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Between 1 September and 24 October 1976, 318 cases of acute viral haemorrhagic fever occurred in northern Zaire. The outbreak was centred in the Bumba Zone of the Equateur Region and most of the cases were recorded within a radius of 70 km of Yambuku, although a few patients sought medical attention in Bumba, Abumombazi, and the capital city of Kinshasa, where individual secondary and tertiary cases occurred. There were 280 deaths, and only 38 serologically confirmed survivors.The index case in this outbreak had onset of symptoms on 1 September 1976, five days after receiving an injection of chloroquine for presumptive malaria at the outpatient clinic at Yambuku Mission Hospital (YMH). He had a clinical remission of his malaria symptoms. Within one week several other persons who had received injections at YMH also suffered from Ebola haemorrhagic fever, and almost all subsequent cases had either received injections at the hospital or had had close contact with another case. Most of these occurred during the first four weeks of the epidemic, after which time the hospital was closed, 11 of the 17 staff members having died of the disease. All ages and both sexes were affected, but women 15-29 years of age had the highest incidence of disease, a phenomenon strongly related to attendance at prenatal and outpatient clinics at the hospital where they received injections. The overall secondary attack rate was about 5%, although it ranged to 20% among close relatives such as spouses, parent or child, and brother or sister.Active surveillance disclosed that cases occurred in 55 of some 550 villages which were examined house-by-house. The disease was hitherto unknown to the people of the affected region. Intensive search for cases in the area of north-eastern Zaire between the Bumba Zone and the Sudan frontier near Nzara and Maridi failed to detect definite evidence of a link between an epidemic of the disease in that country and the outbreak near Bumba. Nevertheless it was established that people can and do make the trip between Nzara and Bumba in not more than four days: thus it was regarded as quite possible that an infected person had travelled from Sudan to Yambuku and transferred the virus to a needle of the hospital while receiving an injection at the outpatient clinic.Both the incubation period, and the duration of the clinical disease averaged about one week. After 3-4 days of non-specific symptoms and signs, patients typically experienced progressively severe sore throat, developed a maculopapular rash, had intractable abdominal pain, and began to bleed from multiple sites, principally the gastrointestinal tract. Although laboratory determinations were limited and not conclusive, it was concluded that pathogenesis of the disease included non-icteric hepatitis and possibly acute pancreatitis as well as disseminated intravascular coagulation.This syndrome was caused by a virus morphologically similar to Marburg virus, but immunologically distinct. It was named Ebola virus. The agent was isolated from the blood of 8 of 10 suspected cases using Vero cell cultures. Titrations of serial specimens obtained from one patient disclosed persistent viraemia of 10(6.5)-10(4.5) infectious units from the third day of illness until death on the eighth day. Ebola virus particles were found in formalin-
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PMID:Ebola haemorrhagic fever in Zaire, 1976. 30 56

Four cases of hepatic angiosarcoma are reported with a review of 99 other cases in the English literature. Angiosarcoma of the liver is associated with chronic exposure to thorotrast, vinyl chloride, arsenicals, radium and possibly copper and with chronic idiopathic hemochromatosis. Although 40% of patients have hepatic fibrosis or cirrhosis at autopsy, the nature of the association between chronic liver disease and hepatic angiosarcoma is unknown. The clinical presentation of hepatic angiosarcoma is nonspecific with abdominal pain, weakness and weight loss common complaints and with hepatomegaly, ascites and jaundice common findings. Liver function tests are usually abnormal but there is no one liver function test or set of tests specific for the tumor. The occurrence of thrombocytopenia and disseminated intravascular coagulation is characteristic of hepatic angiosarcoma and may be related to local consumption of clotting factors and formed blood elements in the tumor. Catastrophic intraabdominal bleeding is also characteristic and occurs in one-fourth of all cases. This complication is likely related to the high incidence of clotting abnormalities and the vascular nature of the neoplasm. Selective hepatic arteriogram and open liver biopsy are the foundations of diagnostic evaluation. Percutaneous liver biopsy should be avoided. Failure to appreciate the possibility of hepatic angiosarcoma in the proper clinical setting, leading to blind percutaneous biopsy, may result in failure to make the diagnosis at the cost of significant morbidity and mortality. Survival of patients with hepatic angiosarcoma is brief; only 3% live longer than 2 years. Treatment of the tumor to date is empirical. There are probably a few patients who might benefit from radical surgery with curative intent. For all others chemotherapy is indicated. Adriamycin is active against hepatic angiosarcoma, but optimal dose and mode of administration require further investigation. Further study is also required to delineate the cause of hepatic angiosarcoma in the 60% of cases without definite epidemiologic association.
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PMID:The clinical features of hepatic angiosarcoma: a report of four cases and a review of the English literature. 36 8

