GeneXpert: A Rapid and Supplementary Diagnostic Tool for Tuberculous Meningitis, Experience from Tertiary Neurocenter.

Background Tuberculous meningitis (TBM) is a highly lethal form of central nervous system tuberculosis (CNS TB) that causes high mortality and morbidity in children and adults. Nonspecific clinical presentation and fewer TB bacilli challenge clinicians resulting in delays in diagnosis and treatment. Aim This study aimed to evaluate the utility of GeneXpert alone and in combination with culture using 1 mL of cerebrospinal fluid (CSF) in a volume constraint situation. Methods A total of 125 clinically confirmed TBM and 110 non-TBM cases, comprised of both infectious and noninfectious diseases. were included in the study. Patient details including clinical signs and symptoms, CSF, and imaging data were collected from the case records. CSF samples were obtained from all the patients and were tested by the mycobacterial culture method and GeneXpert test. The performance of both the tests was statistically calculated and reported in the form of sensitivity and specificity. Results Out of 125 TBM cases, 40 were detected positive by culture and 26 by GeneXpert. All 110 non-TBM cases were identified negative by both methods. The sensitivity and specificity of GeneXpert in comparison with culture were 27 and 100%, respectively. The culture was found to be more sensitive (32%) than GeneXpert. But the assay was able to detect a considerable number of clinically confirmed culture-negative TBM cases. Conclusion GeneXpert is a rapid test and including this as an adjunctive test along with the culture in routine clinical practice can improve the diagnosis of TBM in volume constraint scenario.

Consumption of spine by tuberculosis in the era of directly observed treatment, short-course and genomic diagnosis.

BACKGROUND: Extra Pulmonary Tuberculosis (EPTB) is a significant health problem in both developing and developed countries. Spinal tuberculosis (STB) is one of the significant forms of EPTB lacking epidemiological data. The present study was conducted to study the clinical, radiological, microbiological and histopathological features, treatment and outcome of Spinal tuberculosis. METHODS: This study was conducted for a duration of 19 years, from 2000 to 2018 at the department of Neuromicrobiology, NIMHANS, Bengaluru. It comprised of 252 patients with STB. All patients were diagnosed with the clinical features and confirmed by radiological, microbiological and histopathological findings. RESULTS: Results were tabulated and statistically studied. The most common age group is 30-40 years with male preponderance. Most patients presented with motor paraplegia/para paresis (99.6%). Thoracic spine was the most common vertebra affected (47.62%). The commonest imaging feature is soft tissue collection (81.74%). Most common histopathological feature was necrotising granulomatous inflammation (65.87%). Microbiology reports showed growth of Mycobacterium tuberculosis (MTB) in 29.76%, Ziehl Neelsen (ZN) smear showed acid fast bacilli (AFB) in 25.79%. Anti tubercular drugs and surgery were advised in 55.55% patients and only anti TB drugs for 39.28%. The entire course of anti tubercular treatment (ATT) was completed in 60.71% and 4.76% were defaulters. CONCLUSION: Spinal tuberculosis is a global disease, timely diagnosis with clinical, imaging, microbiological, histopathological features and complete course of anti-tubercular treatment along with symptomatic treatment appears to be safe and effective.

Device-Associated Meningitis by Linezolid-Resistant Staphylococcus haemolyticus in a Vancomycin- Hypersensitive Patient.

Postsurgical device-related meningitis caused by multidrug-resistant coagulase-negative staphylococci often complicates the treatment options. We report a rare and, to our knowledge, the first clinical case report of drain-associated meningitis caused by methicillin- and linezolid-resistant Staphylococcus haemolyticus following linezolid therapy in a vancomycin-hypersensitive patient subsequently treated with cotrimoxazole, resulting in clinical improvement. The molecular mechanisms responsible for linezolid resistance were found to be the presence of G2576T mutation in domain V of 23srRNA region, which often arises during linezolid usage and also carriage of cfr gene, which promotes resistance independent of antibiotic pressure. We emphasize on monitoring the rational use of linezolid to avoid the spread of resistance and also comprehensive perioperative care to prevent health care-associated infection.

Methicillin-resistant Staphylococcus aureus intracranial abscess: An analytical series and review on molecular, surgical and medical aspects.

PURPOSE: Intracranial abscess caused by methicillin-resistant Staphylococcus aureus (MRSA) is rare and unexplored. The aim of the present study is to examine the prevalence, clinical and molecular characteristics, treatment options and outcome of MRSA intracranial abscess over a period of 6 years. PATIENTSAND METHODS: A total of 21 patients were included in this retrospective study. The demographic and clinical details of all the patients were collected. Molecular typing including staphylococcal cassette chromosome mec typing, spa typing and polymerase chain reaction of Panton-Valentine leucocidin toxin (PVL) gene for the latter 6 isolates was performed. RESULTS: The paediatric population was the most affected group (33.3%). The primary route of infection was post-operative/trauma in 7 (33.3%) cases. All the patients were treated surgically either by aspiration or excision. Fifteen (71%) patients received anti-MRSA treatment with vancomycin or linezolid, where linezolid-treated patients showed better prognosis. Of the 11 patients who were on follow-up, unfavourable outcome was observed in 3 (27.3%) cases and 8 (72.7%) cases improved. The molecular typing of six isolates revealed four community-associated (CA) MRSA, one each of livestock-associated (LA) and healthcare-associated MRSA with PVL gene noted in all. CONCLUSION: We propose that timely diagnosis, surgical intervention and appropriate anti-MRSA treatment would contribute to better outcome. The occurrence of CA-MRSA and LA-MRSA infection in the central nervous system signifies the threat from the community and livestock reservoir, thus drawing attention towards surveillance and tracking to understand the epidemiology and implement infection control measures.

