A Case of Brain Abscess Caused by Actinomyces Cardiffensis and Parvimonas Micra.

Brain abscesses occur in 0.3-1.3 per 100,000 worldwide each year with 0.4-0.9 in Japan alone. Most of the causes are direct infection from a nearby infectious lesion and are rarely caused by an odontogenic infection. Here, we reported a case of brain abscess suspected to be associated with odontogenic infection. The patient was a 55-year-old woman. Blurred eyes and pain in the left eye noted, for which she consulted an ophthalmologist, but her eyes were normal. She was conscious and was able to converse clearly, but she could not read the letters and had difficulty in writing at the time of admission. A brain abscess was diagnosed based on the head magnetic resonance imaging (MRI) and clinical course, and a small craniotomy abscess drainage was performed. A. cardiffensis and P. micra were detected in the abscess, suggesting the involvement of periodontal disease bacteria. After the surgery, antimicrobial treatment was performed for about 2 months. At the same time, perioperative treatment was performed. On the 70th day after the surgery, tooth extraction, which was considered as the source of infection, was performed. The patient was discharged 74 days after surgery. A good turning point was obtained without relapse of symptoms.

Older patients with intraventricular hemorrhage are prone to infection after external ventricular drainage.

BACKGROUND: External ventricular drainage (EVD) is a life-saving and emergent procedure in neurosurgery. However, infection is the main problem in patients with EVD. The present study aims to analyze the infection rate of patients with EVD and to investigate the factors that contribute to infection and mortality rates. METHODS: The data of patients who underwent emergent EVD procedure between 2018 and 2019 were retrospectively analyzed in this study. The demographic features of the patients were recorded. The correlation between age, gender, indication and duration of EVD, and the infection and mortality rate were investigated. RESULTS: In this study, 47 patients underwent emergent EVD in two years. Thirty (63.83%) patients were male, and 17 were female with a mean age of 28.02 years. The mean duration of drainage was 6.2 days. Fifty-eight cerebrospinal fluid (CSF) samples were analyzed during the drainage period and CSF culture was positive in 14 (24.14%) samples. The most common microorganism was Staphylococcus epidermidis. The infection rate was high in older and male patients with duration longer than six days. Nine (19.15%) patients died during the treatment period and six of them had IVH. CONCLUSION: The duration of EVD should be shorter in patients older than 65 years with the diagnosis of intraventricular hemorrhage, which is mostly related to dea.

Choosing the therapy for neurological infection with rapidly growing mycobacteria.

The management of neurological infections due to non-tubercular mycobacteria is extremely challenging because of scarce literature, issues with penetration, lack of easily available susceptibility platforms and adverse effects associated with long term therapy. We report a case of a young girl with neurological infection due to rapidly growing mycobacteria to discuss the factors that should be considered while choosing the therapy for such rare and persistent infections.

The imaging features of cerebral septic infarction in two patients with infective endocarditis.

BACKGROUND: Neurologic complications are frequently seen in infective endocarditis (IE) and were identified in about 70% of patients with IE. However, the imaging features of the cerebral septic infarction were less investigated. PURPOSE: To demonstrate the imaging features of the cerebral septic infarction of IE. MATERIAL AND METHODS: Two patients were clinically diagnosed as IE according to the modified Duke criterion. We studied their imaging profiles and reviewed the literature of the imaging features of neurologic complications of IE. RESULTS: The critical features are multiple ischemic and hemorrhagic lesions, most of which locate at the cortical-medullary junction. The septic infarctions are irregular patchy in shape and have characteristic imaging features indicating complications of IE. CONCLUSION: Magnetic resonance imaging (MRI) with different sequences can detect the features and provide clinical evidence to physicians to make the correct diagnoses and then the treatment plans.

Intracranial Complications of Pediatric Sinusitis.

