Dolutegravir plus boosted darunavir versus recommended standard-of-care antiretroviral regimens in people with HIV-1 for whom recommended first-line non-nucleoside reverse transcriptase inhibitor therapy has failed (D2EFT): an open-label, randomised, phase 3b/4 trial

BACKGROUND

Randomised comparative data on efficacy and safety of second-line antiretroviral therapy (ART) after failure of non-nucleoside reverse transcriptase inhibitors (NNRTIs) across diverse geographical settings are scarce. The aim of this study was to evaluate optimal second-line ART for people with HIV.

METHODS

D2EFT is a completed international, randomised, open-label, phase 3b/4 trial evaluating three second-line ART strategies in adults (aged ≥18 years) with HIV-1 for whom first-line NNRTI therapy has failed. The study was done at 28 sites across 14 countries in Asia, Africa, and Latin America. It was originally designed to compare recommended standard of care (ritonavir-boosted darunavir [800 mg darunavir plus 100 mg ritonavir once daily] plus two nucleoside reverse transcriptase inhibitors [NRTIs; dosed once or twice daily]) with a novel nucleoside sparing regimen of dolutegravir (50 mg once daily) with ritonavir-boosted darunavir. The study was adapted during the first year to add a third arm of dolutegravir (50 mg once daily) with fixed tenofovir disoproxil fumarate (300 mg once daily) plus either lamivudine (300 mg once daily) or emtricitabine (200 mg once daily). Participants were randomly assigned with a computer-generated, blocked randomisation scheme (block size of two) stratified by site, previous tenofovir disoproxil fumarate use, and HIV viral load. The trial was designed to evaluate non-inferiority of either interventional arm against standard of care for the primary outcome of virological suppression, as determined by HIV RNA load of less than 50 copies per mL at 48 weeks. The prespecified non-inferiority margin was 12%. Comparisons were made with a modified intention-to-treat population, including all participants randomly assigned but excluding administrative withdrawals. This study is registered with ClinicalTrials.gov, NCT03017872.

FINDINGS

1190 individuals were screened; 828 participants were enrolled between Nov 1, 2017, and Dec 31, 2021. Two participants were unable to receive their assigned regimen for administrative reasons; and 826 participants were included in analyses. Median age was 39 years (IQR 33-46), and 450 (54%) participants were female. Baseline median CD4 count was 206 cells per μL (23-354) and median HIV RNA was 15 400 copies per mL (3600-65 986). The proportion of participants with HIV RNA of less than 50 copies per mL at 48 weeks was 194 (75%) of 257 in the ritonavir-boosted darunavir plus two NRTIs group, 222 (84%) of 264 in the ritonavir-boosted darunavir plus dolutegravir group, and 227 (78%) of 291 in the dolutegravir with tenofovir disoproxil fumarate plus either lamivudine or emtricitabine group. Compared with ritonavir-boosted darunavir plus two NRTIs, the difference in virological suppression was 8·6% (95% CI 1·7 to 15·5; p=0·016) for dolutegravir plus ritonavir-boosted darunavir and 6·7% (-1·2 to 14·4; p=0·093) for dolutegravir with tenofovir disoproxil fumarate plus either lamivudine or emtricitabine. Six deaths occurred, none of which were related to treatment. 19 pregnancies (11 livebirths) occurred with no congenital defects.

INTERPRETATION

In individuals experiencing failure of an NNRTI-based first-line ART, a switch to either dolutegravir plus ritonavir-boosted darunavir or dolutegravir with tenofovir disoproxil fumarate plus either lamivudine or emtricitabine, without universal access to genotyping, was non-inferior in achieving viral suppression compared with ritonavir-boosted darunavir plus two NRTIs. These global data support the most recent WHO treatment guidelines.

FUNDING

UNITAID; National Institute of Allergy and Infectious Diseases, USA; National Health and Medical Research Council, Australia; ViiV Healthcare; and Janssen.

A Multicenter Cohort Study on the Adverse Effects Evaluation After Messenger RNA COVID-19 Vaccination Among Pregnant Healthcare Employees in Penang General Hospitals

Introduction

The year 2020 saw the emergence of novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which became a great threat to public health worldwide. The exponential spread of the disease with millions of lives lost worldwide saw the emergence of an accelerated vaccine development with emergency approval from well-known regulatory bodies such as the US Food and Drug Administration, followed by widespread vaccine deployment despite a paucity in safety profile data. This issue becomes even more pronounced when it involves expectant mothers considering the possible undesirable effect toward the unborn child.

