Chronic Candida albicans meningitis misdiagnosed as polymyalgia rheumatica and successfully treated with voriconazole.

The outcome of chronic meningitis depends to a large degree on the causative pathogen and the interval between onset of symptoms and diagnosis. We present a patient with a delayed diagnosis and several complications, for whom adequate therapy resulted in a favorable outcome. In a 76-year-old male patient, Candida albicans meningitis was diagnosed 4 months after the onset of symptoms. CSF findings (protein >1000 mg/L, predominance of intrathecal immunoglobulin A synthesis, lactate concentrations of approx. 10 mmol/L, leukocyte counts around 1000/µl, variable differential leukocyte counts) resembled tuberculous meningitis. In spite of the long interval without treatment, voriconazole 200 mg every 12 h for 7 weeks followed by fluconazole 300 mg/day maintenance therapy for 7 months led to a recovery with only mild deficits. The case illustrates that 1. C. albicans can cause chronic meningitis in patients without severe immune defects, 2. patients can survive C. albicans meningitis with mild long-term sequelae even when diagnosis and adequate treatment are delayed, and 3. voriconazole as a sole agent may be suitable for treatment of C. albicans meningitis.

Aneurysm of the superficial temporal artery following parotid gland surgery--case report and review of the literature.

Possible complications of parotid gland surgery are numerous, just as the reasons for aneurysms of the superficial temporal artery. The occurrence of such an aneurysm as a consequence of parotidectomy, however, has so far only been published once. Here, we report of an aneurysm of the superficial temporal artery following parotid gland surgery. It presented as a pulsating mass in the preauricular region. Combining clinical examination, duplex ultrasound, and CT scan, the diagnosis was readily established and treated with a circumscribed revision at low risk and without complications.

The approximate planimetric method: a simple, rapid and reliable method for estimation of lesion size in acute ischemic stroke.

Magnetic resonance imaging is increasingly used in stroke trials for early diagnosis and follow-up of lesion size. Since volumetric measurement remains a laborious and time-consuming task, a rapid and reliable method for the assessment of lesion size has been developed and validated in diffusion weighted imaging (DWI) and fluid attenuated inversion recovery (FLAIR) sequences. These were serially obtained in 40 patients less than 8 h after the onset of symptoms of a middle cerebral artery territory stroke (day 1), as well as on days 3 and 18. For each of 16 (DWI) or 20 (FLAIR) transverse sections obtained on each occasion, lesion size was estimated as a percentage of the total hemisphere. Percentage values from all sections were summed up and expressed as arbitrary units. Results obtained using this approximate planimetric method (APM) were compared with those from a standard volumetric approach. Lesion volumes as determined by both methods were highly correlated (DWI: r = 0.966, FLAIR: r = 0.979, p < 0.001). To conclude, the APM is simple, rapid and reliable for the estimation of lesion size in acute ischemic stroke. It can be recommended for broader application in clinical trials.

Erythropoietin therapy for acute stroke is both safe and beneficial.

BACKGROUND: Erythropoietin (EPO) and its receptor play a major role in embryonic brain, are weakly expressed in normal postnatal/adult brain and up-regulated upon metabolic stress. EPO protects neurons from hypoxic/ ischemic injury. The objective of this trial is to study the safety and efficacy of recombinant human EPO (rhEPO) for treatment of ischemic stroke in man. MATERIALS AND METHODS: The trial consisted of a safety part and an efficacy part. In the safety study, 13 patients received rhEPO intravenously (3.3 X 10(4) IU/50 ml/30 min) once daily for the first 3 days after stroke. In the double-blind randomized proof-of-concept trial, 40 patients received either rhEPO or saline. Inclusion criteria were age <80 years, ischemic stroke within the middle cerebral artery territory confirmed by diffusion-weighted MRI, symptom onset <8 hr before drug administration, and deficits on stroke scales. The study endpoints were functional outcome at day 30 (Barthel Index, modified Rankin scale), NIH and Scandinavian stroke scales, evolution of infarct size (sequential MRI evaluation using diffusion-weighted [DWI] and fluid-attenuated inversion recovery sequences [FLAIR]) and the damage marker S100ss. RESULTS: No safety concerns were identified. Cerebrospinal fluid EPO increased to 60-100 times that of nontreated patients, proving that intravenously administered rhEPO reaches the brain. In the efficacy trial, patients received rhEPO within 5 hr of onset of symptoms (median, range 2:40-7:55). Admission neurologic scores and serum S100beta concentrations were strong predictors ofoutcome. Analysis of covariance controlled for these two variables indicated that rhEPO treatment was associated with an improvement in follow-up and outcome scales. A strong trend for reduction in infarct size in rhEPO patients as compared to controls was observed by MRI. CONCLUSION: Intravenous high-dose rhEPO is well tolerated in acute ischemic stroke and associated with an improvement in clinical outcome at 1 month. A larger scale clinical trial is warranted.