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Liu MZ, Dai XH, Zeng MT, Chen EQ. Clinical treatment of cryptococcal meningitis: an evidence-based review on the emerging clinical data. J Neurol 2024; 271:2960-2979. [PMID: 38289535 DOI: 10.1007/s00415-024-12193-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/07/2024] [Accepted: 01/13/2024] [Indexed: 05/30/2024]
Abstract
Cryptococcal meningitis (CM) is a fatal fungal central nervous system (CNS) infection caused by Cryptococcus infecting the meninges and/or brain parenchyma, with fever, headache, neck stiffness, and visual disturbances as the primary clinical manifestations. Immunocompromised individuals with human immunodeficiency virus (HIV) infection or who have undergone organ transplantation, as well as immunocompetent people can both be susceptible to CM. Without treatment, patients with CM may have a mortality rate of up to 100% after hospital admission. Even after receiving therapy, CM patients may still suffer from problems such as difficulty to cure, poor prognosis, and high mortality. Therefore, timely and effective treatment is essential to improve the mortality and prognosis of CM patients. Currently, the clinical outcomes of CM are frequently unsatisfactory due to limited drug choices, severe adverse reactions, drug resistance, etc. Here, we review the research progress of CM treatment strategies and discuss the suitable options for managing CM, hoping to provide a reference for physicians to select the most appropriate treatment regimens for CM patients.
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Affiliation(s)
- Mao-Zhu Liu
- Center of Infectious Diseases, West China Hospital, Sichuan University, No.37 Guo Xue Xiang, Wuhou District, Chengdu, 610041, China
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xin-Hua Dai
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Ming-Tang Zeng
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - En-Qiang Chen
- Center of Infectious Diseases, West China Hospital, Sichuan University, No.37 Guo Xue Xiang, Wuhou District, Chengdu, 610041, China.
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Mathurin M, Devatine S, Kopp-Derouet A, Guillonnet A, Alanio A, Lourenco N, Manda V, Delcey V, Molina JM, Sellier P. Cryptococcal meningitis and cerebral vasculitis in a patient with primary intestinal lymphangiectasia: a case report. Eur J Clin Microbiol Infect Dis 2023; 42:1263-1267. [PMID: 37668805 DOI: 10.1007/s10096-023-04657-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/24/2023] [Indexed: 09/06/2023]
Abstract
Primary intestinal lymphangiectasia (Waldmann's disease) is a rare exudative enteropathy without precisely assessed infectious risk. We report the case of a 49-year-old male patient with meningitis and cerebral vasculitis due to Cryptococcus neoformans complicating Waldmann's disease diagnosed 12 years ago. The treatment combined liposomal amphotericin B, 3 mg/kg daily plus flucytosine 25 mg/kg/6 h, both intravenously during 15 days, then fluconazole 800 mg daily during 8 weeks, and finally 200 mg daily indefinitely. Dexamethasone 0.4 mg/kg daily during the first week was gradually decreased over 2 months. The outcome was good, and the patient is still followed 3 years later without any recurrence.
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Affiliation(s)
- Martin Mathurin
- Department of Infectious Diseases, Hôpital Lariboisière, Saint-Louis-Lariboisière-Fernand Widal Hospitals, AP-HP, 2 Rue Ambroise Paré, 75010, Paris, France.
| | - Sandra Devatine
- Department of Infectious Diseases, Hôpital Lariboisière, Saint-Louis-Lariboisière-Fernand Widal Hospitals, AP-HP, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Aude Kopp-Derouet
- Department of Infectious Diseases, Hôpital Lariboisière, Saint-Louis-Lariboisière-Fernand Widal Hospitals, AP-HP, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Antoine Guillonnet
- Department of Neuroradiology, Lariboisière-Fernand Widal Hospitals, AP-HP, Paris, France
| | - Alexandre Alanio
- Laboratoire de Parasitologie-Mycologie, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Université de Paris, Paris, France
- Unité de Mycologie Moléculaire, Centre National de Référence Mycoses Invasives Et Antifongiques, CNRS UMR2000, Institut Pasteur, Paris, France
| | - Nelson Lourenco
- Department of Gastroenterology, Assistance Publique-Hôpitaux de Paris, Saint-Louis- Lariboisière-Fernand Widal Hospitals, Paris, France
| | - Victoria Manda
- Department of Infectious Diseases, Hôpital Lariboisière, Saint-Louis-Lariboisière-Fernand Widal Hospitals, AP-HP, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Véronique Delcey
- Department of Infectious Diseases, Hôpital Lariboisière, Saint-Louis-Lariboisière-Fernand Widal Hospitals, AP-HP, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Jean-Michel Molina
- Department of Infectious Diseases, Hôpital Lariboisière, Saint-Louis-Lariboisière-Fernand Widal Hospitals, AP-HP, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Pierre Sellier
- Department of Infectious Diseases, Hôpital Lariboisière, Saint-Louis-Lariboisière-Fernand Widal Hospitals, AP-HP, 2 Rue Ambroise Paré, 75010, Paris, France.
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Lasry D, Cantarovich M, Sandal S. Sequelae of Cryptococcal-Immune Reconstitution Inflammatory Syndrome in a Kidney Transplant Recipient: A Case Report. Can J Kidney Health Dis 2023; 10:20543581231172399. [PMID: 37163140 PMCID: PMC10164251 DOI: 10.1177/20543581231172399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 03/14/2023] [Indexed: 05/11/2023] Open
Abstract
Rationale Cryptococcal-immune reconstitution inflammatory syndrome (C-IRIS) is a rare but recognized clinical entity in solid organ transplant recipients, though its clinical course and sequelae remain largely poorly described. Presenting Concerns of the Patient We present the case of a kidney transplant recipient who presented with headache and fever. A cerebrospinal fluid analysis was performed and found to be compatible with cryptococcal meningitis. After down titration of immunosuppression and antifungal initiation, the patient initially improved. Weeks later, they experienced a sudden deterioration in mental status, prompting admission to the intensive care unit (ICU). Diagnosis This deterioration was attributed to C-IRIS, which developed following rapid de-escalation of immunosuppression in response to the diagnosis of cryptococcal meningitis. Interventions The initial episode of C-IRIS responded well to high-dose steroids; however, maintenance immunosuppression was not increased. Outcomes Within 2 months, the patient presented again to the hospital with a pulmonary infiltrate and multifocal ischemic strokes. Novel Findings We argue this to be a case of relapsing multisystem C-IRIS, thus expanding the known spectrum of manifestations of C-IRIS in renal transplant recipients. We propose that following the diagnosis of C-IRIS, maintenance immunosuppression be escalated to avoid the risk of relapse and inflammatory-mediated organ dysfunction.
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Affiliation(s)
- David Lasry
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Marcelo Cantarovich
- Division of Nephrology, Department of Medicine, Royal Victoria Hospital, McGill University Health Centre, Montreal, QC, Canada
- The Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Multi-organ Transplant Program, Departments of Medicine and Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Shaifali Sandal
- Division of Nephrology, Department of Medicine, Royal Victoria Hospital, McGill University Health Centre, Montreal, QC, Canada
- The Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Multi-organ Transplant Program, Departments of Medicine and Surgery, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Medicine, McGill University Health Centre, Montreal, QC, Canada
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King CJ, Ngo TH, Constante M. Meningovascular Neurosyphilis Presenting as Multiple Ischemic Infarcts in a Young Adult. Cureus 2023; 15:e36405. [PMID: 37090294 PMCID: PMC10115213 DOI: 10.7759/cureus.36405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2023] [Indexed: 04/25/2023] Open
Abstract
Neurosyphilis occurs when the spirochete Treponema pallidum invades the cerebrospinal fluid (CSF). Clinical presentation depends on an individual's immune response and invasion location, with all possible involvement of meningeal, vascular, and/or parenchymatous tissues. Meningovascular neurosyphilis occurs when both the meninges and vasculature are affected and can lead to headaches, photophobia, neck stiffness, cranial nerve palsies, and/or ischemic brain infarctions due to infectious arteritis. The following report describes the rare case of a 32-year-old male patient presenting with multiple ischemic brain infarctions of varying ages. The stepwise diagnostic approach as described allowed the medical team to reach the final diagnosis of meningovascular neurosyphilis with concomitant acquired immunodeficiency syndrome (AIDS). This case emphasizes the importance of maintaining high clinical suspicion in all young adult patients who present with acute neurological deficits.
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Affiliation(s)
| | - Teresa H Ngo
- Neurology, Western University of Health Sciences, Pomona, USA
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Imaging of Uncommon Bacterial, Rickettsia, Spirochete, and Fungal Infections. Neuroimaging Clin N Am 2023; 33:83-103. [DOI: 10.1016/j.nic.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Duong MT, Rudie JD, Mohan S. Neuroimaging Patterns of Intracranial Infections: Meningitis, Cerebritis, and Their Complications. Neuroimaging Clin N Am 2023; 33:11-41. [PMID: 36404039 PMCID: PMC10904173 DOI: 10.1016/j.nic.2022.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Neuroimaging provides rapid, noninvasive visualization of central nervous system infections for optimal diagnosis and management. Generalizable and characteristic imaging patterns help radiologists distinguish different types of intracranial infections including meningitis and cerebritis from a variety of bacterial, viral, fungal, and/or parasitic causes. Here, we describe key radiologic patterns of meningeal enhancement and diffusion restriction through profiles of meningitis, cerebritis, abscess, and ventriculitis. We discuss various imaging modalities and recent diagnostic advances such as deep learning through a survey of intracranial pathogens and their radiographic findings. Moreover, we explore critical complications and differential diagnoses of intracranial infections.
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Affiliation(s)
- Michael Tran Duong
- Division of Neuroradiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Jeffrey D Rudie
- Department of Radiology, Scripps Clinic and University of California San Diego, 10666 Torrey Pines Road, La Jolla, CA 92037, USA
| | - Suyash Mohan
- Division of Neuroradiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Hamed MF, Enriquez V, Munzen ME, Charles-Niño CL, Mihu MR, Khoshbouei H, Alviña K, Martinez LR. Clinical and pathological characterization of Central Nervous System cryptococcosis in an experimental mouse model of stereotaxic intracerebral infection. PLoS Negl Trop Dis 2023; 17:e0011068. [PMID: 36656900 PMCID: PMC9888703 DOI: 10.1371/journal.pntd.0011068] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/31/2023] [Accepted: 01/02/2023] [Indexed: 01/20/2023] Open
Abstract
Infection of the Central Nervous System (CNS) by the encapsulated fungus Cryptococcus neoformans can lead to high mortality meningitis, most commonly in immunocompromised patients. While the mechanisms by which the fungus crosses the blood-brain barrier to initiate infection in the CNS are well recognized, there are still substantial unanswered questions about the disease progression once the fungus is established in the brain. C. neoformans is characterized by a glucuronoxylomannan (GXM)-rich polysaccharide capsule which has been implicated in immune evasion, but its role during the host CNS infection needs further elucidation. Therefore, the present study aims to examine these key questions about the mechanisms underlying cryptococcal meningitis progression and the impact of fungal GXM release by using an intracerebral rodent infection model via stereotaxic surgery. After developing brain infection, we analyzed distinct brain regions and found that while fungal load and brain weight were comparable one-week post-infection, there were region-specific histopathological (with and without brain parenchyma involvement) and disease manifestations. Moreover, we also observed a region-specific correlation between GXM accumulation and glial cell recruitment. Furthermore, mortality was associated with the presence of subarachnoid hemorrhaging and GXM deposition in the meningeal blood vessels and meninges in all regions infected. Our results show that using the present infection model can facilitate clinical and neuropathological observations during the progression of neurocryptococcosis. Importantly, this mouse model can be used to further investigate disease progression as it develops in humans.
