Pneumococcal meningitis with normal cerebrospinal biochemistry and no pneumococci at microscopy, mimicking a stroke: a case report.

BACKGROUND: Bacterial meningitis commonly presents with symptoms such as headache, impaired consciousness, neck stiffness, and fever. In most cases, cerebrospinal fluid analysis will yield white cell counts >100/mm3. Atypical presentations occur, especially in the very young or very elderly and the immunocompromised. We report an unusual case of pneumococcal meningitis in a healthy 78-year-old Danish woman who presented with clinical features mimicking a stroke with normal cerebrospinal fluid parameters and without microscopic evidence of bacteria. CASE PRESENTATION: The patient was admitted after being found unconscious on her bed. Upon admittance, she was considered confused, with a temperature of 39.4 °C and slight neutrophilic leukocytosis, but no neck stiffness. A neurological examination revealed bilateral horizontal nystagmus, unstable eye movements, and suspected right-sided gaze paralysis. Cerebrospinal fluid analysis revealed normal parameters, and the microscopy result was negative for bacteria. The most likely diagnosis was considered to be stroke with concomitant infection. However, cerebrospinal fluid and blood cultures subsequently were rapidly positive for pneumococci. Neither immunodeficiency nor blood contamination was considered a likely cause of this discrepancy. CONCLUSIONS: This case emphasizes the need to consider a multidisciplinary approach and empirical meningitis treatment until diagnostic results from microbiological cultures are obtained.

Prolonged Cerebrospinal Fluid Neurofilament Light Chain Increase in Patients with Post-Traumatic Disorders of Consciousness.

The mechanisms involved in secondary brain injury after the acute phase of severe traumatic brain injury (TBI) are largely unknown. Ongoing axonal degeneration, consequent to the initial trauma, may lead to secondary brain injury. To test this hypothesis, we evaluated the cerebrospinal fluid (CSF) level of neurofilament light chain (NF-L), a proposed marker of axonal degeneration, in 10 patients who developed a severe disorder of consciousness after a TBI, including 7 in a minimally conscious state and 3 with unresponsive wakefulness syndrome (time since brain injury, 309 ± 169 days). CSF NF-L level was measured with a commercially available NF-L enzyme-linked immunosorbent assay. CSF NF-L level was very high in all 10 patients, ranging from 2.4- to 60.5-fold the upper normal limit (median value, 4458 pg/mL; range, 695-23,000). Moreover, NF-L level was significantly higher after a severe TBI than in a reference group of 9 patients with probable Alzheimer's disease, a population with elevated levels of CSF NF-L attributed to neuronal degeneration (median value, 1173 pg/mL; range, 670-3643; p < 0.01). CSF NF-L level was correlated with time post-TBI (p = 0.04). These results demonstrate prolonged secondary brain injury, suggesting that patients exhibit ongoing axonal degeneration up to 19 months after a severe TBI.

[CSF RT-PCR standardization in pediatric patients with enteroviral central nervous system infection]. / Estandarización de RT-PCR en LCR de pacientes pediátricos con infección del sistema nervioso central por enterovirus.

OBJECTIVE: We standardized the RT-PCR panviral CSF and determined its applicability in detecting acute enterovirus infection in the central nervous system in children under 15 years. MATERIAL AND METHODS: RT-PCR was performed directly in CSF samples of 10 pediatric patients with suspected CNS infection and 9, with different conditions of the central nervous system. RESULTS: 80% (8/10) of RT-PCR samples were positive for enterovirus in patients with suspected CNS infection and no sample was positive in patients with different ailments. CONCLUSIONS: Since enteroviruses are among the main etiologies of pediatric encephalitis, RT-PCR could be particularly useful for rapid detection in CSF.

[Beware of unconspicious cerebro spinal fluid]. / Gefahrenquelle unauffälliger Liquorstatus.

Nowadays with a lot of diagnostic facilities it is also difficult to find the right diagnose of herpes encephalitis. The aim of this case report was to give an overview about strategies of diagnostic and therapy of the herpes encephalitis.

