Screening CT of the brain determined by CD4 count in HIV-positive patients presenting with headache.
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BACKGROUND AND PURPOSE: Few studies have examined HIV-positive patients presenting with uncomplicated headache for clinical variables that might be predictive of those patients who would most benefit from CT. Because of the value of CD4 counts in predicting the relative risk of developing opportunistic infections and neoplasms, we assessed the diagnostic yield of screening CT in HIV-positive patients presenting with headache as sorted by CD4 count. METHODS: We reviewed CT scan results and CD4 counts in patients presenting with headache uncomplicated by altered mental status, meningeal signs, neurologic findings, or symptoms of subarachnoid hemorrhage. For analysis, scans were considered positive or negative and were grouped according to CD4 counts of less than 200 cells/microL, 200 to 499 cells/microL, and equal to or greater than 500 cells/microL. The results were then analyzed using the chi2 test. RESULTS: One hundred seventy-eight HIV-positive patients underwent a total of 204 unenhanced and contrast-enhanced CT examinations. One hundred twenty-eight (62.7%) of the scans were negative, and 76 (37.3%) were positive. Of the positive scans, 58 (76.3%) showed atrophy only and 18 (23.7%) showed mass lesions or white matter lesions. All cases that were positive for mass lesions or white matter lesions occurred in patients with CD4 counts less than 200 cells/microL (P = .04). CONCLUSION: A recent CD4 count provides an important predictor variable when considering performing CT in HIV-positive patients presenting with uncomplicated headache. Performing CT of the head for patients with CD4 counts equal to or greater than 200 cells/microL is of questionable value considering the low prevalence of positive CT findings. For this select group of patients, MR imaging may be more appropriate than CT. Patients with CD4 counts less than 200 cells/microL should undergo CT because of the high prevalence of positive scans. (+info)
Phase I trial of all-trans retinoic acid in patients with treated head and neck squamous carcinoma.
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Although retinoids show promise for prevention of second primary upper aerodigestive tract tumors, the optimum retinoid, dose, and schedule are unknown. All-trans retinoic acid (ATRA) has greater affinity for retinoic acid receptors and may be more active than other retinoids but has a shorter plasma half life and may up-regulate its own metabolism. We defined the maximum long-term tolerable dose, dosing frequency, pharmacokinetics, and toxicity of ATRA in patients with treated squamous cell carcinoma of the head and neck (SCCHN). Twenty-one patients were randomized to 45, 90, or 150 mg/m2 ATRA either once daily, or as divided doses every 8 h, for 1 year. Pharmacokinetics were assessed periodically. Fourteen men and seven women with previous SCCHN of initial stage I-IV were treated. Grade > or =3 toxicities (reversible) included headache and hypertriglyceridemia in 5 and 6 patients each, mucositis in 2 patients, and hyperbilirubinemia, elevated alkaline phosphatase, colitis, lipasemia, xerostomia, eczema, and arthritis in 1 patient each. The 150-mg/m2 dose was not tolerable. Doses were reduced for grade > or =3 toxicity in seven of eight patients at 90 mg/m2 daily. Three of nine patients at 45 mg/m2/day required dose reduction, two at the once-daily dose. Day 1 ATRA area under the plasma concentration versus time curve (AUC) increased with dose, and after 1-2 months of continued dosing, the AUC declined in 7 of 13 patients (54%) studied. ATRA AUC did not correlate with toxicity severity or frequency. Fifteen mg/m2/day every 8 h is a tolerable dose for 1 year in patients with treated SCCHN. ATRA pharmacokinetics did not correlate with toxicity. (+info)
Histopathologic features of Burkholderia cepacia pneumonia in patients without cystic fibrosis.
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We present the histopathologic features of fatal Burkholderia cepacia pneumonia in three adults (one man [age 44 years] and two women [aged 40 and 43 years]). In all patients, the pulmonary infiltrates initially were localized (right middle lobe, left upper lobe, and right middle lobe) but rapidly progressed. Two open-lung biopsies and one pneumonectomy specimen showed necrotizing granulomatous inflammation merging with areas of more conventional necrotizing bronchopneumonia In one patient, a mediastinal lymph node also showed stellate necrotizing granulomas. Vasculitis was absent. B. cepacia was cultured from the open-lung biopsies and bronchial wash specimens in two patients and from postmortem cultures of lung, subcarinal lymph nodes, and blood in the third. The histopathology in these patients resembles that of melioidosis, which is caused by a related organism, Burkholderia pseudomallei. B. cepacia needs to be considered in the differential diagnosis of necrotizing granulomatous inflammation. In addition, given the rarity with which B. cepacia is identified as a cause of pneumonia in the immunocompetent host, isolation of B. cepacia should trigger a workup for underlying immunodeficiency or lead to an investigation to exclude the possibility of a nosocomial infection. (+info)
Cryptococcal meningitis in non-HIV-infected patients.
