Severe symptomatic aseptic chemical meningitis following myelography: the role of procalcitonin

Symptomatic aseptic, chemical meningitis is a rare complication of myelography. Its acute clinical course and standard laboratory findings are indistinguishable from those of bacterial meningitis. The authors present a case of severe postmyelographic chemical meningitis and compare CSF and serum inflammatory markers to a group of seven patients with proven bacterial meningitis. As in viral meningitis, procalcitonin might be able to discriminate between bacterial and chemical causes of CNS inflammation.     

Nervous system infections in patients with cancer

The diagnostic approach to the patient with cancer with suspected CNS infection depends on an analysis of the patient's immune defect, the time course of development of manifestations of infection, and the type of clinical syndrome with supportive evidence for a specific diagnosis coming from laboratory and neuroradiographic data. Most patients with CNS infections can be grouped into those with signs of meningitis or meningoencephalitis and those with focal mass lesions. A smaller group presents with stroke-like onset. Except for the group with strokes, those with focal deficits usually present in a more indolent fashion, whereas those with meningitis and encephalitis present more acutely [63]. Patients with B-lymphocyte dysfunction are susceptible to encapsulated bacterial pathogens. Patients with T-lymphocyte impairment develop CNS infections that are caused by intracellular pathogens, particularly viruses (HSV, JC, CMV, HHV-6), Nocardia, Aspergillus, and Toxoplasma. Many noninfectious entities, such as drug treatment complications, radiation effects, recurrent tumor, and paraneoplastic syndromes, can mimic CNS infections. Although cryptococcosis, bacterial meningitis, and some viral infections are easily diagnosed from Gram's stain, culture, or PCR, patients with mass lesions may require tissue biopsy to confirm diagnosis. Patients with cancer differ from normal hosts in the distribution of pathogens, and there is a wider range of differential diagnostic issues, both infectious and noninfectious, for the relatively few clinical syndromes that present as potential CNS infections.     

Neuro-Intensive Care of Patients with Acute CNS Infections

Infections in the central nervous system (CNS) are caused by a wide range of microorganisms resulting in distinct clinical syndromes including meningitis, encephalitis, and pyogenic infections, such as empyema and brain abscess. Bacterial and viral infections in the CNS can be rapidly fatal and can result in severe disability in survivors. Appropriate identification and acute management of these infections often occurs in a critical care setting and is vital to improving outcomes in this group of patients. This review of diagnosis and management of acute bacterial and viral infections in the CNS provides a general approach to patients with a suspected CNS infection and also provides a more detailed review of the diagnosis and management of patients with suspected bacterial meningitis, viral encephalitis, brain abscess, and subdural empyema.     

Unusual presentation of tuberculous meningitis.

We present 4 cases of tuberculous meningitis with atypical clinical features and CSF findings. Two patients had initially normal CSF examination, one developed internuclear ophthalmoplegia, while the other had deterioration of consciousness. The third patient presented with paranoid psychosis, and the fourth had a picture mimicking acute bacterial meningitis and he developed right hemianopia due to a tuberculoma detected by MRI. All recovered completely with anti-tuberculous treatment.     

Rapidly progressive encephalopathy caused by Coxsackie meningoencephalitis in an elderly male

Enteroviruses and Coxsackie viruses are common causes of aseptic meningitis and encephalitis in children. These infections usually have a benign, self-limited course. However, they can have a florid presentation in immunocompromised patients, such as neonates, patients exposed to immunosuppressive drugs, such as transplant recipients and patients with agammaglobulinemia. We present a rare case of rapidly progressive acute encephalopathy caused by Coxsackie meningoencephalitis and complicated by refractory status epilepticus in an immunocompetent adult male. Our case highlights the importance of having a broad differential in patients presenting with rapidly progressive acute encephalopathy. Although rare, an enterovirus infection caused by a Coxsackie virus subtype can have a severe presentation causing significant morbidity. This case, also underscores the importance of searching for underlying immunodeficiency in malignant presentations of common viral infections. Hence, rapidly progressive acute encephalopathy due to coxsackievirus can occur in immunocompetent individuals. Aggressive and systematic diagnostic and therapeutic approach in such severe cases can influence overall outcomes.     

