Focal Manifestations Research Articles

Detection of Insulinomas Using Dual-Time-Point 68Ga-DOTA-Exendin 4 PET/CT.

Insulinomas are predominantly benign neuroendocrine tumors originating from beta cells within the islets of Langerhans of the endocrine pancreas. Because surgical resection represents the only curative therapy option, exact tumor localization and discrimination of insulinomas from focal or diffuse manifestations of congenital hyperinsulinism are crucial for optimal treatment strategies. We investigated the diagnostic value of glucagon-like peptide 1 receptor PET/CT using Ga-DOTA-exendin 4 for detecting insulinomas and compared the diagnostic value of PET scans performed at 2 time points. In 10 patients with clinically and biochemically suspected insulinoma, PET/CT was performed at 1 hour (PET1) and 2 hours (PET2) after injection of Ga-DOTA-exendin 4. In this retrospective analysis, tracer uptake was visually assessed in both scans by 2 independent readers. SUVmax and tumor-to-background ratio (TBR) of focal lesions were assessed. Imaging results were compared with histopathologic findings, if patients underwent resection. Increased focal Ga-DOTA-exendin 4 uptake was observed in 8 of 10 patients concordantly by both readers. Seven patients with focal uptake underwent surgery with tumor enucleation and histopathologic proof of insulinoma (7/8). Two of 10 patients without focal uptake were considered to suffer from diffuse form of congenital hyperinsulinism and consequently received medical treatment. A significant increase of tumoral SUVmax on PET2 (PET1: SUVmax 20.2 ± 8.2 g/mL; PET2: SUVmax 24.7 ± 7.9 g/mL; P = 0.0018) did not result in a significant improvement in TBR (PET1: TBR 4.9 ± 1.7; PET2: TBR 4.3 ± 1.2; P = 0.2892). Focal uptake of Ga-DOTA-exendin 4 reliably indicated insulinomas as histopathologically confirmed in all patients undergoing consecutive surgery. The diagnostic value of PET2 was not found to be superior to PET1, indicating that a single 1-hour Ga-DOTA-exendin 4 PET/CT scan is a sufficient and convenient approach for patient care.

Efficiency of anti-B-cell therapy in patients with neuropsychiatric manifestations of systemic lupus erythematosus: a report of clinical cases

The paper describes two patients with systemic lupus erythematosus (SLE) with severe nervous system damage characterized by diffuse and focal neuropsychiatric manifestations of SLE due to of the central nervous system involvement and damage to the peripheral nervous system as local mononeuritis of the lower extremities in one case and severe peripheral neuropathy manifested by multiple mononeuritis of the lower extremities in the other. Anti-B cell therapy with rituximab is noted to have an effect.

Neurolymphomatosis of the lumbosacral plexus and its branches: case series and literature review

BackgroundNeurolymphomatosis (NL) is a direct process of invasion of peripheral nerves by lymphoma. It occurs in roughly 5% of patients with lymphoma and represents a particularly difficult diagnostic dilemma when it is the presenting focal manifestation of occult lymphoma.Case presentationWe present 3 examples of invasion of the lumbosacral plexus and its branches. These cases demonstrate a protean clinical picture with regards to the time relationship to the clinical course of lymphoma and the neuroanatomical extent of lumbosacral plexus invasion. We demonstrate the complementary role of different imaging modalities. A review of the literature summarizes 23 reports where lumbosacral plexus invasion was the index manifestation, at the time of first diagnosis or recurrence of lymphoma. This series confirms the strong preponderance of B-cell type (92%). There is a marked predilection for involvement of the sciatic nerve (74%), either focally or in a longitudinally extensive fashion, from the ischium to the popliteal fossa. There can also be restricted and discrete involvement of tibial and fibular branches. In recent years, ultrasound and CT have been given a more limited role, as screening tools or as a guide for biopsy. MRI neurography and PET-CT have become leading diagnostic modalities for diagnosis, staging and assessment of treatment response.ConclusionThe diagnosis of NL may be challenging, and it was once only reached at autopsy. Improved diagnostic imaging of focal or even asymptomatic disease offers new hope for earlier diagnosis and successful targeted therapy.

