Meningoencefalitis: etiología infecciosa en pacientes pediátricos de un hospital de referencia / Meningoencephalitis: infectious etiology in pediatric patients at a reference hospital

Resumen Introducción: Las causas de meningoencefalitis, meningitis o encefalitis pueden ser infecciosas o no infecciosas. Para el diagnóstico microbiológico se requieren cultivos y pruebas moleculares. El objetivo del estudio fue describir las causas infecciosas de meningoencefalitis y su presentación clínica. Métodos: Estudio transversal realizado en el Hospital Civil de Guadalajara Dr. Juan I. Menchaca. Se incluyeron pacientes mayores de 28 días de vida con síndrome de meningitis, encefalitis o meningoencefalitis. Se identificó la etiología infecciosa mediante cultivos, tinciones de Gram y pruebas moleculares de líquido cefalorraquídeo. Se compararon las características de pacientes con y sin diagnóstico etiológico. Resultados: Se incluyeron en el estudio 50 pacientes con meningoencefalitis (n = 25), meningitis (n = 19) o encefalitis (n = 6). La mediana de edad fue de un año y el 62% de los pacientes fueron de sexo masculino. Se realizó diagnóstico etiológico infeccioso en el 42%: el 65.2% (n = 15) se debió a virus y el 34.8% (n = 8) a bacterias. En los pacientes con diagnóstico etiológico, se presentó un mayor número de leucocitos en líquido cefalorraquídeo (92 leu/mm3 vs. 12 leu/mm3, p = 0.001). Fue más frecuente el antecedente de gastroenteritis (razón de momios [RM]: 3.5; intervalo de confianza al 95% [IC 95%]: 1.007-12.1; p = 0.04) y ante la exploración, fue más frecuente la rigidez de cuello (RM: 3.8; IC 95%: 1-15.2; p = 0.04). Conclusiones: El 42% de los pacientes con meningitis, encefalitis o meningoencefalitis tuvieron diagnóstico etiológico infeccioso. La causa más frecuente fue el enterovirus.

Abstract Background: The etiologies of meningoencephalitis, meningitis or encephalitis may be infectious or non-infectious. For the microbiological diagnosis it is necessary to perform cultures and molecular tests. The objective of this study was to describe the infectious causes of meningoencephalitis and their clinical presentation. Methods: Cross-sectional study performed at the Hospital Civil de Guadalajara Dr. Juan I. Menchaca. Patients older than 28 days of life with meningitis, encephalitis or meningoencephalitis syndrome were included in the study. Infectious etiology was identified through cultures, Gram stains, and molecular tests of cerebrospinal fluid. The characteristics of patients with and without etiological diagnosis were compared. Results: Fifty patients with meningoencephalitis (n = 25), meningitis (n = 19) or encephalitis (n = 6) were included in the study. The mean age was one year and 62% were male. An infectious etiological diagnosis was performed in 42%; 65.2 % (n = 15) were viruses and 34.8% (n = 8) bacteria. In patients with etiological diagnosis, a higher number of leukocytes were found in cerebrospinal fluid (92 leu/mm3 vs. 12 leu/mm3, p = 0.001); the history of gastroenteritis was more frequent (odds ratio [OR]: 3.5; 95% confidence interval (CI): 1.007-12.1; p = 0.04) and upon examination, neck stiffness was more common (OR: 3.8; 95% CI: 1-15.2; p = 0.04). Conclusions: 42 % of the patients with meningitis, encephalitis or meningoencephalitis had an infectious etiological diagnosis; the most frequent cause was enterovirus.

Mycoplasma pneumoniae: manifestaciones neurológicas y controversias diagnósticas. A propósito de un caso / Mycoplasma pneumoniae: neurologic manifestations and diagnostic controversies. A case report

Mycoplasma pneumoniae (Mp) es el agente causal de un 30% de las manifestaciones respiratorias de la población general. La neumonía ocupa el primer lugar dentro de este grupo. Las manifestaciones neurológicas representan las formas más frecuentes de presentación clínica extrapulmonar (40%). Las encefalitis y meningoencefalitis son las formas más habituales de sintomatología neurológica asociada a infección por Mp. La presentación de más de una variante clínica en un mismo paciente asociada a primoinfección por Mp es posible. El diagnóstico serológico plantea, habitualmente, controversias en su interpretación. A partir del caso de una niña de 7 años con inyección conjuntival, adenopatía cervical, rash descamativo y fotofobia con "pseudoedema de papila bilateral", que desarrolla durante su evolución parálisis facial periférica y meningitis aséptica, se analizarán las controversias que se plantean en relación con la interpretación diagnóstica asociada al compromiso neurológico por Mp.

