Search results for: tuberculous encephalopathy

Authors: Shishen Xie, Yingda L. Xie

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Tuberculosis (TB) is a potentially serious infectious disease that remains a health concern. The Interferon Gamma Release Assay (IGRA) is a blood test to find out if an individual is tuberculous positive or negative. This study applies statistical analysis to the clinical data of interferon-gamma levels of seventy-three subjects who diagnosed pulmonary TB in an anti-tuberculous treatment. Data analysis is performed to determine if there is a significant decline in interferon-gamma levels for the subjects during a period of six months, and to infer if the anti-tuberculous treatment is effective.

Keywords: data analysis, interferon gamma release assay, statistical methods, tuberculosis infection

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Authors: Ghoul Rachid Brahim

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Introduction: Tuberculous spondylodiscitis is an infection of the spine by Mycobacterium tuberculosis. Tuberculous spondylodiscitis still remains a topical disease in developing countries and continues to pose a public health problem in endemic countries. Materials and methods: Clinical case: This is a 12-year-old child followed in pediatrics for weight loss and progressively worsening low back pain. The neurological examination found an irritative pyramidal syndrome in both lower limbs with a severe lumbar spinal syndrome. The radiological assessment: (Rx of the spine supplemented by CT and MRI) shows L1L2 spondylodiscitis. Treatment: The child is put on anti-tuberculosis treatment, and the spine is restrained with a corset. Control MRI shows a worsening of the dorsal kyphosis with a backward movement of the posterior wall and spinal cord compression. The child is operated on via the posterior approach (the operative procedure consists of an L1 laminectomy and D11 L3 osteosynthesis). Results: Spinal cord décompression and stabilization of the spine. Conclusion: Tuberculous spondylodiscitis in children remains a rare, aggressive, and progressive condition. The prognosis depends on the diagnosis's precocity and the therapeutic management quality.

Keywords: tuberculous spondylodiscitis, mycobacterium tuberculosis, laminectomy, MRI

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Authors: Ndarusanze Berchmans

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This research work focused on the analysis of the observations of tuberculous meningitis in HIV-positive patients who were treated by the Prince Regent Charles Hospital in Bujumbura. A number of 246 seropositive patients were examined by the laboratory of Prince Regent Charles in the period between 2010 and 2015. We did a retrospective study; we used data from the registers of the laboratories mentioned above; the objective was to approach the epidemiological, biological, clinical, and therapeutic characteristics of tuberculosis meningitis infection: 124 women (50.40% of AIDS patients) and 122 men (49.59% of AIDS patients) were subject to the diagnosis by identification of cerebrospinal fluid (CSF). The average age of the patients was 30 years for this period. The population at risk has an average age of between 34 and 42 years for the years between 2010-2015. From 2010 to 2012, cases of opportunistic diseases (e.g., tuberculous meningitis and Cryptococcus neoformans meningitis), often found in immunocompromised, were observed at a high rate; in this period, there was a disturbance of the rhythm providing antiretroviral drugs to people with AIDS. The rate of the two meningitis (tuberculous meningitis and Cryptococcus neoformans meningitis) remained above 10% to gradually decrease until 2015, with the gradual return of antiretrovirals. This period records an overall average of 25 cases of tuberculous meningitis, or a percentage of 10.16%. For the year 2015, there were 4 cases of tuberculous meningitis out of a total of 35 seropositive examined (11.42%). This year's percentage shows that the number of tuberculous meningitis cases has fallen from the rate in previous years. This is the result of the care given by associations against HIV/AIDS to HIV-positive people. This decrease in cases of tuberculous meningitis is due to the acquisition of antiretrovirals by all HIV-positive people treated by hospitals. For the moment, these hospitals are taking care of many AIDS patients by providing them permanently with antiretrovirals; Besides that, there are many patients who are supported by associations whose activities are directed against HIV/AIDS.

Keywords: Cryptococcus neoformans meningitis, tuberculosis meningitis, neurological complications, epidemiology of meningitis

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Authors: W. Ling, Mohamed Saufi Bin Awang

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Introduction: Mycobacterium tuberculosis post a major health problem worldwide. Central nervous system (CNS) infection by mycobacterium tuberculosis is one of the most devastating complications of tuberculosis. Although with advancement in medical fields, we are yet to understand the pathophysiology of how mycobacterium tuberculosis was able to cross the blood-brain barrier (BBB) and infect the CNS. CNS TB may present with nonspecific clinical symptoms which can mimic other diseases/conditions; this is what makes the diagnosis relatively difficult and challenging. Public health has to be informed and educated about the spread of TB, and early identification of TB is important as it is a curable disease. Case Report: A young 21-year-old Malay gentleman was initially presented to us with symptoms of ear discharge, tinnitus, and right-sided headache for the past one year. Further history reveals that the symptoms have been mismanaged and neglected over the period of 1 year. Initial investigation reveals features of inflammation of the ear. Further imaging showed the feature of chronic inflammation of the otitis media and atypical right cerebral abscess, which has the same characteristic features and consistency. He further underwent a biopsy, and results reveal positive Mycobacterium tuberculosis of the otitis media. With the results and the available imaging, we were certain that this is likely a case of disseminated tuberculosis causing CNS TB. Conclusion: We aim to highlight the challenge and difficult face in our health care system and public health in early identification and treatment.

Keywords: central nervous system tuberculosis, intracranial tuberculosis, tuberculous encephalopathy, tuberculous meningitis

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Authors: Shahla Afshar Paiman, Sedigheh Madani, Zahra Hosseininezhad

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Introduction: The most common causes of appendix luminal obstruction are fecaliths and lymphoid follicle hyperplasia. Appendicitis is a very rare Gastrointestinal complication of varicella zosterand it is mostly observed in immune-compromised patient. Case presentation: Here we reported a case of varicella zoster-related perforated appendicitis with synchronous encephalopathy as a first presentation of chickenpox in a 10-year-old boy. He had no history of immunodeficiency or predisposing factors and his diagnosis is confirmed by both serological lab tests and abdominal fluid (peritoneal secretion) PCR. Conclusion: Varicella zoster could cause appendicitis as first presentation, along with other critical complications look likes encephalopathy.

