Meningitis with cranial polyneuritis and cavernous sinus thrombosis by Borrelia crocidurae: First autochthonous case in Europe

Borrelia crocidurae is endemic in West Africa, where it represents the leading cause of tick-borne relapsing fever (TBRF). TBRF typically presents with high fever and systemic symptoms, followed by recurrent episodes. Neurological complications may occur during febrile relapses. B. crocidurae is considered the most neurotropic agent of TBRF and is associated to severe neurological manifestations i.e. meningitis and encephalitis. To date, European cases of B. crocidurae infection have been reported in travelers returning from endemic areas. We report the first autochthonous case in Europe of B. crocidurae infection, presenting as meningitis with cranial polyneuritis and cavernous sinus thrombosis that were not preceded by classic febrile recurrences.

Effectiveness of the retreatment of patients with multibacillary leprosy and episodes of erythema nodosum leprosum and/or persistent neuritis: a single-center experience

BACKGROUND

Erythema nodosum leprosum may appear before, during or after treatment of leprosy and is one of the main factors for nerve damage in patients. When it occurs or continues to occur after treatment, it may indicate disease recurrence and a new treatment may be instituted again.

OBJECTIVE

To evaluate the retreatment of patients with multibacillary leprosy who underwent standard treatment with multidrug therapy, but developed or continued to present reactions of erythema nodosum leprosum and/or neuritis 3-5 years after its end.

METHOD

For this objective, a new treatment was performed in 29 patients with multibacillary leprosy who maintained episodes of erythema nodosum and/or neuritis 3-5 years after conventional treatment.

RESULTS

In general, we observed that 27 (93.10%) had no more new episodes after a follow up period of eight months to five years. In five of these patients the reason for the retreatment was the occurrence of difficult-to-control neuritis, and that has ceased to occur in all of them.

STUDY LIMITATIONS

Small number of patients..

CONCLUSION

In the cases observed, retreatment was an effective measure to prevent the occurrence of erythema nodosum leprosum and/or persistent neuritis.

A critical appraisal on pure neuritic leprosy from India after achieving WHO global target of leprosy elimination

BACKGROUND

Clinical data on pure-neuritic leprosy (PNL) is limited.

OBJECTIVE

To study the clinical and epidemiological features of PNL in the leprosy post-elimination era.

METHODS

This was a retrospective analysis of the clinic records of leprosy patients from January 2006 to June 2013. Data regarding age, sex, disease duration, presenting complaints, nerves affected, complications and treatment received were extracted from PNL cases.

RESULTS

Among 906 registered leprosy cases, 48 (5·3%) were found to have PNL. The mean age was 36·9 ± 16·2 years and predominantly males were affected (85·4%). The mean delay between onset of symptoms and diagnosis was 2·1 ± 2·2 years. Multiple nerves were affected in 36 patients (75%) and 12 (25%) had only one nerve involved. Visible deformities at presentation were noted in 32 (66·7%) patients. Forty patients (83·3%) were treated with multi drug therapy-multibacillary (MDTMB) regimen and three (6·25%) were treated with MDT-paucibacillary regimen. Twenty-one patients (43·8%) were considered positive responders to treatment. There was no correlation between the duration of NFI and treatment outcome.

CONCLUSION

PNL continues to occur in the post-elimination era. Grade 2 deformities are common in PNL compared to other leprosy patients because of delayed diagnosis and treatment. Distinct diagnosis and treatment guidelines and sensitisation of health care workers and physicians to the occurrence of PNL is the need of the day.

Nerve abscess in primary neuritic leprosy

Nerve abscess is an infrequently reported complication of leprosy. We describe a patient with a pure neuritic type of leprosy with multiple nerve abscesses, who presented with tingling and numbness in the medial aspect of his right forearm and hand. Subsequently he developed pain, redness and swelling over the medial side of his right elbow and the flexor aspect of his right wrist. High-resolution ultrasound showed diffuse thickening of the right ulnar nerve with hypoechoic texture housing a cystic lesion with internal debris suggesting an abscess, at the cubital tunnel. Histopathological examination of the pus and tissue obtained from the abscess revealed presence of granulomas with lepra bacilli. The patient responded to surgery and multidrug therapy. In conclusion, the nerve abscess as the first manifestation of leprosy is uncommon and a high index of suspicion is required to make a correct diagnosis.

