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PubMed1991

Osteoarticular complications of brucellosis.

Two hundred and sixty three patients with a diagnosis of brucellosis between January 1984 and December 1987 were studied prospectively. Sixty five patients (25%) developed osteoarticular complications. These patients had a more prolonged course than those with no complications. Spondylitis in 38 (58%) and sacroiliitis in 29 (45%) were the most prevalent. There were no significant laboratory, serological, or bacteriological differences between patients with and without osteoarticular complications. At diagnosis 47 patients (72%) showed radiographic abnormalities, commonly in axial sites but rarely in peripheral sites. Radionuclide bone scan was positive with no radiographic abnormalities in 17 (26%) of cases. Fifty seven patients received medical treatment alone, 51 (89%) being cured with a single course of treatment. Treatment failed or there was a relapse in six patients (11%), of whom five had spondylitis. Eight of the 65 patients (12%), all of whom had spondylitis and paravertebral or epidural abscesses, also required surgical treatment.

Adolescent↗

PubMed2002

Thoracic complications of illicit drug use: an organ system approach.

Illicit drug use constitutes a major health problem and may be associated with various thoracic complications. These complications vary depending on the specific drug used and the route of administration. Commonly abused drugs that may play a role in causing thoracic disease include cocaine, opiates, and methamphetamine derivatives. Intravenously abused oral medications may contain filler agents that may be responsible for disease. Thoracic complications may be categorized as pulmonary, pleural, mediastinal, cardiovascular, and chest wall complications. Pulmonary complications of drug abuse include pneumonia, cardiogenic edema, acute lung injury, pulmonary hemorrhage, and aspiration pneumonia. Filler agents such as talc may result in panacinar emphysema or high-attenuation upper-lobe conglomerate masses. The primary pleural complication of illicit drug use is pneumothorax. Mediastinal and cardiovascular complications of illicit drug use include pneumomediastinum, cardiomyopathy, myocardial infarction, aortic dissection, and injection-related pseudoaneurysms. Chest wall complications include diskitis and vertebral osteomyelitis, epidural abscess, necrotizing fasciitis, costochondritis, and septic arthritis. Categorization of thoracic complications of illicit drug use may facilitate understanding of these disorders and allow accurate diagnosis.

Aortic Dissection↗

PubMed2003

MR imaging findings in spinal infections: rules or myths?

PURPOSE: To systematically evaluate magnetic resonance (MR) imaging findings described as being indicative of spinal infection in patients with proven spinal infection. MATERIALS AND METHODS: Contrast material-enhanced spinal MR images obtained in 46 consecutive patients (22 women, 24 men; mean age, 58.2 years) with culture or histologic examination results positive for spinal infection were systematically evaluated by two observers. Tuberculous and postoperative infections were excluded. Disk signal intensity and disk height, presence of the nuclear cleft, vertebral signal intensity alterations, endplate erosions on T1-weighted MR images, and presence of paraspinal or epidural inflammation were evaluated. Patient charts and surgical reports were reviewed. RESULTS: In the 44 patients with disk infection, MR imaging criteria with good to excellent sensitivity included presence of paraspinal or epidural inflammation (n = 43, 97.7% sensitivity), disk enhancement (n = 42, 95.4% sensitivity), hyperintensity or fluid-equivalent disk signal intensity on T2-weighted MR images (n = 41, 93.2% sensitivity), and erosion or destruction of at least one vertebral endplate (n = 37, 84.1% sensitivity). Effacement of the nuclear cleft was only applicable in 18 patients (n = 15, 83.3% sensitivity). Criteria with low sensitivity included decreased height of the intervertebral space (n = 23, 52.3% sensitivity) and disk hypointensity on T1-weighted MR images (n = 13, 29.5% sensitivity). Involvement of several spinal levels occurred in seven (16%) patients. Other spinal infections included isolated vertebral osteomyelitis (n = 1) and primary epidural abscess (n = 1). CONCLUSION: Most MR imaging criteria commonly used to diagnose disk infections offer good to excellent sensitivity. In atypical manifestations of proven spinal infections, however, some of the classically described MR imaging criteria may not be observed.

