Prostatic hyperplasia in acromegaly, a myth or reality: a case-control study

CONTEXT

Disorders of the prostate gland are more prevalent in patients with acromegaly. GH-insulin-like growth factor 1 (IGF1) axis plays an additive role in prostatic growth and development.

OBJECTIVE

To correlate the structural and histopathological changes of the prostate and prostatic symptoms with GH/IGF1 in patients with acromegaly.

DESIGN

Case-control study, from January 2012 to November 2013.

SETTING

Tertiary referral centre university hospital in Northern India.

PATIENTS

Fifty-three men with acromegaly and 50 healthy men matched for age and BMI.

MAIN OUTCOME MEASURES

International Prostate Symptom Score (IPSS), prostate-specific antigen (PSA) levels, dimensions of the prostate on trans-rectal ultrasonography, parameters on uroflowmetry, and immunopositivity with anti-IGF1 antibody in prostatic tissue biopsies.

RESULTS

Despite low serum testosterone levels (8.9 nmol/l vs 14.3 nmol/l, acromegaly vs control), patients with acromegaly had marginally higher IPSS, PSA levels, and grades of enlarged prostate and obstructive features on uroflowmetry compared with controls. Dimensions of the prostate on ultrasonography were also significantly higher in patients. These changes were present irrespective of age, current gonadal status, and disease activity. Evidence of prostatic hyperplasia on biopsy was seen in six of 14 patients (42.8%) who underwent prostatic biopsy while it was absent in the controls. Immunohistochemistry with anti-IGF1 antibody showed moderate positivity in all the 14 patients who underwent biopsy with benign prostatic hyperplasia, compared with mild positivity in 21% of controls. Similarly, 14 control patients with prostatic malignancies showed variable positivity, four patients had strong, two each had mild and moderate positivity, while six were negative.

CONCLUSIONS

In patients with acromegaly, there is a higher frequency of structural changes in the prostate, along with greater prostatic volume and obstructive features, compared with healthy controls, irrespective of age, gonadal status, and disease activity.

Diagnostic utility of serum GH, IGF-1 and IGFBP3 in patients of acromegaly with uncontrolled diabetes: a pilot study

PURPOSE

Diagnosis of acromegaly in presence of uncontrolled diabetes mellitus is not well validated.

METHOD

The study included 10 patients of active acromegaly with uncontrolled blood glucose, 10 patients of type 2 diabetes mellitus with poor glycemic control and 10 healthy subjects. The growth hormone level following oral glucose tolerance test and insulin-like growth factor-1 (IGF-1) and insulin-like growth factor-binding protein-3 (IGFBP-3) were done at baseline in all the 3 groups and it was repeated after short term glycemic control in type 2 diabetics and acromegalics with diabetics

RESULTS

In the acromegalic group the basal GH value was very high (36.5 + 1.6) ng/ml and it was non-suppressible (32.5 + 1.43) ng/ml after OGTT. The mean IGF-1 and IGFBP-3 values were also high at baseline (208.38 + 38.51) ng/ml, and 7322 + 370 ng/ml respectively. In the non-acromegalic diabetic patients, the basal growth hormone value was marginally elevated (2.3 + 0.02) ng/ml. However, it was suppressible to 0.2 + 0.04 ng/ml after oral glucose load. In them the IGF-1 and IGFBP-3 values were not elevated and comparable to that of healthy controls.

CONCLUSIONS

Basal serum GH and IGFBP-3 levels are not influenced by degree of glycemic control however serum IGF-1 levels should be interpreted with caution in patients of acromegaly with diabetes. Oral glucose load test has discriminating ability to diagnose acromegaly even with poorly controlled diabetes.

Choice of fluid therapy in patients of craniopharyngioma in the perioperative period: A hospital-based preliminary study

BACKGROUND

Electrolyte imbalance and acute diabetes insipidus (DI) are the most common complications in patients undergoing craniopharyngioma surgery. Improper management of water and electrolyte imbalance is common cause of morbidity and mortality. Data is sparse and controversial regarding the choice of fluid therapy in this population during perioperative period.

METHODS

In this retrospective-prospective study involving 73 patients (58 retrospective), the type of fluid therapy was correlated with occurrence of hypernatremia, hyponatremia, DI, morbidity, and mortality. In the retrospective study, 48 patients received normal saline and 10 received mixed fluids as per the prevailing practice. In the prospective group, five patients each received normal saline, half normal saline, and 5% dextrose randomly.

RESULTS

The sodium values were significantly higher in first 48 h in the group that received normal saline compared with other groups (P < 0.001). The use of normal saline was associated with higher incidence of hypernatremia, DI, and mortality (P = 0.05), while the group that received 5% dextrose was associated with hyponatremia, hypoglycemia, and seizures. There was no perioperative hypotension with use of any of the fluids.

CONCLUSION

Our results indicate half normal saline was fluid of choice with diminished incidence of water and electrolyte abnormalities without increase in mortality during postoperative period.

