BACKGROUND Aim of the paper is to prove that indications for cholangiojejunostomy, in cases when a mean and long term palliation may be expected, are better than those offered by the use of prostheses, without the well known and early bile duct complications. METHODS Between 1984 and 1995, 12 patients with obstructive jaundice due to malignancy at the hepatic hilum were treated by segment III Roux-en-y or omega cholangiojejunostomy. In 1 patient with no communication between right and left lobe of the liver, biliary-enteric bypass to segment VI duct was also undertaken; in another with neoplastic stenosis of pylorus gastrojejunostomy was performed. Seven patients had carcinoma of the gallbladder, three hilar cholangiocarcinoma, one gastric carcinoma and one recurrent pancreatic carcinoma. RESULTS There were two postoperative deaths, one for myocardial infarction and one for biliary peritonitis. Six patients had complications: four biliary fistulas with spontaneous resolution and two wound infections. Seven of the ten surviving patients experienced complete resolution of jaundice for at least 4 months. The mean survival of surviving patients was 9.7 months. Nine patients developed recurrent jaundice. CONCLUSIONS Segment III cholangiojejunostomy is a good palliative treatment in most patients with malignant hilar obstruction.

Cholecystolithotomy and cholecystojejunostomy has been carried out on 11 patients with severe hypertension from cirrhosis. The indications were frequently recurring attacks of biliary cholic or acute cholecystitis at onset. There was 1 postoperative death from cardiac infarction and only minor in-hospital morbidity. None of the remaining patients has to date developed post-cholecystojejunostomy sequelae. Except the case of extensive inflammation on gangrena, this procedure appears to be a safe and definitive operation, alternative to subtotal cholecystectomy.

This study describes a case of pulmonary aspergilloma in a neutropenic patient affected with myelodysplastic syndrome. It reports the therapeutic efficacy of itraconazole, emphasizing in particular the possible interaction with quinidine, with QT prolongation--at ECG--disappeared after quinidine withdrawal.

A confidential questionnaire was given to 241 students of the nursing school of a Milano Hospital to record the knowledge on HIV infection and their experience with HIV patients during their training in wards different from Infectious Departments. The results evidence a good level of knowledge, comparable to the italian young population (according to other studies) of the same age. Nursing students from the very beginning of their practical training, happen to care for asymptomatic HIV positive subjects, therefore the school should provide knowledge and information on the HIV infection before the beginning of the practical training.

A case of thrombotic thrombocytopenic purpura (TTP) in a 40-year-old bisexual man unaware of being HIV positive is reported. The hematologic syndrome represented the first clinical manifestation of this viral infection. The clinical picture, characterized by severe hemolytic microangiopathic anemia, thrombocytopenia, fluctuating neurologic abnormalities and fever, quickly improved after plasma exchange and corticosteroid therapy. Two blood tests showed severe depletion of the CD4+ lymphocyte count and HIV antigenemia was positive. This case represents a clinical epiphenomenon of HIV infection in an advanced phase. According to recent CDC criteria the patient should be considered in AIDS. Antiretroviral treatment was started and after nine months of follow-up there has been no relapse.

OBJECTIVE:To evaluate the presence of autonomic nervous system (ANS) involvement in HIV-positive drug users. DESIGN:We investigated 37 HIV-positive (and 18 HIV-negative controls) intravenous heroin users who were without symptoms and signs of autonomic or peripheral neuropathy. METHODS:The patients were clinically and immunologically assessed and subjected to a battery of five cardiovascular reflex function tests. RESULTS:The tests revealed ANS involvement in 22 HIV-positive subjects but only in one HIV-negative subject. Immunoglobulin (Ig) G and C1q immune complex levels were significantly higher in HIV-positive subjects with severe cardiovascular reflex function tests alteration compared to those with normal tests. In a follow-up of 17 HIV-positive subjects, nine presented deteriorated reflexes in the tests and higher IgG immune complex levels. CONCLUSIONS:The results confirm that, by using sufficiently sensitive tests, signs of preclinical autonomic neuropathy can frequently be found in HIV-positive intravenous heroin users, as previously observed in homosexual patients, and suggest the existence of an HIV-related autoimmune pathogenesis. Early diagnosis of ANS involvement could be important, since the presence of autonomic dysfunction could increase the risk of cardiorespiratory arrest during invasive procedures.

