An unusual case of rapidly progressive contractures: Case report and brief review

An 8-year-old boy, diagnosed as cervical dystonia, was referred to our tertiary center. After a trivial trauma he had developed painful lumps in the axial region, which was followed by restricted movements of neck, shoulder, and abdominal muscles over 4 months. He had kyphoscoliosis, torticollis, rigid abdomen, and multiple muscle contractures. He also had short great toes. A detailed skeletal survey showed calcification in the soft tissues surrounding the shoulder anterior chest wall, thorax, and paraspinal muscles; there was also beaking of vertebrae, which was confirmed by CT thorax. This report showcases the diagnostic challenge posed by myositis ossificans progressiva, which can rarely cause rapidly progressing muscle contractures. A brief review of literature is also presented.

Intrathecal gadolinium-enhanced magnetic resonance cisternography in cerebrospinal fluid rhinorrhea: road ahead?

Accurate localization of cerebrospinal fluid (CSF) fistula in a patient with CSF rhinorrhea is challenging and often involves multiple imaging studies with associated expense and patient discomfort. Intrathecal contrast-enhanced computed tomography (CT) and unenhanced magnetic resonance (MR) cisternography using constructive interference in steady state (CISS-3D) sequences are currently being used in attempt to localize the leakage site but with varying degrees of success. Our purpose is to evaluate the utility of intrathecal gadolinium-enhanced MR cisternography (GdMRC) in patients with CSF rhinorrhea. Ten consecutive patients of CSF rhinorrhea (five spontaneous, four post-traumatic, and one post-operative) were evaluated with GdMRC. Nine of the patients underwent intrathecal contrast CT and CISS-3D examinations in addition. Each of studies was reviewed independently by three neuroradiologists blinded to results of other modalities. Surgery was planned after consensus and surgical correlation obtained in nine cases. The fistulous site was clearly demonstrated by using GdMRC in eight patients, CISS-3D in six, and intrathecal CT in three patients. The site of leakage was confirmed surgically in all the patients. One patient was found to be false negative both by intrathecal CT and GdMRC, and in one patient no fistulous site was demonstrated by any of the modalities and surgery was not offered. No adverse reaction was seen in any of the patients. GdMRC is a novel method of confirmation and localization of CSF fistula with potential for routine clinical application. Diagnosis and localization of fistulous site is better demonstrated due to its high-contrast resolution, absence of bony artifacts, and direct multi-planar imaging.

Cholesterol ester storage disease with unusual neurological manifestations in two siblings: a report from South India

Cholesterol ester storage disease is a rare autosomal recessive storage disorder resulting from lysosomal acid lipase deficiency. Two siblings manifested with hepatosplenomegaly, ptosis, and bilateral external ophthalmoplegia. Evaluation revealed hyperlipidemia and bilateral adrenal calcifications. Leukocyte acid lipase levels were significantly low in both the patients, compared with controls, suggesting a diagnosis of cholesterol ester storage disease. Ptosis and external ophthalmoplegia have hitherto not been reported in cholesterol ester storage disease.

Vertebral body signal changes in spinal cord infarction: histopathological confirmation

Spinal cord infarctions are rare. They are difficult to diagnose clinically and remain undiagnosed even after extensive investigations. Magnetic Resonance (MR) features include hyperintensity of the cord on T2W images. Few cases of spinal cord infarction associated with vertebral body infarction are reported in the literature. We describe another five cases of spinal cord infarction with histopathological confirmation of the vertebral body signal changes. MR examinations of five patients who presented with acute spontaneous spinal cord syndrome were reviewed. Abnormal MR features of the spinal cord included signal changes within the parenchyma, best demonstrated on T2W images. These cord changes were associated with vertebral body T2 hyperintensity in all the patients and in one patient, the computed tomography guided biopsy of vertebral body lesion reported infarction. MR is sensitive to detect spinal cord infarctions and associated vascular and bony changes. The associated signal abnormalities in the bone marrow are a corroborative sign in the diagnosis of spinal cord infarction which was proved by histopathology.

Disappearing saccular intracranial aneurysms: do they really disappear?

SUMMARY

Evolution and natural history of cerebral aneurysms is a dynamic process. Spontaneous regression in size or complete disappearance of an aneurysm is a known phenomenon, more commonly noted in giant intracranial aneurysms. However, reappearance or regrowth of such aneurysms is rare with few anecdotal reports. We report a series of four cases including one giant aneurysm, which either disappeared or regressed on sequential angiograms. Regrowth or reappearance of two of these previously disappeared or regressed aneurysms was noted and endovascularly treated while the other two cases are being followed up. The decision to follow up was crucial considering the nature of the aneurysms to change in morphology under the influence of various hemodynamic factors.

