Mark Corson

By Q. Ningal. Florida Atlantic University. 2018.

Sixteen percent of the patients who were screened received a recommendation for a Helping patients understand how they can brief intervention generic 100mg vermox amex, 3 purchase vermox 100 mg line. Interventions delivered in an empathetic counseling style are more effective than those that rely on confrontation or † 78 It is difficult to compare the effectiveness rates of coercion generic vermox 100mg fast delivery. While brief interventions can avert different research trials and programs as many of the development of a more serious substance use 79 them use restricted populations and vary in the length problem, individuals with the disease of and intensity of the intervention. Despite these addiction require more intensive care and should methodological discrepancies, there are strong data be treated or referred to specialty care. Studies reporting successful outcomes tend to reflect situations where participation was Interventions voluntary and may not reflect outcomes in a population with mandatory participation. The combination of screening and brief Furthermore, most of these studies examine the use * interventions has shown positive results for of screening and brief interventions in primary care 80 81 settings as it pertains to alcohol use and not to other tobacco, alcohol, illicit drugs and the misuse drug use. Another large- interventions, brief treatments or referrals to scale study found that smokers who reported that specialty treatment for those who screened they had received a brief smoking cessation ‡ positive for risky alcohol and/or illicit drug use intervention from their primary care provider at baseline were associated with a 38. Tobacco One study, conducted in a primary care setting with patients who screened positive for risky When clinics and medical offices require alcohol use, found a greater decline in the § screening for tobacco use, tobacco-using number of people who reported binge drinking patients are likelier to achieve smoking among those receiving a brief intervention (from cessation. Those with moderate Defined in this study as consuming more than five risk substance use patterns received brief drinks on one occasion during the previous 30 days. Consuming more than 20 drinks during the past There was no control or comparison group in this week for men and more than 13 drinks during the study. The intervention participants also experienced 55 percent fewer nonfatal motor vehicle crashes Other Drugs 94 and 46 percent fewer arrests. Another study found that a 30-minute brief intervention was Although the research on screening and brief associated with significantly fewer at-risk interventions for other drug use is quite limited * patients being arrested for driving under the and therefore data supporting these services is influence of alcohol during the next three years scarcer than in relation to tobacco and risky (11. In one study based screening and brief intervention programs conducted at six health care sites across the found that 82 percent of the studies included in country, patients who screened positive for drug † 96 the review demonstrated a positive effect. Six months after receiving these routinely screening all pre-surgical patients for interventions, the percentage of patients risky use and addiction can prevent reporting past month marijuana, cocaine, complications from surgery, and brief methamphetamine, heroin or other drug use-- interventions or referral to treatment can prevent including the misuse of prescription sedatives 97 the presenting condition from worsening. However, for patients who engage in risky alcohol use this study did not contain a control condition so have been associated with a 47 percent reduction the extent to which substance use would have in re-injuries requiring emergency department or decreased without these interventions cannot be trauma center admission and a 48 percent determined. Brief interventions with follow-up Patients in the study reported significant are more effective than single-contact increases in health status (from fair to good) and 99 interventions: a review comparing multi- employment (from 31. There also interventions found that those who received were significant decreases in the percentage of multi-session brief interventions reported a 13 to patients reporting past-month emotional 34 percent greater reduction in the average problems (from 25. A Pre- and Post-Past Month Use of Specific Drugs among Screening and Patients* Exposed to Screening and Interventions Brief P 65 Baseline Interventions in E Health Care and 6 Month Follow Up R C 37 Other Settings E N 21 18 While screening and T 12 10 6 3 3 5 brief interventions can be provided in a broad Marijuana Cocaine Methamphetamine Heroin Other Drugs 107 range of venues, * Who report any illicit drug use at baseline. Physicians and other health care providers, including dental professionals, nurses and pharmacists, typically Another study found that a screening and brief * are a consistent, trusted and influential presence intervention program for heroin and cocaine in the lives of children and adults and their users