Reversal of subclinical adrenal insufficiency through antituberculosis treatment in TB patients: a longitudinal follow up.

BACKGROUND & OBJECTIVE: Subclinical adrenal insufficiency has been shown to occur in patients with tuberculosis. Whether this insufficiency can be reversed with therapy and on long-term follow up, is not known. We studied the effect of antituberculosis treatment (ATT) with respect to reversal of the adrenal insufficiency, as assessed by response to standard dose adrenocorticotropin (ACTH) stimulation test in TB patients. METHODS: One hundred and five HIV-negative tuberculosis patients were studied. Of these, 72 patients had pulmonary and 33 had extrapulmonary forms of the disease. Baseline (pre-treatment) standard-dose ACTH stimulation test was done on all the subjects, following which, they were put on standard antituberculosis therapy, depending on the type of disease and were followed up for a period of 30 months. ACTH stimulation tests were performed at follow up, every 6 months. RESULTS: Baseline (pre-treatment) standard-dose ACTH stimulation test revealed an impaired response in 52 of 105 patients (49.5%). At 6 months, the percentage of responders had increased to 71 per cent with a gradual increasing trend noted thereafter. At 24 months, 31 of the 32 patients (97%) who were followed up demonstrated a normal response to ACTH stimulation. The percentage of responders was comparable in both pulmonary [21 of 22 patients (95%)] and extrapulmonary TB [10 of 10 patients (100%)] groups at follow up. INTERPRETATION & CONCLUSION: Our study shows that nearly half of patients with active tuberculosis had a subclinical adrenal insufficiency indicated by an impaired response to ACTH stimulation test. This insufficiency reverse with therapy in most patients on long-term follow up.

Albendazole in single CT ring lesions in epilepsy.

Single, small, enhancing lesions that often resolve spontaneously are frequent findings on CTs of Indian patients with seizures. Based on ELISA and biopsy data, the majority of these lesions are probably cysticercosis. To determine if these patients should be treated with albendazole, we performed a double-blind, randomized, placebo-controlled study involving 75 patients with seizures and the appropriate CT abnormality without neurologic abnormality on examination. Patients were randomized to albendazole (15 mg/kg/d) and placebo for 1 week, and we obtained serial CTs at the end of 1 week, 1 month, and 3 months. All patients completed a 3-month follow-up and none had systemic evidence of tuberculosis or cysticercosis. The lesions varied in size from 3 mm to 2.1 cm, with an average size of 1.18 cm. Serum ELISA for cysticercosis was positive in 30 and CSF ELISA was positive in 20 of 45 patients. Forty patients received albendazole and 35 received placebo. At the end of 3 months, a total of 68 patients showed resolution. Thirty-five of 40 patients who received albendazole showed resolution, as opposed to 33 of 35 patients on placebo. We conclude that albendazole therapy was not beneficial.

Inflammatory lesions of the basal ganglia and thalamus: review of twenty-one cases.

We report a series of 21 patients with basal ganglia and thalamic granulomas or abscesses treated over 7 years. Among them, 15 were tubercular, 5 were pyogenic, and 1 was fungal. Pyogenic abscesses, usually hematogenous, also occurred secondary to osteomyelitis of the skull and chronic otitis media. The fungal abscess developed in a nonimmunocompromised patient with no intercurrent malignancy. Evidence of tuberculosis elsewhere in the body was detected in only 7 patients with tuberculomas. The computed tomographic (CT) image morphology characterizing an abscess or a tuberculoma was present in all except 2 patients with tuberculomas. The fungal abscess resembled a malignant glioma. The only hospital mortality occurred in a deeply unconscious patient with a thalamic pyogenic abscess. A 12-month or longer follow-up in 16 patients showed that 3 continued to be handicapped neurologically, and 2 died 13 and 16 months later, respectively. We conclude that inflammatory lesions at these sites are not uncommon and that CT scans are diagnostic in the great majority. Doubtful diagnosis merits stereotactic aspiration or biopsy of the lesion. Satisfactory results follow adequate medical therapy.

