First report of Bickerstaff's brainstem encephalitis caused by Salmonella Dublin: a case report.

BACKGROUND: Diseases caused by nontyphoid Salmonella can range from mild, to self-limiting gastroenteritis and severe invasive infection. Relatively rarely, Salmonella may cause severe encephalopathy. CASE PRESENTATION: We report a suspected case of Bickerstaff's brainstem encephalitis caused by Salmonella Dublin. A young man presented with impaired consciousness, ataxia, dysarthria, limb weakness, and restricted eyeball abduction. His clinical symptoms were consistent with Bickerstaff's brainstem encephalitis. CONCLUSIONS: This is the first case report of Bickerstaff's brainstem encephalitis caused by Salmonella Dublin in the literature. After treatment, he recovered and was discharged. Early antibiotic treatment of sepsis may control the disease and avoid serious encephalopathy.

Burkholderia pseudomallei Rapidly Infects the Brain Stem and Spinal Cord via the Trigeminal Nerve after Intranasal Inoculation.

Infection with Burkholderia pseudomallei causes melioidosis, a disease with a high mortality rate (20% in Australia and 40% in Southeast Asia). Neurological melioidosis is particularly prevalent in northern Australian patients and involves brain stem infection, which can progress to the spinal cord; however, the route by which the bacteria invade the central nervous system (CNS) is unknown. We have previously demonstrated that B. pseudomallei can infect the olfactory and trigeminal nerves within the nasal cavity following intranasal inoculation. As the trigeminal nerve projects into the brain stem, we investigated whether the bacteria could continue along this nerve to penetrate the CNS. After intranasal inoculation of mice, B. pseudomallei caused low-level localized infection within the nasal cavity epithelium, prior to invasion of the trigeminal nerve in small numbers. B. pseudomallei rapidly invaded the trigeminal nerve and crossed the astrocytic barrier to enter the brain stem within 24 h and then rapidly progressed over 2,000 µm into the spinal cord. To rule out that the bacteria used a hematogenous route, we used a capsule-deficient mutant of B. pseudomallei that does not survive in the blood and found that it also entered the CNS via the trigeminal nerve. This suggests that the primary route of entry is via the nerves that innervate the nasal cavity. We found that actin-mediated motility could facilitate initial infection of the olfactory epithelium. Thus, we have demonstrated that B. pseudomallei can rapidly infect the brain and spinal cord via the trigeminal nerve branches that innervate the nasal cavity.

Multisystemic Listeriosis in a Common Brushtail Possum (Trichosurus vulpecula) and Two Common Ringtail Possums (Pseudocheirus peregrinus).

A single free-ranging common brushtail possum (Trichosurus vulpecula) and 2 captive sibling common ringtail possums (Pseudocheirus peregrinus)from a zoological facility in Sydney, Australia, were diagnosed with multisystemic listeriosis. The brushtail was found dead in an animal enclosure while the ringtails presented with signs of cardiovascular collapse and died shortly thereafter. All 3 animals were culture positive forListeria monocytogenesand demonstrated focal suppurative lesions within the brainstem in addition to fulminant disease in other areas of the thorax and/or abdomen. Listeriosis in phalangeriformes species has rarely been reported, and brainstem lesions have not previously been described. It is speculated that access to the brainstem by the organism may have occurred hematogenously or via retrograde migration along cranial nerves. Sources of infection and the possibility of transmission between animals are also discussed.

Misdiagnosed murine typhus in a patient with multiple cerebral infarctions and hemorrhage: a case report.

BACKGROUND: Rickettsias cause a wide spectrum of tick-, flea-, or mite-borne infections. Rickettsial infections have no classical manifestations and can often lead to encephalitis, which can be fatal if improperly diagnosed. CASE PRESENTATION: A 74-year-old male farmer was admitted to the hospital with fevers and a headache that had lasted for 10 days, followed by 4 days of unconsciousness, and his condition continued to deteriorate. Images showed multiple acute lesions in the brain stem, and bilateral cerebral and cerebellar hemispheres. He was finally diagnosed with endemic typhus and treated with antibiotics that resulted in improvement. CONCLUSION: The present report describes a patient with a rickettsial infection and subsequent deterioration to coma because of an initial misdiagnosis. Because of the similarity to other infectious diseases, physicians should be more vigilant towards the history and radiologic results to ensure early detection and avoid complications which may prove to be fatal.

Listerial brainstem encephalitis--treatable, but easily missed.