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Affiliation(s)
- Mohamed F. Hamed
- Department of Oral Biology, University of Florida College of Dentistry, Gainesville, Florida, United States of America
- Department of Pathology, Faculty of Veterinary Medicine, Mansoura University, Mansoura, Egypt
| | - Vanessa Enriquez
- Department of Oral Biology, University of Florida College of Dentistry, Gainesville, Florida, United States of America
| | - Melissa E. Munzen
- Department of Oral Biology, University of Florida College of Dentistry, Gainesville, Florida, United States of America
| | - Claudia L. Charles-Niño
- Department of Oral Biology, University of Florida College of Dentistry, Gainesville, Florida, United States of America
- Department of Microbiology and Pathology, University Health Sciences Center, University of Guadalajara, Guadalajara, Mexico
| | - Mircea Radu Mihu
- Advanced Critical Care, Nazih Zuhdi Transplant Institute, Advanced Cardiac Care and 24/7 Shock Service, Integris Baptist Medical Center, Oklahoma City, Oklahoma, United States of America
- Department of Medicine/Cardiology, Oklahoma State University Health Science Center, Tulsa, Oklahoma, United States of America
| | - Habibeh Khoshbouei
- Department of Neuroscience, University of Florida, Gainesville, Florida, United States of America
- Center for Translational Research in Neurodegenerative Disease, University of Florida, Gainesville, United States of America
| | - Karina Alviña
- Department of Neuroscience, University of Florida, Gainesville, Florida, United States of America
- Center for Translational Research in Neurodegenerative Disease, University of Florida, Gainesville, United States of America
| | - Luis R. Martinez
- Department of Oral Biology, University of Florida College of Dentistry, Gainesville, Florida, United States of America
- Center for Translational Research in Neurodegenerative Disease, University of Florida, Gainesville, United States of America
- Center for Immunology and Transplantation, University of Florida, Gainesville, United States of America
- Emerging Pathogens Institute, University of Florida, Gainesville, Florida, United States of America
- * E-mail:
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Infratentorial Cryptococcus neoformans meningoencephalitis with cerebellar infarction: A rare case report. Heliyon 2022; 8:e12185. [PMID: 36568664 PMCID: PMC9768310 DOI: 10.1016/j.heliyon.2022.e12185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/15/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022] Open
Abstract
Background Cryptococcal meningoencephalitis (CM), is a highly fatal fungal infection of the central nervous system (CNS), affecting not only immunocompromised patients, but also apparently immunocompetent patients. CM is mainly caused by Cryptococcus neoformans (C. neoformans), while viral hepatitis B (HBV) tends to be a rare inducement. According to the literature, the most common cerebral area affected by CM was frontal lobe, while infratentorial lesions were rare, especially those complicated with cerebellar infarction. Methods This study capitally analyzed the clinical data of an elderly female suffering from infratentorial CM complicated with cerebellar infarction, with a history of chronic HBV. Results The patient suffered from the symptoms of dizziness, insanity, low-grade fever, and high cranial pressure throughout the course of the disease. Her MRI findings were hydrocephalus and infratentorial lesions, including bilateral cerebellums and meningeal enhancement. The pathogene was Cryptococcus revealed by both the cytology and ink stain of cerebrospinal fluid, and was confirmed to be C. neoformans by the Next generation sequencing (NGS). After 12 days of intravenous amphotericin B (AMB) treatment, the patient developed oliguria, and 3 days after the termination of AMB treatment, the renal function recovered. Brain MRI reexamination after the treatment showed that the diffused lesions in the cerebellum were significantly decreased, and acute infarction occurred on the left cerebellum although it was asymptomatic. The patient took fluconazole 400mg per day after discharge, without complaints during the follow-up two months later. Conclusion C. neoformans infection may be a possible pathogeny in chronic HBV patients with meningoencephalitis. Cerebellar infarction might be a complication of CM, therefore MRI is supposed to be re-examined during antifungal therapy. Additionally, monitoring renal function plays a vital role after AMB treatment, and renal function may recover after termination.
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Muacevic A, Adler JR. A Case Reflecting the Impact of a Deferred Transesophageal Echocardiogram on a COVID-19 Disease Patient. Cureus 2022; 14:e33007. [PMID: 36712750 PMCID: PMC9879349 DOI: 10.7759/cureus.33007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2022] [Indexed: 12/29/2022] Open
Abstract
COVID-19 has been amongst us for over two years and has seen a strong response from the international health community regarding mobilization. There has also been the advancement of vaccine science-regulations surrounding the day-to-day decisions regarding patients who tested positive for the virus. Guidelines for treatment continue to vary. While this may benefit most patients, more objective metrics in deciding elective, urgent, and emergent procedures have been proposed. In this paper, a patient who tested positive for the virus was refused a procedure ( transesophageal echo ) based on COVID status, which may have contributed to a delay in treatment and detrimental outcomes.
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Tu J, Zhang S, Liu Q, Lin Y. Cerebral infarction in HIV-negative patients with cryptococcal meningitis: its predictors and impact on outcomes. BMC Infect Dis 2022; 22:825. [PMID: 36352352 PMCID: PMC9644505 DOI: 10.1186/s12879-022-07827-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/31/2022] [Indexed: 11/11/2022] Open
Abstract
Background Descriptions of the patterns of acute/subacute cerebral infarction (ASCI) in HIV-negative patients with cryptococcal meningitis (CM) are scarce, and the predictors of ischemic stroke and outcomes following ASCI remain unclear. Aim To study the clinical characteristics and evaluate the predictors of ASCI in HIV-negative patients with CM and assess the impact of ischemic stroke on the outcomes of the patients. Methods We retrospectively analyzed the data of 61 HIV-negative patients with CM treated between January, 2016 and February, 2022, and among them, 53 patients with complete neuroimaging and cerebrospinal fluid (CSF) data were enrolled in this study. The cohort was stratified by the occurrence of ASCI diagnosed based on MRI evidences for comparison of the clinical characteristics (consciousness disturbance, GCS score, duration of symptoms, and treatment), CSF parameters, imaging findings (meningeal inflammation, hydrocephalus, posterior fossa exudates) and outcomes of the patients. A favorable outcome was defined as a modified Rankin scale (mRS) score ≤ 2 and a poor outcome as a mRS score > 2. Logistic regression analysis was used to identify the risk factors of ASCI in the HIV-negative patients with CM. Results Of the 53 HIV-negative patients with CM, 14 (26.4%) had ASCI. The incidences of fever, headache, neck stiffness, duration of symptoms, CSF parameters, meningeal enhancement in brain MRI and the treatment regimens were similar between the patients with and those without ASCI. Most of the infarcts (92.9%) were of the lacunar type, involving both the anterior and posterior territories. Basal ganglia-corona radiata and the brainstem-cerebellum were the most frequently involved sites. Univariate logistic regression analysis suggested that consciousness disturbance (P = 0.002), MRI evidence of hydrocephalus (P = 0.042) and posterior fossa exudates (P = 0.028) were predictors of ASCI in these HIV-negative patients with CM. Multivariate analysis identified consciousness disturbance as a significant predictor of ASCI (P = 0.020). Compared with the patients without ASCI, the HIV-negative patients with CM and ASCI had poorer outcomes (P = 0.001). Conclusion ASCI can occur in HIV-negative patients with CM, presented commonly as multiple lacunar infarctions involving all the cerebrovascular territories. The presence of consciousness disturbance, hydrocephalus and posterior fossa exudates may increase the risk of ASCI in patients with CM. ASCI is associated with a poor outcome of the HIV-negative patients with CM.
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Belayneh A, Abatneh E, Abebe D, Getachew M, Kebede B, Dessie B. Off-label medication use in pediatrics and associated factors at public hospitals in east Gojjam zone, Ethiopia. SAGE Open Med 2022; 10:20503121221096534. [PMID: 35600710 PMCID: PMC9118902 DOI: 10.1177/20503121221096534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 04/04/2022] [Indexed: 11/17/2022] Open
Abstract
Objective Due to a lack of appropriate pediatric preparations, health providers frequently use adult formulations in an off-label manner. This study aimed to assess pediatric off-label medication use patterns and associated factors in East Gojjam, Ethiopia. Methods Institutional-based cross-sectional study was conducted from December 2020 to June 2021 at three randomly selected hospitals. Data were collected by using self-structured questionnaires and a data abstraction checklist from health care workers and prescriptions, respectively. The collected data were analyzed using SPSS version 25. Logistic regression analysis was used to assess the association between independent and dependent variables. Results A total of 285 eligible health professionals from the pediatric unit and pharmacies, and 1,800 eligible prescriptions were involved in the study. The response rate of healthcare workers was 94.37%. Around 74.4% of professionals had good knowledge about off-label medication. Only 8% of participants had taken training on pediatric off-label medications. Of all prescriptions, 27.6% of them have contained at least one off-label medication. Phenobarbitone (16.1%) and phenytoin (12.7%) were the most frequently prescribed off-label medication. In all, 496 (27.6%) prescriptions contained off-label drugs in the form of overdose, cutting adult tablets into small portions, and formulating tablets/capsules into solution. Lack of information on off-label prescribing, shortage of pediatric drugs, and suitable dosage forms showed significant association with off-label prescribing with p-value < 0.001. Conclusion Almost one-third of pediatric prescriptions contained off-label medication. Only a small number of healthcare workers had taken training on pediatric off-label medications. Lack of sufficient information on risks of off-label medication, shortage of pediatric medication, and suitable pediatric dosage forms were associated with the use of off-label medication compared to non-use. Further research should be done on the long-term effects associated with off-label prescribing in pediatrics to assess whether the potential risks are balanced with the therapeutical benefit.