Adult↗

PubMed2001

Intracranial complications of frontal sinusitis in children: Pott's puffy tumor revisited.

The objective of the present study is to describe the diagnosis and treatment of intracranial complications of frontal sinusitis (Pott's puffy tumor) in a series of pediatric patients at our institution. A rare entity, Pott's puffy tumor has been reported in only 21 pediatric cases in the literature of the antibiotic era. The hospital records and radiographic files at Rainbow Babies and Childrens Hospital, Cleveland, Ohio, USA, over the previous 16 years were retrospectively reviewed in a search for patients with the diagnosis of Pott's puffy tumor, defined as scalp swelling and associated intracranial infection. There were 6 male patients and 1 female patient. Ages ranged from 11 to 18 years (median 14.5 years). Intracranial infections consisted of epidural abscess in 5 patients, subdural empyema in 4 and brain abscess in 1. Intraoperative cultures grew anaerobic organisms in 1 patient, microaerophilic streptococcus in 5 patients, Klebsiella species in 1 patient and Streptococcus pneumoniae in another. All patients presented with frontal scalp swelling, and other common symptoms included headache, fever, nasal drainage and frontal sinus tenderness. Five patients were treated with antibiotics prior to their presentation. Four patients presented with neurologic decompensation characterized by varying degrees of hemiparesis, obtundation, pupillary dilatation or aphasia. All patients underwent craniotomy and evacuation of the intracranial infection. Even severely impaired patients demonstrated full neurologic recovery. Despite the widespread use of antibiotics, neurosurgical complications of sinusitis continue to occur. A high degree of suspicion, along with prompt neurosurgical intervention and the use of appropriate antibiotics, can result in favorable outcomes in even the sickest patients.

Adolescent↗

PubMed1997

Pyogenic infectious spondylitis: clinical, laboratory and MRI features.

Pyogenic infectious spondylitis (PIS) is an uncommon but serious inflammatory disorder of the discovertebral junction with frequent involvement of neural structures including the spinal cord. We report a series of 41 patients (age range 21-75 years, mean age 59 years) with primary PIS confirmed by signal abnormality of the intervertebral disk and adjacent vertebral bodies on magnetic resonance imaging. The prevailing clinical symptom was focal back pain aggravated by percussion in 90% of patients. Radicular signs or symptoms were present in 59% and spinal cord symptoms in 29% of patients, respectively. Evidence of inflammation consisted of an elevated sedimentation rate in 76%, leukocytosis in 61% and fever in 61% of individuals. Predisposing factors such as diabetes mellitus, previous nonspinal surgery and other sites of infection or inflammation were identified in 17 (41%) patients and 30 (73%) were older than 50 years. The lumbar spine was most often affected and PIS was associated with an epidural abscess in 15 (37%) patients. Increased alertness for PIS in the context of focal back pain with clinical or laboratory signs of inflammation is needed to speed up its detection.

Abscess↗

PubMedDate not supplied

Primary squamous cell carcinoma of the middle ear invading the cochlea. A histopathological case report.

This report describes the histopathological changes in the temporal bone of a 71-year-old man who died of meningitis and epidural abscess complicated by primary squamous cell carcinoma of the middle ear. The present case is unusual and differs somewhat from previously reported cases of the primary squamous cell carcinoma of the middle ear in three respects: 1) an extensive invasion of the cancer into the membranous labyrinth, 2) cholesterol deposits in the cochlear spiral canal, and 3) presence of ossifying labyrinthitis. Among these findings, extensive involvement of the inner ear by cancer destroying the lower part of the otic capsule is particularly unusual. It is assumed that squamous cell carcinoma overcame the biological resistance to neoplastic infiltration which probably exists in the otic capsule and the membranous labyrinth.

Aged↗

PubMed1997

Safety of esophagoscopy in the irradiated esophagus.

