Microbiological profile and infection potential of different cryopreserved skull flaps after decompressive hemicraniectomy. Is cryopreservation at - 80 ℃ better?

OBJECTIVE

Patterns of cryopreservation of explanted skull bone flaps have long been a matter of debate, in particular the appropriate temperature of storage. To the best of our knowledge no study to date has compared the microbiological profile and the infection potential of skull bone flaps cryostored at the same institution at disparate degrees for neurosurgical purposes. In the context of our clinical trial DRKS00023283, we performed a bacterial culture of explanted skull bone flaps, which were cryopreserved lege artis at a temperature of either - 23 °C or - 80 °C after a decompressive hemicraniectomy. In a further step, we contaminated the bone fragments in a s uspension with specific pathogens (S. aureus, S. epidermidis and C. acnes, Colony forming unit CFU 103/ml) over 24 h and conducted a second culture.

RESULTS

A total of 17 cryopreserved skull flaps (8: - 23 °C; 9: - 80 °C) explanted during decompressive hemicraniectomies performed between 2019 and 2020 as well as 2 computer-aided-designed skulls (1 vancomycin-soaked) were analyzed. Median duration of cryopreservation was 10.5 months (2-17 months). No microorganisms were detected at the normal bacterial culture. After active contamination of our skull flaps, all samples showed similar bacterial growth of above-mentioned pathogens; thus, our study did not reveal an influence of the storage temperature upon infectious dynamic of the skulls.

Indirect comparison of efficacy between different antibiotic prophylaxis against the intracranial infection after craniotomy

BACKGROUND

Many studies had shown that prophylactic use of antibiotics could significantly reduce the intracranial infection (ICI) rate of craniotomy. However, there has been no comparison of these antibiotics.

METHODS

An electronic database search was performed, from inception to June 102,020. Randomized controlled trials (RCT) using different intravenous antibiotics (IVA) against the ICIs after craniotomy were considered. The primary outcome was the incidence rates of ICIs. An indirect treatment comparison (ITC) was conducted to compare the protective effect among the diverse antibiotic prophylaxis to prevent ICIs after craniotomy. Risk of potential bias was assessed.

RESULTS

A total of 3214 patients after craniotomy in 11 studies were included, 159 patients experienced postoperative ICI, including 33 patients in the antibacterial group and 126 in the control group. The calculate results of meta-analysis showed that except fusidic acid, preoperative intravenous injection of cephalosporin, clindamycin, vancomycin, and penicillin can significantly reduce the incidence of ICI after craniotomy, and ITC showed there was no statistically significance difference in the rates of post craniotomy ICI between the various antibiotics.

CONCLUSION

The current evidence shows that low-grade antibacterial drugs can be selected to prevent ICI after craniotomy, but this may be due to the limited number of studies per antibiotic. It still needs more high-quality, large sample RCT to confirm.

SYSTEMIC REVIEW REGISTRATION

PROSPERO CRD42019133369.

Intrathecal or intraventricular antimicrobial therapy for post-neurosurgical intracranial infection due to multidrug-resistant and extensively drug-resistant Gram-negative bacteria: A systematic review and meta-analysis

This review investigated the effectiveness and safety of intrathecal (ITH) or intraventricular (IVT) antimicrobial therapy for post-neurosurgical intracranial infection due to multidrug-resistant (MDR) and extensively drug-resistant (XDR) Gram-negative bacteria. Electronic databases including PubMed, EMBASE and the Cochrane Library databases were searched for clinical studies that compared the addition of ITH/IVT therapy with intravenous (IV) monotherapy in the treatment of post-neurosurgical intracranial infection due to MDR/XDR Gram-negative bacteria. Eligible articles were analysed using Stata/SE software v.12.0. Publication bias was assessed using Begg's funnel plot and Egger's test. Nine studies involving 296 patients were included. The odds ratio (OR) for death (IV+ITH/IVT versus IV) reported in the included studies ranged from 0.02-0.93. The overall pooled OR was 0.15 [95% confidence interval (CI) 0.08-0.28; P < 0.001] and the risk of mortality was significantly different between the two groups. Microbiological clearance was significantly different between the two groups, with a pooled OR of 0.02 (95% CI 0.01-0.10; P < 0.001). In observational studies, addition of ITH/IVT antimicrobial therapy is associated with a lower risk of mortality and a higher microbiological clearance rate, with mild adverse effects, in patients with post-neurosurgical intracranial infection due to MDR/XDR Gram-negative bacteria. A well-designed randomised controlled trial is necessary to address this important issue.

