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A 36-year-old female was admitted with a 3-month history of headache and gait disturbance. Magnetic resonance imaging demonstrated a large tumor in the right cerebellopontine angle and syringomyelia in the upper cervical cord associated with caudal displacement of the cerebellar tonsil. Complete removal of the tumor resulted in disappearance of these associated conditions. Herniation of the cerebellar tonsil and distortion of the brain stem had probably caused disturbance of cerebrospinal fluid flow, which combined with obstruction of the spinal canal, caused the syrinx.     

Benfluorex, a hypotriglyceridemic drug, reduces lipid peroxidation and alleviates adverse metabolic complications of copper deficiency

To provide histological diagnoses of brain diseases, CT-guided stereotactic brain biopsy (CT-SBB) has been widely used because of its less invasive technique compared with open brain biopsy (OBB). However, CT-SBB is not always diagnostic. We report a case of multiple intracranial tuberculoma whose diagnosis was not made by CT-SBB but by OBB. The patient is a 46-year-old man with insulin-dependent diabetes mellitus who had been receiving immunosuppressive agents (azathioprine, cyclosporin, and prednisolone) after renal transplantation for diabetic renal failure for 9 years. He gradually developed febrile, headache and unsteady gait. Brain MRI demonstrated multiple intracranial lesions involving left fronto-temporal and right parietal lobes, left cerebellar hemisphere, and the fourth ventricle. Although the MRI findings were consistent with those of previously reported cases of intracranial tuberculoma, other conditions, such as malignant lymphoma and toxoplasmosis, were not ruled out. Therefore, CT-SBB targeting the left temporal lobe lesion was done for definitive diagnosis, but it revealed only mild perivascular infiltration of mononuclear cells and hemorrhage. He was transferred to our clinic for further evaluation. On examination, mild truncal and limb ataxia on the left were noted in addition to the neurological findings corresponding to diabetic retinopathy and neuropathy. Despite vigorous laboratory examinations, including repeated bacterial cultures and PCR of cerebrospinal fluid, no evidence of tuberculous infection was obtained. A tentative diagnosis of multiple intracranial tuberculoma was made, and anti-tuberculous drugs (isoniazid 400 mg, ethambutol 750 mg, and pyrazinamide 1.5 g) were administered. Since his symptoms deteriorated because of ventricular dilatation resulting from the enlarged lesion in the fourth ventricle after a temporary clinical improvement, VP-shunting and OBB from the left temporal lobe lesion were done. The excised lesion was firmly encapsulated and the histological examination revealed typical pathology of tuberculoma. Ziehl-Neelsen staining and PCR for Mycobacterium tuberculosis of the biopsied specimen were also positive. Further administration of increased doses of anti-tuberculous drugs (isoniazid 600 mg, ethambutol 500 mg, pyrazinamide 2.0 g and intramuscular injection of streptomycin 0.3 g twice a week) eventually ameliorated the symptoms and shrank the lesions. In case of intracranial tuberculoma, the needle of CT-SBB may not penetrate the firm capsule of tuberculoma and only the surrounding brain tissue may be obtained as in the present case. Therefore, it is recommended to consider OBB from the beginning for definitive diagnosis of intracranial tuberculoma. Paradoxical worsening of the clinical and laboratory findings of tuberculosis in spite of appropriate anti-tuberculous therapy as seen in the present case has been described in both pulmonary and extra-pulmonary tuberculosis. The phenomenon, called transient worsening, could happen and we have to keep it in mind during the treatment of intracerebral tuberculoma.     

The radiodensity of medications seen on x-ray films

A 44-year-old Japanese man was diagnosed as having late adult-onset dentatorubral-pallidoluysian atrophy (DRPLA), whose CAG repeats in the DRPLA gene were 60 and 15. He developed gait disturbance, limb ataxia, pyramidal tract signs, dementia, and psychiatric symptoms including character changes within a few years of the above diagnosis. His T 2-weighted brain MRI showed symmetric high-signal lesions in the cerebral white matter and brain stem, in addition to cerebellar, brain stem, and cerebral cortical atrophy. Since the results of RI cisternography indicated that he manifested the clinical features of normal pressure hydrocephalus (NPH), V-P shunt operation was done. In a week after the operation, his gait disturbance, pyramidal tract signs, dementia and psychiatric symptoms were remarkably improved. White matter lesions have been thought to be concomitant with late adult-onset DRPLA patients, but some of these patients may have characteristics of NPH pathophysiology.     

