Murine typhus presenting with status epilepticus.

Patients with rickettsial infection usually present with a febrile illness, headache, arthromyalgia and various biochemical abnormalities. Neurologic involvement is rare in murine typhus. Here, we report a case of a patient who presented with status epilepticus secondary to Rickettsia typhi infection.

Case Report: Fulminant Murine Typhus Presenting with Status Epilepticus and Multi-Organ Failure: an Autopsy Case and a Review of the Neurologic Presentations of Murine Typhus.

Murine typhus (MT) is an important cause of febrile illness in endemic areas, and there is an epidemiologic resurgence of this infection currently transpiring in Texas and California. Fatal cases and severe neurological complications are rare. A fatal case of MT in a middle-aged man is reported with a course culminating in multi-organ failure and refractory status epilepticus. An autopsy revealed hemorrhagic pneumonia, acute tubular necrosis, and ischemic necrosis in the liver, adrenals, and brain. We have also reviewed the neurologic complications of MT.

Mild Lung Tuberculosis in a Patient Suffering from Status Epilepticus Caused by the Syndrome of Inappropriate Secretion of Antidiuretic Hormone (SIADH).

A 76-year-old woman was diagnosed with lung tuberculosis. On the second day of anti-tuberculosis treatment, she became unconscious and developed status epilepticus accompanied by hyponatremia. The hyponatremia was caused by the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Detailed examinations revealed that the patient's status epilepticus had occurred due to hyponatremia, which was caused by lung tuberculosis-associated SIADH. Previous case reports noted that patients with tuberculosis-associated SIADH showed mild clinical manifestations. They also reported that extensive lung involvement was associated with SIADH development. We herein report a rare case of SIADH complicated with status epilepticus that was caused by tuberculosis with mild lung involvement.

Status epilepticus in scrub typhus.

Scrub typhus is an emerging infection, and there is little information about status epilepticus (SE) in scrub typhus. We report the clinical spectrum and outcome of SE in scrub typhus. In a 3-year prospective hospital-based observational study, all scrub typhus patients with SE were included. Scrub typhus was diagnosed by immunochromatography assay. SE was defined if convulsions lasted longer than 5 min. The patients' demographic, clinical, computed tomography (CT), magnetic resonance imaging (MRI), and electroencephalography (EEG) findings were noted. Response to antiepileptic drugs (AEDs) and outcome at 1 month and 1 year were recorded. Between 2012 and 2014, there were 66 patients with scrub typhus admitted with central nervous system (CNS) involvement, 10 (15.2%) of whom had SE (generalized convulsions in 5, secondary generalized in one). The median age of the patients was 34 (range 18-71) years and seven were female. The duration of SE ranged between 10 min and 48 h. SE responded to one AED in five patients, two AEDs in three patients, and more than two AEDs in two patients. Cranial MRI findings were normal. All patients recovered completely with doxycycline by 1 month and AED was withdrawn by 8 months in all. Although 15% patients with scrub typhus may have SE, they have good outcome.

What is hiding behind bubbles of air? An unusual Streptococcus pyogenes meningitis.

Streptococcus pyogenes is a rare but aggressive cause of meningitis, which often evolves in a poor outcome with fatal consequences. Although lumbar puncture and CT scan of the brain are the gold standard of diagnosis of cerebral infections, they can have some limitations. We report and describe the clinical history and neuroimaging of a 36-year-old woman admitted to the emergency department of our hospital three days after the onset of earache and otorrhoea. When the patient developed an emergent refractory status epilepticus, the CT scan of the brain showed an unusual pneumocephalus. However, the MRI study of the brain revealed a pachymeningitis with partial thrombosis of the right transverse sinus and subdural empyema due to a S. pyogenes otitis media. Prompt diagnosis and the specific findings of the MRI allowed rapid correct treatment and thus led to a good outcome for the patient.

Acute phase proteins and white blood cell levels for prediction of infectious complications in status epilepticus.

INTRODUCTION: Infections in status epilepticus (SE) patients result in severe morbidity making early diagnosis crucial. As SE may lead to inflammatory reaction, the value of acute phase proteins and white blood cells (WBC) for diagnosis of infections during SE may be important. We examined the reliability of C-reactive protein (CRP), procalcitonin (PCT), and WBC for diagnosis of infections during SE. METHODS: All consecutive SE patients treated in the ICU from 2005 to 2009 were included. Clinical and microbiological records, and measurements of CRP and WBC during SE were analyzed. Subgroup analysis was performed for additional PCT measurements in the first 48 hours of SE. RESULTS: A total of 22.5% of 160 consecutive SE patients had infections during SE. Single levels of CRP and WBC had no association with the presence of infections. Their linear changes over the first three days after SE onset were significantly associated with the presence of infections (P = 0.0012 for CRP, P = 0.0137 for WBC). Levels of PCT were available for 31 patients and did not differ significantly in patients with and without infections. Sensitivity of PCT and CRP was high (94% and 83%) and the negative predictive value of CRP increased over the first three days to 97%. Specificity was low, without improvement for different cut-offs. CONCLUSIONS: Single levels of CRP and WBC are not reliable for diagnosis of infections during SE, while their linear changes over time significantly correlate with the presence of infections. In addition, low levels of CRP and PCT rule out hospital-acquired infections in SE patients.

