Tuberculous radiculomyelitis (arachnoiditis) associated with tuberculous meningitis

Abstract. A 17-year-old man who presented with progressive quadriparesis is reported. About 8 months prior to admission, he had miliary tuberculosis, and that improved with anti-tuberculous therapy. He had also developed tuberculous meningitis and tuberculous myelitis, respectively. He regularly took anti-tuberculous drugs until this illness. Neurological findings were compatible with cervical cord lesion. CSF analysis indicated a predominate lymphocytic pleocytosis with a high protein level and low sugar profile. MRI findings revealed a multi-loculated arachnoid cyst at C1-C3 level with pressure affecting the adjacent spinal cord and evidence of myelitis at C3-T1 level. Hemi-larminectomy and removal of the arachnoid cyst were performed, but without improvement. A CSF culture yielded M. tuberculosis, that was susceptible to anti-tuberculous drugs.     

Hepatic Visceral Larva Migrans: Evolution of the Lesion, Diagnosis, and Role of High-Dose Albendazole Therapy

An nnusual presentation of hepatic involvement of visceral larva migrans is described. A 45-yr-old male presented with fever, pain in the right upper qnadrant, and persistent eosinophilia. Ultrasound initially detected a solitary hypoechoic area in the right lobe of the liver which rapidly progressed to multiple lesions with peripheral hyperechoic lesions. Aspiration from the lesion revealed Charcot-Leyden crystals and sheets of eosinophils. Serology for Toxocara canis was strongly positive. Prolonged and high-dose albendazole therapy, in combination with antibiotics, was required to treat the patient effectively.     

Longitudinal myelitis as an initial manifestation of systemic lupus erythematosus

Transverse myelitis is a rare and serious complication of systemic lupus erythematosus (SLE). A longitudinal involvement of the spinal cord with lupus-related transverse myelitis is more unusual. Only 7 cases have been reported. We describe a 53-year-old woman presenting with short-term paraplegia as an initial manifestation of SLE with longitudinal myelitis. She had a partial response to treatment with pulse cyclophosphamide and high-dose corticosteroids after follow-up more than 2 years. To the best of our knowledge, this is the first case report of "longitudinal" myelitis as an initial presentation of SLE. Magnetic resonance imaging typically shows increased signal intensity in T2-weighted images, cord swelling, and contrast enhancement over several spinal segments. The possibility of SLE should be kept in mind in women presenting with paraplegia with no apparent cause.     

带状疱疹性脊髓炎九例分析

目的探讨带状疱疹性脊髓炎的临床特点及治疗方法。方法对9例确诊带状疱疹性脊髓炎患者的临床资料进行回顾分析。结果 8例患者有典型皮疹;8例患者脊髓病变部位均与皮疹分布区相一致;4例患者合并基础疾病;1例患者脑脊液中检测出VZA-IgG;MRI异常者7（7/8）例;7例患者抗病毒治疗后症状好转,2例患者半年内死亡。结论带状疱疹性脊髓炎主要依据皮疹与脊髓炎症之间短暂的时间关系,腰椎穿刺脑脊液检查及脊髓MR I检查有助于除外其他原因导致的脊髓疾患,抗病毒治疗可能有效果,激素疗效尚不明确。     

Myelitis associated with atopic disorders in Japan: a retrospective clinical study of the past 20 years

OBJECTIVE: To clarify the clinical features of myelitis associated with atopic disorders in Japanese patients. SUBJECTS AND METHODS: We retrospectively studied the clinical, immunological and electrophysiological features of 68 consecutive patients with myelitis of acute or subacute onset diagnosed at Kyushu University Hospital during the past 20 years. RESULTS: While only 2 of 28 (7%) patients with myelitis diagnosed between 1979 and 1993 had either atopic dermatitis (AD) or bronchial asthma (BA), 19 of 40 (48%) patients with myelitis diagnosed between 1994 and 1998 did. Among the 40 patients with myelitis diagnosed between 1994 and 1998, 19 patients with either AD or BA as well as 21 patients without either disease showed a significantly higher level of serum total IgE, higher frequency of hyperIgEaemia and higher frequency of mite antigen-specific IgE than 82 healthy controls. Myelitis patients with AD presenting as persistent paresthesia/dysesthesia in all four limbs showed cervical cord lesions on MRI and abnormalities in upper limb motor evoked potentials but no abnormalities in the cerebrospinal fluid (CSF), while myelitis patients with BA showed preferential involvement of the lower motor neurons clinically and electromyographically. In addition, 12 patients with myelitis who had hyperIgEaemia and mite antigen-specific IgE but neither AD nor BA showed incomplete transverse myelitis with mild motor disability and few CSF abnormalities. CONCLUSION: The clinical features of myelitis associated with atopic disorders were in part distinguished by the type of preceding atopic disorder, and also were different from those of hyperIgEaemic myelitis with no preceding atopic disorders.     

