Giant vertebro-basilar aneurysm. Frontal syndrome]

A 72-year-old man presented with an apparent frontal syndrome. He also had bilateral trigeminal neuralgia, a pyramidal syndrome of all 4 limbs, balance disturbances, a horizontal nystagmus when looking to the left and a right velopalatine paralysis. CT scan with contrast showed a hyperdense rounded lesion in the left cerebello-pontine angle. Cerebral angiography showed this to be a large aneurysm of the end of the vertebral arteries. The patient died suddenly. Autopsy confirmed the site and presence of the aneurysm. Balance disturbances, the pyramidal syndrome and velopalatine paralysis could all be explained by brain stem compression and the bilateral nature of the trigeminal neuralgia by compression of the trigemino-thalamic tract. The apparent frontal syndrome, the authors suggest could have resulted from subacute raised intracranial pressure.     

A comparision of brain biopsy and CSF-PCR in the diagnosis of CNS lesions in AIDS patients

Twenty patients with AIDS who had intracranial lesions underwent both brain biopsy and cerebro-spinal fluid (CSF) examination to compare histological diagnosis with the polymerase chain reaction (CSF-PCR) for the identification of infectious agents. CSF-PCR was performed for herpes simplex virus, varicella zoster virus, cytomegalovirus (CMV), JC virus (JCV), Epstein-Barr virus (EBV), Toxoplasma gondii and Mycobacterium tuberculosis. A definitive diagnosis was obtained by brain biopsy in 14 patients (2 with astrocytoma, 12 with brain infection). CSF-PCR was positive for EBV DNA in 3 of 3 cases of primary cerebral lymphoma, positive for JCV DNA in 6 of 7 biopsy-proven (and one autopsy-proven) cases of progressive multifocal leukoencephalopathy (PML). CSF-PCR was positive for CMV DNA in one biopsy-proven and one autopsy-proven case of CMV encephalitis (the former also had PML) and positive for M. tuberculosis DNA in one case of tuberculous encephalitis. None of the five toxoplasmic encephalitis cases (one definite, four presumptive) were T. gondii DNA positive. There was close correlation between histology and CSF-PCR for CMV encephalitis, PML and PCL. Antitoxoplasma therapy affected the sensitivity of both histological and CSF-PCR methods. Received: 8 November 1995 Received in revised form: 9 July 1996 Accepted: 19 July 1996     

First-year results of a community-based study of stroke incidence in Umbria, Italy

The SEPIVAC study (Italian initials for "epidemiologic study of incidence of acute cerebrovascular disease") is a community-based epidemiologic survey of incidence and outcome of cerebrovascular disease in the territory of the 6th Local Health Unit, Umbria, Italy, where 49,101 people live. All cases were registered with the study either by notification from general practitioners or by check of hospital admission within the study area and in the two hospitals of Perugia. Death certificates were looked at as well. Patients were registered with the study when the clinical picture fulfilled the definition of stroke and transient ischemic attack (TIA) adopted for this study. Patients were followed up at approximately 30 days and 6 months. During the first year of the study (September 1, 1986 to August 31, 1987), 189 cases were registered: 108 suffered a "first ever in a lifetime" stroke, 30 a recurrent stroke, and 51 a "first ever in a lifetime" transient ischemic attack. Sixty-one percent of patients (71% of first strokes) had a computed tomography scan. For our study, the crude annual incidence rate of first stroke was 2.2 per 1,000 (confidence intervals 1.81-2.66); the standardized rate to the European population was 1.36 (confidence intervals 1.06-1.74). At least 83% of first strokes were due to cerebral ischemia; in 26 cases a clinical diagnosis of lacunar ischemia was made. The 30-day case fatality rate was 21%; 25% of our patients had recovered completely or almost completely after 1 month.     

The association of access to medical care with regular source of care and sociodemographic characteristics in patients with HIV and tuberculosis

