Retinochoroiditis secondary to Rickettsia typhi infection: a case report.

BACKGROUND: To report a case of unusual presentation of retinochoroiditis caused by Rickettsia typhi in a patient without prior uveitis. CASE PRESENTATION: In this case, we describe a 24-year-old male soldier with no previous eye disease, who was referred to our ophthalmology department due to bilateral retinochoroiditis and vitritis. The patient initially presented with a paracentral scotoma in his right eye persisting for 7 days and scattered dark spots in his left eye for 2 days in June 2023. Preceding these ocular symptoms, he experienced a two-week episode of fever, headaches, night sweats, and rapid weight loss of 10 kg. A transient rash covered his body briefly. His mother had a history of recurrent eye inflammation. Physical examination revealed bilateral keratic precipitates on the lower corneal periphery, 1 + anterior vitreous cells, small retinal lesions and mild optic discs elevation. Fluorescein angiography indicated mild discs hyperfluorescence, and the clinically visible round punctate lesions on OCT showed inner retinal hyper-reflective lesion with a depth till outer plexiform layer possibly suggestive of a retinitis lesion. Laboratory tests were normal except thrombocytosis, elevated ESR, liver enzymes and ACE levels, with positive Rickettsia typhi serology tests. Rheumatology and infectious disease consultations ruled out autoimmune diseases, confirming Rickettsia typhi infection. Treatment included systemic doxycycline and prednisone, with improvement of visual acuity, ocular symptoms, OCT abnormalities and resolution of inflammation. Prednisone was discontinued, and after two months, additional improvement was seen clinically, with preserved retinal structures on OCT. CONCLUSION: This study explores retinochoroiditis as a rare ocular presentation of Rickettsia typhi, an unusual infection in the Middle East. Previously reported ocular manifestations include conjunctivitis, vitritis, post infectious optic neuropathy and a few cases of uveitis. Ocular symptoms followed systemic illness, highlighting the need for awareness among clinicians. Diagnosis relies on seroconversion, with fluorescein angiography and OCT aiding in assessment. Empiric doxycycline and systemic corticosteroid therapy is recommended. Ocular symptoms resolved in two months. Awareness of these ocular manifestations is essential for timely diagnosis and management. Further research is needed to fully understand this aspect of murine typhus.

Neonatal frontal lobe: sonographic reference values and suggested clinical use.

BACKGROUND: Intraventricular hemorrhage (IVH) and post-hemorrhagic hydrocephalus (PHHC) remain major problems among premature infants. The need, timing and type of ventricular drainage are based on sonographic ventricular measures, without assessment of the dimensions of the frontal lobe. The aim of our study was to establish new reference values for sonographic frontal lobe cortico-ventricular thickness (FL-CVT) in a large cohort of infants. METHODS: All normal head ultrasound scans that were performed in our center during the first 4 days of life between January 2014 and December 2016 were retrospectively evaluated. RESULTS: Scans were evaluated and plotted to create a reference range for the thickness of the frontal lobe in normal infants of 24-40 weeks' gestation. The FL-CVT increased significantly during gestation. Calculating the area under the curve of the FL-CVT in 9 infants with post-hemorrhagic-hydrocephalus (PHHC) reveals a 20% mean loss of FL-CVT. The impact of increasing ventricular dilatation and of the various ventricular drainage procedures on the frontal lobe growth were described in two infants demonstrating the potential clinical value of this tool. CONCLUSIONS: Head ultrasound provides a simple, non-invasive method for measuring the thickness of the frontal lobe, which grows significantly between 24 and 40 weeks' gestation. In premature infants with PHHC, we suggest the use of the FL-CVT measure, in addition to ventricular size measures, as a direct assessment of the impact of the enlarged ventricles on the surrounding brain parenchyma. This could assist in the management of PHHC and determine the need and optimal timing for intervention.

Experience with intramuscular glucagon for infants with early neonatal hypoglycemia.

Parenteral options for treating neonatal hypoglycemia (NH) include: intramuscular (i.m.) glucagon or intravenous (i.v.) glucose 10%. So far, the role of i.m. glucagon in treating NH has not been adequately assessed. We retrospectively studied 236 neonates with NH. One hundred and twenty-one infants received oral glucose-fortified-milk-based formula (OGFM) and their blood glucose level (BGL) was maintained thereafter. Two groups of infants required intervention: (a) OGFM + i.m. glucagon (n = 77, 32.6%) and (b) OGFM + i.v. glucose bolus (n = 38, 16.1%). BGL1, BGL2 and BGL3 denote pre-treatment BGL, 2-2.5 h post-treatment and BGL within 2.5-4 h post-treatment; respectively. The two groups were compared regarding two outcome measures: Outcome no. 1: BGL2 ≥ 45 mg/dL and outcome no. 2: BGL3 ≥ 45 mg/dL. Compared to i.v. glucose, the i.m. glucagon group had significantly more infants with BGL2 ≥ 45 mg/dL (40% vs. 76%, p = 0.028), and marginal significant difference regarding BGL3 ≥ 45 mg/dL (62% vs. 77%, p = 0.08). Univariate analysis showed that i.m. glucagon, male gender, vacuum extraction, cesarean delivery and one or more NH risk factors were significantly associated with outcome measure no. 1. I.m. glucagon, small for gestational age status, cesarean delivery, BGL1 and NH risk factors were associated with outcome measure no. 2. Multi-variate analysis showed that i.m. glucagon was significantly and independently associated with BGL2 ≥ 45 mg/dL. I.m. glucagon is worth consideration as a treatment option for NH.