Cysticercosis in the Czech Republic

The authors report 10 cases of cysticercosis registered by the National Reference Laboratory for tissue helminthiasis. Six Czech citizens and four foreigners contracted the disease. Four of 6 Czech citizens were contaminated abroad. Six patients suffered from nervous manifestations of cysticercosis, 2 from muscular or subcutaneous cysticercosis and 2 patients had an asymptomatic course of the infection. The prerequisite of successful treatment with new anthelmintics is early diagnostics.     

Albendazole therapy for neurocysticercosis: a prospective double-blind trial comparing 7 versus 14 days of treatment. Cysticercosis Working Group in Peru

OBJECTIVE: To compare the effectiveness of two regimens of albendazole therapy for neurocysticercosis. DESIGN: Randomized, double-blind clinical trial. SETTINGS: Patients admitted to neurologic wards in Lima, Peru. PATIENTS: Adult patients with active neurocysticercosis demonstrated by CT and Western blot (immunoblot). INTERVENTION: One week (n = 25) versus 2 weeks (n = 25) of albendazole therapy. MEASUREMENTS: Decrease in the number of cysts on CT. RESULTS: Effectiveness of albendazole was 78%, with no difference between the groups when compared 3 months after therapy. Complete cure was obtained in only 38% of patients. Patients with more than 20 cysts had poorer responses to therapy. The clinical course and EEG evolution improved in most patients. Side effects were present in 38% of patients, mainly mild, transient gastrointestinal symptoms. Therapy was also associated with exacerbation of neurologic symptoms. Two patients died in the first year after therapy, both because of aggregated infections of ventricle-peritoneal shunts. One-year follow-up CT showed lesions in three of 10 patients presumed to be cured 3 months after therapy. CONCLUSIONS: Extension of albendazole therapy for more than 7 days adds no benefits for the patients.     

Therapy for neurocysticercosis: a reappraisal

Accepted approaches to therapy for the different forms of neurocysticercosis are reviewed. Therapy must be individualized according to the level of disease activity and the location of the parasite. Patients with inactive disease should receive only symptomatic treatment. In contrast, patients with parenchymal brain cysts must receive a course of anticysticercal drugs. Both albendazole and praziquantel are useful; however, recent evidence favors the former as the drug of choice for this form of the disease. Albendazole (but not praziquantel) is also effective in the treatment of giant subarachnoid cysts; such medical treatment obviates surgery in some cases. Patients with ventricular cysts may also benefit from medical therapy; however, surgery is the current approach to this type of lesion, as it is to spinal cysticercosis. Although intraocular cysts have classically been resected by surgery, a recent study indicates that albendazole is equally effective. For patients with mixed forms of neurocysticercosis, therapeutic measures related to--but not directly targeting--the disease (i.e., steroid administration for brain edema or shunt placement for hydrocephalus) should be contemplated before therapy with anticysticercal drugs is instituted.     

Treatment of neurocysticercosis with a two week course of albendazole

Ten cases of cerebral cysticercosis, treated with 2-week course of albendazole, were reported. The results were excellent. 9 patients were responded to this regimen in both the clinical outcomes and CT scan findings. These results indicated that a 2-week course of albendazole is effective for treatment of neurocysticercosis.     

Spinal cord compression in metastatic cervical cancer

Spinal cord compression secondary to metastatic cervical cancer may not be considered as a possible cause of neurologic symptoms by primary care physicians who do not often treat these patients. Delays in diagnosis and treatment may result in irreversible but potentially preventable neurologic changes. This report describes 5 cases of spinal cord compression in patients with metastatic cervical carcinoma, 2 of whom were previously undiagnosed with cervical cancer. These 2 patients represent 1.6% (2 of 121) of all new cervical cancer cases diagnosed during this time period. Two of 5 patients (40%) with spinal cord compression showed improvement following therapy by regaining the ability to walk, while none of the remaining patients had further acute deterioration of neurologic function. The mean survival of patients presenting with spinal cord compression from cervical cancer in this series was 4 months (maximum 6 months). This series illustrates the relative frequency with which spinal cord compression is seen in patients with a new diagnosis of invasive cancer. This diagnosis should be considered when evaluating neurologic complaints in known cervical cancer patients or any woman with apparent pelvic pathology. Rapid diagnosis and treatment of these lesions, while not likely to improve overall survival significantly, can improve function and alleviate symptoms.     

