Rhomboencephalitis

Metagenomic Sequencing for Diagnosing Listeria-Induced Rhombencephalitis in Patient and Contaminated Cheese Samples: A Case Report

Among the various causes of rhomboencephalitis, Listeria monocytogenes infection is the most common. However, conventional microbiological methods often yield negative results, making diagnosis challenging and leading to extensive, often inconclusive, diagnostics. Advanced molecular techniques like metagenomic next-generation sequencing (mNGS) offer a powerful and efficient approach to pathogen identification. We present a case of life-threatening rhomboencephalitis in a 32-year-old immunocompetent patient where extensive microbiological, immunological, and biochemical tests were inconclusive. Given the patient's consumption of unpasteurized homemade cheese, neurolisteriosis was suspected, and mNGS was employed on clinical samples (CSF, serum, urine) and the food source to identify the pathogen. mNGS detected L. monocytogenes in both patient samples and the cheese. Mapping reads were distributed across the genome, with 18.9% coverage in clinical samples and 11.8% in the cheese sample. Additionally, the Listeriolysin (hlyA) gene was detected with 22.3% coverage in clinical samples and 12.3% in the food source, confirming neurolisteriosis. The patient fully recovered following antibiotic treatment. This case underscores the importance of mNGS in diagnosing CNS infections when conventional methods yield negative results, and supports its inclusion in diagnostic protocols for suspected neurolisteriosis, particularly when traditional methods prove inadequate.

Comparison of Clinical Diagnosis and Autopsy Findings of Early Neonatal Deaths: Diagnostic Challenges and the Value of Autopsy in Identifying Rare Pathologies

BACKGROUND

In a non-forensic hospital setting, neonatal death within the first week of life is often related to premature birth and/or lung diseases. Without post-mortem examination, the identification of the cause of death may be challenging. Autopsy can confirm the clinical diagnosis, uncover additional information or change the diagnosis. Our study aimed to assess the correlation between the clinical diagnosis and post-mortem findings in early neonatal deaths.

METHODS

The retrospective study included autopsy cases with neonatal deaths within the first 7 days of life (arbitrary time interval 2006-2021). Discrepancies between clinical and histopathological findings were classified into 3 groups: (i) full agreement, (ii) additional findings discovered by autopsy, or (iii) autopsy changed the diagnosis.

RESULTS

A cohort of 27 cases could be identified and lung pathologies were the most common finding (56%). Additional findings could be discovered in 48% of cases. Major discrepancies which changed the clinical diagnosis could be found in 11% (n = 3/27) of cases.

CONCLUSION

Frequently, post-mortem examinations validate the clinical diagnosis while revealing crucial information in a few cases. In these discrepant cases, autopsy findings can provide information for genetic counselling and quality control of clinical management.

A Case of Fulminant Listeria Rhombencephalitis with Brainstem Abscesses in a 37-Year-Old Immunocompetent Patient: From Vestibular Neuritis to Ondine's Curse

We present a rare case of Listeria monocytogenes (LM) rhombencephalitis with the formation of multifocal abscesses in a young immunocompetent patient. His initial symptoms of dizziness, headache, and feeling generally unwell were put down to a coincidental coinfection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The unfortunate rapid progression to trigeminal, hypoglossal, vagal, facial, and abducens nuclei palsies, and then an acquired central hypoventilation syndrome, known as Ondine's curse, required a prolonged intensive care unit (ICU) stay, and prolonged mechanical ventilation. As they continued to deteriorate despite targeted antibiotic treatment, surgical drainage of the abscesses was seen as the only meaningful available treatment option left to contain the disease. Postoperatively, the patient's strength rapidly improved as well as the severity of the cranial nerve palsies. After prolonged rehabilitation, at 3 months of follow-up, the patient was weaned off mechanical ventilation, independently mobile, and was left with only minor residual neurologic deficits. This case highlights a number of interesting findings only touched upon in current literature including the route of entry of LM into the central nervous system, the rare entity of acquired central hypoventilation syndrome, and finally the use of surgical intervention in cerebral LM infections.

Recurrent Rhombencephalitis Associated With Anti-GAD65 Antibody

A 66-year-old man developed diplopia, ataxia, and right-hand dexterity loss. Brain MRI revealed T2-hyperintensities in the right cerebellar peduncles, pons, medulla, and cerebellum (Figure 1, A-D).

Weakness in the intensive care unit

When asked to assess patients in an intensive care unit (ICU) who have respiratory muscle weakness, oropharyngeal weakness and a vulnerable airway, our immediate thought may be of Guillain-Barré syndrome or myasthenia gravis, but there are many other possible causes. For example, previously unrecognised chronic neurological conditions may decompensate and require ICU admission. Clinicians can use various clinical clues to help recognise them and need to understand how patterns of weakness reflect differing causes of reduced consciousness on ICU. Additionally, patients admitted to ICU for any reason may develop weakness during their stay, the most likely cause being ICU-acquired weakness. Assessing patients in ICU is challenging, hampered by physical barriers (machines, tubes), medication barriers (sedatives) and cognitive barriers (delirium, difficulty communicating). Nonetheless, we need to reach a clinical diagnosis, organise appropriate tests and communicate clearly with both patients and ICU colleagues.

Paediatric rhombencephalitis presenting with bradycardia: a good recovery despite cardiac involvement

Rhombencephalitis is a rare condition, often caused by infection, commonly presenting with myoclonic jerks, ataxia and cranial nerve palsy. Typically, it has a high morbidity and mortality, with worse prognosis associated with cardiopulmonary involvement. Herein, we present the case of a 10-year-old boy, presenting with headache, vomiting, symptomatic bradycardia and rapidly progressing ophthalmoplegia from a sixth nerve palsy, without additional brainstem symptoms. Previously, pericarditis, myocarditis and heart failure have been associated with rhombencephalitis, but not bradycardia. The cause of his rhombencephalitis was presumed viral, but despite extensive screening, the virus responsible was never isolated. Following treatment with intravenous antibiotics and antivirals in a high dependency unit, he recovered well with no neurological deficit on discharge and marked radiological improvement on MRI 4 weeks later. Although rare, rhombencephalitis should be considered in a child presenting with neurological symptoms, particularly alongside a cranial nerve palsy, developing over a rapid time course.

Post-infectious rhombencephalitis after coronavirus-19 infection: A case report and literature review

A wide number of neurological manifestations have been described in association with coronavirus disease 19 (COVID-19). We describe an unusual case of a young man who developed severe rhombencephalitis after COVID-19. He demonstrated clinical and radiological improvement with high dose corticosteroids, plasma exchange and intravenous immune globulin. Our findings, along with previously reported cases that we review here, support an autoimmune para- or post-infectious mechanism and highlight a possible role for immunotherapy in patients with rhombencephalitis after COVID-19.