SELECTED SUMMARIES

and their relationship to the central nervous system. Eur J Pediatr Surg1991;1:7>-9.

11 Kanamaru K, Waga S. Congenital dermoid cyst of the anterior fontanelle in aJapanese infant. Surg NeuroI1984;21:287-90.

12 Wong TT, Wann SL, Lee LS. Congenital dermoid cysts of the anteriorfontanelle in Chinese children. Childs Nerv Syst 1986;2:175-8.

13 Adeloye A. Subgaleal dermoid cyst of the anterior fontanelle (Adeloye-Odeku Disease). In: Neurosurgery in Africa. Ibadan:lbadan University Press,1989:141-5.

14 Tan EC. Takagi T. Congenital inclusion cysts over the anterior fontanelle inJapanese children. A study of five cases. Childs Nerv Syst 1993;9:81-3.

15 Saito M. Takagi T, Ishikawa T. Dermoid cyst of the anterior fontanelle.Advantage of MRI for the diagnosis. Brain Dev 1988;10:252-5.

16 Pannell BW. Hendrick EB, Hoffman HJ. Humphreys RP. Dermoid cysts ofthe anterior fontanelle. Neurosurgery 1982;10:317-23.

Short course chemotherapy for tuberculosis oflymph nodes

Campbell lA, Ormerod LP, Friend JAR, Jenkins PA,Prescott RJ (British Thoracic Society Research Committee.)Six months versus nine months chemotherapy for tuber-culosis of lymph nodes: Final results. Respir Med 1993;87:621-3.

SUMMARYA 6-month regime of rifampicin and isoniazid supplemented bypyrazinamide in the first 2 months is as effective in the treatmentof pulmonary tuberculosis as the previously recommended9-month regime. The authors tested whether this was also truefor tuberculosis of the lymph nodes and this is the final report oftheir study started in 1986.

They treated 199 patients aged 16 to 80 years with cervical,axillary or chest wall lymph nodal tuberculosis who had not hadcheinotherapy. Patients who had active pulmonary tuberculosisand those with hepatic, renal or visual impairment or pregnancywere excluded from the study. The patients were randomized toone of the following three regimes:

Regime I. Initial 2 months of isoniazid, ethambutol andrifampicin, followed by isoniazid and rifampicin for atotal of 9 months.

Regime II. Initial 2 months of isoniazid, rifampicin andpyrazinamide followed by isoniazid and rifampicin for atotal of 9 months.

Regime III. Initial 2 months of isoniazid, rifampicin andpyrazinamide followed by isoniazid and rifampicin for atotal of 6 months.

The patients received the drugs in the following doses-isoniazid, 300 mg daily; rifampicin, 450 mg for patients under50 kg and 600 mg for those above 50 kg; pyrazinamide, 1.5 gfor patients under 50 kg and 2 g for those over 50 kg; andethambutol, 15mg per kg per day. All the drugs were given oncedaily and corticosteroids were avoided during treatment.

The position and diameter of the lymph nodes, length ofbiopsy or resection scars, the presence of fluctuation or sinusformation, and any new procedures or nodes were recordedbefore the treatment and at 1,2,3,6,9,12,18, and 30 monthsafter its commencement.

Of the 199 patients enrolled in the study, 157 completed thetreatment as planned-50 on regime I, 56 on regime II and 51

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17 Martinez-Lage JF, Almagro Navarro MJ, Poza-Poza M, Puche Mira A, SolaPerez J. Dermoid cyst of the anterior fontanelle in children. Clinical significanceand differentiation from encephalocele. An Esp Pediatr 1992;36:355-8.

18 Ohta T, Waga S, Handa H. Sinus-pericranii. J Neurosurg 1975;42:704-12.19 Ojikutu N, Mordi VPN. Congenital inclusion dermoid cyst located over the

region of the anterior fontanelle in adult Nigerians. JNeurosurg 1980;52:724-7.20 Oliveira HA. Inclusion dermoid cyst of the anterior fontanelle region in adults.

Report of a case. Arq Neuropsiquiatr 1989;47:375-7.

