We described the development of prolonged disseminated cutaneous herpes zoster in two patients with acquired immunodeficiency syndrome. Both patients developed hyperkeratotic, verrucous lesions that progressed despite acyclovir therapy. The biopsy specimens were typical of herpes infection. The development of acyclovir-resistant varicella-zoster virus during therapy was suspected clinically in the first patient and documented in vitro in the second patient. The inability to mount an effective cell-mediated immune response contributed to the prolonged course of cutaneous zoster in our patients. The hyperkeratotic nature of the skin lesions may reflect their chronic nature. Treatment with inadequate doses of acyclovir, allowing viral persistence and the selection of resistant strains of virus, may also be implicated. We recommend prolonged high-dose intravenous acyclovir therapy in the initial management of herpes zoster in patients with acquired immunodeficiency syndrome.
Infection by Yersinia pseudotuberculosis has become of increasing pathological importance. Patients normally present with symptoms similar to those of appendicitis, due to mesenteric adenitis. We present the case of 3 patients infected by Yersinia pseudotuberculosis who in addition to fever and abdominal pain had a palpable abdominal mass, so great was the enlargement of the mesenteric nodes. In 2 patients a laparotomy was carried out, followed by biopsy of a mesenteric lymph node. The diagnosis of Yersinia infection was confirmed by bacterial culture of the biopsied material and also by serology. In the third patient, serological studies and ultrasonic imaging of the abdomen led to early diagnosis and surgery was avoided. We suggest that a diagnosis of mesenteric adenitis due to Yersinia pseudotuberculosis should now be considered in all patients presenting with an abdominal mass, and in whom there is an appropriate clinical and epidemiological history. The diagnosis should be confirmed by abdominal ultrasound (alternatively Computerised Axial Tomography or Magnetic Resonance Imaging) and serological studies. In this way, unnecessary surgery can be avoided.
We describe a 42-year-old man with features of both Behçet's disease and relapsing polychondritis. The term MAGIC syndrome (mouth and genital ulcers with inflamed cartilage) has previously been used to describe similarly affected patients. We discuss the diagnostic criteria and pathogenetic mechanisms.
Colonic Perforation after in that in the resected specimen in Case 3 there were numerous red patches on the antimesenteric border of the descending colon. These were acutely congested patches that had not actually infarcted, and in Case 4 similar patches in the sigmoid colon actually showed full-thickness necrosis which had not perforated, presumably because of the proximal perforation. Why these lesions should be more common in the colon than in the small bowel is difficult to explain if the condition is due to vascular changes resulting from back pressure. Cases 1, 3, and 4 perforated in inferior mesenteric vein territory, but Case 2 involved superior mesenteric vein territory, and Schaffer (1960) described a case in which there was an " unexpectedly excellent result " in a " miracle baby " who had two ileal perforations closed at laparotomy, and these occurred after an exchange transfusion. More small-bowel perforations may be reported once the association between bowel perforation and exchange transfusion becomes more appreciated; but it may be that the more complex venous system of the small bowel damps down any sudden rises in portal pressure more effectively than the large-bowel venous system. Continuous monitoring of the injection pressure during exchange transfusion could avoid large and dangerous pressure variations.
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