Thoracoscopic McKeown esophagectomy in a patient with an azygos lobe

BACKGROUND

The azygos lobe is a relatively rare anatomical variation, and there have been no reports, until date, of thoracoscopic McKeown esophagectomy for esophageal cancer in a patient with an azygos lobe. The azygos lobe can be diagnosed by chest X-ray or CT, and is usually not associated with any symptoms. However, surgeons should be aware that transthoracic surgical procedures in patients with an azygos lobe could be associated with a high risk of complications.

CASE PRESENTATION

An 83-years-old man was brought to our emergency room with fever, severe headache, and difficulty in moving. MRI revealed a brain abscess, which was treated by abscess drainage and systemic antibiotic treatment. Further examinations to determine the cause of the brain abscess revealed esophageal cancer. In addition, CT revealed an azygos lobe in the right thoracic cavity. Although intrathoracic adhesions were anticipated on account of a previous history of bacterial pyothorax, we decided to perform esophagectomy via a thoracoscopic approach. Despite the difficulty in dissecting the intrathoracic adhesions, we were able to obtain the surgical field thoracoscopically. Then, we found the azygos lobe, as diagnosed preoperatively, and the azygos vein was supported by the mesentery draining into the superior vena cava. After dividing the mesentery, we clipped and cut the vessel, and both ends were further ligated. After these procedures, we safely performed esophagectomy with 3-field lymph node dissection. The postoperative course was uneventful, and the patient was discharged on the 21st postoperative day.

CONCLUSIONS

Although there was a firm adhesion in the thoracic cavity, preoperative recognition of the azygos lobe could help in preventing intraoperative injury. Especially, esophageal surgeons are required to deal with the azygos lobe safely to avoid serious intraoperative injury.

[A Case of Bacterial Meningitis in Which Occurrence of Ataxie Optique Led to Detection of a Small Subdural Abscess and Pialitis]

We report the case of a 69-year-old man with bacterial meningitis who presented with ataxie optique in the peripheral part of the left visual field in both hands. A detailed neurological examination with contrast-enhanced brain MRI in the early stage of the clinical course identified a small subdural abscess and pialitis in the right parietal area. A favorable outcome was obtained with antibiotic therapy alone. In a case with higher brain dysfunction of unknown cause in the clinical course of bacterial meningitis, a detailed neurological examination may be helpful to identify the causative site. (Received September 25, 2023; Accepted October 31, 2023; Published March 1, 2024).

Clinical features, etiologies, and outcomes of central nervous system infections in intensive care: A multicentric retrospective study in a large Brazilian metropolitan area

PURPOSE

The goal of this study was to investigate severe central nervous system infections (CNSI) in adults admitted to the intensive care unit (ICU). We analyzed the clinical presentation, causes, and outcomes of these infections, while also identifying factors linked to higher in-hospital mortality rates.

MATERIALS AND METHODS

We conducted a retrospective multicenter study in Rio de Janeiro, Brazil, from 2012 to 2019. Using a prediction tool, we selected ICU patients suspected of having CNSI and reviewed their medical records. Multivariate analyses identified variables associated with in-hospital mortality.

RESULTS

In a cohort of 451 CNSI patients, 69 (15.3%) died after a median 11-day hospitalization (5-25 IQR). The distribution of cases was as follows: 29 (6.4%) had brain abscess, 161 (35.7%) had encephalitis, and 261 (57.8%) had meningitis. Characteristics: median age 41 years (27-53 IQR), 260 (58%) male, and 77 (17%) HIV positive. The independent mortality predictors for encephalitis were AIDS (OR = 4.3, p = 0.01), ECOG functional capacity limitation (OR = 4.0, p < 0.01), ICU admission from ward (OR = 4.0, p < 0.01), mechanical ventilation ≥10 days (OR = 6.1, p = 0.04), SAPS 3 ≥ 55 points (OR = 3.2, p = 0.02). Meningitis: Age > 60 years (OR = 234.2, p = 0.04), delay >3 days for treatment (OR = 2.9, p = 0.04), mechanical ventilation ≥10 days (OR = 254.3, p = 0.04), SOFA >3 points (OR = 2.7, p = 0.03). Brain abscess: No associated factors found in multivariate regression.

CONCLUSIONS

Patients' overall health, prompt treatment, infection severity, and prolonged respiratory support in the ICU all significantly affect in-hospital mortality rates. Additionally, the implementation of CNSI surveillance with the used prediction tool could enhance public health policies.

