BackgroundThe purposes of this study are to examine if the human glucocorticoid receptor (hGR) isoform-α mRNA and hGR protein expressions are deficient in the acute phase of sepsis (S) compared to systemic inflammatory response syndrome (SIRS) and healthy subjects (H) and to evaluate if the hGRα and hGR alterations are associated with cortisol changes and if they are related to (1) extracellular and intracellular heat shock proteins (HSP) 72 and 90α; (2) ACTH, prolactin, and interleukins (ILs); and (3) outcome.MethodsPatients consecutively admitted to a university hospital intensive care unit (ICU) with S (n = 48) or SIRS (n = 40) were enrolled in the study. Thirty-five H were also included. Total mRNA was isolated from peripheral blood samples and cDNA was prepared. RT-PCR was performed. Intracellular hGR and HSP expression in monocytes and/or neutrophils was evaluated using four-colour flow cytometry. Serum prolactin, ACTH, and cortisol concentrations were also measured. ELISA was used to evaluate serum ILs and extracellular (e) HSPs (eHSP72, eHSP90α).ResultshGR protein was higher in S compared to H and SIRS; hGRα mRNA was higher in S compared to H (p < 0.05). In sepsis, hGR protein and eHSP72 were higher among non-survivors compared to survivors (p < 0.05). The hGR MFI and hGRα mRNA fold changes were significantly related to each other (r s = 0.64, p < 0.001). Monocyte hGR protein expression was positively correlated with extracellular and intracellular HSPs, cortisol, and ILs and negatively to organ dysfunction (p < 0.05). HSPs, hGR, and cortisol were able to discriminate sepsis from SIRS (AUROC > 0.85, p < 0.05). In sepsis, monocyte-hGR protein and eHSP72 were strong predictors of mortality (AUROC > 0.95, p < 0.04).ConclusionsAcute-phase sepsis is associated with increased hGR expression and cortisol concentrations, possibly implying no need for exogenous steroids. At this stage, hGR is able to predict sepsis and outcome and is related to stress-activated bio-molecules and organ dysfunction.

The creation of an abdominal stoma is a common procedure performed as part of the treatment for many conditions. Common complications include poor stoma siting, high output, skin irritation, ischaemia, retraction, parastomal hernia and prolapse. An extremely rare stoma complication is parastomal evisceration. We present a case of a 48-year-old woman who presented to us with parastomal evisceration as a late complication of a transverse colostomy. It is the second case reported as a complication of this procedure but the first that occurred after such a long postoperative period (almost 18 months). The creation of a permanent or temporary stoma is a common procedure performed as part of the treatment of many conditions. It has a 6-59% complication rate. Common complications include poor stoma siting, high output, skin irritation, ischaemia, retraction, stenosis and prolapse. 1 An extremely rare stoma complication is parastomal evisceration, with only seven cases reported in the literature. 2-8This is the evisceration of abdominal viscera through a pre-existing stoma, either in the immediate postoperative period owing to suture line disruption or later as a result of ostomy wall necrosis. We report a case of a 48-year-old female patient who presented with parastomal evisceration 18 months after the creation of a transverse colostomy. Case historyA 48-year-old woman presented to our surgical department with a parastomal hernia, significant colostomy prolapse, partial colostomy necrosis, and evisceration of small bowel and omentum through the colostomy (Fig 1). The colostomy was an end colostomy at the transverse colon, which had been created laparoscopically 18 months previously, when the patient was diagnosed with stage IV rectal cancer (liver and ovarian metastasis) and a rectovaginal fistula. She was diagnosed initially as having ovarian tumours, which were resected, and the histopathology report revealed an adenocarcinoma of colorectal origin. She received chemotherapy (folinic acid, fluorouracil, oxaliplatin and bevacizumab), to which there was significant response, but following the chemotherapy, she developed severe pulmonary fibrosis, which was treated with high dose cortisone. Her past medical history included posttraumatic cardiac dysrhythmias and a pacemaker had been implanted for that reason. Visceral reduction and colostomy reversal was performed, followed by a right hemicolectomy. Given the excellent response to chemotherapy, the small pelvis was explored, in an attempt to resect the uterus en bloc with the rectum so as to restore bowel continuity without any stoma but that was not feasible. Instead, a class II hysterectomy was performed owing to a palpable diffuse hardness of the uterus. Intestinal continuity was restored with a side-to-side ileotransverse anastomosis. A loop colostomy was created at the sigmoid colon. The abdominal wall was reconstructed with primary closure. The whole procedure was carried out under combined epidural and spinal anaesthesia with intravenous sedation (remifen...

Inflammatory pseudotumor of the spleen with expression of follicular dendritic cell markers is an extremely rare lesion with only a few cases reported previously. The present study reports on an inflammatory pseudotumor of the spleen 10 × 8 × 7 cm in size that was incidentally found in a 61-year-old man and increased gradually in size during a period of 3 months. Abdominal ultrasonography revealed a well-circumscribed splenic mass, and abdominal computed tomography confirmed the presence of a well-circumscribed isodense lesion in the splenic hilum with inhomogenous enhancement in the early-phase images and no enhancement on delayed-phase contrast-enhanced images. Magnetic resonance imaging of the abdomen showed a well-defined isodense tumor on T1-weighted images with mildly increased signal intensity on T2-weighted images, and this is only the second study that provides MRI findings of this entity. The patient underwent an uncomplicated open splenectomy for definitive histologic diagnosis. Under microscopic examination, the lesion was an admixture of lymphocytes, plasma cells and spindle cells. In situ hybridization analysis for Epstein-Barr virus (EBV) revealed that most of the spindle cells were positive for EBV, and immunochemistry showed the expression of the follicular dendritic cell markers CD21, CD35 and CD23 within the tumor. The diagnosis of inflammatory pseudotumor-like follicular dendritic cell tumor was established.