Fifty-eight patients with mild to moderately severe acute pancreatitis were randomly allocated to treatment with or without nasogastric suction (27 and 31 patients respectively). Intravenous fluids and pethidine hydrochloride were also given. The two groups were comparable clinically at the start of the study. There were no differences between the two groups in the mean duration of the following features: abdominal pain or tenderness; absence of bowel movements; raised serum amylase concentration; time to resumption of oral feeding; and days in hospital. Prolonged hyperamylasaemia (serum amylase greater than 0.33 mU/l) occurred in one patient in the suction group and in three patients in the non-suction group. A mild recurrence of abdominal pain after resumption of oral feeding occurred in three patients in the suction group and in two patients in the non-suction group. Two patients in the suction group developed overt consumption coagulopathy and two others pulmonary complications. No patient in the non-suction group had complications. The findings suggest that most patients with mild to moderately severe acute pancreatitis do not benefit from nasogastric suction. The procedure should be elective rather than mandatory in treating this condition.
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PMID:Is nasogastric suction necessary in acute pancreatitis? 69 50

A case of Vibrio cholerae non-O1 septicemia is described in this paper. A 45-year-old male with a three year history of liver cirrhosis, was admitted to our division with hematemesis, abdominal pain, high fever and a loss of consciousness. Three days before onset of symptoms, he traveled to Ishigaki Island and ate a raw lobster. Two days after, his temperature rose to 39.7 degrees C and the blood pressure dropped to 36/- mmHg. By endoscopic examination, an ulcer was found in the stomach, and the bleeding was stopped by electrical coagulation. Blood culture showed growth of V. cholerae non-O1. The organism was found to be sensitive to OFLX, CZX, MINO, LMOX and CP. Although DIC, infections of fungus and MRSA occurred as complications, he recovered by adequate procedures. Subsequently, he left this division after eight weeks. There are various reports related to V. cholerae non-O1 septicemia in foreign countries, but few cases have been reported in Japan. And these cases had severe underlying diseases such as leukemia and liver cirrhosis.
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PMID:[A case of Vibrio cholerae non-O1 septicemia with liver cirrhosis]. 140 1

A 30-year-old man with symptomatic acquired immunodeficiency syndrome presented with abdominal pain and disseminated intravascular coagulation. Radiographic studies revealed thickening of the gallbladder wall. Following stabilization of the coagulation disorder, the patient underwent a cholecystectomy, and the gallbladder was found to contain Kaposi's sarcoma (KS). There have been no previously published reports of KS found in the gallbladder of a living patient in the absence of cutaneous manifestations of KS. The current case illustrates that KS is a multi-focal systemic disease which may have extracutaneous primary manifestations.
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PMID:Kaposi's sarcoma of the gallbladder. 145 84

The syndrome of haemolysis, elevated liver enzymes and low platelets (HELLP Syndrome) is a consequence of severe preeclampsia/eclampsia. The clinical course is characterized by an unusual presentation with abdominal pain, and manifestations of inadequate haemostasis and excessive bleeding are common. Maternal and perinatal morbidity and mortality are high. We report our experience with 33 patients over a five-year period. The mean gestational age (GA) of the pregnancies was 34 +/- 2.8 wk including 11 patients who delivered 12 neonates of less than 34 wk GA. The most common presenting complaints were right upper quadrant or epigastric pain in 25 patients (76%) and nausea or vomiting in 14 patients (42%). Diagnosis was missed or delayed in 12 patients (36%). Thirty-one patients (94%) were delivered by Caesarean section and a deteriorating maternal condition was the most common indication for operative delivery. Twenty-three patients received general anaesthesia, eight received epidural anaesthesia and there were no complications related to the anaesthetic. There was clinical evidence of abnormal haemostasis: seven patients had excessive blood loss at Caesarean section, two had postpartum haemorrhage, three developed DIC and four developed wound haematoma. The average decrease in haemoglobin concentration was 32 g.L-1 and twelve patients (36%) received blood transfusions. There was one stillbirth. There were no neonatal deaths but morbidity was prominent and related primarily to prematurity. Delayed or missed diagnosis is common in HELLP syndrome and a premature delivery by Caesarean section is usual.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Obstetrical anaesthesia for patients with the syndrome of haemolysis, elevated liver enzymes and low platelets. 173 44

Although formalin ingestions have previously been reported in the literature, technology has only recently been developed to measure both formaldehyde and formate levels in plasma. Methanol, formaldehyde, and formate levels were followed in the case reported here until the patient's death approximately 13 h after the ingestion. The clinical course was marked by an initial profound CNS depression followed by an apparent clinically quiescent period. Severe abdominal pain and retching preceded the development of seizures, DIC, severe hypotension, and cardiac arrest. Methanol levels rose throughout this 13-h course. Formate and formaldehyde levels increased until bicarbonate and ethanol therapy were instituted. The "fixing" of the stomach by formaldehyde may have produced delayed absorption following formalin ingestion. Therapeutic implications are discussed.
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PMID:Formate levels following a formalin ingestion. 232 60

