AN UNUSAL CASE OF SPINAL NEUROCYSTICERCOSIS-A CASE REPORT
Posted by on Thursday, 22nd July 2010
INTRODUCTION:-
Neurocysticercosis is most common parasitic infestation of CNS1. The incidence of spinal involvement is 1.5-3%4.Spinal neurocysticercosis usually appear due to mass effect. Most cases occur in subarachnoid space but intra medullary location is extremely rare1. Here we report a case of intramedullary neurocysticercosis (reported about 50 cases sofar) 4 and discuss the disease.
KEY WORDS:-
Neurocysticercosis (NCC), Spinal neurocysticercosis (SNCC), intra medullary, Tinea Solium, MRI.
CASE REPORT:-
A 26 year named BC , from Salepur presented to this hospital in June 2008 with c/o of head ache & neck pain(1 month), numbness of right side of face(15 days),inability to hold objects properly in right hand (15days).He was alright 1 month back. Started with continuous headache relieved with analgesics, without associated vomiting, nasal stuffiness or blurring of vision. After 15 days he developed numbness of right side of face & noticed weakness of right hand which gradually progressed so that he could not hold any object properly. There was no history of fever, root pain, or convulsion. There was no bladder or bowel involvement. There was no h/o Diabetes, trauma, hypertension or tuberculosis. Family history was not suggestive. He was not habituated to alcohol or smoking. There was no contact history& he was unmarried.
On examination he was of average built having BP- 130/80 mm of Hg; pulse 68/ min, regular; without pallor, jaundice or lymphadenopathy.
CNS examination revealed patient to be conscious with normal higher functions including speech. All the cranial nerves were intact except diminished pain sensation on right side of face. Motor system showed normal bulk with increased tone of muscles in legs & arms. Power was grade V in both lower limbs but grade IV in both upper limbs. Hand grip was weak on both sides, right >left. Bicep & triceps reflexes were exaggerated on both sides with normal supinators. Knee & ankle jerks on both sides were exaggerated. Plantar was extensor on right but flexor on left. Sensory system was normal. Skull & spine was normal without any meningeal or cerebellar signs. Fundus was normal.
Other systems like CVS, GIT, respiratory did not reveal any abnormalities.
Routine investigations like Hb%, DC, TLC, FBS, urea, creatinine serum K+, Na+ were normal. ESR was 25/1st hour & Mx was negative. Chest X-ray & cervical spine X’ray were normal. CSF study was normal. MRI of brain & spinal cord showed ring enhancing tiny lesions at cervico medullary junction inside the medullary central canal with consequent syrinx formation..(Figure-1,Figure-2) Anticystocercal antibody was positive.
A young male presenting with gradual onset of assymetrical weakness of upper & lower limbs, with headache & diminished pain sensation of right side of face without significant involvement of lower limbs with features of UMN involvement in the form of hypertonia & hyper reflexia of all limbs below C4 without sensory level a provisional diagnosis of high cervical cord compression ( intramedullary) was thought of, probably involving trigeminothalamic tract(right) & corticospinal tract below pyramid (right). With the investigations the patient was diagnosed as a case of SNCC with obstructive syringomyelia.
The patient was treated with Albendazole 400 mg twice daily for 28 days with oral prednisolone in tapering dose.In the next followup after one month he complained of progressive weakness of upper limbs with no response to Albendazole.Hence he was advised for neurosurgical consultation for excision of the cyst.
DISCUSSION:-
Neurocysticerosis is the most common parasitic infestation of CNS caused by ingestion of eggs of Taenia Solium3.T.Solium has its definite host in human being where adult worm stays in intestine laying eggs which are taken by pigs who are intermediate hosts. The embryo cross the intestine and reside in CNS, muscles, eyes and skin as cysticerci.Human beings have the disease when they ingest the eggs instead of Pigs. The eggs hatch in the intestine and develop into cysticerci in the above mentioned organs.
Usual organs involved in Neurocysticerosis are brain, eye, subcutaneous tissues.Common presentation of cysticerosis of brain are headache, seizure and focal neurological deficit.
Spinal neurocysticerosis is a rare presentation; the incidence ranging from 0.7-5.85%1,3.Spinal forms have been identified in vertebral, extradural, intradural, intramedullary regions.Intramedullary cysticerosis is very uncommon1. Migration of the cysticercus through the ventriculo-ependyal pathway and haematogeneous dissemination has been identified as pathogenic mechanism1,4.
