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Mina Y, Kline A, Manion M, Hammoud DA, Wu T, Hogan J, Sereti I, Smith BR, Zerbe CS, Holland SM, Nath A. Neurological manifestations of nontuberculous mycobacteria in adults: case series and review of the literature. Front Neurol 2024; 15:1360128. [PMID: 38742044 PMCID: PMC11089811 DOI: 10.3389/fneur.2024.1360128] [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: 12/22/2023] [Accepted: 04/08/2024] [Indexed: 05/16/2024] Open
Abstract
Introduction Nontuberculous mycobacteria (NTM) mediated infections are important to consider in cases with neuroinflammatory presentations. We aimed to characterize cases of NTM with neurological manifestations at the National Institutes of Health (NIH) Clinical Center and review the relevant literature. Materials and methods Between January 1995 and December 2020, six cases were identified. Records were reviewed for demographic, clinical, and radiological characteristics. A MEDLINE search found previously reported cases. Data were extracted, followed by statistical analysis to compare two groups [cases with slow-growing mycobacteria (SGM) vs. those with rapidly growing mycobacteria (RGM)] and evaluate for predictors of survival. NIH cases were evaluated for clinical and radiological characteristics. Cases from the literature were reviewed to determine the differences between SGM and RGM cases and to identify predictors of survival. Results Six cases from NIH were identified (age 41 ± 13, 83% male). Five cases were caused by SGM [Mycobacterium avium complex (MAC) n = 4; Mycobacterium haemophilum n = 1] and one due to RGM (Mycobacterium abscessus). Underlying immune disorders were identified only in the SGM cases [genetic (n = 2), HIV (n = 1), sarcoidosis (n = 1), and anti-interferon-gamma antibodies (n = 1)]. All cases were diagnosed using tissue analysis. A literature review found 81 reports on 125 cases (SGM n = 85, RGM n = 38, non-identified n = 2). No immune disorder was reported in 26 cases (21%). Within SGM cases, the most common underlying disease was HIV infection (n = 55, 65%), and seizures and focal lesions were more common. In RGM cases, the most common underlying condition was neurosurgical intervention or implants (55%), and headaches and meningeal signs were common. Tissue-based diagnosis was used more for SGM than RGM (39% vs. 13%, p = 0.04). Survival rates were similar in both groups (48% SGM and 55% in RGM). Factors associated with better survival were a solitary CNS lesion (OR 5.9, p = 0.01) and a diagnosis made by CSF sampling only (OR 9.9, p = 0.04). Discussion NTM infections cause diverse neurological manifestations, with some distinctions between SGM and RGM infections. Tissue sampling may be necessary to establish the diagnosis, and an effort should be made to identify an underlying immune disorder.
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Affiliation(s)
- Yair Mina
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ahnika Kline
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Maura Manion
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Dima A. Hammoud
- Center for Infectious Disease Imaging, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Tianxia Wu
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Julie Hogan
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Irini Sereti
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Bryan R. Smith
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Christa S. Zerbe
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Steven M. Holland
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Avindra Nath
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
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2
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Yang JH, Vuong KT, Moodley A, Chuang NA, Chen DY. A Case of Tuberculosis-Associated Acute Disseminated Encephalomyelitis in a Seven-Month-Old Infant. Cureus 2021; 13:e16299. [PMID: 34381655 PMCID: PMC8351760 DOI: 10.7759/cureus.16299] [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: 07/09/2021] [Indexed: 11/18/2022] Open
Abstract
A seven-month-old previously healthy female infant presented with acute onset encephalopathy and left focal weakness in the setting of three months of non-productive cough. She was diagnosed with pulmonary tuberculosis (TB), and neuroimaging showed multifocal non-enhancing T2 hyperintensities in the brain and longitudinal T2 hyperintensity in the spinal cord consistent with acute disseminated encephalomyelitis (ADEM). However, her cerebrospinal fluid (CSF) did not show evidence of TB infection. She was treated with high-dose steroids for five days with a steroid taper along with antitubercular medications with a remarkable recovery in gross motor function. This case suggests a previously unreported association between TB and an immune-mediated demyelinating syndrome in children that is clinically distinct from other more common forms of TB-associated central nervous system (CNS) complications.
