BACKGROUND: Tuberculosis (TB) remains an important public health problem in developing countries.... more BACKGROUND: Tuberculosis (TB) remains an important public health problem in developing countries. OBJECTIVE: To evaluate the clinical presentation, management, and long-term outcome in 6 patients with tuberculous brain abscesses (TBA), an uncommon form of central nervous system (CNS) TB. METHODS: A search of medical records of a single referral neurological center in Mexico City from 2002 to 2007 retrieved 149 patients with CNS TB; 6 of them (4%) met Whitener's criteria for TBA and were included in this review. RESULTS: Five of six patients had a previous history of TB. Three patients were referred to our center under antituberculous treatment (ATT) for pulmonary and lymph node TB, and two patients were receiving ATT for TB meningitis at diagnosis of TBA. All presented with symptoms of intracranial hypertension and hemiparesis. On imaging studies, 3 patients had a single, deep multiloculated lesion and another three had separated lesions, all patients underwent surgery and received long courses of ATT. One patient died after surgery and the rest recovered with moderate to severe neurological sequelae. The residual lesions in 5 patients resolved in follow-up CT or MRI studies at a mean time of 10 months. CONCLUSIONS: Early surgery confirms the diagnosis of TBA. Some patients may require additional surgical procedures if enlargement or recurrence of the lesion occurs. No evidence of drug resistance was found in our cases, and we found only two reports of TBA with primary resistance to ATT in a selective literature review. TBA does not seem to be a consequence of drug resistance. Sequelae are common, and long-term ATT with close clinical and imaging follow-up is mandatory.
The authors present the case of a 69 year old woman who developed bladder incontinence and confus... more The authors present the case of a 69 year old woman who developed bladder incontinence and confusion. A CT scan showed severe hydrocephalus and calcifictions, prompting a ventriculoperitoneal shunt placement. On the day after operation the patient presented left hemifacial spasm. MR revealed a subarachnoid cysticercus rostral to the pons, and surgical excision was proposed. She refused surgery and was placed on prednisone. Brainstem auditory responses were absent on the left side 2 months after shunting and were still abnormal 53 months later. The hemifacial spasm disappeared 3 months after shunt placement and has not recurred in 5 years of follow-up.
We report a case of a 32-year-old man who presented with subarachnoid hemorrhage. As revealed by ... more We report a case of a 32-year-old man who presented with subarachnoid hemorrhage. As revealed by lumbar puncture, the cerebrospinal fluid had low glucose, high protein levels, and pleocytosis with 5% of eosinophils. Cultures were negative. Enzyme-linked immunosorbent assay and complement fixation reactions for cysticercosis in cerebrospinal fluid were positive. An angiogram revealed an aneurysm of the right anteroinferior cerebellar artery. At surgery, the aneurysm was found to be surrounded by thickened leptomeninges, which histologically presented dense inflammation and remains of Cysticercus. The aneurysm could not be clipped, and it was wrapped. Postoperatively, the patient had dizziness and right ear tinnitus. He received prednisone therapy on alternate days and subsequently received albendazole for subarachnoid cysticerci. At the 4-year follow-up, the patient was asymptomatic and had normal cerebrospinal fluid. Although we cannot rule out a congenital aneurysm, its location inside an area of severe arachnoiditis around a cysticercus suggests an inflammatory origin. This type of vascular lesion not reported before should be suspected in patients with chronic cysticercotic meningitis.
We report the case of a 30-year-old man with known HIV-positive status who developed, 4 months pr... more We report the case of a 30-year-old man with known HIV-positive status who developed, 4 months prior to admission, recurrent left partial motor seizures followed by left hemiparesis. At another hospital, contrasted CT scan of the head revealed right frontal hypodense lesion with mass effect and focal contrast enhancement. A small left occipital lesion was also present. HIV-associated brain toxoplasmosis was considered and phenytoin, pyrimethamine, clindamycin and antiretrovirals were administered. Hemiparesis improved but, 3 weeks prior to admission, he developed progressive headache and bilateral visual defects. Upon admission to our center, he was found with left homonymous hemianopsia, right hemiparesis and a large hypodense left occipital lesion on a head CT scan. Proton MR spectroscopy showed lactate at 1.3 ppm, amino acids at 0.9 ppm, and diffusion-weighted imaging (DWI) revealed hyperintensity at the lesion, suggesting a pyogenic abscess. Aspiration yielded purulent material and Nocardia asteroides grew in culture. The patient was treated with trimethoprim–sulfametoxazole and recovered with a mild visual field residual defect.
