The clinical characteristics and outcome of cryptococcal meningitis with AIDS in a tertiary hospital in China: an observational cohort study.

BACKGROUND: Despite the profound impact of antiretroviral therapy in the control of AIDS mortality, central nervous system opportunistic infections remains a significant burden in AIDS patients. This retrospective study aims to elucidate the clinical characteristics, outcome and risk factors of cryptococcal meningitis (CM) poor prognosis in AIDS patients from a tertiary hospital in China. METHODS: Clinical data from 128 patients admitted in Beijing Ditan Hospital, Capital Medical University from November 2008 to November 2017 was collected. The cohort was stratified based on treatment outcome (effective 79%, and ineffective 21%), and Multivariate Logistic regression analysis used to identify risk factors of poor disease prognosis. RESULTS: Age, incidence of cerebral infarction, the proportion of consciousness disorder, and fasting plasma glucose was higher in the ineffective treatment group than the effective treatment group. The duration of treatment in the induction period of the ineffective group was significantly shorter than that of the effective group. Multivariate Logistic regression analysis indicated that the occurrence of cerebral hernia and consciousness disorder were risk factors for the prognosis of AIDS patients with CM infection, while the duration of treatment in the induction period was a indicative of a better prognosis in AIDS with CM infection complications. Finally, shunt decompression therapy correlated with a better disease outcome. CONCLUSIONS: This retrospective study exposes the main risk factors associated with worse disease prognosis in AIDS patients with CM infection complications.

[Predictive value of serum procalcitonin and hypersensitive C-reactive protein levels in patients with acute cerebral infarction complicated with infection].

OBJECTIVE: To analyze the changes of early procalcitonin (PCT) and hypersensitive C-reactive protein (hs-CRP) in patients with acute cerebral infarction, and to explore the predictive value of both for acute cerebral infarction with infection. METHODS: 206 acute cerebral infarction patients admitted to the department of neurology of Feicheng Mining Center Hospital from May 2014 to May 2019 were enrolled. Clinical data of patients and serum PCT and hs-CRP levels at 24, 48 and 72 hours after onset were collected. Patients were divided into infected group (n = 69) and non-infected group (n = 137) according to whether infection occurred within 5 days after onset. And 60 healthy people in the same period were selected as the healthy control group. The trends of serum PCT and hs-CRP levels in each group were analyzed. The receiver operating characteristic (ROC) curve was used to analyze the values of serum PCT and hs-CRP levels in identifying acute cerebral infarction with infection. RESULTS: The serum level of PCT at 24, 48 and 72 hours in the infected group and the non-infected group were significantly higher than those in the healthy control group, and the serum level of PCT at 48 hours and 72 hours in the infected group were significantly higher than those in the non-infected group (µg/L: 0.28±0.08 vs. 0.19±0.03, 0.31±0.07 vs. 0.15±0.06, both P < 0.05). Compared with 24 hours, the serum PCT level in the infected group at 48 hours and 72 hours were significantly increased, but decreased in the non-infected group. The serum hs-CRP level in the infected group at 24, 48 and 72 hours were significantly higher than those in the non-infected group and the healthy control group (mg/L: 5.86±1.73 vs. 5.45±1.08, 5.25±1.33; 8.01±2.41 vs. 5.67±2.13, 5.25±1.33; 14.25±2.19 vs. 12.30±1.87, 5.25±1.33; all P < 0.05). And the serum hs-CRP level in the non-infected group at 72 hours was significantly higher than that in the healthy control group. Compared with 24 hours, the serum hs-CRP level in the infected group and non-infected group at 48 hours and 72 hours were significantly increased. It was shown by ROC curve analysis that serum PCT and hs-CRP levels at 24 hours had no predictive value for infection in patients with acute cerebral infarction [area under ROC curve (AUC) was 0.440, 0.576 respectively, both P > 0.05]. At 48 hours, the AUC of serum PCT in diagnosis of acute cerebral infarction with infection was 0.850 [95% confidence interval (95%CI) = 0.784-0.916], the sensitivity and specificity were 66.7% and 97.8% when the cut-off of PCT was 0.25 µg/L; the AUC of serum hs-CRP was 0.759 (95%CI = 0.689-0.830), the sensitivity and specificity were 66.7% and 76.6% when the cut-off of hs-CRP was 6.80 mg/L; the AUC of PCT combined with hs-CRP was 0.911 (95%CI = 0.859-0.964), the sensitivity was 90.5%, the specificity was 86.9%. At 72 hours, the AUC of serum PCT in diagnosis of acute cerebral infarction with infection was 0.952 (95%CI = 0.916-0.989), the sensitivity and specificity were 89.9% and 93.4% when the cut-off of PCT was 0.23 µg/L; the AUC of serum hs-CRP was 0.753 (95%CI = 0.678-0.828), the sensitivity and specificity were 60.9% and 83.2% when the cut-off of hs-CRP was 14.01 mg/L; the AUC of PCT combined with hs-CRP was 0.954 (95%CI = 0.918-0.991), the sensitivity was 97.1%, and the specificity was 89.8%. The results showed that the diagnostic value of serum PCT at 48 hours and 72 hours were higher than those of hs-CRP, and the predictive value of PCT combined with hs-CRP was higher than those of single index. CONCLUSIONS: Acute cerebral infarction itself has an effect on serum PCT level; serum PCT level above 0.23 µg/L at 72 hours after onset and reference to serum hs-CRP level have a high predictive value for the diagnosis of infection in patients with acute cerebral infarction.

