Specificity of immunoblotting analyses in eosinophilic meningitis

Angiostrongylus cantonensis and Gnathostoma spinigerum are the two most common causative parasites of eosinophilic meningitis (EOM). Serological tests are helpful tools for confirming the identity of the pathogen. Recent reports determined the specificity of such tests by using normal healthy controls. There have been limited studies done to rule out the cross-reactivity between these two causative parasites of EOM. This study aims to assess the specificity of the serological test in EOM by using each condition as a control for the other. Thirty-three patients with a diagnosis of EOM were enrolled. Sera from 22 patients with a positive 29-kDa antigenic diagnostic band of A. cantonensis were tested for the 21 and 24-kDa antigenic bands of G. spinigerum. Similarly, sera of 11 gnathostomiasis patients were tested for the 29-kDa diagnostic band for A. cantonensis. Only one patient in the angiostrongyliasis group had a positive result for the 21 and 24-kDa antigenic bands of G. spinigerum, while no gnathostomiasis patients showed a positive result for the 29-kDa antigenic band of A. cantonensis. The specificity of the 21 and 24-kDa antigenic bands for gnathostomiasis and the 29-kDa antigenic band for A. cantonensis was 95.5 percent and 100 percent, respectively. The antigenic bands for the diagnosis of gnathostomiasis and angiostrongyliasis in EOM were highly specific.

Peripheral eosinophilia as an indicator of meningitic angiostrongyliasis in exposed individuals

The diagnosis of meningitic angiostrongyliasis (MA) is based on clinical criteria. A lumbar puncture is used as a diagnostic tool, but it is an invasive procedure. The blood eosinophil levels are also assessed and used in the diagnosis of this disease. We enrolled 47 patients with serologically proven MA and 131 controls with intestinal parasite infections. An absolute eosinophil count model was found to be the best marker for MA. An eosinophil count of more than 798 cells led to sensitivity, specificity, positive predictive and negative predictive values of 76.6 percent, 80.2 percent, 58.1 percent and 90.5 percent, respectively. These data support the use of testing for high blood eosinophil levels as a diagnostic tool for MA in individuals that are at risk for this disease.

Evaluation of IgG4 and total IgG antibodies against cysticerci and peptide antigens for the diagnosis of human neurocysticercosis by ELISA.

To support the clinical diagnosis of human neurocysticercosis (NCC), we evaluated two peptides, HP6-3 and Ts45W-1, as well as crude saline extract (SE) of Tenia solium cysticerci as antigens for the detection of specific IgG4 subclass and total IgG antibodies by an enzyme-linked immunosorbent assay (ELISA). The sera of definitive diagnosed NCC patients, patients infected with other parasitoses and healthy controls were examined. The diagnostic sensitivity for IgG4 and total IgG detection of the ELISA against SE antigen was 100% and 64.3% with a high amount of cross-reactions to taeniasis saginata at 88.9% (8/9) and 100% (9/9), respectively. The SE-based IgG4-ELISA showed the highest specificity (80.9%). Both peptide-based IgG4-ELISAs provided a superior sensitivity (78.6%) to the total IgG tests whereas their specificity was 66.7% for HP6-3 and 69.8% for Ts45W-1 only. The SE-based ELISA for the detection of specific IgG4 antibody can be used for the diagnosis of neurocysticercosis as well as for serological surveys of NCC endemic areas. The peptide-based IgG4 ELISAs potentially provide a reliable and cost effective alternative method independent from live parasite supply.

Seizure in non-HIV cryptococcal meningitis.

