Nitin Verma

Endoscopic lavage for antibiotic unresponsive severe Acinetobacter baumanii ventriculitis: an unexplored treatment option

Dear Editor, Ventriculitis and meningitis are known complications following head injury and neurosurgical procedures and significantly contribute to morbidity and mortality. Recently, Acinetobacter baumanii infection has become a real cause of concern and a challenge to treat because of its ability to develop resistance to almost all antibiotics [1–3]. Acinetobacter ventriculitis requires prolonged courses of intravenous (IV) and intrathecal (IT) antibiotics, and even then mortality exceeds 30 % [2, 3]. We present a case of post-traumatic severe A. baumanii ventriculitis refractory to IV/IT antibiotics that was cured following one-time endoscopic ventricular lavage. To best of the authors’ knowledge, no description of endoscopic lavage for managing ventriculitis exists in the English-language literature. The case is being presented to stress the potential role endoscopy can play in managing severe ventriculitis. A 45-year-old man suffered from severe head injury (GCSE1VtM2) in a road traffic accident. Non-contrast-enhanced computed tomography (NCCT) revealed right frontal contusion and frontal bone fracture with midline shift (Fig. 1a, b). The patient underwent decompressive craniectomy, following which the mass effect and midline shift decreased (Fig. 1c, d). Postoperatively, the patient developed cerebrospinal fluid (CSF) rhinorrhoea and underwent re-exploration and repair of the ACF floor and packing of the frontal sinus. CSF rhinorrhoea stopped but the patient developed fever, neck rigidity and hydrocephalus (Fig. 1e, f). A left frontal external ventricular drain (EVD) was placed to drain infected CSF and empirical IV antibiotics were started (Fig. 1g). CSF culture revealed A. baumanii sensitive to colistin and tigecycline. IV tigecycline and colistin were started. Frontal EVD was converted to ommaya chamber for ITcolistin administration (500, 000/day) and an occipital EVD was placed for CSF drainage (Fig. 1h). However, despite receiving culture-based IVand IT antibiotics for 8 weeks, high-grade fever persisted and his CSF picture continued to be meningitic, rather worsened to the extent of drainage of purulent CSF through EVD. Repeated CSF cultures grew A. baumanii sensitive to tigecycline and colistin. NCCT revealed ventriculomegaly with debris in occipital horns (Fig. 1i, j). At this stage, a decision to do endoscopic lavage was taken. Through left frontal burr hole, endoscopic aspiration of ventricular pus and thorough saline lavage was done. Right ventricular pus was drained via septum pellucidotomy. Frontal ommaya and occipital EVD were replaced (Fig. 1k, l). Postoperatively, IV/IT antibiotics were continued. CSF from EVD became clear and CSF sugar and cell counts normalised within next 2 weeks. Multiple postoperative CSF cultures were sterile. The ventricle size became normal (Fig. 1m), long tunnel EVD was then removed and the patient was discharged. During a follow-up visit at 4 months, the patient was found to have hydrocephalus (Fig. 1m, n), for which a left occipital ventriculoperitoneal (VP) shunt was placed. The bone flap was also replaced. CSF analysis revealed non-meningitic picture and the culture was sterile. A postoperative scan showed decreased ventricular size (Fig. 1o, p). Treatment of ventriculitis is difficult as, amongst all intracranial compartments, ventricles attain the lowest antibiotic concentrations after IV administration [1]. This factor is compounded by impaired CSF outflow from infected ventricles, which now act as reservoirs of infection. The situation gets further complicated if the infective organism is * Amandeep Kumar aman_jagdevan@yahoo.co.in

Inverse Uhthoff's symptom

Two cases of optic neuritis are presented in whom an inverse Uhthoffs symptom was elicited, i.e., an improvement in visual acuity instead of expected deterioration following exercise. The probable mechanisms for the genesis of inverse Uhthoffs symptom are discussed.

Paired discharging sinuses at medial canthus of left eye and dorsum of nose in a 2-year toddler since birth associated with interfalcial dermoid

Twin nasal dermal sinus with associated intracranial dermoid located in interfalcial region is a very rare occurrence and is reported only in the occipital and temporal regions. However, multiple sinuses located in the canthus and dorsum of nose are not reported till date. Authors report an interesting first case of interfalcial dermoid cyst associated with twin discharging dermal sinuses, who underwent successful surgical repair in the world literature. The authors report the management of an unusual case and the review has been discussed briefly.

Ultrasonography in orbital retinoblastoma

Retinoblastoma is the commonest intraocular malignancy in childhood. One of the biggest problems in managing these tumors is to detect early extraocular spread, since this alters the surgical treatment and the ultimate morbidity in these patients.Ultrasonic evaluation is considered an essential part of the leucocoria work-up. the echo-graphic characters of this lesion are now well known, but the features of orbital extension have never been adequately stressed in the literature before.Seventy-two cases of leucocoria were investigated fully. A diagnosis of retinoblastoma with orbital extension was made in nine of them (ultimately confirmed). Echographically, a loss of ocular coat contour, Tenons space enlargement, optic nerve enlargement and fat pattern alteration (B mode) and a widened retrobulbar spike complex with decreased motility were found to be diagnostic. New features that were found to be absolutely typical of intraocular and clinically evident extraocular retinoblastoma will also be demonstrate...

Ultrasonographic evaluation of rhabdomyosarcomas

Eighty-three patients under 20 years of age presenting with proptosis were investigated fully. Careful A, B and M mode ultrasonography allowed the authors to return a diagnosis of orbital rhabdomyosarcoma in ten of them, which was subsequently confirmed by histopathology. One false positive was observed – an orbital liposarcoma, the findings of which were quite similar.The cystic picture, pseudo-encapsulation, loss of the optic nerve pattern (B mode) and the scale pattern with loss of normal motility were found to be diagnostic echographic characteristics. these features were found to be totally different from comparable ultrasonic characteristics of true cysts and orbital inflammatory disease.The features of liposarcoma of the orbit and those of early and established ocular compression are also discussed. the authors found that careful ultrasonographic imaging of the orbit is by far the most reliable method available in evaluating a given case of proptosis: it is rapidly performed even in children and ob...