Staphylococcus-induced proliferative glomerulonephritis and cerebral hemorrhage - fatal complications in a young female with postpartum cardiomyopathy and an implanted left ventricular assist device: a case report and review of the literature.

Background: The continuous-flow left ventricular assist device (CF-LVAD) is used to save the lives of patients in the final stage of congestive heart failure, replacing the pump function of the left ventricle. Although quality of life increases significantly, CF-LVAD-related complications might prove fatal, as in the case presented in this paper.Methods: A 20-year-old female, during her second pregnancy, presented with signs of heart failure. Emergency caesarean section was necessary to save the baby, but peripartum cardiomyopathy developed in the mother. The use of an implantable cardioverter-defibrillator (ICD) was necessary 5 years later. As the clinical progression was unfavorable under medical treatment, with the patient reaching INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) Profile 1 (refractory cardiogenic shock), the treatment of choice was the implantation of a CF-LVAD.Results: After 3 years of follow-up (at the age of 28), the patient presented with a positive hemoculture for Staphylococcus aureus. Prolonged antibiotic therapy and attentive follow-up was prescribed. Although an effective antiplatelet and anticoagulant treatment was applied, and despite therapeutic values of prothrombin time and international normalized ratio (INR), the patient died as result of a fatal cerebral hemorrhage. The autopsy also revealed septic emboli, disseminated intravascular coagulation, and focal proliferative glomerulonephritis.Conclusions: Although the benefits of CF-LVAD are significant, bleeding episodes can be severe and LVAD-associated infection can trigger glomerular injury and increase mortality.

Cerebral Paragonimiasis With Hemorrhagic Stroke in a Developed Country.

Paragonimiasis is a food-borne parasitic disease caused by Paragonimus lung flukes, which are epidemic in Asia. Cerebral paragonimiasis accounts for <1% of symptomatic paragonimiasis but is the most common extrapulmonary infection. Cerebral paragonimiasis often mimics stroke and sometimes causes severe neurological sequelae. A 61-year-old woman was admitted to the hospital for severe headache. A head computed tomography scan revealed intracerebral hemorrhage with subarachnoid hemorrhage. The patient also had lesions in the lungs. She frequently ate Japanese mitten crab. Peripheral blood examination results of increased eosinophilia and immunological testing results confirmed the diagnosis of Paragonimus westermani infection. The patient was successfully treated with praziquantel as the first-line agent. Cerebral paragonimiasis is currently rare in developed countries; however, it is an important disease to consider.

Disseminated echinococcosis: follow your heart.

: In this report, we present a rare case of cardiac echinococcosis presenting with cerebral haemorrhage due to rupture of a mycotic aneurysm in a peripheral branch of the media cerebral artery. Further investigations lead to discovery of multiple cysts in the heart and liver. The complementary use of transthoracic and transoesophageal echocardiography, MRI and computed tomography lead to the final diagnosis of disseminated echinococcosis and allowed precise evaluation of the anatomical and structural characteristics of the cardiac mass, its boundaries and its relationship with the surrounding anatomic structures.

Malaria retinopathy and cerebellitis in a 9-year-old boy in the United States.

Malarial retinopathy is characterized by retinal whitening, vessel change, and hemorrhages usually associated with a white center. We present the case of a 9-year-old boy who presented with a systemic Plasmodium falciparum infection, hemorrhagic cerebellitis and malarial retinopathy characterized by "fire flare" hemorrhages (scleral icterus with subconjunctival hemorrhages), Roth spot-like hemorrhages, and subhyaloid hemorrhage. To our knowledge, this is the first reported case of hemorrhagic cerebellitis secondary to P. falciparum infection in the United States.

Intracerebral bleed, right haemiparesis and seizures: an atypical presentation of vivax malaria.

Falciparum malaria is notoriously known to produce life-threatening complications. Despite growing reports of chloroquine resistance and severe disease, vivax malaria continues to be viewed as a benign disease. We report a rare case of a 47-year-old healthy man from a malaria-endemic region, presenting with intracerebral bleed, right haemiparesis, aphasia and seizures following vivax malaria. This was successfully managed conservatively, without any neurosurgical intervention, with combination therapy of intravenous artesunate, oral hydroxychloquine and primaquine. In a country where Plasmodium vivax is responsible for majority of cases of malaria, it is high time the national malaria control programmes focus on the elimination of P. vivax in addition to its more dangerous counterpart, P. falciparum.