OBJECTIVE: The authors studied the prevalence of seizure in non-HIV cryptococcal meningitis. MATERIAL AND METHOD: The records of non-HIV adult patients (age >15 years) diagnosed as cryptococcal meningitis in Srinagarind Hospital (Khon Kaen University) from 1990 to 1994 were reviewed All subjects were studied for the rate, pattern, and long-term result ofseizure. RESULTS: There were 105 cases. Eight patients (7.6%) had seizures at initial presentation. The pattern of seizure of six patients was generalized tonic-clonic seizure (GTC) and the others were focal seizure. Only one case still had seizures after treatment with conventional therapy of cryptococcal meningitis. At ten years follow up, ten cases had died, one patient still had seizures (the same case that had seizures after treatment) and one case with developed GTC after improvement of meningitis. CONCLUSION: GTC was the common pattern of seizure in non-HIV cryptococcal meningitis and mostly controlled by standard regimen of therapy for cryptococcal meningitis without any antiepileptic drugs.

Clinical outcomes of patients with cardiogenic cerebral emboli in Srinagarind Hospital.

We retrospectively studied the functional outcomes and recurrence rates of patients 15 years and older in whom cardiogenic cerebral embolism was diagnosed at Srinagarind Hospital, Khon Kaen, Thailand, during the period of 1993-2002. Ninety patients were included in this study. Ages ranged from 16-80 years (mean 48.3 years). The majority of cardiac abnormalities were rheumatic heart diseases (with or without atrial fibrillation) and nonvulvular atrial fibrillation. At 3 months and 1 year after stroke, improvement in functional outcome (measured by RDS, motor strength, and GCS) were 74.4% and 55.6%, mortality rates of 13.3% and 16.7%; and recurrence rates of 8.9% and 16.7%, respectively. A GCS < 9 or motor power < or = 1 or RDS > or = 4 upon presentation were poor prognostic factors.

Cerebrospinal fluid adenosine deaminase activity for the diagnosis of tuberculous meningitis in adults.

We studied adenosine deaminase (ADA) activity in cerebrospinal fluid (CSF) of 16 cases of tuberculous meningitis, 4 cases of cryptococcal meningitis, 5 cases of bacterial meningitis, 12 cases of eosinophilic meningitis, 26 cases of aseptic meningitis, 6 cases of carcinomatous meningitis and 108 cases with normal CSF. The mean CSF ADA values for the different groups were: 39.44 +/- 41.46, 13.00 +/- 7.43, 34.20 +/- 40.81, 3.17 +/- 4.82, 10.03 +/- 9.23, 8.67 +/- 13.60, and 2.58 +/- 2.90 U/I, respectively. Comparing the ADA activity between patients with tuberculous meningitis and non-tuberculous meningitis, the receiver-operating characteristic (ROC) curve identified a CSF ADA level of 15.5 U/I as the best cut-off value to differentiate between the two, with a sensitivity of 75% and a specificity of 93%, with an area under the curve of 0.92. When tuberculous meningitis was compared with aseptic and carcinomatous meningitis, the ROC curve identified a CSF ADA level of 19.0 U/I as the best cut-off value for differentiation, with a sensitivity of 69% and a specificity of 94%, with an area under the curve of 0.83. The level of CSF ADA may be useful as a complementary tool in the early diagnosis of tuberculous meningitis.

Acetylcholine receptor antibody in Thai generalized myasthenia gravis patients.

The authors studied acetylcholine receptor antibody (AChR Ab) in twenty-six Thai patients diagnosed as having generalized myasthenia gravis and fifteen control cases. AChR Ab assay was done by radio-immunoassay technique and reported by titer in nmole/L. The positive result was defined by titer more than 0.5 nmole/L. In the myasthenia gravis group, age ranged from 18 to 64 years old with mean of 34 years old. The female: male ratio was 4.2:1. Duration of disease before taking blood sample ranged from 1 month to 14 years with a mean of 3.9 year The AChR Ab could be detected in 21 out of 26 patients (80.7%). In the control group, tests were all negative. The results of the test made the sensitivity of 80.7% and specificity of 100%. The positive predictive value was 100%, the negative predictive value was 75%, and the prevalence was 60.3%. There was no correlation between AChR Ab titer and clinical features. This test is a very valuable test in case of uncertainly in the diagnosis of myasthenia gravis.

C reactive protein for differentiating bacterial from aseptic meningitis in Thai patients.