Keywords: Varicella zoster, appendicitis, encephalitis, children

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Authors: Omar Sorour, Michael Leahy, Thomas Irvine, Vladimir Koren

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Introduction: Covid encephalitis is a rare yet dangerous complication, particularly affecting the older and immunocompromised. Symptoms range from confusion to delirium, coma, and seizures. Although neurological manifestations have become more well-characterized in COVID patients, little is known about whether priorneurological abnormalities may predispose patients to COVID encephalopathy. Case Description: A 73 y.o. male with a CT and MRI-confirmed stable, prior 9 mm cavernoma in the right frontal lobe and no past history of seizures was hospitalized with generalized weakness, abdominal pain, nausea, and shortness of breath with subsequent COVID pneumonia. Three days after the initial presentation, the patient developed a spontaneous generalized tonic-clonic seizure consistent with presumed COVID encephalitis, along with somnolence and confusion. A day later, the patient had two other seizure episodes. Follow-up EEG suggested an inter-ictal epileptic focus with sharp waves corresponding to roughly the same location as the patient’s pre-existing cavernoma. The patient’s seizures stopped shortly thereafter, while his encephalopathy continued for days. Conclusion: We illustrate that a pre-existing anatomic cortical abnormality may act as a potential nidus for new-onset seizure activity in the context of suggested COVID encephalopathy. Future studies may further demonstrate that manifestations of COVIDencephalopathy in certain patients may be more predictable than initially assumed.

Keywords: cavernoma, covid, encephalopathy, seizures

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Authors: Mohd Jaish Siddiqui

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Laryngeal TB is extremely rare in the pediatric population, accounting for 1% of all cases. Here, we present a case of laryngeal TB with miliary tuberculosis and tuberculous encephalitis, presented with sore throat, hoarseness, severe cough and, acute obstruction the larynx, sputum for AFB was negative, T-SPOT was positive and X-pert was positive, bronchoscopy revealed multiple nodules and edema around the larynx, epiglottis, bilateral arytenopharyngeal folds and vocal cord. Enhanced MRI revealed multiple small nodules in bilateral cerebral hemispheres and right thalamus, however CSF was negative. We reviewed the LTB cases that were published up to 2021. A total of twenty fine cases were identified in English literature. The most common manifestation was hoarseness of voice with 80% followed by stridor 40% of cases. Pulmonary involvement was found in 36% of cases, whereas, 45% of cases had no underlying TB. We did not find any case who developed tuberculous encephalitis in the literature.

Keywords: laryngeal tb, treatment, tuberculous encephalitis, children

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Authors: Erwin Geroleo, Higinio Mappala

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Introduction Overt Hepatic Encephalopathy (OHE) is the most dreaded outcome of liver cirrhosis. Aside from the triggering factors which are already known to precipitate OHE, there is growing evidence that an altered gut microbiota profile (dysbiosis) can also trigger OHE. MHE is the mildest form of hepatic encephalopathy(HE), affecting about one-third of patients with cirrhosis, and close 80% of patients with cirrhosis and manifests as abnormalities in central nervous system function. Since these symptoms are subclinical most patients are not being treated to prevent OHE. The gut microbiota have been evaluated by several studies as a therapeutic option for MHE, especially in decreasing the levels of ammonia, thus preventing progression to OHE Objectives This study aims to evaluate the efficacy of probiotics in terms of reduction of ammonia levels in patient with minimal hepatic encephalopathies and to determine if Probiotics has role in the prevention of progression to overt hepatic encephalopathy in adult patients with minimal hepatic encephalopathy (MHE) Methods and Analysis The literature search strategy was restricted to human studies in adults subjects from 2004 to 2022. The Jadad Score Calculation was utilized in the assessment of the final studies included in this study. Eight (8) studies were included. Cochrane’s Revman Web, the Fixed Effects model and the Ztest were all used in the overall analysis of the outcomes. A p value of less than 0.0005 was statistically significant. Results. These results show that Probiotics significantly lowers the level of Ammonia in Cirrhotic patients with OHE. It also shows that the use of Probiotics significantly prevents the progression of MHE to OHE. The overall risk of bias graph indicates low risk of publication bias among the studies included in the meta-analysis. Main findings This research found that plasma ammonia concentration was lower among participants treated with probiotics (p<0.00001).) Ammonia level of the probiotics group is lower by 13.96 μmol/ on the average. Overall risk of developing overt hepatic encephalopathy in the probiotics group is shown to be decreased by 15% as compared to the placebo group Conclusion The analysis showed that compared with placebo, probiotics can decrease serum ammonia, may improve MHE and may prevent OHE.

Keywords: minimal hepatic encephalopathy, probiotics, liver cirrhosis, overt hepatic encephalopathy

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Authors: Hang T. T. Tran, Ha T. Le, Hanh T. P. Tran, Hung V. Cao, Giang T. H. Nguyen, Dien M. Tran, Tobias Alfvén, Linus Olson

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Background: Hypoxic Ischemic Encephalopathy is one of the major causes of neonatal death and those who survive with severe encephalopathy are more likely to develop adverse long-term outcomes such as neurocognitive impairment and cerebral palsy, which is a huge burden, especially in low-middle income countries. It is important to have a long-term follow-up for early detection and promote early intervention for these groups of high-risk infants. Aim: To determine the neurological outcome of cooling infants at 18 months and identify an optimized neurological examination scale for Hypoxic Ischemic Encephalopathy infants in Vietnam. Method: Descriptive study of neurodevelopmental outcomes at 18 months of HIE infants who underwent therapeutic hypothermia treatment in Vietnam. All survived cooling infants were assessed at discharge and at 6, 12, and 18 months by a pediatric physical therapist and a neurologist using two assessment tools: Ages and Stages Questionnaires and the Hammersmith Infant Neurological Examination scale to detect impairments and promote early intervention for those who require it. Results: During a 3-year period, a total of 130 neonates with moderate to severe HIE underwent therapeutic hypothermia treatment using Phase change material mattress (65% moderate, 35% severe – Sarnat). 43 (33%) died during hospitalization and infancy; among survivors, 69 (79%) completed 3 follow-ups at 18 months. At 18 months, 25 had cerebral palsy, 11 had mild delayed neurodevelopment. At each time-point, infants with a normal/mildly delayed neurodevelopment had significantly higher Ages and Stages Questionnaires and Hammersmith Infant Neurological Examination scores (p<0.05) than those with cerebral palsy. Conclusion: The study showed that the Ages and Stages Questionnaires and Hammersmith Infant Neurological Examination is a helpful tool in the process of early diagnosis of infants at low and high neurological risk and identifying those infants needing specific rehabilitation programme.

