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Brain infarcts in adults with bacterial meningitis
of mixed venous blood during normoxic acute isovolemic hemodilution in pigs. Anesth Analg 1990; 70: 523-29. 3 van Woerkens ECSM, Trouwborst A, van Lanschot JJB. Profound hemodilution: what is the critical level of haemodilution at which oxygen delivery dependent oxygen consumption starts in an anesthetized human? Anesth Analg 1992; 75: 818-21. 4 Zetterström H, Wiklund L. A new normogram facilitating adequate hemodilution. Act Anaesthesiol Scand 1986; 30: 300-04. 5 Güdemann C, Wiesel M, Staehler G. Intraoperative autotransfusion in urologic cancer surgery by using membrane filters. Vox Sang 1994; 67S2: 116.
Anorexia
nervosa
and
intussusception
SiR-Pseudo-obstruction of the intestine, characterised by recurring symptoms of small bowel obstruction but no evidence of organic obstruction, is seen in teenagers or young adults including patients with eating disorders. We recently treated a patient with anorexia nervosa who developed intestinal obstruction due to intussusception. A 32-year-old woman was admitted to hospital complaining of left lower abdominal pain. She had a 12-year history of anorexia nervosa with previous episodes of binging and purging. There was localised resistance to palpation in her left lower abdominal quadrant with severe tenderness. Radiological examination suggested mechanical obstruction. Due to her poor nutritional status (body mass index: 9-7), supportive treatment was started but with no evidence of resolution of the obstruction. At operation, invagination and strangulation were found in the jejunum, and gangrenous bowel was resected. She recovered slowly after the operation. Patients with anorexia nervosa may have gastrointestinal dysmotility such as delayed gastric emptying’ and pseudoobstruction. However, we know of no reports on intestinal obstruction caused by intussusception in anorexia nervosa. Because of the high-risk for operation in these patients, early diagnosis is essential.
Masayuki Namiki, Sumiharu Morita, Masato Kasuga Okada, Masayoshi *Akio Inui,
Second Department of Internal Medicine and Second Department of Kobe University School of Medicine, Kobe 650, Japan
1 Inui A, Okano H, Miyamoto M, et al. Delayed gastric bulimic patients. Lancet 1995; 346: 1240.
Surgery,
emptying in
S=subcortical, C=cortical. ’Lister/a monocytogenes (4), and one each with Haemophilus influenzae, Escherichia coli, Pseudomonas aerugmosa, Staphylococcus aureus, and Streptococcus vindans; 2Pseudomonas aerugmosa. Table: Characteristics of brain infarcts in bacterial meningitis
normal CT; he died within 24 hours without repeat scanning or necropsy. In nine patients, brain infarction developed within the first week. In eight, the first clinical signs of infarction developed after the onset of antibiotic treatment. Two patients had more than one episode of infarction; two of these occurred 6 and 9 days after onset of treatment. Subcortical infarcts (all with diameters of less than 2 cm) in the were distributions of the lenticulostriate, tuberothalamic, or thalamoperforating arteries. Cortical infarcts were compatible with pial artery or cortical vein occlusion. Apart from meningitis, all case histories were unremarkable, except that of a 61-year-old man with Pseudomonas infection, who had vegetations on a prosthetic aortic valve at necropsy. None of the 31 CT-scans performed-for a variety of reasons-in the 43 patients without focal signs showed focal abnormalities. Patients with tuberculous meningitis (known for its tendency to cause brain infarcts) were included, but even without them the incidence of brain infarction would still be high (19%, 95% CI 10-33%). Since brain infarction was only diagnosed when documented with CT we may have underestimated its occurrence. However, only one patient had focal signs without early CT evidence of infarction and in 31 CT scans of 44 patients without focal signs, no evidence for infarction was found. Patients referred from other hospitals may have represented unusual cases, but in the 49 patients admitted from their homes the incidence was still 22% (95% CI 12-37%). The possible bias introduced by the selection criterion of positive CSF culture is difficult to ascertain. There were another eight patients with clinical signs and CSF-findings compatible with bacterial meningitis, but sterile CSF culture (most had been treated with antibiotics before admission). None of these had focal signs or an infarct on CT. If they had been included the incidence of brain infarcts would have been 24% (95% CI
