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July 1993, Volume 43, Issue 7

Case Reports

Abstracts from The Journals of The East

Fatema Jawad  ( 7/6, Rimpa Plaza, M. A. Jinnah Road, Karachi. )

Estimation of Serum Copper and Zinc for diagnosis and prognosis In Upper Respiratory Tract Malig­nancy.Khan, N., Nabi, N. and Hasan, S.A. Pak.J. OtolaryngoL, 1992;8:200-202.
Trace element studies especially on copper and zinc in malignancy, suggest them to serve as markers for diagnosis and prognosis of the disease. Serum copper, zinc and Cu/Zn ratio were estimated in 46 cases of histologically proven malignancies of upper respiratory tract. There were 22 cancer larynx cases, 8 nasal cavity malignancy, 10 of tonsils and 6 cases had lesions in the glottis and bronchus. Control group comprised of 50 healthy volunteers. Serum Cu and Zn were estimated by atomic absorption spectrophotometer. The fall in serum Zn and rise in serum Cu and the Cu/Zn ratio was found to be statistically significant in the malignancy cases as com­pared to the controls. Significant elevation of serum Cu and Cu/Zn ratiq and decline in serum Zn was noted in metastatic growths when compared with localized tumours. In 16 cases of cancer of the larynx these trace elements were estimated two weeks postoperatively. The serum Cu level and Cu/Zn ratio altered significantly whereas Zn levels showed no change. The rise in serum Cu in malignancies could be attributed to extensive tissue necrosis leading to exces­sive: release of Cu in the circulation. The decrease in serum Zn levels is attributed to a decline in the albumin fraction which combines about 60 percent of plasma Zn and serves as a transporter. The estimation of these trace elements can thus help in supporting the diagnosis and extent of malignan­cies. Also serum Cu and Cu/Zn ratio predict the response to treatment in laryngeal cancer cases.
Helicobacter Pylon associated Gastritis and its response to Amoxicillin/Calvulanate Potassium. Khan, AS. and Rehman, A. Proceeding S.Z.P.G.M.I., 1992;6:20-23.
One hundred and eighty-five patients with dyspep­sia were endoscoped and biopsied. 145 cases were positive for H. pylon gastritis, with evidence of chronic gastritis. 40 of these patients were randomly selected for treatment with amoxicillin/calvulanate potassium (au­gmentin) in a dose of 375 mg 8 hourly orally for two weeks. All the subjects underwent a physical examina­tion, haematological assessment with SGPT and BUN estimation. They recorded a change in their symptoms on a selfrecording patient diary. Endoscopywith biopsy was repeated after 2 weeks. Eradication of H. pylon was found in 32 cases whereas 8 patients had persisting infection. Symptomatic improvement was observed in 32 individuals and one complained of worsening of the symptoms. Endoscopic evaluation revealed normal mucosa in 10 cases, mild gastritis in 25 and moderate in 5 patients. 4 cases with moderate gastritis had improved to mild gastritis after two weeks therapy. H. pylon has been implicated to cause gastritis. Dyspepsia has a strong correlation with the presence Of H. pylon and the positivity increases with advancing age. Also developing countries have a higher incidence of H. pylon as compared to developed parts of the world. The presented study found 78.3 percent of the cases with dyspepsia to be positive for H. pylon although 25 percent of the patients had a normal mucosa endoscopically. The single antibiotic use gave symptomatic relief in 85 percent cases and histological clearance in 80 percent cases. This being a preliminary study does not include long term eradication. It is also advisable to take a biopsy in symptomatic individuals as the normal appearing mucosa can be misleading.
Coeliac Disease complicated by Lyinphoma. Butt, J.A and Haider, Q. J.Pak.Instit.Med.Sc., 1991;2: 120-121.
