A clinical approach to hypertrophic pachymeningitis / Abordagem diagnóstica para paquimeningite hipertrófica

ABSTRACT Importance: Hypertrophic pachymeningitis (HP) is a non-usual manifestation of rheumatologic, infectious, and neoplastic diseases. Etiological diagnosis is a challenge, but when made promptly it creates a window of opportunity for treatment, with the possibility of a total reversal of symptoms. Observations: HP is an inflammatory process of the dura mater that can occur as a manifestation of sarcoidosis, granulomatosis with polyangiitis, and IgG4-related disease. The HP case evaluation is extensive and includes central nervous system imaging, cerebrospinal fluid analysis, serology, rheumatologic tests, and systemic survey for other manifestations sites. After systemic investigation, meningeal biopsy might be necessary. Etiology guides HP treatment, and autoimmune disorders are treated with corticosteroids alone or associated with an immunosuppressor. Conclusion: HP is a manifestation of several diseases, and a precise etiological diagnosis is crucial because of the difference among treatments. An extensive investigation of patients with HP helps early diagnosis and correct treatment.

RESUMO Importância: Paquimeningite hipertrófica (PH) é uma manifestação não usual de doenças reumatológicas, infecciosas e neoplásicas. O diagnóstico etiológico por vezes é um desafio, entretanto quando realizado em tempo cria uma janela de tratamento com a possibilidade de reversão total dos sintomas. Observações: A PH é um processo inflamatório da dura-máter que pode ocorrer como manifestação da sarcoidose, granulomatose com poliangeíte e doença relacionada à IgG4. A avaliação dos casos de PH é extensa e inclui imagem do sistema nervoso central, análise de líquor, sorologias, provas reumatológicas e rastreio sistêmico para doença em outros sítios. Por vezes, após toda a investigação sistêmica, a biópsia de meninge é necessária. A etiologia orienta o tratamento da HP, sendo que em doenças autoimunes adota-se o uso de corticosteroides isolados ou associados a um imunossupressor. Conclusão e Relevância: A PH é uma manifestação de várias doenças, e seu diagnóstico etiológico preciso é fundamental, visto a diferença entre os possíveis tratamentos. Uma investigação ampla nos casos de PH ajuda no diagnóstico precoce e tratamento adequado.

Paquimeningitis hipertrófica posinfecciosa: presentación de caso clínico / Post-infection hypertrophic pachymeningitis: a clinical case report

La paquimeningitis hipertrófica es una entidad infrecuente que puede ser idiopática o secundaria, y dado que incluso un diagnóstico acertado y un correcto tratamiento pueden dejar secuelas neurológicas graves o, incluso, producir la muerte, presentamos este caso en el que consideramos que la causa fue una meningitis que no recibió tratamiento adecuado al inicio de los síntomas y que tuvo una respuesta satisfactoria al tratamiento con corticoides, inicialmente en altas dosis.

Eosinophilic meningitis caused by Angiostrongylus cantonensis: an emergent disease in Brazil

Eosinophilic meningitis (EoM) is an acute disease that affects the central nervous system. It is primarily caused by infection with the nematode Angiostrongylus cantonensis. This infection was previously restricted to certain Asian countries and the Pacific Islands, but it was first reported in Brazil in 2007. Since then, intermediate and definitive hosts infected with A. cantonensis have been identified within the urban areas of many states in Brazil, including those in the northern, northeastern, southeastern and southern regions. The goals of this review are to draw the attention of the medical community and health centres to the emergence of EoM in Brazil, to compile information about several aspects of the human infection and mode of transmission and to provide a short protocol of procedures for the diagnosis of this disease.

