A very unusual organism causing stroke-like symptoms.

A 78-year-old man presented to hospital with new onset confusion and fever. The working diagnosis was of delirium due to an infection of unknown source, and empirical i.v. antibiotic treatment was given. Two days later, he deteriorated and developed clinical features in keeping with a total anterior circulation stroke. Brain imaging was unremarkable. Blood cultures grew an organism subsequently identified as Facklamia languida. Following treatment with broad-spectrum antibiotics, his condition improved. A diagnosis of F. languida septicaemia, leading to presumed (unwitnessed) seizure and Todd's paresis was made. The patient went on to make a full recovery and was discharged home. Stroke mimics are common and may be eminently treatable. Around a quarter of patients initially suspected to have a stroke are subsequently found to have an alternative diagnosis.

Cerebrospinal fluid shunt infection caused by Corynebacterium sp: case report and review.

BACKGROUND: A 36-year-old immunocompetent woman with a posterior fossa arteriovenous malformation (PF-AVM) and hydrocephalus presented with low fever and mental confusion 4 days after ventriculoperitoneal shunting (VPS). METHODS: Cerebrospinal fluid (CSF) and ventricular catheter tip cultures isolated Corynebacterium sp. Similar to previous cases in the literature, species determination was not possible. However, the antibiotic sensitivity profile of this isolate suggested Corynebacterium jeikeium. Conversion to external ventricular drainage (EVD) was done and intravenous vancomycin was administered for 21 days. RESULTS AND CONCLUSIONS: The patient showed progressive improvement. Since the first CSF shunt infection caused by Corynebacterium sp., 16 other cases in the literatures have been reported. Additionally, this study reports the difficulties in recognizing CSF shunt infection caused by this agent and the possible clinical or laboratory patterns as observed in the literature.

Community-acquired pneumonia in younger patients is an entity on its own.

Community-acquired pneumonia (CAP) is now most frequent in elderly patients. CAP in the younger patient has attracted much less attention. Therefore, we compared patients with CAP aged 18 to <65 yrs with those aged ≥ 65 yrs. Data from the prospective multicentre Competence Network for Community Acquired Pneumonia Study Group (CAPNETZ) database were analysed for potential differences in baseline characteristics, comorbidities, clinical presentation, microbial investigations, aetiologies, antimicrobial treatment and outcomes. Overall, 7,803 patients were studied. The proportion of younger patients (aged <65 yrs) was 52.3% (18 to <30 yrs 6.4%; <40 yrs 17.1%; <50 yrs 29.4%). Comorbidity was present in only half of the younger patients (46.6% versus 88.2%). Fever and chest pain were more common. Most younger patients presented with mild CAP (74.0% had a CRB-65 [corrected] score of 0 (confusion of new onset, [corrected] respiratory rate of ≥ 30 breaths · min(-1), blood pressure <90 mmHg or diastolic blood pressure ≤ 60 mmHg, age ≥ 65 yrs)). Overall, Streptococcus pneumoniae and Mycoplasma pneumoniae were the most frequent pathogens in the younger patients. Short-term mortality was very low (1.7% versus 8.2%) and even lower in patients without comorbidity (0.3% versus 2.4%). Long-term mortality was 3.2% versus 15.9%, also lower in patients without comorbidity (0.8% versus 6.1%). Most of the differences found clearly arise after the fifth or within the middle of the sixth decade. CAP in the younger patient is a clinically distinct entity.

Sacroiliitis infected with group A streptococcus in a child presenting with confusion and combativeness.

Group A streptococcus-associated severe invasive infection (streptococcal toxic shock syndrome) has been described. Streptococcal toxic shock syndrome occurs when the infecting strain of group A streptococcus produces superantigens. Confusion and combativeness are well known as the common symptoms of streptococcal toxic shock syndrome. We encountered a child who suffered from pyogenic sacroiliitis, with confusion and combativeness. Group A streptococcus was isolated from the patient's blood culture. However, his disease did not fulfill the criteria of streptococcal toxic shock syndrome. Pyogenic sacroiliitis in children is rare, but patients with pyogenic sacroiliitis due to group A streptococcus infection could show confusion and combativeness as clinical signs, similar to the signs in streptococcal toxic shock syndrome.