Objective: The aim of this study was to determine if cerebrospinal fluid (CSF) levels of homovani... more Objective: The aim of this study was to determine if cerebrospinal fluid (CSF) levels of homovanillic acid (HVA) are related to the clinical features of delirium in a group of patients with acute onset neurological illness. Methods: Fifty-one patients with probable acute brain infection were classified as delirious and nondelirious according to Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) and Delirium Rating Scale (DRS). CSF HVA concentration was analyzed by high-performance liquid chromatography. Results: Delirium was present in 60.8% of the total sample. HVA levels were not significantly different between delirious and nondelirious patients. Remarkably, patients with psychotic symptoms shown higher levels of CSF HVA as compared to nonpsychotic patient values. In addition, HVA levels were positively correlated to specific items of DRS such as delusions (r=0.463, P=.001), hallucinations (r=0.438, P=.001), cognitive dysfunction (r=0.286, P=.042) and fluctuation of symptoms (r=0.280, P=.046) in the total sample. Subanalyses excluding patients taking antipsychotic drugs revealed that HVA CSF levels were higher in those patients with delusions, and furthermore, the dopamine metabolite remained positively correlated to delusion subscale of DRS. Conclusions: Our results suggest that psychotic symptoms in delirious patients may be related to increased dopamine neurotransmission, as reflected by increased CSF HVA concentration, providing direct evidence to support the dopaminergic theory of psychosis.
Journal of Chromatography B-analytical Technologies in The Biomedical and Life Sciences, 2007
Citrulline and nitric oxide (NO) are synthesized by NO synthase (NOS) in a 1:1-stoichiometry. In ... more Citrulline and nitric oxide (NO) are synthesized by NO synthase (NOS) in a 1:1-stoichiometry. In this study, we determined by HPLC arginine and citrulline concentrations by fluorescence detection and nitrate levels by UV absorbance detection in the cerebrospinal fluid (CSF) from patients with acute hydrocephalus that underwent ventricular drainage. We found increased citrulline concentration (50.6 ± 17.2 versus 20.9 ± 2.0 M) and decreased arginine/citrulline molar ratio (0.42 ± 0.11 versus 1.12 ± 0.16) in hydrocephalus patients, while arginine and nitrate concentrations and citrulline/nitrate molar ratio remained with little change. Citrulline has been determined as a marker of NOS activity in some studies, but it remains to be determined the extent at which this statement holds true, since other biochemical pathways also regulate the concentration of this amino acid. Our results suggest that citrulline is primarily synthesized from NOS in acute hydrocephalus. The evaluation of sample deproteinization by addition of methanol for the analysis of amino acids in CSF is also reported.
The authors present the case of a 59-year-old woman with an 8 months history of lancinating pain ... more The authors present the case of a 59-year-old woman with an 8 months history of lancinating pain and hyphestesia on the right side of the face along with hearing impairment. She had poor tolerance to carbamazepine. A non-enhancing cystic image was observed at the right cerebellopontine angle on magnetic resonance imaging. The patient underwent surgery. Through a right retromastoid minicraniectomy and under microscopic magnification the VII and VIII cranial nerve complex was found involved by multiple adhesions around a cysticercus. After the cyst was removed a loop of the anteroinferior cerebellar artery was identified compressing the V right nerve at its root entry zone. Decompression was performed by the insertion of a Teflon implant. The postoperative course was uneventful and trigeminal neuralgia (TN) disappeared after surgery. Five previous cases of cranial nerve hyperactive dysfunction syndromes, four of trigeminal neuralgia and one of hemifacial spasm associated to cerebellopontine angle cysticercosis are briefly commented. We suggest that in some of these cases microvascular compression was probably present, and during surgery of cerebellopontine angle cysticercus by either trigeminal neuralgia or hemifacial spasm, vascular compression must be carefully searched and treated when found.
Intracranial arteritis is a well-known complication of cerebral cysticercosis. The aim of this st... more Intracranial arteritis is a well-known complication of cerebral cysticercosis. The aim of this study was to explore the possible role of transcranial Doppler (TCD) in the evaluation of cysticercotic arteritis in 9 patients with subarachnoid cysticercosis and stroke. Arteritis of main basal vessels was detected by TCD in 7 of 10 arterial lesions that were demonstrated by cerebral angiography. The Doppler pattern was occlusive in 2 cases and stenotic in 5. In the 3 patients with lacunar infarcts, both cerebral angiography and TCD were normal. In 6 arterial lesions followed serially with TCD a stenotic pattern resolved within 4 and 6 months in 3 cases and remained in the stenotic range at 12 months in 1 case, whereas an occlusive pattern persisted at 6 and 18 months in the other 2 cases. In conclusion, TCD may be useful to detect and follow up cerebral vasculitis due to chronic cysticercotic arachnoiditis.
