Faculty Bibliography

A 61-year-old woman who was a New York City hospital employee developed fatal inhalational anthrax, but with an unknown source of anthrax exposure. The patient presented with shortness of breath, malaise, and cough that had developed 3 days prior to admission. Within hours of presentation, she developed respiratory failure and septic shock and required mechanical ventilation and vasopressor therapy. Spiral contrast-enhanced computed tomography of the chest demonstrated large bilateral pleural effusions and hemorrhagic mediastinitis. Blood cultures, as well as DNA amplification by polymerase chain reaction of the blood, bronchial washings, and pleural fluid specimens, were positive for Bacillus anthracis. The clinical course was complicated by liver failure, renal failure, severe metabolic acidosis, disseminated intravascular coagulopathy, and cardiac tamponade, and the patient died on the fourth hospital day. The cause of death was inhalational anthrax. Despite epidemiologic investigation, including environmental samples from the patient's residence and workplace, no mechanism for anthrax exposure has been identified

Conventional sigmoidoscopy and rectal biopsy are very useful in the diagnosis, differential diagnosis, and management of inflammatory bowel disease. The rectal biopsy is particularly important in establishing the diagnosis of Crohn's disease when the rectal mucosa is grossly normal. The sigmoidoscopy and biopsy serve to assess the response to medical therapy in inflammatory bowel disease and are important adjuncts to colonoscopy in surveillance for dysplasia and carcinoma in patients with ulcerative colitis. Sigmoidoscopy is quick, requires no preparation, is cost effective, and the biopsies are extremely safe with the use of the cupped bronchoscopic forceps

Surveillance has become an established concept to find dysplasia as a premalignant lesion in ulcerative colitis. Since the advent of colonoscopy and the access of the entire colon to biopsy, utilization of the rigid sigmoidoscope and rectal biopsies has been markedly reduced. We have reviewed 940 rectal biopsies obtained from 360 patients with ulcerative colitis of various extent and duration to determine the yield of dysplasia and assess the value of this procedure. The rectal biopsies had been performed for a variety of reasons in the course of clinical management of ulcerative colitis in addition to surveillance. Dysplasia was found in 10.8% of the patients--higher than has been demonstrated by colonoscopy. In four of the 39 patients with dysplasia a carcinoma coexisted (2) or developed subsequently (2). In no instance did dysplasia serve to warrant the colectomy that disclosed the carcinoma, but earlier discovery of the dysplasia or more intense surveillance once it had been found might have led to earlier discovery of the carcinoma. The yield of dysplasia was greater in those with onset of ulcerative colitis in childhood. In more than half, including 71% of patients with onset in childhood, the dysplasia was found before they had the disease for 9 years. Surveillance, therefore, should begin earlier in young patients with ulcerative colitis. Sigmoidoscopic biopsies do not substitute for colonoscopic biopsies in a surveillance program. Nevertheless, the ease of obtaining rectal biopsies, the relatively large yield of dysplasia, and the need for frequent sigmoidoscopy in the clinical management of ulcerative colitis all warrant a high priority role for rectal biopsies to supplement that of colonoscopic biopsies

Desensitization to sulfasalazine was successful in 40/47 (85%) patients with IBD who previously had hypersensitivity reactions. The desensitization with sulfasalazine was well-tolerated with no serious complications in short- or long-term follow-up. The course of IBD was subsequently favorable in 35/40 (87%) for extended periods including 17/17 (100%) with ulcerative colitis. Desensitization should be attempted in patients who have had typical hypersensitivity reactions to sulfasalazine