Definitive diagnosis of the fat embolism syndrome (FES) may be difficult clinically beause the classic FES triad, respiratory distress, encephalopathy and cutaneous petechiae, is barely seen totally. Although the pathophysiology of the FES is poorly understood and remains controversial, the embolization of fats and fatty acids from bone marrow to pulmonary capillaries is believed to be an important event in initiating the syndrome. We, therefore, evaluated the usefulness of bronchoalveolar lavage (BAL) in establishing the diagnosis of FES in trauma patients with long-bone fractures. The BALF of 2 patients with difinite FES and of 3 patients with possible FES at the time was of BAL was examined. FES was associated with significantly greater numbers of polymorphonuclear leukocytes and intracellular fat droplets than found in patients who underwent elective surgery for long-bone fractures. We conclude that BALF would be a useful tool in the rapid and specific diagnosis of FES in trauma patients.

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A 60-year-old woman suddenly became nearly asphyxiated. She was intubated orally, but it was too difficult to ventilate her manually. Bronchofibroscopy revealed airway obstruction by foreign matter, but it was too difficult to remove with forceps. Emergency tracheostomy was then performed, and after removal with forceps, the patient recovered dramatically. The matter was determined to consist of pseudomembranes histologically, and Staphylococcus aureus was detected in a bronchial biopsy specimen. Based on these findings a diagnosis of necrotizing tracheobronchitis (NTB) was made. NTB is not a very common disease, especially in adults. Sloughing of pseudomembranes may occur in NTB, however, and cause paroxysmal dyspnea or asphyxia. In such cases, not only should intubation be attempted but bronchofibroscopy and, if necessary, immediate tracheostomy.

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We present the case of a 38-year-old female with subarachnoid hemorrhage due to a minor leak from an anterior communicating aneurysm. CT scans of the brain failed to detect the hemorrhage, and the patient was treated for menigitis for two weeks. At the onset of minor leaks, the patient developed headaches associated with nausea and loss of consciousness which lasted for a few minutes. A general physician gave the patient antibiotics and antiepileptic agents, after diagnosing meningitits, because the CT scans failed to reveal any evidence of hemorrhage. The patient's clinical symptoms gradually improved, but similar episodes occurred on the 11th and 20th day afterthe first, and she was referred to our clinic and admitted for precise clinical evaluation of her clinical symptoms. We also were unable to find any evidence of hemorrhage on CT scans. Since the patient's history strongly suggested subarachnoid hemorrhage, we performed a lumbar puncture and obtained bloody cerebrospinal fluid, confirming the diagnosis of subarachnoid hemorrhage. Cerebral angiography demonstrated an anterior communicating aneurysm, and on the same day, the neck of the aneurysm was successfully clipped. The patient's postoperative course was uneventful, and she was discharged on the 24th postoperative day without sequelae. Minor leaks from cerebral aneurysms reportedly occur relatively often within several weeks prior to amajor aneurysmal rupture. The detection of minor leaks is strongly correlated with an excellent prognosis, if minor leaks are found and treated before a major rupture. CT scanning is not always effective in detecting minor leaks. Lumbar puncture, however, is an important method of detecting them.

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Four cases of spontaneous pneumomediastinum (SP) are reported. Severe cough induced SP in the first case, violent vomiting in the second case, jogging with underlying SLE and pulmonary fibrosis in the third case, and a back contusion with closed vocal cords in the fourth case. In second case, spontaneous rupture of the esophagus (Boerhaave's syndrome) was suspected and surgery was performed, but the findings were negative. Gastrografin swallow is essential to rule out Boerhaave's syndrome. Fiberoptic bronchoscopy can be recommended to rule out a traumatic respiratory tract injury. SP is usually a benign, self-limited disease of young men and parturient women and frequently occurs with no apparent precipitating cause. Supportive care is usually effective.

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A 20-year-old man presented with severe exophthalmos on the left as a result of a traffic accident. X-ray films revealed that foreign bodies, suspected of being parts of the windshield, had extended into the orbital apex. An intracranial lesion, however, could not be excluded. Craniotomy (fronto-zygomatic approach) was performed to remove the orbital foreign bodies, while preserving the optic nerve, and to identify intracranial foreign bodies in a wide surgical field. No dural lacerations or intracranial foreign bodies were observed during surgery. Total removal of the orbital foreign bodies was accomplished via the left fronto-zygomatic approach. Postoperatively, there was marked improvement in the severe exophthalmos, and visual acuity was restored. This type of surgical procedure is a good approach for removing deep orbital foreign bodies and checking for the presence of possible intracranial foreign bodies.

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A 39-year-old woman was admitted with complaints of fever and severe dyspnea. Chest X-ray revealed bilateral widespread opacity with glass shadow. In addition arterial blood gas analysis revealed severe hypoxemia (PaO₂ 44.1mmHg, 100% mask). On the day of admission, she was intubated and ventilated mechanically with FiO₂ 1.0, PEEP 10cm H₂O. Subsequently, treatment with intravenous minocycline (200mg/day) was started. The abnormal chest X-ray findings and hypoxemia improved by day 5. On the 12th day of her hospital stay, she was successfully weaned from the ventilator. Analysis of complement fixation antibodies against Chlamydia showed a significant rise, 1:128. The titer of IgM antibodies to Chlamydia psittaci by the microplate immunofluorescent antibody technique was 20 (normal:10>). This disease was considered to be acute pneumonia due to fulminant psittacosis causing acute respiratory failure. Psittacosis should always be borne in mind as a possible cause of fulminant pneumonia with acute respiratory failure, and such a situation can be handled successfully if emergency care including mechanical ventilation is available.

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A case of glufosinate poisoning is reported. A shizophrenic 39-year-old woman took 55 g of glufosinate to commit suicide. Seven hours later, she was found to be asymptomatic at a local hospial. Twenty-three hours later she developed generalized convulsive movements with consciousness disturbance and was transferred to our hospital. Since her consciousness and respiration were rapidly deteriorating, she required mechanical ventilation. Glufosinate poisoning was proven by urine qualitative analysis using thin-layer chromatography. She was treated with forced diuresis and direct hemoperfusion for 3 days. Four days later, urine qualitative analysis failed to reveal any glufosinate and she was smoothly weaned from mechanical ventilation. The patient was discharged without any sequelae after a 12-day hospitalization. It has been documented in animal experiments that the central nervous system is a major target of acute glufosinate toxicity. BASTA^TM herbicide contains 18.5% ammonium glufosinate and a surface active agent. A previously described case of BASTA^TM poisoning showed decreased systemic vascular resistance and hypovolemic shock caused by the surface-active agent. It seems important to give adequate attention to the toxicitiy of both glufosinate and the surface-active agent in cases of BASTA^TM poisoning.

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