Multifocal skeletal tuberculosis: Experience in diagnosis and treatment

Objectives

Multifocal skeletal tuberculosis (MSTB) is an uncommon presentation of skeletal tuberculosis. In order to provide more clinically meaningful information on the diagnosis and management of MSTB, we present a case of MSTB with multiple tuberculous lesions in multiple locations, along with a review of 13 MSTB cases from different studies.

Patients and methods

A 29-year-old male patient with a one-year history of back pain was initially diagnosed with ankylosing spondylitis and arthritis deformans, and received treatment with oral glucocorticosteroid and leflunomide for 24 weeks. The back pain worsened with weight loss and fever one month prior to admission to our hospital. The diagnosis, MSTB, with 26 tuberculous lesions in 19 locations, was made by clinical findings, bone scan (computed topography and Tc-99m HDP scintigraphy), and bone marrow smear.

Result

Multiple antituberculous drugs, with supportive and immune-enhancing therapies cured the patient.

Conclusions

This case indicates that MSTB may develop in patients on long-term immunosuppressive drugs. In addition, our experience, along with previously reported data, suggest that strong clinical suspicion is required for an early diagnosis of MSTB, and chemotherapy, combined with supportive and immune-based therapies is effective for the treatment of MSTB.     

Determination and occurrence of retinoic acids and their 4-oxo metabolites in Liaodong Bay, China, and its adjacent rivers

Retinoic acids (RAs) and their metabolites play an important role in abnormal morphological development and are speculated to be a possible cause for the increased rates of deformities in wild frog populations. In the current study, a method using ultra-performance liquid chromatography-electrospray ionization tandem mass spectrometry was developed for simultaneously analyzing all-trans-RA (at-RA), 13-cis-RA (13c-RA), 9-cis-RA (9c-RA), and their 4-oxo metabolites, all-trans-4-oxo-RA (at-4-oxo-RA), 13-cis-4-oxo-RA (13c-4-oxo-RA), and 9-cis-4-oxo-RA (9c-4-oxo-RA) in wastewaters and surface waters. Method detection limits were matrix dependent, ranging from 0.02 to 0.37 ng/L. The method was used to investigate the occurrence of RAs and 4-oxo-RAs in Liaodong Bay and its adjacent rivers. Of these six retinoids, at-RA, 13c-RA, at-4-oxo-RA, and 13c-4-oxo-RA were detected in river waters at detection frequencies of 100%, 92%, 48.6%, and 21.6%, and concentrations of 0.05 to 1.23 ng/L, less than 0.03 to 0.41 ng/L, less than 0.02 to 1.00 ng/L, and less than 0.06 to 0.81 ng/L, respectively. Retinoic acids were detected for the first time in the aquatic environment and were found to be more persistent than 4-oxo-RAs. The hazard quotient for mortality of frog embryos caused by induction by retinoids detected in the current study was then estimated, and the value was calculated to be 0.09. No retinoid was detected in seawaters.     

Outcome of patients with nasal natural killer (NK)/T-cell lymphoma treated with radiotherapy, with or without chemotherapy

BACKGROUND: This study reviews the outcome of patients with nasal natural killer (NK)/T-cell lymphoma treated at the Therapeutic Radiology Department, National Cancer Centre, Singapore, from 1997 to 2003. METHODS: Twenty-one consecutive patients treated with radiotherapy, with or without chemotherapy, were retrospectively reviewed. RESULTS: The median age was 44 years (range, 27-86 years). Thirteen patients had stage I disease, five had stage II disease, and three had stage IV disease. Immunophenotyping was CD 56+ in 18 patients. Median follow-up for patients still alive was 23.4 months (range, 8.9-78.5 months). A median dose of 50 Gy (range, 35-56 Gy) was delivered. Sixteen patients also received chemotherapy. Two-year overall survival was 52.8%. Five patients had rapidly progressive disease, with a median survival of 89 days from diagnosis. The other 16 patients had complete remission, after which four relapsed. There were two local relapses. CONCLUSIONS: This disease often carries a poor prognosis, despite multimodality treatment. Radiotherapy may contribute to local control in some patients.     

Factors affecting early mortality in spontaneous rupture of hepatocellular carcinoma

BACKGROUND: Spontaneous rupture of hepatocellular carcinoma (HCC) is a catastrophic surgical emergency with high mortality rates. The aim of this study is to determine the factors associated with the prognosis and to assess the outcome of different management strategies. METHODS: A retrospective study of 34 consecutive patients with spontaneous rupture of HCC was conducted from January 1996 to January 2004. Clinical, biochemical and operative factors influencing 30-day mortality were analysed. RESULTS: In our study, 30-day mortality rate was 32% (n = 11). Presence of cirrhosis, Child's C status, shock on admission, higher blood transfusion requirement, raised alpha-fetoprotein, raised alkaline phosphatase, raised aspartate transaminase, and raised indocyanine green at 15 min were all associated with increased risk of 30-day mortality on univariate analysis (P < 0.05). On multivariate analysis, only shock on admission (P = 0.001) and higher blood transfusion requirement (P = 0.01) were significant independent factors affecting early mortality. Surgical intervention was associated with a better 30-day survival as compared with medical therapy or transarterial embolization. The median survival time of patients undergoing curative resection was significantly longer than that of patients who had surgery for haemostasis only (420 vs 205 days). The overall median survival was 161 days. CONCLUSIONS: Spontaneous rupture of HCC is a potentially salvageable complication of HCC. Poor prognosis is associated with poor liver reserve, advanced disease and severity of haemorrhage. Shock and blood transfusion requirement are the only independent factors affecting early mortality.     

《岭南卫生方》作者考

考证李璆、王棐、王南容、章杰作为《岭南卫生方》作者之身世及游历或仕宦岭南的时间和著述等,推断出《岭南卫生方》编著的时间,当在宋绍兴九年至十八年（1139-1148）之间。     

Miller-Dieker syndrome associated with tight filum terminale

An 8-year-old female was diagnosed with Miller-Dieker syndrome with typical facial presentation. Brain magnetic resonance imaging disclosed lissencephaly, and chromosome study revealed 17p13.3 deletion. She developed infantile spasms at an early age, and her seizures were poorly controlled by multiple antiepileptics. Recurrent urinary tract infections were diagnosed during routine out-patient department follow-up. Urodynamic study disclosed a neurogenic bladder. Spinal magnetic resonance imaging revealed a tethered cord resulting from tight filum terminale, and untethering surgery was performed. Four months after the surgery, repeated urine cultures indicated that she was free from the urinary tract infection. Urodynamic study after untethering surgery demonstrated improved compliance of the urinary bladder.