"Headache and fever" is a common presentation to the urgent care and emergency department setting and can have many etiologies. We present a case of a 10-year-old girl who presented with headache and fever and was found to have intracranial extension of sinusitis despite lack of typical sinus or chronic upper respiratory tract infection symptoms. This case illustrates the need in the emergency department or urgent care to keep a broad differential diagnosis for pediatric headache, especially when initial interventions are unsuccessful. We also review the epidemiology of pediatric sinusitis, age at sinus development, and associated intracranial complications.

Neurobrucellosis.

PURPOSE: Neurobrucellosis (NB) is a rare complication of brucellosis. NB presents with avariety of clinical manifestations, and the symptoms are always atypical. Our aim was to analyze the demographic characteristics, clinical manifestations, laboratory findings, imaging findings, treatments and outcomes of patients with NB. MATERIAL AND METHOD: We retrospectively reviewed the data from 17 patients with NB hospitalized at the Chinese People's Liberation Army General Hospital between 1 January 2005 and 31 October 2016. RESULTS: The following symptoms were recorded: 10/17 (59%) patients had fever, and 9/17 (53%) patients had a disorder affecting urination and defecation. Involvement of the cranial nerves was documented in 12/17 (71%) patients. The positivity rates of the tests were as follows: serum standard tube agglutination (STA), 15/17 (88.2%); cerebrospinal fluid STA, 10/17 (59%). The radiologic findings were categorized into four types: normal, white matter changes, vascular insult and inflammatory changes. Patients were treated with different combinations of rifampicin, doxycycline, ceftriaxone sodium and sulphamethoxazole for a total of six months. Two (12%) patients deteriorated, and two (12%) patients were lost to follow-up. The remaining patients (76%) were cured, but sequelae occurred in six patients. CONCLUSIONS: NB should be kept in mind in patients with autonomic dysfunction, especially disorders of urination and defecation. Hearing loss due to vestibulocochlear nerve injury seems to be typical for NB. The high incidence of sequelae may be related to a long disease course and the involvement of the central nervous system. Early detection, diagnosis and treatment could decrease mortality and sequelae.

Polymerase chain reaction based detection of bacterial 16S rRNA gene in the cerebrospinal fluid in the diagnosis of bacterial central nervous system infection in the course of external cerebrospinal fluid drainage. Comparison with standard diagnostics currently used in clinical practice.

BACKGROUND AND PURPOSE: External drainage of cerebrospinal fluid (CSF) is a commonly used neurosurgical procedure. Complications of the procedure comprise central nervous system (CNS) bacterial infections, the frequency of which is estimated at around 6-10%. Detection of these infections is ineffective in many cases. The aim of the study was to evaluate the usefulness of a polymerase chain reaction (PCR)-based detection of bacterial 16S rRNA gene (16S rDNA) in the CSF. MATERIAL AND METHODS: The study group consisted of 50 patients. Clinical signs of CNS infection were monitored and routine laboratory and microbiological tests were performed. The results of standard methods were compared with the bacterial 16S rDNA detection. RESULTS: Using cultures, CNS infection was diagnosed in 8 patients, colonization of the drainage catheter in 6 patients, and sample contamination in 7 patients. In the group of the remaining 29 patients, no positive CSF culture was obtained and 13 of these patients also had all negative results for 16S rDNA detection. For the remaining 16 patients of this group, CNS infection, colonization of the catheter and sample contamination were diagnosed via PCR alone. Routine biochemical CSF tests and blood inflammatory parameters had a supporting value. CONCLUSIONS: Routine hospital tests do not provide rapid and efficient detection of the external drainage related bacterial CNS infection. It is justified to use several diagnostic methods simultaneously. The16S rDNA determination in CSF can increase the probability of detection of possible pathogens.

