Oral trimethoprim-sulfamethoxazole in the treatment of cerebral toxoplasmosis in AIDS patients--a prospective study

Toxoplasma encephalitis is the commonest cause of intracranial mass lesions in AIDS patients. Effective therapy includes pyrimethamine plus sulfadiazine, clindamycin with pyrimethamine, and co-trimoxazole. This study examines the efficacy of oral co-trimoxazole in 20 AIDS patients with toxoplasmosis and seeks to confirm the experience of Torre et al.

Spectrum of myelopathies in HIV seropositive South African patients

The authors determined the cause of myelopathies in 33 HIV seropositive individuals in KwaZulu/Natal, South Africa. The main associations were with human T-cell lymphotrophic virus-I, tuberculosis, herpes zoster, and syphilis. A novel association with probable bilharziasis was noted. Only one case of vacuolar myelopathy was identified. Opportunistic infections will probably persist until routine antiretroviral therapy becomes widely available in South Africa.

Sequence of the env gene of some KwaZulu-Natal, South African strains of HTLV type I

Phylogenetic analysis of HTLV-I suggests three main subtypes, namely, cosmopolitan, Central African, and Australo-Melanesian. HTLV-I is endemic in KwaZulu-Natal, South Africa. However, sequence data on the local strains are limited to the LTR region. The env gene of the local strain was amplified and sequenced from the peripheral blood of five seropositive individuals. Four had HTLV-I-associated myelopathy and one had infective eczema. The sequence analysis of the env gene showed a greater then 99% homology of the local strains. They were closely related to the North American strains (99.3%), followed by the Japanese strains (98.3-98.9%). Phylogenetic studies linked the local strains to the cosmopolitan subtype. This study provides new sequence data on the env gene of the local HTLV-I strain.

Multiple sclerosis in black South Africans and Zimbabweans

Multiple sclerosis is rare among the indigenous black people of Africa. The first account of a black patient with multiple sclerosis in South Africa was published as late as 1987. Since then a search to find black patients with multiple sclerosis in Southern Africa has continued. Seven black patients have now been traced in South Africa and five in Zimbabwe in whom a diagnosis of multiple sclerosis can be accepted. Six of the 12 patients became blind, or nearly so, from severe optic neuritis. Multiple sclerosis in these few black patients more often resembled the disorder as it occurs in oriental people than among white people in southern Africa or the black people of North America or the Caribbean.

Electroencephalogram and computerised cerebral tomography findings in eclampsia

OBJECTIVE

To define more clearly the neuropathophysiology of eclampsia.

DESIGN

A prospective study relating to computerised cerebral tomography (CAT) scan and electroencephalogram (EEG) findings in eclampsia.

SETTING

A large referral centre in a developing society.

SUBJECTS

Thirty-two women with eclampsia.

MAIN OUTCOME MEASURES

Abnormalities in EEG and CAT scan findings.

RESULTS

Approximately 45% of the women studied had CAT scan abnormalities, while 90% had EEG abnormalities. A burst suppression pattern on EEG examination was found in four women suggesting a temporary dissolution of cerebral function to the midbrain level as the cause of seizures.

CONCLUSIONS

EEGs are probably more sensitive than CAT scans in detecting the extent of the pathology in the brain in women with eclampsia.

Prevalence and transmission of HTLV-I infection in Natal/KwaZulu

A community-based seroprevalence survey for human T-cell lymphotropic virus type I (HTLV-I) was undertaken in the Ngwelezane district of Natal/KwaZulu. A total of 1,018 individuals was interviewed for risk factors and had blood drawn for serological examination. To exclude antibody cross-reactivity between anti-HTLV-I and anti-HTLV-II all Western blot HTLV-I-positive samples were further subjected to a Select HTLV test. For comparison, anonymous HIV testing was done. The areas of residence of patients with myelopathy associated with HTLV-I were also ascertained. The seroprevalence of HTLV-I was 2.6% (95% confidence interval (CI) 1.62-3.58). An age-related rise in HTLV-I seropositivity from 1.3% in the 15-24-year age group to 6.1% in the over 55-year-old group was noted. There was no significant association between HTLV-I antibody positivity and marital status, occupation, history of blood transfusion, scarification, age at first sexual experience and number of sexual partners. Anti-HIV-1 antibody testing revealed a positivity of 3.5% (95% CI 2.4-4.68) and the relative risk for co-infection with both HTLV-I and HIV-1 in the 15-24-year group was 1.16 (95% CI 1.08-1.24). The study also identified the first HTLV-II-seropositive case in the Natal/KwaZulu region. Up to December 1991, 90 cases of HTLV-I-associated myelopathy/tropical spastic paraparesis were seen at the Neurology Unit, Wentworth Hospital. The patients came from all parts of Natal, from Pongola in the north to Transkei in the south. The Natal/KwaZulu region is, therefore, an endemic HTLV-I area.

