Low Yield of Positive Cerebrospinal Fluid (CSF) Culture and Bacterial PCR Tests In Paediatric Patients With A Normal CSF White Cell Count.

The aim was to review paediatric patients who had a positive cerebrospinal fluid culture or bacterial PCR test, yet had a normal CSF white cell count for age. Patients were included if they had a CSF sample sent for culture (between 2005 and 2015) or bacterial PCR (2010-2015), however neurosurgical and neurology patients were excluded. Of the 2,482 patients reviewed, there were 101 patients with laboratory-confirmed bacterial meningitis included, of which 27 were positive by culture and PCR, 26 by culture alone and 48 were positive by PCR only. Eighteen (18%) of these patients had CSF white cell counts within normal range. Only one case with a normal CSF white cell count, where the lumbar puncture was done after six days of antibiotics, was deemed to be clinically significant. Bacterial PCR should not be routinely requested in patients with a normal CSF white cell count, unless their blood culture is positive or unless clinically indicated based on the assessment of a senior paediatrician.

Isolation of NDM-1-producing Klebsiella pnemoniae in Ireland, July 2011.

We report the identification of New Delhi metallo-betalactamase 1 (NDM-1)-producing Klebsiella pnemoniae in Ireland. The organism was resistant to multiple antibiotic classes, including carbapenems, and PCR and sequencing confirmed the presence of the blaNDM-1 gene, carried on a 98 kb plasmid. The organism was isolated from an infant, who was born in India and moved to Ireland at the age of four months. This is the first reported isolation of an NDM-1-producing Enterobacteriaceae strain in Ireland.

Amyloid precursor protein mRNA levels in the mononuclear blood cells of Alzheimer's and Down's patients.

Amyloid precursor protein (APP) is expressed by many non-neural tissues and it is possible that over-expression of the APP gene in non-neural tissue is responsible for the deposition of amyloid beta-protein in the brain and elsewhere. One possible source of beta-protein is circulating mononuclear blood cells which have previously been shown to express APP. To test this hypothesis, RNA was isolated from the mononuclear blood cells of patients suffering from Alzheimer's disease (n = 27), Down's syndrome (n = 13), senile dementia non-Alzheimer type (n = 14) and from normal individuals (n = 48). The relative abundance of mRNA coding for different splicing variants of the amyloid precursor protein (APP) mRNA was measured using multiprobe oligonucleotide solution hybridisation (MOSH). There was no significant difference in APP mRNA levels between any of the groups. This indicates that Alzheimer's disease is not characterised by an increase in production of APP in circulating mononuclear blood cells.

Evaluation of a prebrushing mouthrinse in controlling dental plaque.

The study was designed to evaluate an advertising claim made for a commercial pre-brushing mouthrinse, that it aided plaque removal. Forty-one subjects completed a six month, randomised, two-group, blind, pragmatic clinical trial. Those in the control group continued with their normal oral hygiene practices whilst those in the study group were given supplies of the test rinse and asked to use it in accordance with the manufacturer's instructions. Mean plaque scores recorded in the test group after one month, three months and six months, were statistically significantly lower than in the control group supporting the claim made on behalf of the test product. The clinical significance of these findings, for example on gingivitis, is uncertain and further research is needed to assess this.

Internuclear ophthalmoplegia in tuberculous meningitis.

Two patients with tuberculous meningitis and internuclear ophthalmoplegia are described. Despite treatment with anti-tuberculosis chemotherapy and corticosteroids, both patients died. In one case autopsy showed severe basal meningitis with diffuse brain stem infarction secondary to widespread vasculitis.

Clinical correlation of CT changes in 64 Chinese patients with tuberculous meningitis.

CT changes in 64 Chinese patients with proven tuberculous meningitis were compared with the clinical features at diagnosis. In patients presenting with advanced disease, hydrocephalus and cerebral infarction were common, and the hydrocephalus in these patients was more likely to require surgery at a later date for control of raised intracranial pressure. New infarctions were only seen in follow-up scans of patients who had presented with disturbed consciousness. Meningeal enhancement, the commonest finding, and intracranial tuberculomata were not related to the severity of disease at presentation. A normal scan in a drowsy patient virtually excludes the diagnosis of tuberculous meningitis.

Suprasellar tuberculoma developing during treatment of tuberculous meningitis requiring urgent surgical decompression.

An adult patient on treatment for tuberculous meningitis developed visual failure due to a tuberculoma compressing both optic nerves and chiasm. Although continued anti-tuberculous chemotherapy is the treatment of choice for intracranial tuberculoma, the rapid deterioration in vision necessitated urgent surgical decompression, which resulted in complete recovery of vision.

Diagnosis of tuberculous meningitis by detection of tuberculostearic acid in cerebrospinal fluid.

Tuberculostearic acid, a structural component of Mycobacterium tuberculosis, was identified by gas chromatography/mass spectrometry with selected ion monitoring in cerebrospinal fluid (CSF) from 13 patients with proven and 8 out of 9 patients with suspected tuberculous meningitis; the negative result was in a patient whose symptoms and CSF abnormalities may have been due to systemic lupus erythematosus. Tuberculostearic acid was found in the CSF of only 1 patient out of 87 with non-tuberculous meningitis or non-infectious disorders; the single false-positive result was probably caused by intrathecal treatment with amikacin. Other aminoglycosides and antituberculous drugs did not interfere with the assay. In serial CSF samples from patients with tuberculous meningitis tuberculostearic acid was still present after 8 months of continuous supervised chemotherapy. Detection of tuberculostearic acid in CSF is a rapid, sensitive, and specific test for tuberculous meningitis, and can be used for retrospective diagnosis in patients who have been started on therapy.

Symptomatic intracranial tuberculoma developing during treatment of tuberculosis: a report of 10 patients and review of the literature.

Ten patients with intracranial tuberculomata which developed during treatment for tuberculosis are described. The initial infection was meningeal in five, miliary in three and pulmonary in two and all improved after treatment was started. However 10 days to five months (mean two months) after the start of treatment, new neurological symptoms and/or signs occurred that led to the recognition of intracranial tuberculomata. CT brain scans suggested tuberculomata in all 10 patients; there were several lesions in five and histological confirmation was obtained in three cases. Earlier CT brain scans (six weeks to five months before) were carried out in five patients and in none was a tuberculoma seen. After treatment with anti-tuberculous drugs and control of raised intracranial pressure when present, five patients made a full recovery, three were left with mild neurological deficit and in two it is too early to assess the outcome.

Polymorphonuclear pleocytosis in the cerebrospinal fluid during chemotherapy for tuberculous meningitis.

Five patients on chemotherapy for tuberculous meningitis developed sudden and unexpected cerebrospinal fluid pleocytosis consisting predominantly of polymorphonuclear leucocytes. The cellular changes, which developed 4-108 days after starting treatment, were not accompanied by an alteration in the clinical state and disappeared within a week whether or not an additional antibiotic was prescribed. Through the cause is uncertain, possible mechanisms are discussed. We are prompted to report these cases because the cytological changes are not well recognised and may cause difficulties in management.