Unilateral meningeal thickening: a rare presentation of tuberculous meningitis.

A rare case of tuberculous meningitis (TBM) causing unilateral thickening of meninges, is described here. The 50 year old male is presented with hemicranial headache and unilateral multiple cranial nerve involvement without any long tract signs. Magnetic resonance imaging (MRI) scan including enhanced studies showed a hemicranial thickening of the meninges. Biopsy of the meninges revealed tuberculosis. The patient improved gradually on antitubercular treatment (ATT). Follow-up at 6 months revealed significant improvement in neurological status. Though tuberculous involvement of the central nervous system (CNS) is very common in India, hemicranial meningeal involvement has never been reported.

Ruptured intracranial aneurysm complicating pregnancy.

Three cases of ruptured intracranial aneurysm during pregnancy are presented. Rupture occurred near term in all three cases. Simultaneous elective cesarean section and clipping of the aneurysm was performed in two cases. Successful maternal and perinatal outcome was achieved in all three patients. The diagnosis and management of the cases are described and discussed.

Albendazole in neurocysticercosis.

BACKGROUND: In India, parenchymatous cysticercus cysts are more common than the meningeal racemose variety which are seen frequently in Latin America. Reports from Mexico suggest that albendazole is effective in the treatment of neurocysticercosis. We, therefore, studied whether this drug changed the natural course of neurocysticercosis in India. METHODS: In a randomized, double-blind, placebo controlled study, we allocated 29 consecutive patients (22 men and 7 women) with multiple cystic lesions on computed tomography (CT) of the head suggestive of cysticercosis to 7 days treatment with albendazole (15 mg/kg/day) or placebo. CT scans were repeated at the end of treatment and 1 and 3 months later to assess the number of cysts and extent of oedema. RESULTS: Sixteen patients received albendazole and 13 placebo. No change was seen at the end of one week. At 3 months, 14 patients in the albendazole group and 10 in the placebo group showed more than 25% reduction in the number of lesions. The difference between the two groups was not significant. CONCLUSION: Albendazole given in a dose of 15 mg/kg/day for 1 week does not change the natural course of neurocysticercosis.

Distribution of vascular lesions in ischaemic stroke: a magnetic resonance angiographic study.

BACKGROUND: Carotid endarterectomy is now an accepted modality for reducing the threat of recurrence of ischaemic strokes in patients with severe carotid artery stenosis. However, the incidence of carotid artery stenosis, and hence the applicability of carotid endarterectomy in the Indian population is not known. We conducted a prospective study to detect and quantify extracranial and intracranial arterial lesions using magnetic resonance angiography in consecutive patients with ischaemic strokes. METHODS: All patients with recent onset of ischaemic stroke (< 4 months) had a magnetic resonance angiography done to evaluate the neck vessels as well as the circle of Willis and its branches. The degree of stenosis of the internal carotid or common carotid artery was measured according to the criteria described by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) collaborators. The site and extent of the extracranial and intracranial arterial lesions were correlated with the clinical features and the pattern of infarcts on magnetic resonance imaging or computerized tomographic scan of the brain. RESULTS: The magnetic resonance angiography was abnormal in 56 out of 100 patients included in the study. Severe stenosis (> 70%) of the extracranial carotid arteries was seen in 26 patients. Lesions suitable for carotid endarterectomy were present in only 11 patients (42.3% of those with severe stenosis). CONCLUSION: Our results are in contrast to those reported from western countries where the likelihood of a surgically correctable lesion being present is 60%-70%. We found operable lesions in only 11%. Intracranial atherosclerotic disease causing strokes is probably more common in India. Therefore, although carotid endarterectomy is the only accepted surgical procedure for secondary prophylaxis of stroke, there is a need to find an alternative surgical intervention for the predominantly intracranial pathology found in the Indian population.

Giant cell tumour of the temporosphenoidal region.

