Medicine
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The classic proposal of intracellular K+ for extracellular H+ exchange as responsible for the hyperkalemia of diabetic ketoacidosis (DKA) has been questioned because experimentally induced organic anion acidosis fails to produce hyperkalemia. It has been suggested, instead, that the elevated serum [K+] of DKA might be the result of the compromised renal function, secondary to volume depletion, that usually accompanies DKA. However, several metabolic derangements other than volume depletion and acidosis, which are known to alter potassium metabolism, also develop in DKA. ⋯ These results indicate that the endogenous ketoacidemia and hyperglycemia observed in DKA, which result primarily from insulin deficit, are the main determinants of increased [K+]p. Since exogenous ketoacidemia and hyperglycemia in the otherwise normal experimental animal do not increase [K+]p, it is postulated that insulin deficit itself may be the major initiating cause of the hyperkalemia that develops in DKA. Renal dysfunction by enhancing hyperglycemia and reducing potassium excretion also contributes to hyperkalemia.
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Suppurative thrombosis of a central vein is a serious complication of central venous catheter use. Surgical removal of the vein, the treatment usually recommended for peripheral vein suppuration, is technically difficult. We describe six patients with central venous septic thrombophlebitis. ⋯ The fourth patient improved clinically with 2 weeks of medical therapy prior to surgery, which showed the clot to be sterile. In contrast, two patients with suppuration adjacent to and secondarily involving a large vein required surgical drainage of the perivenous collection. Patients with central venous septic thrombophlebitis can be successfully managed with prompt catheter removal, intravenous antibiotics, and anticoagulation, but surgery should be considered when there is a suppurative focus around the vein.
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Clinical and laboratory features as well as immunogenetic markers were analyzed in 150 patients with SLE to determine if demographic factors--age at diagnosis, sex and race--influenced the expression of disease. The overall series included 103 white females, 35 black females, 10 white males and 2 black males; the mean age at diagnosis was 32.5 years. Males had a significantly older mean age at diagnosis than females (40.4 versus 31.8 years) and a significantly higher frequency of peripheral neuropathy (50% versus 18.8%). ⋯ Similar findings were noted when blacks aged 35 and above were compared to those aged 17 and below at diagnosis. In whites, the frequency of both anti-Ro(SS-A) and La(SS-B) antibodies increased with increasing age as did that of HLA-DR3; HLA-DR2, however, was more frequent in those with younger age at diagnosis. These data suggest the existence of two serologic-genetic subsets of SLE with different age at diagnosis.
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Review Case Reports
Thrombophlebitis and cellulitis due to Campylobacter fetus ssp. fetus. Report of four cases and a review of the literature.
Four cases of acute thrombophlebitis and cellulitis due to C. fetus ssp. fetus are reported, with a review of 18 previously reported cases. Vascular infection with thrombophlebitis due to C. fetus ssp. fetus occurred predominantly in adult male patients with underlying debilitating, immunocompromising illnesses resulting in a mortality rate of 32%. ⋯ Diagnosis of C. fetus ssp. fetus thrombophlebitis or cellulitis is based on clinical suspicion and recovery of the agent from blood culture; the latter requires an average incubation period of 8 days. Empiric therapy with erythromycin, and an aminoglycoside or chloramphenicol is recommended in suspect patients pending results of blood cultures.
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In an autopsy study of patients with cancer, 14.6% had pathologic evidence of cerebrovascular disease (CVD), and in 7.4% clinical symptoms of CVD had been present in life. The usual risk factors for CVD were overshadowed by pathophysiologic abnormalities related to the neoplasm, including direct effects of the tumor, coagulation disorders, infections and diagnostic or therapeutic procedures. In patients with leukemia, hemorrhages (72.4%) were much more common than ischemic infarcts. ⋯ The clinical presentation of CVD in patients with cancer is more often a diffuse encephalopathy, with or without localizing signs, than the typical acute onset of a focal deficit. This was particularly true with intravascular coagulation, septic infarction and subdural hematoma. Our study suggests that by knowing the clinical setting, neurologic features and laboratory findings, one can, in many instances, make an accurate clinical diagnosis that, in some cases, leads to effective treatment.