Paramedian Forehead Flap for Repair of Refractory High-Flow Anterior Skull Base CSF Leak

The paramedian forehead flap (PMFF) has been well described for nasal reconstruction. However, it has never been reported for use in the repair of high flow anterior skull base cerebrospinal fluid (CSF) leaks. The patient was a 55 year-old African American male cocaine abuser who initially presented with a high flow anterior skull base CSF leak, extensive pneumocephalus, and intra-cerebral and intra-ventricular abscesses with an oro-nasal-cerebral fistula. The patent initially underwent bi-frontal craniotomy, exenteration of the frontal sinus, abdominal fat graft, resection of intra-cerebral abscesses, and repair of high flow anterior skull base CSF leak with a pedicled pericranial flap (PF). Eighteen months after the patient's surgery, he had resumed his use of cocaine and suffered necrosis of his PF. This caused his high flow CSF leak to recur. After extensive psychiatric treatment, he stopped cocaine use and was subsequently repaired with a pedicled de-epithelialized PMFF originating off the bilateral supratrochlear arteries. The patient has had no CSF leak for 3 years, and primary closure of the forehead was achieved with good cosmetic outcome. This case highlights the use of PMFF for the treatment of recurrent high flow anterior skull base CSF leak. It also highlights the importance of treatment of the patient's underlying medical disorder, in this case, the patient's addiction to cocaine. We provide a detailed discussion for the use of the de-epithelialized PMFF and how it can be utilized as a vascularized reconstructive technique to repair complex refractory CSF leaks.

Intracranial invasive group A streptococcus: a neurosurgical emergency in children

OBJECTIVE

Invasive group A streptococcus (iGAS) infections are associated with a high rate of morbidity and mortality. CNS involvement is rare, with iGAS accounting for only 0.2%-1% of all childhood bacterial meningitis. In 2022, a significant increase in scarlet fever and iGAS was reported globally with a displacement of serotype, causing a predominance of the emm1.0 subtype. Here, the authors report on iGAS-related suppurative intracranial complications requiring neurosurgical intervention and prolonged antibiotic therapy.

METHODS

The authors performed a retrospective chart review of consecutive cases of confirmed GAS in pediatric neurosurgical patients.

RESULTS

Five children with a median age of 9 years were treated for intracranial complications of GAS infection over a 2-month period between November 2022 and December 2022. All patients had preceding illnesses, including chicken pox and upper respiratory tract infections. Infections included subdural empyema with associated encephalitis (n = 2), extradural empyema (n = 1), intracranial abscess (n = 1), and diffuse global meningoencephalitis (n = 1). Streptococcus pyogenes was cultured from 4 children, and 2 were of the emm1.0 subtype. Antimicrobial therapy in all patients included a third-generation cephalosporin but varied in adjunctive therapy, often including a toxin synthesis inhibitor antibiotic such as clindamycin. Neurological outcomes varied; 3 patients returned to near neurological baseline, 1 had significant residual neurological deficits, and 1 patient died.

CONCLUSIONS

Despite the worldwide increased incidence, intracranial complications remain rarely reported resulting in a lack of awareness of iGAS-related intracranial disease. Awareness of intracranial complications of iGAS and prompt referral to a pediatric neurology/neurosurgical center is crucial to optimize neurological outcomes.

Brain Nocardiosis Defined by 18 F-Fluorocholine PET/CT

ABSTRACT

Nocardia infection (nocardiosis) is usually acquired by inhalation; so pulmonary nocardiosis is the most common clinical presentation. Extrapulmonary localization occurs through hematogenous dissemination or contiguous spread. Nocardia can involve the central nervous system in a very reduced number of patients, mainly in immunocompromised. We present a case of a 56-year-old woman with a history of aggressive systemic mastocytosis, treated with chemotherapy 1 year ago. Patient reported intense headache, disorientation, and blurry vision without other symptoms being diagnosed with a rare brain nocardiosis by Nocardia cerradoensis . Neither bacteremia nor pulmonary involvement was detected. Brain PET/CT illustrated 18 F-fluorocholine avidity on brain abscesses.

