Irreversible neurological manifestations in undiagnosed disseminated gonococcal infection.

Neisseria gonorrhoeae causes a common sexually transmitted infection with manifestations ranging from asymptomatic to urethritis and pelvic inflammatory disease to disseminated infections including septic arthritis. Serious complications may arise in unrecognised or inappropriately treated infections.We report a young, healthy woman who developed fever and joint pain and was diagnosed with an inflammatory arthritis. After starting immune suppressing treatments, she experienced right wrist drop and progressive muscle atrophy, joint contractures and sensory loss. Electrodiagnostic studies showed patchy, mixed neurogenic and myopathic features. Areas of muscle oedema on extremity MRI led to a right brachioradialis biopsy, which showed only nonspecific changes. Other testing, including lumbar puncture and MRI of the brain/spine was noncontributory. Additional history revealed unprotected intercourse with a new partner prior to symptom onset. Urine gonorrhoeae PCR was positive, and right shoulder arthrocentesis confirmed septic arthritis. After intravenous antibiotic treatment with ceftriaxone, she demonstrated slow, incomplete symptomatic improvement.

Progressive multifocal leukoencephalopathy in systemic lupus erythematosus treated with pembrolizumab.

This case report discusses a patient with systemic lupus erythematosus (SLE) treated with low-dose azathioprine who developed progressive multifocal leukoencephalopathy (PML). PML is a rare, severe, demyelinating disease linked to John Cunningham polyomavirus (JCV) reactivation.Treated with pembrolizumab, an immune checkpoint inhibitor, the patient initially improved. However, after the fourth dose, her condition rapidly worsened resulting in treatment discontinuation and death. Similar cases highlight the complex interplay of factors in PML development in SLE patients, including immunosuppression and genetic factors. The use of pembrolizumab in PML and SLE necessitates careful consideration of potential complications.

Coinfection of cerebral toxoplasmosis and neurosyphilis as the first manifestation of AIDS.

A male in his 30s with a medical history of newly diagnosed HIV with a CD4 count of 292 cells/mm3 presented with a bilateral frontal headache and left upper and lower extremity weakness and paraesthesias. A few months prior, the patient experienced a desquamating rash on his scalp and a pruritic, papular genital rash, which both self-resolved. CT head without contrast revealed extensive vasogenic oedema involving the right basal ganglia, thalamus, temporal and occipital lobes. MRI of the brain with and without contrast revealed two enhancing masses in the right lentiform nucleus and right temporal-occipital junction with associated vasogenic oedema. Cerebrospinal fluid (CSF) studies confirmed cerebral toxoplasmosis with positive CSF Toxoplasma gondii PCR and neurosyphilis with positive serum rapid plasma reagin and CSF venereal disease research laboratory test. He was treated with trimethoprim/sulfamethoxazole and intravenous penicillin G with the resolution of his symptoms.

COVID-19 autism spectrum disorder-like transient neurocognitive clinical presentation.

The COVID-19 pandemic has impacted the general population in different ways, including the vulnerable population of children with special needs.In this case report, we will discuss the emergence of a transient, full-blown picture of autism spectrum disorder (ASD) in a child who contracted a COVID-19 infection, and his gradual improvement over the course of a few months. This broadens our perspective on the possible neurocognitive clinical presentations of COVID-19 infection.

Refractory singultus and area postrema syndrome as a presentation of neurocysticercosis.

Neurocysticercosis (NCC) is the most common parasitic infection of the central nervous system, caused by the pork tapeworm, Taenia solium Common presenting features are seizures, headaches and focal neurodeficits. The present report details the anecdote of a middle-aged Asian man, who presented with subacute onset of persistent nausea, vomiting and hiccups. Following unsuccessful trials with numerous prokinetic, antipsychotic, muscle relaxant and anticonvulsant medications, as well as an uneventful battery of gastrointestinal tests, he was referred for neurological evaluation. The constellation of symptoms was congruent with the diagnosis of area postrema syndrome. Although initial CT scan of brain was normal, MRI with contrast evaluation revealed a circumscribed, ring-enhancing lesion of the dorsal medulla oblongata, reminiscent of colloid vesicular stage of NCC. The patient was successfully treated with steroids and albendazole. The association of refractory singultus, nausea and vomiting and NCC is thus far, not reported in the literature.

Recovery from acute haemorrhagic leucoencephalitis secondary to COVID-19.

