- [Show abstract] [Hide abstract] ABSTRACT: A somnolent 31 year old female was admitted with flaccid lesion of the right side of her body and motoric aphasia under the clinical signs of a left hemispheric apoplexy. Directly after ruling out a dissection of the left internal carotid artery by Doppler-sonography, an echocardiographic examination was performed to exclude cardiac embolism. The echocardiogram showed a large left atrial myxoma. The patient was consecutively referred to cardiac surgery where an excision of the myxoma to prevent further embolism was performed on the same day. The detailed history revealed that two years ago, a transitory hyperthyreosis and a struma diffusa I-II was diagnosed and 21 months ago, the patient had undergone bilateral adrenalectomy because of a primary Cushing syndrome. In summary, this case represents an incomplete course of multiple endocrine neoplasms known as >>myxoma complex<< and firstly reported by Carney and coworkers (Carney complex). This complex is described as a multisystemic complex with neoplasms of multicentric location containing mesenchymal tumors (myxoma), pigmented skin lesions (lentiginosis), endocrine activ tumors (adrenocortical, testicular and hypophysic) and tumors of the peripheral nervs (Schwannoma). This case report describes in detail the findings of the presented case together with a brief literature review.
- [Show abstract] [Hide abstract] ABSTRACT: Die pulmonale Thrombendarteriektomie ist vor einer Lungentransplantation die wichtigste Therapieform für Patienten mit persistierender pulmonaler Hypertonie nach einer Lungenembolie. Die vorgestellte Kasuistik berichtet über eine junge Patientin mit juvenilem Diabetes mellitus. Während eines stationären Aufenthaltes kam es katheterassozüert zu einer Staphylokokkensepsis mit Trikuspidalklappenendokarditis und nachfolgender ausgedehnter Lungenembolie. Vier Jahre nach dem Ereignis wurde aufgrund einer zunehmend verminderten Belastbarkeit wegen höhergradiger pulmonaler Hypertonie eine erfolgreich verlaufende pulmonale Thrombendarteriektomie durchgeführt. Im Langzeitverlauf kam es zu einer deutlichen Besserung der Belastbarkeit und Lebensqualität, die Patientin ist wieder voll arbeitsfähig und konnte nach unproblematischer Gravidität ein gesundes Mädchen gebären. Pulmonary thromboendarterectomy presents an efficient option of treatment for patients with chronic pulmonary hypertension after pulmonary thromboembolism. We report about the case of a young lady with juvenile diabetes mellitus. During a hospital stay she suffered a catheter-associated endocarditis of the tricuspid valve and pulmonary thromboembolism. Four years after the event she had a lower exercise tolerance due to pulmonary hypertension and underwent a pulmonary thromboendarterectomy. During long time follow-up her exercise tolerance normalized and she had an uneventful delivery of a girl.
- [Show abstract] [Hide abstract] ABSTRACT: Ein 70jähriger Patient wurde mit progredienter Dysphasie, Desorientiertheit und Somnolenz stationär aufgenommen. Richtungsweisende Befunde ergaben sich aus der körperlichen Untersuchung, dem EKG, dem Röntgen-Thorax und dem Schädel-CT sowie den routinemäßig erhobenen Laborparametern nicht. Eine ausgeprägte metabolische Azidose ließ daher bei Ausschluß einer Urämie und Ketoazidose an eine Intoxikation denken. Hierbei kommt insbesondere eine Kohlenmonoxid-, Salizylat-, Methanol- oder, wie im vorliegenden Falle eine Äthylenglykol-Vergiftung in Frage. Therapeutisch müssen dabei neben einer primären Giftelimination eine rasche Zufuhr von Äthanol, ein Azidose- und Elektrolytausgleich sowie insbesondere eine baldige Hämodialyse durchgeführt werden.
- [Show abstract] [Hide abstract] ABSTRACT: Differentiation between hypertrophic cardiomyopathy and hypertensive heart disease is a diagnostic challenge. Asymetric septal hypertrophy has been emphazied as a characteristic but not specific feature of hypertrophic cardiomyopathy. This diagnostic dilema is created in patients with systemic hypertension and marked left ventricular hypertrophy. We performed discriminanz analysis in order to select those M-mode echocardiographic and 2-D echocardiographic parameters which permit the best distinction between the two diseases. The combined critera of the clasical M-mode echocardiographic septal thickness and septal to posterior wall ratio, left ventricular mass index as well as the 2-D echocardiographic defind septal and/or anterior free wall segment and the 2-D echocardiographically assessed left ventricular mass index improve the diagnostic specificity.
- [Show abstract] [Hide abstract] ABSTRACT: Stress-echocardiography has become an widely accepted non-invasive method in the diagnosis of coronary artery disease. By the use of pharmacological agents to induce cardiovascular stress, even patients who are unable to exercise due to different accompanying diseases can be investigated. To date, especially dipyridamole and dobutamine have emerged to be useful agents to induce pharmacological stress for the induction of ischemia in patients with suspected coronary artery disease. Different protocols have been suggested for dipyridamole and dobutamine echocardiography. The aim of this paper is, besides presenting the two recommended protocols, to discuss the potential advantages and disadvantages of the two pharmacons and to give a critical validation including the results of current studies and own experiences.
- [Show abstract] [Hide abstract] ABSTRACT: The development of IHD in five phases is described. Fibrinogen is a major, independent cardiovascular risk factor. This is documented in six prospective studies. Furthermore fibrinogen is of significant influence in the progression of IHD. tPA-Ag, a marker of PAI 1 activity in plasma, is a new risk indicator for the development and progression of IHD. This is shown by data of the Physicians' Health study and the ECAT-AP study. Experimental and clinical data suggest a role of PAI 1 in the pathogenesis of IHD, yet PAI 1 is not useful as risk indicator for the progression of the disease. CRP is possibly a marker of disease activity in IHD.