implemented during a routine medical visit professional position grants them the authority was related to greater abstinence among and credibility to deliver effective, evidence- intervention versus control participants from based interventions to patients at risk for cocaine use (22. Six months after screening to health messages once they are in a health care positive for amphetamine use, individuals who † setting. Patients view additional screening, received brief interventions were significantly information, brief intervention or referral to likelier to be abstinent than users who received treatment as part of the health care they sought only self-help booklets. The use of technology to assist in who received brief interventions also showed the completion of screening and brief decreased psychiatric distress scores and 106 interventions holds promise for helping to depression levels. Integrating motivation to reduce drug use, the second on screening and brief interventions into routine reducing cravings through muscle relaxation and self medical check-ups can be an effective way of talk, the third on controlling thoughts about drug use and the fourth on coping with lapses and developing ‡ skills to use in high-risk situations. Strategy Recommends:  The American Dental Association advises  Increasing health care providers’ dentists to address the issue of risky use and knowledge and use of screening and brief addiction with patients and refer them to intervention techniques through enhanced 118 appropriate addiction treatment if needed. And, the regarding the benefits of implementing these National Quality Forum has endorsed screening services in health care and other settings have and brief interventions for tobacco and alcohol been found in primary care settings, clinical use in general health and mental health-care 114 121 trials are lacking in this area. Among these 11 high-priority areas are screening and providing counseling for adolescent alcohol use and screening all individuals for illicit drug use. Associate in Psychiatry, Children’s Hospital Boston Emergency and Trauma Care The U. The earliest Because there is no universally safe level of study--conducted in 1957--was a controlled trial substance use during pregnancy, any use should with 200 dependent drinkers at Massachusetts be screened for and addressed. Patients who had a College of Obstetricians and Gynecologists nonjudgmental, respectful conversation inviting recommends that because of these risks, all them to attend an outpatient program were more women--regardless of present pregnancy status-- likely than other patients to complete one should be screened for alcohol use at least yearly appointment (65. Another study found that pregnant smokers in community health centers  The American College of Emergency who received brief interventions were more Physicians recommends screening and brief likely to be abstinent by the end of their 136 interventions for alcohol use. The fact that dental health Screening and brief interventions in prenatal maintenance and treatment require routine and care settings have been found to reduce alcohol often repeated visits makes dental professionals 145 use significantly, as well as the chances of a consistent and potentially influential presence 146 low birth-weight deliveries. Brief in the lives of people who engage in risky use of 157 interventions for alcohol use among pregnant addictive substances. Dental patients are women are effective even when provided in a receptive to their dentists’ involvement in the community setting by non-medical prevention and treatment of risky use and 147 professionals. A 2005 survey of patients visiting an 148 and partners are particularly effective. They also effective in addressing such use among those can be instrumental in controlling the diversion 152 with psychiatric conditions. For example, a of prescription medications for misuse by study evaluating the effectiveness of a screening monitoring the number of prescriptions filled by and brief intervention program in a primary a patient, looking for false or altered prescription 159 health and mental health care setting at a forms and recognizing when a patient is † 160 university found that six weeks after receiving “doctor shopping” or in need of treatment. High School, College and University Settings Dental Care Screening and brief intervention programs Dental professionals can play a unique role in reduce risky use of addictive substances among detecting substance use among their patients, students by changing their attitudes, beliefs and providing brief interventions and referring expectations regarding tobacco, alcohol and 154 161 patients to treatment. The program consists of 163 two one-hour interviews and a brief online of risky alcohol or other drug use. In the second interventions because of the high rates of interview, students receive personalized face-to- substance use in the college population; an face feedback about their alcohol use compared * estimated 67. To date, the majority of the factors for drinking and strategies for reducing 166 screening- and intervention-related research alcohol use and related problems.