BACKGROUND: Tuberculosis (TB) remains an important public health problem in developing countries.... more BACKGROUND: Tuberculosis (TB) remains an important public health problem in developing countries. OBJECTIVE: To evaluate the clinical presentation, management, and long-term outcome in 6 patients with tuberculous brain abscesses (TBA), an uncommon form of central nervous system (CNS) TB. METHODS: A search of medical records of a single referral neurological center in Mexico City from 2002 to 2007 retrieved 149 patients with CNS TB; 6 of them (4%) met Whitener's criteria for TBA and were included in this review. RESULTS: Five of six patients had a previous history of TB. Three patients were referred to our center under antituberculous treatment (ATT) for pulmonary and lymph node TB, and two patients were receiving ATT for TB meningitis at diagnosis of TBA. All presented with symptoms of intracranial hypertension and hemiparesis. On imaging studies, 3 patients had a single, deep multiloculated lesion and another three had separated lesions, all patients underwent surgery and received long courses of ATT. One patient died after surgery and the rest recovered with moderate to severe neurological sequelae. The residual lesions in 5 patients resolved in follow-up CT or MRI studies at a mean time of 10 months. CONCLUSIONS: Early surgery confirms the diagnosis of TBA. Some patients may require additional surgical procedures if enlargement or recurrence of the lesion occurs. No evidence of drug resistance was found in our cases, and we found only two reports of TBA with primary resistance to ATT in a selective literature review. TBA does not seem to be a consequence of drug resistance. Sequelae are common, and long-term ATT with close clinical and imaging follow-up is mandatory.
The authors present the case of a 69 year old woman who developed bladder incontinence and confus... more The authors present the case of a 69 year old woman who developed bladder incontinence and confusion. A CT scan showed severe hydrocephalus and calcifictions, prompting a ventriculoperitoneal shunt placement. On the day after operation the patient presented left hemifacial spasm. MR revealed a subarachnoid cysticercus rostral to the pons, and surgical excision was proposed. She refused surgery and was placed on prednisone. Brainstem auditory responses were absent on the left side 2 months after shunting and were still abnormal 53 months later. The hemifacial spasm disappeared 3 months after shunt placement and has not recurred in 5 years of follow-up.
We report a case of a 32-year-old man who presented with subarachnoid hemorrhage. As revealed by ... more We report a case of a 32-year-old man who presented with subarachnoid hemorrhage. As revealed by lumbar puncture, the cerebrospinal fluid had low glucose, high protein levels, and pleocytosis with 5% of eosinophils. Cultures were negative. Enzyme-linked immunosorbent assay and complement fixation reactions for cysticercosis in cerebrospinal fluid were positive. An angiogram revealed an aneurysm of the right anteroinferior cerebellar artery. At surgery, the aneurysm was found to be surrounded by thickened leptomeninges, which histologically presented dense inflammation and remains of Cysticercus. The aneurysm could not be clipped, and it was wrapped. Postoperatively, the patient had dizziness and right ear tinnitus. He received prednisone therapy on alternate days and subsequently received albendazole for subarachnoid cysticerci. At the 4-year follow-up, the patient was asymptomatic and had normal cerebrospinal fluid. Although we cannot rule out a congenital aneurysm, its location inside an area of severe arachnoiditis around a cysticercus suggests an inflammatory origin. This type of vascular lesion not reported before should be suspected in patients with chronic cysticercotic meningitis.
We report the case of a 30-year-old man with known HIV-positive status who developed, 4 months pr... more We report the case of a 30-year-old man with known HIV-positive status who developed, 4 months prior to admission, recurrent left partial motor seizures followed by left hemiparesis. At another hospital, contrasted CT scan of the head revealed right frontal hypodense lesion with mass effect and focal contrast enhancement. A small left occipital lesion was also present. HIV-associated brain toxoplasmosis was considered and phenytoin, pyrimethamine, clindamycin and antiretrovirals were administered. Hemiparesis improved but, 3 weeks prior to admission, he developed progressive headache and bilateral visual defects. Upon admission to our center, he was found with left homonymous hemianopsia, right hemiparesis and a large hypodense left occipital lesion on a head CT scan. Proton MR spectroscopy showed lactate at 1.3 ppm, amino acids at 0.9 ppm, and diffusion-weighted imaging (DWI) revealed hyperintensity at the lesion, suggesting a pyogenic abscess. Aspiration yielded purulent material and Nocardia asteroides grew in culture. The patient was treated with trimethoprim–sulfametoxazole and recovered with a mild visual field residual defect.