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Affiliation(s)
- Jennifer H Yang
- Pediatric Neurology, Rady Children's Hospital, San Diego, USA.,Pediatric Neurology, University of California San Diego, San Diego, USA
| | - Kim T Vuong
- Pediatrics, University of California San Diego, San Diego, USA.,Pediatrics, Rady Children's Hospital, San Diego, USA
| | - Amaran Moodley
- Pediatric Infectious Diseases, University of California San Diego, San Diego, USA.,Infectious Diseases, Rady Children's Hospital, San Diego, USA
| | | | - Dillon Y Chen
- Pediatric Neurology, University of California San Diego, San Diego, USA.,Pediatric Neurology, Rady Children's Hospital, San Diego, USA
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3
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Niederschweiberer J, Lauerer M, Schweyer K, Maegerlein C, Liesche F, Hofer S, Berthele A, Lingor P. Acute disseminated encephalomyelitis following Tdap vaccination and bacterial meningoencephalitis. Mult Scler Relat Disord 2020; 46:102471. [PMID: 32877821 DOI: 10.1016/j.msard.2020.102471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/25/2020] [Accepted: 08/26/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Association of Acute Disseminated Encephalomyelitis (ADEM) with both recent vaccination and viral infections is well described in current literature. However, the coincidence of ADEM and bacterial infections has been rarely documented. In this report, we present a case of ADEM which occurred after bacterial meningoencephalitis and prior vaccination against tetanus, diphtheria, and pertussis (Tdap). CASE PRESENTATION A 62-year old woman was hospitalized with an upper respiratory tract infection three weeks after Tdap triple vaccination. A few days after admission, she became somnolent and developed meningism. Cerebrospinal fluid (CSF) analysis revealed pleocytosis and increased protein/lactate levels compatible with bacterial meningoencephalitis. The patient was treated with intravenous antibacterial triple therapy in combination with dexamethasone leading to a significant improvement of clinical symptoms and improvement of CSF parameters. Five days later, the patient's condition worsened again, and she developed aphasia and right-sided hemiparesis. A magnetic resonance imaging (MRI) scan revealed distinct fluid-attenuated inversion recovery sequence (FLAIR)-hyperintense lesions in both hemispheres. Following brain biopsy, the diagnosis of ADEM was made and methylprednisolone pulse therapy was initiated for five days leading to a nearly complete remission of symptoms. CONCLUSION ADEM is a neurological syndrome which may be associated with bacterial infection of the central nervous system (CNS). We hypothesize that the preceding Tdap triple vaccination may have contributed to the development of ADEM.
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Affiliation(s)
- J Niederschweiberer
- Department of Neurology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany.
| | - M Lauerer
- Department of Neurology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany.
| | - K Schweyer
- Department of Neurology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany.
| | - C Maegerlein
- Department of Neuroradiology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany.
| | - F Liesche
- Department of Neuropathology, Technical University of Munich, School of Medicine, Institute of Pathology, Munich, Germany.
| | - S Hofer
- Technical University of Munich, School of Medicine, Klinikum Freising, Stroke Unit, Freising, Germany.
| | - A Berthele
- Department of Neurology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany.
| | - P Lingor
- Department of Neurology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany.
