Acute severe spinal cord dysfunction in bacterial meningitis in adults: MRI findings suggest extensive myelitis

Noncompressive myelopathy in acute community-acquired bacterial meningitis: Report of seven cases and review of literature

BACKGROUND AND PURPOSE

Bacterial meningitis is a severe disease with high rates of complications and unfavorable outcome. Complications involving the spinal cord are rarely reported.

METHODS

Cases of noncompressive myelopathy were identified from a nationwide cohort study of adults with community-acquired bacterial meningitis in the Netherlands. The American Spinal Injury Association Impairment Scale was used to classify the severity of spinal cord dysfunction. Subsequently, we reviewed the literature on noncompressive myelopathy as a complication of bacterial meningitis.

RESULTS

Noncompressive myelopathy was reported in seven of 3047 episodes of community-acquired bacterial meningitis (0.2%). The median age of these patients was 51 years (range = 17-77). Causative pathogens were Streptococcus pneumoniae in three, Streptococcus agalactiae in two, and Neisseria meningitidis and Haemophilus influenzae both in one. Paresis of legs (n = 6) or arms and legs (n = 1) was the presenting symptom, occurring after a median duration of 9 days after admission (range = 2-28). Spinal magnetic resonance imaging showed T2-weighted abnormalities of the spinal cord in six of seven patients. Improvement of spinal cord function during admission was noted in four of seven patients. The literature review yielded 15 additional cases. Among patients from our cohort and the literature, there was no significant association between immunosuppressive therapy and subsequent improvement of spinal cord function (5/8 patients with immunosuppressive therapy [63%] vs. 5/14 without immunosuppressive therapy [36%], p = 0.44).

CONCLUSIONS

Noncompressive myelopathy is an uncommon but severe complication of bacterial meningitis. Improvement after diagnosis is expected, but all patients had persistent neurological deficits.

Transverse Myelitis: A Case-Based Discussion of Infectious Etiologies

Transverse myelitis (TM) is a frequently encountered inpatient neurological condition, usually with a broad differential of etiologies narrowed down by detailed history, temporal profile of symptom evolution, and pertinent diagnostic studies. We report a rare case of a 39-year-old man who presented with subacute onset of headaches and confusion, and three days later developed quadriplegia and areflexia. He was diagnosed with acute longitudinally extensive transverse myelitis (LETM) related to Epstein-Barr virus (EBV) superimposed on an initial presentation of streptococcal meningitis. As both etiologies are under-reported, we compare our case to the few similar cases in the literature to guide discussion of the clinical and radiologic findings of parainfectious TM related to EBV and streptococcal meningitis. Readers will have the challenge of attributing our patient's myelitis to one of these parainfectious sources and are encouraged to evaluate for rare infectious etiologies in acute settings.

Spinal cord infarction: a rare but serious complication of pneumococcal meningoencephalitis

Here, we report the case of a woman in her 40s who came with pyogenic meningitis and infarcts in the brain. While on treatment with antibiotics, she developed new-onset weakness involving bilateral lower limbs and one upper limb 2 weeks into the course of illness. MRI of the spine showed an infarct in the spinal cord. Spinal cord infarction as a complication of pyogenic meningitis is not well recognised unlike tuberculosis meningitis. Unlike ischaemic strokes where thrombolysis is done, for stroke related to infections, there are no definite strategies. Our patient was treated with physiotherapy, continued on antibiotics and slowly recovered over months and at 18-month follow-up, she was walking with a walker. The exact mechanism of thrombosis is not known but may be due to inflammation of the arterial wall and activation of the procoagulant cascade by infection-triggered inflammation. Spinal cord infarction can occur at any phase of the infection and may occur despite appropriate response to antibiotic treatments.

Cervical myelitis: a practical approach to its differential diagnosis on MR imaging

BACKGROUND

 Differential diagnosis of non-compressive cervical myelopathy encompasses a broad spectrum of inflammatory, infectious, vascular, neoplastic, neurodegenerative, and metabolic etiologies. Although the speed of symptom onset and clinical course seem to be specific for certain neurological diseases, lesion pattern on MR imaging is a key player to confirm diagnostic considerations.