Chronic hypouricemia by dysfunction of the renal tubule. Observation in a case

A case of hypertensive intracerebellar hematoma surgically treated and cured was reported. The 41-year-old male had two cerebrovascular attacks with headache and vomiting followed by left hemiparesis. Drowsiness and dysarthria appeared the next day. The patient was admitted to a hospital, where right facial palsy, loss of right gag reflex and paralytic hemiplegia on the left side were noted. On the 7th day, the patient's consciousness became clear byt the other neurological evidences did not change. On the 14th day, bradycardia and central hyperventilation appeared and he became drowsy again. The patient was transferred to the authors' clinic. When the patient was admitted, he showed typical cerebellar signs such as nystagmus, ataxia, and slurring speech with pyramidal sign on left side and cranial nerves paralysis on right side, and also showed the changes of vital signs as a medullary syndrome in the late stage of the course. The vertebral angiogram revealed a space taking process in the right cerebellar hemisphere. The old blood (30g) was removed by suboccipital craniectomy. The hematoma cavity had a communication with the IVth ventricle through a small perforation in the medial wall of the hematoma. Spontaneour intracerebellar hematoma including of hypertensive origin is not rare in the reports of autopsy but surgically treated case has only rarely been reported. The main reason of few survivals should be in its fulminate course.     

Case report of miliary TB, with mediastinal TB involving the aorta, trachea and esophagus with death due to hemorrhage from perforation of aorta into the esophagus during treatment

A 32-year-old male was diagnosed as having miliary tuberculosis in May 1990. In spite of antituberculosis chemotherapy, he developed tuberculous meningitis and intracranial tuberculoma in September 1990. Miliary shadows on chest X-ray disappeared in December 1990. However, he developed left atelectasis, and bronchofiberscopy revealed soft tumor in the left main bronchus in January 1991. He suddenly vomited large amounts of blood and expired in February 1991. At autopsy, tuberculous lymphadenitis and cavitation were noted in the mediastinum, through which the left main bronchus, esophagus and descending aorta communicated. The patient died of massive bleeding which resulted from the rupture of tuberculous aortitis into the esophagus. This is a very rare case of tuberculous aortic aneurysm rupturing into both the bronchus and esophagus.     

A case of early-onset cortical cerebellar atrophy with rhythmic skeletal myoclonus in the left upper limb

A 19-year-old man developed progressive unsteady gait and speech disturbance two years ago. He recently noticed muscle twitches in the left limb. Neurological examination revealed scanning speech, saccadic ocular movement, ataxia of trunk and limbs predominant on the left side. Rhythmic myoclonus was present at rest around the left shoulder and arm, and amplified by raising the left arm. There was no myoclonus in the soft palate. MRI revealed only a cerebellar atrophy. This patient was diagnosed as having cortical cerebellar atrophy with rhythmic skeletal myoclonus (RSM). Tc-99m ECD SPECT showed a decrease in the blood flow of the right thalamus when the myoclonus was enhanced by raising the left upper limb, which suggests that the cerebello-thalamo-cortical system as well as Guillain-McIlaret triangle is involved in the development of RSM.     

Transfixion of cervical cord by a glass fragment--report of a case (author's transl)

