תוצאת חיפוש

Monocytic Ehrlichiosis - An Emerging Pathogen

Irena Zikonov, Israel Potasman

Dept. of Internal Medicine A and Infectious Disease Unit, B'nai Zion Medical Center and Technion Faculty of Medicine, Haifa

Ehrlichiosis is an emerging zoonotic disease transmitted to man by ticks. Its clinical features include fever, headache, myalgia, nausea and rash. The diagnosis requires a high index of suspicion; the disease has a specific serology, and has never been reported in Israel.

We describe a 52-year-old man hospitalized with fever, a diffuse rash, arthralgia and epididymitis. Skin biopsy disclosed necrotizing small vessel disease consistent with periarteritis nodosa. Acute phase serum titer for E. chaffeensis was 1:256. Fever promptly subsided following ciprofloxacin.

Is Official Data on Reported Morbidity Valid? Hepatitis A in Israel as an Example

Yehuda Lerman, Gabriel Chodik, Hava Aloni, Shai Ashkenazi

Occupational Health and Rehabilitation Institute, Ra'anana, Schneider Children's Hospital, Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University

Hepatitis A is one of the most frequently reported notifiable infectious diseases in Israel. The annual incidence as reported is around 70/100,000. The physician or the diagnostic laboratory notifies the district health office of the Ministry of Health.

The purpose of this research was to evaluate the sensitivity of passive surveillance of hepatitis A morbidity among adults, 18 years and over. Methods included study of notifications to the Ministry of Health or hospitalizations of cases of hepatitis A and of positive laboratory tests results (IgM) for hepatitis A. We estimated the extent of under-reporting by 2 different methods of extrapolation.

Data based on passive surveillance among the adult population, between 1.1.1993-31.12.1994, comprised less than 1/5 of the actual number of cases. Physicians notified about 6.2% of their hepatitis A patients. 5.1% of the notifications to the district health office were sent twice or more, usually both by the physicians and labs.

The official data on hepatitis A morbidity, based on passive surveillance, are considerably underestimated. Physicians and public health officials should be aware that such data may not accurately reflect the magnitude of the risk or the amount of disease that can be prevented. Efforts should be made to improve this situation.

Knowledge and Practice of Primary Care Physicians Relating to Streptococcal Pharyngitis

S. Leshem, H. Tabenkin, E. Dan, A. Tamir

Family Medicine Dept., Emek Medical Center and Northern District of Kupat Holim; and Northern Branch of Specialization Institute, Faculty of Life Sciences, Ben-Gurion University of the Negev, Beer Sheba

Knowledge and practice of primary care physicians as to diagnosis and treatment of group A, b-hemolytic streptococcal pharyngitis, and the degree to which they agreed with the medical literature and current clinical guidelines were examined. The study was conducted in a group of 195 general physicians, pediatricians, and family medicine specialists and residents. The data were collected using questionnaires which included personal information and questions relating to b-hemolytic streptococcal pharyngitis and were analyzed by chi-square and t-tests, and logistic regression, as appropriate. A new dependent variable, good clinical practice (GCP), was defined as the total number of correct answers to the questions in the questionnaire. 147 of the 195 eligible physicians returned completed questionnaires, a compliance rate of 76%.

96.6% cited pV as the drug of choice at a daily dosage of 1 g (43.7%) or 2 g (25.4%), for 10 days (90%). 133 physicians (90%) stated that the goal of penicillin therapy for beta-hemolytic streptococcal pharyngitis is to prevent late complications. 116 physicians (82%) cited rheumatic fever as a complication of group A beta-hemolytic streptococcal pharyngitis, preventable by appropriate antibiotic therapy. However, only 84 (59%) cited glomerulonephritis as a preventable complication.

When the knowledge and attitudes of the respondents was analyzed in terms of the new variable, GCP, a significant association (p<0.001) was found between physicians’ attitudes and variables such as where they had studied medicine, and work seniority. Those with less seniority and or medical graduates of the Americas demonstrated greater knowledge and better clinical judgment than their more senior colleagues and graduates of European and Asian medical schools. Most primary care physicians in northern Israel treat group A b-hemolytic streptococcal pharyngitis as recommended in the medical literature.

The level of medical studies in Israel and the Americas and the quality of training of residents in family medicine and pediatrics, have a positive influence on the degree of knowledge of as common a subject as b-hemolytic streptococcal pharyngitis. Emphasis should be placed on continuing medical education among primary care physicians, particularly veteran general physicians and those who studied in European or Asian medical schools.