Electroencephalographic and imaging profile in a subacute sclerosing panencephalitis (SSPE) cohort: A correlative study

OBJECTIVE

There are only a few studies correlating diverse radiological and EEG features of subacute sclerosing panencephalitis (SSPE). The objective of the study was to (a) describe EEG profile and (b) correlate it with the clinical and imaging data of patients with confirmed SSPE.

METHODS

This study was conducted at a University teaching hospital in south India and involved 58 patients (M:F=37:21, age: 12.3, SD 4.8 years) of SSPE. Diagnosis of SSPE was based on the characteristic clinical manifestations, and raised IgG (1:625) anti-measles antibody in cerebrospinal fluid (CSF) by ELISA in all the patients. Scalp EEGs were recorded on 16 channel machines using standard parameters and procedures. The EEG, clinical and imaging data were reviewed.

RESULTS

EEGs were frequently abnormal: typical (37) and atypical (21). Diffuse slowing of background activity (BGA) was noted in 46 records being asymmetrical in six. Periodic complexes were periodic (32), quasi-periodic (21) or a-periodic (4). Periodic complexes (PC) (amplitude: 370.7, SD 171.2 microV; duration - 1.7, SD 2.0 s; inter-complex interval: 8.4, SD 9.2s) were symmetrical in 39 and asymmetrical in 19. CT (32) and MRI (23) scans were normal in 16 patients while others had white matter (15), cerebral edema (8), cerebral atrophy (8), basal ganglia (2), and thalamic (2) changes. There was an independent association of frontally dominant slowing of BGA (p=0.04) and typical PCs (p=0.03) with the diffuse cerebral edema on imaging. White matter changes correlated with slowing of BGA (p=0.04), but not with typical PC (p=0.16).

CONCLUSIONS

This study provides valuable insight into the structural and clinical correlates of EEG changes in SSPE.

SIGNIFICANCE

Irrespective of the incidence of occurrence of SSPE in a community, a clinician should be aware of the wide spectra of EEG findings. This study also discusses the possible underlying structural and clinical correlates.

Sequential MRI changes in Wilson's disease with de-coppering therapy: a study of 50 patients

Wilson's disease (WD) is clinically and radiologically a dynamic disorder. However, there is a paucity of studies involving sequential MRI changes in this disease with or without therapy This study looked at serial MRI changes and their clinical correlate in patients with WD The severity of MRI changes using 1.5 T MRI in 50 patients with WD was graded based on alteration in signal intensity of focal lesions and atrophy. Details of clinical manifestations, Schwab and England Activities of daily living (MSEADL) score, Neurological Symptom Score (NSS) and Chu staging were recorded. Clinical severity and disability scores were correlated with MRI scores using SPSS v10 The mean age at onset of illness and diagnosis was 12.8+/-5.6 years and 14.4+/-6.0 years, respectively. At the time of first MRI, patients had been treated for 49.0+/-77.3 months. At a follow-up of 24.2+/-12.2 months, clinically 36 patients had improved, 9 remained the same and 5 had worsened. Serial imaging revealed an improvement in MRI parameters in 35 patients, no significant changes in 10, worsening in 4 and an admixture of resolving and evolving changes in 1. The overall MRI score improved from 8.2+/-5.7 to 5.9+/-6.6. There was an improvement in measures of disability and impairment in all: Chu stage, 11.5+/-0.7 to 1.3+/-0.6; MSEADL score (%), 79.7+/-27.6 to 88.0+/-25.4; NSS, 10.6+/-11.2 to 8.0+/-11.6, with good clinico-radiological correlation. Patients with extensive changes, white-matter involvement and severe diffuse atrophy had a poor prognosis In conclusion, the majority of patients with WD showed variable improvement in clinical and MRI features when treated.

Intermediate maple syrup urine disease: neuroimaging observations in 3 patients from South India

Maple syrup urine disease is a disorder of branched-chain keto acid metabolism. Three children were diagnosed with the intermediate form of maple syrup urine disease during routine evaluation of mental retardation. Clinical features were characterized by mental retardation, seizures, autistic features, and movement disorder in the form of dystonia. High-performance liquid chromatography of the urine and serum revealed elevated levels of branched-chain amino acids, suggesting a diagnosis of maple syrup urine disease. Magnetic resonance imaging showed diffuse hyperintense signals in the white matter along with involvement of the thalami and globus pallidus. Magnetic resonance imaging in the intermediate form showed myelination in the posterior limb of the internal capsule, in contrast to the classic form of the disease. Knowledge about the neuroimaging findings of this rare disease will help to narrow down the differential diagnosis when evaluating children with unexplained mental retardation and seizures.