Successful voriconazole treatment of Talaromyces marneffei infection in an HIV-negative patient with osteolytic lesions

Talaromyces marneffei (T. marneffei) is a dimorphic fungus that causes systemic infection in immunocompromised patients. Here, we present a case of T. marneffei infection in an immunocompetent patient with an osteolytic lesion. Diagnosis was established by fungal culture. The patient responded rapidly to intravenous voriconazole, followed by oral voriconazole. We reviewed 18 reported cases of T. marneffei infection with osteolytic lesions, which suggests a much higher rate of osteolytic lesions in immunocompetent patients than previously thought.

[Injury by skull osteolytic secundary syphilis]

Bone involvement of syphilis can be observed in tertiary and congenital syphilis. It is infrequent during the secondary stage. The skull is the most affected bone in secondary syphilis, and its most frequent form of presentation is proliferative osteitis. If the skull is affected, headache is usual and can be as intense as in meningitis. Osteolyitic lesions may be seen in complimentary imaging studies, with a moth eaten aspect. These lesions raise concern over a number of differential diagnoses, among which are infectious, inflammatory and neoplastic diseases. The definitive diagnosis is made by bone biopsy of the compromised bone. Molecular techniques in the affected tissues increases diagnostic performance. There is no standardized treatment protocol for syphilis since there are no guidelines available. We report a case of a 19 year old female, presenting with a unique osteolytic lesion in the skull due to secondary syphilis.

Inhibitory effect of 1,25-dihydroxyvitamin D3 on Porphyromonas gingivalis-induced inflammation and bone resorption in vivo

OBJECTIVE

To investigate whether intragastric administration of 1,25-dihydroxyvitamin D₃ (1,25(OH)₂D₃) could inhibit the bone resorption and inflammation in a mouse calvarial model infected by Porphyromonas gingivalis (P. gingivalis).

DESIGN

Live P. gingivalis ATCC 33277 was injected once daily for 6days into the subcutaneous tissue overlying the calvaria in mice. At the same time, 1,25(OH)₂D₃ (50μg/kg per day) was administered by gavage for 9days, starting 3d before the infection. Mice were killed under ether anesthesia 8h after the last injection of P. gingivalis. Micro-computed tomography scanning was used to evaluate calvarial bone loss. Tartrate-resistant acid phosphatase was used to detect osteoclast activity. Real-time PCR was used to assess the mRNA expressions of OPG, RANKL, c-Fos, NFATc1, CTSK and TRAP in calvarial bone and IL-6, IL-10, IL-1β, IL-12p40 and TNF-α in soft tissue. The levels of serum IL-6, IL-10 were determined by ELISA.

RESULTS

1,25(OH)₂D₃ treatment apparently attenuated bone resorption in P. gingivalis-induced mouse calvarial model and markedly reduced the number of osteoclasts. The expression levels of RANKL and osteoclast-related genes such as c-Fos, NFATc1, CTSK and TRAP were also decreased by 1,25(OH)₂D₃. Besides, 1,25(OH)₂D₃ inhibited the expression of pro-inflammatory cytokines IL-6, IL-12p40 and TNF-α and enormously elevated the expression of anti-inflammatory cytokine IL-10.

CONCLUSION

1,25(OH)₂D₃ may decrease bone resorption in vivo via suppressing the expression of osteoclast-related genes and its anti-inflammatory properties.

[COMPUTED TOMOGRAPHIC EXAMINATION OF CRANIAL LESIONS, A PALEORADIOLOGICAL APPROACH]

BACKGROUND AND PURPOSE

Introducing the multidisciplinary paleoradiology research at the Institute of Diagnostic Imaging and Radiation Oncology of the Kaposvár University, highlighting the cases with potential central nervous system involvement--from the scanning methods to the 3D printing--in order to draw attention to the historical background and clinical aspects of certain pathological conditions.

METHODS

The authors developed the examination protocols for three different CT scanners. Among the examined archaeological remains cranial lesions were identified in 26 cases, from which 4 cases with potential central nervous system involvement are demonstrated. The scanning parameters and the advantages of secondary image reconstructions (multiplanar reconstruction, maximum intensity projection, three-dimensional volume rendering technique) are presented with the cases.

RESULTS

The authors demonstrate a case with destructive skull lesions due to syphilis from the 15th century AD, a condition rarely seen or even unknown nowadays in the modern world. With the CT images of the skull base fracture from the Iron Age, signs of healing could be verified. Using the CT images a non-invasive approach is presented in the case of the craniofacial osteosarcoma in order to visualize the local status and the direct intracranial propagation. Advantages of the 3D VRT reconstructions are shown in the case of unilateral coronal suture synostosis.

CONCLUSION

Paleoradiological CT examinations serve as a non-invasive, non-destructive tool for studying archaeological remains and artifacts. The special applications provided by the imaging modality contribute to the conventional paleopathological investigations.