Seizures complicating infantile and childhood bacterial meningitis

In this study, 116 patients, at least 1 month of age but younger than 5 years, were identified with culture-proven bacterial meningitis. A comparison was made between the clinical data of the patients with and without seizures during hospitalization. Seizures during acute bacterial meningitis accounted for 47% (55/116) of the episodes. Time interval between the onset of bacterial meningitis and that of seizures was 1 to 20 days (mean, 4 days). Twelve of these 55 patients had one or more afebrile seizures after completing the treatment. At follow-up of at least 1 year after completing treatment, 26 patients had good outcomes, whereas the other 29 patients had poor outcomes. A strong correlation between the findings of abnormalities through neuroimaging and the occurrence of seizures during hospitalization was observed. The long-term outcomes of patients with infantile and childhood bacterial meningitis, who had seizures during the acute phase of bacterial meningitis, were worse than the outcomes of those who did not have such seizures. No child developed late seizures unless there were acute seizures. Factors associated with seizures during acute bacterial meningitis include disturbed consciousness on admission, abnormal neuroimaging findings, and low glucose and high concentration of total proteins in cerebrospinal fluid.     

Late-onset frontotemporal dementia associated with progressive supranuclear palsy/argyrophilic grain disease/Alzheimer's disease pathology

Progressive supranuclear palsy (PSP) is typically manifested by vertical supranuclear gaze palsy, frequent falls early in the disease course, axial rigidity and poor response to levodopa. Prominent anterograde memory dysfunction with subsequent impairment in other cognitive domains is characteristic of Alzheimer's disease (AD). No clear clinical syndrome has been identified in argyrophilic grain disease (AGD). Frontotemporal dementia (FTD) is characterized by apathy, emotional blunting, disinhibition, and impairment in executive functioning despite relatively preserved memory and visuospatial abilities. Cognitive deficits are known to occur in PSP; however, overt clinical FTD without parkinsonism or supranuclear gaze palsy associated with PSP pathology has rarely been documented. We report an elderly patient with the typical clinical, neuropsychometric, and neuroimaging features of FTD who had autopsy findings most consistent with PSP plus AGD and AD in limbic structures. We suggest that PSP with or without coexisting AD and AGD be included in the differential diagnosis of patients presenting with FTD.     

Late-onset frontotemporal dementia associated with progressive supranuclear palsy/argyrophilic grain disease/Alzheimer’s disease pathology

Progressive supranuclear palsy (PSP) is typically manifested by vertical supranuclear gaze palsy, frequent falls early in the disease course, axial rigidity and poor response to levodopa. Prominent anterograde memory dysfunction with subsequent impairment in other cognitive domains is characteristic of Alzheimer’s disease (AD). No clear clinical syndrome has been identified in argyrophilic grain disease (AGD). Frontotemporal dementia (FTD) is characterized by apathy, emotional blunting, disinhibition, and impairment in executive functioning despite relatively preserved memory and visuospatial abilities. Cognitive deficits are known to occur in PSP; however, overt clinical FTD without parkinsonism or supranuclear gaze palsy associated with PSP pathology has rarely been documented. We report an elderly patient with the typical clinical, neuropsychometric, and neuroimaging features of FTD who had autopsy findings most consistent with PSP plus AGD and AD in limbic structures. We suggest that PSP with or without coexisting AD and AGD be included in the differential diagnosis of patients presenting with FTD.     

Aseptic meningitis and viral myelitis

Meningitis and myelitis represent common and very infrequent viral infections of the central nervous system, respectively. The number of cases of viral meningitis that occurs annually exceeds the total number of meningitis cases caused by all other etiologies combined. Focal central nervous system infections, such as occur in the spinal cord with viral myelitis, are much less common and may be confused with noninfectious disorders that cause acute flaccid paralysis. This article reviews some of the important clinical features, epidemiology, diagnostic approaches, and management strategies for patients with aseptic meningitis and viral myelitis. Particular focus is placed on the diseases caused by enteroviruses, which as a group account for most aseptic meningitis cases and many focal infections of the spinal cord.     

Cerebral trunk abscess due to Neisseria meningitidis in a 28-year-old immunocompetent patient

Meningococcal disease can manifest in very different clinical situations. Meningococcal meningitis and fulminant meningococcemia (or purpura fulminans) are the most common forms of these infections, but many other manifestations can be seen including septic arthritis, pericarditis, pleurisy and conjunctivitis. Brain abscesses have also been described; they are a rare complication of meningococcal disease. We report the case of a 28-year-old immunocompetent patient who developed meningococcal infection associated with brain abscesses and oligo-arthritis.     