METHODS

 The differentiation between acute complete transverse myelitis and acute partial transverse myelitis makes it possible to distinguish between certain entities, with the latter often being the onset of multiple sclerosis. Typical medullary MRI lesion patterns include a) longitudinal extensive transverse myelitis, b) short-range ovoid and peripheral lesions, c) polio-like appearance with involvement of the anterior horns, and d) granulomatous nodular enhancement prototypes.

RESULTS AND CONCLUSION

 Cerebrospinal fluid analysis, blood culture tests, and autoimmune antibody testing are crucial for the correct interpretation of imaging findings. The combination of neuroradiological features and neurological and laboratory findings including cerebrospinal fluid analysis improves diagnostic accuracy.

KEY POINTS

  · The differentiation of medullary lesion patterns, i. e., longitudinal extensive transverse, short ovoid and peripheral, polio-like, and granulomatous nodular, facilitates the diagnosis of myelitis.. · Discrimination of acute complete and acute partial transverse myelitis makes it possible to categorize different entities, with the latter frequently being the overture of multiple sclerosis (MS).. · Neuromyelitis optica spectrum disorders (NMOSD) may start as short transverse myelitis and should not be mistaken for MS.. · The combination of imaging features and neurological and laboratory findings including cerebrospinal fluid analysis improves diagnostic accuracy.. · Additional brain imaging is mandatory in suspected demyelinating, systemic autoimmune, infectious, paraneoplastic, and metabolic diseases..

Spine MRI: A Review of Commonly Encountered Emergent Conditions

Over the last 2 decades, the proliferation of magnetic resonance imaging (MRI) availability and continuous improvements in acquisition speeds have led to significantly increased MRI utilization across the health care system, and MRI studies are increasingly ordered in the emergent setting. Depending on the clinical presentation, MRI can yield vital diagnostic information not detectable with other imaging modalities. The aim of this text is to report on the up-to-date indications for MRI of the spine in the ED, and review the various MRI appearances of commonly encountered acute spine pathology, including traumatic injuries, acute non traumatic myelopathy, infection, neoplasia, degenerative disc disease, and postoperative complications. Imaging review will focus on the aspects of the disease process that are not readily resolved with other modalities.

Serum levels of neurofilament light chain, neuron-specific enolase and S100 calcium-binding protein B during acute bacterial meningitis: a prospective cohort study

PURPOSE

Acute bacterial meningitis (ABM) is a severe disease with an overall poor outcome. Neurofilament (NFL) has shown to be a promising biomarker of neuroaxonal injury in various neurological disorders but has not been investigated in ABM. The aims of this study were (i) to obtain a temporal profile of NFL, neuron-specific enolase (NSE) and S100B in serum during ABM, and (ii) to evaluate their use as biomarkers of severity (Glasgow coma score) and prognosis (Glasgow Outcome Score, GOS and death) in severe ABM.

METHODS

Fifteen adults with severe community-acquired ABM who were admitted to the intensive care unit (ICU) and fulfilled the inclusion criteria were included. Lumbar puncture and blood tests were performed on admission, and blood tests were performed three times daily during the ICU stay. GOS was obtained day 30.

RESULTS

Serum NFL was significantly elevated in ABM patients compared to healthy controls, both at admission and throughout the observation period (p < .01). NFL increased significantly from day 1 up to day 3-6 (p < .0001), peaking day 6. NSE increased significantly from admission up to day 3 (p < .01). At day 5-6, the serum values were not significantly different from values at admission. The highest median serum value of S100B was observed at admission (0.10 µg/L, IQR 0.06-0.14), significantly decreasing day 4-6 (p < .05). None of the investigated biomarkers revealed significant correlation with severity and prognosis.

CONCLUSION

This study represents a first clinical observation of the temporal profile of NFL in serum, in severe ABM. No correlation with severity or prognosis.

Herpes simplex virus type 2 myelitis mimicking ICU-acquired weakness as a complication of meningococcal meningitis: A case report

Herpes simplex virus 2 (HSV-2) is a well-known cause of neurological complications. This case study describes the first reported case of reactivated HSV-2 myelitis, which was induced by immunosuppression due to sepsis. During the treatment of meningococcal meningitis, the patient developed quadriparesis and was later diagnosed as HSV-2 myelitis, mimicking ICU-acquired weakness. The case emphasizes the importance of excluding viral myelitis before making the diagnosis of ICU-acquired weakness.

