Primary leptomeningeal melanocytosis presenting as chronic meningitis

We report a patient with primary leptomeningeal melanocytosis presenting as chronic meningitis. A previously healthy 27-year-old man presented with 2 months of severe headaches and photophobia. A lumbar puncture was notable for a highly elevated cerebrospinal fluid (CSF) protein level without pleocytosis. Imaging at the time of admission suggested only meningitis without the presence of parenchymal lesions. On the basis of the CSF findings, early meningeal biopsy was performed, leading to the diagnosis of a meningeal melanocytic neoplasm. Early meningeal biopsy should be considered in patients with meningitis when the CSF profile suggests the possibility of a central nervous system neoplasm.     

新型隐球菌性脑膜炎与结核性脑膜炎的临床特点比较

目的对比和分析综合性医院新型隐球菌性脑膜炎(CNM)与结核性脑膜炎(TBM)的临床特点。方法分析62例CNM及219例TBM患者的一般资料、临床症状、脑脊液细胞学(CSFC)、头颅影像学的特点。结果两种脑膜炎均呈亚急性或慢性起病相对于TBM,CNM延误诊断时间更长、临床症状中癫痫出现比率(24.2%)、头颅影像学中脑膜强化出现比率(17.7%)较高,腰穿脑脊液(CSF)压力(268.7±67.6mmH_2O)、CSF单核细胞占比(21.0±17.5%)高,CSF白细胞计数(84.8±88.1×10~6/L)、CSF糖(1.9±1.4mmol·L~(-1))较低。结论两种脑膜炎临床表现不典型,两者之间不易鉴别,容易误诊漏诊。临床上需综合判断,CSF瑞氏吉姆萨染色和改良抗酸染色有助于两者病原学确诊。     

Glioblastoma multiforme and the meningeal syndrome.

Brain tumors rarely may produce acute steile meningitis (the meningeal syndrome) resulting from the spillage of blood, lipid products of tumor necrosis, or malignant cells into the cerebrospinal fluid (CSF). The frequency of the associated meningeal syndrome is a function of tumor type and of the tproximity of tumor necrosis to the ventricles. The meningeal syndromes of lipid-induced chemical inflammation are seen most commonly with epidermoids, craniopharyngiomas, and infarcted pituitary adenomas. I report a patient with the rare association of the meningeal syndrome with glioblastoma multiforme. The lipid irritants of glioblastomas and craniopharyngiomas are similar chemically and can be detected in the CSF. The anti-inflammatory and immunosuppressant properties of steroids provide a rational basis for their efficacy in treatment of the syndrome.     

Myelomatous meningitis: a case report

Multiple myeloma is characterized by the production of a monoclonal immunoglobulin. Myelomatous meningitis is a rare occurrence in multiple myeloma. The signs of meningeal myelomatosis include impairment of consciousness, cranial nerve palsies, convulsions and plasmatic cells in the cerebrospinal fluid. Atypical, plasmatic cells in the cerebrospinal fluid are an important finding for the diagnosis of meningeal myeloma. A combination of radiation therapy and chemotherapy is the usual treatment. Patients with meningeal myelomatosis can have a good response to treatment initially, but their prognosis is poor and death occurs within a few months. We present the case of a woman with myelomatous meningitis. Multiple myeloma was diagnosed by serum protein electrophoresis and bone marrow aspiration. This case and a review of the literature show that clinical manifestations of meningeal myeloma are non-specific.     

Tumor necrosis factor-alpha, interleukin-1beta and interleukin-6 in the cerebrospinal fluid of newborn with meningitis

