A 20-year-old male patient is presented as a case of trichinous myocarditis with clinical symptoms and electrocardiographic evidence of an acute inferior myocardial infarction. He recovered rapidly and completely without any specific therapy. This seems to be a distinct rarity, having never been previously reported, but is of importance because of the almost uniformly excellent prognosis in this condition in contradistinction to that of a bona fide myocardial infarction occurring at this age.
The established serological tests for trichinosis are often negative during the period when laboratory investigation is most likely to be useful.
Another serological test, the immunofluorescence test, appears to be more promising in this respect. The results were based on studies involving experimental animals and human patients. In two rabbits orally infected with Trichinella spiralis larvae, antibodies were demonstrable by immunofluorescence on the fourth day after infection, by complement fixation on the eighth and tenth days, and by the precipitin test on the thirteenth and twenty-eighth days, respectively. In three human cases the immunofluorescence antibody test was positive two weeks (the earliest blood samples available) after onset, while precipitin and complement fixation tests did not become positive until the end of the fourth week. The immunofluorescence test thus becomes positive at least two weeks earlier than the other two, a factor which undoubtedly increases its value in diagnosis.
A two-family outbreak of 11 cases of trichinosis with one fatality has been described. Efforts were made to obtain an early assessment of the severity of parasitization on the basis of initial clinical appearance, serial electrocardiograms, changes in eosinophil count, serum protein analyses and SGOT levels. The diagnoses were confirmed by muscle biopsy and by Suessenguth-Kline flocculation tests on serum. Factors portending a severe illness included: (a) rapid decline in total eosinophil count, (b) very low levels of serum albumin, (c) elevation of α1- and α2-fractions of serum proteins. A review of current serological methods available for the diagnosis of trichinosis has been presented and emphasis has been placed on the importance of interpreting laboratory tests in conjunction with clinical signs and symptoms. The severity and duration of illness in these cases have shown the importance of enforcing present public health regulations designed to prevent this illness being acquired by humans through consumption of infected pork.
Trichinosis is world-wide in distribution, occurring in tropical, temperate, and polar regions. Although incidence of the disease appears to be declining in most regions, it is still widely distributed in Europe and is increasing in many parts of Africa. In recent years, the incidence of trichinosis in the United States also has increased. This article reviews the nature of immunity to trichinosis.
Trichinosis is a food-borne zoonotic disease caused by the nematode, Trichinella spp., and had been reported several times in Korea. Recently, there was an additional outbreak, involving 5 patients, the findings from which are reported herein. On 30 November 2010, 8 persons ate sashimi of the meat of a wild boar. Then, 2-3 weeks later, they complained of myalgia and fever. Unfortunately, muscle biopsy was not performed, but ELISA was performed using their sera. Two people among 8 were positive for Trichinella on the 34th day post-infection (PI), and 3 patients who initially revealed negative ELISA were additionally proved to be positive for trichinosis on the 42nd day PI. Hence, the confirmed patients of trichinosis were 5 in total in the present outbreak. They were treated with albendazole and discharged uneventfully. This was the fifth outbreak of trichinosis in Korea.
Trichinella; trichinosis; wild boar; ELISA; outbreak
The therapeutic efficacy of ketoconazole and mebendazole was studied in ICR/CD-1 mice infected with Trichinella spiralis for 17 to 20 weeks. Efficacy of both drugs was over 70% when compared with results in control mice. This study indicates that both ketoconazole and mebendazole should be considered in the treatment of trichinosis in humans.
To summarize, we have been able to demonstrate: (1) In a case of acute trichinosis an extensive leucocytosis, with great absolute and relative increase in the number of eosinophilic cells in the blood, associated with a coincident decrease in the quantity of neutrophilic elements. (2) From the examination of specimens of muscle removed during life, besides the peculiar degenerations of the muscle, a longitudinal splitting of some of the fibres; a remarkable transverse splitting of others; a great proliferation of nuclei, about many of which vacuoles are seen; and large numbers of polymorphonuclear eosinophilic cells, which are especially prevalent in the more degenerated areas. (3) In a second case (after death), besides similar changes in the muscle, large numbers of eosinophiles throughout the infested portion. (4) In two other cases, during life, a great increase of the eosinophilic cells in the blood, with a coincident decrease of the polymorphonuclear neutrophiles, associated with leucocytosis, though of less extent than in the first case. (5) In pieces of muscle removed in these last two cases changes in most respects similar to those cited in the first case, but of less degree. (6) The similar character of the nuclei of the eosinophiles and the neutrophiles both in the blood and in the muscle, and the presence in the first case of certain cells which might be regarded as forms transitional between neutrophiles and eosinophiles, suggesting the possibility that the increase in the latter elements may, in these instances, take place in the muscles by direct transition from the neutrophiles.