Initial presentation of acute transverse myelitis in systemic lupus erythematosus: demographics, diagnosis, management and comparison to idiopathic cases

To describe and compare the diagnosis, demographics and management of systemic lupus erythematosus (SLE) related versus idiopathic acute transverse myelitis during the initial presentation of the disease. We undertook a chart review of the hospital records of patients admitted to our hospital from 1994 until 2007 and had the diagnosis of SLE related and idiopathic acute transverse myelitis. Demographics, laboratory and imaging studies, diagnosis and treatment were recorded in both groups and analyzed in a case control fashion. We identified 15 patients with SLE-related acute transverse myelitis (SLE-ATM) and 39 idiopathic (I-ATM) cases between 1994 and 2007. Patients with SLE were more likely to be African American, have CNS demyelinating lesions on MRI, a high IgG% on their CSF analysis and a higher sedimentation rate on presentation. Treatment with high-dose steroids was instituted in both groups of patients, though SLE patients had a longer hospital stay by an average of 5 days. SLE-ATM patients were more likely to be African American as compared to I-ATM patients, have CNS demyelinating lesions on MRI, a high IgG% on CSF analysis and a higher sedimentation rate on presentation. The hospital stay for SLE patients was 5 days longer than the idiopathic patients. This study underlines the importance of early diagnosis of patients who develop ATM related to SLE.     

Acute eosinophilic pneumonia due to toxocariasis with bronchoalveolar lavage findings.

A previously healthy young man presented with breathlessness, diffuse pulmonary infiltrates on the chest x-ray film, and a high degree of peripheral blood eosinophilia. Analysis of bronchoalveolar lavage (BAL) fluid showed 64 percent eosinophils. A diagnosis of toxocariasis was eventually reached on the basis of a positive enzyme-linked immunosorbent assay (ELISA) for Toxocara canis. The routine performance of the ELISA test for Toxocara in the diagnostic approach to pulmonary infiltration with eosinophilia could reveal an undetermined, sometimes unsuspected, number of cases of adult toxocariasis with pulmonary involvement. A high degree of eosinophilia in the differential cell count of BAL fluid may eventually prove to be a useful clue in favor of such a diagnosis.     

Longitudinal myelitis associated with systemic lupus erythematosus: clinical features and magnetic resonance imaging of six cases.

Myelopathy is a rare central nervous system (CNS) complication associated with systemic lupus erythematosus (SLE). Acute transverse myelitis (ATM) is the most frequent form of SLE-related myelopathy. Magnetic resonance imaging (MRI) typically shows increased signal intensity in T2-weighted images and cord swelling. In the present paper, we describe six cases of SLE-related myelopathy with multiple increased signals in the T2-weighted images involving continuous levels of the cervical and thoracic spinal cord, a distinctive feature recently named 'longitudinal myelitis'. The clinical and laboratory findings are similar to those presented by ATM patients, including paraparesis, sensory level and sphincter disturbances. Four patients had positive antiphospholipid antibodies (aPL) suggesting that this could be a characteristic of longitudinal myelitis. Treatment in all cases included high doses of corticosteroids and immunosuppressive agents (intravenous (i.v.) cyclophosphamide). Anticoagulation therapy was given to one patient and two others received low doses of aspirin. The outcome was mainly unfavorable with slow improvement in only one case, no improvement in two and relapse of the myelopathy in the remaining three. In conclusion, longitudinal myelitis is an unusual form of SLE-related myelopathy, it might be associated with aPL and it has a poor prognosis.     