Secretory meningioma: a diagnostic pitfall

CONTEXT

Secretory meningioma is a rare subtype of meningiomas, displaying epithelial and secretory differentiation of meningothelial cells. It has unique radiological, morphological, and immunohistochemical features, but runs a benign course. Radiological picture because of the variable degrees of peritumoral edema can be confused with aggressive neoplasms. Morphologically, it is difficult to distinguish secretory meningioma from other tumors having a clear cell appearance and aggressive clinical behavior.

MATERIALS AND METHODS

Retrospective analysis over a period of 16 years (1997-2012) brought out five cases diagnosed as secretory meningioma. The slides were restained and subject to special stains and immunohistochemistry and the clinical details were retrieved.

RESULTS

On histopathology, the tumors showed a characteristic vacuolated appearance due to the presence of variably sized intracytoplasmic lumina. Another unique feature was the presence of hyaline inclusions within these intracytoplasmic lumina and in the intercellular spaces. These inclusions were periodic acid-Schiff positive diastase-resistant, yellowish-orange on Elastic Van Giesson stain and strongly carcinoembryonic antigen positive.

CONCLUSION

Owing to its rarity and unique morphology secretory meningioma poses a diagnostic challenge to the pathologists. As this tumor follows a benign course, it is crucial to correctly diagnose this entity to avoid unnecessary over treatment.

Ruptured venous aneurysm of cervicomedullary junction

Background:

Ruptured venous aneurysm is often seen with arterio-venous malformation (AVM) or developmental venous anomaly (DVA). However, isolated venous aneurysm is unusual.

Case Description:

We present a case of ruptured venous aneurysm that presented with subarachnoid hemorrhage (SAH) and intraventricular hemorrhage (IVH). Digital substraction angiography (DSA) revealed a saccular contrast filling pouch in the left lateral aspect of cervicomedullary junction (CMJ). Endovascular intervention was not a viable option. During surgery, a saccular pliable structure approx. 1.5 × 1 cm was found in the subarachnoid space that was clipped and excised. There were no arterial feeders, no evidence of surrounding AVM, and no dilated perimedullary vein.

Conclusion:

This is perhaps the first reported case of ruptured venous aneurysm (without associated AVM) of CMJ, which was successfully managed surgically. The possible etiologies remain an unnoticed head trauma or a congenital vessel wall abnormality. Surgically clipping and excision remains the treatment of choice for such lesion.

Congestive heart failure in acromegaly: A review of 6 cases

BACKGROUND

Though cardiac involvement is common in acromegaly, overt congestive heart failure is uncommon.

MATERIALS AND METHODS

This is retrospective analysis of hospital record between 1996 and 2007. We analyzed records of 150 consecutive patients with acromegaly. We included the patients with acromegaly those who had overt congestive heart failure either at presentation or during the course of illness for the present analysis. The diagnosis of acromegaly and congestive cardiac failure were based on standard criteria.

RESULTS

Out of 150 patients with acromegaly, 6 patients had overt CHF (4.0%), of which 4 presented with the features of CHF and 2 developed during the course of illness. Three patients had hypertension and 1 had diabetes. Baseline echocardiography showed severe biventricular dysfunction and global hypokinesia in all. Angiography showed dilated hypokinetic left ventricle with normal coronaries in 3, it was confirmed at autopsy in 1. Three underwent trans-sphenoidal surgery, 1 received somatostatin analogue as primary treatment modality. Normalization of growth hormone and IGF-1 led to improvement in cardiac function in 1, 1 patient lost to follow up, and 4 died during the course of illness. In 1 patient, autopsy was performed and cardiac specimen revealed normal coronaries, concentric ventricular hypertrophy, and dilatation with myofibrolysis and interfascicular fibrosis.

CONCLUSION

Prevalence of overt CHF is 4% in present series. Overt CHF carries poor prognosis and hence, this complication should be recognized at earliest, and medical management to normalized cardiac function should be given utmost priority.

Pituitary metastasis as a presenting manifestation of silent systemic malignancy: A retrospective analysis of four cases

BACKGROUND

Pituitary metastasis as a presenting manifestation of silent systemic malignancy is rare. We describe four such cases.

MATERIALS AND METHODS

Four patients (0.7%) of malignancy with pituitary metastasis out of 540 patients of sellar mass within a period of 10 years were analyzed for clinical, hormonal and radiological findings.

RESULT

The age range of these patients was 39-60 years with lag time ranging from 2to 5 months. Pituitary pathology was presenting manifestation in all 4 patients including diabetes insipidus, ophthalmoplegia and variable anterior pituitary hormone deficiency. 2 patients had bronchogenic carcinoma and one each had squamous cell and adenocarcinoma with unknown primary. Diagnosis of pituitary metastasis was confirmed in three on pituitary mass histopathology and in one it was based on rapidly appearing mass in a short time.

CONCLUSION

Rapidly appearing mass in the sellar region, short lag time,sudden onset of ophthalmoplegia, -symptoms and signs disproportionate to the size of mass, presence of diabetes insipidus and destroyed but normal sized sella should invoke the suspicion of pituitary metastasis.

