Occasional Cause Research Articles

The far lateral approach to lumbar disc herniations.

The diagnosis of extreme lateral lumbar disc herniation (ELLDH) as a cause of lumbar radiculopathy was first described by Abdullah in 1974 [1]. This discal pathology has been recognized for many years as an occasional cause of negative disc exploration and immediate failure of classical disc surgery in sciatica [1,18, 24, 25, 29, 31, 30, 31, 33, 35, 41]. Only since the introduction of computed tomography (CT) for the diagnosis of lumbar disc disease have the characteristics of ELLDH become fully appreciated [3, 6,13,17,23, 30,32,47]. Myelography alone was an insufficient diagnos- tic tool to detect this specific pathology. With the rapid development of neuroradiologic diagnostic imaging, including magnetic resonance imaging (MRI) [13, 32], recognition of this particular type of lumbar disc disease has increased its incidence, ranging from 0.7% to 11.7% of the total operated herniated discs [1, 22, 24, 45]. In a recent review of our series of patients with lumbar disc disease we found an overall incidence of ELLDH of 5.8% over a period of 8 years [38]. 78% of all ELLDH occured at the L4-L5 and L5-S1 levels, with an almost equal frequency, but the overall incidence of ELLDH per level varied relative to the level of the pathological disc.

Septic and non-septic olecranon bursitis in the accident and emergency department--an approach to management.

Olecranon bursitis is relatively common. One third of episodes are septic. Most of the remainder are non-septic, with occasional rheumatological causes. Trauma can cause both septic and non-septic olecranon bursitis. Clinical features are helpful in separating septic from non-septic olecranon bursitis, but there may be local erythema in both. Aspiration should be carried out in all cases, and if the presence of infection is still in doubt, microscopy, Gram staining, and culture of the aspirate will resolve the issue. Septic olecranon bursitis should be treated by aspiration, which may need to be repeated, and a long course of antibiotics. Some cases will need admission, and a few will need surgical treatment. Non-septic olecranon bursitis can be managed with aspiration alone. Non-steroidal anti-inflammatory drugs probably hasten symptomatic improvement. Intrabursal corticosteroids produce a rapid resolution but concern remains over their long term local effects. Recovery from septic olecranon bursitis can take months.

Study on occurrence of human calicivirus (Mexico strain) as cause of sporadic cases and outbreaks of calicivirus-associated diarrhoea in the United Kingdom, 1983-1995.

The use of a recently developed EIA using antisera raised against purified baculovirus expressed recombinant Mexico virus (rMx) capsid protein is described for screening for human calicivirus in stools. The results show that MX-like viruses have been circulating in the UK periodically since 1983 and were an occasional cause of sporadic cases of diarrhoea in infants and outbreaks of infection among elderly patients in hospitals and old people's homes. Further evidence is presented that some strains of caliciviruses with characteristic surface morphology (HuCVs) and some with an indistinct appearance, small round structured viruses (SRSVs) are antigenically related to MxV. Tests on SRSVs from four unrelated outbreaks typed as UK3 failed to react in the Mx EIA or recombinant Norwalk virus (rNV) EIA. A 2-month survey of 206 children treated in two London hospitals for diarrhoea showed that only one was positive for MxV, a child known to be infected with HIV-1. None of the samples reacted in the rNV EIA.

The history of alcoholism: Brühl‐Cramer's concepts and observations

In 1819 the German-Russian doctor C. von Brühl-Cramer published one of the most important books in the history of alcoholism. He coined the term Trunksucht (which was translated as dipsomania by Hufeland), and he defined it as a physical disease. He discussed aetiology (assuming the consumption of spirits as the main occasional cause and annoyance or depressive feelings as other causes), and pathogenesis (suspecting that repetitive or noxious stimuli provoke a craving for continued intoxication). His recommendations on therapy were influenced by the contemporary ideas on treatment by the laws of chemistry and by concepts of excitability. He offered a classification in terms of continuous, remittent, intermittent, periodic and mixed forms of dipsomania. He described different sequelae, including neuropathy (in which the paresis began at the most distant parts of the limbs), dementia, suppression of the immune system and fetal alcohol syndrome (considering the typical features as proneness to diseases, mental retardation, hyperactivity, facial dysmorphism, incomplete growth). He examined ethnological factors based on his observations in multi-racial Russia. Passages of his work are presented. Relations with works of his contemporaries (especially with Trotter) and influences on later concepts of alcoholism are discussed.

