Toxocara canis myelitis: clinical features, magnetic resonance imaging (MRI) findings, and treatment outcome in 17 patients.

Toxocara myelitis is a rare disease. Few cases have been reported in the literature. Patients present with myelopathy, occasional eosinophilia in blood and cerebrospinal fluid (CSF), with abnormal signals on magnetic resonance imaging (MRI). In the current study we report 17 cases of isolated Toxocara myelitis from a single tertiary referral center in Lebanon, with description of the clinical presentation, laboratory data, MRI findings, and response to antihelminthic treatment. Clinical and laboratory data were collected for 17 patients who presented with evidence of spinal cord disease. The clinical presentation included sensory, motor, and autonomic dysfunction, predominantly in the lower extremities. Patients exhibited a subacute or chronic course; this was either slowly progressive or remitting-relapsing with mild to moderate disability. The patients underwent extensive blood and CSF workup as well as MRI of the spinal cord and brain. Only 2 patients had a high eosinophil count in the CSF, although blood eosinophilia was seen in 6 patients. All patients tested positive for Toxocara canis antibodies in the blood and CSF. MRI of the spinal cord revealed a single characteristic lesion in the spinal cord with fusiform enlargement that was isointense on T1-weighted images and hyperintense on T2-weighted images. Nodular enhancement was seen after gadolinium injection. Treatment with albendazole, with or without steroids, resulted in marked neurologic improvement and normalization of the MRI in all patients.The finding of a single inflammatory MRI lesion in the spinal cord with positive Toxocara canis serology in the blood and CSF in cases of subacute or chronic myelitis suggests the diagnosis of Toxocara myelitis, irrespective of the presence of eosinophilia. Antihelminthic treatment is associated with a good outcome.

Neurobrucellosis presenting with hearing loss, gait disturbances and diffuse white matter disease on brain magnetic resonance imaging (MRI).

PURPOSE: To report an unusual case of neurobrucellosis. METHODS: A 48-year-old man was admitted to Rafik Hariri University Hospital (RHUH) for progressive gait disturbances, hearing loss, and some episodes of chills without documented fever. The neurological examination showed gait ataxia, tremor in the legs and mild cognitive decline. The physical exam was otherwise normal. RESULTS: Magnetic resonance imaging (MRI) of brain showed diffuse, bilateral, confluent, subcortical, and periventricular white matter disease. Serum agglutination test (SAT) for Brucella was positive in blood and cerebrospinal fluid (CSF). The patient was treated with a combination of ceftriaxone for one month, and doxycycline and rifampicin for one year and his condition stabilized. Literature review was performed. The possible underlying pathophysiological mechanisms are discussed. CONCLUSION: Neurobrucellosis is a very rare complication of human brucellosis, and can present with a variety of central nervous system symptomatology (CNS) and MRI changes suggestive of leukoencephalopathy. Its diagnosis could be challenging and should always be suspected in patients presenting with CNS manifestations and/or diffuse white matter disease visualized on brain MRI, especially in Brucella endemic areas.

Right hemisphere language mapping in patients with bilateral language.

PURPOSE: The configuration of language cortex in the dominant left hemisphere has been well described in the literature. However, language representation in the right hemisphere, particularly in patients with some degree of bilateral language, remains unclear. Herein, we report six patients who underwent electrocortical stimulation (ECS) for language mapping following implantation of a right subdural electrode array (SEA). METHODS: The medical records of six bilateral language patients with right SEA implantation at the Minnesota Epilepsy Group between January 1996 and July 2004 were retrospectively reviewed. Language lateralization was based on the results of the intracarotid amobarbital procedure performed preoperatively. Anatomical localization of the SEA for each patient was verified using colored photographs of the cortical surface before and after SEA placement and by review of MRI scans taken with the SEA in place. Frontal and temporal language areas were identified by errors in any language modality including automatic speech, reading, naming, repetition, and comprehension during ECS. RESULTS: Language maps revealed the presence of frontal and/or temporal language areas analogous to the classic essential language areas of the dominant left hemisphere in four of six patients. One patient had a widespread distribution of single-language-error sites over the right temporal lobe. One patient had a silent language map. CONCLUSION: Our results identified the presence of language cortex in the right hemisphere in five of six patients classified with bilateral language based on intracarotid amobarbital procedure. These areas are assumed to be accessory language zones in relation to the left hemisphere. Further exploratory studies are needed to evaluate their clinical significance.