C-reactive protein in serum and cerebrospinal fluid in various neurological disorders: Apparent local consumption during bacterial meningitis

The level of C-reactive protein (CRP) was determined in the cerebrospinal fluid (CSF) by particle counting immunoassay. In non-neurological patients (N = 24), CRP was detectable only in 10 samples at concentrations ranging from 1.5 to 37 μg/l. The multiple sclerosis group did not differ from the controls. The highest CRP levels were found in viral and bacterial, including tuberculous, infections of the nervous system, with overlapping results for the various types of infections. However, in serum, the levels of CRP were much higher in pyogenic than in viral meningitis. We compared the CSF CRP/serum CRP ratio to the same ratio for albumin and found a significant correlation between the two ratios in viral, but not in bacterial, infections. These results suggest a local consumption of CRP during bacterial meningitis.     

血清尿酸水平与中枢神经系统感染的相关性研究

目的 探讨血清尿酸(serum uric acid,SUA)与中枢神经系统感染(central nervous system infections,CNSI)发病机制的关系,为CNS1的病情评估及临床治疗开辟新途径.方法 收集CNSI患者357例,包括病毒性(脑膜)脑炎(病脑)97例、脑囊虫病65例、结核性(脑膜)脑炎(结脑)74例、隐球菌性(脑膜)脑炎(隐脑)75例以及细菌性(脑膜)脑炎(化脑)46例,以132例多发性硬化( multiple sclerosis,MS)患者及89名健康体检者( healthy controls,HC)作为对照.各CNSI组给予临床常规药物治疗:病脑患者予盐酸伐昔洛韦等抗病毒,脑囊虫病患者予阿苯达唑驱虫,结脑患者给予异烟肼、利福平、乙胺丁醇、吡嗪酰胺、莫西沙星5联抗结核,隐脑患者予两性霉素B、5氟胞嘧啶、氟康唑等抗真菌,化脑患者给予头孢曲松钠等抗细菌治疗.检测各组对象治疗前及治疗后病情稳定时的静脉血SUA水平并进行比较.结果 CNSI患者中病脑、脑囊虫病、化脑、结脑和隐脑组SUA水平[分别为(264.94±120.67)、(264.86士96.97)、(170.22士102.02)、(200.04士129.81)、(179.59士106.77) μmol/L]均显著低于HC组[(312.06土92.76)μmol/L](均P＜0.01).病脑组和脑囊虫病组SUA水平与MS组[(244.48±111.86) μmol/L]无统计学差异(均P＞0.05),而化脑、结脑和隐脑组SUA水平均低于MS组(均P＜0.01),也低于病脑组(均P=0.000)和脑囊虫病组(均P＜0.01).治疗后CNSI各组患者SUA水平(病脑、脑囊虫病、结脑、隐脑和化脑组分别为(290.92士111.80)、(278.59士80.86)、(458.89±189.32)、(232.41土138.11)、(195.73士103.69)μmol/L]较治疗前[(242.86士105.12)、(249.07±90.59)、(240.17士169.74)、(181.06±101.89)、(153.11士120.55)μmol/L]均明显升高.结论 CNSI患者SUA水平降低.     

Cerebrospinal Fluid TNF-α, IL-6, and IL-8 in Children With Bacterial Meningitis

ObjectiveWe evaluated the levels of cerebrospinal fluid concentrations of tumor necrosis factor-α, interleukin-6, and interleukin-8 in bacterial meningitis in children.MethodsThe study included children up to 14 years of age admitted to a pediatric ward with fever, headache, vomiting, and seizures. The diagnosis of bacterial meningitis was based on clinical features: physical examination, blood and cerebrospinal fluid cytochemical findings, Gram stain, and bacterial culture. The cerebrospinal fluid levels of tumor necrosis factor-α, interleukin-6, and interleukin-8 were measured in 57 children with bacterial meningitis, 15 with viral meningitis, and 15 controls by enzyme-linked immunosorbent assay methods.ResultsThe mean concentrations of cerebrospinal fluid, tumor necrosis factor-α, interleukin-6, and interleukin-8 were 1108 ± 183, 652 ± 287, and 442 ± 120 pg/mL, respectively, in children with bacterial meningitis and were significantly increased in those in the viral meningitis group (tumor necrosis factor-α : 711 ± 105, IL-6 : 272 ± 161, IL-8 : 175 ± 62 pg/mL; P < 0.001) or control (390 ± 37, 59 ± 17, 19 ± 13 pg/mL, respectively, P < 0.001). At optimum cutoff level based on the receiver operating characteristic curve, cerebrospinal fluid cytokines (tumor necrosis factor-α, interleukin-6, and interleukin-8) showed sensitivity and specificity of 100% for the diagnosis of bacterial meningitis. For differentiation of bacterial from viral meningitis, cerebrospinal fluid level of tumor necrosis factor-α, IL-6, and IL-8 showed sensitivity and specificity of 94.7% and 86.7%, 80.7% and 53.3%, and 89.5% and 86.7%, respectively.ConclusionThe increased concentration of cerebrospinal fluid tumor necrosis factor-α, interleukin-6, and interleukin-8 in children with meningitis suggests a role in the pathogenesis of bacterial meningitis and these levels might prove to be useful in children whose diagnosis is in question.     

