TB or not to be? Kikuchi-Fujimoto disease: a rare but important differential for TB

A 29-year-old British Pakistani woman presented with a 2-month history of drenching fevers, night sweats, lethargy and tender cervical and axillary lymphadenopathy. Initial investigations, bloods and imaging were unremarkable. Fever persisted during her admission, and treatment for tuberculosis (TB) lymphadenitis was started postbiopsy until histology confirmed a diagnosis of Kikuchi-Fujimoto's disease (KFD). KFD has a non-specific presentation of fever, night sweats and lymphadenopathy and commonly raises a clinical suspicion of a number of other serious conditions such as TB, lymphoma, HIV, systemic lupus erythematous, toxoplasmosis and infectious mononucleosis. Although rare, KFD should be considered to be a differential diagnosis for fever of unknown origin and tender lymphadenopathy in otherwise well individuals. This case demonstrates the importance of a timely histological biopsy diagnosis to prevent an incorrect diagnosis and administration of unnecessary medications.

Autoimmune encephalitis: a case series and comprehensive review of the literature

Encephalitic syndromes are a common medical emergency. The importance of early diagnosis and appropriate treatment is paramount. If initial investigations for infectious agents prove negative, other diagnoses must be considered promptly. Autoimmune encephalitides are being increasingly recognized as important (and potentially reversible) non-infectious causes of an encephalitic syndrome. We describe four patients with autoimmune encephalitis--3 auto-antibody positive, 1 auto-antibody negative--treated during the last 18 months. A comprehensive review of the literature in this expanding area will be of interest to the infectious diseases, general medical and neurology community.

Acute central nervous system infections in adults--a retrospective cohort study in the NHS North West region

BACKGROUND

Over the last 15 years, bacterial meningitis has received considerable attention, including national guidelines, whilst viral central nervous system (CNS) infections have been relatively neglected. A recent pilot study suggested that management of patients with suspected viral encephalitis was often suboptimal.

AIM

To examine the relative incidence, clinical features and management of suspected acute CNS infections in adults across the NHS North West Region.

DESIGN

A multicentre cross-sectional retrospective cohort study at 10 hospitals across the region over 3 months (from September to December 2007). Following a screen of all patients who had cerebrospinal fluid (CSF) analysis or received intravenous aciclovir and/or third-generation cephalosporin, those with clinical features suspicious of a CNS infection were included. Management was compared with the national meningitis and regional encephalitis guidelines.

RESULTS

Three hundred and eighty-five patients were screened; 217 patients had a suspected CNS infection and 44 (20%) had a CNS infection: 18 aseptic meningitis (one herpes simplex virus [HSV]-2), 13 purulent meningitis (four Streptococcus pneumoniae) and 13 encephalitis (three HSV-1). The median (range) time from admission to suspicion of CNS infection and to LP was longer for patients with encephalitis than meningitis [4 (0.3-312) vs. 0.3 (0.1-12) h, P<0.001, and 23 (4-360) vs. 12 (2-48) h, P=0.042, respectively]; and the median time to treatment was longer for aciclovir than cephalosporin [7 (0.5-312) vs. 3 (0.3-312) h, P=0.002].

DISCUSSION

Encephalitis was as common as purulent meningitis, and HSV as common as Streptococcus pneumoniae. However, the management of patients with encephalitis was worse than meningitis. National encephalitis guidelines are needed.

Successful reversal of threatening carotid artery occlusion in HIV-associated non-aneurysmal vasculitis

We report a case of HIV-associated carotid vasculitis, causing cerebral infarction. Immediate corticosteroid treatment was followed by improvement, with radiological documentation of reversal of the vasculitic changes, preventing arterial occlusion. Vasculitis should be considered as a diagnosis in stroke in HIV and steroid treatment considered as a potentially life-saving intervention.

Sensorineural Hearing Loss Due to Secondary Syphilis

We present a case of sudden sensorineural hearing loss occurring as a complication of secondary syphilis. Syphilis affecting the inner ear, or otosyphilis, is well described in historical literature, but has rarely been reported in recent times. However, following the resurgence of syphilis in the UK, unusual manifestations such as otosyphilis are likely to be seen increasingly commonly.

