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Ectopic secretion of growth hormone-releasing-hormone (GHRH) is a rare cause of acromegaly-representing less than 1% of patients. A 25-year-old woman was admitted to the hospital with acromegaly and a 6 x 6 cm infrahepatic mass. Sellar magnetic resonance imaging indicated diffuse pituitary enlargement consistent with hyperplasia. The infrahepatic mass was resected, and the histopathological diagnosis was a well-differentiated invasive neuroendocrine carcinoma of the duodenum with metastases to local lymph nodes. The tumor cells contained cytoplasmic immunoreactivity for GHRH. Because increased IGF-1 concentrations persisted after the operation, the patient was treated with octreotide long-acting repeatable (LAR) injections of 20 mg/month. Growth hormone and IGF-1 levels normalized. After 6 years of surveillance, a left paraaortic mass was detected by uptake of indium 111 octreotide. Surgical exploration revealed metastatic neuroendocrine carcinoma in a 2.5-cm lymph node. Postoperatively, the IGF-1 concentration was mildly elevated. Octreotide LAR therapy is being continued at 10 mg/month. This case suggests that octreotide treatment may have a beneficial effect on disease course and can be maintained for as long as 7 years in a patient with acromegaly due to a GHRH-secreting neuroendocrine carcinoma.

There are few reports concerning Mycobacterium tilburgii infection in humans because this bacterium is non-cultivatable. Herein, using new molecular techniques, we report the case of an immunocompromised patient with fatal disseminated lymphadenitis that was caused by M. tilburgii.26 years old Caucasian HIV negative female patient presented with abdominal pain. Her clinical assessment revealed disseminated lymphadenitis, that was acid fast bacilli positive. Further molecular evaluation showed the causative agent as M. tilburgii. Despite anti mycobacterial therapy and careful management of intervening complications patient died because of an intraabdominal sepsis. This is the first fatal M. tilburgii infection in the literature. This case points the importance of careful management of patient's immune status and intervening infections besides implementation of effective drug treatment.

Fever of unknown origin (FUO) is defined as the body temperature higher than 38.3 degrees C on several occasions and lasting longer than 3 weeks, with the aetiology remaining uncertain after 1 week of investigation. In this study, we reviewed 57 patients with FUO hospitalised in our inpatient department between 1998 and 2003. The median age of the patients was 44 years (17-84), and 26 were males (46%), while 31 were females (54%). In 24 patients (42%), infectious diseases such as tuberculosis (12 patients) and brucellosis (5 patients) were found under the aetiology of FUO. Inflammatory rheumatic diseases were the second most common cause of FUO (17 patients, 30%), while malignancies were found in 10 patients (18%). In six patients (10%), aetiology could not be identified. In conclusion, infectious diseases especially tuberculosis and brucellosis are the leading causes of FUO in our country.

Systemic lupus erythematosus (SLE) is a multisystemic disease which potentially involves various organs including the skin, joints, kidneys, liver, hematopoetic system, and serous membranes. It is rarely seen in elderly males. The most common cardiovascular involvement type is pericarditis. Anti-Ro antibodies may be associated with neonatal lupus which causes heart blocks. Recent literature indicates that anti-Ro antibodies may be associated with various rhythm and conduction disturbances in the adulthood. The most common finding associated with anti-Ro antibodies is prolonged corrected QT (QTc) interval. Herein, we present an elderly male patient with anti-Ro-positive SLE associated with prolonged QTc interval and AV blocks that significantly improved after corticosteroid treatment.

We investigated the clinical and laboratory findings of hypogonadism and feminization in male patients with viral or alcoholic cirrhosis to determine whether chronic liver disease plays a primary role in the development of sexual dysfunction and hormonal changes. Two groups of male patients with liver cirrhosis (23 alcoholic, 33 viral) age- and Child's grade-matched, and 20 age-matched healthy men, as a control group, were included in this study. Clinical signs of hypogonadism and feminization were examined in the cirrhotic patients. Follicle-stimulating hormone, luteinizing hormone, prolactin, testosterone, free testosterone, estradiol, androstenedione, dehydroepiandrosterone sulfate, and sex hormone-binding globulin were estimated in all groups. Seminal fluid was also analyzed in 7 alcoholic and 15 viral cirrhotics. Serum levels of estradiol, androstenedione, and sex hormone-binding globulin were significantly higher, and free testosterone and dehydroepiandrosterone sulfate levels were significantly lower in both groups of cirrhotics compared with the control group. Child's C patients in both groups of cirrhotics were found to have higher estradiol and lower free testosterone levels than child's A and B patients. Alcoholic and viral cirrhotics had markedly reduced sperm motility and density. The differences between alcoholic and viral cirrhotic patients in the clinical signs of hypogonadism, serum levels of sex steroids, and the results of seminal fluid analysis were not statistically significant. These findings suggest that liver cirrhosis per se, independent of etiology, causes hypogonadism and feminization, and that the degree of hypogonadism and feminization correlates well with the severity of liver failure.