Mycoplasma pneumoniae (Mp) is responsible for 30% of the respiratory manifestations of the general population. Pneumonia occupies the first place within this group. Among the extra-respiratory forms (40%), the neurological ones are the most frequent. Meningoencephalitis and aseptic meningitis are the most common. The presentation of more than one clinical variant in the same patient associated with primoinfection by Mp is possible. In relation to the serological diagnosis, controversies in interpretation sometimes occur. This is a 7-year-old girl with conjunctival injection, cervical adenopathy, photophobia with bilateral papilla pseudoedema, and scaly rash that develops peripheral facial paralysis and aseptic meningitis. We will discuss diagnostic controversies.

Histoplasmosis en el sistema nervioso central en una paciente pediátrica inmunocompetente / Central nervous system histoplasmosis in an immunocompetent pediatric patient

La histoplasmosis en el sistema nervioso central es una enfermedad poco frecuente, con mayor prevalencia en pacientes inmunosuprimidos, secundaria a enfermedad diseminada (5%-10%), con una alta tasa de mortalidad en caso de demorarse el diagnóstico y su tratamiento. Presentamos a una niña de 12 años previamente sana, que desarrolló meningoencefalitis por Histoplasma capsulatum sin evidencia de enfermedad generalizada. La paciente era oriunda de una región infestada por murciélagos de Tucumán, República Argentina, y desarrolló, durante 18 meses previos a su internación, cefalea y síndrome febril. Las imágenes del sistema nervioso central mostraron meningoencefalitis, que sugirió tuberculosis. Recibió tratamiento antibiótico y tuberculostático, sin mejoría. Luego recibió anfotericina B liposomal durante 6 semanas. Neurológicamente, mejoró de manera considerable. Por último, el cultivo de líquido cefalorraquídeo permitió aislar Histoplasma capsulatum. Se discuten las dificultades diagnósticas y el tratamiento de neurohistoplasmosis en pacientes inmunocompetentes, como también se intenta alertar acerca de la presencia de una cepa de Histoplasma capsulatum con afinidad por el sistema nervioso central.

Neurohistoplasmosis is a rare disease, most prevalent in immunosuppressed patients, secondary to disseminated disease with a high mortality rate when diagnosis and treatment are delayed. We report a previously healthy 12 year old girl, from a bat infested region of Tucuman Province, Argentine Republic, who developed meningoencephalitis due to Histoplasma capsulatum. Eighteen months prior to admission the patient started with headaches and intermittent fever. The images of the central nervous system showed meningoencephalitis suggestive of tuberculosis. She received antibiotics and tuberculostatic medications without improvement. Liposomal amphotericin B was administered for six weeks. The patient's clinical status improved remarkably. Finally the culture of cerebral spinal fluid was positive for micelial form of Histoplasma capsulatum. The difficulties surrounding the diagnosis and treatment of neurohistoplasmosis in immunocompetent patients are discussed in this manuscript, as it also intends to alert to the presence of a strain of Histoplasma capsulatum with affinity for the central nervous system.

Meningoencefalitis bacteriana en niños menores de 15 años / Bacterial meningoencephalitis affecting children under 15 years of age

Introducción: la meningoencefalitis bacteriana es una enfermedad de distribución universal que afecta individuos de todas las edades, pero especialmente a los niños. Objetivo: identificar las características clínicas y microbiológicas de la meningoencefalitis bacteriana. Métodos: se realizó un estudio descriptivo y retrospectivo en niños menores de 15 años ingresados en la Unidad de Cuidados Intensivos Pediátricos del Hospital Pediátrico Luis Ángel Milanés Tamayo, de Bayamo, Granma, en el periodo comprendido desde el 1ro. de enero de 2008 al 31 de diciembre de 2012. El universo estuvo conformado por 22 pacientes egresados con el diagnóstico de meningoencefalitis bacteriana, y la muestra por 18 casos que cumplieron con los criterios de inclusión y exclusión. Resultados: predominó el grupo de edad de 1 a 4 años con el 50 por ciento; la desnutrición se presentó en 5 de los casos estudiados. La media del tiempo transcurrido entre el inicio de los síntomas hasta el diagnóstico, y al inicio del tratamiento médico fue de ±3 días (DS: 1,129); los síntomas inespecíficos y la hipertensión endocraneana se presentaron en un 38,9 por ciento y 88,8 por ciento respectivamente. El Streptococcus pneumoniae fue el germen más frecuentemente aislado en el estudio del líquido cefalorraquídeo, y el edema cerebral la complicación más frecuente de la enfermedad. Conclusiones: la enfermedad estudiada afectó las edades más tempranas, con predominio de los síntomas de hipertensión endocraneana, y una celularidad elevada, y el tiempo entre el inicio de los síntomas al diagnóstico y al tratamiento médico fue corto

