Candida Dublinensis Meningitis in an Immunocompetent Host: A Case Report and Review of the Literature.

Objectives: This study presents a case of Candida dubliniensis meningitis in an immunocompetent injection drug user and provides a literature review of CNS infections related to C dubliniensis. Methods: A 32-year-old man with a history of opioid use disorder presented with seizures and underwent extensive diagnostic evaluations, including imaging, lumbar puncture, and tissue biopsies. Treatment consisted of antifungal therapy and placement of ventriculoperitoneal shunt (VPS). Results: C dublinensis meningitis was identified on culture from a posterior fossa arachnoid sample. The patient demonstrated leptomeningeal enhancement on imaging, which resolved following 20 weeks of fluconazole. The development of hydrocephalus necessitated placement of VPS. Additional published cases of C dublinensis meningitis revealed varying presentations, diagnostic methods, and treatment regimens. Discussion: C dublinensis meningitis is a rare condition affecting both immunocompromised and immunocompetent individuals, particularly those with intravenous drug use. The diagnosis can be challenging, often requiring repeat lumbar punctures, extensive CSF sampling, or meningeal biopsy. Treatment involves a combination of antifungal agents, such as amphotericin B and fluconazole. Intracranial hypertension and hydrocephalus may necessitate surgical intervention. In conclusion, C dublinensis meningitis should be considered as a potential etiology of meningitis, particularly in those with a history of injection drug use.

Imaging of congenital and developmental cystic lesions of the brain: a narrative review.

INTRODUCTION: Congenital and developmental intracranial cysts represent a large heterogenous group with varied presentations and etiologies. They can range from normal variants to pathologic lesions often associated with known congenital syndromes or acquired insults. While some are incidentally found, others are symptomatic or may become symptomatic over time. The preferred type of neuroimaging for timely diagnosis helps determine appropriate management and treatment, if indicated. AREAS COVERED: In this narrative review article, authors present a comprehensive description of developmental cystic lesions. Imaging descriptions are provided for each type of cystic lesion as well as several representative images. EXPERT OPINION: As advanced neuroimaging techniques become more ubiquitous in clinical use, more light may be shed on the natural history of certain intracranial cystic lesions throughout the lifespan. This includes prenatal imaging for early identification and prognostication to surveillance imaging into advanced age to ascertain associations of certain cystic lesions with age-related cognitive dysfunction.

Characteristics and evolution of cerebral aneurysms among adults living with HIV: A retrospective, longitudinal case series.

OBJECTIVE: Previous research indicates an increased risk of cerebral aneurysm formation in adults living with human immunodeficiency virus (ALWH), however there are few longitudinal studies on the risk factors for and outcomes of cerebral aneurysms in this population. We aim to describe the characteristics and evolution of cerebral aneurysms in a large cohort of ALWH. MATERIALS AND METHODS: A chart review was completed for all adults evaluated at an urban, safety-net U.S. hospital between January 1, 2000, and October 22, 2021, with history of both HIV and at least one cerebral aneurysm. RESULTS: A total of 82 cerebral aneurysms were identified amongst 50 patients (52% female sex). Forty-six percent of patients with a nadir CD4 count less than 200 cells/mm3 (N=13) and 44% of patients with maximum viral load >10,000 copies/mL (N=18) developed new aneurysms or were found to have aneurysm growth over time compared with 29% of patients with a CD4 nadir above 200 cells/mm3 (N=21) and 22% of patients with maximum viral load

Validation of a Crisis Standards of Care Model for Prioritization of Limited Resources During the Coronavirus Disease 2019 Crisis in an Urban, Safety-Net, Academic Medical Center.

OBJECTIVES: The coronavirus disease 2019 pandemic has overwhelmed healthcare resources even in wealthy nations, necessitating rationing of limited resources without previously established crisis standards of care protocols. In Massachusetts, triage guidelines were designed based on acute illness and chronic life-limiting conditions. In this study, we sought to retrospectively validate this protocol to cohorts of critically ill patients from our hospital. DESIGN: We applied our hospital-adopted guidelines, which defined severe and major chronic conditions as those associated with a greater than 50% likelihood of 1- and 5-year mortality, respectively, to a critically ill patient population. We investigated mortality for the same intervals. SETTING: An urban safety-net hospital ICU. PATIENTS: All adults hospitalized during April of 2015 and April 2019 identified through a clinical database search. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 365 admitted patients, 15.89% had one or more defined chronic life-limiting conditions. These patients had higher 1-year (46.55% vs 13.68%; p < 0.01) and 5-year (50.00% vs 17.22%; p < 0.01) mortality rates than those without underlying conditions. Irrespective of classification of disease severity, patients with metastatic cancer, congestive heart failure, end-stage renal disease, and neurodegenerative disease had greater than 50% 1-year mortality, whereas patients with chronic lung disease and cirrhosis had less than 50% 1-year mortality. Observed 1- and 5-year mortality for cirrhosis, heart failure, and metastatic cancer were more variable when subdivided into severe and major categories. CONCLUSIONS: Patients with major and severe chronic medical conditions overall had 46.55% and 50.00% mortality at 1 and 5 years, respectively. However, mortality varied between conditions. Our findings appear to support a crisis standards protocol which focuses on acute illness severity and only considers underlying conditions carrying a greater than 50% predicted likelihood of 1-year mortality. Modifications to the chronic lung disease, congestive heart failure, and cirrhosis criteria should be refined if they are to be included in future models.

Central nervous system disease with JC virus infection in adults with congenital HIV.

