CITATION: Edelstein, C. L. & Welke, H. 1991. Spontaneous kidney rupture in polyarteritis nodosa presenting as an acute abdome. South African Medical Journal, 79:52-53.The original publication is available at http://www.samj.org.zaAn acute abdomen in a patient with polyarteritis nodosa (PAN) is a perplexing and challenging problem for both the physician and the surgeon.Publisher’s versio

Edelstein, C. L.

Welke, H.

Довнар, Т. И.

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52 SAMJ VOL 79 5 JAN 1991The collagen and calcium content as well as the mean bonemineral content were significantly lower in the fracture group thanBone properties of osteoporotic patleptswith femoral neck fractures ~To the Editor: The most detrimentaJ:ccmsequence of osteoporosisis the increased incidence of physical disability due to fracrures,especially subcapital femur neck fracrures. In all types of osteo-porosis the earliest and most striking change occurs in trabecularbone, where the trabeculae become thin and sparse, with subse-quent fracrure. In hip osteo-arthritis, osteoporosis and femur neckfracrures seldom occur. The question whether osteo-arthritic bonehas different biochemical and biophysical qualities arises.This study concerns the mechanical characteristics and bio-chemical composition of cancellous bone at the upper femoralregion. Freshly excised femoral heads and femor"al neck specimenswere obtained from 100 patients, of whom 50 underwent total hipreplacement for hip osteo-arthritis and 50 required a hip prosthesisfor subcapital femur neck fracrure. All patients were white, theage range was 60 - 80 years, and the female/male ratio was 2:1.The osteo-arthritis and fracrure groups were absolutely comparablewith regard to age and sex distribution. The following variableswere examined: (i) the apparent density (p =vg}~~e g/cm3) of thefemoral heads and specimens were measured using the Archimedesprinciple; I (ii) hydroxyproline as an index of collagen and thecalcium content were measured by spectrophotometry as describedby Baily er alY, (iil) total bone mineral content was measured byusing the computed tomography (CT) technique developed in ourlaboratory' - a Siemens Somatom II scanner was used at 96 kVand 125 kV respectively; and (iv) compressive stress, stram andmodules of elasticity were measured as previously described; andcorrelated with the above results.The mean values obtained for each group were as follows:eO0...~If-Z "!..LJCl:f-(.f). ,Z0(.f)(.f)!..LJ : ..CC0...~ .. :0 :.u•0' .., , " .35 ."I. Mueller K, Trias A, Ray RD. Bone densiry and composition. J Bone JointSurg [Am] 1966; 48: 140-148.2. Baily P. The biochemistry of lungs in relation to silicosis. Arch BiochemBiophys 1960; 87: 144-148. .3. Baily P, Kilroe-Smith TA, Haringron IS. Biochemistry of lungs in relationto silicosis, Arch Environ Health 1964; 8: 547-554.4, Van Papendorp OH, Pistorius S, Hough FS, In vilro determination of boneminetal content of the femut neck. S Air MedJ 1988; 73: 363-364.5. Van Papendorp OH. Die meganies-fisiese eienskappe van die trabekulb-e(kanselleuse) been van die femurnek. S Air Tydskr vir NalUurwerenskap enTegnologie 1986; 5: 138-142.6. Martens M, Van Audekerche R, Delpon P, De Meester P, Muller IC. Themechanical characteristics of cancellous bone at the upper femoral region. JBiomechanics 1983; 16: 971-983.7. Leichter 1. Margulies JY, Weinrib A er al. The relationship between bonedensiry, mineral content and mechanical strength in the femoral neck. ClinOrlhop 1982; 163: 272-281.8. Lindahl 0, Lindgren GH. Cortical bone in man: variation of the amountand densiry with age and sex, Aaa Orlhap Scand 1967; 38: 133-140.9. Weinttoub S, Papo I, Ashkenagi M, Tardiman R, Weissman SL, Salama R.Osteo-arthritis of the hip and ftactures of the ptoximal end of the femur.Aaa Orrhop Scand 1982; 53: 261-264.10. Solomon L. The femoral trabecular pattern in patients with ostee-arthritisand those with fracrures of the femoral neck. J Bone Join! Surg [Br] 1979;61: 257.Department of PhysiologyUniversity of PretoriaSpontaneous kidney rupture inpolyarteritis nodosa presenting asan acute abdomenD. H. van Papendorpin the'osteo-arthritic controls. Bone density