Nitric oxide (NO) has an important role in the inflammatory arthropathies. This study investigated NO levels in the synovial fluid and plasma of patients with primary osteoarthritis (OA) of the knee. Twenty-seven cases with primary knee OA and 13 controls were recruited for the study. Nitrate/nitrite levels of synovial fluid and plasma were measured by Griess reaction, and interleukin-1 beta (IL-1 beta) levels were measured quantitatively by a sandwich immunoassay technique. We found a significant increase in the synovial fluid nitrate/nitrite levels in cases with primary OA of the knee compared to controls (50.26+/-23.63 microg/l vs 32.49+/-10.05 microg/l, p=0.002) as well as increased plasma nitrate/nitrite levels (57.06+/-23.32 microg/l vs 39.98+/-16.36 microg/l, p=0.012). There was no difference in plasma and synovial fluid IL-1 beta concentrations between the study and control groups. These results may be considered as supporting evidence that NO might be one of the factors responsible for cartilage destruction in primary osteoarthritis of the knee.

We present a young woman with extrapulmonary sarcoidosis who had been treated for tuberculosis 15 years earlier. The initial diagnosis had been made on the basis of liver biopsy. The patient later developed bilateral visual loss secondary to uveitis. We identified noncaseating granulomatous lesions in the kidney, intra-abdominal lymph node, and previous liver biopsy specimens. Although rare, renal sarcoidosis can manifest itself as hypercalcemic nephropathy, granulomatous interstitial nephritis, renal tubular dysfunction, or glomerulonephritis. Corticosteroids are the treatment of choice.

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare disorder characterized by intravascular hemolysis, hemoglobinuria, and thrombosis. Thrombotic attacks are life threatening and are responsible for nearly 50% of PNH-related deaths. Compared with thrombotic events, bleeding related to thrombocytopenia in PNH is quite rare. This report describes an atypical clinical presentation with problems in the diagnosis and management of a woman who presented with a splenic infarct followed by massive intra-abdominal bleeding due to splenic rupture. She also developed a renal infarct during hospitalization after diagnosis.

The aims of this study were to examine the plasma nitrate/nitrite (NOx; two end products of nitric oxide metabolism) and endothelin‐1 (ET‐1) concentrations in patients with liver cirrhosis, and to investigate whether there is a relationship between these two vasoactive parameters and the course of disease. Twenty‐eight patients with liver cirrhosis (11 HBV‐related, four HCV‐related, four alcohol‐related, and nine with idiopathic etiology) and 25 healthy subjects (controls) were included in the study. The venous plasma concentrations of NOx and ET‐1 were significantly higher (P

We aimed to evaluate the diagnostic values of soluble transferrin receptor (sTfR) concentration, transferrin-ferritin index (soluble transferrin receptor concentration/log ferritin), ferritin levels and other related parameters in geriatric patients with anemia of chronic disease (ACD) and iron deficiency (IDA). Forty-four elderly subjects (median age 73 [63-94]) and twenty healthy subjects (median age 49 [44-56]) were enrolled into this study, divided into four groups: twenty middle aged healthy subjects (group A), fifteen elderly patients with IDA (group B), fourteen elderly patients with ACD (group C) and fifteen nonanemic geriatric subjects (group D). Hemoglobin, mean corpuscular volume, serum iron concentration and transferrin saturation levels of the patients in IDA group were found significantly lower than those in both non-anemic group and healthy subjects. Serum sTfR concentrations of the patients in IDA group were significantly higher than those in non-anemic geriatric group, ACD group and healthy subjects. Transferrin-ferritin index of the patients with IDA was significantly higher than that in non-anemic geriatric and ACD group. Serum ferritin levels of the patients in IDA group did not show any differences when compared with the other groups. Serum ferritin was highly specific for IDA (95%) when compared with ACD, although its sensitivity was low (38%). STfR values were negatively correlated with both transferrin and ferritin levels (p = 0.042 r = -0.40; and p = 0.034 r = -0.41, respectively). In conclusion, serum soluble transferrin receptor and transferrin-ferritin index may be used together with serum ferritin to distinguish the iron deficiency state in the elderly.

