The cause of fever and pulmonary infiltrate: a difficult etiological diagnosis

Adult-onset Still's disease is a rare condition that typically presents itself with intermittent fever, arthralgia and salmon colored rash. The involvement of the in lung is less common and very rare. Diagnosis is relatively difficult because of the presence of non-specific symptoms and the lack of serological markers specific to the disease. We report the case of a patient having a pulmonary infiltrate/infiltration compatible with pneumonia, cutaneous/skin rash and persistence of fever with multiple admissions to the Emergency Room due to the failure of treatment with antibiotics. After an appropriate work-up, a diagnosis of adult-onset Still's disease was made

Management of acute pancreatitis: current knowledge and future perspectives

In recent years, a number of articles have been published on the treatment of acute pancreatitis in experimental models and most of them concerned animals with mild disease. However, it is difficult to translate these results into clinical practice. For example, infliximab, a monoclonal TNF antibody, was experimentally tested in rats and it was found to significantly reduce the pathologic score and serum amylase activity and also to alleviate alveolar edema and acute respiratory distress syndrome; however, no studies are available in clinical human acute pancreatitis. Another substance, such as interleukin 10, was efficacious in decreasing the severity and mortality of lethal pancreatitis in rats, but seems to have no effect on human severe acute pancreatitis. Thus, the main problem in acute pancreatitis, especially in the severe form of the disease, is the difficulty of planning clinical studies capable of giving reliable statistically significant answers regarding the benefits of the various proposed therapeutic agents previously tested in experimental settings. According to the pathophysiology of acute pancreatitis, the efficacy of the drugs already available, such as gabexate mesilate, lexipafant and somatostatin should be re-evaluated and should be probably administered in a different manner. Of course, also in this case, we need adequate studies to test this hypothesis

An easy ultrasonographic diagnosis of pneumonia in Emergency room

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Spontaneous Cholecystocutaneous Fistula

Spontaneous cholecystocutaneous fistula is a rare complication of chronic calculous cholecystitis because currently gallstones are diagnosed and treated at an early stage. This occurrence is possible even if it seems actually to be rare. We report the case of a 90-year-old woman admitted to our hospital with diarrhea of 4 days duration and low-grade fever (37.5°C). On physical examination, she had a 10 × 10 cm erythematous swelling and discomfort of the upper right abdominal quadrant; the skin and mucosae were dry. Transabdominal ultrasonography showed a gallbladder with abnormalities of the wall, a single gallstone impacted in the infundibulum and a fluid collection with irregular margins containing fluctuating echoes adjacent to the anterior abdominal wall of the upper right abdominal quadrant. A diagnosis of spontaneous cholecystocutaneous fistula with an abdominal purulent collection was reached. Due to the high anesthesiological risk of the patient, conservative management was carried out with fluids, broad-spectrum antibiotic, albumin and calcium supplementation. Computed tomography drainage of the purulent collection was also carried out. Both clinical and laboratory parameters substantially improved during the following two days, but on the third day of hospitalization, the patient died from a sudden arrhythmic event

Long-Standing Pancreatic Hyperenzymemia: Is It a Nonpathological Condition?

Chronic nonpathological pancreatic hyperenzymemia is characterized by a chronic, abnormal increase in the serum concentrations of the pancreatic enzymes including amylase, pancreatic isoamylase, lipase and trypsin. The diagnostic work-up that the physicians should recommend to subjects with hyperenzymemia to definitively assess this syndrome is still an open question. A 72-year-old female was admitted to our Pancreas Unit in December 2008 for the presence of long-standing pancreatic hyperenzymemia of 42 years duration. On admission, serum amylase activity was 160 IU/l (reference range 8–78 IU/l), serum pancreatic isoamylase activity was 91 IU/l (reference range 13–53 IU/l) and serum lipase activity was 127 IU/l (reference range 8–78 IU/l). Other laboratory examinations revealed normal blood tests except for total serum cholesterol, HDL cholesterol and serum triglycerides that was slight elevated. Abdominal ultrasonography demonstrated no alteration of the pancreatic gland. A magnetic resonance cholangiopancreatography was carried out according to our diagnostic work-up of patients with unexplained pancreatic hyperenzymemia. This examination revealed two small cystic lesions: one of 6 mm in diameter in the head of the pancreas and the other one of 9 mm in diameter in the body of the pancreatic gland. The duct of Wirsung was normal and the two cystic lesions were diagnosed as branch-type intrapapillary mucinous tumors of the pancreas. All patients with pancreatic hyperenzymemia should be strictly followed in high volume centers for pancreatic disease in order to early diagnose the possible appearance of morphological pancreatic alterations

Acute abdominal pain in emergency room: Is it always a simple diagnosis?

