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Conservative and surgical management of focal cerebral infection
Conservative and surgical management of focal cerebral infwtion H.W.
Mauser*,
0. van Nieuwenhuizen*,
F.C. Tummers*,
introduction
Summary
Computerized transmission tomography has made the early diagnosis of focal cerebral infection more accurate and different authors have shown the possibility of non-surgical therapy with antibiotics and with or without corticosteroid@. In the pre-CT-period this conservative treatment was discussed already3. More recently successful non-surgical treatment of encapsulated abscesses has been reported4”. We report two children in whom intracerebral infection was diagnosed and treatment was guided by the clinical picture and repeated CT-scans. Complete conservative treatment was not possible in these two patients, but whith the help of the CT-scans exact localization and optimal timing of the surgical intervention were made possible. Case reports Case 1. A l4-year-old girl was admitted to our hospital because of three focal seizures, located on the left arm and left side of the face. One month before admission she had sinusitis, which was treated by favage and with antibiotics. No bacterial cultures were done. She did not fully recover. On admission the patient looked ill, with a
* Department of Child Neurology,
and J. Willemse*.
After the introduction of CT-scanning the management of focal cerebral infections has been modified. Based on the data of two patients and on the literature the authors discuss the choice between fully conservative, immediately neurosurgical or delayed neurosurgical treatment. It is the author’s opinion that by closely foIlo~ng the infectious process too early neurosurgical intervention can be avoided and thus unnecessary sacrifice of viable neural tissue. Key words: cerebral infection, computer tomography, conservative treatment.
temperature of 38.5” C. Neurological examination revealed no disturbance of consciousness, no meningea~ irritation, no edema of the optic discs and no focal deficit. CT-scanning showed a hypodense area in the right frontal lobe and a minimum shift of the midline. After contrastinjection a patchy hyperdensity appeared and minimal signs of demarcation were seen. The area was surrounded by considerable edema (Fig. 1). A focal cerebral infection in the right frontal lobe was diagnosed and conservative treatment was started with high doses of antibiotics (flucloxacilline 6 times daily 2 g, chloramphenical 4 times daily 750 mg,
University Hospital Utrecht, The Netherlands.
Address for correspondence and reprint requests: J. Wiiiemse, Department of Child Neurology, Catharijnesingel 101, 3511 GV Utrecht, The Netherlands. Accepted
University Hospital,
4.6.85
Clin Nemo1 Neurosurg 1985. Vool. 87-3
199
Fig. 1. Admission
CT-scan
of the first case
Fig. 2. CT-scan
three weeks after dragnosis (first case)
metronidazol 4 times daily 500 mg, all intravenous). On the second day the clinical state deteriorated following a left-sided seizure. Somnolence, vomiting and moderate left-sided hemiparesis were noted. A second CT-scan three days after the diagnosis showed no alterations except for more edema. Dexamethasone was given for seven days (0.25 mg/kg). followed by marked amelioration of the clinical picture. Three weeks after diagnosis a third CT-scan showed a well-delineated abscess with a diameter of 3.4-4 cm (Fig. 2). Another CT-scan. four weeks after diagnosis, showed no improvement and it was decided to drain the abscess. A week after operation CT-scanning showed no abnormalities except for a slight rest of demarcation of the abscess (Fig. 3). Seven weeks after admission the patient left the hospital without neurological deficits. Eight months later the patient did well, except for a focal seizure. A control CT-scan showed no signs of focal cerebral infection. Fig. 3. CT-scan
200
after operation
(first case)
Case 2. A 12-year-old girl was admitted to our hospital
Fig. 4. First CT-scan of the second case five days after admission
Fig. 5. CT-scan seven days after diagnosis (second case)
because of headache, left-sided earpain and meningeal irritation. She had a record of recur-
lar hemisphere (Fig. 4). Focal cerebral infection was diagnosed and conservative treatment was continued. The same antibiotics were continued and flucloxacilline 6 times daily 1 g iv. was added. Subsequent surgical exploration on the left inner ear showed mastoiditis and a cholesteatoma, but no dural perforation. One week after the diagnosis of focal cerebral infection severe headache, moderate meningeal signs, minimal nystagmus and hemiataxia persisted. Pale optic discs were seen now. A control CT-scan revealed a well encapsulated left cerebellar abscess and a slight increase in diameter of the lateral ventricles (Fig. 5). It was now decided to treat the abscess surgically and complete extirpation of the abscess was performed. CT-scanning after operation (Fig. 6) showed a low density zone in the left cerebellar hemisphere. The size of the lateral ventricles was normalized. Six weeks after operation she left the hospital without neurological deficits. Eight months later the patient was in a good neurological condition.