Pneumococcal Meningitis Complicated by Spinal Cord Dysfunction and Acute Polyradiculopathy

Background: Meningitis caused by Streptococcus pneumoniae is associated with devastating clinical outcomes. A considerable number of patients will develop long-term neurologic complications. Hearing loss, diffuse brain edema, and hydrocephalus are frequently encountered. Acute spinal cord dysfunction and polyradiculopathy can develop in some patients.

Case Report: A 63-year-old female was admitted to our hospital with sudden-onset bilateral lower extremity weakness. On admission, the patient had evidence of spinal cord dysfunction given the abnormal motor and sensory physical examination findings and the absent sensation with a sensory level at dermatome T4 on neurologic examination. Computed tomography myelography did not show evidence of spinal cord compression or transverse myelitis. Cerebrospinal fluid examination was positive for pneumococcal meningitis. The patient was treated with antibiotics and steroids. Nerve conduction studies demonstrated the absence of response, suggesting damage to the peripheral nerves and polyradiculopathy. The patient was treated with plasmapheresis for possible Guillain-Barré syndrome; however, she did not improve despite appropriate antibiotics, steroids, and plasmapheresis. She developed persistent quadriparesis, sensory impairments in upper and lower extremities, and bowel and bladder sphincter dysfunction.

Conclusion: Our case demonstrates the development of spinal cord dysfunction (supported by the sudden onset of paraplegia and the presence of a sensory level) and polyradiculopathy (flaccid paralysis, ascending weakness, and absence of response in neurophysiologic studies suggesting severe damage to the peripheral nerves). The appearance of either complication is unusual, and the simultaneous occurrence of both complications is even more uncommon.

Staphylococcus Toxin-Mediated Motor Polyneuropathy

Staphylococcus aureus infection is known to cause a variety of neurologic complications, most involving the CNS, however, rarely have cases of S. aureus affecting the peripheral nervous system been reported in literature. We report a case of S. aureus toxin-mediated motor polyneuropathy in a patient presenting with acute flaccid quadriplegia.

Infectious Myelopathies

PURPOSE OF REVIEW

This article reviews bacterial, viral, fungal, and parasitic pathogens associated with myelopathy. Infectious myelopathies may be due to direct infection or parainfectious autoimmune-mediated mechanisms; this article focuses primarily on the former.

RECENT FINDINGS

Some microorganisms exhibit neurotropism for the spinal cord (eg, enteroviruses such as poliovirus and flaviviruses such as West Nile virus), while others are more protean in neurologic manifestations (eg, herpesviruses such as varicella-zoster virus), and others are only rarely reported to cause myelopathy (eg, certain fungal and parasitic infections). Individuals who are immunocompromised are at increased risk of disseminated infection to the central nervous system. Within the last few years, an enterovirus D68 outbreak has been associated with cases of acute flaccid paralysis in children, and emerging Zika virus infection has been concurrent with cases of acute flaccid paralysis due to Guillain-Barré syndrome, although cases of myelitis have also been reported. Associated pathogens differ by geographic distribution, with myelopathies related to Borrelia burgdorferi (Lyme disease) and West Nile virus more commonly seen in the United States and parasitic infections encountered more often in Latin America, Southeast Asia, and Africa. Characteristic CSF and MRI patterns have been identified with many of these infections.

SUMMARY

A myriad of pathogens are associated with infectious myelopathies. Host factors, geographic distribution, clinical features, CSF profiles, and MRI findings can assist in formulating the differential diagnosis and ultimately guide management.

Anterior spinal cord syndrome as a rare complication of acute bacterial meningitis in an adult

Acute bacterial meningitis is not an uncommon central nervous system infection. In severe cases, it can be associated with various neurological or systemic complications. However, acute spinal cord dysfunction rarely occurs. We report a case of bacterial meningitis complicated with spinal cord infarction despite adequate treatment with antibiotics and corticosteroid therapy. He had residual paraplegia and was fully dependent in the activity of daily living.

