Hepatic cerebrospinal fluid pseudocyst: a case report and review of the literature

An abdominal pseudocyst is a rare, but important complication in patients with a ventriculo-peritoneal (VP) shunt insertion. Several predisposing factors for this complication have been suggested, including infection, obstruction or dislodgement, but the pathophysiology is still unknown. However, the abdominal inflammatory process is accepted widely as a hypothesis for the formation of an abdominal pseudocyst. In this study, we report the case of a 21-year-old male that presented with a high-grade fever, poor appetite, shortness of breath and unconsciousness 1 week after receiving a VP shunt insertion for obstructive hydrocephalus. Ultrasonography and computed tomographic scans of the abdomen revealed a well-defined large hepatic cyst surrounding the peritoneal tube of the VP shunt. A hepatic cerebrospinal fluid (CSF) cyst was diagnosed and Staphylococcus epidermis was cultured via CSF. After externalization of the VP shunt and adequate antibiotic treatment, the hepatic cyst was resolved. There was no recurrence observed in the regular follow up.     

Factors predictive of acute renal failure and need for hemodialysis among ED patients with rhabdomyolysis

OBJECTIVE: We assessed the primary causes of rhabdomyolysis, the factors associated with the development of acute renal failure (ARF), and the need for hemodialysis (HD) among a series of patients presenting to an urban emergency department with rhabdomyolysis. METHODS: A chart review between January 1992 and December 1995 was conducted of patients aged 18 years or older with a diagnosis of rhabdomyolysis and an initial serum creatine phosphokinase greater than 1000 U/L. Patients were excluded if they had evidence of myocardial ischemia, cerebrovascular insufficiency, or the development of rhabdomyolysis after hospitalization. Demographic information, presumed causative factors, past medical history, medication usage, and laboratory data were collected. RESULTS: Ninety-seven patients (93 men, 4 women) were enrolled, with a mean age of 35.7 years. The most common causes of rhabdomyolysis were cocaine (30), exercise (29), and immobilization (18). Seventeen of 97 (17.5%) patients developed ARF; 8 patients (8.25%) needed HD. Several clinical and laboratory factors were statistically associated with development of ARF and need for HD. The only variable that was predictive of both ARF and need for HD in separate multivariate regression models was the initial creatinine (Cr). Initial blood urea nitrogen also was predictive of the need for HD. No patient developed ARF with an initial Cr less than 1.7 mg/dL. CONCLUSION: Acute renal failure and need for HD are common complications of rhabdomyolysis. Except for initial serum Cr and blood urea nitrogen, clinical and laboratory factors were not reliable predictors for the development of ARF or need for HD.     

Streptococcal toxic shock syndrome in children without skin and soft tissue infection: report of four cases

Streptococcal toxic shock syndrome is a fulminant, highly fatal disease characterized by evidence of group A beta-haemolytic streptococcus infection and early shock with consecutive organ failure. In adults, affected individuals usually have preceding skin or soft tissue infection. However, in paediatric patients, except for varicella, the background focus is usually respiratory tract infection, and early diagnosis of streptococcal toxic shock syndrome in such patients is difficult. We report four previously healthy children with streptococcal toxic shock syndrome. Pharyngitis was identified in three cases. All of them had constitutional symptoms such as fever, vomiting, diarrhoea, abdominal pain and physical findings of tachycardia and diffuse abdominal tenderness, but no concomitant skin infection. CONCLUSION: Streptococcal toxic shock syndrome should be considered in paediatric patients with fever, vomiting, diarrhoea, abdominal pain and early shock. Early diagnosis, prompt initiation of antibiotics and aggressive fluid therapy are lifesaving for such patients.     

Epstein-Barr virus associated post-transplantation lymphoproliferative disorder with hemophagocytosis in a child with Wiskott-Aldrich syndrome

A 23-month-old boy with Wiskott-Aldrich syndrome (WAS) received human leukocyte antigen (HLA)-one locus mismatched, unmanipulated allogeneic bone marrow graft from his mother. An Epstein-Barr virus (EBV)-associated post-transplantation lymphoproliferative disorder (PTLD) of donor cell origin and hemophagocytosis syndrome with fever, lymphadenopathy, hepatosplenomegaly, seizures, involuntary movements and pancytopenia developed 52 days after transplantation. It was difficult to decide on the treatment strategy because the patient presented with B-cell hyperplasia that morphologically appeared malignant but was oligoclonal by heavy-chain analyses. Despite of donor leukocyte transfusion, low dose chemotherapy, and anti-B cell monoclonal antibody immunotherapy, the patient died 107 days after transplantation.     