- [Show abstract] [Hide abstract] ABSTRACT: Coagulation studies were performed in a patient who had been bitten by a snake of the species Bothrops neuwiedi. The patient presented with hemorrhagic necrosis at the envenomization site and considerable bleeding from venous puncture sites. He developed a severe defibrination syndrome with a clottable fibrinogen level of approximately 0.1 g/l. Fibrinogen was not measurable by clotting time assay. Fibrin degradation products were greatly elevated. Treatment with antivenom caused an anaphylactic reaction within ten minutes and serum sickness after three days. In vitro experiments revealed that B. neuwiedi venom directly activates Factors II and X, but does not activate Factor XIII. In vivo consumption of Factor XIII after B. neuwiedi envenomization is ascribed to the action of Factor IIa. At low venom concentrations clotting is initiated by activation of prothrombin by the venom either directly or via Factor X activation. Treatment with heparin might be beneficial in coagulopathy secondary to snake bite by reducing circulating active thrombin. The venom contains thrombin-like proteases which cause slow clotting of fibrinogen, and plasmin-like components causing further proteolysis of fibrinogen and fibrin. Antivenom has no effect on the proteolytic action of the snake venom. The in vivo effects of antivenom are presumably caused by acceleration of the elimination of venom components from the circulation. Intravenous administration of antivenom caused normalization of blood coagulation parameters within 48 h.
- [Show abstract] [Hide abstract] ABSTRACT: To assess the role of the fibrinolytic system in the pathogenesis of restenosis after percutaneous transluminal coronary angioplasty (PTCA), we determined the components of this system in a retrospective study, including 16 patients with restenosis (gr. A) and 19 patients with long-term success (gr. B). In both groups at baseline fibrinolytic activity (FA) is unchanged, whereas tissue plasminogen activator antigen (tPA-Ag) is significantly increased (gr. A: 147.0%; gr. B: 139.8%; p less than 0.01). Fibrinolytic capacity (FC) and tPA-Ag release are significantly reduced in the restenosis group (FC: 46.5%, p less than 0.05; tPA-Ag release: 48.3%, p less than 0.01) compared to normal controls as well as to gr. B (FC: 84.3%, p less than 0.05; tPA-Ag release: 79.0%, p less than 0.05). Relating to the contact activation system, F XII (79.5%, p less than 0.05) is significantly, and F XI (82.3%) is clearly reduced in gr. A. Protein C (PC) is significantly elevated in gr. B (117.5%, p less than 0.05). There is a negative correlation between plasminogen activator inhibitor (PAI 1) and HDL-cholesterol (r = 0.37, p less than 0.05). It appears, that there is a typical pattern of defective fibrinolysis in patients with restenosis after PTCA and that this might be a pathogenetic factor in the development of restenosis.
- [Show abstract] [Hide abstract] ABSTRACT: A 43-year-old man had severe upper abdominal pain and weight loss of 8 kg for over three months. He underwent a laparotomy because, computed tomography having revealed numerous mesenteric and para-aortic lymph nodes, a malignant lymphoma was suspected. Histological examination of a mesenteric lymph node demonstrated exclusively extraintestinal Whipple's disease. The symptoms completely disappeared after the administration of 1.2 mega U penicillin G and 1 g streptomycin daily for 14 days, followed by twice daily 160 mg trimethoprim and 800 mg sulphamethoxazole.
- [Show abstract] [Hide abstract] ABSTRACT: The major constituents of the hemostatic potential, i.e., platelets and the plasma factors of coagulation and fibrinolysis, guarantee the integrity of the vessel wall and provide effective hemostasis in case of vascular damage. The equilibrium between anticoagulant and procoagulant forces which is essential for the maintenance of the fluidity of blood is controlled by inhibitors, the fibrinolytic system, and the clearance of activated components by the reticuloendothelial system. The proper function of this humoral balance is essentially dependent on hemodynamic factors such as adequate circulation and capillary perfusion.
- [Show abstract] [Hide abstract] ABSTRACT: To evaluate the availability of the fibrinolytic system in patients suffering from acute respiratory distress syndrome, ARDS, induced by septicemia or trauma, the following parameters were analysed: fibrinogen, FG, antithrombin III, AT III, plasma prekallikrein, PPK, plasminogen, PG, alpha 2-antiplasmin, alpha 2-AP, alpha 2-macroglobulin, alpha 2-MG, urokinase-inhibitor, UK-I, streptokinase-inhibitor, SK-I, C1-inhibitor, C1-I, alpha 1-antitrypsin, alpha 1-AT, and fibrinogen-fibrin degradation products, FDP. Survivors and non-survivors of septicemia induced ARDS showed a characteristic feature: marked increase of FG and pronounced decrease of AT III and PPK in the coagulation system; concerning the fibrinolytic system a decrease of PG, alpha 2-AP and alpha 2-MG as well as an increase of inhibitors of PG-activators (PG-antiactivators) UK-I, SK-I, C1-I and alpha 1-AT; the FDP-titer was elevated. This constellation of parameters is interpreted as indicative of a marked procoagulant stimulation rendering the organism a state of hypercoagulability coinciding with a diminished availability of the fibrinolytic system, due to exhaustion of the fibrinolytic potential and increase of PG-antiactivators. In the trauma group initially the rise of FG, SK-I, C1-I and alpha 1-AT is absent independent of the outcome, but develops with progression of the disease. As ARDS is more frequently associated with septicemia, diminished availability of the fibrinolytic system simultaneously with increased procoagulant stimulation may be a particular pathophysiologic mechanism in the pathogenesis of ARDS.