Successful treatment of primary cerebral mucormycosis: Role of microbiologist.

Fungal brain abscess is rare with a rapidly progressive disease with fulminant course and invariably fatal outcome, unless diagnosed early and treated rapidly. We report a 56‑year‑old woman diagnosed to have fungal abscess who recovered completely following amphotericin B treatment. She presented with weakness of the right hand, deviation of mouth to left and aphasia for 2 days. Computed tomography of the brain revealed a left frontal capsuloganglionic hypodense lesion. Stereotactic biopsy was performed, and microbiological confirmation of non‑septate fungal hyphae from pus from aspirate within 2 h helped initiate timely and appropriate treatment leading to cure. Histopathology and culture later confirmed mucormycosis.

A variant epidemic methicillin resistant Staphylococcus aureus-15 cavernous sinus thrombosis and meningitis: A rare occurrence with unusual presentation.

Septic cavernous sinus thrombosis (CST) is an uncommon clinical syndrome. Although Staphylococcus aureus (S aureus) is the most common bacterial pathogen causing CST, it is infrequent as a cause of meningitis. We report the first case of CST and meningitis from Bengaluru, Karnataka, caused by community-acquired epidemic methicillin resistant Staphylococcus aureus-15 (EMRSA-15), in a previously healthy individual without known risk factors; the patient recovered following treatment with vancomycin. The isolate was genotyped as belonging to staphylococcal cassette chromosome mec type IV and sequence type 22 and carried the panton-valentine leucocidin gene. It is the first Indian EMRSA-15 disease isolate from a case of meningitis. EMRSA-15 has been a major problem in hospitals in UK and it is a cause for great concern in Indian hospitals too.

Nocardial brain abscess in an immunocompetent host.

Nocardial infection of the central nervous system is rare and usually manifests as brain abscess. Here we describe an elderly gentleman who presented with signs and symptoms of an intracranial mass lesion localising to the frontal lobe. Clinical examination and CT scan suggested neoplasia as the probable diagnosis. A biloculated abscess was seen at surgery. Aspiration of the contents and examination of pus revealed Nocardia asteroides . Treatment included total excision and prolonged antibiotic therapy which resulted in an excellent outcome.

Investigation of an outbreak of device-related postoperative ventriculitis: a lesson learnt.

Pseudomonas aeruginosa (P aeruginosa) is one of the most common nosocomial pathogens. We report our experience of a device-related outbreak of postoperative ventriculitis caused by P aeruginosa thus initiating investigation of the unusual occurrence. Five neurosurgical patients were affected, postoperatively. The investigations entailed extensive screening of the common sources of contamination for colonization of P aeruginosa. Sterilized instruments used for surgery, including the ultrasonic aspirator (USA) sets and other hollow devices, were randomly sampled and cultured. Conventional culture methods yielded P aeruginosa, with almost similar antibiotic sensitivity pattern in all the patients and the ultrasonic aspirator, clinching the source of contamination. Routine surveillance, identification of unusual patterns, molecular epidemiological typing would be helpful in quick control of outbreaks of postoperative infections.

Cryptococcal meningitis: Clinical, diagnostic and therapeutic overviews.

Cryptococcal meningitis has emerged as a leading cause of infectious morbidity and mortality in patients with AIDS. Among the human immunodeficiency virus (HIV)-seropositive subjects, cryptococcal meningitis is the second most common cause of opportunistic neuro-infection. Current trends are changing due to the marked improvement of quality and length of life produced by highly active antiretroviral therapy (HAART). The introduction of generic HAART in India has resulted in an increase in the number of individuals getting treatment for HIV infection, as the cost of highly active antiretroviral therapy (HAART) has decreased 20- fold. Cryptococcal meningitis occurs in non-HIV patients who are immunodeficient due to diabetes, cancer, solid organ transplants, chemotherapeutic drugs, hematological malignancies etc and rarely in healthy individuals with no obvious predisposing factors. Diagnosis of cryptococcal meningitis is fairly straightforward once the diagnosis is considered in the differential diagnosis of chronic meningitis. Treatment of a patient with cryptococcal infection is a challenge for both the physician and the patient, but rewarding, as many would recover with timely and adequate antifungal therapy.

Central nervous system cladosporiosis: An account of ten culture-proven cases.

