Borrelia burgdorferi adhere to blood vessels in the dura mater and are associated with increased meningeal T cells during murine disseminated borreliosis.

Borrelia burgdorferi, the causative agent of Lyme disease, is a vector-borne bacterial infection that is transmitted through the bite of an infected tick. If not treated with antibiotics during the early stages of infection, disseminated infection can spread to the central nervous system (CNS). In non-human primates (NHPs) it has been demonstrated that the leptomeninges are among the tissues colonized by B. burgdorferi spirochetes. Although the NHP model parallels aspects of human borreliosis, a small rodent model would be ideal to study the trafficking of spirochetes and immune cells into the CNS. Here we show that during early and late disseminated infection, B. burgdorferi infects the meninges of intradermally infected mice, and is associated with concurrent increases in meningeal T cells. We found that the dura mater was consistently culture positive for spirochetes in transcardially perfused mice, independent of the strain of B. burgdorferi used. Within the dura mater, spirochetes were preferentially located in vascular regions, but were also present in perivascular, and extravascular regions, as late as 75 days post-infection. At the same end-point, we observed significant increases in the number of CD3+ T cells within the pia and dura mater, as compared to controls. Flow cytometric analysis of leukocytes isolated from the dura mater revealed that CD3+ cell populations were comprised of both CD4 and CD8 T cells. Overall, our data demonstrate that similarly to infection in peripheral tissues, spirochetes adhere to the dura mater during disseminated infection, and are associated with increases in the number of meningeal T cells. Collectively, our results demonstrate that there are aspects of B. burgdorferi meningeal infection that can be modelled in laboratory mice, suggesting that mice may be useful for elucidating mechanisms of meningeal pathogenesis by B. burgdorferi.

In Vitro infection of human dura-mater fibroblasts with Staphylococcus aureus: colonization and reactive production of IL-1beta.

OBJECTIVE: Post-operative meningitis, caused mainly by Staphylococcus aureus and Gram-negative rods, is a life-threatening complication after neurosurgery, and its pathogenesis is far from clear. The purpose of this work was to study the experimental infection of human dura-mater fibroblasts and whole human dura by S. aureus. METHODS: In vitro cultures of human dura-mater fibroblasts and organotypic cultures of small pieces of human dura mater were inoculated with a human-derived S. aureus strain. The pattern of bacterial infection as well as cytokines secretion by the infected fibroblasts was studied. RESULTS: Our results suggest that colonisation of human dura-mater fibroblasts in culture and whole dura-mater tissue by S. aureus includes bacterial growth on the cell surface, fibroblast intracellular invasion by bacteria and a significant synthesis of interleukin 1beta (IL-1beta) by the infected cells. CONCLUSION: This is the first report of human dura-mater fibroblast infection by S. aureus. Hopefully, these results can lead to a better understanding of the pathogenesis of meningitis caused by this bacterial species and to a more rational therapeutic approach.

Community-associated methicillin-resistant Staphylococcus aureus-infected chronic scalp wound with exposed dura in a 10-year-old boy: vacuum-assisted closure is a feasible option: case report.

BACKGROUND AND IMPORTANCE: Since the introduction of vacuum-assisted closure (VAC) in 1997, it has been used successfully in treating difficult wounds, including spinal wounds and wounds in pediatric patients. There are no reports on VAC therapy in pediatric patients on the scalp, especially with exposed dura. This report describes a 10-year-old boy with a chronic wound of the scalp with exposed dura after multiple neurosurgical interventions who was treated successfully with VAC. CLINICAL PRESENTATION: A 10-year-old mentally disabled boy with Apert syndrome suffered from a chronic wound with community-associated methicillin-resistant Staphylococcus aureus (MRSA) infection after multiple neurosurgeon operations. For wound closure, VAC therapy was initiated on the bony defect with exposed dura. The wound healed successfully, and the MRSA disappeared. CONCLUSION: The aims of VAC therapy are formation of new granulation tissue, wound cleansing, and bacterial clearance. In this case, the VAC device was excellent for temporary coverage of the defect and for wound cleaning, and it allowed a thick bed of granulation tissue to form over the dura, even with minimal constant negative pressure. The application and management were feasible even in a mentally disabled child. With this experience, we are encouraged to use the VAC device in difficult wounds, even in the head and neck area in children, and to bring this treatment into the outpatient clinic.

Falcotentorial subdural empyema: analysis of 10 cases.