Neurosífilis meningovascular con trombosis de la arteria basilar / Meningovascular neurosyphilis with basilar artery thrombosis, a case report and literature review

Se presenta el caso clínico de un paciente de 54 años, negativo para VIH, con enfermedad cerebrovascular por trombosis de la arteria basilar, secundaria a neurosífilis meningovascular. La neurosífilis es el compromiso del sistema nervioso central por Treponema pallidum subespecie pallidum en cualquier estadio de la entidad e incluye las formas asintomáticas y sintomáticas de la infección; sus formas de presentación son diversas y dependen de la localización y la extensión de las lesiones. La recomendación actual es el tratamiento con 4 millones de unidades de penicilina cristalina cada 4 horas por 14 días.

Herein a case is described of a 54-years old patient, HIV negative, with cerebro-vascular disease by basilar artery thrombosis secondary to meningovascular neurosyphilis. Neurosyphilis is the impairment at any stage of the central nervous system by Treponema pallidum subspecies pallidum and includes asymptomatic and symptomatic forms of infection. The presentation can take many forms, depending on the location and extent of tissue damage. The currently recommended treatment is crystalline penicillin, 4 million units every 4 hours for 14 days.

Tratamiento Antimicrobiano / Antibiotic treatment

Las Meningitis Bacterianas Agudas (MBA) siguen constituyendo un capítulo de extraordinario interés dentro de los procesos infecciosos. El conocimiento de la epidemiología local es fundamental. La terapia específica con antibióticos debe ser aplicada en forma precoz, con drogas bactericidas de buena concentración en líquido cefalorraquídeo. El conocimiento de la resistencia de los gérmenes causales de las MBA es capital para el logro de un tratamiento eficaz, buscando la menor morbi-mortalidad posible. Cada paciente debe individualizarse en función de la edad, factores asociados y evolución del caso

Acute bacterial meningitis (ABM) remains a chapter of extraordinary interest in infectious processes. Knowledge of local epidemiology is essential. Specific therapy with the use of antibiotics must be used early, using antibacterial drugs with good concentration in cerebrospinal fluid. Knowledge of the resistance of the causative organisms of the MBA is valuable in achieving an effective treatment, seeking the lowest possible morbidity and mortality. Each patient should be individualized for each patient age, associated factors and its evolution. Treatment should be individualized for each patient age, associated factors and clinical course

Acanthameba meningitis with successful outcome.

We report a rare cause of sub acute meningitis in a 15-yr-old immunocompetent female child with successful outcome. The etiological agent was Acanthameba. The child was sucessfully treat with combination of Ketoconazole. Rifampicin, cotrimoxa zole and for a period of 9 month.

Subdural effusion complicating neonatal meningitis: successful treatment with acetazolamide.

Postmeningitis subdural effusion is rare in neonates when compared to infants and children. For treatment, various modalities are described. Serial subdural punctures and surgical drain placement are advised for cases having a mass effect on imaging. We report a neonate with symptomatic postmeningitis subdural effusion, who failed to respond to serial subdural punctures, but subsequently managed successfully with acetazolamide. He had no recurrence further. His development was normal at 18 months of age.

Recurrent meningitis secondary to isolated C3 deficiency.

A 5-year-old child presented with the second episode of meningitis when we started investigating her to find a cause for recurrent episode of meningitis. During this she suffered from a third attack after which she was diagnosed as having isolated C(3) deficiency. She was put on penicillin prophylaxis and vaccinated against encapsulated bacteria, after which she is now doing well.

Enterobacter sakazakii in infants: novel phenomenon in India.

E. sakazakii has been implicated in necrotizing enterocolitis, bloodstream and central nervous system infections, with mortality rates of 40-80%. Two cases of E. sakazakii infections; one preterm very low birth weight neonate with meningitis and a two month infant with bacteraemia, are described for the first time in India. The first baby succumbed to the infection while the other responded to appropriate therapy. Powdered infant milk formulae have been implicated in causing neonatal infections and the first baby was on formula feed with classic signs of sepsis and meningitis. The second infant was on breast feed and probably developed nosocomial E. sakazakii bacteraemia.

