[Herpetic meningoencephalitis in the elderly. Apropos of 13 cases]

In a retrospective analysis of 13 cases of Herpes simplex encephalitis (mean age: 67.2 +/- 6.4 years; ten women, three men), the authors conclude that this infection is more often due to Herpes simplex virus 1 in the elderly. Diagnosis is difficult at an early stage, and must be suspected in case of confusion (9/13), especially feverish (11/13), associated with neurological signs (10/13), and particularly epilepsy (5/13). It requires a lumbar puncture which collect a clear and lymphocytic fluid. Prognosis of this encephalitis depends on early diagnosis and an presumptive therapy with acyclovir. EEG is helpful showing periodic activity (10/13). CT scan and MRI can show unspecific abnormalities, but often too late. Laboratory findings will secondarily confirm the diagnosis quite frequently, using new Elisa methods. Polymerase chain reaction allows earlier diagnosis. Geriatric cases seem more often due to reinfection or to endogen virus reactivation rather than to primary infection.

[Acute meningoencephalitis caused by non-poliomyelitic enterovirus]

Enterovirus are ubiquitous pathogenic agents, whose only hosts are human. Their protean clinical presentation does not allow an etiological diagnosis grounded only on clinical basis. Despite their known neurotropism, a symptomatic infection of the central nervous system is not the rule. Nevertheless, with the ecological changes induced by the viral vaccines introduced during the last decades and the frequency of infection by these agents, especially among children, non-poliomyelitic enterovirus assume a major role as a cause of viral meningitis and encephalitis in the paediatric age. The epidemiological and clinical context should rule the request of serologic tests to achieve a final diagnosis.

Encephalopathy associated with Salmonella enteritidis infection

A 15-year-old boy who presented with a short history of a diarrhoeal illness associated with encephalopathic features is described. Salmonella enteritidis phage type 4 was cultured from his stool. Although encephalopathy in the absence of CNS infection or electrolyte disturbance is well described in enteric fever, it is very rare in infections with non-typhoidal Salmonella serotypes and has not previously been described in association with S. enteritidis infection.

Mycoplasma pneumoniae infection and neurological disease

The cases are reported of 13 children seen over a 22 month period who presented with a variety of acute neurological illnesses associated with Mycoplasma pneumoniae infection. Although presentation with a decreased level of consciousness or seizures was common, psychosis, hemiparesis, cranial nerve palsies, and Guillain-Barré syndrome were also seen. In contrast with published reports, only one child had an associated chest infection. Although some children have been left with residual disability, most have made a complete recovery. In this recent experience, M pneumoniae is a not rare cause of neurological illness in childhood and may present in unusual ways.

Prolonged meningoencephalitis due to Epstein-Barr virus with favorable outcome in a young infant

We present a case of meningoencephalitis due to EBV in a 2-month-old infant, without mononucleosis, which persisted for more than 5 months. Evidence for persistence of the infection was provided by a convulsive disorder and prolonged CSF pleocytosis, combined with persistent moderate anemia. Despite the persistence of the infection, the child continued to develop normally. This case demonstrates that EBV meningoencephalitis occurring in young patients may present with only subtle clinical findings and may have a favorable prognosis.

Diagnostic ultrastructure of Listeria monocytogenes in human central nervous tissue

The pathogenesis of Listeria monocytogenes infection of the human central nervous system is poorly understood and ultrastructural aspects are not documented. A case of fatal human L. monocytogenes meningoencephalitis is described, in which diagnosis was confirmed by blood culture and in which special staining (Brown's) showed slender gram-positive bacilli in inflamed areas of the brainstem at autopsy. Electron microscopy of blocks rescued from formalin revealed rods, up to 2.5 microns long x 0.4 microns in diameter, with gram-positive type cell walls and distinctive conic ends, the latter being apparent in axial section only. The organism was either free within the cytoplasm or within endosomes or phagosomes of macrophages, smooth muscle cells, and endothelial cells. In one instance, one was seen adhering to the luminal aspect of the vascular endothelium. Central nervous system parenchymal cell infection was suspected but not confirmed. Intra-cytoplasmic bacteria were surrounded by an electron-transparent halo and, beyond that, a cloud of host-derived microfilaments, as previously described by others in vitro and in animals. The morphology of L. monocytogenes is compared with that of other intracellular pathogens and is found to be distinctive, suggesting the value of ultrastructural study in diagnosis. Such work could also help to solve outstanding pathogenetic questions of central nervous system invasion and spread.

An epidemic of encephalitis and meningoencephalitis in children caused by echovirus type 30 in Shanghai

An outbreak of viral central nervous system infection occurred from May to September, 1991 in Shanghai, China. Totally 376 cases were admitted into our hospital, 54% with encephalitis and 46% with meningoencephalitis. Echovirus type 30 was isolated from CSF and stools of the patients. Only 3 of the patients were under 1 year of age. CSF examination revealed the cell count from 0-1600 x 10(6)/L. Interestingly, 9 had CSF PMNs over 90% and 13 had low sugar levels. EKG was randomly done in 20 patients and 15 demonstrated myocarditis. The outcome was uneventful in all except 1 who had psychological problem at the time of discharge.