OBJECTIVE: To analyze the usefulness of determining the cerebrospinal fluid (CSF) levels of tumor necrosis factor-alpha (TNF-alpha), interleukin-1beta (IL-1beta) and interleukin-6 (IL-6) for the early diagnosis and evaluation of the prognosis of neonatal meningitis. METHOD: We studied 54 newborn that underwent lumbar puncture. Thirty patients had meningitis and 24 were the control group. CSF and sera were obtained at the moment of suspicion of meningitis and stored at -70 degrees C. Cytokines were performed by enzyme-linked immunosorbent assay method. RESULTS: CSF cytokines were detected in all the newborn with meningitis. TNF-alpha was detected in the CSF in 63.3% of the neonates, IL-1beta in 73.3% and IL-6 in 96.6%. The CSF levels were significantly higher than serum in neonates with meningitis. There was no correlation between the CSF levels of cytokines and neurologic complications. CONCLUSION: The detection of TNF-alpha, IL-1beta and IL-6 in the CSF is of great value in order to achieve a early diagnosis of neonatal meningitis. Among the three cytokines analyzed, IL-6 was the best indicator of meningeal inflammation.     

Aseptic meningitis after transsphenoidal management of Rathke’s cleft cyst: case report and review of the literature

Aseptic meningitis after transsphenoidal surgery (TSS) for treatment of Rathke’s cleft cyst (RCC) is a rare complication caused by the leakage of the cyst contents within the subarachnoid space. We present a case of aseptic meningitis occurring after TSS for a RCC. During surgery, the cyst wall was subtotally removed, and intraoperative cerebrospinal fluid (CSF) leakage was observed. The patient developed meningeal signs and symptoms on the first postoperative day. CSF examinations were highly suggestive of aseptic meningitis. Histological examination confirmed a granulomatous inflammatory reaction of the RCC wall. Preexisting inflammation, subtotal cyst wall resection, intraoperative erosion of the diaphragma sellae and placement of a lumbar drain may be risk factors for the development of aseptic meningitis.     

A case of aseptic meningitis caused by relapsing polychondritis]

We report a patient of relapsing polychondritis (RP) with antecedent aseptic meningitis. A 65-year-old man has developed headache and fever. Neurological examination showed meningeal signs, and cerebrospinal fluid (CSF) examination revealed meningeal inflammation which contained 450 polymorphonuclear cells/microl, 302 mononuclear cells/microl, and 0 red cells/microl, with 79 mg protein/dl. Serologic testing for autoimmune disease as well as the culture and cytology of CSF were negative. He admitted our hospital as having aseptic meningitis and experienced antibiotic therapy. However, his pyrexia continued and he developed repeating visual and hearing impairment reacting to steroid. Three months later, he became behaviorally deaf, and bilateral auricular chondritis occurred with nonerosive seronegative inflammatory polyarthritis. The result of condral biopsy was consistent with the diagnosis of RP showing cartilage surrounded by an intense inflammatory cell response with a decreased number of chondrocytes. A clinical diagnosis was made and prednisolone 60 mg/day was begun with the result of resolution of the auricular chondritis, and slight improvement of his deafness. Aseptic meningitis is a rare complication of RP. Only one report detailed RP patient who had preceding meningitis. RP is a potentially lethal disease resulting from suffocation by airway collapse, the complications of a cardiac large vessel, and so on. For improvement of a life prognosis, an early diagnosis and treatment are indispensable. Although RP is a rare discovery, it is necessary that RP should be taken into consideration and be differentiated as a cause of relapsing aseptic meningitis.     

Diagnostic value of atypical lymphocytes in cerebrospinal fluid from adults with enteroviral meningitis

We have noted two morphologically distinct types of atypical lymphocytes (AL) in the cerebrospinal fluid (CSF) of adult patients with meningitis: one, which we designate type-I AL, with multilobulated nuclei resembling those of the abnormal cells in adult T-cell leukaemia (ATL); and another, type-II AL, characterized by large lymphocytes with basophilic cytoplasm and nuclei containing coarse chromatin. Type-I AL were detected in 25 of 39 patients (64%) with enteroviral and in 11 of 109 (11%) with aseptic meningitis presumed to be caused by other viruses, but not in meningitis resulting from Cryptococcus neoformans (n = 14), Mycobacterium tuberculosis (n = 19) or acute bacterial infection (n = 49). Type-I AL were not seen in herpes zoster (n = 15) aseptic meningeal reactions (n = 15), or in leptomeningeal carcinomatosis (n = 14). Type-II AL were often present in meningitis of various aetiologies and in aseptic meningeal reactions, but not in leptomeningeal carcinomatosis. The presence of type-I AL in the CSF was found to be indicative of enteroviral meningitis with the highest predictive value (69%), while type-II AL had a lower diagnostic positive predictive value in meningitis of the five aetiologies above. Type-I AL immunostained for CD4, while type-II AL were stained for CD8. The presence of type-I AL in CSF strongly suggests enteroviral meningitis, which warrants careful follow-up without antifungal, antituberculous or antibacterial agents. However, type-I AL, which are likely to be virally transformed lymphocytes, must be distinguished from ATL cells, which frequently involve the meninges. Received: 29 May 1997 Received in revised: 1 November 1997 Accepted: 20 March 1998     