Clinical and Laboratory Characteristics for the Diagnosis of Bacterial Ventriculitis After Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: The diagnosis of nosocomial bacterial ventriculitis in patients with subarachnoid hemorrhage (SAH) can be challenging. METHODS: We performed a retrospective study on the diagnostic accuracy of clinical and laboratory characteristics for the diagnosis of bacterial ventriculitis in 209 consecutive patients with an aneurysmal SAH admitted in a tertiary referral center from 2008 to 2010. Diagnostic value of clinical characteristics and inflammatory indexes in CSF and blood were determined for three diagnostic categories: (1) no suspicion for bacterial ventriculitis; (2) clinical suspicion for bacterial ventriculitis, defined as initiation of empirical antibiotic treatment for ventriculitis, but negative CSF cultures; and (3) CSF culture-positive bacterial ventriculitis. RESULTS: Empirical antibiotics for suspected ventriculitis was initiated in 48 of 209 (23 %) patients. CSF cultures were positive in 11 (5 %) patients. Within the group of suspected ventriculitis, only longer duration of CSF drainage and lower CSF red blood cell counts predicted for culture positivity. None of the other clinical features or inflammatory indexes in CSF and blood were associated with culture-proven bacterial ventriculitis. CONCLUSIONS: Nosocomial bacterial ventriculitis in patients with aneurysmal SAH is often suspected but confirmed by culture in a minority of cases. Improvement of diagnostics for nosocomial bacterial ventriculitis in patients with aneurysmal SAH is needed.

Cerebrospinal Fluid Infection Associated with Silver-Impregnated External Ventricular Drain Catheters.

OBJECTIVE: Silver-impregnated external ventricular drains (EVDs) have reduced the number of cases of ventriculitis. Risk factors for developing ventriculitis associated with plain EVD catheters have been well documented and incorporated into clinical practice, but risk factors in association with silver EVDs are unknown. Therefore, we sought to determine the risk factors for developing ventriculitis in patients with a silver EVD. METHODS: Prospectively collected data on consecutive patients undergoing insertion of a silver-impregnated EVD between October 2011 and September 2013 were analyzed. Cerebrospinal fluid (CSF) infection was defined as positive CSF microbiologic culture. Univariate and multivariate regression was performed to identify independent risk factors for CSF infection. RESULTS: There were 362 EVDs placed in 263 patients (142 women; median age 52 years; interquartile range, 40-62 years). There were 15 infections (6.4 per 1000 days of EVD drainage) recorded. Gram-negative organisms (8 of 15) were most commonly observed, although Staphylococcus was the most common genus (7 of 15; 46%) identified. Univariate analysis indicated that patients requiring EVD replacement (P < 0.0001), patients requiring bilateral EVDs (P < 0.0001), and patients with a CSF leak (P < 0.0001) were at increased risk of infection. Only need for EVD replacement remained significant on multivariate analysis (P < 0.0001, odds ratio = 15.9, confidence interval = 4.5-55.9). CONCLUSIONS: We identified an infection rate of 5.2% in this large contemporary series of patients undergoing silver EVD insertion according to a set protocol. These data suggest that targeting strategies to reduce Staphylococcus species is important, and increased vigilance for an increased incidence of gram-negative organisms is needed. Decreasing the need for EVD replacement is important in reducing infection rates further.

Analysis on the risk factors of intracranial infection secondary to traumatic brain injury.

OBJECTIVE: To discuss the characteristics and risk factors for intracranial infection post traumatic brain injury to prevent and better the clinical care. METHODS: Retrospective study of 520 patients with traumatic brain injury were included, 308 male and 212 female. The risky factors of intracranial infection were identified. RESULTS: Thirty two cases (6.54%, 32/520) of intracranial infection were diagnosed. Intracranial infection most likely happened 4-10 days after injury. Cerebrospinal fluid leakage, drainage, multiple craniotomies were significant related to intracranial infection. Logistic regression predicted cerebrospinal fluid leakage and drainage as independent factors. CONCLUSION: Intracranial infection is a serious complication after traumatic brain injury. Patients with drainage or cerebrospinal fluid leakage are more risky for intracranial infection. Aggressive precaution should be taken to better outcome.

Early monitoring of ventriculostomy-related infections with procalcitonin in patients with ventricular drains.