Balloon Angioplasty of Native Coarctation of the Aorta

Benjamin Zeevi, Galit Bar-Mor, Michael Berant

Cardiac Catheterization Unit, Schneider Children's Medical Center, Petah Tikva, and Sackler School of Medicine, Tel Aviv University

The use of balloon dilatation to treat native coarctation of the aorta is gaining acceptance among interventional pediatric cardiologists, but is still controversial. We describe our experience with this procedure in 21 children, mean age 5.6 years and mean weight 21.1 kg. Most had an additional congenital heart defect, most commonly a bicuspid aortic valve. 17 were asymptomatic, 3 had tachypnea and 1 infant had severe congestive heart failure and was ventilated. The mean systolic blood pressure was 129.7 mm Hg.

Balloon dilatation was successful in 90% (19), decreasing the mean maximal systolic gradient from 35.3 to 9 mm Hg (p<0.001), and increasing the narrowest area from 3.9 to 8.2 mm (p<0.001), with a mean balloon-to-coarctation width-ratio of 2.8. There were no complications. Of 15 who underwent repeat cardiac catheterization at a mean interval of 10.6 months, 2 had a maximal systolic gradient of more than 20 mm Hg. 1 of these underwent successful repeat angioplasty and the other, who also had a small aneurysm, underwent surgical repair successfully. 2 others had small aneurysms and they are being followed clinically.

All patients were seen again after a mean interval of 31 months. The mean systolic blood pressure was 104 mm Hg, significantly lower than before intervention (p<0.002). 1 had an increased pressure gradient between right arm and leg of 35 mm Hg at later follow-up, and repeat cardiac catheterization demonstrated a good result 13 months after the initial procedure. She is awaiting a third catheterization. Overall, 90% had good mid-term results.

Based on our experience and recent reports, balloon angioplasty is safe and effective in most children older than 7 months and should be considered a viable alternative to operation for discrete aortic coarctation. Further long-term evaluation is needed.

Neurological Manifestations of Non A-G Viral Hepatitis

Rifaat Safadi, Yaron River, Yosef S. Haviv, Yaron Ilan

Liver Unit, Division of Medicine and Neurology Dept., Hadassah University Hospital, Jerusalem

Guillain-Barre and other neurologic syndromes rarely occur as complications of viral hepatitis (A, B and C). Other neurologic syndromes have also been reported in serologically defined viral hepatitis, including mononeuritis, auditory neuritis, and seizures. Chronic hepatitis B and mononeuritis multiplex are found together in 31-54% of patients with periarteritis nodosa. The mechanisms of these associations are unknown, but may include direct cytotoxicity of the virus or immune-mediated damage. Vasculitis of the vasa nervorum plays an intermediate role, at least in some cases. We describe a 36-year-old man with acute non A-G hepatitis complicated by Guillain-Barre syndrome. The neurological manifestation resolved completely without specific therapy within 6 days, as the hepatitis resolved.

Multisystem Disease Caused by BCG Imitating Miliary Tuberculosis

I. Tsikonov, D. Yeshurun, J.E. Naschitz

Dept. of Medicine A, Bnai Zion Medical Center and B. Rappaport Faculty of Medicine, The Technion, Haifa

As the prevalence of tuberculosis is on the rise in western countries, we present a 79-year-old man who developed a pulmonary tuberculosis-like syndrome following immunotherapy with BCG for carcinoma of the urinary bladder. The symptoms subsided following 3-drug antitubercular treatment, and the addition of steroids following negative cultures for Mycobacterium tuberculosis. The course of this disease, named BCG-osis, is much more favorable than miliary tuberculosis, even with milder treatment. It is important to keep in mind this phenomenon now that there is increasing treatment of cancers with BCG.

Cerebellar Infarction: Clinical Presentation, Diagnosis and Treatment

Y. Skurnik, S. Brandiner, G. Gandelman, Z. Shtoeger

Medical Dept., Kaplan Medical Center, Rehovot (Affiliated with Hebrew University-Hadassah Medical School, Jerusalem) and Dept. H, Harzfeld Hospital, Gedera

Cerebellar infarction is relatively infrequent and accounts for about 2% of all strokes. Its clinical presentation and course are variable. It may resemble vestibulitis in mild cases, but the presentation may be more dramatic in other cases. Cerebellar infarction may cause life-threatening complications such as acute hydrocephalus or brain stem compression, resulting from their mass effect in the posterior fossa or extension of the infarct to the brain stem.

