Carcinomatous Meningitis as the Presenting Manifestation of Gallbladder Carcinoma: Case Report and Review of the Literature

The primary tumors that typically cause carcinomatous meningitis include lung cancer, breast cancer, leukemia, lymphoma and melanoma. A variety of neurological signs and symptoms can be seen depending on the extent and location of the meningeal metastasis. Once the diagnosis of carcinomatous meningitis is confirmed, the search for the primary tumor can be a challenge and at times may require extensive radiographic or even surgical evaluation to obtain specimen for pathological confirmation. Here we report a patient who presented with bilateral cranial nerve VIII and cerebellar symptoms, and was diagnosed with carcinomatous meningitis. Only after an exploratory laporatomy did it become clear that the initial symptoms were related to a metastatic gallbladder carcinoma.     

Persistent increase of matrix metalloproteinases in cerebrospinal fluid of tuberculous meningitis

Matrix metalloproteinase (MMP)-2 and MMP-9 were analyzed by gelatin zymography and an enzyme-linked immunosorbent assay (ELISA) in a cerebrospinal fluid (CSF) from patients with tuberculous meningitis (n=24), acute aseptic meningitis (n=23) and the control (n=10). The MMP-2 and MMP-9 levels were significantly higher in the samples from the tuberculous meningitis patients than those from either the aseptic meningitis patients or the controls. In tuberculous meningitis, the patients with late neurologic complications had higher MMP-2 and MMP-9 levels than those without. The persistent increase in the MMP-2 and MMP-9 levels was associated with the development of complications following tuberculous meningitis. Inhibiting the MMPs may be an effective strategy for preventing or reducing the complications in tuberculous meningitis.     

Interleukin-8 levels in children with bacterial,tuberculous and aseptic meningitis

Objective : Interleukin-8 (IL-8) is produced in monocytes and vascular endothelial cells in response to stimulation with bacteria or lipopolysaccharides, and is released from these cells into blood stream or tissue fluid.Methods Cerebrospinal fluid (CSF) levels of interleukin-8 in 56 children with nonbacterial, bacterial and tuberculous meningitis (TBM), and in 15 control subjects were analyzed to evaluate the involvement of this cytokine in the pathogenesis acute bacterial meningitis and their discriminative value between different etiologies of meningitis. The kinetics of IL-8 concentrations during the course of bacterial meningitis was also evaluated in patients. IL-8 levels were significantly higher in bacterial and TBM than in aseptic meningitis and in control subjects (p<0.0001).Results: There was no difference in the levels of IL-8 between the non-bacterial meningitis and control groups. The analysis of the kinetics of production of IL-8 in patients with bacterial meningitis showed that the SSF concentrations of this cytokine decreased to undetectable values in recovery stage. Conversely in patients with TBM the concentrations of IL-8 were elevated in two weeks after beginning the specific treatment.Conclusion : The results suggest that determining IL-8 levels may be useful in the differential diagnosis.     

Primary neuroleptospirosis

Leptospirosis is an important zoonosis of worldwide distribution. It is uncommon for leptospirosis to present as a primary neurological disease. In this study of patients who presented with an acute neurological disease, and who were subsequently found to have leptospirosis, aseptic meningitis was the commonest manifestation. The other presentations were myeloradiculopathy, myelopathy, Guillain-Barré syndrome-like presentation, meningoencephalitis, intracerebral bleed, cerebellar dysfunction, iridocyclitis, and tremor/rigidity. Treatment consists of antibiotics, crystalline penicillin being the drug of choice, which reduces the course of illness if given early. The role of steroids is controversial. The prognosis after primary neuroleptospirosis is generally good but altered sensorium and seizures herald a worse prognosis.     

Motor and somatosensory evoked potentials in tuberculous meningitis: a clinico-radiological correlation

OBJECTIVE: The sensory and motor functions in severe tuberculous meningitis (TBM) may be difficult to assess clinically and may be helped by evoked potential studies. Lack of motor and somatosensory evoked potential studies in TBM prompted the present study. METHODS: All the patients with TBM underwent detailed neurological evaluation and cranial CT scan study. Motor and somatosensory evoked potentials to both upper and lower limbs were carried out bilaterally. The outcome was defined on the basis of 3 month Barthel Index (BI) score into good (BI > 12) and poor (BI < 12). RESULTS: Forty-one highly probable patients with TBM whose ages ranged between 8 and 64 years and 14 of whom were females were included in this study. Twenty-three patients were in stage III (meningitis, neurological signs and altered sensorium), 12 in stage II (meningitis with neurological sign) and the remaining patients were in stage I (meningitis only). Cranial CT scan was carried out in all and MRI in 18 patients. On CT scan hydrocephalus was present in 21, infarction in 14 and tuberculoma in 4 patients. Motor evoked potential (MEP) was abnormal in 18 patients (36 limbs) and SEP in 9 patients (23 limbs). Upper limb central motor conduction time to abductor digiti minimi (CMCT-ADM) was abnormal in 15 and that to tibialis anterior (TA) in 21 limbs. CMCT abnormality was lateralized in 6 and only upper or lower limbs were involved in 11 patients. The SEP abnormalities were lateralized in 2 patients and only upper or lower limbs were involved in 3. The MEP changes correlated with stage of TBM and outcome whereas SEP with outcome only. CONCLUSION: Motor and somatosensory evoked potentials may be helpful in objective documentation of respective motor and sensory functions in TBM patients with altered sensorium.     