Objective: The aim of this study was to determine if cerebrospinal fluid (CSF) levels of homovani... more Objective: The aim of this study was to determine if cerebrospinal fluid (CSF) levels of homovanillic acid (HVA) are related to the clinical features of delirium in a group of patients with acute onset neurological illness. Methods: Fifty-one patients with probable acute brain infection were classified as delirious and nondelirious according to Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) and Delirium Rating Scale (DRS). CSF HVA concentration was analyzed by high-performance liquid chromatography. Results: Delirium was present in 60.8% of the total sample. HVA levels were not significantly different between delirious and nondelirious patients. Remarkably, patients with psychotic symptoms shown higher levels of CSF HVA as compared to nonpsychotic patient values. In addition, HVA levels were positively correlated to specific items of DRS such as delusions (r=0.463, P=.001), hallucinations (r=0.438, P=.001), cognitive dysfunction (r=0.286, P=.042) and fluctuation of symptoms (r=0.280, P=.046) in the total sample. Subanalyses excluding patients taking antipsychotic drugs revealed that HVA CSF levels were higher in those patients with delusions, and furthermore, the dopamine metabolite remained positively correlated to delusion subscale of DRS. Conclusions: Our results suggest that psychotic symptoms in delirious patients may be related to increased dopamine neurotransmission, as reflected by increased CSF HVA concentration, providing direct evidence to support the dopaminergic theory of psychosis.
Journal of Chromatography B-analytical Technologies in The Biomedical and Life Sciences, 2007
Citrulline and nitric oxide (NO) are synthesized by NO synthase (NOS) in a 1:1-stoichiometry. In ... more Citrulline and nitric oxide (NO) are synthesized by NO synthase (NOS) in a 1:1-stoichiometry. In this study, we determined by HPLC arginine and citrulline concentrations by fluorescence detection and nitrate levels by UV absorbance detection in the cerebrospinal fluid (CSF) from patients with acute hydrocephalus that underwent ventricular drainage. We found increased citrulline concentration (50.6 ± 17.2 versus 20.9 ± 2.0 M) and decreased arginine/citrulline molar ratio (0.42 ± 0.11 versus 1.12 ± 0.16) in hydrocephalus patients, while arginine and nitrate concentrations and citrulline/nitrate molar ratio remained with little change. Citrulline has been determined as a marker of NOS activity in some studies, but it remains to be determined the extent at which this statement holds true, since other biochemical pathways also regulate the concentration of this amino acid. Our results suggest that citrulline is primarily synthesized from NOS in acute hydrocephalus. The evaluation of sample deproteinization by addition of methanol for the analysis of amino acids in CSF is also reported.
The authors present the case of a 59-year-old woman with an 8 months history of lancinating pain ... more The authors present the case of a 59-year-old woman with an 8 months history of lancinating pain and hyphestesia on the right side of the face along with hearing impairment. She had poor tolerance to carbamazepine. A non-enhancing cystic image was observed at the right cerebellopontine angle on magnetic resonance imaging. The patient underwent surgery. Through a right retromastoid minicraniectomy and under microscopic magnification the VII and VIII cranial nerve complex was found involved by multiple adhesions around a cysticercus. After the cyst was removed a loop of the anteroinferior cerebellar artery was identified compressing the V right nerve at its root entry zone. Decompression was performed by the insertion of a Teflon implant. The postoperative course was uneventful and trigeminal neuralgia (TN) disappeared after surgery. Five previous cases of cranial nerve hyperactive dysfunction syndromes, four of trigeminal neuralgia and one of hemifacial spasm associated to cerebellopontine angle cysticercosis are briefly commented. We suggest that in some of these cases microvascular compression was probably present, and during surgery of cerebellopontine angle cysticercus by either trigeminal neuralgia or hemifacial spasm, vascular compression must be carefully searched and treated when found.
Intracranial arteritis is a well-known complication of cerebral cysticercosis. The aim of this st... more Intracranial arteritis is a well-known complication of cerebral cysticercosis. The aim of this study was to explore the possible role of transcranial Doppler (TCD) in the evaluation of cysticercotic arteritis in 9 patients with subarachnoid cysticercosis and stroke. Arteritis of main basal vessels was detected by TCD in 7 of 10 arterial lesions that were demonstrated by cerebral angiography. The Doppler pattern was occlusive in 2 cases and stenotic in 5. In the 3 patients with lacunar infarcts, both cerebral angiography and TCD were normal. In 6 arterial lesions followed serially with TCD a stenotic pattern resolved within 4 and 6 months in 3 cases and remained in the stenotic range at 12 months in 1 case, whereas an occlusive pattern persisted at 6 and 18 months in the other 2 cases. In conclusion, TCD may be useful to detect and follow up cerebral vasculitis due to chronic cysticercotic arachnoiditis.
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Papers by Jose Luis Soto