A case of giant cell tumour of the temporo-sphenoidal region and superior part of infratemporal fossa is presented along with a brief review of the literature. The tumour mass was removed by curettage using a Weber-Fergusson incision with transection of the zygoma. There was no recurrence at three-year follow up.

Parapharyngeal neurofibromas.

This paper is a retrospective study of 15 patients with parapharyngeal neurofibromas operated over a six year period. No patient presented with a neurological deficit. CT scans revealed a well encapsulated moderately enhancing mass in ten cases. The tumour was removed by a transcervical approach in ten cases while in five a cervical-transpharyngeal route with mandibulotomy was used; in three of the latter group the tumour was retropharyngeal. In two cases a recurrence was successfully excised. It was realized that a mandibulotomy was required when the internal carotid was displaced medially, or if the tumour extended to the base of skull or when its vertical diameter exceeded 8 cm.

Cold abscess due to malignant pleural mesothelioma.

A middle aged male presented to us with a cold abscess on the left side of chest which later proved to be a malignant pleural mesothelioma. The clinical, radiological and histopathological findings have been discussed.

Adrenocortical reserve and morphology in tuberculosis.

Ninety seven patients (63 males, mean age 31.8 years, SD 2.3) with various forms of tuberculosis were studied. All of them were HIV negative. Thirty normal control subjects (16 males, mean age 36.4 years, SD 1.8) were also studied. Fifty-eight of the 97 patients (59.8%) were malnourished (BMI < 18 kg/m2). The mean basal serum cortisol was lower in the TB group (n = 91) (351 nmol/1; SD 150) as compared to the normal control group (n = 8) (402 nmol/1; SD 93) but this difference did not attain statistical significance. Following administration of synthetic ACTH (cosyntropin), the 30 and 60 minutes mean serum cortisol values in the TB group were significantly lower as compared to the normal control group (p < 0.05). Forty five of the 91 patients (49.5%) who underwent the ACTH stimulation test had compromised adrenal reserve. Fourteen of the 86 patients (16.3%) in whom adrenal morphology was studied revealed adrenal gland enlargement on abdominal CT scan. ACTH stimulation was done in 12 of these 14 patients and eight of them had compromised adrenal reserve. Repeat ACTH stimulation done six months to one year after treatment in 13 patients revealed significantly increased 30 minutes (p < 0.05) and 60 minutes (p < 0.05) serum cortisol values. While nine of these 13 patients were negative responders before treatment, only three of them had evidence of compromised adrenal reserve after one year of antituberculosis treatment, (p < 0.05). Serum cortisol values in patients with drug-sensitive and drug-resistant tuberculosis did not differ significantly. Patients with drug-resistant tuberculosis had a higher prevalence of adrenal gland enlargement (7 of the 30) as compared to those with drug-sensitive tuberculosis (7 of the 56) (p = NS). Subclinical adrenal insufficiency is prevalent in a significant number of patients with both drug-sensitive and drug-resistant tuberculosis, and in some of these it is associated with adrenal gland enlargement. The compromised adrenal reserve and enlargement seem to reverse with therapy.

Transsynaptic neuronal degeneration of optic nerves associated with bilateral occipital lesions.

A case is reported of a 9-year old male who presented with abnormal behaviour and progressive diminution of vision. Pupils were middilated in both eyes but the pupillary reflexes were preserved. Fundus examination revealed a bilateral optic atrophy and radiological investigations showed a bilateral occipital calcification. We hereby document a case of retrograde transsynaptic neuronal degeneration of the visual system secondary to bilateral occipital lesions. Transsynapptic neuronal degeneration of optic nerves consequent to occipital lobe lesions is a rare phenomenon. Experimentally occipital lobe ablation in non-human primates has been shown to result in optic atrophy. Herein, we document a case of retrograde transsynaptic neuronal degeneration of the visual system secondary to bilateral occipital lesions.

Neurones in the dorsal horn of the rat responding to scrotal skin temperature changes.

