New-onset focal epilepsy in adults: Antiepileptic drug treatment.

Focal epilepsy, non-syndromic, is by far the most prevalent epilepsy in adults. Antiepileptic drug (AED) prescription in patients with new-onset focal epilepsy is often challenging. The factors that determine AED of choice depends both on the patient-specific and AED-specific variables. Monotherapy should the initial strategy. Failure to monotherapy can be due to lack of efficacy, severe adverse events, or a hypersensitivity reaction. In such patients, the next strategy should be alternate monotherapy trials. In patients who fail up to three monotherapy trials, duotherapy with drugs having different primary mechanisms of action should be the next step. Multiple duotherapy should be tried before considering adding polytherapy. In spite of such pragmatic strategies, about 25% of patients may never become seizure free for any complete year throughout follow-up. Patients in this group should be evaluated for non-pharmacological treatment options, particularly epilepsy surgery.

Rabies, tetanus, leprosy, and malaria.

The developing world is still endemic to rabies, tetanus, leprosy, and malaria. Globally more than 55000 people die of rabies each year, about 95% in Asia and Africa. Annually, more than 10 million people, mostly in Asia, receive postexposure vaccination against the disease. World Health Organization estimated tetanus-related deaths at 163000 in 2004 worldwide. Globally, the annual detection of new cases of leprosy continues to decline and the global case detection declined by 3.54% during 2008 compared to 2007. Malaria is endemic in most countries, except the US, Canada, Europe, and Russia. Malaria accounts for 1.5-2.7 million deaths annually. Much of the disease burden related to these four infections is preventable.

Fungal infections of the central nervous system.

The epidemiology of invasive fungal infections in immunocompromised patients is rapidly changing. Several of the fungi have worldwide distribution. However, some have specific geographical distribution. Sinocranial aspergillosis, mostly described from countries with temperate climates, occurs mostly in otherwise immunocompetent individuals Most of the systemic fungal pathogens have been associated with central nervous system (CNS) involvement. The major advances in CNS fungal infections are in the pathobiology, new diagnostic tools, and new therapies. In spite of these developments, there is still considerable delay in the diagnosis of CNS fungal infection. CNS fungal infections are associated with considerable morbidity and mortality. To achieve good outcomes early diagnosis and early institution of appropriate therapies are the key issues.

Intracranial Aspergillus granuloma.

Intracranial fungal granulomas are rare and of the histologically verified granulomas, Aspergillus spp. is the commonest causative fungal pathogen. Most of the reported large series of aspergillus granulomas are from countries with temperate climate like India, Pakistan, Sudan, and Saudi Arabia. In contrast to disseminated aspergillosis that occurs in immunosuppressed individuals, most of the intracranial aspergillus granulomas are reported in immunocompetent individuals. The temperature, humidity, high spore content in the atmosphere during ploughing, and occupation as agricultural worker are implicated in the pathogenesis. The sinocranial spread is the most common route of intracranial extension. Extracerebral firm fibrotic lesions and skull base lesions are common. Extensive fibrosis and large number of multinucleated giant cells are the characteristic histological features and these pathological features have therapeutic relevance.