rent otitis. On admission the temperature was 38.5” C and she was lethargic. Neurological examination revealed meningeal irritation, but no signs of focal neurological deficit. In the nuchal region there were some painful lymph-nodes and there were signs of an otitis on the left side. At lumbar puncture the opening pressure was 200 mm. The CSF contained 2665 cells (100% polynuclear) and the protein level was 1.14 grll (normal 0.150.45 gr/l). Bacterial cultures of the CSF were negative. The diagnosis of meningitis was made and the patient was treated with antibiotics (penicilline G 6 times daily 4 x lo6 E i.v., chloramphenicol 4 times daily 750 mg i.v.). Temperature and meningeal irritation decreased. In the following days she developed anisocory, rotatory nystagmus and left-sided hemiataxia. CT-scanning, five days after admission, showed no pathology; after contrastinjection there was enhancement in the left cerebel-
201
Fig. 6. CT-scan
after operation
(second
case).
Discussion
Before the introduction of the CT-scan the mortality of focal cerebral infection was 30-60%‘. Missed or too late diagnosis is the most important cause of this high mortality. Other causes Table
1. Development
CT
of brain abscess
202
et al. 1%1)
Stage 11
Stage III
focal hypodensity
hypodense area irregular borderline
ring enhancement perifocal hypodensity
demarcation liquefaction irregular borderline perifocal edema
capsule perifocal
early vascular reaction polymorphonuclear cell response
formation of granulation tissue glial proliferation
collagen formation of granulation tissue formation of glial fibres
2nd week
3rd week
6th week
diffuse diffuse
hyperdense
inflammation edema
petechial micro
to Mahser
Stage I
punctiform foci macro
(according
are brain-herniation due to lumbar puncture” and according to some authors, operation before the focal infection is fully encapsulated”. If a focal infection is not fully encapsulated complete removal is doubtful and the risk of contamination or needless removal of viable brain tissue is high”‘. However, other authors refused a delay of surgery and advocated operation as soon as the diagnosis has been established in order to prevent the risk of clinical deterioration with brain-herniation”. With the advent of the CT-scan early diagnosis of focal cerebral infection has been made possible’?-‘“. Gradation of focal infection can be established by morphological’5 (see Table 1) and by clinical8 (see Table 2) parameters. With repeated CT-scanning the optimal moment for operation (total encapsulation) can be detected5.‘0.‘3,‘” and complete conservative treatment of focal neurological deficit shortly after the start of conservative treatment without alteration of consciousness is not an indication for surgical intervention”. The use of dexamethasone in focal cerebral infection has been discussed extensively in the literature. Some found decreased enhancement of the encapsulated abscess in CT-scanning“, but others could not confirm the decreased enhancements. In experiments with rabbits the inhibition by dexamethasone of the inflammatory reaction around the infective process was noted, thus causing a delay of the fibrous encapsulationlX. In experiments with dogs this inhibi-
edema
hemorrhage
Table 2. Neurological state of patients with focal cerebral infection (according to Van Alphen 1976b) Grade I
Alert, slight neurological symptoms
Grade II
Drowsky and/or moderate to severe neurological symptoms
Grade III
Subcomatose, responsive to painful stimuli
Grade IV
Not responsive to painful stimuli, or with disturbance of vital functions.