Clinical features alone are insufficient for the diagnosis and for follow-up of patients with cerebellar infarction. However the advent of CT and MRI and their availability enable early diagnosis of cerebellar infarction, and early recognition of the development of acute hydrocephalus or brain stem compression which require surgical decompression. The prognosis of most cases is good when treatment is appropriate.

Cocaine "Mules"

Ornit Yanai, Jehuda Hiss

L. Greenberg Institute of Forensic Medicine, Tel Aviv (Affiliated with the Sackler Faculty of Medicine, Tel Aviv University)

We present 2 cases of "body-packer" syndrome (BPS) in which the "mules" carrying the packages of narcotics arrived at Ben-Gurion Airport presented symptoms of acute cocaine intoxication due to the bursting of packages of narcotics they were transporting within their gastro-intestinal systems.

Acute cocaine overdose due to sudden massive release of the drug into the digestive system in BPS, may cause psychosis, convulsions and eventually death. Blood levels of cocaine between 0.25 and 5 mcg/ml are toxic and occasionally lethal. When a package bursts within the digestive tract of a smuggler or blocks the intestines, an immediate laparotomy is necessary to evacuate the "ovules" and the remains of the drug from stomach and intestines. Patients merely suspected of being body packers can be diagnosed by physical examination and by means of various imaging methods. They can be conservatively treated with fluids and mild laxatives and kept under close supervision until the remaining packages are naturally discharged.

Sudden onset of psychotic behavior in travelers from South America or other drug-producing countries should raise suspicion of body-packer syndrome. The relevant authorities should therefore be aware of the symptoms and consider their potentially dangerous outcome.

Ilizarov Reconstructive Surgery in Complex Problems of the Musculoskeletal System

H. Shtarker, G. Volpin, A. Lerner, H. Stein, S. Wientroub, D. Hendel

Depts. of Orthopedic Surgery, Western Galilee Hospital, Naharyia, Rambam Medical Center, Haifa, Dana Children Hospital, Tel Aviv-Sourasky Medical Center, and Rabin Medical Center (Golda Campus, and Hasharon Hospital), Petah Tikva

The Ilizarov technique is an important modality of reconstructive surgery for limb deformities, such as malunion and nonunion of fractures, persistent osteomyelitis, and bone loss following complex limb injuries, as well as in limb- lengthening procedures. It has received wide recognition in the Western world over the past decade. In MEDLINE we found 537 articles published between 1971-1995 that describe the use of this technique. Of these, only 18 were published between 1971-1975, while 261 were published between 1991-1995.

The present paper describes the developments and updates in this method, as a result of the large experience gained by the authors in a number of centers in Israel using this technique. The Ilizarov apparatus is a circular frame that allows accurate control, much more than any other external fixator, during correction of limb deformities and limb-lengthening. It is minimally invasive, and open techniques and use of internal hardware and bone grafts are not needed.

Based on our experience, we suggest that this method requires careful preoperative planning and meticulous surgical technique. More important, cooperation between surgeon and patient throughout the lengthy treatment is a prerequisite to ensure complete success, even in the most complicated cases.

The Challenge of Space-Occupying Lesions in the Iliopsoas Space

Irena Tsikonova, Jochanan E. Naschitz, Simona Croitoru, Elisha Barmeir, Daniel Yeshurun

Depts. of Medicine and Diagnostic Imaging, Bnai Zion Medical Center, and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

Mass lesions in the iliopsoas compartment (MLIPC) are uncommon in patients in departments of medicine and their incidence and etiologies are unclear. In a prospective study we diagnosed various MLIPCs in 7 patients during a 10-year period, representing 0.03% of admissions. Symptoms included abdominal or flank pain (4 cases), pain along the thigh (5), diminished psoas muscle strength (2), fever (2), and hypotension (1). MLIPC was suspected on clinical grounds in 5 cases. In all cases the diagnosis was established by computed tomography (CT). Tissue was sampled by needle biopsy in 4 and on surgery in 1. MLIPCs were caused by hemorrhage (2), infection (2), neoplasia (2) and inflammatory mass (1). Often MLIPCs are life-threatening so their timely diagnosis by early CT scan is important.

