Meningitis and spondylodiscitis due to Nocardia nova in an immunocompetent patient.

BACKGROUND: Disseminated nocardiosis is a very rare disease. By now only few cases of meningitis and spondylodiscitis have been reported. To our knowledge, this is the first case of meningitis caused by Nocardia nova. CASE PRESENTATION: We report on a case of bacteraemia, meningitis and spondylodiscitis caused by N. nova in an immunocompetent patient. We describe the long, difficult path to diagnosis, which took two months, including all diagnostic pitfalls. After nocardiosis was diagnosed, intravenous antibiotic therapy with ceftriaxone, later switched to imipenem/cilastatin and amikacin, led to rapid clinical improvement. Intravenous therapy was followed by oral consolidation with co-trimoxazole for 9 months without any relapse within 4 years. CONCLUSIONS: Establishing a diagnosis of nocardiosis is a precondition for successful antibiotic therapy. This requires close communication between clinicians and laboratory staff about the suspicion of nocardiosis, than leading to prolonged cultures and specific laboratory methods, e.g. identification by 16S rDNA PCR.

Cerebral protection vs no cerebral protection: timing of stroke with CAS.

Since its development in the late 1980s the discussion of risk and benefit of carotid artery stenting (CAS) compared to carotid endarterectomy (CEA) is still ongoing. In this discussion the increasing technical inventions in CAS like PDs, different stent designs and materials and their effect upon the complication rates are playing increasingly important roles. We present a review of mono- or oligocentre studies with greater collectives, one review study and multi centre studies SPACE I, EVA-3S and preliminary data from the ICSS-trial, in which subgroups of patients were treated with or without protection devices. Despite the results of several retrospective studies mostly with historic comparator cohorts rather than concurrent the results of the most recent multi centre prospective randomized trials seem to show a benefit for unprotected stenting. The complication rates for protected vs. unprotected groups in SPACE I showed 8.3% vs. 6.5% and the pooled data from SPACE I and EVA-3S 8.1% vs. 7.3%. A subgroup analysis of SPACE I aiming at the impact of the stent design on peri-interventional complication rate shows that the pOE rate was significantly lower in patients treated with a closed cell stent (5.7%, 95% CI: 3.7-8.3%) than in those treated with an open cell stent (11.0%, 95% CI: 6.2-17.8%) (P=0.047). The most recent data from prospective multi centre trials support the presumption that PDs do not reduce, but may increase the periinterventional complication rate. Whereas many older single centre studies promoting PDs do show conceptual problems. The stent design appears to have a more important impact on the resulting complications in CAS, than the PDs.

[Carotid artery stenting via transbrachial approach]. / Stenting der Arteria carotis interna über den transbrachialen Zugang.

PURPOSE: The transbrachial approach as an alternative access site for carotid artery stenting (CAS) has mainly been published as case reports. This paper evaluates transbrachial CAS at our institute for the past 5 years and refers to the complications and results of this method. MATERIALS AND METHODS: From January 2003 to April 2008, we performed 299 CAS of which 12 (4%, 11 male, 1 female) were performed with a transbrachial approach. The average age of these patients was 67.4 years (+/- 9.75). The average degree of stenosis of the treated carotid artery was assessed by Doppler ultrasound (81.5% +/- 10.66) and digital subtraction angiography (DSA) using the NASCET criteria (75.9% +/- 9.75). 9 / 12 patients (75%) were treated because of symptomatic stenosis. RESULTS: The transbrachial approach was performed in 8 patients because of high-grade stenosis of the femoral and/or iliac arteries. 4 patients showed severe elongation of the aortic arch. 11 of 12 (92%) of the transbrachial CAS were performed successfully. The approach was judged to be only slightly more challenging than puncture of the femoral artery. No minor or major complications occurred at the access site. 3 of 11 patients (27%) showed residual stenosis after CAS of 24% (+/- 7.78). CONCLUSION: The transbrachial approach for CAS is rarely required compared to the transfemoral approach. Especially in cases of femoral or iliac artery stenosis and severe elongated and calcified aortic arches, it is an elegant alternative approach with rare complications.

Dentomaxillofacial imaging in Proteus syndrome.

Proteus syndrome is a rare condition that involves atypical growth of the bones, skin and head and a variety of other symptoms. Only a few authors have reported on the craniofacial manifestations so far. The authors present a case of a 7-year-old girl with Proteus syndrome in which the facial skeleton showed unilateral overgrowth. The analysis of the radiological evaluation revealed a bialveolar prognathism, a skeletal class III, a dolicocephalic growth pattern and a left convex face scoliosis. On the left side, the lesser wing of the sphenoid was elevated and the ethmoidal cell complex was hypertrophic. The left ramus and body of the mandible were enlarged. The asymmetric dental development with a precocious dental age on the affected side was the most striking feature on the panoramic view. Early diagnosis and therapy depend on clinical evaluation and imaging. Therefore, further evaluations on the craniofacial features of patients with Proteus syndrome are necessary in order to establish a list of characteristic symptoms.

A comparison of two intraoral CCD sensor systems in terms of image quality and interobserver agreement.

PURPOSE: Two intraoral CCD sensor systems were compared with respect to image quality and interobserver agreement. MATERIALS AND METHODS: Forty intraoral images from each of the sensors (Trophy RVG5, Sirona Sidexis) were examined by 4 observers in terms of anatomical landmarks and general image quality. The images were divided into 2 groups--filtered and unfiltered. Kappa values for interobserver agreement were calculated for all assessed points. RESULTS: The Trophy sensor showed better image quality in the filtered group, and the Sirona sensor demonstrated good image quality in the unfiltered group. Moderate to substantial interobserver agreement was achieved. The use of filters increased edge artefacts. Sensor specific artefacts in the Trophy system were observed.