Listerial brainstem encephalitis (LBE) is an uncommon form of listerial central nervous system infection that progresses rapidly and is invariably fatal unless detected and treated early. We report on six adult patients with LBE, of whom five were managed or co-managed by our unit during the period January - June 2012. All presented with a short prodromal illness followed by a combination of brainstem signs, including multiple cranial nerve palsies with emphasis on the lower cranial nerves, ataxia, motor and sensory long-tract signs, a depressed level of consciousness and apnoea. In two cases the diagnosis was delayed with adverse outcomes. LBE may be difficult to diagnose: clinicians may not be aware of this condition, the brainstem location may not be recognised readily, general markers of inflammation such as the erythrocyte sedimentation rate, C-reactive protein level or white cell count may be normal, and the cerebrospinal fluid is typically normal or there are only mild and nonspecific findings. Serological tests are unreliable, and diagnosis is achieved through blood cultures, magnetic resonance imaging and clinical recognition.

Molecular characterization of encephalitic bovine listeriosis from southern Brazil.

Reports of bovine listeriosis in Brazil are uncommon, being restricted to citations within retrospective studies, resulting in scarce documented information of this important disease of cattle. This manuscript describes the molecular findings associated with spontaneous encephalitic listeriosis in two steers from distinct herds within the state of Paraná, southern Brazil. Both animals demonstrated altered consciousness suggestive of brain stem dysfunctions and died a few days after the initial onset of disease. Polymerase chain reaction (PCR) assays were designed to target specific genes of infectious neurological agents of cattle. These included bovine herpesvirus 1 and 5 (BoHV-1 and BoHV-5), ovine herpesvirus 2 (OvHV-2), Listeria monocytogenes, and Histophilus somni. Rabies virus was discarded in evaluations done at the official state diagnostic laboratory. Gross alterations were insignificant; histopathology demonstrated rhombencephalitis associated with macrophage-predominant, multifocal to coalescing microabscesses and extensive perivascular cuffings in both steers. The L. monocytogenes PCR assay amplified the 172-bp amplicon of the listeriolysin gene from the brain stem of both animals and from the telencephalon, thalamus, and cerebellum of one of them. Phylogenetic analyses demonstrated that the strains derived from this study clustered with known strains of L. monocytogenes lineage I. The BoHV-1 and BoHV-5, OvHV-2, and H. somni PCR assays were negative. These results confirm the participation of L. monocytogenes lineage I in the etiopathogenesis of the neurological disease herein described and represent the first complete description of encephalitic listeriosis in cattle from Brazil.

Successful treatment of brainstem blastomycosis with fluconazole.

The lipid formulation of amphotericin B is the initial drug of choice for central nervous system blastomycosis, but it is costly and associated with significant toxicity. This case report details a patient with primary pulmonary blastomycosis with dissemination to the skin, one joint, and the brainstem that was successfully treated solely with high-dose fluconazole.

Efficacy of alertness training in a case of brainstem encephalitis: clinical and theoretical implications.

Although attention functions are often impaired after stroke, traumatic brain injury or inflammatory diseases, little is known about the time course and the long-term efficacy of training-induced improvement. The present single case study evaluates the time course and longitudinal stability of attention improvement after alertness training by repeatedly testing the subject between individual training sessions as well as one and seven months after the end of the training. The outpatient (M.P.) trained developed severe alertness deficits following brainstem encephalitis in 2003 without signs of cortical damage, and since then had not achieved full recovery. In 2008, M.P. participated in 15 treatment sessions on 15 separate working days over a period of three weeks. In each session a 45-minute alertness training task was administered, using the CogniPlus ALERT computer training program. Attention performance was assessed by neuropsychological tests four years, one year, and immediately before the therapy after every third training session and three times after the termination of therapy. Furthermore, a self-report questionnaire measured subjective experience of attention in everyday life situations. In order to compare the performance between training sessions, a procedure specialised for psychometric single-case diagnosis was used to analyse the data. Surprisingly, even after three consecutive training sessions, M.P. showed immense improvement in alertness. Furthermore, after two weeks she felt more energetic and more able to concentrate. Six months after the end of the training the improvement remained stable. The unexpectedly fast time course of recovery induced by the training, as well as the stable long-term effects, probably depend on intact cortical structures. In M.P. it appeared that top-down control of the alertness network on impaired brainstem arousal structures had been re-activated by the training procedure and had remained stable across a long time period.

Brainstem abscess caused by Haemophilus influenza and Peptostreptococcus species.