could not be confirmed19. Additionally it has been suggested that corticosteroids reduce antibiotic penetration in the brain abscess*O.The use of dexamethasone is only advised for a short time if clinical deterioration has been ‘caused perifocal edema according to CT-scanning. According to Rosenblum et aL4, abscesses with a diameter of more than three centimeters will need surgical treatment. Based on the literature and the little but favourable experience with our two reported cases we propose the following management in patients with focal cerebral infection. In every patient, with clinical suspicion of a focal cerebral infection a CT-scan is made immediately. In this way the risk of lumbar, puncture will be avoided. As soon as the diagnosis has been established treatment with intravenous antibiotics is started. During the antibiotic treatment the patient is followed closely. Surgical intervention is performed: 1. whenever a neurological life-threatening situation develops 2. if CT-scanning shows an encapsulated abscess with a diameter more than three centimeters 3. if with repeated CT-scanning the encapsulated abscess with a diameter less than three centimeters fails to decrease. Otherwise antibiotic treatment is continued. Surgical intervention is not indicated, when CT-scanning suggests perifocal edema to be the cause of deterioration. In this case dexamethasone will be used for a short time. Maybe continuous intracranial pressure readings will be useful to detect an increasing intion
tracranial pressure before the patient deteriorates clinically. So the acute intervention might be timed more precisely than is possible at the moment. References BERG B,FRANKLIN G,CUNEO
R,BOLDREY
E,STRIMLlNG 8.
Nonsurgical cure of brain abscess: early diagnosis and follow-up with computerized tomography. Ann Neurol 1978; 3:474. WEISBERG LA. Cerebral computerized tomography in intracranial inflammatory disorders. Arch Neurol 1980; 37: 137. HEINEMAN Hs, BRAUDE AI, 0sTERHoLM JL. Intracranial suppurative disease. Early presumptive diagnosis and successful treatment without surgery. J Am Med Assoc 1971; 218:1542. ROSENBLUM
ML,HOFFJT,NORMAL
D,EDWARDS
MS,BERG
Non-operative treatment of brain anscesses in selected high-risk patients. J Neurosurg 1980; 52:217. WEISBERG LA. Cerebral computerized tomography in intracranial inflammatory disorders. Arch Neurol 1980; 37:137.
BO.
TER BERGJWM,MEVISSEN-VERHAGEN
EAE,VEIGA-PIRESJA,
Het hersenabsces: nieuwe inzichten in diagnostiek en behandeling. Ned Tijdschr Geneeskd 1982; 12650. SAMSON DS, CLARK K. A current review of brain abscess. Am J Med 1973; 54:201. VAN ALPHEN HAMDREISSEN HR. Brain abscess and subdural empyema Factors influencing mortality and results of various surgical techniques. J Neurol Neurosurg Psychiatry 1976; 39:481. BIEMOND A. Hersenziekten, diagnostiek en therapie. Chapter 46.1972; Ed: Bohn, Haarlem (4th edition) 612. PENDL G, SCHULSIER H, PERNECZ A, KOOS W. Surgical treatment of brainabscesses with special consideration of acute and sub-acute abscesses. In: Schiefer W, Klinger M, Brock M (Ed): Advances in Neurosurgery, Springer Verlag 1981; 9:57. VAN ALPHEN HAM. Het hersenabsces. Ned Tijdschr Geneeskd 1976; 120:918. ROZENBERG-ARSKA
M, VERHOEF
J.
CLAVERIA LE, DIJ BOULAY GH, MOSELEY IF. IIItTRCTRIIiR~
infections: investigations by computerized axial tomography. Neuroradiology 1976; 12:59. JOUBERT MJ, STEPHANOV s. Computerized tomography and surgical treatment in intracranial suppuration. J Neurosurg 1977; 47173. NIELSEN H, GILDENSTED c. Computed tomography in the diagnosis of cerebral abscess. Neuroradiology 1977; 12:207. MAHSERHC,GERHARDL,FLOSSDARFR,CLASHE. Development of brain abscesses-computerized tomogram compared with morphological studies. In: Schiefer W, Klinger M, Brock M (Ed): Advances in Neurosurgery. Springer Verlag 1981; 9:32. ROSENBLUMML,HOFFJT,NORMALD,VEINSTEIN PR,PIT~SL. Decreased mortality from brain abscesses since advent of computerized tomography. J Neurosurg 1978 49:658. NEWPF, DAVlSKR, BALLAN’rtNE HT. Computed tomography in cerebral abscess. Radiology 1976; 121641. QUARTEYGRC,JOHNSONJA,ROZDILSKYB. Decadroninthe treatment of cerebral abscess. An experimental study. J Neurosurg 1976; 45:301.
203
DR, YEAGER AS. Neuropathological and computerized tomographic findings in experimental brain abcess. J Neurosurg 1981; 55590. JAWETZ E, MERRIL ER. Effect of cortisone on the therapeutic efficiacy of antibiotics in experimental infections. Arch Int Med 1954: 93:X50.