Pure neuritic leprosy in patients from a high endemic region of Colombia

Agua de Dios was a leprosarium for leprosy patients' obligatory isolation (1872-1961). Its leprosy incidence is the highest in Colombia (1.5-7/10000). Relapses are common. Government grant of US$ 200 per month subsidy is available to patients with disabilities. Spontaneous consultation with neural symptoms is frequent and simulation to get the subsidy has to be considered. We studied 36 subjects (2007-2009), with ages from 29-78, 19 of them men, with neural symptoms of 6 months to 20 years evolution. All had clinical examination, bacteriological examination, skin and nerve biopsies, electromyography (EMG), PCR for M. leprae, IgM anti-PGL1, and lepromin A. All but two are household contacts of leprosy patients. Symptoms were hypoesthesia of the hands and feet, and difficulty using hands with loss of muscular strength. None had skin lesions. Three had thickening of ulnar nerve. Lepromin was positive in all; bacteriology and biopsies were negative in all. The speed and amplitude of neural conduction were altered in 34 patients; two women had normal EMG and were considered to be feigning the disease; 21 were diagnosed as PNL by clinical, epidemiological and EMG findings; five of them had a positive PCR and one, high titers for IgM anti PGL1. Nine other subjects had diabetes and six carpal tunnel syndrome (CTS). Slow progression of disease, the lack of neural enlargement and the neural biopsies without inflammation suggest that most of these patients could have spontaneously cured PNL, as happens with other cases of paucibacillary leprosy. Diabetes and CTS are important differential diagnoses of PNL. Patients were treated with MDT and received the state subsidy.

Anti-ganglioside antibodies-mediated leptospiral meningomyeloencephalopolyneuritis

A case of leptospirosis complicated with meningo-myelo-encephalo-polyneuritis and nephrotic syndrome is presented. Anti-ganglioside antibodies were detected for the first time in a patient with neurological complications of leptospirosis. Possible pathogenic mechanisms and treatment options of these rare manifestations are discussed.

Age is an important risk factor for onset and sequelae of reversal reactions in Vietnamese patients with leprosy

BACKGROUND

Reversal, or type 1, leprosy reactions (T1Rs) are acute immune episodes that occur in skin and/or nerves and are the leading cause of neurological impairment in patients with leprosy. T1Rs occur mainly in patients with borderline or multibacillary leprosy, but little is known about additional risk factors.

METHODS

We enrolled 337 Vietnamese patients with leprosy in our study, including 169 subjects who presented with T1Rs and 168 subjects with no history of T1Rs. A multivariate analysis was used to determine risk factors for T1R occurrence, time to T1R onset after leprosy diagnosis, and T1R sequelae after treatment.

RESULTS

Prevalence of T1Rs was estimated to be 29.1%. Multivariate analysis identified 3 clinical features of leprosy associated with T1R occurrence. Borderline leprosy subtype (odds ratio, 6.3 [95% confidence interval, 2.9-13.7] vs. polar subtypes) was the major risk factor; 2 other risk factors were positive bacillary index and presence of > 5 skin lesions. In addition, age at leprosy diagnosis was a strong independent risk factor for T1Rs (odds ratio, 2.4 [95% confidence interval, 1.3-4.4] for patients aged > or = 15 years old vs. < 15 years old). We observed that T1Rs with neuritis occurred significantly earlier than pure skin-related T1Rs. Sequelae were present in 45.1% of patients who experienced T1Rs after treatment. The presence of a motor or sensory deficit at T1R onset was an independent risk factor for sequelae, as was the age at diagnosis of leprosy (odds ratio, 4.4 [95% confidence interval, 1.7-11.6] for patients > or = 20 years old vs. < 20 years old).