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Affiliation(s)
- Anteneh Belayneh
- Department of Pharmacy, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Eyasu Abatneh
- School of Medicine, Debre Markos University, Debre Markos, Ethiopia
| | - Dehinnet Abebe
- Department of Pharmacy, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Melese Getachew
- Department of Pharmacy, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Bekalu Kebede
- Department of Pharmacy, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Bekalu Dessie
- Department of Pharmacy, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
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Gibson JF, Bojarczuk A, Evans RJ, Kamuyango AA, Hotham R, Lagendijk AK, Hogan BM, Ingham PW, Renshaw SA, Johnston SA. Blood vessel occlusion by Cryptococcus neoformans is a mechanism for haemorrhagic dissemination of infection. PLoS Pathog 2022; 18:e1010389. [PMID: 35446924 PMCID: PMC9022829 DOI: 10.1371/journal.ppat.1010389] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/21/2022] [Indexed: 11/18/2022] Open
Abstract
Meningitis caused by infectious pathogens is associated with vessel damage and infarct formation, however the physiological cause is often unknown. Cryptococcus neoformans is a human fungal pathogen and causative agent of cryptococcal meningitis, where vascular events are observed in up to 30% of patients, predominantly in severe infection. Therefore, we aimed to investigate how infection may lead to vessel damage and associated pathogen dissemination using a zebrafish model that permitted noninvasive in vivo imaging. We find that cryptococcal cells become trapped within the vasculature (dependent on their size) and proliferate there resulting in vasodilation. Localised cryptococcal growth, originating from a small number of cryptococcal cells in the vasculature was associated with sites of dissemination and simultaneously with loss of blood vessel integrity. Using a cell-cell junction tension reporter we identified dissemination from intact blood vessels and where vessel rupture occurred. Finally, we manipulated blood vessel tension via cell junctions and found increased tension resulted in increased dissemination. Our data suggest that global vascular vasodilation occurs following infection, resulting in increased vessel tension which subsequently increases dissemination events, representing a positive feedback loop. Thus, we identify a mechanism for blood vessel damage during cryptococcal infection that may represent a cause of vascular damage and cortical infarction during cryptococcal meningitis. Meningitis is a life threatening form of infection in the brain that is difficult to treat. How infection spreads from the blood to cause meningitis is not well understood. Here we have shown how infection with the fungus Cryptococcus neoformans can be spread from the blood by blocking and bursting blood vessels. Using zebrafish larvae, we were able to follow the same infections over a period of days to understand how this infection behaves in blood vessels. We found that fungal cells become stuck within blood vessels depending on their size. These cells grow within blood vessels, resulting in the blood vessels becoming wider. We measured increased tension in blood vessels suggesting that, with the bloackage and widening of vessels, there was increased local blood pressure. We found that vessel blockage was associated with their rupture and spreading of fungus into the surround tissue. Finally, by increasing the tension in vessels we could increase the number of blood bursting events supporting our conclusion that blood vessel blockage leads to the spread of the infection outside of blood vessels.
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Affiliation(s)
- Josie F. Gibson
- Department of Infection, Immunity and Cardiovascular disease, Bateson Centre and Florey Institute, University of Sheffield, United Kingdom
- Institute of Molecular and Cell Biology, Agency of Science, Technology and Research (A-Star), Singapore
| | - Aleksandra Bojarczuk
- Department of Infection, Immunity and Cardiovascular disease, Bateson Centre and Florey Institute, University of Sheffield, United Kingdom
- Faculty of Physical Education, Gdansk University of Physical Education and Sport, Gdansk, Poland
| | - Robert J. Evans
- Department of Infection, Immunity and Cardiovascular disease, Bateson Centre and Florey Institute, University of Sheffield, United Kingdom
| | - Alfred Alinafe Kamuyango
- Department of Infection, Immunity and Cardiovascular disease, Bateson Centre and Florey Institute, University of Sheffield, United Kingdom
| | - Richard Hotham
- Department of Infection, Immunity and Cardiovascular disease, Bateson Centre and Florey Institute, University of Sheffield, United Kingdom
| | - Anne K. Lagendijk
- Division of Genomics of Development and Disease, Institute for Molecular Bioscience, University of Queensland, Brisbane, Australia
| | - Benjamin M. Hogan
- Division of Genomics of Development and Disease, Institute for Molecular Bioscience, University of Queensland, Brisbane, Australia
| | - Philip W. Ingham
- Institute of Molecular and Cell Biology, Agency of Science, Technology and Research (A-Star), Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Stephen A. Renshaw
- Department of Infection, Immunity and Cardiovascular disease, Bateson Centre and Florey Institute, University of Sheffield, United Kingdom
| | - Simon A. Johnston
- Department of Infection, Immunity and Cardiovascular disease, Bateson Centre and Florey Institute, University of Sheffield, United Kingdom
- * E-mail:
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Quinn CM, Kasibante J, Namudde A, Bangdiwala AS, Kabahubya M, Nakasujja N, Lofgren S, Elliott A, Boulware DR, Meya DB, Cresswell FV. Neurocognitive outcomes of tuberculous meningitis in a primarily HIV-positive Ugandan cohort. Wellcome Open Res 2022; 6:208. [PMID: 35949653 PMCID: PMC9334841 DOI: 10.12688/wellcomeopenres.16967.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2022] [Indexed: 11/20/2022] Open
Abstract
Background: The toll of tuberculous meningitis (TBM) in both mortality and disability is considerable, but advancements in rehabilitation have the potential to improve the functional abilities and the quality of survivors' lives. However, the typical phenotype of neurocognitive impairment in TBM survivors remains unstudied in HIV-predominant populations in sub-Saharan Africa. Methods: We tested 36 survivors of TBM in Uganda with a comprehensive battery of neurocognitive assessments at 8 and 24 weeks after diagnosis, and compared results to a representative cohort of HIV-uninfected Ugandans. Results: While participants had a broad range of impairments at eight weeks, there was marked improvement by 24 weeks, when a phenotype of impairment including deficits in motor functioning, verbal learning and memory, processing speed, and executive function emerged. These deficits were present despite good clinician-rated functional status. The majority (23/27, 85%) had evidence of moderate to severe depression at week 8, and at week 24 (18/24, 75%). Conclusion: These findings highlight the need for more comprehensive neurocognitive assessment in the survivors of TBM, and further investment in and study of rehabilitation, including management of depression, to improve long-term outcomes in this population.
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Affiliation(s)
- Carson M Quinn
- School of Medicine, University of California San Francisco Medical Center, San Francisco, CA, USA
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - John Kasibante
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Alice Namudde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Mable Kabahubya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Noeline Nakasujja
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Psychiatry, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Sarah Lofgren
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, 55455, USA
| | - Alison Elliott
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
- Medical Research Council/Uganda Virus Research-Institute Uganda Research Unit on AIDS, Entebbe, Uganda
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, 55455, USA
| | - David B Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Fiona V Cresswell
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
- Division of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, UK
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14
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Priyadarshi M, Tirlangi P, Kadnur H, Jadon R. CNS cryptococcosis presenting with cerebellar stroke and spinal arachnoiditis. BMJ Case Rep 2022; 15:e246824. [PMID: 35131790 PMCID: PMC8823087 DOI: 10.1136/bcr-2021-246824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2021] [Indexed: 11/03/2022] Open
Abstract
A 67-year-old man presented with a low-grade fever for 2 months, weakness of all four limbs for five days and altered sensorium for two days. He was recently diagnosed with AIDS and was treatment-naive. Investigations revealed a CD4 count of 27cells/mm3 MRI brain and spine exhibited bilateral cerebellar lesions with diffusion restriction, and severe arachnoiditis at the level of the lumbar spine. High suspicion of central nervous system tuberculosis in an endemic country like ours, led us to start antitubercular therapy and steroids. Repeated lumbar punctures resulted in a dry tap leading to a delay in diagnosis. Serum cryptococcal antigen detection came positive, following which antifungal treatment was initiated. Later a small amount of cerebrospinal fluid sample was obtained which confirmed the diagnosis of cryptococcosis. However, the patient worsened and succumbed to the illness. This case highlighted the rare presentation of cryptococcal cerebellar stroke and spinal arachnoiditis.
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Affiliation(s)
- Megha Priyadarshi
- Infectious Disease Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Praveen Tirlangi
- Infectious Disease Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Harshit Kadnur
- Infectious Disease Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ranveer Jadon
- Medicine, All India Institute of Medical Sciences, New Delhi, India
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15
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Abu-Rumeileh S, Garibashvili T, Hagemann JB, Still V, Bachhuber F, Otto M, Tumani H, Senel M. A one-year longitudinal evaluation of cerebrospinal fluid and blood neurochemical markers in a patient with cryptococcal meningitis complicated by ischemic stroke. J Neurol Sci 2022; 432:120090. [PMID: 34923332 DOI: 10.1016/j.jns.2021.120090] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/08/2021] [Accepted: 12/10/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Samir Abu-Rumeileh
- Department of Neurology, University of Ulm, Ulm, Germany; Department of Neurology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | | | | | - Veronika Still
- Department of Neurology, University of Ulm, Ulm, Germany
| | | | - Markus Otto
- Department of Neurology, University of Ulm, Ulm, Germany; Department of Neurology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Hayrettin Tumani
- Department of Neurology, University of Ulm, Ulm, Germany; Specialty Clinic of Neurology Dietenbronn, Schwendi, Germany
| | - Makbule Senel
- Department of Neurology, University of Ulm, Ulm, Germany.
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16
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Tarhan B, Mehkri Y, De Prey J, Hu C, Tuna IS, Shuhaiber H. Cryptococcosis Presenting as Cerebrovascular Disease. Cureus 2021; 13:e19442. [PMID: 34926024 PMCID: PMC8654049 DOI: 10.7759/cureus.19442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2021] [Indexed: 11/08/2022] Open
Abstract
Infection plays a complex role in cerebrovascular disease and is believed to have both direct and indirect mechanisms on stroke pathogenesis. if not diagnosed and treated promptly, this may have devastating consequences. Management of infection-related strokes focuses on the treatment of the underlying infection with appropriate antimicrobial drugs and the prevention of medical complications. This can lead to devastating neurological deficits. We present two cases of cryptococcal meningoencephalitis that presented with an atypical cerebral infarction. A 55-year-old male with a history of unknown autoimmune disease presented with acute onset cognitive changes and no stroke-like symptoms. A 35-year-old male with no history of autoimmune disease or other existing immunodeficiency presented with breakthrough seizure a long with stroke-like symptoms. Both patients developed multiple cerebral infarcts in multiple vascular territories, with histologic and radiologic findings consistent with a central nervous system cryptococcosis. They were subsequently diagnosed with cryptococcal meningoencephalitis and started on the appropriate anti-fungal regimen with amphotericin B and flucytosine. Prior to discharge to an inpatient rehabilitation facility, both patients were notably improved and near their neurologic baseline. It is important to understand the pathogenesis of cryptococcal infection in the central nervous system because it produces a wide variety of clinico-radiographic features that can be overlooked. Clinicians should keep infection-mediated cerebral infarcts in mind, regardless of risk factors, in order to expedite antimicrobial therapy and minimize adverse events.
