CNS toxoplasmosis presenting as hydrocephalus is a very rare entity. We present three cases of HIV positive patients whose brain imaging revealed hydrocephalus and who improved with anti toxoplasma medication along with intravenous steroids and did not require any CSF shunting procedures. The mechanism of hydrocephalus in CNS toxoplasmosis is usually due to compression of CSF outflow pathway by ring enhancing lesions but even in their absence hydrocephalus can be rarely seen due to ventriculitis. Hence in HIV positive patients with unexplained hydrocephalus CNS toxoplasmosis should be considered and such patients if started on treatment early have a good prognosis without requiring neurosurgical intervention.
Epidermal growth factor receptor (EGFR)--tyrosine kinase inhibitors (TKI) like erlotinib and gefitinib have been approved as monotherapy for the treatment of patients with locally advanced or metastatic non small cell lung cancer (NSCLC) after failure of at least one prior chemotherapy regimen. The use of EGFR-TKI is associated with unique and dramatic dermatologic side effects. We report 2 patients with NSCLC developing a typical acneiform (papulo-pustular) eruption shortly after initiation of EGFR-TKI.
OBJECTIVES: Poor adherence to medication treatment can have devastating consequences for patients with mental illness. The goal of this project was to develop recommendations for addressing adherence problems to improve patient outcomes.
METHODS: The editors identified important topics and questions concerning medication adherence problems in serious mental illness that are not fully addressed in the literature. A survey was developed containing 39 questions (521 options) asking about defining nonadherence, extent of adherence problems in schizophrenia and bipolar disorder, risk factors for nonadherence, assessment methods, and interventions for specific types of adherence problems. The survey was completed by 41 (85%) of the 48 experts to whom it was sent. Results of the literature review and survey were used to develop recommendations for assessing and improving adherence in patients with serious mental illness.
RESULTS: ASSESSING ADHERENCE: The experts endorsed percentage of medication not taken as the preferred method of defining adherence, with 80% or more of medication taken endorsed as an appropriate cut-off for adherence in bipolar disorder and schizophrenia. Although self- and physician report are the most common methods used to assess adherence in clinical settings, they are often inaccurate and may underestimate nonadherence. The experts recommend that, if possible, clinicians also use more objective measures (e.g., pill counts, pharmacy records, and, when appropriate, serum levels such as are used for lithium). Use of a validated self-report scale may help improve accuracy.
SCOPE OF THE PROBLEM: The majority of the experts believed the average patient with schizophrenia or bipolar disorder in their practices takes only 51%-70% of prescribed medication. FACTORS ASSOCIATED WITH NONADHERENCE: The experts endorsed poor insight and lack of illness awareness, distress associated with specific side effects or a general fear of side effects, inadequate efficacy with persistent symptoms, and believing medications are no longer needed as the most important factors leading to adherence problems in schizophrenia and bipolar disorder. The experts considered weight gain a side effect that is very likely to lead to adherence problems in patients with schizophrenia and bipolar disorder; sedation was considered a more important contributor to adherence problems in bipolar disorder than schizophrenia. The experts rated persistent positive or negative symptoms in schizophrenia and persistent grandiosity and manic symptoms in bipolar disorder as the most important symptomatic contributors to adherence problems in these illnesses.
INTERVENTIONS: It is important to identify the specific factors that may be contributing to a patient's adherence problems in order to customize interventions to target those problems. Multiple problems may be involved, requiring a combination of interventions.
CONCLUSIONS: Adherence problems are complex and multidetermined. The experts recommended customized interventions focused on the underlying causes.
The present study was carried out to determine the antinociceptive, anti-inflammatory and antipyretic activities of the aqueous extract of Bauhinia purpurea leaves using animal models.
A young man presented with primary multi-drug resistant tuberculosis. The institution of second-line regimes with insufficient efficacy due to clinical inexperience, unreliable sensitivity reports and the inavailability of second-line drugs led to the development of an organism that was resistant to ten anti-tuberculous drugs. Accurate sensitivity testing done in an overseas laboratory enabled the institution of a six-drug regimen that has resulted in clinical cure.
