Brust Jc 2012 Current Diagnosis And Treatment Neurology Pdf
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Submit Manuscript. Journal Home. Editorial Board. Submit to this journal. Current issue. DOI: Int J Respir Pulm Med This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. A year-old Guatemalan male presented with six months of headaches and neck pain.
MRI of the cervical spine demonstrated multiple inflammatory processes, both within the paraspinal soft tissue as well as within the bone itself, including the appearance of total destruction of C1.
Microbiologic confirmation of Mycobacterium tuberculosis was made by fine needle aspiration. The patient was treated medically with appropriate anti-tuberculosis therapy coupled with aggressive pain control and careful neurological follow-up. Follow-up MRI at the end of treatment showed complete radiographic resolution. The patient had no neurologic sequelae. Aggressive pain management coupled with close neurologic follow-up and institution of appropriate TB treatment can often avoid surgical intervention, which generally involves the placement of hardware with resultant downstream management issues.
Tuberculosis TB of the spine, also known as Pott's disease, is the most common form of skeletal TB [ 1 ]. While the general consensus in the literature is that surgical stabilization should be reserved for patients with neurological sequelae or spinal instability [ 1 , 2 ] we have found that, in clinical practice, patients are often surgically treated. This is frequently due to either the initial at times frightening radiographic findings or severe pain, which is often not adequately managed in the context of rifampin drug interactions.
We describe a case of advanced cervical spine tuberculosis in a young patient who was treated medically with appropriate anti-tuberculosis therapy and subsequently showed complete resolution of his skeletal findings on MRI. A year-old male presented to the emergency room with severe neck pain and headache without any history of trauma. Symptoms had been present for six months and treated on an outpatient basis as migraine headaches.
He denied fever, chills, cough, difficulty swallowing, leg or arm weakness, bowel or bladder incontinence, change in appetite, or other sites of pain. He did note night sweats and weight loss of over 20 pounds. He worked as a dishwasher with no occupational exposures. Born in Guatemala, he had been in the U. He denied exposure to tuberculosis in the past and had no history of any previous TB screening; he had received BCG vaccination during early childhood. On physical exam, vital signs were normal with the exception of slight tachycardia.
Neurological exam had no significant findings. Tenderness to palpation was noted in the posterior base of the neck.
There was limited range of motion secondary to pain but no palpable swelling or mass. One BCG vaccination scar was noted on the upper arm. Chest radiograph showed significant mediastinal lymphadenopathy, especially in the azygoesophageal recess.
Lungs were clear except for mild post-obstructive pneumonitis associated with azygoesophageal recess adenopathy. In addition, there was an inflammatory process extending from the C6 level to the skull base with extension through neural foramina into the spinal canal, with involvement of the clivus and the C1 and C2 vertebral bodies Figure 1A.
A separate similar appearing inflammatory process was present on the left side extending from the C4-C7 levels Figure 1B. Right-sided cervical adenopathy was present. Within the posterior mediastinum there was a small abscess and surrounding inflammatory process adjacent to the T3 vertebral body Figure 1C.
There is a second similar appearing process centered at the T3 level in the posterior mediastinum green arrow. Figure D: Sagittal contrast enhanced T1 weighted image obtained post-therapy demonstrates complete resolution of the abscesses. View Figure 1. Patient was admitted to the hospital where an ultrasound guided biopsy of the posterior neck mass was performed.
Pathology demonstrated necrotizing granulomata, which were acid-fast bacilli AFB smear negative. Fiberoptic bronchoscopy was also performed with no demonstration of any endobronchial pathology; washings were also AFB smear-negative. Tuberculin skin testing was positive at 14 mm. Serum HIV testing was negative. The patient was started on 4 daily anti-tuberculosis drugs isonaizid [INH], rifampin, pyrazinamide, and ethambutol under directly observed treatment DOT conditions, along with aggressive pain management.
He was discharged to the local TB clinic. Within two weeks Mycobacterium tuberculosis was cultured from his neck mass aspirate, sputa expectorated , and bronchial washings. Drug susceptibility testing demonstrated that his organism was fully susceptible to all drugs. Once his susceptibilities were known, his TB medications were adjusted accordingly with immediate discontinuation of ethambutol. After the first two months, his regimen was again switched, dropping pyrazinamide and retaining INH and rifampin three times per week for ten months.
This regimen is consistent with CDC guidelines; in the U. Images obtained at the end of treatment demonstrate complete resolution of the abscesses Figure 1D. Surgical decompression of the upper cervical abscess and stabilization with hardware had been considered early due to involvement of the skull base and the upper cervical vertebrae with the potential for bone destruction and spinal instability.
Given his young age and lack of neurologic findings, it was elected to follow him carefully at least twice per week with a careful neurologic examination with the intent to operate if neurological compromise appeared.
Pain control was problematic during his first two months of treatment. This was likely exacerbated by the use of rifampin, which causes increased breakdown of narcotics via induction of cytochrome P in the liver [ 3 ]. Pain was eventually controlled with micrograms of Duragesic patches every 72 hours coupled with mg ibuprofen with each meal and PRN Percocet.