CONCLUSION

In addition to specific clinical features of leprosy, age is an important risk factor for both T1R occurrence and sequelae after treatment for T1Rs.

Primary neuritic leprosy: a reappraisal at a tertiary care hospital

AIM

To study the clinico-epidemiological profile of primary neuritic leprosy.

METHODS

Retrospective analysis of the leprosy records of clinically diagnosed patients of PNL who attended the Leprosy Clinic from 2000 to 2004 was carried out for details of presenting complaints, age and sex distribution, duration, number of nerves involved and pattern of nerve enlargement, BI (skin), nerve abscess, and deformities.

RESULTS

There were 32 (4.6%) patients of PNL out of a total of 686. Majority (56.2%) had complaints for less than a year. There were 29 (90.6%) males, and 3 (9.4%) females, with 15-30 years as the commonest age-group (65.6%) involved. Paraesthesia and numbness were the presenting complaints in 20 (62.5%), and motor deficit (paresis) in 11 (34.4%); deformities (claw hand, foot drop, trophic changes) were seen in 16 (50%) cases. Polyneuritic pattern was noted in 21 (63.56%) patients and mononeuritic in 11 (16.5%) with ulnar nerve as the most commonly enlarged nerve (63.6%). Nerve abscess was noted in 4 (12.5%) cases. Slit-skin smear was positive in 2 (6.2%) cases only.

DISCUSSION

PNL continues to be common in India. Sensory complaints are early and more common. The disease is more common in males. Polyneuritic pattern was predominant, and the ulnar nerve was the most commonly involved nerve. Majority of the cases belong to the tuberculoid spectrum. Early diagnosis depends on complete neurological examination in order to reduce the sequelae of the disease.

Use of oxcarbazepine to treat a pediatric patient with resistant complex regional pain syndrome

We describe a 12-year-old patient with severe, protracted complex regional pain syndrome type I. His pain did not respond to gabapentin, amitriptyline, physical therapy, opioids, or nonsteroidal drugs. Sympathetic or regional block was not attempted because of persistent bacteremia and severe local sepsis. His pain responded dramatically to the addition of oxcarbazepine, with rapid improvement in his symptoms and functional status. We suggest that oxcarbazepine might be a useful adjunct in the treatment of gabapentin-resistant complex regional pain syndrome type I in children and should be considered.

PERSPECTIVE

Oxcarbazepine's antinociceptive effect is mediated via sodium channel inhibition in neuropathic models and by inhibition of substance P and prostaglandins in anti-inflammatory models. The efficacy of oxcarbazepine in this patient might be attributable to these mechanisms or possibly to synergism with either gabapentin or the anti-inflammatory effects produced by amitriptyline.

Motor and sensory polyneuritis with distal conduction failure as uncommon complication of an acute Rickettsia conorii infection

Rickettsia conorii is endemic in the Mediterranean region. Infections are mostly benign and neurological involvement is unusual. We describe a case of a man who presented with acute facial nerve palsy followed by flaccid tetraparesis due to an electrophysiologically established polyneuritis with distal conduction failure. Elevated IgM antibody titres for R. conorii were documented by indirect immunofluorescent antibody test. After doxycycline therapy, the patient presented a rapid clinical improvement. Repeated electrophysiological examinations revealed significantly restored compound muscles, and sensory action potentials, corresponding to the clinical course after treatment and ex juvantibus, indicate the causative relation between R. conorii infection and the described clinical syndrome.

Small-fiber polyneuropathy in leprosy without skin changes: study of 17 cases

Leprosy is one of the most common diseases of the peripheral nerves. In some cases there is only neural involvement without skin changes (neuritic form). The neuropathy has often a distal stocking and glove distribution with thermal and pinprick anesthesia and preservation of proprioception. There is no weakness, the tendon reflexes may be preserved and sometimes the nerves are thickened. We reported 17 patients with a predominantly small-fiber polyneuropathy due to leprosy. All patients had distal temperature and pain anesthesia with different individual variations. The tendon reflexes were normal in seven patients and in eight there was thickening of the nerves. The nerve conduction was normal in three patients. Sural nerve biopsy consisted of: 1) inflammatory infiltrates, 2) vacuolated "foamy" cells, 3) fibrosis of endoneurium, perineurium, and epineurium, 4) partial or total loss of nerve fibers, 5) large number of bacilli. We concluded that in countries where leprosy is frequent, nerve biopsy is an obligatory procedure in patients with predominantly small-fiber polyneuropathy.

