Intracranial mycotic infections in neurosurgical practice

Intracranial mycotic infections requiring neurosurgical intervention are being diagnosed more frequently. This study is a review of 17 cases of intracranial mycotic infections that were treated in a neurosurgical unit in Saudi Arabia over an 8-year period. A primary focus of infection was identified in 41% of patients while 18% of patients had a predisposing factor. Forty-seven percent of patients presented with a brain abscess (solitary 29%, multiple 18%) while 35% had a granuloma. 18% meningitis and ventriculitis and 12% hydrocephalus. The Aspergillus species and Ramichloridium machenziei were the commonest pathogens. Following the appropriate surgical and antimicrobial treatment, the mortality rate was 41% and there was evidence of residual disease at follow-up in 18%. The reason for a fatal outcome was failure to consider a fungal aetiology and to obtain a tissue diagnosis early-because of late referral (2 cases), as well as failure to respond to antimycotic therapy (4 cases) and rupture of the internal carotid artery due to Aspergillus arteritis (one case). It is concluded that an early tissue diagnosis is crucial in the management of intracranial mycotic infection so that the appropriate surgical and antimycotic treatment can be started early.

Neurosurgical management of intraventricular haemorrhage in preterm infants

A review of intraventricular haemorrhage (IVH) diagnosed in 103 preterm infants from 1983 to 1993 describes the presenting features and management of this condition. In this 10-year period, 37 infants with IVH developed post-haemorrhagic hydrocephalus (PHH), defined as ventriculomegaly, raised intracranial pressure and increasing head circumference. PHH was treated by external ventricular drainage and/or ventriculo-peritoneal shunting; but other drainage procedures like lumbar punctures and subcutaneous ventricular reservoir were used occasionally. Relative indications, merits and demerits of these various surgical options is discussed and results summarized. High incidence of neuro-developmental handicap and its correlation with the grade of haemorrhage and PHH is emphasized. External ventricular drainage (EVD) was found to be an effective and safe therapy for rapidly progressive PHH and increased intracranial pressure. Ultimate outcome depended mainly on the grade of haemorrhage, severity of PHH and promptness of its neurosurgical management.

Choroidal detachment associated with retinal detachment as a presenting finding

Choroidal detachment along with retinal detachment as a presenting finding is rare. We identified five such cases presenting to our ophthalmology practice between 1964 and 1991. The patient is usually myopic and presents with marked visual loss, profound hypotony and a marked anterior chamber reaction. The pathogenesis seems to revolve around the hypotony and myopia and an unstable choroidal vascular system. Management usually involves a scleral buckling procedure with cryotherapy under direct visualization to release choroidal and subretinal fluid, possibly preceded by a few days of anti-inflammatory therapy. The overall prognosis is poor owing to delays in diagnosis and the postoperative development of proliferative vitreoretinopathy.

Prognostic indicators and risk factors for increased duration of acute diarrhoea and for persistent diarrhoea in children

To identify the prognostic indicators and risk factors for increased duration of acute diarrhoea and for occurrence of persistent diarrhoea (i.e. acute episodes lasting longer than 14 days) in children under three years, a systematic sample (3690) of patients attending a large treatment centre in Bangladesh was analysed using multiple regression, logistic regression and stratified (Mantel-Haenszel) analysis. Significant prognostic indicators or risk factors for increase in duration of acute diarrhoea, after adjusting for confounders, include bloody or mucoid diarrhoea, concomitant signs of chest infection, presence of vitamin A deficiency signs, decreased weight for age, routine use of contaminated surface water, lack of breastfeeding and increasing age; presence of rotavirus or enterotoxigenic Escherichia coli or Vibrio cholerae 01 in stool had negative association. In logistic regression and stratified analysis these factors, except for lack of breastfeeding and age, were also found to be risk factors or prognostic indicators of persistent diarrhoea. Policy implications of these findings for programmes to reduce morbidity and mortality from persistent diarrhoea include development of effective vaccines against dysentery-causing Shigella, programmes to prevent vitamin A deficiency, protein energy malnutrition and acute respiratory infections in children, and long-term programmes to provide clean water for all day-to-day needs.