A man in his 50s presented with sudden onset expressive aphasia and right-sided facial droop after experiencing coryzal symptoms and malaise for 7 days prior to admission. A brain MRI showed a rapidly progressive mass effect across both hemispheres and cerebrospinal fluid analysis revealed neutrophil predominance with raised protein levels. Acute disseminated encephalomyelitis was provisionally diagnosed, and high-dose methylprednisone was initiated.On admission to the high dependency unit, the patient tested positive for COVID-19 and was treated with appropriate therapeutic agents for severe COVID-19. A subsequent brain biopsy confirmed a demyelinating process, strongly indicating a diagnosis of acute haemorrhagic leucoencephalitis when correlated with the presence of severe oedema on imaging. Nine sessions of plasma exchange were provided over 18 days.At the time of writing, the patient has made an excellent recovery. We urge clinicians to consider this diagnosis and these treatment options for an otherwise devastating condition.

Parvimonas micra orbital cellulitis complicated with cerebral venous thrombosis and mycotic aneurysm.

Parvimonas micra is a gram-positive anaerobic coccus typically found in the human oral cavity, upper respiratory tract and gastrointestinal system. It occasionally causes intra-abdominal abscesses, spondylodiscitis and other infections. There are very few case reports on mycotic aneurysm related to P. micra We describe a rare case of P. micra orbital cellulitis complicated with meningitis, cerebral venous thrombosis and internal carotid artery mycotic aneurysm, which was successfully treated with the combination of endovascular therapy and antibiotics. Additionally, the patient received 6 months of anticoagulation therapy for cerebral venous thrombosis.

Granulomatous amoebic encephalitis due to Acanthamoeba spp complicating multidrug-resistant tuberculous meningitis in an immunocompetent individual.

Granulomatous amoebic encephalitis due to Acanthamoeba spp is a rare, near-fatal central nervous system infection. It is often seen in immunocompromised individuals. Here we describe a survivor of this infection who was co-infected with multidrug-resistant tuberculosis. He presented to us with features of meningitis and a history of chronic cough. The chest X-ray was classical for pulmonary tuberculosis. Neuroimaging was suggestive of encephalitis; herpes simplex virus PCR was negative. Cerebrospinal fluid (CSF) showed lymphocytic pleocytosis. Wet mounts revealed trophozoites of Acanthamoeba Currently, he is being treated with oral bedaquiline, levofloxacin, linezolid, clofazimine, cycloserine and pyridoxine for tuberculosis. He received intravenous amikacin and oral cotrimoxazole and fluconazole for Acanthamoeba infection for 1 month. The resolution was confirmed by repeating the CSF wet mount, culture and neuroimaging. He was then discharged with oral rifampicin, cotrimoxazole and fluconazole. He is currently under our close follow-up.

Case of cervicodorsal tuberculosis involving seven contiguous vertebrae in a young child.

We present a rare case of a male child in middle childhood who presented to the emergency department with neck pain, neck deformity, low-grade fever, breathing difficulty and swallowing difficulty. The patient had a significant history of weight loss and loss of appetite. On examination, neurological deficits were observed, including mildly increased tone in bilateral lower limbs, reduced power in both lower limbs, exaggerated knee and ankle jerks, and upgoing plantar reflexes. Radiographs and MRI revealed a kyphotic deformity with apex at the T1 vertebra, lytic lesions in seven contiguous vertebrae and a large prevertebral abscess extending from C2 to T5. The patient underwent a posterior-only surgical approach with decompression, abscess drainage and stabilisation, resulting in successful cord decompression and correction of the kyphotic deformity. At 18 months follow-up, the patient is doing well with improvement to normal neurology and full return of a child to normal activities.

Inflammatory progressive multifocal leukoencephalopathy with human T-cell lymphotropic virus-1 coinfection.

A middle-aged man with progressive multifocal leukoencephalopathy (PML) in a human T-cell lymphotropic virus type-1 (HTLV-1) carrier on haemodialysis presented with mild dysarthria and ataxia. Brain MRI revealed asymmetric T2-hyperintense lesions in the cerebral white matter, cerebellum and brainstem. A small amount of JC virus (JCV) genome in cerebrospinal fluid was detected by PCR and cerebellar biopsy demonstrated JCV-DNA presence. Pathological findings showed demyelinating lesions and glial cells with mildly enlarged nuclei, accompanied by T-lymphocytes, neutrophils and plasma cell infiltration. The CD4+/CD8+ratio was 0.83. High-dose corticosteroid therapy was effective for inflammatory PML lesions, and the administration of mefloquine combined with mirtazapine led to favourable outcome. The encephalitis in this case is considered to have occurred secondarily to JCV infection in the presence of HTLV-1 infection. Therefore, it is crucial to investigate the presence of HTLV-1 in order to understand the aetiology of this brain inflammation.