OBJECT: Parafalcine subdural empyema and those along the superior and inferior surface of the tentorium are rare entities. We present a series of 10 patients where we have attempted to describe the pathophysiology, clinical features, and management of subdural empyema. METHODS: The study group included 10 cases of falcotentorial subdural empyemas managed between 2004 and 2010. The mean age group was 14.4 years. Seven patients had empyema along the falx or superior surface of tent, and the remaining three had empyema along the inferior surface of tent. Fever, raised intracranial pressure symptoms, falx syndrome, and seizures were the usual presenting features. These patients had an indolent presentation as compared to convexity subdural empyemas. The diagnosis was made based on radiology. Chronic suppurative otitis media was a causative factor in five patients; in the remaining patients, the source was ascribed to be hematogenous. All patients were treated with antibiotic therapy (6 weeks) ± surgery. Two patients were treated conservatively, and the remaining eight patients underwent definitive surgery in the form of craniotomy (supratentorial)/craniectomy (infratentorial) and evacuation of pus. The pus was limited within two leaves, one adherent to the falx/tent and the other one to the pia-arachnoid of adjacent parenchyma. The wall along the falx or tent could be peeled off easily and was excised in all cases to lay open the cavity widely. The wall along pia-arachnoid was left as it is. Pus culture was positive in four and blood culture positive in two cases. There was only a single mortality in our series. The outcome was assessed by the Glasgow Outcome Scale. The mean duration of follow-up was for 18.8 months, and all patients who survived had a good outcome. CONCLUSION: Falcotentorial empyema remains a rare entity. The presentation is indolent as compared to convexity subdural empyemas, possibly due to its limitation secondary to arachnoid adhesions at the junction of falx, tent, and convexity dura. The main stay of management remains craniotomy, evacuation, and partial excision of the wall, laying it completely open, unless it is extremely thin. With appropriate surgery and antibiotic therapy, a good outcome can be expected.

Epidural abscess caused by community-associated methicillin-resistant Staphylococcus aureus strain USA300 in Japan.

We report a case of epidural abscess caused by community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) strain USA300 in a previously healthy 25-year-old American woman who lived in Japan for more than 1 year. She started to complain of severe headache that continued for about 10 days after improvement of subcutaneous abscesses caused by MRSA. Computed tomography (CT) and magnetic resonance imaging (MRI) showed epidural abscess. As epidural abscess was not improved by treatment with vancomycin and ceftriaxone, craniotomy and drainage were performed, and the severe headache disappeared. Characteristics of the MRSA strain isolated from the abscess were identical to those of strain USA300; multilocus sequence typing sequence type 8, staphylococcal cassette chromosome mec type IVa, Panton-Valentine leukocidin positive, arginine catabolic mobile element positive, and pulsed-field gel electrophoresis type USA300. This may be the first report of epidural abscess caused by USA300 strain in Japan. Because CA-MRSA strains, including USA300, have begun to spread in Japan, epidural abscess should be taken into account in the diagnosis of previously healthy patients with persistent headache accompanied by skin lesions.

[Meningomyeloradiculitis in an immunocompetent patient]. / Méningomyéloradiculite àCandida albicans chez un sujet immunocompétent.

INTRODUCTION: Candida infection limited to the central nervous system is extremely rare, and may be confused with tuberculosis on the grounds of the clinical and cerebrospinal fluid findings. CASE REPORT: A 23-year-old immunocompetent drug addict presented with alternating sciatica over a period of several months, followed by multiple cranial nerve involvement in the setting of marked weight loss. The histopathologic examination of a leptomeningeal neurosurgical biopsy was required to establish the diagnosis of neuromeningeal infection with Candida albicans. CONCLUSION: This case report underlines diagnostic difficulties of candidal meningitis and reviews current therapeutic recommendations.

An intradural-extramedullary gas-forming spinal abscess in a patient with diabetes mellitus.

Spinal infections are commonly reported to be located in the extradural or intramedullary spaces. Infection involving the intradural-extramedullary space are uncommon. We report a patient with uncontrolled diabetes mellitus and an infected foot ulcer who presented with a cervical cord abscess and intradural gas. Early diagnosis and aggressive treatment are necessary for a favourable outcome in gas-forming intradural spinal abscesses. To our knowledge, a gas-forming intradural spinal abscess has not been reported previously and we discuss the relevant literature.

Isolated subacute tuberculous spinal epidural abscess of the cervical spine: a brief report of a special case.

A tuberculous spinal epidural abscess is seen rarely as a late complication of Pott's disease or in immunocompromised patients. Such abscesses in isolation are rare indeed and very uncommon in the developed and developing world. We report a patient with an isolated subacute tuberculous spinal epidural abscess without disc or vertebral involvement and no primary focus or risk factors associated with the development of spinal tuberculosis.

Calvarial tuberculosis: an unusual presentation (2007: 8b).

We describe a case of calvarial tuberculosis with an associated extra-dural collection. This presentation has rarely been reported in the literature and the magnetic resonance imaging features are not well documented.

The clinical challenge of recognizing infratentorial empyema.

