Eosinophilic Meningitis Due to Infection With Paragonimus kellicotti.

Paragonimus kellicotti is an emerging pathogen in the United States with 19 previously reported cases, most in Missouri. Pulmonary symptoms with eosinophilia are most common, though 1 case did involve the central nervous system with few symptoms. We describe the first 2 cases of eosinophilic meningitis due to Paragonimus kellicotti.

Treatable neurological disorders misdiagnosed as Creutzfeldt-Jakob disease.

OBJECTIVE: Heightened awareness of Creutzfeldt-Jakob disease (CJD) among physicians and the lay public has led to its frequent consideration in the differential diagnosis of patients with rapidly progressive dementia (RPD). Our goal was to determine which treatable disorders are most commonly mistaken for CJD. METHODS: We performed a retrospective clinical and neuropathological review of prion-negative brain autopsy cases referred to the US National Prion Disease Pathology Surveillance Center at Case Western Reserve University from January 2006 through December 2009. RESULTS: Of 1,106 brain autopsies, 352 (32%) were negative for prion disease, 304 of which had adequate tissue for histopathological analysis. Alzheimer disease (n = 154) and vascular dementia (n = 36) were the 2 most frequent diagnoses. Seventy-one patients had potentially treatable diseases. Clinical findings included dementia (42 cases), pyramidal (n = 20), cerebellar (n = 14), or extrapyramidal (n = 12) signs, myoclonus (n = 12), visual disturbance (n = 9), and akinetic mutism (n = 5); a typical electroencephalogram occurred only once. Neuropathological diagnoses included immune-mediated disorders (n = 26), neoplasia (n = 25, most often lymphoma), infections (n = 14), and metabolic disorders (n = 6). INTERPRETATION: In patients with RPD, treatable disorders should be considered and excluded before diagnosing CJD. Misdiagnosed patients often did not fulfill World Health Organization criteria. RPD with positive 14-3-3 cerebrospinal fluid protein should not be regarded as sufficient for the diagnosis of CJD. Adherence to revised criteria for CJD, which include distinctive magnetic resonance imaging features of prion disease, is likely to improve diagnostic accuracy.

Trends in tuberculosis mortality in the United States, 1990-2006: a population-based case-control study.

OBJECTIVE: We assessed demographic and temporal trends of tuberculosis (TB)-related deaths in the United States and examined associated comorbidities listed on death certificates. METHODS: We analyzed TB-related mortality from 1990 through 2006 by examining multiple-cause-of-death data from the National Center for Health Statistics. We assessed age-adjusted mortality rates, secular trends, associations with demographic variables, and comorbid conditions. RESULTS: From 1990 through 2006, TB was reported as a cause of death among 53,505 people in the U.S. with a combined overall mean age-adjusted mortality rate of 1.16 per 100,000 person-years. The age-adjusted TB mortality rate declined from 2.22 per 100,000 person-years in 1990 to 0.47 per 100,000 person-years in 2006, demonstrating mean annual decline of about 10%. People aged 75 years and older; males; foreign-born people; and those of Hispanic, Asian, black, and Native American race/ethnicity had comparatively elevated TB-related mortality rates. The mortality rate in foreign-born people was more than two times higher than in U.S.-born people. About 89% of deaths among people of Asian race/ethnicity and nearly 50% among black people were foreign-born individuals. Human immunodeficiency virus and selected autoimmune diseases were more common in TB-related deaths. CONCLUSIONS: TB mortality decreased substantially from 1990 through 2006, but remains an important cause of preventable mortality. The observed decrease was more pronounced among U.S.-born people than among foreign-born people. Disparities in TB-related mortality and the identification of important comorbid conditions can inform strategies targeting subpopulations at increased risk for fatal TB infection.

Lingual Artery-Retromandibular Vein Fistula Four Years after an Uncomplicated Carotid Endarterectomy: Case Report and Review of Possible Etiologies and Treatment Options.

