Tick paralysis with atypical presentation: isolated, reversible involvement of the upper trunk of brachial plexus.

Tick paralysis is a disease that occurs worldwide. It is a relatively rare but potentially fatal condition. The only way to establish the diagnosis is to carefully search for the tick paralysis. It is caused by a neurotoxin secreted by engorged female ticks. Tick paralysis generally begins in the lower extremities and ascends symmetrically to involve the trunk, upper extremities and head within a few hours. Although early-onset prominent bulbar palsy and isolated facial weakness without generalised paralysis are rare, there is no report in the English literature concerning isolated, reversible involvement of the upper trunk of brachial plexus caused by tick bite. We report a case of isolated, reversible involvement of the upper trunk of brachial plexus as a variant of tick paralysis. Diagnosis was confirmed with needle electromyography and nerve conduction examination. Within 2 weeks, the patient was fully recovered. The purpose of presenting this case is to remind clinicians that tick paralysis should be considered even in cases with atypical neurological findings admitted to the emergency department.

Tuberculous meningitis in adults in Turkey: epidemiology, diagnosis, clinic and laboratory [corrected].

A retrospective study was performed to assess the epidemiology, diagnosis, clinic, and laboratory of the patients with tuberculous meningitis (TBM) in a multicentral study. The medical records of adult cases with TBM treated at 12 university hospitals throughout Turkey, between 1985 and 1998 were reviewed using a standardized protocol. The diagnosis of TMB was established with the clinical and laboratory findings and/or microbiological confirmation in cerebrospinal fluid (CSF). The non-microbiologically confirmed cases were diagnosed with five diagnostic sub-criteria which CSF findings, radiological findings, extra-neural tuberculosis, epidemiological findings and response to antituberculous therapy. A total of 469 patients were included in this study. Majority of the patients were from Southeast Anatolia (164 patients, 35.0%) and (108 patients, 23.0%) from East Anatolia regions. There was a close contact with a tuberculous patient in 88 of 341 patients (25.8%) and with a tuberculous family member in 53 of 288 patients (18.4%). BCG scar was positive in 161 of 392 patients (41.1%). Tuberculin skin test was done in 233 patients and was found to be negative in 75. Totally 115 patients died (24.5%) of whom 23 died in 24 hour after admittance. The diagnosis was confirmed with clinical findings and CSF culture and/or Ziehl-Nelson staining in 88 patients (18.8%). Besides clinical criteria, there were three or more diagnostic sub-criteria in 252 cases (53.7%), two diagnostic sub-criteria in 99 cases (21.1%), and any diagnostic sub-criteria in 30 patients (6.4%). Since TBM is a very critical disease, early diagnosis and treatment may reduce fatal outcome and morbidity.

Predictors of outcome in patients with tuberculous meningitis.

OBJECTIVE: To assess predictors of mortality and neurological sequelae in patients with tuberculous meningitis (TBM). METHODS: Patients with TBM treated at 12 university hospitals in Turkey between 1985 and 1997 were evaluated using a standardised protocol applied retrospectively. Variables associated with hospital mortality as well as with the presence of neurological sequelae at 6 months were determined using logistic regression models. RESULTS: Four hundred and thirty-four patients between the ages of 13 and 83 years (mean 33 years) were evaluated. Sixty-eight per cent of these patients presented with Medical Research Council Stage II or III. One hundred and one patients (23.3%) died and 67 (27%) of evaluable survivors had neurological sequelae. In multi-variable analysis, convulsion (OR 3.3, 95%CI 1.2-9.0, P = 0.02), comatose mental status (OR 6.0, 95%CI 3.6-10.2, P = 0.01), and delayed or interrupted treatment (OR 5.1, 95%CI 2.4-11.2, P = 0.01) were shown to be predictors for mortality. The presence of extra-meningeal tuberculosis (OR 2.1, 95%CI 1.1-4.2, P = 0.035), cranial nerve palsy (OR 2.6, 95%CI 1.4-4.2, P = 0.01), hemiparesia/focal weakness (OR 9.3, 95%CI 3.8-22.6, P = 0.01), hemiplegia/multiple neurological deficit (OR 7.1, 95%CI 2.14-23.38, P = 0.01) and drowsiness (OR 4.2, 95%CI 2.04-8.82, P = 0.01) were independent predictors of neurological sequelae at 6 months following hospital discharge. CONCLUSION: The results of this study emphasise the importance of prompt and uninterrupted anti-tuberculosis therapy for tuberculous meningitis. The presence of seizures or coma on admission to hospital are important predictors for mortality, while the presence of focal neurological signs is a predictor for persistent neurological sequelae in survivors.

Postoperative wound infections.

A prospective study of postoperative wound infection was carried out over a two year period in Cumhuriyet University Medicine Faculty Hospital in Sivas, Turkey. Examination of wounds, with cultures of all suspicious wounds using standard bacteriological methods was performed. Of a total of 4146 surgical wounds, 188 (4.53%), became infected. High infection rates were noted after colon resection (32.1%), gastric and oesophageal operations (21.1%), cholesystectomy (17.2%), and splenectomy (10.2%). Low infection rates were noted after thyroidectomy, mastectomy, caesarean section and abdominal hysterectomy. The commonest causative organisms were coagulase-negative staphylococci 21.7%, Staphylococcus aureus 19.7%, Escherichia coli 19.7%, Enterobacter spp. 17.6%, and Pseudomonas spp. 10.7%.