Acute primary meningoencephalitis from entamoeba Naegleria Fowleri. Report of a clinical case with a favourable outcome

The Authors describe a primary amoebic acute meningoencephalitis case from Naegleria Fowleri, where the parasite was found in the cerebrospinal fluid and in culture. The case had a favorable outcome after treatment with amphotericin B.

Epstein-Barr virus genomic sequences and specific antibodies in cerebrospinal fluid in children with neurologic complications of acute and reactivated EBV infections

Four children with infectious mononucleosis (IM) and one with reactivated Epstein-Barr virus (EBV) infection had concomitant central nervous system disorders. Cerebrospinal fluid (CSF) samples from all five patients contained EBV genomic sequences and EBV-specific antibodies in the neurologic stage, but not during convalescence. Cerebrospinal fluid from two non-neurologic IM patients had neither EBV DNA nor EBV antibodies. The EBV-positive CSF of the five with neurological disorders were aseptic in culture and all negative for other human herpesvirus DNAs and antibodies: herpes simplex virus types 1 and 2, cytomegalovirus, varicella-zoster virus, and human herpesvirus 6. Epstein-Barr virus DNA and EBV antibodies were not detected in the CSF of 17 EBV-seropositive patients with mumps meningitis, rubella encephalitis, unknown febrile convulsion, or partial epilepsy. It is suggested that EBV plays a causal role in neurologic manifestations in patients with acute and reactivated EBV infections, through direct viral invasion and immunopathological reactions.

[Double meningoencephalitis with herpes simplex virus and rubella virus]

A 47-year-old man suffered from a headache, fever and memory disturbance. He was admitted to Morimoto Hospital. Neurological examination revealed disturbance of memory of recent events. Cranial nerves were normal. Muscle strength of the extremities was normal, except for Barré's sign of the right upper extremity. Deep tendon reflexes were exaggerated bilaterally, and extensor plantar response of the left side was elicited. Sensory examination showed no abnormality. Cerebellar sign was not recognized. Meningeal sign was slightly but clearly showed. CT scan demonstrated brain swelling at the right insular cortex region followed by severe hydrocephalus with dilatation of the lateral and the third ventricles. Cerebrospinal fluid showed high CSF pressure (250 mmH2O), pleocytosis (C.C. 359/mm3) and elevated protein level (213 mg/dl). Virological examination revealed herpes simplex virus (HSV) (CF) 32x, HSV-1 IgG (EIA) 4,050X, rubella virus IgE (EIA) 6,060X, cytomegalovirus (CMV) IgG (EIA) 1,130X in serum and HSV (CF) 1X, HSV-1 IGg (EIA) 1,430X, rubella virus IgG (EIA) 1,480X, CMV IgG (EIA) 587X in CSF. The ratio of serum/CSF of HSV and rubella virus titers by EIA methods were 2.83 and 4.10, respectively. He was treated by acyclovir 1,000 mg/day and gamma globulin, but his condition get worse acutely and died at 15th hospital days. This case was considered as a meningoencephalitis caused by simultaneous HSV and rubella virus infection.

Mumps virus meningoencephalitis complicated by subarachnoid haemorrhage

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Leptomeningeal toxoplasmosis after allogeneic marrow transplantation. Case report and review of the literature

A 37-year-old woman with chronic myelogenous leukemia underwent allogeneic bone marrow transplantation with CD8-depleted marrow from an HLA-identical sister. On day 43 post-transplant, the patient developed a headache and became lethargic and tremulous. Magnetic resonance imaging (MRI) of the brain showed abnormal meningeal and superficial parenchymal enhancement anteriorly. The spinal fluid had an elevated protein level with normal glucose and a neutrophilic pleocytosis. At autopsy, Toxoplasma meningoencephalitis was seen. On review of the literature, headache and confusion at 1-2 months post-transplant are common presenting signs of central nervous system toxoplasmosis. The predominance of neutrophils in the spinal fluid in this patient probably reflects the meningeal component of the infection and is an unusual finding. The presentation of toxoplasmosis in marrow transplant recipients is quite pleomorphic, and a definite diagnosis is difficult to obtain antemortem. Empiric therapy with pyrimethamine and sulfadiazine should be considered for marrow transplant recipients with neurologic deficits for which there is no other apparent etiology.

A field study of ovine listerial meningo-encephalitis with particular reference to cerebrospinal fluid analysis as an aid to diagnosis and prognosis

In a field study of listerial meningo-encephalitis involving 21 sheep from six silage-fed flocks, the neurological signs included profound depression, circling, involvement of the trigeminal and facial cranial nerves and lateral recumbency with propulsive limb movements. Within the six flocks the incidence of listerial meningo-encephalitis did not exceed 1% of the adult sheep at risk. Eleven of 18 (61%) adult animals were 2 years old. Evidence of an intrathecal inflammatory response in suspected listerial meningo-encephalitis cases was indicated by an increased cerebrospinal fluid (CSF) protein concentration greater than 0.4 g/l in 18 of 21 cases (86%), increased white cell count above 0.012 x 10(9)/l in 17 cases (81%) and lymphocyte percentage below 50% in all animals. None of the CSF parameters proved to be a reliable prognostic indicator because of the range of CSF values obtained and the small number of sheep which recovered.