Introduction: bacterial meningoencephalitis is a universal disease affecting individual of all ages, but particularly the children. Objective: to identify the clinical and microbiological characteristics of the bacterial meningoencephalitis. Methods: a retrospective and descriptive study was conducted in children aged less than 15 years, who were admitted to the pediatric intensive care service of Luis Angel Milanes Tamayo pediatric hospital located in Bayamo, Gramma province, in the period of January 1st 2008 to December 31st 2012. The universe of study was 22 patients discharged from hospital after diagnosis of bacterial meningoencephalitis, and the sample was composed by 18 cases who met the inclusion and exclusion criteria. Results: the one to four years age group predominated, accounting for 50 por ciento and malnutrition was present in 5 of the studied cases. The mean time elapsed from the starting of symptoms to the diagnosis, and at the beginning of the medical therapy was ±3 days (SD: 1.129); the non-specific symptoms and the endocranial hypertension were observed in 38.9 and 88.8 percent, respectively. Streptococcus pneumoniae was the most frequently isolated germ in the cerebrospinal fluid study, and the cerebral edema was the commonest complication. Conclusions: the studied disease affected the smaller ages, in which the endocranial hypertension symptoms and raised cellularity predominated, and the time elapsed from the beginning of the symptoms to the diagnosis and the medical treatment was short

Soap bubble appearance in brain magnetic resonance imaging: cryptococcal meningoencephalitis

Although cryptococcal infections begin in the lungs, meningoencephalitis is the most frequently encountered manifestation of cryptococcosis among individuals with advanced immunosuppression. As the infection progresses along the Virchow-Robin spaces, these structures may become dilated with mucoid material produced by the capsule of the organism. We report a case of a 24-year-old man with cryptococcal meningoencephalitis in which magnetic resonance imaging showed clusters of gelatinous pseudocysts in the periventricular white matter, basal ganglia, mammillary bodies, midbrain peduncles and nucleus dentatus with a soap bubble appearance.

Histopathological and molecular characterization of encephalitic listeriosis in small ruminants from northern Paraná, Brazil

Listeriosis is a disease primarily of ruminants caused by the Gram-positive bacterium Listeria monocytogenes. Ruminants either demonstrate manifestations of the encephalitic, septicemic, or reproductive form of listeriosis. The pathological and molecular findings with encephalitic listeriosis in a 5.5-month-old, male, mixed-breed goat and a 3-year-old Texel-crossed sheep from northern Paraná, Brazil are described. Clinically, the kid demonstrated circling, lateral protrusion of the tongue, head tilt, and convulsions; the ewe presented ataxia, motor incoordination, and lateral decumbency. Brainstem dysfunctions were diagnosed clinically and listeriosis was suspected. Necropsy performed on both animals did not reveal remarkable gross lesions; significant histopathological alterations were restricted to the brainstem (medulla oblongata; rhombencephalitis) and were characterized as meningoencephalitis that consisted of extensive mononuclear perivascular cuffings, neutrophilic and macrophagic microabscesses, and neuroparenchymal necrosis. PCR assay and direct sequencing, using genomic bacterial DNA derived from the brainstem of both animals, amplified the desired 174 base pairs length amplicon of the listeriolysin O gene of L. monocytogenes. Phylogenetic analyses demonstrated that the strains associated with rhombencephalitis during this study clustered with known strains of L. monocytogenes lineage I from diverse geographical locations and from cattle of the state of Paraná with encephalitic listeriosis. Consequently, these strains should be classified as L. monocytogenes lineage I. These results confirm the active participation of lineage I strains of L. monocytogenes in the etiopathogenesis of the brainstem dysfunctions observed during this study, probably represent the first characterization of small ruminant listeriosis by molecular techniques in Latin America, and suggest that ruminants within the state of Paraná were infected by the strains of the same lineage of L. monocytogenes.

Meningoencephalitis associated with Mycoplasma pneumoniae / Meningoencefalite associada ao Mycoplasma pneumoniae

We report a case of a child with meningoencephalitis of atypical etiology. The patient developed the disease after an infection in the upper airways with unfavorable evolution. The clinical recovery was only possible after the administration of adequate antibiotic therapy for the etiological agent. This case report describes a child with meningoencephalitis of atypical etiology. The patient developed the disease after an infection in the superior airways with negative evolution. The clinical recovery was possible only after the introduction of adequate antibiotic therapy for the etiological agent.