Streptococcus pluranimalium: Emerging Animal Streptococcal Species as Causative Agent of Human Brain Abscess.

BACKGROUND: Streptococcus pluranimalium is a new and emerging animal streptococcal species associated with primary infection in bovine and avian species. Data in the literature regarding its pathogenic significance in human beings are limited. We hereby report a case of brain abscess caused by S. pluranimalium in a healthy adult male. S. pluranimalium, a causative agent of brain abscess, was unanticipated, and to the best of our knowledge, this is one of the rare cases reported in the medical literature. CASE DESCRIPTION: A 44-year-old male presented with headache and occasional episodes of vomiting for 2 weeks, weakness of the left upper and lower limbs for 1 week, and 1 episode of generalized tonic clonic seizure 2 days back. He was afebrile and had no history of loss of consciousness or head trauma. His physical and neurologic examination was unremarkable. Magnetic resonance imaging of the brain revealed a focal ring enhancing lesion in right posterior parietal lobe, suggestive of infective etiology. The patient underwent right parietooccipital craniotomy and excision of cerebral abscess, from which S. pluranimalium was isolated. The patient responded to treatment with intravenous ceftriaxone, vancomycin, and metronidazole without any residual neurologic sequelae. CONCLUSION: Clinical data regarding epidemiology, pathogenic mechanisms, and zoonotic potential of S. pluranimalium in human beings are lacking. The number of cases of human infections with S. pluranimalium are steadily increasing. Hence further detailed study of the pathogenesis of S. pluranimalium in human beings is warranted, which may help to develop new strategies to prevent and treat infection with this bacterium.

Methicillin-Resistant Staphylococcus aureus central nervous system infections--Analysis and outcome.

INTRODUCTION: Methicillin-Resistant Staphylococcus aureus (MRSA)-associated infections are potentially devastating and fatal. It has two distinct pathogenic mechanisms: postoperative and spontaneous. In the study presented here, we review the epidemiology, clinical features, response to treatment, and outcome of MRSA central nervous system infections at our tertiary referral institute. MATERIAL AND METHODS: In this analysis, we reviewed the medical records of all patients who were diagnosed with S. aureus meningitis between January 2010 and December 2012. Clinical information included predisposing factors, past medical history, comorbidities, mode of acquisition of infection, as well as therapeutic management, length of treatment, and clinical outcomes were analyzed. RESULTS: A total of 34 cases of MRSA meningitis were diagnosed during the study period. There were 28 (82.4%) cases of postoperative meningitis and 6 (17.6%) cases of spontaneous meningitis. A majority (24/28) of the patients had one or the other predisposing conditions for the infection. Compared with patients with postoperative meningitis, patients with spontaneous meningitis had a significantly older (31.93 yrs vs 55.8 yrs; p = 0.021) and higher frequency of community-acquired infection (100% vs. 39%; p = 0.007). In patients with postoperative meningitis, the median postoperative day when the infection manifested clinically was day- 19 (range, 3-90 days). A total of 25/34 (74%) patients received definitive antibiotic (vancomycin and/or linezolid based) therapy. Nine patients were continued on empirical antimicrobial therapy (combination of ceftriaxone, amikacin, and metronidazole), as the organism was sensitive to those drugs. There were no in-hospital mortalities in our series, though 3/34 patients (8.8%) were discharged with Glasgow coma score (GCS)< 8 and 8/34 patients (23.5%) were discharged with GCS 9-12 from the hospital. CONCLUSION: In acute bacterial meningitis, there is a progressive shift from methicillin-sensitive strains to methicillin-resistant strains in recent years. Although most patients have a favorable response to vancomycin and linezolid, the beneficial effect of combined antimicrobial therapy or alternative antibiotics needs to be evaluated.

An unusual infection, an unusual outcome--Fonsecaea pedrosoi cerebral granuloma.

Phaeohyphomycosis is caused by pigmented fungi that are not normally pathogenic. Fonsecaea is a rare cause of cerebral infections, most of which are caused by F. monophora. Brain infections caused by F. pedrosoi are very rare, and there are only a few case reports describing this. Most infections take the form of abscesses (epidural or intracerebral). The authors report a rare case of a contained fungal granuloma caused by F. pedrosoi. The patient presented with epilepsy, which was treated as a case of extratemporal lesion-related epilepsy. The diagnosis was made after resection. The authors describe the clinical course of this patient.