Journal of the Royal Society of Medicine Volume 85 July 1992 The development of ulcerative colitis in the isolated colonic segment used for vaginoplasty supports the concept that the colonic manifestations of ulcerative colitis as well as the systemic features are due to a systemic abnormality albeit of uncertain nature'0 rather than an ingested luminal factor present within the colon. References 1 Komorowski RA. Histologic spectrum of diversion colitis. Am J Surg Pathol 1990;14:548-54 2 Ma CK, Gottlieb C, Haas PA. Diversion colitia: a clinicopathological study of 21 cases. Hum Pathol 1990;21:429-36 3 Roediger WEW. Role of anaerobic bacteria in the metabolic welfare of the colonic mucosa in man. Gut 1980;21:793-8 4 Agarwal VP, Schimmel EM. Diversion colitis: a nutritional deficiency syndrome? Nutr Rev 1989;47:257-61 5 Roediger WEW. Utilisation of nutrients by isolated epithelial cells of the rat colon. Gastroenterology 1982;83:424-9
419
6 Ardwani MSM, Newsholme EA. Fuel utilisation in colonocytes of the rat. Biochem J 1985;231:713-19 7 Mortenson FV, Heison I, Birke H, Korsgaard N, Nielsen PJ. Microcirculatory and trophic effects of short chain fatty acids in the human rectum after Hartmann's operation. Br J Surg 1991;78:1208-11 8 Glickman RM. Extrainstina ations of inflammatory bowel disease. In: Wilson JD, Braunwald E, Isselbacher KJ, et al. eds. Harrison's principles of internal medicine, 12th edn. New York: McGraw Hill, 1991:1278 9 Froese DD, Haggitt RC, Friend WG. Ulcerative colitis in the autotansplanted neovagina. Gasroenterology 1991;100:1749-52 10 Roediger WE. What sequence of pathogenetic events lead to acute ulcerative colitis? Dis Colon Rectum 1988;31:482-7
(Accepted 15 January 1992)
Unusual telangiectasia in a nuclear veteran
Case presented to Section of Dermatology, 16 May 1991
S E Handfield-Jones MRCP1 M M Black FRCP' K Liddell FRCP2 'St John's Dermatology Centre, St Thomas' Hospital, London SEI 7EH and 2Eastbourne District General Hospital, Eastbourne BN2 2UD Keywords: radiation; nuclear veterans; telangiectasia
I,
We report the case of a patient who developed unusual telangiectasia on the trunk and limbs associated with stucco keratoses and atrophy of the skin. The patient had been an observer during two of the hydrogen bomb tests in 1957, subsequently staying in the test area for 3 months. We discuss the aetiology of the cutaneous abnormalities and the possible connection with his exposure to ionizing irradiation.
Case report A 63-year-old retired electrical technician had noticed dilated blood vessels on the trunk and limbs increasing in severity over the past 10 years. In addition he had many warty lesions in the same areas. He had no previous skin problems and his general health was good. There was no family history of skin disease. The lesions were asymptomatic but the patient was concerned about the significance of the lesions because he was a nuclear veteran. In 1957, whilst serving in- the British Navy, he had witnessed two hydrogen bomb tests at the Malden- Islands. These tests, known as the 'Grapple series', exploded air of megaton hydrogen bombs. The patient had been on board an observer ship within 25 miles of the tests and wvs ot board wearing only cotton protective clothing to 'watch the explosions. He had stayed in the area for the subsequent 3 months taking samples for analysis. On examination he had both stellate and leash telangiectases, with an irregular broken pattern, involving the chest, outer arms and legs (Figure 1). There was sparing of the back and inner arms. There was slight atrophy in the involved areas. There were multiple stucco keratoses which were most numerous in the areas of telangiectasia. He had no malignant or pre-malignant skin lesions. He had tpe II skin, had never been a sun bather and had never been severely sunburnt. There was no evidence of other skin disease, and general examination was normal.