Encephalitis and myelitis in tropical countries: Report from the Task Force on Tropical Diseases by the World Federation of Societies of Intensive and Critical Care Medicine

Tropical diseases are those that occur primarily or solely in the tropics, and as such include infectious diseases that are particularly prevalent in hot, humid conditions. The incidence of encephalitis in tropical countries is reported to be as high as 6.34/100,000/year. The term encephalitis implies inflammation of the brain and includes the presence of encephalopathy with two and more of the following features: fever, seizures and/or focal neurological findings; a cerebrospinal fluid pleocytosis; electroencephalographic findings or abnormal neuroimaging suggestive of encephalitis. Transverse myelitis (TM) is an inflammation of the spinal cord which has a wide variety of clinical presentations depending on the degree (severity of myelin and neuronal injury) and site of spinal cord involvement. In the present article we discuss the various forms of tropical, viral encephalitides and myelitis and the diagnosis and management.

Magnetic Resonance Imaging and Clinical Features in Acute and Subacute Myelopathies

Differential diagnosis of acute and subacute transverse myelopathy includes inflammatory, infectious, vascular, metabolic and paraneoplastic etiologies. Information on the diagnostic approach to transverse myelopathy with regard to daily clinical practice is provided. The differentiation between five lesion patterns on magnetic resonance imaging (MRI) in myelitis may be helpful: (1) longitudinal extensive transverse myelitis, (2) short segment ovoid or peripherally located, (3) "polio-like", (4) granulomatous and (5) segmental with rash. A correlation with these imaging features is supported if the clinical course and neurological symptoms are known. Although the mean interval from onset to nadir of symptoms in spinal cord infarction is 1 h, an overlap with a fulminant course of myelitis is possible, and impaired diffusion may also occur in acute inflammatory processes. As a result, laboratory testing, including aquaporin-4 antibodies and cerebrospinal fluid analysis, is crucial for the correct interpretation of imaging findings. Moreover, the discrimination of acute complete and acute partial transverse myelitis is advantageous in order to identify diverse entities, the latter often being a precursor to multiple sclerosis. Additional brain imaging is mandatory in suspected demyelinating, infectious, neoplastic and systemic autoimmune disease. A symmetrical lesion pattern restricted to individual tracts or dorsal columns indicates subacute combined degeneration of the spinal cord and, in addition to deficiency syndromes, a paraneoplastic etiology should be considered.

Suspected bacterial meningomyelitis: The first presenting clinical feature of neuromyelitis optica spectrum disorder

A rare case of neuromyelitis optica spectrum disorder, suspected to be bacterial meningomyelitis as the initial manifestation, is reported. The patient presented with initial symptoms of meningomyelitis and fever. Cerebrospinal fluid analysis revealed pleocytosis (1280×10⁶/L [98% lymphocytes]) and glucose level of 1.8mmol/L. Magnetic resonance imaging revealed >3 vertebral, longitudinally extensive transverse myelitis and area postrema lesions. Right optic neuritis was experienced 20months after the first attack. Serum anti-aquaporin-4 antibody was positive, and a diagnosis of neuromyelitis optica spectrum disorder was made, supporting the hypothesis that the pathogenesis of neuromyelitis optica is triggered by infection.

Gas-Containing Cervical Epidural Abscess Accompanying Bacterial Meningitis in an Adult

Gas-containing spinal epidural abscesses are uncommon. Moreover, acute spinal epidural abscesses rarely complicate bacterial meningitis in adults. Here, we report a rare case of a gas-containing cervical epidural abscess accompanying bacterial meningitis. In spite of aggressive fluid and continuous antibiotic therapy after the isolation of Streptococcus anginosus and Streptococcus constellatus in the cerebrospinal fluid cultures, the patient showed remaining motor dysfunction and bladder involvement. Our experience suggests that the effort to prevent neurologic deterioration by emergent surgical decompression and drainage of pus is mandatory to avoid additional spinal cord dysfunction in patients with spinal epidural abscesses accompanying bacterial meningitis.

Andrographolide attenuates LPS-stimulated up-regulation of C-C and C-X-C motif chemokines in rodent cortex and primary astrocytes

Background

Andrographolide is the major bioactive compound isolated from Andrographis paniculata, a native South Asian herb used medicinally for its anti-inflammatory properties. In this study, we aimed to assess andrographolide’s potential utility as an anti-neuroinflammatory therapeutic.

Methods

The effects of andrographolide on lipopolysaccharide (LPS)-induced chemokine up-regulation both in mouse cortex and in cultured primary astrocytes were measured, including cytokine profiling, gene expression, and, in cultured astrocytes, activation of putative signaling regulators.