Stab wound of the spinal cord caused by accident occurred in the home life is rare absolutely. One case of stab wound of the cervical spinal cord caused by penetrated and retained glass fragment within the spinal canal was reported. A 30-year-old woman was hospitarized on August 16, 1971. with complaint of left hemiparesis, gait disturbance and sensory impairment on the right side. A glass door fell down on the patient's neck on April 14, 1971. and one glass fragment was removed from the patient's left neck by one of the patient's family and no immediate spinal cord symptom appeared and no physician was consulted at that time. One and a half month after the injury the patient rod a motor bicycle and pain and severe stiffness in the shoulder and neck, and headache. These subjective symptom disappeared by rest and same subjective symptom repeated in following five days. Three and a half months after the injury the patient found sensation loss in the right foot and gait distrubance appeared. After the sensory impairment extended to the cervical level which was accompanied by left hemiparesis. On examination, the patient was found to have merked weakness of left limbs, spastic gait and severe impairment of touchpain- and thermosensation below the fifth cervical level but deep sensation was preserved. All tendon reflexes showed marked exaggeration and pathological reflexes were proved. Roentgenograms of the cervical spine revealed a long triangular glass fragment which had been retained in the spinal canal between the first and second cervical vertebrae. The air myelogram suggested the glass fragment had transfixed the cervical spinal cord. Laminectomy was performed and the glass fragment which had a shape of a sharp pointed surgical knife was removed by gentle move in the opposite direction of invation. Following removal of the foreign body, the patient's left hemiparesis recovered to normal state at four months after the operation and right sensory impairment also improved. The cervical spinal cord may be injured in the following way: the right lateral spinothalamic tract may be injured by the skewer injury due to glass fragment but injury of the left same tract may be avoided because of oblique direction of penetration of the glass fragment in the spinal cord. On the other hand, the left pyramidal tract may be compressed by glass fragment and not injured, because left hemiparesis recovered very well postoperatively.     

A 61-year-old man with progressive gait disturbance, freezing, and vertical gaze paresis who developed esophagus cancer

We report a 61-year-old Japanese man who died of complications of esophagus cancer surgery. He was well until his 55 years of the age, when he had an onset of speech disturbance and hand writing. He was seen by a neurologist who prescribed Menesit 600 mg/day. His symptoms improved with this medication. In 1993, three years after the onset, he started to show gait disturbance and easy to fall. In 1995, he noted difficulty in eye opening. He visited our clinic on October 26, 1996. On examination, he showed vertical gaze paresis, masked face, nuchal rigidity, small step gait, freezing phenomena, and festination. His mental status was normal. He was treated with 800 mg/day of Menesit, 800 mg/day of L-dops, and 10 mg/day of bromocriptine with little improvement in his symptoms. Cranial CT scan revealed some dilatation of the third ventricle. Subsequent clinical course was one of the slow progression of his parkinsonism. In September of 1997, he noted difficulty in swallowing. He was admitted to the gastrointestinal service of our hospital on October 14, 1997. On admission, neurologic status was essentially similar to the previous one, but he showed more advanced state of his parkinsonism. Upper gastrointestinal series revealed a mass lesion of about 11.5 cm in length protruding into the lower esophagus lumen. Subtotal esophagus resection including the mass was performed on December 2, 1997. The stomach was elevated for anastomosis with the upper esophagus. No metastases were found in the mediastinum except for two lymph nodes in the para-esophageal region. The subsequent course was complicated by marked elevation of GOT, GPT, LDH, total bilirubin as well as direct bilirubin, alkaliphosphatase, and amylase starting in the evening of the surgery. On December 7, leukocytosis and pneumonic shadow were seen involving his right lung. On December 10, he developed cardiopulmonary arrest. He was once resuscitated; however, he developed cardiac arrest again seven hours later and pronounced dead. He was discussed in a neurologic CPC. The chief discussant arrived at the conclusion that the patient had PSP and the cause of the death was ascribed to circulatory disturbance to the liver. The discussant also thought that the terminal course was complicated by cholangitis or cholecystitis, sepsis, and pulmonary embolism. Surgical specimen of the esophagus tumor revealed carcinosarcoma. Postmortem examination revealed yellowish discoloration of the peritoneum and mesenterium, and accumulation of clouded ascites indicating the presence of peritonitis. Inflammatory change extended to the mediastinum. On microscopic examination, various kinds of bacilli and candida spores were seen. The liver was enlarged and a perforation was noted in the gallbladder causing biliary necrosis in the adjacent liver. An extensive infarct was seen in the left lobe of the liver; this was found to be due to obstruction of the hepatic artery at the site of the duodenohepatic mesenterium and obstruction of intrahepatic portal vein secondary to retrograde intrahepatic cholangitis in the left lobe. A piece of surgical threads was seen adjacent to the hepatic artery; foreign body granulomatous reaction was seen surrounding the surgical thread. The rupture of the gallbladder appeared to be due to the obstruction of the left branch of the hepatic artery. Neuropathologic examination revealed extensive degeneration of the pallidum, the substantia nigra, and the subthalamic nucleus and presence of neurofibrillary tangles in the remaining neurons. The neuropathologic findings were consistent with progressive supranuclear palsy, although the pathologic changes in the midbrain tegmentum was only mild gliosis.     