Carcinoma of the esophagus is a disease with a poor prognosis. Surgery is considered the treatment of choice. Patients who are surgically unresectable may receive radiotherapy, plus or minus chemotherapy. While this offers reasonable palliation, a significant number of patients develop benign or malignant strictures. Frequent esophagoscopy with dilation is required if they are to swallow. Patients with strictures or malignancy of the esophagus are more prone to complications if they undergo an esophagoscopy. We examined the morbidity of esophagoscopy in a group of patients who had received radiotherapy for carcinoma of the esophagus. Over a 10-year period, 21 patients receiving irradiation for carcinoma of the esophagus were examined. All patients underwent esophagoscopy for staging and diagnosis. The tumor locations were upper (6), middle (6), and lower (9) esophagus. The T-stages were 1 (7), 2 (6), 3 (6), and 4 (2). Five patients had dilation of a malignant stricture at the time of diagnosis. Fever developed and resolved within 24 hours in 2 patients. Following completion of irradiation, a total of 83 esophagoscopies were performed (range 1 to 11 per patient). Six patients with no tumor or stricture underwent 8 esophagoscopies (3 rigid, 5 flexible). There was 1 episode of minimal bleeding and 1 fever that resolved within 24 hours. Ten patients with malignant strictures underwent 62 esophagoscopies (5 rigid, 57 flexible). There were 17 (27%) episodes of fever (all resolved within 24 hours) and 14 (22%) episodes of bleeding. Five patients with benign strictures underwent 13 esophagoscopies (2 rigid, 11 flexible). One patient had a perforation that resolved with conservative treatment, and 1 patient developed an epidural abscess 2 months following dilation. This patient is the only one that required surgical intervention and had prolonged hospitalization. Esophagoscopy of the irradiated esophagus can be performed relatively safely and excellent palliation obtained. Morbidity consisting of minimal bleeding, and fever lasting less than 24 hours, is frequent but self-limited.

Adult↗

PubMed1988

Intracranial phycomycosis: case reports.

Cerebral phycomycosis is a rare disease. We describe two patients with unusual features of focal intracranial phycomycosis: a diabetic patient with chronic epidural abscess and a healthy individual with an isolated intracerebral abscess. Biopsy established the diagnosis in both patients. Treatment was successful in the patient with intracerebral abscess.

Adult↗

PubMed1993

A risk/benefit analysis of spinal manipulation therapy for relief of lumbar or cervical pain.

Approximately 12 million Americans undergo spinal manipulation therapy (SMT) every year. Renewed interest in this method requires an analysis of its reported risks and possible benefits. This review describes two patients with spinal cord injuries associated with SMT and establishes the risk/benefit ratios for patients with lumbar or cervical pain. The first case is a man who underwent SMT for recurrent sciatica 4 years after chemonucleolysis. During therapy, he developed bilateral sciatica with urinary hesitancy. After self-referral, myelography demonstrated a total block; he underwent urgent discectomy with an excellent result 3 months after surgery. The second patient with an indwelling Broviac catheter and a history of lumbar osteomyelitis underwent SMT for neck pain. Therapy continued for 3 weeks despite the development of severe quadriparesis. After self-referral, he underwent an urgent anterior cervical decompression and removal of necrotic bone and an epidural abscess with partial neurological recovery. An analysis of these cases and 138 cases reported in the literature demonstrates six risk factors associated with complications of SMT. These include misdiagnosis, failure to recognize the onset or progression of neurological signs or symptoms, improper technique, SMT performed in the presence of a coagulation disorder or herniated nucleus pulposus, and manipulation of the cervical spine. Clinical trials of SMT have been summarized in several recent articles.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1980

Frontal sinus fractures--their suppurative complications and surgical management.

A series of 54 patients treated for frontal sinus fractures at Charity Hospital, New Orleans, from 1967-77 is presented. There were a large number of suppurative complications related to the various medical and surgical managements. Initial treatments included: observation (15), exploration and open reduction (22), obliteration (16), and ablation (1). Four patients with open fractures were not explored and developed recurrent frontal sinusitis; one progressed to an osteomyelitis. Two with posterior table fractures were not explored and developed meningitis (one was then obliterated and developed an epidural abscess). Three patients developed frontal sinus abscesses after obliterations for anterior wall fractures. Fat gave fewer complications than the other commonly used materials. Exploration is advocated for most frontal sinus fractures. Obliteration should be avoided when possible. Fat is the material of choice when obliteration is required.

