Bilateral Necrosis Research Articles

Bilateral Retrobulbar Neuritis Due to Varicella Zoster Preceding Retinal Necrosis in a Patient with AIDS

Objective: The purpose of this study is to describe a case report of varicella zoster (VZV) infection presenting as bilateral retrobulbar neuritis affecting optic tracts, chiasm, and bilateral optic nerves preceding bilateral progressive outer retinal necrosis in a single patient with AIDS.Methods:The clinical course of a single patient with confirmed VZV infection will be described including presentation, diagnosis, and treatment.Results:The affected patient presented with acute, bilateral vision loss, and headache. The patient’s history was devoid of past, concurrent, or subsequent development of herpes zoster dermatitis. The patient lacked signs of meningeal irritation or infection. Diagnosis of VZV arachnoiditis and retrobulbar optic neuritis were confirmed by radiological and CSF examination and preceded the clinical identification of retinal involvement. Despite early, aggressive treatment with intravenous antiviral and steroids, as well as intravitreal antiviral therapy, complete bilateral visual loss resulted.Conclusion: Varicella zoster continues to present uniquely in patients with acquired immune deficiency syndrome. Absence of retinal involvement doesn’t rule out retrobulbar visual pathways involvement by VZV. The astute clinician should be aware of this presentation and suspect the involvement of varicella zoster in immunocompromised patients presenting with retrobulbar optic neuritis and meningeal involvement with normal fundus exam.

Acute Disseminated Encephalomyelitis with Bilateral Thalamic Necrosis

Acute disseminated encephalomyelitis is a monophasic inflammatory demyelinating disease of the central nervous system involving the white matter, and to a lesser extent, the gray matter. Bilateral thalamic lesions have been reported in 12% of pediatric patients with acute disseminated encephalomyelitis. In most cases, there is a benign clinical course and complete resolution of the lesions. Here, we describe a case in which acute disseminated encephalomyelitis is associated with severe neurological deficits and bilateral thalamic necrosis. Necrosis should be considered in cases of acute disseminated encephalomyelitis with persistent severe neurological deficits. Its presence is a poor prognostic indicator.

Bronchial Complications Following Lung Transplantation

Introduction Bronchial complications owing to the airway anastomosis in lung transplantation are important causes of morbidity and mortality. They occur in up to 27% of cases as defined by stenosis, necrosis, and dehiscence. Treatment depends on the type of complication. Objective To report our experience to treat this complication. Methods Between 2000 and 2007, we performed 71 lung transplants of which 36 were bilateral. The total number of anastomoses was 107:52 to the right and 55 to the left. The telescoping technique was initially used (14 initial unilateral transplants), and after October, 2003 it was changed to an end-to-end anastomosis (57 transplants and 93 anastomoses). Results Eight patients developed bronchial complications including two that were bilateral. There were 4 stenosis, 3 dehiscences, and 3 necrosis complications (9.4%). The complication rate for telescoping anastomosis was 21.4%, and for the end-to-end technique, 7.5%. The treatment of the stenosis used metallic or plastic self-expandable stents. Two bronchial dehiscences resulted in case of bronchopleural fistulae, empyema, and death; the other patient experienced spontaneous resolution. Concerning bronchial necrosis, 1 patient developed fistulization to the pulmonary artery and massive hemoptysis, and the other with bilateral necrosis, a spontaneous resolution. Conclusion Our bronchial anastomosis complication rate was comparable with that in other reports. The rate for the telescoping technique was greater compared with the end-to-end technique. The treatment of bronchial stenosis with a self-expandable prosthesis showed good results.

Functional outcomes of bilateral hip necrosis: total hip arthroplasty versus extracorporeal shockwave

This study compared the functional outcomes of total hip (THA) in one and shockwave (ESWT) in the other in 17 patients with bilateral hip necrosis. In THA side, only one type of prosthesis was used and all components were press fixed. In ESWT side, each hip received 6,000 impulses of shockwave at 28 kv. The evaluations included pain score and Harris hip score, radiographs and MR images. The magnitudes of improvement in pain and function favored the ESWT side. Thirteen patients rated ESWT better than THA; four patients reported comparable results between THA and ESWT, and none graded THA better than ESWT. Better functional outcomes were observed after ESWT for early hip necrosis than THA for late cases in patients with bilateral hip disease.

