Mardjohan Hardjasudarma

Pediatric spinal blastomycosis: case report.

A 5-year-old male patient presented with flank pain, limping, weight loss, and cachexia. Magnetic resonance imaging revealed destructive vertebral changes, an epidural mass, psoas abscesses, and lack of involvement of the disc spaces. Blastomyces dermatitidis was isolated from a needle aspiration specimen. Sparing of the disc spaces, an unusual finding, suggested that the spread of infection was by way of paravertebral structures and surrounding potential spaces. Management was simplified by using gadolinium contrast-enhanced magnetic resonance imaging, which indicated that the epidural mass was mainly solid, thereby obviating abscess drainage.

Inadvertent Use of Ionic Contrast Material in Myelography: Case Report and Management Guidelines

A 38-year-old man with chronic low back pain underwent myelography and was inadvertently injected with ionic contrast medium. Within minutes, he started complaining of muscle spasms in his lower extremities, followed by respiratory distress and myoclonus. Immediate intravenous treatment with fluids, antihistamines, and supplemental oxygen was started. Within 1 hour after the myelogram, he was intubated and paralyzed with a neuromuscular blocking agent. Shortly thereafter, he began receiving triple anticonvulsant therapy and a lumbar drain was inserted to allow for the evacuation of cerebrospinal fluid. Electroencephalographic monitoring, which initially showed that the patient was in status epilepticus, subsequently showed no more episodes of seizure activity. Massive rhabdomyolysis, renal failure, and metabolic derangement were prevented. He was then extubated and regained full consciousness. He was discharged on the 13th day of hospitalization with mild amnesia and some cognitive dysfunction. A review of the literature reveals descriptions of 9 of 15 patients who survived similar episodes. We conclude that prompt identification of the contrast medium error and prompt intervention are crucial to increase significantly the chances of survival. Elective paralysis, anticonvulsant therapy, and cerebrospinal fluid drainage are the recommended modes of treatment.

Chylous effusion complicating chronic lymphocytic leukemia.

We present a case of chylous effusion (CE) occurring in a patient with chronic lymphocytic leukemia (CLL), an observation which has rarely been reported. Therefore, CLL should be added to the differential diagnosis of nontraumatic chylothorax. CE in CLL can be successfully managed by irradiation of the mediastinum.

Inadvertent Use of Ionic Contrast Material in Myelography

A 38-year-old man with chronic low back pain underwent myelography and was inadvertently injected with ionic contrast medium. Within minutes, he started complaining of muscle spasms in his lower extremities, followed by respiratory distress and myoclonus. Immediate intravenous treatment with fluids, antihistamines, and supplemental oxygen was started. Within 1 hour after the myelogram, he was intubated and paralyzed with a neuromuscular blocking agent. Shortly thereafter, he began receiving triple anticonvulsant therapy and a lumbar drain was inserted to allow for the evacuation of cerebrospinal fluid. Electroencephalographic monitoring, which initially showed that the patient was in status epilepticus, subsequently showed no more episodes of seizure activity. Massive rhabdomyolysis, renal failure, and metabolic derangement were prevented. He was then extubated and regained full consciousness. He was discharged on the 13th day of hospitalization with mild amnesia and some cognitive dysfunction. A review of the literature reveals descriptions of 9 of 15 patients who survived similar episodes. We conclude that prompt identification of the contrast medium error and prompt intervention are crucial to increase significantly the chances of survival. Elective paralysis, anticonvulsant therapy, and cerebrospinal fluid drainage are the recommended modes of treatment.

Spinal epidural compression in head and neck cancer: report of five cases

Patients with newly diagnosed head and neck cancer (HNC) during a 13-year period were retrospectively studied for the development of spinal epidural compression (SEC). Of the 759 patients studied, 5 developed epidural compression (1%), 4 of whom were relatively young. SEC occurred simultaneously with HNC in 2 patients and long after the diagnosis of HNC in 3 individuals. There was no observed tendency to involve a particular segment of the spine. Local control of HNC following definitive treatment along with regained ability to walk after palliative radiotherapy in a patient was associated with long-term survival. Recommendations are made for aggressive treatment of SEC to achieve a satisfactory outcome.

Computed tomography of traumatic dislocation of the lens

Various conditions, particularly trauma, can cause dislocation of the lens. The characteristic findings of this condition are easily demonstrated with computed tomography, which is the examination of choice. This is illustrated by the three cases in this report, which includes discussion of the various ophthalmologic and imaging aspects.