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Affiliation(s)
- Bedirhan Tarhan
- Pediatric Neurology, University of Florida, Gainesville, USA
| | - Yusuf Mehkri
- Neurosurgery, University of Florida, Gainesville, USA
| | | | - Calvin Hu
- Neurology, University of Florida, Gainesville, USA
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17
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Liu J, Li M, Liang JY, Xu XF, Zeng WG, Wang YJ, Jiang Y, Peng FH. Autoimmune diseases in HIV-negative cryptococcal meningitis. Future Microbiol 2021; 16:1251-1259. [PMID: 34674547 DOI: 10.2217/fmb-2020-0318] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Aim: The purpose of our study was to assess the differences between HIV-negative cryptococcal meningitis (CM) patients with and without autoimmune diseases. Methods: A total of 43 CM patients with autoimmune diseases and 67 without autoimmune diseases were enrolled for analysis. Results: CM patients with autoimmune diseases had higher fever, modified Rankin Scale scores, C-reactive protein and erythrocyte sedimentation rate, but had lower rates of visual and hearing symptoms, ventriculoperitoneal shunts, MRI meningeal enhancement and amphotericin B treatment, as well as lower cerebrospinal fluid pressure and fungal counts. When divided according to gender, each group had lower intracranial pressure and higher inflammation indicators. No differences in outcomes, sequelae and mortality hazard were found. Fluconazole treatment was a prognostic factor for CM without autoimmune diseases. Conclusions: Both antifungal and anti-inflammatory therapy should be considered in CM patients with autoimmune diseases.
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Affiliation(s)
- Jia Liu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Min Li
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jia-Yin Liang
- Department of Laboratory, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xiao-Feng Xu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Wen-Gao Zeng
- Department of Neurology, Changsha Central Hospital, Changsha, 410018, China
| | - Yi-Jie Wang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ying Jiang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Fu-Hua Peng
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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18
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Miao J, Ren Z, Zhong Z, Yan L, Xia X, Wang J, Yang J. Mesenchymal Stem Cells: Potential Therapeutic Prospect of Paracrine Pathways in Neonatal Infection. J Interferon Cytokine Res 2021; 41:365-374. [PMID: 34672801 DOI: 10.1089/jir.2021.0094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Infection is the leading cause of admission and mortality in neonatal intensive care units. Immature immune function and antibiotic resistance make the treatment more difficult. However, there is no effective prevention for it. Recently, more and more researches are focusing on stem cell therapy, especially mesenchymal stem cells (MSCs); their potential paracrine effect confer MSCs with a major advantage to treat the immune and inflammatory disorders associated with neonatal infection. In this review, we summarize the basal properties and preclinical evidence of MSCs and explore the potential mechanisms of paracrine factors of MSCs for neonatal infection.
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Affiliation(s)
- Jiayu Miao
- Department of Pediatrics, Guangdong Women and Children Hospital, Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Zhuxiao Ren
- Department of Neonatology, and Guangdong Women and Children Hospital, Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Zhicheng Zhong
- Department of Prenatal Diagnosis Center, Guangdong Women and Children Hospital, Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Longli Yan
- Department of Neonatology, and Guangdong Women and Children Hospital, Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Xin Xia
- Department of Neonatology, and Guangdong Women and Children Hospital, Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Jianlan Wang
- Department of Neonatology, and Guangdong Women and Children Hospital, Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Jie Yang
- Department of Neonatology, and Guangdong Women and Children Hospital, Guangzhou Medical University, Guangzhou, People's Republic of China
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19
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Yang FY, Hung JL, Lin SK. Percheron Artery-Plus Syndrome: A Syndrome Beyond Stroke Chameleon. J NIPPON MED SCH 2021; 88:375-379. [PMID: 34471065 DOI: 10.1272/jnms.jnms.2021_88-414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The artery of Percheron (AOP) is an anatomical variant of the thalamoperforating arteries. AOP occlusion can cause bilateral paramedian thalamic infarctions and is referred to as a "stroke chameleon" because it lacks the classic signs of stroke. Coexistence of AOP occlusion and other neurologic disease is rare and can cause disturbance of consciousness. A 78-year-old woman had acute onset of left limb weakness and drowsy consciousness. Brain magnetic resonance angiography (MRA) revealed acute bilateral paramedian thalamic infarctions. However, serum and cerebrospinal fluid (CSF) cryptococcal antigen titers were 1:16 and 1:128, respectively. The CSF culture grew Cryptococcus neoformans. Although consciousness and muscle power improved after treatment, the patient later died of pneumonia. A 68-year-old woman developed acute disturbance of consciousness followed by delirium. Brain MRA revealed acute bilateral paramedian thalamic infarctions. Elevated free thyroxine, anti-thyroperoxidase, and anti-thyroglobulin antibodies were detected. She received 3 days of steroid pulse therapy followed by oral prednisolone. Her consciousness gradually improved after Hashimoto encephalopathy and stroke were controlled. AOP occlusion was diagnosed early in these two patients. However, other concomitant life-threatening diseases could have been overlooked because of the complicated diagnostic determination. Further serum cryptococcal antigen, anti-TPO Ab, and anti-TG Ab surveys might help to exclude cryptococcal meningitis and Hashimoto encephalopathy. CSF study is warranted when central nervous system infection is strongly suspected. This "Percheron artery-plus syndrome" comprises multifaceted disorders beyond the stroke chameleon and requires attention.
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Affiliation(s)
- Fu-Yi Yang
- Stroke Center and Department of Neurology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - Jeng-Luen Hung
- Department of Emergency, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - Shinn-Kuang Lin
- Stroke Center and Department of Neurology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation.,School of Medicine, Tzu Chi University
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20
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Quinn CM, Kasibante J, Namudde A, Bangdiwala AS, Kabahubya M, Nakasujja N, Lofgren S, Elliott A, Boulware DR, Meya DB, Cresswell FV. Neurocognitive outcomes of HIV-associated tuberculous meningitis. Wellcome Open Res 2021; 6:208. [PMID: 35949653 PMCID: PMC9334841 DOI: 10.12688/wellcomeopenres.16967.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2021] [Indexed: 12/15/2022] Open
Abstract
Background: The toll of tuberculous meningitis (TBM) in both mortality and disability is considerable, but advancements in rehabilitation have the potential to improve the functional abilities and the quality of survivors' lives. However, the typical phenotype of neurocognitive impairment in TBM survivors remains unstudied in HIV-predominant populations in sub-Saharan Africa. Methods: We tested 36 survivors of TBM in Uganda with a comprehensive battery of neurocognitive assessments at 8 and 24 weeks after diagnosis, and compared results to a representative cohort of HIV-uninfected Ugandans. Results: While participants had a broad range of impairments at eight weeks, there was marked improvement by 24 weeks, when a phenotype of impairment including deficits in motor functioning, verbal learning and memory, processing speed, and executive function emerged. These deficits were present despite good clinician-rated functional status. The majority (23/27, 85%) had evidence of moderate to severe depression at week 8, and at week 24 (18/24, 75%). Conclusion: These findings highlight the need for more comprehensive neurocognitive assessment in the survivors of TBM, and further investment in and study of rehabilitation, including management of depression, to improve long-term outcomes in this population.
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Affiliation(s)
- Carson M Quinn
- School of Medicine, University of California San Francisco Medical Center, San Francisco, CA, USA
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - John Kasibante
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Alice Namudde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Mable Kabahubya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Noeline Nakasujja
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Psychiatry, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Sarah Lofgren
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, 55455, USA
| | - Alison Elliott
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
- Medical Research Council/Uganda Virus Research-Institute Uganda Research Unit on AIDS, Entebbe, Uganda
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, 55455, USA
| | - David B Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Fiona V Cresswell
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
- Division of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, UK
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21
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1217] [Impact Index Per Article: 405.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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22
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Abstract
PURPOSE OF REVIEW This article reviews current epidemiologic trends, clinical presentations, and diagnostic strategies for central nervous system (CNS) infections in human immunodeficiency virus-negative (HIV) patients immunocompromised by their underlying disease or by receipt of immunosuppressive or immunomodulating therapies. Three patient groups are considered: (1) cancer patients; (2) hematopoietic or solid organ transplantation recipients; and (3) patients with autoimmune or inflammatory conditions requiring therapies that alter the host immune response. RECENT FINDINGS Clinical presentations, associated neuroimaging, and cerebrospinal fluid (CSF) abnormalities differ between immunocompromised and immunocompetent patients. Infections can trigger the emergence of neurotropic antibodies or inflammatory conditions due to treatment with cancer immunotherapies. Unbiased metagenomic assays to identify obscure pathogens help clinicians navigate the increasing range of conditions affecting the growing population of patients with altered immunity. Awareness of clinical presentations and disease and drug-specific risks is important for early diagnosis and intervention in these often life-threatening infections and their noninfectious mimes.
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Affiliation(s)
- Amy A Pruitt
- Department of Neurology, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA.
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23
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Kumar M, Dhar N, Tiwari A, Siddiqui MS. Comparison of patterns of infarction in TB and cryptococcal meningitis. Trans R Soc Trop Med Hyg 2021; 115:1160-1167. [PMID: 33962464 DOI: 10.1093/trstmh/trab070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/21/2021] [Accepted: 04/16/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND To compare the frequency and patterns of stroke, the specificity of tubercular zone (TBZ) infarction and its effect on outcomes in TB (TBM) and cryptococcal meningitis (CM). METHODS This retrospective study was conducted at two tertiary centres in India from May 2018 to July 2020. Sixty-one patients with TBM and 22 with CM were included. The primary outcome was the proportions of TBM and CM patients with infarction. Secondary outcomes included the anatomical locations of infarction and in-hospital mortality. RESULTS Infarction was noted in 52.5% of patients with TBM and in 54.5% of those with CM (p=0.87), with caudate head infarcts in 9.4% vs 41.7% (p=0.01), cerebellar in 9.4% vs 33.3% (p=0.05), thalamic in 25% vs 0% and lobar in 28.1% vs 0%, respectively. In TBM, the infarcts were located in the TBZ in 3 (9.4%), in the ischaemic zone in 23 (71.9%), while 6 (18.8%) patients showed infarcts in both, while in CM, the infarcts were in 0 (0%), 6 (50%) and 6 (50%) patients, respectively. Infarcts were not associated with in-hospital mortality, either in TBM or CM. CONCLUSION Caudate head and cerebellar infarction was more common in CM, while thalamic and lobar infarcts were more frequent in TBM. TBZ infarcts were not specific to TBM.