Propionibacterium Acnes Infections After Cranial Neurosurgery

Background:

Propionibacterium acnes (P. acnes) is a relatively avirulent organism that is part of the normal skin flora. Most patient isolates are considered contaminants but, in a small subset of patients, particularly in the post-neurosurgery setting, the organism can cause significant infections. We reviewed our experience with the occurrence and management of P. acnes infections after cranial neurosurgical procedures over a five-year period.

Methods:

Patients with positive cultures for P. acnes between 1996 and 2001 were identified by review of the Saskatoon Health Region microbiology laboratory database. Of the 141 positive cultures, a review of hospital records identified six patients with P. acnes infections after neurosurgical procedures. A review of the literature related to P. acnes associated CNS infections was conducted.

Results:

All patients had undergone a craniotomy or burrhole placement, and one patient had received prior radiotherapy. There were no P. acnes-related ventriculoperitoneal shunt infections. All patients presented with scalp swelling and three had purulent discharge. Symptoms occurred more than two months after the initial surgery in five of six patients, while one patient developed symptoms three years post-operatively. Management for all patients included removal of the craniotomy flap and treatment with parenteral antibiotics, followed in most cases by oral antibiotics. A good response without relapse of infection was seen in five patients; one patient had recurrent infection after cranioplasty.

Conclusion:

P. acnes is a rare but important cause of infection after craniotomy. Wound debridement, removal of the bone flap and adequate antibiotic coverage result in cure in the majority of patients.

Actinomycotic osteomyelitis of the cranial vault presenting with headache: an unusual presentation

A case of left parietal calvarial actinomycotic osteomyelitis in a young woman is described. She had no predisposing illnesses. She had delivered a live child at term and presented in the puerperal period. No extracranial focus of infection was identified. She responded well to a combination of surgery and medical therapy and had an excellent outcome. The authors emphasise the importance of establishing a histopathological diagnosis since radiological signs are non-specific and unreliable.

A rare case of primary tuberculous osteomyelitis of skull vault

In recent years, there has been a substantial increase in number of reports involving uncommon sites involving in tuberculosis. Rise in number of HIV positive patients has made the scenario worse. Calvarial tuberculosis has beenreported very rarely in world literature till now. We are reporting a case of primary tuberculous osteomyelitis of frontal bone in a 15-year-old female. With prompt as well as careful diagnostic workup and treatment, we were able to halt the disease progression and excellent response to treatment was observed in follow up.

Tuberculous osteomyelitis of the bone flap following craniotomy

A patient of tuberculous osteomyelitis of the bone flap following craniotomy for acute subdural hemorrhage which was treated at Surat Municipal Institute of Medical Education & Research (SMIMER) from June 2010 has been reported. This report emphasizes the fact that while treating osteomyelitis of bone flap following craniotomy, possibility of tuberculosis should be considered, especially in our country. Treatment wise, the disease responded readily to routine anti-tubercular chemotherapy.

Septicemia, meningitis, and skull osteomyelitis complicating infected cephalhematoma caused by ESBL-producing Escherichia coli

An infected cephalhematoma is a rare condition in neonates. We report a case of an 18-day-old neonate who was diagnosed with an infected cephalhematoma caused by an extended spectrum beta-lactamase (ESBL)-producing Escherichia coli complicated with septicemia, meningitis, and skull osteomyelitis. He was successfully treated with meropenem and surgical incision and drainage. ESBL-producing E. coli may cause infection of a cephalhematoma in neonates.

Calvarial tuberculosis: an unusual presentation (2007: 8b)

We describe a case of calvarial tuberculosis with an associated extra-dural collection. This presentation has rarely been reported in the literature and the magnetic resonance imaging features are not well documented.

Craniovertebral tuberculosis: a retrospective review of 13 cases managed conservatively

STUDY DESIGN

Retrospective review of 13 cases with craniovertebral tuberculosis treated conservatively.

OBJECTIVE

To evaluate the results of conservative treatment of craniovertebral tuberculosis and compare with the literature.

SUMMARY OF BACKGROUND DATA

Craniovertebral tuberculosis is a rare entity even in endemic countries, and there is no consensus in the literature regarding conservative or surgical management for the same. Reports range from radical surgery to totally conservative approach. We report our experience in treating such patients conservatively.

METHODS

A retrospective review of 13 patients diagnosed with craniovertebral tuberculosis was performed. All patients were treated conservatively with cervical traction for initial 3 months followed by a brace along with multidrug antitubercular drugs for 18 months.

RESULTS

All patients responded favorably to conservative treatment. Follow-up averaged 43 months (range, 16-65 months). No patient deteriorated neurologically. All patients had symptomatic improvement. Failure to reduce atlantoaxial dislocation/lateral subluxation of the dens completely was seen in 2 cases.