Adolescent↗

PubMed1981

Rare complications following ethmoidectomies: a report of eleven cases.

Intranasal ethmoidectomy is one of the most difficult operations to teach residents. An accurate knowledge of the regional topographic anatomy is of utmost importance. Friedman and Kerr reported complications of 1000 cases of consecutive intranasal ethmoidectomies performed at the Mayo Clinic from 1957 to 1972. The complication rate was 2.8%. Meningitis, cerebrospinal fluid rhinorrhea, loss of olfaction, and nasolacrimal duct obstruction were reported. No blindness, loss of occular motility, excision of brain tissue or intracranial vessel damage occurred in their series. We are reporting a series of 8 cases of very rare complications following intranasal ethmoidectomies: 1. Optic nerve damage resulting in total blindness (3 cases). 2. Loss of occular motility (2 cases). 3. Cerebrospinal fluid leak resulting in 8 episodes of pseudomonas meningitis and epidural abscess (1 case). 4. Cavernous sinus--internal carotid artery fistula (1 case). 5. Anterior cranial fossa brain damage resulting in death (1 case). These cases, which were either referred to us or came up for our review, are described in detail. A search of the world literature demonstrates a lack of emphasis on such complications. The pitfalls of intranasal ethmoidectomy are considered and ways to avoid such dreadful complications are discussed.

Adult↗

PubMed2002

Lumbar and lumbosacral tuberculous spondylodiscitis in adults. Redefining the indications for surgery.

We have reviewed, retrospectively, 66 adult patients who were treated for lumbar or lumbosacral tuberculosis. A total of 45 had a paravertebral or epidural abscess, 24 had clinical instability and 18 presented with a radiculopathy, of which six also had a motor deficit. The diagnosis was usually made on clinical and radiological grounds and they were followed up until there were clinical and radiological signs of full recovery. Conservative treatment with antituberculous drugs was successful in 55 patients (83%). None had persistent instability, radiculopathy or neurological compromise. We feel that tuberculous spondylodiscitis, especially in the lumbar spine, can usually be satisfactorily managed conservatively and that there are few indications for surgical treatment.

Adult↗

PubMed2002

Neurologic complications after heart transplantation.

OBJECTIVE: Neurologic complications are known as important cause of morbidity and mortality in orthotopic heart transplantation. Our aim was to identify the frequency and outcome of neurologic complications after heart transplantation in a prospective observational study. METHOD: From September 93 to September 99, as part of our routine heart transplantation protocol all patients with end-stage cardiac failure were evaluated by the same neurologist before and at the time of any neurologic event (symptom or complaint) after transplantation. RESULTS: Out of 120 candidates evaluated, 62 were successfully transplanted (53 male; median age 45.5 years, median follow-up 26.8 months). Fifteen patients (24%) had ischemic, 22 (35%) idiopathic, 24 (39%) Chagas' disease and 1 (2%) had congenital cardiomyopathy. Neurologic complications occurred in 19 patients (31%): tremor, severe headache, transient encephalopathy and seizures related to drug toxicity or metabolic changes in 13; peripheral neuropathy in 4; and spinal cord compression in two (metastatic prostate cancer and epidural abscess). No symptomatic postoperative stroke was observed. CONCLUSIONS: Although frequent, neurologic complications were seldom related to persistent neurologic disability or death. Most of the complications resulted from immunosuppression, however, CNS infection was rare. The absence of symptomatic stroke in our series may be related to the lower frequency of ischemic cardiomyopathy.

Adolescent↗

PubMed2003

[Septic spondylodiscitis: diagnosis and treatment].

We studied retrospectively 24 patients with septic discitis of different etiologies (hematogenic, primary and infantile) and the different aspects involved in its diagnosis and treatment. Erythrocyte sedimentation rate proved to be a valuable parameter and should always be interpreted carefully along with the clinical and neuroimaging findings. Biopsies should be reserved for doubtful cases with atypical course. Clinical treatment should be initiated after the following situations have been ruled out: sepsis, neurological deficit, severe deformity, epidural abscess and foreign body (primary disease). The surgical approach may be chosen based on the stage of disease, being preferably posterior in suppurative forms and anterior in the non-suppurative stage. Based on our experience and on information gathered by literature review, we propose an algorithm to guide diagnosis and treatment in patients with septic discitis.

