Septic cortical thrombophlebitis

Meningoencephalitis with Streptococcus equi Subspecies equi Leading to a Dural Arteriovenous Fistula

Invasive infection with Lancefield group C streptococci in humans is extremely rare, with the vast majority of clinical isolates belonging to Streptococcus dysgalactiae subsp. equisimilis. We report a case of meningoencephalitis in a 69-year-old man caused by Streptococcus equi subsp. equi, a microbe that causes strangles in Equus caballus (i.e., the horse). This is only the fourth infection with this subtype of the central nervous system (CNS) reported in humans. The invasiveness of these bacteria, known to be capable of releasing strongly immunogenic exotoxins, is illustrated by white matter lesions that are present in the acute phase. This patient initially recovered well after treatment with antibiotics and glucocorticoids. However, the patient was readmitted 5 months later with multiple intraparenchymatous cerebral haemorrhages. Cerebral angiography confirmed the presence of a suspected superficial dural arteriovenous fistula (DAVF), which is seldom reported after CNS infection. The invasiveness of these bacteria was illustrated by white matter lesions present in the acute phase and the occurrence of a de novo dural arteriovenous fistula in the follow-up period.

Bacterial meningitis in neonates and infants - the sonographic picture

Bacterial meningitis is a major diagnostic and therapeutic problem among children and neonates, with severe, rapidly progressing course and potentially life-threatening complications. Early antibacterial treatment is essential for the patient’s favorable prognosis. Cerebral imaging plays an important role in the diagnostic process alongside physical examination and laboratory tests. Magnetic resonance imaging is the gold standard for diagnosing bacterial meningitis. Because of limited availability of magnetic resonance imaging, cranial ultrasound is the first imaging procedure to be performed (if the anterior fontanelle is preserved providing an adequate acoustic window). The safety and reliability of ultrasound examination, possibility to perform the examination at bedside without the need for sedation make cranial ultrasound a useful tool both for preliminary diagnostic investigation and for the monitoring of both treatment and long-term complications. Sonographic findings in patients with bacterial meningitis and possible complications are diverse. Changes can be seen on the surface of the brain, in the extra-axial space, in the ventricular system and in brain tissue. In some cases they can also be visible in the lumbosacral segment of the spinal cord. This paper presents ultrasound characteristics of lesions associated with bacterial meningitis in neonates and infants, based on the authors’ own material and data from the available literature.

Cushing's triad in pneumococcal meningitis due to brainstem ischemia: early detection by diffusion-weighted MRI

An infant with pneumococcal meningitis developed signs of raised intracranial pressure during the progression of the disease, including loss of consciousness, hypertension, bradycardia, and respiratory depression. However, both the emergency computed tomography scan findings and intracranial pressure measured by lumbar puncture were normal. Diffusion-weighted magnetic resonance imaging identified multiple lesions with restricted diffusion suggestive of ischemia in the brainstem, explaining the signs observed in the patient. These lesions could not be identified on T(2)-weighted images at that time.

Sonographic findings in bacterial meningitis in neonates and young infants

Cranial sonography plays an important role in the initial evaluation of infants with suspected bacterial meningitis and in monitoring for complications of the disease. Echogenic widening of the brain sulci, meningeal thickening and hyperemia suggest the diagnosis in an at-risk population. Sonography can identify the presence of extra-axial fluid collections, and color Doppler sonography can be very helpful in differentiating benign enlargement of subarachnoid spaces from subdural effusions. Intraventricular debris and stranding, and an irregular and echogenic ependyma are highly suggestive findings associated with ventriculitis. Sonography can play an important role in the detection of postinfectious hydrocephalus, in the determination of the level of obstruction, and in the evaluation of intracranial compliance. Focal or diffuse parenchymal involvement can represent parenchymal involvement by cerebritis, infarction, secondary hemorrhage or early abscess.

[Isolated cortical vein thrombosis. Clinical and neuroradiological aspects]

Isolated cortical vein thrombosis is only rarely diagnosed, although it presents with typical signs on imaging, presented in the paper. We report on five patients with this diagnosis, who all presented with focal sensomotoric seizures. Imaging with CT and MRI was the leading method. All patients were treated with oral anticoagulation and showed full recovery.

Vascular and Parameningeal Infections of the Head and Neck

Vascular and parameningeal infections of the head and neck are rare but frequently life threatening. These infections include intracranial and extracranial septic venous thrombophlebitis, arterial mycotic aneurysms and erosions, subdural empyema, and epidural abscesses. They usually arise as complications of otogenic, oropharyngeal, or paranasal sinus infections, and management involves an aggressive combined medical-surgical approach.