We describe a 69-year-old man who presented with a four-month history of polyuria and polydipsia. Plasma vasopressin levels were undetectable, and a dehydration test was abnormal. Based on these findings, a diagnosis of central diabetes insipidus has been established. Hematologic studies showed acute monocytic leukemia. A relationship between the hematologic and endocrine disturbance has been hypothesized, and histological examination at autopsy showed leukemic infiltration of the pituitary stalk. This patient represents the third case in the world literature of central diabetes insipidus associated with acute monocytic leukemia.

Vasopressin and its analogue terlipressin are potent vasoconstrictors which reduce mesenteric blood flow and have been used in the therapy of variceal hemorrhage. This vasoconstrictor effect applies on vascular beds throughout the body. Since in literature vasopressin is rarely described to determine lactic acidosis, we report of a patient in whom a severe metabolic (probably lactic) acidosis appeared, associated with terlipressin administration for bleeding esophageal varices. By exclusion, the temporal sequence with terlipressin therapy, the contemporary increase of arterial blood pressure and autoptic data in the case presented make likely a diagnosis of terlipressin-induced lactic acidosis. Because of the seriousness of metabolic acidosis observed in our patient we suggest a careful monitoring of acid-base parameters in patients under treatment with vasopressin analogues.

Ben-Haim et al (Chest 1988; 94:656) describe an HIV-positive intravenous heroin addict presenting with fever, respiratory distress and diffuse miliary infiltrates on chest x-ray film due to talc granulomatosis. The authors suggest that such talc crystals should be regarded as a possible cause of pulmonary granulomatosis and should be considered in the differential diagnosis of pulmonary disease in heroin addicts suspected to have AIDS. On the other hand, intravenous heroin addicts (IHA) frequently present normal chest x-ray films and no respiratory symptoms, but about 40 percent show alterations of pulmonary function almost exclusively represented by a reduction in the carbon monoxide-diffusing capacity (Dco).1Overland ES Nolan AJ Hopewell PC Alteration of pulmonary function in intravenous drug abusers. Prevalence, severity and characterization of gas exchange abnormalities.Am J Med. 1980; 68: 231-237Abstract Full Text PDF PubMed Scopus (57) Google ScholarIHA constitute a population at risk for HIV infection; in Italy, they make up about 60 to 70 percent of AIDS cases. The role of HIV infection in the pathogenesis of respiratory function alterations in IHA is still unknown. Since HIV has been isolated in lung tissue of patients with AIDS,2Chayt KJ Harper ME Marselle LM Lewin EB Rose RM Oleske JM et al.Detection of HTLV-III RNA in lungs of patients with AIDS and pulmonary involvement.JAMA. 1986; 256: 2356-2359Crossref PubMed Scopus (123) Google Scholar,3Dean NC Golden JA Evans LA Warnock ML Addison TE Hopewell PC Levy JA Human immunodeficiency virus recovery from bronchoalveolar lavage fluid in patients with AIDS.Chest. 1988; 93: 1176-1179Crossref PubMed Scopus (24) Google Scholar it is possible to hypothesize that the Dco reduction in IHA could be caused by an alveolitis due to the direct localization of HIV in lung tissue or to an immune-mediated response to HIV antigens.4Saldiva PHN Delmonte VC Dolhnikoff M Silveira PSP Necropsy findings in the lung in acquired immune deficiency syndrome in Brazil.Chest. 1988; 94: 11SGoogle Scholar In order to evaluate the role of HIV infection in alterations of respiratory function in IHA, we prospectively studied a group of 33 IHA (23 men and ten women), 12 HIV-negative and 21 HIV-positive. Six belonged to group II CDC classification system, 11 to group III and four to group IV. For all patients the following tests were taken: clinical examination, hemoglobin concentrations, CD4 and CD8 lymphocyte counts, anti-HIV antibodies assay (ELISA and Western blot), chest x-ray film, respiratory function tests (TLC, FEV1, FVC, FEV1/FVC and Dco expressed as a percentage of predicted values) and blood gas analysis (pH, PaO2, PaCO2, SaO2). None of the subjects presented with respiratory symptoms and/or infiltrates on chest x-ray film. In both groups and for each smoker, cigarette consumption in pack/years was calculated as the number of packs (20 cigarettes/pack) smoked per day multiplied by the number of years the subject