Acute abdominal pain is characterized by pain arising from the abdominal area, of non-traumatic origin with a maximum duration of five days and represents a true medical emergency. It is also one of the most common reasons for referral to an emergency department and the most common cause for no trauma-related hospital admissions. Hematologic disorders represent the 0.3% of all admissions for acute abdominal pain. We report a rare case of retroperitoneal bulky mass due to anaplastic large T-cell lymphoma. This entity represents a rare tumor and early diagnosis leads to a correct diagnosis of the origin of the acute abdominal pain and chemotherapy is vital to ensure good prognosis

Acute pancreatitis associated with massive paraesophageal hernia involving the presence of the pancreatic body and tail

Acute pancreatitis is an acute inflammation of the pancreas and, according to the 2013 Revised Atlanta Classification, the majority of cases have only a mild clinical course without organ dysfunction. The primary objectives in the treatment of acute pancreatitis are essentially relief of pain, electrolyte and fluid support and energy intake other than removal of the causal agent. Even if in Italy gallstones especially are the predominant etiological factor, there are also less frequent causes associated with acute pancreatitis and we believe that the case of acute pancreatitis associated with massive incarcerated paraesophageal hernia involving the presence of the body and tail of the pancreas in the thorax is worth reporting

Autoimmune Pancreatitis Associated with High Levels of Chromogranin A, Serotonin and 5-Hydroxyindoleacetic Acid

We report a case of a male patient with autoimmune pancreatitis in whom biochemical examination revealed high plasma chromogranin A concentrations, histological demonstration of a small lymphocytic infiltrate and rapid decrease in size of the pancreatic mass following short-lasting therapy with methylprednisolone. To our knowledge, this is the first patient with autoimmune pancreatitis who had a simultaneous increase of serum chromogranin A levels, circulating and urinary serotonin concentrations and urine 5-hydroxyindoleacetic acid concentrations. This is one of the few cases of mass forming pancreatitis with small lymphocytic infiltrate found in a Caucasian patient and rapid decrease in size of the pancreatic mass following short-lasting therapy with methylprednisolone

Pseudoaneurysm of the splenic artery mimicking a solid lesion

A 64-year-old man presented to the hospital because of hematemesis; on admission, he had weakness and pale skin, tachycardia and hypotension. Laboratory tests revealed severe anemia (hemoglobin 7.8 g/dL); liver, renal and pancreatic function tests were normal. An upper digestive endoscopy revealed a gastric ulcer of the cardia, treated with metallic clips and adrenalin injection. The patient was treated with fluids and was transfused with three units of red blood cells. In the previous two months, due to the presence of bloating and diarrhea, associated with abdominal distension, a colon-computed tomography (CT) revealed a large retroperitoneal hypodense mass, 53x37 mm in size, without contrast enhancement localized between the body and the tail of the pancreas and the stomach, near the splenic artery and without signs of infiltration. To better define the mass, endoscopic ultrasound and biopsy were performed; however histopathology of multiple biopsies was not diagnostic, because of the presence of necrotic tissue and inflammatory cells. Since hematemesis recurred, the patient underwent a second upper digestive endoscopic examination, but no source of bleeding was found. Then a new contrast enhanced CT was performed that showed a size reduction of the mass, the presence of blood in the stomach and a small pseudoaneurysm of the splenic artery. Because of these findings an angiograpghic study was carried out; angiography confirmed a splenic artery pseudoaneurysm that was successfully embolized with metal microcoils

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ABSTRACT Context The absence of a definition and a widely accepted ranking system to classify surgical complications has hampered proper interpretation of the surgical outcome. Patients Sixty-one patients undergoing distal pancreatectomy. Main outcome measures The complications were classified according to the Clavien-Dindo classification; each grade was evaluated regarding the length of the postoperative stay and was compared to the most important complications. Results Thirty (49.2%) patients had no complications; out of the thirty-one (50.8%) patients with complications, 9 (14.5%) had grade I, 15 (24.6%) had grade II, 6 (9.8%) had grade III, and 1 (1.6%) had grade IV. There were no postoperative deaths (grade V). A progressive increase in the length of hospitalization from patients with no complications to those having grade IV (P<0.001) was noted. Postoperative pancreatic fistula and postpancreatectomy hemorrhage rates did not significantly increase from Clavien-Dindo grade I to grade IV (P=0.118 and P=0.226, respectively). The severity of a postpancreatectomy hemorrhage, instead, was positively related to the grade of the Clavien-Dindo classification (P=0.049) while postoperative pancreatic fistula resulted near the significant value (P=0.058). Conclusions The Clavien-Dindo classification is a simple way of reporting all complications following distal pancreatectomy. It allows us to distinguish a normal postoperative course from any deviation and the severity of complications and it may be useful for comparing postoperative morbidity between different pancreatic centers