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A 93 year old man with a severe anaemia with possible origin in the gastrointestinal tract refused any clarifying examinations except palliative blood transfusions. Within half a year, he received 48 red blood cell transfusions without any diagnostic or other therapeutically steps. To further decide on treatment strategies, we discussed this problematic case with our local ethic committee and found a reasonable treatment solution

It is important to know the diagnostic procedure and therapy of polymyositis (PM) inspite of its rare incidence. We describe a case with PM, interstitial lung disease, high titers of anti-Jo-1-antibodies and affection of the right hand, that could be followed over 11 years. The differentiation of PM from neurologic diseases and toxic myopathies is mentioned. The patient was successfully treated with cyclosporin over a period of 20 months, but he is now in remission while receiving steroids alone. We emphasize the importance of early treatment of PM with high-dose steroids and the addition of immunosuppressive drugs (azathioprin, methotrexate, cyclophosphamid) in cases with high disease activity or resistance to steroids. In the treatment of PM/DM immunoglobulins play an increasingly important role. The problems of long-term treatment with steroids are of special interest.

Idiopathic hypereosinophilic syndrome (IHES) is a multi-system disorder of unknown origin with eosinophilic infiltration of bone marrow and various organs, including the gastrointestinal tract. Involvement of the heart has a poor prognosis. The etiology of eosinophilic gastroenteritis (EGE) also is unclear. In this disease there is exclusive involvement of the gastrointestinal tract (including liver/bile ducts) and prognosis usually is good. Transition from one disease to the other has not yet been described. We report the 20 years' history of a male patient with an initial IHES without gastrointestinal symptoms and transition to a clinically pure EGE with resolution of any other involvement. At the age of 45 years the patient developed IHES with fever and constitutional symptoms. Fluctuating eosinophilia and symptoms necessitated continuous steroid therapy. After a 10 years' disease course watery diarrhea and malabsorption syndrome became more and more prominent. On the other hand, bone marrow eosinophilia regressed completely and blood eosinophilia partially. Biopsies showed a severe EGE of the mucosal type with involvement of the whole gastrointestinal tract. Besides the prominent eosinophilia there was a dense infiltration of the intestinal mucosa with T-lymphocytes invading the epithelium. We postulate that the destructive eosinophilic/lymphocytic inflammation is caused by a pathologic proliferation of T-lymphocytes with liberation of type 2 helper cell cytokines and consecutive stimulation of eosinophils.

In 4 women patients aged over 60 years under anticoagulation, abdominal pain, which was in part clearly localizable, and signs of acute bleeding suddenly occurred. All were under treatment with marcoumar, while one was also in the transitional phase from parenteral to oral therapy with heparin. Initially, apart from pain on pressure, there were no local signs of bleeding. In the acute stage it was impossible to distinguish clinically between abdominal wall bleeding and intraperitoneal bleeding. Ultrasound provided the diagnosis of abdominal wall bleeding in all cases. All of them were successfully treated by conservative means.

During 1979 4 patients were observed who developed short episodes of fever as high as 104 degrees F after oral intake of 25--100 mg nomifensine (Alival). In all four cases a clear fever spike was produced by reexposure to the drug. The reaction time was 4--6 hours. this drug-induced fever appeared initially 2--4 weeks after the commencement of Alival therapy. No other cause for the fever was identifiable. In one patient an allergic alveolitis was suspected to be a further reaction. In another patient a concomitant granulomatous hepatitis was possibly also due to this drug. It is probable that the febrile reactions have an allergic mechanism. Allergologic investigations have not yet been completed.

We report on the clinical signs, diagnosis and 8-year course in a 54-year-old female patient with myeloma and gastrinoma with liver metastasis and associated Cushing syndrome treated for the last 3 years with the new H+/K+-ATPase inhibitor omeprazole which has successfully suppressed the massive gastric acid hypersecretion.

Four patients are described who developed granulomatous hepatitis 4-6 weeks after treatment with nomifensin. The granulomas were located both in the portal tract and the liver parenchyma, and contained eosinophils and a few polynuclear giant cells. Serum alkaline phosphatase, alanine aminotransferase and bilirubin were raised in three, two and one patient respectively. After medication was discontinued all abnormalities disappeared within 6-10 weeks. After oral intake of 25-50 mg nomifensin all patients experienced paroxysms of high body temperature for several hours. Reexposure in one patient resulted in another fever spike 6 hours after ingestion. No other cause of the fever or the granulomatous hepatitis was identifiable. The clinical data, especially the simultanous occurrence of drug fever and the histologic pattern, are compatible with an allergic mechanism of the liver granulomas. In the presence of high fever and abnormal liver tests in relation to nomifensin treatment, an allergic drug reaction should be considered.

A 56-year-old patient with severe acquired myasthenia gravis refractory to conventional therapy underwent a series of plasma exchanges. Three single exchanges did not improve her status. A series of intensive plasma exchanges of 6 liters each on 4 consecutive days reduced her anti-acetylcholine receptor antibodies to one-tenth of the initial value. The reduction was accompanied by an impressive clinical improvement. This study confirms that antibodies can be removed by plasma exchange. It further shows that the clinical improvement appears to be closely related to the quantity of antibodies removed.

When humans are primarily impaired or overtaxed in their more elaborate abilities of coping with the social environment they seem to fall back on more primitive coping behaviours known from other mammals in severe conflict situations. This seems true for some behaviours in early childhood autism. Ethology has specialized in analyzing such non-verbal behaviour. Ethological motivation analysis, the study of context dependence and of the development of such behaviours in the individual patient should be exploited for their interpretation. Mere description of behaviour is not likely to contribute much. Psychiatric thinking on the interaction of genetic and environmental factors does not fully agree with ethological and biological views.

In a Swiss multicenter study with determination of lipid and lipoprotein parameters in a central laboratory, the efficacy of simvastatin, MSD, was evaluated in patients with primary hypercholesterolemia. Lipid and lipoprotein values were determined in 109 patients before and after 6 weeks' therapy with 10 mg simvastatin per day. A significant decrease in total cholesterol, LDL-cholesterol and apo B, of 21.1, 25.8 and 24.1% respectively, was observed. No influence of simvastatin on apo A-II was found, but HDL-cholesterol and apo A-I were slightly increased (+6.1 and 4.4% respectively). The data show that HMG-CoA reductase inhibitors constitute a new class of effective drugs for the treatment of hypercholesterolemia.

Human purin metabolism is summarized briefly and the terms primary and secondary gout are defined. Asymptomatic hyperuricemia as a risk factor for gout, urate nephropathy and ischemic heart disease is discussed. Treatment modalities of hyperuricemia are presented.

A 53-year-old, previously healthy man developed persistent diarrhea 4 days after ingestion of smoked but uncooked pork sausages in the Southern Tyrol. On his return to Switzerland he ate the same sausages and was admitted to hospital with migrating muscle pain, fever and chills. While fever and diarrhea soon regressed, the patient exhibited neurologic symptoms and change of character. The leukocyte count was 14 000/mm3 with 39% eosinophils. 40 days after hospitalization a second muscle biopsy established the diagnosis of Trichinella spiralis infection. At the same time, serologic tests were positive for Trichinella spiralis. Epidemiology, parasitology, symptomatology, diagnosis, therapy, prophylaxis and prognosis of trichinellosis are briefly discussed.