Carcinomatous meningitis presenting with isolated headache

INTRODUCTION: Carcinomatous meningitis reveals a solid cancer in 10 percent of cases. OBSERVATION: Our patient developed isolated headache which progressively worsened. Cranial Computerized Tomography (CT) was normal. Brain MRI showed multiples areas of contrast enhancements meningeal tissue associated with small nodulars deposits. Repeated cerebrospinal fluid (CSF) examinations revealed elevated tumor markers suspect cells. The diagnosis of pulmonary adenocarcinoma was established during systematic follow-up. CONCLUSION: The diagnosis of carcinomatous meningitis can be difficult to establish because of the non-specific clinical presentation and the absence of suggestive context; negative CSF-cytology is frequent. MRI and elevated tumor markers in the CSF compared with the serum level contribute significantly to diagnosis.     

Intrathecal cytostatic chemotherapy of meningitis carcinomatosa. Clinical manifestation and cerebrospinal fluid cytology in a case of metastatic carcinoma of the breast.

Effects of intrathecal cytostatic chemotherapy on the clinical symptoms and cerebrospinal fluid (CSF) findings are being demonstrated in a case of metastatic carcinoma of the breast with sighns of meningeal irritation and cranial nerve involvement. Clinical symptoms disappeared after repeated intrathecal applications of methotrexate. CSF cell counts were reverted to normal but tumor cells were found to be persistant in CSF over a period of 19 months. Risks of combined intrathecal and systemic cytostatic therapy and possible effects of parenteral citrovorum factor applications are being discussed. The importance of continued intrathecal chemotherapy and of regular and thorough examination of CSF cells in meningitis carcinomatosa is emphasized. Cytological methods included investigations on viable CSF cells.     

Difficulty in diagnosing chronic meningitis caused by capsule-deficient Cryptococcus neoformans

We report a case of chronic meningitis due to capsule-deficient Cryptococcus neoformans which could not be diagnosed by routine morphological and immunological cerebrospinal fluid (CSF) examination. Repeated CSF examination and culture did not disclose the fungal body, and the cryptococcal antigen tests were always negative. Culture of ventricular fluid showed non-encapsulated cultured cells which were stained positively by indirect immunofluorescence using diluted sera from another patient diagnosed with cryptococcal meningitis. Inoculation of dispersed colonies into mice resulted in encapsulated C neoformans. It is important to suspect capsule-deficient C neoformans when the conventional diagnostic approaches fail to identify the organism or antigens.     

广州管圆线虫病致嗜酸细胞性脑膜炎九例患者临床和脑脊液细胞学特点

目的 总结北方地区出现的广州管圆线虫感染引起的嗜酸细胞性脑膜炎病例的临床特点,并探讨脑脊液细胞学对该病的诊断意义.方法 对中国医学科学院北京协和医院收治的9例在北京地区发病的患者进行临床观察和脑脊液细胞学等检查,总结分析并复习文献.结果 9例患者中男性4例,女性5例.临床表现为急性起病(9例)、发热(9例)、头痛(9例),伴恶心或呕吐(3例)、脑膜刺激征(7例)、视乳头水肿(2例)、肢体感觉异常(7例)、脑神经受累(3例)和肢体瘫痪(1例)等.临床分型:脑膜型8例,脊髓型1例.神经影像学:4例存在软脑膜弥漫强化,脑和脊髓实质点片状异常信号者4例.脑脊液检查:全部患者均有压力升高,白细胞均升高[(70～780)×106/L],蛋白均升高,5例有葡萄糖减低.脑脊液细胞学:嗜酸细胞比例均升高.1例(仅行1次腰穿)嗜酸细胞比例5%,其余8例脑脊液嗜酸细胞多次枪查在45%～90%,呈现以嗜酸细胞为主的炎症,伴激活淋巴细胞和单核细胞,偶见浆细胞,未见寄生虫虫体.结论 脑脊液嗜酸细胞比例超过50%的脑膜炎应高度怀疑广州管圆线虫病.临床结合脑脊液细胞学对诊断广州管圆线虫病有一定实用意义.     