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Affiliation(s)
- Mritunjai Kumar
- Department of Neurology, All India Institute of Medical Sciences, Rishikesh, 249203, India.,Department of Neurology, All India Institute of Medical Sciences, Raipur, 492099, India
| | - Nikita Dhar
- Department of Neurology, All India Institute of Medical Sciences, Rishikesh, 249203, India
| | - Ashutosh Tiwari
- Department of Neurology, All India Institute of Medical Sciences, Rishikesh, 249203, India
| | - Md Sabah Siddiqui
- Department of Internal Medicine, All India Institute of Medical Sciences, Raipur, 492099, India
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24
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Zeroing in on the cause of stroke. DER NERVENARZT 2021; 92:375-378. [PMID: 33564891 DOI: 10.1007/s00115-021-01084-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/05/2021] [Indexed: 10/22/2022]
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25
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Nathan CL, Emmert BE, Nelson E, Berger JR. CNS fungal infections: A review. J Neurol Sci 2021; 422:117325. [PMID: 33516057 DOI: 10.1016/j.jns.2021.117325] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 12/23/2020] [Accepted: 01/19/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Cody L Nathan
- Departments of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian E Emmert
- Departments of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ernest Nelson
- Departments of Pathology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph R Berger
- Departments of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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26
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Pan D, Wong N, Toovey O, Hills G, Stephenson I. A Multicenter, Longitudinal Cohort Study of Cryptococcosis in Human Immunodeficiency Virus–Negative People in the United States. Clin Infect Dis 2020; 71:3014-3015. [DOI: 10.1093/cid/ciaa296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Daniel Pan
- Department of Respiratory Medicine, University of Leicester, Leicester, United Kingdom
- Infectious Diseases Unit, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Nicholas Wong
- Infectious Diseases Unit, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Oliver Toovey
- Infectious Diseases Unit, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - George Hills
- Infectious Diseases Unit, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Iain Stephenson
- Infectious Diseases Unit, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
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27
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Belayneh A, Tadese E, Molla F. Safety and Biopharmaceutical Challenges of Excipients in Off-Label Pediatric Formulations. Int J Gen Med 2020; 13:1051-1066. [PMID: 33204140 PMCID: PMC7667588 DOI: 10.2147/ijgm.s280330] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/14/2020] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND One of the major challenges in pediatric treatment is the lack of suitable drug preparations specifically designed and marketed for children. Most of the FDA approved drug formulations for adults have not been approved for use in pediatric patients. Shortage of suitable pediatric dosage information often leads health professionals to use adult formulations in an off-label manner. The aim of this work was to review the safety and biopharmaceutical challenges of commonly found excipients in off-label pediatric formulations as well as to show the current progress to alleviate pediatric toxicity related to excipients. METHODS Research findings and medical case reports were searched from credible sources including Scopus, PubMed, OVID, Google Scholar, Embase, Cochrane Library, and Web of Science. RESULTS As several studies and clinical case reports have revealed, off-label adult formulations usage causes pediatric patients to become exposed to potentially harmful excipients, which are essential components of drug products. In addition to their toxicities, some of the excipients affect the biopharmaceutical property of different drugs. Immature organ and body composition, large body surface area and slower metabolism and elimination capabilities of pediatrics are the main causes of toxicities associated with different excipients. Recent studies have also shown that good progress is being made to develop safe and suitable excipients for pediatric use. CONCLUSION A risk and benefit assessment should be done before using off-label formulation as excipients cause mild to severe toxicities and biopharmaceutical problems to pediatric patients.
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Affiliation(s)
- Anteneh Belayneh
- Department of Pharmacy, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Ebisa Tadese
- Department of Pharmaceutics, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Fantahun Molla
- Department of Pharmaceutics, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
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28
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Affiliation(s)
- Jordan D Anderson
- From the Departments of Medicine (J.D.A., V.T.H., B.D.L., J.L.) and Pathology (K.T.W.), Brigham and Women's Hospital, Boston
| | - Vincent T Ho
- From the Departments of Medicine (J.D.A., V.T.H., B.D.L., J.L.) and Pathology (K.T.W.), Brigham and Women's Hospital, Boston
| | - Kyle T Wright
- From the Departments of Medicine (J.D.A., V.T.H., B.D.L., J.L.) and Pathology (K.T.W.), Brigham and Women's Hospital, Boston
| | - Bruce D Levy
- From the Departments of Medicine (J.D.A., V.T.H., B.D.L., J.L.) and Pathology (K.T.W.), Brigham and Women's Hospital, Boston
| | - Joseph Loscalzo
- From the Departments of Medicine (J.D.A., V.T.H., B.D.L., J.L.) and Pathology (K.T.W.), Brigham and Women's Hospital, Boston
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Hassanpour S, Kim HJ, Saadati A, Tebon P, Xue C, van den Dolder FW, Thakor J, Baradaran B, Mosafer J, Baghbanzadeh A, de Barros NR, Hashemzaei M, Lee KJ, Lee J, Zhang S, Sun W, Cho HJ, Ahadian S, Ashammakhi N, Dokmeci MR, Mokhtarzadeh A, Khademhosseini A. Thrombolytic Agents: Nanocarriers in Controlled Release. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2020; 16:e2001647. [PMID: 32790000 PMCID: PMC7702193 DOI: 10.1002/smll.202001647] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/10/2020] [Indexed: 06/11/2023]
Abstract
Thrombosis is a life-threatening pathological condition in which blood clots form in blood vessels, obstructing or interfering with blood flow. Thrombolytic agents (TAs) are enzymes that can catalyze the conversion of plasminogen to plasmin to dissolve blood clots. The plasmin formed by TAs breaks down fibrin clots into soluble fibrin that finally dissolves thrombi. Several TAs have been developed to treat various thromboembolic diseases, such as pulmonary embolisms, acute myocardial infarction, deep vein thrombosis, and extensive coronary emboli. However, systemic TA administration can trigger non-specific activation that can increase the incidence of bleeding. Moreover, protein-based TAs are rapidly inactivated upon injection resulting in the need for large doses. To overcome these limitations, various types of nanocarriers have been introduced that enhance the pharmacokinetic effects by protecting the TA from the biological environment and targeting the release into coagulation. The nanocarriers show increasing half-life, reducing side effects, and improving overall TA efficacy. In this work, the recent advances in various types of TAs and nanocarriers are thoroughly reviewed. Various types of nanocarriers, including lipid-based, polymer-based, and metal-based nanoparticles are described, for the targeted delivery of TAs. This work also provides insights into issues related to the future of TA development and successful clinical translation.
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Affiliation(s)
- Soodabeh Hassanpour
- Department of Analytical Chemistry, Faculty of Science, Palacky University Olomouc, 17. Listopadu 12, Olomouc, 77146, Czech Republic
| | - Han-Jun Kim
- Department of Bioengineering, Center for Minimally Invasive Therapeutics (C-MIT) and California NanoSystems Institute University of California-Los Angeles, Los Angeles, CA, 90095, USA
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA, 90024, USA
| | - Arezoo Saadati
- Pharmaceutical Analysis Research Center, Tabriz University of Medical Sciences, Tabriz, 516614731, Iran
| | - Peyton Tebon
- Department of Bioengineering, Center for Minimally Invasive Therapeutics (C-MIT) and California NanoSystems Institute University of California-Los Angeles, Los Angeles, CA, 90095, USA
| | - Chengbin Xue
- Department of Bioengineering, Center for Minimally Invasive Therapeutics (C-MIT) and California NanoSystems Institute University of California-Los Angeles, Los Angeles, CA, 90095, USA
| | - Floor W van den Dolder
- Department of Bioengineering, Center for Minimally Invasive Therapeutics (C-MIT) and California NanoSystems Institute University of California-Los Angeles, Los Angeles, CA, 90095, USA
- Division Heart and Lungs, Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, GA, 3508, The Netherlands
- Regenerative Medicine Center Utrecht, University Medical Center Utrecht, Utrecht, CT, 3584, The Netherlands
| | - Jai Thakor
- Department of Bioengineering, Center for Minimally Invasive Therapeutics (C-MIT) and California NanoSystems Institute University of California-Los Angeles, Los Angeles, CA, 90095, USA
| | - Behzad Baradaran
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, 516614731, Iran
| | - Jafar Mosafer
- Research Center of Advanced Technologies in Medicine, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, 9519633787, Iran
| | - Amir Baghbanzadeh
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, 516614731, Iran
| | - Natan Roberto de Barros
- Department of Bioengineering, Center for Minimally Invasive Therapeutics (C-MIT) and California NanoSystems Institute University of California-Los Angeles, Los Angeles, CA, 90095, USA
| | - Mahmoud Hashemzaei
- Department of Pharmacodynamics and Toxicology, School of Pharmacy, Zabol University of Medical Sciences, Zabol, 9861618335, Iran
| | - Kang Ju Lee
- Department of Bioengineering, Center for Minimally Invasive Therapeutics (C-MIT) and California NanoSystems Institute University of California-Los Angeles, Los Angeles, CA, 90095, USA
| | - Junmin Lee
- Department of Bioengineering, Center for Minimally Invasive Therapeutics (C-MIT) and California NanoSystems Institute University of California-Los Angeles, Los Angeles, CA, 90095, USA
| | - Shiming Zhang
- Department of Bioengineering, Center for Minimally Invasive Therapeutics (C-MIT) and California NanoSystems Institute University of California-Los Angeles, Los Angeles, CA, 90095, USA
| | - Wujin Sun
- Department of Bioengineering, Center for Minimally Invasive Therapeutics (C-MIT) and California NanoSystems Institute University of California-Los Angeles, Los Angeles, CA, 90095, USA
| | - Hyun-Jong Cho
- Department of Bioengineering, Center for Minimally Invasive Therapeutics (C-MIT) and California NanoSystems Institute University of California-Los Angeles, Los Angeles, CA, 90095, USA
- College of Pharmacy, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea
| | - Samad Ahadian
- Department of Bioengineering, Center for Minimally Invasive Therapeutics (C-MIT) and California NanoSystems Institute University of California-Los Angeles, Los Angeles, CA, 90095, USA
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA, 90024, USA
| | - Nureddin Ashammakhi
- Department of Bioengineering, Center for Minimally Invasive Therapeutics (C-MIT) and California NanoSystems Institute University of California-Los Angeles, Los Angeles, CA, 90095, USA
- Jonsson Comprehensive Cancer Center, Department of Radiology and Department of Chemical and Biomolecular Engineering, University of California-Los Angeles, Los Angeles, CA, 90095, USA
| | - Mehmet R Dokmeci
- Department of Bioengineering, Center for Minimally Invasive Therapeutics (C-MIT) and California NanoSystems Institute University of California-Los Angeles, Los Angeles, CA, 90095, USA
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA, 90024, USA
- Jonsson Comprehensive Cancer Center, Department of Radiology and Department of Chemical and Biomolecular Engineering, University of California-Los Angeles, Los Angeles, CA, 90095, USA
| | - Ahad Mokhtarzadeh
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, 516614731, Iran
| | - Ali Khademhosseini
- Department of Bioengineering, Center for Minimally Invasive Therapeutics (C-MIT) and California NanoSystems Institute University of California-Los Angeles, Los Angeles, CA, 90095, USA
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA, 90024, USA
- Jonsson Comprehensive Cancer Center, Department of Radiology and Department of Chemical and Biomolecular Engineering, University of California-Los Angeles, Los Angeles, CA, 90095, USA
- Department of Chemical and Biomolecular Engineering, Henry Samueli School of Engineering and Applied Sciences, University of California - Los Angeles, Los Angeles, CA, 90095, USA
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30
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Kahathuduwa CN, Wakefield S, West BD, Blume J, Dassanayake TL, Weerasinghe VS, Mastergeorge A. Effects of L-theanine-caffeine combination on sustained attention and inhibitory control among children with ADHD: a proof-of-concept neuroimaging RCT. Sci Rep 2020; 10:13072. [PMID: 32753637 PMCID: PMC7403383 DOI: 10.1038/s41598-020-70037-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 07/21/2020] [Indexed: 01/01/2023] Open
Abstract
We examined the acute effects of L-theanine, caffeine and their combination on sustained attention, inhibitory control and overall cognition in boys with attention deficit hyperactivity disorder (ADHD). L-Theanine (2.5 mg/kg), caffeine (2.0 mg/kg), their combination and a placebo were administered in a randomized four-way repeated-measures crossover with washout, to five boys (8-15 years) with ADHD. Functional magnetic resonance imaging (fMRI) was performed during a Go/NoGo task and a Stop-signal task ~ 1 h post-dose. NIH Cognition Toolbox was administered ~ 2 h post-dose. Treatment vs. placebo effects were examined in multi-level mixed-effects models. L-Theanine improved total cognition composite in NIH Cognition Toolbox (p = 0.040) vs. placebo. Caffeine worsened and L-theanine had a trend of worsening inhibitory control (i.e. increased Stop-signal reaction time; p = 0.031 and p = 0.053 respectively). L-Theanine-caffeine combination improved total cognition composite (p = 0.041), d-prime in the Go/NoGo task (p = 0.033) and showed a trend of improvement of inhibitory control (p = 0.080). L-Theanine-caffeine combination was associated with decreased task-related reactivity of a brain network associated with mind wandering (i.e. default mode network). L-Theanine-caffeine combination may be a potential therapeutic option for ADHD-associated impairments in sustained attention, inhibitory control and overall cognitive performance.