Pathogens distribution and drug resistance in patients with acute cerebral infarction complicated with diabetes and nosocomial pulmonary infection.

BACKGROUND: This study aims to investigate the pathogen distribution and drug resistance in patients with acute cerebral infarction complicated with diabetes mellitus and nosocomial pulmonary infection. METHODS: From August 2015 to December 2017, 172 pathogenic bacterial strains from patients with acute cerebral infarction complicated with diabetes mellitus and nosocomial pulmonary infection in our hospital were identified, and the drug sensitivity was analyzed. RESULTS: Among these 172 strains of pathogenic bacteria, gram negative bacteria was the main cause of pulmonary infection in hospitalized patients with acute cerebral infarction, accounting for 75.6% of all pathogens. Furthermore, 80% of diabetic patients with cerebral infarction had lung infection induced by gram negative bacteria, which was significantly higher than that in non-diabetic patients (72.2%). Moreover, the drug resistance rate in the diabetic group (68.3%) was significantly higher than that in the non-diabetic group (54.3%). Gram positive bacteria accounted for 19.1% of all pathogenic bacteria. The infection rate of gram-positive bacteria in diabetic patients with cerebral infarction was 14.7%, which was lower than that in the non-diabetic group (22.6%). The drug-resistance rate was higher in the diabetic group (45.5%) than in the non-diabetic group (28.2%). Furthermore, the fungal infection rate in patients with lung infection in these two groups was 5.3 and 5.2%, respectively, and fungi presented with high sensitivity to commonly used antifungal agents. CONCLUSION: In patients with acute cerebral infarction complicated with diabetes mellitus and nosocomial pulmonary infection, the majority of pathogens are multidrug-resistant gram negative bacilli. Pathogen culture should be conducted as soon as possible before using antibiotics, and antimicrobial agents should be reasonably used according to drug sensitivity test results.

Risk factors analysis of nosocomial pneumonia in elderly patients with acute cerebral infraction.

