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Intramedullary tuberculoma (IMT) is a form of spinal tuberculosis which provides a challenge to the internist because there lacks clear diagnostic and treatment guidelines to date. Although rare, it should be included on the differential diagnosis of any patient who presents with progressively worsening symptoms of radiculopathy and a new spinal lesion on imaging. Traditional methods for detection of tuberculosis including tuberculosis spot test and the Ziehl-Neelsen stain have limited utility in diagnosing IMT. In this report, we describe the clinical course, diagnosis and treatment regimen of an adult male with intramedullary tuberculoma of the thoracic spinal cord

Dear Editor:Treatment of pain at the end of life is a priority for hospice patients. Ketorolac is indicated for short-term treatment of moderate to severe pain in patients requiring opiate-level analgesia. 1 Recommendations are to limit use to five days of therapy by either oral or parenteral routes. The risks include bleeding in patients on NSAIDs and renal failure. 2,3 In our 10-year community hospice experience, continuous subcutaneous infusion of ketorolac has improved analgesia with minimal harm for durations exceeding five days.We reviewed all hospice patients over a period of 10 years who received subcutaneous ketorolac for more than five days. Patients over 18 years of age and not receiving other forms of ketorolac were included. Exclusion criteria included patients who died before infusion, had subcutaneous infusion for less than five days, or received ketorolac via methods other than subcutaneous delivery.The 88 eligible patients had a mean age of 65 years (range 27-92); 57% (n = 50) were female. Seventy-five patients had a diagnosis of malignancy and 13 had a noncancer terminal diagnosis. Five patients (5.7%) received ketorolac subcutaneous infusion in the general inpatient hospice unit only. Thirty-seven patients (42%) were in home hospice only. Forty-six (52%) were treated in both the general inpatient hospice unit and home hospice.The average inpatient days on ketorolac was 3.81 (range 0-21), and average home days on ketorolac was 19.59 (range 0-238). The average length of infusion for all patients on ketorolac was 23.49 days (range 6-238). Subcutaneous sites were located most commonly on the arm, abdomen, and thigh. Site complications were rare. Seventy-one patients (81%) remained on the ketorolac until death. Eighty-six patients were prescribed concurrent opiate therapy. Four patients concurrently received NSAID medications other than ketorolac, including ibuprofen, and another four patients received concurrent steroid therapy. One patient was prescribed a lidocaine patch concurrently.Serious adverse events included nausea/vomiting (n = 12) and gastrointestinal bleeding (n = 2). Hematuria was the only renal event (n = 3). Other adverse events were edema (n = 8), hallucinations (n = 1), back hemorrhage (n = 1), apnea (n = 1), and epistaxis (n = 1). Seventeen patients (19%) discontinued ketorolac subcutaneous infusion, only five due to complications.In the 67 patients where pain scores were recorded, 38 (57%) had a positive response of at least two points over five days. There was a significant reduction of average pain scores from day 1 to day 5 ( p < 0.001), with an average day 1 score of 5.03, day 3 score of 3.31, and day 5 score of 2.89.Use of long-term ketorolac subcutaneous infusion provided good pain relief and was well tolerated in hospice patients nearing death. Ketorolac offered greater ease of administration than other analgesics and was continued until the time of death in most patients. Many patients initiated the infusion safely in the home hospice setting. The retrospective uncontroll...

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