BRIEF CLINICAL

OBSERVATIONS

J. v.d. NAALT,M.D. H.HAAXMA-REICHE,M.D.,P~.D. E.F. SMIT,M.D. P.E.PosTMus,M.D.,P~.D. State University Hospital Groningen, The Netherlands 1. Postmus PE, Smit EF. Berendsen HH. Sleijfer DTh, Haaxma-Reiche H. Treatment of brain metastases of small cell lung cancer with teniposide. Semin Oncol (in press). Z.Grahame-Smith DG. Aronson JK. Drug interactions. In: Grahame-Smith DG. Aronson JK. Oxford textbook of clinical pharmacology and drug therapy. Oxford: Oxford University Press, 1985: 158-72. 3. Van Echo DA, Egorin MJ. Arsner J. The pharmacology of carboplatin. Semin Oncol 1989; 16: 1-6. 4. Newell D. Eeles RA. Gumbrell LA, Boxall FE, Horwith A. Calvert AH: Carboplatin and etoposide pharmacokinetics in patients with testicular teratoma. Cancer Chemother Pharmacol 1989; 23: 367-72. 5.Teunissen MWE, Willemse PHB, Sleijfer DTh, Sluiter WJ. Breimer DD: Antiovrine metabolism in patients with disseminated tesiicular cancer and the influence of cytostatic treatment. Cancer Chemother Pharmacol 1984; 13: 181-5 Submitted February

15, 1990, and accepted February 23, 1990

ROSTRAL BASILAR REVERSIBLE ISCHEMIC NEUROLOGIC DEFICIT IN AN HIV-INFECTED PATIENT WITH CRYPTOCOCCAL MENINGITIS Transient neurologic deficits (TND) and cerebral infarctions are being increasingly recognized as complications of acquired immunodeficiency syndrome (AIDS)-related illnesses [l]. Cerebral infarction is more common than TND in AIDS patients with cryptococcal meningitis. Whether all episodes of TND are transient ischemic attacks (TIA) is unclear from the limited number of reports. We report an unusual but clear-cut episode of TIA in an AIDS patient with cryptococcal meningitis. This 26-year-old, previously healthy woman was admitted to the hospital because of severe headaches. She reported feeling ill for the previous 3 weeks with headaches, back pain, poor appetite, weight loss, and malaise. She had been examined several times for these complaints, and had been found to be afebrile with a normal blood count and no evidence of systemic infection. Four days prior to admission, she underwent computed tomographic (CT) scanning of the brain, results of which were normal, and a spinal tap revealing acellular fluid and normal glucose and protein levels.

248

August

1990

The American

Journal

On the day of her admission, she The protein value in the CSF was 80 mg/dL and the glucose value had no fever but did have a stiff neck and was complaining of a se- was 48 mg/dL. The red blood cell vere headache and backache. count was 2 and the white blood cell count was 77, with 70% lymThrush was noted in her pharynx, and molluscum contagiosum le- phocytes and 15% mononuclear sions were widely distributed on cells. Yeast cells were seen in the spinal fluid, and cryptococcal antithe skin. She was mildly lethargic but was lucid, oriented, and able to gen was positive. She had no heart give a cogent account of her diffimurmur and no evidence of sysculties. During the examination temic emboli. she suddenly became more letharOn the day of admission she was gic, and within a few moments be- treated with dexamethasone, amcame deeply comatose and unrephotericin B, and flucytosine. The sponsive to pain, with a dilated, headache and neurologic abnorfixed left pupil. Within a few minmalities resolved. She was found to utes she awoke but was lethargic be human immunodeficiency virus and somnolent. She was able to co- (HIV)-positive. At the time of her operate with the examiner and her discharge from the hospital 3 visual fields were intact. Visual weeks later, she still complained of acuity was 20170 in the left eye and an occasional mild headache, re20125 in the right eye. There was lieved by acetaminophen, but othbilateral papilledema but no hemerwise felt well and was neurologiorrhage or exudate. tally intact. The CSF was acellular, The pupils were unequal, with and within 3 months the CSF crypthe left being larger and slightly tococcal antigen titer fell to 1:lB. oval. Both reacted sluggishly to This patient with cryptococcal light. Brisk nystagmus to the left meningitis associated with HIV inwas present. There was converfection presented with transient gence spasm with bilateral pseudoischemia of the rostral basilar arsixth-nerve palsies and complete tery. Nystagmus, dysarthria, puparalysis of upward gaze. The left pillary abnormalities, conjugate arm and leg were clumsy, hypotongaze paresis, and coma indicate inic, and mildly weak. Sensation to volvement of the midbrain; the pinprick was impaired on the en- dense hemianesthesia indicates thalamic involvement, and the detire left side of the body, sharply demarcated at the midline. The velopment of cortical blindness indeep tendon reflexes were de- dicates ischemia in the distribution creased in the left arm and hyperof both posterior cerebral arteries. active at both knees. The plantar We believe the cause to have been responses were flexor. related to inflammation in the basAs this examination was being ilar cisterns. The improvement folcompleted, the patient again be- lowing dexamethasone treatment came less responsive and her could have been due to its anti-inspeech slurred. She became com- flammatory effect, its lowering of pletely blind, but her pupils re- increased intracranial hypertenmained reactive, indicating cortical sion, or coincidence. Cerebral vasculitis causing blindness. An emergency unenhanced CT stroke is a known complication of scan was normal. By the time CT tuberculosis [2]. To our knowledge, scanning was completed, she was however, transient rostra1 basilar fully alert, lucid, and speaking nor- ischemia, as opposed to infarction, has not been reported in any chronmally. There was no nystagmus and no convergence spasm, and the ic lymphocytic meningitis; nor has pupils were equal and round and this kind of vascular complication reacted well to light bilaterally. been previously reported in cryptoThere were full extraocular move- coccal meningitis in AIDS patients. We conclude that TIA may occur ments. Mild hypotonia and weakin AIDS patients with cryptococcal ness of the left hand were noted. The sensory deficit resolved. The meningitis and that cryptococcal deep tendon reflexes became nor- meningitis should be considered in mal and the plantar responses were the differential diagnosis of TND flexor. A lumbar puncture revealed in patients with or at risk for AIDS. markedly elevated pressure with ROBERTD.RAFAL,M.D. the cerebrospinal fluid (CSF) gushMartinez Veterans Administration Medical Center ing over the top of the manometer.