Prevalence of Intracranial Aneurysms in Patients With Systemic Vessel Aneurysms: A Nationwide Cohort Study.

Background and Purpose- Most aneurysms are a focal manifestation of a systemic condition. Some reports have suggested genetic and environmental factors may play a role in pathogenesis. The aim of the present study was to evaluate the prevalence of intracranial aneurysms (IA) in a large cohort of patients with other systemic vessel aneurysms and dissections (OVAD) and identify potential risk factors for IA in this population. Methods- We defined OVAD as systemic vessel aneurysms, excluding aortic dissections and aneurysms. A cohort of 1.1 million patients was extracted from the population-based cohort from the Korea National Health Insurance Service, which holds almost all medical data including diagnostic codes, procedures, and personal information. Using χ2 or Fisher exact test, the prevalence of the IA concerning OVAD status was analyzed. Results- In OVAD individuals, 25.7% (261/1017) of patients had been concurrently diagnosed with IA. The odds ratios for having concurrent IA in patients with OVAD were 56.31 (95% CI, 48.821-64.949; P=0.000). OVAD patients with dyslipidemia were >7× likely to be affected by IA (adjusted odds ratio, 7.7 [95% CI, 6.59-9.01]; P=0.000). Hypertension, diabetes mellitus, old age (>60 years), and male sex had increased odds for having concurrent IA by 5.89, 3.48, 1.83, and 1.35, respectively. Subgroup analysis with socioeconomic or disability revealed that the prevalence of IA was significantly higher in all groups. Uncertainty regarding the temporal sequence of onset and lack of detail on disease severity and subtype prevented more conclusive results. Conclusions- Patients with OVAD have a higher prevalence of IA than control groups. Therefore, we may approach aneurysms as systemic disease, and further investigations about their pathophysiology must follow.

AORTIC DISSECTION PRESENTING AS SEIZURE

The most common presentation for aortic dissection (AD) is chest pain and back pain. However, patients may present atypically with focal neurologic manifestations, causing a delay in initiation of management of this time sensitive diagnosis. We describe a case of a male with Stanford Type A AD

The value of highly specific C-reactive protein HS-CRP in migraine headache

Background: Migraine is a well known neurologic disease, ordinarily portrayed by intermittent assaults of incapacitating headache and manifestations of autonomic nervous system disturbances. In about 33% patients, headache attacks are joined by transient “focal neurologic aura manifestations”. Migraine is a neurovascular disease accompanied by cranial vascular contractile dysfunction, neurogenic inflammation and cortical spreading depression. Brain tissue activation results in the production of peptides by the perivascular trigeminal areas which lead to an inflammatory response with dilation of extraparenchymal blood vessels. Inflammatory vasculopathy accompany repeated assaults of migraine attacks. A number of studies showed the elevation of certain inflammatory markers in association with migraine such as adhesion molecules, interleukins and C-reactive protein (CRP).
 Aim of the study: To evaluate the role of HS-CRP in patients with migraine
 Patients and methods: Current cased control study included 100 patients with migraine headache and 100 apparently healthy subjects. Variables included in the present study are: age, gender and the level of highly specific C-reactive protein (HS-CRP). The study was conducted at the neurology unit, Al-Dewaniyah teaching hospital, Al-dewaniyah province, Iraq. The study started on January 2018 and ended at June 2018.
 Results: Current study included 100 migraine patients with a mean age of 31.46 ±5.75 years and 100 control subjects with a mean age of 30.55 ±5.54 years and there was no significant difference in mean age between the two groups (P=0.255). Patients group included 23 men (23%) and 77 women (77%) whereas, control group included 24 men (24%) and 76 women (76%); no significant difference was encountered between the two groups with respect to gender (P=0.868). The level of Hs CRP in terms of median and inter-quartile range (IQR) in patients group was significantly higher than that of control group, 4.6 (4.9) versus 1.5 (2) µg/dl (P<0.001). There was no significant difference in the level of Hs CRP between men and women in patients group, 5.3 (5.7) versus 4.6 (4.8) µg/dl (P=0.680), as shown in figure 2. There was no significant correlation between age and level of Hs CRP in patients group (r = -0.056, P =0.581).
 Conclusion: The present study showed that Hs CRP is significantly higher in patients with migraine headache and this may explain the inflammatory role in the pathogenesis and prognosis of migraine headache.

