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HISTORY AND CLINICAL FINDINGS: A 45-year-old women presented with muscular weakness, restlessness and blurred vision. She had been taking 25 mg hydrochlorothiazide daily and had ingested 7 liters of herbal tea during the day of admission. INVESTIGATIONS AND CLINICAL FINDINGS: Laboratory data showed severe hyponatremia (108 mmol/l, normal range 136 - 152), reduced potassium, glomerular filtration rate as well as plasma and urine osmolality, while the osmolality of the urine was lower than that of the plasma. Creatine kinase and myoglobin were elevated more than one hundredfold. CT scans of the brain was normal. TREATMENT AND COURSE: The normovolemic hyponatremia had caused encephalopathy and rhabdomyolysis resulting in temporary disorder of renal function. Despite of immediately started infusion of standard sodium solution to elevate the serum sodium level slowly the encephalopathy deteriorated initially, but ultimately recovered completely. CONCLUSION: Patients with severe hyponatremic encephalopathy require an immediate treatment, but the sodium level should not be elevated by more than 10 mmol/l per day, in order to avoid spontaneous pontine myelinolysis. Even when the hyponatremia is carefully corrected, the encephalopathy may deteriorate in the course of treatment.

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The development of eosinophilic gastritis immediately after Helicobacter pylori eradication has not previously been described: A 62-year-old woman developed eosinophilic gastritis immediately after a triple therapy for Helicobacter pylori eradication, consisting of pantoprazole, amoxicillin and clarithromycin. She suffered from burning epigastric pain and loss of appetite. Blood eosinophilia, gastritis and eosinophilic infiltration of the gastric corpus wall were detected. The treatment with low-dose prednisolone led to remission of the blood eosinophilia, complaints, gastritis and eosinophilic infiltration. The remission persisted after the prednisolone treatment had been finished. Eosinophilic gastritis can be diagnosed only by pathohistological examination. This need for biopsy should be stressed, because the usual gastritis treatment with proton pump inhibitors fails in cases of eosinophilic gastritis. Helicobacter pylori does not seem to play a significant role in the aetiopathology of this disorder. In our case, we suggest that the eradication drug therapy actually caused the disease.

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A 78 year old woman had suffered ten spontaneous bone fractures, the first occurring when she was 57 years old. She is now wheel-chair bound. After 21 years, the underlying osteomalacia due to oligosymptomatic celiac disease with malabsorption was diagnosed. The treatment consists of a gluten free diet and substitution of calcium and vitamin D until there is a normalisation of calcium, vitamin D and alkaline phosphatase. Any spontaneous fracture deserves a careful search for metabolic bone disease. An elevation of alkaline phosphatase indicates osteomalacia rather than osteoporosis.

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A 35 year old male suffered from fever till 39 degrees C and malaise since 6 months; infectious or neoplastic causes have been ruled out. Ultrasonography revealed a hypoechoic lesion of 75 mm diameter in the liver. The histologic examination of the needle biopsy showed an inflammatory process, and the final diagnosis was inflammatory pseudotumor. EBV specific LMP-1 protein was detected within the tumor immunohistochemically. A liver segment resection was performed, and the patient has been well and without fever since then for 18 months. Inflammatory pseudotumor is a rare but important differential diagnosis in cases of hypoechoic liver lesions associated by fever, if there is no abscess or malignancy. The diagnosis must be confirmed histologically, because imaging techniques cannot reliably classify the lesion.

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The treatment of viral hepatitis or malignomas with interferon (IFN) can increase the incidence of autoimmune disease. This paper reviews published case and study reports. The incidence of overt autoimmune diseases under IFN treatment is about 3%. Autoantibodies can be detected in 23% of the patients. Autoimmune thyroid diseases are the most frequent ones, but nearly all autoimmune diseases can occur. Beside benign and reversible courses chronic developments and lethal outcomes are possible. Actual concepts concerning the pathogenesis of IFN-associated autoimmunity include induction of MHC and other molecules as well as the modulation of lymphocyte functions. Clinical and paraclinical controls are necessary under treatment with IFN and during follow-up.

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The induction of insulin antibodies and the development of an insulin allergy were observed in a male diabetic patient treated with insulin during alpha-IFN therapy of renal cell carcinoma. Diabetes and renal cell carcinoma were diagnosed at the same time. The patient was treated with biosynthetic human insulin and nephrectomy was performed. Four months later, antineoplastic chemotherapy was started (alpha-IFN, vinblastin). Six weeks after initiation of alpha-IFN injections, the patient reported signs of insulin allergy. Significant titers of insulin antibodies of both the IgG and IgE subclasses were found in the serum at that time and during follow-up, but not before the treatment with alpha-IFN. None of the other autoantibodies investigated were positive.

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