A 20-year-old female presented with sudden onset of abdominal pain, diarrhoea and vomiting progressing to fever, tachycardia and mild hypotension. Within 12 hours, a petechial rash appeared on the face and abdomen, spreading to the extremities. Laboratory findings confirmed the diagnosis of acute meningococcaemia. Clinical features of endotoxic shock, vasculitis and skin necrosis rapidly ensued. Aggressive treatment to control the septicaemia, disseminated intravascular coagulation and unstable cardiovascular state ultimately proved successful. Approximately 6 weeks later, amputation of some of the digits and extensive skin grafting were carried out in the Regional Burns Unit. However, serious psychological side effects gradually began to appear which required urgent psychiatric intervention. For an active young woman the challenge of coping with such a severe illness and coming to terms with the disability and disfigurement resulting from it was almost overwhelming. It was, perhaps, particularly hard because of the threat posed to her ambition to complete her nursing education and become a nurse. Little was found in the nursing literature on acute meningococcaemia. But this illness provides considerable challenges not only to those who suffer from it, but also to those who nurse them. A final brief review of published literature on acute meningococcaemia and the clinical manifestations and outcome of it is provided for those who wish to know more about it.
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PMID:Acute meningococcaemia: a case study. 232 67

We experienced 57 episodes of Pseudomonas aeruginosa bacteremia in 55 patients with hematologic disorders in a 16-year period. Ninety-five percent of the patients had hematologic malignancies such as acute leukemia. All but one patient received cytotoxic or immunosuppressive therapy at or prior to the onset of bacteremia. Seventy-seven percent of the episodes occurred during profound granulocytopenia of below 100/mm3. All the patients acquired their infection in the hospital, and 96% had received antibiotic therapy during the preceding two weeks. Periodontal, anorectal, lower respiratory tract, and urogenital infections were the sources of bacteremia in about three-quarters of the episodes. Periodontal infection tended to progress to cellulitis of the face or the floor of the mouth, often resulting in bacteremia of the unimicrobial type, while anorectal infection predisposed to abscess formation, frequently leading to bacteremia of the polymicrobial type. Cellulitis at onset was seen in 35% of the episodes. Most sites of infection did not become apparent until one to three days after the onset of fever, probably because of depressed inflammatory response associated with severe granulocytopenia. The majority of patients complained of gastrointestinal symptoms such as nausea and vomiting, abdominal pain, diarrhea, and abdominal fullness at the onset of bacteremia. Major complications included bacteremic shock (63%), impaired consciousness (25%), ecthyma gangrenosum or hemorrhagic gangrenous cellulitis (18%), and jaundice (12%). Furthermore, there were one case each of endocarditis and disseminated intravascular coagulation. It was thus suggested that the clinical picture of P. aeruginosa bacteremia complicating hematologic disorders is influenced by the predisposing conditions associated with the underlying diseases and their treatment.
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PMID:[Pseudomonas aeruginosa bacteremia associated with hematologic disorders [I]. Predisposing factors and clinical manifestations]. 250 86

Burn patients complicated with hematemesis or typical melena were reviewed. Patients with only positive occult blood in the feces were not included. The incidence rate was 1.51%. This complication occurred in any age-group with similar incidence. Unstable burn shock in early stage was one of the important factors for this complication. The morbidity (16.5%) in early shock group was significantly (P less than 0.01) higher than in non-shock group (0.3%). It appeared mainly within three weeks postburn and predominantly in the first week (55.7%). Ulceration might occur in the whole gastrointestinal tract but duodenum was the most frequent site, where ulceration was recognized in 12 out 22 cases, either at postmortem or at operation. The frequency of ulceration in other portions was as follows: stomach 7, oesophagus 3, jejunum 1 and colon 1. The haemoglobin prior to or after hemorrhage had been determined in 54 cases. The decreased values varied from 1 to 10.8 g (mean 3.54 +/- 2.02 g). Of the 70 cases, 31.4% were complicated by haemorrhagic shock, and there were no distinct prodromal symptoms prior to bleeding, except in 25.5% cases there was a complaint of abdominal pain. Of the 49 deaths, 7 died of haemorrhagic shock, 4 of DIC, 1 of abdominal pain. Of the ulcer and 37 of septicemia. Our data showed that the mortality rate was rather high, especially when it coexisted with sepsis. The diagnosis and some problems about therapy are discussed in this paper.
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PMID:[Burns complicated by gastrointestinal haemorrhage--an analysis of 70 cases]. 251 34


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