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Affiliation(s)
- Chanaka N Kahathuduwa
- Department of Laboratory Sciences and Primary Care, School of Health Professions, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX, USA.
- Department of Psychiatry, School of Medicine, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX, USA.
- Department of Human Development and Family Studies, College of Human Sciences, Texas Tech University, Lubbock, TX, USA.
| | - Sarah Wakefield
- Department of Psychiatry, School of Medicine, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX, USA
- Department of Human Development and Family Studies, College of Human Sciences, Texas Tech University, Lubbock, TX, USA
| | - Blake D West
- Department of Human Development and Family Studies, College of Human Sciences, Texas Tech University, Lubbock, TX, USA
| | - Jessica Blume
- Department of Human Development and Family Studies, College of Human Sciences, Texas Tech University, Lubbock, TX, USA
| | - Tharaka L Dassanayake
- Department of Physiology, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- School of Psychology, The University of Newcastle, Callaghan, NSW, Australia
| | - Vajira S Weerasinghe
- Department of Physiology, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Ann Mastergeorge
- Department of Human Development and Family Studies, College of Human Sciences, Texas Tech University, Lubbock, TX, USA
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Axente E, Sima F. Biomimetic Nanostructures with Compositional Gradient Grown by Combinatorial Matrix-Assisted Pulsed Laser Evaporation for Tissue Engineering. Curr Med Chem 2020; 27:903-918. [PMID: 31526343 DOI: 10.2174/0929867326666190916145455] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 08/15/2019] [Accepted: 09/07/2019] [Indexed: 01/16/2023]
Abstract
There is permanent progress with the fabrication of smart bioactive surfaces that could govern tissue regeneration. Thin coatings of two or more materials with compositional gradient allow the construction of arrays with different chemical and physical features on a solid substrate. With such intelligent bio-platforms, cells can be exposed to a tissue-like biomimetic micro-environment with precise characteristics that directs cells fate towards specific phenotypes. We have introduced combinatorial matrix-assisted pulsed laser evaporation (C-MAPLE) as an alternative approach for the fabrication in a single-step process of either organic or inorganic thin and nanostructured coatings with variable composition. A continuous reciprocal gradient of two biomolecules can be achieved by C-MAPLE with discrete areas exhibiting physicochemical specificity that modulates intracellular signaling events. Herein, we present a review of the current combinatorial laser strategies and methods for fabricating thin organic and inorganic films with compositional gradient with emphasis on the surface influence on cell responsiveness. In particular, the specific biological potential of surface functionalization with thin coatings of biopolymers, proteins and drugs will be discussed. Laser deposition combinatorial processes are considered an emerging unconventional technology that can be widely applied to produce composite multilayers and micro-patterns for faster cell colonization and tissue engineering.
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Affiliation(s)
- Emanuel Axente
- Center for Advanced Laser Technologies (CETAL), National Institute for Laser, Plasma and Radiation Physics (INFLPR), 77125 Magurele, Romania
| | - Felix Sima
- Center for Advanced Laser Technologies (CETAL), National Institute for Laser, Plasma and Radiation Physics (INFLPR), 77125 Magurele, Romania
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Abstract
PURPOSE OF REVIEW To summarize the differential diagnosis and diagnostic approach of sudden unresponsiveness with normal vital signs in various settings, including the ICU. RECENT FINDINGS Sudden unresponsiveness may be either transient or persistent, and may result from primary brain diseases or nonstructural systemic conditions. Life-threatening causes should always be discriminated from those more benign. Regional epidemiology, for example regarding intoxications, and evolving therapeutic management, for example for ischemic stroke, should always be taken into account for optimal opportunity for rapid diagnosis and best management. SUMMARY Sudden unresponsiveness with normal vital signs should trigger immediate and focused diagnostic evaluation to find or exclude those conditions requiring urgent, and possibly life-saving, management.
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Kumar Mishra A, Lal A, Kant Sahu K. Steroid in cryptococcal meningitis. J Clin Neurosci 2020; 76:255-256. [PMID: 32291241 DOI: 10.1016/j.jocn.2020.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/05/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Ajay Kumar Mishra
- Department of Internal Medicine, 123 Summer Street, Saint Vincent Hospital, Worcester, MA 01608, USA.
| | - Amos Lal
- Department of Pulmonary Medicine and Critical Care, Mayo Clinic, Rochester, MN 5777, USA.
| | - Kamal Kant Sahu
- Department of Internal Medicine, 123 Summer Street, Saint Vincent Hospital, Worcester, MA 01608, USA.
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Nigam M, Wang M, Commander L. Clinical Reasoning: Immunocompetent patient with multiple cranial nerve palsies, ataxia, and cognitive decline. Neurology 2020; 94:e225-e229. [PMID: 31932407 DOI: 10.1212/wnl.0000000000008793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Minali Nigam
- From the School of Medicine (M.N.) and Departments of Neurology (M.W.) and Pathology (L.C.), University of North Carolina at Chapel Hill.
| | - Michael Wang
- From the School of Medicine (M.N.) and Departments of Neurology (M.W.) and Pathology (L.C.), University of North Carolina at Chapel Hill
| | - Leah Commander
- From the School of Medicine (M.N.) and Departments of Neurology (M.W.) and Pathology (L.C.), University of North Carolina at Chapel Hill
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Dean O, Buda A, Adams HR, Mwanza-Kabaghe S, Potchen MJ, Mbewe EG, Kabundula PP, Moghaddam SM, Birbeck GL, Bearden DR. Brain Magnetic Resonance Imaging Findings Associated With Cognitive Impairment in Children and Adolescents With Human Immunodeficiency Virus in Zambia. Pediatr Neurol 2020; 102:28-35. [PMID: 31604645 PMCID: PMC7924094 DOI: 10.1016/j.pediatrneurol.2019.08.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 08/24/2019] [Accepted: 08/29/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Cognitive impairment is common in children and adolescents with human immunodeficiency virus (HIV). Brain magnetic resonance imaging (MRI) is a potentially useful tool to investigate the pathophysiology of HIV-associated cognitive impairment and may serve as a biomarker in future clinical trials. There are few published data on brain imaging in children with HIV in sub-Saharan Africa. METHODS Thirty-four perinatally infected subjects with HIV and age-matched HIV-exposed uninfected controls between the ages nine and 17 years were recruited from the Pediatric Center of Excellence in Lusaka, Zambia, as part of the HIV-associated Neurocognitive Disorders in Zambia study. Brain MRI sequences were acquired, and clinical and volumetric assessments were performed. Subjects underwent a comprehensive neuropsychologic battery, and cognitive impairment status was classified using a global deficit score approach. Regression models were used to evaluate relationships between MRI findings and cognitive function. RESULTS We identified cerebrovascular disease in seven of 34 subjects with HIV compared with zero of 17 controls (21% vs 0%, P = 0.04). We also identified decreased total brain volumes (1036 vs 1162 cm3, P = 0.03) and decreased cortical thickness in the right temporal lobes (3.12 vs 3.29 mm; P = 0.01) and right fusiform gyri (3.10 vs 3.25 mm; P = 0.02) of HIV-infected subjects with cognitive impairment. CONCLUSIONS These findings support the hypothesis that brain volumes may be useful biomarkers for cognitive outcomes in children with HIV. Further studies are necessary to investigate mechanisms of cerebrovascular disease and volume loss in children with HIV.
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Affiliation(s)
- Owen Dean
- University of Rochester School of Medicine, Rochester, New York, USA
| | - Alexandra Buda
- University of Rochester School of Medicine, Rochester, New York, USA
| | - Heather R. Adams
- Division of Child Neurology, Department of Neurology, University of Rochester School of Medicine, Rochester, New York, USA
| | | | - Michael J. Potchen
- Department of Radiology, University of Rochester School of Medicine, Rochester, New York, USA
| | - Esau G. Mbewe
- Department of Psychology, University of Zambia, Lusaka, Zambia
| | | | | | - Gretchen L. Birbeck
- Division of Epilepsy, Department of Neurology, Rochester, New York, USA,University of Zambia School of Medicine, Lusaka, Zambia
| | - David R. Bearden
- Division of Child Neurology, Department of Neurology, University of Rochester School of Medicine, Rochester, New York, USA
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Ellis JP, Gaskell K, Peirse M, Gormley J, Kalata N, Burgess PI, Mopamboli P, Manda CA, Kiire CA, Maccormick I, Gondwe E, Molloy S, Harrison TS, Lalloo DG, Heyderman RS. Ophthalmic features of HIV associated cryptococcal meningitis in Malawian Adults: an observational study. Wellcome Open Res 2019. [DOI: 10.12688/wellcomeopenres.15067.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Cryptococcal meningitis (CM) is the commonest neurological complication in patients with advanced HIV. Visual disturbance is a frequent presenting symptom. Papilloedema is commonly reported but other ophthalmic findings are not well described. Methods: We performed an observational study comparing severely immunocompromised HIV-infected patients with and without CM to determine the nature and prevalence of retinal pathology attributable to CM. 70 adult patients were enrolled in Blantyre Malawi, 35 with CM and 35 HIV-infected patients without CM. Results: 79% (19/24) of CM patients examined on day one had evidence of retinal abnormalities compared to 17% (6/35) of HIV-infected controls (p <0.001). In the CM group, retinal whitening was the commonest abnormality (50%), followed by optic disc swelling (29%), haemorrhage (25%) and vascular abnormalities (7%). Retinal whitening was the only abnormality observed in the comparator group (17%). In CM, there was no significant difference between those with and without retinal abnormalities in fungal burden (13,550 cfu/ml vs. 9,150 cfu/ml; p = 0.65), CD4 count (28 cells/µl vs. 76 cells/µl; p = 0.79) or CSF opening pressure (21cm H20 vs. 27cm H20; p = 0.5). There was no association between presence/absence of retinal abnormalities and death (40% 10-week mortality vs. 26%; p = 0.6). Conclusions: Whether the presence of CM retinopathy could be used as a marker of disease severity warrants further investigation. The observed ophthalmic findings provide a descriptive framework for CM retinopathy to be utilised in future CM studies. Trial registration: ISRCTN (ISRCTN45035509) 19/06/2012.