Thrombotic microangiopathy in pregnancy

Following the initial reports by Moschowitz in 1925 [ 1 Moschcowitz E An acute febrile pleiochromic anemia with hyaline thrombosis of the terminal arterioles and capillaries. Arch Int Med. 1925; 36: 89-98 Crossref Scopus (362) Google Scholar ] and by Baehr et al. in 1936 [ 2 Baehr G Klemperer P Schifrin A An acute febrile anemia and thrombocytopenic purpura with diffuse platelet thrombosis of capillaries and arterioles. Trans Assoc Am Phys. 1936; 51: 43-49 Google Scholar ], Singer [ 3 Singer K, Bornstein FP, Wile SA: Thrombotic thrombocytopenic purpura. Hemorrhagic diathesis with generalized platelet thromboses. Blood 1047;2:542–7. Google Scholar ] and Gasser [ 4 Gasser C Gautier C Steck A Siebenmann RE Oechslin R Hemolytic–uremic syndrome: bilateral necrosis of the renal cortex in acute acquired haemolytic anemia. Schweiz Med Wochenschchr. 1955; 85: 905-909 PubMed Google Scholar ] suggested the terms of “thrombotic thrombocytopenic purpura, TTP” and of “hemolytic uremic syndrome, HUS” to describe related disorders consisting of Coombs' negative hemolytic anemia, thrombocytopenia, and renal failure. TTP and HUS, commonly referred to as thrombotic microangiopathies (TMA), share features of microangiopathic hemolytic anemia (MAHA), thrombocytopenia, and microvascular thrombotic lesions, and their clinical and pathologic features often overlap. However, TTP and HUS are to be considered different entities, which may both complicate the course of pregnancy and imitate more frequently occurring syndromes, like pre-eclampsia, acute fatty liver, HELLP and SLE in association with antiphospholipid antibodies [ 5 Sibai BM Imitators of severe preeclampsia. Obstet Gynecol. 2007; 109: 956-966 Crossref PubMed Scopus (116) Google Scholar ].

Methyl alcohol poisoning - a morphological study for 20-years period

The clinical manifestations of methanol poisoning have been the subject of several review articles over the past forty years (2, 11), though de tailed post mortem pathologic studies are relatively few. The earliest autopsy studies on methanol poisoning have emphasized the acute changes secondary to hypoxic or ischemic in jury to the gray matter, cerebral oedema and acute neuronal in jury. Post mortem studies of individuals, who survive intoxication several days or weeks have shown brain in jury characterized by bilateral putamen necrosis, particularly affecting the lateral portions of the nuclei (1, 10). In some of the cases there has also been a dramatic pattern of white matter hemorrhagic necrosis, involving the centrum semiovale, especially affecting subcortical regions /10/. The precise mechanism of methanol toxicity remains a matter of debate /2/. The observed lesions represent direct toxic effects of methanol and its metabolites and injury, secondary to anoxia and acidosis. In jury to the putamen likely represents a selective toxic effect, possibly potentiated by poor venous drain age. The pathogenesis of the white matter hemorrhagic necrosis remains unexplained /6/. Scripta Scientifica Medica 2008; 40(2): 175-176.