Spinal Cord and Spinal Nerve Root Involvement (Myeloradiculopathy) in Tuberculous Meningitis

Most of the information about spinal cord and nerve root involvement in tuberculous meningitis is available in the form of isolated case reports or case series. In this article, we evaluated the incidence, predictors, and prognostic impact of spinal cord and spinal nerve root involvement in tuberculous meningitis.In this prospective study, 71 consecutive patients of newly diagnosed tuberculous meningitis were enrolled. In addition to clinical evaluation, patients were subjected to magnetic resonance imaging (MRI) of brain and spine. Patients were followed up for at least 6 months.Out of 71 patients, 33 (46.4%) had symptoms/signs of spinal cord and spinal nerve root involvement, 22 (30.9%) of whom had symptoms/signs at enrolment. Eleven (15.4%) patients had paradoxical involvement. Paraparesis was present in 22 (31%) patients, which was of upper motor neuron type in 6 (8.4%) patients, lower motor neuron type in 10 (14%) patients, and mixed type in 6 (8.4%) patients. Quadriparesis was present in 3 (4.2%) patients. The most common finding on spinal MRI was meningeal enhancement, seen in 40 (56.3%) patients; in 22 (30.9%), enhancement was present in the lumbosacral region. Other MRI abnormalities included myelitis in 16 (22.5%), tuberculoma in 4 (5.6%), cerebrospinal fluid (CSF) loculations in 4 (5.6%), cord atrophy in 3 (4.2%), and syrinx in 2 (2.8%) patients. The significant predictor associated with myeloradiculopathy was raised CSF protein (>250 mg/dL). Myeloradiculopathy was significantly associated with poor outcome.In conclusion, spinal cord and spinal nerve root involvement in tuberculous meningitis is common. Markedly raised CSF protein is an important predictor. Patients with myeloradiculopathy have poor outcome.     

Clinical and neuroimaging features of enterovirus71 related acute flaccid paralysis in patients with hand-foot-mouth disease

ObjectiveTo investigate clinical and neuroimaging features of enterovirus71 (EV71) related acute flaccid paralysis in patients with hand-foot-mouth disease.MethodsNine patients with acute flaccid paralysis met the criterion of EV71 induced hand-foot-mouth disease underwent spinal and brain MR imaging from May 2008 to Sep 2012.ResultsOne extremity flaccid was found in four cases (3 with lower limb, 1 with upper limb), two limbs flaccid in three cases (2 with lower limbs, 1 with upper limbs), and four limbs flaccid in two cases. Spinal MRI studies showed lesion with high signal in T2-weighted images (T2WI) and low signal T1-weighted images (T1WI) in the spinal cord of all nine cases, and the lesions were mainly in bilateral and unilateral anterior horn of cervical spinal cord and spinal cord below thoracic 9 (T9) level. In addition, the midbrain, pons, and medulla, which were involved in 3 cases with brainstem encephalitis, demonstrated abnormal signal. Moreover, spinal cord contrast MRI studies showed mild enhancement in corresponding anterior horn of the involved side, and strong enhancement in its ventral root.ConclusionsEV71 related acute flaccid paralysis in patients with hand-foot-mouth disease mainly affected the anterior horn regions and ventral root of cervical spinal cord and spinal cord below T9 level. MR imaging could efficiently show the characteristic pattern and extent of the lesions which correlated well with the clinical features.     

造血干细胞移植后继发脑膜造血-1例报告

目的报告1例多发性骨髓瘤患者异基因骨髓造血干细胞移植后发生放射性脊髓炎,1月后又出现髓外脑膜造血的病例,探讨此例髓外脑膜造血的发病因素.方法对该患者在接受非亲缘性供者骨髓移植后7月继发髓外脑膜造血的临床资料进行分析,并结合文献复习.结果脑脊液中发现造血细胞,包括有核红细胞,幼稚粒细胞和巨核细胞,MRI见脊髓T11以下线性增强.结论放射性脊髓炎可能导致髓外脑膜造血,鞘内注射阿糖胞苷和甲氨喋呤治疗使其缓解.     

Eosinophilic meningitis caused by Angiostrongylus cantonensis associated with eating raw snails: correlation of brain magnetic resonance imaging scans with clinical findings

Angiostrongylus cantonensis is the most common cause of eosinophilic meningitis worldwide. Human infection occurs after ingestion of the worms in raw snails or fish that serve as intermediate hosts. Two outbreaks of central nervous system infection with A. cantonensis occurred in Kaoshiung, Taiwan, during 1998 and 1999 among Thai laborers who ate raw snails. A detailed clinical studies of 17 of these patients was conducted, including study of 13 patients who underwent magnetic resonance imaging (MRI) scans of the brain. The MRI scans revealed high signal intensities over the globus pallidus and cerebral peduncle on T1-weighted imaging, leptomeningeal enhancement, ventriculomegaly, and punctate areas of abnormal enhancement within the cerebral and cerebellar hemisphere on gadolinium-enhancing T1 imaging, and a hyperintense signal on T2-weighted images. There was a significant correlation between severity of headache, cerebrospinal fluid (CSF) pleocytosis, and CSF and blood eosinophilia with MRI signal intensity in T1-weighted imaging (P < 0.05). Eosinophilic meningitis produced by A. cantonensis needs to added to the list of causes of hyperintense basal ganglia lesions found on T1-weighted MRI scans in tropical countries.     