Dengue-associated longitudinally extensive transverse myelitis.

We diagnosed a patient with dengue fever who developed acute onset of sensorimotor quadriparesis with bladder involvement, and facial nerve involvement. Despite initial negative results in routine investigations and cerebrospinal fluid analysis, spinal MRI confirmed longitudinally extensive transverse myelitis. The aetiological workup was negative, prompting an investigation into the presence of dengue in the cerebrospinal fluid, which returned positive. This case underscores the importance of considering rare neurological complications in dengue, the value of advanced diagnostic techniques and the potential effectiveness of tailored interventions in challenging cases.

Syndrome of inappropriate antidiuretic hormone release secondary to central nervous system coccidioidomycosis with vasculitis.

A man in his 60s presented to the clinic due to night sweats and weight loss following pneumonia. He was found to have hyponatraemia due to a syndrome of inappropriate antidiuretic hormone (SIADH). CT of the thorax was concerning for pulmonary nodules. He was ultimately diagnosed with pulmonary coccidioidomycosis (CM) and started on fluconazole 400 mg daily with improvement in symptoms. Due to the report of headaches, head MRI was conducted which suggested central nervous system (CNS) involvement. Cerebrospinal fluid analysis was consistent with CNS CM and head magnetic resonance angiography confirmed the presence of CNS vasculitis. Fluconazole dose was increased to 800 mg daily which the patient continued to tolerate and showed improvement. This report depicts a case of SIADH associated with CNS CM with vasculitis and demonstrates the importance of high clinical suspicion for SIADH secondary to CNS CM in the setting of hyponatraemia and headache.

Neonatal herpes simplex virus encephalitis with intracranial bleeding in a newborn baby with concurrent rhesus incompatibility.

We report a baby with neonatal herpes simplex virus (HSV) encephalitis concurrent with Rrhesus (Rh) incompatibility. He was delivered by a Ggravida 2 mother with a history of miscarriage in her previous pregnancy at a gestation age of 4 months. She had Bblood group 0 and Rrhesus negative. The baby was noticed to have jaundice on day one1 of life accompanied by generalised petechiae on the face and upper chest. A full blood picture revealed severe anaemia and severe thrombocytopaenia and HSV 1/2 IgM was positive. MRI of the brain showed multiple extensive haemorrhagic lesions on the frontal-temporal regions.

Spinal cord infarction: a rare but serious complication of pneumococcal meningoencephalitis.

Here, we report the case of a woman in her 40s who came with pyogenic meningitis and infarcts in the brain. While on treatment with antibiotics, she developed new-onset weakness involving bilateral lower limbs and one upper limb 2 weeks into the course of illness. MRI of the spine showed an infarct in the spinal cord. Spinal cord infarction as a complication of pyogenic meningitis is not well recognised unlike tuberculosis meningitis. Unlike ischaemic strokes where thrombolysis is done, for stroke related to infections, there are no definite strategies. Our patient was treated with physiotherapy, continued on antibiotics and slowly recovered over months and at 18-month follow-up, she was walking with a walker. The exact mechanism of thrombosis is not known but may be due to inflammation of the arterial wall and activation of the procoagulant cascade by infection-triggered inflammation. Spinal cord infarction can occur at any phase of the infection and may occur despite appropriate response to antibiotic treatments.

Cerebellar progressive multifocal leucoencephalopathy identified by the shrimp sign.

Progressive multifocal leucoencephalopathy (PML) is a demyelinating disease caused by the John Cunningham (JC) virus, which may get reactivated under certain immunosuppressive states such as AIDS, immunomodulatory therapy and haematological malignancies. PML has been reported rarely even in immunocompetent individuals where no immunodeficiency was present. PML characteristically involves periventricular and juxtacortical white matter. Isolated cerebellar or brainstem PML may be seen rarely. We present a case of a man in his 70s who presented with rapidly progressive cerebellar ataxia, ptosis and bipyramidal signs. Investigations excluded a direct viral cerebellar infection, acute disseminated encephalomyelitis, paraneoplastic cerebellar degeneration or any structural cerebellar lesion. MRI PET study revealed the classical shrimp sign which raised the possibility of cerebellar PML, and the same was confirmed by a positive JC virus PCR in the cerebrospinal fluid. Our patient had no known immune-compromising state, but further workup revealed a low CD4 count suggestive of idiopathic CD4 lymphopenia. The case illustrates the importance of the shrimp sign on MRI, the possibility of cerebellar involvement of PML as well as the need to consider a differential diagnosis of PML even in individuals with no obvious immunocompromised state.