Therapeutic Management of the Overlapping Syndromes of Atypical Parkinsonism.

Progressive supranuclear palsy, corticobasal degeneration and multiple system atrophy account for approximately 10% of neurodegenerative parkinsonism. Considerable clinical overlap exists between these disorders that extends to features considered characteristic of each disease. Clinical diagnostic criteria have attempted to increase the accuracy of clinical diagnosis as accurate diagnosis is necessary to inform prognosis and to facilitate the recognition of disease-modifying treatments. Currently no such treatment exists. Nevertheless, many clinical trials aiming to change the natural history of these diseases are ongoing. The spread and accumulation of abnormal proteins are among the pathophysiological mechanisms targeted. For the time being, however, only symptomatic treatment is available. Levodopa is used to treat parkinsonism, but patients usually show a poor or transient response. Amantadine is also used in practice for the same indication. Botulinum toxin can alleviate focal dystonic manifestations. Addressing non-motor manifestations is limited by the potential of available drugs to impact on other aspects of the disease. Most of the new symptomatic formulations under study are focused on orthostatic hypotension in multiple system atrophy. Exercise, occupational, physical, and speech therapy and psychotherapy should always accompany pharmacological approaches.

Widespread myofascial dysfunction and spinal sensitization in women with endometriosis-associated chronic pelvic pain

Despite optimal surgical/hormonal treatment, some women with endometriosis continue to have chronic pelvic pain (endo-CPP). Comorbid non-pelvic pain, myofascial dysfunction, and sensitization have rarely been reported in this population. We systematically assessed the presence and distribution of pain, myofascial dysfunction, and spinal sensitization in women with endo-CPP. Women (18–50 years) with endo-CPP after optimized surgical/hormonal treatment were evaluated. Participants underwent gynecologic examination of pelvic floor muscles to identify tenderness/spasm. Neuromusculoskeletal examination included assessment of paraspinal tactile allodynia (Von Frey monofilament) and hyperalgesia (Wartenburg pinwheel). Myofascial trigger points (MTrPs) were identified in 13 regions bilaterally. Pressure-pain thresholds (PPTs) were measured over interspinous ligaments and MTrPs. Twenty-eight women with endo-CPP for a median of 12 years (range 1–20) were evaluated. All had pelvic floor muscle spasm on gyn examination. All endorsed the pelvic floor as a major focus of pain, which was described as focal in 19/28. All women had widespread myofascial dysfunction with MTrPs in more than two-thirds of assessed regions. Low PPTs (< 9 b/in 2 ) were found over interspinous ligaments in 24(86%) women. Widespread spinal segmental sensitization (allodynia and hyperalgesia) was present in 15(53%) subjects. Thoracic sensitization was present in 19(68%) women and lumbosacral sensitization related to the pelvic region in 17(61%). While cervical sensitization was detected in only 2(7%), 22(79%) reported recurrent, severe headaches and 14(50%) experienced orofacial pain. Women with endo-CPP can have myofascial dysfunction beyond the pelvic focus of pain, demonstrated by widespread diffuse and regional allodynia, hyperalgesia, MTrPs, and lowered PPTs, likely reflecting central sensitization. Sensitization may be initiated and maintained by pelvic floor spasm and may account for pain persisting after resection of endometriosis lesions and despite continued use of hormonal treatment. These diffuse and focal myofascial and central nervous system manifestations warrant consideration in management of pain in this population.