Efficacy and tolerance of early high‐dose corticosteroid therapy in Vogt‐Koyanagi‐Harada disease

Abstract Purpose Early high dose corticosteroid therapy with "adequate" duration has become the mainstay therapy in Vogt‐Koyanagi‐Harada (VKH) disease. This work report the tolerance and side‐effects in a small series of VKH patients having received “maximal” Inflammation Suppressive Therapy (IST). Methods Medical records of VKH patients seen in the the COS uveitis clinic in Lausanne were analyzed. Standard care consisted in prolonged high IST including high dose oral prednisone (60‐200 mg/day), slowly tapered, with or without initial 3‐day megadose (500‐1000 mg of methylprednisolone) intravenous pulse therapy with adjunction of immunosuppressive therapy if necessary. Follow‐up time, total prednisone dose, duration of therapy, adjunctive immunosuppressive treatments, major side‐effects, clinical outcomes were recorded. Results Nine patients were included. Initial oral daily corticosteroid dose was above 60 mg of prednisone in all patients. Immunosuppressive therapy was used in 6 patients either to reinforce IST or to obtain a corticosteroid‐sparing effect. Major side effects were recorded in one patient who developed a bilateral aseptic hip necrosis needing bilateral hip replacement. Clinical outcomes were favorable in 8/9 patients with no sunset‐glow fundus at the one year follow‐up visit and with 7/9 patients beeing treatment free after a slow, mostly indocyanine green angiographically controlled tapering over more than 2 years. Conclusion High dose IST was relatively well tolerated and associated with favorable clinical outcome. Side‐effects of maximal IST are not to be minimized, but seem however acceptable in view of the favorable outcome induced. Treatment duration was found to be much longer than usually recommended in textbooks.

MAGNETIC RESONANCE IMAGING OF FELINE HIPPOCAMPAL NECROSIS

The clinical, neuropathologic, and magnetic resonance (MR) imaging features in four cats with necrosis of the hippocampus and piriform lobe are described. All cats had acute generalized seizures and behavioral changes including aggression, salivation, polyphagia, and disorientation. Routine hematologic, serum chemistry, and cerebrospinal fluid analyses were normal. MR imaging abnormalities were restricted to the area of the hippocampus and piriform lobe. The lesions were T2-hyperintense, T1-hypointense, and were characterized by various degrees of contrast enhancement. Lesions were consistent with necrotizing encephalitis. Two cats were euthanized and underwent postmortem examination within a week after MR imaging due to the lack of response to antiepileptic drug therapy and progressive encephalopathy [corrected] The remaining two cats lived for about four months and were then euthanized because of persistent behavioral and neurologic signs; only one of these cats underwent postmortem examination with histopathologic examination. Histopathological findings were typical of severe, diffuse, bilateral symmetric necrosis, and degeneration of neurons in the hippocampus and piriform lobe, but an etiologic agent was not apparent. This apparently unique feline syndrome, now reported in Switzerland and Italy, has no known cause at this time.

Retrobulbar Optic Neuritis and Meningoencephalitis Following Progressive Outer Retinal Necrosis due to CMV in a Patient with AIDS

We report on a 34-year-old male patient with AIDS who developed retrobulbar optic neuritis and meningoencephalitis following bilateral progressive outer retinal necrosis (PORN) caused by cytomegalovirus (CMV). This case documents the presumed association of PORN with retrobulbar optic neuritis, and CMV meningoencephalitis in an AIDS patient.

Acute bilateral tongue necrosis – a case report

We report the case of an 88-year-old lady who presented with acute necrosis of the whole tongue. Giant cell arteritis was suspected, and early treatment with corticosteroids led to complete resolution and no need for further intervention. We emphasise the importance of early diagnosis of giant cell arteritis and treatment with corticosteroids to stabilise the condition and to avoid serious ocular complications.

Bilateral ischemic necrosis of the tongue due to disseminated intravascular coagulation

Ischemic necrosis of the tongue is a rare condition because the tongue has a rich blood supply. Temporal arteritis appears to be the most frequent cause of tongue necrosis. The case is presented of an 82-year-old man who developed bilateral ischemic necrosis of the tongue. The necrosis was considered to be a consequence of thrombosis of the bilateral lingual arteries due to disseminated intravascular coagulation. To the authors’ knowledge, this is the first reported case of necrosis of the tongue secondary to disseminated intravascular coagulation.

