Case Report: Encephalitis Caused by Balamuthia mandrillaris in a 3-Year-Old Iranian Girl.

It is about half a century since free-living amoebae were recognized as pathogenic organisms, but there is still much we should learn about these rare fatal human infectious agents. A recently introduced causative agent of granulomatous amoebic encephalitis, Balamuthia mandrillaris, has been reported in a limited number of countries around the world. A 3-year-old girl was referred to our tertiary hospital because of inability to establish a proper diagnosis. She had been experiencing neurologic complaints including ataxia, altered level of consciousness, dizziness, seizure, and left-sided hemiparesis. The patient's history, physical examination results, and laboratory investigations had led to a wide differential diagnosis. Computed tomography (CT) scan and magnetic resonance imaging analyses revealed multiple mass lesions. As a result, the patient underwent an intraoperative frozen section biopsy of the brain lesion. The frozen section study showed numerous cells with amoeba-like appearances in the background of mixed inflammatory cells. Medications for free-living amoebic meningoencephalitis were administered. PCR assay demonstrated B. mandrillaris as the pathogenic amoeba. Unfortunately, the patient died 14 days after her admission. To our knowledge, this is the first report of B. mandrillaris meningoencephalitis in the Middle East and the first time we have captured the organism during a frozen-section study.

A case of neurocysticercosis with an unusual presentation on high seas.

Every seafarer undergoes a medical examination prior to joining a ship. Some disorders cannot be detected and they may appear while at sea. Diagnosing and managing them becomes extremely difficult for the Master being the caregiver on board. Large crude carriers often perform long voyages and due to their sheer size, do not enter any port. Helicopter evacuation of a sick or injured crew is the norm. They operate under strict chartering time lines which do not permit deviation from course. A case of hemiparesis on left side of body in a young hitherto healthy seafarer which was later diagnosed as a case of neurocysticercosis is described.

Schistosomal Cervical Myelopathy

Schistosomiasis is an infectious disease caused by trematode platyhelminths of the genus Schistosoma. The involvement of the cervical spinal cord is rare, with few cases reported in the literature. The management of such patients is particularly challenging, since clinical and radiological findings may be confounded with other inflammatory diseases and/ or spinal cord tumors. We describe a 20-year old male with a history of swimming outdoors. He first presented pain in the back of the neck extending to shoulders and upper limbs paresis associated with four limbs hyperreflexia. The magnetic resonance imaging (MRI) showed a hypointense T1-weighted lesion in the cervical spinal cord, which was hyperintense on T2 images. The serologic testing was negative for schistosomiasis. A cervical cord biopsy at the C5-C6 level showed Schistosoma eggs in the histopathological examination. The treatment was performed using a single dose of praziquantel 50 mg/kg, with prednisone 40 mg/day for 3 weeks. On the follow-up, 1 year later, the patient presented mild reduction of the vibratory sensitivity in the distal third of both legs. Our illustrative case strengthens that, in endemic regions, Schistosoma mansoni infestation should be included in the differential diagnosis of intramedullary expansive lesions.

A esquistossomose é uma doença infecciosa causada por platelmintos trematódeos do gênero Schistosoma. O acometimento da medula espinhal cervical é raro, com poucos casos apresentados na literatura. O manejo desses pacientes é particularmente difícil, uma vez que os achados clínicos e radiológicos podem ser confundidos com outras doenças inflamatórias e/ou tumores da medula espinhal. Descrevemos um homem de 20 anos de idade com história de natação ao ar livre. Primeiramente, ele apresentou cervicalgia que se estendeu até os ombros e paresia dos membros superiores, associada à hiperreflexia de quatro membros. A ressonância magnética (RM) mostrou lesão hipointensa em T1 na medula espinhal cervical, a qual foi hiperintensa nas imagens em T2. O teste sorológico foi negativo para esquistossomose. Uma biópsia da medula cervical ao nível C5-C6 evidenciou ovos de Schistosoma no exame histopatológico. O tratamento foi realizado com dose única de praziquantel 50 mg/ kg, com prednisona 40 mg/dia por 3 semanas. No seguimento de 1 ano, o paciente apresentou discreta redução da sensibilidade vibratória no terço distal de ambas as pernas. Nosso caso ilustrativo reforça que, em regiões endêmicas, a infestação pelo Schistosoma mansoni deve ser incluída no diagnóstico diferencial de lesões expansivas intramedulares.