Polysaccharide purified from Ganoderma lucidum induced activation and maturation of human monocyte-derived dendritic cells by the NF-kappaB and p38 mitogen-activated protein kinase pathways

Ganoderma lucidum, a fungus native to China, has been widely used to promote health and longevity in the Chinese. The polysaccharide component with a branched (1-->6)-beta-D-glucan moiety of G. lucidum (PS-G) has been reported to exert anti-tumor activity and activation of natural killer cells. In this study, we investigated the effects of PS-G on human monocyte-derived dendritic cells (DC). Treatment of DC with PS-G resulted in the enhanced cell-surface expression of CD80, CD86, CD83, CD40, CD54, and human leukocyte antigen (HLA)-DR, as well as the enhanced production of interleukin (IL)-12p70, p40, and IL-10 and also IL-12p35, p40, and IL-10 mRNA expression, and the capacity for endocytosis was suppressed in DC. In addition, treatment of DC with PS-G resulted in enhanced T cell-stimulatory capacity and increased T cell secretion of interferon-gamma and IL-10. Neutralization with antibodies against Toll-like receptor (TLR)-4 inhibited the PS-G-induced production of IL-12 p40 and IL-10, suggesting a vital role for TLR-4 in signaling DC upon incubation with PS-G. Further study showed that PS-G was able to augment inhibitor of kappaB (IkappaB) kinase and nuclear factor (NF)-kappaB activity and also IkappaB alpha and p38 mitogen-activated protein kinase (MAPK) phosphorylation. Further, inhibition of NF-kappaB by helenalin and p38 MAPK by SB98059 prevented the effects of PS-G in the expression of CD80, CD86, CD83, CD40, CD54, and HLA-DR and production of IL-12p70, p40, and IL-10 in various degrees. Taken together, our data demonstrate that PS-G can effectively promote the activation and maturation of immature DC, suggesting that PS-G may possess a potential in regulating immune responses.     

Simultaneous ipsilateral ruptures of the anterior cruciate ligament and patellar tendon: a case report

The simultaneous diagnosis of ipsilateral patellar tendon rupture and anterior cruciate ligament tear is rare. Surgical repair is complicated by different rehabilitation regimens as well as anterior cruciate ligament graft choices. We present a case where at the same operative setting, the patellar tendon was repaired, and the anterior cruciate ligament reconstructed with autologous hamstring graft.     

Variable pump flow-based Doppler ultrasound method: a novel approach to the measurement of access flow in hemodialysis patients

Decreasing vascular access flow (Qa) is an important predictor of future access thrombosis and malfunction for hemodialysis (HD) patients. Among all of the methods for determining Qa, the variable pump flow (VPF) Doppler method measures Qa according to the change in Doppler signal between the arterial and the venous needles under different pump flow. After this technique was combined with spectral analysis of Duplex Doppler imaging, the variable pump flow-based Doppler ultrasound method (VPFDUM) for Qa measurement was developed. This study compared the reproducibility and correlation of Qa measurements for three different methods-VPFDUM, ultrasound dilution method (UDM), and conventional Doppler ultrasound method (CDUM)-in 55 HD patients. The mean value of Qa by VPFDUM (870.8 +/- 412.0 ml/min) was close to that by UDM (868.6 +/- 417.9 ml/min) but higher than that by CDUM (either of the above values versus 685.1 +/- 303.6 ml/min; P < 0.005). The mean values of coefficient of variation were similar by VPFDUM (1.6%) and UDM (1.4%) but lower than that by CDUM (either of the above values versus 6.8%; P < 0.01). The correlation coefficient and intraclass correlation coefficient of the repeated Qa measurements by VPFDUM (0.985 and 0.993; P < 0.001) were also similar to those by UDM (0.992 and 0.995; P < 0.001) but slightly higher than those by CDUM (0.917 and 0.948; P < 0.005). Either the reproducibility of VPFDUM (r=0.98, P < 0.0001) or the correlation between VPFDUM and UDM (r=0.99, P < 0.0001) in Qa measurements is good. The unassisted patency of vascular access at 6 mo was significantly poorer in patients with Qa <500 ml/min than those with Qa >500 ml/min (13.6% versus 92.2%; P < 0.0001). In conclusion, VPFDUM is a noninvasive, accurate, and reliable procedure for Qa measurement and prediction of the prognosis of vascular access in HD patients.     

The effects of indocyanine green and endoillumination on rabbit retina: an electroretinographic and histological study

AIM: To evaluate the functional and morphological retinal toxicity associated with intravitreal injection of indocyanine green (ICG) dye in rabbit eyes during vitrectomy with endoillumination. METHODS: 20 eyes of 10 New Zealand pigmented rabbits were used in the study. All eyes underwent pars plana vitrectomy and removal of posterior vitreous cortex under endoillumination. In one eye of each rabbit, intravitreal injection of 0.1 ml of 2.5 mg/ml ICG was applied for 30 seconds followed by 10 minutes of endoillumination. The control eye had endoillumination only without ICG injection. Dark adapted and light adapted electroretinograms (ERGs) were performed before the surgery and 1 week after surgery for serial comparisons. Rabbits were killed 1 week after surgery and eyes were enucleated for histological examination. RESULTS: Serial ERG comparisons showed significant reduction in the light adapted a-wave amplitude (p = 0.037) and significant delays in the dark adapted and light adapted b-wave latencies (p = 0.020 and p = 0.038, respectively) in the ICG treated eyes. Histological examinations demonstrated loss of photoreceptor outer segments with focal absence of photoreceptors in some areas in the ICG injected eyes. CONCLUSIONS: Vitrectomy followed by intravitreal injection of 2.5 mg/ml ICG for 30 seconds with endoillumination may result in retinal toxicity causing functional and morphological retinal damages in rabbit eyes. The lowest concentration of ICG should be used if necessary for intraocular use to prevent potential retinal toxicity.