Neurobrucellosis

PURPOSE OF REVIEW

Brucellosis is one of the most common zoonosis worldwide, affecting 500 000 people, annually. Neurobrucellosis incidence is approximately 4%, and it is almost always heterogeneous. As there are no typical clinical features, its diagnosis is frequently misdiagnosing by other infections.

RECENT FINDINGS

Neurobrucellosis picture includes meningitis, meningoencephalitis, encephalitis, cranial neuropathies, intracranial hypertension, sinus thrombosis, hemorrhages radiculitis, peripheral neuropathy, myelitis, and psychiatric manifestations. The diagnosis should be based on symptoms and signs suggestive of neurobrucellosis, not explained by other neurological disease, cerebrospinal fluid analysis, a positive Brucella serology or culture, and a response to specific antibiotics, with a significant improvement of cerebrospinal fluid parameters.

SUMMARY

Neurobrucellosis can be insidious, and despite its global distribution, it is still unrecognized and frequently goes unreported. The understanding of the current epidemiology is necessary for eradication of the disease in humans, as well as the disease control in animals and prevention based on occupational hygiene and food hygiene.

Neurobrucellosis Presenting with Features of Demyelinating Disorder in a Pediatric Patient

Brucellosis is an endemic disease in Saudi Arabia, which can present with variable clinical manifestations. It is a zoonotic disease transmitted from animals to humans. Brucellosis is a multisystemic disease that can present with any system involvement; and neurobrucellosis is a serious complication, sometimes leading to permanent neurological deficit, if treatment is not started promptly. Herein, we present a 6-year boy with neurobrucellosis, who developed demyelination of cerebral white matter and presented with fever and seizures. Key Words: Neurobrucellosis, Demyelination, White matter.

Sporadic actinomycosis of the hip complicated by Central Nervous System infection

Actinomycosis is caused by the Gram positive filamentous Actinomyces bacterial species that are normal commensals of the oral cavity. Due to their low virulence, disease is rare in the immune competent patient. Although it may afflict any system in the body, involvement of the musculoskeletal system is uncommon. Here in, we describe the case of a 60 year old lady presenting with low grade fever, left hip pain and drowsiness. She was diagnosed as left hip actinomycosis on Computed tomogram (CT) guided biopsy and histopathological analysis of infiltrative lesions identified on Magnetic Resonance Imaging (MRI). She also had meningitis diagnosed on cerebrospinal fluid analysis which improved with treatment of actinomycosis. Actinomycosis of the hip is rare, and occurs in the presence of described predisposing factors. To the best of our knowledge, this is the first case of sporadic actinomycosis of the hip complicated by meningitis in an immune competent individual.

Linezolid for the Treatment of Patients with Central Nervous System Infection

Objective:

To review the available evidence regarding the use of linezolid for the treatment of patients with central nervous system (CNS) infections.

Data Sources:

Relevant studies were identified through searches of the PubMed, Current Contents, and Cochrane databases (publications archived until October 2006).

Study Selection and Data Extraction:

Case reports, case series, prospective and retrospective studies, and randomized controlled trials were eligible for inclusion in our review if they evaluated the effectiveness and safety of linezolid for the treatment of patients with CNS infections.

Data Synthesis:

In 18 (42.9%) of the 42 relevant cases identified, patients had undergone neurosurgical operations and/or had prosthetic devices. Meningitis was the most common CNS infection, accounting for 20 (47.6%) cases. Other CNS infections included brain abscesses (14; 33.3%), ventriculitis (5; 11.9%), and ventriculo-peritoneal shunt infection (3; 7.1%). In the 39 patients in whom the responsible pathogen was isolated, those predominantly responsible for the CNS infections were: penicillin–nonsusceptible Streptococcus pneumoniae (7; 17.9%), vancomycin-resistant enterococci (6; 15.4%), Nocardia spp. (5; 12.8%), methicillin-resistant Staphylococcus epidermidis (4; 10.3%), and methicillin-resistant Staphylococcus aureus (3; 7.7%). Of the 42 patients who received linezolid for the treatment of CNS infections, 38 (90.5%) were either cured or showed clinical improvement of the infection. The mean duration of follow-up was 7.2 months; no recurrent CNS infection was reported.