This occurs more com- Spontaneous Bacterial Empyema monly on the right buy vermox 100mg with visa, as there are a greater number (Spontaneous Bacterial Pleuritis) of diaphragmatic defects compared with the left hemidiaphragm discount 100mg vermox fast delivery. In from pleural fluid of a cirrhotic patient with addition to case reports vermox 100mg visa, there have been only two hepatic hydrothorax who has a neutrophil count retrospective series totaling 15 episodes and a 250/μL, similar to spontaneous bacterial perito- prospective study of 24 episodes. It can also be diagnosed if pleural tive trial, 120 patients with hepatic hydrothorax fluid culture is negative and the pleural fluid were hospitalized during a period of 4 years. However, spontaneous bacterial All patients had advanced cirrhosis, and most had empyema is a misnomer because, in the vast been hospitalized on previous occasions with majority of cases, the pleural fluid is not purulent clinical signs of progressive liver dysfunction. Pleural fluid culture results responsible for this infection are enteric bacteria, were positive in 18 (75%) of the 24 episodes using which may reach the ascitic fluid by migration a more sensitive method of culture (inoculation of across the bowel wall or through hematogenous pleural fluid into a tryptic soy broth blood culture spread. In patients with cirrhosis who have were Escherichia coli in eight patients, Streptococcus impaired reticuloendothelial system function, sp in four patients, Enterococcus sp in three intrahepatic and portosystemic shunting of blood patients, Klebsiella pneumoniae in two patients, and is likely to cause persistent bacteremia. The etiologic diagnosis Therefore, a thoracentesis should be per- was confirmed in four of the six culture-negative formed, in addition to paracentesis and blood patients, two by ascitic fluid culture, one by blood cultures, in cirrhotic patients with suspected culture, and one by both ascitic and blood infection. The 1-year, 3-year, 5-year, formed at the level of the mainstem bronchi, is and 10-year survival rates are 78%, 63%, 51%, and the preferred surgical technique. Although a single-lung allograft with nor- mal pulmonary vasculature can accommodate the Criteria Description entire right ventricular output without elevation of pulmonary artery pressures, in times of graft General selection Untreatable end-stage obstructive compromise, such as rejection or infection, severe criteria or restrictive pulmonary paren- chymal or pulmonary vascular ventilation-perfusion abnormalities can develop. Any patient with end-stage pulmonary or Guidelines for Recipient Selection cardiopulmonary disease with the capacity for rehabilitation can be considered for transplanta- There has been a revision of the original tion. However, patients who are receiving nonin- this limit is somewhat arbitrary, numerous patients vasive ventilatory support can be considered for with end-stage pulmonary disease are young to transplantation. Those patients with poor nutritional status may be Relative Contraindications too weak to withstand the surgical procedure; those patients who are obese make more difficult surgical Systemic or Multisystem Disease: Transplantation candidates and may have greater mortality rates than nonobese patients. Subsequently, only be accepted if their disease is well controlled pretransplant low-dose therapy with corticoste- and there is no resulting end-organ damage. Bone densitometry should be part of hepatitis B-antigen positivity, and hepatitis C with the pretransplant evaluation, and treatment should biopsy-documented liver disease. Active malig- be initiated in those patients with evidence of os- nancy within the previous 2 years is also a contra- teoporosis that is symptomatic or in those who are indication to transplantation. Disease-Specific Criteria for Lung Transplantation* or melanoma greater than or equal to level 2, the Disease Criteria waiting period should be at least 5 years. The potential can- didate should be sick enough to have a limited from measurements of body mass index, degree of life expectancy but not so disabled that the indi- airway obstruction, dyspnea score, and exercise vidual will be unable to withstand the procedure. In Pseudomonas aeruginosa and B cepacia, that are resis- 2002, a predictive model5 for selecting patients with tant in vitro to all groups of antibiotics. Therefore, because of the antibiotic therapy, the incidence of bronchitis and individuality of the progression of this disease, pneumonia, and 1-year survival rates appear to be precise criteria for transplantation have not similar between groups. Some newer data date for transplantation, several studies are usually have suggested that those patients with coloniza- performed for further assessment. In those patients who are cardiac index ( 2 L/min/m2), a right atrial pressure in the pretransplant phase for the treatment of of 15 mm Hg, or low or declining 6-min walk test suppurative lung disease, sputum cultures should distances should be considered for transplantation. The usual donor selection criteria liminary data after the first year of the new alloca- include age 60 to 65 years, no history of signifi- tion system suggest that patients with pulmonary cant lung disease, and a limited