Schizophrenia-like psychosis as the presenting feature of neurosyphilis in a non-human immunodeficiency virus-infected Indian man: A reminder of a forgotten complication!

Syphilis is a great masquerader of several diseases. About 4%-10% of patients with untreated syphilis may develop neurosyphilis (NS). Psychiatric manifestations may rarely be the presenting feature of NS. We describe herein a case of an elderly man who presented with psychosis and after thorough workup was diagnosed to be a case of a NS. Schizophrenia-like psychosis as the presenting and the only manifested feature of NS in a nonhuman immunodeficiency virus-infected patient was a unusual and noteworthy feature in the present case.

Evaluation of facial artery perforator-based flaps in reconstruction of facial defects.

INTRODUCTION: Several flaps have been described for reconstructing facial or oral defects. Flaps such as forehead and pectoralis major are often too bulky for small-to-moderate-sized defects, for which nasolabial flaps are often ideal. However, nasolabial flaps have limited mobility and reach and may need two stages, particularly for intraoral defects. According to recent literatures, facial artery provides numerous small cutaneous perforators, based on which skin flaps can be islanded, with greater mobility and reach for reconstruction of small-to-moderate-sized intraoral and facial defects in one stage. Our study aims to evaluate the reliability and versatility of facial artery perforator-based flaps in the reconstruction of such defects. MATERIALS AND METHODS: A ethical committee-approved retrospective study was conducted on data of the patients attending our outpatient department between February 2014 and October 2015 with small-to-moderate-sized facial/oral lesions. The total sample size was 23. We studied the relation of flap survival with size of flap, route of inset and neck dissection, functional and aesthetic outcomes and feasibility of adjuvant therapy in cases of malignancies. RESULTS AND ANALYSIS: A wide range of facial defects, especially intraoral defects, could be reconstructed in one stage using facial artery perforator-based flaps. The flaps were reliable. Complications included only partial skin loss of the flaps in a few cases. Complications were directly related to the length of the flaps and the route of inset. Functional and aesthetic outcomes were satisfactory and none of the flaps showed any significant post-radiotherapy changes. CONCLUSIONS: We concluded that facial artery perforator flap can be a simple, safe, versatile and one-stage alternative to the traditional flaps in the reconstruction of small-to-moderate-sized facial defects. Neck dissection can be safely done in the same sitting.

White matter changes in Wilson's disease: A radiological enigma.

Wilson's disease is a metabolic disorder which presents with hepatitis or hepatic decompensation commonly. Neurologic manifestations are late and include movement disorders, personality changes, and seizures. Magnetic resonance imaging (MRI) brain shows high signal changes in putamen, lentiform nucleus, thalamus, and brainstem. White matter lesions are rare. We report a child of Wilson's disease who presented to us with dystonia, rigidity, myoclonus and had symmetrical white matter changes in the fronto-parietooccipital region. Diffusion restriction in bilateral frontoparietal areas was also seen which is rare in chronic cases like ours. Atypical MRI characteristics should be considered in patients with clinical signs of neurological involvement in Wilson's disease as it is a devastating but treatable disease.

Paraspinal transposition flap for reconstruction of sacral soft tissue defects: a series of 53 cases from a single institute.

STUDY DESIGN: Case series. PURPOSE: To describe paraspinal transposition flap for coverage of sacral soft tissue defects. OVERVIEW OF LITERATURE: Soft tissue defects in the sacral region pose a major challenge to the reconstructive surgeon. Goals of sacral wound reconstruction are to provide a durable skin and soft tissue cover adequate for even large sacral defects; minimize recurrence; and minimize donor site morbidity. Various musculocutaneous and fasciocutanous flaps have been described in the literature. METHODS: The flap was applied in 53 patients with sacral soft tissue defects of diverse etiology. Defects ranged in size from small (6 cm×5 cm) to extensive (21 cm×10 cm). The median age of the patients was 58 years (range, 16-78 years). RESULTS: There was no flap necrosis. Primary closure of donor sites was possible in all the cases. The median follow up of the patients was 33 months (range, 4-84 months). The aesthetic outcomes were acceptable. There has been no recurrence of pressure sores. CONCLUSIONS: The authors conclude that paraspinal transposition flap is suitable for reconstruction of large sacral soft tissue defects with minimum morbidity and excellent long term results.