Delayed puberty in girls

Most girls go through puberty with awareness of their sexuality and recognition of the physical changes but with little concern for the details such as onset or rate of progress. Some girls and most mothers are not eager for sexual maturity and recognition of delay is late, unless there are complicating features. Diagnosis of delay and its cause may require careful observation over several months and judicious selection of appropriate tests. It is important not to jump to conclusions which may be wrong. Identification of the occasional serious cause is important since harm may result from delay. Recognition of constitutional delay from long-term causes of hypogonadotrophic hypogonadism may be difficult and replacement treatment may be advisable to gain oestrogen benefits with deferment of final diagnosis. Where there is a fundamental defect of the ovaries or genital tract which will prevent fertility, the condition must be communicated with sensitivity but without ambiguity. Conditions which are reversible so far as pubertal development is concerned require accurate diagnosis and, usually, long-term management.

Radiologic Findings in Two AIDS Patients with Rhodococcus equi Pneumonia

Rhodococcus equi (R. equi) has been reported as an occasional cause of pulmonary infection in severely immunocompromised hosts, including AIDS patients. Our purpose is to describe the radiologic findings in two AIDS patients with R. equi pneumonia. Chest radiographs showed right-upper-lobe consolidation and cavitation in both patients. Chest CT confirmed upper mediastinal involvement and precarinal lymphadenopathy in both cases. Multiple lung nodules related to the bronchi were also identified in one patient. In an AIDS patient from a rural area or with exposure to horses, the possibility of R. equi infection should be considered when cavitary pneumonia is present, even if there is mediastinal involvement and/or lymphadenopathy, or if multiple lung nodules are also present.

Microbiology Relevant to Recurrent Miscarriage

The best evidence suggests that infection is an occasional cause of sporadic spontaneous abortion, and, consistent with statistical probability, recurrent miscarriage due to infection occurs with a frequency that is much lower. In the medical literature, the limited evidence linking infection and recurrent pregnancy loss in humans remains largely anecdotal and generally cannot be reproduced in prospective studies. This observation reflects the low frequency with which the necessary microbial and maternal factors combine to cause recurrent miscarriage. The patient's susceptibility to chronic infection must play a determining role in some of the reported cases. Susceptibility factors that allow severe chronic infection, such as immunocompromise, are rare in the general infertility population and may remain unrecognized in broad cumulative studies. Probable factors that play a role in the risk of abortion due to infection are the following: 1. Primary exposure during early gestation 2. The capability of the organism to cause placental infection 3. The development of an infectious carrier state 4. Immunocompromise caused by immunosuppressants, chemotherapy, corticosteroids, or acquired immune deficiency syndrome. Exposure to a microbe that can establish chronic infection that can spread to the placenta in an immunocompromised patient is probably the most obvious risk situation for habitual abortion. In routine medical practice, it is not necessary or efficient to screen universally for the unexpected, but it is necessary to be aware of the rare possibilities. Most patients with a history of recurrent miscarriage will not benefit from an extensive infection workup. All patients should first be categorized according to their own personal risk infection, as outlined in Table 2.(ABSTRACT TRUNCATED AT 250 WORDS)

Enterovirus 71 infections and neurologic disease--United States, 1977-1991.