Iy BRITI RH, ENZMANN
x
204
Mauser*,
0. van Nieuwenhuizen*,
F.C. Tummers*,
introduction
Summary
Computerized transmission tomography has made the early diagnosis of focal cerebral infection more accurate and different authors have shown the possibility of non-surgical therapy with antibiotics and with or without corticosteroid@. In the pre-CT-period this conservative treatment was discussed already3. More recently successful non-surgical treatment of encapsulated abscesses has been reported4”. We report two children in whom intracerebral infection was diagnosed and treatment was guided by the clinical picture and repeated CT-scans. Complete conservative treatment was not possible in these two patients, but whith the help of the CT-scans exact localization and optimal timing of the surgical intervention were made possible. Case reports Case 1. A l4-year-old girl was admitted to our hospital because of three focal seizures, located on the left arm and left side of the face. One month before admission she had sinusitis, which was treated by favage and with antibiotics. No bacterial cultures were done. She did not fully recover. On admission the patient looked ill, with a
* Department of Child Neurology,
and J. Willemse*.
After the introduction of CT-scanning the management of focal cerebral infections has been modified. Based on the data of two patients and on the literature the authors discuss the choice between fully conservative, immediately neurosurgical or delayed neurosurgical treatment. It is the author’s opinion that by closely foIlo~ng the infectious process too early neurosurgical intervention can be avoided and thus unnecessary sacrifice of viable neural tissue. Key words: cerebral infection, computer tomography, conservative treatment.
temperature of 38.5” C. Neurological examination revealed no disturbance of consciousness, no meningea~ irritation, no edema of the optic discs and no focal deficit. CT-scanning showed a hypodense area in the right frontal lobe and a minimum shift of the midline. After contrastinjection a patchy hyperdensity appeared and minimal signs of demarcation were seen. The area was surrounded by considerable edema (Fig. 1). A focal cerebral infection in the right frontal lobe was diagnosed and conservative treatment was started with high doses of antibiotics (flucloxacilline 6 times daily 2 g, chloramphenical 4 times daily 750 mg,
University Hospital Utrecht, The Netherlands.
Address for correspondence and reprint requests: J. Wiiiemse, Department of Child Neurology, Catharijnesingel 101, 3511 GV Utrecht, The Netherlands. Accepted
University Hospital,
4.6.85
Clin Nemo1 Neurosurg 1985. Vool. 87-3
199
Fig. 1. Admission
CT-scan
of the first case
Fig. 2. CT-scan
three weeks after dragnosis (first case)
metronidazol 4 times daily 500 mg, all intravenous). On the second day the clinical state deteriorated following a left-sided seizure. Somnolence, vomiting and moderate left-sided hemiparesis were noted. A second CT-scan three days after the diagnosis showed no alterations except for more edema. Dexamethasone was given for seven days (0.25 mg/kg). followed by marked amelioration of the clinical picture. Three weeks after diagnosis a third CT-scan showed a well-delineated abscess with a diameter of 3.4-4 cm (Fig. 2). Another CT-scan. four weeks after diagnosis, showed no improvement and it was decided to drain the abscess. A week after operation CT-scanning showed no abnormalities except for a slight rest of demarcation of the abscess (Fig. 3). Seven weeks after admission the patient left the hospital without neurological deficits. Eight months later the patient did well, except for a focal seizure. A control CT-scan showed no signs of focal cerebral infection. Fig. 3. CT-scan
200
after operation
(first case)
Case 2. A 12-year-old girl was admitted to our hospital
Fig. 4. First CT-scan of the second case five days after admission
Fig. 5. CT-scan seven days after diagnosis (second case)
because of headache, left-sided earpain and meningeal irritation. She had a record of recur-
lar hemisphere (Fig. 4). Focal cerebral infection was diagnosed and conservative treatment was continued. The same antibiotics were continued and flucloxacilline 6 times daily 1 g iv. was added. Subsequent surgical exploration on the left inner ear showed mastoiditis and a cholesteatoma, but no dural perforation. One week after the diagnosis of focal cerebral infection severe headache, moderate meningeal signs, minimal nystagmus and hemiataxia persisted. Pale optic discs were seen now. A control CT-scan revealed a well encapsulated left cerebellar abscess and a slight increase in diameter of the lateral ventricles (Fig. 5). It was now decided to treat the abscess surgically and complete extirpation of the abscess was performed. CT-scanning after operation (Fig. 6) showed a low density zone in the left cerebellar hemisphere. The size of the lateral ventricles was normalized. Six weeks after operation she left the hospital without neurological deficits. Eight months later the patient was in a good neurological condition.