Cervical pseudarthrosis in ankylosing spondylitis. A case report

STUDY DESIGN: This report illustrates two different cases of cervical pseudarthrosis in ankylosing spondylitis. OBJECTIVES: To point out the extreme rarity of this condition at cervical level, to discuss the pathogenesis, and to stress the necessity of surgical management. SUMMARY AND BACKGROUND DATA: Pathogenesis of pseudarthrosis in ankylosing spondylitis is discussed. Several factors are involved: trauma, which may be major or minor and undetected; stress fracture; and inflammatory changes. Major trauma was the cause of pseudarthrosis in the first patient, whereas stress fracture and inflammatory changes were the probable causes in patient 2. In patient 1 there were signs and symptoms of cord compression. Patient 2 was referred because of functional disability resulting from kyphosis and because of potential neurologic risk. METHODS: Cervical fusion was performed in both patients. Patient 1 underwent posterior fusion; patient 2 had combined fusion. Patient 1 also underwent a lamineotomy. RESULTS: The course of the disorder after surgery was uneventful in both patients. Neurologic symptoms subsided in patient 1; kyphosis was corrected in patient 2. Both patients resumed their preoperative activities. Follow-up evaluation was done 6 years after surgery in patient 1 and 2 years after surgery in patient 2. CONCLUSIONS: Pseudarthrosis of the cervical spine in ankylosing spondylitis is extremely rare. Presentation of the two patients was different in terms of pathogenesis and signs and symptoms. Surgical treatment is advocated for this disorder.     

Nocardia abscess of the choroid plexus: clinical and pathological case report

OBJECTIVE: Cerebral Nocardia abscesses are rare, accounting for approximately 1 to 2% of all cerebral abscesses. Prompt aggressive surgical treatment involving craniotomy and excision of these lesions has been advocated by many authors, because these lesions have significantly higher morbidity and mortality rates than do most other cerebral abscesses. We report an atypical presentation of cerebral nocardiosis localized to the choroid plexus of the lateral ventricle. CLINICAL PRESENTATION: A 56-year-old man presented with a 3-week history of fever, cough, and progressive headache and an ensuing 3-day history of progressive lethargy, confusion, and gait ataxia. Radiographic studies demonstrated a loculated contrast-enhancing left lateral ventricular lesion with significant perilesional parenchymal edema that was thought preoperatively to be a neoplasm. INTERVENTION: The patient underwent a craniotomy for resection of the lesion. Intraoperatively, a reddish gray lesion with purulent exudate was encountered within the left lateral ventricle intimately adherent to the choroid plexus as well as to the ependyma and subependymal veins. A frozen section demonstrated an organizing abscess wall. The lesion was resected in its entirety, and multiple cultures were sent for analysis. CONCLUSION: Microbiology cultures grew Nocardia asteroides. A course of intravenous antibiotics was started, which included trimethoprim-sulfamethoxazole, amikacin, and ceftriaxone. Two weeks after surgery, at the time of discharge, the patient's neurological status had improved considerably. Although Nocardia abscesses have been documented to occur throughout the central nervous system, the presentation of a lesion confined to the choroid plexus of the lateral ventricle with significant parenchymal edema is unusual and demonstrates that Nocardia abscesses must be considered in the differential diagnosis of a contrast-enhancing intraventricular mass lesion involving the choroid plexus.     

