Intestinal Lesions Due to Rhodococcus equi in a Patient With Advanced Retroviral Disease and Pulmonary Infection: A Case of Colonic Malakoplakia.

In humans, Rhodococcus equi (R. equi) is a zoonotic infection usually involving immunocompromised subjects, only rarely affecting immunocompetent subjects. Herein, we describe an R. equi infection in a 50-year-old Russian man with acquired immune deficiency syndrome (AIDS) who presented with pulmonary cavitary lesions and clinical manifestation of colonic malakoplakia. A colonoscopy examination showed ulceration and mucosal erosion, and the histological findings confirmed the colonic malakoplakia. The patient recovered from pulmonary and gastrointestinal disease after four weeks of antibiotic treatment with intravenous ciprofloxacin and oral azithromycin and also underwent subsequent long-term oral antibiotic treatment to achieve clinical and immune restoration after antiretroviral therapy. Infectious disease pathology subspecialties should always consider R. equi chronic infection as a cause of malakoplakia in patients with AIDS. As only a few cases of colonic malakoplakia associated with R. equi are reported in the literature, these cases are important to describe, especially for clinical and treatment management.

Malignancy course of pituitary adenoma in MEN1 syndrome: Clinical-Neuroradiological signs.

Pituitary carcinomas (PCa) are extremely rare, indistinguishable from pituitary adenomas on histopathological grounds and have a poor prognosis. Most PCa start as PRL or ACTH secreting tumors in males, with relapsing invasive behaviour, refractoriness to medical and radiotherapy and increasing hormonal levels. The presence of distant metastases is still required for the diagnosis of PCa. The association with genetic endocrine diseases must be taken into account, since it adds further risk of evolution towards malignancy. Intradural spinal metastases have also been reported, so a complete craniospinal MR evaluation is recommended, when clinically indicated. We report a case of PCa, associated with MEN1 syndrome, with evidence of meningeal spread to the tentorium cerebelli, clival dura and spinal drop metastases mimicking spinal nerves schwannomas.

Frequency and determinants for hemorrhagic transformation of posterior cerebral stroke : Posterior ischemic stroke and hemorrhagic transformation.

BACKGROUND: hemorrhagic transformation is a threatening ischemic stroke complication. Frequency of hemorrhagic transformation differs greatly among studies, and its risk factors have been usually studied in patients with anterior ischemic stroke who received thrombolytic therapy. We evaluated, in a hospital-based series of patients with posterior ischemic stroke not treated with thrombolysis, frequency and risk factors of hemorrhagic transformation. Patients with posterior circulation stroke were seen in our Department during the period January 2004 to December 2009. Demographic and clinical information were collected. We estimated risk for spontaneous hemorrhagic transformation by means of uni- and multivariate logistic regression analyses. RESULTS: 119 consecutive patients were included (73 males, 61.3%). Hemorrhagic transformation was observed in 7 patients (5.9%). Only clinical worsening was significantly associated with hemorrhagic transformation (OR 6.8, 95% CI 1.3-34.5). CONCLUSIONS: Our findings indicate that patients with posterior have a low risk of spontaneous hemorrhagic transformation, suggesting that these patients might have greater advantage from intravenous thrombolysis.

Multimodal surgical and medical treatment for extensive rhinocerebral mucormycosis in an elderly diabetic patient: a case report and literature review.

Diabetes is a well-known risk factor for invasive mucormycosis with rhinocerebral involvement. Acute necrosis of the maxilla is seldom seen and extensive facial bone involvement is rare in patients with rhino-orbital-cerebral mucormycosis. An aggressive surgical approach combined with antifungal therapy is usually necessary. In this report, we describe the successful, personalized medical and surgical management of extensive periorbital mucormycosis in an elderly diabetic, HIV-negative woman. Mono- or combination therapy with liposomal amphotericin B (L-AmB) and posaconazole (PSO) and withheld debridement is discussed. The role of aesthetic plastic surgery to preserve the patient's physical appearance is also reported. Any diabetic patient with sinonasal disease, regardless of their degree of metabolic control, is a candidate for prompt evaluation to rule out mucormycosis. Therapeutic and surgical strategies and adjunctive treatments are essential for successful disease management. These interventions may include combination therapy. Finally, a judicious multimodal treatment approach can improve appearance and optimize outcome in elderly patients.

Unusual MRI findings in an immunocompetent patient with EBV encephalitis: a case report.

