A Case of Brain Tuberculosis With an Unusual Presentation Mimicking Viral Fever During a Dengue Outbreak in Bangladesh.

Both dengue and tuberculosis are endemic in South Asian countries, including Bangladesh. Here we report an interesting case presenting as suspected dengue fever and eventually diagnosed as a case of brain tuberculosis. A 27-year-old immunocompetent male presented to us with fever, headache, retro-orbital pain, and photophobia for five days. He had no other complaints, and clinical examination findings were normal. Full blood count revealed neutrophilic leukocytosis; dengue antigen test and anti-dengue antibody test were negative. Magnetic resonance imaging (MRI) of the brain showed both supra and infra-tentorial multiple small (2-4 mm) gadolinium-enhancing lesions suggestive of tuberculomas. A cerebrospinal fluid study revealed lymphocytic pleocytosis with raised protein, low sugar level, and positive Gene Xpert MTB/RIF (Cepheid, California, US) assay test. Investigations did not reveal the involvement of other organs except for the brain. We started standard anti-tuberculosis therapy (HRZE) along with steroids and pyridoxine, and the patient became symptom-free within one week. The patient was discharged with the advice of follow-up after one month. The clinical course and all investigation findings of this case are presented. Central nervous system tuberculosis may present with non-specific signs and symptoms and may be misdiagnosed as other infections, including dengue, particularly during an ongoing epidemic. It may cause significant morbidity and mortality when the diagnosis is delayed due to its vague clinical presentation.

PET Neuroimaging Reveals Serotonergic and Metabolic Dysfunctions in the Hippocampal Electrical Kindling Model of Epileptogenesis.

Glucose metabolism and serotonergic neurotransmission have been reported to play an important role in epileptogenesis. We therefore aimed to use neuroimaging to evaluate potential alterations in serotonin 5-HT1A receptor and glucose metabolism during epileptogenesis in the rat electrical kindling model. To achieve this goal, we performed positron emission tomography (PET) imaging in a rat epileptogenesis model triggered by electrical stimulation of the hippocampus using 2-deoxy-2-[18F]fluoro-D-glucose (18F-FDG), a radiolabeled analog of glucose, and 2'-methoxyphenyl-(N-2'-pyridinyl)-p-18F-fluoro-benzamidoethylpiperazine (18F-MPPF), a radiolabeled 5-HT1A receptor ligand, to evaluate brain metabolism and 5-HT1A receptor functionality. Since the 5-HT1A receptor is also highly expressed in astrocytes, glial fibrillary acidic protein (GFAP) immunofluorescence was performed to detect astrogliosis arising from the kindling procedure once the study was finalized. Lastly, in vitro18F-MPPF autoradiography was performed to evaluate changes in 5HT1A receptor expression. 18F-FDG PET showed reduction of glucose uptake in cortical structures, whereas 18F-MPPF PET revealed an enhancement of tracer binding potential (BPND) in key areas rich in 5-HT1A receptor involved in epilepsy, including septum, hippocampus and entorhinal cortex of kindled animals compared to controls. However, in vitro 5-HT1A receptor autoradiography showed no changes in densitometric signal in any brain region, suggesting that the augmentation in BPND found by PET could be caused by reduction of synaptic serotonin. Importantly, astroglial activation was detected in the hippocampus of kindled rats. Overall, electrical kindling induced hypometabolism, astrogliosis and serotonergic alterations in epilepsy-related regions. Furthermore, the present findings point to 5-HT1A receptor as a valuable epileptogenesis biomarker candidate and a potential therapeutic target.

Ticagrelor Versus Prasugrel for the Treatment of Patients with Type 2 Diabetes Mellitus Following Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis.