Isolation and characterization of a mutant of Saccharomyces cerevisiae affected in the FLO1 locus

BACKGROUND: With the progression of acquired immunodeficiency virus (AIDS) and human immunodeficiency virus (HIV) infection to endemic areas of cysticercosis, the simultaneous diagnosis of both diseases is an expected event. METHODS: Among 91 patients with AIDS or HIV infection studied from 1987 to 1993 at a neurologic reference center in Mexico City, 2 patients with AIDS and neurocysticercosis were found. Five previously reported cases were jointly reviewed. RESULTS: The first patient presented with increased intracranial pressure of rapid progression. A single giant cyst was surgically excised and cysticercus was confirmed on histopathologic examination. The second patient had brain toxoplasmosis and concurrent neurocysticercosis as an incidental finding. CONCLUSIONS: Neurocysticercosis in HIV infection/AIDS may appear as a life-threatening condition or as an incidental finding. All reported cases have been found in advanced stages of HIV infection. Management must be individualized depending on the clinical form of cysticercosis, stage of HIV infection, and coexisting opportunistic conditions. Surgery may be lifesaving and some patients apparently responded to cysticidal drugs.     

Subcutaneous cysticercosis

With the increasing numbers of immigrants coming to the United States from areas where Taeniasis and cysticercosis are endemic, it is important to be familiar with some of these more common entities. We present a patient with both neurologic and soft tissue cysticercosis as well as a review of the available literature.     

Cerebral cysticercosis: why it should be treated

BACKGROUND: In Guadeloupe, cases of neurocysticercosis have been rarely observed in people recently immigrated from Haiti. We followed 2 women with seizures, associated with meningitis or encephalitis. CASE REPORT: Computed tomography scan and muscle X-ray have displayed specific features of cysticercosis with small diffuse calcifications. This was associated with positive antibodies for cysticercosis. After respectively 5 and 17 years, these patients developed recurrent manifestations of neurocysticercosis with subacute, quite silent meningitis after pregnancy, with CSF increased cells count (180 lymphocytes/mm3), raised protein level (0.6 g/l) and positive antibodies for cysticercosis in the first case, and cortical granuloma with fever and repetitive seizures in the second. DISCUSSION: These observations suggest that the patients were chronically infested, for more than 5 years. Although the brain lesions were quiescent for many years, new lesions responsible for inflammatory cysts occurred while they still lived outside her native endemic area. In such cases, treatment would benefit to the patient by breaking down the auto-infestation cycle.     

Treatment of stable burst fracture of the atlas (Jefferson fracture) with rigid cervical collar

STUDY DESIGN: A retrospective review of a clinical series. OBJECTIVE: To evaluate the use of a rigid cervical collar alone as the treatment for stable Jefferson fracture, and to devise an algorithm for treatment of Jefferson fracture with or without an associated cervical injury. SUMMARY OF BACKGROUND DATA: The traditional treatment for Jefferson fracture, if there is no indication for surgery, is immobilization by halo vest. Because halo vest placement is associated with intracranial infection and a significant degree of patient discomfort, slightly less rigid forms of external immobilization may be useful for the treatment of stable Jefferson fractures. No standard protocol calling for the use of one form of stabilization device has been reported. MATERIALS: The medical records and radiographs of 16 consecutive patients with Jefferson fracture during a 2-year period were reviewed. Each patient underwent a complete cervical radiograph series and a computed tomographic scan. The mean C1 lateral mass displacement was 1.8 mm. Cervical spine radiographs, including lateral flexion-extension views were obtained 10 to 12 weeks after injury before the removal of an external immobilization device. RESULTS: Of these 16 patients, 1 sustained a complete injury, and 7 sustained an incomplete injury. Eight patients were neurologically intact. Twelve patients sustained a stable Jefferson fracture and were treated with a rigid cervical collar (Miami-J collar [Jerome Medical, Moorestown, NJ]) alone from 10 to 12 weeks. The patient sustaining the complete neurologic injury died of multisystem trauma. All 15 live patients showed no instability on their follow-up plain radiographs before the removal of an external stabilization device. Six patients underwent further plain radiographs approximately 1 year after the fracture and similarly demonstrated no instability. CONCLUSIONS: Isolated stable burst fracture of the atlas can be treated effectively with a rigid cervical collar alone for 10 to 12 weeks with good neurologic recovery and segmental stability. Unstable Jefferson fractures with concurrent unstable fracture of other cervical vertebrae, especially C2, requires surgical stabilization.     