Since first described in 1974, enterovirus 71 infections have been associated with severe neurologic disease, and widespread infection was suspected in 1987. To investigate enterovirus 71 activity further, data were reviewed for isolations reported nationally during 1977-1991, virology laboratories were contacted regarding isolations during 1985-1989, and medical records were reviewed for respective patients, 1985-1989. From 1977 to 1991, 193 culture-confirmed enterovirus 71 infections were identified: > or = 1 isolate each year. In 1987, 45 persons in 17 states were infected compared with a maximum of 22 persons in 1-8 states in the other years. Of these 45, 27 (60%) had the following: paralysis (6), Guillain-Barré syndrome (1), meningitis (18), or encephalitis (2). Enterovirus 71 has been endemic in the United States since at least 1977, was identified more frequently in 1987 than in other years, and continues to be an occasional cause of severe neurologic disease.

Long-Term Investing in Politicians; Or, Give Early, Give Often

THE political history of the United States is filled with stories about the power of money in shaping public decisions, and concern about this power is a frequent cause for public debate and an occasional cause for public legislation. Nonetheless, despite years of research by political scientists and economists, the extent to which money actually buys political influence on a regular basis remains a mystery. Virtually all scholarly work attempting to document a systematic effect of money on public decisions focuses on the relationship between campaign contributions-especially Political Action Committee (PAC) contributions-and congressmen's roll-call voting behavior.1 Overall, the

The type 4 pilin of Moraxella nonliquefaciens exhibits unique similarities with the pilins of Neisseria gonorrhoeae and Dichelobacter (Bacteroides) nodosus

Moraxella nonliquefaciens is a bacterium which is part of the normal flora of the human upper respiratory tract and is an occasional cause of disease. Using a previously cloned type 4 pilin gene (tfpQ) from Moraxella bovis as a hybridization probe, we have cloned an 826 bp Sau3 AI fragment which contains an M. nonliquefaciens type 4 pilin gene (tfpA) from strain NCTC 7784. The pilin gene is expressed in Escherichia coli. We have examined NCTC 7784 and nine other M. nonliquefaciens strains by genomic Southern hybridization using tfpA as a probe, and they all appeared to have more than one pilin gene. While the predicted amino acid sequence of the M. nonliquefaciens tfpA pilin has conserved regions as compared to pilins of M. bovis and M. lacunata, it also shows similarities to both the type 4 pilin of Neisseria gonorrhoeae and the type 4 pilin of Dichelobacter nodosus (formerly Bacteroides nodosus).

Anoxic Asphyxia – a Cause of Industrial Fatalities: A Review

The investigation of commercial diving accidents has indicated that the danger of anoxia, from the inhalation of gases not containing oxygen, is not fully recognized. The problem is more common in a variety of general industrial situations and is an occasional cause of death in anaesthesia. It is a particular hazard with inert gases, which, because they are recognized to be non-toxic, give a false sense of security. The pathological findings consist of pulmonary oedema and petechial haemorrhages, mainly in the brain, lungs and myocardium. Whenever possible, a minimum oxygen content should be included in all gases liable to be respired, but where this is not possible, oxygen analysers and alarms should be provided. Where a general hazard exists, personnel must be warned of the danger.

Absent or Faint Renal Uptake on Bone Scan

A review of 14,296 unselected bone scans identified 889 scans showing absent or faint renal uptake. The majority of cases were associated with renal insufficiency (816/889; 91.8%), while widespread metastatic bone disease was the most common cause in a group of patients without renal disease (53/889; 6.0%). Of the 140 patients with prostate cancer, 108 (77.1%) had evidence of bone metastasis, 19 of whom (17.6%) revealed absent or faint renal uptake, demonstrating that poor renal uptake is more frequently associated with prostate cancer than with any other malignancy. Of note was that 162 out of 328 (49.4%) patients with stomach cancer at varying stages showed evidence of bone metastasis, and 14 of them (8.6%) showed poor renal images on bone scan. Interestingly, ankylosing spondylitis and rheumatoid arthritis were occasional causes of lack of renal activity (4 and 3 cases, respectively). A case of adult-form osteopetrosis, showing strikingly increased uptake mainly in the long bones with markedly diminished renal uptake, was also included in this study. Of the 53 bone scans with metastatic disease showing poor renal uptake, 44 (83.0%) revealed evidence of diffuse or multiple metastases in both spine and ribs, while 49 (92.5%) showed malignant involvement in three or more regions and 35 (66.0%) in four or more regions, suggesting widespread bone involvement in most cases.