Several factors are implicated in the increased vulnerability of multiple trauma victims to infection, especially in intensive care units. The incidence of EVD related infections ranges from 5 to 20%. To assess the accuracy of serum procalcitonin (PCT) in predicting central nervous system (CNS) infection in patients with EVDs. Thirty-six adult patients with severe head trauma were enrolled in this prospective study, after exclusion of other causes of fever; patients were subjected to sampling of C-reactive protein (CRP), PCT, and cerebrospinal fluid (CSF) cultures every other day. Five patients developed ventriculostomy-related infections, and all had an elevated serum PCT concentration. Patients with negative CSF cultures had mean serum PCT <2.0 ng/ml, while patients with positive culture had early elevation of serum PCT with mean of 4.18 ng/ml, CRP did not show similar early changes. Patients who acquire CNS infection had prolonged length of stay in hospital and length of ventilation. In absence of other nosocomial infections, early high serum PCT concentrations appear to be a reliable indicator of bacterial CNS infection in patients with EVD.

Whole cerebrospinal axis infection after lumbar epidural injection: a case report.

PURPOSE: Lumbar epidural injection is a popular treatment for degenerative lumbar disease. Although post-procedural epidural infection is rare, meningitis and epidural abscess are life-threatening conditions, and need additional medical and surgical intervention. The purpose of this article is to report a patient with fatal whole cerebrospinal axis infection after lumbar epidural injections. METHODS: A 64-year-old female patient presented with septic shock and quadriparesis. In the past, this patient had received lumbar epidural injections several times for degenerative spondylolisthesis at L4-5 in another hospital. The magnetic resonance imaging showed epidural abscess, a compressed dura and spinal cord from C1 to S2, and cerebral meningitis. We performed laminectomies and removal of the abscesses. Her mental status was diminished to a deep, drowsy state after three postoperative weeks. Brain computed tomography scans revealed hydrocephalus. Therefore, ventriculoperitoneal shunting was performed. RESULTS: Methicillin resistant Staphylococcus epidermidis was cultured from blood samples. The patient's infection was completely controlled and her mental status improved to alert; however, her quadriparesis remained. CONCLUSIONS: Although lumbar epidural injection is an effective procedure to treat lumbar radicular pain, this procedure can induce fatal complications such as sepsis and epidural abscess. LEVEL OF EVIDENCE: 5.

Long subcutaneous tunnelling reduces infection rates in paediatric external ventricular drains.

PURPOSE: The aim of this study is to report the efficacy of long subcutaneous tunnelling of external ventricular drains in reducing rates of infection and catheter displacement in a paediatric population. METHODS: In children requiring external ventricular drainage, a long-tunnelled drain was placed and managed according to a locally agreed guideline. End points were novel CSF infection incurred during the time of drainage and re-operation to re-site displaced catheters. Data were compared to other published series. RESULTS: One hundred eighty-one long-tunnelled external ventricular drains (LTEVDs) were inserted. The mean age was 6.6 years (range 0-15.5 years). Reasons for insertion included intraventricular haemorrhage (47 %), infection (27 %), tumour-related hydrocephalus (7.2 %), as a temporising measure (17 %) and trauma (2.2 %). The overall new infection rate for LTEVD was 2.76 %. If the 48 cases where LTEVDs were inserted to treat an existing infection are excluded, the infection rate was 3.8 % (5/133). The mean duration of insertion was 10 days (range 0-42 days). Four LTEVDs (2.2 %) were inadvertently dislodged, requiring reinsertion. Thirteen patients required removal of EVD alone. There was a significant difference (p < 0.05) when comparing our infection rate to 14 publications of infection rates in short-tunnelled EVDs; however, there was no difference when comparing our data to three publications using LTEVDs. CONCLUSION: The use of an antibiotic-impregnated LTEVD, managed according to a predefined guideline, is associated with significantly reduced infection and displacement rates when compared with contemporary series. It is suggested that this reduction is of both clinical and economic benefits.

Encephalitis.

Encephalitis is an infectious or inflammatory disorder of the brain that presents with fever, headache, and an altered level of consciousness. There may also be focal or multifocal neurologic deficits, and focal or generalized seizure activity. Of the infectious etiologies, herpesviruses are the most common and some of the few treatable viral causative agents of encephalitis. The etiology, clinical presentation, diagnosis, and treatment of viral encephalitis is discussed in this chapter.