Method

This was a retrospective cohort study which was conducted at six general hospitals in the state of Penang, Malaysia. All the pregnant employees who have consented to take the mRNA COVID-19 vaccine and participate in this study were monitored from the time of their first vaccination and up to 28 days after they delivered their babies.

Results

All the participants had adequate maximum vertical pocket (MVP) and no obvious anomalies or detection of intrauterine growth restriction (IUGR) were detected during the second trimester. However, one subject was reported to have miscarried during the second trimester. The reported mean neonate birth weight was 3.0 kg with the mean Apgar score of 8.8 and 9.8 at 1 and 5 min, respectively. Approximately seven (5.8%) neonates were reported to be small for their gestational age. Another three (2.5%) neonates were reported to have anomalies.

Conclusion

As a whole, the inference that can be made from this study is that mRNA COVID-19 vaccine appears to be safe in pregnant women regardless of the trimester as the findings did not show obvious safety warning signs.

Comparing the efficacy of tocilizumab with corticosteroid therapy in treating COVID-19 patients: a systematic review and meta-analysis

PURPOSE

Tocilizumab has shown equivocal outcomes in reducing mortality in COVID-19. The corticosteroids appear to be an affordable alternative to tocilizumab. This study aims to estimate the efficacy of tocilizumab and the corticosteroids particularly dexamethasone and methylprednisolone and to identify possible determinants of their efficacy.

METHODS

Five electronic databases were searched for studies involving tocilizumab, dexamethasone, and methylprednisolone in treating COVID-19. We included case-control and randomized or partially randomized trials. Meta-regression for patient baseline characteristics, co-medications, and tocilizumab dose regimens was performed to identify contributing factors to drug efficacy.

RESULTS

Thirteen randomized controlled trials (RCTs) and twenty-four case-control studies were included in our meta-analysis involving 18,702 patients. Meta-analysis among the RCTs showed that a summary estimate favoring mortality reduction (OR 0.71, 95%CI 0.55 - 0.92) contributed mainly by tocilizumab and dexamethasone. Among case-control studies, meta-analysis showed mortality reduction (OR 0.52, 95%CI 0.36 - 0.75) contributed by tocilizumab and tocilizumab-methylprednisolone combination. Methylprednisolone alone did not reduce mortality except for one study involving high dose pulse therapy. Meta-analysis also found that all three drugs did not significantly reduce mechanical ventilation (OR 0.72, 95%CI 0.32 - 1.60).

CONCLUSION

Tocilizumab and dexamethasone emerge as viable options in reducing mortality in severe COVID-19 patients. A tocilizumab-corticosteroid combination strategy may improve therapeutic outcome in cases where single therapy fails.

Unusual cause of hemorrhagic pleural effusion: A case report

BACKGROUND

Infected aortic aneurysms are uncommon and difficult to treat. We present a case of infected aortic aneurysm with recurrent nontyphoidal Salmonella bacteremia.

CASE SUMMARY

A 68-year-old gentleman presented with non-specific symptoms and was found to have nontyphoidal Salmonella bacteremia and was treated with intravenous ceftriaxone. However his condition did not improve, and he developed a multiloculated right pleural effusion. Thoracocentesis was done to drain hemorrhagic pleural fluid. Chest computed tomography demonstrated descending thoracic aorta saccular aneurysm with periaortic hematoma likely due to recent bleed and extending to the right pleural cavity. He was referred to cardiothoracic surgery team and was planned for medical therapy in view of hemodynamic stability and no evidence of active leakage. He completed intravenous antibiotic for 5 wk and refused surgical intervention. Unfortunately, he was admitted twice for recurrent nontyphoidal Salmonella bacteremia. Finally, he agreed for surgical intervention and underwent endovascular aortic repair 3 mo later. Postoperatively, his condition remained stable with no recurrence of infection.

CONCLUSION

Our case highlights the importance of high index of suspicion of infected aortic aneurysm in patients with Salmonella bacteremia with high-risk factors such as atherosclerosis.

Efficacy of Ivermectin Treatment on Disease Progression Among Adults With Mild to Moderate COVID-19 and Comorbidities: The I-TECH Randomized Clinical Trial

IMPORTANCE

Ivermectin, an inexpensive and widely available antiparasitic drug, is prescribed to treat COVID-19. Evidence-based data to recommend either for or against the use of ivermectin are needed.