Peripheral nerve lesions in HTLV-I associated myelopathy (HAM/TSP)

Peripheral nerve dysfunction (PND) was found in as many as 43% of our patients with human T-cell lymphotropic virus type I (HTLV-I)-associated myelopathy (HAM/TSP). To evaluate the PND further we biopsied the sural nerve in 6 patients. The histological features were varying degrees of demyelination, remyelination, axonal atrophy and degeneration, and perineurial fibrosis. "Globule" or "sausage" formation was prominent in two of the specimens. Inflammatory infiltrates were absent. No deposits of IgG, IgM, IgA, or complement were detected in the biopsies. No viral antigen or proviral DNA was detected. It is proposed that the PND and the histological findings noted are part of HTLV-I-associated disease and not an unrelated disorder. The pathogenesis of the PND remains unclear. There was no evidence of direct viral infection. The histological findings could represent primary changes induced by viral-triggered release of soluble factors, such as cytokines or secondary changes to more proximal disease, e.g., root involvement.

The clinicoradiological profile of cerebral venous thrombosis

The clinical presentation, diagnostic and radiological aspects and the probable aetiology in 20 consecutively studied patients with cerebral venous thrombosis (CVT) are described. In this retrospective analysis patients were evaluated extensively according to a stroke investigative protocol. Computed tomography signs for CVT may be identified in the majority of cases and frequently obviate the need for angiography. In those patients in whom no satisfactory precipitating factor was recognised further haematological tests revealed abnormalities that are known causes of thrombosis in 7 patients. Eighty-five per cent of the patients made an excellent recovery. It is concluded that CVT can often be diagnosed non-invasively, the presumptive cause can be found in the majority of patients and the prognosis is excellent.

The environmental dependency syndrome, imitation behaviour and utilisation behaviour as presenting symptoms of bilateral frontal lobe infarction due to moyamoya disease

The environmental dependency syndrome, imitation behaviour and utilisation behaviour may be the earliest and most subtle signs of bifrontal lobe dysfunction. A case is described in which these signs constituted the predominant deficits. The lesions responsible were bifrontal infarcts caused by moyamoya disease. The patient made an excellent recovery.

HTLV-I-associated myelopathy: clinicopathologic correlation with localization of provirus to spinal cord

A 49-year-old South African man developed a rapidly progressive myelopathy 14 months after blood transfusion and died 1 year after the onset of symptoms. Detailed pathologic examination of the spinal cord was consistent with the diagnosis of HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP). Although no HTLV-I viral particles, antigens, or nucleic acids were detected in situ, polymerase chain reaction assays revealed HTLV-I proviral DNA in cervical, thoracic, and lumbar levels of the spinal cord, with the greatest amount being detected at the thoracic level. These findings suggest that the pathogenesis of HAM/TSP depends on direct infection of neural or immune elements within the spinal cord.

Spinal cord schistosomiasis. A clinical, laboratory and radiological study, with a note on therapeutic aspects

Fourteen patients with schistosomiasis of the spinal cord are described. They fall into two groups: 7 patients had clinical and computer-assisted myelographic evidence of lesions in the conus medullaris or cauda equina, or both. The clinical picture in the remaining 7 patients was usually that of acute or subacute transverse myelitis with normal or equivocal CT myelographic appearances. Granulomas containing bilharzial ova were found in 2 female patients with conus swelling subjected to laminectomy and biopsy. In 1 of these the ova were identified as S. haematobium while in the second, unidentified bilharzial ova were found. A presumptive diagnosis of spinal cord schistosomiasis was made in the remaining 12 patients based on characteristic clinical and investigative profiles. All 13 patients tested showed evidence of bilharzial infection based on positive blood serology or the detection of bilharzial ova, or both. All but 1 patient showed at least one of the following abnormalities on CSF examination: pleocytosis, an elevated protein content and as indicated by the presence of oligoclonal IgG bands, an elevated IgG index and an increased CSF IgG synthesis rate. A CSF bilharzia enzyme-linked immunosorbent assay (ELISA) test, developed to indicate the presence of schistosomal infection within the theca, was found to be sensitive although not entirely specific for the diagnosis of spinal cord schistosomiasis. Eleven of the 14 patients showed rapid clinical improvement, 8 after praziquantel and corticosteroid treatment, 2 after operation and 1 spontaneously. Significant reductions in the CSF cell count, protein concentration and bilharzia ELISA titre, and in intrathecal antibody production, occurred following praziquantel and corticosteroid therapy. The CSF sugar level showed a significant rise. A reduction in conus size was observed in 3 patients when CT myelography was repeated after medical therapy. The normalization of most of the laboratory parameters after combined medical treatment with praziquantel and corticosteroids, together with clinical and radiological improvement, strengthened the presumptive diagnosis of cord schistosomiasis and supports the policy of early intensive medical treatment (as opposed to surgical therapy) for this condition when diagnosed on indirect evidence.

