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con ned to the subarachnoid space but frequently penetrates the pia and ependyma and invades the underlying brain, so that the process is truly a meningoencephalitis Other pathologic changes depend on the chronicity of the disease process and recapitulate the changes that occur in the subacute and chronic stages of the pyogenic meningitides (Table 32-1) Cranial nerves are often involved by the in ammatory exudate as they traverse the subarachnoid space indeed, far more often than with typical bacterial meningitis Arteries may become in amed and occluded, with infarction of brain Blockage of the basal cisterns frequently results in a meningeal obstructive tension type of hydrocephalus Marked ependymitis with blocking of the CSF in the aqueduct or fourth ventricle is a less common cause The exudate may predominate around the spinal cord, leading to multiple spinal radiculopathies and compression of the cord Clinical Features Tuberculous meningitis occurs in persons of all ages Formerly it was more frequent in young children, but now it is more frequent in adults, at least in the United States The early manifestations are usually low-grade fever, malaise, headache (more than one-half the cases), lethargy, confusion, and stiff neck (75 percent of cases), with Kernig and Brudzinski signs Characteristically, these symptoms evolve less rapidly in tuberculous than in bacterial meningitis, usually over a period of a week or two, sometimes longer In young children and infants, apathy, hyperirritability, vomiting, and seizures are the usual symptoms; however, stiff neck may not be prominent or may be absent altogether Because of the inherent chronicity of the disease, signs of cranial nerve involvement (usually ocular palsies, less often facial palsies or deafness) and papilledema may be present at the time of admission to the hospital (in 20 percent of the cases) Occasionally the disease may present with the rapid onset of a focal neurologic de cit due to hemorrhagic infarction, with signs of raised intracranial pressure or with symptoms referable to the spinal cord and nerve roots Hypothermia and hyponatremia have been additional presenting features in several of our cases In approximately two-thirds of patients with tuberculous meningitis there is evidence of active tuberculosis elsewhere, usually in the lungs and occasionally in the small bowel, bone, kidney, or ear In some patients, however, only inactive pulmonary lesions are found, and in others there is no evidence of tuberculosis outside of the nervous system In the previously mentioned Cleveland series, which comprised 35 patients, active pulmonary tuberculosis was found in 19, inactive in 6, and involvement of the nervous system alone in 9; only 2 of the 35 patients had nonreactive tuberculin tests (Hinman), somewhat different from the general experience noted below Among our adult patients, tuberculous meningitis is now seen almost exclusively in those with AIDS, in alcoholics, and in immigrants from the Far East and India One recent case with an atypical organism occurred in an otherwise healthy local professor who spent several months in East Africa Except for the emergence of drug-resistant organisms, the HIV infection does not appear to change the clinical manifestations or the outcome of tuberculous meningitis However, others disagree, insisting that the course of the bacterial infection is accelerated in AIDS patients, with more frequent involvement of organs other than the lungs If the illness is untreated, its course is characterized by confusion and progressively deepening stupor and coma, coupled with cranial nerve palsies, pupillary abnormalities, focal neurologic de cits, raised intracranial pressure, and decerebrate postures; invariably, a fatal outcome then follows within 4 to 8 weeks of the onset. microsoft excel 2010 barcode add in Barcode Excel Add-In TBarCode Office: Create Barcodes in Excel
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You can then generate barcodes using fonts on your favorite applications such as Microsoft Word, Microsoft Excel, Adobe PDF, printing press software or other ... 402 The bipolar transistor modeling the behavior of bipolar transistors, so that their operation is easier to understand A dual-diode NPN transistor model is shown in Fig 22-3 The base is formed by the connection of the two diode anodes The emitter is one of the cathodes, and the collector is the other Figure 32-2 MRI in tuberculous meningitis There is gadolinium enhancement of the basal meninges, re ecting intense in ammation that is accompanied by hydrocephalus and cranial nerve palsies . how to generate barcode in asp.net using c#, ean-8 check digit excel, crystal reports qr code, code 39 font crystal reports, crystal reports data matrix barcode, birt data matrix barcode excel 2010 microsoft Barcode Add-In for Word & Excel Download and Installation
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