CONCLUSIONS

We think that all patients with craniovertebral junction tuberculosis can be managed adequately using conservative means regardless of the extent of bony destruction with a good patient outcome. Surgery should be reserved for only a selective few where diagnosis is in doubt and there is initial severe or progressive neural deficit with/without respiratory distress in presence of documented mechanical compression and documented dynamic instability following conservative treatment.

Osteomyelitis in the head and neck

CONCLUSION

All bones of the facial skeleton and spine are susceptible to osteomyelitis due to various predisposing conditions. Current radiological tools are sufficient to provide adequate diagnosis. Treatment can be conservative resection of the diseased bone with adequate clearance in all cases except in cases of osteomyelitis due to osteoradionecrosis (ORN) where resection has to be more radical.

OBJECTIVE

In today's antibiotic era, osteomyelitis in the head and neck is a rare occurrence. Dealing with osteomyelitis in head and neck bones is not the same as in other bones of the body due to the nature of the bones, complex anatomy of the region, and esthetics. Our purpose was to analyze the behavior of osteomyelitis in the head and neck bones and its management.

MATERIALS AND METHODS

A total of 84 cases of osteomyelitis in head and neck were reviewed in a 10-year period. Pus for culture, antibiotic sensitivity, and radiology were the main investigations. A medical line of treatment was effective in acute cases. Surgery was opted for in chronic cases.

RESULTS

Mandible, frontal bone, cervical spine, maxilla, temporal bones, and nasal bones were involved, in descending order of frequency, i.e. the mandible was the most common bone affected. Nine patients were diagnosed as having acute osteomyelitis (11%); 75 were diagnosed as having chronic osteomyelitis (89%). Radiation-induced ORN leading to osteomyelitis was the most common cause of osteomyelitis of the mandible (13 of the 32 cases; 41%). Odontogenic infections and chronic sinusitis each gave rise to osteomyelitis in 3 of 10 cases (30%) of the patients with osteomyelitis of the maxilla. Chronic sinusitis was the main cause of frontal bone osteomyelitis in all 20 cases (100%). Tuberculosis (10 of 15 cases; 67%) and malignancy (5 of 15 cases; 33%) were the main predisposing factors in cervical spine osteomyelitis. Malignant external otitis (MEO) with diabetes mellitus was an underlying factor in all four cases of osteomyelitis of the temporal bone. Of the 18 patients with a diagnosis of ORN, the mandible was found to be the most susceptible bone (13 cases; 72%), followed by the maxilla (four cases; 22%) and cervical spine (1 case). Acute osteomyelitis responded to antibiotics. Sequestrectomy was carried out in all chronic cases but in cases of ORN more radical surgery was performed.

The role of free flaps in the treatment of persistent scalp osteomyelitis

OBJECTIVE

To evaluate the efficacy of the combination of an extensive surgical debridement and simultaneous free flap repair in case of troublesome cranial osteomyelitis.

METHODS

Five patients with persistent, frontal bone osteomyelitis were treated with surgical debridement of the infected bone and reconstruction with a free flap. In all patients, osteomyelitis occurred after neurosurgical procedures and lasted from 1 to 7 years. A latissimus dorsi muscle flap with a split skin graft has been performed.

RESULTS

No flap failure occurred and donor site morbidity was negligible. No signs of osteomyelitis or soft tissue infection were observed during the mean follow-up period of 3.2 years. Furthermore, the contour of the cranium could be preserved without a need for bone grafts or implants.

CONCLUSION

In our experience, the combination of an extensive surgical debridement and a free flap transfer is demonstrated to be an effective treatment for "chronic" osteomyelitis of the cranium.

When the Bone Flap Hits the Floor

OBJECTIVE:

There is no published data in the neurosurgical literature describing the incidence, treatment, or outcome of contaminating a bone flap. We reviewed our departmental experience to determine methods of prevention and assess our treatment strategies.

METHODS:

We retrospectively reviewed all incidents of dropped bone flaps during a craniotomy at a single medical center during a 16-year period. In addition, a questionnaire was mailed to neurosurgeons in the United States and abroad asking their own experience and method of management.

RESULTS:

Fourteen incidents of dropped bone flaps occurred during a 16-year period. Follow-up varied from 2 to 176 months. The bone flap was dropped while elevating the bone (n = 4), when handing the bone off the field (n = 4), and during plating (n = 4). The context was unknown in two cases. Management included soaking the flap in betadine and/or antibiotic solution (n = 8), autoclaving (n = 2), or discarding the bone flap and replacing with a mesh cranioplasty (n = 3). The treatment remains unknown in one case. No instances of infection were noted in follow-up. In response to the survey, 66% (33 out of 50) of the polled neurosurgeons had experienced this complication during their practice, and 83% would replace the bone flap after disinfection.