Disseminated nocardiosis with persistent neurological disease.

A man in his 80s with a history of sarcoidosis on chronic prednisone presented to the emergency department with several days of dyspnoea. A chest X-ray showed signs of pneumonia, and the patient was admitted. Blood and pleural fluid cultures grew Nocardia farcinica; therefore, the patient was started on treatment with trimethoprim-sulbactam and imipenem. Brain imaging showed evidence of dissemination of the infection to the central nervous system (CNS). The patient's admission was complicated by pleural effusions, acute kidney injury and pancytopenia, and therefore, his antibiotic regimen was ultimately transitioned from trimethoprim-sulfamethoxazole (TMP-SMX), meropenem and linezolid to imipenem and tedizolid. The patient received imipenem and tedizolid for the remainder of the admission. A repeat MRI of the brain was performed after 6 weeks of this dual antibiotic therapy, which unfortunately revealed persistent CNS disease. His regimen was then broadened to TMP-SMX, linezolid and imipenem. Despite these measures, however, the patient ultimately passed away from the infection.

Varicella-zoster virus vasculopathy in a patient with multiple sclerosis receiving natalizumab.

We present a case of a woman in her 30s with relapsing-remitting multiple sclerosis, treated with natalizumab, who developed ophthalmic varicella zoster virus (VZV) infection, with subsequent vasculopathy causing cerebral ischaemic lesions. She was treated with acyclovir, prednisolone and acetylsalicylic acid and fully recovered. VZV vasculopathy is associated with stroke and immunomodulating treatments may increase the risks of these adverse events. To date, nine VZV-related vasculopathy cases in patients treated with natalizumab have been reported in English literature and are summarised in this paper. Although rare, VZV intracerebral vasculopathy is an important differential diagnosis in patients with unexplained new-onset neurological symptoms after a herpes zoster infection. Treatment guidelines for VZV vasculopathy and for continuing treatment of multiple sclerosis after such an event are currently not established.

Typhoid spondylodiscitis of the cervical spine.

Spinal infection comprises pyogenic and non-pyogenic spondylodiscitis. This condition may manifest with non-specific clinical symptoms, elevated infective parameters and imaging findings that are difficult to distinguish. The cornerstone of a definitive diagnosis and subsequent successful treatment lies in tissue analysis through culture and histopathological studies. In this context, we present a case of Salmonella pyogenic spondylodiscitis affecting the C5/C6 vertebrae, complicated by Salmonella bacteraemia and characterised by mechanical neck pain that curtails daily activities and overall functioning, although without neurological deficits. The uniqueness of this case stems from its occurrence in an immunocompetent individual from a non-endemic area, with no identifiable sources of Salmonella infection or preceding gastrointestinal symptoms.

Varicella zoster encephalitis in an immunocompetent patient.

Encephalitis is inflammation of the brain parenchyma, most often caused by viruses. Historically, data have shown herpes simplex virus 1 and 2 to be the most common causes of viral encephalitis, with cases due to varicella zoster virus (VZV) more often seen in older age and immunocompromised states. However, emerging data show VZV as an increasingly common culprit of encephalitis in young, immunocompetent patients. PCR analysis of the cerebrospinal fluid is the most accurate diagnostic modality for viral encephalitis. Appropriate and complete treatment hinges on accurate identification of the cause of encephalitis, underscoring the need for comprehensive testing. We present a case of VZV encephalitis in an immunocompetent male patient in his 40s.

Rapid progression of probable Creutzfeldt-Jakob disease with concomitant COVID-19 infection.

A previously healthy man in his 80s was admitted to a district general hospital with rapidly progressing dementia, gait abnormalities and myoclonus alongside COVID-19 infection. Investigations showed mild elevation of C-reactive protein and neutrophils, unremarkable CT head and mildly raised protein in cerebrospinal spinal fluid (CSF). Brain MRI revealed bilateral cortical and striatal diffusion restriction and electroencephalogram (EEG) findings showed diffuse activity slowing with high amplitude sharp/slow-wave complexes. He was diagnosed with probable sporadic Creutzfeldt-Jakob disease (CJD) and management prioritised comfort and care. He passed away two weeks following admission and a mere 8 weeks after the first onset of symptoms.We present the first documented case of probable CJD with concomitant COVID-19 infection in the UK. We identified six other cases worldwide identified in our literature review. These cases suggest a role of COVID-19 in the rapid progression of CJD and add to the growing evidence of its neuroinflammatory role in other forms of neurodegenerative diseases.