We describe a case of adult chickenpox which was complicated by severe varicella pneumonia, mild hepatitis and thrombocytopenia. The hepatitis and the thrombocytopenia were asymptomatic clinically and were diagnosed on biochemistry and blood count results. These eventually improved without specific interventions. The pneumonia, however, deteriorated rapidly despite the early commencement of oxygen supplementation, acyclovir and antibiotic. Subsequently, systemic corticosteroid therapy was initiated and the patient was ventilated in the intensive care unit. The patient eventually recovered.
Twenty-seven cases of ascaris cholecystitis and cholangitis were managed in a surgical unit of a general hospital in Yangon, Myanmar, from January 1989 to March 1990. Nineteen women and eight men with a mean age of 42 years were studied. Main clinical manifestations were right hypochondrial pain, fever, chills, rigors, nausea, vomiting and jaundice. Diagnosis was established by abdominal ultrasonograms in all cases. Laparotomy was performed in all cases because of failure to respond to initial conservative treatment. Live and dead ascarids were found in the gall bladder and biliary ductal system. Cholecystectomy, bile duct exploration, worm extraction and T-tube drainage were done in all cases. There were no deaths. Two patients developed minor wound sepsis. During the follow-up period ranging from 3 to 12 months, there was no recurrence of symptoms in all patients. All patients were given antihelminthics before discharge and three weeks later.
A female patient who presented with left empyema thoracis caused by Actinomyces odontolyticus is reported. She responded to treatment with penicillin and metronidazole but after 3 weeks developed leucopenia complicated by gram-negative septicaemia. Leucopenia improved rapidly on withdrawal of metronidazole. Treatment was continued with a prolonged course of penicillin and she made an uneventful recovery.
Twenty-seven patients with peptic ulcer (19 with duodenal ulcer (DU) and eight with gastric ulcer (GU] refractory to H2-antagonists were treated with 40 mg of omeprazole once daily for 4-8 weeks, depending on the rate of ulcer healing. Clinical assessment, endoscopy and laboratory tests were performed at entry, after 2 and after 4 weeks, and if unhealed, also after 8 weeks' treatment. Ten healed patients were given a maintenance therapy of omeprazole 20 mg daily for up to 12 months during which the patients returned for endoscopy, gastric biopsy and laboratory tests at 3-monthly intervals. The initial treatment healed 15 of 19 (79%) DU patients in 2 weeks and all DU patients by 4 weeks. Seven of eight (87%) GU patients healed in 4 weeks and only one required 8 weeks' treatment. Symptom relief was rapid, with most patients being symptom-free within the first day of treatment. Six patients received 12 months' continuous maintenance therapy, one patient 9 months and three patients 6 months' treatment. All patients remained in remission whilst on omeprazole therapy. No adverse events were reported throughout the study. There were no clinically significant changes in haematology or blood chemistry after healing or during the long-term treatment. Biopsy samples revealed no histological changes in the gastric mucosa at any stage. Omeprazole 40 mg therefore was found to produce rapid healing and symptom relief in Asian patients with H2-antagonist-resistant peptic ulcers. Maintenance therapy with omeprazole 20 mg daily was shown to be safe and effective in preventing recurrence of peptic ulceration.
Albendazole, a new anthelmintic drug was evaluated in Malaysia in 91 patients, with single or mixed infections of Ascaris, Trichuris, and hookworm. Albendazole was administered as a single dose of 400 mg, 600 mg, or 800 mg. The cure rate for Ascaris at all three doses was 100% at days 14 and 21 post-treatment; for hookworm it was 98.8%, 100% and 98%, respectively, at day 14 and 68.8%, 100% and 84%, respectively, at day 21; for Trichuris it was 31.2%, 57.1% and 42.3%, respectively, at day 14 and 27.3%, 60.9% and 48.0%, respectively, at day 21. The egg reduction rate at day 21 was 100% at all three doses for Ascaris, 94.5%, 100% and 96.1%, respectively, for hookworm; and 39.2%, 85.1% and 72.8%, respectively, for Trichuris. There were no side effects, and biochemical examination of blood and urine did not indicate any unfavourable changes. Based on this trial, the recommended dosage for Ascaris and hookworm is a 400 mg single dose, and for Trichuris is a 600 mg single dose. Albendazole appears to be more effective than other available anthelmintic drugs.