[Meningoencephalitis after Mycoplasma pneumoniae infection]

A 15 year-old boy developed meningoencephalitis two weeks after onset of a respiratory tract infection caused by Mycoplasma pneumoniae. Central nervous complications are seen in 2-7% of patients hospitalized for M pneumoniae infection. Meningoencephalitis, meningitis, ataxia, polyradiculitis, psychosis and a few cases of apoplexy have been reported. In clinical practice one should be aware of M pneumoniae in the differential diagnosis of patients with suspected microbiologically induced central nervous complications. The pathogenetic aspects and prognosis are briefly discussed.

[Etiologic structure and clinical characteristics of acute viral infections of the central nervous system with hyperproteinorachia]

Clinical syndrome of acute viral meningitis and meningoencephalitis may be induced by different viruses. Etiologic diagnosis may be set by the isolation of the virus from the liquor and by the detection of specific antibodies in the blood and liquor. Our aim was to determine viral etiology of AVI with special reference to hyperproteinorachia. The study was conducted in 55 patients treated at the Clinic of Infectious Diseases in Novi Sad, with clinical picture of acute meningitis or meningoencephalitis, with pleocytosis above 50 ml in the cerebrospinal fluid. Depending on the levels of proteinorachia the patients were divided into the group with proteinorachia levels below 1g/l (34 patients) and above 1 g/l (21 patients). In the first group the most common was herpes simplex- and adenoviral etiology while in the second group most frequently found were choriolymphocytic meningitis virus (LCM) and herpes simplex virus. The protein level was in correlation with the severity of the clinical features and the duration of the treatment.

Pathology associated with meningoencephalitis during bacterial kidney disease of salmonids

The neural pathology associated with spontaneous cases of bacterial kidney disease (BKD), in five species of commercially reared salmonids, was investigated histopathologically and with immunofluorescence. Patterns of localisation of the causative organism of BKD within the central nervous system suggest that haematogenous spread to the meninges, particularly the tela choroidea posterior, the tela choroidea and vascularised capsule of the saccus dorsalis and epiphysis of the epithalamus, and the saccus vasculosus of the hypophysis, appears to be a frequent route by which the central nervous system becomes infected. Retrograde extension from the posterior uvea to the floor of the diencephalon along the epineurium and perineurium of the optic nerve also may be a mechanism of neural invasion. Extension appeared to occur from these sites into adjacent areas of the meninges, the neural parenchyma and ventricles. Demonstration of bacteria within salmonid ependymal cells, as well as the apparent ability of salmonid ependymal cells to respond metaplastically suggest a similarity to mammalian type III ependymal cells (tanycytes). Based on this study, it is apparent that teleosts can survive protracted severe brain damage. This, combined with the apparent similarities of neural response to infection between the salmonids used in this study and higher vertebrates, suggests that teleosts may be a useful lower vertebrate model for studying the pathogenesis and sequelae of bacterial meningitis.

[Fulminant meningoencephalitis due to Listeria monocytogenes]

We present a case of meningoencephalitis due to Listeria monocytogenes type IV in a patient in which the diagnosis of small-cells malignant diffuse non-Hodgkin's lymphoma had been established. He was hospitalized with vague clinical manifestations and without showing any neurological focus. Hours later, he presented clinical brain stem semiology. Within a 24-hour period, Listeria monocytogenes was isolated from blood and cephalorhachidian fluid (being the first time that this microorganism had been isolated for the past 20 years in our laboratory). The patient evolved to a state of coma, with Cheyne-Stokes's respiration, abolition of pupillary reflexes, decerebration position and exitus laetalis. The affection of the central nervous system has been fully documented. However, its fulminant presentation, as in the case that we present here, is less frequent, although it has been described in the literature by other authors, like Finegold et al., with cases in which the interval between the onset of the neurological focality and death ranged from 8 to 16 hours. The antibiogram showed a wide sensibility to several groups of drugs, despite the fast evolution of the disease that prevented the modification of the initial antibiotherapy (Vancomicine and imipenem).

The cerebrospinal fluid in the diagnosis of tuberculous meningoencephalitis: review of the literature

We review the literature on the biochemical, cytological and immunological changes in the cerebrospinal fluid (CSF) in tuberculous meningoencephalitis, emphasizing the inconsistency and low specificity of the CSF findings described in classic accounts of this disease. We consider separately the possible causes of yellow or bloody fluid. The development of accurate techniques of analysis does not diminish the importance of the clinical findings and history in the early diagnosis of this disease.