Induction of a marked eosinophilia by cyclophosphamide in Toxocara canis infected SJL mice

Cyclophosphamide (Cy) is known to produce a marked eosinophilia in mice after antigen challenge. In this study, we studied the effect of Cy on eosinophilia in helminthic infection. Peripheral blood eosinophils were counted in SJL mice following a large dose of Cy injection, infection with Toxocara canis, and both Cy injection and T. canis infection simultaneously. Following the injection with Cy (150 mg/kg), the eosinophil counts fell sharply, then rose abruptly to six times the normal level followed by a decrease. Infection with T. canis induced eosinophilia in mice. However, when mice were both infected with T. canis and given Cy injection, the eosinophilia was markedly enhanced. The results suggest that the marked eosinophilia in mice induced by Cy is not only observed in antigen challenge but also in helminthic infection.     

Neuroschistosomiasis due to Schistosoma mansoni: a review of pathogenesis, clinical syndromes and diagnostic approaches

Neuroschistosomiasis (NS) is the second most common form of presentation of infection by the trematode, Schistosoma mansoni. Granulomatous inflammatory reaction occurs as a result of schistosome eggs being transmitted to spinal cord or brain via the vascular system, or by inadvertent adult worm migration to these organs. The two main clinical syndromes are spinal cord neuroschistosomiasis (acute or subacute myelopathy) and localized cerebral or cerebellar neuroschistosomiasis (focal CNS impairment, seizures, increased intracranial pressure). Presumptive diagnosis of NS requires confirming the presence of S. mansoni infection by stool microscopy or rectal biopsy for trematode eggs, and serologic testing of blood and spinal fluid. The localized lesions are identified by signs and symptoms, and confirmed by imaging techniques (contrast myelography, CT and MRI). Algorithms are presented to allow a stepwise approach to diagnosis.     

Myocarditis associated with visceral larva migrans due to Toxocara canis

A 26-year-old man who was diagnosed with myocarditis presented eosinophilia after having eaten raw meat several times before the admission. Since the antibody titer against Toxocara canis was high, we diagnosed that he had visceral larva migrans due to Toxocara canis associated with myocarditis and eosinophilia. He was then treated with oral albendazole and prednisolone for 4 weeks and eosinophil count and hepatic enzymes were normalized along with the decrease in the antibody titer. We consider that his myocarditis was probably caused by direct larval migration and/ or by hypersensitivity reaction, for which combined therapy with albendazole and prednisolone was effective.     

钩端螺旋体L型脊髓炎(附15例报告)

目的 探讨钩体Ｌ型脊髓炎发病机理和防治。方法 以１５例钩体Ｌ型脊髓炎临床表现，实验室检查，并复习文献。结果 急性及亚急性或慢性脊髓损害各７，８例，双下肢瘫７例，四肢瘫８例，均有明显的传导束型节段型感觉障碍及排尿障碍，血培养钩体Ｌ型阳性８例，原型钩体６例，尿培养，钩体Ｌ型５例，ＣＳＦ培养钩体Ｌ型５例，血清钩体ＭＡＴ阳性７例，结论 钩体Ｌ型脊髓炎的发生可能与钩体Ｌ型直接损伤脊髓或供血血管，钩体Ｌ型致间     

Combined sclerosis of the spinal cord revealing vitamin B 12 deficiency: geriatric characteristics apropos of a case evaluated by MRI

INTRODUCTION: Cobalamin deficiency is common in the elderly. However, most of the patients are asymptomatic or present with few symptoms. A subacute combined degeneration of the spinal cord accounts for only 10% of the neurological complications. Revealing forms of this myelopathy are exceptional, and were rarely documented by magnetic resonance imaging (MRI) study. EXEGESIS: We report a case of subacute combined degeneration of spinal cord in an 81-year-old woman evaluated by a spinal cord MRI. We discuss the role of the spinal cord radiographic study in the diagnosis, the etiopathogeny of cobalamin deficiency and the benefit of vitamin supplementation even at a late stage of the disease in geriatrics patients. CONCLUSION: The spinal cord MRI is useful in the diagnosis of late-form combined spinal cord degeneration. The high frequency of atrophic gastritis in elderly prevents the identification of a deficiency of the cobalamin etiology. The treatment relies on vitamin therapy even in the late stages. The severe disability of cobalamin deficiency neurological complications must encourage an earlier diagnosis in elderly patients.     