Case report: radical radiotherapy for early laryngeal cancer in a patient with human immunodeficiency virus: no evidence of increased toxicity

There are very few reported cases of laryngeal squamous cell carcinoma (SCC) in patients with a background of human immunodeficiency virus (HIV) infection. We report a case of a 42-year-old man who developed a T2 N0 left vocal cord well differentiated SCC with an 11 year history of HIV infection. He successfully completed a course of radical radiotherapy 66 Gy in 33 fractions over 47 days. During his treatment he experienced only a grade 1 Radiation Therapy Oncology Group (RTOG) acute toxicity reaction to the larynx and no weight loss. At 32 months follow up he remains disease free and has no significant late morbidity. Prior to his radiotherapy his CD4 count was 350 cells mm(-3); we discuss the view that the treatment chosen needs to be individually tailored with respect to the patient's immune status.

BKV-DNA and JCV-DNA in CSF of patients with suspected meningitis or encephalitis

BACKGROUND

Few studies have looked for the polyoma viruses JC or BK virus in the central nervous system (CNS) of patients without neurological symptoms or with neurological symptoms other than progressive multifocal leukoencephalopathy (PML). PCR-microplate hybridization method was employed for the detection of BKV-DNA or JCV-DNA in cerebrospinal fluid (CSF) specimens from patients with suspected meningitis or encephalitis.

MATERIALS AND METHODS

A total of 181 CSF specimens from 151 patients with suspected meningitis or encephalitis was examined for BKV or JCV using PCR-microplate hybridization method. None of the patients had (clinically diagnosed) PML. A control group consisting of 20 CSF specimens from normal subject was also included.

RESULTS

BKV DNA was found in five out of 131 (3.8%) and JCV DNA in two out of 131 (1.5%) of the patients with suspected meningitis or encephalitis by PCR ELISA. BKV or JCV DNA was not detected in CSF samples of any of 19 HIV positive patients. BKV and JCV DNAs were detected respectively in two CSF samples in which Mycobacterium tuberculosis (TB) PCR was also positive. Another patient who was positive for JCV PCR died with a diagnosis of cerebral lymphoma. Among the BK virus infected patients there was a patient with a previous history of hemolytic uremia and acute renal failure. Neither BKV nor JCV DNA was found in any of the 20 CSF samples from normal patients undergoing lumbar puncture for myelography as a part of an investigation of lower back pain.

CONCLUSION

These results suggest that BK virus may be associated with neurological diseases either in immunocompetent or immunocompromised patients. Detection of BKV and JCV DNA in the CSF of the patients suspected to have either meningitis or encephalitis suggests that these viruses may have an etiological role. Thus, diagnostic tests for BK and JC viruses should be included in the investigative program for meningitis or encephalitis patients.

The development of cytomegalovirus-induced adrenal failure in a patient with AIDS while receiving corticosteroid therapy

We report a case of Addisonian crisis due to cytomegalovirus (CMV) adrenalitis occurring in a patient with AIDS while receiving supraphysiological doses of steroids for the treatment of Pneumocystis carinii pneumonia. The case highlights the importance of considering the diagnosis of adrenal failure in AIDS, even in patients receiving supraphysiological doses of steroids.

TB PCR in the early diagnosis of tuberculous meningitis: evaluation of the Roche semi-automated COBAS Amplicor MTB test with reference to the manual Amplicor MTB PCR test

SETTING

Cecilia Makiwane Hospital, Mdantsane, Eastern Cape, Republic of South Africa.

OBJECTIVE

To assess the role of the semi-automated Roche COBAS AMPLICOR(TM)Mycobacterium tuberculosis PCR test in the diagnosis of tuberculous meningitis (TBM).

DESIGN

Eighty-three specimens of cerebrospinal fluid (CSF) were collected prospectively from 69 patients with suspected TBM. The COBAS AMPLICOR TB PCR test was compared with the manual AMPLICOR(TM)TB PCR test, clinical and cerebrospinal fluid (CSF) findings, direct ZN smear and radiometric TB culture.

RESULTS

CSF from 7/40 (17.5%) patients treated for TBM were positive by TB COBAS AMPLICOR(TM). The sensitivity of the test was not significantly different (p=0.375) from the manual TB AMPLICOR(TM)PCR test. The comparative sensitivities of the TB COBAS AMPLICOR(TM)PCR and the manual AMPLICOR PCR for detecting cases of definite and probable TBM from CSF collected within 9 days of commencing antituberculosis treatment were 40% and 60% respectively. All 29 patients not treated for TBM were negative by COBAS AMPLICOR(TM), giving a specificity of 100%.