Conclusions:

The limited published data suggest that linezolid may be considered for the treatment of patients with CNS infections in cases of failure of previously administered treatment or limited available options.

Central nervous system nocardiosis in Queensland: A report of 20 cases and review of the literature

Nocardia infection of the central nervous system (CNS) is an uncommon but clinically important disease, often occurring in immunocompromised individuals and carrying a high mortality rate. We present 20 cases of microbiologically proven CNS nocardiosis diagnosed in Queensland from 1997 to 2015 and review the literature from 1997 to 2016.Over 50% of cases occurred in immunocompromised individuals, with corticosteroid use posing a particularly significant risk factor. Nine (45%) patients were immunocompetent and 3 had no comorbidities at time of diagnosis. Nocardia farcinica was the most frequently isolated species (8/20) and resistance to trimethoprim-sulfamethoxazole (TMP-SMX) was found in 2 isolates. Overall, 35% of our patients died within 1 year, with the majority of deaths occurring in the first month following diagnosis. Interestingly, of the 7 deaths occurring at 1 year, 6 were attributed to N farcinica with the seventh isolate being unspeciated, suggesting the virulence of the N farcinica strain.

[Ocular syndromes in patients with neurobrucellosis]

OBJECTIVE

To investigate the clinical features of ocular syndromes in patients with neurobrucellosis.

METHOD

This is a retrospective series case study. The clinical data of 5 patients with neurobrucellosis, who were treated in Department of Neurology, Beijing Tongren Hospital, Captical Medical Uinversity, from May 2009 to January 2015, were collected. Their epidemiological information, clinical manifestation, laboratory and radiologic examination, therapy and prognosis were analyzed.

RESULTS

Among the five patients, there were 3 males and 2 females, and their ages ranged from 20 to 67 years. The median age was 25 years. All patients had ever exposed to sheep. 1 patient lived close to a slaughterhouse and 2 patients lived in epidemic areas of brucellosis. 5 patients presented with binocular vision loss, 8 eyes with fundus edema, 3 patients with ophthalmoplegia;4 patients with fever,4 patients with headache,3 patients with neck stiffness,1 patient with movement and sensation disorders. Cerebrospinal fluid (CSF) pressure elevated, white cell number and protein increased with glucose reduction were detected respectively in 3 cases. While, CSF chloride decreased in 2 cases. Serum agglutination test for brucella was positive in 5 patients. Serum brucella culture was positive in 1 patient and CSF brucella culture was positive in 1 patient. Brain magnetic resonance imaging (MRI) showed that the optic nerve was involved in 3 patients,the meninges were involved in 1 patient and the brain white matter was involved in 1 patient. The combination of rifamycin, tetracycline, ceftriaxone sodium or quinolone were given to all patients and showed appreciated effects.

CONCLUSIONS

The clinical features of ocular syndromes are atypical in patients with neurobrucellosis. Vision loss and ophthalmoplegia are more common to be seen. Neurobrucellosis should be considered when patients with ocular signs and other system symptoms without a definite diagnosis.

[Paracoccidiomicosis in the central nervous system: a case report]

Paracoccidioidomycosis is a fungal disease which can compromise the central nervous system (CNS).We present a case of an immunocompetent 45 year old man from Satipo, Peru who developed paracoccidioidomycosis in the CNS without any apparent point of entry or infection. The patient was diagnosed by imaging with a cerebellar granuloma, followed by a craniotomy where tissue and secretion of the granuloma abscess was obtained. Histological and microbiological diagnoses were performed on the tissue and secretion, respectively. Yeasts were observed in the histological section and growth of the fungus in the culture. The patient initially received antifungals, then acquired an intrahospital infection, received colistin and subsequently died. The case report emphasizes the importance of early and correct diagnosis for good outcomes of paracoccidioidomycosis cases.