Keywords: encephalopathy, phase-change-material, neurodevelopment, cerebral palsy

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Authors: Parveen Kundu, Zile Singh, Kunika Kundu, Swaran Kaur

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Context: Tuberculous osteomyelitis is a relatively uncommon condition that can present with various clinical and radiological features, often mimicking bone tumors or tumor-like lesions. In endemic countries like India, tuberculosis should be considered as a potential differential diagnosis for lytic bone lesions. This study aimed to highlight the different presentations of tuberculosis that can mimic tumors or tumor-like lesions in bone and emphasize the successful outcome of antitubercular therapy (ATT) in treating these cases. Research Aim: The main objective of this research was to explore the varied presentations of tuberculosis that mimic bone tumors or tumor-like lesions both clinically and radiologically, focusing on different bones. The study aimed to raise awareness among clinicians about this possibility and highlight the importance of histopathological confirmation before initiating treatment for lytic bone lesions. Methodology: This study utilized a retrospective review of 22 patients with suspected lytic bone lesions, who were subsequently diagnosed with tuberculous osteomyelitis through histopathological examination. The cases were collected over a period of ten years. Eleven cases required curettage for extensive lesions with sequestrations, while all 22 patients received 12 months of antitubercular therapy. Findings: The study included 14 male and 8 female patients, ranging in age from 3 to 61 years, with an average age of 22.05. The clinical and radiological presentations varied, with examples including bone cysts in the metaphyseal area of long bones, lesions resembling chondroblastomas, giant cell tumors, and osteoid osteoma, as well as multifocal lytic lesions resembling metastasis or multiple myeloma. One patient had lesions in both the clavicle and hand. Lesions mimicking chondromas were also observed in the phalanges of the hand and foot metatarsal. All patients showed resolution of the lesions and no residual disability following ATT. Theoretical Importance: This study highlights the importance of considering tuberculosis as a potential differential diagnosis for lytic bone lesions, particularly in endemic regions. It emphasizes the need for histopathological confirmation to accurately diagnose tuberculous osteomyelitis, as this is considered the gold standard. Data Collection and Analysis Procedures: Data for this study were collected retrospectively from medical records and radiological images of the 22 patients. The cases were analyzed based on clinical presentation, radiological findings, and histopathological confirmation. The outcomes of antitubercular therapy were also assessed. The data were summarized and presented descriptively. Question Addressed: This study aimed to address the question of how tuberculosis can mimic different bone tumors and tumor-like lesions clinically and radiologically. It also aimed to assess the successful outcome of antitubercular therapy in treating these cases. Conclusion: Tuberculous osteomyelitis can present with varied clinical and radiological features, often mimicking bone tumors or tumor-like lesions. Clinicians should consider tuberculosis as a potential diagnosis for lytic bone lesions, especially in endemic areas. Histopathological confirmation is essential for accurate diagnosis. Antitubercular therapy is an effective treatment for tuberculous osteomyelitis, leading to the resolution of the lesions with no residual disability.

Keywords: tuberculosis, tumor, curettage, bone

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Authors: S. H. Jang

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Posterior reversible encephalopathy syndrome (PRES) is characterized by acute neurologic symptoms (visual loss, headache, altered mentality and seizures) and by typical imaging findings (bilateral subcortical and cortical edema with predominatly posterior distribution). Nephrotic syndrome is a syndrome comprising signs of proteinuria, hypoalbuminemia, and edema. It is well known that hypertension predispose patient with nephrotic syndrome to PRES. A 45-year old male was referred for suddenly developed vertigo, disequilibrium. He had previous history of nephrotic syndrome. His medical history included diabetes controlled with medication. He was hospitalized because of generalized edema a few days ago. His vital signs were stable. On neurologic examination, his mental state was alert. Horizontal nystagmus to right side on return to primary position was observed. He showed good grade motor weakness and ataxia in right upper and lower limbs without other sensory abnormality. Brain MRI showed increased signal intensity in FLAIR image, decreased signal intensity in T1 image and focal enhanced lesion in T1 contrast image at whole midbrain, pons and cerebellar peduncle symmetrically, which was compatible with vasogenic edema. Laboratory findings showed severe proteinuria and hypoalbuminemia. He was given intravenous dexamethasone and diuretics to reduce vasogenic edema and raise the intra-vascular osmotic pressure. Nystagmus, motor weakness and limb ataxia improved gradually over 2 weeks; He recovered without any neurologic symptom and sign. Follow-up MRI showed decreased vasogenic edema fairly. We report a case of brain stem PRES in normotensive, nephrotic syndrome patient.

Keywords: posterior reversible encephalopathy syndrome, MRI, nephrotic syndrome, vasogenic brain edema

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Authors: Marawan Abd Elbaset Mohamed, Hanan A. Ogaly, Rehab F. Abdel-Rahman, Ahmed-Farid O.A., Marwa S. Khattab, Reham M. Abd-Elsalam

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Liver fibrosis is a severe worldwide health concern due to various chronic liver disorders. Hepatic encephalopathy (HE) is one of its most common complications affecting liver and brain cognitive function. Beta-Carotene (B-Car) is an organic, strongly colored red-orange pigment abundant in fungi, plants, and fruits. The study attempted to know B-Car neuroprotective potential against thioacetamide (TAA)-induced neurotoxicity and cognitive decline in HE in rats. Hepatic encephalopathy was induced by TAA (100 mg/kg, i.p.) three times per week for two weeks. B-Car was given orally (10 or 20 mg/kg) daily for two weeks after TAA injections. Organ body weight ratio, Serum transaminase activities, liver’s antioxidant parameters, ammonia, and liver histopathology were assessed. Also, the brain’s mitogen-activated protein kinase (MAPK), nuclear factor kappa B (NF-κB), antioxidant parameters, adenosine triphosphate (ATP), adenosine monophosphate (AMP), norepinephrine (NE), dopamine (DA), serotonin (5-HT), 5-hydroxyindoleacetic acid (5-HIAA) cAMP response element-binding protein (CREB) expression and B-cell lymphoma 2 (Bcl-2) expression were measured. The brain’s cognitive functions (Spontaneous locomotor activity, Rotarod performance test, Object recognition test) were assessed. B-Car prevented alteration of the brain’s cognitive function in a dose-dependent manner. The histopathological outcomes supported these biochemical evidences. Based on these results, it could be established that B-Car could be assigned to treat the brain’s neurotoxicity consequences of HE via downregualtion of MAPK/NF-κB signaling pathways.