Neointima and neoatherosclerotic characteristics in bare metal and first- and second-generation drug-eluting stents in patients admitted with cardiovascular events attributed to stent failure: an optical coherence tomography study.

The aim of this study was to assess neoatherosclerotic plaque morphology in bare metal (BMS) and first- and second-generation drug-eluting stents (DES) in patients presenting with an event attributed to stent failure. Thirty-five patients (11 implanted with BMS, 13 with a first-generation and 11 with a second-generation DES) admitted with an event due to stent failure who had neoatherosclerotic lesions on optical coherence tomography were included in the analysis. The lumen and stent borders were detected and the lipid and calcific tissue were identified in the neointima and their burden was estimated. The neointima attenuation and backscatter indices were computed and compared between the different stent types. Although there were no differences in the neointima burden, the BMS group exhibited thinner fibrous caps (p<0.001), and a numerically increased incidence of lipid-rich plaques (p=0.052) and macrophage accumulation (p=0.012). Neointima discontinuities (p=0.009) and thrombus (p=0.032) were seen more often in first-generation DES. In all stent types, neoatherosclerosis had focal manifestations. In neoatherosclerotic lesions the attenuation and backscatter indices were increased in BMS (p=0.031 and p=0.018, respectively) compared to DES; however, there were no differences between stents in the attenuation indices in subsegments located distally to neoatherosclerotic lesions which had low values in all stent types. Although there are differences in lipid burden and neointima characteristics in different stent types, in all stents neoatherosclerosis has focal manifestations indicating that, irrespective of the stent type, focal triggers are involved in the generation of vulnerable neolesions.

Ophthalmoscopy skills in primary care: a cross-sectional practitioner survey

Ophthalmoscopy is challenging to master. Medical professionals regularly practising ophthalmoscopy exhibit greater confidence1–3 and competence.4 Methods practised in veterinary medicine include direct, PanOptic and indirect ophthalmoscopy (Fig 1). Direct ophthalmoscopy...

Ictal source imaging and electroclinical correlation in self-limited epilepsy with centrotemporal spikes

PurposeTo elucidate the localization of ictal EEG activity, and correlate it to semiological features in self-limited epilepsy with centrotemporal spikes (formerly called “benign epilepsy with centrotemporal spikes”). MethodsWe have performed ictal electric source imaging, and we analysed electroclinical correlations in three patients with self-limited epilepsy with centrotemporal spikes. ResultsThe source of the evolving rhythmic ictal activity (9.7-13.5Hz) localized to the operculo-insular area. The rhythmic EEG activity was time-locked to the contralateral focal motor seizure manifestation: facial rhythmic myoclonic jerks, with the same frequency as the analysed ictal rhythm. In all three patients, the seizures had fluctuating course with pauses of clinical and electrographic seizure activity, ranging from 0.4 to 7s. ConclusionSource imaging of ictal EEG activity in patients with self-limited epilepsy with centrotemporal spikes showed activation of the operculo-insular area, time-locked to the contralateral focal myoclonic jerks. Fragmented seizure dynamics, with fluctuating course, previously described as a hallmark in patients with psychogenic non-epileptic seizures, can occur in rolandic seizures.

How Long Should Routine EEG Be Recorded to Get Relevant Information?

The optimal duration of routine EEG (rEEG) has not been determined on a clinical basis. This study aims to determine the time required to obtain relevant information during rEEG with respect to the clinical request. All rEEGs performed over 3 months in unselected patients older than 14 years in an academic hospital were analyzed retrospectively. The latency required to obtain relevant information was determined for each rEEG by 2 independent readers blinded to the clinical data. EEG final diagnoses and latencies were analyzed with respect to the main clinical requests: subacute cognitive impairment, spells, transient focal neurologic manifestation or patients referred by epileptologists. From 430 rEEGs performed in the targeted period, 364 were analyzed: 92% of the pathological rEEGs were provided within the first 10 minutes of recording. Slowing background activity was diagnosed from the beginning, whereas interictal epileptiform discharges were recorded over time. Moreover, the time elapsed to demonstrate a pattern differed significantly in the clinical groups: in patients with subacute cognitive impairment, EEG abnormalities appeared within the first 10 minutes, whereas in the other groups, data could be provided over time. Patients with subacute cognitive impairment differed from those in the other groups significantly in the elapsed time required to obtain relevant information during rEEG, suggesting that 10-minute EEG recordings could be sufficient, arguing in favor of individualized rEEG. However, this conclusion does not apply to intensive care unit patients.