OBJECTIVE

To determine the efficacy of ivermectin in preventing progression to severe disease among high-risk patients with COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

The Ivermectin Treatment Efficacy in COVID-19 High-Risk Patients (I-TECH) study was an open-label randomized clinical trial conducted at 20 public hospitals and a COVID-19 quarantine center in Malaysia between May 31 and October 25, 2021. Within the first week of patients' symptom onset, the study enrolled patients 50 years and older with laboratory-confirmed COVID-19, comorbidities, and mild to moderate disease.

INTERVENTIONS

Patients were randomized in a 1:1 ratio to receive either oral ivermectin, 0.4 mg/kg body weight daily for 5 days, plus standard of care (n = 241) or standard of care alone (n = 249). The standard of care consisted of symptomatic therapy and monitoring for signs of early deterioration based on clinical findings, laboratory test results, and chest imaging.

MAIN OUTCOMES AND MEASURES

The primary outcome was the proportion of patients who progressed to severe disease, defined as the hypoxic stage requiring supplemental oxygen to maintain pulse oximetry oxygen saturation of 95% or higher. Secondary outcomes of the trial included the rates of mechanical ventilation, intensive care unit admission, 28-day in-hospital mortality, and adverse events.

RESULTS

Among 490 patients included in the primary analysis (mean [SD] age, 62.5 [8.7] years; 267 women [54.5%]), 52 of 241 patients (21.6%) in the ivermectin group and 43 of 249 patients (17.3%) in the control group progressed to severe disease (relative risk [RR], 1.25; 95% CI, 0.87-1.80; P = .25). For all prespecified secondary outcomes, there were no significant differences between groups. Mechanical ventilation occurred in 4 (1.7%) vs 10 (4.0%) (RR, 0.41; 95% CI, 0.13-1.30; P = .17), intensive care unit admission in 6 (2.4%) vs 8 (3.2%) (RR, 0.78; 95% CI, 0.27-2.20; P = .79), and 28-day in-hospital death in 3 (1.2%) vs 10 (4.0%) (RR, 0.31; 95% CI, 0.09-1.11; P = .09). The most common adverse event reported was diarrhea (14 [5.8%] in the ivermectin group and 4 [1.6%] in the control group).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial of high-risk patients with mild to moderate COVID-19, ivermectin treatment during early illness did not prevent progression to severe disease. The study findings do not support the use of ivermectin for patients with COVID-19.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04920942.

Self-reported symptom study of COVID-19 chemosensory dysfunction in Malaysia

Alterations in the three chemosensory modalities-smell, taste, and chemesthesis-have been implicated in Coronavirus Disease 2019 (COVID-19), yet emerging data suggest a wide geographic and ethnic variation in the prevalence of these symptoms. Studies on chemosensory disorders in COVID-19 have predominantly focused on Caucasian populations whereas Asians remain understudied. We conducted a nationwide, multicentre cross-sectional study using an online questionnaire on a cohort of RT-PCR-confirmed adult COVID-19 patients in Malaysia between 6 June and 30 November 2020. The aim of our study was to investigate their presenting symptoms and assess their chemosensory function using self-ratings of perceived smell, taste, chemesthesis, and nasal blockage. In this cohort of 498 patients, 41.4% reported smell and/or taste loss when diagnosed with COVID-19, which was the commonest symptom. Blocked nose, loss of appetite, and gastrointestinal disturbances were independent predictors of smell and/or taste loss on multivariate analysis. Self-ratings of chemosensory function revealed a reduction in smell, taste, and chemesthesis across the entire cohort of patients that was more profound among those reporting smell and/or taste loss as their presenting symptom. Perceived nasal obstruction accounted for only a small proportion of changes in smell and taste, but not for chemesthesis, supporting viral disruption of sensorineural mechanisms as the dominant aetiology of chemosensory dysfunction. Our study suggests that chemosensory dysfunction in COVID-19 is more widespread than previously reported among Asians and may be related to the infectivity of viral strains.Study Registration: NMRR-20-934-54803 and NCT04390165.

Efficacy of Early Treatment with Favipiravir on Disease Progression among High Risk COVID-19 Patients: A Randomized, Open-Label Clinical Trial

BACKGROUND

Role of favipiravir in preventing disease progression in COVID-19 remains uncertain. We aimed to determine its effect in preventing disease progression from non-hypoxia to hypoxia among high risk COVID-19 patients.

