| BACKGROUND: akinetic mutism is a behavioral state wherein a patient seems to be awake but does not move or speak. Several patients are reported to have developed mutism after posterior fossa surgery. We present a patient who developed akinetic mutism after total excision of a choroid plexus papilloma of the fourth ventricle, and who was treated with bromocriptine. CASE DESCRIPTION: An 18-year-old woman was admitted with akinetic mutism, which had developed 6 days after posterior fossa surgery. She had had no neurologic deficit in the first 5 days after surgery and could communicate with her family. Despite antioedematous therapy and daily lumbar punctures to drain cerebrospinal fluid, there was no clinical improvement after she entered the akinetic mute state. brain magnetic resonance revealed ventriculomegaly; brain single photon emission computed tomography revealed bilateral reduction of perfusion in the frontal region. Because daily lumbar drainage did not result in clinical improvement, shunt placement was not considered. bromocriptine therapy was begun at a dose of 2x2.5 mg; 24 hours later, the patient started to speak and move her upper extremities. Further improvement occurred over the following week when the dose was increased to 3x2.5 mg. bromocriptine was replaced with a placebo to determine whether the neurologic improvement was caused by the medicine. The patient's neurologic status deteriorated progressively; therefore, bromocriptine was restarted and she was discharged from the hospital. During the 6 months of follow-up, the patient has remained in good health. CONCLUSIONS: The etiology of akinetic mutism is not clear. Monoaminergic pathways, particularly dopaminergic cell groups, are most probably involved in this syndrome, because bromocriptine has a dramatic effect on these patients, as demonstrated in our case. ( info) |
2/811. Villous tumour of the duodenum. The occurrence of a villous tumour of the duodenum in an 18-year-old female patient is reported. This is the youngest patient who has been recorded as having this type of tumour. Fibre-optic endoscopy with biopsy of the tumour permitted a pre-operative diagnosis to be made. ( info) |
3/811. Squamous cell papillomatosis of esophagus following placement of a self-expanding metal stent. The esophageal self-expanding metal stent has gained widespread acceptance for the management of tracheoesophageal fistulas and the palliative management of malignant esophageal strictures. The complications associated with its use can be classified as either immediate or delayed. The most frequent delayed complications include tumor ingrowth, stent migration, reflux of gastric contents, bleeding, and perforation. This case report illustrates an otherwise unrecognized delayed complication of a self-expanding metal stent. Near complete ingrowth of the stent by squamous mucosal hyperplasia occurred within six weeks of the metal stent's placement. This finding supports the hypothesis that mucosal injury and regeneration underlies the etiology of esophageal squamous cell papilloma formation. ( info) |
4/811. Removal of benign tumors using the CO 2 laser. The CO 2 laser is most widely used for treatment of lesions affecting the oral mucosa. This paper concerns the use of CO 2 laser surgery in benign tumors. Thirty-seven cases of benign tumors were treated and two of them, a papilloma and a reactional fibroma, are described in detail. ( info) |
5/811. CO 2 laser surgery in hemophilia treatment. The use of CO 2 laser surgery between 1985 and 1991 in south africa and portugal for treatment of disorders in patients with mild to moderate cases of hemophilia A is discussed. Six cases of oral procedures and excision of skin tumors performed during this period are reported. In most of the cases of mild hemophilia no pre- or postoperative infusion of factor viii or desmopressin (DDAVP) was required. In some cases of moderate hemophilia, patients were infused with desmopressin (0.3 mug/kg body weight) and were treated postoperatively with the use of nasal desmopressin spray (150 mug to each nostril for four weeks following surgery). factor viii levels were measured before surgery. Follow up of four weeks was uneventful. The mean average power of the CO 2 laser was 20 W continuous and the pulse duration was 0.1 s for ablational procedures. For dermatologic procedures, a flexible plastic CO 2 laser hollow fiber was used (Flexilase, Sharplan, Allandale, NJ). We concluded that CO 2 laser surgery for hemophiliacs has a confirmed place in modern laser technology provided the standard precautions are taken and facilities are available. ( info) |