INTRODUCTION: Antiplatelet therapy is very important following percutaneous coronary intervention (PCI). New generation P2Y12 inhibitors (ticagrelor and prasugrel) might potentially replace clopidogrel for the treatment of post-interventional acute coronary syndrome (ACS). In this analysis, we aimed to systematically compare the post-interventional clinical outcomes and bleeding events observed with ticagrelor versus prasugrel in patients with type 2 diabetes mellitus (T2DM). METHODS: EMBASE, MEDLINE, the Cochrane Central Register of Controlled Trials, and www.ClinicalTrials.gov were carefully searched for publications comparing the post-coronary interventional outcomes following ticagrelor versus prasugrel use in patients with T2DM. Adverse clinical outcomes and bleeding events were considered as the endpoints. Statistical analysis was carried out by the Revman software (version 5.3). Odds ratios (OR) and 95% confidence intervals (CI) were used to represent the data during subgroup analysis. RESULTS: A total of 2004 participants with T2DM were included in this analysis. Following PCI, mortality (OR 1.00, 95% CI 0.57-1.76; P = 0.99, I2 = 19%), myocardial infarction (OR 0.86, 95% CI 0.42-1.75; P = 0.67, I2 = 0%), major adverse cardiac events (OR 0.73, 95% CI 0.42-1.27; P = 0.27, I2 = 0%), and stroke (OR 0.72, 95% CI 0.20-2.59; P = 0.61, I2 = 0%) were not significantly different between ticagrelor and prasugrel. In addition, total bleeding events (OR 0.87, 95% CI 0.55-1.40; P = 0.58, I2 = 6%), Thrombolysis in Myocardial Infarction (TIMI) defined minor bleeding (OR 2.39, 95% CI 0.58-9.91; P = 0.23, I2 = 0%), TIMI defined major bleeding (OR 1.42, 95% CI 0.27-7.45; P = 0.68, I2 = 0%), bleeding defined according to the Bleeding Academic Research Consortium (BARC) major bleeding (OR 0.55, 95% CI 0.22-1.36; P = 0.20, I2 = 0%), BARC minor bleeding (OR 1.44, 95% CI 0.52-3.99; P = 0.48, I2 = 0%), and total minimal bleeding (OR 3.12, 95% CI 0.55-17.59; P = 0.20, I2 = 0%) were also not significantly different. CONCLUSION: Ticagrelor and prasugrel were not associated with significantly different adverse clinical outcomes and bleeding events in these patients with T2DM. Therefore, both antiplatelet agents might safely be used in patients with T2DM following coronary intervention. However, this head-to-head comparison still remains a major challenge which should be resolved in larger clinical trials.

Comparing mortality between fibrinolysis and primary percutaneous coronary intervention in patients with acute myocardial infarction: a systematic review and meta-analysis of 27 randomized-controlled trials including 11 429 patients.

OBJECTIVES: We aimed to improve the limitations encountered in previously published studies and then compare mortality in patients with acute myocardial infarction (AMI) who were treated with either fibrinolysis or a primary percutaneous coronary intervention (PPCI). METHODS: EMBASE, MEDLINE, and the Cochrane databases were searched for trials comparing fibrinolysis with PPCI in patients with AMI. The only endpoint that was assessed in this analysis was all-cause mortality. Therefore, in-hospital, short-term, mid-term, and long-term mortality were analyzed, whereby odds ratios (OR) with 95% confidence intervals (CIs) were calculated using the RevMan 5.3. RESULTS: A total of 11 429 patients obtained from 37 studies (involving 27 trials) were included. The results of this analysis showed that fibrinolytic therapy was associated with significantly higher in-hospital and mid-term mortality (OR: 0.61; 95% CI: 0.46-0.82, P=0.001 and OR: 0.73; 95% CI: 0.54-0.99, P=0.04, respectively). Short-term and long-term mortality were also significantly higher in the fibrinolytic group (OR: 0.76; 95% CI: 0.65-0.90, P=0.001, and OR: 0.82; 95% CI: 0.71-0.96, P=0.01, respectively) compared with PPCI. CONCLUSION: This analysis of 11 429 patients showed a significantly higher mortality rate to be associated with fibrinolysis compared with PPCI in these patients with AMI. Hence, compared with fibrinolysis, PPCI is expected to be the preferred method of revascularization in patients with AMI, especially in PCI-capable centers.

Carcinoma of Maxillary Sinus Masquerading as Odontogenic Infection.

Malignant tumours of maxillary sinus are rare. They are usually diagnosed in the late stages when they perforate the sinus walls. The presence of large air space in the maxillary sinus facilitates asymptomatic growth of the sinus malignancy. The clinical presentation of these tumours depends on the sinus wall involved by the disease. The medial wall is usually the first to become eroded, leading to nasal obstruction, epistaxis or discharge. Rarely, symptoms of maxillary sinus carcinoma can resemble dental infection and the affected patients may visit dental clinic seeking treatment. This report presents a case of carcinoma of maxillary sinus mimicking odontogenic infection. Computed tomographic findings explained the reason for the present lesion to masquerade as an inflammatory condition. The importance of advanced imaging modalities for prompt identification of such lesions is discussed.

[(18)F]FDG PET Neuroimaging Predicts Pentylenetetrazole (PTZ) Kindling Outcome in Rats.