smoked. Data were analyzed by the Student's t-test. A “p” value less than 0.05 was defined as significant. All values are expressed as means ± SD. HIV-positive subjects did not show statistically significant differences compared with HIV-negative subjects for age (26.3 ± 5.1 years, ranging from 17 to 43, vs 29 ± 4.1 years, ranging from 24 to 35); length of intravenous drug use (7.3 ± 3.6 years, ranging from one to 15, vs 7.2 ± 4.8 years, ranging from 1 to 18); number of cigarettes smoked (13.8 ± 7.7 pack/years, ranging from 0 to 30, vs 16.8 ± 7.4 pack-years, ranging from 0 to 26); hemoglobin concentrations (14.3 ± 1.2 g/dl, ranging from 12.5 to 16, vs 14.7 ± 1.6 g/dl, ranging from 12.1 to 17.1); and CD8 lymphocyte counts (1.088 ± 0.444 × 109/L, ranging from 0.296 × 109 to 2.043 × 109, vs 0.922 ± 0.514 × 109/L, ranging from 0.222 × 109 to 1.966 × 109). HIV-positive subjects showed a statistically significant reduction in Dco compared with HIV-negative subjects (74.6 ± 14.1 percent, ranging from 50 to 107, vs 86.9 ± 6.6 percent, ranging from 79 to 100, p<0.01) and CD4 lymphocyte counts (0.785 ± 0.428 × 109/L, ranging from 0.145 × 109 to 1.715 × 109, vs 1.236 ± 0.464 × 109/L, ranging from 0.848 × 109 to 2.051 × 109, p<0.01). Significant correlations between Dco and CD4 lymphocyte counts were not found. Dco was <80 percent in 15 of 19 (79 percent) HIV-positive subjects and in one of 11 (9 percent) HIV-negative subjects. The four HIV-positive subjects with normal Dco (>80 percent) were in group III and IV of the CDC classification.These data show that HIV-positive IHA present more frequently than HIV-negative IHA alterations in respiratory function, suggesting interstitial pulmonary disease. The absence of respiratory symptoms and/or chest x-ray abnormalities suggest subclinical pulmonary disease5Israel HL Gottlieb JE Schulman ES Hypoxemia with normal chest roentgenogram due to Pneumocystis carinii pneumonia. Diagnostic errors due to low suspicion of AIDS.Chest. 1987; 92: 857-859Crossref PubMed Google Scholar or an interstitial pneumopathy due to HIV.6Ognibene F Masur H Suffredini AF Travis W Rogers P Kovacs JA et al.Asymptomatic human immunodeficiency virus seropositive individuals often have evidence of nonspecific pneumonitis at bronchoscopy. IV International Conference on AIDS, Stockholm1988: 7506Google Scholar An alveolitis composed of cytotoxic T-lymphocytes directed against HIV-infected alveolar macrophages has been effectively demonstrated in patients with HIV infection.7Guillon JM Autran B Denis M Fouret P Plata F Mayaud CM Akoun GM Human immunodeficiency virus-related lymphocytic alveolitis.Chest. 1988; 94: 1264-1270Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar Since the Dco reduction is prevalent in HIV-positive subjects, since it is already present in the asymptomatic stage of infection and is not related to CD4 lymphocytes reduction, we suggest that pulmonary involvement could be due to a direct action of HIV rather than a subclinical opportunistic infection. Ben-Haim et al (Chest 1988; 94:656) describe an HIV-positive intravenous heroin addict presenting with fever, respiratory distress and diffuse miliary infiltrates on chest x-ray film due to talc granulomatosis. The authors suggest that such talc crystals should be regarded as a possible cause of pulmonary granulomatosis and should be considered in the differential diagnosis of pulmonary disease in heroin addicts suspected to have AIDS. On the other hand, intravenous heroin addicts (IHA) frequently present normal chest x-ray films and no respiratory symptoms, but about 40 percent show alterations of pulmonary function almost exclusively represented by a reduction in the carbon monoxide-diffusing capacity (Dco).1Overland ES Nolan AJ Hopewell PC Alteration of pulmonary function in intravenous drug abusers. Prevalence, severity and characterization of gas exchange abnormalities.Am J Med. 1980; 68: 231-237Abstract Full Text PDF PubMed Scopus (57) Google Scholar IHA constitute a population at risk for HIV infection; in Italy, they make up about 60 to 70 percent of AIDS cases. The role of HIV infection in the pathogenesis of respiratory function alterations in IHA is still unknown. Since HIV has been isolated in lung tissue of patients with AIDS,2Chayt KJ Harper ME Marselle LM Lewin EB Rose RM Oleske JM et al.Detection of HTLV-III RNA in lungs of patients with AIDS and pulmonary involvement.JAMA. 1986; 256: 2356-2359Crossref PubMed Scopus (123) Google Scholar,3Dean NC Golden JA Evans LA Warnock ML Addison TE Hopewell PC Levy JA Human immunodeficiency virus recovery from bronchoalveolar lavage fluid in patients with AIDS.Chest. 