Management of syringomyelia associated with tuberculous meningitis: A case report and systematic review of the literature

Determinants of tuberculosis (TB) syringomyelia, its management options and outcomes are still under investigation. The aim of this study is to present a case of TB syringomyelia with markedly improved symptoms status-post surgery and to understand the clinical characteristics and outcomes of 33 TB syringomyelia cases reported in the literature. Specifically, we examined the differences between patients who were managed medically and those who underwent surgical intervention. Inclusion criteria for the cases were (1) syringomyelia caused by TB infection rather than co-occurrence of these conditions, (2) management protocol described, and (3) post-treatment outcome described. The median age was 30 years (interquartile range (IQR): 23–40) with 55% males. The median time between TB onset to syringomyelia diagnosis was 2 years. Nineteen patients were surgically treated, 11 were medically treated, and 3 received no treatment. Twenty-one patients showed improvement in at least one prior symptom, but no patient experienced a full recovery. Those that underwent surgical intervention were more likely to have TB meningitis (95% vs. 64%, p < 0.05) upon initial TB presentation and have a greater interval between TB onset and syringomyelia presentation (median of 2.6 vs. 0.33 years, ns). A greater proportion of the surgically managed patients experienced improvement in any symptom (74% vs. 45%, ns). Future case-controlled studies with larger sample sizes are required to validate and further understand the outcomes of surgically-managed TB syringomyelia.     

The utility of dithiothreitol treatment of periprosthetic tissues and explanted implants in the diagnosis of prosthetic joint infection

PurposeThe methods used for the processing of periprosthetic tissues and explanted implants to improve culture outcome especially in biofilm mediated prosthetic joint infections (PJIs) are still debated upon. Studies have reported that Dithiothreitol (DTT) pretreatment of infected devices gives similar results as sonication. However, none of them evaluated the DTT treatment of periprosthetic tissues and explanted implants in the same cohort. We evaluated the diagnostic utility of DTT treatment of periprosthetic tissue and explanted implants, as compared to the normal saline treatment of periprosthetic tissues and sonication of explanted implants for the diagnosis of PJI.MethodsSeventy-three revision arthroplasty cases were prospectively included in this study. Three to five tissue specimens and the explanted implants were collected from each patient. Periprosthetic tissue samples were processed by both normal saline and DTT treatments. Explanted implants were subjected to both DTT treatment and sonication. Musculoskeletal Infection Society (MSIS) PJI criteria was used as the reference standard for the diagnosis of PJI.ResultsOf the 73 cases enrolled, 34 had PJI and 39 were aseptic failures. The sensitivity of DTT treated periprosthetic tissue culture (PTC) and saline treated PTC was similar (66.6% vs 58.8%, P = 0.25). The specificity of both was 100%. Sonication and DTT treatment of explanted implants showed comparable sensitivity (85.3% vs 82.4%) and specificity (100% vs 97.4%), P > 0.99. Compared to DTT treated PTC, culture of DTT treated explanted implants significantly improved the diagnosis of PJI (P = 0.03).ConclusionsWe could verify that DTT can be used to improve culture outcome in laboratories where biofilm detaching sonication techniques are not available for infected implants. In addition, we showed that it is possible to use DTT for treating tissue biopsies, but larger studies are required to confirm our findings.     

The use of dried cerebrospinal fluid filter paper spots as a substrate for PCR diagnosis of the aetiology of bacterial meningitis in the Lao PDR

We investigated whether dried cerebrospinal fluid (CSF) conserved on filter paper can be used as a substrate for accurate PCR diagnosis of important causes of bacterial meningitis in the Lao PDR. Using mock CSF, we investigated and optimized filter paper varieties, paper punch sizes, elution volumes and quantities of DNA template to achieve sensitive and reliable detection of bacterial DNA from filter paper specimens. FTA Elute Micro CardTM (Whatman, Maidstone, UK) was the most sensitive, consistent and practical variety of filter paper. Following optimization, the lower limit of detection for Streptococcus pneumoniae from dried mock CSF spots was 14 genomic equivalents (GE)/μL (interquartile range 5.5 GE/μL) or 230 (IQR 65) colony forming units/mL. A prospective clinical evaluation for S. pneumoniae, S. suis and Neisseria meningitidis was performed. Culture and PCR performed on fresh liquid CSF from patients admitted with a clinical diagnosis of meningitis (n = 73) were compared with results derived from dried CSF spots. Four of five fresh PCR-positive CSF samples also tested PCR positive from dried CSF spots, with one patient under the limit of detection. In a retrospective study of S. pneumoniae samples (n = 20), the median (IQR; range) CSF S. pneumoniae bacterial load was 1.1 × 10⁴ GE/μL (1.2 × 10⁵; 1 to ×.1 × 10⁶ DNA GE/μL). Utilizing the optimized methodology, we estimate an extrapolated sensitivity of 90%, based on the range of CSF genome counts found in Laos. Dried CSF filter paper spots could potentially help us to better understand the epidemiology of bacterial meningitis in resource-poor settings and guide empirical treatments and vaccination policies.     