1. Micro-electrode recordings have been made from single neurones in the dorsal horn of male rats anaesthetized with urethane. Scrotal temperature was altered within the range 13-43 degrees C by means of a thermode. The mean firing rate of neurones was correlated with step and ramp changes of temperature.2. In the region where the scrotal nerve enters the cord, 47% of the neurones were responsive to scrotal temperature: half were excited by warming and half by cooling. Most of these thermally responding units were not affected when the scrotal skin was touched and only one-fifth responded to both modalities.3. Both the ;warm' and ;cold' groups of neurones showed responses to step changes of temperature which were classified as dynamic plus static, dynamic only or static only. Comparison of these responses with those published for the scrotal thermoreceptors showed that the incoming thermal information was being processed in the dorsal horn.4. Histological examination of the cord showed that recording sites were in laminae I to V of the dorsal horn.

Neurones in the ventrobasal complex of the rat thalamus responding to scrotal skin temperature changes.

1. In rats the scrotal temperature was raised or lowered with a water-perfused thermode while micro-electrode recordings were made of unit activity in the ventrobasal complex of the thalamus. The electrodes were aimed at the region where evoked responses had been found by electrical stimulation of the scrotum. Recording sites were marked by iontophoresis of dye from the micro-electrode.2. Changes in firing rate of thalamic neurones were only found in the scrotal temperature range of 31-40 degrees C. Within this range, 72% of the 123 cells tested were excited or suppressed by skin warming. At temperatures above or below this range, activity was not affected. Most of the cells responded just to temperature and only 7% were also excited by touch.3. Raising temperature in the range 31-40 degrees C caused 82% of the thermally responding cells to increase their firing rate and 18% to decrease their rate. Individual neurones showed a sudden and maintained change in their activity for scrotal temperature increases of only 2, 1 or even 0.5 degrees C. Mean firing rates changed by factors of about 8 or more with these temperature increases and further warming did not change the rate. These step-like changes in firing rate were found at different points over the whole skin temperature range of 31-40 degrees C, but most were between 33 and 38 degrees C.4. For a given neurone the step-like change in activity occurred once its critical temperature was reached, irrespective of whether this was achieved by a step increase of skin temperature over 1-2 sec or by a slow ramp increase lasting several minutes.5. It is not possible to say whether the skin warm receptors, cold receptors or both were responsible for these thalamic responses, but the results do show that incoming thermal information is considerably processed when it reaches the thalamic level.

Neurones in the somatosensory cortex of the rat responding to scrotal skin temperature changes.

1. In rats the scrotal temperature was raised or lowered with a water-perfused thermode while micro-electrode recordings were made of unit activity in the somatosensory (SI) cortex. The electrodes were inserted in the area where the largest evoked potentials had been found from electrical stimulation of the scrotum.2. Changes in firing rate of cortical neurones were found only in the scrotal temperature range of 32-41 degrees C. Within this range 40% of all the cells tested were excited or suppressed by skin warming. At temperatures above or below this range, activity was not affected. Most of the cells responded just to temperature and only 14% were also excited by touch.3. Raising temperature in the range 33-41 degrees C caused 83% of the thermally responding cells to decrease their firing rate and 17% to increase their rate. Individual neurones showed a sudden and maintained change in their activity for scrotal temperature increases of only 2, 1 or even 0.5 degrees C. Mean firing rates changed several-fold with these temperature increases and further warming did not change the rate. These step-like changes in firing rate were found at different points over the whole skin temperature range of 33-41 degrees C but most were between 35 and 39 degrees C.4. For a given neurone the step-like change in activity occurred once its critical temperature was reached, irrespective of whether this was achieved by a step increase of skin temperature over 1-2 sec, or by a slow ramp increase lasting several minutes.5. The results are very similar to those found in the thalamus (preceding paper), but the proportions of cortical cells which were excited or suppressed on skin warming were the reverse of the proportions seen in the thalamus.

False-negative IV-DSA in external jugular phlebectasia.

We report a patient with external jugular phlebectasia in whom we performed intravenous digital subtraction angiography but failed to demonstrate the lesion. Direct injection of contrast into the lesion is the preferred method of radiological demonstration.