Ring-enhancing lesions in neonatal meningitis: an analysis of neuroradiology pitfalls through exemplificative cases and a review of the literature

Tuberculosis Presenting as Isolated Wrist Swelling: A Case Report and Review of Literature

Background. Tuberculosis is a common disease entity in South East Asian countries with a significant global burden. An extra skeletal manifestation such as monoarticular TB is common, but isolated involvement of the wrist is rare. Case Summary. A 53-year-old Sri Lankan male with long-standing diabetes presented with an isolated hand swelling for a 7-month duration. His initial imaging and MRI showed multiple destructive lesions in the carpal bones, surrounding focal fluid collections and found to have caseous material intraoperatively. His histology and microbiological studies were positive for TB with no other concurrent evidence of TB elsewhere. Conclusion. Different presentations of tuberculosis should be considered when patients are presenting with atypical clinical and initial basic investigation findings in relation to monoarticular pathologies.

HSV-Encephalitis Reactivation after Cervical Spine Surgery

Background

Herpes simplex virus encephalitis (HSVE) is a viral neurological disorder that occurs when the herpes simplex virus (HSV) enters the brain. The disorder is characterized by the inflammation of the brain and a significant decline in mental status. HSVE reactivation after neurosurgery, although rare, can cause severe neurological deterioration. The high morbidity rate among untreated patients necessitates prompt diagnosis and management.

Case Description

We report a case of a 78-year-old woman with no known prior history of HSVE and declining mental status eleven days after a posterior C3-T1 decompression and instrumented fusion following resection of an intradural extramedullary tumor, confirmed to be meningioma on final pathology. Reactivation of HSV-1 encephalitis was suspected to be the underlying cause of her symptoms, though MRI scans of the brain for HSVE were negative. The patient reacted positively to a 21-day treatment of acyclovir and was discharged with a neurological status comparable to her preoperative baseline. This case contributes to the literature in that it is the first reported instance of HSVE reactivation after intradural cervical spinal surgery with negative MRI findings.

Conclusion

We recommend utilizing multiple tests, including PCR, EEG, and MRI, for postoperative neurosurgery patients that have decreased mental status in order to quickly and correctly diagnose/treat patients who are HSVE positive. Clinicians should consider the possibility of receiving false-negative results from PCR, CSF, EEG, or MRI tests before terminating treatment for HSVE reactivation.