We report a case of multiple myeloma that presented as a fluctuating sixth cranial nerve palsy in the absence of widespread signs of systemic disease. A 63-year-old woman presented with horizontal diplopia of two weeks duration that subjectively changed over time. Ocular examination showed a fluctuating sixth nerve palsy. A computed tomography (CT) scan of the brain showed multiple, enhancing, soft tissue, mass-like lesions involving the left cavernous sinus and the apex of both petrous bones. Based on bone marrow biopsy and hematologic findings, she was diagnosed with multiple myeloma. Multiple myeloma may be included in the differential diagnosis of a fluctuating sixth nerve palsy, and although ophthalmic signs are rare and generally occur late in the course of multiple myeloma, they can still be its first signs.
Fluctuating; Multiple myeloma; Sixth cranial nerve palsy
During a 10 year period 24 patients with definite multiple
sclerosis with isolated cranial nerve palsies were studied (third and
fourth nerve: one patient each, sixth nerve: 12 patients, seventh
nerve: three patients, eighth nerve: seven patients), in whom cranial
nerve palsies were the presenting sign in 14 and the only clinical sign
of an exacerbation in 10 patients. MRI was carried out in 20 patients
and substantiated corresponding brainstem lesions in seven patients
(third nerve: one patient, sixth nerve: four patients, eighth nerve:
two patients). Additional abnormal findings of electro-oculography, or
masseter reflex, or blink reflex, or combinations of these were found
in 20 patients and interpreted in favour of a brainstem lesion at the
level of the respective cranial nerve. In 11 of 14 patients with
isolated cranial nerve palsies as the presenting sign of multiple
sclerosis, dissemination in space was documented by MRI, and in the
remaining three by evoked potentials. In patients with multiple
sclerosis with isolated cranial nerve palsies, MRI is the most
sensitive method of documenting dissemination in space and
electrophysiological testing the most sensitive at disclosing brainstem lesions.
Asymptomatic catheter-associated urinary tract infections (CAUTIs) are common in hospitalized patients. They are associated with a low incidence of sequelae and morbidity, and in most patients resolve spontaneously on removal of the catheter. As a result, it is not recommended that asymptomatic catheter-associated bacteriuria or candiduria be treated with antimicrobial agents while the catheter remains in place because it may lead to the evolution of resistant flora.
To assess the current management of patients with CAUTIs with respect to antimicrobial therapy at The Ottawa Hospital and the University of Ottawa Heart Institute, Ottawa, Ontario.
A prospective observational study over a period of 26 consecutive days was conducted at The Ottawa Hospital (General and Civic campuses) and the University of Ottawa Heart Institute. Inpatients with an indwelling catheter, a positive urine culture and the absence of UTI signs or symptoms were assessed. Patients were followed for five days to determine whether antimicrobials were prescribed.
From March 3 to March 28, 2003, 29 of 119 patients screened met inclusion criteria. Of these 29 patients, 15 (52%) were prescribed antimicrobials and were therefore considered to be inappropriately managed. Differences were observed between the appropriate and inappropriate management groups in terms of duration of stay to positive urine culture and whether yeast or bacteria were isolated from the culture.
Antimicrobial agents were prescribed in over one-half of CAUTI cases, contrary to recommendations from the literature. Education is required to bring this strongly supported recommendation into clinical practice.
Asymptomatic; Bacteriuria; Candiduria; Urinary catheter; Urinary tract infection
A 62-year-old woman has been suffered from cavernous sinus thrombophlebitis which was confirmed by four-vessel angiography, orbit magnetic resonance imaging, and blood culture. Three weeks after recovery of cavernous sinus thrombophlebitis, right eye proptosis and complete third, fourth, and sixth cranial nerve palsies developed. Best-corrected visual acuity decreased to 20/70 in the right eye. Repeat magnetic resonance imaging demonstrated a 1.5-cm-sized mass in the right cavernous sinus, suspicious for mycotic aneurysm. Amphotericin B supplementation was begun and was followed by successful transarterial Guglielmi detachable coil embolization. Four months later, extraocular movement was normalized, and visual acuity improved to 20/25 in the right eye.
