Recurrence of Disseminated Mycobacterium avium intracellulare Presenting as Spondylodiscitis and Epidural Abscess in a Patient with Acquired Immune Deficiency Syndrome (AIDS).

BACKGROUND Mycobacterium avium intracellulare complex (MAI) is a member of the non-tuberculous mycobacteria family, which can cause both pulmonary and non-pulmonary disease. In patients with advanced HIV, it is known to cause disseminated disease. We present a case of a 65-year-old man who has sex with men (MSM) with AIDS, found to have spondylodiscitis and an epidural abscess, who had recently completed treatment for disseminated MAI. CASE REPORT The patient was a 65-year-old with AIDS secondary to HIV and a prior history of disseminated MAI, who presented with severe back pain. Upon presentation to the hospital, an MRI was performed, which was suggestive of spondylodiscitis and an epidural abscess. He was taken to surgery for a minimally invasive T12-L1 laminectomy and evacuation of the epidural abscess. Both traditional cultures and acid-fast bacillus (AFB) cultures were negative. Due to worsening pain, he was taken back to surgery for a repeat debridement and biopsy. Repeat cultures were positive for MAI. He was started on rifabutin, ethambutol, azithromycin, and moxifloxacin. Moxifloxacin was subsequently discontinued. He has had problems tolerating the treatment regimen, but is planned to complete an 18-24-month course. CONCLUSIONS For patients with AIDS who have a diagnosis of spondylodiscitis and an epidural abscess, an opportunistic infection such as MAI should be considered. A repeat biopsy should be considered if suspicion is still high, even despite initially negative cultures. Treatment regimens should be prolonged, despite difficulty with medication compliance.

Adjustable shunt valve reprogramming at home: safety and feasibility.

OBJECTIVE: Shunt valve resistance changes using a specialized magnetic programming device permit noninvasive changes to cerebrospinal fluid drainage. In selected cases between 2001 and 2005, patients and families used shunt valve programming devices at home. This study examines the safety and efficacy of this practice. METHODS: We conducted a retrospective review of the medical records of patients who had been given a shunt valve-programming device for home use. A survey was mailed to patients or family members requesting information regarding their experiences with the shunt valve programming device. Patient and family responses were tabulated and a statistical analysis was performed. RESULTS: Twenty patients or families returned the survey. The median patient age was 19.6 years (range, 6-48 yr); 25% were male. Seventeen patients had pseudotumor cerebri, one had an arachnoid cyst, and two had slit ventricle syndrome. Fifteen patients had lumboperitoneal shunts, one had a ventriculoperitoneal shunt, three had cisterna magna shunts, and one had an arachnoid cyst-to-peritoneal shunt. No adverse events were attributable to the use of the home shunt valve programmer. Thirty-five percent of respondents used the programmer at least once every week, 40% used the programmer between once a week and once a month, and 25% used the programmer less frequently than once per month. Overall, 85% of respondents reported that they benefited "very much" from the use of a home shunt valve programmer and 15% of respondents benefited "somewhat." CONCLUSION: Providing shunt valve programming devices to selected patients for home use is a safe practice associated with high patient satisfaction. However, the selection of appropriate patients, comprehensive patient education, and close patient-physician communication are crucial to the success of this practice.

Correction of sagittal craniosynostosis using a novel parietal bone fixation technique: results over a 10-year period.

Isolated sagittal synostosis is a common form of craniosynostosis affecting roughly 1 in 5,000 children at birth. This results in a scaphocephalic head shape with a characteristically elongated anterior-posterior dimension and narrowed biparietal diameter. We present our experience with the correction of scaphocephaly due to sagittal synostosis using cranial vault reconstruction with a novel form of parietal bone fixation in 21 patients over 10 years. The medial fixation results in a hinging effect whereby transverse brain growth at the squamoid suture is enhanced. This results in excellent cosmetic results that are immediate and durable without the need for postoperative molding helmets. Furthermore, the complications associated with this procedure are limited.

Intradural spinal Wilm's tumor metastasis: case report.