Keywords: beta-carotene, liver injury, MAPK, NF-κB, rat, thioacetamide

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Authors: Wenjie Wu, Peng Cheng, Zehua Zhang, Fei Luo, Feng Wu, Min Zhong, Jianzhong Xu

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Background: There has been limited research into the therapeutic efficacy of rapid diagnosis of spinal tuberculosis complicated with pulmonary tuberculosis. We attempted to discover whether the utilization of a DNA microarray assay to detect multidrug-resistant spinal tuberculosis complicated with pulmonary tuberculosis can improve clinical outcomes. Methods: A prospective study was conducted from February 2006 to September 2015. One hundred and forty-three consecutive culture–confirmed, clinically and imaging diagnosed MDR-TB patients with spinal tuberculosis complicated by pulmonary tuberculosis were enrolled into the study. The initial time to treatment for MDR-TB, the method of infection control, radiological indicators of spinal tubercular infectious foci, culture conversion, and adverse drug reactions were compared with the standard culture methods. Results: Of the total of 143 MDR-TB patients, 68 (47.6%) were diagnosed by conventional culture methods and 75 (52.4%) following the implementation of detection using the DNA microarray. Patients in the microarray group began rational use of the second-line drugs schedule more speedily than sufferers in the culture group (17.3 vs. 74.1 days). Among patients were admitted to a general tuberculosis ward, those from the microarray group spent less time in the ward than those from the culture group (7.8 vs. 49.2 days). In those patients with six months follow-up (n=134), patients in the microarray group had a higher rate of sputum negativity conversion at six months (89% vs. 73%). In the microarray group, the rate of drug adverse reactions was significantly lower (22.2% vs. 67.7%). At the same time, they had a more obvious reduction of the area with spinal tuberculous lesions in radiological examinations (77% vs. 108%). Conclusions: The application of the CapitalBio™ DNA Microarray assay caused noteworthy clinical advances including an earlier time to begin MDR-TB treatment, increased sputum culture conversion, improved infection control measures and better radiographical results

Keywords: tuberculosis, multidrug-resistant, tuberculous spondylitis, DNA microarray, clinical outcomes

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Authors: S. A. El-Marasy, S. A. El Awdan, R. M. Abd-Elsalam

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This study aimed to investigate the possible neuroprotective effect of chrysin on thioacetamide (TAA)-induced hepatic encephalopathy in rats. Also, the effect of chrysin on motor impairment, cognitive deficits, oxidative stress, neuroinflammation, apoptosis and histopathological damage was assessed. Male Wistar rats were randomly allocated into five groups. The first group received the vehicle (distilled water) for 21 days and is considered as normal group. While the second one received intraperitoneal dose of TAA (200 mg/kg) at three alternative days during the third week of the experiment to induce HE and is considered as control group. The other three groups were orally administered chrysin for 21 days (25, 50, 100 mg/kg) and starting from day 17; rats received intraperitoneal dose of TAA (200 mg/kg) at three alternative days. Then behavioral, biochemical, histopathological and immunohistochemical analyses were assessed. Then behavioral, biochemical, histopathological and immunohistochemical analyses were assessed. Chrysin reversed TAA-induced motor coordination in rotarod test, cognitive deficits in object recognition test (ORT) and attenuated serum ammonia, hepatic liver enzymes, reduced malondialdehyde (MDA), elevated reduced glutathione (GSH), reduced nuclear factor kappa B (NF-κB), tumor necrosis factor-alpha (TNF-α) and Interleukin-6 (IL-6) brain contents. Chrysin administration also reduced Toll-4 receptor (TLR-4) gene expression, caspase-3 protein expression, hepatic necrosis and astrocyte swelling. This study depicts that chrysin exerted neuroprotective effect in TAA-induced HE rats, evidenced by improvement of cognitive deficits, motor incoordination and histopathological changes such as astrocyte swelling and vacuolization; hallmarks in HE, via reducing hyperammonemia, ameliorating hepatic function, in addition to its anti-oxidant, inactivation of TLR-4/NF-κB inflammatory pathway, and anti-apoptotic effects.

Keywords: chrysin, hepatic encephalopathy, oxidative stress, rats, thioacetamide, TLR4/NF-κB pathway

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Authors: Samir Malhotra, Rajan K. Khandotra, Rakesh K. Dhiman, Neelam Chadha

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There is paucity of data about safety and efficacy of probiotic treatment on patient outcomes in cirrhosis. Specifically, it is important to know whether probiotics can improve mortality, hepatic encephalopathy (HE), number of hospitalizations, ammonia levels, quality of life, and adverse events. Probiotics may improve outcomes in patients with acute or chronic HE. However, it is also important to know whether probiotics can prevent development of HE, even in situations where patients do not have acute HE at the time of administration. It is also important to know if probiotics are useful as primary prophylaxis of HE. We aimed to conduct an updated systematic review and meta-analysis to evaluate the safety and efficacy of probiotics in patients with cirrhosis. We searched PubMed, Cochrane library, Embase, Scopus, SCI, Google Scholar, conference proceedings, and references of included studies till June 2017 to identify randomised clinical trials comparing probiotics with other treatments in cirrhotics. Data was analyzed using MedCalc. Probiotics had no effect on mortality but significantly reduced HE (14 trials, 1073 patients, OR 0.371; 95% CI 0.282 to 0.489). There was not enough data to conduct a meta-analysis on outcomes like hospitalizations and quality of life. The effect on plasma ammonia levels was not significant (SMD -0.429; 95%CI -1.034 – 0.177). There was no difference in adverse events. To conclude, although the included studies had a high risk of bias, the available evidence does suggest a beneficial effect on HE. Larger studies with longer periods of follow-up are needed to determine if probiotics can reduce all-cause mortality.