Head and neck emergencies: bacterial meningitis, encephalitis, brain abscess, upper airway obstruction, and jugular septic thrombophlebitis

Head and neck infectious disease emergencies can be rapidly fatal without prompt recognition and treatment. Empiric intravenous (IV) antibiotics should be initiated immediately in any patient with suspected bacterial meningitis, and IV acyclovir in any patient with suspected encephalitis. Surgical intervention is often necessary for brain abscesses, epiglottitis, and Ludwig's angina. A high index of suspicion is often needed to diagnose epiglottitis, Ludwig's angina, and Lemierre's syndrome. Brain infections can have high morbidity among survivors. In this article, the causes, diagnostic tests, treatment, and prognosis are reviewed for some of the more common head and neck infectious disease emergencies.

Central nervous system relapse of Whipple's disease

A 50-year-old man presented with a 12 kg weight loss in 8 months. Upper gastrointestinal endoscopy findings showed strong erosion and diffuse bleeding in the duodenum. Histopathological findings showed PAS staining-positive macrophages consistent with Whipple's disease. He was treated with trimethoprim-sulfamethoxazole. His condition initially improved. However, during his 6-year course of treatment he developed a central nervous system relapse. Tropheryma whipplei DNA was detected by a polymerase chain reaction in his cerebrospinal fluid. This relapse was successfully treated with ceftriaxone sodium (CTRX). We considered that as initial therapy for Whipple's disease, it would be important to administer CTRX for at least a few months, due to its high translatability to CSF.

Staphylococcus aureus brainstem abscess in a Brazilian Amazon man. Case report

The brainstem is an uncommon site for a brain abscess. It accounts for less than 4% of all posterior cranial fossa abscesses, and less than 1% of all intracranial abscesses. The pons is the most common site for these abscesses. The aim of the present report was to describe the case of a Brazilian Amazon man with a brainstem abscess (BSA) managed with combined surgical drainage and systemic antibiotic therapy. This case reinforces the importance of an early suspicion of BSA in patients with unexplained fever and neurologic deficits, especially sixth and seventh cranial nerve lesions, to minimize permanent damage.

Neurobrucellosis: clinical, diagnostic, therapeutic features and outcome. Unusual clinical presentations in an endemic region

Brucellosis is a zoonotic infection and has endemic characteristics. Neurobrucellosis is an uncommon complication of this infection. The aim of this study was to present unusual clinical manifestations and to discuss the management and outcome of a series of 18 neurobrucellosis cases. Initial clinical manifestations consist of pseudotumor cerebri in one case, white matter lesions and demyelinating syndrome in three cases, intracranial granuloma in one case, transverse myelitis in two cases, sagittal sinus thrombosis in one case, spinal arachnoiditis in one case, intracranial vasculitis in one case, in addition to meningitis in all cases. Eleven patients were male and seven were female. The most prevalent symptoms were headache (83%) and fever (44%). All patients were treated with rifampicin, doxycycline plus trimethoprim-sulfamethoxazole or ceftriaxone. Duration of treatment (varied 3-12 months) was determined on basis of the CSF response. In four patients presented with left mild sequelae including aphasia, hearing loss, hemiparesis. In conclusion, although mortality is rare in neurobrucellosis, its sequelae are significant. In neurobrucellosis various clinical and neuroradiologic signs and symptoms can be confused with other neurologic diseases. In inhabitants or visitors of endemic areas, neurobrucellosis should be kept in mind in cases that have unusual neurological manifestations.

Acute central nervous system infections in adults--a retrospective cohort study in the NHS North West region

BACKGROUND

Over the last 15 years, bacterial meningitis has received considerable attention, including national guidelines, whilst viral central nervous system (CNS) infections have been relatively neglected. A recent pilot study suggested that management of patients with suspected viral encephalitis was often suboptimal.

AIM

To examine the relative incidence, clinical features and management of suspected acute CNS infections in adults across the NHS North West Region.

DESIGN

A multicentre cross-sectional retrospective cohort study at 10 hospitals across the region over 3 months (from September to December 2007). Following a screen of all patients who had cerebrospinal fluid (CSF) analysis or received intravenous aciclovir and/or third-generation cephalosporin, those with clinical features suspicious of a CNS infection were included. Management was compared with the national meningitis and regional encephalitis guidelines.