A case of the brainstem tactile hallucinosis due to pontine hemorrhage

A 53-year-old man with hypertension was admitted to our hospital, for somnolence, horizontal gaze palsy, right hemiparesis and right sensory disturbance. Brain CT scan revealed a high density area from the left lower pontine tegmentum to the left tegmentum of the lower midbrain. As he became alert, he reported visual hallucination. Two weeks after onset of stroke, he complained tactile hallucination on his right half body with sensory disturbance. After disappearance of the visual hallucination, the tactile hallucination had been persisted. This is the first report of peduncular hallucinosis with long-persisted tactile hallucination due to brainstem bleeding. Tactile hallucination was suggested to be associated with sensory disturbance and extensive destruction of the brain stem tegmentum.     

Tuberculous meningitis: a clinical and laboratory study of 20 patients in Qatar

Twenty cases of tuberculous meningitis were diagnosed at the Hamad Medical Corporation between 1990 and 1995. Most of the patients (90%) were expatriates. The most common presenting features were fever, headache, neck stiffness and altered mental status. Five patients were in stage 1 disease at the time of presentation, 11 in stage 2, and four in stage 3. Examination of cerebrospinal fluid showed at least one abnormal finding in all patients, and culture grew Mycobacterium tuberculosis in 50%. A positive tuberculin skin test in 50% of patients, abnormal chest X-ray in 35%, abnormal CT scan or MRI showing tuberculoma or hydrocephalus in 55%, and positive sputum culture for M. tuberculosis in 15% helped establish the diagnosis. All the patients were treated with antituberculous drugs and steroids. Seventeen (85%) survived, three with severe neurological sequelae; three (15%) died. Poor outcome was associated with advanced stage of disease at presentation and high CSF protein. Tuberculous meningitis continues to be an important disease in Qatar, especially in expatriates, and should be considered in the differential diagnosis in any patient presenting with fever and change in sensorium.     

Extrapulmonary tuberculosis. An unusual case

Skeletal tuberculosis with extravertebral location is rare. We report a case of tuberculous osteomyelitis simultaneously affecting two right ribs and the left ulna. We emphasize the diagnostic problems (failure or delay in diagnosis) in extrapulmonary tuberculosis interesting uncommon sites and having relatively indolent presenting symptoms.     

Flap of the musculus latissimus dorsi to prevent alveolar air leakage from sectional plane of the lung after resection of metastatic pulmonary and chest wall tumor

Alveolar air leakage after pulmonary resection usually heals with adequate pleural drainage, but must be more actively treated if leakage may be severe. If left untreated, the postresection space can lead to empyema. We used a muscle flap to prevent alveolar air leakage from a large sectional plane of the lung resected because of metastases in the lung and chest wall. A 48-year-old man complained of pain and a mass on the right side of his back. He had undergone resection and chemotherapy for clear cell sarcoma that originated on the back of the left hand when 43 years of age, wedge resection of the right lower lobe of the lung for a metastatic pulmonary tumor at 46 years, and lobectomy of the same lobe for a recurrence of the metastatic pulmonary tumor at 47 years. The diagnosis was of a metastatic tumor to the right chest wall with peripheral pulmonary tumors of the right upper and middle lobes. Resection of the chest wall and the lung including the tumors was done. Much air leakage from the extensive sectional plane of the right upper and middle lobes was seen intraoperatively, and this plane was therefore covered with a flap of the musculus latissimus dorsi. Chest tubes were removed on day 7 postoperatively when air leakage was no longer seen. Subcutaneous emphysema, which appeared on day 14 postoperatively, required redrainage of the pleural air space, but pleurodesis was effective. Use of a muscle flap was simple and effective for covering of a sectional plane of the lung, and should be considered when alveolar air leakage may be extensive.     