Este relato de caso descreve uma criança com menignoencefalite de etiologia atípica. A paciente desenvolveu a doença após infecção de vias aéreas superiores, com evolução desfavorável. Houve recuperação clínica somente após introdução de antibioticoterapia adequada para o agente etiológico.

Meningoencephalitis caused by a zygomycete fungus (Basidiobolus) associated with septic shock in an immunocompetent patient: 1-year follow-up after treatment

Zygomycosis is an infection caused by opportunistic fungi of the Zygomycetes class, specifically those from the Mucorales and Entomophthorales orders. It is an uncommon disease, mainly restricted to immunocompromised patients. We report a case of a 73-year-old male patient with a history of fever (39°C) lasting for 1 day, accompanied by shivering, trembling, and intense asthenia. The patient was admitted to the intensive care unit with complex partial seizures, and submitted to orotracheal intubation and mechanical ventilation under sedation with midazolam. The electroencephalogram showed evidence of non-convulsive status epilepticus. There is no fast specific laboratory test that permits confirmation of invasive fungal disease. Unless the physician suspects this condition, the disease may progress rapidly while the patient is treated with broad-spectrum antibiotics. Differential diagnosis between fungal and bacterial infection is often difficult. The clinical presentation is sometimes atypical, and etiological investigation is not always successful. In the present case, the histopathological examination of the biopsy obtained from the right temporal lobe indicated the presence of irregular, round, thick-walled fungi forming papillae and elongated structures of irregular diameter, with no septa, indicative of zygomycete (Basidiobolus). Treatment with liposomal amphotericin B and fluconazole was initiated after diagnosis of meningoencephalitis by zygomycete, with a successful outcome.

Cryptococcus gattii meningoencephalitis in an HIV-negative patient from the Peruvian Andes / Meningoencefalite causada por Cryptococcus gattii em um paciente HIV-negativo procedente dos Andes Peruanos

We report a case of an immunocompetent Peruvian patient from the Andes with a one-month history of meningoencephalitis. Cryptococcus gattii was identified from a cerebrospinal fluid culture through assimilation of D-proline and D-tryptophan as the single nitrogen source. Initially, the patient received intravenous antifungal therapy with amphotericin B. The patient was discharged 29 days after hospitalization and continued with oral fluconazole treatment for ten weeks. During this period, the patient showed clinical improvement with slight right-side residual weakness. Through this case report, we confirm the existence of this microorganism as an infectious agent in Peru.

Nós reportamos o caso de um paciente peruano immunocompetente proveniente dos Andes com história de um mês com meningoencefalite. Foi identificado o Cryptococcus gattii na cultura de liquido cerebrospinal através da assimilação de D-prolina e D-tryptofano como fonte única de nitrogênio. Inicialmente, o paciente recebeu tratamento antifúngico intravenoso com amfotericina B. O paciente foi liberado 29 dias depois da hospitalização, seguindo tratamento oral durante 10 semanas com fluconazol. Durante este período, o paciente apresentou melhoria clinica e uma leve fraqueza residual direita. Com o reporte do caso, nós confirmamos a existência desse microorganismo como agente infeccioso em nosso país.

Caracterización epidemiológica y microbiológica de las meningoencefalitis bacterianas / Epidemic and microbiological characterization of bacterial meningoencephalitis

Fundamento: las meningoencefalitis bacterianas constituyen un problema de salud en el planeta representando un reto para los médicos por el manejo del paciente para garantizarle la vida. Se ejecutó el presente trabajo en el Centro Provincial de Higiene, Epidemiologia y Microbiología de Camagüey. Objetivo: mostrar el comportamiento epidemiológico y microbiológico de la meningoencefalitis en la provincia. Método: se realizó un estudio descriptivo y analítico para determinar aspectos acerca del comportamiento epidemiológico y microbiológico de las MEB en la provincia de Camagüey desde el año 2000 hasta el 2008. Constituyeron la muestra ciento noventa y seis casos. Resultados: se demostró un descenso de la morbimortalidad con elevación de la letalidad. Se aislaron ciento ocho cepas. Se diagnosticaron microorganismos como: Streptococcus pneumoniae, Neisseria meningitidis y Haemophilus influenzae tipo b. En infantes se aislaron Salmonella B, Klebsiella pneumoniae, Veillonella y Streptococcus agalactiae. En los adultos hubo una “explosión bacteriana” representada por enterobacterias, bacilos gramnegativos no fermentadores, Staphylococcus aureus y Micrococcus. Encontramos cuarenta cepas causales de fallecimientos: en niños a expensas de Streptococcus pneumoniae, Neisseria meningitidis y Haemophilus influenzae, y, en adultos, Streptococcus pneumoniae y el 100 por ciento de enterobacterias, bacilos no fermentadores y Staphylococcus aureus. Conclusiones: el estudio bacteriológico por examen directo y cultivo del LCR constituyó la prueba de oro para el diagnóstico de las meningoencefalitis bacteriana.