RESULTS

Three hundred and eighty-five patients were screened; 217 patients had a suspected CNS infection and 44 (20%) had a CNS infection: 18 aseptic meningitis (one herpes simplex virus [HSV]-2), 13 purulent meningitis (four Streptococcus pneumoniae) and 13 encephalitis (three HSV-1). The median (range) time from admission to suspicion of CNS infection and to LP was longer for patients with encephalitis than meningitis [4 (0.3-312) vs. 0.3 (0.1-12) h, P<0.001, and 23 (4-360) vs. 12 (2-48) h, P=0.042, respectively]; and the median time to treatment was longer for aciclovir than cephalosporin [7 (0.5-312) vs. 3 (0.3-312) h, P=0.002].

DISCUSSION

Encephalitis was as common as purulent meningitis, and HSV as common as Streptococcus pneumoniae. However, the management of patients with encephalitis was worse than meningitis. National encephalitis guidelines are needed.

[Neurobrucellosis: description of 5 cases in Setif Hospital, Algeria]

PURPOSE

Brucellosis is a major ubiquitous zoonosis transmitted from livestock to humans. It is a public health problem in developing countries. Between 2003 and 2005, the incidence of brucellosis in Algeria showed a 181% increase from 8.79 to 24.71. Between 2005 and 2007, the incidence remained almost stable. The estimated mean incidence of neurobrucellosis is 4% with clinical manifestations that are variable and often multi-focal in the same patient. The purpose of this retrospective study is to describe 5 cases of neurobrucellosis managed in our department between 2001 and 2007.

MATERIALS AND METHODS

It was a retrospective study 5 patients. There were 2 women and 3 men with a mean age of 20 years.

RESULTS

Neurological involvement occurred immediately in all patients. Clinical manifestations were variable with meningoencephalitis in 2, meningoencephalitis associated with a polyperipheral neuropathy in 1, meningomyeloradiculitis in 1, and acute diffuse encephalitis in 1. Definitive diagnosis was based on isolation of bacteria from a blood specimen in 1 case and detection of antibodies in blood and cerebrospinal fluid in 4. All patients were treated using a combination of 3 of the following 4 drugs: doxycycline, rifampicine, cotrimoxazole and aminoside. Treatment was associated with corticosteroid therapy in 3 cases.

DISCUSSION

Neurobrucellosis can affect any part of the nervous system and can mimic any neurological disease. Early detection and treatment is the only predictor of favorable outcome of neurobrucellosis, but there is no standardized treatment protocol. Neurobrucellosis should be included in differential diagnosis for any patient presenting central or peripheral neurological manifestations especially in endemic zones.

Principles of antimicrobial therapy

We have discussed important factors involved in choosing appropriate antimicrobial regimens for the treatment of bacterial meningitis and brain abscess to illustrate common themes relevant to the treatment of these diseases. We have limited this review to these conditions for two main reasons: (1) the principles involved in optimal antimicrobial therapy for these diseases likely apply to others CNS infections, such as viral and fungal diseases; and (2) little pharmacological information is currently available for other types of CNS infections. Many of the studies addressing the relevant pharmacological and microbiological aspects of antimicrobial therapy for CNS infections have been performed in experimental animal models and, as a result, the information derived from these studies may be different when examined in appropriate human studies. Our current understanding of appropriate antimicrobial therapy for CNS infections may be summarized as follows: 1. Choose bactericidal antimicrobials that effectively cross the BBB to achieve CSF concentrations well above the MBC (≥ 10-fold) for the suspected bacterial pathogen(s). 2. Take into consideration the relevant PD parameters the bactericidal activity of the antimicrobials used to treat bacterial meningitis, such as t > MBC or AUC/MBC. 3. Tailor the antimicrobial regimen based on microbiological information, once available. However, with respect to brain abscess therapy, keep in mind that anaerobes are commonly involved, but difficult to culture, and consider including antianaerobic therapy even if the bacterial cultures do not grow anaerobes. 4. Treat bacterial meningitis caused by nonmeningococcal pathogens for 7-10 days, but monitor clinical progress to determine whether the patient should continue on a more prolonged antimicrobial course. Meningococcal meningitis may be treated with 3-4 days of effective antimicrobial therapy, again with the caveat that the patients clinical course should dictate duration of therapy. 5. Treat brain abscess, preferably after aspiration/drainage, for at least 6 weeks with intravenous antimicrobials for brain abscess on the clinical response (e.g., improved symptoms, lack of new neurological findings) and radiographic changes (e.g., reduction in cavity size).

