Seven months after the third perforation he is now

Seven months after the third perforation, he is now finishing the 1-year anti-TB regimen. He is currently healthy, has resumed his work routine, and has not suffered further medical mishaps. A chest X-ray showed clearing of the lesions except for the linear fibrosis in the right upper lobe (Fig. 1B).
Discussion The paradoxical response during the course of anti-TB drugs is a known phenomenon. As reported in previous studies, it may involve a single segment of intestine, usually the terminal ileum, or, occasionally, may be multiple in locations. They usually occur between 2 days and 4 months after the initiation of anti-TB therapy. Of course, caution should be exercised that such perforation be differentiated from uncontrolled TB progression due to nonresponse to treatment or poor immunity of the patient. When perforation occurs shortly after the institution of anti-TB therapy, it may merely be representing the natural progression of the disease. These should be differentiated from the intestinal perforation despite otherwise good response from the anti-TB treatment, the so-called paradoxical phenomenon. Immunity of such patients is assumed to be recovering, as evidenced by the leucocytosis seen during their succeeding perforations. It has been suggested that a reduced imidazoline receptors as a result of anti-TB therapy results in impaired ulcer healing and a reduced tendency to adhesions and reinforcement by the mesentery. This was documented by our operative findings of very flimsy adhesions up to the third operation. Normally at this time, in a patient receiving reoperative management, adhesion would be expected to be maximal. A review of the literature reveals that there is at most a single episode of intestinal perforation during TB treatment, with two episodes occasionally. Jayaswal et al from India reported three episodes of recurrent TB perforation of the small intestine associated with miliary TB of the lung in a 33-year old soldier from India, within a span of 51 days, specifically 7 days, 28 days, and 54 days after anti-TB treatment, respectively. On each occasion, local suture of perforations with biopsy of gut was done. Each time the biopsy of the intestines showed caseating granuloma. Their findings suggested uncontrolled intestinal involvement and probable usual progression of the disease. It is now an accepted fact transforming factor segmental resection of the perforation is the norm of treatment rather than its closure because of the higher leakage rate and fistula formation in the latter prodecure. Our patient is the second patient reported in the literature to have three successive recurrent perforations. Unlike the previous patient, segmental resection of the involved perforated bowel was performed each time in our patient, adding chances for recovery of immunity. Succeeding pathological examinations of the resected perforated bowels showed neither any remnant granuloma nor any acid-fast bacilli, suggesting the continuing curative response of the intestines to the anti-TB treatment. Likewise, the paucity and flimsy adhesions showed a less hyperplastic response of recuperating intestines as opposed to the usual hypertrophic ileocecal masses. However, as enigmatic as the paradoxical response phenomenon, we are only a passive witness to the development of such a phenomenon: the occurrence of perforation despite the improving pathological condition of the previously infected small intestine. We hope that three perforations will be the maximum number of perforations in a patient experiencing such a phenomenon. More understanding of our immunity response mechanism causing these phenomena is needed.
Conclusion
Introduction In the literature, case reports of spinal subarachnoid hematoma (SSAH) are rare, and most of the patients have some predisposing factors, including iatrogenic or traumatic mechanisms, tumors, vascular lesions, anticoagulant therapies, or coagulopathy, either singly or variously combined. Among them, very few cases of SSAH after a traumatic event without anticoagulant therapies or coagulopathy have been reported in the English literature. The rare incidence makes the diagnosis of the disease more difficult. We present a case of SSAH at the C1 level detected 3 days after a blunt head trauma.