Spectrum of infections occurring in patients of autoimmune rheumatic diseases on treatment with biological versus conventional disease-modifying antirheumatic drugs: A comparative study.

Background: The era of biological therapy has revolutionized in the management of autoimmune rheumatic diseases. There have been conflicting results about the incidence of infections related to these drugs. The purpose of this study was to compare the spectrum and severity of infection between patients on biological disease-modifying antirheumatic drugs (bDMARDs) versus conventional disease-modifying antirheumatic drugs (cDMARDs). Materials and Methods: This hospital-based prospective observational study was conducted in a tertiary care hospital, and a total 200 patients were enrolled in this study. Patients on either bDMARDs or cDMARDs for at least six weeks presenting with evidence of infection were included. Patients with known immunodeficiency states, multiple comorbidities, and patients on prednisolone >7.5 mg were excluded. Data was expressed as percentage and mean ± SD. Kolmogorov-Smirnov analysis was performed for checking linearity of the data, and analysis of variance (ANOVA) followed by Tukey's HSD test were used to test the significance of difference between more than two parameters in parametric data. Results: Rheumatoid arthritis in 58 patients (29%) were the commonest ones presenting with infections, followed by systemic lupus erythematosus in 37 patients (18.5%). 135 patients (67.5%) were on cDMARDs and 65 patients (32.5%) on bDMARDs. Respiratory tract infection in 47 (34.8%) patients was found to be the commonest infection due to cDMARDs. Incidence of infection was higher with biologics, and types of infection in patients receiving infliximab and etanercept were significantly different from that of cDMARDs. Patients receiving etanercept had higher risk of infections and re-infections, but they were milder compared to cDMARDs. A significantly higher frequency of re-infection was found in patients who had not received vaccination. Conclusion: This study emphasizes that TNF-α inhibitors are significantly associated with higher risk of infections. Patients on etanercept have significantly higher but milder infections as compared to cDMARDs. Vaccination plays a pivotal role in prevention of re-infections.

Intra-arterial onyx embolisation of sphenobasilar sinus fistula using pressure cooker technique: case report and review of the literature.

Dural arterio-venous fistulas of the middle cranial fossa may occur within the dura of lesser or greater sphenoid wings. Lesser sphenoid wing fistulas rarely recruit cortical venous drainage and mostly drain in the cavernous sinus. On the other hand, greater sphenoid wing dural fistulas, also known as paracavernous fistulas or sphenobasilar and sphenopetrosal sinus fistulas, are much more notorious as they almost always connect with the superficial middle cerebral vein resulting in secondary cortical venous reflux and varix formation. Curative transarterial or transvenous endovascular embolisation of fistulous connection is the primary therapeutic strategy, particularly using onyx via the transarterial approach. In the present case we describe a 62-year-old man who presented with significant subarachnoid haemorrhage, intraparenchymal and intra-ventricular bleed. Digital subtraction angiography showed a middle cranial fossa dural arteriovenous fistula in the region of the sphenobasilar sinus with cortical venous reflux and varix formation. The patient underwent successful transarterial endovascular embolisation with complete elimination of the fistula using onyx 34, onyx 18, squid 12 and a Scepter XC balloon using the pressure cooker technique. We also report the development of facial nerve palsy due to inadvertent reflux of onyx in the petrosal branch of the middle meningeal artery.

Lumbar Canal Diameter Evaluation by CT Morphometry-Study of Indian Population.

STUDY DESIGN: A cross-sectional study. BACKGROUND: To document dimensions of the lumbar vertebrae and bony canal in an Indian population and to compare with other studies from the subcontinent as well as from other parts of world. METHODS: An observational study was conducted on the basis of a review of thin-cut (3 mm) computed tomographic images of lumbar vertebrae. A total of 302 patients were studied, and various dimensions were analyzed. RESULTS: In general, the vertebral and bony spinal canal dimensions were found to be greater in male patients. Comparison of populations revealed statistically significant differences in the spinal canal between an Indian population and others. OVERVIEW OF LITERATURE: Lumbar canal stenosis is a condition in which the anteroposterior and lateral dimensions of the bony spinal canal are less than normal for corresponding age and sex. Numerous studies have been conducted to determine morphometry of the lumbar vertebrae and spinal canal, mostly in western populations, using fresh cadaver or osteologic specimens. These studies did not mention the difference between the vertebral parameters in men and women. Moreover, many of these studies have limitations such as a small sample size and lack of demographic data including race, age, and sex. In this study, we have conducted morphometric analysis of the lumbar vertebrae in a relatively large number of Indian patients by using computed tomography scan. The morphometric data thus compiled may provide a baseline of body and canal dimensions that could guide clinical experts in their practice. CONCLUSIONS: The dimensions of the lumbar vertebrae and bony canal thus obtained shall provide a baseline normative data for evaluation of patients presenting with low backache and lumbar canal stenosis in an Indian population.

Giant Tuberculomas of Brain: Rare Neoplastic Mimic.

OBJECTIVE: Tuberculosis continues to be a major infectious disease in developing parts of the world. Primarily central nervous system tuberculosis manifests as meningitis, tuberculoma, or a brain abscess; however, rarely it may manifest as a large neoplastic mass such as lesion known as giant tuberculoma. Especially in central parts of India, the incidence of giant tuberculoma is quite high in pediatric population that too in posterior fossa of brain. Often, they are wrongly reported as neoplastic masses on imaging. The objective of this study was to evaluate different imaging appearances of a giant tuberculoma. MATERIALS AND METHODS: In this prospective study, all cases of giant tuberculoma presenting to a large tertiary care center in central India for 2 years (duration 2016-2018) were imaged and followed up. A total of nine patients, six females and three males, aged 4-16 years were studied on a 3-Tesla Siemens magnetic resonance imaging (MRI) scanner. RESULTS: In total, nine patients were included with 11 giant tuberculomas. Of 11, eight were infratentorial and three were supratentorial in location. On T2-weighted image sequence, these lesions showed central hypointensity with a peripheral hyperintense rim. Most observed finding on T1-weighted image sequence was central isointensity with peripheral hyperintense rim. Advanced imaging sequences such as magnetic resonance spectroscopy and magnetization transfer were also applied. CONCLUSION: To the best of our knowledge, this is the largest series of giant tuberculoma in the pediatric population reported so far in any part of the world. We have described the various MRI imaging findings of this lesion in great details. Management of such rare cases and pertinent literature is reviewed briefly.