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4
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Oliveira MCB, Sato DK, Soares-Neto HR, Lucato LT, Callegaro D, Nitrini R, Medeiros RSS, Misu T, Fujihara K, Castro LH. Leukoencephalopathy resolution after atypical mycobacterial treatment: a case report. BMC Neurol 2015; 15:159. [PMID: 26329680 PMCID: PMC4557863 DOI: 10.1186/s12883-015-0415-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 08/25/2015] [Indexed: 11/25/2022] Open
Abstract
Background Association of leukoencephalopathy and atypical mycobacteriosis has been rarely reported. We present a case that is relevant for its unusual presentation and because it may shed further light on the pathogenic mechanisms underlying reversible encephalopathies. Case report We report the case of a Hispanic 64-year-old woman with cognitive decline and extensive leukoencephalopathy. Magnetic resonance imaging revealed white-matter lesions with increased water diffusivity, without blood–brain-barrier disruption. Brain biopsy showed tissue rarefaction with vacuolation, mild inflammation, few reactive astrocytes and decreased aquaporin water-channel expression in the lesions. Six months later, she was diagnosed with atypical mycobacterial pulmonary infection. Brain lesions resolved after antimycobacterial treatment. Conclusion We hypothesize leukoencephalopathic changes and vasogenic edema were associated with decreased aquaporin expression. Further studies should clarify if reversible leukoencephalopathy has a causal relationship with decreased aquaporin expression and atypical mycobacterial infection, and mechanisms underlying leukoencephalopathy resolution after antimycobacterial treatment. This article may contribute to the understanding of pathogenic mechanisms underlying magnetic resonance imaging subcortical lesions and edema, which remain incompletely understood.
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Affiliation(s)
- Marcos C B Oliveira
- Department of Neurology, Faculdade de Medicina da Universidade de Sao Paulo, Av. Dr. Enéas de Carvalho Aguiar, 255, 5o andar, sala 5011, 05403-900, São Paulo, SP, Brazil.
| | - Douglas Kazutoshi Sato
- Departments of Neurology, Tohoku University School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan.
| | - Herval R Soares-Neto
- Department of Neurology, Faculdade de Medicina da Universidade de Sao Paulo, Av. Dr. Enéas de Carvalho Aguiar, 255, 5o andar, sala 5011, 05403-900, São Paulo, SP, Brazil.
| | - Leandro T Lucato
- Institute of Radiology, Faculdade de Medicina da Universidade de Sao Paulo, Av. Dr. Enéas de Carvalho Aguiar, 255, 5o andar, sala 5011, 05403-900, São Paulo, SP, Brazil.
| | - Dagoberto Callegaro
- Department of Neurology, Faculdade de Medicina da Universidade de Sao Paulo, Av. Dr. Enéas de Carvalho Aguiar, 255, 5o andar, sala 5011, 05403-900, São Paulo, SP, Brazil.
| | - Ricardo Nitrini
- Department of Neurology, Faculdade de Medicina da Universidade de Sao Paulo, Av. Dr. Enéas de Carvalho Aguiar, 255, 5o andar, sala 5011, 05403-900, São Paulo, SP, Brazil.
| | - Raphael S S Medeiros
- Department of Pathology, Faculdade de Medicina da Universidade de Sao Paulo, Av. Dr. Enéas de Carvalho Aguiar, 255, 5o andar, sala 5011, 05403-900, São Paulo, SP, Brazil.
| | - Tatsuro Misu
- Multiple Sclerosis Therapeutics, Tohoku University School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan.
| | - Kazuo Fujihara
- Multiple Sclerosis Therapeutics, Tohoku University School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan.
| | - Luiz H Castro
- Department of Neurology, Faculdade de Medicina da Universidade de Sao Paulo, Av. Dr. Enéas de Carvalho Aguiar, 255, 5o andar, sala 5011, 05403-900, São Paulo, SP, Brazil.
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Pillai S, Tantsis E, Prelog K, Ramanathan S, Webster R, Ouvrier RA, Kesson A, Brilot F, Dale RC. Confirmed enterovirus encephalitis with associated steroid-responsive acute disseminated encephalomyelitis: an overlapping infection and inflammation syndrome. Eur J Paediatr Neurol 2015; 19:266-70. [PMID: 25576193 DOI: 10.1016/j.ejpn.2014.12.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 12/17/2014] [Accepted: 12/17/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Inflammatory disorders of the central nervous system have generally been separated into infectious or immune-mediated aetiologies. However, there are emerging examples of confirmed infectious viral infection of the brain followed by secondary inflammation or autoimmunity that is amenable to immune suppressive therapies. METHODS We report four children with confirmed enterovirus encephalitis (CSF enterovirus PCR positivity), who had MRI evidence of inflammatory demyelination compatible with ADEM. RESULTS Two patients had a monophasic course, whereas two had a biphasic course. Serum myelin oligodendrocyte glycoprotein antibodies were negative in two tested patients, although all patients had mirrored CSF and serum oligoclonal bands. All four patients only improved with introduction of immune therapy (corticosteroids in three, corticosteroid and intravenous immunoglobulin in one). CONCLUSION These cases provide a further example of the overlap between CNS infection and immune mediated CNS disease. Randomised controlled trials investigating immune therapies in encephalitis are required.