Hypoparathyroidism--presenting 40 years after thyroid surgery

BACKGROUND: Latanoprost represents a new therapeutic option in the treatment of chronic open angle glaucoma. It has only recently been reported for the first time that latanoprost caused cystoid macular edema in pseudophakic patients. CASE REPORT: A 60-year-old pseudophakic patient who suffered from a 10-year history of glaucoma, revealed a cystoid macular edema on fluorescence angiography after 10 days of treatment with latanoprost. One week after cessation of latanoprost therapy the cystoid edema in fluorescence angiography had resolved and the vision improved from 0.4 to 0.8. CONCLUSIONS: With respect to this severe complication, latanoprost should be used with great care and in clear indications, particularly in patients with risk of blood-aqueous leakage e.g. pseudophakic patients.     

Neuroimaging and pathology of the spinal cord in compressive cervical myelopathy

Magnetic resonance imaging (MRI) has enabled us to see the spinal intramedullary pathology as differences in signal intensity. Intramedullary high intensity lesions were observed on T2-weighted MRI in patients with cervical spondylotic myelopathy (20.0%) and ossification of the posterior longitudinal ligament (OPLL) of the cervical spine (25.7%). The frequency of this findings was proportional to the clinical severity of myelopathy and degree of spinal cord compression. The pathophysiological basis of such signal abnormality was presumed to vary from acute edema to chronic myelomalacia. The intramedullary lesion on MRI is considered to be the main site of lesion responsible for the neurological symptom because of a good correlation between the neurological level and high intensity level. We found from nine autopsy cases of OPLL that there are distinct differences in severity and extent of pathological changes between the spinal cord with a boomerang-shaped cross-section and that with a triangular-shaped cross-section. In the boomerang-shaped cases, major pathological changes were restricted to the gray matter and the white matter was relatively well preserved. Secondary wallerian degeneration was restricted to the fasciclus cuneatus the fibers of which were derived from the affected segments. In the cases of a triangular shape, pathological changes were more severe, both white and gray matter were involved. There were severe pathological changes over more than one segment, and both descending degeneration of the lateral pyramidal tracts and ascending degeneration of the posterior column, including the fasciclus gracilis, were observed. In conclusion, it is clinically very important to understand the pathological basis of the compressed spinal cord on neuroimages.     

Permeability of the blood-ocular barrier in adolescent and adult diabetic patients

Transverse myelitis has been cited as a rare and unusual complication of systemic lupus erythematosus (SLE). A review of the literature reveals only 10 cases of transverse myelitis as the initial presentation of SLE, and only one with reported benefits from antimalarial therapy. The case of a 30-year-old woman is reviewed. She presented to the emergency room with complaints of hypogastric and low back pain. The ensuing course was one of frank urinary retention and rapidly progressing quadriparesis. Magnetic resonance imaging of the spine revealed marked edema of the cervical and thoracic spine. A diagnosis of SLE was based on positive antinuclear antibodies and leukopenia. The patient was treated with high dose methylprednisolone, plasmapheresis and pulse cyclophosphamide for 3 months. Subsequently, treatment was begun with hydroxychloroquine, and significant improvement in her neurologic and functional status was achieved after 1 month of therapy. Ten months after her onset of symptoms, the patient suffered an acute exacerbation of paraparesis and urinary retention. Again, she improved clinically after high dose methylprednisolone and pulse cyclophosphamide for 1 month. Hydroxychloroquine was continued throughout the duration of therapy.     