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There are few reports on cryptococcal meningitis in non-HIV-infected patients in subtropical areas. We reviewed 94 non-HIV-infected patients microbiologically diagnosed with cryptococcal meningitis and hospitalized at National Taiwan University Hospital, 1977-1996. Forty-two patients (44.7%) had underlying diseases. The main initial manifestations were headache (86.2%), vomiting (72.3%) and fever (69. 1%). The 30 patients with T-cell suppression had more acute illnesses (median duration of symptoms: 14 days vs. 29 days), less typical presentations of meningitis, and reduced inflammatory responses compared with the 64 without T cell suppression. There was no statistical difference between patients who received amphotericin B treatment for 10 weeks and those received amphotericin B with subsequent fluconazole treatment, in terms of mortality rate and recurrence rate. Seventy-five patients (79.8%) had satisfactory clinical responses, and two relapsed. Eighteen patients died (19.1%) and 10 of these died within 2 weeks of hospitalization. Patients in this series had outcomes comparable with those from temperate and even tropical countries with high percentages of immunocompetent hosts. Factors significantly associated with death were lymphoma, semicoma, leukocytosis, and initial high titres of cryptococcal antigen in cerebral spinal fluid (especially >/=1 : 512). On multivariate analysis, lymphoma and initial high cryptococcal antigen titres were independent predictors of mortality. (+info)
Headache in an emergency room in Brazil.
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CONTEXT: When experiencing a headache attack, Brazilian patients usually look for a primary care service, where they are seen by general clinicians. In the town of Ribeirao Preto, these clinicians routinely refer patients to the Emergency Room of the University Hospital. OBJECTIVE: The objective of this study was to evaluate the quality of primary care by analyzing retrospectively the medical records of patients with a complaint of headache seen in this emergency room during the year of 1996. DESIGN: retrospective study. SETTIING: Emergency Room of the Universital Hospital, Ribeirao Preto, Sao Paulo, reference unit. PARTICIPANTS: 1254 patients. The patients who sought the Emergency Room (ER) of the University Hospital of Ribeirao Preto, during the year of 1996 with a complaint of headache were studied retrospectively. MAIN MEASUREMENTS: Etiology, age, diagnosis, secondary cause, laboratory tests. RESULTS: Of the 1254 patients seen (61% women), 1190 (94.9%) were discharged after the administration of parenteral analgesics before they had spent 12 hours in the room. Only 64 (5.1%) patients remained for more than 12 hours. Of the patients who spent less than 12 hours in the room, 71.5% had migraine or tension type headache and did not require subsidiary exams for diagnosis. Of the patients who spent more than 12 hours in the room, 70.3% had secondary headaches. CONCLUSIONS: We conclude the primary care for headache is unsatisfactory in the Ribeirao Preto region. Many patients with primary headache are referred to tertiary care services, indicating the need for the dissemination of the diagnostic criteria of the International Headache Society to general practitioners. (+info)
Vaccination of high-risk breast cancer patients with mucin-1 (MUC1) keyhole limpet hemocyanin conjugate plus QS-21.
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Our objective was to determine whether an immune response can be generated against MUC1 peptide and against tumor cell MUC1 after vaccination with MUC1-keyhole limpet hemocyanin (KLH) conjugate plus QS-21 in breast cancer patients. Nine patients with a history of breast cancer but without evidence of disease were treated with MUC1-KLH conjugate plus QS-21, containing 100 microg of MUC1 and 100 microg of QS-21. s.c. vaccinations were administered at weeks 1, 2, 3, 7, and 19. Peripheral blood was drawn at frequent intervals to assess antibody titers. Skin tests were placed at weeks 1, 3, 9, and 21 to determine delayed type hypersensitivity reactions. Common toxicities included a local skin reaction at the site of the vaccine, usually of 4-5 days' duration, and mild flu-like symptoms usually of 1-2 days' duration. High IgM and IgG antibody titers against synthetic MUC1 were detected. IgG antibody titers remain elevated from a minimum of 106-137 weeks after the first vaccination. Binding of IgM antibody to MCF-7 tumor cells was observed in seven patients, although there was minimal binding of IgG antibody. Two patients developed significant antibody titers post-high-dose chemotherapy and stem cell reinfusion. There was no evidence of T cell activation. This MUC1-KLH conjugate plus QS-21 was immunogenic and well tolerated in breast cancer patients. Additional trials are ongoing to determine the optimal MUC1 peptide for use in larger clinical trials. Further investigation of vaccine therapy in high-risk breast cancer is warranted. (+info)
Surveillance for possible estuary-associated syndrome--six states, 1998-1999.
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Pfiesteria piscicida (Pp) is an alga that has been associated with fish kills in estuaries (where fresh water mixes with salty seawater) along the eastern seaboard and possibly with human health effects. Since June 1, 1998, surveillance for possible estuary-associated syndrome (PEAS), including possible Pp-related human illness, has been conducted in Delaware, Florida, Maryland, North Carolina, South Carolina, and Virginia. This report summarizes passive surveillance for PEAS during June 1, 1998-December 31, 1999, which indicated no persons had illnesses that met PEAS criteria. (+info)
Cranial subdural haematoma associated with dural puncture in labour.
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A 23-yr-old primagravida sustained a dural puncture during epidural catheter insertion and developed a headache that settled with oral diclofenac and codydramol. On the third day after delivery, she convulsed twice without warning. As plasma urate was increased, the putative diagnosis of an eclamptic fit was made, and magnesium therapy was started. A contrast CT scan revealed that the cause of the patient's symptoms was a subdural haematoma with raised intracranial pressure. A coincidental arteriovenous malformation was noted. This case emphasises the need to consider the differential diagnoses of post-partum headache. The management of acute intracranial haematoma is described. (+info)