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Affiliation(s)
- Sekhar Pillai
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research, Australia; TY Nelson Department of Neurology, the Children's Hospital at Westmead, Australia
| | - Esther Tantsis
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research, Australia; TY Nelson Department of Neurology, the Children's Hospital at Westmead, Australia; Discipline of Paediatrics and Child Health, University of Sydney, Australia
| | - Kristina Prelog
- Department of Radiology, the Children's Hospital at Westmead, Australia
| | - Sudarshini Ramanathan
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research, Australia; Discipline of Paediatrics and Child Health, University of Sydney, Australia
| | - Richard Webster
- TY Nelson Department of Neurology, the Children's Hospital at Westmead, Australia
| | - Robert A Ouvrier
- TY Nelson Department of Neurology, the Children's Hospital at Westmead, Australia
| | - Alison Kesson
- Department of Infectious Diseases and Microbiology, the Children's Hospital at Westmead, Australia; Discipline of Paediatrics and Child Health, University of Sydney, Australia; Marie Bashir Institute, University of Sydney, Australia
| | - Fabienne Brilot
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research, Australia; Discipline of Paediatrics and Child Health, University of Sydney, Australia
| | - Russell C Dale
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research, Australia; TY Nelson Department of Neurology, the Children's Hospital at Westmead, Australia; Discipline of Paediatrics and Child Health, University of Sydney, Australia.
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Huhn K, Lee DH, Linker RA, Kloska S, Huttner HB. Pneumococcal-meningitis associated acute disseminated encephalomyelitis (ADEM) - case report of effective early immunotherapy. SPRINGERPLUS 2014; 3:415. [PMID: 25140291 PMCID: PMC4137046 DOI: 10.1186/2193-1801-3-415] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 08/01/2014] [Indexed: 11/26/2022]
Abstract
Introduction Unvaccinated patients with history of splenectomy are prone to fulminant courses of Streptococcus pneumoniae-associated bacterial meningitis. Besides direct brain damage those patients may additionally suffer from parainfectious syndromes, notably vasculitis and acute disseminated encephalomyelitis (ADEM). Differentiation and treatment of these immunological reactions is challenging. Methods Case report. Results A 61 year-old woman with history of splenectomy without vaccination for S. pneumoniae presented with progressive headache and meningism. CSF-analysis revealed pleocytosis with microbiological evidence for pneumococcal meningitis. After unsuspicious initial cranial CT imaging and initiation of appropriate antibiotic therapy, MRI two days later showed widespread FLAIR- and T2-hyperintense white matter lesions that further progressed upon follow-up MRI and that fulfilled imaging criteria of ADEM. Meanwhile the patient deteriorated and required mechanical ventilation. Cranial angiography showed no signs of vasculitis or vasospasms. Screening for autoimmune diseases remained negative, however oligoclonal bands turned positive. Brain biopsy mainly revealed perivascular CD4+ T-cells and demyelinated areas. Despite ongoing acute meningitis, a 10-day corticosteroid-pulse was initiated followed by steroid-tapering. Within 4 weeks, clinical and MRI findings ameliorated. In an one-year follow-up visit, the patient significantly recovered, MRI lesions were markedly reduced and no further relapses occurred. Conclusion Acute pneumococcal meningitis in unvaccinated splenectomized patients may be complicated by a monophasic course of parainfectious ADEM that can be controlled with high-dose corticosteroids. Parainfectious vasculitis or cerebritis are important differential diagnoses and exact differentiation of these entities is important to initiate early appropriate immunotherapy.