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Jha A, Adhikari S, Sigdel KR, Paudyal B, Basnyat B, Kayastha G, Pradhan S, Risal U, Poudel J. Case Report: Cryptococcal meningitis in an apparently immunocompetent patient in Nepal - challenges in diagnosis and treatment. Wellcome Open Res 2019; 4:55. [PMID: 31289752 PMCID: PMC6600853 DOI: 10.12688/wellcomeopenres.15187.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2019] [Indexed: 12/31/2022] Open
Abstract
A 50 year old woman from Nepal had clinical features suggestive of meningitis. Cerebrospinal fluid (CSF) analysis was normal except for the presence of cryptococcal antigen. The inclusion of test for Cryptococcus in the CSF helped in making the diagnosis of cryptococcal meningitis in our patient who was apparently immunocompetent. Treatment with liposomal amphotericin B could not be started on time due to financial constraints. The patient had a stroke and further deteriorated. Liposomal amphotericin B is stocked by the government of Nepal for free supply to patients with visceral leishmaniasis, but the policy does not allow the drug to be dispensed for other infections. The family members of our patient acquired the drug within a few days from a government center using their political connections and following administering the treatment the patient improved. This case demonstrates the utility of considering cryptococcal meningitis as a differential diagnosis, and including tests for Cryptococcus when dealing with immunocompetent patients presenting with meningitis. It also demonstrates the effects of the sociopolitical situation on health care delivery in low- and middle-income countries (LMICs) such as Nepal.
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Affiliation(s)
- Ashish Jha
- Internal Medicine, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Sudeep Adhikari
- Internal Medicine, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Keshav Raj Sigdel
- Internal Medicine, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Buddhi Paudyal
- Internal Medicine, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Buddha Basnyat
- Internal Medicine, Patan Academy of Health Sciences, Lalitpur, Nepal.,Oxford University Clinical Research Unit, Patan Hospital, Lalitpur, Nepal
| | - Gyan Kayastha
- Internal Medicine, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Sumita Pradhan
- General Surgery, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Ujjwol Risal
- Internal Medicine, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Jiwan Poudel
- Internal Medicine, Patan Academy of Health Sciences, Lalitpur, Nepal
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Malik I, Atif M, Riaz F, Asghar S, Ahmad N. Pediatric Antibiotic Pack Size Compliance With the Dosage Regimen: A Descriptive Study. Ther Innov Regul Sci 2019:2168479019853770. [PMID: 31189341 DOI: 10.1177/2168479019853770] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The unavailability of appropriate pediatric drug pack size is a global issue. Antibiotics are the lifesaving and most frequently prescribed therapeutic agents given to pediatrics. The objective of this study was to assess the compliance of pediatric antibiotic pack size with the standard dosage regimen. METHODS A descriptive study design was employed. Data were collected from a community pharmacy in Bahawalpur, Pakistan, between August 1, 2017, and September 30, 2017. Five most commonly prescribed antibiotics were selected and calculations were made to check the appropriateness of packaging size by comparing the quantity of product in the available pack with the dosage regimen recommended by the British National Formulary for Children (BNFC). RESULTS Only 16 clarithromycin, 9 amoxicillin, 1 cefotaxime, and 1 metronidazole packaging sizes were sufficient to meet the dosage regimen for treatment. None of the available pack sizes for gentamicin matched the recommended duration of treatment. The study findings revealed that the available pack sizes either had leftover or a shortfall of antibiotic formulation. Highly inappropriate dosage forms (containing either excess and less quantity) of antibiotics were intravenous infusions and oral suspensions. CONCLUSION The study concluded that the packaging sizes of antibiotics failed to supply the recommended dosage regimen to pediatrics for common indications. This may contribute to development of antibiotic resistance among pediatric patients. Health policy makers should devise strict rules and regulations to ensure the availability of child-specific antibiotic pack sizes.
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Affiliation(s)
- Iram Malik
- 1 Department of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
| | - Muhammad Atif
- 1 Department of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
| | - Fatima Riaz
- 1 Department of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
| | - Saima Asghar
- 1 Department of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
| | - Nafees Ahmad
- 2 Faculty of Pharmacy and Health Sciences, University of Balochistan, Quetta, Pakistan
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Response to Ajay Kumar Mishra, et al. Lacunar strokes in Cryptococcal meningitis. J Stroke Cerebrovasc Dis 2019; 28:1785-1786. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.02.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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40
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Letter to Editor on “Lacunar Stroke in Cryptococcal Meningitis: Clinical and Radiographic Features”. J Stroke Cerebrovasc Dis 2019; 28:1783-1784. [PMID: 30885460 DOI: 10.1016/j.jstrokecerebrovasdis.2019.02.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 02/16/2019] [Indexed: 11/21/2022] Open
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41
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Ellis JP, Gaskell K, Peirse M, Gormley J, Kalata N, Burgess PI, Mopamboli P, Manda CA, Kiire CA, Maccormick I, Gondwe E, Molloy S, Harrison TS, Lalloo DG, Heyderman RS. Ophthalmic features of HIV associated cryptococcal meningitis in Malawian Adults: an observational study. Wellcome Open Res 2019. [DOI: 10.12688/wellcomeopenres.15067.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Cryptococcal meningitis (CM) is the commonest neurological complication in patients with advanced HIV. Visual disturbance is a frequent presenting symptom. Papilloedema is commonly reported but other ophthalmic findings are not well described. Methods: We performed an observational study comparing severely immunocompromised HIV-infected patients with and without CM to determine the nature and prevalence of retinal pathology attributable to CM. 70 adult patients were enrolled in Blantyre Malawi, 35 with CM and 35 HIV-infected patients without CM. Results: 79% (19/24) of CM patients examined on day one had evidence of retinal abnormalities compared to 17% (6/35) of HIV-infected controls (p <0.001). In the CM group, retinal whitening was the commonest abnormality (50%), followed by optic disc swelling (29%), haemorrhage (25%) and vascular abnormalities (7%). Retinal whitening was the only abnormality observed in the comparator group (17%). In CM, there was no significant difference between those with and without retinal abnormalities in fungal burden (13,550 cfu/ml vs. 9,150 cfu/ml; p = 0.65), CD4 count (28 cells/µl vs. 76 cells/µl; p = 0.79) or CSF opening pressure (21cm H20 vs. 27cm H20; p = 0.5). There was no association between presence/absence of retinal abnormalities and death (40% 10-week mortality vs. 26%; p = 0.6). Conclusions: Whether the presence of CM retinopathy could be used as a marker of disease severity warrants further investigation. The observed ophthalmic findings provide a descriptive framework for CM retinopathy to be utilised in future CM studies. Trial registration: ISRCTN (ISRCTN45035509) 19/06/2012.
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42
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Peng TJ, Kimbrough T, Tolchin BD. Clinical Reasoning: A 71-year-old man receiving treatment for cryptococcal meningitis, developing new-onset lethargy. Neurology 2019; 92:815-820. [DOI: 10.1212/wnl.0000000000007379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Sood V, Pattanashetti N, Ramachandran R, Gupta KL. Deceptively asymptomatic cryptococcaemia in a renal transplant recipient: the lull before a storm. BMJ Case Rep 2019; 12:12/4/e228115. [PMID: 31005864 DOI: 10.1136/bcr-2018-228115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Cryptococcal infection constitutes around 3% of opportunistic infections in solid organ transplant recipients. Most common organ affected in renal transplant recipients (RTRs) is central nervous system and usually presents with chronic meningoencephalitis (CME). Ischaemic stroke as a consequence of cryptococcal meningoencephalitisis rare and possibly due to the involvement of intracranial vessel by exudates causing vasculitis-related thrombosis. In this context, we describe an unusual case of asymptomatic cryptococcaemia in an RTR, progressing on to acute ischaemic stroke secondary to acute CME with near complete neurological recovery following timely diagnosis, early and appropriate antifungal treatment. The index case attempts to re-emphasise the significance of mandatory screening required to exclude the possibility of dissemination of cryptococcaemia in RTRs besides highlighting the requirement of prolonged induction phase with combination therapy, particularly in presence of stroke.
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Affiliation(s)
- Vivek Sood
- Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Navin Pattanashetti
- Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Raja Ramachandran
- Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Krishan Lal Gupta
- Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Jha A, Adhikari S, Sigdel KR, Paudyal B, Basnyat B, Kayastha G, Pradhan S, Risal U, Poudel J. Case Report: Cryptococcal meningitis in an immunocompetent patient in Nepal - challenges in diagnosis and treatment. Wellcome Open Res 2019; 4:55. [DOI: 10.12688/wellcomeopenres.15187.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2019] [Indexed: 11/20/2022] Open
Abstract
A 50 year old woman from Nepal had clinical features suggestive of meningitis. Cerebrospinal fluid (CSF) analysis was normal except for the presence of cryptococcal antigen. The inclusion of test for Cryptococcus in the CSF helped in making the diagnosis of cryptococcal meningitis in our patient who was apparently immunocompetent. Treatment with liposomal amphotericin B could not be started on time due financial constraints. The patient had a stroke and further deteriorated. Liposomal amphotericin B is stocked by the government of Nepal for free supply to patients with visceral leishmaniasis, but the policy does not allow the drug to be dispensed for other infections. The family members of our patient acquired the drug within a few days from a government center using their political connections and following administering the treatment the patient improved. This case demonstrates the utility of considering cryptococcal meningitis as a differential diagnosis, and including tests for Cryptococcus when dealing with immunocompetent patients presenting with meningitis. It also demonstrates the effects of the sociopolitical situation on health care delivery in low- and middle-income countries (LMICs) such as Nepal.