Fine needle aspiration cytology of leprous neuritis

OBJECTIVE

To document the cytomorphologic features of leprous neuritis and their correlation with bacterial density.

STUDY DESIGN

A partly retrospective, partly prospective study of the fine needle aspiration cytology of enlarged nerves in leprosy. Cytomorphologic features of nerve aspirates from 28 patients were studied. May-Grünwald-Geimsa and Ziehl-Neelsen staining methods were employed.

RESULTS

Five cytomorphologic patterns were observed in smears of nerve aspirates in 19 group I patients with concurrent skin and nerve lesions: (1) inflammation composed of epithelioid cell granulomas (5), bacillary index (BI) = 0; (2) epithelioid cell granulomas with necrosis (5), BI = 0-1+; (3) acellular necrosis (5), BI = 0-4+; (4) macrophage granuloma (3), BI = 5-6+; and (5) granulation tissue (1), BI = 1+. In 9 group II patients with pure neuritic leprosy, 3 patterns were seen: (1) epithelioid cell granulomas (5), BI 0-6+; (2) epithelioid granulomas with necrosis (1), BI = 0; and (3) acellular necrosis (3), BI = 0-6+.

CONCLUSION

The entire spectrum of leprosy is seen in nerve aspirates. Necrosis is often a prominent feature. Recognition of the range of cytomorphologic patterns and their correlation with BI contribute to accurate calibration of the disease in nerves, resulting in appropriate choice of treatment.

[Neuritic leprosy disclosed by reversal reaction]

We report a case of neuritic borderline tuberculoid leprosy with lingering insidious growth disclosed by a brutal reversal reaction. Inflammatory polyarthralgia and sensory and motor loss in the median and ulnar territories, without skin lesions, suggested vasculitis. A few weeks later, inflammatory skin lesions developed leading to the diagnosis of biopsy proven leprosy. Leprosy should be considered as a possible diagnosis in patients with multineuritis, especially when associated with rheumatic or cutaneous manifestations. Early skin biopsy in neuritic leprosy is discussed.

Pathology and pathogenesis of leprous neuritis; a preventable and treatable complication

In conclusion, it may be said that many advances have been made in the diagnosis, treatment and prevention of nerve damage. It is now a well accepted fact that the affinity of M. leprae for Schwann cells and the property of M. leprae to grow in cooler sites of the body have made certain segments of nerve trunks vulnerable. Trauma that supervenes the inflammation and swelling severely aggravates the nerve damage. The reactive phase in all forms of leprosy, the etiology of which is not clearly understood, produces intraneural caseous necrosis in tuberculoid disease and microabscesses in lepromatous disease, causing much irreversible damage to nerves. The steroid treatment that is administered during the reactive phase has helped greatly to stop further damage, although the damage already done to nerves is not always reversible. Preventive measures like detecting the disease before nerve trunks are infected and offering prompt and adequate antileprosy therapy as early as possible have helped to reduce the prevalence of deformities. It is hoped that administering steroids along with antileprosy therapy to prevent active inflammation and or fibrosis of the nerve will reduce the prevalence of nerve damage significantly. Measures which provide rest for the infected nerve to prevent trauma should be explored.

Endothelial cells and the pathogenesis of lepromatous neuritis:insights from the armadillo model

Selective infection of peripheral nerves is a unique property of Mycobacterium leprae that results in serious injury, but its basis is unexplained. Recent evidence from infected armadillos suggests that endothelial cells of peripheral nerve vasculature may be the gatekeepers by which M. leprae infects nerves. The pathogenesis of neuropathy in leprosy may thus entail a dynamic sequence of adhesion, immunologic, and inflammatory processes involving peripheral nerve endothelial cells.