CONCLUSION

The COBAS AMPLICOR(TM)TB PCR test is a rapid and highly specific diagnostic test for TBM. However, there was a non-significant trend favouring slightly greater sensitivity using the manual AMPLICOR(TM)TB PCR test.

Use of Roche AMPLICOR Mycobacterium tuberculosis PCR in early diagnosis of tuberculous meningitis

Several nucleic acid-based amplification tests are available for the detection of Mycobacterium tuberculosis, but few data are available on their use in the diagnosis of tuberculous meningitis (TBM). We performed a prospective study to assess the Roche AMPLICOR Mycobacterium tuberculosis PCR test (TB AMPLICOR) for use in the diagnosis of TBM and compared it with direct Ziehl-Neelsen staining of smears, radiometric culture for M. tuberculosis, and clinical and cerebrospinal fluid (CSF) findings. Eighty-three CSF specimens collected from 69 patients with suspected meningitis in South Africa were tested by TB AMPLICOR. On the basis of clinical and laboratory findings, 40 of these patients were treated for TBM and 29 patients were not treated for TBM. Ten CSF samples from 10 patients were positive by TB AMPLICOR. Seven of these 10 patients were classified as having definite TBM, 2 were classified as having probable TBM, and 1 was classified as having possible TBM. The sensitivity of TB AMPLICOR for detecting cases of definite and probable TBM in patients from whom CSF specimens had been collected less than 10 days into antituberculosis treatment was 60.0%. Specimens from all 29 patients not treated for TBM were negative by the TB AMPLICOR, giving a 100% specificity. TB AMPLICOR is therefore more sensitive than the combination of Ziehl-Neelsen staining of smears and radiometric culture for M. tuberculosis and is a rapid and highly specific diagnostic test for TBM.

HIV-testing study of immigrants with pulmonary tuberculosis

The increasing prevalence of tuberculosis (TB) and human immunodeficiency virus (HIV), particularly in Africa and Asia, led us to investigate the prevalence of HIV infection in immigrants with pulmonary TB at the time of arrival in the UK. We performed anonymous HIV testing of stored sera from 39/65 immigrants referred to our unit between January 1991 and December 1994, who had culture-positive pulmonary TB. None of the 39 patients tested was positive for either HIV-1 or HIV-2, and the characteristics of the 26 patients for whom no serum was available were similar to those of the tested group. Despite the need to consider concomitant HIV infection in any patient with TB, particularly those from an area of HIV endemnicity, the present data do not suggest that recently arrived refugees, asylum seekers, immigrants or long-term visitors to the UK constitute a group in whom dual infection of HIV and Mycobacterium tuberculosis is common.

A histological and histochemical study of the cricopharyngeus muscle in man

The human cricopharyngeus muscle was investigated by dissection and by histological, histochemical and morphometric methods. Muscle fibres in the cricopharyngeus were found to be similar in appearance to those of the lateral part of the quadriceps femoris, although they were generally much smaller and more variable in size. The endomysial connective tissue was markedly increased in the cricopharyngeus and muscle spindles were not found. Certain features normally considered to be pathological were also noted in the cricopharyngeus muscles. The fibre type population consisted mainly of histochemically 'slow-twitch' richly oxidative fibres. This finding is consistent with the proposed function of this muscle in its sphincteric role in deglutition, vomiting, eructation and in the control of aerophagia.

A histological and histochemical study of the cricopharyngeus muscle in the guinea-pig

Histological, histochemical and morphometric methods were used to investigate the cricopharyngeus muscle in the guinea-pig and to compare it with the extensor digitorum longus and soleus muscles. The cricopharyngeus comprised uniformly small diameter fibres otherwise similar in appearance to those found in skeletal limb muscles. Several fibre type profiles were distinguished within the cricopharyngeus, all of which had homogeneously high oxidative activity, whilst the majority were histochemically fast (Type II). Muscle spindles were not observed in the cricopharyngeus muscles. Compared to the surrounding musculature the cricopharyngeus has a higher oxidative activity and may thus be suitably adapted for the maintenance of tonic contraction, forming a part of the upper oesophageal sphincter.