Most common involved site is the mid thoracic vertebrae with involvement of the cervical spine much less common [ 6 ]. Due to its rarity in developed countries like the United States, this diagnosis can often be missed or delayed.
Since a delay in diagnosis can lead to poorer outcomes, prompt recognition and treatment is essential [ 7 , 8 ]. Ideally, diagnosis of spinal TB is made by a combination of imaging, preferably MRI, and culture of Mycobacterium tuberculosis from biopsy samples [ 9 , 10 ]. Often the spinal lesions are accompanied by the presence of a large para-spinal abscess. The presence of such collections, often referred to as "cold abscesses," in the absence of fever, is very suggestive of TB [ 12 - 14 ].
Current literature supports medical treatment with four-drug therapy as first-line treatment for tuberculosis of the spine [ 1 , 15 - 17 ]. Given the risks of surgical intervention, it should be pursued only when necessary; indications include neurological sequelae, spinal instability, significant kyphosis, refractory pain, or failure of medical treatment [ 2 , 15 , 18 , 19 ].
In our experience, frightening radiographs have occasionally pushed early surgical intervention given the belief that stabilization is needed to avoid neurologic complications. We have also seen patients sent for surgical stabilization after minimal attempts at pain management. As our patient was young and without neurological symptoms, the hope was to avoid surgical stabilization with hardware, which, along with the risk of infection, would have reduced his range of motion and potentially decreased quality of life.
Close neurological follow-up with appropriate TB medications and aggressive pain control allowed for successful medical management. Indications for surgery should not be solely based on imaging; one must instead look at the complete clinical picture. Rapid initiation of treatment coupled with aggressive pain management and close medical follow-up served to solve the problem of this pain in the neck without turning an acute problem into a chronic one.
All Rights Reserved. Review Process. Open Access. Join Us. Abstract A year-old Guatemalan male presented with six months of headaches and neck pain. Case Report A year-old male presented to the emergency room with severe neck pain and headache without any history of trauma. Orthop Trauma Annu Rev Pharmacol Toxicol Moon MS Tuberculosis of the spine. Controversies and a new challenge. Spine Phila Pa Turgut M Spinal tuberculosis Pott's disease : its clinical presentation, surgical management, and outcome.
A survey study on patients. Neurosurg Rev Int Orthop J Neurosurg Postgrad Med J J Bone Joint Surg Br Arch Med Res Eur Spine J 4: Eur Spine J J Spinal Cord Med J Neurosurg Spine 6: Nene A, Bhojraj S Results of nonsurgical treatment of thoracic spinal tuberculosis in adults. Spine J 5: Clin Neurol Neurosurg J Orthop Traumatol
Medical Big Data: Neurological Diseases Diagnosis Through Medical Data Analysis
Diagnosis of neurological diseases is a growing concern and one of the most difficult challenges for modern medicine. An estimated 6. Current diagnosis technologies e. In general, analysis of those medical big data is performed manually by experts to identify and understand the abnormalities. It is really difficult task for a person to accumulate, manage, analyse and assimilate such large volumes of data by visual inspection. This system improves consistency of diagnosis and increases the success of treatment, save lives and reduce cost and time.
NCBI Bookshelf. Neurological disorders pose a large burden on worldwide health. Although this is a seemingly small overall percentage, dementia, epilepsy, migraine, and stroke rank in the top 50 causes of disability-adjusted life years DALYs Murray and others In , neurological disorders constituted 5. Migraine leads the list of neurological disorders, representing more than 50 percent of neurological YLDs or 2. The neurological burden of disease is expected to grow exponentially in low- and middle-income countries LMICs in the next decade Murray and others
John C.M. Brust, MD. Professor of Signs, Diagnostic Studies, Treatment, and Prognosis. transcranial direct current stimulation or thalamic deep brain ing or chewing), manual automatisms (eg, picking at clothes Neurology ;78(21) Data from Hemphill JC, Greenberg SM, Anderson CS, et al: Guide-.
CURRENT Diagnosis & Treatment: Neurology, 3e
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Multiple sclerosis MS is a chronic autoimmune, inflammatory neurological disease of the central nervous system CNS. The course of MS is highly varied and unpredictable. In most patients, the disease is characterized initially by episodes of reversible neurological deficits, which is often followed by progressive neurological deterioration over time.
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Frederick C. Much interest and controversy surround the clinical implications of the age-related decline in circulating testosterone T in aging men 1 and the decision to treat symptomatic men with androgen replacement 2 , 3. There is a seductive simplicity to the conceptualization of low T in the elderly man as a straightforward problem of an age-related deficiency state—boosting the hormone level with treatment will remedy multiple problems of senescence whether they are sexual dysfunction, mobility limitation, diabetes, or cardiovascular disease.
Springer Professional. Back to the search result list. Table of Contents. Issue archive. Activate PatentFit. Hint Swipe to navigate through the articles of this issue Close hint. Abstract Diagnosis of neurological diseases is a growing concern and one of the most difficult challenges for modern medicine.
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