Tumor necrosis factor-alpha, interleukin-6, and interleukin-8 secretion and the acute-phase response in patients with bacterial and tuberculous osteomyelitis

Osteomyelitis, or bone infection, is a major worldwide cause of morbidity. Treatment is frequently unsatisfactory, yet little is known about pathogenesis of infection. Plasma tumor necrosis factor (TNF), interleukin (IL)-6, and IL-8 concentrations were measured before and after lipopolysaccharide stimulation of whole blood from patients with bacterial and tuberculous osteomyelitis and from controls. Patients with bacterial and tuberculous osteomyelitis mounted an acute-phase response and were anemic and febrile. However, plasma IL-6 concentrations were significantly elevated in only tuberculous osteomyelitis patients (vs. controls, P < .05). IL-6 concentrations correlated with erythrocyte sedimentation rate, C-reactive protein level, and plasma albumin concentration, all acute-phase markers. There were no other correlations between cytokine concentrations and clinical data. Following ex vivo stimulation, TNF, IL-6, and IL-8 were secreted equally by patients and controls. In summary, tuberculous osteomyelitis is characterized by elevated systemic IL-6 concentrations associated with an acute-phase response. For further insight into immunopathology of osteomyelitis, studies on infected bone are required.     

Metastatic renal tumor of malignant salignant salivary-gland-like tumor of the lung: A case report

A 17-year-old woman was admitted to our hospital for the investigation of asymptomatic gross hematuria. Twenty nine months ago, she had received the right lower lobectomy because of the malignant salivary gland type mixed tumor of the bronchus. The intravenous pyelography and the right retrograde pyelography showed the irregular wall of the right renal pelvis. The computerized tomography showed a hypodense tumor which occupied the lower half of the right kidney. Cystoscopy showed bleeding from the right ureteral orifice. Chest X-ray revealed multiple lung metastases at the first examination, but right nephrectomy was performed because gross hematuria continued. The tumor thrombus, which spreaded into vena cava, was removed. The pathological diagnosis was the metastatic renal tumor of malignant salivary gland type mixed tumor. The patient died 102 days postoperatively.     

Primary pulmonary hemangiopericytoma: a case report

Primary pulmonary hemangiopericytoma is a very rare tumor. A case of the disease is reported, together with a review of the literature. The patient was a 78-year-old male, who was admitted to hospital with an abnormal shadow on his chest x-ray. A primary tumor, located in the left S4, was resected, and a final diagnosis of hemangiopericytoma of pulmonary origin was made. The disease recurred in the left lower lobe 14 months postoperatively. The patient received radiotherapy and is alive to date, 23 months after the operation.     

Thoracic arachnoid cyst presenting incomplete features of Brown-Séquard syndrome: a case report

Spinal intradural arachnoid cyst presenting incomplete features of Brown-Séquard syndrome is very rare. Only 6 cases have been reported. We report one in a thoracic lesion. A 42-year-old man noticed thermohypesthesia in his right leg, and monoparesis in his left leg. On admission, he presented incomplete features of Brown-Séquard syndrome below the Th7 level. MRI showed the spinal cord to be displaced antero-laterally to the right at Th6-7 level. Myelography and CT myelography failed to show the cyst wall, but an arachnoid cyst was totally removed with T5-8 osteoplastic laminotomy. Sensory disturbance has not changed postoperatively, but motor weakness in his left leg recovered within one month after the operation. No cystic lesion has been detected by MRI during the ten months since the operation. We investigated all seven cases in the literature including our case which showed incomplete features of Brown-Séquard syndrome. As regards to the location of the cyst, all cases were at the mid-thoracic level. And four cases were at the midline. These results suggest that the mechanism of Brown-Séquard syndrome associated with spinal arachnoid cyst may be related not only to the laterality of the lesion but also to the asymmetrical circulation in the watershed area.     

Entamoeba histolytica: computer-assisted modeling of phosphofructokinase for the prediction of broad-spectrum antiparasitic agents