Eosinophilia, granuloma formation and migratory behaviour of larvae in the congenitally athymic mouse infected with Toxocara canis

Peripheral blood eosinophilia, histology of skeletal muscle and brain, and larval recovery were compared between congenitally athymic nude mice (nu/nu) and thymus-bearing heterozygous littermates (nu/+) for 6 weeks following oral infection with Toxocara canis eggs. By comparing patterns of peripheral blood eosinophil levels in nu/+ and nu/nu, two types of eosinophilias, one T cell dependent and the other independent, were observed. Eosinophil infiltration and granuloma formation around larvae in the skeletal muscle were weaker in degree in nu/nu than nu/+. The total number of larvae in nu/+ decreased from 2 to 6 weeks after infection. This decrease was directly related to a decrease in larval number in skeletal muscle, not in brain or other tissues. In contrast, no significant decrease of the total number of larvae was observed in nu/nu. The results indicate that eosinophilia, granuloma formation and larval recovery are closely related to cell-mediated immune mechanisms in T. canis -infected mice.     

亚急性联合变性与维生素B12缺乏和巨幼红细胞贫血的研究

目的探讨亚急性联合变性(SCD )与维生素B12(VB12)缺乏和巨幼红细胞贫血(MA)的相关性.方法分析36例SCD的神经损害程度与贫血程度和血清VB12水平之间的相关性;对比MRI、神经电生理检查在SCD诊断中的敏感性和特异性.监测SCD脑脊液髓鞘碱性蛋白(MBP)浓度的动态变化.分析开始治疗时间对疗效和预后的影响.结果患者治疗前Hb平均含量(77.1±11.2 ) g/L ,表明SCD大都伴贫血,但其程度与SCD神经损害程度无直线相关关系(r=-0.1917、0.0926,P＞ 0.5).治疗前平均血清VB12水平(87.0±21.4) ng/L,异常率47.2 %, 治疗后很快恢复, 但神经体征改善较慢,二者无直线相关关系(r=0.207、0.101,P>0.5).诱发电位综合阳性率100%,并可在临床症状出现前或在SCD初期出现.MRI检查阳性率为71.4%,部分病灶治疗后缩小或消失.脑脊液MBP水平治疗前(3.96±1.66 ) ng/L.治后3个月有显著改善(2.25±1.66) ng/L.确诊6个月后开始治疗者,神经功能改善不显著.结论 SCD多由VB12缺乏引起,常伴MA,但血清VB12水平不能作为诊断或排除SCD的惟一标准.MRI可显示SCD的多数脊髓和脑部病灶,治疗后可缩小或消失.诱发电位为早期确诊和发现隐匿病灶提供帮助.脑脊液MBP水平可反映SCD神经髓鞘损害和修复的程度.早期诊断和治疗可降低永久神经功能损害的范围和程度.     

Clinical evaluation of meningeal carcinomatosis associated with primary lung cancer]

We evaluated diagnosis and treatment of four cases of meningeal carcinomatosis associated with primary lung cancer: case 1; small cell carcinoma (64 years old), case 2; small cell carcinoma (50 years old), case 3; adenocarcinoma (53 years old), and case 4; adenocarcinoma (55 years old). Determination of tumor markers in cerebrospinal fluid (CSF) together with the MRI findings that Gd-DTPA-enhanced T1-weighted image showing high intensity signal along the spinal cord was clinically useful in the diagnosis of meningeal carcinomatosis. Two of four patients received intrathecal chemotherapy and/or CSF drainage through Ommaya-Reservoir, resulting in dramatic improvement of various symptoms such as motor weakness and vesicorectal disorder. Intrathecal chemotherapy and placement of an Ommaya-Reservoir for CSF drainage should be considered to provide better Quality of Life (QOL) when patient can tolerate it.