Keywords: cirrhosis, hepatic encephalopathy, meta-analysis, probiotic

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Authors: Abeer N. Alshukairi, Abdulrahman A. Alrajhi, Abdulfattah W. Alamri, Adel F. Alothman

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We described the nosocomial transmission of a pre-XDR or an MDR case of pulmonary tuberculosis in a HIV negative health care worker in an area endemic for MDR & XDR tuberculosis. With inadequate therapy and non-compliance, his strain developed acquired resistance and he presented with extra-pulmonary XDR tuberculosis in the form of multi-focal osteomyelitis and encysted pleural effusion. He was cured after 2 years of therapy with various anti-tuberculous drugs in addition to interferon gamma.

Keywords: osteomyelitis, treatment, XDR tuberculosis, successful treatment

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Authors: N. Jait, M. Maamar, H. Khibri, H. Harmouche, N. Mouatssim, W. Ammouri, Z. Tazimezaelek, M. Adnaoui

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Introduction: Uveitis presents with inflammation of the uvea, intraocular, of heterogeneous etiology and presentation. The objective of our study is to describe the clinical and therapeutic characteristics of infectious uveitis in HIV+ and HIV- patients. Patients and Methods: This is a retrospective study conducted at the internal medicine department of CHU Ibn Sina in Rabat over a period of 12 years (2010–2021), collecting 42 cases of infectious uveitis. Results: 42 patients were identified. 34% (14 cases) had acquired immunosuppression (9 cases: 22% had HIV infection and 12% were on chemotherapy), and 66% were immunocompetent. The M/F sex ratio was 1.1. The average age was 39 years old. Uveitis revealed HIV in a single case; 8/9 patients have already been followed, their average viral load is 3.4 log and an average CD4 count is 356/mm³. The revealing functional signs were: ocular redness (27%), decreased visual acuity (63%), visual blurring (40%), ocular pain (18%), scotoma (13%), and headaches (4%). The uveitis was site: anterior (30%), intermediate (6%), posterior (32%), and pan-uveitis (32%); unilateral in 80% of patients and bilateral in 20%. The etiologies of uveitis in HIV+ were: 3 cases of CMV, 2 cases of toxoplasmosis, 1 case of tuberculosis, 1 case of HSV, 1 case of VZV, and 1 case of syphilis. Etiologies of immunocompetent patients: tuberculosis (41%), toxoplasmosis (18%), syphilis (15%), CMV infection (4 cases: 10%), HSV infection (4 cases: 10%) , lepromatous uveitis (1 case: 2%), VZV infection (1 case: 2%), a locoregional infectious cause such as dental abscess (1 case: 2%), and one case of borreliosis (3% ). 50% of tuberculous uveitis was of the pan-uveitis type, 75% of the uveitis by toxoplasmosis was of the posterior type. Uveitis was associated with other pathologies in 2 seropositive cases (cerebral vasculitis, multifocal tuberculosis). A specific treatment was prescribed in all patients. The initial evolution was favorable in 67%, including 12% HIV+. 11% presented relapses of the same seat during uveitis of the toxoplasmic, tuberculous and herpetic type. 47% presented complications, of which 4 patients were HIV+: 3 retinal detachments; 7 Retinal hemorrhages. 6 unilateral blindness (including 2 HIV+ patients). Conclusion: In our series, the etiologies of infectious uveitis differ between HIV+ and HIV- patients. In HIV+ patients most often had toxoplasmosis and CMV, while HIV - patients mainly presented with tuberculosis and toxoplasmosis. The association between HIV and uveitis is undetermined, but HIV infection was an independent risk factor for uveitis.

Keywords: uveitis, HIV, immunosuppression, infection

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Authors: Angelis P. Barlampas

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Purpose of Learning Objective: This case depicts the need for cooperation between the emergency department and the radiologist to achieve the best diagnostic result for the patient. The clinical picture must correlate well with the radiology report and when it does not, this is not necessarily someone’s fault. Careful interpretation and good knowledge of the limitations, advantages and disadvantages of each imaging procedure are essential for the final diagnostic goal. Methods or Background: A patient was brought to the emergency department by their relatives. He was suddenly confused and his mental status was altered. He hadn't any history of mental illness and was otherwise healthy. A computing tomography scan without contrast was done, but it was unremarkable. Because of high clinical suspicion of probable neurologic disease, he was admitted to the hospital. Results or Findings: Another T was done after 48 hours. It showed a hypodense region in both thalamic areas. Taking into account that the first CT was normal, but the initial clinical picture of the patient was alerting of something wrong, the repetitive CT exam is highly suggestive of a probable diagnosis of bilateral thalamic infractions. Differential diagnosis: Primary bilateral thalamic glioma, Wernicke encephalopathy, osmotic myelinolysis, Fabry disease, Wilson disease, Leigh disease, West Nile encephalitis, Greutzfeldt Jacob disease, top of the basilar syndrome, deep venous thrombosis, mild to moderate cerebral hypotension, posterior reversible encephalopathy syndrome, Neurofibromatosis type 1. Conclusion: As is the case of limitations for any imaging procedure, the same applies to CT. The acute ischemic attack can not depict on CT. A period of 24 to 48 hours has to elapse before any abnormality can be seen. So, despite the fact that there are no obvious findings of an ischemic episode, like paresis or imiparesis, one must be careful not to attribute the patient’s clinical signs to other conditions, such as toxic effects, metabolic disorders, psychiatric symptoms, etc. Further investigation with MRI or at least a repeated CT must be done.

Keywords: CNS, CT, thalamus, emergency department

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Authors: Vasundhara Arora, Anupam Jhobta, Suresh Thakur, Sanjiv Sharma