The novel ETA receptor antagonist HJP-272 prevents cerebral microvascular hemorrhage in cerebral malaria and synergistically improves survival in combination with an artemisinin derivative.

AIM: To investigate the association between vasculopathy and survival during experimental cerebral malaria (ECM), and to determine whether targeting the endothelin-1 (ET-1) pathway alone or in combination with the anti-malaria drug artemether (a semi-synthetic derivative of artemisinin) will improve microvascular hemorrhage and survival. MAIN METHODS: C57BL/6 mice infected with Plasmodium berghei ANKA (PbA) were randomly assigned to four groups: no treatment, artemether treated, ET(A) receptor antagonist (HJP-272) treated, or HJP-272 and artemether treated. The uninfected control mice were treated with HJP-272 and artemether. We analyzed survival, cerebral hemorrhage, weight change, blood glucose levels and parasitemia. KEY FINDINGS: Our studies demonstrated decreased brain hemorrhage in PbA-infected (ECM) mice treated when HJP-272, a 1,3,6-trisubstituted-2-carboxy-quinol-4-one novel ET(A) receptor antagonist synthesized by our group, is used in conjunction with artemether, an anti-malarial agent. In addition, despite adversely affecting parasitemia and weight in non-artemether treated infected mice, HJP-272, seemed to confer some survival benefit when used as adjunctive therapy, though this did not reach significance. SIGNIFICANCE: Previous studies demonstrate that the endothelin pathway is associated with vasculopathy, neuronal injury and inflammation in ECM. As demonstrated here, components of the ET-1 pathway may be important targets for adjunctive therapy in ECM, and may help in preventing hemorrhage and in improving survival when used as adjunctive therapy during malaria infection. The data presented suggest that our novel agent, HJP-272, may ameliorate alterations in the vasculature which can potentially lead to inflammation, neurological dysfunction, and subsequent death in mice with ECM.

[Toxocara canis cerebral vasculitis revealed by iterative strokes]. / Vascularite cérébrale àToxocara canis révélée par des AVC itératifs.

INTRODUCTION: Cerebral vasculitis is a rare and severe condition, posing problems for diagnosis and treatment. Toxocara canis cerebral vasculitis is exceptionally rare, with only 4 cases having been reported. We report an additional case revealed by iterative strokes. OBSERVATION: A 49-years-old Laotian man presented with right ACA infarction associated with contrast enhancement of cerebrospinal fluid, and multiple segmental stenoses in small and medium caliber encephalic arteries, in a context of hypereosinophilia and chronic headaches. Laboratory tests showed lymphocytic meningitis and T. canis antibody IgE in the blood and CSF. The diagnosis of T. canis cerebral vasculitis was retained. During follow-up, the patient presented again with left pontine hemorrhagic stroke. Conventional cerebral angiography confirmed progression of vasculitis despite treatment. CONCLUSION: This case-report illustrates the diagnostic and therapeutic difficulties associated with vasculitis.

Immunoblot diagnostic test for neurognathostomiasis.

Neurognathostomiasis is a rare but severe form of human gnathostomiasis. Diagnosis of neurognathostomiasis is made presumably by using clinical manifestations. Serologic tests for neurognathostomiasis are not widely available and limited. We studied 12 patients with diagnoses of neurognathostomiasis at Srinagarind Hospital, Khon Kaen University, Thailand. There were three types of neurognathostomiasis (five patients with intracerebral hemorrhage, one patient with subarachnoid hemorrhage, and six patients with myelitis). All patients were tested for antibodies against Gnathostoma spinigerum by an immunoblotting technique. The sensitivity and specificity of the 21-kD and 24-kD diagnostic bands were 83.3% and 100%, and 91.7% and 100%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value for the 21-kD and 24-kD diagnostic bands were all 100%. Both diagnostic bands are a helpful diagnostic tool for neuro gnathostomiasis and show good diagnostic properties.

Disseminated angiostrongylosis with fatal cerebral haemorrhages in two dogs in Germany: a clinical case study.