Fluoroscopy-Guided Lumbar Drainage of Cerebrospinal Fluid for Patients in Whom a Blind Beside Approach Is Difficult

ObjectiveTo evaluate the rates of technical success, clinical success, and complications of fluoroscopy-guided lumbar cerebrospinal fluid drainage.ResultsThe technical and clinical success rates were 99.0% (95/96) and 89.6% (86/96), respectively. The mean hospital stay for an external lumbar drain was 4.84 days. Nine cases of minor complications and eight major complications were observed, including seven cases of meningitis, and one retained catheter requiring surgical removal.ConclusionFluoroscopy-guided external lumbar drainage is a technically reliable procedure in difficult patients with failed attempts at a bedside procedure, history of lumbar surgery, difficulties in cooperation, or obesity.     

Profiles of acute bacterial meningitis isolates in children in National Hospital,Abuja

Background:

Acute bacterial meningitis (ABM) is an important cause of morbidity and mortality throughout the world. It is an acute medical emergency that requires urgent rational antibiotic therapy, especially in neonates and young infants. Determining the pattern and susceptibility of isolates of ABM among children for prompt treatment of this important cause of mortality and morbidity is very important. This study determined the types and the antimicrobial susceptibility pattern of ABM isolates among children at the National Hospital, Abuja.

Materials and Methods:

This is a retrospective study carried out at the National Hospital Abuja (NHA), Nigeria. Laboratory data for a period of 3 years, January 2010-December 2013 were reviewed, and all bacterial isolates and their antibiotics sensitivity testing results for children aged 0-15 years, and other relevant information extracted and analyzed. Study center was the NHA.

Results:

Twenty-eight bacterial pathogens were isolated from a total of 542 cerebrospinal specimens over the study period, giving a yield of 5.2%. The four most common pathogens isolated were Staphylococcus aureus (32.2%), Klebsiella pneumoniae (21.5%), Streptococcus pneumoniae (17.6%), and Escherichia coli (14.3%). Whereas, 28.6% of all the infections occurred in neonates alone, children 2 years and below had 85.7% of all the infections, with male preponderance. Isolates of S. aureus and S. pneumonia tested were both 100% susceptible to amoxicillin-clavulanic acid and Cefuroxime; S. pneumoniae was equally sensitive to Ceftriaxone. K. pneumoniae was 100% sensitive to Imipenem, but 83% to ceftriaxone. 75% of the isolated E. coli strains were sensitive to ceftriaxone, amoxicillin-clavulanic acid, and amikacin, 100% sensitive to imipenem.

Conclusion:

Meningitis in children as seen in the National hospital is almost equally caused by both Gram-positive and Gram-negative organisms, predominantly by S. aureus, S. pneumoniae, K. pneumoniae, and E. coli. Available drugs remain active against these organisms.     

国内22年肺隐球菌病回顾性分析

目的　回顾国内 2 2年来肺隐球菌病的诊疗进展。方法　检索 1980～ 2 0 0 1年中文生物医学期刊数据库 (CMCC)收录的有关肺隐球菌病的文献资料 ,统计分析并总结 6 7例肺隐球菌病患者的临床资料。结果　肺隐球菌病好发于青中年男性 ,其临床表现及影像学表现呈多样性和无特异性 ,易并发隐球菌性脑膜炎 (31 34% ) ,临床上极易误诊 ;确诊主要依靠各种临床标本的涂片、培养和病理学检查 ;治疗手段主要包括手术切除和抗真菌药物的治疗。结论　临床上提高对该病的认识是提高确诊率的关键。强调抗真菌药物的治疗作用 ,尤其是术前术后应用 ,可减少术后隐球菌的播散导致隐球菌性脑膜炎。     

Aseptic colon resection by an invagination technique

A new aseptic colon resection by an invagination technique is presented. The bowel to be resected is invaginated down into the healthy intestine, and the anastomosis is sutured in one layer of continuous suture before transection by a diathermy wire, placed in the intestinal lumen via the anus. Sections of bowel that cannot be invaginated,e.g.,because of a tumor, are first removed by transection between pairs of cable ties, which close the lumen. Twenty dogs were operated on without receiving prophylactic antibiotics. In 10, the intestine was transected between cable ties. An imprint, taken from the anastomosis and subcutis, was cultured. The bacterial count at the anastomosis exceeded 100 in only three cases; in the subcutis, this was the case in one dog. One wound infection developed. Serial barium enemas at 1, 2, 3, and 4 weeks revealed no anastomotic leakage. One early death because of a total anastomotic dehiscence was encountered, and two dogs were killed because of wound dehiscence and anastomotic stricture, respectively. It is concluded that, in dogs, the method is easily and safely performed, but further experimental studies are needed.This study was supported with grants from Fonden til Laegevidenskabens Fremme, Kraeftens Bekaempelse, Sygekassernes Helsefond, and Aarhus Universitets Forskningsfond.     

Idiopathic hypertrophic pachymeningitis presenting with occipital neuralgia

BackgroundAlthough occipital neuralgia is usually caused by degenerative arthropathy, nearly 20 other aetiologies may lead to this condition.MethodsWe present the first case report of hypertrophic pachymeningitis revealed by isolated occipital neuralgia.

Results and conclusions

Idiopathic hypertrophic pachymeningitis is a plausible cause of occipital neuralgia and may present without cranial-nerve palsy. There is no consensus on the treatment for idiopathic hypertrophic pachymeningitis, but the usual approach is to start corticotherapy and then to add immunosuppressants. When occipital neuralgia is not clinically isolated or when a first-line treatment fails, another disease diagnosis should be considered. However, the cost effectiveness of extended investigations needs to be considered.