Diffusion-weighted imaging and proton MR spectroscopy in the characterization of acute disseminated encephalomyelitis

INTRODUCTION

Acute disseminated encephalomyelitis (ADEM) is usually a monophasic illness characterized by multiple lesions involving gray and white matter. Quantitative MR techniques were used to characterize and stage these lesions.

METHODS

Eight patients (seven males and one female; mean age 19 years, range 5 to 36 years) were studied using conventional MRI (T2- and T1-weighted and FLAIR sequences), diffusion-weighted imaging (DWI) and proton magnetic resonance spectroscopy (MRS). Apparent diffusion coefficient (ADC) values and MRS ratios were calculated for the lesion and for normal-appearing white matter (NAWM). Three patients were imaged in the acute stage (within 7 days of the onset of neurological symptoms) and five in the subacute stage (after 7 days from the onset of symptoms).

RESULTS

ADC values in NAWM were in the range 0.7-1.24 x 10(-3) mm/s2 (mean 0.937 +/- 0.17 mm/s2). ADC values of ADEM lesions in the acute stage were in the range 0.37-0.68 x 10(-3) mm/s2 (mean 0.56 +/- 0.16 mm/s2) and 1.01-1.31 x 10(-3) mm/s2 (mean 1.24 +/- 0.13 mm/s2) in the subacute stage. MRS ratios were obtained for all patients. NAA/Cho ratios were in the range 1.1-3.5 (mean 1.93 +/- 0.86) in the NAWM. NAA/Cho ratios within ADEM lesions in the acute stage were in the range 0.63-1.48 (mean 1.18 +/- 0.48) and 0.29-0.84 (mean 0.49 +/- 0.22) in the subacute stage. The ADC values, NAA/Cho and Cho/Cr ratios were significantly different between lesions in the acute and subacute stages (P < 0.001, P < 0.027, P < 0.047, respectively). ADC values were significantly different between lesions in the acute (P < 0.009) and subacute stages (P < 0.005) with NAWM. In addition, NAA/Cho and Cho/Cr ratios were significantly different between lesions in the subacute stage and NAWM (P < 0.006, P < 0.007, respectively).

CONCLUSION

ADEM lesions were characterized in the acute stage by restricted diffusion and in the subacute stage by free diffusion and a decrease in NAA/Cho ratios. Restricted diffusion and progressive decrease in NAA/Cho ratios may help in staging the disease.

Hepatic myelopathy: a rare complication following extrahepatic portal vein occlusion and lienorenal shunt

A 19-year-old gentleman presented with slowly progressive spastic paraparesis, 2 years after the therapeutic lienorenal shunt for portal hypertension secondary to cirrhosis and portal vein occlusion. After 2 years of initial evaluation, the motor functions had not worsened further. He did not have any obvious clinical or EEG features of hepatic encephalopathy. Other causes for myelopathy were ruled out. Contribution of portal vein occlusion to portosystemic shunting has not been reported previously in patients with 'hepatic myelopathy.' This uncommon complication needs to be considered in patients with shunt surgery for relieving portal hypertension.

Wilson’s disease: cranial MRI observations and clinical correlation

INTRODUCTION

Study of MRI changes may be useful in diagnosis, prognosis and better understanding of the pathophysiology of Wilson's disease (WD). We aimed to describe and correlate the MRI abnormalities of the brain with clinical features in WD.

METHODS

MRI evaluation was carried out in 100 patients (57 males, 43 females; mean age 19.3+/-8.9 years) using standard protocols. All but 18 patients were on de-coppering agents. Their history, clinical manifestations and scores for severity of disease were noted.

RESULTS

The mean duration of illness and treatment were 8.3+/-10.8 years and 7.5+/-7.1 years respectively. MRI of the brain was abnormal in all the 93 symptomatic patients. The most conspicuous observations were atrophy of the cerebrum (70%), brainstem (66%) and cerebellum (52%). Signal abnormalities were also noted: putamen (72%), caudate (61%), thalami (58%), midbrain (49%), pons (20%), cerebral white matter (25%), cortex (9%), medulla (12%) and cerebellum (10%). The characteristic T2-W globus pallidal hypointensity (34%), "Face of giant panda" sign (12%), T1-W striatal hyperintensity (6%), central pontine myelinosis (7%), and bright claustral sign (4%) were also detected. MRI changes correlated with disease severity scores (P<0.001) but did not correlate with the duration of illness.