PNEUMATOSIS CYSTOIDESINTESTINALIS: AN EXPERIENCE WITH HYPERBARIC OXYGEN TREATMENT*

Gut wall gas cysts are uncommon and are an occasional cause of abdominal symptoms. Their aetiology is uncertain and both bacterial infection and chronic airways disease are popularly held theories. At Prince Henry Hospital (PHH) between 1980 and 1986, 8 patients with pneumatosis cystoides intestinalis (PCI) underwent 11 courses of hyperbaric oxygen treatment (HBO). This is the largest reported series of HBO treatment of PCI. In April 1990 attempts were made to recall all patients to assess cyst and symptom status. Two had died from unrelated causes; the other six were reviewed--of these, one declined further endoscopy and the other five consented. The 11 courses of treatment all resulted in pronounced symptomatic responses. This was followed by 7 early symptomatic recurrences and 4 long-term cures. These four remain asymptomatic and cyst-free at a minimum of 4 years to a maximum of 9 years follow-up. Of these 4 cures, cyst resolution was documented immediately post-HBO treatment in two and not assessed in two. In the 7 recurrences, failure of cyst resolution was documented immediately post-HBO treatment in six and not assessed in one. Three patients had chronic airways disease, and two of these have complete resolution of PCI. It is concluded that HBO treatment is effective for PCI provided it is continued until cyst resolution has occurred and not just until symptomatic improvement. These observations suggest that PCI is curable and argues against the pulmonary theory of aetiology.

Posterior impingement syndrome of the ankle

Posterior Impingement Syndrome of the ankle is an occasional cause of pain at the back of the ankle in patients such as ballet dancers and footballers who have to forcibly plantar flex their foot. The pain is due to crushing of the soft tissue at the back of the ankle, and usually there is an enlarged posterior tubercle of the talus present or else an os trigonum. When the condition is remembered, It is easy to diagnose, and removal of the excess bone brings about rapid relief.

Human, small round structured viruses, caliciviruses and astroviruses

Epidemiological studies on SRSVs, human calicivirus and astroviruses have been limited by the problems of establishing them in cell culture and the inability to transmit them to animals or to use strains from animals as a source of antigen for diagnostic tests. The use of EM and the subsequent development of RIAs and EIAs in a few research centres has shown that they are a cause of outbreaks and sporadic cases of diarrhoea and vomiting. SRSVs have increasingly been recognized as a major cause of outbreaks of gastroenteritis in the community and in hospital wards. The symptoms of illness are generally mild and of short duration and patients seldom require medical attention. However, because of the high attack rates and large numbers of persons of all age groups involved, there is often considerable economic loss and disruption of services. Evidence is accumulating that polluted water, molluscan shellfish, and contaminated cold foods are major sources of infection. Recently a SRSV has been shown to be the cause of epidemics and sporadic cases of waterborne enterically transmitted non-A, non-B hepatitis (hepatitis E virus) which have occurred in the USSR, India, Mexico and Africa. Astroviruses and human caliciviruses are occasional causes of outbreaks of vomiting and diarrhoea in infants and the elderly which can necessitate the closure of hospital wards and cause considerable disruption. Symptoms are generally mild and of short duration and therefore the majority of cases are unlikely to be investigated by laboratories. Diagnosis of infections is at present limited to the few laboratories that have developed their own assays or have access to electronmicroscopy facilities.

Is There an Allergic Synovitis?