To investigate the risk factors of nosocomial pneumonia (NP) in elderly patients with acute cerebral infarction (ACI).In this study, 324 aged 70 years and over patients with ACI who were admitted to the inpatient department of TianJin First Hospital (China) from January 2012 to February 2018 were retrospectively analyzed. The patients were divided into NP group (80 patients) and non-NP group (244 patients) according to whether NP was occurred 48 hours after hospitalization. Baseline profiles and biochemical analyses were compared between 2 groups. Information regarding risk factors for NP in elderly patients with ACI was collected from all patients. Associations with NP and outcome were evaluated.Among the total patients, NP occurred in 80 (24.69%) patients. There were no statistically significant differences between risk of NP and sex, current drinking, diabetes mellitus, stroke history, and levels of serum UA, TG, HDL-C, LDL-C, Glucose, chloride, potassium. Multivariate logistic regression analysis showed that the independent risk factors for NP were living alone (OR 4.723; CI 1.743∼12.802; P = .002), initial NIHSS score (OR 1.441; CI 1.191∼1.743; P = .000), NRS2002 score (OR 0.139; CI 0.087∼0.223; P = .000), BMI (OR 1.586; CI 1.353∼1.858; P = .000), a past pneumonia history (OR 0.073; CI 0.017∼0.321; P = .001), atrial fibrillation (AF) (OR 0.129; CI 0.033∼0.499; P = .003), CRP (OR 1.050; CI 1.017∼1.085; P = .003), BUN (OR 0.603; CI 0.448∼0.812; P = .001) and Cr (OR 1.036; CI 1.015∼1.057; P = .001). Level of albumin was an independent protective factor of NP in elderly patients with ACI (OR 0.865; CI 0.750∼0.999; P = .048). Furthermore, elderly patients with ACI who had NP had worse clinical outcomes both during hospitalization and after discharge (P < .05).We identified significant risk factors for NP in elderly patients with ACI, including living alone, initial NIHSS score, malnutrition, a past pneumonia history, AF, CRP, and Renal function were associated with NP in elderly patients with ACI. The clinical course was worse and the duration of hospital stay was longer in NP patients than in non-NP patients.

Refractory Mycoplasma pneumoniae pneumonia with concomitant acute cerebral infarction in a child: A case report and literature review.

RATIONALE: Mycoplasma pneumoniae pneumonia, a common cause of community-acquired pneumonia in children, is rarely complicated with acute cerebral infarction. PATIENT CONCERNS: We present a 7-year-old boy with severe M pneumoniae pneumonia who developed impaired consciousness, aphasia, and reduced limb muscle power 7 days postadmission. DIAGNOSES: Mycoplasma pneumoniae pneumonia with concomitant acute cerebral infarction. INTERVENTIONS: The patient recovered with aggressive antibiotic therapy, antiinflammation therapy with methylprednisolone, and gamma immunoglobulin and anticoagulation therapy with aspirin and low molecular weight heparin along with rehabilitation training. OUTCOMES: At 8 days postadmission, his consciousness was improved and at the 6-month follow-up visit, his muscle power of bilateral upper and lower limbs was normal except still poor right handgrip power. LESSONS: Stroke or cerebral infarction should be considered and promptly managed in rare cases of M pneumoniae pneumonia with neurologic manifestations.

Bilateral haemorrhagic basal ganglia infarction associated with early-onset group B streptococcus meningitis.

A 2-day-old infant presented with poor feeding and grunting. Investigations revealed a raised C reactive protein of 164. Full septic screen was done, which subsequently confirmed a diagnosis of group B streptococcus meningitis. Baby was apyrexial and haemodynamically stable. There were no obvious neurological manifestations, and a routine cranial ultrasound scan was done, which revealed echogenic changes in the basal ganglia and thalami. MRI brain showed extensive haemorrhagic infarction within the lentiform and caudate nuclei with involvement of both posterior limbs of the internal capsule. This was followed by triventricular hydrocephalus needing shunt procedure. The clinical course was complicated by infantile spasms, which were treated with vigabatrin and steroids and subsequent global developmental delay and cerebral palsy.

Meningococcal meningitis with neurological complications and meningococcemia due to serogroup W sequence type 11 complex.

Invasive meningococcal disease (IMD) caused by the serogroup W (MenW) sequence type-11 complex strain has recently emerged worldwide. Meningococcal infections due to this strain are associated with high case fatality and often atypical clinical manifestations. However, the annual IMD incidence was low, and MenW is rare in Japan. We described the first Japanese case of meningococcal meningitis and meningococcemia caused by this strain in a previously healthy 27-year-old woman. This case showed various neurological complications such as abducens palsy, cerebellitis, and cerebellar infarction, and reactive arthritis. This case provides useful information on the possibility of spreading IMD strains and the cause of various complications.

Biomarkers of Cerebral Injury and Inflammation in Pediatric Tuberculous Meningitis.

