Phaeohyphomycosis causes a wide spectrum of systemic manifestations and can affect even the immunocompetent hosts. Involvement of the central nervous system is rare. A 48-year-old farmer presented with chronic headache, fever, and impaired vision and hearing. Serial MRIs of the brain showed enhancing exudates in the basal cisterns, and lesions in the sella and perichiasmatic and cerebellopontine angle regions along with enhancement of the cranial nerves and leptomeninges. Cerebrospinal fluid (CSF) showed lymphocytic pleocytosis with elevated protein and decreased glucose on multiple occasions. Clinical, imaging, and CSF abnormalities persisted despite treatment with antitubercular drugs and steroids for 2 years. Biopsy of the dura mater at the cervicomedullary junction revealed necrotizing granulomatous lesions, neutrophilic abscesses, and giant cells containing slender, pauci-septate, pigmented fungal hyphae. Fungal culture showed growth of Fonsecaea pedrosoi, which is classically known to cause brain abscesses. Here, we report the diagnostic odyssey in a patient with chronic meningitis from a region endemic for tuberculosis and describe the challenges in establishing the accurate diagnosis. Lack of therapeutic response to an adequate trial of empirical antitubercular therapy warrants search for alternative causes, including fungal meningitis. We highlight the uncommon manifestation of F. pedrosoi with chronic meningitis as well as the protracted clinical course despite not receiving antifungal therapy.
Introduction: Whipple's disease (WD) is a very rare systemic disease caused by the gram-positive bacillus Tropherymawhippleii 1st described in the year 1907. It is a disease with multisystem involvement and high degree of suspicion is needed for diagnosis. However the classical (OMM)oculomasticatory (OFMM)oculofacial-skeletal myorhythmia clubbed with dementia, head ache and other neurologic features should deserve an attempt to confirm whenever possible and therapeutic trial as it is one of the treatable dementias. Males are more affected and probable route of infection is oral though clustering of cases is not reported so far. Case Report: 63 year old hypertensive patient presented with abdominal pain, weight loss, dementia, ataxia, extrapyramidal features, falls, up gaze palsy,oculomastigatory skeletal myorhythmia,skin of the face showing nodules which were pigmented and itchy fallowing HAJ pilgrimage.. Investigations for immune mediated,vasculitic,paraneoplastic, sarcoid were noncontributory. Duodenal biopsy showed nonspecific changes. MRI was consistent with changes reported in Whipples. Patient responded to treatment of Whipples disease. Discussion and Conclusion: Our patient presented with the typical and unique oculomastigatory myorhythmia clubbed with systemic features of whipplesdisese and showed response to treatment. Limitation of our report we could not do PCR due to lack of availability. This case is being reported for its rarity and to create awareness regarding the typical eye movements.
Introduction: Endoscopic repair of Cerebrospinal fluid (CSF) rhinorrhea has been the most popular and the most accepted among the Otorhinolaryngologists. The advancement in the endoscopes enable surgeons to manage cerebrospinal fluid rhinorrhea adequately with good result. Objective: The aim of this study was to evaluate the outcome of endoscopic CSF rhinorrhea repair with multilayer grafts. Outcome was identified in terms of postoperative complications like infection (mainly meningitis), nasal bleeding, graft failure and CSF leak, revision surgery. Methodology: A retrospective prospective study was conducted in 21 patients who had undergone endoscopic CSF rhinorrhea repair with use of multilayer grafts in a period of January 2016 to December 2018 in Department of ENT and Head and Neck Surgery in MAA ENT HOSPITAL, HYDERABAD, INDIA. All the patients were diagnosed according to history, clinical examination, diagnostic nasal endoscopy, CSF fluid analysis and radiological investigation. The materials used for the repair of CSF rhinorrhea were surgicel, temporalis fascia, conchal chondroperichrondrium, middle turbinate free mucoperiosteum graft, thigh fat and fascia lata. The follow up period of patients range from 14-44 months. The outcome of endoscopic CSF repair with use of multilayer grafts was evaluated by electronic records regarding recurrence of CSF rhinorrhea post-surgery, hospital admission, revision surgery and digital record of rigid endoscopic findings for the status of graft uptake and CSF leak. Results: In all patients, CSF leak was successfully repaired with use of multilayer grafts in first attempt without any complication. There was female predominance with male to female ratio of 1:6.The mean age of presentation was 43.09years. All 21 patients were presented with spontaneous CSF leak with unknown cause. In 21 patients only one patient presented with bilateral cerebrospinal fluid leak. Cribri form plate was the commonest site of defect in which defect medial to middle turbinate was the commonest followed by ethmoid roof and lateral wall of sphenoid. None of the patients developed meningitis after surgery. None of the patients required lumbar drain. None of the patients presented with cerebrospinal fluid rhinorrhea postoperatively. Conclusions: Endoscopic repair of Cerebrospinal fluid rhinorrhea with the use of multilayer grafts is the safer and effective method with good outcome.
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