PURPOSE: To examine satisfaction with access to health care in two populations, one with HIV and one with TB, and examine the effect of having a regular doctor and sociodemographic characteristics. DESIGN: Cross-Sectional survey. PATIENTS: A sample of HIV inpatients hospitalized at seven Los Angeles sites (N = 217) and TB outpatients chosen randomly from the Los Angeles County TB Registry Census (N = 313). ANALYSIS: We performed bivariate and multivariate regression analyses of satisfaction with access to care on gender, race/ethnicity, age, education, income, insurance, and having a regular doctor. MAIN OUTCOME MEASURES: A six-item scale of satisfaction with access to care (range 0-100; Cronbach's alpha 0.87). RESULTS: The mean satisfaction with access score for the HIV sample was significantly lower than the TB sample (53.5 vs. 61.2, p<0.001). The HIV sample multivariate analysis (including all the variables) showed that increasing age (p<0.021 and having a regular doctor (p<0.002) were associated with better access, and that low income (p<0.005) was associated with poor access. In the TB sample analysis, only increasing age was associated with better satisfaction with access to care (p< 0.01). CONCLUSION: HIV patients receiving care in the private sector reported less satisfaction with access to care compared to TB patients receiving care in the public health sector. The traditional factors of socio-economic status and having a regular doctor were associated with satisfaction with access-to-care in the HIV sample but not the TB sample. Our findings suggest that certain characteristics of the TB public health programs may explain these differences and suggests that, perhaps, the existence of a similar public health program for vulnerable low-income populations with HIV would improve their satisfaction with access, as well.     

Pyrosequencing for detection of mutations in the connexin 26 (GJB2) and mitochondrial 12S RNA (MTRNR1) genes associated with hereditary hearing loss

Hereditary hearing loss (HHL) is one of the most common congenital disorders and is highly heterogeneous. Mutations in the connexin 26 (CX26) gene (GJB2) account for about 20% of all cases of childhood deafness, and approach 50% in documented recessive cases of non-syndromic hearing loss. In addition, a single mitochondrial DNA mutation, mt1555A>G, in the 12S rRNA gene (MTRNR1), is associated with familial cases of progressive deafness. Effective screening of populations for HHL necessitates rapid assessment of several of these potential mutation sites. Pyrosequencing links a DNA synthesis protocol for determining sequence to an enzyme cascade that generates light whenever pyrophosphate is released during primer strand elongation. We assessed the ability of Pyrosequencing to detect common mutations causing HHL. Detection of the most common CX26 mutations in individuals of Caucasian (35delG), Ashkenazi (167delT), and Asian (235delC, V37I) descent was confirmed by Pyrosequencing. A total of 41 different mutations in the CX26 gene and the mitochondrial mt1555A>G mutation were confirmed. Genotyping of up to six different adjacent mutations was achieved, including simultaneous detection of 35delG and 167delT. Accurate and reproducible results were achieved taking advantage of assay flexibility and experimental conditions easily optimized for a high degree of standardization and cost-effectiveness. The standardized sample preparation steps, including target amplification by PCR and preparation of single-stranded template combined with automated sequence reaction and automated genotype scoring, positions this approach as a potentially high throughput platform for SNP/mutation genotyping in a clinical laboratory setting. .     

Osteomyelitis caused by Enterobacter cancerogenus infection following a traumatic injury: case report and review of the literature

We report a case of osteomyelitis caused by Enterobacter cancerogenus resistant to aminopenicillins in a 56-year-old male who had a motorcycle accident and suffered from multiple bone fractures with abundant environmental exposure. E. cancerogenus has rarely been associated with human infections, and its clinical significance remains unclear.     

Validation of a pXO2-A PCR assay to explore diversity among Italian isolates of Bacillus anthracis strains closely related to the live, attenuated Carbosap vaccine

Several circulating Bacillus anthracis strains isolated in Italy and belonging to the A1.a cluster, genotype 3 (A1.a-3) are genotypically indistinguishable from Carbosap, a live attenuated vaccine strain, containing both pXO1 and pXO2 plasmids. The genotype was assessed by using eight-locus multilocus variable-number tandem repeat analysis. We describe here the use of a ninth locus able to explore variability among strains that have the same genotype. It is important to be able to genotype the wild isolate of B. anthracis strains from outbreaks of anthrax in areas where Carbosap vaccination of cattle and sheep is common practice. A total of 27 representative field strains isolated in Italy and four vaccinal strains, namely, Carbosap, Sterne, Pasteur I, and Pasteur II, were characterized by a ninth marker, called pXO2-A. Twenty-three field strains were genotype 3 and therefore identical to Carbosap. The marker was in the pXO2 plasmid and is based on the polymorphism of the already-known VX2-3 locus. Detection was obtained by PCR with fluorescence-labeled forward primers in order to produce appropriate fragments for capillary electrophoresis with an ABI 310 genetic analyzer. Genetic relationships showed heterogeneity in all of the examined samples. Interestingly, with respect to genotype 3, samples grouped into eight different subtypes, A to H, and the subtype G, had only two samples indistinguishable from Carbosap. The results of the present study confirm the validity of a hierarchical progressive protocol for discrimination among closely related isolates.