6/811. Borderline malignant change in recurrent mullerian papilloma of the vagina. Malignant change occurred in a benign, recurrent vaginal mullerian polyp. The patient, a 49 year old woman with cerebral palsy, presented with a polypoid mass in the vagina. At four years of age she had presented with a haemorrhagic polyp, and over the following years she had recurrent irregular bleeding and regrowth of the polypoidal mass, requiring a total of 10 operations to excise the polyp. Histological examination of the specimen showed typical mullerian features with tubal, endometrioid, and endocervical cell types. There were significantly abnormal nuclei, indicating low grade or borderline malignancy. review of previous biopsies showed similar mullerian features but no atypia. This is the first reported case of borderline malignant change in a previously benign recurrent mullerian papilloma of the vagina. Definitive radical surgery or radiotherapy is contraindicated in this patient and she remains under follow up. ( info) |
7/811. An aggressive and invasive growth of juvenile papillomas involving the total respiratory tract. A malignant course of juvenile laryngeal papillomatosis has rarely been reported. In the present case the patient had had laryngeal papillomas since the age of three years. The papillomas gradually spread to the entire respiratory system, and during 30 years the patient was operated on more than 80 times. At present an invasive tumour spreading from the tongue into the parapharyngeal space, extending to the cranial base, has been demonstrated by magnetic resonance imaging (MRI). Intralesional therapy with Cidofovir, a promising antiviral drug against human papillomavirus (HPV) infection, was started with some clinical effect, although only on the superficial tumour growth. histology of removed tumour tissue has demonstrated a mixture of exophytic and inverted growth pattern, and has mainly been interpreted as benign, in spite of a focally high mitotic index and an intermittent lack of maturation in the epithelium. In the most recent biopsies a verrucous carcinoma has been diagnosed. Expression of p53 was noted to increase in papillomas with time. All samples have been shown to harbour HPV 11, but no other HPV types. ( info) |
8/811. Mucin-producing biliary papillomatosis associated with gastrobiliary fistula. We report a case of mucin-producing biliary papillomatosis in a 78-year-old woman. Abdominal ultrasound (US) and computed tomography (CT) showed wall thickening and dilatation of the intrahepatic bile duct (IHBD), as well as a nodular lesion, 1.2 cm in diameter, in the left branch of the IHBD. Gastric endoscopy revealed excretion of bile-containing mucin on the anterior wall of the body of the stomach. Endoscopic ultrasonography (EUS) showed gastrobiliary fistula and discharge of mucin into the stomach. Needle biopsy of the biliary tumor revealed papillary proliferation, but no malignant cells were recognized histologically. Therefore this patient was diagnosed as having mucin-producing biliary papillomatosis forming gastrobiliary fistula. She did not present with obstructive jaundice, probably because of the fistula. She is alive, without obstructive jaundice, 16 months after the diagnosis without having had surgery. This is, to our knowledge, the first reported case of biliary papillomatosis forming gastrobiliary fistula and with the patient free of obstructive jaundice. ( info) |
| Utilizing a ventricular perfusion technique, the rate of CSF formation was determined in a 2-year-old child before and after removal of a 74 g choroid plexus papilloma from the left lateral ventricle. Preoperatively, the CSF formation rate was 1.05 /- SD 0.01 ml/min (1,656 ml/day). Postoperatively, the CSF formation rate was reduced fivefold to 0.20 /- SD 0.01 ml/min (288 ml/day). Whereas these data are regarded as conclusive evidence of CSF overproduction by a choroid plexus papilloma, the pathogenesis of generalized ventricular enlargement in this case was due to part to obstruction of the subarachnoid pathways. ( info) |
| A case of choroid plexus papilloma resembling meningioma of cerebellopontine (CP) angle with its extension to foramen magnum is presented. Occurrence of this tumour in CP angle is very rare. Its extension towards foramen magnum is further rare. It was a real diagnostic enigma preoperatively as the tumour was resembling meningioma upto some extent on radiological study. Retromastoid craniectomy with microsurgical excision of tumour and its extension was achieved in toto. Tumour was attached to few rootlets of lower cranial nerves which were preserved. Attachment of the tumour with lower cranial nerves again caused diagnostic confusion with neurofibroma intraoperatively. ( info) |