Nematode eggs observed in cytology of cerebrospinal fluid diagnostic for intramedullary Spirocerca lupi spinal cord migration.

Spinal spirocercosis due to aberrant Spirocerca lupi nematode migration is an emerging etiology for acute myelitis in dogs in Israel, causing severe, mostly nonsymmetrical hind limb paresis or paralysis, and sometimes tetraparesis or tetraparalysis. So far, incidental identification of parasites during spinal surgery or at necropsy provides the only definite diagnosis, while antemortem diagnosis of this condition has been uncertain. Specifically, antemortem diagnosis is based on the typical clinical presentation of acute, progressive, asymmetrical hind limb paresis or paralysis, with moderate to severe eosinophilic to mixed cerebrospinal fluid (CSF) pleocytosis and increased CSF protein concentration. Exclusion of other differential diagnoses also requires using spinal cord imaging. In this novel report, we document a case of an intradural spinal spirocercosis in a dog, diagnosed antemortem, by detecting S lupi eggs in the CSF, and subsequent treatment, resulting in the resolution of the clinical signs.

A clinical case of neosporosis in a 4-week-old holstein friesian calf which developed hindlimb paresis postnatally.

A 4-week-old female Holstein Friesian calf presented with hindlimb paresis. Neurologic examination of spinal reflexes revealed depressed or absent reflexes of the hindlimbs. Menace responses on both sides disappeared on examination of cranial nerves. The calf was finally diagnosed with Neospora caninum infection by pathological findings including nonsuppurative inflammation associated with cysts in the cerebrum and spinal cord. High levels of antibody against recombinant surface antigen 1 of N. caninum (NcSAG1) were detected by ELISA from both serum and cerebrospinal fluid (CSF) samples. This result suggests that detection of antibodies against N. caninum by NcSAG1-ELISA in serum and CSF could be useful for the clinical diagnosis of neosporosis in calves with acquired neurological signs.

Hemiparesis post cerebral malaria.

Cerebral malaria is one of the most serious complications in the Plasmodium falciparum infection. In endemic areas, the cerebral malaria interested mainly children. The occurrence in adults is very rare and most interested adult traveling in tropical zones. This case report describes a motor deficit post cerebral malaria in a young adult traveling in malaria endemic area. This complication has been reported especially in children and seems very rare in adults.

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.

Neurological sequelae in survivors of cerebral malaria.

INTRODUCTION: Cerebral malaria is a common cause of neurological sequelae and death in childhood. Information on persistent neurological sequelae post hospital discharge and their predisposing factors are scarce. METHODS: This is a prospective study describing persisting neurological impairments post discharge among children treated for cerebral malaria. In addition the study was designed to investigate the frequency of persistent neurologic deficits and the risk factors for their persistence in these patients. The case records of 160 patients treated for CM at the Paediatrics Department of University College Hospital, Ibadan from January 2004 to November 2006 were reviewed to recruit cases. Recruited survivors were then followed up for information concerning the presence and persistence of neurological sequelae. RESULTS: A total of 160 children aged 9 months to 134 months were admitted and treated for CM during the study period. One hundred and thirty one (81.9%) survived while 29 (18.1%) died. The 131 survivors of cerebral malaria consisted of 64 boys and 67 girls. Neurological sequelae occurred in 13.7% of survivors of cerebral malaria at discharge and 4.6% at follow up. Six children with neurological deficits at discharge had persistence of deficits 6 months post-hospital discharge and one at 24 months. No associations were found between hypoglycemia, anemia, age, sex and multiplicity of convulsions, and persistence of neurologic sequelae. The persisting neurologic deficits among survivors at follow up were: memory impairment (1.5%), seizure disorders (0.8%), visual impairment (0.8%), speech impairment (0.8%), monoparesis (0.8%) and hyperactivity (0.8%) at follow up. The longest persisting sequelae lasted for at least 24 months. CONCLUSION: Neurologic deficits are not uncommon complications of CM. Neurologic sequelae may persist for as long as 24 months or more in survivors of childhood CM. There is no association between the risk factors for neurologic deficits and persistent neurologic sequelae.

Clinico-radiological aspects of neurocysticercosis in pediatric population in a tertiary hospital.