Nécrose des surrénales maternelles au troisième trimestre de la grossesse dans le cadre d’un syndrome des antiphospholipides : à propos d’un cas

Adrenal necrosis, a rare life threatening complication of antiphospholipid syndrome, is difficult to diagnose during pregnancy. We report the case of a 33-year-old woman with bilateral adrenal necrosis which started during the third trimester of her second pregnancy. Antiphospholipid syndrome had been diagnosed few years ago, after a thrombotic event. The pregnancy was uneventful until 36 weeks plus five days, when the patient was admitted for bilateral back ache, initially considered as uterine contractions. Labour was induced because pain persisted and was associated with major thrombocytopenia. A healthy infant was delivered vaginally on the second day, adrenal failure was diagnosed based on intense asthenia, persistent severe lumbar pain, low blood sodium and cortisol. Bilateral adrenal oedema was documented by CT scan and MRI. Symptoms resolved following administration of hydrocortisone and fludrocortisone. This case illustrates the difficulty to diagnose adrenal necrosis in the third trimester of pregnancy.

A case of bilateral parietal cortical laminar necrosis with a loss of vertiginous sensation

Animal experiments demonstrated that there are vestibular cortical areas at the parietal cortex. Moreover, in humans, recent functional neuroimaging studies revealed that caloric stimulation activated the parietoinsular vestibular cortex and optokinetic stimulation activated the parieto-occipital cortex. These activations indicate that the parietal vestibular areas play some role in nystagmus generation or in spatial information processing in the eye movement tasks. The aim of this communication was to present a patient giving some information about parietal cortical function in nystagmus production and vertigo. We report a 51-year-old, heavy alcoholic man with Bálint syndrome, constructional disability, limb-kinetic apraxia and ideo-motor apraxia. Brain magnetic resonance imaging demonstrated bilateral parietal cortical laminar necrosis anterior to the parieto-occipital sulci without any involvement of the primary sensory and parietoinsular cortices. Optokinetic nystagmus (OKN) was not elicited whereas cold caloric stimulation fully evoked nystagmus toward the opposite side with oscillopsia when eyes opened. However, he did not feel vertiginous sensation when the eyes were closed. These findings suggest that the parietal cortices are indispensable for OKN production and vertiginous sensation.

Spontaneous bilateral necrosis of the tongue: a manifestation of giant cell arteritis?

Giant cell arteritis is a chronic vasculitis, which involves large- and medium-sized branches of the arteries originating from the aortic arch. This disease is a diagnostic challenge with a wide range of clinical symptoms and findings due to different affected vessels. Classic symptoms are temporally located headache, thickened temporal artery and jaw claudication. Furthermore, visual symptoms like diplopia or loss of vision can occur. The tongue has an excellent blood supply and ischemic ulceration due to giant cell vasculitis is usually unilateral and rarely described in literature. We present a patient with a spontaneous bilateral tongue necrosis and are convinced that this extraordinary case must be deemed to be a manifestation of giant cell arteritis, although it does not completly satisfy the usually used diagnostic criteria formulated by the American College of Rheumatology.

Nécrose papillaire bilatérale lors d’un traitement par indinavir

Papillary necrosis results from ischemia of the renal medulla and papillae, induced by a variety of mechanisms. Papillary necrosis is a rare adverse effect of continuous protease-inhibitor therapy with indinavir. We describe the case of a patient who developed bilateral papillary necrosis. It was reversible after treatment interruption and increased hydration. This case shows the need to monitor kidney markers in patients under continuous treatment with indinavir.

Multiple Complications in a Sickle Cell Disease Patient: A Case Report

Summary This case report illustrates the multiple complications experienced by a sickle cell anaemia patient. Although he enjoyed fairly good health till age 16 years; he subsequently suffered grade four bilateral femoral head necrosis, cerebella infarct and cerebral atrophy from cumulative effect of repetitive vasoocclussion, recurrent overwhelming septicaemia, fixed flexion deformities and decubitous ulcer as a sequelae of earlier complications. He eventually became bed ridden. Financial constraint seriously compounded these problems. The determinants, of which type of the wide-ranging complications of SCD a particular patient will eventually develop, remain elusive.