Figure 1. Patient's keg showing telangiectasia, atrophy and stucco keratoses
Skin biopsy of telangiectatic skin showed dilated vessels only (Figure 2). There was minimal elastotic change on elastin van Gieson staining. Warty lesions were confirmed as stucco keratoses. A full blood count was normal. Digcussion Telangiectasia can be an isolated finding in otherwise normal skin or can be secondary to other dermatoses'. Our patient had no family history or associated systemic changes to suggest a diagnosis of hereditary haemorrhagic telangiectasia or ataxia telangiectasia2. The history and appearance would be unusual for a diagnosis of essential telangiectasia8. There is no evidence -of any of the conditions known to be associated with secondary telangiectasia such as rosacea, dermatomyositis, lupus erythematosus or mastocytosis. He has not used treatment that could give rise to telangiectases such as topical or systemic steroids.
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Journal of the Royal Society of Medicine Volume 85 July 1992
also marked interindividual variation in susceptibility to irradiation such that a dosage that would be without effect in the majority could have adverse effect in an idiosyncratic case2.
Figure 2. Skin biopsy showing prominent telangiectasia
Radiation, both solar and ionizing are known to cause telangiectasia. Our patient has only a minor degree of solar damage, both clinically and histologically, and the vascular changes seem disproportionate to this. His total exposure to ionizing radiation is impossible to calculate. The nuclear tests he witnessed were several hundred times more powerful than Hiroshima and the bombs tested were thought to be 'dirty' in terms of radioactivity4. Our knowledge of the effects of ionizing radiation on human skin comes from three major sources; clinical use, wartime use in Hiroshima and Nagasaki and nuclear tests. In clinical use cutaneous sde effects of irradiation are well recognized to include telangictaia which is a charc feature of chronic radiodermatitisP. In patients treated with whole body electron beam therapy, wideadtel sia may lead to an appearance similarto that seen in our patient. Investigations into the survivors oHirsima also sugg that vascular damage maybe seen many years later in those who were apparently uniijured. However our patient was exposed to a fusion as opposed to a fission bomb. Studies of servicemen exposed to nuclear' weapons tests have not commented on cutaneous vascular changes, however the largest studies have not included cliical examination and have concentrated -on cancer mOrtality7. The is
'Spontaneous' rectus sheath haematoma a rare cause of abdominal pain
M N SiddiqUi FRCS' Q Abid MB BS' T Qaseem MRCP2 S Hameed MRCP2 M Ahmed FRCS' Departments of 'Surgery and 2Medicine, The Aga Khan University Hospital, Stadium Road, PO Box 3500, Karachi, Pakistan Keywords: rectus sheath; haematoma; acute abdomen; diagnosis
Rectus sheath haematoma is an uncommon cause of acute abdominal pain. An estimated 60-93% are initially mis-diagnosedl2. Awareness of this entity may not only help in early diagnosis but prevent unnecessary surgical intervention2. Ultrasound has been recommended as an aid to diagnosis3 4. We present two cases of this interesting condition which ultrasound scanning failed to diagnose and was clearly shown using computerized tomographic scanning (CT).
