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Miyoshi IC, de Toledo AHN, Pereira FV, Villarinho LDL, Dalaqua M, de Ávila Duarte J, Reis F. Infectious Myelitis. Semin Ultrasound CT MR 2023; 44:424-435. [PMID: 37555684 DOI: 10.1053/j.sult.2023.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Myelitis is an extensive group of pathologies, including inflammatory, demyelinating, and infectious disorders, sometimes mimicking tumors. This article will discuss infectious myelitis, mainly the patterns of spinal cord involvement caused by each infectious agent and the contribution of magnetic resonance imaging as a major tool to establish the specific diagnosis.
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Affiliation(s)
| | | | | | | | - Mariana Dalaqua
- Departement d'Imagerie Médicale, Réseau Hospitalier Neuchatelois, Pourtalès, Switzerland
| | - Juliana de Ávila Duarte
- Department of Radiology and Diagnostic Imaging, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Fabiano Reis
- Medicine Department of Anesthesiology, Oncology and Radiology, UNICAMP, Campinas, SP, Brazil.
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Gligorijevic N, Kaljevic M, Radovanovic N, Jovanovic F, Joksimovic B, Singh S, Dumic I. Adrenal Abscesses: A Systematic Review of the Literature. J Clin Med 2023; 12:4601. [PMID: 37510716 PMCID: PMC10380332 DOI: 10.3390/jcm12144601] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 07/01/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023] Open
Abstract
Objective: To summarize the existing knowledge about adrenal gland abscesses, including etiology, clinical presentation, common laboratory and imaging findings, management and overall morbidity and mortality. Design: Systematic literature review. Methods: We performed a search in the PubMed database using search terms: 'abscess and adrenal glands', 'adrenalitis', 'infection and adrenal gland', 'adrenal abscess', 'adrenal infection' and 'infectious adrenalitis'. Articles from 2017 to 2022 were included. We found total of 116 articles, and after applying exclusion criteria, data from 73 articles was included in the final statistical analysis. Results: Of 84 patients included in this review, 68 were male (81%), with a mean age of 55 years (range: 29 to 85 years). Weight loss was the most frequent symptom reported in 58.3% patients, followed by fever in 49%. Mean duration of symptoms was 4.5 months. The most common laboratory findings were low cortisol (51.9%), elevated ACTH (43.2%), hyponatremia (88.2%) and anemia (83.3%). Adrenal cultures were positive in 86.4% cases, with Histoplasma capsulatum (37.3%) being the leading causative agent. Blood cultures were positive in 30% of patients. The majority of the adrenal infections occurred through secondary dissemination from other infectious foci and abscesses were more commonly bilateral (70%). A total of 46.4% of patients developed long-term adrenal insufficiency requiring treatment. Abscess drainage was performed in 7 patients (8.3%) and adrenalectomy was performed in 18 (21.4%) patients. The survival rate was 92.9%. Multivariate analysis showed that the only independent risk factor for mortality was thrombocytopenia (p = 0.048). Conclusion: Our review shows that adrenal abscesses are usually caused by fungal pathogens, and among these, Histoplasma capsulatum is the most common. The adrenal glands are usually involved in a bilateral fashion and become infected through dissemination from other primary sources of infection. Long-term adrenal insufficiency develops in 46% of patients, which is more common than what is observed in non-infectious etiology of adrenal gland disorders. Mortality is about 7%, and the presence of thrombocytopenia is associated with worse prognosis. Further prospective studies are needed to better characterize optimal testing and treatment duration in patients with this relatively rare but challenging disorder.