OBJECTIVE: Wilm's tumor metastasis to the central nervous system (especially the spine) is rare. We present a case of a lumbosacral intradural drop metastasis in a male child with a remote history of intracerebral Wilm's tumor metastases. CLINICAL PRESENTATION: A 7-year-old boy with known metastatic Wilm's tumor was discovered to have left frontal and parietal metastases. He subsequently underwent craniotomy and gross total resections of those lesions. Four years later, he developed low back pain and lower extremity weakness and was found to have an intradural lumbosacral lesion without intracranial recurrence. INTERVENTION: The patient underwent lumbar laminectomy for resection of the intradural lesion. The tumor was found to be in the subarachnoid space and displaced the nerve roots of the cauda equina to the periphery of the thecal sac. The nerve roots were matted and encased within tumor tissue, thereby limiting the surgery to biopsy only. Postoperatively, the patient received radiation to the lesion. Unfortunately, follow-up imaging 4 months later revealed little tumor regression, and the patient's neurological condition did not improve significantly. CONCLUSION: Spinal intradural Wilm's tumor metastases are rare. This is the only reported case in the literature of a probable drop metastasis from an intracerebral source. Although the optimal treatment for intra- or extradural Wilm's tumor spine metastases is not known, our patient did not make significant neurological improvement with radiation therapy.

Surgery for low-grade gliomas: current evidence and controversies.

Despite decades of studies, the surgical management of cerebral low-grade gliomas remains quite controversial. Recommendations range from observation with biopsy to radical resection. This controversy arises from several factors, chief of which is the lack of prospective, randomized studies specifically addressing the issue of resection. Nevertheless, the available data, with its inherent inadequacies, must be used to help guide the care of these patients. This article reviews the current literature on the role of surgery for these tumors and attempts to put forward reasonable treatment options in an area where even the American Association of Neurological Surgeons can find no standard management to recommend aside from biopsy prior to the onset of therapy.

Endoscopic, single-catheter treatment of Dandy-Walker syndrome hydrocephalus: technical case report and review of treatment options.

Optimal treatment for hydrocephalus related to Dandy-Walker syndrome (DWS) remains elusive. Patients with DWS-related hydrocephalus often require combinations of shunting systems to effectively drain both the supratentorial ventricles and posterior fossa cyst. We describe an endoscopic technique, whereby a frontally placed, single-catheter shunting system effectively drained the supratentorial and infratentorial compartments. This reduces the complexity and potential risk associated with the combined shunting systems required by so many with DWS-related hydrocephalus.

Immunotherapy for malignant glioma: current approaches and future directions.

Traditional therapies for the treatment of malignant glioma have failed to make appreciable gains regarding patient outcome in the last decade. Therefore, immunotherapeutic approaches have become increasingly popular in the treatment of this cancer. This article reviews general immunology of the central nervous system and the immunobiology of malignant glioma to provide a foundation for understanding the rationale behind current glioma immunotherapies. A review of currently implemented immunological treatments is then provided with special attention paid to the use of vaccines, gene therapy, cytokines, dendritic cells and viruses. Insights into future and developing avenues of glioma immunotherapy, such as novel delivery systems, are also discussed.

Endoscopic cyst fenestration outcomes in children one year of age or less.

The use of endoscopic fenestration (EF) is becoming an increasingly common treatment for symptomatic intracranial cysts. Very little data exist regarding outcomes for this procedure in children 1 year of age or younger. We retrospectively reviewed the clinical outcomes of 8 children 1 year of age or less treated at our institution with endoscopic cyst fenestration. The mean follow-up was roughly 2.5 years. These data were combined with 17 other cases obtained from the published literature. EF was successful in rendering patients shunt-free or minimizing the number of ventricular catheters in 18 of 26 operations. There were 8 outright failures -- two in 1 patient. Given the risks and complications of cerebrospinal fluid shunting in children less than 1 year of age, we advocate the consideration of EF as initial treatment of symptomatic intracranial cysts.

Lumbar CSF shunting preferentially drains the cerebral subarachnoid over the ventricular spaces: implications for the treatment of slit ventricle syndrome.

Based on a proposed pathophysiology of slit ventricle syndrome (SVS), we have hypothesized that lumboperitoneal shunting exerts effects in SVS patients by increasing the buffering capacity for raised intracranial pressure (ICP) via an increase in cerebrospinal fluid drainage from the cerebral subarachnoid space (SAS). We describe 3 SVS patients with patent lumbar subarachnoid drainage but under-functioning ventriculoperitoneal shunts (VPS) who presented with ventriculomegaly (not SVS), and persistence of shunt malfunction like symptoms. Revision of the VPS resulted in complete resolution of symptoms despite a finding of low pressure in the ventricular space. This supports the hypothesis that lumboperitoneal shunting preferentially drains the SAS over the intraventricular space and in these cases allows the 'SVS' ventricles to enlarge by creating a pressure gradient from ventricles to SAS through the cortical mantle.