In addition to telangiectasia our patient had numerous stucco keratoses which were in a similar distribution to the vascular changes. This type of seborrhoeic wart is not uncommon but are not usually as numerous as those seen in our patient. These lesions are not a recognized feature of radiation damage, however other keratotic lesions, both pre-malignant' and benign"0 are reported as a postirradiation finding. It is impossible to establish a definite causative link between this man's exposure to ionizing irradiation and his skin findings. However our patient shows an unusual degree and pattern of both telangiectasia and stucco keratoses for which we are unable to find any other cause. References 1 Goldman MP, Bennett RG. Treatment oftelangiectasia: a review. J Am Acad Dermatol 1987;17:167-82 2 Gatti RA, Boder E, Vinters HV, et aL Ataxia telangiectasia: an interdisciplinary approach to pathogenesis. Medicine 1991; 70:99-117 3 Shelley WB. Essential progressive telangiectasia. JAMA 1971; 216:13434 4 M iken R. No conceivable injury. Australia: Penguin, 1986:143 5 didtH, Sherwin WK. Reactions to ionizing radiation. JAm Acad Dermatol 1980;3:551-79 6 T1iy A, Wakano Y, Otake M, Dock D. Capillary microscopic obswvdtion on the superficial minute vessels of atomic bomb surdivors Hiroshima, 1972-73. Radiat Res 1977;72:353-63 7 SDaSC, Kendall GM, Fell TP, et aL A summary of mortality and incidence of cancer in the men from the United Kingdom's qb nuclear weapon tests and experimental prgrammes. BMJ 198836:332-8 8 Pearce N, 3Prior I, Methven D, et al. Follow up of New Zealand paricipants in British atmospheric nuclear weapons tests in the PcifI; 31.1J 1990;300:1161-6 9 Vastq JP, Hunter JAA, Mallet RB, Rodger A. Post irradiation conca lkeratoses. J R Soc Med 1989;82:166-7
(Accepted 5 February 1992)
Case reports Case 1 A 57-year-old woman was admitted via the accident and emergency department. She gave a few hour history of sudden onset of severe epigastric pain radiating to the chest after lifting a bed. She was a known, poorly-controlled hypertensive. On examination she was in-pain with a pulse of 90/min and a blood pressure of 200/100 mmHg. This was associated with tenderness in the epigastrium. Initial diagnosis included a possible myocardial infarct, perforated duodenal ulcer or pancreatitis. Electoardiogram, chest/abdominal X-rays, cardiac enzymes and serum amylase, were normal. Haemoglobin was 12.8 gldl, white blood count (WBC) 18.6x109/l, platelet (Pt) 265x 100/l, prothrombin time (T) 17/13, activated partial thromboplastin time (APE 42/33. Abdominal ultrasound scan failed to reveal any abnormality. Within 12 h she became pyrexial (390C) and a surgical consultation was sought. She was found to be tachycardic and markedly tender in the epigastrium with vague epigastric fullness. Bowel sounds were normal. A possible diagnosis of a liver abscess was made and a CT scan was ordered. The CT scan clearly demonstrated a haematoma ofthe left rectus abdominis muscle (Figure-- 1). Ultrasound-guided aspiration yielded 10 cm3 of blood-stained fluid which failed to yield any organisms. Treatment was conservative and all her symptoms settled within 6 days.
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6 Ardwani MSM, Newsholme EA. Fuel utilisation in colonocytes of the rat. Biochem J 1985;231:713-19 7 Mortenson FV, Heison I, Birke H, Korsgaard N, Nielsen PJ. Microcirculatory and trophic effects of short chain fatty acids in the human rectum after Hartmann's operation. Br J Surg 1991;78:1208-11 8 Glickman RM. Extrainstina ations of inflammatory bowel disease. In: Wilson JD, Braunwald E, Isselbacher KJ, et al. eds. Harrison's principles of internal medicine, 12th edn. New York: McGraw Hill, 1991:1278 9 Froese DD, Haggitt RC, Friend WG. Ulcerative colitis in the autotansplanted neovagina. Gasroenterology 1991;100:1749-52 10 Roediger WE. What sequence of pathogenetic events lead to acute ulcerative colitis? Dis Colon Rectum 1988;31:482-7
(Accepted 15 January 1992)
Unusual telangiectasia in a nuclear veteran
Case presented to Section of Dermatology, 16 May 1991
S E Handfield-Jones MRCP1 M M Black FRCP' K Liddell FRCP2 'St John's Dermatology Centre, St Thomas' Hospital, London SEI 7EH and 2Eastbourne District General Hospital, Eastbourne BN2 2UD Keywords: radiation; nuclear veterans; telangiectasia
I,
We report the case of a patient who developed unusual telangiectasia on the trunk and limbs associated with stucco keratoses and atrophy of the skin. The patient had been an observer during two of the hydrogen bomb tests in 1957, subsequently staying in the test area for 3 months. We discuss the aetiology of the cutaneous abnormalities and the possible connection with his exposure to ionizing irradiation.