Posterior arm flap in management of axillary contracture.

INTRODUCTION: Management of post burn contracture can be difficult, particularly for the axilla. Any handicap related to upper limb has a detrimental physical, psycohological, and economical effect. PATIENTS AND METHODS: We have released 20 axillae in 16 patients. These patients had axillary contracture for long duration and 5 had been operated previously by release and skin graft. We used posterior arm fasciocutaneous flaps for coverage of the defect after release of contracture. RESULTS AND CONCLUSION: All the patients had a good post op release. Their range of movement is excellent. No post op splintage was utilised in any of the cases with no incidence of recontracture.

Revisiting Gavello's procedure for single-stage reconstruction of the earlobe: The vascular basis, technique and clinical uses.

BACKGROUND: Deformities or loss of the earlobe may be congenital, or acquired due to trauma, bites, burns or tumour excision. A variety of single-stage and two-stage procedures have been described for earlobe reconstruction, of which Gavello's procedure was one of the earliest. OBJECTIVE: To revisit Gavello's procedure with reference to the vascular supply of the flap, and discuss the relevance of the technique in current practice. METHODS: The authors discuss the vascular basis of Gavello's flap, and describe the clinical application of the single-stage Gavello's procedure in diverse clinical situations, including congenital absence of earlobe, post-burn earlobe deformity and traumatic amputation of the earlobe. RESULTS: Excellent cosmetic results have been achieved in all different clinical situations in the authors' experience, with preservation of earlobe shape and volume, good colour match and a well-concealed scar in the donor area. DISCUSSION: Gavello's procedure is a simple, one-stage procedure that relies entirely on local tissue for earlobe reconstruction; the flap has a predictable vascular supply, skin grafting is not required and the procedure can be used for large defects. An intact donor area over the postauricular mastoid region is a prerequisite. CONCLUSION: The simple, century-old Gavello's procedure is still of great value for reconstruction of earlobe defects of diverse etiology.

HISTORIQUE: Les anomalies ou la perte du lobe de l'oreille peuvent être d'origine congénitale ou être acquises en raison d'un traumatisme, de morsures, de brûlures ou d'excision d'une tumeur. Diverses interventions en une ou deux étapes ont été décrites pour reconstruire le lobe de l'oreille. L'intervention de Gavello est l'une des plus anciennes. OBJECTIF: Examiner l'intervention de Gavello compte tenu de la capacité vasculaire du lambeau et exposer la pertinence de cette technique dans la pratique actuelle. MÉTHODOLOGIE: Les auteurs abordent la base vasculaire du lambeau de Gavello et décrivent l'application clinique de l'intervention de Gavello en une étape dans diverses situations, y compris l'absence congénitale de lobe d'oreille, une malformation du lobe de l'oreille après une brûlure et une amputation traumatique du lobe de l'oreille. RÉSULTATS: Les auteurs ont remarqué d'excellents résultats esthétiques dans toutes sortes de situations cliniques, qui permettent de préserver la forme et le volume du lobe de l'oreille ainsi que d'obtenir une bonne correspondance de la couleur et une cicatrice bien cachée au foyer du donneur. EXPOSÉ: L'intervention de Gavello est une intervention simple en une étape qui fait entièrement appel à des tissus locaux pour reconstruire le lobe de l'oreille. Le lambeau a une capacité vasculaire prévisible, la greffe de peau est inutile et l'intervention peut être utilisée pour des anomalies importantes. La région de la mastoïde postauriculaire du donneur doit être intacte. CONCLUSION: L'intervention de Gavello, qui est simple et existe depuis un siècle, est toujours très précieuse pour la reconstruction d'anomalies du lobe de l'oreille d'étiologies variées.

Acute disseminated encephalomyelitis after mixed malaria infection (Plasmodium falciparum and Plasmodium vivax) with MRI closely simulating multiple sclerosis.

