Cricopharyngeal myotomy in neurogenic oropharyngeal dysphagia.

OBJECTIVE: Cricopharyngeal myotomy as an independent procedure has been performed on fourteen patients with a variety of neuromuscular disorders, suffering from neurogenic oropharyngeal dysphagia in the interval between 1994-1997. All of them were referred from a neurophysician or physiatrist after failure of improvement by medical treatment. METHODS: The selection of patients for operation was based mainly on clinical evaluation and simple exclusion criteria without manometric studies. RESULTS: There was dramatic improvement in twelve, with recurrent laryngeal nerve palsy and temporary pharyngeal fistula in two patients. No mortality was recorded. CONCLUSION: We conclude that cricopharyngeal myotomy is a simple, safe and effective procedure with acceptable morbidity. It should be considered as a rehabiliation procedure for patients with dysphagia due to various neurologic disorders based on simple, clinical exclusion criteria without the need for the tedious, time consuming and expensive manometric studies.

ELISA versus routine tests in the diagnosis of patients with systemic and neurobrucellosis.

Sera from patients in different stages of brucellosis as well as sera and cerebrospinal fluid (CSF) from patients with central nervous system (CNS) brucellosis and controls, were tested by ELISA for Brucella-specific IgG, IgM and IgA. The results were compared with culture findings, micro-agglutination (MA), slide agglutination with Rose Bengal (RB), and Brucella melitensis stained antigens (SA). In sera of patients with acute brucellosis (296), ELISA was positive for IgM (100%), IgG (97%) and IgA (98%), and comparable results were found in sera of patients with subacute brucellosis (44): IgG (100%), IgM (86%) and IgA (100%). However, in patients with chronic brucellosis (40), IgG and IgA were consistently positive (100%) while IgM was only positive in 33% of their sera. The MA and RB showed similar results, being more positive in patients with acute (98%) and subacute (84%) than in chronic (61%) brucellosis. The SA and culture showed significantly lower positive results. In the CSF of patients with CNS brucellosis (45), ELISA was positive in 100%, 20% and 85% for IgG, IgM and IgA, respectively, compared to 13% positive by culture, 25% by MA and 22% by RB. ELISA was negative in the CSF specimens from patients with brucellosis without CNS involvement (66), or meningitis other than Brucella (62), and no meningitis (144). Thus, ELISA with its IgG, IgM and IgA profiles is the test of choice in the diagnosis of patients with brucellosis, especially those with chronic or CNS infection.

Clinical categories of neurobrucellosis. A report on 19 cases.

Brucellosis rarely can present with involvement restricted to the nervous system. We describe a total of 19 cases of neurobrucellosis in whom the clinical presentation lay in three distinct categories. The first was an acute presentation with meningoencephalitis. The disease also presented in a chronic form where the brunt of the illness can either be in the peripheral or the central nervous system (CNS). The chronic peripheral form is that of a proximal polyradiculoneuropathy. The central form is that of diffuse CNS involvement, predominantly with myelitis or cerebellar involvement with or without cranial nerve palsies. Although the two chronic forms, 'peripheral' and 'central', are distinct, some overlap is possible. This was not observed for the acute form. The pathology of the three presentations may be different, being a direct effect of infection in the acute form, and an immune-related process, possibly demyelinating in nature, in the chronic forms. The response to treatment in the acute and chronic forms is also different, being much better in the acute form. Awareness of the condition and performance of the appropriate serological tests will differentiate neurobrucellosis from other chronic CNS infections, especially tuberculosis and neurosyphilis.

Internal carotid artery occlusion in a young female with mitral valve prolapse.

A healthy 28 year old housewife presented with sudden right hemiplegia and aphasia. No predisposing factors could be ascertained apart from posterior cusp mitral value prolapse on two dimensional echocardiography. Extensive investigations confirmed the presence of cerebral infarction and persistent occlusion of the left internal carotid artery near its origin.

Rapid diagnosis of central nervous system brucellosis by ELISA.

The diagnosis of central nervous system (CNS) brucellosis was made by determining Brucella-specific IgG, IgM and IgA in cerebrospinal fluid (CSF) specimens, using an enzyme-linked immunosorbent assay (ELISA) method. A total of 68 CSF specimens including 10 from patients with brucellosis of the nervous system, 4 with Brucella infection but without CNS involvement, 38 with meningitis other than due to Brucella and 16 with no meningitis were studied. Of the 10 CSF specimens from patients with CNS brucellosis, Brucella-specific IgG was detected in all 10, IgM in 7 and IgA in 8. The 10 patients were also seropositive for anti-Brucella IgG and IgM, and 9 were seropositive for IgA. No Brucella-specific IgG, IgM or IgA was detected in the CSF of 4 patients with brucellosis but without CNS involvement, even though the blood of these patients had high titres of anti-Brucella IgG, IgM and IgA. In addition, none of the CSF specimens from the 38 patients with meningitis other than due to Brucella, or from the 16 patients without meningitis, had detectable anti-Brucella antibodies. This study indicates that the Brucella ELISA on CSF is a reliable, rapid, sensitive and specific assay in the diagnosis of CNS brucellosis.