BACKGROUND: Infratentorial empyema is an uncommon complication of bacterial meningitis. Very little is known about its recognition and appropriate management. METHOD: We present a patient with infratentorial subdural empyema and compare findings with 41 cases with infratentorial empyema reported in the literature. RESULTS: Many patients with infratentorial empyema presented as subacute meningitis with neck stiffness and decreased consciousness. Diagnosis was often delayed. The minority had cerebellar findings and cranial nerve deficits. Clues to the diagnosis were presence of otitis, sinusitis, or mastoiditis and recent surgery for these disorders. The majority of patients underwent craniotomy; conservative treatment with antibiotics was associated with relapse of symptoms. The mortality rate was high especially in those with subdural empyema. CT failed to clearly visualize infratentorial subdural empyema in several reported cases. CONCLUSIONS: Infratentorial empyema is a life-threatening rare complication of bacterial meningitis. MRI, including diffusion-weighted imaging, is the preferred imaging technique in patients with suspected or proven bacterial meningitis and associated ear-nose-throat infection with deterioration in consciousness and neurologic signs that suggest a posterior fossa lesion. Neurosurgery should be regarded as first choice therapy.

Papilledema as a manifestation of a spinal subdural abscess.

Papilledema is an uncommon presentation of spinal cord processes. Spinal subdural abscess (SSA) is a rare site of post-operative infection. We report a patient who developed papilledema as the primary manifestation of a post-operative lumbar subdural abscess. A spinal abscess should be considered in the post-operative spinal surgery patient who develops papilledema in the setting of persistent back pain. The increased intracranial pressure associated with lumbar spinal cord abscess most likely results from a markedly elevated cerebrospinal fluid (CSF) protein or the disruption of CSF flow in the spinal cul-de-sac.

Pyogenic intradural abscess: a case report.

STUDY DESIGN: A case report of pyogenic intradural abscess is described. OBJECTIVES: The rarity of the presentation and its successful management are discussed. SUMMARY OF BACKGROUND DATA: Intradural abscesses are exceptionally rare. METHOD: The abscess was drained by performing a posterior midline lumbar durotomy, and intravenous antibiotics were initiated. RESULT: At the 1 year follow-up, the patient has made significant neurologic recovery. CONCLUSION: Intradural pyogenic abscess secondary to chronic pyogenic spondylodiscitis is a rare manifestation. MRI is a vital component in diagnosis, which revealed key pathologic features within the dural sac as well as in the vertebral column. An emergency decompression and appropriate antibiotic regimen is the solution for a favorable outcome.

Acinetobacter baumanii meningitis: a rare complication of incidental durotomy.

Despite the frequency of dural tears in spinal surgery, meningitis is a rare complication reported to occur with a frequency of 0.18%. To the best of our knowledge, no case of Acinetobacter baumanii meningitis has been reported in the literature after a dural tear secondary to lumbar spine discectomy. This case highlights the importance of repairing all dural tears and commencing antibiotics that cover uncommon bacteria in those who develop symptoms of meningitis in this setting.

Atypical intradural spinal tuberculosis: report of three cases.

OBJECTIVE: To report three cases of intradural spinal tuberculosis (TB) by calling attention to atypical forms of spinal TB. SETTING: A University Hospital, Istanbul, Turkey. METHODS: Histopathological, radiological, surgical and physical examination findings of three patients with spinal TB were retrospectively reviewed. RESULTS: Based on histopathological, surgical and radiological findings, diagnosis of intramedullary abscess had been made in the first case and early and late phases of arachnoiditis in the other two patients, respectively. The clinical outcome was evaluated as satisfactory for the patient with intramedullary abscess who had been treated with medical and surgical interventions. The remaining two patients with arachnoiditis, who had been treated by shunting or simple decompression, had a relatively less favorable clinical outcome. CONCLUSION: Spinal TB, in its atypical forms, is a rare clinical entity and low index of suspicion on the part of the surgeon may result in misdiagnosis such as neoplasm. In cases presenting with an intraspinal mass lesion, possibility of a tuberculous abscess and/or a granuloma should be considered in the differential diagnosis.

In vitro study of bacterial adherence to processed dura mater, processed pericardium, pericardium in saline, and human sclera.

