Cryptococcal infection of the ventriculoperitoneal shunt in an immunocompetent patient

Patient: Male, 52 Final Diagnosis: Cryptococcal ventriculoperitoneal shunt infection Symptoms: Confusion • fever • Lethargy Medication: Amphotericin B • Flucytosine Clinical Procedure: Ventriculoperitoneal shunt removal Specialty: Infectious disease OBJECTIVE: Rare disease BACKGROUND: Ventriculoperitoneal shunting is an effective treatment for hydrocephalus. Ventriculoperitoneal shunt (VPS) infection is a common complication. Cryptococcus neoformans as an implicated organism is rare. In this report, we describe a patient with cryptococcal VPS infection. CASE REPORT: A 52-year-old male with normal pressure hydrocephalus, status post implantation of VPS one year prior to the presentation; who was admitted with a fever, lethargy and confusion for three days. He was treated empirically with intravenous cefepime and vancomycin for VPS infection. The CSF analysis from both the lumbar puncture and the VPS was significant for a low white blood count, low glucose and high protein. Other work-up including India ink and cryptococcal antigen was unrevealing. He remained febrile despite antibiotic treatment for 5 days. The CSF from the shunt was sent for analysis again and it demonstrated similar results from the prior study, but the culture was now positive for Cryptococcus neoformans. The patient was started on oral flucytosine and intravenous liposomal amphotericin B. The VPS was removed and an externalized ventricular catheter was placed. The patient showed rapid resolution of the symptoms. CONCLUSIONS: To date, there was a total of nine reported cases of cryptococcal VPS infection upon review of the literature. Our presenting case and the literature review highlight the difficulties in making an accurate diagnosis of cryptococcal shunt infection. There were case reports of false negative cryptococcal antigen tests with culture proven cryptococcal meningitis. The CSF culture from the shunt remains a mainstay for identifying cryptococcal shunt infection. Cryptococcal shunt infections are rare and early diagnosis and treatment is essential for patient management which involves shunt replacement with concomitant administration of intravenous antifungal medication. High clinical suspicion is crucial and shunt culture preferably from the valve is recommended

Hemobilia from biliary angiodysplasia diagnosed with cholangioscopy

Biliary angiodysplasia is extremely rare. Our background search revealed only a few case reports in the English literature. We present a case of angiodysplasia of the proximal common bile duct in a patient with subacute upper gastrointestinal bleeding and symptomatic anemia. A standard esophagogastroduodenoscopy with subsequent dedicated duodenoscopy revealed blood-stained bile draining from the major ampulla orifice. A contrast-enhanced magnetic resonance cholangiopancreatography was unrevealing for any pancreaticobiliary pathology. The patient subsequently underwent an endoscopic retrograde cholangiopancreatography and SpyGlass® cholangioscopy, which demonstrated intermittent bleeding from angiodysplasia in the proximal common bile duct

Maximum-Area Rectangles in a Simple Polygon

We study the problem of finding maximum-area rectangles contained in a polygon in the plane. There has been a fair amount of work for this problem when the rectangles have to be axis-aligned or when the polygon is convex. We consider this problem in a simple polygon with n vertices, possibly with holes, and with no restriction on the orientation of the rectangles. We present an algorithm that computes a maximum-area rectangle in O(n^3 log n) time using O(kn^2) space, where k is the number of reflex vertices of P. Our algorithm can report all maximum-area rectangles in the same time using O(n^3) space. We also present a simple algorithm that finds a maximum-area rectangle contained in a convex polygon with n vertices in O(n^3) time using O(n) space

Largest Similar Copies of Convex Polygons in Polygonal Domains

Given a convex polygon with k vertices and a polygonal domain consisting of polygonal obstacles with n vertices in total in the plane, we study the optimization problem of finding a largest similar copy of the polygon that can be placed in the polygonal domain without intersecting the obstacles. We present an upper bound O(k1

The Effects of Tolerance of Ambiguity on EFL Task-Based Writing

1999This study was designed to investigate EFL task-based writing of Korean university students who differed in the degree of tolerance of ambiguity. With this goal, the present study attempted to explore whether or not a low degree of tolerance of ambiguity interferes with the performance of task-based writing and how a low degree of tolerance of ambiguity is related to the task-based writing proficiency. Results showed that the degree of tolerance of ambiguity affected the writing performance. In a holistic scoring system, the high tolerance of ambiguity (HTA) group achieved better score than the low tolerance of ambiguity group (LTA), and the influence of tolerance of ambiguity varied with L2 proficiency. The results also indicated that in an analytic scoring system, HTA and LTA groups' scorings on the components of organization and vocabulary were different. Finally, this study suggests that tolerance of ambiguity should be considered as an important factor for the low proficient students in foreign language writing and that explicit and direct directions should be included to diminish the uncertainty in an EFL task-based writing class

A study of the causal relationship between IT governance inhibitors and its success in Korea enterprises

노트 : Proceedings of the 41st Hawaii International Conference on System Sciences - 2008 행사명 : 41st Hawaii International Conference on System Sc