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Aims and Objectives: Intracranial tuberculosis (TB) is one of the most devastating manifestations of TB and a challenging public health issue of considerable importance and magnitude world over. This study elaborates on the imaging spectrum of neurotuberculosis on magnetic resonance imaging (MRI) in 29 clinically suspected cases from a tertiary care hospital. Materials and Methods: The prospective hospital based evaluation of MR imaging features of neuro-tuberculosis in 29 clinically suspected cases was carried out in Department of Radio-diagnosis, Indira Gandhi Medical Hospital from July 2017 to August 2018. MR Images were obtained on a 1.5 T Magnetom Avanto machine and were analyzed to identify any abnormal meningeal enhancement or parenchymal lesions. Microbiological and Biochemical CSF analysis was performed in radio-logically suspected cases and the results were compared with the imaging data. Clinical follow up of the patients started on anti-tuberculous treatment was done to evaluate the response to treatment and clinical outcome. Results: Age range of patients in the study was between 1 year to 73 years. The mean age of presentation was 11.5 years. No significant difference in the distribution of cerebral tuberculosis was noted among the two genders. Imaging findings of neuro-tuberculosis obtained were varied and non specific ranging from lepto-meningeal enhancement, cerebritis to space occupying lesions such as tuberculomas and tubercular abscesses. Complications presenting as hydrocephalus (n= 7) and infarcts (n=9) was noted in few of these patients. 29 patients showed radiological suspicion of CNS tuberculosis with meningitis alone observed in 11 cases, tuberculomas alone were observed in 4 cases, meningitis with parenchymal tuberculomas in 11 cases. Tubercular abscess and cerebritis were observed in one case each. Tuberculous arachnoiditis was noted in one patient. Gene expert positivity was obtained in 11 out of 29 radiologically suspected patients; none of the patients showed culture positivity. Meningeal form of the disease alone showed higher positivity rate of gene Xpert (n=5) followed by combination of meningeal and parenchymal forms of disease (n=4). The parenchymal manifestation of disease alone showed least positivity rates (n= 3) with gene xpert testing. All 29 patients were started on anti tubercular treatment based on radiological suspicion of the disease with clinical improvement observed in 27 treated patients. Conclusions: In our study, higher incidence of neuro- tuberculosis was noted in paediatric population with predominance of the meningeal form of the disease. Gene Xpert positivity obtained was low due to paucibacillary nature of cerebrospinal fluid (CSF) with even lower positivity of CSF samples in parenchymal form of the manifestation. MRI showed high accuracy in detecting CNS lesions in neuro-tuberculosis. Hence, it can be concluded that MRI plays a crucial role in the diagnosis because of its inherent sensitivity and specificity and is an indispensible imaging modality. It caters to the need of early diagnosis owing to poor sensitivity of microbiological tests more so in the parenchymal manifestation of the disease.

Keywords: neurotuberculosis, tubercular abscess, tuberculoma, tuberculous meningitis

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Authors: Vaibhavi Birle

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Posterior reversible encephalopathy syndrome is a rare clinic-radiological syndrome associated with acute changes in blood pressure during pregnancy. It is characterized symptomatically by headache, seizures, altered mental status, and visual blurring with radiological changes of white matter (vasogenic oedema) affecting the posterior occipital and parietal lobes of the brain. It is being increasingly recognized due to increased institutional deliveries and advances in imaging particularly magnetic resonance imaging (MRI). In spite of the increasing diagnosis the prediction of PRES and patient factors affecting susceptibility is still not clear. Hence, we conducted the retrospective study to analyse the factors associated with PRES at our tertiary centre.

Keywords: pres syndrome, eclampsia, maternal outcome, fetal outcome

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Authors: Merrick Lopez, Aashish Abraham, Melissa Egge, Marissa Hood, Jui Shah

Abstract:

A 3 year old male with unknown medical history presented initially with encephalopathy, intubated for respiratory failure, and admitted to the pediatric intensive care unit (PICU) with refractory shock. During resuscitation in the emergency department, he was found to be in severe metabolic acidosis with a pH of 7.03 and escalated on vasopressor drips for hypotension. His initial sodium was 174. He was noted to have burn injuries to his scalp, forehead, right axilla, bilateral arm creases and lower legs. He had rhabdomyolysis (initial creatinine kinase 5,430 U/L with peak levels of 62,340 normal <335 U/L), cardiac injury (initial troponin 88 ng/L with peak at 145 ng/L, normal <15ng/L), hypernatremia (peak 174, normal 140), hypocalcemia, liver injury, acute kidney injury, and neuronal loss on magnetic resonance imaging (MRI). Soft restraints and a shock collar were found in the home. He was critically ill for 8 days, but was gradually weaned off drips, extubated, and started on feeds. Discussion Electrical injury, specifically lightning injury is an uncommon but devastating cause of injury in pediatric patients. This patient with suspected abusive use of a dog shock collar presented similar to a lightning strike. Common entrance points include the hands and head, similar to our patient with linear wounds on his forehead. When current enters, it passes through tissues with the least resistance. Nerves, blood vessels, and muscles, have high fluid and electrolyte content and are commonly affected. Exit points are extremities: our child who had circumferential burns around his arm creases and ankles. Linear burns preferentially follow areas of high sweat concentration, and are thought to be due to vaporization of water on the skin’s surface. The most common cause of death from a lightning strike is due to cardiopulmonary arrest. The massive depolarization of the myocardium can result in arrhythmias and myocardial necrosis. The patient presented in cardiogenic shock with evident cardiac damage. Electricity going through vessels can lead to vaporization of intravascular water. This can explain his severe hypernatremia. He also sustained other internal organ injuries (adrenal glands, pancreas, liver, and kidney). Electrical discharge also leads to direct skeletal muscle injury in addition to prolonged muscular spasm. Rhabdomyolysis, the acute damage of muscle, leads to release of potentially toxic components into the circulation which could lead to acute renal failure. The patient had severe rhabdomyolysis and renal injury. Early hypocalcemia has been consistently demonstrated in patients with rhabdomyolysis. This was present in the patient and led to increased vasopressor needs. Central nervous system injuries are also common which can include encephalopathy, hypoxic injury, and cerebral infarction. The patient had evidence of brain injury as seen on MRI. Conclusion Electrical injuries due to lightning strikes and abusive use of a dog shock collar are rare, but can both present in similar ways with respiratory failure, shock, hypernatremia, rhabdomyolysis, brain injury, and multiorgan damage. Although rare, it is essential for early identification and prompt management for acute and chronic complications in these children.

Keywords: cardiogenic shock, dog shock collar, lightning strike, rhabdomyolysis

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Authors: Rabab Makki, Deputy Chief Dietitian

Abstract:

Malnutrition is commonly seen in Liver Disease patients. Prevalence of malnutrition in cirrhosis, is as high as 65-90%. Protein depletion and reduced muscle function are common. There are many mechanisms of malnutrition in liver cirrhosis e.g. insulin resistance, low respiratory quotient, increased glucogenesis etc. Nutrition support improves outcome in patients unable to maintain an intake of 35-40 Kcal/kg and 1.2-1.5 gm/kg/day. Simple methods of assessment such as subjective global assessment, calorie counting, MMC are useful. The value of BCAAs remains uncertain despite a considerable number of studies. Normal protein diets have been given safely to patients with hepatic encephalopathy. Restriction of protein not more than 48 hours pre- and pro-biotic, glutamine, fish oil etc are all part of the latest advanced techniques used.