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Lacunar Stroke in Cryptococcal Meningitis: Clinical and Radiographic Features. J Stroke Cerebrovasc Dis 2019; 28:1767-1772. [PMID: 30655043 DOI: 10.1016/j.jstrokecerebrovasdis.2018.12.043] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 12/28/2018] [Accepted: 12/31/2018] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Cryptococcal meningitis carries a high mortality, and survivors are left with considerable neurologic sequelae and marked disability. We lack a clear understanding of the pathogenesis of neurologic sequelae and description of stroke features in this population. We aim to describe clinical and radiographic features and predictors of stroke in a cohort of patients with cryptococcal meningitis. METHODS We collected key information on patients diagnosed with cryptococcal meningitis at the University of Colorado Hospital between 2000 and 2018 (n = 42). Of those, 32 had neuroimaging studies available. Bivariate and risk ratio estimates regression models were performed to identify predictors of stroke. RESULTS We found a 26% ischemic stroke complication rate in individuals with cryptococcal meningitis. Most strokes were acute (75%), lacunar (100%), multiple (88%), bilateral (63%), and involving the basal ganglia (75%). Presence of malignancy (38% versus 8%, P = .085) was higher in stroke in individuals with cryptococcal meningitis, although not statistically significant. Every unit decrease in hemoglobin and serum sodium were predictors for 1.35 and 1.14 times increase in the risk of ischemic stroke, respectively. The presence of hyponatremia carried a RR of 5.7 (95% confidence interval, 1.7-34, P = .005). Cryptococcal meningitis lead to death in 19% of patients and a considerable rate of neurologic sequela among survivors. CONCLUSIONS Cryptococcal meningitis carries a high risk of lacunar stroke, particularly in the basal ganglia. Cryptococcal meningitis-associated stroke is common and frequently associated with neurologic disability among survivors. We need to understand the possible role of malignancy, anemia, and hyponatremia in the onset of ischemic stroke.
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Zhou W, Lai J, Huang T, Xu Y, Hu S. Cryptococcal meningitis mimicking cerebral infarction: a case report. Clin Interv Aging 2018; 13:1999-2002. [PMID: 30349219 PMCID: PMC6188113 DOI: 10.2147/cia.s181774] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Cryptococcal meningitis (CM) is the most common type of fungal meningitis. The clinical symptoms of CM are nonspecific, and neuroimaging characteristics are variable. Herein, we present a case of a senile female with CM that was once misdiagnosed as cerebral infarction. Her condition worsened and she developed hydrocephalus. No apparent predisposing factors of CM were reported in this patient. The diagnosis of CM was definitely made after India ink staining of cerebrospinal fluid was positive. This case indicates that clinicians should bear cryptococcal infection in mind when the symptoms are nonspecific and neuroimaging findings are atypical.
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Affiliation(s)
- Weihua Zhou
- Department of Psychiatry, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China, .,The Key Laboratory of Mental Disorder's Management in Zhejiang Province, Hangzhou 310003, China, .,Brain Research Institute of Zhejiang University, Hangzhou 310003, China,
| | - Jianbo Lai
- Department of Psychiatry, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China, .,The Key Laboratory of Mental Disorder's Management in Zhejiang Province, Hangzhou 310003, China, .,Brain Research Institute of Zhejiang University, Hangzhou 310003, China,
| | - Tingting Huang
- Department of Psychiatry, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China,
| | - Yi Xu
- Department of Psychiatry, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China, .,The Key Laboratory of Mental Disorder's Management in Zhejiang Province, Hangzhou 310003, China, .,Brain Research Institute of Zhejiang University, Hangzhou 310003, China,
| | - Shaohua Hu
- Department of Psychiatry, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China, .,The Key Laboratory of Mental Disorder's Management in Zhejiang Province, Hangzhou 310003, China, .,Brain Research Institute of Zhejiang University, Hangzhou 310003, China,
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Cerebrovascular Injury Following Scorpion Sting and Snake Envenomation: A Case Series. Can J Neurol Sci 2018; 45:669-674. [PMID: 30289088 DOI: 10.1017/cjn.2018.328] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Neurological complications following snake and scorpion bite are diverse. Literature regarding patterns of cerebrovascular injury (CVI) and outcomes among these patients is scarce. This is a descriptive study of the clinical profile, brain imaging findings, mechanisms of injury, vascular territory involvement and outcomes of CVI following scorpion and snake envenomation, in a tertiary care center in South India.MethodologyPatients with scorpion sting- and snake envenomation-related complications were retrospectively enrolled. Neuroimaging was performed on five patients with each envenomation, and they were found to have neurological involvement. On imaging, three patients were found to have a CVI. Clinical, radiological parameters and outcomes of these patients were studied. We also performed a review of the literature and analyzed the finding of all the cases.ResultIn all, three patients each had evidence of CVI in imaging. An additional 32 reports of scorpion sting-related CVI and 35 reports of snake envenomation-related CVI were identified from the literature. There was a male predominance among these patients. Mean age of the patients with scorpion sting was 42.8 years as compared with 33 years for the patients with snake envenomation. Features of severe envenomation were present in all patients. Persistently depressed sensorium and new-onset focal neurological deficits were seen in 70% of all patients. Infarcts were seen in 88% of patients with snake envenomation and 53% of patients with a scorpion sting. Mortality was 28% among patients with a scorpion sting as compared with 8% with snake envenomation. CONCLUSION Cerebrovascular injuries are uncommon neurological manifestations following scorpion and snake envenomation. These tend to occur in younger patients. Infarcts are more common than bleeds.
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Peek K, Bryant J, Carey M, Dodd N, Freund M, Lawson S, Meyer C. Reducing falls among people living with dementia: A systematic review. DEMENTIA 2018; 19:1621-1640. [DOI: 10.1177/1471301218803201] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background People diagnosed with dementia are at greater risk of falls. Given the increasing incidence of dementia globally, high quality and methodologically rigorous research is needed to inform evidence-based practice initiatives. Aims To describe the published literature related to describing, reducing or preventing fall incidences for people living with dementia including: (1) trends in the total number of intervention and non-intervention studies between 1997 and 2016; (2) the methodological quality of identified intervention studies; and (3) the effectiveness of interventions designed to reduce the incidence of falls among people living with dementia. Methods A systematic review of five databases was conducted to identify studies reporting any aspect of falls incidence for people with a diagnosis of dementia. Studies meeting the eligibility criteria were coded as intervention or non-intervention studies. Intervention studies were assessed using Cochrane’s Effective Practice and Organisation of Care tool. Data about the effectiveness of interventions meeting Effective Practice and Organisation of Care criteria were extracted. Results Seventy-two eligible studies were identified; 57 were non-intervention studies, and 15 were intervention studies. The number of published studies increased between 1997 and 2016, peaking in 2013 ( n = 10). Of the 15 intervention studies, seven studies met Effective Practice and Organisation of Care design criteria with one study rated low risk on all eight Effective Practice and Organisation of Care risk of bias domains. One high-risk exercise-based intervention study demonstrated a significant reduction in falls among people living with dementia. Conclusions There is currently insufficient evidence to endorse any intervention to reduce falls for people living with dementia in any setting. More high-quality intervention studies are needed.
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Affiliation(s)
- Kerry Peek
- School of Medicine and Public Health, University of Newcastle, Australia
| | | | | | | | | | - Samuel Lawson
- School of Medicine and Public Health, University of Newcastle, Australia; Hunter Medical Research Institute, Australia
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Li Z, Tremble SM, Cipolla MJ. Implications for understanding ischemic stroke as a sexually dimorphic disease: the role of pial collateral circulations. Am J Physiol Heart Circ Physiol 2018; 315:H1703-H1712. [PMID: 30239233 DOI: 10.1152/ajpheart.00402.2018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
We investigated structural and functional differences in primary and pial collateral circulations in adult normotensive male and female Wistar rats. Male ( n = 10) and female ( n = 7) rats were subjected to middle cerebral artery (MCA) occlusion and changes in relative cerebral blood flow in MCA and pial collateral territories were measured by multisite laser-Doppler flowmetry. Rats were then transcardially perfused with a mixture of carbon black and latex, perfusion fixed, and imaged to compare primary and pial collateral structure between male ( n = 4) and female ( n = 3) rats, including lumen diameters and number. To study pial collateral function, leptomeningeal anastomoses (LMAs) were isolated and pressurized from male ( n = 7) and female ( n = 6) rats. Myogenic tone and reactivity to pressure, vascular function to pharmacological activator, or inhibitor of ion channels was measured and compared. There was no difference between relative cerebral blood flow in both MCA and pial collateral territories during occlusion and reperfusion between groups. Compared with male LMAs, female LMAs had similar myogenic tone (24.0 ± 7.3% vs. 16.0 ± 3.7%, P > 0.05) and reactivity to increased pressure and similar vascular responses to vasoconstrictive and vasodilatory stimuli. Additionally, compared with female LMAs, male LMAs had similar numbers (21 ± 1 vs. 20 ± 2, P > 0.05) and diameters (30.5 ± 2.0 vs. 26.2 ± 0.6 μm, P > 0.05), and no sex difference was detected in the diameter of arterial segments of circle of Willis. Together, our data establish no sex difference of cerebral collateral structure or function, suggesting that the reduced severity of stroke outcome in female rats is not likely due to differences in the cerebral collateral circulation. NEW & NOTEWORTHY Our work compared the function of leptomeningeal anastomoses between male and female adult normotensive rats with no sex difference found. We also confirmed no sex difference in primary and pial collateral structure in Wistar rats. Our findings suggest that the reduced severity of stroke in premenopausal women and reproductively intact female rodents is not likely due to improved primary and pial collateral circulations.
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Affiliation(s)
- Zhaojin Li
- Department of Neurological Sciences, University of Vermont Robert Larner College of Medicine , Burlington, Vermont
| | - Sarah M Tremble
- Department of Neurological Sciences, University of Vermont Robert Larner College of Medicine , Burlington, Vermont
| | - Marilyn J Cipolla
- Department of Neurological Sciences, University of Vermont Robert Larner College of Medicine , Burlington, Vermont.,Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Vermont Robert Larner College of Medicine , Burlington, Vermont.,Department of Pharmacology, University of Vermont Robert Larner College of Medicine , Burlington, Vermont
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Zimelewicz Oberman D, Patrucco L, Cuello Oderiz C. Central Nervous System Vasculitis for Cryptococcosis in an Immunocompetent Patient. Diseases 2018; 6:E75. [PMID: 30200288 PMCID: PMC6163809 DOI: 10.3390/diseases6030075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 08/25/2018] [Accepted: 08/28/2018] [Indexed: 02/03/2023] Open
Abstract
Cryptococcal meningitis is a life-threatening condition caused by a fungal pathogen, Cryptococcus neoformans, that can infect both immunosuppressed and immunocompetent hosts. It is an important cause of morbidity and mortality in severely immunodeficient patients. However, in an immunocompetent patient it represents a diagnostic challenge, mainly because it is extremely rare, but also because of its nonspecific clinical manifestation. Neurovascular involvement in cryptococcal meningitis is rare and not well known and only few reports have described this association. We describe a cryptococcal meningitis in an immunocompetent patient associated with central nervous system vasculitis.
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Affiliation(s)
| | - Liliana Patrucco
- Department of Neurology, Hospital Italiano de Buenos Aires, Potosí 1199, Argentina.
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