Brain microbial populations in HIV/AIDS: α-proteobacteria predominate independent of host immune status.

The brain is assumed to be a sterile organ in the absence of disease although the impact of immune disruption is uncertain in terms of brain microbial diversity or quantity. To investigate microbial diversity and quantity in the brain, the profile of infectious agents was examined in pathologically normal and abnormal brains from persons with HIV/AIDS [HIV] (n = 12), other disease controls [ODC] (n = 14) and in cerebral surgical resections for epilepsy [SURG] (n = 6). Deep sequencing of cerebral white matter-derived RNA from the HIV (n = 4) and ODC (n = 4) patients and SURG (n = 2) groups revealed bacterially-encoded 16 s RNA sequences in all brain specimens with α-proteobacteria representing over 70% of bacterial sequences while the other 30% of bacterial classes varied widely. Bacterial rRNA was detected in white matter glial cells by in situ hybridization and peptidoglycan immunoreactivity was also localized principally in glia in human brains. Analyses of amplified bacterial 16 s rRNA sequences disclosed that Proteobacteria was the principal bacterial phylum in all human brain samples with similar bacterial rRNA quantities in HIV and ODC groups despite increased host neuroimmune responses in the HIV group. Exogenous viruses including bacteriophage and human herpes viruses-4, -5 and -6 were detected variably in autopsied brains from both clinical groups. Brains from SIV- and SHIV-infected macaques displayed a profile of bacterial phyla also dominated by Proteobacteria but bacterial sequences were not detected in experimentally FIV-infected cat or RAG1⁻/⁻ mouse brains. Intracerebral implantation of human brain homogenates into RAG1⁻/⁻ mice revealed a preponderance of α-proteobacteria 16 s RNA sequences in the brains of recipient mice at 7 weeks post-implantation, which was abrogated by prior heat-treatment of the brain homogenate. Thus, α-proteobacteria represented the major bacterial component of the primate brain's microbiome regardless of underlying immune status, which could be transferred into naïve hosts leading to microbial persistence in the brain.

Imaging of rickettsial, spirochetal, and parasitic infections.

This article is an update and literature review of the clinical and neuroimaging findings of the commonly known rickettsial, spirochetal, and eukaryotic parasitic infections. Being familiar with clinical presentation and imaging findings of these infections is crucial for early diagnosis and treatment especially in patients who live in or have a travel history to endemic regions or are immunocompromised.

Infectious myelitis.

Infections are an uncommon but very important etiology of myelitis as a correct diagnosis would allow for timely treatment and recovery. The term "myelitis" is generally used to describe an inflammatory pathologic process affecting the spinal cord and causing an interruption of the ascending and descending pathways, and, therefore, partial or complete loss of function. The onset may be acute or subacute, and the etiology may be cumbersome to determine. This article will review the most recently published literature regarding the infectious agents causing myelitis with an emphasis on diagnosis and treatment.

Intracerebral infections as a complication of deep brain stimulation.

BACKGROUND: Intracerebral infections after deep brain stimulation (DBS) are rare. The published material is limited to 2 case reports. A review of 20 publications of 3,818 patients focusing on complications of DBS did not reveal one single case. For that reason, we decided to present our own experience of 4 patients with this complication. OBJECTIVES: To analyze and present our material regarding intracerebral infections after DBS. METHODS: Four patients with intracerebral infection after DBS were retrospectively analyzed. RESULTS: The 4 patients exhibited signs of intracerebral infection 2-14 days after DBS for Parkinson's disease. CT and MRI verified signs of possible cerebral involvement. In 3 patients, positive cultures were obtained from the extracted electrodes. All patients recovered completely following treatment with antibiotics and removal of the implanted hardware. Two of the patients were later re-implanted. CONCLUSIONS: Intracerebral infection is a rare complication of DBS. It does, however, occur occasionally and should be taken into consideration when evaluating the risks of DBS.