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Affiliation(s)
- Nikola Gligorijevic
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Marija Kaljevic
- Department of Hospital Medicine, Saint Francis Hospital and Medical Center, Hartford, CT 06105, USA
- Division of Internal Medicine, University of Connecticut, Farmington, CT 06030, USA
| | - Natasa Radovanovic
- Department of Endocrinology, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine, Dartmouth College, Hanover, NH 03755, USA
| | - Filip Jovanovic
- Department of Internal Medicine, Merit Health Wesley, Hattiesburg, MS 39402, USA
| | - Bojan Joksimovic
- Department of Pathological Physiology, Faculty of Medicine Foca, University of East Sarajevo, 73300 Foca, Bosnia and Herzegovina
| | - Sandra Singh
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Igor Dumic
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
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Fernando Nicolas-Cruz C, Ariza-Varon M, Gustavo Mondragón-Soto M, Suarez-Venegas A, Villalobos-Diaz R, Marian-Magaña R, Moreno-Jiménez S, Luis Soto-Hernández J. Cryptococcoma mimicking a brain tumor in an immunocompetent patient: A case and illustrative report. INTERDISCIPLINARY NEUROSURGERY 2023. [DOI: 10.1016/j.inat.2022.101688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Panda AK, Hazra S, Anthony A, Kushwaha S. Cryptococcal infection causing longitudinal extensive transverse myelitis in an immunocompetent individual: Case report and literature review. Front Neurol 2023; 14:1171572. [PMID: 37122302 PMCID: PMC10133556 DOI: 10.3389/fneur.2023.1171572] [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] [Received: 02/22/2023] [Accepted: 03/20/2023] [Indexed: 05/02/2023] Open
Abstract
Cryptococcal CNS infections in immunocompetent individuals are occasionally reported in literature. The spinal manifestations of cryptococcal CNS infections are epidural abscess, chronic arachnoiditis, intramedullary granuloma, myelitis and vasculitis. We report a rare case of CNS cryptococcal infection presenting as a longitudinal extensive transverse myelitis (LETM) in an immunocompetent male. This report highlights cryptococcus as an important etiology among infectious causes in acute LETM patients in-spite of the immunocompetent status of the patient and the utility of CRAG (cryptococcal antigen) for diagnosis in such patients. We also present a literature review of all reported cases of cryptococcal myelitis.
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Transverse Myelitis Associated with Cryptococcus neoformans in an Immunocompetent Patient. Case Rep Infect Dis 2022; 2022:2000246. [PMID: 35237455 PMCID: PMC8885289 DOI: 10.1155/2022/2000246] [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: 12/26/2021] [Accepted: 01/31/2022] [Indexed: 11/29/2022] Open
Abstract
Cryptococcus neoformans is a microscopic fungus that despite its pervasiveness in the environment rarely causes infection in immunocompetent patients. In immunosuppressed patients, infections involving the central nervous system (CNS) usually present as meningitis or meningoencephalitis. Cryptococcal infections are known to cause significant morbidity and mortality in immunosuppressed patients as it is difficult to eradicate even with adequate antifungal treatment. A 44-year-old Hispanic male presented to the hospital with headache, progressive urinary retention, neck and back pain, and right upper and bilateral lower extremity weakness for five days. Imaging revealed small foci in the white matter and revealed diffuse abnormal signal involving the cervical medullary junction extending up to the thoracic spine. Analysis of cerebral spinal fluid (CSF) obtained via lumbar puncture was positive for the Streptococcus antigen with cultures also growing Cryptococcus neoformans. Upon evaluation, patient was not found to be immunocompromised. This report works to highlight an atypical presentation of a cryptococcal CNS infection to raise awareness amongst clinicians hoping to prevent a delay in diagnosis of this disease given its high mortality.
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Abstract
PURPOSE OF REVIEW The patient who presents with an acute spinal cord syndrome with weakness/paralysis of the limbs presents a diagnostic. Two important syndromes are acute transverse myelitis (ATM) and acute flaccid paralysis (AFP). Both can be caused by a number of infectious and noninfectious causes. Since 2014 there have been outbreaks of acute flaccid myelitis (a subgroup of AFP) in the United States, with a national surveillance program underway. In addition, there have been increasing reports of ATM from new and emerging pathogens, and opportunistic infections in immunocompromised hosts. RECENT FINDINGS Infectious causes of ATM or AFP need to be ruled out first. There may be important clues to an infectious cause from epidemiologic risk factors, immune status, international travel, MRI, and laboratory findings. We summarize key features for the more common pathogens in this review. Advances in laboratory testing have improved the diagnostic yield from cerebrospinal fluid, including real-time polymerase chain reaction, metagenomic next-generation sequencing, and advanced antibody detection techniques. These tests still have limitations and require clinical correlation. SUMMARY We present a syndromic approach to infectious myelopathies, focusing on clinical patterns that help narrow the diagnostic possibilities.
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