1988; 93: 1176-1179Crossref PubMed Scopus (24) Google Scholar it is possible to hypothesize that the Dco reduction in IHA could be caused by an alveolitis due to the direct localization of HIV in lung tissue or to an immune-mediated response to HIV antigens.4Saldiva PHN Delmonte VC Dolhnikoff M Silveira PSP Necropsy findings in the lung in acquired immune deficiency syndrome in Brazil.Chest. 1988; 94: 11SGoogle Scholar In order to evaluate the role of HIV infection in alterations of respiratory function in IHA, we prospectively studied a group of 33 IHA (23 men and ten women), 12 HIV-negative and 21 HIV-positive. Six belonged to group II CDC classification system, 11 to group III and four to group IV. For all patients the following tests were taken: clinical examination, hemoglobin concentrations, CD4 and CD8 lymphocyte counts, anti-HIV antibodies assay (ELISA and Western blot), chest x-ray film, respiratory function tests (TLC, FEV1, FVC, FEV1/FVC and Dco expressed as a percentage of predicted values) and blood gas analysis (pH, PaO2, PaCO2, SaO2). None of the subjects presented with respiratory symptoms and/or infiltrates on chest x-ray film. In both groups and for each smoker, cigarette consumption in pack/years was calculated as the number of packs (20 cigarettes/pack) smoked per day multiplied by the number of years the subject smoked. Data were analyzed by the Student's t-test. A “p” value less than 0.05 was defined as significant. All values are expressed as means ± SD. HIV-positive subjects did not show statistically significant differences compared with HIV-negative subjects for age (26.3 ± 5.1 years, ranging from 17 to 43, vs 29 ± 4.1 years, ranging from 24 to 35); length of intravenous drug use (7.3 ± 3.6 years, ranging from one to 15, vs 7.2 ± 4.8 years, ranging from 1 to 18); number of cigarettes smoked (13.8 ± 7.7 pack/years, ranging from 0 to 30, vs 16.8 ± 7.4 pack-years, ranging from 0 to 26); hemoglobin concentrations (14.3 ± 1.2 g/dl, ranging from 12.5 to 16, vs 14.7 ± 1.6 g/dl, ranging from 12.1 to 17.1); and CD8 lymphocyte counts (1.088 ± 0.444 × 109/L, ranging from 0.296 × 109 to 2.043 × 109, vs 0.922 ± 0.514 × 109/L, ranging from 0.222 × 109 to 1.966 × 109). HIV-positive subjects showed a statistically significant reduction in Dco compared with HIV-negative subjects (74.6 ± 14.1 percent, ranging from 50 to 107, vs 86.9 ± 6.6 percent, ranging from 79 to 100, p<0.01) and CD4 lymphocyte counts (0.785 ± 0.428 × 109/L, ranging from 0.145 × 109 to 1.715 × 109, vs 1.236 ± 0.464 × 109/L, ranging from 0.848 × 109 to 2.051 × 109, p<0.01). Significant correlations between Dco and CD4 lymphocyte counts were not found. Dco was <80 percent in 15 of 19 (79 percent) HIV-positive subjects and in one of 11 (9 percent) HIV-negative subjects. The four HIV-positive subjects with normal Dco (>80 percent) were in group III and IV of the CDC classification. These data show that HIV-positive IHA present more frequently than HIV-negative IHA alterations in respiratory function, suggesting interstitial pulmonary disease. The absence of respiratory symptoms and/or chest x-ray abnormalities suggest subclinical pulmonary disease5Israel HL Gottlieb JE Schulman ES Hypoxemia with normal chest roentgenogram due to Pneumocystis carinii pneumonia. Diagnostic errors due to low suspicion of AIDS.Chest. 1987; 92: 857-859Crossref PubMed Google Scholar or an interstitial pneumopathy due to HIV.6Ognibene F Masur H Suffredini AF Travis W Rogers P Kovacs JA et al.Asymptomatic human immunodeficiency virus seropositive individuals often have evidence of nonspecific pneumonitis at bronchoscopy. IV International Conference on AIDS, Stockholm1988: 7506Google Scholar An alveolitis composed of cytotoxic T-lymphocytes directed against HIV-infected alveolar macrophages has been effectively demonstrated in patients with HIV infection.7Guillon JM Autran B Denis M Fouret P Plata F Mayaud CM Akoun GM Human immunodeficiency virus-related lymphocytic alveolitis.Chest. 1988; 94: 1264-1270Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar Since the Dco reduction is prevalent in HIV-positive subjects, since it is already present in the asymptomatic stage of infection and is not related to CD4 lymphocytes reduction, we suggest that pulmonary involvement could be due to a direct action of HIV rather than a subclinical opportunistic infection.