Neuro-infections to be borne in mind]

We presented atypical manifestations in tuberculous meningitis (TbM) and herpes simplex encephalitis (HSE), lymphocytic dominant cerebrospinal fluid pleocytosis in bacterial meningitis, and a hitherto easily overlooked critical illness polyneuropathy (CIP) associated with sepsis. 1) We presented 2 TbM patients with atypical manifestations. One patient was a 25-year-old man who exhibited polymorphonuclear (PMN) dominant pleocytosis in CSF throughout his clinical course. He died the next day after a CSF culture yielded the growth of tuberculous bacilli, before receiving appropriate anti-TBM therapy. This was a rare TbM example of persistent PMN dominant CSF pleocytosis. The other patient was a 39-year-old woman whose CSF pleocytosis changed from lymphocytic dominant to PMN dominant about 1 month after the initiation of antituberculous chemotherapy. This CSF change was followed by multiple cerebral infarcts due to vauculitis caused by TbM. Administration of prednisolone caused marked improvement of the patient's symptomatology. Tuberculomas appeared transiently during anti-TbM therapy, consistent with paradoxical progression of tuberculoma. 2) A few patients with HSE may show atypical CSF findings such as PMN dominant pleocytosis, absence of pleocytosis, and low sugar value. Our national survey of HSE patients showed following percentages of these atypical findings: PMN dominant pleocytosis observed in 10% of the patients in the early stage and at the time of exacerbation, no pleocytosis in 0.9% (1 patient), and low sugar value in 4%. 3) Bacterial meningitis typically causes PMN dominant CSF pleocytosis. However, Listeria meningitis (LM) may cause lymphocytic dominant pleocytosis in 30% of the patients, particularly in elderly ones. We showed one such 69-year-old patient with persistent lymphocytic dominant CSF pleocytosis throughout the clinical course. 4) CIP, septic encephalopathy and critical illness myopathy are 3 major complications associated with sepsis. CIP is a frequent cause of neuromuscular weakness due to axonal dysfunction, which occurs to critically ill patients with sepsis, particularly when multiple organ dysfunctions are present. We showed our CIP patient associated with acute bacterial endocarditis and multiple organ failure. We should bear in mind these atypical manifestations, and frequent and important complications associated with sepsis such as CIP, to provide appropriate management to patients with neuro-infection and sepsis.     

Infectious ventriculitis in relation with neurocysticercosis in Burkina Faso

IntroductionVentriculitis is an uncommon entity, which is defined as localized meningitis in the cerebral ventricles. It usually occurs in a context of immunodepression, where its presence may suggest primary brain lymphoma, certain viral infections including cytomegalovirus (CMV) and much more rarely, tuberculous meningitis.ObservationA 48-year-old immunocompetent male was admitted to the neurology department of the Ouagadougou teaching hospital with the diagnosis of infectious ventriculitis in relation with neurocysticercosis (NCC). The diagnosis was based on several arguments including brain CT scan (dilated lateral and third ventricles with ependymal enhancement and scattered parenchymatous cystic hypodensities exhibiting enhancement after contrast injection), the notion of exposure (the patient raised pigs), residence in an endemic zone of cysticercosis, and test results: CSF analysis (aseptic meningitis), positive ELISA for NCC in both CSF and blood. The good clinical and biological outcome after treatment with albendazole was another argument favoring the diagnosis.ConclusionThis illustrates the importance of searching for NCC in patients with ventriculitis residing in an endemic zone for cysticercosis.     

Neurotrophin-4 and glial cell line-derived neurotrophic factor in cerebrospinal fluid from meningitis/encephalitis patients

The neurotrophin-4 and glial cell line-derived neurotrophic factor levels were measured in cerebrospinal fluid from 61 patients with bacterial meningitis, viral meningitis, or encephalitis, and other diseases by means of two-site enzyme-linked immunoassay. Elevated cerebrospinal fluid levels of neurotrophin-4 were demonstrated in four of the 11 patients with bacterial meningitis, and seven of the 23 patients with viral meningitis or encephalitis. None of the other patients demonstrated elevation of the neurotrophin-4 level in cerebrospinal fluid. The neurotrophin-4 levels in cerebrospinal fluid were correlated with the numbers of total and mononuclear cells in patients with viral meningitis/encephalitis. In patients with bacterial meningitis, three of the four patients with elevated neurotrophin-4 levels exhibited persistent abnormalities on computed tomography, and one revealed transient subdural effusion. On the other hand, none of the seven patients without neurotrophin-4 elevation had persistent computed tomography abnormalities, and five patients demonstrated transient computed tomography abnormalities. The glial cell line-derived neurotrophic factor levels were below the detection limit, or only slightly higher than the detection limit, in the patients with or without central nervous system infections. Although the precise roles of neurotrophin-4 and glial cell line-derived neurotrophic factor in central nervous system infections remain to be determined, neurotrophin-4 might play a neuroprotective or immunomodulatory role in central nervous system infections.     