Correlation between ADAMTS13 activity and neurological impairment in acute thrombotic microangiopathy patients.

Differential diagnosis between thrombotic thrombocytopenic purpura (TTP) and other thrombotic microangiopathies (TMA) is usually difficult because of frequently overlapping clinical presentations. Severely depressed ADAMTS13 activity (<10%) seems distinctive for TTP because of its pathogenetic role. However a long debate exists in the literature about its sensibility and specificity. Our aim was to search for clinical differences between TMA patients referred to our laboratory, comparing them for protease activity<10 versus≥10%. ADAMTS13 activity≥10% patients (n=73) showed a higher prevalence of drug- (p=0.005) and cancer-associated (p<0.001) TMA. Mean platelet count and renal dysfunction prevalence was lower (p<0.001), while neurological impairment was more frequent (p=0.001) in the<10% ADAMTS13 activity group (n=109), confirming previous literature findings. When taken neurological manifestations singularly, epilepsy (p=0.04), focal motor deficit (p<0.001) and cranial nerve palsy (p=0.007) were more frequent in the<10% activity group. In our case series, a<10% ADAMTS13 activity depicts a group of patients with clinical features similar to TTP patients. Focal motor impairment or epileptic manifestations could further address toward a TTP diagnosis. Studies about treatment efficacy and follow-up are advised to determine whether laboratory findings can guide therapeutic decisions.

Psychiatric presentations of central nervous system tumors

IntroductionFor the most part, central nervous system (CNS) tumors present themselves with focal neurologic sing or manifestations resulting from increased intracranial pressure. However, in particular cases, these tumors may present exclusively psychiatric symptoms.ObjectiveThis communication explores importance of CNS tumors as differential diagnosis of various psychiatric disorders.AimsHighlight the need of acknowledging this important differential diagnosis (CNS tumors) in current psychiatry practice, while presenting a clinical case as an example of the subject.MethodsIt is exposed a bibliographic review of the topic, followed by the description of a clinical case regarding a patient with pituitary adenoma and simultaneous installation of psychotic symptoms namely delusional paranoid ideation.ResultsThe authors present a case report of a 66-year-old patient admitted compulsively in a Psychiatric ward in the context of behavioral changes associated with delusional ideation of paranoid content. Multidisciplinary assessed by specialties of Psychiatry, Neurology, Neurosurgery, Endocrinology and Psychology, concluded by the presence of nonfunctioning pituitary adenoma associated with cognitive major disturbance.ConclusionsThe tumors of the CNS can be associated with a whole variety of psychiatric symptoms such as psychosis, anxiety, depression or cognitive impairment, even in the absence of organic/neurological symptoms. Its role in the genesis of psychiatric symptomatology makes these neoplasias an important differential diagnosis, whose clinical approach should include different medical specialties integrated as a multidisciplinary team.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Functional and Morphological Parameters with Tissue Characterization of Cardiovascular Magnetic Imaging in Clinically Verified "Infarct-like Myocarditis".