Background: Tuberculous meningitis (TBM) leads to death or disability in half the affected individuals. Tools to assess severity and predict outcome are lacking. Neurospecific biomarkers could serve as markers of the severity and evolution of brain injury, but have not been widely explored in TBM. We examined biomarkers of neurological injury (neuromarkers) and inflammation in pediatric TBM and their association with outcome. Methods: Blood and cerebrospinal fluid (CSF) of children with TBM and hydrocephalus taken on admission and over 3 weeks were analyzed for the neuromarkers S100B, neuron-specific enolase (NSE), and glial fibrillary acidic protein (GFAP), in addition to multiple inflammatory markers. Results were compared with 2 control groups: patients with (1) a fatty filum (abnormal filum terminale of the spinal cord); and (2) pulmonary tuberculosis (PTB). Imaging was conducted on admission and at 3 weeks. Outcome was assessed at 6 months. Results: Data were collected from 44 patients with TBM (cases; median age, 3.3 [min-max 0.3-13.1] years), 11 fatty filum controls (median age, 2.8 [min-max 0.8-8] years) and 9 PTB controls (median age, 3.7 [min-max 1.3-11.8] years). Seven cases (16%) died and 16 (36%) had disabilities. Neuromarkers and inflammatory markers were elevated in CSF on admission and for up to 3 weeks, but not in serum. Initial and highest concentrations in week 1 of S100B and NSE were associated with poor outcome, as were highest concentration overall and an increasing profile over time in S100B, NSE, and GFAP. Combined neuromarker concentrations increased over time in patients who died, whereas inflammatory markers decreased. Cerebral infarcts were associated with highest overall neuromarker concentrations and an increasing profile over time. Tuberculomas were associated with elevated interleukin (IL) 12p40, interferon-inducible protein 10, and monocyte chemoattractant protein 1 concentrations, whereas infarcts were associated with elevated tumor necrosis factor α, macrophage inflammatory protein 1α, IL-6, and IL-8. Conclusions: CSF neuromarkers are promising biomarkers of injury severity and are predictive of mortality. An increasing trend suggested ongoing brain injury, even though markers of inflammation declined with treatment. These findings could offer novel insight into the pathophysiology of TBM.

Central retinal artery occlusion and cerebral infarction associated with Mycoplasma pneumonia infection in children.

BACKGROUND: Central retinal artery occlusion (CRAO) is an arterial ischemic stroke, rarely occurred in children accompanied with asymptomatic cerebral infarction and almost never involved in severe pneumonia related to Mycoplasma pneumonia infection. CASE PRESENTATION: An 8-year-old boy with severe pneumonia related to Mycoplasma pneumonia infection that developed loss of vision in the left eye on the 14th day. No light perception and no pupillary reaction to light were found in the left eye. The fundus examination revealed a cherry red spot with severe retinal edema at the macular and peripapillary area, and the optic disc was pale in the left eye but normal in the right eye, suggesting CRAO in the left eye. No obvious neurological symptoms and signs were observed on presentation. Magnetic resonance imaging of the brain showed an abnormal signal of the left lentiform nucleus, caudate nucleus and within the temporal lobe, suggesting an acute cerebral infarction. The analysis of cerebrospinal fluid showed an increasing leukocyte count, but no any pathogenic microorganisms were found. His respiratory symptoms disappeared promptly after therapy, and the patient was discharged after 11 days later, but there was no light in the left eye 2 months after discharge. CONCLUSION: M. pneumoniae infection could be developed the risk for cerebral ischemic stroke, including CRAO in children with severe pneumonia. CRAO is a devastating ophthalmologic event leading to a severe impairment of vision. Patients treated within about 6 h of vision loss had a better visual outcome after the onset of vision loss.

A Delayed Cerebral Vasospasm with Infarction Is Secondary to Listeria monocytogenes Meningitis: MRI and MRA Are Diagnostically Useful.

Among patients with bacterial meningitis, a cerebral vasospasm typically occurs during the acute phase. We experienced a case of delayed cerebral vasospasm with infarction that was secondary to Listeria monocytogenes meningitis. An 82-year-old woman with Listeria monocytogenes meningitis, whose symptoms had been improving after the initiation of antibacterial therapy, fell into a coma on day 15 and developed generalized seizure. Magnetic resonance imaging (MRI) and MR angiography (MRA) indicated a cerebral vasospasm with multiple infarctions. The risk of vascular complications following acute bacterial meningitis requires close follow-up to identify neurological changes and a low threshold for vascular evaluation. In such cases, MRI and MRA have diagnostic utility.

