Neurofibromatosis type I is a genetic autosomal dominant disorder with multisystem involvement and is particularly challenging for the anesthesiologist in emergency surgery. The presence of neurofibromas can cause airway difficulty, make delivery of gases difficult, and blood pressure variations during general anesthesia. Regional anesthesia becomes challenging due to the presence of spinal and intracranial tumors, and in undiagnosed situations, it becomes tricky. This is a case report of anesthesia management in a pregnant patient with undiagnosed neurofibromatosis for an emergency cesarean section.
A 26-year-old man was listed for excision of a vestibular schwannoma. Abnormally anterior palatoglossal arches were noted during pre-operative anaesthetic evaluation (Fig. 1). The palatoglossal arches are ridges created by the palatoglossus muscles, one of the four pairs of extrinsic muscles of the tongue [1]. Rarely, the attachment of palatoglossus muscles can be so anterior that it might make displacement of the tongue challenging during laryngoscopy [2].In the absence of other risk factors for difficult airway management, and considering the risk of raised intracranial pressure with awake tracheal intubation, we planned for tracheal intubation under general anaesthesia.Following induction of general anaesthesia with fentanyl 150 lg and propofol 180 mg, facemask ventilation was straightforward. Direct laryngoscopy was performed with a size 4 Macintosh blade: the tongue was displaced from right to left Figure 1 Abnormally anterior palatoglossal arches within the patient's oral cavity.
Background: Tuberculosis (TB) remains the number one killer infectious disease in developing countries. There were an estimated 8.8 million incident cases of TB (range, 8.5 million-9.2 million) globally in 2010. Most of the estimated number of cases in 2010 occurred in Asia (59%) and Africa (26%). India alone accounted for an estimated one quarter (26%) of all TB cases worldwide. The clinical manifestations of TB could be either Pulmonary or Extra pulmonary (EPTB), the former being the commonest. In India, EPTB accounts for 10 to 15 percent of all types of TB. Mycobacterium tuberculosis complex shares high genomic similarities. Genotyping of M. tuberculosis helps in tracking the transmission links between individuals, and demonstrated instances in which epidemiologically linked people were in fact, infected with unrelated strains.Methods: Spacer-oligonucleotide typing and 12 loci mycobacterial interspersed repetitive units (MIRU) were performed to find genetic profiles of M. tuberculosis strains isolated from extrapulmonary tuberculosis patients. The spoligotyping results were compared with the world Spoligotyping Database of Institute Pasteur de Guadeloupe (SpolDB4). One hundred twenty five isolates of extrapulmonary tuberculosis were characterized and their drug susceptibility test (DST) was performed using BACTEC MGIT 960Results: Based on the spoligotyping method, 110 strains displayed known patterns and 15 isolates were absent in the database. Predominant spoligotypes belonged to the CAS family (57.27%). Overall, 28 different patterns were identified, including 12 clusters and 16 unique patterns. The largest clade comprised 38 strains belonging to the CAS1 DEL lineage. The combination of spoligotyping and 12-loci MIRU demonstrated maximal discriminatory power. We observed a significant association between Beijing family strains and drug-resistance.
Conclusion:The present study demonstrated that CAS family isolates were the most prevalent genotype in extrapulmonary tuberculosis. Spoligotyping in combination with 12-loci MIRU is the most discriminatory tool for epidemiological analysis of M. tuberculosis from extrapulmonary tuberculosis.
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