Lead-induced peripheral neuropathy following Ayurvedic medication

Lead poisoning following intake of Ayurvedic medication is one of the recent areas of concern. We report a case of a 58-year-old type II diabetic man who was stable with diet control and 30 mg pioglitazone per day. He took Ayurvedic medication for generalized weakness and developed peripheral neuropathy following its intake. He was found to have high blood and urinary lead levels and was diagnosed to have subacute lead poisoning. He was treated with d-Penicillamine for 8 weeks, following which his lead levels became normal. The use of d-Penicillamine was proved highly effective in treating a case of lead poisoning.

Adolescent acromegaly: clinical parameters and treatment outcome

BACKGROUND

Adolescent acromegaly is a rare disorder and these patients present with tall stature/gigantism, tumor mass effects and menstrual irregularities.

PATIENTS AND METHODS

34 consecutive (26 males) patients having onset of disease prior to 21 years of age were included in this retrospective analysis. Their clinical features and treatment outcome were studied.

RESULTS

Mean age and lag time at presentation were 21.6 +/- 3.9 years and 5.1 +/- 3.5 years respectively. Common presenting manifestations included acral enlargement, tumor mass effects and menstrual irregularities. Mean height at presentation was 174.6 +/- 13.7 cms (range: 150-210 cm) and one third had gigantism (height > or =97th percentile, WHO growth charts). Hypertension and glucose intolerance were seen in 15% and 23.5% respectively. Mean nadir GH after glucose load was 58.2 +/- 13.7 ng/ml and IGF -1 was 534.8 +/- 132.8 ng/ml. Half of the patients had concomitant hyperprolactinemia. Almost all (97%) had macroadenoma and anterior pituitary hormone deficiencies were frequent (75%). Patients with gigantism were younger (19.6 +/- 4.9 vs. 22.6 +/- 2.9 years; p = 0.001), had higher GH values (66.68 +/- 27.22 vs. 53.98 +/- 15.99 ng/ml; p = 0.04) and hypogonadism was more common (90.9% vs. 56.5%, p = 0.03) than those with normal stature. 32 patients (94.1%) were treated primarily with surgery, 7 (21.9%) received post operative radiotherapy. Mean duration of follow up was 33.1 +/- 10.1 months. Only 30% had nadir GH values of <1 ng/ml.

CONCLUSION

One third of adolescent patients had acrogigantism. These patients were younger, had higher GH levels and concurrent hypogonadism was more common. Cure could be achieved only in about one third of the patients.

Effect of pneumoperitoneum on intracranial pressure during supratentorial craniotomy: a case report

Laparoscopic surgery has become the method of choice for many procedures previously performed by open techniques. However, its use in patients with a potentially decreased intracranial compliance warrants caution. We report a case of combined glioma excision and laparoscopic cholecystectomy procedures with evaluation of the effects of pneumoperitoneum on ICP and operative field. The clinical implications, safety and recommendations of conducting laparoscopic surgeries in neurosurgical patients are discussed. Performing pneumoperitoneum in patients with marginal intracranial compliance needs interdisciplinary discussions and ICP monitoring is mandatory.

Tamoxifen use in Indian women--adverse effects revisited

BACKGROUND

Tamoxifen is generally considered a safe drug for Indian women with breast cancer. Indian women seem to tolerate tamoxifen therapy better than western women, but there are no data regarding safety and local adverse effect profiles in typical Indian populations.

METHODS AND RESULTS

A total of 3,000 case records of patients who had received tamoxifen daily for any period of time, between January 1988 and December 2007, were identified for study. Hot flashes were reported by 800 (26%), mild vaginal dryness by 450 (15%) and vaginal discharge by 300 (10%), with vaginal bleeding experienced by 40 (1.3%) patients. A total of 1,100 (36.6%) asymptomatic patients had a thickened endometrium(defined as >8mm in thickness) on ultrasonography. Endometrial curettage was performed in all of these. None of the patients developed endometrial carcinoma. Fatty infiltration of liver was found in 1,440 (48%) patients with a mean time interval for development of 7 months (range 6-30 months).

CONCLUSIONS

Fatty infiltration of liver is found in almost half of the Eastern Indian women who receive tamoxifen. Increased endometrial thickness, which remains asymptomatic, was documented in more than one third of patients on ultrasound examination. Tamoxifen seems to have a negligible potential for causation of uterine malignancies in eastern Indian women. Rates of hysterectomies in Indian patients on tamoxifen are substantially lower than those of western patients on tamoxifen.

Posterior midline approach for large anterior/anterolateral foramen magnum tumours

The standard surgical approaches described for excision of anterior or anterolaterally placed foramen magnum (FM) tumours are the far lateral approach, the extreme lateral approach and the transoral approach. In general the posterior midline approach is considered not suitable for these lesions. We have operated on 27 patients with benign anterior/anterolaterally placed FM tumours in the last 8 years. Thirteen of these were operated via the posterior midline approach. All these 13 patients had large or giant tumours displacing the cervicomedullary region posteriorly and laterally. This allowed adequate access through this approach with minimal handling of neural tissue. For small lesions, the far lateral approach was used. Most of the patients improved significantly neurologically. We recommend the standard midline posterior approach for large/giant FM tumours as the tumour size itself provides enough working space for the surgeon. For small lesions, the far lateral approach is preferred.

