Therapeutic study, level IV.
A case history is presented of a 12 year old girl with pulmonary arteriovenous fistula. The diagnosis was based on clinical and radiological signs and on physiological evidence for a large arteriovenous shunting of blood in the lungs. As an unexpected other finding, diffusing capacity was markedly decreased. The largest radiologically apparent fistula, situated in the right lower lobe, was resected; peroperative clamping of pulmonary arterial blood supply to the affected lobe substantiated the presence of an arteriovenous fistula. Following surgery, arteriovenous shunting was found to be only slightly decreased (from 30 % to 25 % of cardiac output). In the resected lobe cavernous angiomata were demonstrated but also multiple capillary teleangiectases and marked thickening of alveolar walls. We suggest that the finding of a decreased diffuing capacity in patients with arteriovenous fistula indicates diffuse pulmonary disease which precludes surgical correction. A review of recent literature on pulmonary arteriovenous fistula is presented.
A 34-year-old Caucasian woman was admitted with an 8-month history of a skin rash and new-onset coagulopathy. Her complete blood count on admission revealed a WBC count of 4,700 per mL, a Hb level of 9.1 g per dL, and a PLT count of 47,000 per mm 3 . A skin biopsy was consistent with a cutaneous gd T-cell lymphoma. A marrow aspirate smear revealed marked hemophagocytosis, showing mature macrophages with engulfed RBCs (A), erythroblasts (B), PLTs (C), and MNCs (D). The prothrombin time (29.2 sec) and partial thromboplastin time (66.6 sec) were prolonged, fibrinogen was depressed (<30 mg/dL), and ferritin (46,610 mg/mL) and lactate dehydrogenase (LDH 2886 u/L) were elevated. Combination chemotherapy with etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin (DA-EPOCH), plus alemtuzumab (a monoclonal antibody to CD52 antigen present on T lymphocytes), was administered from Hospital Days 2 through 7 under an institutional review board-approved protocol for treatment of lymphoma. Treatment was associated with a rapid reduction of ferritin (see right figure, green line) and LDH (blue line) and return of fibrinogen (red line) to normal levels. During the 10 days of therapy for her hemophagocytosis-associated hematologic complications, she received 12 units of RBCs, 11 single-donor PLT transfusions, 5 units of FFP (blue arrows), and 6 units cryoprecipitate (fuchsia arrows). Between Days 10 and 19, she required an additional 8 units of RBCs, 13 units of single-donor PLTs, and 8 doses of granulocytes for chemotherapy-related pancytopenia and an associated fungal infection. Her cytopenias resolved by Day 20, and she was discharged in stable condition.Hemophagocytosis can occur in autoimmune diseases, viral infections, and T-cell lymphomas associated with hypercytokinemia and activation of the mononuclear phagocytic system. In addition to cellular engulfment, leading to anemia and thrombocytopenia, a coagulopathy attributed to hypofibrinogenemia can occur secondary to engulfment of fibrinogen via phagocytosis-associated membrane attack complex receptors on mononuclear phagocytes. Treatment is directed toward control of the underlying disease. Intensive blood bank support may be required during treatment of this syndrome.
UJNTIL very lately, surgeons were unacquainted with the use of the inosculating vessels, gnd dreaded to tie even the smaller arteries. So completely were they fettered by the fear of gangrene, that a person with aneurism of the brachial, or popliteal artery, had no alternative, but to submit to amputation, or die from hemorrhage; and those who had the disease in the larger vesselswere allowed to perish, without even an attempt being made to save them. CASE OF OLUTEAL ANEURISM. To the surgeons of the present day we are indebted for the improvements in thii part of the profession. Even the celebrated Cheselden doubted the surgeon who told him, that he had tied with success the brachial artery. Bromfield stigmatized the tying the femoral artery, as an ex. travagant proposition. Dr. Monro, who was an excellent anatomist, says, that it is " dangerous to trust to common anastomosis round the elbow :" and intimates, that the success in tying the brachial artery, was chiefly owing to a lusus nature. He little expected that, in a few years, surgeons, without any assistance from these irregularities of nature, would tie not only the brachial, btit the femoral, the axillary, the subclavian, the carotid, and the great iliac arteries. * A surgeon in attempting to extirpate the parotid gland, epened so mny vesels about the angle of the jaw, that the patient was in danger of expiring from hemorrhage. Mr. Lynn, who was present, prevented the bleeding, by tying the trunk of the carotid artery on the fore part of the neck. This occurred in the Westminster %spital 15 years ago. I am sorry to add, thAt tlie case was not succesful. The person died three wee'ks after the operatio. Mr. Abemetby tied this artery when accidentaUy wounded, but the patient died of inflammation of the brain. Mr. A. Cooper, was the first who ventured to tie the carotid arteiy for aneurini of this vesel. Mr. Travers was the second who tied
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