Unusual forms of spinal tuberculosis

Objective The incidence of tuberculosis (TB) is increasing in both developing and developed worlds, and children, in particular, represent a high-risk group for acquiring the disease. TB of the central nervous system is the most severe, life-threatening form of TB in infants and children. Approximately 10% of all patients with TB have central nervous system involvement. Materials and methods We have selected four pediatric cases of unusual spinal TB that presented to our institution during the last 5 years. These include TB arachnoiditis, intramedullary spinal cord tuberculoma, TB spondylitis of the odontoid peg, and one child with tuberculous extradural abscess. Conclusion TB may involve the intramedullary, extramedullary intrathecal compartment, or the extrathecal vertebral compartment in the form of an arachnoiditis, abscess, and spondylitis, respectively, often with unusual imaging presentations.     

Microbiology and Epidemiology of Infectious Spinal Disease

Objective

Infectious spinal disease is regarded as an infection by a specific organism that affects the vertebral body, intervertebral disc and adjacent perivertebral soft tissue. Its incidence seems to be increasing as a result of larger proportion of the older patients with chronic debilitating disease, the rise of intravenous drug abuser, and the increase in spinal procedure and surgery. In Korea, studies assessing infectious spinal disease are rare and have not been addressed in recent times. The objectives of this study are to describe the epidemiology of all kind of spinal infectious disease and their clinical and microbiological characteristics as well as to assess the diagnostic methodology and the parameters related to the outcomes.

Methods

A retrospective study was performed in all infectious spinal disease cases presenting from January 2005 to April 2010 to three tertiary teaching hospitals within a city of 1.5 million in Korea. Patient demographics, risk factors, clinical features, and outcomes were assessed. Risk factors entailed the presence of diabetes, chronic renal failure, liver cirrhosis, immunosuppressants, remote infection, underlying malignancy and previous spinal surgery or procedure. We comparatively analyzed the results between the groups of pyogenic and tuberculous spinal infection. SPSS version 14 statistical software was used to perform the analyses of the data. The threshold for statistical significance was established at p<0.05.

Results

Ninety-two cases fulfilled the inclusion criteria and were reviewed. Overall, patients of tuberculous spinal infection (TSI) and pyogenic spinal infection (PSI) entailed 20 (21.7%) and 72 (78.3%) cases, respectively. A previous spinal surgery or procedure was the most commonly noted risk factor (39.1%), followed by diabetes (15.2%). The occurrence of both pyogenic and tuberculous spondylitis was predominant in the lumbar spine. Discs are more easily invaded in PSI. At initial presentation, white cell blood count and C-reactive protein levels were higher in PSI compared to TSI (p<0.05). Etiological agents were identified in 53.3%, and the most effective method for identification of etiological agents was tissue culture (50.0%). Staphyococcus aureus was the most commonly isolated infective agent associated with pyogenic spondylitis, followed by E. coli. Surgical treatment was performed in 31.5% of pyogenic spondylitis and in 35.0% of tuberculous spondylitis cases.

Conclusion

Many previous studies in Korea usually reported that tuberculous spondylitis is the predominant infection. However, in our study, the number of pyogenic infection was 3 times greater than that of tuberculous spinal disease. Etiological agents were identified in a half of all infectious spinal disease. For better outcomes, we should try to identify the causative microorganism before antibiotic therapy and make every effort to improve the result of culture and biopsy.     

Ascending myelitis with high antibody titer to herpes simplex virus in the cerebrospinal fluid

Summary A pregnant 21-year-old woman developed ascending myelitis over a period of several weeks. Oligoclonal IgG bands and a high antibody titer to herpes simplex virus appeared in the cerebrospinal fluid with an increased cerebrospinal fluid to serum antibody ratio of 1 to 4.

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Zusammenfassung Bei einer 21jährigen schwangeren Frau entwickelte sich im Verlaufe einiger Wochen eine aufsteigende Myelitis. Im Liquor fanden sich oligoklonale IgG-Bande und ein hoher Titer der Antikörper gegen Herpes-Simplex-Virus. Das Verhältnis der Antikörper im Liquor und im Serum war erhöht im Verhältnis von 1:4.

