Tuberculosis of the nervous system. A clinical, radiological and pathological study of 39 consecutive cases in Riyadh, Saudi Arabia.

Thirty-seven consecutive adults and 2 children with tuberculosis of the nervous system were studied. Twenty-eight patients (72%) had intracranial or intraspinal tuberculomas and only 11 patients (28%) had tuberculous meningitis. Of the 14 patients (36%) with intracranial tuberculomas 6 presented with epilepsy of late onset including convulsive status epilepticus(2). The 6 patients with multiple tuberculomas some of which were situated in the infratentorial compartment were surprisingly free of major neurological disability of systemic disturbance. Thirteen patients (33%) presented with spinal cord compression due to tuberculoma. Eight of these had associated bony abnormalities such as collapsed vertebrae and loss of pedicles usually regarded as characteristic of malignant disease and 2 presented with clinical features of acute transverse myelitis. Eleven patients (28%) had tuberculous meningitis. One of these died, 1 had a protracted illness with gait ataxia and hydrocephalus and 1 other patient was disabled by hemiplegia, dysphasia and epilepsy but the remaining 8 recovered fully. Tuberculosis outside the nervous system was found in 13 patients (33%) in 12 (31%) of whom it was pulmonary. Acid fast bacilli were demonstrated by Ziehl-Neelsen stain in 16 patients (52%) out of 31 from whom specimens were available. Mycobacterium tuberculosis was eventually cultured from only 6 specimens. These data suggest that the clinical and radiological features of tuberculosis of the nervous system in Saudi Arabia may differ substantially from those reported from other countries. In our study there was low morbidity and low fatality rate. Two patients had infratentorial tuberculomas, and 8 patients had bony abnormalities in the vertebral column, typical of malignant disease.

Guillain-Barré syndrome in Kenya: a clinical review of 54 patients.

During an 8-year period, Guillain-Barré syndrome (GBS) was diagnosed in 54 Kenyans. Overall, the outcome was poor. Only 26 patients (48%) walked unaided within 3 month of the height of their paralysis. Five patients (9%) died from respiratory failure and 14 (26%) remained severely disabled from bilateral foot drop by the end of 16 months. Paralysis of lower cranial nerves and sphincter dysfunction were frequently associated with respiratory failure. Whether these features can predict the likelihood of respiratory failure developing requires further evaluation.

Neurological syndromes of brucellosis.

Eleven patients with brucellosis presented with neurological features closely simulating transient ischaemic attacks, cerebral infarction, acute confusional state, motor neuron disease, progressive multisystem degeneration, polyradiculoneuropathy, neuralgic amyotrophy, sciatica and cauda equina syndrome. Most patients improved quickly after adequate antibiotic treatment but chronic cases responded poorly. These protean neurological manifestations of brucellosis indicate that the underlying pathological mechanisms are diverse.

The pattern of infection of the nervous system in Riyadh: a review of 121 cases.

Analysis of 121 consecutive cases with infection of the nervous system showed that the majority were the granulomatous infections, tuberculosis and brucellosis (53 cases (44 per cent)). Thirty-nine patients had tuberculosis and 14 had brucellosis. The clinical and microbiological pattern of infection differs from that frequently reported from Western countries. Tuberculosis lesions presented with features of intracranial space occupying lesions (14), spinal cord compression (13) and lumbosacral root compression (1 child). Ten adults and one child had tuberculous meningitis. Pyogenic meningitis present in 38 cases (31 per cent), was most common in children. The infecting organism was identified in 26 patients; Gram-positive cocci in 17, Haemophilus influenzae in four and other Gram-negative organisms in five. Eleven patients had brain abscesses, caused by bacterial infection in eight, fungal infection in two and Toxoplasma gondii in one. Nineteen patients had clinical and pathological features of viral meningitis. Fourteen patients (12 per cent) died including six children with pyogenic meningitis.

Worldwide incidence of primary nervous system neoplasms. Geographical, racial and sex differences, 1960-1977.

International and interregional comparisons of average annual age-adjusted incidence rates for primary tumours of the nervous system showed marked variations. The highest rates were observed in those areas having high socioeconomic levels. In communities with multiple racial groups the highest rates were in Caucasians. Migrant populations retained rates close to those found in the country of origin. The majority of populations showed modest increases only while about one-third showed a decrease in the incidence rates during a period of approximately 15 years. Overall, there was a male excess. It is suggested that differences in medical practices (including availability of specialist expertise), diagnostic facilities and individual registry practices account for some of the variations observed. However, the possible aetiological roles of genetic, racial, hormonal and environmental factors need to be evaluated to explain the consistently higher incidence rates in Caucasians and in males of all races.

Cerebral infarction and left ventricular mass: a clinical and echocardiographic study.