Sequelae of Haemophilus influenzae meningitis

Fourteen children who had had Haemophilus influenzae meningitis more than two years earlier have been compared with their siblings. WISC, Frostig and Bender psychological tests and neurological examination were performed so that subject/sibling differences could be analysed. On neurological examination, subjects overall performed worse than the controls, although no "hard" neurological signs were found. Prolonged fever during the meningitis was associated with poorer results in psychological tests. In the subjects, there was a significant increase in left lateral dominance which may have been due to brain damage by the meningitis. However, most subjects did not differ significantly from their siblings in the tests, suggesting that prompt and adequate treatment of bacterial meningitis can prevent sequelae.     

Recurrent aseptic meningitis following non- steroidal anti-inflammatory drugs--a reminder

Non-steroidal anti-inflammatory drugs (NSAIDs) are rarely associated with side-effects affecting the central nervous system. A case of NSAID-induced recurrent aseptic meningitis is presented. Seven episodes of aseptic meningitis were documented in the patient's life-time (up to the age of 30). General practitioners' records available for the latest four episodes showed that a NSAID (naproxen, piroxicam or diclofenac) was prescribed in the month prior to admission on each occasion. The patient was symptom free for a 3-year period during which no NSAID was prescribed. Clinicians should always elicit a careful drug history (including over-the-counter medications) in patients with aseptic meningitis and be aware of this unusual side-effect of NSAIDs.     

Acute bacterial meningitis at the 'Complexe Pédiatrique' of Bangui, Central African Republic

To precis the aetiologies of children meningitis and the susceptibility to antibiotics of bacteria responsible for meningitis in Bangui, we conducted a prospective study between October 2004 and September 2005, at the 'Complexe Pédiatrique de Bangui', Central African Republic (CAR). Children from 1 day to 16 years with suspected meningitis and who underwent a lumbar puncture were enrolled. Gram staining, culture on chocolate blood medium, cell count, biochemistry (protein level, glucose ratio), capsular antigen detection were performed for each cerebrospinal fluid. MICs were determined by the E-test method. Four hundred and seventeen patients were enrolled during the study period; 130 were proven acute bacterial meningitis and 37 probable bacterial meningitis. Among proven bacterial meningitis, Streptococcus pneumoniae was the most common organism responsible for meningitis (62 cases, 48%) followed by Haemophilus influenzae (46 cases, 35%) and by Neisseria meningitidis and Salmonella sp. (8 cases, 6% each). Ninety-four percent and 96% of S. pneumoniae strains tested remain susceptible to benzylpenicilline and chloramphenicol, respectively. A beta-lactamase was detected in 92% of H. influenzae strains tested. However, MICs 50% and 90% for amoxicillin were found to be 1 and 4 mg/l, respectively and 33% of these strains were resistant to chloramphenicol. The global mortality rate was 35% (59/167). This mortality rate was 47% for S. pneumoniae, 33% for H. influenzae, 62% for Salmonella sp. and 13% for N. meningitidis. The probabilistic treatment with ampicillin and chloramphenicol usually administered for children meningitis in Bangui must be reconsidered particularly in cases of H. influenzae meningitis. It is of importance to reduce the presentation delays of children with suspected meningitis in Bangui. The H. influenzae b immunization would allow a dramatic reduction of meningitis cases and deaths in Central African children.     

Adult bacterial meningitis: aetiology, penicillin susceptibility, risk factors, prognostic factors and guidelines for empirical antibiotic treatment

Episodes of adult bacterial meningitis (ABM) at a Danish hospital in 1991-2000 were identified from the databases of the Department of Clinical Microbiology, and compared with data from the Danish National Patient Register and the Danish National Notification System. Reduced penicillin susceptibility occurred in 21 (23%) of 92 cases of known aetiology, compared to an estimated 6% in nationally notified cases (p < 0.001). Ceftriaxone plus penicillin as empirical treatment was appropriate in 97% of ABM cases in the study population, and in 99.6% of nationally notified cases. The notification rate was 75% for penicillin-susceptible episodes, and 24% for penicillin-non-susceptible episodes (p < 0.001). Cases involving staphylococci, Pseudomonas spp. and Enterobacteriaceae were under-reported. Among 51 ABM cases with no identified risk factors, nine of 11 cases with penicillin-non-susceptible bacteria were community-acquired. Severe sequelae correlated independently with age, penicillin non-susceptibility, mechanical ventilation and non-transferral to a tertiary hospital (p < 0.05; logistic regression). Other factors that correlated with severe sequelae by univariate analysis only were inappropriate clinical handling, abnormal consciousness, convulsions and nosocomial infection. Overall, the data indicated that neither age alone, community-acquired infection nor absence of identified risk factors can predict susceptibility to penicillin accurately. Recommendations for empirical antibiotic treatment for ABM should not be based exclusively on clinical notification systems with possible unbalanced under-reporting.