The value of immunological approaches to the diagnosis of schistosomal myelopathy

Myelopathy due to schistosome infection is a rare, yet probably frequently unrecognized, form of schistosomiasis. This condition is clinically difficult to diagnose, and without specific biopsy evidence final confirmation relies largely on circumstantial evidence. We describe here immunological attempts to diagnose schistosomal myelopathy. ELISA performed on the cerebrospinal fluid (CSF) was the most successful, detecting 12/12 cases tested prior to or within one month of treatment. This is based on a "normal" value established on neurological patients without myelopathy. Only 13/149 non-schistosomal myelopathy patients from an endemic area gave positive results in this test. Oligoclonal bands were detected in the CSF of 5/9 schistosomal myelopathy patients and 11/18 cases of myelopathy of other known causes, but in 0/7 cases of myelopathy where the cause was not established. Western blotting was unable to distinguish between myelopathy due to schistosomiasis and other causes. It is recommended that the ELISA be performed on CSF and the results be compared with a "normal" level for neurological patients. In our laboratory this system gives a high sensitivity and a negative result can be confidently used to exclude schistosomal myelopathy.

Sialidosis type I: first report in the Indian population. A clinical, biochemical and electrophysiological study

Sialidosis type I has been described in several ethnic groups but to the best of our knowledge has not been reported in Indian families. We report on the clinical, biochemical and electrophysiological features in three siblings born to parents of South Indian origin. The diagnosis was missed for two years as they were labelled as cases of Ramsay-Hunt Syndrome.

Myelopathy associated with human T cell lymphotropic virus type I (HTLV-I) in natal, South Africa. A clinical and investigative study in 24 patients

Unexplained spastic myelopathy in black (Zulu) patients, similar to that seen in the tropics, has previously been described from Natal, South Africa. Following reports linking the human T cell lymphotropic virus type I (HTLV-I) to spastic myelopathy, we undertook a prospective and retrospective search for HTLV-I antibodies in 36 patients who were labelled as having unexplained myelopathy; 24 (66%) were positive and HTLV-I was isolated from 4 out of the 6 patients whose peripheral blood lymphocytes were cultured. Eighteen (75%) gave a short history (less than 6 months). There was a female preponderance (71%), spinothalamic dysfunction was common (55%) and as many as half were severely disabled (50% wheelchair bound). Routine laboratory studies showed no specific trends apart from hypergammaglobulinaemia and CSF pleocytosis (greater than 5 cells/microliter in 66% of patients). The total CSF protein was raised (greater than 0.4 g/l) in 45% of patients. The IgG index was greater than 0.7 in 15 of 19 patients. Conventional myelography did not show any specific abnormalities. Computer assisted myelography was undertaken in 22 patients; 3 showed arachnoiditis and 2 spinal cord atrophy. Periventricular lucencies were seen in 1 of 10 patients who had computed tomography of the head. Nerve conduction studies demonstrated abnormalities in 46% of the patients indicating that subclinical peripheral nerve dysfunction was common. Visual evoked responses were abnormal in only 1 patient but brainstem auditory evoked response studies showed some abnormality in 42% of the patients. The finding of HTLV-I antibodies in a significant number, and the isolation of HTLV-I from the blood in 6 of our black patients with noncompressive myelopathy, represents a substantial clinical advance. Future studies should define more clearly the role of the virus in this disorder.

Motor neuron disease in blacks. Epidemiological observations in Natal

A series of 86 black, Indian and white patients with motor neuron disease were analysed retrospectively. Although the material does not allow statistically valid conclusions, there are sufficient cases among blacks to allow two prima facie observations in this population group: (i) motor neuron disease has an earlier age of onset than in whites and Indians; and (ii) more patients come from peripheral and rural areas than would be expected in prevailing circumstances.

Phenytoin auto-induction? Case reports

Auto-induction of phenytoin metabolism is considered by many to be insignificant. Two cases, in which elimination of phenytoin apparently increased with continuous use, are presented. The first patient showed an increase in elimination capacity (Vmax) from 511 mg/d to 613 mg/d over a period of 5 months. The second patient showed an increase in Vmax from 512 mg/d to 570 mg/d over a period of 1 year. In neither case was compliance in question. The recognition that therapeutic failure may be due to enzyme induction could obviate expensive diagnostic procedures as well as narrow down the therapeutic alternatives.