One hundred and two stroke patients were studied. Thirty-three (32 per cent) were hypertensive by the WHO criteria. Eighty-three (83 per cent) had cerebral infarction and three patients suffered from spontaneous intracerebral haemorrhage. The mean left ventricular mass was calculated from echocardiographic measurements and compared with that of controls. Neither cases nor controls had valvular or congenital heart disease, or disease processes that may be associated with myocardial infiltration. Mean left ventricular mass of all cases was significantly greater than that of controls (p less than 0.025) and that of the cases over the age of 50 years was also significantly greater than that of controls of the same age (p less than 0.02). The clinically normotensive cases had greater left ventricular mass than the normotensive controls (p less than 0.02). Meanwhile left ventricular mass in patients aged 50 and under was not significantly different from the appropriate control group (p greater than 0.2). These data indicate that the frequency of arterial hypertension among victims of cerebral infarction is greater than may be ascertained clinically particularly in those over 50.

Protean manifestations of Wilson's disease: a review of seven Saudi patients.

The clinical picture and laboratory data of five symptomatic and two asymptomatic cases of Wilson's disease in four unrelated Saudi families are reported. More than one member was affected in two families. The oldest and youngest patients were twenty and eight years respectively. The two oldest patients were siblings and presented with neurological disturbance only while the youngest two were unrelated and had predominantly hepatic involvement. A mixture of hepatic cirrhosis and extrapyramidal syndrome was encountered in one patient only and Kayser-Fleischer rings in three. The initial presentation of one patient who subsequently developed cirrhosis closely simulated subacute glomerular nephritis. Although only three patients showed clinical or biochemical evidence of liver disease either initially or in later stages, liver biopsy demonstrated a spectrum of morphological changes in all the seven cases. These findings indicate that a positive family history, Kayser-Fleischer rings and simultaneous hepatic and brain involvement need not be present and that subclinical hepatic involvement may be commoner than is generally realised in Wilson's disease. That seven cases were seen at one centre, which takes a largely unselected patient population, in a four-year period only, suggests that this preventable and treatable disease may be frequent in Saudi Arabia.

International mortality from primary nervous system neoplasms: distribution and trends.

International comparisons of average annual age-adjusted mortality rates for primary tumours of the nervous system for 1951 through 1958 and 1967 through 1973 showed marked geographical variation for both study periods. For the majority of countries, the mortality rates increased by at least 40% in the in the intervening 15-year period, while in 20% of the countries the rates increased by over 100%. The percentage increases varied from 12.2 to 345.5. The improvement in the diagnosis of these tumours, particularly among elderly individuals (who have the highest age-specific incidence rates for these neoplasms), presumably accounts for most of this change. However, it is possible that the increase may not be fully accounted for by these factors alone. It is therefore suggested that further epidemiological studies are undertaken to determine more accurately the causes and implications of this worldwide increase in mortality rates from primary tumours of the nervous system.

Primary intracerebral hemorrhage and heart weight: a clinicopathologic case-control review of 218 patients.

The mean heart weight as a measure of arterial hypertension of patients who died from spontaneous intracerebral hemorrhage (primary intracerebral hemorrhage or PIH) was compared with that of controls from the same autopsy population. All patients with valvular or congenital heart disease or disease processes associated with myocardial infiltration were excluded. In 206 cases of PIH, hypertension was diagnosed if heart weight greater than or equal to the mean heart weight of autopsy controls for either sex, plus 1.5 SD. Only 94 (46%) of all cases of PIH were hypertensive by this criterion. However, hypertension was five times more frequent in the cases than in the controls. The site of hemorrhage was clearly defined in 183 cases (88.8%) only. Of these, 80 (43.7%) had lobar hemorrhage and 69 (37.7%) bled in the basal ganglia. Only 26 cases (12.6%) had evidence of previous cerebral or myocardial infarction and there was no instance of previous intracerebral hemorrhage. These data show that arterial hypertension was present in about half the cases of PIH and suggest that other as yet unidentified risk factors for PIH may be more common than is realized. Patients who died from PIH had been healthy all their lives with no evidence of cardiovascular or cerebrovascular disease, and the PIH was their first evidence of disease.

Heredofamilial syndrome of spastic paraplegia, dysarthria and cutaneous lesions in ive siblings.

Five children, three sisters and two brothers aged between three months and 12 years, are described. They all developed a facial desquamating rash of butterfly distribution at the age of about two months, and motor retardation which later was characterized by spasticity, predominantly affecting the lower limbs. The three children who were old enough for speech to be tested had dysarthria. There was no family history of neurological disease, nor was there consanguinity among the parents or grandparents. EEGs were diffusely abnormal in four of the five children, but did not show any specific or diagnostic features. Plasma immunoglobulin tests were normal, and tests for collagen disease were negative. The authors are not aware of previous reports of this condition, but believe that it is a variant of familial spastic paraplegia, with atypical features.