thrombomodulin and anti-endothelial cell antibody (AECA) measurements were carried out by ELISA methods. RESULTS - Paraoxonase activity in the MCTD patients was lower than in the control population (118.5 ± 64.6 U/l vs. 188.0 ± 77.6, p<0.001). The arylesterase activity was also significantly lower in the patients (p<0.001). The reduction of paraoxonase activity was in correlation with the age of the patients, the duration of the disease and with vascular (eye, cardiac, cerebral) disorders. The total cholesterol and triglicerid levels of the patients were significantly increased compared to the control group, while in the apoA1 levels a significant reduction was seen. A very strong correlation was observed between the reduction of paraoxonase activity and the increase of endothelial cell activation markers (thrombomodulin, vWFAg, AECA). There was no difference in the values of patients with or without corticosteroid treatment. CONCLUSIONS - The results suggest that in MCTD there is an increased risk for atherosclerosis. Apart from an elevated cholesterol and triglicerid level, a reduced paraoxonase level and activity may also play a role in the development of atherosclerosis,. Therefore, in patients with MCTD, due to the increased oxidative processes and the impaired elimination of free radicals, a sustained damage to the endothelial cells occurs, which is indicated by increased levels of thrombomodulin, vWFAg, and anti-endothelial antibody.]

Lege Artis Medicinae

[Telemedicine]

GRÉTSY Zsombor

Lege Artis Medicinae

[The effect of tiotropium on exacerbation and airflow in patients with COPD]

MOLDVAY Judit

Lege Artis Medicinae

[’THE CYCLE OF VIOLENCE’ IN THE LIFE OF ALCOHOLICS]

GEREVICH József, BÁCSKAI Erika

[INTRODUCTION - ’The cycle of violence’ have long been a known phenomenon. The present research is aimed at answering the question of whether abuse suffered in childhood creates a tendency to aggressive behaviour in adulthood and whether there is a connection between these two forms of behaviour. METHODS - The sample studied comprised 235 clinically treated alcoholics. The instruments used for the investigation were the European Addiction Severity Index (EuropASI), the Buss and Perry Aggression Questionnaire, and the Janus Questionnaire. RESULTS - The most important finding is that persons who were physically abused in childhood by their parents were very likely to strike or beat someone in the course of their lives (χ2=9.79, p<0.001). Within the most aggressive group, 18 % had not suffered abuse in childhood, while 81 had been abused (χ2=13.25, p<0.001). If the patient had been physically abused, struck or beaten, that person later abused, struck or beat someone else (Pearson r=.397). CONCLUSION - The results draw attention to the importance of preventing and treating aggression in alcoholics undergoing clinical treatment.]

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[Helicobacter pylori infection and practical questions of therapy]

RÁCZ István

[According to our knowledge, Helicobacter pylori is a major factor in the pathogenesis of peptic ulcer disease. The prevalence of Helicobacter pylori infection is 70-80% in ulcer patients with the bacteria colonising the mucous surface of the antral mucosa. Eradication therapy against the bacteria leads to complete healing of ulcer disease in about 85-90% of cases. Indications for the eradication and recommended treatment modalities are outlined in several consensus reports; however, in everyday practice a case by case decision is necessary. Present paper summarises two different cases. In the first, the patient has suffered from several relapses of ulcer disease and a successful eradication was performed. Despite of the healing of the ulcer, this patient continued to have prolonged dyspeptic symptoms which called for maintenance antisecretory therapy. The second case is an example that even in a Helicobacter pylori infected patient there could be other reasons for the ulcer pathogenesis. Thorough examinations revealed duodenal manifestation of Crohn’s disease as the background. The message of presented cases is that in each patient individual adaptation of diagnostic and therapeutic algorithms is recommended.]

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.

Hypertension and nephrology

[About the care of patients with hyperuricaemia and gout]

[This consensus document is intended to provide guidance for the effective and efficient treatment of asymptomatic individuals with high uric acid levels and gout patients.]

Clinical Neuroscience

[What happens to vertiginous population after emission from the Emergency Department?]

MAIHOUB Stefani, MOLNÁR András, CSIKÓS András, KANIZSAI Péter, TAMÁS László, SZIRMAI Ágnes

[Background – Dizziness is one of the most frequent complaints when a patient is searching for medical care and resolution. This can be a problematic presentation in the emergency department, both from a diagnostic and a management standpoint. Purpose – The aim of our study is to clarify what happens to patients after leaving the emergency department. Methods – 879 patients were examined at the Semmel­weis University Emergency Department with vertigo and dizziness. We sent a questionnaire to these patients and we had 308 completed papers back (110 male, 198 female patients, mean age 61.8 ± 12.31 SD), which we further analyzed. Results – Based on the emergency department diagnosis we had the following results: central vestibular lesion (n = 71), dizziness or giddiness (n = 64) and BPPV (n = 51) were among the most frequent diagnosis. Clarification of the final post-examination diagnosis took several days (28.8%), and weeks (24.2%). It was also noticed that 24.02% of this population never received a proper diagnosis. Among the population only 80 patients (25.8%) got proper diagnosis of their complaints, which was supported by qualitative statistical analysis (Cohen Kappa test) result (κ = 0.560). Discussion – The correlation between our emergency department diagnosis and final diagnosis given to patients is low, a phenomenon that is also observable in other countries. Therefore, patient follow-up is an important issue, including the importance of neurotology and possibly neurological examination. Conclusion – Emergency diagnosis of vertigo is a great challenge, but despite of difficulties the targeted and quick case history and exact examination can evaluate the central or peripheral cause of the balance disorder. Therefore, to prevent declination of the quality of life the importance of further investigation is high.]