Feasibility of using diffuse reflectance spectroscopy for the quantification of brain edema

Many diseased states of the brain can result in the displacement of brain tissues and restrict cerebral blood flow, disrupting function in a life-threatening manner. Clinical examples where displacements are observed include venous thromboses, hematomas, strokes, tumors, abscesses, and, particularly, brain edema. For the latter, the brain tissue swells, displacing the cerebral spinal fluid (CSF) layer that surrounds it, eventually pressing itself against the skull. Under such conditions, catheters are often inserted into the brains ventricles or the subarachnoid space to monitor increased pressure. These are invasive procedures that incur increased risk of infection and consequently are used reluctantly by clinicians. Recent studies in the field of biomedical optics have suggested that the presence or absence of the CSF layer can lead to dramatic changes in NIR signals obtained from diffuse reflectance measurements around the head. In this study, we consider how this sensitivity of NIR signals to CSF might be exploited to non-invasively monitor the onset and resolution of brain edema.

Audiological findings in glomus tumours

Glomus tumours involving the middle ear and the cerebellopontine angle are reported with emphasis on audiological findings. Magnetic resonance imaging (MRI), angiographic and pathological results are presented. Audiological tests, including impedance audiometry, evoked otoacoustic emissions and auditory brainstem responses, are valuable in evaluation of the effect of glomus tumours on the auditory system as well as their pathological extent.

Early Treatment of Spinal Epidural Compression in Breast Cancer Patients without Neurological Deficits Has the Potential for Improved Outcome.

To the Editor: The most widely recognized features of spinal cord compression (SCC), such as limb weakness, sensory loss, bowel and bladder dysfunction, occur late in the natural history of metastatic tumor compression of the spinal cord (1). Recent observations (2,3) of imaging-detected occult spinal cord compromise in cancer patients with normal neurological examination could represent incipient SCC in our view. Intuitively in this particular situation, treatment is probably initiated with haste even though it may be unclear how soon therapy should be administered. Such uncertainty can lead to longer intervals between radiological diagnosis and palliative treatment. Cancer patients deserve the opportunity to be diagnosed and treated at a stage in their disease when the likelihood of benefit is greatest. Unfortunately, delays in diagnosis and treatment have occurred in clinical oncological practice (1,4). We hypothesized that patients with spinal epidural compression (SEC) by metastatic breast cancer (MBC) and without neurologic deficits (WND) obtain benefits (in terms of prolonged survival and preservation of neurologic function) when treatment is rendered earlier than when there is delay in the initiation of radiotherapy. In this context, we performed a retrospective analysis of a consecutive case series of SEC-MBC-WND treated at our institution. In the 17-year period of this study, between 1992 and 2008, of the 105 patients who had MBC in the spine, 25 (24%) developed SEC-WND, and received radiotherapy for palliation. The average interval between the diagnosis of breast cancer and detection of SEC was 29.2 months (range 0–139 months). The majority (76%) of the patients were between 45 and 64 years of age. Seventeen individuals had neck or back pain experienced for several days to a few months and eight women were asymptomatic. SEC, demonstrated by computed tomographyor magnetic resonance imaging, was most frequently located in the thoracic (48%) segments of the spine and then in the lumbar (32%) and cervical (16%) parts of the vertebral column; one patient (4%) had more than one site of simultaneous SEC. The exhibited radiological pattern of SEC was metastatic tumor impingement on the thecal sac (72%) or reaching but not deforming the surface of the spinal cord/cauda equina (28%). Extraspinal systemic disease was also present in almost all (92%) of the patients. Prompt radiotherapy, defined as the initiation of treatment on the same day of referral for therapy, was administered to 13 patients. In another group of 12 women, irradiation was delayed which meant that the onset of treatment was 24 hours or longer after the day of referral; the median period of delay was 2 days (range 1–11 days). In most cases, the reasons for treatment delay were not discernible from chart reviews. Palliative fractionated megavoltage external beam irradiation was usually to a total dose of 30 Gy given in 10 fractions. Among the evaluable 13 symptomatic patients, pain relief was achieved post-treatment in 92% of the cases. The overall 1and 2-year survival rates were 58% and 25%, respectively; the median survival was 15 months (95% CI: 10.2–19.8 months). The cumulative survival rate at 2 years was better in patients who were treated earlier compared to that of women whose irradiation was delayed (Table 1); however, the difference was not statistically significant. At the time of this analysis, all of the patients have died. None of the evaluable subjects from both groups experienced deterioration of neurological function prior to their demise. We undertook this investigation because the rarity of SEC-MBC-WND makes determination of the optimum timing of treatment and its effects poorly understood. The incidence of such a neoplastic complication Address correspondence and reprint requests to: Federico L. Ampil, MD, Louisiana State University Health, 1501 Kings Highway, Shreveport, LA 71130, USA, or e-mail: fampil@lsuhsc.edu

Positive response of advanced oropharyngeal cancer with trismus to chemoradiation.

Letters to the Editor are welcomed. They may report new clinical or laboratory observations and new developments in medical care or may contain comments on recent contents of the Journal. They will be published, if found suitable, as space permits. Like other material submitted for publication, letters must be typewritten, double-spaced, and submitted in duplicate. They must not exceed two typewritten pages in length. No more than five references and one figure or table may be used. See “Information for Authors” for format of references, tables, and figures. Editing, possible abridgment, and acceptance remain the prerogative of the Editors.