ADELOLA ADELOYECollege of Medicine

University of MalawiB1antyreMalawi

on regime III. A total of 165 patients were followed up for30 months. The treatment was modified or extended in18 patients and 10 had drug toxicity mainly to pyrazinamide,rifampicin and isoniazid. At 30 months, residual measurablelymph nodes were reported in 6 (12%) patients on regime I,10 (18%) on regime II and 10 (17%) on regime III. Four patientson regime I, 2 on regime II and 3 on regime III were judged tohave a relapse by their physicians and were re-treated. Threepatients on regime I, 5 on regime II and 4 on regime III werefound to have enlarged nodes during follow up. None of thedifferences between the three treatment groups approachedstatistical significance (chi-squared contingency table test). Acomparison of the distribution of the size of lymph nodes at anystage of the follow up also showed no treatment differences.Thus, the 6-month and 9-month regimes are equally effectivewith the shorter treatment carrying the advantage of increasedconvenience and reduced cost.

COMMENTTuberculosis of the lymph nodes is the commonest form ofextra-pulmonary tuberculosis. Short-course chemotherapyhas been assessed in patients with pulmonary tuberculosisbut not in tuberculosis of the lymph nodes. The addition ofpyrazinamide, which is a bactericidal drug has enabled theduration of the treatment of pulmonary tuberculosis to bereduced to 6 months.'

The British Thoracic Society'S (BTS) first controlled trialfor lymph node tuberculosis compared two l8-monthregimes of either isoniazid and rifampicin or isoniazid andethambutol, both supplemented with streptomycin for thefirst two months. 2 A satisfactory response was seen with bothand no microbiological relapse occurred when the treatmentwas stopped. The second BTS lymph node study" comparedl8-month with 9-month regimes of isoniazid and rifampicin,supplemented with ethambutol for the first 2 months. Thisshowed that a 9-month course was as effective as the onewhich lasted 18 months.

The present study was undertaken to test whether an evenshorter 6-month regime using pyrazinamide was as effectiveas 9 months of treatment. It also would allow the rates ofresolution in the pyrazinamide and ethambutol regimes to becompared. The first report of the study in 19924 showed thatthere was no difference in the speed of resolution of nodes,in the percentage of patients with residual nodes at the end ofthe treatment or in the numbers developing fluctuation orsinuses. However, 7 patients in the ethambutol group andonly 1given pyrazinamide needed aspiration of pus from lymphnodes (p=0.OO5). This may be because pyrazinamide is

126

bactericidal and kills bacilli which are intracellular, makingglands less likely to become fluctuant on treatment.

McCarthy and Rudd" in a retrospective series during1981-85 reported successful treatment in 40 out of 41 patientstreated with regime III. Dutt et al." found rifampicin andisoniazid daily for 1 month, followed by twice weekly for8 months, a satisfactory regime for non-pulmonary tuber-culosis in 350 patients with sensitive organisms, 14 of whomhad lymph node disease. The Indian study in children?showed a 98% cure rate at the end of 3 years, using anintermittent regime of thrice weekly supervised isoniazid,rifampicin, pyrazinamide and streptomycin for 2 months,followed by twice weekly streptomycin and isoniazid for4 months. The regime was well tolerated and drug toxicityrequiring interruption or alteration of treatment occurred inonly 7.3% of the patients. Most of the children in this studyhad multiple lymph node involvement with 41% having fouror more groups of nodes affected.

The results of the previous studies3•4•7 as well as the presentone have shown that lymph nodes may enlarge and newnodes may appear during and after chemotherapy. Thesenodes may show histological features characteristic of tuber-culosis but are sterile on culture. It is possible that thedevelopment of new nodes in these cases represents animmunological response to the tubercular protein.' Surgicalexcision of these lymph nodes is not necessary even if theyenlarge after treatment because this is usually transient.Surgery is now rarely indicated except for diagnosis and fordraining of lymph node abscesses in a few patients.t or forobtaining cosmetically acceptable scars.

Total surgical excision of tuberculous nodes followed bychemotherapy has no advantage over simple chemotherapy. 8

The small number of events during the follow up period

Ultrasonographic diagnosis of acute alcoholichepatitis

Sumino Y, Kravetz D, Kanel GC, McHutchison JG,Reynolds TB (Division of Gastrointestinal and LiverDiseases and Department of Pathology, School of Medicine,University of Southern California, Los Angeles, California,USA.) Ultrasonographic diagnosis of acute alcoholichepatitis 'pseudoparallel channel sign' of intrahepatic arterydilatation. Gastroenterology 1993;105:1477-82.