Still's disease is a seronegative arthritis of children which, in a limited number of cases, can affect adults. The diagnosis of adult-onset Still's disease is characterized by high fever, arthritis and negative serologic tests for rheumatoid factor and antinuclear antibodies and by at least two minor symptoms (leukocytosis, evanescent rash, serositis, hepato- or splenomegaly, and lympho-adenopathy). Since many diseases present analogous manifestations and the adult-onset Still's disease is generally diagnosed by exclusion, we report two patients, aged 26 and 39, with Still's disease, the former with a classic clinical feature, the latter with a clinical feature characterized by severe hepatic abnormalities. The determination of histocompatibility antigens can be useful because some of them (HLA-DR4 in case 1 and HLA-DRw6 in case 2) are frequently associated with the adult-onset Still's disease. The role of anti-inflammatory therapy (acetylsalicylic acid, indomethacin, steroids) must be emphasized, whose efficacy can constitute the pathognomonic element on which the diagnosis of adult-onset Still's disease can be based in a proper clinical pattern.

Sputum specimens from 15 patients with respiratory disease were reported to have positive cultures for Mycobacterium gordonae, an organism generally considered to be non-pathogenic for man. None showed typical radiological changes for mycobacteriosis. Mycobacterium gordonae was also isolated from some components of the aerosol therapy instrument. Because aerosol therapy was used for 4 patients only, we were not able to establish whether the Mycobacterium gordonae was only a colonizer. We suggest that its isolation in culture must be evaluated in an adequate clinical context before concluding that it is pathogenic.

We report a case of a patient with hypothyroidism due to amiodarone. The short-term administration (1 g/die for 10 days) of potassium perchlorate (KClO4) led to normalization of serum thyroid hormone concentrations and marked reduction of thyrotropic hormone. The reduction of KClO4 (400 mg/die) and its following withdrawal led to reappearance of hypothyroidism signs. No side-effects or toxic reactions occurred during KClO4 therapy. This anion competitively inhibits thyroid iodide transport, reducing intrathyroidal iodide content and removing thyroid hormone synthesis inhibition. We suggest KClO4 therapy when amiodarone-associated hypothyroidism impairs a pre-existent cardiac disease and when a quick restoration of euthyroidism is necessary. Nevertheless, we emphasize that its effect can be transitory in cases of short-term treatment or low doses.

We describe a patient with acute B-lymphocyte lymphoblastic leukemia who developed laboratory changes (not detectable free thyroxine, TSH 66 μlU/ml) suggesting severe primary hypothyroidism. Histological examination at autopsy showed massive leukemic infiltration of the thyroid gland: the progressive reduction of thyroid hormone levels with concomitant increase in TSH levels observed over a three-month period from the onset of the hemopathy suggests a cause-effect relationship between leukemic infiltration of the thyroid gland and hypothyroidism.