     

Recurrent bacterial meningitis accompanied by a spinal intramedullary abscess

Bacterial meningitis is rarely complicated by an intradural spinal abscess, and recurrent meningitis is an uncommon presentation of a spinal intramedullary abscess. Here, we report a 63-year-old patient with recurrent meningitis as the first manifestation of an underlying spinal intramedullary abscess. To the best of our knowledge, no previous report has been issued on recurrent meningitis accompanied by a spinal intramedullary abscess in an adult. In this article, the pathophysiological mechanism of this uncommon entity is discussed and the relevant literature reviewed.     

Transverse myelitis with systemic Lupus Erythematosus

Zusammenfassung Eine 17jährige Patientin, welche seit 4 Jahren einen erwiesenen systemischen Lupus Erythematosus hatte, wurde wegen nephritischen Erscheinungen aufgenommen. Während einer Behandlung mit Corticosteroiden wurde in der dritten Woche eine akute Querschnittsmyelitis diagnostiziert.Trotz Erhöhung der Corticosteroiddosen verschied die Patientin 48 Std nach Auftreten der ersten myelitischen Symptome.     

Primary spinal leptomeningeal astrocytoma

Summary This autopsy case report describes a clinically aggressive, histologically well-differentiated, diffuse, primary leptomeningeal astrocytoma. This rare tumour produced a meningitic clinical picture associated with hydrocephalus, focal spinal cord necrosis, and signs of spinal and cranial nerve root irritation. Despite the microscopic features, death occurred approximately 7 weeks after the first meningeal symptoms.This case was Diagnostic Case 15 of the 29th (1989) Annual Meeting of the Canadian Association of Neuropathologists     

Case series of two patients with Fibrocartilaginous Embolism mimicking Transverse Myelitis of the Spinal Cord

Fibrocartilaginous Embolism (FCE) refers to the extrusion of some of the fibro-cartilaginous nucleus pulposus material from within the inter-vertebral disc to eventually embolize into one of the spinal cord vessels with resultant spinal cord infarction. According to a 2016 review, AbdelRazek et al. (2106) [1] there are 41 pathologically confirmed and 26 clinically suspected cases in the literature till the end of 2015. We add two more clinically diagnosed cases.     

系统性红斑狼疮合并中枢神经系统感染34例临床分析

目的研究分析系统性红斑狼疮(SLE)合并中枢神经系统感染的临床表现。方法回顾性分析2001年1月至2011年12月石家庄平安医院34例SLE合并中枢神经系统感染患者临床资料,提出临床特征及其相关危险因素。结果 34例SLE合并中枢神经系统感染,发生率为1.44%;其中结核性脑膜炎25例(73.53%),新型隐球菌脑膜炎7例(20.59%),病毒性脑膜炎2例(5.88%)。给予内科常规治疗,25例结核性脑膜炎痊愈21例,死亡4例;7例隐球菌脑膜炎痊愈3例,死亡4例。病毒性脑膜炎痊愈1例,死亡1例。本文SLE合并中枢神经系统感染34例中总共死亡9例(26.47%)。全部患者在诊断前均经过糖皮质激素治疗,28例患者应用较大剂量激素治疗,18例患者联合免疫抑制剂治疗。SLE合并中枢神经系统感染的临床特点主要为高热、头痛及意识障碍;狼疮活动度评分(SLEDAI)平均9±3分。脑脊液检查发现糖和氯化物降低明显。结论①系统性红斑狼疮合并中枢神经系统感染以结核性脑膜炎最常见;②肾上腺皮质激素、免疫抑制剂的应用是SLE合并感染的危险因素;③SLE合并中枢神经系统感染与狼疮活动度无关,而神经精神狼疮多发生于狼疮高度活动期,SLEDAI评分对二者鉴别诊断有意义;④狼疮合并中枢神经系统感染以高热、头痛及颅内压增高为主要表现,反复腰穿脑脊液检查对SLE合并中枢神经系统感染的诊断和判断预后有重要价值。     

A Clinical Analysis of Surgical Treatment for Spontaneous Spinal Infection

Objective

The purpose of the study was to determine the clinical effects of anterior radical debridement on a series of patients with spontaneous spinal infection.

Methods

We retrospectively analyzed the clinical characteristics of 32 patients who underwent surgical treatment from January 2000 to December 2005 in our department. The average follow-up Period was 33.4 months (range, 6 to 87 months). Thirty-two patients presented with the following : 23 cases with pyogenic spondylitis, eight with tuberculous spondylitis and one with fungal spondylitis. The indications for surgery were intractable pain, failure of medical management, neurological impairment with or without an associated abscess, vertebral destruction causing spinal instability and/or segmental kyphosis.