CONCLUSION

MRI changes were universal but diverse and involved almost all the structures of the brain in symptomatic patients. A fair correlation between MRI observations and various clinical features provides an explanation for the protean manifestations of the disease.

Survival of a five-strain cocktail of Escherichia coli O157:H7 during the 60-day aging period of cheddar cheese made from unpasteurized milk

The U.S. Food and Drug Administration Standard of Identity for Cheddar cheeses requires pasteurization of the milk, or as an alternative treatment, a minimum 60-day aging at > or =2 degrees C for cheeses made from unpasteurized milk, to reduce the number of viable pathogens that may be present to an acceptable risk. The objective of this study was to investigate the adequacy of the 60-day minimum aging to reduce the numbers of viable pathogens and evaluate milk subpasteurization heat treatment as a process to improve the safety of Cheddar cheeses made from unpasteurized milk. Cheddar cheese was made from unpasteurized milk inoculated with 10(1) to 10(5) CFU/ml of a five-strain cocktail of acid-tolerant Escherichia coli O157:H7. Samples were collected during the cheese manufacturing process. After pressing, the cheese blocks were packaged into plastic bags, vacuum sealed, and aged at 7 degrees C. After 1 week, the cheese blocks were cut into smaller-size uniform pieces and then vacuum sealed in clear plastic pouches. Samples were plated and enumerated for E. coli O157:H7. Populations of E. coli O157:H7 increased during the cheese-making operations. Population of E. coli O157:H7 in cheese aged for 60 and 120 days at 7 degrees C decreased less than 1 and 2 log, respectively. These studies confirm previous reports that show 60-day aging is inadequate to eliminate E. coli O157:H7 during cheese ripening. Subpasteurization heat-treatment runs were conducted at 148 degrees F (64.4 degrees C) for 17.5 s on milk inoculated with E. coli O157:H7 at 10(5) CFU/ml. These heat-treatment runs resulted in a 5-log E. coli O157: H7 reduction.

Prognostic factors in patients presenting with severe neurological forms of Wilson's disease

BACKGROUND

Wilson's disease (WD), a metabolic disorder, is believed to be potentially reversible, even in its severe form. However, some patients do not respond to treatment.

AIM

To analyse prognostic factors in severe WD.

DESIGN

Retrospective audit.

METHODS

A total of 140 patients were regularly followed from February 2002 to May 2004. Twenty-nine (18 males, 11 females) had severe disease, as defined by Modified Schwab and England Activities of Daily Living score (MSEADL) of < or=50% or Chu stage of 3. We analysed their clinical, laboratory and MRI features with respect to prognosis.

RESULTS

For the severe form, mean age at symptom onset was 11.5 +/- 6.4 years, and at diagnosis, 13.3 +/- 7.0 years. Mean Neurological Symptom Score (NSS), Chu stage, and MSEADL were 26.5 +/- 8.2, 2.7 +/- 0.5 and 24.8 +/- 17.4, respectively. Twenty-one patients underwent MRI; 14 had repeat MRI. Following treatment, 14 (group A) had progressive worsening, including death in two, while 15 (group B) had sustained clinical improvement. Baseline demographic, clinical and laboratory features and MRI scores did not significantly differ between the two groups. However, diffuse white-matter abnormalities were more extensive in group A. Full-dose initial penicillamine therapy could have contributed to worsening in four patients. Drug compliance was poor in both groups but resumption of treatment did not benefit patients in group A. Serial MRI showed regression of lesions only among patients with clinical improvement.

DISCUSSION

Severe WD remains a therapeutic challenge, with early diagnosis and treatment are essential. Specific MRI observations, a 'start low-go slow' regimen for penicillamine, and compliance may have prognostic significance. In absence of clinical predictors, genetic attributes need to be explored.

Relevance of occlusion test in endovascular coiling of posterior cerebral artery (p2 segment) aneurysms

SUMMARY

P2 segment aneurysms are located on the posterior cerebral artery (PCA) between the junction of the posterior communicating artery with the PCA and the quadrigeminal cisternal part of the PCA. We reviewed our experience with endovascular coiling in such aneurysms. Clinical and pre-procedural data from four patients, referred for endovascular treatment of P2 segment aneurysms, were retrospectively studied for factors influencing post-interventional neurological deficits caused by ischemia of the PCA distal territory. Balloon occlusion was done in three patients and patient tolerance was assessed using clinical and anatomic criteria. Embryologic and anatomic features of the PCA were reviewed. Balloon occlusion test and endovascular coiling of aneurysms was possible in three patients. Control angiogram after embolization showed elimination of aneurysms from the circulation and the distal PCA filled through leptomeningeal anastomoses. One patient deteriorated due to aneurysmal rupture soon after the balloon occlusion test and coiling could not be done. In the other three patients post-intervention CT and MRI images showed PCA territory infarcts in spite of demonstration of good collateral circulation distal to the occluded PCA. In conclusion, P2 aneurysms can be effectively treated by endovascular coiling without a balloon occlusion test. While the balloon occlusion test does not contribute to clinical decision-making it may be associated with potential morbidity and mortality.