Decompressive surgery for acute subdural haematoma leading to contralateral extradural haematoma: a report of two casesand review of literature

Development of a contralateral epidural haematoma during or immediately after cranial surgery is a well-described entity. However, in a case of acute subdural haematoma where the brain is usually tense, postoperative development of contralateral extradural haematoma is uncommon. We report two cases of contralateral extradural haematoma after decompressive surgery for acute subdural haematoma. We recommend routine postoperative CT immediately after cranial surgery for head trauma. This would help in timely detection and treatment of such a complication.

Shunt surgery effects on cerebrospinal fluid flow across the aqueduct of Sylvius in patients with communicating hydrocephalus

We aimed to visualize and quantify the flow of cerebrospinal fluid (CSF) across the aqueduct of Sylvius in patients with communicating hydrocephalus using phase contrast MRI, and to evaluate the effect of ventriculoperitoneal (VP) shunt surgery on flow. We investigated aqueductal CSF flow using cine cardiac-gated phase contrast MRI in 10 normal volunteers and 10 patients with communicating hydrocephalus (who underwent VP shunt surgery). For qualitative evaluation, we used an in-plane phase contrast sequence in the midsagittal plane. Quantitative through-plane measurements were performed in the axial plane perpendicular to the aqueduct. The aqueduct area ranged from 0.02 cm(2) to 0.27 cm(2) in the shunt group; and from 0.01 cm(2) to 0.04 cm(2) in the control group (p<0.05). Aqueductal stroke volume (mean, standard deviation SD) ranged from 1.9 microL to 33.17 microL (17.41 microL, 10.1132) in the control group; and from 5.63 microL to 256 microL (87.20 microL, 79.0383) in the study group. Post-operatively the aqueductal stroke volume reduced significantly, ranging from 0.60 microL to 48.77 microL (13.19 microL, 18.08) (p<0.05). Peak systolic velocity (PSV) values in the patients before shunt surgery ranged from -1.05 cm/s to -8.10 cm/s (-4.39cm/s, 2.7619) and peak diastolic velocities (PDV) ranged from 0.62 cm/s to 5.16 cm/s (3.33 cm/s, 1.4451). Post- shunt; PSV values ranged from -0.37 cm/s to -3.90 cm/s (1.78 cm/s, 1.5143) and PDV range was 0.32 cm/s to 4.43 cm/s (1.78 cm/s, 1.6782). The post-operative reduction in velocity was significant (p<0.05). Thus, the aqueductal CSF flow after VP shunt was similar to flow in healthy volunteers.

Rational use of glucocorticoid during pituitary surgery--a pilot study

BACKGROUND & OBJECTIVE

The conventionally used perioperative glucocorticoid replacement protocol in patients with pituitary tumours is far from optimal. In this study we evaluated the validity of a modified protocol for perioperative glucocorticoid replacement in non-functioning pituitary macroadenomas.

METHODS

A total of 24 consecutive patients with non functioning pituitary macroadenomas were included in this interventional study. Patients with a pre-operative 0800 h cortisol of > or = 350 nmol/l (> or = 12.6 microg/dl) did not receive glucocorticoid replacement during perioperative (d(0)-d-(2)) period, while those with < or = 100 nmol/l (< or = 3.6 microg/dl) received glucocorticoid replacement. Those patients with 0800 h cortisol value between > 100-349 nmol/l (> 3.6-12.6 microg/dl) required them to undergo an insulin induced hypoglycaemia (IIH). In response to IIH, patients with a peak cortisol of < 550 nmol/l (< 19.8 microg/dl) received glucocorticoid replacement. Post-operatively, patients on day 3 with 0800 h cortisol of < or = 100 nmol/l (< or = 3.6 microg/dl) received hydrocortisone 10 mg/m(2) per day; those between > 100-449 nmol/l (> 3.6-16 microg/dl) received hydrocortisone replacement only if they had symptoms of adrenal insufficiency (AI) or during stress; while patients with > or = 450 nmol/l (> or = 16.0 microg/dl) did not receive any glucocorticoid replacement. Retesting was done at 12 wk in 23 subjects based on the algorithm.

RESULTS

Pre-operatively, 8 (35%) patients were hypocortisolic and received glucocorticoid supplementation, thereby sparing 15 (65%) subjects from glucocorticoid replacement. On d(3) of surgery, 13 (57%) patients were hypocortisolic, but only 6 with serum cortisol of < or = 100 nmol/l (< or = 3.6 microg/dl), had symptoms and were substituted with glucocorticoid. Remaining seven patients, with serum cortisol between >100-349 nmol/l (> 3.6-12.6 microg/dl), were asymptomatic and advised glucocorticoid support only during stress but none required. Overall, 17 (74%) patients were spared from unnecessary glucocorticoid support. At 12 wk, 13 (57%) patients were hypocortisolic and only 6 either with serum cortisol level of < or = 100 nmol/l (< or = 3.6 microg/dl) or symptomatic for AI received glucocorticoids. Post-operative complications including diabetes insipidus and CSF leak remarkably decreased.

