Intravenous Thrombolysis in a Young Patient with Acute Stroke due to Posterior Cerebral Artery Dissection.

Infarcts of the territory of posterior cerebral artery (PCA) are common and their clinical presentations are well known. However, stroke in young adults originating at the PCA is relatively rare. We describe the case of a young female patient with right PCA infarcts that were probably caused by spontaneous arterial dissection. Dissection was successfully treated with intravenous recombinant tissue plasminogen activator. Herein, we discuss the mechanism, management, serial magnetic resonance angiography results, and functional outcome of treatment.

Japanese viral encephalitis mimicking stroke with an initial manifestation of hemiplegia.

Japanese encephalitis (JE) is an endemic disease in Taiwan. After the program to vaccinate children against JE was implemented in 1968, the incidence of JE gradually started to decrease, but it is still an important infectious disease here. Neurological manifestations in JE vary highly during the initial stage of the disease. Focal neurological symptoms, such as hemiplegia, are rarely reported. A 46-year-old male with the initial presentation of abrupt hemiplegia and fever developed mental confusion after 1 day. No bacterial pathogen was isolated from the blood or cerebrospinal fluid (CSF). A diagnosis of JE was confirmed based on the presence of JE virus-specific immunoglobulin M in the CSF and serum samples. It is necessary to consider JE when a patient presents with abrupt hemiplegia with fever followed with mental confusion and seizure, especially if the patient comes from a JE-endemic area.

Intravenous paraquat poisoning.

Paraquat is a substance that is highly poisonous to humans. Oral ingestion is the most common pathway of poisoning. Intravenous paraquat poisoning is rare and is strongly associated with attempted suicide. The clinical presentations of such a scenario would appear to be quite different from those of oral ingestion. Herein, we present a case of an intravenous drug abuser who injected paraquat in an effort to commit suicide. He received hemoperfusion and intravenous cyclophosphamide treatment and parenteral pulse therapy with methylprednisolone. Nevertheless, he suffered from dyspnea at around 48 hours post-exposure. His condition improved transiently, but he eventually died from severe hypoxia. The findings from our case and those of previously reported cases indicate the grave prognosis and lack of effective management of intravenous paraquat poisoning.

Abdominal nontuberculous mycobacterial infection in a university hospital in Taiwan from 1997 to 2003.

BACKGROUND/PURPOSE: Abdominal nontuberculous mycobacterial infection is a rare condition. Continuous ambulatory peritoneal dialysis (CAPD)-associated peritonitis is the most common manifestation of infection due to nontuberculous mycobacteria (NTM). There are limited data on the clinical manifestations of nontuberculous mycobacterial infection. This study investigated the diagnostic features, clinical presentation, mycobacteriology, treatment and outcome of all abdominal NTM infections treated over a 7-year period at a major teaching hospital in Taiwan. METHODS: The medical records of all patients with a diagnosis of abdominal NTM infection from January 1997 through to December 2003 were retrospectively reviewed. RESULTS: All 11 patients with abdominal NTM infections identified during the 7-year period were included. Among these patients, six were male and five were female, with a mean age of 64.5 years. The disease manifested as peritonitis (9 patients, 82%), splenic abscess (1, 9%), or perirenal abscess (1, 9%). Most patients (73%) had underlying malignancy, most often hepatoma (45%). Immunocompromised status (liver cirrhosis, malignancy, acquired immunodeficiency syndrome) was noted in 10 patients (91%). None of our patients who developed NTM peritonitis had received CAPD. The peritoneal fluid appearance varied considerably, with no particular predominance of clear, turbid, bloody, or chylous findings. Rapidly growing mycobacteria were the major etiology (46%) of abdominal NTM infection, and Mycobacterium abscessus played a major role (27%). Overall, eight patients died, and only one patient survived longer than 1 year. Seven patients (64%) died before diagnosis. CONCLUSION: Abdominal NTM infection is frequently overlooked because of its rarity and nonspecific symptoms, with consequent delays in diagnosis and treatment. In immunocompromised patients with ascites from any cause (liver cirrhosis, malignant ascites, etc.), NTM peritonitis should be considered early in the differential diagnosis of symptoms including fever, abdominal pain and weight loss. The poor prognosis of abdominal NTM infection appears to be related to the severity of underlying conditions, most often malignancy.

Emergence of disseminated infections due to nontuberculous mycobacteria in non-HIV-infected patients, including immunocompetent and immunocompromised patients in a university hospital in Taiwan.