Mycobacterial neuritis in a cat

A 2-year-old spayed female domestic shorthair cat was referred for evaluation of rapidly progressive lameness of the right hind limb, which was paralyzed. Histologic examination of biopsy specimens revealed pyogranulomatous inflammation affecting the sciatic, common peroneal, and tibial nerves, and slender, beaded, acid-fast bacilli within macrophages, nerve fibers, and degenerate axons. A diagnosis of mycobacterial neuritis was made and the cat was treated with clofazimine and enrofloxacin for extended periods. Treatment was partially effective; the goal of returning normal function to the limb was not achieved, but disease progression was halted and the cat remained a viable pet.

Delayed facial paralysis after stapedotomy using KTP laser

OBJECTIVE

Delayed facial paralysis after stapes surgery is uncommon and has been reported after traditional, nonlaser techniques for stapedotomy. The purpose of this paper is to inform the reader of the potential risk of delayed facial nerve paralysis associated with the use of the potassium titanyl phosphate (KTP) laser for stapedotomy. Etiologic mechanisms are discussed.

STUDY DESIGN

The study was a descriptive study-case report.

SETTING

The study was conducted at a university-based otologic practice.

PATIENTS

Two patients with otosclerosis and delayed onset facial palsy 5 to 7 days after uncomplicated stapedotomy using the KTP laser were included in the study.

INTERVENTION

Potassium titanyl phosphate laser stapedotomy was performed. Patients received treatment of facial palsy with a tapering course of oral steroids.

MAIN OUTCOME MEASURE

House-Brackmann facial nerve grade scores were used.

RESULTS

Improvement of House-Brackmann facial nerve scores from Grade VI to Grade I-II in one patient, and improvement from Grade IV to Grade I-II in the other was seen.

CONCLUSION

The probable etiology of delayed facial palsy is viral neuritis from reactivation of dormant virus within the facial nerve, initiated by thermal stress of the KTP laser. Presentation and resolution of the facial palsy is similar to other types of delayed facial palsy resulting from nonlaser techniques of stapes surgery and other types of middle ear and neurotologic surgeries previously reported.

[Otorhinolaryngological manifestations of varicella-zoster virus]

Otological complications of varicella-zoster syndrome (Ramsay Hunt syndrome) include facial paralysis, tinnitus, hearing loss, vertigo, dysgeusia, and skin rash. The lower cranial nerves sometimes are affected by this neuritis. A case is reported of a woman without immune-system impairment who had cranial multineuritis with unilateral involvement of the VII, VIII, IX and X cranial nerves after infection with varicella-zoster virus without herpetic lesions.

Neuritic Hansen's disease: an unusual presentation and a diagnostic challenge on fine-needle aspirate

Fine-needle aspiration cytology is now routinely used in the diagnosis of cervical lumps. We report on a case of leprous neuritis which presented as a cervical swelling. A diagnosis of leprosy was suggested on the basis of globi within histiocytes. These histiocytes differed from those classically described in leprosy. Retrospective review demonstrated the presence of occasional nerve fragments, and some of these closely resembled granulomas. The possible close resemblance of this lesion to tuberculosis and a histiocytic proliferative disorder is highlighted. Recognition of nerve fragments along with histiocytes should suggest the diagnosis.