INTERPRETATION & CONCLUSION

The protocol used was safe and spared unnecessary use of glucocorticoids peri- and post-operatively. However, more number of patients are to be studied to substantiate the validity of this protocol.

Imaging features of endolymphatic sac tumours: case report with review of literature

Papillary endolymphatic sac tumours (ELSTs) are rare lesions of the temporal bone often confused with other more common entities. However, the radiologic differentiation is important for both surgical planning and also to alert the pathologist as regards the true origin. We present a case of a large ELST with some specific radiological findings.

Subgaleal suction drain leading to fatal sagittal sinus haemorrhage

The use of wound drains in surgical practice, very often falls into the realm of habit, rather than science. The utility of a prophylactic drain in surgical wounds may be questionable, but this practice is not uncommon, despite complications. We report a case of fatal haemorrhage from the superior sagittal sinus, due to a closed negative suction drain of the craniotomy wound in an infant operated upon for a growing fracture skull.

Retroperitoneal plexiform neurofibroma mimicking psoas abscesses

Retroperitoneal plexiform neurofibroma is a rare finding in neurofibromatosis type I, or von Recklinghausen's disease. A case of retroperitoneal plexiform neurofibroma mimicking psoas abscesses is reported here with its CT and MRI findings.

Raised intracranial pressure in hepatic encephalopathy

Intracranial hypertension secondary to cerebral edema is the cause of death in 50%-80% of patients with fulminant hepatic failure (FHF). This is rarely seen in chronic hepatic failure. The genesis of cerebral edema in FHF is poorly understood. The grade of encephalopathy and coagulopathy are the most important predictors of outcome in FHF. However, it is important to emphasize that intracranial pressure (ICP) may not reflect clinical course. Decerebrate posturing may be seen with ICP recording of 16 mmHg, while a quarter of the patients may have brain damage without clinical signs of raised ICP. ICP monitoring is therefore vital. The gold standard for ICP monitoring is the intraventricular method. Non-invasive methods like computerized tomography scan and magnetic resonance imaging have poor correlation with ICP. Other methods like transcranial Doppler and jugular venous oximetry measurement of brain metabolites need evaluation. The main indications for ICP monitoring in FHF are (a) patients in grade III or IV encephalopathy and (b) patients undergoing liver transplantation. Generally, patients with an ICP >40 mmHg with cerebral perfusion pressure <50 mmHg for over 2 hours are poor subjects for liver transplant.

Calvarial tuberculosis

BACKGROUND

Calvarial tuberculosis is rare, even in areas where tuberculosis is endemic. Primary calvarial tuberculosis, with no evidence of tuberculosis elsewhere in the body is a rarer entity.

METHODS

Seven cases of calvarial tuberculosis are presented. The relevant clinicoradiological features and management are discussed.

RESULTS

Two cases of primary calvarial tuberculosis could only be diagnosed after surgery. The other cases were diagnosed with the help of fine needle aspiration cytology (FNAC) and biopsy.

CONCLUSION

A high index of suspicion and awareness of this condition may lead to more cases being diagnosed early. Surgery may be avoided in selected cases that can be treated primarily with antitubercular therapy.

An unusual case of neonatal brain abscess following Klebsiella pneumoniae septicemia

A case of solitary brain abscess in a term neonate caused by Kiebsiella pneumoniae is described. K. pneumoniae, although a common cause of neonatal septicemia, is rarely implicated as an etiological agent for cerebral abscess in this age-group. The interest of this case lies in the rarity of the causative organism and atypical features. In the absence of predisposing factors in the neonate, we suspect that the infection was transmitted vertically from the mother before or at the time of delivery since there was evidence of asymtomatic urinary tract infection in the antenatal period.

Cytodiagnosis of hydatid disease presenting with Horner's syndrome: a case report

BACKGROUND

The diagnosis of echinococcosis is based on clinical, radiologic and serologic findings. Fine needle aspiration (FNA) is useful in evaluating the lesion when the presentation is atypical. We report a case of hydatid cyst at the lung apex in which the diagnosis was made on FNA, with no adverse reaction to the aspiration.

CASE

A 30-year-old male, a chronic smoker, presented with pain radiating to the medial two fingers of the right hand for two years. He also had miosis and ptosis of the right eye and anhidrosis of the right side of theface. There was wasting of small muscles in the right hand. Magnetic resonance imaging revealed a hyperintense mass at the apex of the right lung, thoracic inlet and adjacent vertebral bodies. A clinical diagnosis of Horner's syndrome due to pancoast tumor was rendered. Ultrasound-guided FNA showed protoscolices, scattered hooklets and bits of acellular laminated membrane, characteristic of echinococcosis. Surgical excision of the cyst was done. Gross and histopathologic examination of the excised cyst confirmed the diagnosis.

