Brain-stem abscess successfully treated by microsurgical drainage: A case report

Abstract

Brain-stem abscess is an uncommon condition associated with high mortality. The best method of treatment is not yet defined. It can be managed by medical treatment alone, stereotactic aspiration of the pus and medical treatment, or surgical excision/drainage of the abscess. We present a case of large brain-stem abscess, treated successfully by surgical drainage after the failure of medical treatment. The patient had a large brain-stem abscess extending from the mid-brain down to the lower pons. She was in a poor neurological condition pre-operatively, and was worsening despite intravenous antibiotics. The abscess was coming close to the surface in the lateral aspect of the mid-brain. The presumed source of infection was multiple dental abscesses. The brain-stem abscess was approached by a subtemporal transzygomatic approach and drained completely after making an incision on the lateral surface of the mid-brain. After the operation, the patient showed steady improvement. At six months after the surgery, the patient was fully conscious, talking fluently, and walking with the help of a walker. Her hemiparesis and co-ordination were improving. Surgical drainage of a brain-stem abscess is indicated when medical therapy fails. Proper anatomical knowledge of the brain-stem and the selection of appropriate surgical approach is important for safe drainage of the abscess. [Neurol Res 2001; 23: 855-861]     

Cotard's syndrome with schizophreniform disorder can be successfully treated with electroconvulsive therapy: case report

We report a case of Cotard's syndrome associated with psychotic symptoms. A 27-year-old man was admitted to hospital with the diagnosis of schizophreniform disorder. His presenting symptoms, which had started 1 month before hospital admission, were somatic delusions of gastrointestinal and cardiovascular malfunction and the absence of a stomach, which resulted in a decrease in weight from 75 kg to 63 kg in 1 month. Cranial computed tomographic images showed dilatation of the lateral and third ventricles, whereas magnetic resonance imaging revealed central atrophy and lateral ventricle dilatation. Single- photon emission computed tomography demonstrated left temporal, left frontal and left parietal hypoperfusion. The patient did not respond to antipsychotic therapies, but he was successfully treated with electroconvulsive therapy. This report emphasizes that Cotard's syndrome may be accompanied by lesions of the left hemisphere and that electroconvulsive therapy could be the first-line therapy in such patients with psychotic disorder.     

Brain-stem abscess successfully treated by microsurgical drainage: a case report.

Brain-stem abscess is an uncommon condition associated with high mortality. The best method of treatment is not yet defined. It can be managed by medical treatment alone, stereotactic aspiration of the pus and medical treatment, or surgical excision/drainage of the abscess. We present a case of large brain-stem abscess, treated successfully by surgical drainage after the failure of medical treatment. The patient had a large brain-stem abscess extending from the mid-brain down to the lower pons. She was in a poor neurological condition pre-operatively, and was worsening despite intravenous antibiotics. The abscess was coming close to the surface in the lateral aspect of the mid-brain. The presumed source of infection was multiple dental abscesses. The brain-stem abscess was approached by a subtemporal transzygomatic approach and drained completely after making an incision on the lateral surface of the mid-brain. After the operation, the patient showed steady improvement. At six months after the surgery, the patient was fully conscious, talking fluently, and walking with the help of a walker. Her hemiparesis and co-ordination were improving. Surgical drainage of a brain-stem abscess is indicated when medical therapy fails. Proper anatomical knowledge of the brain-stem and the selection of appropriate surgical approach is important for safe drainage of the abscess.     

Prolonged catatonic stupor successfully treated with aripiprazole in an adolescent male with schizophrenia: a case report

We present the case of a fifteen-year-old adolescent male with schizophrenia who had long-term catatonic stupor and was successfully treated with aripiprazole. The onset of his stupor manifested rapidly after experiencing prodromal symptoms for two months. He was left untreated without adequate food ingestion for three weeks because of his parents' religious faith, and was severely dehydrated and malnourished upon admission to our hospital. After his physical recovery, treatment with risperidone (0.5-2.0 mg, 5 weeks) was started. However, hypersedation occurred, and the risperidone was switched to aripiprazole, with dose increases up to 18 mg/day (5 months). As a result, he recovered from his totally noncommunicative state. Aripiprazole, which has a unique pharmacological mechanism of action distinct from other atypical antipsychotics and an excellent safety profile, may be effective in the treatment of some schizophrenic patients with stupor, which sometimes carries a risk of physical debilitation and requires special attention due to the risk of adverse drug reactions.     

Lymphocytic hypophysitis: an underestimated disease affecting the sellar region

Hypophysitis is an inflammation of the pituitary gland and includes a heterogeneous group of diseases presenting with impaired pituitary gland function. Hundreds of cases have been reported after Goudie and Pinkerton's initial report on a young postpartum woman who died after progressive lymphocytic infiltration of the adenohypophysis in 1962. A 17-year-old woman presented with a three-year history of headache, galactorrhoea and excessive weight gain. The patient had used oral contraceptives for several years until one year previously. Her examination demonstrated only bilateral heteronymous hemianopsia. Laboratory investigation revealed elevated prolactin and decreased gonadotropin levels. Magnetic resonance imaging showed a sellar mass with suprasellar extension. Surgical removal of the lesion was performed via a transsphenoidal approach. A diagnosis of lymphocytic hypophysitis was confirmed by histopathological evaluation. Hypophysitis is an underestimated disease affecting the pituitary gland. Cases are usually diagnosed as adenomas and treated with surgical removal. This case is presented due to the extremely rare infiltration of the pituitary gland by predominantly lymphocytes.     

