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1/42. Outbreak of severe neurologic involvement associated with enterovirus 71 infection.

    enterovirus 71 has been associated with several outbreaks, as well as sporadic cases, of central nervous system infection and has a worldwide distribution. Seven children with encephalitis and five with aseptic meningitis caused by enterovirus 71 were seen at Otsu Municipal Hospital during the summer of 1997. The infections were confirmed serologically, although detection of the viral genome in cerebrospinal fluid was unsuccessful. Seven children were diagnosed as having hand-foot-and-mouth syndrome, two were diagnosed as having herpangina, and three patients younger than 12 months old developed no eruptions. The skin or mucosal manifestations of this outbreak demonstrated considerable variation. The enterovirus 71 strain that caused the outbreak had a strong neurovirulent tendency. Among the patients with encephalitis, symptoms originating from the impairment of diencephalon were seen in four patients, and those originating from cerebellar impairment were seen in two patients. brain magnetic resonance imaging in one patient revealed an abnormality in the pons. The neurologic manifestations associated with enterovirus 71 infection may be characterized by involvement of the cerebellum, brainstem, and diencephalon. enterovirus 71 is one of the pathogenic viruses that cause hand-foot-and-mouth syndrome, as well as a variety of other clinical manifestations. The most important of these is neurologic disease, especially in infants and young children. ( info)

2/42. Unusual presentations of neuroborreliosis (lyme disease) in childhood.

    Two children with atypical neuroborreliosis (cranial polyneuritis and acute transverse myelitis) are presented. The diagnosis was confirmed by the determination of specific antibodies against borrelia burgdorferi in both serum and CSF. neuroimaging findings were nonspecific, indicating, however, that neuroborreliosis should be included in the differential diagnosis of cases with cranial polyneuritis and acute transverse myelitis in childhood. ( info)

3/42. Multilocular cysticeral and hydatid cysts of the brain: a report of three cases.

    Three cases of multilocular parasitic brain cysts are presented; two cases of specific form of neurocysticercosis and one case of multilocular hydatid cyst. MRI shows features seen in other cystic lesions of the CNS. In all cases the diagnosis was established by neurosurgical brain biopsy. The authors indicate that the parasitic disease should be taken into consideration in differential diagnosis of tumor-like cystic brain lesions. ( info)

4/42. Impact of cerebrospinal fluid PCR on the management of hiv-infected patients with varicella-zoster virus infection of the central nervous system.

    Over a 2 year period, we identified five hiv-infected patients who presented with central nervous system infection caused by varicella-zoster virus, three with myelitits, and two with meningoencephalitis. All five patients were profoundly immunocompromised. Clinical presentation of these patients overlapped to a significant extent with diseases caused by other viruses, e.g. CMV. Indeed, in one case, a dual infection with CMV was diagnosed, but the respective role of each virus was ascertained by in situ hybridisation. At the time of CNS involvement, only one patient had active VZV cutaneous lesions, which were instrumental in diagnosing her condition. In contrast, PCR for VZV dna in the CSF was helpful in making a diagnosis in the four other cases, one of which was confirmed by a post mortem. Of these five patients, two patients developed VZV disease while receiving oral acyclovir and had foscarnet treatment initiated when MRI demonstrated widespread lesions. They did not respond to antiviral therapy. The three other patients had intravenous acyclovir initiated at a time when no or limited parenchymal lesions were observed by MRI. Two of these three patients had VZV infection diagnosed solely on the basis of PCR: all three responded to treatment. Our data show that reactivation of VZV involving the central nervous system occurs frequently in the absence of cutaneous lesions. PCR of cerebrospinal fluid may help in making an early diagnosis which is probably a prerequisite for successful treatment of VZV infection of the CNS. ( info)

5/42. mycobacterium fortuitum infection of ventriculoperitoneal shunt.

    mycobacterium fortuitum is one of the rapidly growing mycobacteria found in soil, dust, and water. It can be isolated as a normal colonizing organism, but as a pathogen this organism causes mainly skin and soft tissue infection preceded by trauma. A wide variety of infections can occur in individuals with predisposing conditions. central nervous system infection with M fortuitum is rare, and meningitis occurs after surgery or trauma. We believe that ventriculoperitoneal (VP) shunt infection with this organism has not been reported in the literature. Practitioners should be aware of this rare entity and should suspect it in the presence of cerebrospinal fluid pleocytosis with sterile culture, and after trauma, surgery, or manipulation of the VP shunt hardware. mycobacterium fortuitum is resistant to most first-line and second-line antituberculous drugs, and treatment should include surgical debridement in addition to prolonged antimicrobial therapy. ( info)