of Medicine

Volume

89

BRIEF CLINICAL

Martinez, JOSEPH

Roger

California

H. FRIEDMAN,

M.D.

Williams General Hospital Providence, Rhode Island

1. Engstrom JW, Lowensteln DH. Bredesen DE. Cerebral infarcbons and transient neurologic deftclts assoelated with acquired lmmunodeficlency syndrome. Am J Med 1989; 86: 528-32. 2. Parsons M. Tuberculous meningitis. Tuberculomas and splnal tuberculosis. A handbook for clinicians. 2nd ed. New York: Oxford Untversity Press, 1988. SubmItted February 7,1990,

and accepted in revised form March 21, 1990

PSEUDOCYST OF THE AURICLE Pseudocyst of the auricle (PCA) is a benign, asymptomatic, noninflammatory cystic swelling involving the anthelix of the ear and resulting from an accumulation of fluid within an unlined intracartilaginous cavity [l]. The condition was initially described by Hartmann in 1885; additional cases were not published until nearly a century later by Engel [2]. Although patients with PCA have not been frequently reported, it is likely that this disorder is more prevalent than the number of published cases implies [3]. To date, this condition has not been described in the internal medicine literature. PCA is predominantly observed

in middle-aged men and most commonly presents as a solitary, unilateral, enlarging, painless, fluidfilled, cystic lesion located on the scaphoid and/or triangular fossa of the auricle (Figure 1) [l-8]. Infrequently, this condition has been described in women, observed (either consecutively or concurrently) on both ears, and/or associated with a prior history of trauma to the involved area [1,2,4,5]. The fluid within the pseudocyst (between 0.5 and 10.0 mL) is sterile, watersoluble, rich in albumin, and usually colored straw-yellow [l-3,5,6]. The absence of an epithelial layer of cells lining the inner surface of the intracartilaginous cavity is the distinctive histologic feature of a PCA. Early pathologic changes in the cartilage surrounding the cavity may include thinning and hyalinization; in older lesions, necrosis of the cartilage and foci of granulation tissue may be observed. The extent of intracartilaginous and surrounding fibrosis is directly proportional to the age of the lesion [l-S]. It is not surprising that the conditions most frequently misdiagnosed histologically instead of PCA were inflammatory disorders of cartilage [8]. Benign and malignant tumors, cystic lesions, inflammatory and vascular disorders, and

OBSERVATIONS

metabolic and systemic diseases comprise the clinical differential diagnosis of PCA [l-6]. Two compatible, not mutually exclusive, unconfirmed mechanisms of pathogenesis for PCA have been proposed: abnormal embryologic development of the auricle with lesions subsequently occurring at the locus minoris resistentiae and cartilage degeneration secondary to the abnormal release of chondrocyte lysosomal enzymes [2,5,6]. Successful therapy of PCA requires resolution of the lesion without recurrence, and both the structural and the cosmetic preservation of the external ear architecture. Earlier efficacious treatment modalities have often included the single or combined use of a chemical irritant, capable of inducing fibrosis of cavity-lining cartilage, to the wall of the cavity and the application of a bilateral pressure dressing to the ear [1,2,6,7]. Recently, a surgical method successfully utilized second-intention healing after filling the defect, created by excising the anterior cavity wall and granulation-tissue-filled fracture of cartilage, with an absorbable collagen matrix sponge; this approach provided an excellent functional and cosmetic result [4]. In summary, PCA is a benign,

Figure 1. Recurrent pseudocyst of the auricle, appearing as a single, unilateral, erythematous, nontender 4.0- X 2.0-cm cystic swelling involving the entire anthelix of his left ear, in a 33year-old man without any antecedent history of trauma to site.

August

1990

The American

Journal

of Medicine

Volume

89

249

Rostral basilar reversible ischemic neurologic deficit in an HIV-infected patient with cryptococcal meningitis.

BRIEF CLINICAL OBSERVATIONS J. v.d. NAALT,M.D. H.HAAXMA-REICHE,M.D.,P~.D. E.F. SMIT,M.D. P.E.PosTMus,M.D.,P~.D. State University Hospital Groningen,...
1MB Sizes 0 Downloads 0 Views