14-35%). In eight of
Brain infarcts in adults with bacterial
meningitis SIR-Brain infarcts may be common in adults with bacterial meningitis, but their frequency cannot reliably be assessed from available necropsy, clinical, or angiographic studies.’ We restrospectively studied all adults admitted to our department over 12 years with acute meningitis and positive cerebrospinal fluid culture. Brain infarction was diagnosed when focal signs were present on admission, or during the course of the disease, with a corresponding lesion, visualised on computed tomography (CT), in the distribution of an artery. 60 patients (mean age 43 yr, range 18-80) met our criteria. 49 had been referred by general practitioners, nine from other hospitals, and in two the referral source was unknown. 16 patients (27%; 95% CI 16-40%) developed brain infarcts (table). Focal signs included hemiparesis (12), hemiparesis and aphasia (2), and brainstem signs (2). One additional patient had hemiparesis and aphasia with a
16 patients, focal ischemia occurred after onset of antibiotic treatment. Since infarction may be related to inflammation of arteries and veins,’ the question arises whether they could be prevented with steroids. In children, dexamethasone appears to improve outcome,2,3 but in most of them the meningitis was caused by Haemophilus influenzae and the effect on brain infarcts was not carefully assessed. In adults this treatment needs to be investigated in controlled clinical trials.
Willy Weststrate, *Albert Hijdra, Jan de Gans Department of Nueurology, Academic Medical Center, University of Amsterdam, PO Box 22700, 1100 DE Amsterdam, The Netherlands 1
2
3
Pfister HW, Borasio GD, Dirnagl U, Bauer M, Einhäupl KM. Cerebrovascular complications of bacterial meningitis in adults. Neurology 1992; 42: 1497-504. Lebel MH, Freij BJ, Syrogiannopoulos GA, et al. Dexamethasone therapy for bacterial meningitis. Results of two double-blind, placebocontrolled trials. N Engl J Med 1988; 319: 964-71. Odio CM, Faingezicht I, Paris M, et al. The beneficial effect of early dexamethasone administration in infants and children with bacterial
meningitis. N Engl J Med 1991;
324: 1525-31.
399
Anorexia
nervosa
and
intussusception
SiR-Pseudo-obstruction of the intestine, characterised by recurring symptoms of small bowel obstruction but no evidence of organic obstruction, is seen in teenagers or young adults including patients with eating disorders. We recently treated a patient with anorexia nervosa who developed intestinal obstruction due to intussusception. A 32-year-old woman was admitted to hospital complaining of left lower abdominal pain. She had a 12-year history of anorexia nervosa with previous episodes of binging and purging. There was localised resistance to palpation in her left lower abdominal quadrant with severe tenderness. Radiological examination suggested mechanical obstruction. Due to her poor nutritional status (body mass index: 9-7), supportive treatment was started but with no evidence of resolution of the obstruction. At operation, invagination and strangulation were found in the jejunum, and gangrenous bowel was resected. She recovered slowly after the operation. Patients with anorexia nervosa may have gastrointestinal dysmotility such as delayed gastric emptying’ and pseudoobstruction. However, we know of no reports on intestinal obstruction caused by intussusception in anorexia nervosa. Because of the high-risk for operation in these patients, early diagnosis is essential.