Background: bacterial meningoencephalitis constitutes a health problem in the planet representing a challenge for doctors because of the patient's management to guarantee him the life. The present work was conducted in the Provincial Center of Hygiene, Epidemiology and Microbiology of Camagüey. Objective: to show the epidemic and microbiological behavior of meningoencephalitis in the province. Method: a descriptive and analytic study to determine aspects about the epidemic and microbiological behavior of bacterial meningoencephalitis in Camagüey province was conducted from the year 2000 up to 2008. The sample was constituted by one-hundred ninety-six cases. Results: a drop of the morbimortality was demonstrated with elevation of lethality. One-hundred-eight strains were isolated. Microorganisms like: Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae type b were diagnosed. In infants Salmonella B, Klebsiella pneumoniae, Veillonella and Streptococcus agalactiae were isolated. In adults there was a bacterial explosion represented by enterobacteria, non fermenting Gram-negative bacilli, Staphylococcus aureus and Micrococcus. We find forty causal strains of deaths: in children at the expense of Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae, and, in adults, Streptococcus pneumoniae and the 100 percent of enterobacteria, non fermenting bacilli and Staphylococcus aureus. Conclusions: the bacteriological study by direct exam and LCR culture constituted the gold test for the bacterial meningoencephalitis diagnosis.

Meningoencefalitis por cryptococcus neoformans en un paciente con lupus eritematoso sistémico tratado con rituximab y micofenolato mofetilo: [revisión] / Meningoencephalitis due to cryptococcus neoformans in systemic lupus erythematosus patient treated with rituximab and mycophenolate mofetil: [review]

Presentamos un paciente con Lupus Eritematoso Sistémico (LES) tratado previamente con Rituximab y Micofenolato Mofetilo que desarrolló una criptococosis meníngea. Los pacientes con LES presentan múltiples defectos en su sistema inmune (SI) que, sumados a los producidos por los tratamientos inmunosupresores, predisponen a infecciones, entre ellas, a las causadas por gérmenes oportunistas. La meningitis por criptococo es una rara y severa complicación en estos pacientes. Rituximab produce una serie de cambios en el SI actuando sobre los linfocitos B, mientras que micofenolato actúa tanto sobre las células T como B. Las alteraciones inmunológicas presentes en nuestro paciente serían producto de la sumatoria de efectos de ambas drogas que explicarían la infección por Criptococcus neoformans.

We presented a systemic lupus erythematosus (SLE) patient previously treated with rituximab and mycophenolate who developed cryptococcal meningitis. SLE patients have multiple defects in the immunity system in addition to the additive effects of immunosuppressive treatments, which predispose to opportunistic infections. Cryptococcal meningitis is a rare and severe complication in SLE patients. Rituximab produces a series of changes in the immune system by acting on B cells, while mycophenolate produces its actions by acting on T and B cells. The immunology system defects in our patient could be done because the additive effects of two drugs that could explain the Cryptococcus neoformans infection.

Clinical behavior of Streptococcus pneumoniae meningoencephalitis / Comportamiento clinico y terapéutico de la meningoencefalitis por Streptococcus pneumoniae

OBJECTIVE: There was an increased number of cases of meningoencephalitis caused by Streptococcus pneumoniae, after the successful vaccination campaigns against Neisseria meningitidis and Haemophilus influenzae. This paper aims at describing the clinical characteristics, the laboratory findings, the complications, and the therapeutic management of these patients, who have been suffering from this disease since 1993 to 2006. METHOD: Twelve children with Streptococcus pneumoniae meningoencephalitis admitted to the pediatric hospital of San Miguel del Padron, City of Havana in this period were assessed. RESULTS: Children under one year are the most frequently affected. Septic shock and brain edema were the most severe complications. Three patients died, implying that this disease has a serious course. Early treatment of brain edema is very important to reduce mortality. The elective drugs for treatment of these cases of Streptococcus pneumoniae meningoencephalitis were vancomycin combined with cephalosporin, cefotaxime or ceftriaxone type. CONCLUSION: Patients with Streptococcus pneumoniae meningoencephalitis show clinical characteristics, complications, and sequels that are different to other bacterial meningoencephalitis, meaning that they could be helpful for physicians considering the differential diagnosis of meningoencephalitis.