Stages and syndromes of neuroborreliosis

To ascertain the varieties of neuroborreliosis, 330 patients were identified at the Departments of Neurology in Würzburg and Giessen from 1979 to 1994. Patients who fullfilled at least one of three strict case definitions based on clinical and laboratory criteria were included in the study. Ninety-one per cent of the patients had second-stage neuroborreliosis (duration of symptoms < or = 6 months). The most common syndrome was a painful spinal meningoradiculitis, alone (37%) or in combination with a cranial radiculitis (29%). Meningoradiculitis cranialis (9%), isolated meningitis (4%) and erythema chronica migrans-associated mono/polyneuritis (3%) were further stage II features. Central nervous system involvement occurred either as an acute meningomyelitis or meningomyeloradiculitis (5%) and meningoencephalitis or meningenocephaloradiculitis (4%). Less than 9% of the patients ran a chronic course (stage III) with a disease duration between 6 months and 9 years, either as acrodermatitis chronica atrophicans associated mono- or polyneuritis (2%) or a chronic progressive encephalomyelitis (6%). Cerebrovascular neuroborreliosis (1%) occurred in both stages; however, the primary nature of the course was a chronic one. Involvement of other organs except the skin was rare (joints 3%, heart 1%) but elevated hepatic enzymes were frequent. Our study demonstrates that neuroborreliosis has to be considered in the differential diagnosis of a wide variety of neurological conditions. Cerebrospinal fluid analysis and the search for specific intrathecal antibody production are important diagnostic procedures.

Isolated neuritis of the sciatic nerve in a case of Lyme disease

Lyme disease is an infectious disease caused by the spirochete Borrelia burgdorferi. The course of the disease is divided into three stages, the second of which may include various types of peripheral nervous system disturbances. We report the case of a patient with persistent deficits caused by the prevalent involvement of the sciatic nerve, confirmed by electrophysiological and neuropathological findings. The most significant bioptic results were axonal degeneration and perivascular inflammation. Damage to a single peripheral nerve as the dominant clinical expression during the course of Lyme disease is an unusual finding that has been rarely described in the literature.

Ulnar neuritis in Hansen's disease results of fifty neurolyses in the arm and elbow

Fifty cases of ulnar nerve neuritis in Hansen disease are reported. The authors analyse the type of lesion, the clinical feature, the treatment, and the results of neurolysis. Many points are emphasized: the requirement to an association antileprosy, chemotherapy and corticotherapy with a careful neurolysis; pain and paresthesia were relieved immediately after neurolysis, recovery within two years after neurolysis; the amount of recovery was directly related to the extent and stage of involvement of the nerve; and thus the sooner procedure give the best result.

Effect of steroid therapy on parameters of peripheral autonomic dysfunction in leprosy patients with acute neuritis

Recent electrophysiological studies on peripheral autonomic dysfunction in leprosy patients show a high prevalence of autonomic dysfunction as measured by abnormal vasomotor reflexes (VMR) and absent sympathetic skin response (SSR). Nothing is known about the reversibility of these autonomic parameters with treatment. Since there is evidence that small fiber function may be the most reversible component in neuropathies, we measured the effect of steroid treatment on autonomic parameters together with motor and sensory functions in leprosy patients with acute neuritis. Control subjects were investigated for repeatability testing of autonomic function. Due to a relatively high variability on repeat VMR testing in the controls, we defined a change in VMR testing as a change of > 30%. With this definition, the VMR of 14.8% of the patients improved, 75% remained unchanged, and 10.2% worsened. Absent SSR became positive in 16.6% and remained unchanged in 83.4%. Improvement in sensory motor functions was seen in 21.2% and 1.3% of the patients, respectively.

Papillitis and vasculitis of the arteria spinalis anterior as complications of hepatitis C reinfection after liver transplantation

It is well known that hepatitis C virus (HCV)-related chronic liver disease may be associated with various immunological disorders including mixed cryoglobulinemia, which is accompanied by cutaneous vasculitis, arthralgias, membrano-proliferative glomerulonephritis, and neuropathy in association with cryoprecipitable immune complexes in serum. We describe here the first case of central nervous system HCV infection with evidence of the virus in the cerebrospinal fluid in association with cryoglobulinemia in a patient who developed recurrent episodes of papillitis and vasculitis of the arteria spinalis anterior after liver transplantation.

