Neera Kohli

A diagnostic rule for tuberculous meningitis

Diagnostic confusion often exists between tuberculous meningitis and other meningoencephalitides. Newer diagnostic tests are unlikely to be available in many countries for some time. This study examines which clinical features and simple laboratory tests can differentiate tuberculous meningitis from other infections. Two hundred and thirty two children (110 tuberculous meningitis, 94 non-tuberculous meningitis, 28 indeterminate) with suspected meningitis and cerebrospinal fluid (CSF) pleocytosis were enrolled. Tuberculous meningitis was defined as positive CSF mycobacterial culture or acid fast bacilli stain, or basal enhancement or tuberculoma on computed tomography (CT) scan with clinical response to antituberculous treatment. Non-tuberculous meningitis was defined as positive CSF bacterial culture or Gram stain, or clinical response without antituberculous treatment. Thirty clinical/laboratory features of patients with tuberculous meningitis and non-tuberculous meningitis were compared by univariate and multiple logistic regression analysis. Five features were independently predictive of the diagnosis of tuberculous meningitis (p < 0.007): prodromal stage ⩾ 7 days, optic atrophy on fundal examination, focal deficit, abnormal movements, and CSF leucocytes < 50% polymorphs. When validated on another set of 128 patients, if at least one feature was present, sensitivity was 98.4% and, if three or more were present, specificity was 98.3%. This simple rule would be useful to physicians working in regions where tuberculosis is prevalent.

Aetiology of intellectual disability in paediatric outpatients in Northern India

Aim  To study the aetiology of intellectual disability in patients presenting to hospital and the diagnostic yield of a standardized examination.

Diagnostic and prognostic role of MRI in spinal trauma, its comparison and correlation with clinical profile and neurological outcome, according to ASIA impairment scale.

Aims and objectives: To evaluate the role of magnetic resonance imaging (MRI) as a non-invasive diagnostic tool in patients with acute and chronic spinal trauma and to compare and correlate the MRI findings with those of patients’ clinical profile and neurological outcome according to ASIA impairment scale to assess prognostic and clinical value of MRI. Materials and Methods: Sixty two patients of spinal trauma formed the study group in a prospective fashion. The patients undergoing MR imaging and magnetic resonance images were analyzed and correlated with findings on neurological examination according to American Spinal Injury Association (ASIA) impairment scale (AIS) at the time of MRI examination and subsequently at sub-acute interval to assess neurological outcome. Statistical Analysis: Sample profile was described in terms of 95% confidence limit and proportion. To describe strength of association between extent of spinal cord injury and outcome, odds ratio, bivariate and multi variant analysis, was used. Pearsons chi square (χ) 2 statistics was applied to test the association between two categorical variables. Data were analyzed using statistical software package, STATA 9.2 and the difference was considered to be significant if ‘P’ value was <0.05. Observation and Results: The cord edema without hemorrhage was the most common MR finding (41.5%). The others were sizable focus of hemorrhage within the cord (33%), epidural hematoma (5.0%), and normal cord (26%). Majority of MR findings correlated well with clinical profile of the patient according to ASIA impairment scale. This study demonstrated that patients with presence of sizable focus of haemorrhage had larger cord edema and more severe grade of initial ASIA impairment scale( AIS) with poor recovery at follow up (P=0.032).Improvement in upper extremity was more than lower extremity. Severe cord compression was also associated with poor neurological outcome; however it was not statistically significant (P=0.149). Conclusions: With this study the authors concluded that various MRI findings in acute spinal cord injury correlated well with the initial clinical findings and on follow-up according to ASIA impairment scale. MRI is useful for initial diagnosis of acute spinal cord injury and its prognostication for predicting neurological recovery.

MRI in congenital duplication of urethra.

Congenital urethral duplication is a rare anomaly, with less than 200 cases described in the literature. The investigations that are usually performed are micturating cystourethrography (MCU) and retrograde urethrography (RGU), which can diagnose the presence of duplication but cannot diagnose the precise relationship of the duplicated urethra with other pelvic structures. MRI, because of the excellent tissue contrast that it provides and its multiplanar ability, can demonstrate with precision, the size, shape and position of the two urethras. We describe below a case where MRI was able to show this exquisitely.

Di Sala syndrome

Di Sala syndrome or fetal warfarin syndrome/fetal warfarin embryopathy is a rare condition as result of fetal exposure due to maternal ingestion of warfarin during pregnancy. The authors report here a male infant with this condition whose mother was suffering from rheumatic mitral valvular heart disease for which she underwent prosthetic mitral valvular replacement surgery and put on injectable long acting penicillin and oral low-molecular weight anticoagulant drug (warfarin) for life long. The patient presented with facial dysmorphism, pectus excavatum, stippled epiphyses dolichocephaly, brachydactyly, polydactyly short neck and growth retardation. Shortened fourth metacarpal bones were also noted in this case which was not yet reported in literatures, to the best of our knowledge.