A rare case of neonatal sepsis/meningitis caused by Pasteurella multocida complicated with status epilepticus and focal cerebritis.

Pasteurella multocida is normally present in respiratory and digestive tract of many domestic and wild animals, but is a rare pathogen in neonatal infection. Here we describe for the first time a case of meningitis complicated by status epilepticus and right parietal lobe cerebritis. The patient showed a dramatic clinical onset characterized by septic appearance and prolonged seizures. Multidrug anticonvulsivant therapy was used to control the status epilepticus, but despite the aggressive treatment electrical crises were still evident 24 hours after the admission. Furthermore, a brain MRI, performed to investigate a persistent intermittent fever even if CSF became sterile, showed a focus cerebritis in the right parietal lobe, early stage of the cerebral abscess. Prolonged antibiotic therapy with steroids was requested to solve the cerebritis area. Interestingly, direct contact between the patient and domestic animals was denied by the family, but the father reported a contact with a rooster, killed and cooked few days before, suggesting, as previously described, that Pasteurella may also be transmitted through asymptomatic human carrier. The patient had a favourable outcome with no medium-term sequelae one month after discharge, but the severity of the clinical course and the unpredictable way of transmission highlight the importance of hygiene measures approaching infants.

Subdural collections due to non-typhi Salmonella infections in two Malaysian children.

Subdural collections caused by Salmonella infection are rarely encountered in children. We present two cases caused by non-typhi Salmonella, one a four-and-a-half-month-old boy presenting with subdural effusion, and the other, a 16-month-old boy with empyema. The diagnosis was confirmed on blood and subdural pus cultures. One patient had status epilepticus following focal fit, and the other had prolonged fever without any localising signs of infection on admission. They responded well to prompt surgical drainage and prolonged systemic antibiotic therapy. Contrary to previous reports, both patients showed favourable outcome in terms of neurological sequelae.

Cerebral malaria owing to Plasmodium vivax: case report.

Cerebral malaria is a diffuse encephalopathy associated with seizures and status epilepticus which can occur in up to one-third of children with severe malaria, particularly that caused by Plasmodium falciparum. We report a unique case of P. vivax infection complicated by status epilepticus. A 4-year-old boy was admitted to the emergency outpatient clinic with intractable seizures for the previous hour. During resuscitation, two episodes of left-focal tonic convulsions occurred and he received phenytoin. Because of a history of P. vivax infection in the family 3 months previously, a blood slide for malaria was undertaken. Thin blood smears demonstrated P. vivax. He was treated with chloroquine and primaquine. An initial EEG was normal but after 3 months of follow-up a second EEG showed generalised epileptic activity. Rarely, cerebral malaria is a presenting complication or occurs during the course of P. vivax infection. In endemic areas such as Turkey, the possibility of cerebral malaria should be considered.

Focal status epilepticus as the first manifestation of paracoccidioidomycosis.

We report a 56-year old man with prolonged focal motor status epilepticus as the first clinical manifestation of paracoccidioidomycosis (PCM) and discuss this unusual presentation. We emphasize the need for a comprehensive work-up and increased awareness for central nervous system involvement in PCM, particularly in endemic areas.

Meningitis is a common cause of convulsive status epilepticus with fever.

AIMS: In children with convulsive status epilepticus (CSE) with fever, to determine the likelihood of acute bacterial meningitis (ABM), the proportion that are treated with antibiotics, and the proportion that have diagnostic CSF sampling. METHODS: Patients with an incident episode of CSE with fever were identified as part of an ongoing prospective population based study of CSE in childhood. RESULTS: There were 49 incident cases of CSE in the first six months. Ascertainment was 96%. Twenty four had CSE with fever, 16 had early parenteral antibiotics, nine had diagnostic CSF sampling, and four had ABM. The population risk of ABM in CSE with fever was significantly higher than that of short seizures with fever (17% v 1.2%). CONCLUSIONS: The classical symptoms and signs of ABM may be absent in CSE with fever. A high index of suspicion for ABM in the child with CSE with fever is paramount. The most appropriate management is suggested to be early parenteral antibiotics and a lumbar puncture when there are no contraindications.

Severe encephalopathy in a child: an uncommon cause.

Cat scratch disease (CSD) is usually a self-limited disease. Although extremely uncommon, the involvement of the central nervous system has been previously reported in CSD. The intention of this paper is to make physicians aware that CSD could be complicated by encephalopathy. Seizures in some patients could be the only clinical manifestation and are resistant to the common anti-epileptic therapy. The seizures resolve with supportive care.