In absence of previous history or subcutaneous nodule it may be difficult to suspect clinically intramedullary cysticerosis.High eosinophil count with soft tissue calcification though suggestive is rare.Result of surgery has not been encouraging due to parenchymal gliosis as a result of toxic waste from larva, pachymeningitis and vascular insufficiency.
But in the era of microsurgery good outcome has been reported. Medical treatment of intramedullary lesions can be considered in patients of stable neurological status but impossible in acute or progressive cases.Post operative anticerceal drugs should be given as it is a generalized disease with focal manifestation1.
SNCC is rare compared to intracranial as cysticerci do not pass through subarachnoid space at cervical level due to its size(sieve effect).Besides CSF reflux at craniovertebral junction propels floating cysts back into intracranial space than spinal canal.
Several possible mechanisms of spinal invasion are:-
(a)Ventricular cysticerci pass through Magendie or Luschka foramen, migrate by gravity through subarachnoid space to inoculate spinal cord commonly cervical region.
(b)Haematogeneous spread explain intramedullary lesion,commonly thoracic area due to increased blood flow.(c) Intraventricular hypertension enables migration through a dilated ependymal canal into spinal cord explaining intramedullary invasion.Other favorable conditions favoring spinal invasion may be due to NCC-related hydrocephalus and/or meningitis, use of antiepileptic drugs like Carbamazepine or Phenytoin which can after immune function leading to parasitic infestation3.
The location of mass lesion, its size, the inflammatory response generated by cyst breakdown are important factors for management.Brain blood flow is 100fold greater than spinal explaining more intraventricular lesion.In spinal form thoracic region having more blood flow explains high incidence.The location of cysticerci is cervical - 34%,thoracic -44.5%, lumbar -15.5% and sacral- 6%.MRI is the investigation of choice.
Concurrent intracranial lesion are seen in spinal involvement. As long as cysticercus is viable there is relative host immune tolerance. Massive antigen response occurs with death of parasite with intensification of immune/inflammatory response.Surgery is required for diagnosis and treatment though outcome is mixed. Albendazole or Praziquantel with or without steroid are used. Albendazole is preferred as blood level are increased with steroid.Spinal intramedullary cysticercosis represents a challenge for diagnosis & surgery. Patient recovery is variable. Despite promising reports the safety and efficacy of medical treatment remains unproved4.
REFERENCE
1. Singh P, Sahai K.-Intramedullary cysticercosis.Neurol India 2004;52:264-5
2. Mohanty A.Venkatrama SK, Das BS,Rao BR,Vasudev MK -Spinal Intramedullary cysticercosis-Neurosurgery.1997; Jan 40(1):82-7
3.Dong Ah Shin & Hyun Chul Shin-Yonsei Med.J.2009,Aug 31;50(4):582-584.
A case of extensive spinal cysticercosis involving whole spinal canal with a h/o cerebral cysticercosis.
4.Agarwal R,Chauhan SPS, Mishra V, Singh PA,Gopal NN-Acta biomed 2008;79,39-41
Focal spinal intramedullary cysticercosis.
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TITLE : STUDY OF SERUM MAGNESIUM AND CALCIUM STATUS IN HYPOKALEMIC DISORDERS
Posted by on Thursday, 22nd July 2010
AIM OF THE STUDY:
Primary 1. Association of serum Ca++, Mg++ level in cases of hypokalemic disorder.
Secondary 2. Response of treatment with potassium supplementation and Mg++ and Ca++ requirement.
MATERIAL AND METHOD:
Fifty cases of hypokalemia, most of them having history of hypokalemic periodic palsy, were taken for study, in department of medicine for November 2003 to April 2005. Detail clinical history, physical examinations and routine laboratory investigations done including mandatory serum Na+, K+, Ca++, Mg++. The laboratory investigation of serum electrolytes were repeated after 2-3 days of K+ supplementation and in resistant hypokalemic cases with magnesium deficiency, Mg++ supplementation was given first and then Ca++ supplementation in combined Ca++ deficiency cases.