CONCLUSION

FNA, though traditionally contraindicated, is a highly desirable, rapid, noninvasive diagnostic mode for echinococcosis. In view of its pathognomonic cytomorphologic features and numerous reports on cytodiagnosis in the literature, it is time to evaluate the diagnostic benefits and weigh the risks against the advantages of the technique.

Suprasellar malignant mixed germ cell tumour presenting as craniopharyngioma

A 15 year old boy presented with diminution in vision of both eyes, diabetes insipidus and hypopituitarism. MRI was suggestive of a large suprasellar and retrosellar craniopharyngioma with stretching of the optic chiasma. Histopathological findings on the first surgical specimen were interpreted as a craniopharyngioma. He was reoperated on account of clinical deterioration and increase in tumour size. Histological examination this time revealed derivatives of all three germ cell lineages along with areas of embryonal carcinoma, and yolk sac tumour besides squamous cysts, establishing the diagnosis of malignant mixed germ cell tumour. Serum and CSF were strongly positive for alpha foetoproteins.

A mathematical outcome prediction model in severe head injury: a pilot study

103 patients of head injury, with a Glasgow coma scale (GCS) score of 8 or less, were studied prospectively. GCS score, brain stem reflexes, motor score, reaction level scale, and Glasgow Liege scale were evaluated as prognostic variables. Linear logistic regression analysis was used to obtain coefficients of these variables and mathematical formulae developed to predict outcome in individual patients.

Pineal cyst presenting with intracystic and subarachnoid haemorrhage: report of a case and review of the literature

A case of a benign pineal cyst in a 70-year-old man who presented with hydrocephalus and apoplexy is reported. Surgical exploration revealed subarachnoid and intracystic haemorrhage. The patient also had bilateral impairment of hearing which improved after excision of the cyst. Patients with a pineal cyst with apoplexy or subarachnoid bleed reported in the literature are reviewed.

Aneurysmal bone cysts of the skull: report of three cases

We report three cases of aneurysmal bone cysts of the skull, a rare site for this type of lesion. The patients were 11, 15 and 44 years old, the duration of symptoms being 72, 24 and 6 months, respectively. The lesions were painful in two cases. Computed tomography in all three cases was suggestive of aneurysmal bone cysts. En bloc excision of the bone cysts demonstrated no dural involvement. There were neither mitotic figures nor any other associated pathology on histopathological examination. Two cases were recurrence free at follow-up of 8 months and 3 years, and the third patient was thought to be recurrence free at 2 years.

Detection of HIV seropositivity during an outbreak of Japanese encephalitis in Manipur

An epidemic outbreak of Japanese encephalitis (JE) occurred during mid 1995. Sixteen serum samples from patients with history of febrile headache, convulsions, mental confusion, neck rigidity etc. were sent to the Department of Virology, School of Tropical Medicine, Calcutta, in August, 1995. Twelve (75%) showed HIV antibody against JEV. Out of these 12 sera showing HIV antibody titre between 1:40 and 1:160, eight (66.6%) showed IgM antibody, giving the presumptive diagnosis of recent JEV infection. Five of these 16 sera showed HIV seropositivity (31.25%). Concomitant JEV and HIV infection could be detected in 3 cases. However, in 2 sera HIV titre were less than 1:20. This is probably the first documentation of concomitant JEV and HIV infection in the eastern India.

A Software programme for data analysis of cerebral aneurysms

Research by traditional methods of collection of data from case files, proformas, registers and master charts is laborious and cumbersome process. Case files in the hospital record section are often not easily accessible and can get lost. Moreover manually recorded and analysed data occupies lot of space. This entire tedious business is highly simplified by using computer software for record keeping and its analysis. We describe the development of a comprehensive, user friendly software programme for neurosurgeons using FoxPro to analyse data of cerebral aneurysm patients. Data entry is done with the help of prompted picklist instead of codes, the selection of which is tapping a key without the need to type it. This entered data is automatically converted into a computer database which generates more than 75 tables and graphs of predetermined nature and covers most of the parameters a neurosurgeon would be interested in. This coded database also generates a discharge summary in a flowing text. The prototype of programme has been used in our first hundred patients of cerebral aneurysm and debugged while analysing the next fifty.

HCV activity in Calcutta--a serological study

HCV infection, a global public health problem is quite prevalent in India. In the present study conducted during February-July 1996 a total of 153 samples of different age groups and of both sexes were tested by ELISA for detection of Anti-HCV antibody. Anti-HCV was found in 13% of multi-transfused cases and in 8.8% cases with multiple needle-stick injury. Maximum seropositivity (20%) could be observed amongst males between 31-40 yrs. age group. HCV activity was noted more in males (13%) than in females (8.2%) and more relatively in subjects without a history of jaundice (11.5%) than those having the features of jaundice (10.5%). An increasing trend has also been observed amongst the multi-transfused cases in Calcutta.