smoking history. Currently, the lung can Survival only be preserved for a period of approximately 4 to 6 h without experiencing significant ischemia/ Actuarial survival rates after transplanta- reperfusion injury. Newer preservative agents may tion are reported at 92%, 78%, 62%, and 50%, increase this time period and permit a larger area respectively, for 1 month, and 1, 3, and 5 years, as for donor allocation. Early mortality Period (ie, at 30 days) is most often to the result of pri- mary graft failure, mortality between 30 days and Patients are typically discharged from the hos- 1 year is most often to the result of infection, and pital within 7 to 14 days after surgery. Some institutions perform surveillance bron- The degree of improvement in lung function choscopy on a routine schedule to detect asymp- postoperatively is the product of many factors. Pathology from exercise testing generally reveals a reduction in biopsy specimens, autopsy specimens, or lung maximum oxygen consumption to 40 to 60% of explants removed during retransplantation reveals predicted in all transplant groups. Reports15,16 have documented the successful use large majority of patients have expressed satisfac- of protective ventilatory strategies, nitric oxide, tion with their transplant decision. The investigators found transplant complications and the approximate time an incidence of 15% for this complication, and it period in which they usually occur. The theoretical causes of airway complications Acute Rejection: Acute rejection can develop include ischemia at the site of the anastomosis, in up to 50% of patients in the first postoperative infection, poor organ preservation, and/or rejec- month, and as many as 90% of patients will have at tion. In patients with severe Clinically, patients with acute rejection present rejection, the alveolar space may be involved, and with cough, shortness of breath, malaise, and fever. Mainte- episodes; however, in those episodes of rejection nance immunosuppression therapy should also occurring after 1 month after transplantation only be augmented. Recurrent noted with acute rejection include a perihilar or persistent acute rejection may initiate conver- flare, and alveolar, or interstitial, localized, or dif- sion in the baseline immunosuppression regimen. Methotrexate, total lympholytic radia- mucociliary clearance, recipient-harbored infection tion, aerosolized cyclosporine, photopheresis, and and, occasionally, the transfer of infection from the newer immunosuppressive agents have been used donor organ. Inhaled the surgical wound, vascular access, and urinary corticosteroids may be added to therapy in cases tract or ventilator-associated pneumonias also of lymphocytic bronchiolitis. In most shown benefit from the use of low-dose azithromy- circumstances, the allograft or graft is the primary cin (via an antiinflammatory mechanism) for treat- location of infection. The incidence of perioperative bacterial antibiotics or suppressive quinolone treatment may pneumonia has been decreased to as low as 10% by be considered. The prevalence of In addition, the limited donor supply does not bacterial pneumonia remains high during the first allow for the common practice of this procedure. It is often difficult to distinguish pneumo- Infections have been a major cause of early nia from other early graft complications such as and late morbidity and mortality after transplan- reperfusion injury, pulmonary edema, rejection, tation, and they remain the leading single specific and other infectious etiologies. Acyclovir amphotericin B, azoles (particularly itraconazole prophylaxis for herpes infection is initiated in most for 3 to 6 months), or aerosolized amphotericin programs after the discontinuation of therapy with has shown promise in decreasing the incidence of ganciclovir. Fungal infections ac- tive for infections caused by Candida albicans, but count for the most significant morbidity and mortal- amphotericin B is still the agent of choice for a ity of all infectious agents after transplantation, and widespread disease. Aspergillus species amphotericin B remains the antifungal agents of exhibits the propensity to invade blood vessels and choice for these infections, although azole agents may present as an infarct or with hemoptysis.

Patients may be asymptomatic or report the vague and subtle symptoms of hypothyroidism discount 100mg vermox, such as fatigue buy vermox 100mg low price. Thyroid hormone replacement can be prescribed in an attempt to relieve symptoms or possibly to reduce cardiovascular risk cheap 100mg vermox free shipping. The overwhelming majority of patients with hypothyroidism can be treated with once-daily dosing of synthetic levothyroxine, which is biochem- ically identical to the natural hormone. Levothyroxine is relatively inexpen- sive, has a long half-life (6-7 days), allowing once-daily dosing, and gives a predictable response. Older thyroid preparations, such as desiccated thyroid extract, are available but are not favored because they have a high content of T3, which is rapidly absorbed and can produce tachyarrhythmias, and the T4 content is less predictable. In older patients and in those with known car- diovascular disease, dosing should start at a low level, such as 25 to 50 μg/d, and increased