Intracranial tuberculoma: paradoxical expansion during medical treatment

Abstract

LETTERS TO THE EDITOR 487 tumour cells. No additional metastases were identified in a thorough search. Such an occurrence may be coincidental but it makes one wonder whether intra-operative seeding of tumour cells should not be a real concern of the surgeon, and what can be done about it?Ami Schattner, Adi Shani Kaplan Hospital, 76100 Rehovot, Israel.Carcinoma of the splenic flexure -a case for extended right hemicolectomy?Sir, We have recently managed a patient with a splenic flexure colonic carcinoma, who had an unusual distribution of lymph node metastases. This questions the validity of transverse colectomy for this condition.The classical treatment of resectable colonic carcinoma has been excision in continuity with its vascular supply in an attempt at reducing local recurrence by removing involved or potentially involved lymph nodes. This is based on Jamieson and Dobson's work' which suggested that the lymphatic drainage ofthe colon followed its main blood supply. However, blood supply to the splenic flexure has been shown to be somewhat variable. Griffiths2 demonstrated that it was supplied by the inferior mesenteric artery via the left colic in 89% of cases and by the superior mesenteric artery via the middle colic in 11 %. He also noted that the middle colic was absent in 22% of cases. These findings were confirmed by Sierocinski3 who found in 100 post-mortem dissections that the middle colic vessel supplied the splenic flexure in only 19. Where the middle colic is absent, the ileocolic supplied the transverse colon and the left colic supplied the splenic flexure.Goligher4 has advocated transverse colectomy for splenic flexure carcinoma, ligating both middle colic at its origin and the ascending branch of the left colic to remove those nodes most likely to be involved.We report the case of an 83 year old female admitted as an emergency with vomiting and abdominal pain. Plain abdominal X-rays and a gastrografin enema revealed a stenotic lesion at the splenic flexure with complete obstruction. At laparotomy a splenic flexure carcinoma was found and an extended right hemicolectomy performed with an end to end ileocolic anastomosis. The patient made an uneventful recovery and was discharged home.Histological examination of the specimen showed a moderately differentiated adenocarcinoma of the splenic flexure with one of eight local lymph nodes involved (Duke's stage C Jass Class IV). However, one node at the ileo-colic junction showed adenocarcinomatous deposits.Aldridge5

Clinical Spectrum of Paradoxical Deterioration During Antituberculosis Therapy in Non-HIV-Infected Patients

“…Twenty-two percent of all episodes were complicated by residual functional deficits. Evaluation of the clinical spectrum of paradoxical response showed a high propensity for central nervous system involvement, described in 49% of all cases reported in the literature [4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,51,52,53,54]. Because the central nervous system is a highly compact and functionally demanding structure confined within the rigid skull bone, symptomatic neurological deterioration may occur with the enlargement or appearance of intracranial tuberculomas during paradoxical response.…”

“…Including the two cases presented here, a total of 143 episodes of paradoxical response was found in the English literature, of which 122 episodes in 104 patients matched our definition (Table 1) [4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,…”