Cardiac magnetic resonance (CMR) has increasingly proved to be a valuable diagnostic tool for evaluating patients with suspected myocarditis. The objective of this study was to evaluate the diagnostic value of functional and morphological parameters including tissue characterization in patients with "infarct-like myocarditis". 43 patients with clinically verified cases of "infarct-like myocarditis" (median time to MRI scanning after admission for acute symptoms 3 days) and 35 control patients matched by age and sex were included in this retrospective case control study. In this study we used a 1.5 T MRI scanner conducting steady-state-free-precession sequences, T2-weighted imaging, T1-weighted imaging before and after contrast administration and late gadolinium enhancement sequences. According to the recommendations for CMR diagnosis of myocarditis (Lake Louise consensus criteria), a scan was positive for acute myocarditis if 2 of 3 CMR criteria were present. 30 % of the patients with "infarct-like myocarditis" had a reduced left ventricular ejection fraction, 11 % had an increased LV end-diastolic volume index and 35 % had an increased LV mass index. The sensitivity of wall motion abnormalities was 63 % with a regional distribution in 49 %. In 47 % of cases regional wall motion abnormalities were present in the lateral left ventricular segments. Pericardial effusions were discovered in 65 % of cases with a circular appearance in 21 % and focal manifestation in 44 %. The diagnostic sensitivity, specificity, and accuracy of CMR in patients with "infarct-like myocarditis" were 67 %, 100 % and 82 %, respectively. The LGE alone was the most sensitive test parameter with 86 %, providing a specificity of 100 % and accuracy of 92 %. Our study results can be applied to the subgroup of patients with "infarct-like myocarditis", where we found that LGE alone was the most sensitive test parameter. In addition to tissue characterization, the functional and morphological analysis of patients with acute myocarditis provides a useful further diagnostic tool. •Infarct-like myocarditis can be diagnosed by CMR with high validity and reliability. •LGE allone performed best with a sensitivity of 86 %. •Functional and morphological CMR parameters in addition to tissue characterization are useful tool in the diagnosis of acute myocarditis.

CXCR2 is a critical mediator of Brucella-induced articular inflammation (INC4P.335)

Abstract Osteoarticular complications are the most common focal manifestation of brucellosis in humans. Little is known about the pathology of osteoarticular brucellosis due to the lack of relevant models. However, we recently reported that ablation of IFN-γ in mice results in articular inflammation during infection with Brucella melitensis. Here, we show that adaptive immune cells are dispensable for Brucella-induced articular inflammation. Wild-type, µMT-/-, and Rag1-/- mice all developed articular inflammation at a similar rate and severity when infected with B. melitensis and depleted of IFN-γ. In addition, minimal levels of cytokines associated with T cell responses were detected in arthritic joints. However, we found increased numbers of neutrophils and macrophages in joints from mice with Brucella-induced arthritis. In addition, the concentration of CCR2 and CXCR2 ligands, was strikingly enhanced in Brucella-infected joints. Interestingly, CXCR2-/-, but not CCR2-/- mice, displayed markedly lower joint inflammation relative to wild-type mice when infected with B. melitensis and depleted of IFN-γ. Collectively, these results show that chemokines, such as CXCR2 ligands, are important mediators of Brucella-induced articular inflammation while adaptive immune cells are not required. Therefore, the targeting of CXCR2 and/or other chemokine receptors may have potential as a complementary antibiotic therapy for the resolution of Brucella-induced arthritis.

Post-treatment vascular leakage and inflammatory responses around brain cysts in porcine neurocysticercosis.

Cysticidal treatment of neurocysticercosis, an infection of humans and pig brains with Taenia solium, results in an early inflammatory response directed to cysts causing seizures and focal neurological manifestations. Treatment-induced pericystic inflammation and its association with blood brain barrier (BBB) dysfunction, as determined by Evans blue (EB) extravasation, was studied in infected untreated and anthelmintic-treated pigs. We compared the magnitude and extent of the pericystic inflammation, presence of EB-stained capsules, the level of damage to the parasite, expression of genes for proinflammatory and regulatory cytokines, chemokines, and tissue remodeling by quantitative PCR assays between treated and untreated infected pigs and between EB-stained (blue) and non stained (clear) cysts. Inflammatory scores were higher in pericystic tissues from EB-stained cysts compared to clear cysts from untreated pigs and also from anthelmintic-treated pigs 48 hr and 120 hr after treatment. The degree of inflammation correlated with the severity of cyst wall damage and both increased significantly at 120 hours. Expression levels of the proinflammatory genes for IL-6, IFN-γ, TNF-α were higher in EB-stained cysts compared to clear cysts and unaffected brain tissues, and were generally highest at 120 hr. Additionally, expression of some markers of immunoregulatory activity (IL-10, IL-2Rα) were decreased in EB-stained capsules. An increase in other markers for regulatory T cells (CTLA4, FoxP3) was found, as well as significant increases in expression of two metalloproteases, MMP1 and MMP2 at 48 hr and 120 hr post-treatment. We conclude that the increase in severity of the inflammation caused by treatment is accompanied by both a proinflammatory and a complex regulatory response, largely limited to pericystic tissues with compromised vascular integrity. Because treatment induced inflammation occurs in porcine NCC similar to that in human cases, this model can be used to investigate mechanisms involved in host damaging inflammatory responses and agents or modalities that may control damaging post treatment inflammation.