OBJECTIVES: Although disseminated nontuberculous mycobacteria (NTM) infection has been increasingly reported in patients with AIDS, this condition is still considered rare in non-HIV-infected patients. METHODS: We retrospectively reviewed the medical records of non-HIV-infected patients treated at National Taiwan University Hospital from January 1997 to December 2004 to search for epidemiological trends in disseminated NTM infection. Data analyzed included etiology, demographic characteristics, underlying disease, initial symptoms and signs, treatment, and outcomes. RESULTS: Disseminated NTM infections occurred in 15 non-HIV-infected patients during the study period. The mean age of these patients was 51 years (range 13-80). Among these patients, eight were males, and eight had various immunocompromised conditions. Fever was an initial presentation in 12 patients (80%). Diagnosis was made by positive blood (seven patients) or bone marrow culture (five patients) in the majority (73%) of patients. Infectious etiologies included Mycobacterium avium complex (MAC) in eight, rapidly growing mycobacteria (RGM) in four and Mycobacterium kansasii in three. The mean time from initial presentation to initiation of anti-NTM therapy was 130 days (ranged from 9 days to 17 months). Mortality was highest in patients with M. kansasii (100%), followed by RGM (25%) and MAC (12.5%). CONCLUSIONS: Although disseminated NTM infection is an emerging condition among patients without HIV infection, it is a condition which is associated with immune deficiency. A high level of clinical suspicion should be maintained for avoiding delayed diagnosis, especially in patients with underlying immunosuppression. Blood culture might play an important role in the early diagnosis of disseminated NTM disease. Early diagnosis can lead to appropriate diagnosis and reduce mortality.

Infected bronchogenic cyst due to Mycobacterium avium in an immunocompetent patient.

We present a patient with intermittent pain over the right chest for 2 years. Computed tomograph of the chest disclosed a cystic tumor over the right posterior basal lung. Pathological examinations of the excised tumor disclosed a granulomatous inflammation within the multilocular bronchogenic cysts and microbiological culture of the tissue yielded Mycobacterium avium. This is the first reported case of infected bronchogenic cyst caused by M. avium in humans.

Lymphadenitis caused by non-tuberculous mycobacteria in a university hospital in Taiwan: predominance of rapidly growing mycobacteria and high recurrence rate.

BACKGROUND AND PURPOSE: Lymphadenitis is the most common manifestation of infection due to non-tuberculous mycobacteria (NTM) in otherwise healthy children. This disease is rare in adults and its geographic variations in etiology and clinical manifestations remain unclear. The aim of this study was to describe the etiology, clinical presentation, treatment, and outcome of NTM lymphadenitis. METHODS: Medical records of patients with culture-proven NTM lymphadenitis treated at a university hospital in Taiwan from January 1997 through December 2004 were retrospectively reviewed. RESULTS: In total, 12 patients with NTM lymphadenitis were identified, including 6 males and 7 adults (> or = 16 years). The majority (83%) of patients presented with an enlarged palpable mass and 9 (75%) had preceding constitutional symptoms. The most common site of lymphadenitis was the cervical area (83%) and 8 patients (75%) had multiple lymph node involvement. Rapidly growing mycobacteria (RGM) accounted for 75% of the etiology of NTM lymphadenitis, followed by Mycobacterium avium complex (MAC) [2 patients]. A high recurrence rate (42%) after primary treatment was noted among those patients who received clarithromycin-containing regimens for a median of 6 months. CONCLUSIONS: This study found that both previously healthy children and adults were susceptible to NTM lymphadenitis. RGM was the most common etiology rather than MAC among NTM species causing lymphadenitis. Inadequate surgical excision of the diseased lymph nodes and insufficient coverage of antimycobacterial therapy both contributed to the high recurrence rate.

Pneumothorax in the ICU: patient outcomes and prognostic factors.

STUDY OBJECTIVE: To identify the prognostic factors for pneumothorax in patients in the ICU. DESIGN: Retrospective cohort study. SETTING: ICU at a university-based teaching hospital. PATIENTS AND METHODS: Sixty patients developed pneumothoraces in the ICU during a period of 36 months. Medical records relating to patients' age, sex, underlying diseases, associated medical conditions, reasons for admission, acute physiology and chronic health evaluation (APACHE) II scores, procedures performed before the development of pneumothorax, occurrences of tension pneumothorax, duration of chest tube placement, chest tube removal, duration of ICU stay, and patient outcomes all were analyzed. A multivariate logistic regression model was applied with variables that were significantly associated with survival in the univariate analysis. The probabilities of chest tube removal were calculated using the Kaplan-Meier method. RESULTS: Thirty-five patients (58%) had procedure-related pneumothoraces. The procedure that most commonly caused pneumothoraces was thoracentesis (n = 19; 54%), followed by central vein/pulmonary artery catheterization (n = 14; 40%) and bronchoscopy/transbronchial lung biopsy (n = 8; 23%). A multivariate logistic regression analysis also showed that pneumothorax due to barotrauma (p = 0.001), tension pneumothorax (p = 0.0023), and concurrent septic shock (p = 0.0476) were significantly and independently associated with death. The log-rank test revealed that the success rate of chest tube removal was higher in patients with procedure-related pneumothoraces (p = 0.0055). CONCLUSIONS: Patients with procedure-related pneumothoraces had better outcomes. Patients with pneumothoraces occurring in the ICU due to barotrauma, or a complicating tension pneumothoraces, carry a higher risk of mortality.