Impact of acute diarrhoea on parasite loads

Parasites and diarrhoea are more frequent in poor populations. Parasite prevalence rates in post-diarrhoeal patients of the International Centre for Diarrhoeal Disease Research (ICDDRB) and in non-diarrhoeal populations of two Dhaka poor socioeconomic communities have been compared to explore if there is any effect of acute diarrhoea on parasite prevalence rates. Stool of a 4% systemic randomly selected sample of diarrhoeal patients and the whole population of two local poor communities have been examined. The results showed that the prevalence of parasites in a post-diarrhoeal population is significantly lower than in a non-diarrhoeal population. These reductions (E. hist. 10.2% vs. 2.03%, G. lamb. 9.7% vs. 3.5%, hookworm 37.4% vs. 4.7% and Ascaris lumbricoides 81% vs. 20.6%) may be attributed mainly to the flushing effect of diarrhoea.

Cryptosporidiosis: a cause of diarrhea in Bangladesh

Fecal samples from diarrheal patients and non-diarrheal controls were examined for Cryptosporidium oocysts in a year-long prospective study at a diarrhea treatment center in Dhaka, Bangladesh. Cryptosporidium oocysts were detected in 42 (3%) of 1,382 diarrheal patients but in none of 235 non-diarrheal controls. In 32 (76%) of 42 patients, no other enteropathogens were detected. Children less than 5 years of age were more commonly infected than older children (4.8% vs. 1.6%, P greater than 0.05) and adults (4.8% vs. 0.2%, P less than 0.01). A higher number of cases were detected during hot and humid months (April--July). Nineteen children less than 5 years of age (index cases) and their 71 family members were followed for 3 weeks after the release of the index cases from the hospital. Diarrhea continued for greater than 14 days (persistent diarrhea) in 8 (32%) index children. Cryptosporidium oocysts were detected in 1 (12.5%) of 8 family members who developed diarrhea during the follow-up period. Index cases excreted oocysts for 3-28 days (12.37 +/- 8.35 days). Almost all the patients recovered with oral rehydration. Cryptosporidium ssp. cause self-limited diarrhea episodes in children less than 5 years of age in Bangladesh, with a low frequency of intrafamilial transmission.

Risk factors for persistent diarrhoea

With a systematically sampled population of children aged under 5 attending this centre for diarrhoeal disease research during 1983-5 a retrospective analysis of persistent diarrhoea (defined as greater than 14 days' duration) was performed to identify the possible risk factors for this syndrome. Of the 4155 children included in the analysis, 410 (10%) gave a history of persistent diarrhoea. A comparison with children with acute diarrhoea matched for age showed that 11 factors were correlated with persistent diarrhoea, and strongly associated factors were stools with blood or mucus, or both, lower respiratory tract infection, malnutrition, vitamin A deficiency, and antibiotic use before presentation. The peak age was 2 years, and there was no sex difference. Deaths occurred more often in the group with persistent diarrhoea. Although Shigella spp, Campylobacter jejuni, and Giardia lamblia were frequently identified, their rates of isolation were not significantly higher among patients with persistent diarrhoea. No seasonal variation was observed in the rates of persistent diarrhoea. Although the introduction of family food to the diet was associated with higher rates, this factor was difficult to separate from the age dependent risks.

Cholera, rotavirus and ETEC diarrhoea: some clinico-epidemiological features

This paper analyses a few selected features from the history and clinical examination of 1258 patients with acute diarrhoea and a single laboratory diagnosis of either cholera, rotavirus, or enterotoxigenic (ETEC) Escherichia coli infection. Age distribution and seasonality in Bangladesh were also studied. The duration of illness before admission was not significantly different in the 3 groups. Cholera occurred especially in the spring and early winter. Most cholera patients were between 3 and 10 years of age. Over 37% of the patients developed severe dehydration. In about 90% of cholera cases, the stools were alkaline (pH greater than 7). ETEC infections were seen mostly in April-May and September-October. Infants were frequently affected but from age 25 onwards the age distribution closely followed that of cholera. Severe dehydration occurred in 8.3% of patients and was more frequent than in rotavirus cases. Stool pH was as frequently acidic as basic. Rotavirus cases were concentrated during the winter in patients under 2 years of age. They had marked vomiting, yet severe dehydration was almost absent. Cough was present in half of them. The stools were usually acidic. In spite of considerable overlap of signs and symptoms between the 3 aetiological groups, a presumptive diagnosis of cholera could be made in patients past infancy and early childhood who showed very severe dehydration. However, age-specific prevalence was strikingly different and seasonal variations considerable.

