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.

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.

Tuberculous skin ulcer following needle-prick injury in a health care professional.

A case of cutaneous inoculation tuberculosis in a 25-year old health care professional is reported. The diagnosis was confirmed by histopathology and isolation of Mycobacterium tuberculosis by BACTEC 460TB radiometric method. Rapid healing of the ulcer was noted in response to surgical debridement and specific anti-tuberculous therapy.

Diagnosis of neurotoxoplasmosis by antibody detection in cerebrospinal (CSF) fluid using Latex Agglutination Test and ELISA.

The present study was carried out to evaluate the utility of Anti-Toxoplasma gondii antibody detection in CSF specimens using Latex Agglutination Test (LAT) and Enzyme Linked Immunosorbent Assay (ELISA) for the diagnosis of NT. The study included CSF specimens from twenty-five HIV seropositive, autopsy proven (histopathological) cases of NT and 29 control cases with CNS diseases other than NT. All the specimens were subjected for antibody detection by LAT, IgG ELISA and IgM ELISA. Out of 25 CSF samples from autopsy proven cases of NT, LAT was positive in 48%, whereas ELISA for IgG antibody was positive in 92% of the cases. IgM antibodies were present in only one case that was also positive by LAT and IgG ELISA. None of the control CSF specimens showed anti-T. gondii antibodies either by LAT or ELISA. Detection of anti-T. gondii IgG antibodies in CSF can be a useful adjunct to the clinical and CT findings in the diagnosis of NT. IgG ELISA is more sensitive when compared to LAT. IgM antibody detection has a negligible value in the diagnosis of NT.

Viral antibodies in blood in obsessive compulsive disorder.

IgG viral antibodies for herpes simplex virus -1, varicella zoster virus, cytomegalovirus, measles and mumps were studied in 76 subjects with obsessive compulsive disorder and compared with a control population. There was a significantly higher titre for some of the antibodies, most specifically for herpes simplex virus type 1 and mumps. This suggests a possible role for these viral infections in the pathogenesis of obsessive compulsive disorder.

Immunoreactive antigenic sites of Cysticercus cellulosae relevant to human neurocysticercosis--immunocytochemical localization using human CSF as source of antibody.

With a view to identify the relevant antigens of Cysticercus cellulosae, recognized within human central nervous system, immunocytochemical localization of antigens on the cestode larva has been carried out using cerebrospinal fluid of patients as the source of primary antibody. CSF from nine proven cases of neurocysticercosis, two cases of culture proven tuberculous meningitis and two cases of spinal disc prolapse with no other infective or neurological disorder were used in this study. The CSF from all the cases of neurocysticercosis intensely reacted with the glycocalyx over the integument of the cyst bladder wall. The other structures recognised by the CSF antibodies were cytoplasm of the tegumentary cytons, stroma and the ductular system of the bladder wall. The cells, stroma and calcareous corpuscles of the scolex reacted variably with the CSF. Tegument of the spiral canal and sucker muscles in the scolex were not immunoreactive. We strongly suggest that the glycocalyx is the most antigenic anatomical structure of the Cysticercus cellulosae and the patients develop antibodies to it.

Primary mycotic abscess of the brain caused by Fonsecaea pedrosoi. Case report.

A case of cerebral abscess caused by Fonsecaea pedrosoi is reported in a nonimmunocompromised 15-year-old boy. In the absence of a primary cutaneous lesion, this fungus was considered to be a primary neuropathogen. The fungus was cultured and characterized from the abscess material obtained at surgery. Prompt therapy using amphotericin B and 5-flucytosine helped in the successful recovery of this patient.

Comparative evaluation of cysticercal antigens and immunoassays in the diagnosis of neurocysticercosis.

Enzyme linked immunosorbent assay (ELISA), dot immunobinding assay (DIA) and passive haemagglutination assay (PHA) were evaluated for the detection of anticysticercal antibodies in cerebrospinal fluids (CSF) from neurocysticercosis (NCC) patients. Results from the three tests were similar. Higher titres of antibodies were observed to the antigens in porcine whole-cyst sonicate than to those in vesicular fluid or scolex or membrane sonicates. Affinity purified parasitic antigens showed a higher degree of specificity and sensitivity in PHA than in ELISA or DIA. Western blot analyses with cyst antigens showed that CSF antibodies from confirmed NCC patients consistently recognized a protein in the region of 64-68 kDa. Other proteins, of 110, 94-97, 80, 72-75, 52, 45, 26-28 and 16-18 kDa, showed heterogenous reactivity, whereas the partially purified antigen of 64-68 kDa showed a high degree of sensitivity and specificity.

The far cry of a TB brain. Report of a case of tuberculous meningitis, multiple tuberculomas and tuberculous abscess.

An unusual case of neurotuberculosis presenting with tuberculous meningitis, tuberculous abscess and multiple tuberculomas is reported. The patient showed a dramatic response and resolution of tuberculomas with antituberculous therapy only after excision of the abscess.

Acute leptomeningitis due to Bacillus anthracis. A case report.

A fatal case of anthrax meningitis in a 45-year-old woman is presented from Karnataka State, South India. The clinical, microbiological and histopathological profile is presented.

Cerebral cladosporiosis--a neuropathological and microbiological study.

Cerebral cladosporiosis is a rare mycotic infection of the brain. So far only 21 culture-proven cases of cerebral cladosporiosis have been listed in literature (FETTER et al. 1967, FETTER and KLINTWORTH, 1978). In view of the rarity of this mycotic infection and its clinical importance we report two cases of culture-proven cerebral cladosporiosis. They presented as meningoencephalitis with extensive areas of haemorrhagic infarctions of frontoparietal lobes. Both patients were middle-aged farmers from Karnataka State, South India. The clinical, neuropathological and mycological features are presented.