False impressions from clear cerebrospinal fluid and a normal computed tomography scan: the pressure is still on for a diagnosis.

We report the case of a 33-year-old man presenting with seizures following a 3 week, non-specific febrile illness characterized by progressive confusion. Despite the presence of risk factors, his HIV serology was negative and he had no premorbid suggestion of immunocompromise. We describe the difficulties in making the diagnosis of cryptococcal meningitis in the presence of cerebrospinal fluid analysis with the only abnormality initially being hypoglycorrhachia. This case also highlights the importance of measuring an opening pressure, a procedure which should be routine, but is often neglected in the performance of lumbar punctures. Finally, this case reinforces the maxim that cranial CT cannot be relied upon alone to diagnose intracranial hypertension, which also requires clinical examination, including fundoscopy.

[Tuberculoma and tuberculous meningeal-radiculitis with paradoxical progression during treatment]. / Tuberculomes et méningoradiculite tuberculeuse d'évolution paradoxale sous traitement.

INTRODUCTION: Neuromeningeal tuberculosis of deleterious, paradoxical, progression despite appropriate antibiotic therapy is rare. OBSERVATION: An immunocompetent woman exhibited an immediately disseminated form of tuberculosis with progressive neurological involvement associating expanding intracranial tuberculomas and meningeal-radiculitis despite adapted anti-tuberculosis quadritherapy. DISCUSSION: During anti-tuberculosis therapy clinical worsening is rare, particularly when 2 different manifestations are associated and the worsening occurs in an immunocompetent patient. This possibility should be systematically evoked in such cases. The explanation of this phenomenon is still unclear.

A case of breathlessness, confusion and diarrhoea.

A 61-year-old woman presented to the emergency department with acute-onset breathlessness, fever, sore throat and confusion. Her initial investigations revealed hyponatremia and middle lobe consolidation. In view of the atypical symptoms and signs, erythromycin was commenced. Urinary legionella antigen was requested and that tested positive. She was one of the first few patients whose findings alerted us to a possible outbreak of legionnaire' disease. We drew the following conclusions from our experience with this and other cases that we saw during the legionnaires' outbreak: an atypical presentation is common, as seen in this lady with confusion. If two cases of atypical pneumonias test positive for legionella within a period of a week, we suggest that public health authorities should be notified to identify the source and contain it. There is a need for continuous and high vigilance for legionnaires' disease.

Antibody response in typhoid fever in endemic Indonesia and the relevance of serology and culture to diagnosis.

Culture and serology were performed on blood and serum samples collected at or shortly after admission from 473 patients presented with suspected clinical typhoid. Clinical symptoms at first presentation including confusion, hepatomegaly, splenomegaly, abdominal pain, anemia, and gastrointestinal bleeding were non-specific as they were observed even more often in non-typhoid patients. Culture confirmed the diagnosis in 65.3% of the patients with typhoid fever as the final diagnosis. The sensitivity (58%) and specificity (98.1%) of a rapid dipstick assay for the detection of S. typhi-specific immunoglobulin M were somewhat lower than those of culture but higher than those of the Widal test. The dipstick assay thus may well be used in the serodiagnosis of typhoid in situation where culture facilities are not available. Combination of test results of dipstick and culture improved sensitivity to 82.5%. In laboratories that perform blood culture the dipstick assay may be used as a rapid screening tests to facilitate a rapid diagnosis. Sensitivity of the dipstick assay strongly increased with duration of illness and was higher for culture positive than for culture negative patients. Duration of illness, and different pathogen and host factors including dose of infection, pathogenicity and antigenicity, and prior antibiotic use are likely to influence the immune response, therefore the result of the dipstick assay. Duration of illness and presence of S. typhi in the blood are major factors that determine severity of disease.

[Mental confusion and multifocal lymphatic and pulmonary tuberculosis. A case report]. / Confusion mentale et tuberculose multifocale ganglionnaire et pulmonaire. A propos d'un cas.

This report describes a case of mental confusion associated with ongoing adenitis and pulmonary tuberculosis in a 20-year-old man with no history of psychiatric disorders. Diagnosis was based on clinical and laboratory findings. Tranquillizers improved mental status and antituberculosis treatment was administered before referring the patient to an internal medicine department. The authors emphasize the rarity of these cases in the Senegalese medical literature and discuss possible diagnostic pitfalls.