[A multicenter epidemiological study of acute bacterial meningitis in children]

Objective: To analyze the clinical epidemiological characteristics including composition of pathogens , clinical characteristics, and disease prognosis acute bacterial meningitis (ABM) in Chinese children. Methods: A retrospective analysis was performed on the clinical and laboratory data of 1 610 children <15 years of age with ABM in 33 tertiary hospitals in China from January 2019 to December 2020. Patients were divided into different groups according to age,<28 days group, 28 days to <3 months group, 3 months to <1 year group, 1-<5 years of age group, 5-<15 years of age group; etiology confirmed group and clinically diagnosed group according to etiology diagnosis. Non-numeric variables were analyzed with the Chi-square test or Fisher's exact test, while non-normal distrituction numeric variables were compared with nonparametric test. Results: Among 1 610 children with ABM, 955 were male and 650 were female (5 cases were not provided with gender information), and the age of onset was 1.5 (0.5, 5.5) months. There were 588 cases age from <28 days, 462 cases age from 28 days to <3 months, 302 cases age from 3 months to <1 year of age group, 156 cases in the 1-<5 years of age and 101 cases in the 5-<15 years of age. The detection rates were 38.8% (95/245) and 31.5% (70/222) of Escherichia coli and 27.8% (68/245) and 35.1% (78/222) of Streptococcus agalactiae in infants younger than 28 days of age and 28 days to 3 months of age; the detection rates of Streptococcus pneumonia, Escherichia coli, and Streptococcus agalactiae were 34.3% (61/178), 14.0% (25/178) and 13.5% (24/178) in the 3 months of age to <1 year of age group; the dominant pathogens were Streptococcus pneumoniae and the detection rate were 67.9% (74/109) and 44.4% (16/36) in the 1-<5 years of age and 5-<15 years of age . There were 9.7% (19/195) strains of Escherichia coli producing ultra-broad-spectrum β-lactamases. The positive rates of cerebrospinal fluid (CSF) culture and blood culture were 32.2% (515/1 598) and 25.0% (400/1 598), while 38.2% (126/330)and 25.3% (21/83) in CSF metagenomics next generation sequencing and Streptococcus pneumoniae antigen detection. There were 4.3% (32/790) cases of which CSF white blood cell counts were normal in etiology confirmed group. Among 1 610 children with ABM, main intracranial imaging complications were subdural effusion and (or) empyema in 349 cases (21.7%), hydrocephalus in 233 cases (14.5%), brain abscess in 178 cases (11.1%), and other cerebrovascular diseases, including encephalomalacia, cerebral infarction, and encephalatrophy, in 174 cases (10.8%). Among the 166 cases (10.3%) with unfavorable outcome, 32 cases (2.0%) died among whom 24 cases died before 1 year of age, and 37 cases (2.3%) had recurrence among whom 25 cases had recurrence within 3 weeks. The incidences of subdural effusion and (or) empyema, brain abscess and ependymitis in the etiology confirmed group were significantly higher than those in the clinically diagnosed group (26.2% (207/790) vs. 17.3% (142/820), 13.0% (103/790) vs. 9.1% (75/820), 4.6% (36/790) vs. 2.7% (22/820), χ²=18.71, 6.20, 4.07, all P<0.05), but there was no significant difference in the unfavorable outcomes, mortility, and recurrence between these 2 groups (all P>0.05). Conclusions: The onset age of ABM in children is usually within 1 year of age, especially <3 months. The common pathogens in infants <3 months of age are Escherichia coli and Streptococcus agalactiae, and the dominant pathogen in infant ≥3 months is Streptococcus pneumoniae. Subdural effusion and (or) empyema and hydrocephalus are common complications. ABM should not be excluded even if CSF white blood cell counts is within normal range. Standardized bacteriological examination should be paid more attention to increase the pathogenic detection rate. Non-culture CSF detection methods may facilitate the pathogenic diagnosis.

[A toddler with complicated otorrhea]

A 4-year-old boy was diagnosed with intracranial abscess following adequately treated otorrhea and mastoiditis. This is an uncommon finding. He underwent mastoidectomy with drainage of the abscess. In cases where patients clinically deteriorate during treatment for otorrhea and mastoiditis, further examination using CT-scan is recommended.

Screening for intimate partner violence in the early postpartum period: Maternal and child health and social outcomes from birth to 5-years post-delivery

BACKGROUND

Intimate partner violence (IPV) during pregnancy is a substantial public health concern, yet little is known about the developmental trajectory of these women and their children after birth.

OBJECTIVE

The objective was to examine maternal and child health as well as social outcomes from birth to 5-years post-delivery associated with a positive (vs. negative) maternal IPV screen around the time of delivery.