CONCLUSION:

Dropping a bone flap during neurosurgery remains an uncommon but preventable complication. Treatment options include discarding the bone followed by cranioplasty versus replacing the bone after treatment with antibiotic irrigation, betadine, and/or autoclaving. Replacement after disinfection is an appropriate option for contaminated bone flaps that avoids the expense and time of cranioplasty.

Intracranial fungal granuloma: analysis of 40 patients and review of the literature

OBJECTIVE

To describe the characteristics of patients diagnosed with intracranial fungal granuloma (IFG) in the largest reported series to date (to our knowledge).

METHODS

A 22-year retrospective, multi-institutional review of 40 patients, aged 16 to 62 years (mean, 40.2 years), was performed in patients with histopathologically confirmed IFG. The variables were symptoms/signs at presentation, predisposing factors, location of granuloma, involvement of paranasal sinuses, diagnostic studies including blood and urine cultures, surgical procedures performed, specific organism identified, treatment, and prognosis. Plain x-rays, computed tomography, and/or magnetic resonance imaging scans were performed.

RESULTS

Predominant symptoms included headache (83%), vomiting (65%), proptosis (48%), and visual disturbances (48%). Other symptoms were fever, nasal congestion, and seizures (7 [18%]). Common signs included papilledema (12 [30%]), with cranial neuropathy (I, III/IV/VI, and V in 4, 7, and 2 patients, respectively), hemiparesis (3), and meningismus (3). Predisposing factors were diabetes (16 [40%]), tuberculosis (7 [18%]), and immunocompromise related to renal transplant (2), non-Hodgkin's lymphoma (1), and human immunodeficiency virus (1). Location was primarily frontal (10 [25%]), with anterior cranial fossa involved in 8 (20%) patients; 6 (15%) patients had sellar/parasellar involvement. Eighteen (40%) had paranasal sinus involvement. Twenty-nine patients underwent craniotomy for resection, with 11 undergoing biopsy (of which 3 were transsphenoidally approached). Histopathology revealed aspergilloma (25 [63%]), mucormycosis (7 [18%]), cryptococcoma (3), cladosporidium (3), Bipolaris hawaiiensis (1), and Candida species(1). Microbiological analysis of the specimen was positive in 28 (60%) patients. All patients were treated with amphotericin B, fluconazole, and/or flucytosine. Only 26 patients completed amphotericin B therapy (due to nephrotoxicity). Mortality was 63%, most commonly due to meningoencephalitis (16 [36%]).

CONCLUSIONS

High index of suspicion of IFG should exist for the following groups: (1) immunocompromised patients with intracranial lesions and (2) diabetic patients with intracranial and rhinocerebral mass lesions. Early diagnosis, surgical decompression, and a complete course of promptly initiated antifungal therapy are associated with better prognosis.

Cranial bacterial infection

Early diagnosis of cranial sepsis is mandatory if morbidity is to be avoided. In the case of structural integrity of the skull, haematogenous spread or extension from adjacent structures, especially the sinuses, are the most common sources of infection. Infections may be limited to compartments by the meninges or spread diffusely. Focal disease includes brain abscess as well as subdural and extradural empyaema. A history or signs of sinus disease should always be sought. Tuberculosis, lyme disease and listeriosis may present specific pathological findings. A series of cases is presented to illustrate the role of imaging in infective disease and to draw attention to diagnostic and management points of which radiologists should be aware.

Direct detection of leptospiral material in human postmortem samples

Leptospiral culture, direct immunofluorescence, and the polymerase chain reaction (PCR) were used to detect leptospiral material in postmortem specimens collected from eight patients who died of leptospirosis. Diagnosis of leptospiral infection was based on clinical summary (premortem) and confirmed by serological analysis and/or culture of leptospires. Leptospiral culture was the least sensitive technique, yielding two isolates (3%) from 65 samples. Both isolates were from the aqueous humour and cerebrospinal fluid of the same patient. Direct immunofluorescence was of intermediate sensitivity for detection of leptospires, confirming the presence of leptospires in 11% (2 of 18) of tissue samples from three patients. PCR analysis was the most sensitive technique for detection of leptospiral material in tissue samples, being positive in 20% (11 of 56) of samples from eight patients. Both samples (cerebellum and liver) positive by immunofluorescence were also positive by PCR. The sensitivity of the PCR assay was 1-10 leptospires ml(-1) sample, and the assay was specific for Leptospira pathogenic species. Multi-system involvement was indicated based on successful amplification of leptospiral DNA from more than one tissue sample, which corroborated with the clinical and pathologic findings. The results suggest that in acute and/or fatal leptospirosis, the pathogenesis of the pathologic features are related to the presence of the organisms in the tissues. In conclusion, PCR combined with serology appears to be a useful tool for diagnosis of leptospirosis and may be invaluable in epidemiological studies.

