Aseptic Meningitis as an Initial Manifestation of Anti-myelin Oligodendrocyte Glycoprotein Antibody-associated Disease.

Antibody against myelin oligodendrocyte glycoprotein (MOG-IgG) associated encephalitis is an important syndrome associated with MOG-IgG. However, there have been no reports of MOG-IgG-associated optic neuritis or demyelination following meningitis without encephalitic symptoms. A 55-year-old woman presented to our hospital with headache, nausea, fever, and nuchal rigidity that had persisted for more than a month. She was hospitalized due to aseptic meningitis and recovered with conservative therapy. However, she was re-admitted due to left optic neuritis and demyelinating lesions. We diagnosed MOG-IgG-associated neuromyelitis optica spectrum disorder (NMOSD). She responded to treatment with intravenous methylprednisolone and oral prednisolone. Aseptic meningitis may be an initial manifestation of MOG-IgG-positive NMOSD.

Erythrocyte-Rich Thrombus Is Associated with Reduced Number of Maneuvers and Procedure Time in Patients with Acute Ischemic Stroke Undergoing Mechanical Thrombectomy.

BACKGROUND: Only few studies have investigated the relationship between the histopathology of retrieved thrombi and clinical outcomes. This study aimed to evaluate thrombus composition and its association with clinical, laboratory, and neurointerventional findings in patients treated by mechanical thrombectomy due to acute large vessel occlusion. METHODS: At our institution, 79 patients were treated by mechanical thrombectomy using a stent retriever and/or aspiration catheter between August 2015 and August 2016. The retrieved thrombi were quantitatively analyzed to quantify red blood cells, white blood cells, and fibrin by area. We divided the patients into two groups - a fibrin-rich group and an erythrocyte-rich group - based on the predominant composition in the thrombus. The groups were compared for imaging, clinical, and neurointerventional data. RESULTS: The retrieved thrombi from 43 patients with acute stroke from internal carotid artery, middle cerebral artery, or basilar artery occlusion were histologically analyzed. Erythrocyte-rich thrombi were present in 18 cases, while fibrin-rich thrombi were present in 25 cases. A cardioembolic etiology was significantly more prevalent among the patients with fibrin-rich thrombi than among those with erythrocyte-rich thrombi. Attenuation of thrombus density as shown on computed tomography images was greater in patients with erythrocyte-rich thrombi than in those with fibrin-rich thrombi. All other clinical and laboratory characteristics remained the same. Patients with erythrocyte-rich thrombi had a smaller number of recanalization maneuvers, shorter procedure times, a shorter time interval between arrival and recanalization, and a higher percentage of stent retrievers in the final recanalization procedure. The occluded vessels did not differ significantly. CONCLUSIONS: In this study, erythrocyte-rich thrombus was associated with noncardioembolic etiology, higher thrombus density, and reduced procedure time.

[A case of adult-onset type II citrullinemia (CTLN2) triggered by an overseas travel].

A 43-year-old male presented with abnormal behavior and consciousness disturbance on the day after traveling abroad and was admitted to our hospital. Laboratory tests showed hyperammonemia and hypercitrullinemia. The electro-encephalogram showed frontal dominant bilateral slow δ burst. He had a peculiar taste for nuts. But he didn't take nuts during the overseas travel for 3 days. The family history revealed that his younger brother died of a status epilepticus of unknown cause at the age of 29. These findings were compatible with hepatic encephalopathy due to adult-onset type II citrullinemia (CTLN2). Gene analysis provided a definite diagnosis of CTLN2. Diet and drug therapy have improved his condition. He is due to have liver transplantation which is the only established radical treatment for CTLN2 if his condition becomes worse. The present case shows that cessation of the habitual intake of nuts only for 3 days could lead to onset of CTLN2.

[Case of NMO (neuromyelitis optica) spectum disorder triggered by interferon alpha, which involved extensive pyramidal tract lesion of the brain].

A 65-year-old woman developed left optic neuritis during the course of peg-interferon alpha (PEG-IFN-α) and ribavirin combination therapy for chronic hepatitis C. Brain T(2)W-MRI disclosed hyperintense lesions in the corpus callosum and white matter. We diagnosed neuromyelitis optica spectrum disorder (NMOSD) on the basis of anti-aquaporin-4 antibody seropositivity. PEG-IFN-α was discontinued, and she received steroid pulse therapy (intravenous high dose methylprednisolone). Two weeks later she also developed right optic neuritis. Repetitive steroid pulse therapy improved the left optic neuritis, but the upper half of the visual field of the right eye remained impaired. One month later she presented with mild dysarthria and mild left hemiparesis. Brain MRI disclosed an extensive pyramidal tract lesion from the right corona radiata to the pedunculus cerebri. This cerebral pyramidal tract lesion is associated with NMOSD. Our case corresponds to the past reports of optic neuritis or multiple sclerosis-like disease triggered by IFN-α. IFN-α may trigger NMOSD via a biological effect characteristic of Type I IFNs, a group that includes IFN-α and IFN-ß.

[An adult case of pandemic (H1N1) 2009 influenza associated encephalopathy].

A healthy 40-year-old man was admitted to our hospital because of impaired consciousness and convulsions starting five days after a high fever. Though rapid influenza diagnostic tests were negative, RT-PCR assay detected influenza A (H1N1) 2009 viral RNA from nasopharyngeal swab specimens. Initially high concentrations of interleukin-6 (IL-6) in serum and cerebrospinal fluid decreased as the symptoms improved, as with past influenza-associated encephalopathy cases. Scattered high signal intensity lesions in the cerebral cortex and right medial thalamus on magnetic resonance imaging (MRI) disappeared, and diffuse brain atrophy remained. It is necessary to be aware of the possibility of healthy adults developing pandemic 2009 influenza A (H1N1)-associated encephalopathy and that rapid influenza diagnostic tests have limited accuracy.

[Probable amebic brain abscess in a homosexual man with an Entamoeba histolytica liver abscess].

A 51-year-old Japanese-Brazilian homosexual man was admitted to a hospital because of fever, headache and right epigastralgia. He had been homosexual for 20 years. An abdominal CT revealed a liver abscess and microscopic examination of the pus of the drainage revealed cystic forms of Entamoeba histolytica. Oral administration of metronidazole 2,250 mg/day was started for amebic liver abscess. He complained of severe throbbing headache, and magnetic resonance imaging (MRI) of the brain showed a brain mass of approximately 2 cm in diameter in the right parietooccipital lobe. An amebic brain abscess was suspected and he was transferred to our hospital. Continuous oral administration of metronidazole for 49 days instead of invasive procedures gradually improved headache, fever and right epigastralgia. On the follow-up MRIs, the brain mass was gradually encapsulated, reduced its size, and finally disappeared. A diagnosis of amebic brain abscess was made on the basis of coexistent amebic liver abscess, MRI findings and a dramatic effectiveness to metronidazole. One should pay attention to E. Histolytica infection in the differential diagnosis of the abscess of the liver and brain since it has been increasing in Japan in recent years.