Miliary cerebrospinal lesions caused by Nocardia beijingensis in an immunocompetent patient.

The genus Nocardia usually infect immunocompromised patients. Pulmonary nocardiosis is the most common Nocardia-induced infection while central nervous system (CNS) is the most common extrapulmonary site to develop nocardial disease. Approximately 54 % cases of previously reported nocardial brain abscesses were solitary lesions, while 38 % cases had multiple lesions; but miliary-like ring enhancing lesions have not been reported previously. We present a case of immunocompetent patient with miliary-like cerebrospinal lesions caused by Nocardia beijingensis. A 68-year-old Japanese man presented with acute-onset headache, vomiting, and progressive disturbance of consciousness. A contrasted magnetic resonance imaging (MRI) scan showed countless miliary-like ring-shaped enhancing lesions on the patient's whole brain, brain stem, and cervical spinal cord. A brain biopsy was performed and Kinyoun stain suggested that the brain lesions were abscesses caused by Nocardia species. 16S ribosomal RNA sequencing identified Nocardia beijingensis as the causative microorganism. The trimethoprim/sulfamethoxazole regimen was continued for 7 months and the patient showed good improvement with recovery of consciousness. Clinical manifestation of Nocardia beijingensis infection is poorly studied. Further cases are needed to be accumulated.

[The Skin Findings Associated with Neurotrauma].

Head trauma is a common condition, but often, serious pathological conditions associated with it are hidden. Skin findings in child abuse cases, such as skull base fracture, battle signs, raccoon eye, open head injury, penetrating wounds, traumatic aneurysm of the superficial temporal artery, traumatic carotid cavernous sinus fistula, and fat embolism have been presented in this paper. It is necessary to observe and record skin findings at the time of consultation and to listen to the detailed medical history that resulted in such an injury. It is important to comprehensively diagnose skin findings through medical history, and image inspection.

[A Case of Bone Marrow Metastasis of Oligodendroglioma with IDH Mutation and 1p/19q Codeletion].

A 71-year-old woman was transferred to our hospital, complaining of a seizure for the first time. A tumor was detected in the right frontal lobe, and a craniotomy was performed with a partial tumor resection. The pathological diagnosis was oligodendroglioma with IDH mutation and 1p/19q codeletion, and irradiation therapy was performed. Six months later, the patient's lactate dehydrogenase(LDH)level elevated remarkably, and the fluoro-deoxyglucose-positron emission tomography/computed tomography showed abnormal uptake in multiple bone marrow locations. Bone marrow aspiration was performed, and the pathological diagnosis was oligodendroglioma metastasis. The patient was given two cycles of chemotherapy with temozolomide(TMZ), and her LDH level reduced to normal. After a few months, the LDH level elevated again, so we gave her two more cycles of TMZ;however, her LDH level did not change. Thereafter, the patient was hospitalized because of paraplegia, which started a few days prior, and right lower jaw swelling. Her CT and magnetic resonance imaging showed metastasis to the thoracic vertebrae and right mandibular bone. Irradiation therapy was performed to these locations, and the patient was given chemotherapy using nimustine(ACNU), procarbazine, and vincristine(PAV). Her LDH levels reduced temporarily, but elevated again. The patient deteriorated slowly and died 20 months after she presented with a seizure. Oligodendroglioma with extracranial metastasis is extremely rare, and this case report is the 68th report. The chemotherapy approach with TMZ or PAV/PCV may be effective against oligodendroglioma metastasis to the bone marrow.

[A Ruptured Middle Cerebral Artery Dissecting Aneurysm Operation in a 2-Year-Old Boy].

We report the case of a ruptured dissecting aneurysm in an infant. A 2-year-old boy suffered sudden headache and nausea. CT scan revealed a subarachnoid hemorrhage, and digital subtraction angiography(DSA)revealed a dissecting aneurysm(3.9mm)at a branch of the right middle cerebral artery(MCA). Eight days after onset, carotid angiography revealed enlargement of the aneurysm(up to 6.8 mm). Right frontotemporal craniotomy and aneurysm trapping with STA-MCA bypass was performed. Two years and two months later, the aneurysm recurred as assessed by magnetic resonance angiography(MRA). DSA revealed the recurrence of the aneurysm(7.8mm)proximal to the previous aneurysm and displayed development of collateral flow through leptomeningeal anastomosis between the branches of the MCA. During the second operation, the aneurysm extended to the artery branch proximal to the previous trapping. Parent artery occlusion without bypass was performed. Postoperative DSA revealed collateral flows through leptomeningeal anastomosis between the branch of the MCA and the branch of anterior cerebral artery. At the 3-year follow-up period, abnormal findings on MRI did not appear and he was healthy without any neurologic abnormalities.