Approximately 34 cases of intracranial tuberculomas with paradoxical response to antituberculous chemotherapy have been documented worldwide. In most of the previously reported cases of this entity an associated tuberculous meningitis has been reported. The majority of these patients were children or young adults, who had inoperably located intracranial tuberculomas in high risk regions developing a few weeks or months after the start of appropriate chemotherapy. 53% of them recovered completely, 37% improved with mild neurological deficits and 10% died. It is interesting that these intracranial tuberculomas developed or enlarged at a stage when systemic tuberculosis was being treated successfully. We report our recent experience with these potentially curable tumours of the central nervous system. The literature is reviewed and diagnostic and therapeutic considerations are discussed. The possible immunological mechanisms of this phenomenon are analysed. In conclusion, patients, who are suspected to be suffering from CNS-tuberculosis should receive a prolonged (12-30 months) course of effective antituberculous therapy. Evidence of new intracranial tuberculomas or the expansion of older existing lesions require no change in the antituberculous drug programme. In such cases systemic dexamethasone as adjuvant therapy for 4 to 8 weeks is worthwhile and effective. Surgical intervention may be necessary in situations with acute complications of CNS tuberculosis such as shunting procedures for the treatment of hydrocephalus. When the diagnosis is not firm and there is no response to therapy within 8 weeks, a stereotactic biopsy of a suspected tuberculoma should be performed. If the largest lesion is not located in high risk deep regions of the brain, it should be total removed surgically. With this combined management, a satisfactory outcome can be obtained in the majority of cases.     

Miliary tuberculosis associated with subcutaneous tuberculous abscess

A 62-year-old woman was admitted because of a tumor on her right thigh, fever, generalized lymphadenopathy, and diffuse nodular shadows on chest X-ray films. She was given a diagnosis of miliary tuberculosis based on the findings of a cervical lymph-node biopsy and a broncho-alveolar lavage. Acute respiratory failure and disseminated intravascular coagulation developed, but resolved after the start of anti-tuberculous therapy. The tumor on the right thigh was diagnosed as a subcutaneous tuberculous abscess because tuberculous bacilli were detected in tumor tissue samples obtained by aspiration. The patient's fever disappeared and the abnormal shadows on her chest X-ray films receded significantly after drainage of the subcutaneous abscess. These findings suggested that miliary tuberculosis was associated with the subcutaneous tuberculous abscess in this case.     

A case of tectal glioma

A case of tectal glioma with mild choked disc is reported. An 11-year-old boy was admitted to our hospital because of visual disturbance and choked disc. Neurologically, the patient had nothing but choked disc. Magnetic resonance imaging (1.5T) was performed. Relative T1 weighted image showed a lesion of low signal intensity, and T2 weighted image showed high intensity, about 1.0 x 1.0 cm in size, at the pineal region. The sagittal view showed a mass at the tectum, and stenosis of the aqueduct. It was diagnosed as tectal glioma. Left occipital craniotomy was performed and the tumor was removed subtotally. Histological examination demonstrated a fibrillary astrocytoma. Radiochemotherapy was performed postoperatively. Tectal glioma is very rare. The differential diagnosis from germ cell tumor or pineal cyst is essential for treatment. The authors performed an operation in order to remove the tumor and determine the course of treatment.     

Vertebral artery injury following mild neck trauma: report of two cases

Two cases of vertebral artery injury following mild neck trauma are reported. A 52-year-old man was hospitalized with gait disturbance 7 days after mild traffic accident. Right vertebral angiogram revealed complete occlusion of the rt. vertebral artery (VA) and MR images revealed infarction in the rt. cerebellar hemisphere and rt. dorsolateral part of the medulla oblongata and revealed the thrombus in the rt. VA. He underwent anticoagulation and became asymptomatic. Angiogram 6 months later revealed the vessel to be normal. A 23-year-old man who has a habit of self-manipulation of his neck was hospitalized on the day when he experienced dysesthesia in the left part of his face and left upper and lower extremities and unsteady gait. MR images revealed multiple infarction in bilateral cerebellar hemispheres and thrombus in bilateral VAs. Bilateral vertebral angiogram revealed severe stenoses of bilateral VAs. He underwent anticoagulation and wore soft collar. Angiogram 20 days after onset revealed improvement of bilateral VA stenoses. He was discharged with no neurological deficit. It is said that vertebral artery injuries in association with head and neck trauma are relatively rare, but this condition is possible to be more common than realized, considering that the case of unilateral VA occlusion or the case with well developed collateral circulation is sometimes well tolerated for ischemia and that this condition can occur even after mild head and neck injury. The diagnosis must be established by vertebral angiogram, but MRI and MRA are very useful as ancillary methods. The therapeutic point is to prevent propagation of the thrombus and distal embolism, accordingly wearing a collar and anticoagulation are important.