Blood Eosinophils to Direct Corticosteroid Treatment of Exacerbations of Chronic Obstructive Pulmonary DiseaseA Randomized Placebo-Controlled Trial Mona Bafadhel1, Susan McKenna1, Sarah Terry1, Vijay Mistry1, Mitesh Pancholi1, Per Venge2,David A. Lomas3, Michael R. Barer1, Sebastian L. Johnston4, Ian D. Pavord1, and Christopher E. Brightling1 1Institute for Lung Health, University of Leicester, Leicester, United Kingdom; 2Department of Medical Sciences, Clinical Chemistry, University ofUppsala, Uppsala, Sweden; 3Cambridge Institute for Medical Research, University of Cambridge, Cambridge, United Kingdom; and 4Department ofRespiratory Medicine, National Heart and Lung Institute, Centre for Respiratory Infections, Imperial College London, London, United Kingdom
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Microsoft word - 10b.balasad_primary_f.docxRomanian Neurosurgery (2012) XIX 1: 63 – 66 63 Primary tuberculomas of the thoracal spinal cord. Case report
D. Balasa1, A. Tunas1, A. Terzi2, C. Serban4, M. Aschie3
Clinical Emergency County Hospital, Constanta 1Neurosurgery, 2Anestesiology, 3Pathology 4 Euromedic Private Unit, Constanta, Neuroradiology Abstract
intramedullary tuberculoma. We present The authors present an unusual case of the case of un unusual case of intramedullary tuberculoma in a HIV- intramedullary tuberculoma in a HIV- negative patient from the southeast part of negative patient from the southeast part of Romania who demonstrated no other signs Romania who demonstrated no other signs of tuberculous infection. Clinical exam: of tuberculous infection and presents no extreme spastic paraparesis in triple flexion, sign of involvement of the bony spinal dorsal pain and bladder and bowel canal. incontinence. Gd enhanced MRI revealed ring enhancing lesion with central Case report
hypointensity, suggesting granulomatous Presentation: This 20 years old young pathology. Surgical excision of the peasant male was referred to our intramedullary lesions was carried out department for evaluation of his followed by anti-tuberculous chemotherapy progressivelly (one year and a half) extreme and Baclofen tablets . !0 days postoperative spastic paraparesis in triple flexion, dorsal MRI showed total resolution of the lesion. pain, bladder and bowel incontinence. Two years follow up showed progressive There was no history of tuberculosis and he resolution of spasticity. Following surgical was HIV seronegative. excision, the patient improved significantly Examination: On examination the pacient sensitive and modest the motility and acused un severe spastic paraparesis in spasticity. The management of this rare triple flexion and the right leg more lesion is discussed and the literature profoundly affected than the left. Patellar and achille relexes was increased. Babinsky Keywords: spinal cord, tuberculosis, sign was positive. Sensory deficit to p
primary tuberculomas inpick and light touch revealed a T4 level right, T5 level left. Chest X-Ray films Intramedullary tuberculomas rest a revealed no abnormalities. lesion extremelly rare (2 of 100 000 cases of Dorsal MRI scan including Gd-DTPA tuberculosis and 2 of 1000 cases of CNS MRI revealed ring enhancing lesion with tuberculosis). Lin and McDonnell (11, 12) central hypointensity, suggesting found only 148 cases of intramedullary granulomatous pathology from T4 to T5 tuberculomas mentioned in the literature. Ratliff (15) present one case of primitive
64 D. Balasa et al Primary tuberculomas of the thoracal spinal cord Operation T4-T5 laminectomy, median mielotomy, microsurgical total resection of a well circumscribed yellow-grey mass located cortically and intramedullary. The lesion was very carefully dissected and totally resected along a definable plane by use of the operating microscope. The gross pathological specimen was an encapsulated, yellow-grey firm mass.
Ppathological examination of the lesion revealed multiple epitheloid cell granulomas with Langerhan's and foreign body type of giant cells. Large areas of caseous necrosis were seen and necrotic Photomicrograph.: Photomicrograph demonstrating epitelioid areas of caseating granulomas with Langhans type giant cells. Van Gieson coloration.
Medical treatment: antituberculous chemotherapy for 52 weeks or more consist of four chemotherapeutic agents to overcome drug resistance: INH 300mg/day, rifampin 600 mg/day, etambuthol 1200 mg/day and pyrazinamide 2000 mg/day and antispastic agents (Baclofen tablets). Ten days postoperative MRI showed total resolution of the lesion. The patients improved significantly sensitivity and modest the motility and spasticity. Follow up period: 2 years.