In vivo induction of proinflammatory cytokines in mouse tissue by Porphyromonas gingivalis and Actinobacillus actinomycetemcomitans

Periodontitis is a chronic inflammatory disease initiated by a multitude of bacteria. Persistent infection leads to generation of various inflammatory mediators, resulting in tissue destruction and osteoclastic resorption of the alveolar bone. This study describes a novel in vivo murine calvarial model to assess the effects of oral pathogens on the expression of three proinflammatory cytokines [interleukin (IL)-1beta, IL-6, and tumor necrosis factor (TNF)-alpha] which are involved in bone resorption. We chose Porphyromonas gingivalis and Actinobacillus actinomycetemcomitans as prototype oral pathogens. We also tested the effects of Streptococcus gordonii, an oral commensal supragingival microorganism, considered a non-pathogen. Live bacteria were injected into subcutaneous tissue overlying the parietal bone of mice calvaria for 6 days. At the end of the experimental period, tissues overlying the calvaria were removed and analyzed for proinflammatory cytokine expression by Northern blotting. Cytokine mRNA was not detected in the tissue over the calvaria of control animals. In contrast, P. gingivalis and A. actinomycetemcomitans elicited mRNA expression of all three cytokines, TNFalpha being the highest (TNFalpha > > IL-1beta > IL-6). P. gingivalis was more potent than A. actinomycetemcomitans in inducing cytokine expression. In contrast, S. gordonii induced only low levels of mRNA for IL-1beta and TNFalpha but no IL-6 mRNA induction. These results suggest that oral microorganisms with access to host tissues elicit a battery of proinflammatory cytokines. There were clear differences in profiles and, interestingly, a commensal bacterium also stimulated bone resorptive cytokine expression in host tissues.

A craniocerebral infectious disease: case report on the traces of Hippocrates

A modern case of complicated sinusitis, with osteitis of the cranium and intraorbital-intracranial empyema, closely corresponds to descriptions reported in the Hippocratic treatise Diseases II. The therapeutic measures suggested in that work can be regarded as suitable according to modern practice. An ancient physician who followed the Hippocratic doctrine probably would have been able to recognize this complicated disease and possibly save the patient.

Tumor necrosis factor modulates fibroblast apoptosis, PMN recruitment, and osteoclast formation in response to P. gingivalis infection

P. gingivalis is an important oral pathogen, which has been closely linked to periodontal disease as well as lesions of endodontic origin. Both infections are associated with a decrease in fibroblast numbers, formation of an inflammatory infiltrate, and bone resorption. The goal of this study was to investigate the role that the host response plays in the capacity of P. gingivalis to stimulate fibroblast apoptosis, PMN recruitment, and osteoclastogenesis. This was accomplished by the use of an in vivo calvarial model in mice with targeted deletion of TNF receptors p55 and p75 and matched wild-type mice. The results indicate that P. gingivalis induces fibroblast apoptosis in vivo and establish for the first time that this involves the stimulation of a host response. Moreover, bacteria-stimulated PMN recruitment and osteoclastogenesis were also dependent upon the host response. The results suggest that much of the damage caused by P. gingivalis infection, including fibroblast apoptosis, at least under some circumstances, results from stimulation of the host response rather than the direct effect of bacterial products. Furthermore, this may represent a more general mechanism by which bacterial challenge induces apoptosis of matrix-producing cells through the induction of TNF.

Fate of free muscle transfer covering chronically infected burned skull

This case report describes a 28-year-old male who sustained a 46,000-V cranial electrical injury that resulted in devascularization, necrosis, and secondary infection of the skull despite bone coverage with a free muscle transfer. In the face of osteomyelitis of the skull, the free muscle transfer and the brain were not compromised. A review of the literature and this case reinforce the practice of leaving the skull in place and covering it with vascularized tissue. Resection of the infected skull and later replacement with alloplastic material were curative.

Cytodiagnosis of tuberculosis of the skull by fine needle aspiration cytology: a case report

Close to one-third of the world's population is believed to be infected with tuberculosis, with the vast majority being in the developing world. However, even in the developed world, the incidence of this disease has been steadily increasing. Tuberculosis is very common in the Indian subcontinent, but at the same time tuberculous infection of the skull is rare and very few cases have been reported. We report a child who presented with a swelling of the frontal bone of the skull. Fine needle aspiration yielded the cytological diagnosis of tuberculosis on the basis of a necrotising granulomatous process with acid-fast bacilli detected on Ziehl Neelsen stain. This procedure obviated the need for an operative procedure and the patient responded to anti-tuberculous therapy. As the incidence of tuberculous infection is on the increase, both in the developed and in the developing world, the importance of diagnosis by newer non-invasive techniques like fine needle aspiration cytology cannot be overemphasized. To the best of our knowledge, this is the first report of its kind in the world literature.