Parkinson's disease in blacks. Observations on epidemiology in Natal

Black patients with idiopathic Parkinson's disease (PD) present for neurological consultation much less frequently than white or Indian patients. That this is due to true rarity of PD among blacks is suggested by the observation that blacks with motor neuron disease and secondary parkinsonism are treated in numbers comparable with whites and Indians. These conclusions are derived from a series of 2,638 inpatient neurological consultations and from data on levodopa usage in three major hospitals in Durban. Lower life expectancy and failure of old people to attend hospital may be factors in the apparent low prevalence of PD among blacks, but other undetermined factors must play a part.

Operculum syndrome from brain abscess in a left-hander

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Palmoplantar keratoderma with amyotrophy

Four members of a South African Black family who have palmoplantar keratoderma with amyotrophy are reported. No neuromuscular defects have been found and the muscle thinning appears to result from disuse atrophy. Volar hyperhidrosis, nail abnormalities and in 2 cases knuckle pads, were additional features. The condition appears to be inherited as an autosomal dominant trait. We are not aware of a similar syndrome having been previously reported.

Ulcerative colitis and interstitial myositis

Amongst the protean extra-intestinal manifestations of inflammatory bowel disease, scant mention is made of muscle involvement. This report outlines the clinical features, electrodiagnostic and muscle biopsy findings in a patient with ulcerative colitis who developed progressive proximal muscle weakness. The demonstration of interstitial myositis is discussed in relation to his underlying disease.

Congenital clubfoot: an electromyographic study

Twenty-five patients with congenital idiopathic clubfoot, aged 1 day to 22 months, were studied electromyographically. No myopathic or neurogenic changes were found in tibialis anterior, peroneus, gastrocnemius, extensor digitorum brevis, and abductor hallucis brevis muscles of the leg and foot. Maximum motor nerve conduction velocities for the peroneal and tibial nerves were normal. It is concluded that conventional electromyographic techniques were unable to demonstrate abnormalities suggesting neuropathic or myopathic changes in idiopathic clubfoot.

Centronuclear myopathy

Centronuclear myopathy occurring sporadically in two African female children is reported, with details of clinical history and histological, histochemical, and ultrastructural findings, and a review of 58 previously reported cases. In spite of distinctive histological features, the clinical presentation of this condition is variable, there are different modes of inheritance, and the pathogenesis remains unclear.

Duchenne's dystrophy associated with unusual musculoskeletal abnormalities. A case report

A case of Duchenne's pseudohypertrophic muscular dystrophy allied with previously unreported musculoskeletal abnormalities is reported. Some of the more characteristic features of Duchenne's dystrophy are reviewed from the literature.

Infantile apnoea due to profound hypocalcaemia associated with vitamin D deficiency. A case report

In this report a 7-week-old infant with stage 1 rickets, profound hypocalcaemia and recurrent apnoea is described. The patient responded initially to calcium supplementation, and subsequently to therapy with vitamin D.

Lumbar puncture--an innocuous diagnostic procedure?

The correct technique and indications for lumbar puncture are described. Possible and probable complications are discussed. The need for early recognition and consultation when complications arise is emphasized.

The diagnosis and significance of isolated third nerve palsy in the African

The clinical spectrum of forty-one cases of isolated third nerve palsy in the African (Negro) population is presented. A high proportion (58%) was due to cerebral aneurysm. Other causes were syphilis (15.5%) diabetes mellitus (11%), and ophthalmoplegic migraine (11%). It is evident from this study that, contrary to accepted thinking on this subject, there are no clinical features which reliably distinguish between these groups. Early cerebral angiography is therefore mandatory.

Carbohydrate metabolism in motor neurone disease

Eight patients with classical motor neurone disease, and eight control patients with neurological disease and matched for degree of wasting, were studied. Both groups had abnormal glucose tolerance, but the patients with motor neurone disease had a significantly lower insulin response both to oral glucose loading and to intravenous tolbutamide. These results suggest that in patients with motor neurone disease there is an impaired synthesis or release of insulin due to islet cell damage. Blood pyruvate and lactate, and cerebrospinal fluid pyruvate, lactate, and citrate, did not differ significantly from the control group. Blood citrate levels were significantly higher in patients with motor neurone disease compared with the controls. Triglyceride levels were raised in patients with motor neurone disease compared to the control patients. This may be secondary to the increased citrate levels.

Acute myopathy in three brothers

Three brothers are reported who presented simultaneously with acute myopathy, which resolved rapidly. Muscle biopsy showed vacuolar degeneration, with no inflammatory changes. An echo virus was grown from the stools of two of them. Their course, together with that of a fourth brother, who had an acute illness with rash, lymphadenopathy and splenomegaly, suggests a possible viral aetiology.