Results

Orally administered andrographolide significantly attenuated mouse cortical chemokine levels from the C-C and C-X-C subfamilies. Similarly, andrographolide abrogated a range of LPS-induced chemokines as well as tumor necrosis factor (TNF)-α in astrocytes. In astrocytes, the inhibitory actions of andrographolide on chemokine and TNF-α up-regulation appeared to be mediated by nuclear factor-κB (NF-κB) or c-Jun N-terminal kinase (JNK) activation.

Conclusions

These results suggest that andrographolide may be useful as a therapeutic for neuroinflammatory diseases, especially those characterized by chemokine dysregulation.

Electronic supplementary material

The online version of this article (doi:10.1186/s12974-016-0498-6) contains supplementary material, which is available to authorized users.

[Tetraplegia revealing a severe pneumococcal meningomyelitis: about a case and literature review]

L'atteinte médullaire est une complication rare des méningites à streptocoque pneumoniae. notre observation clinique décrit le cas d'une Jeune femme immunocompétente qui s'est présentée au service d'accueil des urgences pour tétraplégie dont les investigations ont mis en évidence une méningite à pneumocoque. Le traitement était basé sur l'antibiothérapie plus une corticothérapie concomitante. L’évolution était marquée par la persistance des séquelles neurologiques.

Transverse myelitis due to Staphylococcus aureus may occur without contiguous spread

STUDY DESIGN

A case report of staphylococcal transverse myelitis.

OBJECTIVES

To illustrate the clinical presentation of acute transverse myelitis due to Staphylococcus aureus, without a contiguous source of infection.

SETTING

National Neuroscience Institute.

CASE REPORT

A 79-year-old female was diagnosed with acute transverse myelitis. Clues to an infectious etiology included fever, raised inflammatory markers and cerebrospinal fluid neutrophilic pleocytosis. Staphylococcal etiology was established based on cerebrospinal fluid and blood cultures. Despite extensive investigations, no contiguous or systemic source of infection could be identified. She was treated with appropriate antibiotics; however, neurological recovery was poor.

CONCLUSIONS

Bacterial myelitis may occur in isolation and the diagnosis should not be discounted when evaluation shows an absence of a contiguous or systemic source of infection.

Meningitis Due to Enterobacter aerogenes Subsequent to Resection of Acoustic Neuroma and Percutaneous Endoscopic Gastrostomy Tube Placement: A Rare Nosocomial Event

We present a case of meningitis after percutaneous endoscopic gastrostomy (PEG) tube placement subsequent to acoustic neuroma resection and cranioplasty. Four days following PEG tube placement the patient developed Enterobacter aerogenes meningitis, requiring explantation of infected cranioplasty material. His condition subsequently improved. Etiology and future intervention strategies are discussed (Infect Control Hosp Epidemiol 2003;24:780-782).

Spinal cord ischemia: aetiology, clinical syndromes and imaging features

INTRODUCTION

The purpose of this study was to analyse MR imaging features and lesion patterns as defined by compromised vascular territories, correlating them to different clinical syndromes and aetiological aspects.

METHODS

In a 19.8-year period, clinical records and magnetic resonance imaging (MRI) features of 55 consecutive patients suffering from spinal cord ischemia were evaluated.

RESULTS

Aetiologies of infarcts were arteriosclerosis of the aorta and vertebral arteries (23.6%), aortic surgery or interventional aneurysm repair (11%) and aortic and vertebral artery dissection (11%), and in 23.6%, aetiology remained unclear. Infarcts occurred in 38.2% at the cervical and thoracic level, respectively, and 49% of patients suffered from centromedullar syndrome caused by anterior spinal artery ischemia. MRI disclosed hyperintense pencil-like lesion pattern on T2WI in 98.2%, cord swelling in 40%, enhancement on post-contrast T1WI in 42.9% and always hyperintense signal on diffusion-weighted imaging (DWI) when acquired.

CONCLUSION

The most common clinical feature in spinal cord ischemia is a centromedullar syndrome, and in contrast to anterior spinal artery ischemia, infarcts in the posterior spinal artery territory are rare. The exclusively cervical location of the spinal sulcal artery syndrome seems to be a likely consequence of anterior spinal artery duplication which is observed preferentially here.