Estrogen screening in evaluation of fetal outcome and infant's development

In an unselected obstetric population of 869 women serial determinations of estriol in serum and urine were performed from the 28th week of pregnancy until delivery. Clinical management was based on ultrasound and nonstress/contraction stress tests only. Data on the development of the infants were available after 1 year in 759 cases (89%) and after 2 years in 661 cases (78%). Serum free estriol (E3) screening during weeks 28-34 of pregnancy revealed a significantly increased risk for reduced Apgar scores, growth retardation and postnatal complications in pregnancies with decreased levels (p less than 0.001). The development of the children was disturbed by a higher incidence of childhood diseases, retardation in speech and bowel and bladder control. The urinary estrogen determinations (UE) during this period of pregnancy showed only a vague connection with birth weight and Apgar scores (p less than 0.05) and no connection to the infant's development. Serial determinations of E3 after the 35th week of pregnancy increased the significance for all parameters tested. If the estrogen concentration was determined in the last 2 weeks before delivery, 50% of the SGA and 60% of the endangered cases could be diagnosed. After reduced E3 serial levels neurological sequelae, reduced body weight, retarded speech and late development of bowel and bladder control were significantly more frequent at age two than after normal E3 levels. The differences obtained by serial UE determinations were less evident. Considering cost-benefit-calculations, an E3 screening of every pregnant woman cannot recommended. In pregnancies at risk serial E3 determinations allow better prognostication of fetal well-being. In the case of reduced E3 values maximum post partum care should be made available for all newborns. Special support should be given to the early infant's development after reduced E3 values have been observed.

Changing pattern of resistant Shiga bacillus (Shigella dysenteriae type 1) and Shigella flexneri in Bangladesh

Shigella dysenteriae type 1 (Shiga bacillus) has made a dramatic comeback in Bangladesh after 10 years when Shigella flexneri was the dominant serogroup. Whereas S. flexneri showed little increase in resistance to the commonly used antimicrobial agents--namely, trimethoprim-sulfamethoxazole (TMP-SMX) and ampicillin-over the years, S. dysenteriae type 1 underwent rapid changes with regard to sensitivity pattern during the last two years. The first TMP-SMX-resistant strain of S. dysenteriae type 1 was detected in September 1982; however, by mid-1984 most strains were resistant while retaining sensitivity to ampicillin. During this period, the ratio of S. flexneri to S. dysenteriae type 1 narrowed from 0.15 to 1. Such propagation of high resistance to TMP-SMX might have been due to widespread use of the drug imported into the country in large quantities. Resistance to ampicillin is increasing rapidly, particularly in S. dysenteriae type 1.

Changes in the trend of shigellosis in Dhaka: family study on secondary infection, clinical manifestation and sensitivity pattern: 1980

The incidence of shigellosis and the death rate have increased and the resistance of shigellae to antibiotics has changed in Dhaka during our experiences. In 1980, we investigated the secondary infection and case rates, infection to case ratio, duration of illness, excretion of shigellae and antibiotic sensitivity pattern in 100 families with cases of shigellosis, culturing rectal swabs obtained by home visits for a 10-day period. Standard methods were used for culture and sensitivity tests. The over-all secondary infection rate in contacts was 27.3% and the case rate 10.7%. The rates were higher for Shigella flexneri than for Sh. dysenteriae. When the index cases were nought to four years old the secondary infection and case rates were higher than when index cases were older. Contacts aged nought to four years had highest attack rates. The average duration of excretion of Sh. flexneri was 4.5 and Sh. dysenteriae 2.6 days. Illness was one day longer for Sh. dysenteriae than for Sh. flexneri. Cases of shigellosis in hospital had higher rates of fever and blood in stool than those who were not in-patients. 40% of Sh. dysenteriae and 14% of Sh. flexneri were sensitive to tetracycline, 0 to 5% to streptomycin and 100% to sulphamethoxazole, trimethoprim and gentamicin. Incidence of Sh. flexneri had increased in 1980 but that of Sh. dysenteriae remained the same as in 1973 although Sh. dysenteriae type 1 appeared to be less infective in 1980 than in 1973.