脑脊液中免疫球蛋白及腺苷脱氨酶测定对三种脑膜炎的诊断价值

目的 对不同病因的脑膜炎患者的脑脊液(CSF)中的免疫球蛋白(Ig)各组及腺苷脱氨酶(ADA)含量进行分析。方法 选取3组脑膜炎患者的CSF标本32份,对其中的Ig成分及ADA的含量进行测定。结果 结脑患者的CGF中ADA含量显著升高,IgG显著增高(P<0.01);化脑患者CGF中IgG显著增高(P<0.01),ADA无显著性变化;病脑患者CSF中Ig、ADA均没有显著性变化。结论 对脑膜炎患者CSF中Ig各组分及ADA含量的联合测定对病因的鉴别诊断具有很高的应用价值。     

Cerebrospinal fluid as informative source of the brain

The examination of cerebrospinal fluid has provided useful information for diagnosis of CNS infections. The progress of analytical technology has brought the possibility to detect very small amounts of chemical substances. I thought that new information from brain should be obtained by using modern analytical technology for several substances in CSF. Free amino acid pattern, glutamine, homocarnosine, glutamic acid decarboxylase (GAD), neuron specific enolase (NSE) and 2',5'-oligoadenylic acid synthetase (2-5 A) in CSF have been examined for information of brain injury and dysfunctions. The results are as follows. 1) The individual difference and constancy of free amino acid pattern in CSF were found in children without any neurological diseases. 2) The levels of free amino acids in CSF increased in the acute phase of bacterial meningitis. 3) High levels of glutamine in CSF of children with acute bacterial meningitis were normalized during the recovery phase. 4) A marked imbalance of free amino acids in CSF was found in children with Lennox-Gastaut syndrome. 5) A decrease of homocarnosine levels in CSF was related with the degree of unconsciousness in children suffering from neurological diseases. 6) High GAD activities in CSF were observed in the acute phase of aseptic meningitis and after intrathecal injection of methotrexate for the therapy against meningeal leukemia. 7) High NSE activities in CSF were found in the acute phase of bacterial meningitis, intracranial hemorrhage, encephalopathy and encephalitis. 8) High 2-5A activities CSF were measured in the acute phase of mumps meningitis with subsequent decreases during the recovery phase. These results suggest that several substances in CSF are useful as markers of brain injury and dysfunction.     

囊虫性脑膜炎(附63例临床分析)

目的 分析63例囊虫性脑膜炎的临床资料，以加强对此病的认识，提高临床医师病的诊断率。方法 选取囊虫性脑膜炎患者63例，对其起病形式、临床症状与体征、辅助检查等进行分析。结果 患者多生活在囊虫病高发地区（95％）；慢性或亚急性起病（95％）；表现为反复发作性头痛（60％），可伴有发热（27％）或痴呆（15％），脑膜刺激征阳性（63％）；血嗜酸性细胞增加（50％）；CSF以淋巴细胞为主（47％），蛋白可升高，囊虫抗体阳性；皮下结节活检被证实为囊虫；非脑囊虫病的典型影像学表现，可伴有脑积水（49％）。结论 囊虫性脑膜炎是一种少见浆液性脑膜炎，应与结核性脑膜炎、霉菌性脑膜炎、梅毒性脑膜炎及原发或继发的脑膜癌变等鉴别。     

The spectrum of primary blastomycotic meningitis: a review of central nervous system blastomycosis