Canine angiostrongylosis is a nematode infection in domestic dogs and wild carnivores. Few single case reports describing the occurrence of this disease in Germany exist and until recently angiostrongylosis has not been considered endemic in this country. The present report focuses on clinical, pathological and parasitological findings in two cases of fatal disseminated canine angiostrongylosis associated with multifocal haemorrhages in the central nervous system. Both animals, which lived in Germany, presented with rapidly progressive neurological signs including depression, ataxia, unilateral central blindness and epileptic seizures. Blood work revealed grossly elevated D-dimers and mild thrombocytopenia. Both animals were subsequently euthanised due to progressive clinical aggravation. Necropsy showed cerebral and lung haemorrhages in both animals. Multiple sections of nematode larvae consistent with Angiostrongylus vasorum were identified on histopathological sections of the brain, heart, kidney and lung in both animals and a predominantly granulomatous inflammation with the occurrence of multinucleated giant cells was observed. Adult nematodes were found in the larger lung arteries of one dog and Angiostrongylus infection was subsequently confirmed by PCR-analysis and sequencing in both dogs. A. vasorum larvae were not detected by faecal Baermann examination performed in one of the dogs. It was concluded that canine angiostrongylosis should be considered as differential diagnosis in dogs in Germany, even if faecal examination is negative. There is currently still a lack of studies investigating the occurrence of angiostrongylosis in dogs and intermediate hosts in Germany which would be necessary to survey the endemic realities of this disease.

A case of ectopic parasitism: Fasciola hepatica larvae burrow through a human brain and mimic cerebral aneurysm.

An 8-year-old boy from Xuan-Han County, Sichuan Province, China presented with 6 months headache, nausea and vomiting. A computed tomography scan revealed multiple cerebral hemorrhages. Etiology of the cerebral hemorrhages was investigated by digital subtraction angiography, and cerebral aneurysm was entertained. Twenty-six days after his admission to the hospital, a flatworm emerged from the right eye of the patient. The worm was identified as Fasciola hepatica, based on the morphological characteristics of the worm.

MRI features of pediatric cerebral paragonimiasis in the active stage.

We retrospectively reviewed the MR images of the brains of six children (age = 5-13 years) who had cerebral paragonimiasis in the early active stage. Diagnosis was based on a positive antibody test enzyme-linked immunosorbent assay (ELISA) for paragonimiasis in serum. The most common finding (in five patients) was irregular hemorrhage of various degrees. Moreover, in three cases some multiple irregular lesions with surrounding edema appeared to be conglomerated and aggregated. The rare appearance (in one patient) was a "tunnel sign," which showed the migrating track of the adult worm. In one patient with abscess and minimal hemorrhage, diffusion-weighted imaging (DWI) showed a heterogeneous high signal of lesions. Other findings included slight (one patient) or marked (one patient) irregular contrast enhancement, and large edematous areas surrounding small centers of hemorrhage (two patients). MR findings of conglomerated lesions with hemorrhage or tunnel sign may help to establish the diagnosis of active-stage cerebral paragonimiasis.

Correlation of retinal haemorrhages with brain haemorrhages in children dying of cerebral malaria in Malawi.

Retinal haemorrhages increase in number with severity of Plasmodium falciparum malaria and occur in 35-40% of children with cerebral malaria. We performed clinical retinal examinations and histopathological examinations of retina, and parietal and cerebellar sections of the brains, in 33 children in Malawi who died with cerebral malaria, severe malaria anaemia, or coma of other causes. Haemorrhages were counted in a standardized fashion: the Spearman correlation coefficient between the number of haemorrhages in retina and brain was 0.741 for parietal tissue and 0.703 for cerebellar (P < 0.01 for both). Severity of haemorrhage in the retina correlates well with that in the brain. Retinal examination in cerebral malaria is a useful tool in predicting some of the pathophysiological processes occurring in the brain.

Interhemispheric transfer of visual motion information after a posterior callosal lesion: a neuropsychological and fMRI study.

Interhemispheric transfer of visual information was investigated behaviourally and with functional magnetic resonance imaging (fMRI) 6 months after a lesion of the posterior two-thirds of the corpus callosum. On tachistoscopical left hemifield presentation, the patient was severely impaired in reading letters, words and geographical names and moderately impaired in naming pictures and colours. In contrast, interhemispheric transfer of visual motion information, tested by verbal report of the direction of short sequences of coherent dot motion presented within the left hemifield, was preserved. The pattern of cerebral activation elicited by apparent motion stimuli was studied with fMRI and compared to that of normal subjects. In normal subjects, apparent motion stimuli, as compared to darkness, activated strongly striate and extrastriate cortex. When presented to one hemifield only, the contralateral calcarine region was activated while regions on the occipital convexity, including putative area V5, were activated bilaterally. A similar activation pattern was found in the patient with a posterior callosal lesion; unilateral left or right hemifield stimulation was accompanied by activation in the contralateral and ipsilateral occipital convexity. Ipsilateral hemifield representation in the extrastriate visual cortex is believed to depend on callosal input. Our observation suggests that this is not the case for visual motion representation and that other, probably parallel, pathways may mediate visual motion transfer after posterior callosotomy.