PARTICIPANTS AND SETTING

Manitoban women giving birth to a live singleton infant from January 1, 2003 to December 31, 2006 were followed from birth to 5-years post-delivery (analytic sample: N = 40,051).

METHODS

Administrative databases from the Manitoba Centre for Health Policy provided data for the study. Descriptive statistics and logistic regression were used to examine relationships between IPV screen response around the time of birth (i.e., current, or history of, violence between parenting partners) with maternal and child health as well as social outcomes.

RESULTS

Women screening positive for IPV had increased odds of diagnosed mood/anxiety disorders, personality disorders, substance use disorders, diabetes, respiratory morbidity, and intentional/non-intentional injury hospitalizations (adjusted odds ratio [AOR] range 1.81-5.59, p < .01). Children of women screening positive for IPV had increased odds of diagnosed attention deficit-hyperactivity disorder, lower respiratory infections, and injury hospitalizations (AOR range 1.53-2.00, p < .01), child welfare organization contact (AOR = 8.84, p <  .01), and of being more developmentally vulnerable at kindergarten across domains of functioning (AOR range 1.69-1.93, p <  .01) than children of mothers screening negative for IPV.

CONCLUSION

A positive IPV screen was associated with poorer maternal and child health, increased child and family services contact, and children being more developmentally vulnerable in the 5-years after delivery.

[Congenital Dermal Sinus with Dermoid Cyst Complicated by Brain Abscess: A Case Report]

Congenital dermal sinus(CDS)is a rare entity of spinal dysraphism, caused by the focal failure of disjunction leading to adhesion between the cutaneous and neural ectoderm. Some reports found that tumors, such as dermoid and epidermoid cysts, meningitis and subdural abscess are often complicated by CDS. A 1-year-old girl was referred to our department for CDS with a dermoid cyst complicated by brain and subdural abscesses. Diffusion weighted imaging and gadolinium-diethylenetriamine penta-aceticacid administration revealed ring-enhancing lesions, suggesting brain abscess, in the left temporal lobe, and subdural abscesses on the bilateral middle cranial bases. T1-and T2-weighted lumbar magnetic resonance imaging revealed CDS. With a preoperative diagnosis of CDS with brain and subdural abscesses, resection of CDS was performed after draining the brain abscess twice. The CDS extended into the spinal canal and it was completely exercised. We then performed sub-total resection of the dermoid cyst in the subdural space. Recent reports showed that dermoid cysts are related to CDS infection and deterioration of the infection, as seen in this case. Complication of dermoid cysts is an important consideration during CDS treatment. While the mechanism of the development of brain abscess in CDS patients has been unclear, this rare but important case revealed the mechanism to be the direct spread of inflammation via CDS.

A Case of Philadelphia Chromosome-Positive Acute Lymphoblastic Leukemia with Aspergillus Brain Abscess and Invasive Pulmonary Aspergillosis Successfully Treated with Voriconazole Followed by Cord Blood Transplantation

A 59-year-old female was diagnosed as pulmonary aspergillosis(IPA)while remission induction therapy for Philadelphia chromosome-positive acute lymphoblastic leukemia. Liposomal amphotericin B improved the fungal serodiagnostic markers, however,the IPA worsened. She also developed an Aspergillus brain abscess,which, while being undetectable on CT,was detected as multiple nodular lesions by MRI. A definitive diagnosis was made by polymerase chain reaction(PCR)of brain biopsy specimens. Voriconazole(VRCZ)was effective,and cord blood transplantation was performed. She has received VRCZ for a long time. There are no relapse of either the IPA or the Aspergillus brain abscess.

Klebsiella pneumoniae brain abscesses in an elderly patient without clinically evident neurological signs and symptoms

PURPOSE

It is difficult to diagnose a brain abscess if the patient does not have clinically evident neurological features. We present the diagnosis and therapeutic course of an elderly woman with multiple Klebsiella (K.) pneumoniae brain abscesses without neurological signs or symptoms.

CASE REPORT

The patient was an 81-year-old woman without diabetes who had been discharged from our hospital about 7 days before this admission with a diagnosis of K. pneumoniae urinary tract and bloodstream infections. She did not have any clinically evident neurological features except for a fever, however focal suppurations were identified in the cerebral hemispheres and lungs by magnetic resonance imaging (MRI) and computed tomography, respectively. After an 11-week course of antibiotic treatment and serial cranial MRI follow-up studies, she was discharged in a stable condition with no neurological sequelae.