rent otitis. On admission the temperature was 38.5” C and she was lethargic. Neurological examination revealed meningeal irritation, but no signs of focal neurological deficit. In the nuchal region there were some painful lymph-nodes and there were signs of an otitis on the left side. At lumbar puncture the opening pressure was 200 mm. The CSF contained 2665 cells (100% polynuclear) and the protein level was 1.14 grll (normal 0.150.45 gr/l). Bacterial cultures of the CSF were negative. The diagnosis of meningitis was made and the patient was treated with antibiotics (penicilline G 6 times daily 4 x lo6 E i.v., chloramphenicol 4 times daily 750 mg i.v.). Temperature and meningeal irritation decreased. In the following days she developed anisocory, rotatory nystagmus and left-sided hemiataxia. CT-scanning, five days after admission, showed no pathology; after contrastinjection there was enhancement in the left cerebel-
201
Fig. 6. CT-scan
after operation
(second
case).
Discussion
Before the introduction of the CT-scan the mortality of focal cerebral infection was 30-60%‘. Missed or too late diagnosis is the most important cause of this high mortality. Other causes Table
1. Development
CT
of brain abscess
202
et al. 1%1)
Stage 11
Stage III
focal hypodensity
hypodense area irregular borderline
ring enhancement perifocal hypodensity
demarcation liquefaction irregular borderline perifocal edema
capsule perifocal
early vascular reaction polymorphonuclear cell response
formation of granulation tissue glial proliferation
collagen formation of granulation tissue formation of glial fibres
2nd week
3rd week
6th week
diffuse diffuse
hyperdense
inflammation edema
petechial micro
to Mahser
Stage I
punctiform foci macro
(according
are brain-herniation due to lumbar puncture” and according to some authors, operation before the focal infection is fully encapsulated”. If a focal infection is not fully encapsulated complete removal is doubtful and the risk of contamination or needless removal of viable brain tissue is high”‘. However, other authors refused a delay of surgery and advocated operation as soon as the diagnosis has been established in order to prevent the risk of clinical deterioration with brain-herniation”. With the advent of the CT-scan early diagnosis of focal cerebral infection has been made possible’?-‘“. Gradation of focal infection can be established by morphological’5 (see Table 1) and by clinical8 (see Table 2) parameters. With repeated CT-scanning the optimal moment for operation (total encapsulation) can be detected5.‘0.‘3,‘” and complete conservative treatment of focal neurological deficit shortly after the start of conservative treatment without alteration of consciousness is not an indication for surgical intervention”. The use of dexamethasone in focal cerebral infection has been discussed extensively in the literature. Some found decreased enhancement of the encapsulated abscess in CT-scanning“, but others could not confirm the decreased enhancements. In experiments with rabbits the inhibition by dexamethasone of the inflammatory reaction around the infective process was noted, thus causing a delay of the fibrous encapsulationlX. In experiments with dogs this inhibi-
edema
hemorrhage
Table 2. Neurological state of patients with focal cerebral infection (according to Van Alphen 1976b) Grade I
Alert, slight neurological symptoms
Grade II
Drowsky and/or moderate to severe neurological symptoms
Grade III
Subcomatose, responsive to painful stimuli
Grade IV
Not responsive to painful stimuli, or with disturbance of vital functions.
could not be confirmed19. Additionally it has been suggested that corticosteroids reduce antibiotic penetration in the brain abscess*O.The use of dexamethasone is only advised for a short time if clinical deterioration has been ‘caused perifocal edema according to CT-scanning. According to Rosenblum et aL4, abscesses with a diameter of more than three centimeters will need surgical treatment. Based on the literature and the little but favourable experience with our two reported cases we propose the following management in patients with focal cerebral infection. In every patient, with clinical suspicion of a focal cerebral infection a CT-scan is made immediately. In this way the risk of lumbar, puncture will be avoided. As soon as the diagnosis has been established treatment with intravenous antibiotics is started. During the antibiotic treatment the patient is followed closely. Surgical intervention is performed: 1. whenever a neurological life-threatening situation develops 2. if CT-scanning shows an encapsulated abscess with a diameter more than three centimeters 3. if with repeated CT-scanning the encapsulated abscess with a diameter less than three centimeters fails to decrease. Otherwise antibiotic treatment is continued. Surgical intervention is not indicated, when CT-scanning suggests perifocal edema to be the cause of deterioration. In this case dexamethasone will be used for a short time. Maybe continuous intracranial pressure readings will be useful to detect an increasing intion
tracranial pressure before the patient deteriorates clinically. So the acute intervention might be timed more precisely than is possible at the moment. References BERG B,FRANKLIN G,CUNEO
R,BOLDREY
E,STRIMLlNG 8.