Acute pneumococcal myelitis in an adult patient

Pneumococcal meningitis represents the most severe community-acquired bacterial meningitis. The disease is frequently associated with various complications. We present a case of pneumococcal meningitis in an immunocompetent adult patient treated with hypothermia. The disease course was complicated with severe myelitis and consequent paraplegia which is an extremely rare complication of pneumococcal disease.

Meningococcal encephalitis associated with cerebellar tonsillar herniation and acute cervicomedullary injury

A 13-year-old girl presented with a progressive ascending paralysis, bulbar dysfunction and finally respiratory arrest. Magnetic resonance (MR) showed acute cervicomedullary injury and hindbrain herniation. An emergency foramen magnum decompression and external ventricular drainage insertion were performed, and meningococcal infection was diagnosed. The patient recovered completely. Meningococcal encephalitis may have an atypical presentation, and a surgery can optimise the outcome.

Pathophysiology and treatment of bacterial meningitis

Bacterial meningitis is a medical emergency requiring immediate diagnosis and immediate treatment. Streptococcus pneumoniae and Neisseria meningitidis are the most common and most aggressive pathogens of meningitis. Emerging antibiotic resistance is an upcoming challenge. Clinical and experimental studies have established a more detailed understanding of the mechanisms resulting in brain damage, sequelae and neuropsychological deficits. We summarize the current pathophysiological concept of acute bacterial meningitis and present current treatment strategies.

Extensive Spinal Cord Injury following Staphylococcus aureus Septicemia and Meningitis

Bacterial meningitis is rarely complicated by spinal cord involvement in adults. We report a case of Staphylococcus aureus septicemia complicated by meningitis and extensive spinal cord injury, leading to ascending brain stem necrosis and death. This complication was investigated by magnetic resonance imaging which demonstrated intramedullary hyperintensity on T2-weighted images and by multimodality evoked potentials. Postmortem microscopic examination confirmed that the extensive spinal cord injury was of ischemic origin, caused by diffuse leptomeningitis and endarteritis.

Acute Meningitis Complicated by Transverse Myelitis

Myelopathy is an infrequently reported complication of bacterial meningitis. We report the case of 32- year old Nepali male who developed acute transverse myelopathy, confirmed by MRI, subsequent to acute bacterial meningitis.

Acute myelopathy with sudden paraplegia as the sole manifestation of meningococcal meningitis

Acute myelopathy with sudden paraplegia is a very rare manifestation of meningococcal meningitis, with only a few cases reported in the literature. In almost all previously reported cases, other clinical manifestations of meningitis, such as fever, headache, and neck stiffness preceded acute myelopathy. In this paper, we report a case of acute myelopathy with sudden paraplegia as the sole manifestation of meningococcal meningitis, in the absence of other clinical manifestations of meningitis.

Acute flaccid paraplegia: a rare complication of meningococcal meningitis

STUDY DESIGN

A case report of spinal cord dysfunction following meningococcal meningitis.

OBJECTIVES

To describe a rare complication of meningococcal meningitis.

SETTING

Spinal Unit, Armed Forces Institute of Rehabilitation Medicine, Rawalpindi, Pakistan.

METHODS

A young healthy male developed meningococcal meningitis followed by acute onset low thoracic flaccid paraplegia with complete motor and sensory loss and sphincter disturbance. He responded well to antibiotics but was not investigated for causes of paraplegia. While at home in a rural area, he developed pressure ulcers, anemia and depression. Magnetic resonance imaging of the whole spine and computed tomography scan of the brain performed after 4 and 10 weeks were normal.

RESULTS

The patient had a comprehensive rehabilitation at our institute. Recovery was complicated by ossification in the right thigh, which responded well to radiotherapy. At 1-year follow-up, the motor deficit and neurogenic bladder and bowel persisted and the patient remained wheelchair dependent for mobility.

CONCLUSION

Several mechanisms have been proposed to explain spinal cord damage after meningitis. These include spinal cord infarction; autoimmune-mediated inflammatory myelopathy and direct infection of the cord. Most probable cause of spinal cord dysfunction in this case was thoracic myelopathy.