Neuro-Beh?et: a follow-up of 4 cases treated with chlorambucil

Four patients diagnosed with Beh?et's disease developing neurologic manifestation are described. Central nervous system findings were observed in three of them and peripheral neuropathy in ther other patient. All the patients were treated with chlorambucil, 0.1-0.2 mg/kg/day as initial dose. Three of them ended the immunosuppressive therapy after a period of treatment between 12-18 months. None of the four patients suffered neurologic relapses once that the therapy with chlorambucil was started. In a similar way to other authors, we think that treatment with chlorambucil in neuro-Beh?et's disease may be useful to reduce morbility related to neurologic relapses.     

Partial ocular tilt reaction due to unilateral cerebellar lesion

We report on two patients each with tonic, contraversive partial ocular tilt reactions due to unilateral cerebellar lesions: one patient had had a caudal cerebellar hemorrhage, the other a posterior inferior cerebellar artery territory infarct. Both patients had tonic contraversive conjugate ocular torsion; one had skew deviation; neither had a head tilt. One patient had no specific neurologic deficit apart from the conjugate ocular torsion, which was first suspected because of a deviation of the subjective visual horizontal. These observations imply that the ocular tilt reaction (OTR), a brainstem otolith-ocular reflex of probable utricular origin, is under the inhibitory control of the ipsilateral caudal cerebellum, possibly the nodulus, and that a patient with a cerebellar infarct can present with imbalance as the only neurologic symptom and with conjugate ocular torsion as the only specific neurologic sign.     

Current trends in the detection and management of carotid body tumors

PURPOSE: Because the natural history of carotid body tumors is believed to be unpredictable, immediate surgical removal has been recommended. The present study reviews our experience in the diagnosis and treatment of these uncommon lesions. METHODS: The medical records of patients who appeared for treatment with carotid body tumors between 1981 and 1997 were reviewed. Patients demographics, mode of presentation, imaging and treatment modalities, Shamblin classification, and neurologic complications (stroke, cranial nerve injuries) were analyzed. RESULTS: Over the past 16 years, 31 patients with 32 carotid body tumors have been evaluated, with an average follow-up of 3.2 years. The patients were arbitrarily classified into two groups on the basis of the mode of detection. Seventy percent (23 of 32) of the tumors discovered on clinical or self-examination were classified as Group 1; 28% (9 of 32) of the tumors detected during duplex scanning for carotid artery disease (8) or MRI (1) were classified as Group 2. The mean size of chemodectomas found on palpation (4.3 +/- 1.7 cm) was larger than that of those detected by duplex ultrasound (2.7 +/- 1.0 cm; p < 0.05, by paired t test). Preoperative embolization was successfully performed in 5 of 6 instances of large tumors; the remaining patient suffered a procedure-related stroke. Thirty-one carotid body tumors were resected. In one case, the tumor was felt by the primary surgeon to be too small (0.9 x 0.7 cm on duplex scan) to warrant immediate excision; this patient is being followed by periodic duplex scanning. Five neurologic complications were noted in Group 1, one after preoperative embolization and four after surgery. One cranial nerve injury occurred in Group 2. One patient had a large recurrent chemodectoma with clinical evidence of metastatic disease. CONCLUSION: The increasing use of sophisticated imaging modalities may allow earlier discovery of carotid body tumors before they can be clinically detected. Resection of carotid body tumors of all sizes in appropriate surgical candidates remains the standard of care. Unfortunately, resection of even small tumors is associated with a low but constant incidence of neurologic complications.     