Classification of acute encephalopathy in respiratory syncytial virus infection.

Infection with respiratory syncytial virus (RSV) is known to be associated with central nervous system symptoms such as convulsions. We investigated cytokines, nitrogen oxide (NO)( x ), and the viral genome in cerebrospinal fluid (CSF) obtained from children with RSV infection-related convulsions or central nervous symptoms and compared the data with type of encephalopathy. Of nine patients enrolled (six boys and three girls; aged 10 days-3 years), one metabolic error, five excitotoxicity, one cytokine storm, and two hypoxia cases were found. The patients presented with unilateral convulsions, generalized convulsions, and convulsions following cardiopulmonary arrest, apnea, and nuchal rigidity. In all patients, a rapid check for RSV of nasal fluid was positive. The RSV genome (subgroup A) was detected in the CSF of five of the nine patients; two patients with hypoxic encephalopathy were negative for the RSV genome. The CSF interleukin (IL)-6 levels were high only in patients with the excitotoxicity and cytokine storm type of encephalopathy. NO( x ) levels were high in all the subject cases. In the excitotoxicity type, NO( x ) levels were significantly higher than those in the control and other groups. NO( x ) level may become an important parameter for the diagnosis and classification of acute encephalopathy in RSV. Strategies to treat each type of encephalopathy, targeting cytokines and free radicals, should be established.

Diffusion-weighted imaging in preclinical Leigh syndrome.

We report on a preterm Japanese male baby with Leigh syndrome, i.e., intrauterine growth restriction, central apnea, and feeding difficulty. These signs improved at 41 weeks of corrected age. At that time, brain magnetic resonance imaging revealed increased signal in diffusion-weighted imaging in the parietal white matter, bilaterally and symmetrically not respecting vascular territory or boundaries. However, clinical improvement deterred us from further investigation. About 3 months later, he manifested frequent ictal apnea with myoclonic seizures and deterioration of consciousness to semicoma. Subsequent diffusion-weighted imaging revealed increased signal in the bilateral symmetric thalamus, internal segments of the globus pallidus, substantia nigra, and pontine tegmentum. Laboratory investigation indicated remarkable elevation of lactate levels in cerebrospinal fluid. The diagnosis was of Leigh syndrome. We think this is the first reported case of Leigh encephalopathy with transient abnormality of diffusion-weighted imaging of the white matter before apparent clinical onset. Leigh syndrome should be included in the differential diagnosis of abnormality of diffusion-weighted imaging in white matter without apparent clinical signs.

Gadolinium encephalopathy in a patient with renal failure.

Gadolinium chelates are extensively used in MRI studies. Neurotoxicity due to gadolinium chelates is minimal and uncommon. A 57-year-old woman in renal failure developed a subacute encephalopathy after inadvertent repetitive gadolinium contrast administration. An unusual MRI appearance with CSF hyperintensity due to gadolinium diffusion into the CSF is also shown.

Cerebrospinal fluid syndromes in HIV-positive patients with acute consciousness compromise

Revisamos as síndromes liquóricas de 100 pacientes HIV-positivos apresentando comprometimento agudo da consciência em pronto-socorro, as correlacionando com dados clínicos. As síndromes mais freqüentes foram: dissociaçäo proteino-citológica absoluta (21), viral (19), neurocriptococose (7), dissociaçäo proteino-citológica relativa (6) e séptica (4), hipoglicorraquia moderada (4 por cento), hipoglicorraquia severa (4 por cento), distúrbio hidroeletrolítico (3 por cento). Um quinto dos pacientes apresentou síndromes liquóricas consideradas suficientes para um diagnóstico ou uma conduta imediata. Os dados clínicos mais comuns foram infecciosos e neurológicos. Houve pouca correlaçäo entre os dados clínicos e as síndromes liquóricas. Comparado a dados de literatura, HIV-positivos tem menor chance de resultados decisivos no exame de líquor. Nós concluimos que, em pacientes HIV-positivos, que se apresentam com alteraçöes agudas da consciência, freqüentemente há resultados inespecíficos no líquor, o que deve ser julgado em funçäo de uma história clínica e exame físicos detalhados

Cerebrospinal fluid syndromes in patients with acute consciousness compromise.