Masayuki Namiki, Sumiharu Morita, Masato Kasuga Okada, Masayoshi *Akio Inui,
Second Department of Internal Medicine and Second Department of Kobe University School of Medicine, Kobe 650, Japan
1 Inui A, Okano H, Miyamoto M, et al. Delayed gastric bulimic patients. Lancet 1995; 346: 1240.
Surgery,
emptying in
S=subcortical, C=cortical. ’Lister/a monocytogenes (4), and one each with Haemophilus influenzae, Escherichia coli, Pseudomonas aerugmosa, Staphylococcus aureus, and Streptococcus vindans; 2Pseudomonas aerugmosa. Table: Characteristics of brain infarcts in bacterial meningitis
normal CT; he died within 24 hours without repeat scanning or necropsy. In nine patients, brain infarction developed within the first week. In eight, the first clinical signs of infarction developed after the onset of antibiotic treatment. Two patients had more than one episode of infarction; two of these occurred 6 and 9 days after onset of treatment. Subcortical infarcts (all with diameters of less than 2 cm) in the were distributions of the lenticulostriate, tuberothalamic, or thalamoperforating arteries. Cortical infarcts were compatible with pial artery or cortical vein occlusion. Apart from meningitis, all case histories were unremarkable, except that of a 61-year-old man with Pseudomonas infection, who had vegetations on a prosthetic aortic valve at necropsy. None of the 31 CT-scans performed-for a variety of reasons-in the 43 patients without focal signs showed focal abnormalities. Patients with tuberculous meningitis (known for its tendency to cause brain infarcts) were included, but even without them the incidence of brain infarction would still be high (19%, 95% CI 10-33%). Since brain infarction was only diagnosed when documented with CT we may have underestimated its occurrence. However, only one patient had focal signs without early CT evidence of infarction and in 31 CT scans of 44 patients without focal signs, no evidence for infarction was found. Patients referred from other hospitals may have represented unusual cases, but in the 49 patients admitted from their homes the incidence was still 22% (95% CI 12-37%). The possible bias introduced by the selection criterion of positive CSF culture is difficult to ascertain. There were another eight patients with clinical signs and CSF-findings compatible with bacterial meningitis, but sterile CSF culture (most had been treated with antibiotics before admission). None of these had focal signs or an infarct on CT. If they had been included the incidence of brain infarcts would have been 24% (95% CI
14-35%). In eight of
Brain infarcts in adults with bacterial
meningitis SIR-Brain infarcts may be common in adults with bacterial meningitis, but their frequency cannot reliably be assessed from available necropsy, clinical, or angiographic studies.’ We restrospectively studied all adults admitted to our department over 12 years with acute meningitis and positive cerebrospinal fluid culture. Brain infarction was diagnosed when focal signs were present on admission, or during the course of the disease, with a corresponding lesion, visualised on computed tomography (CT), in the distribution of an artery. 60 patients (mean age 43 yr, range 18-80) met our criteria. 49 had been referred by general practitioners, nine from other hospitals, and in two the referral source was unknown. 16 patients (27%; 95% CI 16-40%) developed brain infarcts (table). Focal signs included hemiparesis (12), hemiparesis and aphasia (2), and brainstem signs (2). One additional patient had hemiparesis and aphasia with a
16 patients, focal ischemia occurred after onset of antibiotic treatment. Since infarction may be related to inflammation of arteries and veins,’ the question arises whether they could be prevented with steroids. In children, dexamethasone appears to improve outcome,2,3 but in most of them the meningitis was caused by Haemophilus influenzae and the effect on brain infarcts was not carefully assessed. In adults this treatment needs to be investigated in controlled clinical trials.
Willy Weststrate, *Albert Hijdra, Jan de Gans Department of Nueurology, Academic Medical Center, University of Amsterdam, PO Box 22700, 1100 DE Amsterdam, The Netherlands 1
2
3
Pfister HW, Borasio GD, Dirnagl U, Bauer M, Einhäupl KM. Cerebrovascular complications of bacterial meningitis in adults. Neurology 1992; 42: 1497-504. Lebel MH, Freij BJ, Syrogiannopoulos GA, et al. Dexamethasone therapy for bacterial meningitis. Results of two double-blind, placebocontrolled trials. N Engl J Med 1988; 319: 964-71. Odio CM, Faingezicht I, Paris M, et al. The beneficial effect of early dexamethasone administration in infants and children with bacterial
meningitis. N Engl J Med 1991;
324: 1525-31.
399