Three cases of meningitis with initial and exclusive neurological involvement prompted a review of the clinical, cerebrospinal fluid, and pathological findings in an additional 78 patients with central nervous system blastomycosis. The first patient of the 3 had progressive cerebellar dysfunction as the result of chronic basilar meningitis. The second had a C8-T1 radiculopathy without other evidence of superior sulcus syndrome, and subsequent acute fatal meningitis. The third had aseptic, benign, self-limited meningitis followed by clinically obvious systemic blastomycosis. Diagnosis is difficult, and it is likely that other cases have been presumptively treated for tuberculous meningitis. A more aggressive approach to diagnosis is proposed that takes into account the condition of the patient, the likelihood of dissemination at necropsy, and the frequent meningeal infections that are negative on culture of lumbar CSF.     

Overview of acute and chronic meningitis.

Meningitis can be subdivided based on time course of onset and duration, cerebrospinal fluid (CSF) profile, and underlying origins into acute aseptic and septic meningitis, recurrent meningitis, and chronic meningitis. These are distinct syndromes that require different management strategies. Most cases of meningitis are caused by infection. The causal agent is generally predictable based on the type of meningitis, host factors, and clues from the history and examination. CSF examination remains the critical diagnostic test.     

Cerebral angioendotheliomatosis in a dog

Summary A 6-year-old dog which presented with weakness of the hind limbs progressed to a cerebral disorder with altered sensorium. The cerebrospinal fluid (CSF) protein was elevated, but no cells were found. Autopsy revealed severe hemorrhages in the basal nuclei and diencephalon. Histology of the lesions showed many meningeal and parenchymal blood vessels filled with neoplastic mononuclear cells. Electron microscopy of the tumor cells demonstrated ribosomes, granular endoplasmic reticulum, mitochondria, and a few lysosomes. Immunocytochemical procedures to demonstrate Factor VIII-related antigen were negative. this appears to be the first recorded case of cerebral angioendotheliomatosis in domestic animals and closely resembles the syndrome in man.     

结核性与化脓性脑膜炎的脑脊液生化指标鉴别诊断

目的研究脑脊液生化指标在结核性脑膜炎和化脓性脑膜炎鉴别诊断中的应用价值。方法选择我院收治的102例结核性脑膜炎患者(结脑组)及89例化脓性脑膜炎患者(化脑组)为研究对象。对全部患者血浆及脑脊液中的蛋白、糖、氯化物和腺苷脱氨酶(ADA)进行检测。同时,对脑脊液与血浆中的蛋白、糖、氯化物和ADA比值进行计算并比较。结果结脑组脑脊液检测中,氯化物水平显著低于化脑组(P0.01),ADA水平显著高于化脑组(P0.01);结脑组血浆检测中,蛋白及氯化物水平显著低于化脑组(P0.01),ADA水平显著高于化脑组(P0.01);结脑组脑脊液与血浆生化指标比值中,蛋白及ADA的比值显著高于化脑组(P0.05),氯化物的比值显著低于化脑组(P0.01)。结论脑脊液中氯化物和ADA水平及脑脊液和血浆中蛋白、ADA及氯化物的比值对结核性脑膜炎和化脓性脑膜炎的早期鉴别诊断具有一定的价值。     

Mollaret脑膜炎的临床和脑脊液特点(附1例报告)

目的探讨Mollaret脑膜炎(MM)的临床与脑脊液(CSF)特点。方法回顾性分析1例MM患者的临床资料。结果本例男,26岁,急性起病,以头痛、发热、恶心、呕吐及脑膜刺激征为主要表现,先后复发4次。每次复发时的症状及体征基本相似,间歇期完全正常。腰穿CSF检查:白细胞81×106/L,以淋巴细胞为主(0.89),蛋白含量0.71 g/L,氯化物116 mmol/L,IgG 79.5 mg/L。经对症治疗3周基本痊愈。结论MM以头痛、发热、恶心、呕吐及脑膜刺激征为主要临床表现,可反复发作,但预后良好。CSF有细胞数和蛋白增高,以淋巴细胞、单核细胞为主,疾病初期可找到特征性Mollaret细胞。