Cryptococcosis is a known opportunistic infection in immunosuppressed hosts. We report our experience of all cases presenting to our Department between December 1975 and September 1988. Eight post-renal transplant patients and three systemic lupus erythematosus (SLE) patients were affected. All were receiving treatment with steroids, in association with either azathioprine or cyclosporin. The diagnosis of cryptococcal meningitis was initially based on a positive cerebrospinal fluid (CSF) cryptococcal antigen, by latex agglutination test, and subsequently confirmed by cultures. Common clinical presentations, in descending order of frequency, included headaches, fever, mental confusion, epilepsy and papilloedema. Meningism was not a prominent feature. CT brain scans were obtained in eight patients and one showed a focal lesion and one showed cerebral atrophy. Four patients also had an abnormal chest X-ray (CXR) and one had disseminated cryptococcosis. Amphotericin and 5-fluorocytosine were the mainstay of therapy, although ketoconazole alone was subsequently used in three selected patients with cure. Four early deaths occurred in patients with delayed diagnosis and treatment, usually in association with other severe concurrent infections. We conclude that awareness of cryptococcosis is essential in immunocompromised hosts presenting with headache with, or without, mental confusion or fever.
Pancytopaenia is a rare clinical presentation of severe leptospirosis. We would like to report a case of severe leptospirosis that progressed to pancytopaenia despite initial penicillin therapy. The patient needed a second course of antibiotic with doxycycline to improve his persistent symptoms and cytopaenia. Persistent pancytopaenia in severe leptospirosis and its management were reviewed.
Matched MeSH terms: Drug Therapy, Combination; Leptospirosis/drug therapy; Pancytopenia/drug therapy
Chloroquine (CQ)-resistant Plasmodium falciparum appears to decrease CQ accumulation in its food vacuole by enhancing its efflux via an active membrane pump, which has been reported to be a P-glycoprotein-like transporter. Rifampicin (RIF) is a P-glycoprotein inhibitor and also has some antimalarial activity. It is hoped that a combination of choloroquine-rifampicin (CQ + RIF) would be advantageous in the treatment of CQ-resistant malaria. Swiss albino mice were inoculated with CQ-resistant P. berghei intraperitoneally, and studied for the effect of CQ versus the combination of CQ + RIF at various doses on the clearance of parasitemia, the survival of the mice, and the recrudescence of malaria. Paradoxically, RIF decreased the survival rate and rate of clearance of parasitemia and increased the rate of recrudescence significantly when combined with various doses of CQ. Our results indicated that RIF worsened the course of the disease, and we concluded that RIF should not be combined with CQ in the treatment of malaria.
Matched MeSH terms: Drug Therapy, Combination; Malaria/drug therapy; Parasitemia/drug therapy
Major challenges of dealing elder patients with diabetes mellitus (DM) are the individualization of consideration in persons with various comorbid types of conditions. In spite of the fact that microvascular and macrovascular problems associated with DM are well documented, there is only a few numbers of reports viewing different conditions, for example, cognitive dysfunction. Cognitive dysfunction is of specific significance due to its effect on self-care and quality of life. All in all, the etiology of cognitive dysfunction in the maturing populace is probably going to be the grouping of ischemic and degenerative pathology. It is likewise trusted that Hyperglycemia is engaged with the system of DM-related cognitive dysfunction. At present, it isn't certain in the case of enhancing glycemic control or utilizing therapeutic agents can enhance the risk of cognitive decay. Amylin was later characterized as an amyloidogenic peptide, confined from a beta cell tumor and called islet amyloid polypeptide (IAPP), and after that, amylin. Conversely, we investigate the beneficial role and hypothesizing the mechanism of amylin related expanding the level and activation of CGRP receptor to enhance the cognition declination amid diabetic dementia.
We report a case of relapsing-remitting opsoclonus-myoclonus-ataxia syndrome (OMAS) in a patient with Hashimoto's encephalopathy, diagnosed after comprehensive evaluation. OMAS as a manifestation of Hashimoto's encephalopathy has been reported once previously. It is hoped that recognition of this entity and early initiation of immunotherapy will improve clinical outcomes for patients.