Immunohistochemical study of cutaneous neuritis in positive lepromin reactions

Sixty skin biopsies taken from positive tuberculoid and borderline-tuberculoid late lepromin reaction were studied using histological techniques. The distribution of mycobacterial antigen and nerves was demonstrated using immunochemical methods. A total of 557 nerve bundles was observed in 51 biopsies; 9 were devoid of nerves in the sections examined; 475 nerve bundles showed some relationship to the inflammatory infiltrate (85%); perineuritis being seen in 144 (30%) and endoneuritis in 5 (0.9%). Mycobacterial antigens inside the granuloma were detected in 59 of the 60 biopsies (98%). Only one specimen, showing a strong tuberculoid reaction, failed to show these antigens. On the contrary, mycobacterial antigen was absent in almost all nerves. Small deposits were detected in the perineurium of one nerve with perineuritis, and inside a Schwann cell of another, the latter belonging to a previously multibacillary patient. The neurotropic tendency of the granuloma does not seem to be stimulated by the presence of mycobacterial antigens inside the nerves, as normally these antigens do not penetrate them. The hypothesis of some antigenic fraction of the neural tissue which cross-reacts with Mycobacterium leprae antigens, thus eliciting a perineural or near-perineural inflammatory reaction is put forward, but needs further investigation.

[Varicella zoster complications]

Varicella zoster virus is known to cause varicella in children and to reactivate years later as shingles. Both the primary disease and the reactivation can cause complications, both in the form of serious affection of organs by the virus itself, and through secondary bacterial infections owing to temporary immune deficiency. Relatively frequent complications include secondary bacterial skin infections, pneumonitis, complications affecting the central nervous system, and hepatitis. We describe a few typical cases seen recently in our department, and review important points connected to treatment and prophylaxis.

[Neurological complications of Mycoplasma pneumoniae infections]

Mycoplasma pneumoniae (Mp) infections are well known for the classical clinical picture of primary atypical pneumonia. The infection shows a predilection for young age groups. Every fourth-fifth year Mp epidemics are seen, lasting several months particularly in autumn/wintertime. The last Mp epidemic in Denmark was seen autumn/winter 1991-1992. The central nervous system (CNS) is involved in less than 0.1% of all Mp infections, but among patients treated in hospital, CNS involvement occurs in up to 7%. Among patients with acute, febrile, nonbacterial CNS affection the incidence of Mp infections is shown to be 5%, with a maximum of 10% during Mp epidemics. In up to 20% the CNS complications are seen without preceding pulmonary symptoms. The pathogenesis is unknown, but probably involves several mechanisms. The spectrum of clinical findings is wide, ranging from mild meningeal signs to severe neurological symptoms and a poor outcome. Mp encephalitis has a particularly high morbidity and mortality. The effect of antibiotic treatment is doubtful, but the treatment is often instituted late. It may be debated, whether early antibiotic treatment can reduce the frequency of the CNS complications and their sequelae. Mp infection should be remembered as a differential diagnosis in any patient with fever and neurological symptoms. It can be recommended to add Mp diagnostic measures to the screening investigations, especially in patients with recent respiratory symptoms and during Mp epidemics. It is important to attempt to detect Mp by culture or polymerase chain reaction (PCR) from throat, respiratory tract and cerebrospinal fluid (CSF). Mp serology from blood and CSF should be performed early in cases where Mp infection is suspected.

Latent herpes simplex virus type 1 in human vestibular ganglia

Viral infection has been considered to be a possible pathogenesis of vestibular neuronitis, and reactivation of the herpes simplex virus (HSV) is one of the most likely causes. However, it remains unknown whether the human vestibular ganglia contain latent HSV. We examined 26 vestibular ganglia from autopsied adults in search of HSV type 1 (HSV-1). To detect HSV-1, we used polymerase chain reaction (PCR), in situ hybridization and immunohistochemical staining. HSV DNA was detected in 6 of 10 vestibular ganglia using the PCR method. However, the latency-associated transcript (LAT) of HSV-1 was negative in all of the 16 vestibular ganglia examined. No HSV antigen was detected in any of the ganglia. These results indicate that HSV-1 is latently infected in the human vestibular ganglia, and that LAT is transcribed weakly or not at all.