NOD2 plays an important role in the inflammatory responses of microglia and astrocytes to bacterial CNS pathogens

While glial cells are recognized for their roles in maintaining neuronal function, there is growing appreciation that resident central nervous system (CNS) cells initiate and/or augment inflammation following trauma or infection. We have recently demonstrated that microglia and astrocytes constitutively express nucleotide-binding oligomerization domain-2 (NOD2), a member of the novel nucleotide-binding domain leucine-rich repeat region containing a family of proteins (NLR) that functions as an intracellular receptor for a minimal motif present in all bacterial peptidoglycans. In this study, we have confirmed the functional nature of NOD2 expression in astrocytes and microglia and begun to determine the relative contribution that this NLR makes in inflammatory CNS responses to clinically relevant bacterial pathogens. We demonstrate the increased association of NOD2 with its downstream effector molecule, Rip2 kinase, in primary cultures of murine microglia and astrocytes following exposure to bacterial antigens. We show that this cytosolic receptor underlies the ability of muramyl dipeptide to augment the production of inflammatory cytokines by glia following exposure to specific ligands for disparate Toll-like receptor homologues. In addition, we demonstrate that NOD2 is an important component in the in vitro inflammatory responses of resident glia to N. meningitidis and B. burgdorferi antigens. Finally, we have established that NOD2 is required, at least in part, for the astrogliosis, demyelination, behavioral changes, and elevated inflammatory cytokine levels observed following in vivo infection with these pathogens. As such, we have identified NOD2 as an important component in the generation of damaging CNS inflammation following bacterial infection.

Management of neurobrucellosis: an assessment of 11 cases

OBJECTIVE

The central nervous system involvement of Brucellosis causes a hard to treat infection with multiple sequelae. The aim of this paper is to discuss the course of neurobrucellosis in response to therapy.

PATIENTS AND METHODS

Patients with neurobrucellosis were evaluated. The diagnosis was established by the isolation of bacteria, abnormal CSF findings and positive serology. Ceftriaxone, rifampicin, doxycycline and trimethoprim sulfamethoxazole were the antibiotic choices for these cases.

RESULTS

We present 11 cases with neurobrucellosis. None of our patients died, albeit one case has a critical situation due to subarachnoid hemorrhage and its' concordant sequelae. Only one of four patients with walking difficulty and two with hearing loss were normalized with therapy. Imaging techniques did not provide any specific contribution regarding the Brucella infection.

CONCLUSIONS

Parenteral ceftriaxone should be used as an initial alternative in the management of neurobrucellosis. Although the therapy should be individualized, the duration of therapy should be a minimum of six months with suitable antibiotics.

Recomendaciones GEIPC-SEIMC y GTEI-SEMICYUC para el tratamiento antibiótico de infecciones por cocos grampositivos en el paciente crítico

In recent years, an increment of infections caused by gram-positive cocci has been documented in nosocomial and hospital-acquired infections. In diverse countries, a rapid development of resistance to common antibiotics against gram-positive cocci has been observed. This situation is exceptional in Spain but our country might be affected in the near future. New antimicrobials active against these multi-drug resistant pathogens are nowadays available. It is essential to improve our current knowledge about pharmacokinetic properties of traditional and new antimicrobials to maximize its effectiveness and to minimize toxicity. These issues are even more important in critically ill patients because inadequate empirical therapy is associated with therapeutic failure and a poor outcome. Experts representing two scientific societies (Grupo de estudio de Infecciones en el Paciente Critico de la SEIMC and Grupo de trabajo de Enfermedades Infecciosas de la SEMICYUC) have elaborated a consensus document based on the current scientific evidence to summarize recommendations for the treatment of serious infections caused by gram-positive cocci in critically ill patients.