An unusual case of Takayasu's arteritis: Evaluation by CT angiography

Takayasus arteritis is a chronic, idiopathic, medium and large vessel vasculitis involving aorta and its main branches. Frequent neurological manifestations include postural syncope, seizures, and blindness. Stroke, as presenting feature of Takayasus arteritis, is unusual. CT angiography reveals characteristic involvement of aortic arch and its branches. Involvement of intracranial vasculature is rather unusual. We are describing an unusual patient of Takayasus arteritis who presented with recurrent disabling syncopal attacks and had extensive involvement of intracranial vasculature. CT angiography revealed severe involvement of aortic arch. There was near complete occlusion at origins of both subclavian arteries, distal flow was maintained by collateral vessels along the chest wall. There was near total occlusion (at origin) of right common carotid with normal flow in distal part. The left common carotid was more severely involved showing greater than 80% narrowing in proximal half of the vessel. CT angiography also revealed involvement of left internal carotid artery, narrowing of left middle cerebral artery and involvement of cortical vessels. Patient was treated with oral corticosteroids. She improved remarkably after two and half months of follow up.

Brainstem involvement in subacute sclerosing panencephalitis

The parieto-occipital region of the brain is most frequently and severely affected in subacute sclerosing panencephalitis (SSPE). The basal ganglia, cerebellum and corpus callosum are less commonly involved. Brainstem involvement is rarely described in SSPE, and usually there is involvement of other regions of the brain. We describe a patient with subacute sclerosing panencephalitis with brain magnetic resonance imaging showing extensive brainstem involvement without significant involvement of other cortical structures. Though rarely described in SSPE, one should be aware of such brainstem and cerebellum involvement, and SSPE should be kept in mind when brainstem signal changes are seen in brain MRI with or without involvement of other regions of brain to avoid erroneous reporting.

MRI in isolated dextrogastria with eventration of the right hemidiaphragm with associated mesentero-axial volvulus

Isolated dextrogastria is the rarest of all visceral transpositions and usually coexists with eventration of the right hemidiaphragm. We herein report a unique case of isolated dextrogastria with eventration of the right hemidiaphragm along with mesentero-axial volvulus. Such a case has not been reported in young children. As the barium study was suboptimal, MRI helped by exquisitely depicting the anomaly without radiation risk to the child.

Preliminary report from the World Health Organisation Chest Radiography in Epidemiological Studies project.

Childhood pneumonia is among the leading infectious causes of mortality in children younger than 5 years of age globally. Streptococcus pneumoniae (pneumococcus) is the leading infectious cause of childhood bacterial pneumonia. The diagnosis of childhood pneumonia remains a critical epidemiological task for monitoring vaccine and treatment program effectiveness. The chest radiograph remains the most readily available and common imaging modality to assess childhood pneumonia. In 1997, the World Health Organization Radiology Working Group was established to provide a consensus method for the standardized definition for the interpretation of pediatric frontal chest radiographs, for use in bacterial vaccine efficacy trials in children. The definition was not designed for use in individual patient clinical management because of its emphasis on specificity at the expense of sensitivity. These definitions and endpoint conclusions were published in 2001 and an analysis of observer variation for these conclusions using a reference library of chest radiographs was published in 2005. In response to the technical needs identified through subsequent meetings, the World Health Organization Chest Radiography in Epidemiological Studies (CRES) project was initiated and is designed to be a continuation of the World Health Organization Radiology Working Group. The aims of the World Health Organization CRES project are to clarify the definitions used in the World Health Organization defined standardized interpretation of pediatric chest radiographs in bacterial vaccine impact and pneumonia epidemiological studies, reinforce the focus on reproducible chest radiograph readings, provide training and support with World Health Organization defined standardized interpretation of chest radiographs and develop guidelines and tools for investigators and site staff to assist in obtaining high-quality chest radiographs.

An innovative modification of sandwich embolization technique for simultaneous management of ruptured pseudoaneurysm of branch of splenic artery and hypersplenism syndrome

Pancreatitis induced ruptured pseudoaneurysm (PSA) of the peri-pancreatic and splenic arteries may become a source of life-threatening hemorrhage. Its management is challenging and requires an individualized and multidisciplinary approach. The index case is a 32-year-old chronic alcoholic male presented with multiple episodes of hematemesis and melena. Pathological and imaging findings were consistent with anemia and acute pancreatitis with ruptured PSA of branch of splenic artery, portal cavernoma formation, and splenomegaly. Thrombosis of PSA sac, embolization of offending branch of splenic artery, and splenic infarction were successfully contemplated in a single session by direct percutaneous embolization with gelfoam and glue as embolic agents under guidance of duplex ultrasound imaging. We describe a modified sandwich embolization technique, its long-term success and complications of simultaneous management of ruptured PSA of branch of splenic artery and hypersplenism syndrome in limited resource scenario.