PURPOSE: Epileptogenesis, i.e., development of epilepsy, involves a number of processes that alter the brain function in the way that triggers spontaneous seizures. Kindling is one of the most used animal models of temporal lobe epilepsy (TLE) and epileptogenesis, although chemical kindling suffers from high inter-assay success unpredictability. This study was aimed to analyze the eventual regional brain metabolic changes during epileptogenesis in the pentylenetetrazole (PTZ) kindling model in order to obtain a predictive kindling outcome parameter. PROCEDURES: In vivo longitudinal positron emission tomography (PET) scans with 2-deoxy-2-[(18)F]fluoro-D-glucose ([(18)F]FDG) along the PTZ kindling protocol (35 mg/kg intraperitoneally (i.p.), 18 sessions) in adult male rats were performed in order to evaluate the regional brain metabolism. RESULTS: The half of the PTZ-injected rats reached the kindled state. In addition, a significant decrease of [(18)F]FDG uptake at the end of the protocol in most of the brain structures of kindled animals was found, reflecting the characteristic epilepsy-associated hypometabolism. However, PTZ-injected animals but not reaching the kindled state did not show this widespread brain hypometabolism. Retrospective analysis of the data revealed that hippocampal [(18)F]FDG uptake normalized to pons turned out to be a predictive index of the kindling outcome. Thus, a 19.06 % reduction (p = 0.008) of the above parameter was found in positively kindled rats compared to non-kindled ones just after the fifth PTZ session. CONCLUSION: Non-invasive PET neuroimaging was a useful tool for discerning epileptogenesis progression in this animal model. Particularly, the [(18)F]FDG uptake of the hippocampus proved to be an early predictive parameter to differentiate resistant and non-resistant animals to the PTZ kindling.

Serotonin Depletion Does not Modify the Short-Term Brain Hypometabolism and Hippocampal Neurodegeneration Induced by the Lithium-Pilocarpine Model of Status Epilepticus in Rats.

It has been reported that fluoxetine, a selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitor, has neuroprotective properties in the lithium-pilocarpine model of status epilepticus (SE) in rats. The aim of the present study was to investigate the effect of 5-HT depletion by short-term administration of p-chlorophenylalanine (PCPA), a specific tryptophan hydroxylase inhibitor, on the brain hypometabolism and neurodegeneration induced in the acute phase of this SE model. Our results show that 5-HT depletion did modify neither the brain basal metabolic activity nor the lithium-pilocarpine-induced hypometabolism when evaluated 3 days after the insult. In addition, hippocampal neurodegeneration and astrogliosis triggered by lithium-pilocarpine were not exacerbated by PCPA treatment. These findings point out that in the early latent phase of epileptogenesis, non-5-HT-mediated actions may contribute, at least in some extent, to the neuroprotective effects of fluoxetine in this model of SE.

Identifying Aarskog Syndrome.

Aarskog syndrome also known as Aarskog-Scott Syndrome, Facio-digito-genital Syndrome or Faciogenital Dysplasia is a rare, X-linked disorder predominantly affecting males, characterized by facial, skeletal and genital anomalies. This is a case report of a 15-year-old male patient who visited our college complaining of poor facial aesthetics. History revealed consanguinity and his sibling to be suffering from the same. A diagnosis of Aarskog syndrome was made based upon the detailed patient history, thorough clinical evaluation and identification of characteristic findings in radiographs. Professional counselling explained him the nature of his condition and treatment options to correct dental anomalies and congenital malformations were advised.

Subacute administration of fluoxetine prevents short-term brain hypometabolism and reduces brain damage markers induced by the lithium-pilocarpine model of epilepsy in rats.

