Case Report: First Successful Treatment of Acanthamoeba Brain Abscess with Combination Surgical Excision and Miltefosine-Led Antimicrobial Therapy.

Acanthamoeba brain abscess is very rare and most often fatal. There remains no standardized regimen for its management. We report a case in northern Australia of an immunosuppressed 57-year-old man who presented with diarrhea and weight loss, and was diagnosed with multiple Acanthamoeba brain abscesses after neurological deterioration. This case is the first successful treatment with surgical excision followed by combination antimicrobial therapy including miltefosine. This case was treated initially as nocardiosis or melioidosis, emphasizing the importance of considering differentials such as Acanthamoeba during workup of atypical infection. We present a literature review of the 14 Acanthamoeba brain abscess cases reported in the English literature, of which five were successfully treated. Our review shows a predilection for multiple brain abscesses and an increased mortality rate compared with the general brain abscess population.

Is cerebrospinal fluid shunting in idiopathic intracranial hypertension worthwhile? A 10-year review.

BACKGROUND: The role of cerebrospinal fluid (CSF) diversion in treating idiopathic intracranial hypertension (IIH) is disputed. METHOD: We conducted a 10-year, retrospective case note review to evaluate the effects of CSF diversion in IIH. Symptoms, signs and details of shunt type, complications and revisions were documented at baseline, 6, 12 and 24 months post-operatively. RESULTS: Fifty-three IIH patients were shunted [predominantly lumboperitoneal (92%)]. The most common symptom pre-surgery was headache (96%). Post-operatively, significantly fewer patients experienced declining vision and visual acuity improved at 6 (p = 0.001) and 12 months (p = 0.016). Headache continued in 68% at 6 months, 77% at 12 months and 79% at 2 years post-operatively. Additionally, post-operative low-pressure headache occurred in 28%. Shunt revision occurred in 51% of patients, with 30% requiring multiple revisions. CONCLUSION: We conclude that CSF diversion reduces visual decline and improves visual acuity. Unfortunately, headache remained in the majority of patients and low-pressure headache frequently complicated surgery. Over half of the patients required shunt revision with the majority of these requiring multiple revisions. We suggest that CSF shunting should be conducted as a last resort in those with otherwise untreatable, rapidly declining vision. Alternative treatments, such as weight reduction, may be more effective with less associated morbidity.

Melioidosis of the central nervous system; A potentially lethal impersonator.

A 57-year-old Australian woman, with a history of hazardous alcohol consumption, presented with a seizure following 2 days of fever and headache. Initial imaging suggested the presence of an isolated brain abscess, however, a thorough physical examination, identified no additional septic focus. Five sets of blood cultures were sterile and serology for Burkholderia pseudomallei was negative. Other investigations including computed tomography of her chest, abdomen and pelvis and a trans-esophageal echocardiogram were normal. Despite the administration of intravenous vancomycin, ceftriaxone, and metronidazole, her condition deteriorated. At emergency craniotomy, the abscess was drained and B. pseudomallei was cultured, confirming a diagnosis of melioidosis. She received 8 weeks of intravenous meropenem, combined with oral trimethoprim/sulfamethoxazole; the trimethoprim/sulfamethoxazole was continued for a total of 12 months. She recovered completely and was able to return to full-time work. Melioidosis, is endemic to Australia and South East Asia and, globally, is estimated to kill 89,000 every year. It can affect almost any organ, but up to 5% have central nervous system (CNS) involvement, where it may present as an encephalomyelitis, brain abscess or meningitis. B. pseudomallei is resistant to many commonly used antibiotics and even in well-resourced settings the case-fatality rate of CNS infection may rise to 50 %. This patient lived in a melioid-endemic region, and, with hazardous alcohol consumption, had a classical risk factor for the disease, but the sterile blood cultures and negative B. pseudomallei serology delayed definitive therapy. Despite the delayed diagnosis, definitive drainage and prolonged anti-bacterial therapy ensured a complete recovery.

Spontaneous Microguidewire Extrusion From the Foot Following Cerebral Aneurysm Treatment: First Case Report.

BACKGROUND AND IMPORTANCE: Microguidewire entrapment and failure related to endovascular therapy is a rare complication with limited case reports available, most of which are from cardiac endovascular intervention. Migration of the microguidewire has been reported in coronary intervention with some resulting in severe complications, but there are no reported cases of spontaneous extrusion of wire fragment following a neurointerventional procedure. We report the first case of a microguidewire entrapment with subsequent fracture, followed by spontaneous extrusion of the wire fragment. CLINICAL PRESENTATION: A 40-yr-old woman was admitted for an elective flow-diversion stent treatment of an unruptured paraophthalamic aneurysm. Microguidewire entrapment occurred during an attempted balloon-aided dilatation of the partially opened stent. Careful attempts failed to retrieve the wire; hence, the decision was made to leave it behind. She presented to her family doctor 6 mo later with spontaneous extrusion of a 60-cm fragment of the retained wire, from her heel ipsilateral to the femoral puncture site. This had not resulted in any further vascular or non-vascular complications. CONCLUSION: Fracture with extrusion is a potential consequence of a retained microguidewires. While this is an extremely rare complication, it is important to alert clinicians and patient about the possibility of wire migration and extrusion. Early follow-up with clinical assessment, and targeted imaging should lead to identification of this occurrence.

Benign fibrous histiocytoma of the thoracic spine: case report and review of the literature.

Benign fibrous histiocytoma (BFH) is a rare skeletal tumor, accounting for approximately 1% of all surgically managed benign bone tumors. Spinal location is very rare, and its management can be challenging, involving excision of tumor and spinal reconstruction and stabilization. The prognosis is good after treatment. The authors present the case of BFH involving the thoracic spine and a review of the literature concerning BFH of the spine.

Anterior clinoid mucocele--clinical presentation, investigations, and management by endoscopic excision: review of literature.

Mucoceles in the anterior clinoid location are exceptionally rare. They present with visual failure and are often misdiagnosed as unilateral optic neuritis. Early recognition with imaging studies and prompt surgical excision is the treatment of choice. Endoscopic surgery achieves this with the least surgical trauma and hospitalization. We report two cases of anterior clinoid mucocele that were treated successfully by endoscopic surgery and also review its management.