OBJETIVO: Existe un incremento de la meningoencefalitis producida por Streptococcus pneumoniae, después de las campañas exitosas de vacunación contra Neisseria meningitidis y Haemophilus influenzae. El objetivo de este trabajo es describir las caracteristicas clinicas, los hallazgos de laboratorio, las complicaciones y el manejo terapéutico de los pacientes que sufrieron esta enfermedad desde 1993 a 2006. MÉTODO: Se estudiaron doce niños con meningoencefalitis por Streptococcus pneumoniae ingresados en el Hospital Pediátrico de San Miguel del Padrón, Ciudad de La Habana en este periodo. RESULTADOS: Los niños menores de un año son los más frecuentemente afectados. El shock séptico y el edema cerebral las mayores complicaciones. Tres pacientes fallecieron. Esta enfermedad ha tenido un curso serio. El tratamiento temprano del edema cerebral es muy importante para reducir la mortalidad. Los medicamentos de elección para tratar la meningoencefalitis por Strepcococcus pneumoniae en los casos estudiados fueron la vancomicina combinada con cefalosporina del tipo de la cefatoxima o la ceftriaxona. CONCLUSION: Los pacientes con meningoencefalitis por Streptoccocus pneumoniae exhibieron características clínica, complicaciones y secuelas las cuales se diferencian de otras meningoencefalitis bacterianas. Por eso estos elementos pueden ayudar a los médicos en el diagnóstico diferencial

sICAM-1 intrathecal synthesis and release during the acute phase in children suffering from Coxsackie A9 and S. pneumoniae meningoencephalitis / Sintesis intratecal de sICAM-1 y liberación durante la fase aguda en niños con meningoencefalitis por Coxsackie A9 y S pneumoniae

The intercellular adhesion molecule is a transmembrane glycoprotein belonging to the immunoglobulin superfamily. Serum and cerebrospinal fluid (CSF) soluble intercellular adhesion molecule 1 (sICAM-1) from normal control children as well as from children with Guillain-Barré syndrome (GBS), with Coxsackie A9 virus meningoencephalitis and with Streptococcus pneumoniae meningoencephalitis were studied. sICAM-1 was quantified using an immunoenzimatic assay and albumin using the immunodiffusion technique in both biological fluids. Increased sICAM-1 values in CSF in patients with GBS correspond to an increase of the albumin CSF/serum quotient. In contrast, in inflammatory diseases like S. pneumoniae and Coxsackie A9 virus meningoencephalitis an increased brain-derived fraction was observed. In particular cases these values are 60-65 percent and 70-75 percent respectively. The results indicate an additional synthesis of sICAM-1 in subarachnoidal space during central nervous system (CNS) inflammatory process. An important role of sICAM-1 in the transmigration of different cell types into CSF during CNS inflammation in children with S. pneumoniae and Coxsackie A9 meningoencephalitis may be suggested.

La molécula de adhesión intercelular es una glicoproteína que pertenece a la superfamilia de las inmunoglobulinas. Se estudiaron los niveles de molécula de adhesión intercelular tipo 1 soluble (sICAM-1) en suero y líquido cefalorraquídeo (LCR) de niños con meningoencefalitis por Streptococcus pneumoniae y por Coxsackie A9 al igual que en niños con sindrome de Guillain-Barré (SGB). sICAM-1 fue cuantificado por ensayo inmunoenzimático y la albúmina por inmunodifusión en ambos líquidos biológicos. Los valores incrementados de sICAM-1 en LCR en los pacientes con GBS corresponden a valores aumentados de razón LCR/suero de albúmina. En contraste, en las enfermedades inflamatorias como las meningoencefalitis por S. pneumoniae y por Coxsackie A9 se observa un incremento en la fracción derivada del cerebro. En casos particulares los valores se incrementan hasta un 60-65 por ciento y 70-75 por ciento respectivamente. Los resultados indican una síntesis adicional de sICAM-1 en el espacio subaracnoideo durante el proceso inflamatorio del sistema nervioso central (SNC). Esto puede sugerir un importante papel del sICAM-1 en la transmigración de diferentes tipos celulares en el LCR durante la inflamación del SNC en niños con meningoencefalitis por S pneumoniae y coxsackie A9.

Amaurose bilateral por menigoencefalite criptocócica: relato de caso / Bilateral amaurosis due to cryptococcus meningoencephalitis: case report

Meningoencefalite criptocócica é infecção causada por um fungo denominado Cryptococcus neoformans. Duas formas são conhecidas: variação gattii e neoformans. A infecção antes da puberdade é rara. Cerca de metade dos pacientes apresentam algum estado imunossupressivo. O papiledema está presente em um terço dos pacientes por ocasião do diagnóstico. Relatamos um caso de meningoencefalite por criptococose em paciente de oito anos de idade, sem relato de doenças prévias, que evoluiu com amaurose bilateral. O diagnóstico foi confirmado por detecção do C. neoformans, var. gattii. O paciente foi tratado com anfotericina B e dexametasona. Na literatura existem poucos relatos de perda visual permanente após meningite por criptococose. A existência de um protocolo para tratamento de pacientes com papiledema é um fator determinante para evitar a perda visual.