Clinical and laboratory characteristics of cerebral infarction in tuberculous meningitis: a comparative study.

Cerebral infarction as a complication of tubercular (TB) meningitis is not uncommon, but an adequate comparison of patients with and without stroke has not been carried out. This study was performed to evaluate the clinical characteristics of cerebral infarction secondary to TB meningitis, and to investigate predictive factors for cerebral infarction in patients with TB meningitis. Patients with TB meningitis were recruited over a period of 56 months. They were divided into two groups, those with and those without stroke. Demographic features and clinical, laboratory, and neuroradiological findings were compared between the two groups. We classified strokes into subtypes using neuroimaging findings. Of the 38 patients who were diagnosed with TB meningitis, eight also experienced cerebral infarction. The percentage of cerebrospinal fluid leukocytes that were neutrophils was significantly higher in patients with stroke (68%) than in patients without stroke (31%; p=0.0001). Upon initial CT imaging, meningeal enhancement was found in 11 patients, and of these patients, six experienced stroke. There were no significant differences between the groups with respect to other clinical and laboratory features, including demographic features, time between meningitis onset and treatment initiation, peripheral white blood cell count, and cerebrospinal fluid findings. Five of the eight patients who developed stroke had lacunar infarcts. One of the three patients with territorial nonlacunar infarction died due to herniation. When treating patients with TB meningitis, the possibility of cerebral infarction should be considered when patients develop focal neurological signs, meningeal enhancement on a CT scan, and sustained polymorphic cerebrospinal fluid pleocytosis.     

Alpha-naphthyl-acetate-esterase activity in cerebrospinal fluid cells

Mono-histiocytes and T-lymphocytes were assessed by the cytochemical alpha-naphthyl-acetate-esterase (ANAE) stain in 50 CSF samples of patients with various neurological diseases. The ANAE-activity of lymphocytes was decreased in multiple sclerosis and subacute sclerosing panencephalitis, while the activity of mono-histiocytes was increased in the group of infarctions and bacterial and viral infections of the central nervous system. In bacterial meningitis and viral meningo-encephalo-radiculitis the number of ANAE-positive lymphocytes increased after treatment and clinical improvement. ANAE staining appears to be a useful additional tool in CSF cytology in these conditions.     

血清降钙素原在鉴别小儿不典型化脓性脑膜炎和病毒性脑炎的作用

目的 对比血清降钙素原(PCT)、C反应蛋白(CRP)、白细胞数(WBC)在鉴别不典型化脓性脑膜炎和病毒性脑炎中的价值.方法 把研究对象分为3组,分别为病毒性脑炎组(viral encephalitis)、不典型化脓性脑膜炎组(atypical bacterial meningitis)和典型化脓性脑膜炎组(typical bacterial meningitis),另选20名性别年龄匹配的正常儿童作为正常对照组(normal control group),分别测PCT值、CRP值和WBC值,各组指标比较应用独立样本t检验及卡方检验,并应用ROC曲线比较三者在鉴别病毒性脑炎和不典型化脓性脑膜炎的敏感性和特异性.结果 血清PCT在不典型化脓性脑膜炎、化脓性脑膜炎组与病毒性脑膜炎组、正常对照组之间差异有统计学意义;血清CRP在病毒性脑炎与化脓性脑膜炎之间差异有统计学意义,但在不典型化脓性脑膜炎与病毒性脑膜炎组之间差异无统计学意义;血清WBC在病毒性脑炎组和不典型化脓性脑膜炎组之间差异无统计学意义,但在典型化脓性脑膜炎组与病毒性脑膜炎组差异有统计学意义.不典型化脓性脑膜炎组与病毒性脑炎组中,PCT对不典型化脓性脑膜炎诊断的ROC曲线下面积93.9%,大于WBC和CRP.结论 不典型化脓性脑膜炎时,PCT升高,病毒性脑炎时PCT升高不明显.PCT在鉴别不典型化脓性脑膜炎和病毒性脑炎时有一定临床应用价值.