[MYCOTIC ANEURYSM OF THE ASCENDING AORTA AND CEREBRAL INFARCTS IN A 17-MONTH OLD CHILD WITH KINGELLA KINGAE ENDOCARDITIS].

Endocarditis is an uncommon presentation of Kingella kingae infection in children. A previously healthy 17 month old child was referred to our emergency department for evaluation of fever lasting eleven days, aphthous stomatitis and a new systolic murmur. Within a few hours of admission, antibiotic therapy was initiated for a presumptive diagnosis of bacteremia and within 24 hours after admission, gram negative coccobacilli were growing in the blood culture. In addition, echocardiography demonstrated a mycotic aneurysm of the ascending aorta with a mobile vegetation. The presumptive diagnosis of Kingella kingae endocarditis was made. Further evaluation by MRI revealed frontal and occipital cerebral infarcts. Due to the presence of presumed septic emboli in conjunction with progressive left ventricular dysfunction, the child was urgently taken to the operating room where aggressive debridement of the infected tissue was performed and the aortic aneurysm was repaired. The patient had an uneventful post-operative course. This case emphasizes the need for a high index of suspicion when evaluating children with community acquired infection. In addition, it also demonstrates the importance of early diagnosis and appropriate treatment of K. kingae endocarditis.

Risk assessment of the outcome for cerebral infarction in tuberculous meningitis.

INTRODUCTION: Cerebral infarction in tuberculous meningitis is a major risk factor for permanent disability. This study assessed the clinical presentation of tuberculous meningitis and risks factors for cerebral infarction. OBSERVATION: Thirty-eight adult patients with tuberculous meningitis were studied between 2002 and 2006. Clinical, radiological, and laboratory data of patients with cerebral infarction were compared with those of patients without cerebral infarction. Patients with cerebral infarction were significantly older (65.1 vs 52.1years), had higher risk assessment scores (3.7 vs 2.2), and more often had basal meningeal enhancement on imaging (92.3% vs 60.0%), mild to moderate sequelae (69.2% vs 4%), an overall poor brain outcome (69.2% vs 8%), aspirin prescription (84% vs 8%), and neurosurgical intervention for hydrocephalus (54.0% vs 16.0%). Cerebral infarction patients were also more likely to have experienced doctor-related delays in antituberculosis (61.5% vs 36%) and corticosteroid (61.5% vs 32%) therapy. DISCUSSION AND CONCLUSION: The Framingham risk score would be an option for tuberculous meningitis patients to access cerebral infarction risk. Contrast-enhanced brain imaging is helpful for exploring basal meningeal enhancement, in order to obtain an early diagnosis. Antituberculosis, corticosteroid, and aspirin therapies should be started immediately when tuberculous meningitis is suspected.

Cerebral infarction and tuberculoma in central nervous system tuberculosis: frequency and prognostic implications.

BACKGROUND: Tuberculoma and cerebral infarctions are serious complications of central nervous system (CNS) tuberculosis. However, there are no studies comparing prognostic value of tuberculoma and infarcts alone and in patients diagnosed with CNS tuberculosis. OBJECTIVE: The objective of this study was to identify frequency and prognostic value of tuberculoma and cerebral infarcts in a large sample of CNS tuberculosis patients. METHODS: Retrospective chart review of patients diagnosed with CNS tuberculosis in a tertiary care hospital in Pakistan over 10-year period was carried out. RESULTS: There were 404 patients included in this study (mean age of 43 years). There were 209 (52%) men and 195 (48%) women. Tuberculoma were present in 202 subjects (50%) while infarcts were present in 25% patients. 147 (36%) had tuberculous meningitis (TBM) without tuberculoma or infarction on CT or MRI, 158 (39%) had TBM with intracranial tuberculomas, 60 (15%) had TBM with cerebral infarction while 39 (10%) had TBM with both tuberculoma and infarction. At discharge, 249 patients (62%) were either normal (Modified Rankin Score (MRS)=0) or mild to moderately disabled (MRS=1-3) while 82 patients (20%) had severe disability (MRS=4-5). 73 (18%) patients died (MRS=6) during hospitalisation. Using logistic regression analysis, significant predictors of poor outcome included old age, high TBM grading, presence of infarction and presence of hydrocephalus. CONCLUSIONS: Tuberculomas were present in 50% of patients, while infarcts were present in 25%. Old age, TBM grading, presence of infarction and hydrocephalus were all predictors of poor outcome.