Variable presentation of neurological melioidosis in Northeast Thailand

We describe three instructive cases of neurologic melioidosis that demonstrate the variable nature of clinical manifestations and disease pathology. The appropriate duration and choice of parenteral and oral antimicrobial therapy for neurologic melioidosis are also discussed.

Pituitary abscess

Pituitary abscess is a rare disease, but one with potentially high mortality and morbidity. We present a 46-year-old man with progressive visual disturbance and general malaise for 1 year. Endocrine studies revealed hypopituitarism, and magnetic resonance imaging revealed a pituitary lesion with suprasellar extension. We attempted to excise the lesion using a transsphenoidal approach, but pus in the pituitary fossa was found at operation, and no tumour was identified. The culture yielded coagulase-negative Staphylococcus. Antibiotics were administered for 3 weeks, and the patient made a good postoperative recovery. He required life-long hormone replacement therapy. After one and a half years of follow-up, he was well and had no evidence of focal or systemic infection. We review the literature regarding pituitary abscess and discuss the appropriate treatment and possible pathological mechanism.

Strategies for the management of bacterial brain abscess

We reviewed the medical and surgical management of brain abscess and compared the results of different methods of treatment. Treatment of brain abscess requires a combination of antimicrobial agents, surgical intervention, and eradication of the primary foci of infection. We believe that pathologic confirmation and/or microbiologic studies are needed to ensure proper management, with the selection of antibiotics based on the available culture and susceptibility results. A 6- to 8-week course of parenteral antibiotics, plus regular follow-up computed tomography scans for at least 3 months to evaluate the therapeutic response is also recommended. The method of surgical treatment is of lesser importance than adherence to the basic principles of abscess management, and which surgical treatment is chosen depends on the patient's clinical status, the neuroradiographic characteristics of the abscess, and the experience of the surgeons who will be carrying out the procedure.

Cure of multiresistant Acinetobacter baumannii central nervous system infections with intraventricular or intrathecal colistin: case series and literature review

OBJECTIVES

CNS infections due to multiresistant Acinetobacter baumannii (MRAB) are an emerging problem in neurosurgical patients. Colistin remains one of the few remaining treatment options for MRAB but has poor CNS penetration. We describe our experience with intraventricular or intrathecal colistin for this infection.

METHODS

Cases known to have received intraventricular or intrathecal colistin for CNS infections due to MRAB were retrospectively reviewed regarding colistin treatment, colistin efficacy and adverse events.

RESULTS

Five patients were identified. All were admissions to the neurosurgical ICU and all were cured of their CNS infections. Three cases were complicated by drug-induced aseptic meningitis or ventriculitis.

CONCLUSIONS

This largest case series to date shows that direct instillation of colistin into the CNS may cause chemical meningitis or ventriculitis but it is an effective treatment option for MRAB CNS infection. Further study of dosing regimens is needed.

[Neurolisteriosis in adults: report of six clinical cases]

INTRODUCTION

Listeria monocytogenes shows a special attraction to infect the central nervous system and its meningeals coats. It affects newborn as well as elderly people, patients with deficiencies in their cellular immune systems, and healthy adults. It presents most commonly as an acute meningitis, although it can present itself as cerebritis, brain stem encephalitis (rhomboencephalitis), and exceptionally as myelitis.

PATIENTS

We describe six clinical cases of neurolisterioris, five of which in healthy adults; we also describe the images and cerebrospinal fluid (CSF) findings,

RESULTS

Three patients contracted acute meningitis, one of them meningoencephalitis, one cerebritis and the last one rhomboencephalitis. The CSF was turbid or slightly turbid with normal glycorrachia in three patients. The diagnosis was made in five through culture of CSF. The patient with the rhomboencephalitis had brain stem microabscesses in the brain magnetic resonance. All the patients had a good outcome under antibiotics treatment.

CONCLUSION

Neurolisteriosis has to be kept in mind as a feasible diagnosis not only in immunocompromised but also in newborn as well as elderly patients. It should also be taken into account in young healthy adults living in regions under poor sanitary conditions where there is no adequate control of food manufacturing.