Large intramedullary abscess of the spinal cord associated with an epidermoid cyst without dermal sinus

✓ An intramedullary abscess of the spinal cord (IASC) represents a rare disease associated with a potentially devastating outcome. Few cases involving children suffering from an IASC have been reported in the neurosurgical literature. In the majority of the reported pediatric cases there were either congenital abnormalities, such as a dermal sinus, or signs of local infections leading to a secondary hemopoietic spread. The authors report the case of an 18-month-old girl with an extensive IASC associated with an epidermoid cyst extending from T-11 to S-2 without evidence of a dermal sinus or history of clinically apparent systemic infection. To their knowledge, this is the first case report of an IASC without a condition facilitating either direct contamination via a dermal sinus or hemopoietic spread from an infectious focus outside the central nervous system. Signs and symptoms, the clinical course, and imaging features are discussed and the relevant literature is reviewed.

Interleukin-6 activation in ischemic stroke caused by Neisseria meningitidis serogroup C

We report an unusual phenomenon in a patient with meningococcal meningitis who developed a brain infarct. Concentrations of interleukin-6 were notably elevated in the cerebrospinal fluid. We also discuss some clinical and pathophysiological features of cerebrovascular injury in meningococcal disease.

Ischemic spinal cord infarction in children without vertebral fracture

Spinal cord infarction in children is a rare condition that is becoming more widely recognized. There are few reports in the pediatric literature characterizing etiology, diagnosis, treatment, and prognosis. The risk factors for pediatric ischemic spinal cord infarction include obstruction of blood flow associated with cardiovascular compromise or malformation, iatrogenic or traumatic vascular injury, cerebellar herniation, thrombotic or embolic disease, infection, and vasculitis. In many children, the cause of spinal cord ischemia in the absence of vertebral fracture is unknown. Imaging diagnosis of spinal cord ischemia is often difficult, due to the small transverse area of the cord, cerebrospinal fluid artifact, and inadequate resolution of magnetic resonance imaging. Physical therapy is the most important treatment option. The prognosis is dependent on the level of spinal cord damage, early identification and reversal of ischemia, and follow-up with intensive physical therapy and medical support. In addition to summarizing the literature regarding spinal cord infarction in children without vertebral fracture, this review article adds two cases to the literature that highlight the difficulties and controversies in the management of this condition.

Acute severe spinal cord dysfunction in a child with meningitis: Streptococcus pneumoniae and Mycoplasma pneumoniae co-infection

Tetraplegia developed abruptly in an 11-y-old with pneumococcal meningitis. Magnetic resonance imaging showed multiple hyperintensities at the brainstem-spinal cord junction. Serological tests were positive for Mycoplasma pneumoniae (microparticle agglutination and specific IgMs). Erythromycin and dexamethasone were started promptly, and 10 d later the patient was discharged with normal neurological function.

CONCLUSION

Tetraplegia during the course of pneumococcal meningitis in an 11-y-old girl disappeared after treatment with ceftriaxone, erythromycin and dexamethasone.

Complication Rate of Transtemporal Hydroxyapatite Cement Cranioplasties: A Case Series Review of 76 Cranioplasties

OBJECTIVE

The objective of this study was to evaluate the complication rate of transtemporal cranioplasties using hydroxyapatite cement (HAC) for repair.

STUDY DESIGN

We conducted a retrospective case review of patients receiving HAC cranioplasties in the Acoustic Neuroma and Skull Base Surgery Program between July 1998 and December 2002.

SETTING

This study was conducted at a tertiary referral center.

PATIENTS

A total of 76 HAC cranioplasties were performed in 72 patients undergoing lateral skull base surgery. Patients undergoing anterior skull base surgery or those in which HAC was used for other reconstructive purposes were excluded from the study.

INTERVENTIONS

We studied transtemporal approaches for otologic procedures requiring cranioplasty.

MAIN OUTCOME MEASURES

Main outcomes measures consisted of complications requiring medical or surgical intervention.

RESULTS

Of the 76 HAC cranioplasties, two cranioplasty grafts became infected, requiring explantation. The first case involved a wound infection that extended into and involved the HAC graft; the second involved seeding of the HAC graft after meningitis after a percutaneous, endoscopic gastrostomy tube placement performed several days after the primary skull base surgery. This gives our series a wound infection incidence rate of 1.3% and an overall complication incidence rate of 2.63%.