Background: Central nervous system (CNS) cladosporiosis is a rare infection caused by Cladophialophora bantiana. It has varied presentation and poor outcome. Most of the available data in the literature are reviews of individual case reports. Objective: To describe the clinical, radiological and mycological features of 10 cases of C. bantiana managed at a single tertiary center. To analyze the various treatment options, factors associated with outcome and to review the relevant literature. Materials and Methods: This is a retrospective study of 10 patients with CNS cladosporiosis managed at National Institute of Mental Health and Neurosciences from 1979 to 2006. It is a descriptive study. The case records were reviewed for clinical presentation, radiological features, management and outcome. Only those patients in whom the fungus could be isolated on culture were included in the study. Results: The age of the patients ranged from three to 42 years. Nine patients presented with features of space-occupying lesion and one patient with chronic meningitis. There were no specific clinical or radiological features. None of patients had impaired immune status. This infection presented as two pathomorphological forms - diffuse meningoencephalitis and focal abscesses. Burr hole tapping and excision are the surgical options. Both patients with burr hole tapping required excision of abscess subsequently. Two out of seven patients with abscess expired compared to all three patients with diffuse meningoencephalitis who expired. Recurrences occurred in four of the five patients following excision of the abscess. Combination antifungal treatment had better result than monotherapy. The outcome was poor with survival of only 50%. Conclusions: Thorough microbiological examination is required to diagnose CNS infection caused by C. bantiana. The outcome is better in patients with abscess. Excision of the abscess followed by combination antifungal therapy results in better outcome. Close follow-up is required due to high risk of recurrence.

Comparative evaluation of BACTEC 460TB system and Lowenstein-Jensen medium for the isolation of M. tuberculosis from cerebrospinal fluid samples of tuberculous meningitis patients.

PURPOSE: To evaluate the role of the radiometric BACTEC 460TB system and the conventional Lowenstein-Jensen (LJ) medium for isolation of M. tuberculosis from cerebrospinal fluid (CSF) samples of tuberculous meningitis (TBM) patients. METHODS: CSF specimens (n=2325) from suspected TBM patients were processed for isolation of mycobacteria by inoculating BACTEC 12B medium and the LJ medium. The isolation of mycobacteria in both media was confirmed by microscopy and biochemical identification. Drug sensitivity testing for the anti-TB drugs was carried out by BACTEC radiometric method. RESULTS: Among the total 2325 CSF specimens processed by both methods, M. tuberculosis was isolated from 256 specimens. The isolation rates were 93% and 39% for the BACTEC system and LJ medium respectively. Both the media supported growth in 32% of the culture-positive specimens. BACTEC system alone yielded growth in 61% and LJ alone in 7%, of the culture-positive specimens. Among 205 isolates tested for drug susceptibility 81% were sensitive to all the drugs tested and 19% were resistant. CONCLUSIONS: The BACTEC 460TB system provides a highly sensitive and rapid tool for the isolation and drug susceptibility testing of M. tuberculosis, from CSF of TBM patients. Use of a solid medium in conjunction with the BACTEC 12B medium is essential for optimal recovery for M. tuberculosis from CSF specimens.

Fatal Group A Streptococcal meningitis in an adult.

Despite the recent resurgence in reports of invasive Group A Streptococcal (GAS) infections worldwide, it remains a rare cause of pyogenic meningitis both in children and adults. We report a case of fatal GAS meningitis in a healthy adult emphasizing the need for clinicians to be aware of its fulminant course, prompting early diagnosis and treatment. There is also a need to consider postexposure chemoprophylaxis in close contacts of such cases.

Bacteriological profile of community acquired acute bacterial meningitis: a ten-year retrospective study in a tertiary neurocare centre in South India.

PURPOSE: Ten years retrospective study to evaluate the bacteriological spectrum of community acquired acute bacterial meningitis (CAABM). METHODS: Cerebrospinal fluid (CSF) samples from 385 clinically suspected cases of pyogenic meningitis were processed for cell counts, cytospin Gram stain, culture, antigen detection by latex agglutination (LAT) and antibiotic susceptibility test. Eighteen of these CSF samples were also subjected to a polymerase chain reaction (PCR) assay for detection of pneumococcal DNA. RESULTS: The etiological agent could be identified in 284 (73.8%) of the total 385 cases by culture and/or smear and /or LAT. Streptococcus pneumoniae was the predominant pathogen accounting for 238 (61.8%) cases. Haemophilus influenzae and Neisseria meningitidis accounted for 7 (1.8%) and 4 (1%) cases respectively. Other gram negative bacilli, Streptococcus spp. and Staphylococcus aureus were isolated from 19 (4.9%), 9 (2.3%) and 7 (1.8%) cases respectively. CONCLUSIONS: Streptococcus pneumoniae remains the major aetiological agent of CAABM both in adults and children in our set-up. No penicillin resistance was detected among the isolates. Further research should focus on preventable aspects of CAABM, especially pneumococcal vaccines, to help reduce the disease burden.

Antimicrobial resistance pattern among aerobic gram-negative bacilli of lower respiratory tract specimens of intensive care unit patients in a neurocentre.