OBSERVATION:
Out of the 50 patients, 25% were males (30-60 years), 40% were females 18-40 years. Commonest presentation were paraplegia (75%), Quadriplegia (25%), vomiting (20%), Hicough (4%), Tetany (2%), Bradycardia (6%), Paralytic ileus (2%) and various ECG changes ie. U wave, increased PR interval, decreased T wave etc. Most of the patients belonged to low socio-economic status and most of them were physical labourers. In moderate to severe hypokalemia, hypomagnesemia was commonly present ( 64%) and hypocalcaemia (28%). Most of these cases responded to K+ supplementation but in some cases with severe hypokalemia associated with hypomagnesemia and hypocalcaemia were resistant to K+ supplementation. In these cases long with K+ , Mg+ supplementation was given, after which patients responded rapidly and satisfactorily. Dramatic improvement was seen in the power of limbs after supplementation of K+. However n 6% patients no significant improvement was seen after 2-3 days and Mg+ was supplemented orally after which there was improvement in power of limbs and serum K+ level rapidly.
Hypokalemia Hypomagnesemia Hypocalcemia
Mild (3.0-3.5 meq/l) 3(6%) 0(0%)
Moderate (2.5 – 3.0 meq/l) 7(14%) 6(12%)
Severe(<2.5 meq/l) 22(44%) 8(16%)
(Incidence of Hypomagnesemia and hypocalcemia according to severity of hypokalemia)
CONCLUSION:
It was observed that in hypokalemic disorders there is derangement of other electrolytes (i.e Serum , Mg++, Ca++). In moderate to severe hypokalemia estimation of serum Mg++ and Ca++ is mandatory and Mg++ replacement should be done after K+ supplementation and before Ca++ supplementation in combined electrolyte disorders to avoid arrythmia.
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STUDY OF SERUM LIPOPROTEIN (A) AS A ARISK FACTOR IN
Posted by on Thursday, 22nd July 2010
AIMS AND OBJECTIVES:
Lp (a) a cholesterol ester rich LDL like particle that contains apo B 100 linked by disulphide bridge to a highly polymorphic glycoprotein  apolipoprotein. Lp(a) has both atherogenic and thrombogenic properties. In this study serum Lp(a) of Coroanry artery disease patients were correlated with of controls to find out any correlation between Lp(a) and Coronary Artery Disease.
MATERIALS AND METHODS:
In the present study 50 percent of cases of newly detected Coronary artery disease with various presentations of acute coronary syndrome (ACS) like unstable angina, NSTEMI & STEMI were taken. Cases were confirmed by clinical criteria, ECG and increased cardiac markers. Lp(a) level was estimated by Nephelometric method. Sample taken either within 6 hours of onset of symptoms or after 28 days of onset of symptoms. 30 suitably age and sex matched controls were taken having no evidence of coronary artery disease and their Lp(a) level estimated. Serum lipid profile (TG, Cholesterol, VLDL, LDL, HDL) were also estimated.
OBSERVATION:
The mean age of the patients in the study was 55.4 years (45-70 years). Anteroseptal MI was predominate (42%) followed by inferior wall MI (28%), anterolateral MI (26%), inferior & RV MI in 4%. Distribution of different risk factors were smoking in 52%, DM in 12%, hypertension in 24%, family history of CAD in 13%, hypercholesterolemia in 24% and hypertriglyceridemia in 17%. In the present study the mean serum Lp(a) in cases was (28.86.0 mg/dl) and the control group was (18.34.0mg/dl) with P value < 0.01).
CONCLUSION:
Patients of coronary artery disease group had significantly higher level of Lp(a) in comparison to controls without coronary artery disease establishing the role of serum Lp(a) as an independent risk factor for coronary artery disease.
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ACUTE INFLAMATORY DEMYELINATING POLYNEUROPATHY (AIDP) FOLLOWING PLASMODIUM FALCIPARUM – A RARE CASE REPORT
Posted by on Thursday, 22nd July 2010
INTRODUCTION:
AIDP following Malaria is a rare clinical presentation. Few cases have been reported so far from India and abroad. It is usually acute onset with rapidly developing areflexic ascending motor paralysis with or without sensory disturbances. Though various mechanisms are postulated it is more likely immunogenic. It responds to I/V immunoglobulin along with anti malarial therapy. Early therapeutic measures lead to good prognosis.