STUDY DESIGN

This was an open-label, randomized clinical trial conducted at 14 public hospitals across Malaysia from February to June 2021 among 500 symptomatic, RT-PCR confirmed COVID-19 patients, aged ≥50 years with ≥1 co-morbidity, and hospitalized within first 7 days of illness. Patients were randomized on 1:1 ratio to favipiravir plus standard care or standard care alone. Favipiravir was administered at 1800mg twice-daily on day 1 followed by 800mg twice-daily until day 5. The primary endpoint was rate of clinical progression from non-hypoxia to hypoxia. Secondary outcomes included rates of mechanical ventilation, intensive care unit (ICU) admission, and in-hospital mortality.

RESULTS

Among 500 patients were randomized (mean age, 62.5 [SD 8.0] years; 258 women [51.6%]; and 251 [50.2%] had COVID-19 pneumonia), 487 (97.4%) patients completed the trial. Clinical progression to hypoxia occurred in 46 (18.4%) patients on favipiravir plus standard care and 37 (14.8%) on standard care alone (OR 1.30; 95%CI, 0.81-2.09; P=.28). All three pre-specified secondary end points were similar between both groups. Mechanical ventilation occurred in 6 (2.4%) vs 5 (2.0%) (OR 1.20; 95%CI, 0.36-4.23; P=.76), ICU admission in 13 (5.2%) vs 12 (4.8%) (OR 1.09; 95%CI, 0.48-2.47; P=.84), and in-hospital mortality in 5 (2.0%) vs 0 (OR 12.54; 95%CI, 0.76- 207.84; P=.08).

CONCLUSIONS

Among COVID-19 patients at high risk of disease progression, early treatment with oral favipiravir did not prevent their disease progression from non-hypoxia to hypoxia.

Talaromyces (Penicillium) Species Infection in the Central Nervous System

Talaromycosis typically occurs as an opportunistic infection among immunocompromised individuals. Infection caused by species other than T. marneffei is uncommon. While most reported cases describe infection in the lungs, we report an extremely rare intracranial Talaromyces species infection. This 61-year-old with end-stage renal disease who was unwell for the previous two months, presented with fever and worsening confusion lasting for three days. Lumbar puncture was suggestive of meningitis. Cerebrospinal fluid (CSF) culture was later confirmed to be Penicillium chrysogenum. The patient was co-infected with Group B Streptococcus sepsis. He improved with amphotericin B and ceftriaxone and was discharged with oral itraconazole for four weeks. However, he died of unknown causes two weeks later at home. Talaromyces species infection in the central nervous system is uncommon. This case highlighted a rare but life-threatening fungal meningitis. Among the four reported cases worldwide, none of the patients survived.

Masking and misleading: concomitant actinomycosis and B-cell lymphoma - a case report and review of literature

We report a 72-year-old patient who presented with an ulcerated palatal mass, weight loss and adrenal insufficiency. Repeated biopsies from the mass revealed actinomycosis with no features of malignancy, while computed tomography scanning revealed a left maxillary sinus mass with invasive features and bilateral large adrenal masses. Blood and urine investigations showed adrenal insufficiency. The patient was treated as actinomycosis with adrenal involvement and was given intravenous penicillin and intravenous hydrocortisone. However, his condition did not improve and new signs appeared, that of left facial swelling and lymphadenopathy. A repeat biopsy of the palatal and adrenal masses revealed B-cell lymphoma. This case highlights the possibility that actinomycosis and lymphoma may share similar clinical presentations and may coexist. Either may mask and/or mimic the other, thus causing a delay in diagnosis. We describe the clinical progress and review the related literature. Interestingly, 9 out of the 12 reported cases of concomitant actinomycosis and malignancy (including this case) involve haematological malignancy. A high index of suspicion and treatment response reassessment is important in the management of either rare clinical entity.

Filariasis in axillary lymph node

A case of adult filarial worms detected in an axillary lymph node of an asymptomatic patient. A 64 year-old Indian female underwent a mammogram and was incidentally found to have punctate microcalcifications in the upper outer quadrant of the left breast with left axillary lymphadenopathy. She has underlying hypertension and diabetes mellitus on oral medications. She has no family history of breast malignancy. Fine needle aspiration of the left axillary lymph node was suggestive of reactive lympha-denitis. Histopathological examination of excisional biopsy of left breast lump showed fibrocystic disease; no evidence of malignancy was detected whereas excisional biopsy of left axillary lymph node showed reactive lymphoid hyperplasia, featuring variably sized lymphoid follicles with intact mantle zone. No expansion of marginal zone was noted. Occasional pigment-laden macrophages were seen. One of the lymph node showed presence of calcified serpinginous tubular bodies, in keeping with non viable parasite organisms with intact outlines of the structures. There were no eosinophilic infiltrates. The possibility of filarial infestation was suspected. Histopathological sample was sent for further identification and confirmed the presence of adult filarial worm.