This study compares the diagnostic value of troponin T (TnT) and myoglobin with creatinine kinase (CK) for myocardial infarction (MI) in a tertiary care centre in a developing nation. The study group comprised 33 acute myocardial infarction patients and 27 healthy controls. Receiver operating characteristic curves for TnT, myoglobin and CK were drawn and areas under the curve calculated. At admission, myoglobin levels had greater diagnostic sensitivity than TnT or CK levels. After 2 h, myoglobin and TnT had equal sensitivity and specificity, whereas CK still had lower sensitivity than myoglobin and TnT. After 4 h there was no difference between the tests. It was concluded that myoglobin levels on admission and TnT at 2 h had the greatest diagnostic rate, whereas all the tests were similar after 4 h for MI.

Peritoneal seeding after abdominal surgery is a well known route of metastasis in intra-abdominal solid tumours. Direct mechanical contamination, local peritoneal trauma and subsequent inflammation, postoperative immunosuppression, and laparoscopic surgery are the proposed predisposing factors for this type of metastasis. These factors probably result in enhanced adhesion or growth of tumour cells. However, this route of metastasis has not yet been reported for lymphomas. Here, we report the first case of peritoneal seeding of lymphoma cells after an abdominal surgery.

Background: High-dose therapy with melphalan and autoPBSCT induce remissions in multiple myeloma but are not able to cure this disease. Eventually, all patients relapse and require further treatment. One possibility suitable particularly for patients who had not been earlier treated with thalidomide is a combination of this drug with dexamethasone. Aims: To retrospectively assess the effectiveness of such treatment in a cohort of patients treated in a single center. The endpoints of the study were: response, EFS, OS and toxicity. Methods: Forty five multiple myeloma patients (23 female/22 male) with a median age of 54 years (range, 33-69 years) were included into the analysis between June 2005 and December 2007. Twenty seven patients were IgG, 10-IgA, 2-nonsecretory, 6-light chain. Clinical stage according ISS: 20 patients in stage 1, 9 in stage 2, 16 in stage 3. Patients have been initially treated with VAD protocol (vincristin/adriamycin/ dexamethasone) followed by cyclophosphamide mobilization and then by tandem high-dose melphalan with autoPBSCT. Relapsing patients were treated according to the following protocol: thalidomide 200 mg/day orally continuously until any sign of progressive disease or relapse, and dexamethasone 40 mg orally for 4 days every 3 weeks. Fifteen patients received enoxaparin and 30 patients acetylsalicylic acid prophylaxis. Response was evaluated using the International Myeloma Working Group Uniform Response Criteria. Moreover, overall survival (OS) and event-free survival (EFS) was assessed. Results: Altogether, 6 patients (13.3%) achieved complete response (CR), 7 patients (15.5%) very good partial response (VGPR), 18 patients (40%) partial response (PR), 11 patients (24.4%) stable disease (SD), and 3 patients (6.6%) progression disease (PD). The median time to response was 12 weeks (range, 12-28 weeks). Duration of treatment TD was 14.6 months (median; range, 3-48.6 months). The median EFS was 24 months (range, 14-41.3 months). The median OS has not been reached. The major adverse events of THALDEX were: peripheral neuropathy, 18 patients (40%); constipation, 12 patients (26.6%); somnolence, 5 patients (11.1%); deep-vein thrombosis, 1 patient (2.2%). Conclusion: THALDEX seem to be effective in multiple myeloma patients relapsing after high dose therapy and tandem PBSCT and well tolerated.

This study investigated the incidence and severity of hepatic osteodystrophy in patients with posthepatitic liver cirrhosis, and the role of hepatocellular injury in bone loss. Twenty-four patients (15 females and 9 males, mean age 49 +/- 13 years) with posthepatitic cirrhosis were enrolled in this study. The control group consisted of 22 healthy age and sex matched adults. The bone mineral density (BMD) was evaluated by dual energy x-ray absorptiometry of the L1-L4 vertebral bodies. A detailed questionnaire was used to assess the epidemiological findings. A statistically significant decrease in BMD of the patients was observed. There were no significant differences in the alkaline phosphatase, parathyroid hormone, calcitonin, 25-hydroxyvitamin D, osteocalcin, free testosterone, luteinizing hormone, follicle stimulating hormone, and estradiol levels, oral calcium intake, urinary calcium, phosphorus and hydroxypyroline excretion between patients and controls. The control group smoked more cigarettes, consumed more coffee and meat, and were exposed the sun light for a longer period than the study group. Multiple regression analysis showed that osteopenia depends significantly on the extent of liver disease. The data shows that the patients with posthepatitic cirrhosis had osteopenia, and that cirrhosis was a direct and independent risk factor.