A 40-year-old man developed acute brainstem dysfunction 3 days after hospital admission with symptoms of the novel SARS-CoV-2 infection (COVID-19). Magnetic resonance imaging showed changes in keeping with inflammation of the brainstem and the upper cervical cord, leading to a diagnosis of rhombencephalitis. No other cause explained the patient's abnormal neurological findings. He was managed conservatively with rapid spontaneous improvement in some of his neurological signs and was discharged home with continued neurology follow up.A 40-year-old never-smoker with minimum alcohol intake, originally from Nigeria and now settled in the UK with his family after moving here 7 years ago, attended the emergency department reporting a 10-day history of persistent fever and progressive dyspnoea on exertion while self-isolating at home during the COVID-19 crisis. He was on long-term treatment with ramipril and amlodipine for hypertension and on dorzolamide (a carbonic anhydrase inhibitor) with timolol maleate eye drops for closed angle glaucoma. He reported malaise, a new cough with yellow sputum and diarrhoea (non-bloody) over 3 days. There was no recent foreign travel or family history of medical conditions but he shared the concern that his wife was currently pregnant.On presentation, temperature was 38.4°C, heart rate regular at 86 beats/minute, blood pressure 129/83 mmHg; oxygen saturation 93% on room air as he was tachypnoeic at 32 breaths/minute. On auscultation, heart sounds were normal but there were bi-basal ABSTRACT Authors: A ST4 Respiratory Medicine, The Shrewsbury and Telford Hospital NHS Trust, Telford, UK; B clinical fellow, The Shrewsbury and Telford Hospital NHS Trust, Telford, UK; C consultant neurologist, The Shrewsbury and Telford Hospital NHS Trust, Telford, UK; D consultant respiratory physician, The Shrewsbury and Telford Hospital NHS Trust, Telford, UKcrackles. There was no gross focal neurological deficit. Initial 12-lead electrocardiography showed sinus tachycardia and chest X-ray showed a right lower zone consolidation. Arterial blood gas on room air revealed hypoxia (PaO 2 8.77 kPa) with pH 7.432, PaCO 2 4.21 kPa, HCO 3-20.6 mmol/L, base excess 2.6 mmol/L, lactate 0.98 mmol/L. Haemoglobin was 139 g/L, white cell count 7.0 × 10 9 /L (lymphocytes 1.2 × 10 9 /L) and C-reactive protein (CRP) marginally raised at 50 mg/L, and similar slight increases were seen in serum gamma glutamyl transferase (GGT) 107 U/L (range 0-75) and alanine aminotransferase (ALT) 88 U/L (range 0-45), with other liver tests and urinary electrolytes within the normal ranges.
Nerve injury is a rare complication of total hip replacement which may be related to the exposure used for the operation. The posterior approach is traditionally associated with injury to the sciatic nerve. We have compared the incidence of nerve injury after primary total hip replacement (THR) using either a posterior or a direct lateral approach. We studied 42 consecutive patients undergoing primary total hip replacement. The surgeons used a posterior (22 patients) or direct lateral (20 patients) approach in accordance with their normal practice. The obturator, femoral, posterior tibial and common peroneal nerves were assessed clinically and electrophysiologically by electromyography (EMG) and measurement of the velocity of nerve conduction before operation and at four weeks after. All patients were free from symptoms of nerve injury after operation but five lesions were identified in four patients by the electrophysiological studies; the obturator nerve was involved in two, the femoral in one, the common peroneal in one and the posterior tibial in one. All these injuries occurred using the lateral approach. Clinical assessment alone underestimates the incidence of nerve injury complicating THR. Our study does not confirm the association of nerve injury with the posterior approach which had been described previously.
Paraffin sections from 29 lung carcinomas (28 primary and 1 metastatic) and 9 pleural malignant mesotheliomas were immunostained with antisera to human hepatocyte growth factor/scatter factor (HGF/SF) and its receptor, met. For HGF/SF, immunoreactivity was demonstrated in all 9 mesotheliomas, 9 of 12 adenocarcinomas, and 7 of 10 squamous cell carcinomas. None of seven cases of small cell anaplastic carcinoma was positive. The adenocarcinomas frequently showed enhanced luminal staining, suggesting possible secretion of HGF/SF, and this pattern of staining was also seen occasionally in bronchial epithelium adjacent to the tumour. Stromal fibroblasts also showed immunoreactivity for HGF/SF in 6/8 cases of mesothelioma but in only 3/12 adenocarcinomas, 1/10 squamous cell carcinomas, and 1/4 small cell anaplastic carcinomas. All tumours stained for met, usually strongly. The staining was mainly cytoplasmic in nature, but some plasma membrane staining was usually evident. Adenocarcinomas showed strong luminal membrane staining, as did adjacent, histologically normal bronchial epithelium. This study demonstrates the presence of HGF/SF and met in most of the tumour types described, particularly mesotheliomas, and suggests that the HGF/SF/met signalling system may play a role in the development of these tumours, either by autocrine or by paracrine mechanisms.
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