Case report A 63-year-old retired electrical technician had noticed dilated blood vessels on the trunk and limbs increasing in severity over the past 10 years. In addition he had many warty lesions in the same areas. He had no previous skin problems and his general health was good. There was no family history of skin disease. The lesions were asymptomatic but the patient was concerned about the significance of the lesions because he was a nuclear veteran. In 1957, whilst serving in- the British Navy, he had witnessed two hydrogen bomb tests at the Malden- Islands. These tests, known as the 'Grapple series', exploded air of megaton hydrogen bombs. The patient had been on board an observer ship within 25 miles of the tests and wvs ot board wearing only cotton protective clothing to 'watch the explosions. He had stayed in the area for the subsequent 3 months taking samples for analysis. On examination he had both stellate and leash telangiectases, with an irregular broken pattern, involving the chest, outer arms and legs (Figure 1). There was sparing of the back and inner arms. There was slight atrophy in the involved areas. There were multiple stucco keratoses which were most numerous in the areas of telangiectasia. He had no malignant or pre-malignant skin lesions. He had tpe II skin, had never been a sun bather and had never been severely sunburnt. There was no evidence of other skin disease, and general examination was normal.
Figure 1. Patient's keg showing telangiectasia, atrophy and stucco keratoses
Skin biopsy of telangiectatic skin showed dilated vessels only (Figure 2). There was minimal elastotic change on elastin van Gieson staining. Warty lesions were confirmed as stucco keratoses. A full blood count was normal. Digcussion Telangiectasia can be an isolated finding in otherwise normal skin or can be secondary to other dermatoses'. Our patient had no family history or associated systemic changes to suggest a diagnosis of hereditary haemorrhagic telangiectasia or ataxia telangiectasia2. The history and appearance would be unusual for a diagnosis of essential telangiectasia8. There is no evidence -of any of the conditions known to be associated with secondary telangiectasia such as rosacea, dermatomyositis, lupus erythematosus or mastocytosis. He has not used treatment that could give rise to telangiectases such as topical or systemic steroids.
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Journal of the Royal Society of Medicine Volume 85 July 1992
also marked interindividual variation in susceptibility to irradiation such that a dosage that would be without effect in the majority could have adverse effect in an idiosyncratic case2.
Figure 2. Skin biopsy showing prominent telangiectasia
Radiation, both solar and ionizing are known to cause telangiectasia. Our patient has only a minor degree of solar damage, both clinically and histologically, and the vascular changes seem disproportionate to this. His total exposure to ionizing radiation is impossible to calculate. The nuclear tests he witnessed were several hundred times more powerful than Hiroshima and the bombs tested were thought to be 'dirty' in terms of radioactivity4. Our knowledge of the effects of ionizing radiation on human skin comes from three major sources; clinical use, wartime use in Hiroshima and Nagasaki and nuclear tests. In clinical use cutaneous sde effects of irradiation are well recognized to include telangictaia which is a charc feature of chronic radiodermatitisP. In patients treated with whole body electron beam therapy, wideadtel sia may lead to an appearance similarto that seen in our patient. Investigations into the survivors oHirsima also sugg that vascular damage maybe seen many years later in those who were apparently uniijured. However our patient was exposed to a fusion as opposed to a fission bomb. Studies of servicemen exposed to nuclear' weapons tests have not commented on cutaneous vascular changes, however the largest studies have not included cliical examination and have concentrated -on cancer mOrtality7. The is
'Spontaneous' rectus sheath haematoma a rare cause of abdominal pain
M N SiddiqUi FRCS' Q Abid MB BS' T Qaseem MRCP2 S Hameed MRCP2 M Ahmed FRCS' Departments of 'Surgery and 2Medicine, The Aga Khan University Hospital, Stadium Road, PO Box 3500, Karachi, Pakistan Keywords: rectus sheath; haematoma; acute abdomen; diagnosis
Rectus sheath haematoma is an uncommon cause of acute abdominal pain. An estimated 60-93% are initially mis-diagnosedl2. Awareness of this entity may not only help in early diagnosis but prevent unnecessary surgical intervention2. Ultrasound has been recommended as an aid to diagnosis3 4. We present two cases of this interesting condition which ultrasound scanning failed to diagnose and was clearly shown using computerized tomographic scanning (CT).
