Toxoplasma granuloma of brainstem: a rare case

Toxoplasmosis is a common opportunistic infection in patients with AIDS in whom it frequently presents as intracranial space-occupying lesions. In the immunocompetent patient the most common manifestation is as asymptomatic cervical lymphadenopathy which may be associated with vague systemic manifestations such as fever or myalgia. In very rare cases people with normal immunity may present with meningoencephalitis polymyositis or myocarditis. It is very rare to encounter a brainstem granuloma due to toxoplasma infection in such patients. We report a non-immunocompromised man who presented with multiple cranial nerve palsies due to a brainstem lesion, which turned out to be a toxoplasma granuloma. He recovered completely after a four-week course of Pyrimethamine and Sulphadoxine. An extensive search of the literature failed to reveal any prior reports of a similar nature. This case is being reported because of its rarity and the complete recovery made by the patient.

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.

Dysmyelinating neuropathy in benign form of megalencephalic leukoencephalopathy with subcortical cysts: a novel observation from south India

A 37-year-old gentleman presented with macrocephaly since early childhood and progressive impairment of motor and cognitive functions. Magnetic resonance imaging revealed extensive white matter involvement and frontotemporal subcortical cysts. Absent ankle jerk and abnormal nerve conduction study raised a possibility of associated peripheral neuropathy. Sural nerve biopsy was suggestive of dysmyelinating neuropathy. This report serves to expand the clinical spectrum of this rare leukodystrophy.

Intracranial metastasis from a glandular variant of atrial myxoma

BACKGROUND

Intracranial metastases from atrial myxoma producing symptomatic mass lesions are very rare with only ten examples reported in the literature. We report a patient with multiple metastases from a cardiac myxoma which had an unusual histopathology mimicking an adenocarcinoma.

CLINICAL PRESENTATION

A 35 year old man presented with left facio-brachial focal motor seizures unresponsive to antiepileptic drugs and these episodes preceded the symptoms of cardiac myxoma. The seizures worsened a year following resection of the cardiac myxoma. The MRI of the brain revealed multiple lesions of heterogeneous intensity, partly solid and cystic situated in the right fronto-parietal, left temporal and occipital lobes.

FINDINGS

Right fronto-parietal craniotomy revealed lesions with haemorrhagic, calcified areas and a large cystic component was decompressed. Histological examination of the lesions in the brain demonstrated prominent glandular differentiation, identical in morphology to the primary cardiac lesion of a glandular variant of atrial myxoma.

CONCLUSION

This report highlights the rare presentation of atrial myxoma with intracranial metastases and reviews previously reported examples. This is only the second case report of a glandular variant of atrial myxoma with metastases to the brain. A pathologist, unaware of this unusual variant of primary atrial myxoma, may mistake the intracranial lesion for a metastatic adenocarcinoma.

Pathology of post traumatic brainstem and hypothalamic injuries

OBJECTIVE

Several autopsy studies of head injury are available but pathology of brainstem and hypothalamic injuries are addressed in very few of them. We studied brains of 47 patients who succumbed to head injury, with special attention to topographical distribution of brainstem and hypothalamic injuries.

MATERIAL AND METHODS

Brains retrieved at autopsy of 47 patients who succumbed to head injury following road traffic accidents (32 cases) or fall from height (15 cases) were examined for brainstem and hypothalamic injuries. Brainstem lesions were grouped into Type I (in absence of raised intracranial pressure and downward herniation) and Type II (secondary to raised ICP and herniation). Lesions were mapped topographically and examined histologically for axonal and myelin changes. Anatomical location of lesions was correlated with mode of injury, site of impact, occurrence of associated lesions, prognosis and survival.

RESULTS

Brain-stem injury was noted in 36 cases (76.5%) [Type I in 7 (14.9%) and Type II in 29 cases (61.7%)]; hypothalamic injuries in 20 (42.5%), and combined hypothalamic and brainstem injuries were seen in 17 (36.1%). 11 had no brainstem/hypothalamic injuries. Brainstem hemorrhages occurred in lower midbrain and upper pons, and hypothalamic injuries involved paraventricular nuclei. In cases with combined injury to brainstem and hypothalamus, lesions involved rostral ventral mesencephalon of brainstem and paraventricular region of hypothalamus. The site of impact had no definite correlation with occurrence of brainstem or hypothalamic injuries though basal fractures and road traffic accidents were more often associated with hypothalamic injuries. Survival of cases with Type I injury was shorter than Type II (14.2 vs. 65.2 hours) due to involvement of raphe/reticular nuclei. Though cases with hypothalamic injuries did not result in early death, involvement of anterior hypothalamus resulted in shorter survival (< 6 hours) compared to posterior. Diffuse axonal injury and hypothalamic involvement were more often seen with Type II brainstem injuries. Cerebral contusions were a common accompaniment of hypothalamic injuries (80%).

CONCLUSIONS

Brainstem and hypothalamic injuries are seen in significant proportion of traumatic brain injuries and may have an important role in determining the survival and prognosis. Insight into mechanisms of injury to hypothalamo-brainstem axis is essential for evolving better therapeutic strategies and prevention of post traumatic long term sequelae.

Toxoplasma seroprevalence in healthy voluntary blood donors from urban Karnataka

BACKGROUND & OBJECTIVES

Although many infections can be transmitted through blood transfusion, it is not possible to carry out screening tests for all. Among the protozoal diseases transmitted by blood transfusion in India the most important is malaria, followed by toxoplasmosis. Screening for malaria is mandatory in India. We evaluated the seroprevalence of Toxoplasma gondii in healthy adult population of blood donors in Karnataka, south India.

METHODS

A total of 1000 serum samples collected in two batches (500 each) in the years 2004 and 2005 from healthy voluntary blood donors were tested for T. gondii antibodies by ELISA method, in addition to the other five mandatory tests.

RESULTS

Overall 20.3 per cent were positive for T. gondii IgG antibody, of which, 63 per cent had high and 7 per cent low avidity, 3.6 per cent IgM positive. IgG titre ranged from 18-362 IU/ml.

INTERPRETATION & CONCLUSION

Our study showed a high prevalence of T. gondii antibodies in healthy voluntary blood population. It may be appropriate to include screening for T. gondii also in the pretransfusion blood testing schedule.

Fatal Group A Streptococcal meningitis in an adult

Despite the recent resurgence in reports of invasive Group A Streptococcal (GAS) infections worldwide, it remains a rare cause of pyogenic meningitis both in children and adults. We report a case of fatal GAS meningitis in a healthy adult emphasizing the need for clinicians to be aware of its fulminant course, prompting early diagnosis and treatment. There is also a need to consider postexposure chemoprophylaxis in close contacts of such cases.

Acute aortic dissection presenting as painful paraplegia

Aortic dissection is a rare potentially life threatening condition. Neurological complications such as paraplegia as presenting manifestation of aortic dissection are exceedingly rare. We describe a 60-year-old man who presented with acute onset paraplegia with bladder involvement, constricting pain in the lower abdomen, bradycardia and succumbed rapidly within 14h of onset of symptoms. Autopsy revealed an unexpected cause of paraplegia with extensive aortic dissection extending from origin to iliac bifurcation (DeBakey type I). The aorta showed extensive atherosclerosis causing medial destruction and dissection. The spinal cord in the vulnerable watershed zone of T12-L1 downwards revealed ischemic softening. No infarcts were seen in other organs as he succumbed rapidly to cardiac tamponade. Acute aortic dissection presenting as paraplegia though rare, should be considered in patients presenting with sudden onset paraplegia with associated severe pain and absent pulses. Prompt diagnosis and timely intervention may help save life and limb.