An in vitro qualitative assay for the detection of antibodies to HIV type 1/2 contained in human saliva

There is ample evidence that saliva contains secretory antibody against most infections. Therefore, saliva has been recommended as a non invasive, safe and effective alternative to serum, for HIV antibody testing. The present study attempted comparative evaluation of antibody detection by serum and saliva specimens in laboratory by ELISA and Western Blot for diagnosis of HIV infection in the Indian situation. From a study of 42 test sera it is concluded that test apart from its simplicity and reproducibility, is almost free from any false positive and false negative reactions.

A study of influenza A virus in the city of Calcutta, India, high lighting the strain prevalence

A decade wide (from 1981 to the end of 1993) study on incidences of influenza was carried out in the city of Calcutta, India, by virus isolation and strain identification. Over 3500 patients with acute respiratory infections were examined and 1950 throat swab specimens were inoculated in embryonated chicken eggs. Only 339 haemagglutinating agents were isolated, which comprised 233 strains of influenza A virus. One hundred forty six (62.66%) of these strains were identified as H3N2, eighty one as H1N1 (34.76%), and only two were H2N2 (0.86%) strains of influenza A viruses, as estimated by haemagglutination inhibition test. This observation indicates that H3N2 is the major prevalent strain followed by H1N1 strains of influenza A virus in Calcutta.

An institutional outbreak of hepatitis E--reported first time from Calcutta city

A sudden outbreak of hepatitis occurred in a micro-epidemic form, amongst the staff members of the School of Tropical Medicine, Calcutta, during May-June, 1995. A total of 21 persons developed jaundice, out of whom 11 members who attended the Virology Department and were tested for detection of different serological markers of hepatitis by ELISA. All the sera (N = 11) showed evidence of non-A, non-B infection by process of exclusion and 9 of the above sera showed evidence of anti-HEV when tested specifically. This is the first documented outbreak of viral hepatitis in respect of Calcutta.

Febrile episode among a floating population of C.R.P.F. Jawans stationed at Calcutta

A virological investigation was carried out to establish the etiologic agent of a febrile outbreak amongst a floating population of C.R.P.F. Jawans, stationed at Calcutta during May-July, 1993. The illness was associated with fever, severe headache, bodyache and arthralgia which lasted for 2-4 days in most of the cases. Fifty cases were examined clinically and blood samples (both acute and convalescent) were subjected to virological study. One mouse-pathogenic agent could be isolated in suckling mice and identified as DEN-3. Sero-investigation of 50 single sera by HI & CF method revealed evidence of presumptive dengue infection in 33, while sero-conversion could be noted in 10 out of 25 available paired sera tested. Results of MAC ELISA revealed evidence of primary dengue infection in 6 out of 12 acute phase sera examined. Thus, the study shows that the episode is strongly suggestive of primary dengue infection.

A serological survey of influenza a antibody in human and pig sera in Calcutta

A study was undertaken with a view to assess the distinct pattern of sero-prevalence of influenza A viruses in the city of Calcutta population during the years of 1981-90. Concurrently, based on the fact of increasing pig population, a study was carried out to establish the activity of the human influenza A virus among pigs with a view to the potential threat of emergence of a new strain of influenza A virus that may surface following co-infection with swine and human influenza A viruses. The percentage positivity of the H3N2 antigen was found to be highest (46%), followed by H1N1 (43%), H2N2 (35%) and H0N1 (19%). A similar pattern was noted with pig sera.

Serosurvey of chikungunya antibody in Calcutta metropolis

Since its first isolation in Calcutta, in 1963, there have been many reports about epidemis of chikungunya virus infection in different parts of India. Calcutta experienced a concurrent epidemic of dengue and chikungunya between 1963 and 1965. But after that there is no report about any chikungunya infection in Calcutta. During routine investigations it is found that chikungunya antibody is on the wane. The present survey for chikungunya antibody showed only 4.37% (n = 17) seropositivity out of 389 sera tested. The highest (12.5%) seropositivity was observed in the age group of 51-55 years and no chikungunya antibody was detected in young and young adults. The findings suggest that chikungunya virus is disappearing from the Calcutta population.

Dengue haemorrhagic fever (DHF) outbreak in Calcutta--1990

An outbreak of Dengue Haemorrhagic Fever (DHF) occurred in Calcutta between September and December, 1990. Children and young adults were the major victims. Haemorrhagic manifestations and shocks were the main features in most of the hospitalised cases. Five mouse pathogenic agents were isolated from 105 acute cases and all were identified as DEN-3. HI and CF test with 55 paired sera revealed evidence of dengue infection in 33 (60 per cent) and flavivirus group reaction including dengue in 17 (30.9 per cent). It was for the first time, that DEN-3 was considered to be the etiologic agent for DHF in Calcutta.