Cladosporiosis in a tomato clownfish (Amphiprion frenatus)

Infection with Cladosporium sp., a deuteromycete, caused a deep dermal ulcer that extended to bone in a cultured tomato clownfish (Amphiprion frenatus). The infection may have been secondary to immunosuppression resulting from transport or confinement-induced stress or may have resulted from chronic exposure to copper. Reports of fungal infections in tropical marine fish are rare.

[Streptomyces somaliensis mycetoma with craniofacial involvement]

Mycetoma is a chronic granulomatous infection of the skin from which grains of the causative organism are eliminated via the sinus tracts. We report a rare case of cephalic mycetoma, which presented with an extensive involvement of the skull vault, base and an extradural granuloma. The diagnosis and treatment of the disease are discussed.

Cat-scratch disease simulating Histiocytosis X

Cat-scratch disease is a self-limited condition commonly causing a benign chronic lymphadenopathy in children. Osteolytic lesions are a rare complication, but have been previously reported. We report a case of a solitary osteolytic lesion of the skull whose clinical, radiographic and pathological features were initially interpreted as being consistent with Histiocytosis X. Subsequently, positive serological titers for Bartonella, a history of a cat-scratch antecedent to the onset of clinical symptoms and review of the original histopathology confirmed the diagnosis of cat-scratch disease. We reviewed the English language literature on osteolytic lesions associated with cat-scratch disease and compare the current case with those previously reported.

Pasteurella multocida infection involving cranial air spaces in White Leghorn chickens

Seven 18-wk-old pullets from a commercial layer flock experiencing increased mortality associated with neurologic and respiratory symptoms were submitted to the California Veterinary Diagnostic Laboratory System at the Turlock Branch for necropsy. Clinical signs included depression, torticollis, swollen eyelids, conjunctivitis, and sinusitis. Meningoencephalitis and suppurative inflammation of the cranial air spaces were found on histopathology. The brain, sinuses, and air spaces of the cranium were infected with Pasteurella multocida. Complicating the condition was Mycoplasma gallisepticum infecting the sinus and paramyxovirus-I affecting the trachea.

Staphylococcus epidermidis produces a cell-associated proteinaceous fraction which causes bone resorption by a prostanoid-independent mechanism: relevance to the treatment of infected orthopaedic implants

Staphylococcus epidermidis is the most commonly isolated coagulase-negative staphylococcus from the skin, gut and upper respiratory tract. Although it is less virulent than Staphylococcus aureus, it has emerged in recent years as an important causative agent of infections associated with metal implants, prosthetic devices and i.v. lines. We have previously demonstrated that a saline wash of S. aureus contained proteins which had potent bone-resorbing activity in vitro. The purpose of this study was to determine whether gently washing S. epidermidis in saline also released osteolytically active proteins. The so-called surface-associated material (SAM) eluted from S. epidermidis in saline was able to induce osteolysis, and activity was heat and trypsin sensitive, suggesting that the active component was proteinaceous. Fractionation studies have suggested that activity is due to a small number of cationic proteins. This SAM-induced bone resorption was not inhibited by the cyclo-oxygenase inhibitor, indomethacin, or the 5-lipoxygenase inhibitors BWA70C and MK886. However, it was partially inhibited by high concentrations of interleukin-1 receptor antagonist and was completely blocked by a neutralizing antibody to tumour necrosis factor-alpha. Thus, the SAM from this organism is a potent osteolytic agent which differs from that of S. aureus SAM in not being inhibited by cyclo-oxygenase inhibitors. As adjunctive therapy is becoming necessary in infectious diseases, either as a result of the side-effects of antibiotics or their lack of efficacy, consideration should be given to the future treatment of bone infections with staphylococci in the light of the different mechanisms of action of the surface proteins produced by these bacteria.

Primary Candida albicans empyema associated with epidural hematomas in craniocervical junction

The case of a 27-year-old patient with chronic candida empyema in the craniocervical junction is presented. Occlusive hydrocephalus at admittance, primary subdural candida empyema, and recurrent epidural bleedings are the outstanding features in the clinical course. Despite intact immunity this patient acquired primary candidosis of CNS. Pathological changes in dura, ventricular system, and CSF required multiple shunt revisions. Antimycotic therapy was performed with a combination of 3 antimycotics. The clinical improvement was prolonged by several complications.

Eikenella corrodens skull infection: a case report with review of the literature

BACKGROUND

Subgaleal abscesses and skull osteomyelitis are very uncommon since the introduction of antibiotics. Eikenella corrodens infection is extremely rare in childhood and has never been reported in calvarial osteomyelitis.