OBJECTIVES: To evaluate the efficacy of serum CRP level differentiating between bacterial and aseptic meningitis in Thai patients. MATERIAL AND METHOD: The authors measured the serum CRP level in patients who were diagnosed clinically as bacterial and aseptic meningitis. RESULTS: The authors evaluated 32 subjects, 12 with bacterial meningitis (all males) and 20 with aseptic meningitis (13 males, 7 females). The mean serum CRP level in the bacterial meningitis and aseptic meningitis group was 209.25 +/- 105.34 (range, 65 to 420) and 67.05 +/- 40.81 (range, 10 to 169) mg/L, respectively (p < 0.001). CONCLUSIONS: Serum CRP can help differentiate between bacterial and aseptic meningitis.

Wernicke's encephalopathy: report of a case.

A case of Wernicke's encephalopathy is reported. A 53-year-old alcoholic man was presented with acute confusion, upward gaze palsy of the left eye and gait ataxia for 5 days. The typical findings upon MRI of the brain showed multiple, scattered, small non-enhanced low signal intensity on T1WI, high signal intensity on T2WI involving at bilateral basal ganglias, and thalami, midbrain, pons, and periventricular regions with evidence of atrophic changes of brain and the mamillary bodies. After treatment with intravenous thiamine 100 mg/day, the left upward gaze palsy was fully recovered at the 8th day of treatment. The mental status and gait ataxia gradually improved.

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.

Initial treatment of cryptococcal meningitis in AIDS.

The comparison of initial treatment with amphotericin B (0.7 mg/kg/d) plus rifampin (600 mg/d) with amphotericin B (0.7 mg/kg/d) alone for 2 weeks, both followed by fluconazole (400 mg/ d) for 8 weeks in the acute treatment of cryptococcal meningitis in AIDS by an open- randomized, controlled, prospective clinical trial is reported. Twenty patients were enrolled in each group. There were no significant differences between the groups in regard to a negative CSF culture for Cryptococcus neoformans in the 2nd and 10th weeks of treatment, time until normal body temperature after treatment, number of patients who died, and persistence of high CSF pressure after completion of treatment. Elevated intracranial pressure was an important factor associated with the patients who died. These results indicate that the combination of amphotericin B plus rifampin is not superior to amphotericin B alone.

Group B streptococcal meningitis and endopthalmitis.

A 45-year-old man who presented with acute purulent meningitis and anterior uveitis of the right eye was reported. The results of hemoculture, CSF culture, and vitreal fluid grew group B beta-hemolytic Streptococci. Meningitis improved after treatment, but the eye was finally eviscerated.

Treatment of eosinophilic meningitis with a combination of albendazole and corticosteroid.

To study the efficacy of the combination of albendazole and prednisolone for the treatment of eosinophilic meningitis, we conducted a pilot study among Thai patients with eosinophilic meningitis. Patients were given a 2-week course of prednisolone, 60 mg/day and albendazole, 15 mg/kg/ day. The primary observation parameter was the number of patients who still had headache after the 2-week course of treatment. Twenty-six patients were enrolled in the study. There were 3 (11.5%) patients who still had headache after the 2-week course of treatment and the median length of time until complete disappearance of headache was 4 days. Serious side effects were not detected. Treatment for 2 weeks with the combination regimen of albendazole and prednisolone is safe and effective for the treatment of eosinophilic meningitis.

Case report: Dengue hemorrhagic fever with encephalopathy in an adult.

Encephalopathy in dengue hemorrhagic fever is a very rare condition and usually occurrs in the febrile stage. We report a 29-year-old woman, who presented with acute fever, thrombocytopenia and positive IgM antibodies for dengue virus. On the fourth hospital day, the fever subsided and she developed a confusional stage. CT scan and MRI of the brain were within normal limits. Electroencephalography (EEG) revealed generalized theta waves. Cerebrospinal fluid was normal. She was treated with supportive treatment. Five days later, she was fully recovered without any neurological deficits. This is a first case of encephalopathy in dengue hemorrhagic fever that developed after the fever subsided.

