Central nervous system norcardiosis with granulomatous pachymeningitis and osteomyelitis of skull vault.

A 34-year-old immunocompetent man weighing 95 kg was operated for a small left parietal scalp swelling in the year 2002. He was well until 2008, when he developed chronic diffuse headache, vomiting and drowsiness. The left parietal dura and overlying vault biopsy showed evidence of granulomatous pachymeningitis with osteomyelitis secondary to nocardiosis. He had responded well to inadequate antibiotic therapy. After a dormant period of 3 years, there was recrudescence of severe raised intracranial tension symptoms in 2011. Magnetic resonance imaging showed diffuse pachymeningeal thickening mainly involving the occipital dura, posterior falx, and tentorium cerebelli. In addition, well-defi ned small nodules with hypointense signals on both T1- and T2-weighted images were seen in occipital lobes. Patient was treated with three drug regime with good recovery at 3 months follow-up. This is a rare case of central nervous system nocardiosis with skull vault osteomyelitis and a protracted clinical course.

Assessment of pulmonary function in amyotrophic lateral sclerosis.

Background. Amyotrophic lateral sclerosis (ALS) is characterised by diffuse and progressive death of motor neurons and deteriorating pulmonary functions. At diagnosis most patients with ALS usually do not have any respiratory complaints. However, sub-clinical pulmonary dysfunction is known. Objective. To study pulmonary dysfunction in patients who clinically and electro-physiologically fulfil El escorial criteria of probable and definite ALS. Methods. We performed a standard battery of pulmonary function tests (PFTs) including spirometry, maximum voluntary ventilation (MVV) and maximum inspiratory and expiratory pressure (MEP, MIP) on 63 patients fulfilling the El escorial criteria for probable and definite ALS. Results were compared between the El escorial groups, bulbar- and limb-onset ALS and with age- and sex-matched healthy volunteers, taken as controls. Results. Only 11% of the patients had respiratory complaints at diagnosis. There was no statistical difference in pulmonary parameters between bulbar- and limb-onset ALS. The pulmonary dysfunction was restrictive. Both definite and probable ALS patients had significant reduction in all the measured pulmonary function parameters. The reduction in definite ALS patients was greater in forced vital capacity percent (FVC%) predicted, peak expiratory flow rate (PEFR) percent predicted and MIP. The proportion of patients with severe and very severe dysfunction was higher in the definite ALS group as compared to probable ALS group. Conclusions. Significant pulmonary dysfunction of restrictive type was noted in ALS patients. Both types of ALS, bulbarand limb-onset, had similar levels of dysfunction.