METHODS

We present a previously healthy 9-year-old boy, with a history of frontal contusion without injury, who developed E corrodens osteomyelitis of the skull. The radiographic findings are reviewed, including skull films and computed tomographic scans. The patient underwent surgical debridement of the lesion, as well as systemic medical therapy with amoxicillin. We review the medical and surgical therapy for such lesions. The differential diagnosis of a posttraumatic scalp swelling is also reviewed.

RESULTS

Good resolution after debridement and antibiotic therapy is reported.

CONCLUSIONS

Surgical intervention is emphasized for the removal of bony sequestrum and nonviable bone while maintaining an intact dura.

Tuberculous osteitis of the skull: a case report and review of the literature

A 13-year-old girl of Pakistani origin presented with a non-tender, fluctuant swelling over her left parietal area and an underlying skull defect. At the apex of the swelling there was a sinus. Cultures of the discharge were positive for Mycobacterium tuberculosis. We present a case report of tuberculosis of the skull and review of the literature. We highlight the difficulty which still exists in establishing a diagnosis of tuberculosis in countries where it is uncommon.

Extensive extraaxial blastomycosis granuloma at the skull base--case report

A 37-year-old female presented with a rare case of intradural, extraaxial Blastomyces dermatitidis granuloma involving a large part of the skull base. She had the principal complaint of worsening vision, but was otherwise healthy. The lesion mimicked an en-plaque meningioma on radiological examination and in gross appearance during surgery. This is a very unusual presentation for a blasto-mycosis granuloma.

Skull osteomyelitis due to Salmonella species: two case reports and review

Osteomyelitis of the skull is a rare disease. We describe two cases due to Salmonella typhimurium and review 10 previously reported cases of salmonella osteomyelitis of the skull. This infection is frequently complicated by extradural abscess, which may be asymptomatic. Diagnostic imaging by means of computed tomographic scanning with contrast or gadolinium-enhanced magnetic resonance imaging should be performed to detect this complication. A good outcome can be expected with a combination of surgery and antibiotic therapy.

Bone resorbing activity of surface-associated material from Actinobacillus actinomycetemcomitans and Eikenella corrodens

The results of this study demonstrate that saline extracted surface-associated material (SAM) of Actinobacillus actinomycetemcomitans and Eikenella corrodens stimulates bone resorption at picomolar concentrations. Various inhibitors of known osteolytic mediators--indomethacin, interleukin-1 receptor antagonist (IL-1ra) and a neutralising antibody to murine tumour necrosis factor (TNF) alpha--were tested to determine the mechanism of action of these SAMs. Bone resorption induced by SAM from E. corrodens was slightly inhibited by indomethacin and almost completely inhibited by blocking the action of TNF alpha; that from A. actinomycetemcomitans was not significantly affected by either of these inhibitors.

Invasive sinusitis with intracranial extension caused by Curvularia lunata

Curvularia lunata has previously been linked to localized sinus infection in immunocompetent hosts. We treated a case of pansinusitis with extensive bone destruction and intracranial extension caused by C lunata. Curvularia lunata was identified when typical fungal macroconidia appeared on culture. Numerous surgical procedures, in addition to a 12-month course of antifungal therapy consisting of 4 g of intravenous amphotericin B and an 8-month course of 400 mg of oral ketoconazole daily, were required to control the infection. This unusual case of invasive sinusitis caused by C lunata alerts the treating physician to the presence of this mold and gives an overview of diagnostic method as well as the management.

Invasive aspergilloma of the skull base

Aspergillus infection originating in the nasal cavity or paranasal sinuses is a rare cause of benign, locally invasive disease affecting the skull base. We describe a case in which extensive disease led to bilateral proptosis and invasion of the anterior cranial fossa.

Rhinocerebral aspergillosis

Aspergillosis is increasingly being recognised as a common fungal infection of the paranasal sinuses. Although the disease is almost endemic in neighbouring Sudan, there are few reported cases from the Kingdom of Saudi Arabia. We report four cases of sinus aspergillosis with involvement of the skull bases and/or intracranial spread; a condition we have termed rhinocerebral aspergillosis. Invasive aspergillosis in our subgroup of patients occurs in otherwise healthy patients with normal immune status, quite unlike most reported cases in the western literature. The causative agent in all our patients was identified as aspergillus flavus, similar to patients reported from Sudan. This is again at variance with the case reports from other geographical locations, where aspergillus fumigatus is the commonest causative agent. Saudi Arabia would appear to represent a distinct geographical enclave, together with Sudan, where rhinocerebral aspergillosis of the sinuses and skull base may be more common than has previously been realised.

Blastomycosis: diagnostic difficulties

In five cases of blastomycosis, invasive procedures were required before the diagnosis was established; these included thoracotomy in two cases and craniotomy in a third case. Radiologic signs in blastomycosis are nonspecific, and the presentations of the disease may be protean and unusual. Certain factors and radiologic appearances should alert the physician and radiologist to the diagnosis.