Atypical cases of gallstone ileus evaluated with multidetector computed tomography

OBJECTIVE: To describe the multidetector computed tomography (CT) findings in 3 patients with atypical gallstone ileus. METHODS: We retrospectively evaluated computed radiography and CT images from three cases of surgically proven gallstone ileus. Two radiologists evaluated by consensus all images for the presence of ectopic gallstone, small bowel obstruction, intrahepatic pneumobilia, cholecystic pneumobilia. One author recorded whether diagnosis of gallstone ileus was made prospectively on radiologic reports and correlated findings to pathology. RESULTS: All cases of gallstone ileus were atypical in that one patient had porcelain gallbladder, one had recurrent pyogenic cholangitis, and one was only 35 years of age. Prospective clinical diagnosis of gallstone ileus was made in only 1 patient at computed radiography and all 3 patients at CT. Retrospectively, small bowel obstruction and cholecystic pneumobilia were identified retrospectively in all 3 patients at both computed radiography and MDCT, and an ectopic gallstone, intrahepatic pneumobilia, and choledochoduodenal fistula was seen in 2, 1, and 0 patients at computed radiography and 3, 2, and 3 patients at CT respectively. CONCLUSION: Multidetector CT is an accurate means to diagnose gallstone ileus, even in patients with atypical features. In particular, multidetector CT is useful for identifying the ectopic gallstone at the transition point between dilated and decompressed bowel.     

Nipah virus encephalitis reemergence, Bangladesh

We retrospectively investigated two outbreaks of encephalitis in Meherpur and Naogaon, Bangladesh, which occurred in 2001 and 2003. We collected serum samples from persons who were ill, their household contacts, randomly selected residents, hospital workers, and various animals. Cases were classified as laboratory confirmed or probable. We identified 13 cases (4 confirmed, 9 probable) in Meherpur; 7 were in persons in two households. Patients were more likely than nonpatients to have close contact with other patients or have contact with a sick cow. In Naogaon, we identified 12 cases (4 confirmed, 8 probable); 7 were in persons clustered in 2 households. Two Pteropus bats had antibodies for Nipah virus. Samples from hospital workers were negative for Nipah virus antibodies. These outbreaks, the first since 1999, suggest that transmission may occur through close contact with other patients or from exposure to a common source. Surveillance and enhancement of diagnostic capacity to detect Nipah virus infection are recommended.     

Visceral leishmaniasis: consequences to women in a Bangladeshi community

Visceral leishmaniasis (VL) or kala-azar (KA) affects the rural poor, causing significant morbidity and mortality. We examined the epidemiological and social impact of KA in an affected village in Bangladesh. A population-based survey of the village residents showed a case fatality rate of 14.7% among females and 5.3% among males. Before initiation of the study, female patients were ill longer than males before they received treatment. Future work needs to focus on understanding the implications of KA on women and to develop sustainable strategies for appropriate and timely access to treatment.     

Distinguishing features of self-limiting adult small-bowel intussusception identified at CT

PURPOSE: To determine if clinical or computed tomographic (CT) findings can be used to distinguish self-limiting cases of adult small-bowel intussusception from those requiring surgery. MATERIALS AND METHODS: Thirty-seven cases of adult small-bowel intussusception were identified by a retrospective computerized search of 69,040 abdominopelvic CT examinations performed over a 4-year period. Two independent readers recorded CT features. Clinical findings and outcomes were determined by review of all available medical records. Outcome was classified as either surgical or self-limiting. Association between predictive variables and outcome was assessed by the Fisher exact test and logistic regression models. A multivariate, stepwise, logistic regression model was used to determine the best predictors of outcome. RESULTS: Six patients (16%) underwent surgery, and all had lead-point tumors. Thirty-one patients were cared for conservatively (84%) and none required surgery at a mean follow-up of 5.2 months (range, 0-46 months). Multivariate, stepwise, logistic regression analysis showed intussusception length was the only variable that was independently predictive of outcome. All 20 patients with an intussusception length of 3.5 cm or less, as measured by either reader, had cases that were self-limiting. Seventeen patients had an intussusception length greater than 3.5 cm, as measured by either reader. Eleven patients had an intussusception that was self-limiting, and six patients had an intussusception that required surgery. CONCLUSION: Intussusception length is the main factor in distinguishing the majority of small-bowel intussusceptions detected at CT that are self-limiting from the minority that require surgery. An intussusception that is shorter than 3.5 cm is likely to be self-limiting.     

Vaccines to prevent respiratory infection: opportunities on the near and far horizon

Illnesses caused by respiratory pathogens result in great loss of life, suffering and commitment of resources for treatment. That the suffering and loss of life can be prevented through immunization has already been clearly shown with existing vaccines, such as those for Haemophilus influenzae type b, Streptococcus pneumoniae, and influenza. The emergence of drug-resistant pathogens is making reliance on therapy more expensive and perhaps less successful, accentuating the need to focus on prevention. Although several effective vaccines to prevent respiratory infections currently exist, they are underutilized globally. Improvements in immunogenicity, efficacy, and ease of administration, and lowering the costs of some of the existing vaccines would augment the potential for prevention worldwide. The greatest opportunities for the prevention of respiratory infections will rest with vaccines that will become available in the future.     

The immunohistology of follicle lysis in lymph node biopsies from homosexual men

Follicle lysis is a characteristic alteration of B cell follicles described recently in lymph node biopsies from homosexual men. It consists of disruption of germinal centers by aggregates of small mature lymphocytes variably associated with erythrocyte extravasation. We studied the immunohistology of follicle lysis identified in lymph node biopsies from 11 homosexual men. The results indicate that follicle lysis has two principal immunohistologic features: (1) intrafollicular aggregates of small lymphocytes predominantly of polytypic mantle B cell phenotype (T015+/Leu-8+/mu+/delta+/k+ or lambda+), and (2) disruption of the normal, unified follicular meshwork of R4/23+ dendritic reticulum cells by these B cell aggregates. These structural alterations may affect the functional integrity of the germinal center as it pertains to the abnormal B cell effector function and the increased prevalence of B cell lymphoma recently documented in the acquired immunodeficiency syndrome and related disorders. Because dendritic reticulum cells weakly express the Leu-3 (T4) antigen, which is known to be an essential component of the receptor for human T- lymphotropic virus type III/lymphadenopathy-associated virus (HTLV- III/LAV) retrovirus infection, it is possible that retroviral infection of dendritic reticulum cells may play a role in the pathogenesis of follicle lysis.     

Dural infolding during C1-2 myelography

Inward buckling of the dura at C1-2 may occasionally occur with hyperextension of the neck and can result in a difficult or unsuccessful puncture when the posterior lateral C1-2 approach is used for cervical myelography. In this circumstance, placement of the head in a neutral or slightly flexed position may widen the posterior subarachnoid space and facilitate the needle puncture.     

MR imaging of the scrotum: normal anatomy

High-resolution magnetic resonance (MR) imaging with a surface coil was utilized to evaluate the normal scrotum. Scrotal contents, spermatic canal, and inguinal regions were visualized within the same field of view. Differences in signal intensity in the testis, epididymis, tunica albuginea, fluid, fat, and spermatic cord allowed for clear delineation of these structures in detail. The high contrast and spatial resolution of MR imaging, coupled with the wide field of view and absence of ionizing radiation, make MR imaging well suited for evaluation of the scrotum.