Meningoencephalitis caused by Streptococcus pneumoniae: a diagnostic and therapeutic challenge. Diagnosis with diffusion-weighted MRI leading to treatment with corticosteroids

Streptococcus pneumoniae is a common cause of bacterial meningitis but only rarely causes other infections such as brain abscess, encephalitis, encephalomyelitis or meningoencephalitis. We report on three adult patients with meningoencephalitis caused by S. pneumoniae. In all three, CT and MRI revealed widespread brain lesions, suggesting extensive parenchymal injury. Diffusion-weighted MRI showed lesions with restricted diffusion, reflecting local areas of ischaemia with cytotoxic oedema secondary to an immunologically mediated necrotising vasculitis and thrombosis. High levels of markers of neuronal, glial and myelin damage were found in the cerebrospinal fluid. According to the literature, brain parenchyma lesions in adults with pneumococcal meningoencephalitis are often associated with death or severe neurological deficit. Our patients were treated with pulse doses of glucocorticoids: this resulted in dramatic clinical improvement and an excellent final neurological recovery.

Cerebral venous thrombosis and Escherichia coli infection in neonates

AIM

To present a possible association between cerebral venous thrombosis (CVT) and infection with Escherichia coli.

METHODS

Four neonates with deep CVT occurring during an E. coli infection are presented.

RESULTS

In these patients the thrombotic disease was found by Doppler ultrasonography. The thrombosis involved at least the sagittal sinus and the transverse sinus according to subsequent MRI scans. The E. coli strains did not produce verotoxin or haemolysin. Disseminated intravascular coagulation was not demonstrated. Three patients presented with seizures. At discharge, all of the patients had signs of neurological damage, but two of them have improved significantly since then. None of the patients has had recurrent (venous) thrombosis.

CONCLUSION

E. coli infections in neonates may predispose to CVT, a finding that has clinical implications.

Supportive management in bacterial meningitis

The central nervous system and systemic complications of bacterial meningitis cause significant morbidity and mortality. This article offers insight into the clinical features, pathogenesis, and management of these complications. In many instances, the improved outcome of intervention is based on clinical suspicion and early recognition. The management of complications is evolving and is presently based mainly on supportive care.

Unusual manifestations of invasive pneumococcal infection

Unusual pneumococcal infections occurred frequently in the preantibiotic age but rapidly declined with the advent of the antibiotic era. Unfortunately, the morbidity and mortality associated with invasive pneumococcal disease remain high despite antibiotic therapy and monumental advances in medical technology. The incidence of invasive pneumococcal disease has increased recently because of the onset of the human immunodeficiency virus (HIV) epidemic and the emergence of antibiotic-resistant pneumococcus. Robert Austrian described the clinical triad of pneumococcal pneumonia, meningitis, and endocarditis, a syndrome that now bears his name. Although seen infrequently today, unusual manifestations of pneumococcal infection such as those Austrian reported still occur. A review of these cases is warranted because, as drug-resistant organisms continue to emerge worldwide, more unusual pneumococcal infections will be seen. Streptococcus pneumoniae is responsible for a remarkable array of disease processes; our literature review uncovered 95 different types of unusual pneumococcal infections representing 2,064 cases. Examples of these infections included pancreatic and liver abscesses, aortitis, gingival lesions, phlegmonous gastritis, inguinal adenitis, testicular and tubo-ovarian abscesses, and necrotizing fasciitis. We also reviewed predisposing underlying illnesses and conditions. Alcoholism, HIV infection, splenectomy, connective tissue disease, steroid use, diabetes mellitus, and intravenous drug use remain common risk factors for invasive pneumococcal infections. Currently, multidrug-resistant S. pneumoniae remains susceptible to vancomycin and several new third-generation fluoroquinolones. As what some fear will be a possible postantibiotic era approaches, clinicians must be able to recognize and manage unusual pneumococcal infections.

Headache: cortical vein thrombosis and response to anticoagulation

Cerebral venous thrombosis (CVT) is being diagnosed more frequently with the use of advanced radiologic imaging. The presentation of CVT includes a wide spectrum of nonspecific symptoms with headache predominating. We present a case with acute, severe headache. The evaluation included a head computed tomography (CT) scan that was normal. The presence of opacified sinuses led to treatment for sinusitis. The patient returned the following day with a generalized tonic-clonic seizure. A magnetic resonance imaging (MRI) study identified an isolated cortical venous thrombosis. This patient was treated with anticonvulsant and anticoagulation therapy. A CVT is an unusual cause of headache and should be considered in patients with atypical presentation or associated seizure, or who are refractory to current therapy. Diagnosis may be made with MRI. Resolution and complete recovery are possible with appropriate therapy.