Nonsurgical cure of brain abscess: early diagnosis and follow-up with computerized tomography. Ann Neurol 1978; 3:474. WEISBERG LA. Cerebral computerized tomography in intracranial inflammatory disorders. Arch Neurol 1980; 37: 137. HEINEMAN Hs, BRAUDE AI, 0sTERHoLM JL. Intracranial suppurative disease. Early presumptive diagnosis and successful treatment without surgery. J Am Med Assoc 1971; 218:1542. ROSENBLUM
ML,HOFFJT,NORMAL
D,EDWARDS
MS,BERG
Non-operative treatment of brain anscesses in selected high-risk patients. J Neurosurg 1980; 52:217. WEISBERG LA. Cerebral computerized tomography in intracranial inflammatory disorders. Arch Neurol 1980; 37:137.
BO.
TER BERGJWM,MEVISSEN-VERHAGEN
EAE,VEIGA-PIRESJA,
Het hersenabsces: nieuwe inzichten in diagnostiek en behandeling. Ned Tijdschr Geneeskd 1982; 12650. SAMSON DS, CLARK K. A current review of brain abscess. Am J Med 1973; 54:201. VAN ALPHEN HAMDREISSEN HR. Brain abscess and subdural empyema Factors influencing mortality and results of various surgical techniques. J Neurol Neurosurg Psychiatry 1976; 39:481. BIEMOND A. Hersenziekten, diagnostiek en therapie. Chapter 46.1972; Ed: Bohn, Haarlem (4th edition) 612. PENDL G, SCHULSIER H, PERNECZ A, KOOS W. Surgical treatment of brainabscesses with special consideration of acute and sub-acute abscesses. In: Schiefer W, Klinger M, Brock M (Ed): Advances in Neurosurgery, Springer Verlag 1981; 9:57. VAN ALPHEN HAM. Het hersenabsces. Ned Tijdschr Geneeskd 1976; 120:918. ROZENBERG-ARSKA
M, VERHOEF
J.
CLAVERIA LE, DIJ BOULAY GH, MOSELEY IF. IIItTRCTRIIiR~
infections: investigations by computerized axial tomography. Neuroradiology 1976; 12:59. JOUBERT MJ, STEPHANOV s. Computerized tomography and surgical treatment in intracranial suppuration. J Neurosurg 1977; 47173. NIELSEN H, GILDENSTED c. Computed tomography in the diagnosis of cerebral abscess. Neuroradiology 1977; 12:207. MAHSERHC,GERHARDL,FLOSSDARFR,CLASHE. Development of brain abscesses-computerized tomogram compared with morphological studies. In: Schiefer W, Klinger M, Brock M (Ed): Advances in Neurosurgery. Springer Verlag 1981; 9:32. ROSENBLUMML,HOFFJT,NORMALD,VEINSTEIN PR,PIT~SL. Decreased mortality from brain abscesses since advent of computerized tomography. J Neurosurg 1978 49:658. NEWPF, DAVlSKR, BALLAN’rtNE HT. Computed tomography in cerebral abscess. Radiology 1976; 121641. QUARTEYGRC,JOHNSONJA,ROZDILSKYB. Decadroninthe treatment of cerebral abscess. An experimental study. J Neurosurg 1976; 45:301.
203
DR, YEAGER AS. Neuropathological and computerized tomographic findings in experimental brain abcess. J Neurosurg 1981; 55590. JAWETZ E, MERRIL ER. Effect of cortisone on the therapeutic efficiacy of antibiotics in experimental infections. Arch Int Med 1954: 93:X50.
Iy BRITI RH, ENZMANN
x
204