6/42. central nervous system (CNS) tuberculosis following allogeneic stem cell transplantation.

    tuberculosis is an uncommon infectious complication after stem cell transplantation. We report a patient who presented with a brain mass, 3 months after pulmonary tuberculosis had been diagnosed and while he was receiving triple antituberculous therapy. He had extensive chronic GVHD. The diagnosis was made after biopsy of the lesion. The cerebral mass was excised, antituberculous treatment was maintained and the patient made a complete neurologic recovery. Six months later, he died of gram-negative septic shock. Mycobacterial infections should be considered in allograft recipients with chronic GVHD and solid lesions in the brain. bone marrow transplantation (2000) 25, 567-569. ( info)

7/42. An unusual complication of tapping a ventriculoperitoneal shunt.

    A case is reported describing a complication of an unsuccessful attempt to aspirate the reservoir of a ventriculoperitoneal shunt system with a suspected shunt infection. This arose due to a misunderstanding of the anatomy of the shunt and resulted in an intracerebral haematoma. The complications of cerebrospinal fluid shunting and the difficulty in the diagnosis thereof are outlined. We discuss the role and method of shunt tapping in diagnosing shunt problems before reviewing the literature describing the rationale. The variation in shunt design is emphasized. Guidelines are then proposed not to dissuade physicians from tapping shunts but to ensure that the procedure is performed safely and in collaboration with neurosurgical units. ( info)

8/42. Herpesvirus dna detection in cerebral spinal fluid: differences in clinical presentation between alpha-, beta-, and gamma-herpesviruses.

    To evaluate the role of 6 human herpesviruses (cytomegalovirus (CMV), Epstein-Barr virus (EBV), human herpesvirus-6 (HHV-6), herpes simplex virus (HSV) types 1 and 2 and varicella zoster virus (VZV)) in infections of the nervous system, cerebrospinal fluid (CSF) samples from 662 patients with suspected viral aetiology to neurological symptoms were investigated for presence of herpesviral dna in a PCR-based study. Of the 69 patients (2 patients had 2 herpesvirus dna detected in CSF) who had herpesvirus dna detected in the CSF, 60 (87%) were non-immunocompromised (CMV 7; HHV-6 6; EBV 16; HSV-1 18; HSV-2 9 and VZV 6) and 9 (13%) were immunocompromised (CMV 3; HHV-6 0; EBV 5; HSV-1 0; HSV-2 1 and VZV 0). The study was performed in a retrospective/prospective manner. The HSV-1, HSV-2, VZV and CMV dna-positive patients usually had typical clinical syndromes, such as encephalitis/myelitis and meningitis, but also other neurological conditions were associated with findings of these viruses. HHV-6 and EBV dna were detected in patients presenting with a variety of neurological symptoms, and in some of the cases, concurrent with diagnosis of other infections of the central nervous system. Despite the overall variability of clinical conditions seen, a pattern associated with each investigated herpesvirus was discernable as regards clinical presentation. ( info)

9/42. CNS infection with clostridium septicum.

    We present an unusual case of clostridium septicum brain infection in a 72-yr-old woman who had no underlying malignant disease. The infection spread from a localized sit to the CNS causing gas formation. The patient died rapidly. ( info)

10/42. central nervous system candidiasis in preterm infants: limited value of biochemical markers for diagnosis.

    Two rare cases of isolated central nervous system (CNS) candidiasis in preterm infants have been diagnosed in a tertiary neonatal centre over the past 6 years. Despite the life-threatening nature of the disease, biochemical infection markers were not useful for the early identification of localized fungal infection. Because the infection was likely to have been blood borne, we postulated that the initial fungal load was probably low and that the organisms were rapidly eliminated from the circulation after a few had been deposited in the CNS. Hence, the absence of fungaemia or systemic involvement precluded the activation of cytokines and cellular markers. Clinicians should be aware of the limitation of biochemical infection markers so that diagnosis and treatment of fungal infection will not be delayed. ( info)
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