The external carotid artery's lingual branch to retromandibular venous fistula following a carotid endarterectomy has not been reported earlier in literature. We report a unique case of an 87-year-old man who had a right-sided carotid endarterectomy in 2009 and presented four years later with complaints of fullness and discomfort in the area of right parotid gland with associated pulsatile tinnitus. A computed tomography (CT) scan of the neck revealed a deep portion of the right parotid gland having abnormal aneurysmal dilatation of a vascular structure, which appeared to be an arteriovenous fistula between branches of right external carotid artery and the retromandibular vein. Conventional catheter angiogram showed a complex arteriovenous fistula seen with the right retromandibular vein receiving multiple small arterial feeders from the right external carotid artery via its lingual artery branch. Slight reflux was noted into the right pterygoid plexus, right maxillary, and right submental veins as well. Surgical treatment was deferred due to high risk of inadvertent facial nerve injury from extensive parotid dissection involved in the procedure. Transarterial embolization of five discrete arterial branches from the right external carotid artery supplying the fistula was performed using particles with resultant remarkable slowing of the venous drainage into the retromandibular vein. After the procedure, his tinnitus and ear fullness resolved completely. The presence of arteriovenous fistula after carotid endarterectomy is a rare yet serious complication and therefore should be diagnosed early and treated promptly. The article highlights the relevant literature on arteriovenous fistula formation in the setting of arterial patch, intraoperative shunting, and surgical-site infections.

In Vivo Characterization of Carotid Neointimal Hyperplasia by use of Optical Coherence Tomography: Before and After Cutting Balloon Angioplasty.

Optical coherence tomography (OCT) is a modern intravascular imaging modality that has the capability to provide detailed, in vivo characterization of the arterial wall and atherosclerotic plaque. The current understanding of the appearance of atherosclerotic plaque via OCT is largely based on coronary arterial studies where OCT information has been employed to guide therapeutic management and permits the immediate evaluation of percutaneous intervention. The clinical success of OCT in the coronary arteries has laid the foundation for investigation of the carotid artery and thus, stroke risk assessment. We report the novel use of OCT for tissue characterization of severe stenosis subsequent to carotid artery stenting (CAS), both before and after treatment with cutting balloon angioplasty.

Risk of contrast-induced nephropathy in patients undergoing endovascular treatment of acute ischemic stroke.

BACKGROUND AND PURPOSE: We report the incidence and risk factors for contrast-induced nephropathy after the use of iodinated contrast for endovascular treatment of acute ischemic stroke. METHODS: A retrospective chart review was performed in 194 consecutive patients who underwent endovascular treatment for acute ischemic stroke between January 2006 and January 2011. No patients were excluded from treatment for elevated creatinine (Cr). Each patient received approximately 150 ml intra-arterial non-ionic low-osmolar contrast agent (Optiray 320) during the endovascular procedure. Contrast-induced nephropathy (CIN) was defined according to the Acute Kidney Injury Network criteria as a relative increase of serum Cr 50% above the baseline or an absolute increase of 0.3 mg/dl at 48 h following the endovascular procedure. RESULTS: Of 194 patients (mean age 65 ± 14 years), 52% were women (n=100) and 25% (n=48) were diabetic. Baseline Cr levels for 191 patients ranged between 0.4 and 2.7 mg/dl. Three patients on chronic hemodialysis had baseline Cr levels ranging between 5.3 and 6.1 mg/dl. Cr was ≤ 1.5 mg/dl in 163 patients (84%) and ≥ 1.5 mg/dl in 31 (16%). Three of the 191 patients (1.5%) developed CIN as noted from Cr measurements between baseline and within 48 h. One patient who developed an elevated Cr level had a known history of chronic renal insufficiency (Cr > 1.5 mg/dl) and two had baseline Cr levels within the normal range. An additional CT angiogram was obtained in 44 patients, none of which developed CIN. Female gender and diabetes were not associated with a higher risk of developing CIN. CONCLUSIONS: The risk of developing CIN is low among patients with acute stroke who undergo emergency endovascular treatment. Treatment of acute stroke should be performed irrespective of Cr levels.