In addition to telangiectasia our patient had numerous stucco keratoses which were in a similar distribution to the vascular changes. This type of seborrhoeic wart is not uncommon but are not usually as numerous as those seen in our patient. These lesions are not a recognized feature of radiation damage, however other keratotic lesions, both pre-malignant' and benign"0 are reported as a postirradiation finding. It is impossible to establish a definite causative link between this man's exposure to ionizing irradiation and his skin findings. However our patient shows an unusual degree and pattern of both telangiectasia and stucco keratoses for which we are unable to find any other cause. References 1 Goldman MP, Bennett RG. Treatment oftelangiectasia: a review. J Am Acad Dermatol 1987;17:167-82 2 Gatti RA, Boder E, Vinters HV, et aL Ataxia telangiectasia: an interdisciplinary approach to pathogenesis. Medicine 1991; 70:99-117 3 Shelley WB. Essential progressive telangiectasia. JAMA 1971; 216:13434 4 M iken R. No conceivable injury. Australia: Penguin, 1986:143 5 didtH, Sherwin WK. Reactions to ionizing radiation. JAm Acad Dermatol 1980;3:551-79 6 T1iy A, Wakano Y, Otake M, Dock D. Capillary microscopic obswvdtion on the superficial minute vessels of atomic bomb surdivors Hiroshima, 1972-73. Radiat Res 1977;72:353-63 7 SDaSC, Kendall GM, Fell TP, et aL A summary of mortality and incidence of cancer in the men from the United Kingdom's qb nuclear weapon tests and experimental prgrammes. BMJ 198836:332-8 8 Pearce N, 3Prior I, Methven D, et al. Follow up of New Zealand paricipants in British atmospheric nuclear weapons tests in the PcifI; 31.1J 1990;300:1161-6 9 Vastq JP, Hunter JAA, Mallet RB, Rodger A. Post irradiation conca lkeratoses. J R Soc Med 1989;82:166-7
(Accepted 5 February 1992)
Case reports Case 1 A 57-year-old woman was admitted via the accident and emergency department. She gave a few hour history of sudden onset of severe epigastric pain radiating to the chest after lifting a bed. She was a known, poorly-controlled hypertensive. On examination she was in-pain with a pulse of 90/min and a blood pressure of 200/100 mmHg. This was associated with tenderness in the epigastrium. Initial diagnosis included a possible myocardial infarct, perforated duodenal ulcer or pancreatitis. Electoardiogram, chest/abdominal X-rays, cardiac enzymes and serum amylase, were normal. Haemoglobin was 12.8 gldl, white blood count (WBC) 18.6x109/l, platelet (Pt) 265x 100/l, prothrombin time (T) 17/13, activated partial thromboplastin time (APE 42/33. Abdominal ultrasound scan failed to reveal any abnormality. Within 12 h she became pyrexial (390C) and a surgical consultation was sought. She was found to be tachycardic and markedly tender in the epigastrium with vague epigastric fullness. Bowel sounds were normal. A possible diagnosis of a liver abscess was made and a CT scan was ordered. The CT scan clearly demonstrated a haematoma ofthe left rectus abdominis muscle (Figure-- 1). Ultrasound-guided aspiration yielded 10 cm3 of blood-stained fluid which failed to yield any organisms. Treatment was conservative and all her symptoms settled within 6 days.
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