Adolescent↗

PubMed1997

Recognition and optimum treatment of brucellosis.

Brucellosis (infection with Brucella spp.) is a common zoonosis in many parts of the world. Human brucellosis is a multisystem disease that may present with a broad spectrum of clinical manifestations. Treatment of brucellosis must effectively control acute illness and prevent complications and relapse. The choice of regimen and duration of antimicrobial therapy should be based on the presence of focal disease and underlying conditions which contraindicate certain specific antibiotics. The regimen of first choice is combination therapy with doxycycline for 45 days and streptomycin for 14 days. Gentamicin or netilmicin for the first 7 days may be substituted for streptomycin. Second-choice regimens consist of combinations of doxycycline and rifampicin (rifampin) for 45 days, or monotherapy with doxycycline for 45 days. Surgery should be considered for patients with endocarditis, cerebral or epidural abscess, spleen abscess or other abscesses which are antibiotic-resistant. Tetracyclines are generally contraindicated for pregnant patients and children < 8 years old. Rifampicin 900 mg once daily for 6 weeks is considered the drug of choice for treating brucellosis in pregnant women. In children < 8 years old the preferred regimen is rifampicin with cotrimoxazole (trimethoprim-sulfamethoxazole) for 45 days. An alternative regimen consists of a combination of rifampicin for 45 days with gentamicin 5 to 6 mg/kg/day for the first 5 days.

Adult↗

PubMed1995

Cranioplasty with split-thickness calvarial bone.

Cranioplasty with autogenous split-thickness calvarial bone was performed in 10 patients. Follow-up for a mean of 19 months (range 2-43 mos) showed satisfactory protection of the brain and cosmetic reconstruction. No serious complication was seen except in one patient with postoperative epidural abscess. Split-thickness calvarial bone graft is recommended in patients with previous infection or high risk of infection, in poorly vascularized recipient sites resulting from multiple operations or irradiation, and in younger patients aged more than 7 years.

Adolescent↗

PubMed1999

Dorsally sequestrated thoracic disc herniation--case report.

A 53-year-old male presented with a rare dorsally sequestrated thoracic disc herniation manifesting as acute low back pain and weakness. He had no history of trauma. Magnetic resonance (MR) imaging demonstrated a mass at T10-11 intervertebral level connected with the T-10 disc. Axial MR imaging showed the mass had surrounded and compressed the dural sac from the lateral and dorsal sites. MR imaging with gadolinium-diethylenetriaminepenta-acetic acid showed slight rim enhancement of the lesion. Computed tomography detected no abnormal calcification. The diagnosis was thoracic disc herniation. Laminectomy resulted in rapid and satisfactory recovery. The histological diagnosis was thoracic disc herniation. MR imaging was very effective for the diagnosis based on the connection between the mass and the disc space. The differential diagnosis includes metastatic epidural tumor, epidural hematoma, and epidural abscess.

Acute Disease↗

PubMed1995

Protracted and recurrent methicillin-resistant Staphylococcus aureus bacteremia despite defervescence with vancomycin therapy.

Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia persisted for 46 days in a 63-year-old patient and recurred over 98 days in a 79-year-old patient, despite vancomycin therapy. Although the fever resolved, patient 1 developed a spinal epidural abscess 38 days after beginning therapy and patient 2 sustained multiple relapses. A time-kill study demonstrated a reduced vancomycin killing rate in both isolates when compared to the killing rate of a control MRSA strain. The bacteremia persisted after increasing the vancomycin dose to achieve trough levels of 15-20 micrograms; it cleared after adding gentamicin. These cases illustrate that MRSA bacteremia may persist during vancomycin therapy despite resolution of fever and may lead to delayed complications, and that adding gentamicin may be necessary for ultimate clearance of the bacteremia.

Aged↗