Cavernous sinus thrombosis; Guglielmi detachable coils embolization; Mycotic aneurysm
Patient: Female, 47
Final Diagnosis: Traumatic bilateral abducens • unilateral hypoglossal nerve palsy
Clinical Procedure: —
Objective: Rare disease
Incidence of unilateral abducens palsy from head trauma has been reported to be as high as 1% to 2.7%, but bilateral abducens nerve palsy is extremely rare.
We present a case in which bilateral abducens nerve and unilateral hypoglossal nerve palsy developed with a high Glasgow Coma Score (GCS) 3 hours after head trauma due to a motor vehicle crash.
This case highlights the occurrence and management of posttraumatic bilateral sixth nerve palsy.
abducens nerve injury; hypoglossal nerve injury; trauma
Neurological findings are described in 200 consecutive cases of suicidal ingestion of organophosphorous insecticides. Miosis is almost universal. We found impairment of consciousness in 10%, fasciculations in 27%, convulsions in 1%, toxic delirium in 50%, and paralysis in 26%. Toxic delirium was attributed to treatment with atropine. Paralytic signs were divided into type 1 signs (present on admission) and type 2 signs (appearing later while on atropine treatment). Type 1 signs, chiefly impaired consciousness and bilateral pyramidal tract signs, respond to atropine. The most common type 2 signs are proximal limb weakness, areflexia, and cranial nerve palsies. EMG studies during type 2 paralysis show a myasthenic response in some cases. Of 36 cases with type 2 signs 15 died from respiratory paralysis after a variable period of artificial respiration. Twenty-one recovered and no residual neurological deficit has been noted. Atropine did not influence type 2 paralysis. It is claimed that type 2 signs differ significantly from those described before as `delayed neurotoxicity' and may represent an alternative mode of human toxicity with organophosphorous compounds.
OBJECTIVE--To examine the extent to which changes in diagnostic methods and classification are responsible for the striking increase in incidence of primary liver cancer in Denmark since 1943. DESIGN--Analysis of the time trends in sex specific, age standardised incidence of primary liver cancer and unspecified liver cancer (either secondary without known primary cancer or not specified as primary cancer) in the entire population from 1943 to 1985. By review of the 727 notifications from three periods of 5 years (1948-52, 1963-7, and 1978-82) the changes in histological diagnosis and classification were assessed. SETTING--Denmark. SUBJECTS--Notifications of liver cancer to the Danish cancer registry. RESULTS--Concomitant with the increase in primary liver cancer, the incidence of the unspecified liver cancer declined. The proportion of histologically diagnosed primary liver cancer rose from 85% to 98%, whereas the proportion for unspecified liver cancer rose from 12% to 51%. When the proportion of primary versus unspecified liver cancer obtained by histological diagnosis was extrapolated to all cases, the annual incidence of primary liver cancer was 4.4 rather than 1.6 per 100,000 population in 1948-52 and 6.0 rather than 5.5 per 100,000 in 1978-82. CONCLUSION--The increase in the incidence of primary liver cancer may be much smaller than the numbers of registered cases indicate. This example emphasises the need to consider diagnostic drift in time trend studies of disease incidence.
A 27-year-old man presented with diplopia without features of raised intracranial pressure. He had left sixth cranial nerve (CN) palsy. Initial investigations in the form of blood tests, cerebrospinal fluid (CSF) opening pressure including CSF analysis and CT head were normal. He represented with paraparesis after 3 weeks. Examination revealed sixth CN palsy (eye twist) and new left-sided twelfth CN palsy (tongue twist), and hence Godtfredsen syndrome was diagnosed. MRI showed vertebral and clivus metastases. He showed partial response to high dose steroid. The statement ‘sixth CN palsy may be a false localising sign’ in neurology, should be followed by ‘....it can also be a true initial sign of clivus mass.’
A 65-year-old patient presented with isolated bilateral third nerve palsy. Neuroimaging demonstrated a 2 cm pituitary mass with extension into the cavernous sinus on the right. The patient went on to experience spontaneous complete resolution of symptoms with associated radiological shrinkage of the mass. Bilateral third nerve palsy is a very rare presenting sign, with only one previous case reported in the literature secondary to a pituitary adenoma. Spontaneous resolution of non-functioning pituitary tumours is reported to occur in approximately 10% of cases. However, there are only a small number of reports to date involving spontaneous regression of tumours with corresponding resolution of cranial nerve palsies.