Meningitis Due to Streptococcus Bovis Type 2

Anat Ben-Ami, Gera Gandelman, David Ergaz, Zev Shtoeger

Dept. of Medicine B, Kaplan Hospital, Rehovot (Affiliated with the Hadassah-Hebrew University Medical School)

Meningitis due to Streptococcus bovis is rare. Only 14 cases having been reported in the English literature. All patients (including the patient described) had an underlying disease or were treated by pharmacological agents that predisposed the patient to the infection. Most were treated by monotherapy with penicillin G (or amoxicillin) and recovered.

We describe a 74-year-old woman who had splenectomy as treatment for hairy cell leukemia 6 months before hospitalization for meningitis and sepsis by S. bovis type 2. She was successfully treated with intravenous amoxicillin. There was neither evidence of endocarditis nor carcinoma of the colon. Although the association between S. bovis meningitis and endocarditis or carcinoma of the gastrointestinal tract is not well established, we recommend a full work-up for GI malignancy and endocarditis in every patient with S. bovis meningitis.

Self-Limited Lymphadenopathy Mimicking Lymphoma or Lupus

I. Solt, N. Gatas, Y. Cohen, D. Rimon

Medical Dept. B and Pathology Dept., Western Galilee Regional Hospital, Naharia and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

Kikuchi-Fujimoto disease in a self-limited lymphadenopathy that can be confused histologically and clinically with lymphoma or systemic lupus erythematosus. It was diagnosed in a 37-year-old woman presenting with fever, cervical, submandibular and axillary lymphadenopathy, weight loss and recurrent urinary tract infections. Lymph node biopsy was consistent with the diagnosis of a histiocytic necrotizing lymphadenitis. Early diagnosis of Kikuchi-Fujimoto disease can prevent harmful treatment.

The Israel Teratogen Information Service: A 10-Year Report 

A. Ornoy, S. Shechtman, J. Arnon

Hebrew University - Hadassah Medical School and Israel Ministry of Health, Jerusalem

The Israel Teratogen Information Service (TIS) was established 10 years ago with the help of the Ministry of Health and the Hebrew University-Hadassah Medical School. During these 10 years we have had 20,631 calls. We describe the results of our experience in counseling.

There was a gradual increase in the number of calls, which in 1997 reached 4,447. Most calls (84.5%) were during pregnancy, while 12% were prior to pregnancy. In 75.7% the calls were due to drug exposure during pregnancy; 10.9% were due to exposure to X-rays; there was maternal infection in 6.6% and in 5% immunization during pregnancy. The callers were: physicians in 46.6%, nurses 18.9%, pregnant women 39.5%, and 4.8% others.

In 76.6% there was no additional risk to the embryo or fetus and in 17.4% there was a small additional risk of less than 1%; a significant additional risk to the fetus was expected in only 6%. In 3625 pregnant women with known outcome there were 8.9% spontaneous and 9.2% induced abortions. Of the 2968 live-born children, 2.3% were malformed, a rate similar to that among controls.

The information provided by the TIS alleviated the fears most pregnant women have, and reduced unnecessary terminations of pregnancy planned because of unjustified fear of the teratogenic effects of agents to which women were exposed. It reduced the number of children born with congenital anomalies, since pregnancies were interrupted whenever there was a high risk for congenital anomalies.

Ultrasonographic Imaging of Superior Sagittal Thrombosis

Ilan Shelef, Avi Cohen, Yehiel Barki

Depts. of Radiology and Neurosurgery, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Ultrasonographic findings of superior sagittal sinus thrombosis include dilated and hyperechoic sinus (direct imaging of the thrombus). No flow should be demonstrated by the various Doppler techniques. In the deeper sinuses, if the thrombus can not be visualized after a negative Doppler study, MR imaging is recommended. Recanalization and reflow can be demonstrated on follow-up study.

Serotonin Re-Uptake Inhibitors as Primary Therapy for Carotid Sinus Hypersensitivity

Amos Katz, Angel Kantor, Alexander Battler

Cardiology Dept., Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Carotid sinus syndrome is a well-recognized cause of unexplained syncope in older patients, and may lead to significant morbidity due to trauma from falls. Dual chamber pacing has been shown to be effective in relieving symptoms due to bradycardia, but not due to vasodepressor response. We report an 84-year-old man with recurrent syncope due to carotid sinus hypersensitivity. He was treated only with a serotonin re-uptake inhibitor and was symptom-free after 3 weeks of therapy. He has remained symptom-free for the past year.