CONCLUSION

Cranial MRI should be performed to identify the presence of brain abscesses in elderly patients with K. pneumoniae bloodstream infections but without clinically evident neurological signs or symptoms. Serial MRI studies are important to monitor the therapeutic course.

Pediatric intracranial abscesses

Intracranial infections in children are a relatively rare, but potentially severe condition. Because of the potential for rapid deterioration, timely diagnosis and treatment are necessary. These infections are categorized based on their intracranial location: epidural abscess, subdural empyema, and brain abscess. They largely arise from direct extension of adjacent infection, hematogenous seeding, or trauma. Clinical presentations of intracranial infections also vary. However, common signs and symptoms include headache, fever, nausea and vomiting, altered mental status, focal neurologic deficits, and seizures. In general, MRI demonstrates a peripherally enhancing lesion with high signal on diffusion weighted imaging (DWI). Bacterial isolates vary, but most commonly are a single pathogen. Successful treatment requires a multidisciplinary team approach including such modalities as antibiotic therapy and surgical drainage. When possible, open surgical evacuation of the abscess is preferred, however, in cases of deep-seated lesions, or in unstable patients, aspiration has also been performed with good results.

[Disseminated nocardiosis presenting as retroperitoneal abscess: a case report]

A 64-year-old man presented to our emergency room with right back pain on July 10, 2009. At the emergency room, abdominal enhanced computed tomography revealed a cystic lesion in the retroperitoneum. Then he was referred to our department. We performed percutaneous drainage of the retroperitoneal lesion and aspirated white pus. The retroperitoneal cystic lesion proved to be an abscess. Microscopic examination of a Gram stained specimen of the abscess revealed gram-positive bacillary fragments ; therefore, we suspected the pathogen to be Nocardia. He had a history of chronic glomerulonephritis and had received treatment consisting of 20 mg prednisolone, and 75 mg cyclosporine per day. He was regularly visiting the department of cardiovascular for follow-up of chronic heart failure. On the day before his visit to our emergency room, his chest X-ray medicine had revealed a nodular shadow. Then he was referred to the department of respiratory medicine and was scheduled to receive a bronchoscopy later. We suspected the nodule of the lung also to be an abscess of Nocardia. Later, head computed tomography (CT) revealed a brain abscess the pathogen of which was Nocardia. Nocardia is a filamentous, gram-positive, branched bacterium and classified as an aerobic actinobacteria. Nocardia species are difficult to diagnose due to non-specific clinical and histological manifestation. We report this case of disseminated nocardiosis presenting as retroperitoneal abscess. The disseminated nocardiosis was diagnosed without delay by percutaneous drainage and appropriate treatment was provided.

Development of a murine model of cerebral aspergillosis

Central nervous system (CNS) Aspergillus infection has a mortality rate in humans that approaches 95%. Because no animal models are available for studying this infection, we sought to develop a murine model of CNS aspergillosis. Inconsistent data were obtained for nonimmunosuppressed CD-1, C57BL/6, and DBA/2N mice after infection by midline intracranial injection of Aspergillus fumigatus. CD-1 mice given cyclophosphamide to produce immunosuppression had continuous pancytopenia. Dose-finding studies in CD-1 mice showed that infection with 5 x 106 conidia/mouse consistently caused 100% mortality by day 5-8; no mice died before day 3. Histologic examination of samples of brain tissue showed focal abscesses containing Aspergillus hyphae. Fungus burdens in brain were higher than those in other organs, although Aspergillus disseminated to the kidneys and the spleen. The model we established provides an opportunity to study immune responses to and therapeutic options for CNS disease in an immunologically defined, genetically manipulable, and inexpensive species.

Focal intracranial infections

Focal intracranial infections are relatively rare, but the consequences of a missed or delayed diagnosis are significant. The clinician is urged to consider these diagnoses in patients with headaches or focal neurologic examinations, particularly in the setting of known or suspected otorhinologic disease. For diagnosis, gadolinium-enhanced MR imaging or MR imaging with angiography are the procedures of choice; CT is far less sensitive and specific. Lumbar puncture is contraindicated in most of these infections. Management of suspected elevation of intracranial pressure and broad empiric antibiotic therapy should be instituted emergently. Early involvement of surgical services is recommended.