Central nervous system Lyme disease

Nervous system infection with Borrelia burgdorferi frequently causes meningitis and rarely causes encephalomyelitis. Altered cognitive function also can occur in the absence of central nervous system infection. Recently developed serodiagnostic tools, such as the C6 assay, and appropriate use of Western blotting promise to improve diagnostic accuracy. Treatment trials have demonstrated the efficacy of relatively brief courses of oral antimicrobial agents, even in peripheral nervous system infection and meningitis. Several well-performed studies have clearly shown that prolonged antimicrobial treatment of "post-Lyme disease" is ineffective. Diagnosis and treatment of Lyme disease continue to improve.

Clinical experience with linezolid for the treatment of central nervous system infections

Linezolid, an oxazolidinone, exhibits bacteriostatic activity against virtually all Gram-positive bacteria and even covers atypical organisms like mycobacteria and Nocardia. However, little is known about its effectiveness for central nervous system (CNS) infections. We report on our good experience with linezolid for the treatment of CNS infections in 10 patients, amongst whom three were caused by mycobacteria. While six of our patients clinically improved during linezolid therapy even after failure of various antibiotics, it was unsuccessful in one case. Side-effects were only mild gastrointestinal problems in one patient after long term-treatment, which however led to the cessation of therapy. Linezolid appears to be a safe alternative to vancomycin for therapy-resistant CNS infections because of its good CSF penetration and few side-effects.

Meropenem

Meropenem is a new carbapenem antibacterial agent with wide spectrum of activity against gram-negative, gram-positive and anaerobic organisms. It is stable against most beta-lactamases produced by gram-negative bacteria and has greatest utility in treating severe infections in hospitalized children. It has good CSF penetrability and useful in treatment of childhood meningitis and infections in neutropenic children. Due to concern relating to emergence of resistance, it should be used as a reserve drug in difficult-to-treat infections caused by resistant organisms or when conventional treatment fails.

[Whipple disease and central nervous system]

Whipple disease (WD) is a rare systemic infection caused by the bacteria Tropheryma whipplei. Slowly progressive dementia, supranuclear ophthalmoplegia, headache, myoclonus, hypothalamic dysfunction, oculomasticatory-skeletal myorythmia are characteristic manifestations when WD involves the central nervous system (CNS). Treatment of cerebral WD should be performed with antibiotics that reach the CNS for at the least one-year. We alert for the early diagnosis of WD in patients with exclusively neurological clinical pictures, sometimes with atypical or non-definitive diagnosis, because it is a potential treatable disease.

[Neurobrucellosis: clinical features and therapeutic responses in 15 patients]

We report a retrospective analysis of 15 cases of neurobrucellosis. Initial clinical manifestations consisted of meningoencephalitis in 5 patients, acute and subacute meningitis in 4, intracranial hypertension in 2, polyradiculoneuritis with albumin-cell dissociation in 2 (one with cerebral and subarachnoid hemorrhage), and transverse myelitis and lumbar epidural abcess with root involvement in 1 each. Cranial nerve involvement was noted in 5 patients. Fever was absent in 3. Transient clinical manifestations mimicking transient ischemic attacks were noted in 3 patients. Unusual central nervous system demyelinating lesions were observed on the MRI in 1 of the patients with meningoencephalitis. Cerebrospinal fluid Wright titers and culture were rarely helpful. Most patients responded favorably with minor neurological sequelae. The most commonly used antibiotics were rifampin, doxycycline, and trimethoprim-sulphamethoxazole, in various combinations for at least 3 months. The differential diagnosis of neurobrucellosis is wide. However, in endemic areas, the disease should be ruled out in all patients who develop unexplained neurological symptoms.

Community-acquired Klebsiella pneumoniae central nervous system infections in adults in Singapore

A series of successfully managed community-acquired Klebsiella pneumoniae infections of the central nervous system (CNS) that occurred in six non-neurosurgical adult patients in Singapore over a 2-year period is reported. Three patients had abscesses that were drained, and three had meningitis; all were treated with third-generation cephalosporins. All six patients were middle-aged adults, three of whom were food handlers. Clinicians should be aware of Klebsiella pneumoniae as an important CNS pathogen, particularly in East Asia. Although third-generation cephalosporins have had a major impact on the outcome of Klebsiella pneumoniae CNS infections, the emergence of extended-spectrum beta-lactamase-producing strains may lead to their reduced efficacy in this clinical setting.