Outbreak of Human Brucellosis from Consumption of Raw Goats' Milk in Penang, Malaysia

We report the largest outbreak of brucellosis in Penang, Malaysia. Brucellosis is not endemic in this region. The index case was a 45-year-old goat farm owner presented with 3 weeks of fever, headache, severe lethargy, poor appetite, and excessive sweating. He claimed to have consumed unpasteurized goat's milk that he had also sold to the public. Tests were negative for tropical diseases (i.e., dengue fever, malaria, leptospirosis and scrub typhus) and blood culture showed no growth. Based on epidemiological clues, Brucella serology was ordered and returned positive. Over a period of 1 year, 79 patients who had consumed milk bought from the same farm were diagnosed with brucellosis. Two of these patients were workers on the farm. Four laboratory staff had also contracted the disease presumably through handling of the blood samples. The mean duration from onset of symptoms to diagnosis was 53 days with a maximum duration of 210 days. A combination treatment of rifampin and doxycycline for 6 weeks was the first line of treatment in 90.5% of patients. One-third of the patients had sequelae after recovering and 21% had a relapse. We highlight the importance of Brucellosis as a differential diagnosis when a patient has unexplained chronic fever.

Blind equalization of a noisy channel by linear neural network

In this paper, a new neural approach is introduced for the problem of blind equalization in digital communications. Necessary and sufficient conditions for blind equalization are proposed, which can be implemented by a two-layer linear neural network. In the hidden layer, the received signals are whitened, while the network outputs provide directly an estimation of the source symbols. We consider a stochastic approximate learning algorithm for each layer according to the property of the correlation matrices of the transmitted symbols. The proposed class of networks yield good results in simulation examples for the blind equalization of a three-ray multipath channel.

Shape recovery from shading by a new neural-based reflectance model

In this paper, we present a neural-based reflectance model of which the physical parameters of the reflectivity under different lighting conditions are interpreted by the network weights. The idea of our method is to optimize a proper reflectance model by an effective learning algorithm and to recover the object surface by a simple shape from shading recursive algorithm with this resulting model. Experimental results, including synthetic and real images, were performed to demonstrate the performance of the proposed method for practical applications.

Learning parametric specular reflectance model by radial basis function network

For the shape from shading problem, it is known that most real images usually contain specular components and are affected by unknown reflectivity. In this paper, these limitations are addressed and a new neural-based specular reflectance model is proposed. The idea of this method is to optimize a proper specular model by learning the parameters of a radial basis function network and to recover the object shape by the variational approach with this resulting model. The obtained results are very encouraging and the performance is demonstrated by using the synthetic and real images in the case of different specular effects and noisy environments.

Photocatalytic degradation of di(2-ethylhexyl)phthalate adsorbed by chitin A

Di(2-ethylhexyl)phthalate (DEHP) is a ubiquitous environmental contaminant due to its extensive use as a plasticiser and its persistence. Currently, there is no cost-effective treatment method for its removal from industrial wastewater. In a previous study, DEHP was effectively adsorbed from aqueous solution by biosorption onto chitinous materials. Biosorption can pre-concentrate DEHP from the aqueous phase for further treatment. As biosorption cannot degrade DEHP, in this study the degradation (and detoxification) of DEHP adsorbed onto chitinous material by photocatalytic oxidation (PCO) is attempted. PCO relies on hydroxyl radical (.OH), which is a strong oxidising agent, for the oxidative degradation of pollutants. It is a non-selective process which can degrade DEHP adsorbed onto chitinous material. The first part of this study is the optimisation of the degradation of adsorbed DEHP by PCO. Adsorption was carried out in the physicochemical conditions optimised in the previous study, with 500 mg/L chitin A and 40 mg/L DEHP at initial pH 2, 22+/-2 degrees C and 150 rpm agitation for 5 min. After optimisation of PCO, a 61% removal efficiency of 10 mg/L of DEHP was achieved within 45 min under 0.65 mW/cm2 of UV-A with 100 mg/L TiO2, and 10 mM of H2O2 at initial pH 12. The optimisation study showed that UV-A and TiO(2) are essential for the degradation of DEHP by PCO. The degradation intermediates/products were identified by GC-MS analysis. GC-MS results showed that the di(2-ethylhexyl) side chain was first degraded, producing phthalates with shorter side chains. Further reaction produced phathalic anhydride and aliphatic compounds such as alkanol and ester. The toxicities of parental and degradation intermediates in the solution phase and on chitinous materials were followed by the Microtox test. Results indicated that toxicity can be removed after 4 h treatment by PCO. Thus the decontamination of DEHP by integrating biosorption and PCO is feasible.