A 52-year-old woman experienced sudden onset of double vision due to a right abducens nerve palsy and was diagnosed as having a pituitary macroadenoma that invaded into the right cavernous sinus. Otherwise, she was asymptomatic despite marked elevation of ACTH (293 pg/ml) and cortisol (24.6 μg/dl) levels. The patient underwent transsphenoidal surgery followed by γ-knife radiosurgery (GKR), which healed the diplopia and ameliorated the hypercortisolemia. The excised tumor was diffusely stained for ACTH with a high (15%) Ki-67 labeling index. Early tumor recurrence occurred twice thereafter, producing right lower cranial nerve palsies with petrosal bone destruction at 8 months and an ipsilateral oculomotor nerve palsy at 12 months after GKR; all palsies resolved completely with the second and third GKRs. Hypercortisolemia worsened rapidly soon after the third GKR, and the patient developed marked weight gain, hypokalemia, and hypertension. Multiple liver lesions were incidentally detected with computer tomography and identified as metastatic pituitary tumor on immunohistochemistry. An ACTH-producing adenoma should be followed carefully for early recurrence and/or metastatic spread when the tumor is an invasive macroadenoma with a high proliferation marker level. The unique aggressive behavior and high potential for malignant transformation of this case are discussed.
Pituitary carcinoma; Corticotroph carcinoma; Cushing's disease; γ-Knife radiosurgery
Sixty-three patients with confirmed intracranial chordoma were studied retrospectively to determine the incidence of various presenting symptoms and signs. Most of the ocular signs were due to cranial nerve involvement. Sixth cranial nerve palsy occurred as the sole presenting sign in 29% of patients, whereas extraocular muscle palsies of various combinations were present in 62%. Visual field defects were demonstrated in 24% of patients, but only 19% had papilledema or optic atrophy. The chordomas arose from the clivus in 92% of patients, but different patterns of cranial nerve involvement occurred which correlated with the different sites of extension of the tumor.
Large schwannomas arising from the oculomotor nerve are very rare. The common site of tumor occurrence in this nerve is the segment within the interpeduncular cistern and the cavernous sinus.
We report a case of a large left-sided oculomotor nerve schwannoma with minimal clinical signs and symptoms of oculomotor nerve involvement resembling a large parasellar mass. The radiological features of the mass were more consistent with a medial sphenoid wing meningioma causing brain stem compression. Complete resection of the tumor was achieved via a left pterional approach. The patient developed complete third nerve palsy postoperatively.
The management of these large benign tumors with brain stem compression includes surgical resection. Intraoperative anatomical preservation of the third nerve was impossible given its course in the tumor. We discuss the pertinent literature and management of large oculomotor schwannomas.
Meningioma; oculomotor schwannoma; skull base
Presentation of primary antiphospholipid syndrome (APS) is usually untrustworthy and unusual presentations are difficult to diagnose on the basis of clinical features alone. This is true especially in young and elderly patients. Cerebral venous thrombosis (CVT) is less frequent than arterial thrombosis in APS. CVT has a wide spectrum of signs and symptoms, which may evolve suddenly or over weeks. It mimics many neurological conditions such as meningitis, encephalopathy, benign intracranial hypertension and stroke. Headache is the most frequent symptom in patients with CVT, and is present in about 80% of cases. The most common pattern of presentation is with a benign intracranial hypertension-like syndrome. Sixth cranial nerve palsy usually manifests as a false localising sign. Patients may have recurrent seizures. Cranial nerve syndromes are seen with venous sinus thrombosis. We present a case of APS with lower cranial nerve palsy, aseptic meningitis and hydrocephalus initially treated as tuberculous meningitis.
Pepsin digestion of musculature from 2253 animals revealed that sylvatic trichinosis occurred in various species of mammals from the eastern to the western Arctic and extended down into the Rocky Mountain and Foothills regions of western Canada. Infections were demonstrated in Arctic fox, red fox, wolf, raccoon, coyote, lynx, bobcat and dog.
Trichinella spiralis spiralis infections were established in sheep by administering infective larvae via gavage or feeding infected musculature. Trichinella spiralis nativa infective larvae had a low infectivity for sheep although light infections may be established in some animals with large infective doses. For the most part, sheep were averse to ingesting musculature mixed in a grain ration unless it was camouflaged with molasses. The heaviest infections usually occurred in the masseter muscle. The fact that sheep are averse to ingesting muscle tissue may reduce the likelihood of trichinosis. Anti-Trichinella antibodies to both T: spiralis spiralis and T. spiralis nativa were produced as demonstrated by the enzyme-linked immunosorbent assay. Seroconversion occurred in several sheep challenged with T. spiralis nativa even though larvae were not recovered from the musculature by pepsin-digestion.