CONCLUSIONS

This retrospective review provides the largest series to date evaluating the incidence of infection in HAC cranioplasties. Despite having a much larger series, our complication rate is the lowest published rate of HAC cranioplasty explantation, and the incidence of superficial wound infections reported here is consistent with the published data for neurosurgical and neurotologic procedures.

Spinal cord infarction as a severe complication of meningococcal meningitis

Spinal cord infarction is a rare complication of bacterial meningitis and is, therefore, generally unknown. We describe a patient who developed a flaccid paraparesis 2 weeks after being diagnosed with meningococcal meningitis. The etiology of spinal cord infarction is multifactorial, but vascular mechanisms and coagulation abnormalities play an important role. Epidural hemorrhage and spinal abscess should be considered in the differential diagnosis.

Pneumococcal meningitis in adults: spectrum of complications and prognostic factors in a series of 87 cases

Studies on the incidence and spectrum of complications and prognostic factors in adults with pneumococcal meningitis are scarce. Therefore, we analysed 87 consecutive cases who were treated in our department between 1984 and 2002. Meningitis-associated intracranial complications developed in 74.7% and systemic complications in 37.9% of cases. Diffuse brain oedema (28.7%) and hydrocephalus (16.1%) developed more frequently than previously reported. The incidences of arterial (21.8%) and venous (9.2%) cerebrovascular complications were also very high. Furthermore, 9.2% of cases developed spontaneous intracranial haemorrhages (two patients with subarachnoid and two with subarachnoid and intracerebral bleedings, all in association with vasculitis; one subject with intracerebral haemorrhage due to sinus thrombosis; and three cases with intracerebral bleedings of unknown aetiology). Other new findings were the incidence of acute spinal cord dysfunction due to myelitis (2.3%) and that of hearing loss (19.5% of all patients and 25.8% of survivors). The in-hospital mortality was 24.1%. Only 48.3% of the patients had a good outcome at discharge [Glasgow Outcome Scale Score (GOS) = 5]. Outcome did not change during the study period, as mortality and GOS were similar for patients treated between 1984 and 1992 and for those treated between 1993 and 2002. Factors associated with a bad outcome (GOS </= 4) were chronic debilitating diseases, low Glasgow Coma Scale Score and focal neurological deficits on admission, low CSF leucocyte counts, pneumonia, bacteraemia and meningitis-associated intracranial and systemic complications. Low CSF leucocyte counts were also associated with the development of meningitis-associated intracranial complications. Age > or =60 years was associated with a higher mortality (36.7 versus 17.5%), but the GOS of the survivors was comparable to that of the surviving younger patients. The causes of death were mostly systemic complications in the elderly and cerebral complications in the younger patients. A haematogenous pathogenesis seemed likely in asplenic patients, while contiguous spread from sinusitis or otitis was the major cause of meningitis in non-asplenic individuals. Furthermore, asplenic patients had a raised incidence of meningitis-associated intracranial complications, but their outcome was similar to that of non-asplenic subjects. The morbidity and mortality of pneumococcal meningitis in adults are still devastating. We report higher incidences (diffuse brain swelling, hydrocephalus, cerebrovascular complications) or new incidences (myelitis, hearing loss, subarachnoid bleeding) of intracranial complications. Our detailed analysis of prognostic factors may help clinicians to identify patients at risk and may also be helpful in the design of clinical trials.

Thoracic myelopathy complicating acute meningococcal meningitis: MRI findings

Spinal cord dysfunction is a rare complication of Neisseria meningitidis (meningococcal) meningitis. We report a 17-year-old patient who had a 3-day history of fever, headache and vomiting, agitation, and unresponsiveness. Cerebrospinal fluid showed a marked polymorphonuclear pleocytosis. Latex particle agglutination was positive for meningococci. The patient was given intravenous antibiotics and intravenous dexamethasone. Over the next 4 days, he developed weakness of the lower extremities, with areflexia and extensor plantar responses. MRI revealed contiguous hyperintensities on T2-weighted images involving the thoracic spinal cord from T4 to T9 and 4 brain abscesses. Five months later, he recovered brain function, but the paraparesis remained. This case illustrates that myelopathy may complicate acute meningococcal meningitis, possibly due to a vasculitis, stroke, autoimmune myelopathy, or direct infection of the spinal cord. Patients with myelopathy associated with acute meningitis should receive spinal MRI. In addition, meningitis should be considered in patients presenting with acute myelopathy.