Nanoadhesion between rough surfaces

A model is developed to describe the adhesion between deformable fractal surfaces over the mesoscopic realm that covers the familiar range of interest in nanotechnology from atomic dimensions to microns. This model helps us gain a quantitative understanding of the variation of adhesion with surface energy, with microstructure of rough surfaces, and with bulk deformability. The present analysis goes beyond the Gaussian distribution of asperity heights by investigating the influence of the microstructure of self-affine fractal surfaces. Our calculation reveals that orders of magnitude increase in adhesion are possible as the roughness exponent decreases.

Fluctuations in dispersion rheology

On the basis of the mesoscopic fluctuations of excess density, an experimentally verified model is developed to describe the effective shear viscosity and modulus of complex dispersions as a function of concentration, frequency, and temperature. A stochastic differential equation is used in the derivation of the zero-shear viscosity that shows large viscosity enhancement over a broad range of concentrations. The scaling behavior of shear thinning is determined from an anomalous diffusion equation. We obtain the shear-thinning exponent 1>beta>1 / 2, which depends on the tenuous fractal structure of the complex systems. The divergence of the shear viscosity in the vicinity of a critical temperature is derived as a dynamic critical phenomenon due to thermal fluctuations, and the critical exponent relates directly to the shear-thinning exponent.

Unusual foreign body causing quadriparesis: case report

OBJECTIVE AND IMPORTANCE

An unusual foreign body traversing the spinal canal at the foramen magnum level is described. Interesting radiological findings and a review of nonmissile penetrating injuries are presented. This case demonstrates the importance of a thorough physical examination and the use of neurodiagnostic imaging in an inebriated, uncooperative patient with neurological dysfunction.

CLINICAL PRESENTATION

The patient presented with quadriparesis confounded by cocaine intoxication. A physical examination revealed only a small punctate lesion in the posterior occipital region.

INTERVENTION

After detection of the foreign body, the patient underwent immediate surgical exploration and removal of the object. The dura was repaired primarily, and the patient was maintained on intravenous antibiotics for 7 days.

CONCLUSION

With physical therapy, the patient was walking with assistance at 2 weeks postsurgery. Upper extremity strength, especially intrinsic hand movement, was most severely affected. At 10 months' follow-up, the patient's only deficits were mild intrinsic hand weakness and incoordination with fine finger movements. Immediate surgical exploration is indicated for patients with retained fragments and progressive neurological dysfunction.

The surgical treatment of metastatic spinal tumors within the intradural extramedullary compartment

The authors retrospectively reviewed the surgical outcomes in 10 cases of symptomatic intradural extramedullary spinal metastases of nonneurogenic origin because the collective experience in treating this rare manifestation of systemic cancer is limited. Pain and weakness were the presenting complaints in 70% of the patients and sensory changes were found in all cases. Cytological tests on one specimen of cerebrospinal fluid (CSF) from each of seven patients showed malignant cells in two cases. Gadolinium contrast-enhanced biplanar magnetic resonance (MR) imaging was effective in localizing the lesion and showed evidence of leptomeningeal carcinomatosis in two cases; myelography showed leptomeningeal carcinomatosis in one case and erroneously identified the lesion as intramedullary in the other. Eight of 10 cases had antecedent intracranial metastatic foci with the interval from presentation of the intracranial lesion to appearance of the spinal disease ranging from 3 to 51 months. The majority of the spinal lesions occurred in the thoracolumbar area. The most frequent histological type was adenocarcinoma and the most frequent source was the lung. In all cases laminectomies, intradural exploration, and biopsy or subtotal excision aided by microscopy and ultrasonography were performed. Results of surgical decompression were poor with only 30% of the patients showing improvement, at a 20% risk of perioperative mortality and a 60% risk of morbidity. Plans for surgical intervention in patients with intradural extramedullary metastases from a distant noneurogenic source should be weighed against the high association with intracranial lesions, overall poor prognosis, and modest symptomatic results of decompression. Comprehensive evaluation including multiple specimens of CSF for cytology and contrast-enhanced MR imaging should be undertaken to exclude patients with diffuse leptomeningeal involvement, who should be treated by means other than surgery.