Tuberculous meningitis in adults: a four-year review during 1997-2000.

We reviewed the charts of all HIV-negative patients 15 years of age or older in whom tuberculous meningitis was diagnosed and treated without corticosteroids at Srinagarind Hospital, Khon Kaen, Thailand during the period of 1997-2000. Forty-five patients were included in this study. The clinical manifestations were subacute to chronic meningitis and they presented in stages 1 and 2, except one case which was in stage 3. All patients were treated with a 6-month course of chemotherapy with good clinical outcomes. The mortality rate was 2.2% and the percent of residual neurological deficits after treatment was 6.7%. The review showed the good clinical outcomes can be had without adjunctive corticosteroid.

Benign form of herpes simplex encephalitis.

A 34-year-old woman who presented with only severe headache for 12 days was reported. She was initially diagnosed with cerebral infarction of the right temporal lobe and treated with aspirin, without improvement. On admission, she had bilateral papilledema. Other findings were unremarkable. CT scan and MRI of the brain revealed an area of cerebritis at the right temporal lobe. Lumbar puncture showed high opening pressure with normal CSF profiles. The patient was treated with intravenous acyclovir which gave a favorable outcome.

Specific IgG antibody subclasses to Angiostrongylus cantonensis in patients with angiostrongyliasis.

Total IgG, IgG1, IgG2, IgG3, IgG4, IgA and IgM specific antibodies against Angiostrongylus cantonensis somatic antigen were determined by enzyme-linked immunosorbent assay (ELISA) in sera from proven human angiostrongyliasis (PA) cases, clinically suspected angiostrongyliasis cases with eosinophilic meningitis (EM) and healthy control (HC). The specific IgA antibody in each of the patient groups was significantly higher than those of the HC group (p < 0.05). The mean ELISA value of the specific IgM in the PA group was not significantly different from that of the HC group (p > 0.05). However, the mean specific IgM ELISA value in the EM group was significantly higher than that of the HC group (p < 0.05). The levels of the specific IgG and IgG subclasses in both patient groups were significantly higher than in the healthy control (HC) group (p < 0.001). Major differences were evident in the distribution of the IgG subclass antibodies between the patient groups. The IgG1 antibody demonstrated the highest sensitivity and specificity while the IgM and IgA responses were generally poor in both patient groups. The levels of the specific IgG antibody subclasses possibly explain immune responses to the parasite.

Streptococcus sanguis meningitis: report of a case.

A 35-year-old woman who presented with acute purulent meningitis and hearing loss was reported. No bacteria was seen with Gram' s stain of cerebrospinal fluid (CSF). CSF grew Streptococcus viridans, which was subsequently identified to be S. sanguis. The patient improved after treatment, including hearing.

Actinomycotic meningitis: report of a case.

A 73-year-old man who presented with acute fever, drowsiness and confusion was reported. Two weeks prior to admission, he attended the Outpatient Department with symptoms of fever and headache for 2 weeks. Eosiophilic meningitis was initially diagnosed, which, in fact, was lymphocytic CSF pleocytosis. He was treated with a high dose of prednisolone. His symptoms improved for 1 week, then he experienced symptoms of fever and headache again. On admission, he had stiffness of the neck. Lumbar puncture showed purulent CSF with gram-positive branching filamentous organisms. CSF grew Actinomyces israelii. The patient died from brain herniation.

Clinical manifestations and outcome of patients with severe eosinophilic meningoencephalitis presumably caused by Angiostrongylus cantonensis.

The clinical manifestations and outcome of patients with severe eosinophilic meningoencephalitis has never been reported. We reported 11 comatose patients with eosinophilic meningoencephalitis. Most of them presented with subacute to chronic headache and fever, followed by acute coma. Cerebrospinal fluid abnormalities were similar to alert patients with eosinophilic meningitis. None of them had received antihelmintic drug and seven patients were treated with corticosteroids. Ten patients died and one patient is still in a coma. Corticosteroids seem to be ineffective in severe eosinophilic meningitis.