A child with neurobrucellosis

An 11-year-old boy presented with chronic meningitis followed by acute flaccid paralysis. The aetiology remained uncertain until the brucellar serology test became positive and there was a good response to specific antimicrobial therapy. Nerve conduction studies confirmed a proximal radiculopathy. Awareness of the condition and performance of the appropriate tests will differentiate neurobrucellosis from other chronic central nervous system infections.

Presence of Chlamydophila psittaci DNA in the central nervous system of a patient with status epilepticus

This study reports an extraordinarily severe and prolonged course of neuroornithosis with generalized status epilepticus as an initial symptom. Direct invasion of the central nervous system by Chlamydophila psittaci was confirmed by the demonstration of specific DNA in the patient's cerebrospinal fluid. The patient recovered slowly under administration of doxycycline.

Nocardiosis with brain abscess due to an unusual species, Nocardia transvalensis

The identification of Nocardia transvalensis, an unusual and probably underrecognized cause of nocardial infection, is clinically significant because of this species' resistance to aminoglycosides, a standard antinocardial therapy. Diagnosis requires analytic methods available predominately in reference laboratories. We report a case of disseminated infection with N transvalensis with primary pulmonary involvement and subsequent development of brain abscesses, and review the literature to date. Familiarity with the epidemiology, pathologic findings, and clinical significance of this and other unusual Nocardia species may increase early identification and antibiotic susceptibility testing in cases of nocardial infection.

Infection of central nervous system by motile Enterococcus: first case report

A 66-year-old man with four indwelling ventriculoperitoneal shunts for multiloculated hydrocephalus from a complicated case of meningitis a year before developed shunt infection based on a syndrome of fever, drowsiness, and cerebrospinal fluid neutrophil pleocytosis in the background of repeated surgical manipulation to relieve successive shunt blockages. The cerebrospinal fluid culture, which yielded a motile Enterococcus species, was believed to originate from the gut. This isolate was lost in storage and could not be characterized further. The patient improved with vancomycin and high-dose ampicillin therapy. He relapsed a month later with Enterococcus gallinarum shunt infection, which responded to high-dose ampicillin and gentamicin therapy. This is probably the first case report of motile Enterococcus infection of the central nervous system.

Infections of the central nervous system in transplant recipients

Central nervous system (CNS) infections, accounting for 4-29% of CNS lesions in transplant recipients, are a significant post-transplant complication. Focal CNS infectious lesions or brain abscesses have been documented in 0.36-1% of the transplant recipients. Mycelial fungi, particularly Aspergillus, are by far the most frequent etiologies of post-transplant brain abscesses. Bacteria, with the exception of Nocardia, are rarely associated with brain abscesses in transplant recipients. Time of onset and concurrent extraneural lesions have implications relevant towards invasive diagnostic procedures in transplant recipients with brain abscesses. Meningoencephalitis in transplant recipients is predominantly due to viruses, e.g., herpesviruses, and less frequently due to Listeria monocytogenes, Toxoplasma gondii, and Cryptococcus. Despite a wide, and at times perplexing array of opportunistic pathogens that can cause CNS infections, the temporal association of the infection with the time elapsed since transplantation, risk factors, clinical manifestations, and neuroimaging characteristics of the lesion can allow a reasoned and rational approach towards the recognition, diagnosis, and appropriate management of CNS infections in transplant recipients.

Divergence paralysis & intracranial hypertension due to neurobrucellosis. A case report

CASE REPORT

A 22 year old female presented with sudden onset of uncrossed diplopia at distance, intracranial hypertension, esotropia and was evaluated. Microbiological tests of CSF and sera showed for brucellosis and the patient received therapy for this and her intracranial hypertension. The papilledema, headache, esotropia and diplopia all disappeared after therapy.

CONCLUSIONS

Diagnostic tests for brucella must be considered for patients who have divergence palsy and papilledema, especially those living in endemic areas.