We reviewed the laboratorycards of 200 analysis of cerebrospinal fluid (CSF) performed to evaluate acute alterations of consciousness in adult patients attended in a neurological emergency room. 61% were men; the mean age was 46 years. The most common clinical data were infective and neurologic. The CSF was abnormal in 149 (74.5%) patients and the most common syndromes were: compressive (21%), hemorrhagic (11.5%), "viral" (8.5%), septic (7.5%), moderate hyperglycorrachia (6.5%), hydroelectrolytic disturbances (5.5%). There were some statistically significant correlations between CSF syndromes and clinical data: septic syndrome and fever and meningeal signs, hemorrhagic syndrome and headache and meningeal signs, CSF hydroelectrolytic disturbance syndrome and seizures, severe hyperproteinorrachia and headache, fever, meningeal signs and vomiting, moderate hyperproteinorrachia and age over 65 and male sex. We classified the abnormal results in two groups: 1--sufficient for an immediate clinical decision; 2--nonspecific. The former group was found in 27.5% of the patients and in 36.9% of the abnormal CSF results. In patients attending to neurologic emergency rooms with acute alterations of consciousness, the examination of the CSF frequently could contribute to an etiologic diagnosis. It must be performed after a rigorous clinical evaluation of the patient.

Cerebrospinal fluid syndromes in patients with acute consciousness compromise

We reviewed the laboratory cards of 200 analysis of cerebrospinal fluid (CSF) performed to evaluate acute alterations of consciousness in adult patients attended in a neurological emergency room. 61 percent were men; the mean age was 46 years. The most common clinical data were infective and neurologic. The CSF was abnormal in 149 (74.5 percent) patients and the most common syndromes were: compressive (21 percent), hemorrhagic (11.5 percent), "viral"(8.5 percent), septic (7.5 percent), moderate hyperglycorrachia (6.5 percent), hidroelectrolytic disturbances (5.5 percent). There were some statistically significant correlations between CSF syndromes and clinical data: septic syndrome and fever and meningeal signs, hemorrhagic syndrome and headache and meningeal signs, CSF hydroelectrolytic disturbance syndrome and seizure, severe hyperproteinorrchia and headache, fever, meningeal signs and vomiting, moderate hyperproteinorrachia and age over 65 and male sex. We classified the abnormal results in two groups: 1 - sufficient for an immediate clinical decision; 2 - nonspecific. The former group was found in 27.5 percent of the patients and in 36.9 percent of the abnormal CSF results. In patients attending to neurologic emergency rooms with acute alterations of consciousness, the ecamination of the CSF frequently could contribute to an etiologic diagnosis. It must be performed after a rigorous clinical evaluation of the patient.

Lymphocytosis of donor origin in cerebrospinal fluid, and marrow aplasia after donor leukocyte infusion for EBV-lymphoproliferative disease.

A 29-year-old woman underwent a T cell-depleted unrelated donor transplant for CML in chronic phase. Sixty-three days after marrow infusion, the patient developed fevers and generalized lymphadenopathy. Lymph node biopsy was consistent with monoclonal EBV-associated immunoblastic lymphoma for which the patient received 10(5) CD3-positive donor leukocytes per kilogram. Six days after leukocyte infusion the patient developed mental status changes without focal neurological deficit. MRI revealed no mass lesions. Cerebral spinal fluid revealed a white blood cell count of 1650 cells/mm3 which were shown to be T lymphocytes of donor origin. The CSF was tested and found to be PCR positive for EBV virus interval repeat 1 sequence (IR1). The lymphocytosis and mental status changes resolved without specific intervention. Subsequently she developed marrow aplasia, which was believed to be secondary to the infusion of donor leukocytes. Possible mechanisms for these two previously unreported side-effects of donor leukocyte infusion are discussed.