[The histopathological effects of different treatments on lung tissue of mice pretreated with cyclophosphamide and steroids in experimental E. coli sepsis]. / Siklofosfamid ve steroid verilen farelerde olusturulan deneysel E. coli sepsisinde uygulanan farkli tedavilerin akciger histopatolojisi üzerine etkileri.

The incidence of gram-negative bacteremia is significantly increasing in recent years by the wide-spread use of cytotoxic and immunosuppressive drugs. Although, the effective antimicrobial drugs are being used in treatment, the mortality rate is still high. In this study, we searched for the histopathological changes occurring on lung tissue in E. coli sepsis, and their severity in different models. Microscopically, all the specimens were examined by the presence of interstitial and peribronchiolar inflammation, congestive atelectasis, and emphysema. The differences between the ratios of histopathological changes in treatment subgroups were not statistically significant. However, the ratio of interstitial and peribronchiolar inflammation and emphysema was significantly decreased in mice received cyclophosphamide, when compared with control group. Besides, the ratio of peribronchiolar inflammation was significantly increased in mice received steroid when compared with control group.

[Antibiotic and specific immunoglobulin G in the treatment of E. coli sepsis in mice previously given steroids]. / Steroid verilen farelerde olusturulan deneysel E. coli sepsisinde antibiyotik ile beraber immünoglobulin G tedavisi.

Experimental E. coli sepsis was constituted in two groups of mice. One of the groups have been immunosuppressed by steroid therapy of ten days (group A) and the other group was normal (group B). Ceftriaxone and Ig G, prepared by vaccinating rabbits with the same strain of E. coli, were used in therapy. The results of the therapy in both were compared. The mortality rate of mice on Ig G therapy was % 70 in group A and % 80 in group B and that on ceftriaxone therapy % 60 and % 50, respectively. The mortality rate was % 30 in both groups with Ig G + ceftriaxone therapy. There wasn't any significance between these. On this research, the treatment of antibiotic together with Ig G decreased the mortality rate. The statistical value of the mortality rate among the treatment groups was not found significant.

[IgG therapy of experimental E. coli sepsis in neutropenic mice]. / Nötropenik farelerde olusturulan E.coli sepsisinde IgG tedavisi.

The treatment of Ceftriaxone and IgG in neutropenic (Group A), and in normal (Group B) mice were investigated in experimental E. coli sepsis. IgG was obtained from the rabbits immunized with same strain. The inoculum dose of infection was 4 x 10(8) bacteria/ml in the experiment. The two groups were divided into four subgroups; Control, IgG. Ceftriaxone and Ceftriaxone + IgG groups. The mortality rates of mice in both groups and bacteria growing in organ cultures are investigated and compared. IgG treatment reduced the mortality in the normal mice, but no significant difference was found between two groups. An addition of IgG to Ceftriaxone treatment significantly decreased the mortality rate in both of the groups (p less than 0.05). But a significant difference was not observed between two subgroups treated with IgG and Ceftriaxone.

[Meningococcal meningitis in adults]. / Eriskinlerde meningokoksik menenjit.

The clinical and laboratory findings, and the results of treatment of 16 Meningococcal meningitis cases, who were hospitalized, are investigated, and discussed with the literature. On application all of the patients had headache, meningeal irritation findings, and fever (% 75), nausea and vomiting (% 62.5), rash (% 56.25), unconsciousness (% 50), coma state (% 31.25), Herpes labialis (% 31.25), affecting of cranial nerves (% 12.5), arthritis (% 12.5), and carditis (% 6.25). At the peripheric blood examinations, all had leucocytosis, and neutrophilia. In the direct examination of the cerebrospinal-fluid, in 15 patients gram negative diplococci were seen, and in 11 patients the microorganisms grew on culture. The patients were given Crystalized-Penicillin in doses of 20-30 million IU/day. In the two cases some complications, resistance, and allergy developed, so the treatment changed. Only a patient died, and in the other cases no relapse and sequel were seen.

Treatment of tuberculous meningitis in adults with a combination of isoniazid, rifampicin and streptomycin: a prospective study.

15 patients with tuberculous meningitis were treated with isoniazid, streptomycin and rifampicin and 14 with isoniazid, streptomycin and ethambutol for 12 months. Both groups received prednisolone at the beginning of treatment. The two groups were compared with regard to clinical improvement, presence of neurological sequelae and mortality. No difference in recovery rate between the groups was observed. 6 patients (21%) died (5 in group I and 1 in group II). Residual sequelae developed in 9 cases (5 in group I and 4 in group II; 31%). The difference between the groups was not significant. The regimen including rifampicin for tuberculous meningitis did not result in any superiority compared to standard therapy.

A case of cutaneous anthrax with toxaemic shock.

We describe a patient who presented with a necrotic black eschar 2 x 2 cm on the neck, extensive erythema around the lesion and massive oedema extending from the lesion to the umbilicus, and involving the whole face. Severe toxaemia and shock developed. Bacillus anthracis was isolated from the lesion. Prednisolone and dopamine failed to reverse the shock. The patient recovered completely with penicillin therapy.