OBJECTIVE: The aim of this study was to describe the natural history of individuals with congenital HIV who develop JC virus (JCV) infection of the central nervous system (CNS). METHODS: We retrospectively evaluated individuals with congenital HIV who met criteria for progressive multifocal leukoencephalopathy (PML) or JCV granule cell neuronopathy (JCV GCN) at three major healthcare centres in the northeast USA. Data on adherence to combined antiretroviral therapy (cART), neurologic symptoms, serum markers of immunity and HIV infection, cerebrospinal fluid (CSF) analyses, radiographic features, modified Rankin Scale (mRS) scores and survival were collected from the electronic medical record up to a censoring date of 1 August 2020. RESULTS: Among 10 adults with congenitally acquired HIV, nine were diagnosed with definitive PML and one was diagnosed with probable JCV GCN. Individuals presented at the time of their PML or JCV GCN diagnosis with a mean mRS of 2.0 (standard deviation 1.0). A premorbid mRS was documented for six patients and was zero in all cases. The most common risk factor was confirmed cART nonadherence in nine individuals. Five individuals with PML and one with JCV GCN died, with a latency from symptom onset to death of approximately 3 months for three individuals, and approximately 2 years for the remaining two. CONCLUSION: Youth-adulthood transition is a high-risk point for dropping off from medical care. The study of this timepoint in people living with HIV could help inform effective care in these individuals.

COVID-19 in patients with myasthenia gravis.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) has rapidly become a global pandemic, but little is known about its potential impact on patients with myasthenia gravis (MG). METHODS: We studied the clinical course of COVID-19 in five hospitalized patients with autoimmune MG (four with acetylcholine receptor antibodies, one with muscle-specific tyrosine kinase antibodies) between April 1, 2020-April 30-2020. RESULTS: Two patients required intubation for hypoxemic respiratory failure, whereas one required significant supplemental oxygen. One patient with previously stable MG had myasthenic exacerbation. One patient treated with tocilizumab for COVID-19 was successfully extubated. Two patients were treated for MG with intravenous immunoglobulin without thromboembolic complications. DISCUSSION: Our findings suggest that the clinical course and outcomes in patients with MG and COVID-19 are highly variable. Further large studies are needed to define best practices and determinants of outcomes in this unique population.

Possible N-methyl-D-aspartate receptor antibody-mediated encephalitis in the setting of HIV cerebrospinal fluid escape.

Discordant elevations of cerebrospinal fluid (CSF) human immunodeficiency virus (HIV) ribonucleic acid (RNA) in chronically treated patients known as 'CSF escape' may present as acute encephalitis. Infectious encephalitis caused by herpes simplex virus (HSV) and other neurotropic viruses have been identified as potential triggers of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. Autoantibody-mediated encephalitis has been infrequently reported in HIV infected patients and may mimic HIV encephalitis. We report two adults infected with HIV presenting with encephalopathy and seizures. Case 1 had a monophasic encephalopathy with detection of NMDAR antibodies in the context of HIV CSF escape. There was a clinical response to immunotherapy and anti-retroviral therapy adjustment. Case 2 initially presented in non-convulsive status epilepticus associated with HIV CSF escape. He responded to treatment with anti-epileptic drugs and anti-retroviral therapy alteration, but had two further neurological relapses. NMDAR antibodies were detected during the relapses and a clinical response was observed following treatment with immunotherapy. Clinicians should consider autoimmune encephalitis in HIV infected patients presenting with encephalopathy and seizures, particularly in cases with concomitant HIV CSF escape.

Neurological Complications of Endocarditis: A Multidisciplinary Review with Focus on Surgical Decision Making.

Infective endocarditis (IE) is a systemic disease with many potential neurologic manifestations including ischemic and hemorrhagic strokes, cerebral microbleeding, infectious intracranial aneurysms, meningitis, brain abscesses, and encephalopathy. The majority of left-sided (heart) IE patients have brain lesions that may alter management decisions, warranting the systematic use of magnetic resonance imaging. Many patients require surgical treatment of valvular disease, and central nervous system lesions weigh into decision making. Data regarding the timing of surgery are conflicting, but earlier surgery appears to be safe in most ischemic strokes, while ideally surgery should be delayed for 3 to 4 weeks in patients with hemorrhagic strokes. IE requires a multidisciplinary team to collaboratively care for the patient. In this article, we review the current understanding and management of the neurological complications of IE and their impact on the performance and timing of cardiac surgery.

Neurosurgical Infections.

Patients in the neurointensive care unit often undergo life-saving neurosurgical interventions that can be associated with serious complications. Infection is a common and sometimes fatal complication of such procedures. Infection may occur not only in the setting of major cranial and spinal surgery, but also with common minor procedures that utilize neurosurgical devices, such as placement of external ventricular drains, ventriculoperitoneal shunts, and deep brain stimulators. In this article, we review the epidemiology and microbiology of these infections, and discuss their general and procedure-specific risk factors and treatment options.

Recent Advances in the Acute Management of Intracerebral Hemorrhage.

Primary intracerebral hemorrhage (ICH) is a common, devastating disease that lacks an effective specific treatment. Mortality is high, functional outcomes are poor, and these have not substantially changed for decades. There is, therefore, considerable opportunity for advancement in the management of ICH. In recent years, a significant amount of research has begun to address this gap. This article is aimed at updating neurologists on the most clinically relevant contemporary research.

Recent Advances in the Acute Management of Intracerebral Hemorrhage.

Primary intracerebral hemorrhage (ICH) is a common, devastating disease that lacks an effective specific treatment. Mortality is high, functional outcomes are poor, and these have not substantially changed for decades. There is, therefore, considerable opportunity for advancement in the management of ICH. In recent years, a significant amount of research has begun to address this gap. This article is aimed at updating neurologists on the most clinically relevant contemporary research.