Romanian Neurosurgery (2012) XIX 1: 63 – 66 65 cases (11, 12). The first report of intramedullary tuberculoma was by Abercrombie in 1828 (1) .The commonest symptoms were progressive lower limbs weakness, paresthesia, and bladder and bowel dysfunction. The major physical findings were paraplegia, either spastic or flaccid. The majority of patients had thoracic sensory level. The MRI characteristics have been described by Jena et al (10) as low intensity rings with or without central hyperintensity on T2 images and low to isointense rings on T1 images. Caseation results in the "target sign" appearance. The choice of treatment is an important consideration. Microsurgical total excision and antituberculous agents are widely used in the treatment of intramedullary tuberculoma. MacDonnel has reported 65% recovery after surgical treatment. Conclusion
•Intramedullary tuberculoma, is a very •Microsurgical total excission and antituberculous chemotherapy consisting of three agents was mandatory for the healing this very large intramedullary lesion. •Motor recovery of this patient is Discussion
difficult considering the extreme spastic Tuberculosis is a chronic bacterial paraparesis in triple flexion and the infection produced by Mycobacterium evolution of the illness of one and a half tuberculosis Tuberculosis of the central nervous system is a rare entity, affecting •Will be necessary in time orthopedic 0,5-2% of patients with sistemic procedures for the treatment of spasticity tuberculosis (14, 3, 15). Intramedullary tuberculomas is a lesion extremelly rare seen only 2 of 100 000 cases of tubeculosis Corespondence address
and 2 of 1000 cases of tuberculosis of Dr. D. Balasa, Department Neurosurgery, central nervous systems disesase. It is Clinical Emergency County Hospital, Boulevard speciffically for the young patients in the Tomis, 145, Constanta, Romania. E-mail: developing countries and is associated firstname.lastname@example.org usually with pulmonay disease, in 69% of 66 D. Balasa et al Primary tuberculomas of the thoracal spinal cord References
9. Gupta VK, Jena A,Sharma A,Guha DK, Khushu S, Gupta AK: Magnetic resonance imaging of intracranial 1. Abercrombie J. Pathological and practical researches tuberculomas. J Comput Assist Tomogr 12:280-285, on disease of the brain and the spinal cord. Edinburg: Waugh and Innes, 1828: 371-2 10. Jena A, Banerji AK,TripathiRI, Gulati PK, Jain RK, 2. Alex H.MacDonel, Robert W.Baird, Michael Khushu S, Supra MI. Demonstration of intramedullary S.Bronze. Intramedullary tuberculomas of the spinal tuberculosis By MRI- A case report of 2 cases. Br J cord:Case report and review. Review of infectious Radiol 64:555-557, 1991 diseases. Vol 12,3:432-436,1990 11. Lin TH:İntramedullary tuberculoma of the spinal 3. Baker RD: Postmortem Examination. Specific cord . J Neurosurg 17:497-499, 1960 Methods and Procedures. Philadelphia, W.B. Saunders, 12. MacDonell AH, Baird RW, Bronze MS:Intra Baird RW, Bronze MS: Intramedullary tubercullomas of the 4. B. Indira Devi, S. Chandra, S. Mongia, spinal cord: Case report and review. Rev Infect Dis Chandramouli, K.V.R. Sastry, S. K. Shankar. Spinal 12:432-439, 1990 Intramedullary Tuberculoma and Abscess: A Rare 13. Mohit AA, Santiago P, Rostomily R. Intramedullary Cause of Paraparesis. Neurology India, Vol 50, No 4, tuberculoma mimicking primary CNS Dec 2002, 494-496 Parmar H, Shah J, Patkar D, Varma 5. Bertrand I, Guillaume JM, Samson M, Gueguen Y: R.Intramedullary tuberculomas. Mr findings in sevens. Tuberculoma Intamedullarire dorsal. Rev Neurol patients. Acta Radiol 41:572-7, 2000 15. Ratliff JK: Intramedullary tuberculoma of spinal 6. Citow JS, Ammirati M : Intramedullary tuberculoma cord. J Neurosurg(Spine) 1999:90:125-128 of the spinal cord. Case report. Neurosurgery 1994; 35: 16. Whiteman M, Espinosa L, Post MDJ, Bell MD, Falcon S: Central nervous system tuberculosis in HİV 7. Dastur HM. Diagnosis and neurosurgical treatment infection patient. Clinical and radiographical finding. of tuberculous disease of the CNS. Neurosurg Review. AJNR Am J Neuroradiol 16:1319-1327, 1995 1983, 6: 111-117 8. GokalpHZ, Ozkal E: Intradural tuberculomas of the spinal cord. J Neurosurg 1985, 55:289
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