Hip septic arthritis in children: assessment of treatment using needle aspiration/irrigation.

INTRODUCTION: This retrospective series evaluated the surgical treatment of hip arthritis in children by needle aspiration-irrigation alone. PATIENTS AND METHODS: Forty-three cases of septic hip arthritis were treated by needle aspiration-irrigation under general anesthesia associated with intravenous then oral administration of antibiotics. Clinical and biological criteria at admission, during hospitalization and at final follow-up were studied to identify any criteria carrying a predictive value for unsuccessful needle aspiration-irrigation. RESULTS: Thirty-eight hips had a favorable outcome in this series, while secondary open arthrotomy was required in five hips for further irrigation. Common criteria found in the group requiring open arthrotomy were a diagnosis delay of at least 6 days between initial clinical symptoms and treatment as well as markedly abnormal biological results at admission. A threshold for the predictive value of certain variables was identified including C-reactive protein above 100, white polynuclear blood count above 15000, and sedimentation rate above 25 in the first hour and 50 in the second hour. DISCUSSION: Treatment modalities for septic arthritis of the hip remain controversial in children and various techniques have been shown to be effective in the literature. Needle aspiration-drainage, the least invasive of these, has been shown to have good results, even in the hip, even though this is a deep, tight, joint which is known to be difficult to drain. Prognostic criteria are difficult to identify, however all authors agree that delayed treatment makes evacuation of intra-articular debris especially difficult. CONCLUSION: Needle aspiration-irrigation is effective in septic arthritis of the hip, as long as basic principles are followed. Delayed treatment and certain biological criteria should be taken into account when selecting a treatment, since negative predictive criteria identified in this series were present in the five hips requiring secondary arthrotomy.

An unusual homonymous visual field defect.

A 75-year-old man suddenly became aware of an inferior right homonymous visual field defect. Although static perimetry suggested a lesion of the left lateral geniculate nucleus, kinetic perimetry indicated that the presumed homonymous horizontal sectoranopia noted on static perimetry was actually an incomplete homonymous hemianopia with incomplete sparing of the temporal crescent. The location of the lesion was subsequently confirmed by magnetic resonance imaging. This case shows the value of kinetic perimetry in assessing homonymous visual field defects.

The perils of a sneeze.

A 51-year-old woman had a 3-day history of severe left supraorbital pain associated with blurred vision of the left eye. Examination revealed visual acuity of 20/20 OD and 20/100 OS. A left relative afferent pupillary defect was present. Neuroimaging revealed a large intra-, supra-, and parasellar mass that had eroded through the sphenoid sinus into the maxillary sinus. Secondary pneumocephalus was present. Pathologic examination of the tissue revealed a pituitary adenoma of the null cell type. To the best of our knowledge, there is only one other case in the literature in which a spontaneous pneumatocele represents the initial manifestation of a pituitary adenoma.

Trigeminal nerve hypertrophy in chronic inflammatory demyelinating polyradiculoneuropathy.

An unusual clinical manifestation of nerve hypertrophy in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is described. A patient with a 13-year history of CIDP developed diplopia and proptosis. Imaging of the neuraxis showed marked bilateral trigeminal nerve hypertrophy and lumbosacral nerve root hypertrophy. Biopsy of the right infraorbital nerve revealed inflammatory infiltrates and extensive onion bulb formation, consistent with CIDP.

Neuro-ophthalmic findings in progressive multifocal leukoencephalopathy.

BACKGROUND: Progressive multifocal leukoencephalopathy (PML) is a demyelinating disorder of the central nervous system found in immunodeficient patients, most frequently now in those infected with HIV. It may represent the initial manifestation of HIV infection. Since the central visual pathways may be affected, a variety of neuro-ophthalmic signs and symptoms can manifest. We studied the clinical, radiographic and histopathological characteristics of patients with PML. METHODS: The charts of 13 patients in whom PML was diagnosed in the Neuro-AIDS clinic at the Montreal Neurological Institute between November 1987 and March 1995 were reviewed. The diagnosis of PML was established by characteristic clinical features together with typical computed tomographic or magnetic resonance imaging findings, such as nonenhancing low-density (on computed tomography) or hyperintense (on T2-weighted magnetic resonance imaging) white-matter lesions, without mass effect. Neuro-ophthalmic findings were based on clinical examination by an ophthalmologist, neuro-ophthalmologist or neurologist. Tissue for pathological examination was obtained by biopsy in one case and at postmortem study in a second case. RESULTS: The most common finding was homonymous hemianopia, in five patients (38%). Other features included nystagmus (in two patients), diplopia with cranial nerve palsy (in one) and cortical blindness (in one). One of the patients exhibited involvement of the brain stem, a site not usually affected by this demyelinating process. INTERPRETATION: The diagnosis of PML should be considered in immunocompromised patients with neuro-ophthalmic findings, particularly those with homonymous hemianopia.