Co-occurrence of Wilson's disease and glioblastoma multiforme--is it a chance association?

We report a patient with glioblastoma multiforme who was subsequently diagnosed to have Wilson's disease. Immunohistochemical studies of the tumor revealed high (> 60%) labeling index for p53 and Rb retinoblastoma protein. Whether this association is like the co-occurrence of retinoblastoma and Wilson's disease due to possible somatic mutation in chromosome 13 needs to be explored.

Expression of Bax and Bcl-2 proteins during hypoxia in cerebral cortical neuronal nuclei of newborn piglets: effect of administration of magnesium sulfate

This study tests the hypothesis that administration of magnesium sulfate, an antagonist of the NMDA receptor ion-channel, will prevent the hypoxia-induced alteration in the expression and the ratio of Bax and Bcl-2 proteins in cerebral cortical neuronal nuclear membranes. Anesthetized, ventilated and instrumented newborn piglets were divided into three groups: normoxic controls (Nx), untreated hypoxic (Hx), and magnesium sulfate-treated hypoxic (Mg-Hx) groups. Cerebral hypoxia was induced by lowering the FiO2 (0.05-0.07) for 1 h and the cerebral cortex was harvested immediately for isolation of neuronal nuclei and hypoxia was confirmed biochemically by a decrease in the tissue levels of ATP and phosphocreatine (PCr). Brain tissue PCr (micromol/g brain) was 2.74+/-0.77 (Nx), 0.38+/-0.09 (Hx, P<0.05 vs. Nx) and 0.69+/-0.60 (Mg-Hx, P<0.05 vs. Nx). The density of immunoblotted proteins was expressed as absorbance (Axmm(2)). The expression of Bax protein (Axmm(2)) was 222+/-31 (Nx), 279+/-32 (Hx), and 148+/-44 (Mg-Hx, P<0.05 vs. Hx). Bcl-2 protein expression was 77+/-1.0 (Nx), 37+/-5.0 (Hx) and 46+/-15 (Mg-Hx, P<0.05 vs. Nx). The ratio of Bax to Bcl-2 proteins increased more than twofold during hypoxia as compared to normoxia (7:1 Hx vs. 3:1 Nx). However, in the magnesium sulfate-treated group the Bax:Bcl-2 ratio was similar to normoxic controls. The data demonstrate that magnesium sulfate treatment prevents both the hypoxia-induced increase in Bax protein expression and the alteration of Bax:Bcl-2 protein ratios. We suggest that magnesium sulfate treatment before and during hypoxia may decrease hypoxia-induced programmed cell death by maintaining the normal ratio of Bax to Bcl-2 proteins.

Effect of low-temperature, high-pressure treatment on the survival of Escherichia coli O157:H7 and Salmonella in unpasteurized fruit juices

The destructive effect of high pressure (615 MPa) combined with low temperature (15 degrees C) on various strains of Escherichia coli O157:H7 and various serovars of Salmonella in grapefruit, orange, apple, and carrot juices was investigated. The three-strain cocktail of E. coli O157:H7 (SEA13B88, ATCC 43895, and 932) was found to be most sensitive in grapefruit juice (8.34-log reduction) and least in apple juice (0.41-log reductions) when pressurized at 615 MPa for 2 min at 15 degrees C. Correspondingly, no injured survivor was detected in grapefruit and carrot juices under similar treatment conditions. No Salmonella spp. were detected in a 2-min pressure treatment (615 MPa, 15 degrees C) of grapefruit and orange fruit juices. Except for Enteritidis, all four serovars tested in the present study have viability loss of between 3.92- and 5.07-log reductions when pressurized in apple juice at 615 MPa for 2 min at 15 degrees C. No injured cells were recovered from grapefruit and orange juices, whereas the same treatment demonstrated reduction in numbers of Salmonella serovars Agona and Muenchen in apple juices and to a lesser extent with Typhimurium, Agona, and Muenchen in carrot juice. The present study demonstrated that low-temperature, high-pressure treatment has the potential to inactivate E. coli O157:H7 strains and different Salmonella spp. in different fruit juices.