at similar increments once every 4 to 6 weeks to an average dose of 1. Overly rapid replacement with the sud- den increase in metabolic rate can overwhelm the coronary or cardiac reserve. Depending on the cause of hypothyroidism and the amount of residual gland function, individual patient needs will vary widely. She denies excess dieting, although she does work out with her team 3 hours daily. She has been reading about her diagnosis on the Internet and wants to try desiccated thyroid extract instead of the medicine you gave her. On examination, she weighs 175 lb, her heart rate is 64 bpm at rest, and her blood pres- sure is normal. Tell her that this delay in resolution of symptoms is normal and schedule a follow-up visit with her in 2 months. Hashimoto thyroiditis is the most common cause of hypothy- roidism with goiter in the United States. It is most commonly found in middle-aged women, although it can be seen in all age groups. Patients can present with a rubbery, nontender goiter that may have “scalloped” borders. Iodine deficiency is exceedingly uncommon in the United States because of iodized salt. Patients with thyroid cancer usually are euthyroid and have a history of head and neck irradiation. Several different autoantibodies directed toward components of the thyroid gland will be present in the patient’s serum; however, of these, antithyroperoxidase antibody almost always is detectable (also called antimicrosomal antibody). On thyroid biopsy, lymphocytic infiltra- tion and fibrosis of the gland are pathognomonic. The presence of these autoantibodies predicts progressive gland failure and the need for hormone replacement. In a young woman with oligomenorrhea, pregnancy should always be the first diagnosis considered. Urine pregnancy tests are easily per- formed in the office and are highly sensitive. In this patient, the next most likely diagnosis is hypothalamic hypogonadism, secondary to her strenuous exercise regimen. These young women are at risk for osteo- porosis and should be counseled on adequate nutrition and offered combined oral contraceptives if the amenorrhea persists. The amount of hormone batch to batch and the patient dose response are believed to be more predictable than with other forms of hormone replacement, such as thyroid extract, which is made from desiccated beef or pork thyroid glands. There is no evidence that the natural hormone replacement is superior to the synthetic form. Other medications, especially iron- containing vitamins, should be taken at different times than levothy- roxine because they may interfere with absorption. Clinical Pearls ➤ The most common causes of oligomenorrhea are disorders of the hypo- thalamic-pituitary-gonadal axis, such as polycystic ovarian syndrome and hypothyroidism. Both hypothyroidism and hyperprolactinemia may cause hypothalamic dysfunction, leading to menstrual irregularities. This page intentionally left blank Case 13 A 49-year-old woman presents to the emergency room complaining of a 4-week history of progressive abdominal swelling and discomfort. She has no other gastrointestinal symptoms, and she has a normal appetite and normal bowel habits. Her medical history is significant only for three pregnancies, one of which was complicated by excessive blood loss, requiring a blood transfusion. She is happily married for 20 years, exercises, does not smoke, and drinks only occasionally. On pointed questioning, however, she does admit that she was “wild” in her youth, and she had snorted cocaine once or twice at parties many years ago. She is thin, her complexion is sallow, her sclerae are icteric, her chest is clear, and her heart rhythm is regular with no murmur. Her abdomen is distended, with mild diffuse tenderness, hypoactive bowel sounds, shifting dullness to percussion, and a fluid wave. Her history reveals a blood transfusion with postpartum hemorrhage and cocaine use. Her abdomen is dis- tended, with mild diffuse tenderness, shifting dullness to percussion, and a fluid wave, consistent with ascites.

Chapter 18: Infections in stroke Mycotic aneurysms as cause of stroke Infectious diseases with similarities Mycotic aneurysms are caused by bacteria or to stroke – toxoplasmosis and malaria fungi and account for a minority (about 3%) of all encephalitis intracranial aneurysms buy 100mg vermox with mastercard. They develop in a significant fraction of patients with infective endocarditis Cerebral toxoplasmosis buy 100 mg vermox overnight delivery, an infection with the proto- (3–16%) cheap 100 mg vermox overnight delivery, due to microemboli that congest the vasa zoan parasite Toxoplasma gondii, mainly occurs in vasorum of the cerebral arteries. The parasite is transmitted by undercooked antimicrobial therapy is frequent (57%) but the meat or cat feces and taken up by the oral route. Reactivation of the dormant parasites during aneurysm formation; (1) septic microemboli to the an impaired immune response leads to lesions with vasa vasorum; (2) hematogenous seeding of bac- a necrotic central area, hyperemic border and some- teria to atherosclerotic vessels; (3) extension from times a thin fibrotic capsule. A feature that distinguishes a contiguous infected focus; and (4) direct contam- these lesions from an abscess is a hypertrophic ination through trauma