Cryptococcal meningitis is caused by the yeast Cryptococcus neoformans. Two varieties are recognized: var. gattii and var. neoformans. It is usually associated with immunosuppressive states, particularly HIV infection. Cryptococcal infection of the central nervous system is uncommon in immunocompetent children and difficult to diagnose. Ocular complications are common. Optic disc swelling was found in 33 percent. The following report describes a case of meningitis caused by C. neoformans var. gattii in an 8 year-old immunocompetent child who developed optic atrophy. The patient was treated with amphotericin B associated with corticosteroids. Possible therapeutic strategies aimed at reducing visual loss in cryptococcal meningitis have great importance to avoid this important morbidity.

Molecular diversity of serial Cryptococcus neoformans isolates from AIDS patients in the city of São Paulo, Brazil

Despite highly active anti-retroviral therapy, cryptococcal meningoencephalitis is the second most prevalent neurological disease in Brazilian AIDS patients, being frequently a defining condition with several episodes. As knowledge of Cryptococcus neoformans isolates in the same episode is critical for understanding why some patients develop several episodes, we investigated the genotype characteristics of C. neoformans isolates in two different situations. By pulsed field gel electrophoresis and random amplifield polymorphic DNA analysis, 54 isolates from 12 patients with AIDS and cryptococcosis were analyzed. Group 1 comprised 39 isolates from nine patients with a single episode and hospitalization. Group 2 comprised 15 isolates from three patients with two episodes and hospitalizations. Except for three patients from group 1 probably infected with a single C. neoformans isolate, the other nine patients probably were infected with multiple isolates selected in different collection periods, or the infecting isolate might have underwent mutation to adapt and survive the host immune system and/or the antifungal therapy. However, the three patients from group 2 presented genetic diversity among isolates collected in both hospitalizations, possibly having hosted the initial isolate in both periods. These data, emphasize that Cryptococcus diversity in infection can contribute to strategies of treatment and prevention of cryptococcosis.

Estudio de 145 episodios de meningoencefalitis aguda bacteriana en adultos cubanos / Study of 145 episodes of acute bacterial meningitis in cuban adults

Objetivo: Caracterizar 145 episodios de meningoencefalitis aguda bacteriana en adultos en el Hospital General Universitario “Dr. Gustavo Aldereguía Lima” en el decenio 1995-2004. Pacientes y métodos: Se trató de un estudio retrospectivo obervacional que describió la frecuencia de variables epidemiológicas, clínicas y microbiológicas, las cuales se relacionaron con la mortalidad mediante un análisis de múltiples variables por regresión logística. Resultados y conclusiones: En 43 episodios la MEB estuvo precedida de otras enfermedades (29.7%); neumonía (13.1%), otitis media supurada (14.5%). Los síntomas y signos más frecuentes fuerron: fiebre (94.5%), cefalea (95.9%), vómitos (73.1%), desorientación (42.8%) y degradación de consciencia (40.7%) y meningismo (83.5%). 45 episodios (31%) se complicaron en las primeras 24 horas, siendo las convulsiones (13.1%), la hipertensión endocraneana (11.7%), la hipertermia (11.7%) y el coma (9.7%) las más frecuentes. Predominó la pleocitosis neutrófila (91.7%), el Streptococcus pneumoniae resultó el microorganismo aislado con más frecuencia (47.6%), mientras que en 59 ocasiones no se demostró microorganismo en el LCR (37.2%) Ocurrieron 29 fallecimientos (20%), 9 en las primeras 24 horas y el resto luego de 24 horas, el 100% de las muertes dependieron de la MEB. La media de edad fue significativamente superior en los fallecidos (58.6 DS = 20 vs 47.7 DS = 18 años), de otra parte la estadía y la celularidad en el LCR promedios, resultaron significativamente inferiores en los fallecidos. Luego del análisis de múltiples variables, haber padecido de neumonía antes de la meningitis (OR = 6.01), tener degradación de consciencia al ingreso (OR = 4.72), convulsionar en las primeras 24 horas (OR = 5.99) y una celularidad menor a 500 células en el LCR (OR = 4.13), se asociaron de forma independiente con el riesgo de morir.Palabras clave: Meningoencefalitis aguda bacteriana, adultos, diagnóstico, mortalidad.

Hospital-based case series of 175 cases of serologically confirmed brucellosis in Bikaner.