Paquimeningitis hipertrófica, glomerulonefritis y vasculitis de pequeños vasos asociada a ANCA / Hypertrophic pachymeningitis, glomerulonephritis and P-ANCA associated small vessel vasculitis

La paquimeningitis hipertrófica es una enfermedad poco frecuente caracterizada por engrosamiento de la duramadre. Presentamos una paciente con esta enfermedad que se manifestó con cefalea crónica y en la que concomitantemente se evidenció una glomerulonefritis necrotizante extracapilar pauciinmune asociada a anticuerpos anticitoplasma de neutrófilos de patrón perinuclear (ANCA-P). El diagnóstico se estableció por resonancia nuclear magnética. Recibió tratamiento inmunosupresor con prednisona y ciclofosfamida con evolución favorable.

Hypertrophic pachymeningitis is a very unusual disease, the main characteristic of which is thickening of the dura mater. We describe a patient who started this illness showing chronic headache and pauci-immune necrotizing extracapillary perinuclear antineutrophil cytoplasmic antibody (P-ANCA) associated glomerulonephritis. The diagnosis was made by brain magnetic resonance image. She received immunosuppressant therapy with prednisonel and cyclophosphamide with clinical improvement.

Colelitíase associada ao uso de ceftriaxona / Cholelithiasis associated with the use of ceftriaxone

Crianca de sete anos recebeu ceftriaxona para o tratamento de meningite, evoluindo com dor em hipocôndrio direito associada a cálculo na vesícula biliar. Após três meses, a ultrassonografia abdominal foi normal. O conhecimento de que a ceftriaxona pode levar ao surgimento de colelitíase pode evitar intervencões cirúrgicas desnecessárias.

Antibiotic resistance of streptococcus pneumoniae from meningitis children in Damascus

Beta-Iactam resistance by Streptococcus pneumoniae is becoming a significant threat to the public health worldwide. However, data concerning antibiotic susceptibility patterns in Syria have not been published. Therefore, we isolated between September 2003 and May 2004, 25 strains of Streptococcus pneumoniae recovered from the cerebrospinal fluid [CSF] of children with pneumococcal meningitis reported to the Children's hospital in Damascus.The susceptibility of the strains were tested against 10 antibiotics using disk diffusion method and against 6 antibiotics using broth macrodilution method and breakpoints from the National Committee for Clinical Laboratory Standards [NCCLS] were used. 64% of the strains were resistant to penicillin whereas 0% resistant to ceftriaxone, cefotaxime and amoxicillin-clavulanate. Resistant to erythromycin and tetracycline was detected in 16%, and 48% of the strains were resistant to sulfamethoxazole-trimethoprim, 0% resistant to vancomycin and imipenem and 4% resistant to ticarcillin. Multi-drug resistant S. pneumoniae was 24% and was much higher in penicillin-resistant strains than in penicillin-susceptible strains. We recommend performing susceptibility tests to all S. pneumoniae isolates to set a susceptibility pattern and choose the optimal antibacterial agent for treatment

Idiopathic hypertrophic cervical pachymeningitis: a case report with 5 year follow up.

Idiopathic hypertrophic pachymeningitis is an extremely rare entity. It usually affects cranial meninges. The spinal form is further uncommon and presents as a chronic progressive disease. We describe a 42 year old female with isolated idiopathic hypertrophic cervical pachymeningitis who had a relapsing remitting course under observation for five years. Laminectomy and immunosuppressive therapy produced temporary and partial relief. The long term course and relevant literature is reviewed.

Tratamiento antibiótico intratecal intraventricular en meningitis infecciosa postquirúrgica / Intrathecal-intraventricular antibiotic treatment in postoperative infectious meningitis

Realizamos una revisión de datos clínicos y microbiológicos de tres pacientes que desarrollaron infecciones postoperatorias, (dos cirugías craneales y una espinal). El tratamiento antibiótico intravenoso aislado falló, y debimos recurrir a la vía intraventricular-intratecal con buenos resultados. El tratamiento antibiótico intraventricular-intratecal aparece como una modalidad útil, en aquellas infecciones postoperatorias en que la terapia sistémica no da resultado.