Chlamydia pneumoniae infection and cerebral infarction risk: a meta-analysis.

BACKGROUND: Chlamydia pneumoniae infection and the risk of cerebral infarction have been previously studied in several publications; however, conflicting results have been reported. This meta-analysis assessed whether C. pneumoniae infection was associated with risk of cerebral infarction. METHODS: Systematic computerized searches of the PubMed and Web of Knowledge were performed. Adjusted odds ratio and 95% confidence interval from original studies were extracted for combined meta-analysis. RESULTS: Twenty-three studies with 2924 cerebral infarction patients and 4692 control patients were included in the meta-analysis. When the positive C. pneumoniae infection was defined by microimmunofluorescence-detected immunoglobulin A, the pooled odds ratio between two groups was 2.04 (95% confidence interval 1.42-2.9). In the most frequently used immunoglobulin A ≥1:16 sub-group, the pooled odds ratio was 2.07 (95% confidence interval 1.31-3.26). When the infection was defined by enzyme-linked immunosorbent assay-detected immunoglobulin A, the pooled odds ratio was 2.89 (95% confidence interval 1.23-6.81). When the infection was defined by microimmunofluorescence-detected immunoglobulin G, the pooled odds ratio was 1.46 (95% confidence interval 1.18-1.81). In the most frequently used immunoglobulin G ≥1:32 sub-group, the pooled odds ratio was 1.43 (95% confidence interval 1.06-1.92). When the infection was defined by enzyme-linked immunosorbent assay-detected immunoglobulin G, the pooled odds ratio was 1.54 (95% confidence interval 0.86-2.74). No significant publication bias was found. Sensitivity analyses showed the results were robust. CONCLUSION: (1) This meta-analysis indicated that C. pneumoniae infection was significantly associated with an increased risk of cerebral infarction. (2) Compared with anti-C. pneumoniae immunoglobulin G, anti-C. pneumoniae immunoglobulin A seemed more effective for predicting the risk of cerebral infarction. (3) No evidence existed that anti-C. pneumoniae-immunoglobulin G detected by enzyme-linked immunosorbent assay could predict the risk of cerebral infarction.

Successful repair of a syphilitic aortic arch aneurysm accompanied by serious cerebral infarction.

We present a 52-year-old male with a syphilitic aortic arch aneurysm accompanied by relevant extensive cerebral infarction. He was admitted to a local hospital for sudden loss of consciousness, where he was diagnosed with serious cerebral infarction. During his treatment, a multilocular aortic arch aneurysm involving the arch vessels was found incidentally. He was transferred to our hospital for surgical treatment. A preoperative routine laboratory test for syphilis was highly positive, which suggested that the aneurysm was likely caused by syphilis and the cerebral infarction was also induced by the involvement of syphilitic aortitis or arteritis. After 2 weeks of antibiotic therapy for syphilis, total arch replacement was performed successfully using meticulous brain protection with antegrade selective cerebral perfusion and deep hypothermia. He recovered without any further cerebral deficits. The pathological examination of the surgical specimen showed some characteristic changes of syphilitic aortitis.

Desulfovibrio desulfuricans bacteremia in a patient hospitalized with acute cerebral infarction: case report and review.

Desulfovibrio spp. can be found in soil, water, and sewage, as well as in the digestive tracts of animals and humans. We report a case of Desulfovibrio desulfuricans bacteremia during hospitalization with acute cerebral infarction following aspiration bronchopneumonia and severe diarrhea, and the case strongly suggests that Desulfovibrio spp. bacteremia can occur as an infection due to disturbance of endogenous gut flora including antibiotic administration. Because Desulfovibrio spp. is difficult to detect in short-time incubation, its bacteremia is possibly overlooked in hospitalized patients. A few clinical cases of D. desulfuricans bacteremia have been reported in Japan, and they are reviewed briefly in this article.