Monitoring of fibrin and fibrinogen degradation products (FDP) in the cerebrospinal fluid of patients with subarachnoid haemorrhage due to ruptured aneurysm. Report of 55 cases.

Fibrin and fibrinogen degradation products in the cerebrospinal fluid (CSF-FDP) were first studied in a group of 29 patients observed during the first and the second week after subarachnoid hemorrhage (SAH), then in a second group of 26 patients for a total of 55 patients. In the latter group only the first FDP value obtained as soon as possible after SAH was taken in consideration. In the whole series of 55 patients several noteworthy factors were found: 1) FDP determination should be performed as soon as possible after SAH; 2) CSF-FDP at or above 40, 80 micrograms/ml was found both in the patients with severe neurological deficits and in those with cerebral ischemia (statistically significant); 3) the significance of CSF-FDP in patients who rebled was also evaluated. In conclusion CSF-FDP could be considered useful in predicting cerebral ischemia.

[Intracranial pressure in cases of non-traumatic cerebral hematoma-- personal observations and review of the literature]. / Cisnienie wewnatrzczaszkowe w przypadkach nieurazowych krwiaków sródmózgowych--obserwacje wlasne i analiza pismiennictwa.

The analysis of intracranial pressure records in 95 cases of non-traumatic intracerebral haematoma is presented. In 74 cases continuous recording was done. No correlation was found between the values of this pressure and consciousness disturbances. Three types of pressure change patterns were demonstrated: type A - low or normal values unchanging in 43 cases, type B - high initial values with normalization during conservative treatment, type C - very high initial values which decreased after operation in only some patients.

[Non-traumatic cerebral hematoma and the mechanisms of intracranial volume compensation]. / Nieurazowy krwiak sródmózgowy a mechanizmy wewnatrzczaszkowej kompensacji objetosciowej.

The results are presented of measurements of the intracranial pressure, pressure instability index and shifting of ventricular structures in 42 patients with non-traumatic intracerebral haematoma. Only the value of the instability index showed a correlation with the state of consciousness. For a more complete assessment of the state of sufficiency of the intracranial pressure compensation mechanism all these parameters should be analysed jointly.

Concentrations of glycine and serine in cerebrospinal fluid during disturbed consciousness; a study of the therapeutic effect of thyrotropin-releasing hormone on the consciousness level.

The concentrations of aliphatic amino acids (glycine, serine, valine, threonine, alanine, leucine, isoleucine) in lumbar cerebrospinal fluid from patients with consciousness disturbances and normal controls were measured. Thyrotropin-releasing hormone (TRH) was administered to patients and the changes of levels of consciousness and amino acid concentrations were followed before and after TRH administration. The concentrations of glycine and serine from patients were significantly higher than those from controls; they returned to the control values with improvement of consciousness disturbances. The influence of TRH upon these amino acid concentrations was not observed. These results suggest that within the central nervous system, an alteration of the level of consciousness is associated with a distortion of glycine and serine metabolism and that TRH itself has no influence upon these amino acid concentrations.

Concentrations of sulfur-containing free amino acids in lumbar cerebrospinal fluid from patients with consciousness disturbances.

The concentrations of sulfur-containing amino acids (taurine, methionine, cystine, cystathionine, homocystine) in lumbar CSF from patients with consciousness disturbances and controls were measured, and it was investigated whether there was any correlation between the sequential changes of these amino acid concentrations and of the level of consciousness. In all patients, thyrotropin-releasing hormone (TRH) was administered and the changes of levels of consciousness and amino acid concentrations were followed before and after administration. The concentrations of taurine and cystathionine from the patients were significantly lower, and methionine and cystine significantly higher than those from the controls; they returned to the control values in parallel with improvement of consciousness level. Homocystine was not detected in either patients or controls. These results suggest that the alteration in the level of consciousness is associated with distortion of sulfur-containing amino acid metabolism within the central nervous system, at least in the CSF.