We present a patient with a solitary brainstem abscess caused by Haemophilus influenza type b (Hib) and Peptostreptococcus species. This is the first report of a Hib brainstem abscess in the English literature. Hib has been mainly associated with respiratory or nasal infections, and a few cases of intracerebral abscesses, but no brainstem abscesses have been described. The literature on solitary brainstem abscesses was reviewed and an overview of the literature between January 1984 and May 2009 is presented.

Nervous signs associated with otitis and cranial osteomyelitis and with Ornithobacterium rhinotracheale infection in red-legged partridges (Alectoris rufa).

A case of nervous signs in red-legged partridges (Alectoris rufa) associated with a severe otitis and osteomyelitis is reported. The outbreak was characterized by abnormal head position, torticollis and difficulty in standing, walking and flying. Pathological, microbiological and molecular genetic data supported an association with Ornithobacterium rhinotracheale (ORT) infection. Clinical signs persisted for several days and were accompanied by weight loss leading to death. Morbidity was approximately 20% and most birds died if untreated. Lesions were mainly characterized by a severe osteomyelitis of the cranial bones and purulent inflammation of the external, middle and inner ears. O. rhinotracheale was isolated from ear samples, skull and brain stem in pure culture. Genetic characterization by pulsed-field gel electrophoresis of the clinical isolates showed that the outbreak was caused by a single strain of ORT. This appears to be the first report of otitis associated with ORT in an avian species.

Fulminant septicemia of Bacillus cereus resistant to carbapenem in a patient with biphenotypic acute leukemia.

We report a case of fulminant septicemia with Bacillus cereus resistant to carbapenem. A 33-year-old man was suffering from febrile neutropenia (FN) on day 15 after the start of remission-induction therapy for biphenotypic acute leukemia under gut decontamination with polymyxin B and nystatin. Meropenem, a carbapenem, was administered according to the guideline for FN. Two days later (on day 17), he complained of severe abdominal pain, lost consciousness, went into sudden cardiopulmonary arrest, and died. Autopsy showed multiple spots of hemorrhage and necrosis caused by bacterial plaque in the brain, lungs, and liver. B. cereus was isolated from a blood sample obtained in the morning on day 17 and it was after his death that the isolated B. cereus was revealed to be resistant to carbapenem. B. cereus obtained from blood samples has been reported to be usually sensitive to carbapenem and also to vancomycin, new quinolones, and clindamycin. If B. cereus resistant to carbapem increases, our method of gut decontamination with polymyxin B and nystatin may have to be changed to one containing a new quinolone for the prevention of septicemia. Careful watching to determine whether B. cereus resistant to carbapem increases may be also important for empiric therapy, because carbapenem is often selected as the initial therapy for FN in patients with severe neutropenia.

Infected intraparenchymal dermoids: an underestimated entity.

Infection secondary to a dermal sinus most commonly occurs in the form of cutaneous, epidural, or subdural abscesses. Rarely, it can result in an intramedullary abscess as a result of a dermal sinus. This study presents a clinicoradiological profile of 19 cases harboring abscesses within the dermoids and highlights the importance of dermal sinus acting as a pathway for infections to enter the nervous system. Emergent exploration, pus drainage, and minimal abscess wall excision along with prolonged antibiotic administration remained the management of choice in all cases. Methicillin-sensitive Staphylococcus aureus was the commonest offending organism. In all, 7 patients recovered to normal neurological status, 5 showed no improvement, and 7 improved partially. Improvement in motor power was noted, albeit partially, but bladder functions failed to recover even at long-term follow-up. Even when such infective complications of dermal sinuses are rare, these are potentially serious and disabling.

Fatal immune reconstitution inflammatory syndrome with human immunodeficiency virus infection and Candida meningitis: case report and review of the literature.

Immune reconstitution inflammatory syndrome (IRIS) is an increasingly recognized phenomenon of paradoxical worsening of patients with acquired immunodeficiency syndrome (AIDS) upon initiation of highly active antiretroviral therapy (HAART). To date, there have been limited reports of IRIS in the central nervous system (CNS). Here, the authors describe a 43-year-old man with AIDS who presented with subacute meningitis. No pathogenic organism was identified by routine diagnostic tests, and he was treated empirically with an antituberculous regimen and initiated on HAART therapy. Soon after, he had a precipitous neurologic decline leading to his death. Postmortem evaluation showed a basilar Candida meningitis as well as vasculitis characterized by CD8+ T-cell infiltration, consistent with IRIS. The authors discuss the challenges in diagnosing fungal meningitides and the risks of initiating HAART therapy in those with possible undiagnosed underlying opportunistic infections. Additionally, the authors review the literature regarding CNS IRIS.