IgG4-related disease of the breast: a systemic disease whose mammary manifestations mimic breast cancer

IgG4-related disease is a newly identified disease entity that has begun to attract attention, and international consensus diagnostic criteria for the condition have recently been proposed. The characteristic features of IgG4-related disease are lymphoplasmacytic infiltration involving a high proportion of IgG4-positive cells, fibrosis exhibiting a storiform pattern, and obliterative phlebitis. It can affect various organs, including the breast (in rare cases). IgG4-related disease has previously been referred to as inflammatory myofibroblastic tumor, plasma cell granuloma, or pseudolymphoma. We have experienced a case of IgG-related disease of the breast. Clinically and cytologically, the lesion was somewhat similar to a malignant tumor. An immunohistochemical examination of a core needle biopsy sample resulted in a correct diagnosis. In addition, a review of the patient’s clinical history revealed that the disease had affected areas other than the breast. Clinicians should be aware that breast lesions can be a focal manifestation of systemic disease, and overdiagnosis should be avoided by performing appropriate pathological analysis.

Brain abscess: Heuristics, principles, pathobiology, practice.

Brain abscess is an uncommon but a compelling reality in neurosurgical practice. Its focal, local, and systemic manifestations conceal its infective and obsessive nature. There are many a lesson that a brain abscess, as a bio-phenomenon, offers to the medical fraternity in general and the neurosurgeons, in particular. From Skt. puyati = to stink, comes the word "pus," meaning something foul, putrid, or rotten. From ab = away, and cedre = to go, comes the term "abscess" which is but nature's ingenious way of creating a fluid-filled cavity that will eventually rupture to an exterior to get rid of the non-self contents and proceed to healing. A brain abscess is special in the sense that it is, in general, more solid than fluid for reasons the human body and brain know best.

Subcutaneous Abscess as a Single Manifestation of Candidiasis

Candida is yeast responsible for the majority of the systemic invasive fungal infections in humans. The incidence of systemic Candida infections has increased, probably due to a rising number of patients with comorbidities and risk factors for invasive candidiasis. Candidemia is a life-threatening infection with high morbidity and mortality especially in individuals at greatest risk of fungal infection, such as patients receiving cancer chemotherapy, immunosuppressive therapy, prolonged antibiotic therapy, neutropenia, recent abdominal surgery, hematological malignancies, central venous catheter, receipt of corticosteroids, parenteral nutrition, etc. In patients infected with the human immunodeficiency virus (HIV) the predominant clinical forms of candidiasis include the mucosal involvement as oral candidiasis, oesophageal candidiasis, Candida vaginitis and Candida balinitis [1]. Although subcutaneous abscess due to Candida species is frequent in non-neutropenic patients after transient candidemia, it is a rare complication in immunocomprimised patients due to HIV/AIDS disease. The few cases reported in the medical literature occur as a complication of bacterial cellulitis, iatrogenic injury, trauma or intravenous drug abuse [2]. We present the clinical history of an HIV patient who developed a subcutaneous abscess due to Candida albicans without fungemia or other focal manifestation of this mycosis.