Keywords: liver cirrhosis, omega 3 for liver disease, nutrition management, malnutrition

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Authors: Mohsen Shirani, Micaela Demichela

Abstract:

During the last decades, a number of food crises such as Bovine Spongiform Encephalopathy (BSE), Mad-Cow disease, Dioxin in chicken food, Food-and-Mouth Disease (FMD), have certainly inflicted the reliability of the food industry. Consequently, the trend in applying different scientific methods of risk assessment in food safety has obtained more attentions in the academic and practice. However, lack of practical approach considering entire food supply chain is tangible in the academic literature. In this regard, this paper aims to apply risk assessment tool (FMEA) with integration of Human Factor along the entire supply chain of food production and test the method in a case study of Diary production, and analyze its results.

Keywords: FMEA, food supply chain, risk assessment, human factor

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Authors: Wu Liching

Abstract:

Aim This case aims to discuss the pathogenesis, clinical manifestations and medical treatment of strokes caused by mitochondrial gene mutations. Methods Diagnosis of ischemic stroke caused by mitochondrial gene defect by means of "next-generation sequencing mitochondrial DNA gene variation detection", imaging examination, neurological examination, and medical history; this study took samples from the neurology ward of a medical center in northern Taiwan cases diagnosed with acute cerebral infarction as the research objects. Result This case is a 49-year-old married woman with a rare disease, mitochondrial gene mutation inducing ischemic stroke. She has severe hearing impairment and needs to use hearing aids, and has a history of diabetes. During the patient’s hospitalization, the blood test showed that serum Lactate: 7.72 mmol/L, Lactate (CSF) 5.9 mmol/L. Through the collection of relevant medical history, neurological evaluation showed changes in consciousness and cognition, slow response in language expression, and brain magnetic resonance imaging examination showed subacute bilateral temporal lobe infarction, which was an atypical type of stroke. The lineage DNA gene has m.3243A>G known pathogenic mutation point, and its heteroplasmic level is 24.6%. This pathogenic point is located in MITOMAP and recorded as Mitochondrial Encephalopathy, Lactic Acidosis, and Stroke-like episodes (MELAS) , Leigh Syndrome and other disease-related pathogenic loci, this mutation is located in ClinVar and recorded as Pathogenic (dbSNP: rs199474657), so it is diagnosed as a case of stroke caused by a rare disease mitochondrial gene mutation. After medical treatment, there was no more seizure during hospitalization. After interventional rehabilitation, the patient's limb weakness, poor language function, and cognitive impairment have all improved significantly. Conclusion Mitochondrial disorders can also be associated with abnormalities in psychological, neurological, cerebral cortical function, and autonomic functions, as well as problems with internal medical diseases. Therefore, the differential diagnoses cover a wide range and are not easy to be diagnosed. After neurological evaluation, medical history collection, imaging and rare disease serological examination, atypical ischemic stroke caused by rare mitochondrial gene mutation was diagnosed. We hope that through this case, the diagnosis of rare disease mitochondrial gene variation leading to cerebral infarction will be more familiar to clinical medical staff, and this case report may help to improve the clinical diagnosis and treatment for patients with similar clinical symptoms in the future.

Keywords: acute stroke, MELAS, lactic acidosis, mitochondrial disorders

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Authors: S. Ibrahim, U. B. Abubakar, S. Danbirni, A. Usman, F. M. Ballah, C. A. Kudi, L. Lawson, G. H. Abdulrazak, I. A. Abdulkadir

Abstract:

Performing culture and characterization of mycobacteria in low resource settings like Nigeria is a very difficult task to undertake because of the very few and limited laboratories carrying out such an experiment; this is a largely due to stringent and laborious nature of the tests. Hence, a rapid, simple and accurate test for characterization is needed. The “SD BIOLINE TB Ag MPT 64 Rapid ®” is a simple and rapid immunochromatographic test used in differentiating Mycobacteria into Mycobacterium tuberculosis (NTM). The 100 sputa were obtained from patients suspected to be infected with tuberculosis and presented themselves to hospitals for check-up and treatment were involved in the study. The samples were cultured in a class III Biosafety cabinet and level III biosafety practices were followed. Forty isolates were obtained from the cultured sputa, and there were identified as Acid-fast bacilli (AFB) using Zeihl-Neelsen acid-fast stain. All the isolates (AFB positive) were then subjected to the SD BIOLINE Analyses. A total of 31 (77.5%) were characterized as MTBC, while nine (22.5%) were NTM. The total turnaround time for the rapid assay was just 30 minutes as compared to a few days of phenotypic and genotypic method. It was simple, rapid and reliable test to differentiate MTBC from NTM.

Keywords: culture, mycobacteria, non tuberculous mycobacterium, SD Bioline

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Authors: Mohammed A. Alfayyadh, Halla A. AlAbdulhadi, Mahdi H. Almubarak

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Purpose: Eales’ disease is an idiopathic vasculitis that affects the peripheral retina. It is characterized by recurrent vitreous hemorrhage as a complication of retinal neovascularization. It is more prevalent in India and affects young males. Here we present a patient with neovascular glaucoma as a rare first presentation of Eales’ disease. Observations: This is a 24-year-old Indian gentleman, who complained of a sudden decrease in vision in the left eye over less than 24 hours, along with frontal headache and eye pain for the last three weeks. Ocular examination revealed peripheral retinal ischemia in the right eye, very high intraocular pressure, rubeosis iridis, vitreous hemorrhage and extensive retinal ischemia in the left eye, vascular sheathing and neovascularization in both eyes. Purified protein derivative skin test was positive. The patient was managed with anti-glaucoma, intravitreal anti-vascular endothelial growth factor and laser photocoagulation. Systemic steroids and anti-tuberculous therapy were also initiated. Conclusions: Neovascular glaucoma is an infrequent complication of Eales’ disease. However, the lack of early detection of the disease in the early stages might lead to such serious complication.