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Affiliation(s)
- Konstantin Huhn
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany
| | - De-Hyung Lee
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany
| | - Ralf A Linker
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany
| | - Stephan Kloska
- Department of Neuroradiology, University Hospital Erlangen, Erlangen, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany
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Fujimori J, Nakashima I, Kuroda H, Fujihara K, Aoki M. Cerebrospinal fluid CXCL13 is a prognostic marker for aseptic meningitis. J Neuroimmunol 2014; 273:77-84. [PMID: 24907903 DOI: 10.1016/j.jneuroim.2014.05.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 05/13/2014] [Accepted: 05/14/2014] [Indexed: 11/16/2022]
Abstract
In exceptional cases, patients with aseptic meningitis eventually develop aseptic meningoencephalitis. To find a candidate marker for the development of aseptic meningoencephalitis in adult patients diagnosed with aseptic meningitis, we compared 12 different cytokines/chemokines in cerebrospinal fluid (CSF) from 5 patients with aseptic meningoencephalitis, 8 patients with aseptic meningitis, and 8 patients with control disease. Only the CXCL13 concentration was significantly elevated in the CSF of the group with aseptic meningoencephalitis compared with the group with aseptic meningitis. Thus, CSF CXCL13 may be a useful marker for predicting the prognosis of aseptic meningitis.
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Affiliation(s)
- Juichi Fujimori
- Department of Neurology, Tohoku Pharmaceutical University Hospital, Sendai, Japan.
| | - Ichiro Nakashima
- Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroshi Kuroda
- Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kazuo Fujihara
- Department of Multiple Sclerosis Therapeutics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masashi Aoki
- Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Japan
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Acute disseminated encephalomyelitis following meningoencephalitis: case report and literature review. Pediatr Emerg Care 2014; 30:254-6. [PMID: 24694880 DOI: 10.1097/pec.0000000000000107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Meningoencephalitis and acute disseminated encephalomyelitis (ADEM) are both neurological disease processes, but there have been few cases of meningoencephalitis progressing to ADEM in the pediatric population. A case of a 4-year-old girl with an initial diagnosis of meningoencephalitis is presented here, whose initial presentation was manifested by prolonged fever, gray matter signal abnormality on brain magnetic resonance imaging, cerebrospinal fluid pleocytosis, and a markedly irritable mental status. As her neurological examination changed with focal abnormalities, a repeat magnetic resonance imaging demonstrated new areas of both gray and white matter signal abnormality, consistent with ADEM. Her symptoms and imaging findings completely resolved with a course of methylprednisolone. Based on the literature and this current case, it is our recommendation to consider ADEM as a diagnosis if meningoencephalitis is not improving.
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Kim WY, Jang SJ, Ok T, Kim GU, Park HS, Leem J, Kang BH, Park SJ, Oh DK, Kang BJ, Lee BY, Ji WJ, Shim TS. Disseminated Mycobacterium intracellulare Infection in an Immunocompetent Host. Tuberc Respir Dis (Seoul) 2012; 72:452-6. [PMID: 23101011 PMCID: PMC3475463 DOI: 10.4046/trd.2012.72.5.452] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Revised: 10/04/2011] [Accepted: 11/16/2011] [Indexed: 12/01/2022] Open
Abstract
Disseminated Mycobacterium avium complex (MAC) infection can occur in immunocompromised patients, and rarely in immunocompetent subjects. Due to the extensive distribution of the disease, clinical presentation of disseminated MAC may mimic malignancies, and thorough examinations are required in order to make accurate diagnosis. We report a case of disseminated Mycobacterium intracellulare disease in an immunocompetent patient, which involved the lung, lymph nodes, spleen, and multiple bones. F-18 fluorodeoxyglucose positron-emission tomography imaging showed multiple hypermetabolic lesions, which are suggestive of typical hematogenous metastasis. However, there was no evidence of malignancy in serial biopsies, and M. intracellulare was repeatedly cultured from respiratory specimens and bones. Herein, we should know that disseminated infection can occur in the immunocompetent subjects, and it can mimic malignancies.
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Affiliation(s)
- Won-Young Kim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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