BACKGROUND: Analysis of the tracheal and bronchial isolates from the lower respiratory tract specimens of the intensive care unit (ICU)-admitted patients, was carried out for the year 2002 with a perspective of looking at the antibiotic resistance pattern. METHODS: Lower respiratory tract secretions (tracheal or bronchoscopic aspirates) of 370 patients were cultured, identified and antimicrobial susceptibility performed by standard methods. RESULTS: Out of samples obtained from 370 patients, 274 (74%) were culture positive. A total of 489 bacterial isolates were recovered from 270 patients; 451 were gram-negative bacilli (GNB) and 38 were Staphylococcus aureus. In four of the patients, Candida spp was isolated. The common GNB isolates were non-fermentative gram-negative bacilli (NFGNB, 31.9%), followed by Pseudomonas aeruginosa (21.5%) and Klebsiella spp (19%). Elderly (24.8%) and adults (19.2%) showed increased rate of GNB isolation. In both tracheal and bronchial GNB isolates, the highest mean resistance was to cefazolin (98.8%) and ampicillin (97.6%) while the lowest mean resistance was to amikacin (48.5%). Isolation of two organisms per specimen (41.4%) was commonly seen. Multidrug resistance to the tested antimicrobials was more frequent in NFGNB (6.6%) and Pseudomonas aeruginosa (5%). There were no remarkable differences in the overall mean drug resistance among tracheal and bronchial GNB isolates. CONCLUSIONS: Isolation practices, antibiotic policies, effective surveillance, maintenance of epidemiological trends of infections and, rapid molecular diagnosis are the need of hour in improved and speedy management of lung infections with resistant organisms.

Neuroleptospirosis - revisited: experience from a tertiary care neurological centre from south India.

BACKGROUND & OBJECTIVES: Leptospirosis is a zoonotic disease commonly reported from south India. Neurological manifestations seen in about 10-15 per cent of cases, are protean and remain unrecognized and diverse. We evaluated the pattern of nervous system involvement in leptospirosis, among patients presenting to the emergency services of a tertiary care neurological centre in south India, and also analysed the outcome and prognostic indicators. METHODS: The diagnosis of neuroleptospirosis was based on clinical and laboratory evidence of hepatorenal syndrome, and serum or CSF positivity for antileptospira antibody by a macroscopic agglutination test (MAT) and by ELISA in a limited number of samples. RESULTS: A total of 31 patients (M:F 27:4, age range 6-68 yr, mean 36.4 +/- 14.3 yr) were treated during the five year period. Acute fever with chills and rigors, headache and vomiting were the presenting manifestations; 25 patients (81%) had altered sensorium for a period ranging from 1- 8 days, four (12.9%) being deeply comatose. Eleven (35.5%) had acute symptomatic seizures at the time of presentation. Conjunctival congestion with or without haemorrhage was seen in 12 patients (38.7%), icterus in 14 (45%) and mild hepatosplenomegaly in 11 (35.5%). Early papilloedema was observed in three. Only three patients had localizing deficits. CT scan was normal in 18 of 27 (67%), while 7 (26%) had diffuse cerebral oedema. CSF pleocytosis with lymphocytic predominance (mean 50 cells/microl) and elevated protein levels (mean 115.5 +/- 67.5 mg %) were noted. Leptospira antibody was detected in serum of all, and 5 of 22 in CSF samples. Eight patients (26%) succumbed. Deep altered sensorium at presentation and raised CSF protein were two poor prognostic indicators. Pathological study of brain in five cases revealed encephalitic features and in addition immune mediated acute disseminated encephalomyelitis (ADEM) like pathology in two cases. INTERPRETATION & CONCLUSION: Neuroleptospirosis should be considered in the differential diagnosis of neuroinfections associated with hepatorenal dysfunction, in endemic areas. Leptospira antibody can be detected in CSF also in some cases. Deep altered sensorium at presentation indicates poor prognosis.

Brain abscess due to cladophialophora bantiana.

Cladophialophora bantiana (Xylohypha bantiana) is a dematiaceous fungus with distinct neurotropism. CNS phaeohyphomycosis due to C. bantiana is an uncommon infectious condition and is associated with high mortality. We report this rare clinical entity in a 22-year-old male, presenting as brain abscess. Etiological diagnosis was made based on fungal culture and histopathological examination. Complete surgical resection of the lesion and treatment with antifungal agents could not save the patient from this frequently fatal infection.

Latex agglutination test in the diagnosis of pyogenic meningitis.

Samples of cerebrospinal fluid (n=204) from pediatric patients with clinically suspected pyogenic meningitis were examined by direct microscopy, bacterial culture and Latex Agglutination Test (LAT). Latex Agglutination Test was done for detection of antigen of Streptococcus pneumoniae and Haemophilus influenzae type b. Among 38 LAT positive cases, culture and/or gram stain was positive in only 20 cases and 18 cases were detected exclusively by LAT. Besides, LAT was useful in detecting the pre-treated cases as 11 out of 55 samples from pre-treated cases were positive by LAT in comparison to culture and/or Gram stain which detected only 4 of 55 cases. LAT is simple, rapid and more reliable test.