The case of a 28 years old male diagnosed as coeliac disease and complicated by lymphoma is presented. The patient came in with a history of chronic diarrhoea of one year’s duration with remissions and relapses. He passed large volumes of stools 10-15 per day, watery and foul smelling with chills and fever. Anorexia, cramping ab­dominal pain, bloating and flatulence were also present. Stools contained undigested food particles and there was marked intolerance to wheat and milk products. The past history gave no significant illness and muscular weak­ness, weight loss and easy fatiguabiity had developed. Small bowel biopsy revealed villous atrophy with plasma cell and lymphocyte infiltration of the jejunal mucosa. A gluten free diet gave improvement in the following 6 months. Addition of tetracycline and folic acid orally prolonged the remission phase further. The patient was re-admitted after having consumed wheat products in a cachectic and dehydrated state. There was non-tender hepatomegaly and palpable, tender small bowel loops in the supra- umbilical region were present. The laboratory tests revealed a polymor­phonuclear leucocytosis, hypokalaemia and elevated blood urea. A further small bowel biopsy showed villous atrophy and intense infiltration of lamina propria with cells having large nuclei and scanty cytoplasm. increased reticulin was seen around the cells and the histopathol­ogy was suggestive of malignant lymphoma of the small bowel. It is known that the incidence of malignancy is greater in patients with coeliac disease. Lymphoma as a càmplication in these cases usually occursover the age of 40 years. Extreme muscle weakness is a striking symptom and it is progressive. Serum globulin may be increased and serum IgA sometimes progressively rises. Alkaline phosphatase levels rise due to osteomalacia. Diagnosis is confirmed by liver or lymph node biopsy or laparotomy and rarely by small bowel biopsy. The presented case developed changes of lymphoma in a very short span but it is believed that such cases should be considered as coeliac disease complicated by lymphoma and not lymphoma presenting as coeliac disease. Burkitt’s Lymphoma Ahmad, S., Hussain, £ and Zaman, S. JAMC., 199 1;4:51-53. The case of Burkitt’s lymphoma in a 13 years old male child is presented. The patient came with severe respiratory distress and a history of developing a progres­sively increasing swelling on the neck since 12 days. A tracheostomy was performed and examination revealed bilateral proptosis with swelling of the right mandible and maxilla almost obliterating the buccal cavity. Dehy­dration was severe and peripheral circulatory failure was present. Temperature was 100°F and a solitary lymph node was palpable in the neck. Haemoglobin was 8.6G/dl and total leucocyte count 6700/cm3. A provi­sional clinical diagnosis of Burkitt\\\'s lymphoma was made and therapy started with cyclophosphamide 300 mg intravenously alongwith vincristine 0.5 mg infusion. Improvement was seen after 36 hours when the swelling subsided and the patient could eat and talk but the vision was lost. Supportive treatment with antibiotics and blood transfusion were given and after a second course of chemotherapy the case was discharged with advice to return after 2 weeks for a third dose. The young boy failed to come as scheduled and on delayed arrival had developed haematemesis and recurrence of the swelling. Blood examination at this stage showed a haemoglobin of 7.3G/dl, total WBC count 6500/cm3, differential count having 50 percent lymphocytes, 17 percent polymorphs, one percent eosinophils, 2 percent monocytes and 30 percent immature blast cells. Bone marrow had 36 percent myeloid cells, 28 percent immature blast cells, 28 percent lymphocytes and 8 percent monocytes. The patient developed severe haematemesis which proved fatal. Burkitt\\\'s lymphoma is a high grade, small non-cleaved cell malignant lymphoma. It is classified as endemic or African type, or non-endemic and South American type. The African type has a strong association with malaria and the Epstein Barr virus. The infection precedes the development of the lymphoma by seven or more months. Jaw swelling is present in 72 percent of the cases. Kidneys are usually affected and paraplegia may have developed. The South American type is associated with immune dysfunction and occurs sporadically in other parts of the world. Jaw involvement is rare. Lymph nodes, bone marrow, lungs and spleen are affected. Combination chemotherapy is highly effective as Burkitt\\\'s lymphomas are extremely sensitive to these drugs.

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