of the arterial wall. Bacterial aneurysms lesions and, in contrast to acute ischemic stroke, onset are usually small, saccular, and localized at multiple is often subacute. Definite diagnosis ysms are the same as for infective endocarditis, requires histological demonstration of the organism mainly viridans group streptococci, S. Enterobacteriaceae, toxoplasmosis in immunocompromised patients, pri- in particular non-typhi Salmonella spp. The pathogenesis of cerebral malaria shares some Among the fungi, Aspergillus spp. The causative organism of malaria tropica is the An important virulence factor of Aspergillus spp. The mortality associated with erythrocytes stick to the endothelium of the cerebral intracranial aspergillosis is at least 85% and patients blood vessels and reduce the microvascular flow. Aside from aneurysm rupture, Aspergillus becomes less deformable and thus travelling through spp. As in stroke, the reduced blood flow impairs the delivery of substrates, which causes hypoxia, reduc- In patients with infective endocarditis and in tion of the blood–brain barrier, and ultimately brain immunocompromised patients, rupture of mycotic swelling. Section 4: Therapeutic strategies and neurorehabilitation regularly observed, but infarction, necrosis, and large The high frequency of aspiration pneumonia in hemorrhages are rare. In a murine model, stroke induces a severe Infectious diseases as immunodepression through over-activation of the complication of stroke sympathetic nervous system. Dampening of the sym- pathetic activation by propranolol prevented pneu- Early-onset infectious complications monia and bacteremia in 80% of the mice and Infectious complications after acute stroke are improved 7-day survival by 50% [41, 42]. In a prospective study of 3866 patients lation of the immune system during a life-threatening with ischemic stroke hospitalized in neurological condition seems paradoxical but it may serve to pre- stroke units in Germany, 7. Other studies report an patients need to be screened for potential aspiration even higher incidence of urinary tract infections of fluids or semi-solids and the diet should be and pneumonia, 24% and 22% respectively [35]. Other measures (position- Stroke-associated pneumonia is associated with a ing, oral hygiene, tube feeding) have been proposed for higher fatality and worse long-term clinical outcome the prevention of aspiration pneumonia. Preventive antimicrobial therapy is effective in a mouse model [45], and a few small clinical trials have Diagnostic work-up of infections been carried out to assess its usefulness. When clinical signs or laboratory testing results placebo started within 24 hours of stroke onset did (e. A diagnostic work-up is guided within 36 hours of stroke onset, was not sufficiently by the clinical signs and symptoms and should powered to show significant differences between the include blood cultures, urine culture, and a chest groups [47]. If pneumonia is suspected, sputum or tracheal antibiotic therapy further trials are needed. Microbiological speci- Therapy of aspiration pneumonia is largely mens should be obtained before antimicrobial dependent on antibiotic treatment. To guide further treatment, proper Pneumonia in stroke patients is most often caused specimens for microbiological analysis, preferably by dysphagia and secondary aspiration. In up to 70% bronchoalveolar lavage and blood cultures, should of stroke patients the cough and swallow reflexes be obtained. Asymptomatic occurrence of bacteria in Chapter 18: Infections in stroke the urine (bacteriuria) needs to be distinguished from Coccidioidomycosis. Rupture of a mycotic aneur- Initial treatment is strongly dependent on local ysm without adequate antimicrobial therapy is resistance patterns and should follow current guide- frequent. Urine cultures should be obtained Cerebral toxoplasmosis results in a slowly prior to the start of antimicrobial therapy. In common, mostly pneumonia and urinary tract cerebral malaria the infected erythrocytes stick to infections. Infectious complications after acute stroke are Chapter Summary common, mostly pneumonia and urinary tract infec- tions. Pneumonia in stroke patients is most often caused by dysphagia and secondary aspiration. To Acute infection in the week preceding stroke is an prevent aspiration pneumonia, post-stroke patients independent risk factor for cerebral infarction; the need to be screened for potential aspiration of fluids “infectious burden concept” states that the aggre- or semi-solids and the diet should be adapted gate burden of microbial antigens determines stroke accordingly. The main risk factors for endocarditis are injection drug use, an underlying structural heart disease (especially prosthetic valves), hemodialysis References and invasive intravascular procedures. Occlusion of cerebral arteries by septic or sterile emboli that originate from vegetations, usually in the 2. Risk of should be carefully selected according to the results myocardial infarction and stroke after acute of antimicrobial susceptibility testing and be given infection or vaccination. Role of Chlamydia pneumoniae in and leads to thrombosis and subsequent ischemia or atherosclerosis. Ischemic stroke is a relatively frequent complication of tuberculous meningitis 7.