[Human pathology caused by free-living amoebae]. / Patologia umana da amebe a vita libera.

Naegleria fowleri, Acanthamoeba spp. and Balamuthia mandrillaris are free-living amoebae that occasionally may induce pathology in human beings. CNS disease due to N. fowleri, called "primary" amoebic meningoencephalitis, is acquired after exposure to polluted waters in swimming pools, rivers, and lakes. The clinical course is acute, often fulminant and characterized pathologically by necrotizing hemorrhagic meningoencephalitis, involving mainly the base of the brain, brainstem and cerebellum. In contrast, some Acanthamoeba spp. and B. mandrillaris cause opportunistic, chronic "granulomatous" encephalitis in subjects pathologically or iatrogenically immunocompromised. There are, most likely, foci of protozoa in lung and skin reaching the CNS by hematogenous route. Only Acanthamoeba spp. can also produce severe, subacute keratitis, mainly today in contact lens wearers.

Disseminated cerebral hemorrhages as unusual manifestation of toxoplasmic encephalitis in AIDS.

Hemorrhagic lesions are uncommon in central nervous system (CNS) toxoplasmosis. We report here the case of a patient with multiple cerebral hemorrhages as the initial manifestation of HIV infection due to CNS toxoplasmosis.

The brain in cerebral malaria: a pathological study of 24 fatal cases in Papua New Guinea.

The pathological features of cerebral malaria in 24 fatal cases are described. The cases included 18 adults aged from 16 to 45 years and 6 children aged from 1 to 15 years. All were unconscious before death. Gross pathological findings in the brain included cerebral oedema, vascular congestion and petechial haemorrhages. Little clinical and laboratory information was available on these patients. Histological examination revealed parasitized red blood cells in all, ring haemorrhages in 6, hyaline material in the wall of medium-sized blood vessels in 4, and vascular thrombosis in 4.

Cerebral hemorrhagic lesions produced by Paragonimus mexicanus. Report of three cases in Costa Rica.

Three cases of cerebral lesions due to Paragonimus mexicanus in Costa Rica are reported, two of which were fatal. At autopsy a hemorrhagic, well circumscribed lesion was found in the hemispheres which microscopically consisted of a recent hemorrhage surrounded by a halo of eosinophils, with giant cell granulomas and Charcot-Leyden crystals. Eggs of P. mexicanus outside the brain were demonstrated in both fatal cases--in an eosinophilic pericarditis in one and in the other in multiple lesions of the liver and lungs. The third patient had a hemorrhagic cerebral lesion which was surgically evacuated; the patient recovered. Eggs were demonstrated in serial sections of the material resected.

Cerebral Malaria.

Cerebral malaria is an acute diffuse encephalopathy associated only with Plasmodium falciparum. It is probably a consequence of the rapid proliferation of the parasites in the body of man in relation to red cell invasion, and results in stagnation of blood flow in cerebralcapillaries with thromobotic occlusion of large numbers of cerebral capillaries. The subsequent cerebral pathology is cerebral infarction with haemorrhage and cerebral oedema. The wide prevalence of P. falciparum in highly endemic areas results in daily challenges to patients from several infected mosquitoes. It is thus important to understand the characteristics of P. falciparum, since this is one of the most important protozoan parasites of man and severe infection from it constitutes one of the few real clinical emergencies in tropical medicine. One of the more important aspects of the practice of medicine in the tropics is to establish a good understanding of the pattern of medical practice in that area. This applies to malaria as well as to other diseases. The neophyte might be somewhat surprised to learn, for example that an experienced colleague who lives in a holoendemic malarious area such as West Africa, sees no cerebral malaria. But the explanation is simple when the doctor concerned has a practice which involves treating adults only. Cerebral malaria is rare in adults, because in highly endemic areas, by the age of 1 year most of the infants in a group under study have already experienced their first falciparum infection. By the time they reach adult life, they have a solid immunity against severe falciparum infections. In fact, "clinical malaria" could occur in such a group under only two circumstances: 1) in pregnancy, a patent infection with P. falciparum might develop, probably due to an IgG drain across the placenta to the foetus;2) in an individual who has constantly taken antimalarials and who may have an immunity at such a low level that when antimalarial therapy is interrupted, clinical malaria might ensue. The above examples emphasise the paramount importance of the clinician dealing with malaria having some insight into the complex immunity processes operative in the human host; these have been reviewed by McGregor.