The role of serotonin (5-hydroxytryptamine; 5-HT) in epileptogenesis still remains controversial. In this regard, it has been reported that serotonergic drugs can alter epileptogenesis in opposite ways. The main objective of this work was to investigate the effect of the selective 5-HT selective reuptake inhibitor (SSRI) fluoxetine administered subacutely (10mg/kg/day×7 days) on the eventual metabolic impairment induced by the lithium-pilocarpine model of epilepsy in rats. In vivo 2-deoxy-2-[(18)F]fluoro-d-glucose ([(18)F] FDG) positron emission tomography (PET) was performed to assess the brain glucose metabolic activity on days 3 and 30 after the insult. In addition, at the end of the experiment (day 33), several histochemical and neurochemical assessments were performed for checking the neuronal functioning and integrity. Three days after the insult, a marked reduction of [(18)F] FDG uptake (about 30% according to the brain region) was found in all brain areas studied. When evaluated on day 30, although a hypometabolism tendency was observed, no statistically significant reduction was present in any region analyzed. In addition, lithium-pilocarpine administration was associated with medium-term hippocampal and cortical damage, since it induced neurodegeneration, glial activation and augmented caspase-9 expression. Regarding the effect of fluoxetine, subacute treatment with this SSRI did not significantly reduce the mortality rate observed after pilocarpine-induced seizures. However, fluoxetine did prevent not only the short-term metabolic impairment, but also the aforementioned signs of neuronal damage in surviving animals to lithium-pilocarpine protocol. Finally, fluoxetine increased the density of GABAA receptor both at the level of the dentate gyrus and CA1-CA2 regions in pilocarpine-treated animals. Overall, our data suggest a protective role for fluoxetine against pilocarpine-induced brain damage. Moreover, this action may be associated with an increase of GABAA receptor expression in hippocampus.

In vivo [¹8F] FDG PET imaging reveals that p-chloroamphetamine neurotoxicity is associated with long-term cortical and hippocampal hypometabolism.

PURPOSE: p-Chloroamphetamine (PCA) is a neurotoxin that selectively degenerates the serotonin (5-HT) axon terminals. In order to study the brain metabolic consequences induced by serotonergic denervation, a single dose of PCA (2.5 or 10 mg/kg i.p.) was administered to male adult rats. PROCEDURES: In vivo regional brain metabolism was evaluated 3 and 21 days after PCA (2.5 or 10 mg/kg; i.p.) injection by 2-deoxy-2-[(18)F] fluoro-D-glucose ([(18)F] FDG) positron emission tomography (PET). At day 22, the following markers of neurotoxicity were determined: (a) 5-HT axon terminal lesion by 5-HT transporter (SERT) autoradiography, (b) reactive gliosis by glial fibrillary acidic protein immunohistochemistry, and (c) eventual neurodegeneration by DAPI/Fluoro-Jade C labeling. RESULTS: An average of 20 % reduction of [(18)F] FDG uptake in most brain areas was observed at day 21 under 10 mg/kg PCA treatment. Instead, 2.5 mg/kg PCA only reduced metabolic activity in neocortex. Likewise, the high dose of PCA exerted a strong decrease (>30 %) in SERT density in several 5-HT innervated regions, but no effect was found in midbrain raphe nuclei, the main source of serotonergic neurons. Although PCA induced astroglial activation both in hippocampus and cortex in response to axotomy, no signs of neuronal death in these areas were detected. CONCLUSIONS: Overall, [(18)F] FDG PET revealed that the reduction of the brain metabolic activity induced by PCA is related to 5-HT axon terminal lesion, with no apparent affectation of neuronal viability.

Validity of the fast scan for diagnosis of intraabdominal injury in blunt abdominal trauma.

BACKGROUND: Blunt abdominal trauma is regularly encountered in the emergency department. The aim of the study is to determine the validity of assessment with sonography for trauma (FAST) scans in the evaluation of BAT in comparison to Computed tomogram/Exploratory laparotomy (CT/FLAP). METHODS: This cross-sectional study was carried out at Ayub Teaching Hospital Abbottabad from January 2010 to December 2011. FAST was performed as part of the primary or secondary survey of the trauma patient in the emergency department in all patients with suspected blunt abdominal trauma. All of them also underwent either CT or ELAP depending on their clinical condition. The validity of FAST scan in comparison to CT/ELAP was documented. RESULTS: Our study included 100 patients with suspected blunt abdominal trauma. The mean age was 3 1.52 ± 16.79 years with 88% males. Road traffic accidents accounted for 80% cases and 20% were due to fall. Seventy percent were hemodynamically stable and 30% were unstable. Haemodynamically unstable patients had significantly more positive FAST scans and more positive CTIELAP (p < 0.05). Of the total, 52% had positive CTIELAP and 54% had positive FAST scan. Majority (28%) had splenic injury. A positive scan had a statistically significant probability of a confirmed blunt abdominal trauma on CT/ELAP; p = O.OO, OR = 8.095, 95% CI = 3.3-19.8. FAST scan had a sensitivity, specificity, positive predictive value and negative predictive value of 76.92%, 70.83%, 74.07% and 73.9% respectively. CONCLUSION: FAST scan had lesser accuracy as compared to previously published local and international data. More work is required before it can be routinely utilized to triage the blunt abdominal trauma patients to laparotomy.