Experimental reactivation of HSV-I in rat vestibular ganglia

Rats with no clinical symptoms after inoculation were administered with cyclophosphamide in order to reactivate HSV-I in the vestibular ganglia. After this immunosuppression, the vestibular ganglia, trigeminal ganglia, cerebrum, cerebellum and brainstem were examined immunohistologically in order to detect HSV-I. HSV-I antigen could not be detected by using indirect immunofluorescence or the ABC method, however, it could be detected by using the PCR method. In this study, latent infection of HSV-I was shown but reactivation could not be established. We need further investigations to determine the reactivation of HSV-I in the vestibular ganglia, to obtain an animal model of vestibular neuronitis.

[Varying clinical pictures among young children with influenza virus type A infections]

The clinical course of Influenza type A virus infections in 47 hospitalized children aged 0-9 years was assessed retrospectively. The infection was diagnosed by demonstration of the virus in the nasopharyngeal secretion during the acute phase of the illness. Out of 21 Influenza A strains in which the subtype was determined, one was found to be H1- and 20 were H3-subtype. Lower respiratory tract disease was the main diagnosis in 21 children, 16 of whom had pneumonia; 14 of these patients were under three years of age. Gastro-intestinal symptoms occurred in 40% of the children over three years of age. Eight patients had febrile convulsions, a girl aged nine years had double vision and vertigo and a female infant aged two months had periodic apnoea and bradycardia. The reasons for hospitalization were febrile convulsions, abdominal pain, lower respiratory tract symptoms and high pyrexia.

[Monoparesis due to the brachial plexus neuritis by herpes zoster virus--report of a case]

A 73-year-old woman suffering from the acute onset monoparesis of her right arm which followed the skin eruption with mild sensory disturbance of right C4-6 level, was reported. Electrophysiological examinations revealed the brachial plexus neuritis and axonal degeneration of the proximal portion, with the evidence of herpes zoster infection. Her paresis of the right arm gradually improved without any medication during her hospital course. It was concluded that herpes zoster should be considered to be one of the causes of acute onset brachial plexopathy.

Inflammation near the nerve cell body enhances axonal regeneration

Although crushed axons in a dorsal spinal root normally regenerate more slowly than peripheral axons, their regeneration can be accelerated by a conditioning lesion to the corresponding peripheral nerve. These and other observations indicate that injury to peripheral sensory axons triggers changes in their nerve cell bodies that contribute to axonal regeneration. To investigate mechanisms of activating nerve cell bodies, an inflammatory reaction was provoked in rat dorsal root ganglia (DRG) through injection of Corynebacterium parvum. This inflammation enhanced regeneration in the associated dorsal root, increasing 4-fold the number of regenerating fibers 17 d after crushing; peripheral nerve regeneration was not accelerated. A milder stimulation of dorsal root regeneration was detected after direct injection of isogenous macrophages into the ganglion. It is concluded that changes favorable to axonal regeneration can be induced by products of inflammatory cells acting in the vicinity of the nerve cell body. Satellite glial cells and other unidentified cells in lumbar DRG were shown by thymidine radioautography to proliferate after sciatic nerve transection or injection of C. parvum into the ganglia. Intrathecal infusion of mitomycin C suppressed axotomy-induced mitosis of satellite glial cells but did not impede axonal regeneration in the dorsal root or the peripheral nerve. Nevertheless, the similarity in reactions of satellite glial cells during 2 processes that activate neurons adds indirect support to the idea that non-neuronal cells in the DRG might influence regenerative responses of primary sensory neurons.

An ultrastructural study of the response of traumatized rabbit tibial nerve to epineurial infection with Mycobacterium leprae

Crushed rabbit tibial nerves were inoculated with a suspension of living Mycobacterium leprae at and just distal to the site of nerve trauma. The resulting changes occurring over a period of time from 40 min to 72 hr post-inoculation were studied electron microscopically. Bacilli were seen in perineurial cells and in macrophages that had infiltrated the perineurium adjacent to epineurial deposits of M. leprae. It is suggested that trauma may weaken the perineurial barrier and facilitate the transperineurial passage of phagocytes, some of which may be laden with M. leprae, and may thus be a means whereby M. leprae enter the endoneurium of peripheral nerves.