PURPOSE: To study bacterial adherence to processed dura mater, processed pericardium, pericardium in saline, and human sclera and the difference in bacterial adherence to these tissues. SETTING: Research Laboratory, Loyola University Medical Center, Maywood, Illinois, USA. METHODS: Specimens of processed dura mater, processed human pericardium, pericardium in saline, and human sclera (N = 32) were exposed to Staphylococcus epidermidis (concentration 3 x 10(8)) for 10, 20, 40, and 60 minutes, washed for 5 seconds, fixed, and processed for scanning electron microscopy (SEM). Each bacterial count represents an average of 50 random SEM fields at x5,000 magnification. After SEM, selected specimens were processed for transmission electron microscopy. RESULTS: The mean number of bacteria/mm(2) +/- SD adhering to the tissues at 10, 20, 40, and 60 minutes, respectively, were dura mater, 107,833 +/- 65,410, 104,500 +/- 13,471, 96,067 +/- 113,884, and 204,267 +/- 153,697; processed pericardium, 131,550 +/- 86,194, 100,900 +/- 20,031, 144,683 +/- 51,730, and 176,933 +/- 111,818; pericardium in saline, 7,925 +/- 1,520, 33,933 +/- 32,085, 1,217 +/- 1,287, and 21,550 +/- 16,436; and human sclera, 4,850 +/- 2,121, 23,700 +/- 17,961, 5,150 +/- 1,273, and 8,175 +/- 8,450. A 2-way analysis of variance showed significant differences among groups (P =.001) and no significant difference in sample time (P =.929). CONCLUSIONS: Bacterial adherence to processed dura mater, processed pericardium, pericardium in saline, and human sclera should be considered when these materials are used clinically during ophthalmic surgery and other surgical specialties. Adequate broad-spectrum antibiotic coverage is needed to prevent infection and subsequent complications in patients.

Experimental induction of chronic borreliosis in adult dogs exposed to Borrelia burgdorferi-infected ticks and treated with dexamethasone.

OBJECTIVE: To develop a method to experimentally induce Borrelia burgdorferi infection in young adult dogs. ANIMALS: 22 healthy Beagles. PROCEDURE: All dogs were verified to be free of borreliosis. Twenty 6-month-old dogs were exposed to Borrelia burgdorferi-infected adult ticks and treated with dexamethasone for 5 consecutive days. Two dogs not exposed to ticks were treated with dexamethasone and served as negative-control dogs. Clinical signs, results of microbial culture and polymerase chain reaction (PCR) testing, immunologic responses, and gross and histologic lesions were evaluated 9 months after tick exposure. RESULTS: Predominant clinical signs were episodic pyrexia and lameness in 12 of 20 dogs. Infection with B burgdorferi was detected in microbial cultures of skin biopsy specimens and various tissues obtained during necropsy in 19 of 20 dogs and in all 20 dogs by use of a PCR assay. All 20 exposed dogs seroconverted and developed chronic nonsuppurative arthritis. Three dogs also developed mild focal meningitis, 1 dog developed mild focal encephalitis, and 18 dogs developed perineuritis or rare neuritis. Control dogs were seronegative, had negative results for microbial culture and PCR testing, and did not develop lesions. CONCLUSIONS AND CLINICAL RELEVANCE: Use of this technique successfully induced borreliosis in young dogs. Dogs with experimentally induced borreliosis may be useful in evaluating vaccines, chemotherapeutic agents, and the pathogenesis of borreliosis-induced arthritis.

Coccidioidomycosis meningitis with massive dural and cerebral venous thrombosis and tissue arthroconidia.

To our knowledge we report the first case of meningitis from Coccidioides immitis associated with massive dural and cerebral venous thrombosis and with mycelial forms of the organism in brain tissue. The patient was a 43-year-old man with late-stage acquired immunodeficiency syndrome (AIDS) whose premortem and postmortem cultures confirmed C immitis as the only central nervous system pathogenic organism. Death was attributable to multiple hemorrhagic venous infarctions with cerebral edema and herniation. Although phlebitis has been noted parenthetically to occur in C immitis meningitis in the past, it has been overshadowed by the arteritic complications of the disease. This patient's severe C immitis ventriculitis with adjacent venulitis appeared to be the cause of the widespread venous thrombosis. AIDS-related coagulation defects may have contributed to his thrombotic tendency.

Nocardia osteomyelitis in a pachymeningitis patient: an example of a difficult case to treat with antimicrobial agents

Antimicrobial agents played a miraculous role in the treatment of bacterial infections until resistant bacteria became widespread. Besides antimicrobial-resistant bacteria, many factors can influence the cure of infection. Nocardia infection may be a good example which is difficult to cure with antimicrobial agents alone. A 66-year-old man developed soft tissue infection of the right buttock and thigh. He was given prednisolone and azathioprine for pachymeningitis 3 months prior to admission. Despite surgical and antimicrobial treatment (sulfamethoxazole-trimethoprim), the infection spread to the femur and osteomyelitis developed. The case showed that treatment of bacterial infection is not always as successful as was once thought because recent isolates of bacteria are more often resistant to various antimicrobial agents, intracellular parasites are difficult to eliminate even with the active drug in vitro, and infections in some sites such as bone are refractory to treatment especially when the patient is in a compromised state. In conclusion, for the treatment of infections, clinicians need to rely on laboratory tests more than before and have to consider the influence of various host factors.