INTRODUCTION: Acute disseminated encephalomyelitis (ADEM) is a monophasic, inflammatory, immune-mediated disorder of the central nervous system. It is particularly difficult to distinguish between ADEM and an initial attack of multiple sclerosis (MS) clinically and based on magnetic resonance imaging (MRI) or cerebrospinal fluid. ADEM is quite rare after malaria infection. Our patient, although diagnosed provisionally of ADEM after mixed malaria infection, had neuroimaging closely simulating MS. CASE REPORT: We report a case of a woman with an adult type 2 diabetes presenting with fever and diagnosed by antigen assay to be suffering from mixed malaria infection (Plasmodium falciparum, Plasmodium vivax). While recovering with artesunate and doxycycline therapy, she developed acute onset bladder retention followed by paraparesis. On examination she had evidence of Upper Motor Neuron (UMN) signs in all the 4 limbs along with truncal sensory loss. DISCUSSION: Her MRI of spine showed T2 hyperintensities suggestive of resolving myelitis. MRI of the brain showed multifocal and confluent areas of demyelination mostly involving the corpus callosum and periventricular region. Lesions, particularly the callosal ones, closely simulated MS. In accordance with the McDonald Criteria and Barkhof's MRI Criteria, this patient did not fit into the diagnosis of MS. Our provisional diagnosis was ADEM.

A rare case of Reifenstein's syndrome in two siblings.

The conditions like gynaecomastia and hypospadius are not uncommon. Approximately 40% of normal men have palpable breast tissue. Hypospadius affects in excess of 1 in 300 boys. But the two conditions together occur very rarely and that too in the siblings. Two brothers in the same family of 16 and 14 years of ages reported with the complaints of bilateral gynaecomastia and hypospadius. USG of breasts of both the brothers revealed well developed duct system. LH, FSH, testosterone, oestradiol levels were within normal limits. Hypospadius was corrected by staged procedure. Gynaecomastia was treated by subcutaneous mastectomy. During 3-year follow-up they reported that their social life was restored, which was disturbed earlier.

Non tuberculous mycobacteria and toxoplasma co-infection of the central nervous system in a patient with AIDS

New-onset seizures are frequent manifestations in patients infected with Human Immunodeficiency Virus (HIV). We describe the clinical and radiological findings in an 25yr old AIDS patient presenting with new onset seizures as the primary manifestation of cerebral toxoplasmosis and Non Tuberculous Mycobacterial [NTM] co-infection. Cranial computed tomography showed a subtle ventricular dilatation whereas magnetic resonance imaging disclosed prominent temporal horn. Toxoplasma tachyzoites and rapidly growing mycobacteria were recovered from CSF. Seizures were complex partial in nature and refractory to antiepileptic therapy.

Non Tuberculous Mycobacteria and toxoplasma co-infection of the central nervous system in a patient with AIDS.

New-onset seizures are frequent manifestations in patients infected with Human Immunodeficiency Virus (HIV). We describe the clinical and radiological findings in an 25yr old AIDS patient presenting with new onset seizures as the primary manifestation of cerebral toxoplasmosis and Non Tuberculous Mycobacterial [NTM] co-infection. Cranial computed tomography showed a subtle ventricular dilatation whereas magnetic resonance imaging disclosed prominent temporal horn. Toxoplasma tachyzoites and rapidly growing mycobacteria were recovered from CSF. Seizures were complex partial in nature and refractory to antiepileptic therapy.

Surgical repair of postlaryngectomy pharyngocutaneous fistulas.

Pharyngo-cutaneous fistula is a common complication after laryngectomy, which increases both the morbidity and the hospital stay. The incidence rate varies from 8.7% to 24.8% in different institutions. The continuous salivary leak is very much troublesome for the patients. There are various predisposing factors out of which preoperative radiotherapy, diabetes, malnutrition is very important. Spontaneous closure occurs in most of the cases on conservative management and only a few need surgical closures. Surgical methods used are direct surgical repair in two layers inner mucosa and outer skin, single distant flap like DP or PMMC, double distant flap like DP and PMMC one for inner mucosa and another for outer skin. Post operative swallowing was satisfactory in all the cases and there was no recurrence of fistula in one and half year follow up.

Pharyngo oesophageal strictures and its reconstruction by delto pectoral flaps.

Delto pectoral flap is a thin and pliable cutaneous axial flap suitable for the reconstruction of pharynx and upper oesophagus. Corrosive stricture of the pharyngo oesophageal area can very well be reconstructed by deltopectoral flap. Oesophageal reconstruction by viscera like stomach or colon often produces anastomic stricture at the upper anastomic site with hypopharynx or upper oesophagus. Delto pectoral flap can also be used to reconstruct this anastomotic stricture. Postoperative swallowing is satisfactory when reconstruction is done with this flap.