Results

The study included 15 (46.9%) males and 17 (53.1%) females ranging in age from 26 to 75 years (mean, 53.1 years). Diabetes mellitus (DM) and pulmonary Tbc were the most common predisposing factors for pyogenic spondylitis and tuberculous spondylitis. Staphylococcus aureus (13%) was the main organism isolated. The most prevalent location was the lumbar spine (75%). Changes in the pain score, Frankel''s classification, and laboratory parameters demonstrated a significant clinical improvement in all patients. However, there were recurrent infections in two patients with tuberculous spondylitis and inappropriate debridement and intolerance of medication and noncompliance. Autologous rib, iliac bone and allograft (fibular) were performed in most patients. However, 10 patients were grafted using a titanium mesh cage after anterior radical debridement. There were no recurrent infections in the 10 cases using the mesh cage with radical debridement.

Conclusion

The findings of this study indicate that surgery based on appropriate surgical indications is effective for the control of spinal infection and prevention of recurrence with anterior radical debridement, proper drug use and abscess drainage.     

Neurotuberculosis among Filipino children: an 11 years experience at the Philippine Children's Medical Center

Tuberculous meningitis (TBM) remains the most common form of neurotuberculosis in children. Four hundred and five cases of tuberculous meningitis (ages 3–156 months) seen at the Philippine Children's Medical Center (PCMC) from 1987 to 1998 were reviewed. Inclusion criteria include clinical and laboratory profile of TBM with pertinent evidence on imaging such as computed tomography and/or cranial sonography or histologic evidence of TBM. Nearly half of the cases were below age 2. The most common neurologic findings were altered sensorium, neck rigidity, motor and cranial deficits. The mortality rate was 16%. The neuropathologic findings in 31 autopsied cases were basal exudates in 100%, hydrocephalus in 71%, caseation necrosis in 68%, and 35% with infarcts. The most important determinant of outcome is the stage of illness at which the diagnosis is made and appropriate treatment is given. Although computed tomography was more definitive, cranial sonography was a very useful diagnostic tool considering the frequent occurrence below age 2. A short course (6 months) anti-tuberculous therapy for neurotuberculosis was shown to be adequate; shunting of cases with hydrocephalus did not show definite benefit.     

Dengue infection: neurological manifestations and cerebrospinal fluid (CSF) analysis

Neurological manifestation is considered a rare complication of dengue infection. Neurological and cerebrospinal fluid (CSF) findings of 13 patients with dengue infection were studied. Seven patients had encephalitis, two had myelitis and four showed Guillain-Barré syndrome (GBS). No alteration in CSF was found from 57% of those with encephalitis. Patients with GBS and myelitis showed a CSF-blood barrier dysfunction. The differences in the CSF may be related to the location of the lesion and multiple mechanisms of the disease in the nervous system.     

Chronische,basale und andere abakterielle Meningitiden

Zusammenfassung Von 144 Fällen mit abakteriellen Meningitiden meist ungeklärter Ätiologie wurden verschiedene bei der stationären Aufnahme erhobene Befunde verglichen. Daraus hob sich eine Gruppe von 8 Zoster-Meningitiden vorwiegend durch die jahreszeitliche Verteilung, durch das relativ hohe Alter der Patienten beim Ausbruch der Erkrankung und durch eine Lymphocytose im Blutbild ab. Eine Gruppe von 32 Fällen mit ausgesprochen basaler Symptomatologie unterschied sich sonst vorwiegend durch die Akuität und die Schwere der Erkrankung. 13 Fälle mit eminent chronischem Verlauf, auf die der Begriff chronisch aseptische Meningitis zutrifft, war durch häufige Monocytose im Blutbild, durch stets vorhandene Eiweißvermehrung im Liquor und durch ein höheres Alter beim Ausbruch der Erkrankung gekennzeichnet. Die Gruppe der abakteriellen Meningitiden mit basaler Symptomatologie, deren differentialdiagnostische Abgrenzung von der tuberkulösen Meningitis offenbar Schwierigkeiten bereitete, wurde deswegen eingehender mit einer Gruppe einwandfrei gesicherter tuberkulöser Meningitiden verglichen. Als Befund von größtem Gewicht für die Diagnose der letzteren erwies sich die Erniedrigung des Liquorzuckers. Darüber hinaus konnten noch weitere 13 Unterscheidungsmerkmale gefunden werden, die dann für die Differentialdiagnose herangezogen werden können, wenn bei erniedrigtem Liquorzucker Zweifel an der tuberkulösen Genese der Erkrankung auftauchen.

