First Reported Case of Neuroleptospirosis Complicated With Anton's Syndrome

Organ Involvement Related to Death in Critically Ill Patients With Leptospirosis: Unsupervised Analysis in a French West Indies ICU

OBJECTIVES

To identify distinct phenotypes of critically ill leptospirosis patients upon ICU admission and their potential associations with outcome.

DESIGN

Retrospective observational study including all patients with biologically confirmed leptospirosis admitted to the ICU between January 2014 and December 2022. Subgroups of patients with similar clinical profiles were identified by unsupervised clustering (factor analysis for mixed data and hierarchical clustering on principal components).

SETTING

All patients admitted to the ICU of the University Hospital of Guadeloupe on the study period.

PATIENTS

One hundred thirty critically ill patients with confirmed leptospirosis were included.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

At ICU admission, 34% of the patients had acute respiratory failure, and 26% required invasive mechanical ventilation. Shock was observed in 52% of patients, myocarditis in 41%, and neurological involvement in 20%. Unsupervised clustering identified three clusters-"Weil's Disease" (48%), "neurological leptospirosis" (20%), and "multiple organ failure" (32%)-with different ICU courses and outcomes. Myocarditis and neurological involvement were key components for cluster identification and were significantly associated with death in ICU. Other factors associated with mortality included shock, acute respiratory failure, and requiring renal replacement therapy.

CONCLUSIONS AND RELEVANCE

Unsupervised analysis of critically ill patients with leptospirosis revealed three patient clusters with distinct phenotypic characteristics and clinical outcomes. These patients should be carefully screened for neurological involvement and myocarditis at ICU admission.

A Fatal Case of Presumptive Diagnosis of Leptospirosis Involving the Central Nervous System

Leptospirosis is a reemerging zooanthroponosis with a worldwide distribution, though it has a higher incidence in areas with tropical climate. A characteristic finding of the disease is its wide spectrum of symptoms and organ involvement, as it can appear either with very mild flu-like manifestations or with multiorgan failure, affecting the central nervous system (CNS) with a concomitant hepatorenal dysfunction (Weil's syndrome) and significant high mortality rate. We report herein a fatal case of a 25 years old female, previously healthy, with impaired neurological status. She had high fever and severe multiorgan failure. The clinical data and the epidemiological factors were not conclusive for the diagnosis, and the first serology test from the cerebrospinal fluid (CSF) and sera samples were negative. When the repetition of the blood test showed elevated IgM antibodies, Leptospirosis was the presumptive diagnosis. Although CNS involvement is rare, the diagnosis should be considered when there is an elevated risk of exposure. The diagnostic protocol should encompass direct evidence of the bacterium and indirect measurement of antibodies. Timely detection and management are imperative to forestall complications and fatality associated with the disease.

Insights into Anton Syndrome: When the brain denies blindness

INTRODUCTION

Anosognosia, a neurological condition, involves a lack of awareness of one's neurological or psychiatric deficits. Anton Syndrome (AS), an unusual form of anosognosia, manifests as bilateral vision loss coupled with denial of blindness. This systematic review delves into 64 studies encompassing 72 AS cases to explore demographics, clinical presentations, treatments, and outcomes.

MATERIALS AND METHODS

The study rigorously followed PRISMA guidelines, screening PubMed, Google Scholar, and Scopus databases without timeframe limitations. Only English human studies providing full text were included. Data underwent thorough assessment, examining patient demographics, etiological variables, and treatment modalities.

RESULTS

Sixty-four studies met the stringent inclusion criteria. Examining 72 AS cases showed a median age of 55 (6 to 96 years) with no gender preference. Hypertension (34.7 %) and visual anosognosia (90.3 %) were prevalent. Stroke (40.3 %) topped causes. Management included supportive (30.6 %) and causal approaches (30.6 %). Improvement was seen in 45.8 %, unchanged in 22.2 %, and deterioration in 11.1 %. Anticoagulation correlated with higher mortality (p < 0.05).

DISCUSSION

AS, an unusual manifestation of blindness, stems mainly from occipital lobe damage, often due to cerebrovascular incidents. The syndrome shares features with Dide-Botcazo syndrome and dates back to Roman times. Its causes range from strokes to rare conditions like multiple sclerosis exacerbation. Accurate diagnosis involves considering clinical presentations and imaging studies, distinguishing AS from similar conditions.

CONCLUSION

This comprehensive review sheds light on AS's complex landscape, emphasizing diverse etiologies, clinical features, and treatment options. Tailored treatments aligned with individual causes are crucial. The study's findings caution against blanket anticoagulation therapy, suggesting a nuanced approach. Further research is pivotal to refine diagnostics and optimize care for AS individuals.

Concomitant Salmonella and Leptospira Meningitis: A Rare Case Report

This study presents a unique case of concurrent salmonella and Leptospira meningitis in a 20-year-old woman with no prior medical history. Coinfection with endemic pathogens is plausible, especially in regions like Pakistan. While Salmonella meningitis is uncommon, it presents a significant medical emergency, particularly in immunocompromised adults. Neuroleptospirosis, though rare, can manifest in certain cases. The patient displayed persistent high fever, confusion, irritability, and a single seizure episode. Initial tests, including blood and cerebrospinal fluid (CSF) cultures and serological examinations, detected Salmonella typhi and positive leptospiral antibodies, respectively. Leptomeningeal enhancement was confirmed by an MRI. Treatment with azithromycin, meropenem, and ceftriaxone led to improvement after seven days. She was advised to complete a 28-day course for Salmonella meningitis. This case emphasizes the importance of considering multiple infectious causes, especially in endemic regions. Timely and thorough diagnostic evaluation, followed by appropriate antimicrobial therapy, is essential for effective management. Further research is warranted to enhance understanding of the epidemiology, clinical features, and optimal treatment strategies for such dual infections.