Nine patients had attacks of joint pain and sometimes swelling precipitated by certain foods or associated with allergic manifestations. All were atopic subjects--three having strong evidence of Type I (immediate) allergy and three 'urticarial arthralgia', in which attacks of severe urticaria and joint pain occurred coincidentally. Food allergy appeared to be responsible for the joint symptoms in three patients and in one it was possible to precipitate swelling of a knee due to synovitis with effusion by drinking milk a few hours beforehand, the synovial fluid having mildly inflammatory features and a relatively high eosinophil count. It seems that allergy is an occasional cause of episodic rheumatic pain or synovitis in certain atopic patients, whether or not they have an underlying arthritis. These are usually Type I hypersensitivity reactions, though it is thought that some food-allergic reactions are immune complex-mediated.

Single Dose of Albendazole in the Treatment of Cutaneous Larva Migrans

<h3>To the Editor.—</h3> The syndrome of cutaneous larva migrans, also known as creeping eruption, is a process commonly found in inhabitants of tropical or subtropical regions of the world. It is caused by penetration of the skin by infective larvae of hookworms from various animals.<i>Ancylostoma braziliense</i>, a hookworm of cats and dogs, causes most cases, although other nematodes, including<i>Ancylostoma caninum, Uncinaria stenocephala</i>, and<i>Bunostomum phlebotomus</i>are occasional causes.¹ Thiabendazole, 25 mg/kg per day orally, for two consecutive days, is currently considered the drug of choice. Alternatively, topical application of an aqueous 10% suspension of the compound (500 mg per 5 ml), has been advocated as equally effective, and essentially devoid of toxic side effects.² As thiabendazole has become unavailable in many countries, and since other suggested alternatives, such as oral or topical mebendazole, have not lived up to early expectations, any addition to the therapeutic armamentarium

Single dose of albendazole in the treatment of cutaneous larva migrans

<h3>To the Editor.—</h3> The syndrome of cutaneous larva migrans, also known as creeping eruption, is a process commonly found in inhabitants of tropical or subtropical regions of the world. It is caused by penetration of the skin by infective larvae of hookworms from various animals.<i>Ancylostoma braziliense</i>, a hookworm of cats and dogs, causes most cases, although other nematodes, including<i>Ancylostoma caninum, Uncinaria stenocephala</i>, and<i>Bunostomum phlebotomus</i>are occasional causes.¹ Thiabendazole, 25 mg/kg per day orally, for two consecutive days, is currently considered the drug of choice. Alternatively, topical application of an aqueous 10% suspension of the compound (500 mg per 5 ml), has been advocated as equally effective, and essentially devoid of toxic side effects.² As thiabendazole has become unavailable in many countries, and since other suggested alternatives, such as oral or topical mebendazole, have not lived up to early expectations, any addition to the therapeutic armamentarium

Evaluation of the adult carrier state in juvenile tinea capitis caused by Trichophyton tonsurans

The anthropophilic dermatophyte Trichophyton tonsurans is an occasional cause of scalp ringworm in adults. An asymptomatic adult carrier state also has been described. In this study the parents and/or grandparents of 50 children with proved T. tonsurans tinea capitis were evaluated. Cultures were obtained from the scalps of 46 asymptomatic adults; 14 of the cultures grew T. tonsurans. This population may provide a source for continued reinfection in children.

Identification of Branhamella catarrhalis in 2.5 min with an indoxyl butyrate strip test

Branhamella catarrhalis, an occasional cause of human respiratory infections, unlike most other members of the family Neisseriaceae, produces a butyrate esterase. This is capable of breaking the ester linkage between butyryl groups and carrier molecules. B. caviae and B. ovis, which are rarely encountered in pathological specimens, also produce butyrate esterase. This property can be used as a rapid test in the identification of B. catarrhalis. The recently reported rapid test for butyrate esterase relies on the release of methylumbelliferate, which can be detected only by using UV light after 5 min of incubation. In the rapid test described here, indoxyl is liberated from indoxyl butyrate by butyrate esterase and spontaneously forms indigo in the presence of oxygen. B. catarrhalis can be distinguished from other oxidase-positive, gram-negative cocci after 2.5 min by inoculating the organism onto a filter paper strip containing this compound.