Antimetastatic efficacy of orally administered ginsenoside Rb1 in dependence on intestinal bacterial hydrolyzing potential and significance of treatment with an active bacterial metabolite

BACKGROUND: Single small enhancing computerized tomographic (CT) lesions (SSECTLs) are common in children with focal seizures. These are considered to represent solitary cysticercus granulomas. Controversy exists regarding their treatment. OBJECTIVE: To evaluate the efficacy of albendazole in cases of focal seizures with SSECTLs. DESIGN: Randomized, placebo-controlled, double blind trial. SETTING: Pediatric service of Nehru Hospital, PGIMER, an urban tertiary care teaching hospital. SUBJECTS: 63 children between 2 and 12 years of age with focal seizures for <3 months and SSECTLs. INTERVENTION: All children were randomly assigned to receive either albendazole (15 mg/kg/ day) or placebo for 28 days. CT scan was done at 1 and 3 months after beginning treatment. Codes opened after 6 months of inclusion in the study showed that 31 had received albendazole and 32 had received placebo. All children were followed up for at least 15 months. RESULTS: Disappearance of lesions on CT scan was noted in 41% of albendazole vs. 16.2% of placebo patients after 1 month of follow-up (P < 0.05) and 64.5% of albendazole- vs. 37.5% of placebo-treated patients after 3 months of follow-up (P < 0.05). During the first 4 weeks of therapy seizure recurrence was seen in 9.7% of albendazole vs. 3.2% of placebo-treated children (odds ratio, 3.32; 95% confidence interval, 0.33 to 33.8). After 4 weeks seizure recurrence was seen in 31.3% of placebo-treated children vs. 12.9% of albendazole-treated children (odds ratio, 3.07; 95% confidence interval, 1.18 to 11.15). CONCLUSIONS: Albendazole therapy results in significantly faster and increased resolution of solitary cysticercus lesions (SSECTLs) and appears to reduce the risk of late seizure recurrences.     

Microsurgery of intramedullary cervical cord tumor

OBJECTIVE: To evaluate whether intramedullary tumor of the cervical spinal cord is amenable to aggressive surgery and to clarify surgical timing and important points for tumor removal. PATIENTS AND METHODS: Fifty-eight patients with intramedullary tumor of the cervical spinal cord were examined by magnetic resonance imaging and treated by microsurgery in Huashan Hospital between May 1988 and December 1994. The results were analysed by F or Chi square tests. RESULTS: Tumors were totally resected in 50 cases (86.2%), subtotally resected in 7 and partially resected in 1. Forty-five (77.6%) patients had their neurological status improved postoperatively. Most patients with moderate neurological deficit can recover remarkably after total tumor removal. Laser surgery is especially helpful for treating lipoma. CONCLUSIONS: Intramedullary tumor of the cervical spinal cord is amenable to total tumor removal. Operation is suitable when a patient presents moderate neurological deficit. Proficient surgical technique and standards for total tumor resection are essential for good results. Preoperative radiotherapy contributes to difficult surgery and poor prognosis, and is not recommended.     

Treatment of progressive cervical spinal instability secondary to hydatid disease. A case report

STUDY DESIGN: A case report of a patient with progressive cervical spinal instability secondary to hydatid disease and the operative therapy. OBJECTIVE: To document how the combination of contemporary imaging, medical, and operative methods has obviated severe neurologic sequelae in a patient's cervical spine ravaged by hydatidosis. SUMMARY OF BACKGROUND DATA: The incidence of hydatid disease in the vertebral column is unusual and rare in the cervical spine. Until recently, patients with spinal hydatid disease have had guarded prognoses, because the various medical and surgical therapies could not effect curative or even palliative results. METHODS: The use of contemporary imaging methods, including computed tomography and magnetic resonance imaging, is described, in conjunction with current anthelminthic therapy and operative spinal instrumentation in this patient with recurrent quadriparesis from progressive hydatid spinal erosion. RESULTS: With the operative and medical therapies described in this case report, the patient has had six successful operative results in 6 years for cervical spinal hydatidosis and remains neurologically normal, with a stable cervical spine. CONCLUSIONS: It is hoped that this case presentation will justify a spirit of guarded optimism in the patient whose spine has been rendered unstable by hydatid disease and that, though a cure is still not likely, at least the past inexorable prognosis of paralysis and death is ameliorated.