Network Localization of Awareness in Visual and Motor Anosognosia

OBJECTIVE

Unawareness of a deficit, anosognosia, can occur for visual or motor deficits and lends insight into awareness itself; however, lesions associated with anosognosia occur in many different brain locations.

METHODS

We analyzed 267 lesion locations associated with either vision loss (with and without awareness) or weakness (with and without awareness). The network of brain regions connected to each lesion location was computed using resting-state functional connectivity from 1,000 healthy subjects. Both domain specific and cross-modal associations with awareness were identified.

RESULTS

The domain-specific network for visual anosognosia demonstrated connectivity to visual association cortex and posterior cingulate while motor anosognosia was defined by insula, supplementary motor area, and anterior cingulate connectivity. A cross-modal anosognosia network was defined by connectivity to the hippocampus and precuneus (false discovery rate p < 0.05).

INTERPRETATION

Our results identify distinct network connections associated with visual and motor anosognosia and a shared, cross-modal network for awareness of deficits centered on memory-related brain structures. ANN NEUROL 2023;94:434-441.

Cerebral infarct induced by severe leptospirosis-a case report and literature review

BACKGROUND

Although most leptospirosis is mild, the severe form can cause multiple complications, with a fatality rate of over 50% even with ICU support. The clinical manifestations of leptospirosis vary depending on organs and tissues involved. Both cerebral artery and coronary artery can be damaged by leptospirosis. Although cerebral arteritis induced by leptospirosis has been reported, cerebral infarction caused by leptospirosis is rarely reported.

CASE PRESENTATION

We report the case of a 79-year-old man admitted to intensive care unit (ICU) because of 3 days duration of fever, bloody sputum and dyspnea. Five days before he was admitted to hospital, he had harvested rice in flooded fields. After admission, leptospira interrogans DNA sequence was identified in bronchoalveolar lavage fluid (BALF) by next-generation sequencing (NGS). Microscopic agglutination test (MAT) showed the serum antibody of Mini serovars was 1,600 and Hebdomadis serovars was 800. On the eighth day of admission, the patient noted left hemiplegia. Cranial CT scan revealed low-density shadow in the right basal ganglia, so cerebral infarction was diagnosed. The patient's condition rapidly deteriorated and he died on the eleventh day of admission despite penicillin treatment, invasive mechanical ventilation and continuous renal replacement support.

CONCLUSION

Neurologic leptospirosis manifested as cerebral occlusion, although rare, might be deadly and should not be ignored.

Aseptic meningitis as the initial presentation of Leptospira borgpetersenii serovar Tarassovi: two case reports and a literature review

BACKGROUND

Leptospirosis is a zoonotic illness caused by pathogenic spirochetes of the genus Leptospira. The disease spectrum ranges from a mild influenza-like presentation to a more serious Weil's syndrome. Leptospirosis rarely presents as a primary neurological syndrome. We report two cases of Leptospira borgpetersenii serovar Tarasssovi presenting as aseptic meningitis in Sri Lanka.

CASE PRESENTATION

We describe case reports of two patients presenting as symptomatic aseptic meningitis due to neuroleptospirosis. Both patients had significant neurological involvement at presentation in the absence of common clinical features of leptospirosis. These patients were initially managed as bacterial or viral meningitis and leptospirosis was suspected due to a history of exposure to contaminated water. Subsequently, they were diagnosed to have neuroleptospirosis by positive Leptospira serology and both patients gained full recovery.

CONCLUSION

Our report highlights the importance of considering leptospirosis as a differential diagnosis in patients with aseptic meningitis in endemic settings. Obtaining a detailed occupational and recreational history is helpful in diagnosing neuroleptospirosis promptly. We report the association of Leptospira borgpetersenii serovar (sv.) Tarassovi (strain bakeri) in causing aseptic meningitis, which has not been reported to the best of our knowledge.

Anton's syndrome as a presentation of Trousseau syndrome involving the bilateral optic radiation

Anton’s syndrome is a rare neuropsychiatric syndrome that is characterized by cortical blindness and anosognosia with visual confabulation, but without global cognitive impairment. We herein report a rare case of Anton’s syndrome as a presentation of Trousseau syndrome involving the bilateral optic radiation. The patient had been diagnosed with gallbladder cancer 2 months previously, and he was admitted to the hospital with confusion and quadriplegia. He was found to be blind, but denied any visual impairment and demonstrated visual confabulation despite evidence of his blindness. These signs were consistent with a diagnosis of Anton’s syndrome. Brain computed tomography (CT) and magnetic resonance imaging revealed infarcts in the bilateral temporo-parieto-occipital junction with hemorrhagic transformation, mainly involving the bilateral optic radiation. The presence of gallbladder cancer with peripheral metastasis on abdominal CT, as well as markedly increased tumor markers and D-dimer levels, supported the presence of cancer-related hypercoagulability and the diagnosis of Trousseau syndrome.