Recurrent outbreaks of Japanese encephalitis in Nagaland (1985-1989)--a seroepidemiological study

Recurrent epidemics of encephalitis in Nagaland, a North-Eastern State of India, following its first appearance in 1985, were investigated both epidemiologically and virologically. Although, no viral agent could be isolated from any of the clinical samples and mosquitoes, detection of JE specific IgM antibodies in many of the CSF and acute blood samples, together with presence of HI and CF antibodies to JE antigen in a number of acute and convalescent sera established the etiologic role of JE virus in this region. A total number of 83 clinically diagnosed cases could only be investigated virologically between 1985-89, where evidence of JE could be established in 34 (40.9 per cent) and flavivirus (including JE in majority) in 17 (21.5 per cent) cases. A limited serological survey among the close contacts of the victims in 1985 revealed JE antibody in 26.6 per cent of them. Analysis of the epidemiological and serological findings of different years revealed that while the outbreaks of 1985, 1987 and 1988 were due to JE infection, the episodes of 1986 and 1989, on the other hand, had chiefly features of high and prolonged fever with limited number of CNS involvement of undetermined origin, where the possibility of malarial infection has been a suspect apart from JE etiology.

Seroepidemiological study of Japanese encephalitis in Dimapur, Nagaland

A seroepidemiological study of Japanese encephalitis (JE) in Dimapur, Nagaland was carried out following an outbreak of the disease between July, 1985 and February, 1986. Altogether 50 persons were affected with 30 (60 per cent) deaths. The attack and death rates per 1000 were more in Nagas viz. 0.55 and 0.34 than non-Nagas viz. 0.33 and 0.20 respectively. All ages and both sexes were affected. Of the nine mosquito species encountered Culex vishnui showed the highest density (44.5/MH). Culture of mosquito pool did not yield any viral agent. A total of 311 serum samples comprising 95 humans, 166 animals and 50 birds were tested for the presence of haemagglutination inhibition (HI) antibodies against Chikungunya and three flavirus antigens, viz. JE, WN and DEN-2. The overall flavivirus HI antibody in humans was positive in 26 (27.3 per cent) almost identical to JE antibody prevalence. The per cent positivity of HI antibodies to JE, WN and DEN-2 were 42.2 per cent, 22.2 per cent and 13.3 per cent in the affected and 14.2 per cent, 10 per cent and 6 per cent in the unaffected area. The activity of Alpha (Chikungunya) virus though very low was significantly higher (chi 2 = 5.57) in the affected area. The prevalence of JE antibody was 77.7 per cent in dogs, 52 per cent in cattle, 34 per cent in pigs and 21.1 per cent in goats. Of the five species of birds, flavivirus and JE antibodies were detected in 21.4 per cent pigeons and 22.2 per cent heron egrettes. Neutralisation test established the distinct role of JE virus over other related flavivirus antigens.

Outbreak of febrile illness due to dengue virus type 3 in Calcutta during 1983

An epidemic of dengue fever broke out in Calcutta between July and August 1983. Persons of all age groups were affected with a preponderance of young adults. Haemorrhagic manifestations and shock were not observed. Virus was isolated from 4 acute phase sera and identified as dengue type 3 (DEN-3), the first isolation of DEN-3 virus in Calcutta. Serotesting with 9 paired blood samples established dengue infection in 7 and a flavivirus group reaction in 2. Examination of 36 single sera revealed presumptive dengue infection in 15 and a flavivirus group reaction in 17, while the remaining 4 were negative to all flavivirus antigens.

Inheritance of fruit-coat colours in Trichosanthes anguina Linn

In Trichosanthes anguina Linn. (Cucurbitaceae), reciprocal crosses among three naturally occurring fruit-coat colour varieties (deep green, green and white) and two yellow fruit-coat colour mutants isolated in the M1 generation showed that a multiple allelic series control the fruit-coat colours. In the F2 generation the fruit-coat colours segregated in a monohybrid ratio with deep green dominant over green, yellow and white, green dominant over yellow and white, and yellow dominant over white. Two yellow fruit-coat colour mutants used in this study were isolated from X-ray- and EMS-treated populations of a white fruit-coat colour variety.

Density of Culex vishnui and appearance of JE antibody in sentinel chicks and wild birds in relation to Japanese encephalitis cases

In the District of Burdwan, a rural area of West Bengal State, India, Japanese encephalitis (JE) virus is endemic. In one village a longitudinal survey was conducted in order to find out whether associations could be established between the density of the vector mosquito Culex vishnui in two types of resting places, the incidence of infections in sentinel chicks exposed at monthly intervals, the prevalence of antibodies in wild birds and the occurrence of clinical infections in the human population. The experiment lasted from August 1981 till August 1982. Meteorologically a summer season (March-June), a rainy season (July-October) and a winter season (November-February) are distinguished. In the sentinel chicks infections were observed in all three seasons; in wild birds antibodies were prevalent throughout the year; these observations suggest perennial transmission of the virus in its maintenance cycle. Human infections were observed periodically with, in August 1982, a pronounced peak; this may point to fluctuations in the level of circulation of the virus in its maintenance cycle and spillover to the human population at times of peak circulation. The peaks may be related to the influx of young non-immune birds and newborn mammals into the animal population in summer. Further studies, including virus isolation attempts from mosquitoes and nestling birds, are required to prove this hypothesis.