OBJECTIVE: To study the clinical spectrum of brucellosis in Bikaner (Northwest India). METHODS: A total of 175 cases were diagnosed as brucellosis during the period of six year (June 1997 to May 2003). They were studied for clinical profile and treated by rifampicin and doxycyclin and additionally streptomycin for initial 14 days in patients of neurobrucellosis. These patients were followed up to 3 months. RESULTS: Patients of brucellosis presented with a wide spectrum of clinical manifestations. Out of 175 cases 155 were from rural area. Age ranged between 12-60 years (124 males, 51 females). Analysis of risk factors revealed history of raw milk ingestion (86.86%), occupational contact with animals (81.14%), handling of infected material (62.28%), household contact (16%) and 2 patients were veterinarian. Joint pain (83.43%) and fever (77.71%) were the commonest presenting feature. Sacroiliac joint was most commonly involved (46.86%). 31 cases had involvement of multiple joints. Other mode of presentation were neurobrucellosis (18.86%), manifested as polyradiculoneuropathy, myeloradiculopathy, meningoencephalopathy and polyradiculomyeloencephalopathy; predominant pulmonary involvement (4.0%) presented as bronchitis, pneumonia and pleural effusion; epididymoorchitis, infective endocarditis, nephrotic syndrome and recurrent abortion. All patients responded well to the treatment. CONCLUSION: Brucellosis is an important emerging zoonotic disease but it is often under-diagnosed due to lack of suspicion and diagnostic facilities despite the fact that cattle farming (an important high risk group) is one of the main occupation in rural area. This report should infuse the awareness about this reemerging disease specifically in high-risk group.

Meningoencephalitis, pancytopenia, pulmonary insufficiency and splenic abscess in a patient with brucellosis

A complicated case of brucellosis with some rare features is reported. Brucellosis is a multisystemic disease. However, disseminated brucellosis with cerebral, pulmonary, hematopoietic and splenic involvement in an otherwise healthy patient is a rare event. In this article, we report a case of disseminated brucellosis who was initially diagnosed as myelodysplastic syndrome [MDS] and meningoencephalitis, pulmonary symptoms, and splenic abscess formation occurred thereafter.

Meningoencefalitis por Mycobacterium avium: complex en una mujer con SIDA / Meningoencephalitits due to Mycobacterium avium: complexin a woman with AIDS

La infección diseminada por Mycobacterium avium Complex (MAC) es una complicación relativamente frecuente en estadios avanzados de la enfermedad por el virus de la inmunodeficiencia humana. Con el advenimiento de la terapia antiretroviral de gran eficacia, la incidencia de MAC ha disminuido sustancialmente, pero los pacientes con un bajo recuento de linfocitos CD4+ permane-cen en riesgo. Pese a ello, el compromiso meningoencefálico es infrecuente. Presentamos un caso de meningoencefalitis por MAC en una mujer con Sida con inmunodepresión severa. La presencia de MAC debe ser considerada en todo paciente con Sida que presente síntomas compatibles con micobacteriosis diseminada y compromiso neurológico

Cutaneous anthrax in Lima, Peru: retrospective analysis of 71 cases, including four with a meningoencephalic complication

El ántrax es una zoonosis producida por el Bacillus anthracis y la infección humana es endémica en diversas partes del mundo, incluyendo el Perú. Más del 95% de las infecciones adquiridas naturalmente son cutáneas y aproximadamente 5% de ellas pueden evolucionar para meningoencefalitis. En este estudio revisamos las características clínicas y epidemiológicas de los pacientes con diagnóstico de ántrax cutáneo evaluados entre 1969 y 2002 en el Hospital Nacional Cayetano Heredia (HNCH) y en el Instituto de Medicina Tropical Alexander von Humboldt, en Lima, Perú. Se incluyeron 71 pacientes [49/71 (69%) del sexo masculino], con edad media de 37 años. Los diagnósticos fueron clasificados como definitivos (44%) o probables (56%). La ocupación más frecuente fue la agricultura (39%). La fuente de infección fue identificada en 63 (88.7%) pacientes. Todos presentaron lesiones ulcerativas con necrosis central. La mayoría de ellos (65%) tuvieron lesiones múltiples, principalmente localizadas en miembros superiores (80%). Cuatro pacientes (5.6%) desarrollaron meningoencefalitis y tres de ellos fallecieron. En conclusión, considerando sus particulares características clínicas y epidemiológicas, el ántrax cutáneo debe ser siempre incluido en el diagnóstico diferencial de las lesiones cutáneas ulcerativas. Los pacientes con sospecha clínica de la enfermedad deben recibir tratamiento precoz con el objetivo de evitar complicaciones neurológicas, las cuales presentan elevados índices de fatalidad.