Severe Myalgia of the Lower Extremities as the First Clinical Feature of Meningococcal Purpura Fulminans

In patients with meningococcal infection, devastating presentations, such as purpura fulminans, which can progress to extensive tissue necrosis of the limbs and digits, have a significant social impact. The case presented herein illustrates such a phenomenon in a patient who developed bilateral necrosis of the lower extremities as a result of infection with Neisseria meningitis. We emphasize that severe myalgia was the first clinical manifestation of meningococcal purpura fulminans in our case. However, myalgia has typically been overlooked and undervalued as an early clinical feature of meningococcal sepsis. Early recognition and prompt initial antibiotic therapy continue to be the cornerstones of the successful management of this dramatic disease, reducing morbidity and mortality.

An Unsuccessful Trial of Immunomodulatory Therapy in Delayed Posthypoxic Demyelination

Delayed posthypoxic demyelination may rarely complicate an episode of severe hypoxia, with or without exposure to carbon monoxide. Following recovery from initial coma, progressive neurologic deterioration ensues with outcomes ranging from death to full recovery. Delayed posthypoxic demyelination is hypothesized to be immunemediated, with support coming from recent animal experiments. We report a 46-year-old man who developed progressive cognitive deficits with abulia approximately 3 weeks after recovering from coma related to alcohol and morphine intoxication. Despite treatment with high-dose steroids and plasmapheresis, he continued to deteriorate and remained in a vegetative state until his death under hospice care more than 2 months after his initial hypoxic insult. Serial brain imaging and postmortem examination showed bilateral necrosis of the globi pallidi and extensive demyelination in the centrum semiovale and corona radiata. Based on an immune-mediated model of disease and given a lack of effective treatments, future use of immunomodulatory therapy may still be worth considering early in the course of this rare and potentially devastating condition.

Herpes zoster em pacientes com lúpus eritematoso sistêmico juvenil

Varicella zoster virus (VZV) infection in patients with juvenile systemic lupus erythematosus (JSLE) has been rarely described. 195 hospitalizations of 77 JSLE patients occurred in a period of 12 years and were followed at the Pediatric Rheumatology Unity of the Instituto da Crianca - Hospital das Clinicas - Universidade de Sao Paulo. Eleven patients (14%), 10 female, had 14 hospitalizations (7.1%) due to VZV. In these patients, the mean age was 16 years and 5 months and the mean duration of the JSLE until the first infection was 4 years. All of these VZV infections were associated with disease activity. All patients presented vesicles and blister lesions along a nerve. The thorax and limbs regions were the most frequently affected. All of the patients received prednisone and 4 cyclophosphamide IV. All patients received acyclovir IV from 7 to 10 days. None of the patients had post-herpetic neuralgia, secondary bacterial infection or died. One patient that was receiving acyclovir had acute blindness by bilateral retinal necrosis vasculitis associated to the VZV, needed two applications of intra-vitreous gancyclovir and immunoglobulin (2 g/kg/dose IV) and her vision partially improved. VZV infection in patients with JSLE was rarely observed and was usually associated with disease activity and steroid use. Infection was controlled with acyclovir without serious adverse complications.

Bilateral afrenal nodules due to histoplasmosis in an elderly

We report a case history of an 84-year-old elderly male patient that presented with a clinical picture suggestive of adrenal failure and bilateral adrenal nodules detected by abdominal computed tomography. A fine needle-guided biopsy was inconclusive for achieving a final diagnosis. The patient died due to septic shock and the autopsy disclosed histoplasmosis with extensive bilateral necrosis of the adrenal glands. Although the adrenal involvement in chronic disseminated histoplasmosis has been described, there have been few reports of the infection being associated with adrenal insufficiency.