was also significantlylower in both the specimens and the femoral heads of the fracrure. group than in the osteo-arthritis group. The fracrure group neededonly 37% of the compressive stress of the ost,!;o-arthrit~s group togive way.' ~Correlations of compression strength and relative density in thefracture and osteo-arthritis groups are depicted in Fig. I.A linear correlation between compression strength and relativedensity was obtained.Several authors have shown a definite relationship betweenmechanical properties of cancellous bone and density.6,7.8 Ourresults show that mechanical bone strength, and especially com-pressive strength of cancellous bone, is directly proportional to thedensity of bone, which in rum is a product of collagen content andmineralisation (r = 0,62 for the osteoarthritis group and 0,55 forthe fracrure group). The results show significantly higher values(P < 0,001) for bone strength, density and both collagen andmineral content in the osteo-arthritis group. This many explainwhy so few osteoporotic fracrures occur in patients with osteo-arthritis and confirms the common clinical observation that patientswith primary osteo-arthritis have a 'bener quality' of bone.9 Theyare less likely to be suffering from osteoporosis, which is consideredthe most important factor responsible for fragility of bone, and aretherefore less prone to subcapital femur neck fractures. 10It appears that measurement of bone mineral content of thefemur by CT may provide a useful tool in the diagnosis ofosteopenic conditions such as osteoporosis. Femoral CT measure-ments provided an index of fracrure risk by revealing a permissivebone mineral level of approximately 160 ± 36 g/l above 'whichfractures are rare and below which fractures may occur.' Further-more, below a bone mineral content of 136 ± 32 g/l fractures arethe rule and absence of frarures is the exception.This srudy demonstrates that in furure mechanical and bio-chemical analysis of in virro bone biopsies may help in the.prevention of femur neck fracrure in subjects at risk..55177 ± 131,33 ± 0,06183 ± 409,24 ± 2,92398 ± 161198,60 ± 6osreo-arrhn'risgroup1,21 ± 0,041,16 ± 0,04136 ± 323,44 ± 1,73162 _ 80100,55 ± 584 ± 9Fraerure groupI,ll ± 0,07Specific gravity (femoral heads)Specific gravity (biopsyspecimens)Collagen content (mg/cm3 drydefaned bone)Calcium content (mg/cm3 drydefaned bone)Mineral content(QCT-scanning) (g/t)Compressive stress (mPa)Modulus of elasticityDENSITY PFig. 1. Correlation of compression strength and relative density inthe fracture and osteo-arthritis groups (e = fracture group; x =osteo-arthritis group).To the Editor: An acute abdomen in a patient with polyarteritisnodosa (PAN) is a perplexing and challenging problem for boththe physician and the surgeon. I The diagnosis of PAN may nothave been established before gastro-intestinal complicationsdevelop.2 .A 27-year-old man was admined to our ward with a 3-weekhistory of fever, myalgia and subcutaneous nodules on the elbow,left ear and scalp. He had mononeuritis· of the right leg andepididymitis. Test-strip analysis of the urine showed haematuria2+ and microscopy showed red blood cells and granular casts.The erythrocyte sedimentation rate was 110 mm/1st h(Westergren) and the white cell count 25 x 109/1. Serum urea andcreatinine values were normal. Testing for hepatitis B surfaceantigen was positive. On day 3 the patient developed an acuteabdomen. Laparotomy revealed a large haematoma in the epigastricarea, as well as a large retroperitoneal haematoma. Biopsy materialfrom a mesenteric mass was compatible with PAN. Treatment wasstarted with prednisone 60 mg/d and cyclophosphamide 100mg/d. Forry days after admission an acute abdomen developedonce again. An ultrasound scan showed a large hypo-echoic massposterolateral to the left kidney, displacing it anteriorly (Fig. I).Despite intensive resuscitation the patient died. Autopsy revealedthat the lower pole of the left kidney had ruptured, with a largefresh peri-renal haematoma. There were also multiple small infarctsof the liver and both kidneys.Fig. 1. Ultrasound scan showing haematoma posterolateral to theleft kidney, displacing it anteriorly (K = kidney; H = haematoma).This patient demonstrated renal and liver complications of PANculminating in death due to spontaneous kidney rupture. This isa rare complication that may be due to rupture of an intra-parenchymal aneurysm. Other renal complications include multiplesegmental renal infarcts, renovascular hypertension and ruptureafter renal biopsy. Without a high index of suspicion, spontaneousperi-renal haematoma may not be diagnosed before surgery oreven autopsy. Early diagnosis and properly timed surgery maydecrease the high mortality rate in this condition.3 Ultrasonographyand computed tomography may help in the diagnosis. .Kidney rupture with peri-renal haematoma should be consideredin patients with PAN presenting with an acute abdomen.We thank Dr A. Shulman for doing the ultrasonography.C. L. EdelsteinH. WelkeDepartment of MedicineUniversity of Stellenbosch andTygerberg HospitalParowvallei, CPI. Matolo NM, Dominic A. Gastrointestinal complications of collagen vasculardiseases - surgical implications. AmJ Surg 1971; 122: 678-682.2. Zizic TM, Classen IN, Stevens MB. Acute abdominal complications ofsystemic lupus erythematosus and polyarteritis nodosa. Am J Med 1982; 73:525-531.3. Cornfield JZ, Johnson ML, Dolehide J, Fowler E. Massive renal hemor-rhage owing to polyarteritis nodosa. J Uro11988; 140: 808-809.SAMJ VOL. 79 5 JAN 1991 53Naloxone in opiate-induced colonicpseudo-obstructionTo the Editor: An otherwise healthy man presented to a casualtydepartment after 2 days of treatment for diarrhoea with loperarnide(Imodium), codeine and Kantrexil, with severe cramping peri-andsubumbilical pain of increasing severity.He was obviously distressed and was sweating, with tachycardiabut no fever. His abdomen was rigid and tender maximally in thesubumbilical region, while bowel sounds were increased.A radiograph of the abdomen revealed gas-filled loops of largebowel with nothing else abnormal. A full blood count was normal.A diagnosis of colonic pseudo-obstruction with compensatorysmall-bowel hyperperistalsis was made, the underlying cause beingbowel opiate receptor stimulation by codeine and loperamide.An intravenous line was established and naloxone 0,4 mg intra-venous and 0,2 mg intramuscular injections were given. Within 2minutes the patient experienced a marked decrease in the severityof the abdominal cramps; shortly thereafter felt well enough todischarge himself from the casualty department. Flatus was passedlater that day, while a normal bowel action followed a day later.There was no recurrence of abdominal cramps, constipation ordiarrhoea during the following week.It is possible that naloxone could be used effectively in treatingopiate (codeine, loperamide and diphenoxylate)-induced consti-pation or pseudo-obstruction instead of or in combination withmore conservative 'drip and suck' management.N. KlingDepartment of AnaestheticsI Military HospitalVoortrekkerhoogtePretoriaFindings on computed tomography ofthe chest in lymphangiomyomatosisTo the Editor: A 54-year-old white woman presented with a 10-year history of insidious increasing exertional dyspnoea. Clinicalexamination at the most recent visit had revealed a few rales in theleft base, which cleared with deep breathing. Lung function testsshowed relatively normal lung volumes but associated reduction inthe diffusing capacity at approximately 50% of predicted value.Radiographs revealed a long-standing diffuse interstitial partern ofunknown causation with slow progression over a period of 10years (Fig. 1, A).Computed tomography (CT) demonstrated multiple thin-walled cysts, less than 20 mm in diameter, scattered at random inFig. 1. A - frontal radiograph demonstrating a nonspecificinterstitial pattern throughout both lungs; B - thin-section eT;and e - magnified portion showing multiple thin-walled cystsscattered randomly throughout both lungs. Lung tissue betweenthe cysts appears normal.

Spontaneous kidney rupture in polyarteritis nodosa presenting as an acute abdomen

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Spontaneous kidney rupture in polyarteritis nodosa presenting as an acute abdomen

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