Tuberculous arachnoiditis

The leptomeninges as a critical organ for normal CNS development and function: First patient and public involved systematic review of arachnoiditis (chronic meningitis)

BACKGROUND & IMPORTANCE

This patient and public-involved systematic review originally focused on arachnoiditis, a supposedly rare "iatrogenic chronic meningitis" causing permanent neurologic damage and intractable pain. We sought to prove disease existence, causation, symptoms, and inform future directions. After 63 terms for the same pathology were found, the study was renamed Diseases of the Leptomeninges (DLMs). We present results that nullify traditional clinical thinking about DLMs, answer study questions, and create a unified path forward.

METHODS

The prospective PRISMA protocol is published at Arcsology.org. We used four platforms, 10 sources, extraction software, and critical review with ≥2 researchers at each phase. All human sources to 12/6/2020 were eligible for qualitative synthesis utilizing R. Weekly updates since cutoff strengthen conclusions.

RESULTS

Included were 887/14286 sources containing 12721 DLMs patients. Pathology involves the subarachnoid space (SAS) and pia. DLMs occurred in all countries as a contributor to the top 10 causes of disability-adjusted life years lost, with communicable diseases (CDs) predominating. In the USA, the ratio of CDs to iatrogenic causes is 2.4:1, contradicting arachnoiditis literature. Spinal fusion surgery comprised 54.7% of the iatrogenic category, with rhBMP-2 resulting in 2.4x more DLMs than no use (p<0.0001). Spinal injections and neuraxial anesthesia procedures cause 1.1%, and 0.2% permanent DLMs, respectively. Syringomyelia, hydrocephalus, and arachnoid cysts are complications caused by blocked CSF flow. CNS neuron death occurs due to insufficient arterial supply from compromised vasculature and nerves traversing the SAS. Contrast MRI is currently the diagnostic test of choice. Lack of radiologist recognition is problematic.

DISCUSSION & CONCLUSION

DLMs are common. The LM clinically functions as an organ with critical CNS-sustaining roles involving the SAS-pia structure, enclosed cells, lymphatics, and biologic pathways. Cases involve all specialties. Causes are numerous, symptoms predictable, and outcomes dependent on time to treatment and extent of residual SAS damage. An international disease classification and possible treatment trials are proposed.

Selective testosterone secreting adrenocortical carcinoma in an infant

Adrenocortical carcinoma in children is a rare tumor of adrenal gland. An infant presented with signs of virilization due to selective testosterone hypersecretion. Diagnosis was established with the help of the computerized tomographic scan and histopathological examination. Following adrenalectomy patient made uneventful recovery and six months later does not have any clinical or laboratory evidence of recurrence or metastasis.

Tuberculous radiculomyelitis complicating tuberculous meningitis: case report and review

Tuberculous radiculomyelitis (TBRM) is a complication of tuberculous meningitis (TBM), which has been reported rarely in the modern medical literature. We describe a case of TBRM that developed in an human immunodeficiency virus (HIV)-infected patient, despite prompt antituberculous treatment. To our knowledge, this is the second case of TBRM reported in an HIV-infected patient. We also review 74 previously reported cases of TBRM. TBRM develops at various periods after TBM, even in adequately treated patients after sterilization of the cerebrospinal fluid (CSF). The most common symptoms are subacute paraparesis, radicular pain, bladder disturbance, and subsequent paralysis. CSF evaluation usually shows an active inflammatory response with a very high protein level. MRI and CT scan are critical for diagnosis, revealing loculation and obliteration of the subarachnoid space along with linear intradural enhancement. As in other forms of paradoxical reactions to antituberculous treatment, there is evidence that steroid treatment might have a beneficial effect.

Tuberculosis of the central nervous system in children

Tuberculosis remains one of the most common and important infectious diseases in the world. Between 1% and 2% of children with untreated tuberculosis infection will develop tuberculous meningitis. In 1997, 186 cases of tuberculous meningitis were reported in the United States. The initial clinical manifestations of tuberculous meningitis are protean, making early disease difficult to recognize. The clinical and radiographic manifestations of tuberculous meningitis result from the combination of basilar meningitis, infarction, and vasculitis. Early diagnosis can be problematic as Mycobacterium tuberculosis is difficult to detect by rapid tests. Although the response to antituberculosis chemotherapy is generally favorable, complications commonly occur, particularly if the diagnosis is delayed. With appropriate public health management of known tuberculosis cases, cases of CNS tuberculosis in children can be prevented.

Syringomyelia associated with post-meningitic spinal arachnoiditis due to Candida tropicalis

A 63 year old man who suffered from syringomyelia related to post-meningitic spinal arachnoiditis caused by Candida tropicalis is reported. The clinical syndrome of syringomyelia developed gradually and a definite diagnosis was delayed for more than 10 years. The patient has partially recovered after surgical treatment. This form of fungal infection and its delayed neurological complication in the form of syringomyelia has not been reported previously, to our knowledge.

Spinal arachnoiditis

A review of the literature points to the many causes of arachnoiditis and the failure of treatment to arrest or reverse its effects. The true incidence cannot be determined, although it is probably lower than might at first appear from the published articles. In the radiological literature the diagnosis seems to derive from an examination of the films alone, often without reference to the clinical findings or appearance at operation. While attempts at treatment are usually unsuccessful, some iatrogenic cases can be prevented by the avoidance of intrathecal steroid injections or unduly rough or repeated surgical exploration of the lumbar vertebral canal.

Mielopatias: aspectos diagnosticos

É feita reavaliação dos aspectos que levaram ao diagnóstico etiológico em 353 pacientes com mielopatia não-traumática e não-tumoral observados no decurso de 20 anos: siringomielia, 5 casos; vascular, 15 casos; carencial, 67 casos; infecciosa ou por infestação, 82 casos; pós-vacinação, pós-infecção ou pós-intoxicação, 31 casos; esclerose múltipla e neuromielite óptica, 20 casos; primária, 133 casos. Em função do diagnóstico são analisados os aspectos que podem contribuir aos conhecimentos sobre os mecanismos fisiopatológicos interessados na deflagração do acometimento medular no que tange às alterações imunobiológicas. Nesse sentido é considerado o papel da necrose, da desmielinização e da inflamação e o respectivo interrelacionamento.