CASE REPORT:
A 16years boy admitted on 18.06.2006 with sudden weakness of all four limbs following 2 days of fever with chill and rigor. Detected to be Falciparum malaria (slide test) and treated locally with chloroquin referred to this hospital.
On admission the patient was febrile, conscious with mild pallor. Other vital signs were normal. Respiratory, CVS and Gastrointestinal system were normal. Neurological examination revealed normal higher intellectual functions without any cranial nerve involvement or pupillary abnormality. Motor examination showed normal bulk and tone of all muscles. Power in both U/L were 3/5 in proximal and 4/5 in distal groups including handgrip weakness. Power in both lower limbs were 2/5 around hip and 3/5 around knee, ankle and feet. There was no abnormal movement. Deep tendon reflexes were absent in all four limbs. Plantar was nonresponsive. All superficial reflexes were absent. Sensory system, autonomic nervous systems were normal without bladder and bowel involvement.
Routine blood examination findings showed Hb- 9gm%, ICT for malaria- PFR ++ and DC, TLC, ESR were normal. Serum electrolytes, urea, creatinine, FBS, and LFT were normal. Chest X-Ray, X-Ray of L.S. Spine and USG of abdomen and pelvis were normal. CSF picture was normal. Nerve conduction study of both median, ulnar and common peroneal nerves revealed gross reduction in amplitude and motor nerve conduction velocity, with prolonged distal latency, and absence of F waves. Sensory was absent in all the nerves.
The patient was treated with full course of injection Artesunate and IV immunoglobulin 24g/day for 5 days. The patient improved after 3 days of completion of immunoglobulin. The patient was discharged in 10th day of admission after fully recovery.
DISCUSSION:
AIDP is seen following viral (herpes virus, CMV, E-B virus etc) bacterial (Campilobacter jejuni, Mycoplasma) or immunization. But it is uncommon following parasitic infection like malaria. It is important to rule out other neurological syndromes that may be unmasked by febrile illness. The pathogenesis of AIDP following malaria is not known. This is possibly to be immunogenic like that occur after viral or bacterial infection. Other possible mechanisms of polyneuropathy may be due to parasitic emboli obstructing vasa nervosum, release of neurotoxins, associated metabolic and nutritional disturbances, immune mediated capillary damage, and release of free radicals and tumor necrosis factors.
AIDP is a variant of GBS encountered rarely following malaria (few case reports after Vivax, Falciparum). Early institution of I/V immunoglobulin results full recovery. Steroid has no role.
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STUDY OF ELECTROCARDIOGRAPHS CHANGES IN SMEAR POSITIVE PULMONARY TB
Posted by on Thursday, 22nd July 2010
AIM OF STUDY:
Cardiac involvement is a well established fact in extensive pulmonary tuberculosis. However, there are few references available in this regard to throw light on the early stages of tuberculosis.
Keeping this in mind the present study was undertaken in the Dept. of Medicine and TB & Resp. Diseases of V.S.S. Medical College, Burla to observe.
1. The Electrocardiographic changes at the time of diagnosis of pulmonary tuberculosis.
2. The effect of ATT on ECG changes.
3. The possible cause of reversibility.
MATERIALS & METHODS :
Selection of patients included all sputum positive pulmonary tuberculosis during 3 years period. Patients having pre-existing cardiac disease, under cardiac glycosides, severe anaemia, pregnancy were excluded from the present study. Patients having other respiratory disorder or any pleural complications were also not included.
RESULTS:
90 cases were taken up in the present study out of which sinus tachycardia (66.6*), sinus bradycardia (4.44%), low voltage & afcjnomial axis (13.3%), S.T. segment depression (11.11%). RVH (8.88%), T. inversion (8.8b%), SSS Syndrome (6.6%) cases were observed.
CONCLUSION:
The exact mechanism of ECG changes is unknown. However the possible explanation could be fever, toxaemia, Broody's effect, direct myocardial involvement, tymphadenopathy causing irritation of uonomic nerve fibres in the hilum and consequent altered sympathetic tone. Above conditions revert with ATT therapy and hence ECG abnormalities also disappear.
Possible explanation for persistence of ECG abnormalities is attributed to positional disturbances of heart and mediastinum secondary to pulmonary fibrosis in extensive diseases.
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