Chronic 'speech catatonia' with constant logorrhea, verbigeration and echolalia successfully treated with lorazepam: a case report

Logorrhea, verbigeration and echolalia persisted unremittingly for 3 years, with occasional short periods of motoric excitement, in a patient with mild intellectual handicap suffering from chronic schizophrenia. The speech catatonic symptoms, previously refractory to various antipsychotics, responded promptly to lorazepam, a benzodiazepine with documented efficacy in the treatment of acute catatonia but not chronic catatonia. It is suggested that pathways in speech production were selectively involved in the genesis of the chronic speech catatonic syndrome, possibly a rare form of chronic catatonia not previously described.     

Sarcoidosis with hydrocephalus: report of a case successfully treated with a ventriculo-peritoneal shunt and methylprednisolone pulse therapy

We describe a female patient with systemic sarcoidosis and hydrocephalus. She was initially satisfyingly treated with peroral steroids. When she later deteriorated, the treatment had to be changed due to side-effects. High dose intravenous methylprednisolone pulse therapy was tried with some, but insufficient, improvement. Therefore, a ventriculoperitoneal shunt operation was performed with immediate improvement. After that she was treated with intravenous methylprednisolone and her condition has remained proper and stable for 5 years. The possibility that pulse therapy might have contributed to the favourable course in our patient is discussed.     

阿立哌唑成功治疗抽动秽语综合征1例报告(英文)

概述:抽动-秽语综合征(Tourette syndrome,TS)是一种儿童期发病的神经精神障碍,特征是多发性运动抽动和发声抽动,病程至少1年。本病例报告描述了一位16岁男孩患有抽动-秽语综合征6年,症状已使其功能严重受损。阿立哌唑10 mg/d治疗一个月左右后,该患者的症状完全消失,恢复了病前的生活。在这种情况下,需要权衡长期使用抗精神病药物潜在的不良反应与持续的抽动秽语症状对患者生活造成的破坏性影响。     

Lymphocytic hypophysitis in children: a novel presentation and literature review

Lymphocytic hypophysitis, an autoimmune mediated chronic inflammation of the pituitary gland, is uncommon in children.(1) The usual presentation is with symptoms secondary to pressure from the enlargement of the gland itself and or impairment of pituitary hormones of varying degrees, in conjunction with a sellar mass.( 2,3) In 80% of cases, partial or panhypopituitarism is present with approximately 75% of cases having multiple hormonal deficiencies.(2) We report the case of a prepubertal female who presented with cyclical vomiting, as her initial symptom of lymphocytic hypophysitis which resolved promptly after pituitary biopsy. This case suggests that cyclical vomiting can be a symptom associated with lymphocytic hypophysitis. Therefore, it should be considered in the differential diagnosis of any child presenting with cyclical vomiting.     

A case of myokymia-cramp syndrome successfully treated with gabapentin

We report a case of "myokymia-cramp syndrome", a rare and benign disease consisting of muscular cramps in the upper and lower limbs associated with generalized myokymias. In our patient, cramps had been present since adolescence and had increased in frequency and duration during the last 3 years, occurring about 8 or 9 times a day. Cramps were mainly nocturnal and also precipitated by walking; a previous treatment with carbamazepine did not improve the symptoms. Gabapentin therapy proved to be very satisfactory in relieving muscular cramps with a relatively low dosage (600 mg/day) and without any remarkable side effects. The possible interpretation of the mechanism involved in gabapentin induced relief of cramps is discussed. Gabapentin should be considered as a safe alternative treatment for muscular cramps.     

Refractory anti-NMDAR encephalitis successfully treated with bortezomib and associated movements disorders controlled with tramadol: a case report with literature review

Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a potentially fatal autoimmune disease, characterized by autoantibody-mediated neurotransmission impairment in multiple brain locations. The course of this condition often comprises altered mental status, autonomic dysfunctions, refractory seizures and hyperkinetic movement disorders. Available disease-modifying therapies include corticosteroids, i.v. immunoglobulins, plasma exchange, rituximab and cyclophosphamide. In a subgroup of patients not responding to B-cell depletion, bortezomib, a proteasome inhibitor, has shown promising evidence of efficacy. The time course of recovery from acute phase may be very slow (weeks/months), and only few data are available in literature about the concurrent management of encephalitis-associated movement disorders. We report a case of severe anti-NMDAR encephalitis in a 29-year-old woman, not responsive to first- and second-line treatments, with persistent involuntary motor manifestations. Starting three months after symptom onset, four cycles of bortezomib have been administered; subsequently we observed a progressive improvement of neurological status. Meanwhile, motor manifestations were controlled after the administration of tramadol, a non-competitive NMDA receptor antagonist.

     

A case of acute thallotoxicosis successfully treated with double-filtration plasmapheresis

The authors report a 48-year-old Chinese woman who presented with acute peripheral neuritis with progressive alopecia. Laboratory examinations disclosed a high blood concentration of thallium (97 microg/L) versus a normal value (0.9 microg/L), and she was diagnosed as having acute thallotoxicosis. After her hospitalization, the cutantest of dimercaptopropansulfonate sodium was positive and the patient refused to take Prussian blue because it caused constipation. She rapidly entered remission after assistance via double-filtration plasmapheresis (DFPP), suggesting the potential efficacy of DFPP for thallotoxicosis.