BACKGROUND: It is well-known that Epstein-Barr virus (EBV) can affect the central nervous system (CNS). CASE PRESENTATION: Herein the authors report unusual timely Magnetic Resonance Imaging (MRI) brain scan findings in an immunocompetent patient with EBV encephalitis. Diffusion weighted MRI sequence performed during the acute phase of the disease was normal, whereas the Fast Relaxation Fast Spin Echo T2 image showed diffuse signal intensity changes in white matter. The enhancement pattern suggested an inflammatory response restricted to the brain microcirculation. Acyclovir and corticosteroid therapy was administered. After three weeks, all signal intensities returned to normal and the patient showed clinical recovery. CONCLUSION: This report demonstrates that EBV in an immunocompetent adult can present with diffuse, reversible brain white matter involvement in the acute phase of mononucleosis. Moreover, our case suggests that a negative DWI sequence is associated with a favorable improvement in severe EBV CNS infection. More extensive studies are needed to assess what other instrumental data can help to distinguish viral lesions from other causes in the acute phase of disease.

Frequency and determinants for hemorrhagic transformation of cerebral infarction.

BACKGROUND: Frequency and associated risk factors for hemorrhagic transformation (HT), a worrying complication of ischemic stroke (IS), are not clearly defined. Our aim was to estimate the overall frequency and risk factors for HT in a hospital-based population. METHODS: A retrospective review of medical records of patients discharged from our department during the period 2004-2006 with a diagnosis of anterior IS. Demographic, clinical and hematological information was collected. Uni- and multivariate logistic regression analyses were used to estimate risk for spontaneous HT. RESULTS: We included 240 patients (125 males, 52%), mean age at admission was 72.5 years. HT was observed in 29 patients (12%). At univariate analysis, consciousness impairment at admission (OR 5.6, 95% CI 1.3-28.2), the presence of early CT signs (OR 2.4, 95% CI 1.1-5.3), infarcts of medium-large size (OR 11.3, 95% CI 4.1-30.8), cardioembolic stroke (OR 2.3, 95% CI 1.1-5.2) and low total cholesterol levels (OR 3.3, 95% CI 1.3-8.2) were significantly associated with HT. At multivariate analysis, only infarct size (OR 10.2, 95% CI 3.2-32.1) was still significantly associated with HT. CONCLUSIONS: Frequency of HT in our study was 12%. Consistently with previous results, HT was associated with the size of ischemic area. As patients included in our study did not receive thrombolytic therapy, our results are applicable to those patients whom clinicians, working in a hospital setting, usually deal with.

Prognostic value of hyperattenuating middle cerebral artery sign at CT in cerebral infarction.

PURPOSE: To assess the prognostic value of hyperattenuating middle cerebral artery sign at CT in acute cerebral infarction. MATERIALS AND METHODS: Ninety-two patients with acute cerebral infarction in the sylvian area were retrospectively reviewed. All patients underwent unenhanced CT 12-24 hours after the onset of symptoms and follow-up CT within 48-72 hours. Initial CT scans were evaluated by consensus by three radiologists to confirm or exclude the presence of hyperattenuating middle cerebral artery sign. History, cardiovascular risk factors and neurological impairment at discharge (mean 25 days) were recorded for each patient. The degree of disability was graded 0 (no disability) to 6 (death). Patients were divided into two groups: patients without (group A) and patients with (group B) hyperattenuating middle cerebral artery sign. A logistic regression analysis was performed to compare the two groups. Results were correlated with cardiovascular risk factors. Kaplan-Meier survival curves were calculated for each group. RESULTS: Hyperattenuating middle cerebral artery sign was present in 18 patients (19.6%) (group B). The percentage of neurological deficits was significantly higher in group B than in group A (p<0.05). Sixteen (88.9%) of the 18 patients in group B had a poor prognostic index (score 3 - 6) with a significantly higher percent difference (41.6%, p<0.05) than patients of group A. Within 10 days of admission, 3 patients (16.7%) died in group A and 6 (8.1%) in group B. However, no significant differences were observed in the Kaplan-Meier survival curves. No correlation with cardiovascular risk factors was observed. CONCLUSIONS: Besides having an important diagnostic value, hyperattenuating middle cerebral artery sign is a reliable predictor of prognosis in terms of disability rather than mortality, as it reflect the larger extension of infarction.