SUMMARYUsing ultrasonography the authors diagnosed acute alcoholichepatitis (AAH) by the presence of parallel tubular structureswithin the liver subsegments. Pulse doppler flowmetry showedthat these structures were formed by a dilated branch of thehepatic artery and an adjacent branch of the portal vein. Theycalled this the 'pseudoparallel channel sign' (PPCS). The PPCSwas then specifically sought by two physician operators in

THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 7, NO.3, 1994

confirms the advice given by the Joint TuberculosisCommittee? that patients can be discharged after completionof the treatment, but should be reassessed if new symptomsdevelop. This study confirms the efficacy of the 6-monthregime>? and since it is as effective as 9 months of treatmentwith regimes I and II, it can be recommended for routine usein patients with sensitive organisms. It is convenient, cheapand will probably improve compliance.

REFERENCESBritish Thoracic Society, A controlled trial of six months' chemotherapy forpulmonary tuberculosis, Final report: Results during the 36 months after theend of chemotherapy and beyond, Br I Dis ChesI1984;78:330-6.

2 Campbell lA, Dyson AJ. Lymph node tuberculosis: A comparison of treat-ments 18 months after completion of chemotherapy. Tubercle 1979;60:9~.

3 British Thoracic Society Research Committee. Short course chemotherapy fortuberculosis of lymph nodes: A controlled trial. BM] 1985;290: 1106--8.

4 British Thoracic Society Research Committee. Six months versus nine monthschemotherapy for tuberculosis of lymph nodes: Preliminary results. Respir Med1992;86:15-19. .

5 McCarthy OR, Rudd RM. Six months chemotherapy for lymph node tuber-culosis. Respir Med 1989;83:425-7.

6 Dutt AK, Moers D. Stead WW. Short-course chemotherapy for extrapulmonarytuberculosis. Nine years experience.Ann Intern Med 1986;104:7-12.

7 Jawahar MS, Sivasubramanian S, Vijayan VK, Ramakrishnan CV.Paramasivan CN, Selvakumar V. et al. Short course chemotherapy for tuber-culous lymphadenitis in children. BM] 1990;301:359-62.

8 Nanda BP, Pandhi NC. Dandapat Me. Peripheral lymph node tuberculosis-Acomparison of various methods of managenient. Indian] Tuberculosis 1986;33:20--3.

9 Ormerod LP for the Joint Tuberculosis Committee. Chemotherapy andmanagement of tuberculosis in the United Kingdom: Recommendations of theJoint Tuberculosis Committee of British Thoracic Society. Thorax 1990;4S:40:Hl.

S. GAUDE GAJANAN

1. N. Medical CollegeBelgaum

Karnataka

77 AAH patients, 119 with other alcoholic liver diseases and49 with non-alcoholic liver disease and 15 healthy volunteers.All patients with non-alcoholic liver disease underwent liverbiopsy. Of the patients with alcoholic liver disease histologicalevidence was available in only 51-it was not done in the othersusually because their prothrombin levels were low. PPCS wasseen in 90% of patients with AAH and in 23% of patients withother alcoholic liver disease. This sign was not detected in thosewith non-alcoholic liver disease or healthy subjects. In 51histologically proved cases of alcoholic liver disease, PPCS hada sensitivity of 82% , a specificity of 87% and an accuracy of 84%in diagnosing AAH, whereas clinical criteria correctly predictedAAH with a sensitivity of 64%, a specificity of 87% and anaccuracy of 75%. Histological criteria for the diagnosis ofAAH were the presence of alcoholic hyaline bodies, hepatocyteswelling, and hydropic change; focal hepatocyte necrosis andpolymorphonuclear cell infiltration, and intrasinusoidal andpericentral collagen deposition. Patients with AAH had moresegments involved with PPCS than those who did not haveAAH. PPCS was most often seen in segments 2 and 3. However,it was also found in the other segments. The authors therebyconcluded that PPCS might be an important diagnostic findinginAAH.