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Chronic, basal and other abacterial meningitidesStatistical comparisons of anamnestic, clinical and laboratory data in tuberculous meningitides

Summary Clinical and laboratory findings in 144 cases of abacterial meningitis or meningo-encephalitis as stated immediately upon hospital admission were compared with each other statistically. The main features of 8 cases of meningo-encephalitis associated with herpes zoster were the seasonal distribution, the age of the patients at the onset of the disease, and the lymphocytosis in the differential blood count. Another group of 32 patients showing a remarkable basal symptomatology differed from the rest by a more acute onset and a more serious disease course as manifested by a higher mortality rate and a more prolonged hospital stay. 13 cases with a remarkable chronic course were notable for the monocytosis revealed by the blood smear, as well as for the consistently found increase of total cerebrospinal fluid protein and the age of the patients at the onset of the disease. It appears that it was always difficult to distinguish this abacterial meningitis with basal symptomatology from meningitis of tuberculous origin. Therefore, we compared our group of patients with one affected with meningitis of unequivocal tuberculous etiology. The most important criterion of the latter seems to be a decrease in CSF glucose. Therefore, in a case with normal or even increased CSF glucose a tuberculous origin may be ruled out at once. Unfortunately a decrease of CSF glucose may also be found in some cases of non-tuberculous etiology. The fact that we found statistical evidence for differences in 13 other points (Table 4) may be helpful in the diagnostic differentiation of such cases.

Herrn Prof. Dr. Georges Schaltenbrand zum 75. Geburtstag gewidmet.     

A Case of Neurocysticercosis in Entire Spinal Level

Cysticercosis is the most common parasitic infection affecting the central nervous system. Spinal neurocysticercosis (NCC) is very rare compared with intracranial NCC and requires more aggressive management because these lesions are poorly tolerated. The authors report a case of intradural extramedullary cysticercosis of the entire level of spine with review of the literature.     

特应性脊髓炎研究进展

特应性脊髓炎也可描述为特发性嗜酸性粒细胞脊髓炎,是一种与过敏因素有关的脊髓炎,被认为是原发性急性横贯性脊髓炎的一种。主要发生地区为日本,自文献报道首例患者以来,日本地区已累计100余例患者,近年来韩国、欧洲地区也有报道。本文拟就特应性脊髓炎的研究进展进行概述。     

Prophylactic antibiotics in pediatric shunt surgery

Introduction The optimal antibiotic prophylaxis for pediatric shunt-related procedures is not clear. There is much inconsistency among different medical centers. This paper summarizes and analyzes the various prophylactic antibiotic regiments used for shunt-related surgeries at different pediatric neurosurgery centers in the world.Materials and methods A survey questionnaire was distributed through the Pediatric Neurosurgery list-server (an e-mail-based special interest group in pediatric neurosurgery). Forty-five completed questionnaires were received, one per medical center, primarily from pediatric neurosurgeons with the following geographic breakdown: 25 from North America, 13 from Europe, and 7 from Asia and other countries. All centers routinely administered prophylactic antibiotics for shunt-related procedures. The drugs of choice were first-generation cephalosporins (23), second-generation cephalosporins (10), naficillin/oxacillin (4), vancomycin (3), clindamycin (1), amoxicillin (1), and mixed protocols in three centers. The initial drug administration (“first dose”) was: in the department before transfer to operating room (5), upon arrival to operating room (11), at induction of anesthesia (13), and at initial skin incision (16). The duration of antibiotic dosage also varied: single dose (13), 24-h administration (26), 48-h administration (2), and longer than 48 h in four centers.Results and discussion Two general tendencies were noted, common to the majority of participating centers. There was a general trend to modify antibiotic treatment protocol in “high-risk” populations. The second common theme noted in more than half of responding centers was the use of long-term antibiotic treatment for externalized devices (such as externalized shunts, external ventricular drains or lumbar drains), usually till the device was in place.