Actinomycosis of the Pancreas

Wednesday, 27 April 2011 05:06
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Abstract

Actinomyces is a normal commensal of the upper aerodigestive tract, colon and female reproductive tract. It can give rise to invasive disease in case of any breach in mucosal integrity, as well as, in patients with immunosuppression. Rarely, actinomycosis can involve the pancreas especially after episodes of pancreatitis or in post operative patients. We observed a case of actinomycosis affecting recurrent intraductal papillary mucinous neoplasm (IPMN) of pancreatic remnant, 5 years after a Whipple's procedure. Our patient, a 66 years old male with a history of Whipple's procedure for IPMN of pancreatic uncinate process, presented with repeated episodes of acute pancreatitis. Repeated radiological investigations (CT, MRI and EUS) revealed resolving pancreatitis with recurrent IPMN of the pancreatic tail. The patient underwent laparobotic assisted resection of the remnant pancreas and spleen 3 months later. Intraoperatively, in addition to the recurrent IPMN of pancreatic tail, we found a dense peripancreatic desmoplastic reaction with areas of thick yellow pus pockets in the remnant pancreatic body. Bacteriology and histopathology revealed it as a recurrent IPMN associated with actinomycosis of pancreas with chronic xanthogranulomatous changes. We conclude that actinomycosis of the pancreas is a rare entity with only 5 cases reported in English literature to the best of our knowledge. If diagnosed preoperatively, early institution of antibiotics can improve the surgical outcome. Fortunately, after diagnosis, we were able to start antibiotics in early postoperative period with successful outcome.

 

Last Updated ( Saturday, 30 April 2011 10:54 )
 

A dramatic, objective antiandrogen withdrawal response

Tuesday, 26 April 2011 10:25
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Abstract

Antiandrogen withdrawal response is an increasingly recognized entity in patients with metastatic prostate cancer. To our knowledge, there have been no reports describing a durable radiologic improvement along with prostate-specific antigen (PSA) with discontinuation of the antiandrogen agent bicalutamide. We report a case in which a dramatic decline of serum PSA levels associated with a dramatic improvement in radiologic disease was achieved with bicalutamide discontinuation.

 

Background

Cancer of the prostate is the most prevalent cancer of American men [1]. At the time of diagnosis almost 50% of the patients have disease that extends beyond the prostate gland. Disseminated prostate cancer is primarily treated by local palliative measures and by testicular androgen ablation (medical or surgical). Non-steroidal antiandrogens are commonly used – either as short-term induction therapy to blunt the surge of testosterone that follows the initiation of luteinizing hormone-releasing hormone (LHRH) analogues, as long-term therapy with LHRH analogues or as single agent salvage treatment in men in whom LHRH analogues or surgical castration have ceased to control the disease. A phenomenon referred to as the antiandrogen withdrawal syndrome or antiandrogen withdrawal response (AAWR) occurring in men receiving non-steroidal antiandrogens was first described in 1993 [2-4]. The AAWR is defined as a 50% decline in prostate specific antigen (PSA) following cessation of an antiandrogen. The pathophysiology of the phenomenon is not completely understood. We report a very dramatic and prolonged antiandrogen withdrawal response and discuss the literature and recent information regarding the pathophysiology of the AAWR.

Last Updated ( Tuesday, 26 April 2011 10:55 )
 

Hepatic artery aneurysm repair

Tuesday, 26 April 2011 00:45
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Introduction

Hepatic artery aneurysms remain a clinically significant entity. Their incidence continues to rise slowly and mortality from spontaneous rupture is high. Repair is recommended in those aneurysms greater than 2 cm in diameter. It is not surprising that vascular comorbidities, such as ischaemic heart disease, are common in surgical patients, particularly those with arterial aneurysms such as these. The decision of when to operate on patients who require urgent surgery despite having recently suffered an acute coronary syndrome remains somewhat of a grey and controversial area. We discuss the role of delayed surgery and postoperative followup of this vascular problem.

 

Case presentation

A 58-year-old man was admitted with a 5.5 cm hepatic artery aneurysm. The aneurysm was asymptomatic and was an incidental finding as a result of an abdominal computed tomography scan to investigate an episode of haemoptysis (Figure 1). Three weeks prior to admission, the patient had suffered a large inferior myocardial infarction and was treated by thrombolysis and primary coronary angioplasty. Angiographic assessment revealed a large aneurysm of the common hepatic artery involving the origins of the hepatic, gastroduodenal, left and right gastric arteries and the splenic artery (Figures 2 and 3). Endovascular treatment was not considered feasible and immediate surgery was too high-risk in the early post-infarction period. Therefore, surgery was delayed for 3 months when aneurysm repair with reconstruction of the hepatic artery was successfully performed. Graft patency was confirmed with the aid of an abdominal arterial duplex. Plasma levels of conventional liver function enzymes and of alpha-glutathione-S-transferase were within normal limits. This was used to assess the extent of any hepatocellular damage perioperatively. The patient made a good recovery and was well at his routine outpatient check-ups.

Last Updated ( Tuesday, 26 April 2011 01:01 )
 

Unusual cause of exercise-induced ventricular fibrillation

Monday, 25 April 2011 23:46
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Unusual cause of exercise-induced ventricular fibrillation in a well-trained adult endurance athlete

Introduction

Sudden death has been defined as "an abrupt unexpected death of cardiovascular cause, in which the loss of consciousness occurs within 1 to 12 hours of onset of symptoms" [1]. Although sudden deaths in athletes are dramatic and tragic occurrences, the total incidence of sudden death during sport is rather low. The annual incidence of sudden deaths in athletes under 35 years is 2.62 per 100,000 for male and 1.07 for female athletes [2], whereas the risk of sudden death in athletes over 60 years old can be 100-fold higher compared with young athletes [3]. The precise diseases responsible for sudden death differ considerably with regard to age. In young athletes, congenital malformations of the heart and/or vascular system cause the majority of deaths and can only be detected noninvasively by complex diagnostics [4,5]. In contrast, the underlying cause in older athletes who die suddenly is usually atherosclerosis of the coronary arteries [3]. Reports of congenital coronary anomalies as a cause of sudden death in older athletes are rare.

Last Updated ( Tuesday, 26 April 2011 00:33 )
 


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