Keywords: case report, Eales’ disease, mycobacterium tuberculosis, neovascular glaucoma

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Authors: Carl Eiselen, Stephen O’Hagan

Abstract:

Background: Q fever, caused by the obligate intracellular bacterium Coxiella burnetii, is an infectious disease with variable systemic manifestations. Its potential to cause ocular complications has not been reported before in Australia. This case study explores the unusual presentation of asymptomatic acute multifocal retinitis (AMR) in a patient with acute Q fever endocarditis and hepatitis in rural Queensland, Australia. Case Presentation: A 48-year-old male gardener presented with flu-like symptoms, weight loss, and encephalopathy. Despite systemic malaise, he had no ocular symptoms. Laboratory investigations confirmed acute Q fever, and imaging studies identified hepatic involvement and endocarditis. The retinal screening revealed asymptomatic AMR, corroborated by fundus examination and SD-OCT. Following treatment with Doxycycline and hydroxychloroquine, both systemic and ocular manifestations improved. Discussion: This is the first documented case of asymptomatic AMR associated with Q fever. The patient’s lack of autoantibodies challenges the established understanding of Q fever endocarditis and suggests potential alternative mechanisms. Conclusion: This case report expands our understanding of the multi-systemic impact of Q fever, highlighting the need for comprehensive clinical evaluation and including retinal screening in the setting of acute infection. The disease's underlying mechanism for ocular involvement is not yet established.

Keywords: Coxiella Burnetti, Q fever, ocular manifestation, acute multifocal retintis, endocarditis

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Authors: Abu Salim Mustafa

Abstract:

The comparisons of mycobacterial genomes have identified several Mycobacterium tuberculosis-specific genomic regions that are absent in other mycobacteria and are known as regions of differences. Due to M. tuberculosis-specificity, the peptides encoded by these regions could be useful in the specific diagnosis of tuberculosis. To explore this possibility, overlapping synthetic peptides corresponding to 39 proteins predicted to be encoded by genes present in regions of differences were tested for antibody-reactivity with sera from tuberculosis patients and healthy subjects. The results identified four immunodominant peptides corresponding to four different proteins, with three of the peptides showing significantly stronger antibody reactivity and rate of positivity with sera from tuberculosis patients than healthy subjects. The fourth peptide was recognized equally well by the sera of tuberculosis patients as well as healthy subjects. Predication of antibody epitopes by bioinformatics analyses using ABCpred server predicted multiple linear epitopes in each peptide. Furthermore, peptide sequence analysis for sequence identity using BLAST suggested M. tuberculosis-specificity for the three peptides that had preferential reactivity with sera from tuberculosis patients, but the peptide with equal reactivity with sera of TB patients and healthy subjects showed significant identity with sequences present in nob-tuberculous mycobacteria. The three identified M. tuberculosis-specific immunodominant peptides may be useful in the serological diagnosis of tuberculosis.

Keywords: genomic regions of differences, Mycobacterium tuberculossis, peptides, serodiagnosis

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Authors: Jeffey George, Varghese Thomas

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Background and Objectives: PHG is an important source of gastrointestinal bleeding in patients with portal hypertension. Aim: To assess the progression to severe portal hypertensive gastropathy(PHG) in patients with cirrhosis who were treated with maximum tolerated dose of propranalol, after variceal eradication to grade II or below. Methods: Cirrhotic patients(child A and B) presenting with upper gastrointestinal bleeding with endoscopic findings of mild or no PHG were followed up over 6 months after variceal eradication to assess the progression to severe PHG. Included patients were randomised to either maximum tolerated doses of propranalol (group A) or to no treatment (group B). Primary end point of the study were the development of gastrointestinal bleed, evidence of hepatic decompensation and death. Progression to severe PHG were compared between the two groups. Results: 56 patients (49 males) were enrolled (group A = 28, group B = 28). 8 patients were excluded from final analysis (gi bleed=5, encephalopathy=2,HCC=1 including 4 deaths).3 patients were lost to follow-up, and 1 developed intolerance to propranalol. Mean dose of propranalol used was 60 mg per day. Progression to severe PHG in the fundus over 6 months was 23.8% in group A versus 15.8 % in group B (p = 0.52). Severe PHG was noted in body in 14.3% in group A versus 21.1% in group B (p = 0.57). 23.8 % in group A had progression to severe PHG compared with 15.8 % in group B (p =0.52). There was no statistically significant difference in the progression of PHG between the two groups(p=0.43). Conclusion: In this short term study propranalol was found not to prevent the progression to severe portal hypertensive gastropathy in cirrhotic patients who had undergone endotherapy for esophageal varices.

Keywords: propranalol, portal hypertensive gastropathy, cirrhotic patients, gastroenterology

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Authors: Samir Kumar Pal

Abstract:

Background: Targeted rapid degradation of bilirubin has the potential to thwart incipient bilirubin encephalopathy. Uncontrolled hyperbilirubinemia is a potential problem in developing countries, including India, because of the lack of reliable healthcare institutes for conventional phototherapy. In India, most of the rural subjects duel in the exchange limit during transport, leading to a risk of kernicterus when they arrive at the treatment centre. Thus, an alternative pharmaceutical agent is needed for the hours. Objective: Exploration of a distinct therapeutic strategy for the control of neonatal hyperbilirubinemia compared to conventional phototherapy in a clinical setting. Method: We synthesized, characterized and investigated a spinel-structured Manganese citrate nanocomplex (C-Mn₃O₄ NC, the nanodrug) along with conventional phototherapy in neonatal subjects. We have also observed BIND scores in order to assess neurological dysfunctions. Results: Our observational study clearly reveals that the rate of declination of bilirubin in neonatal subjects with nanodrug oral administration and phototherapy is faster compared to that in the case of phototherapy only. The associated neural dysfunctions were also found to be significantly lower in the case of combined therapy. Conclusion: This study demonstrates that combined therapy works better than conventional phototherapy only for the control of hyperbilirubinemia. We have observed that a significant portion of neonatal subjects requiring blood exchange has been prevented with the combined therapeutic strategy. Further compilation of a drug-safety-dossier is warranted to translate this novel therapeutic chemo preventive approach to clinical settings.

Keywords: nanodrug, nanoparticle, Neonatal hyperbilirubinemia, alternative to phototherapy, redox modulation, redox medicine

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