INTRODUCTION: Neurocysticercosisis common in developing countries including Nepal. Clinicalpresentations vary depending on the CT scan findings of head. Adequate information of neurocysticercosis in children from Western Nepal is lacking. This study was conducted with an objective of evaluating the most common clinical and radiological picture in children suffering from NCC at a tertiary care teaching hospital in Western Nepal. METHODS: Hospital records of all pediatric inpatients, admitted from 16th June 2010 to 15th December 2012, consistent with the diagnosis of Neurocysticercosis were reviewed. RESULTS: Forty nine cases of neurocysticercosis were enrolled. Their age varied 2.6 years to 14 years with the mean age of 10.6 years and the peak age was at 12 years with slight male predominance, ratio being male:female 1.2:1. The commonest presentation was seizures (n=38; 77.5 %); partial seizures being most common. Most of the lesions were single (n=44; 89.8%), predominantly in the parietal region (n=20; 40.8%) and most were in transitional stage (61.22%) in Computed tomography (CT).However, number of lesions from CT scan of head showed no significance in association with seizure types (p=0.84). In addition, perilesional edema and scolex within the lesion were noted in 67.34% and 18.36% of the cases respectively. CONCLUSIONS: Any child presenting with acute onset of afebrile seizure should be screened for neurocysticercosis provided other common infective and metabolic causes are ruled out. CT scan is the valuable diagnostic tool to support our diagnosis.

Percutaneous CT-guided treatment of recurrent spinal cyst hydatid.

The involvement of spinal column in cyst hydatid disease is rare and hard to treat. The gold standard treatment is total removal of the cysts without rupture. However, recurrence after surgery is almost inevitable and reoperations carries technical difficulties and higher morbidity. We present a 69-year-old woman with two cystic masses at the T12 level, which compress the spinal cord causing severe paresis in her left leg. Under local anestesia, the cysts were aspirated and irrigated with 20% hypertonic saline solution via bilateral T12 transpedicular route. We aimed to report that percutaneous CT guided treatment should be considered as an alternative therapeutic option in case of recurrent spinal cyst hydatid.

Primary spinal extradural hydatid cyst in a child: case report and review of the literature.

Spinal hydatid cyst is a rare but serious condition. An 8-year-old boy presented with back pain, progressive weakness and numbness in both legs. Magnetic resonance imaging (MRI) of the lumbar region showed a cystic lesion with regular contour located in extradural space. There was cerebrospinal fluid- (CSF-) like signal intensity on T1- and T2-weighted images. The lesion had excessively compressed the dural sac and caudal roots, and expanded to the L3 and L4 neural foramina. The case was explored with L2, L3, L4 laminectomy and the hydatid cyst was removed totally. The clinical presentation, diagnosis and surgical treatment of this rare case of spinal hydatid disease is discussed, and all available cases of primary extradural hydatid cyst reported in the literature are presented.

Toxoplasmic encephalitis in patients with acquired immunodeficiency syndrome--four case reports.

Four patients, all males aged 40-64 years, presented with toxoplasmic encephalitis associated with human immunodeficiency virus (HIV) infection manifesting as nonspecific neurological deficits such as epilepsy or hemiparesis. Magnetic resonance imaging showed single or multiple lesions with ring enhancement, mimicking metastatic brain tumor or brain abscess. Marked eosinophilia was noted in three patients. Two patients who received anti-toxoplasma chemotherapy in the early stage had a good outcome. However, the other two patients suffered rapid neurological deterioration and needed decompressive surgery, resulting in a poor outcome. Toxoplasma diffusely infects the whole central nervous system from the early stage. The outcome for patients who needed emergency surgery was poor. Therefore, this rare but increasingly common infectious disease must be considered in the differential diagnosis of a patient with neuroimaging findings similar to those of metastatic tumor or brain abscess. Appropriate chemotherapy should be started immediately after HIV-positive reaction is identified in patients with single or multiple mass lesions with ring enhancement.

Clinics in diagnostic imaging (52). Spinal cord schistosomiasis.

A 2-year-old Brazilian boy presented with bilateral leg weakness and constipation, followed by development of progressive paraparesis and bladder dysfunction. Neurological examination revealed flaccid paraparesis. Blood tests and CSF analysis showed eosinophilia. The MR examination revealed a spinal cord mass extending from T9 to L1 levels, with a heterogeneously-enhancing solid component and a cystic component. Stool tests for Schistosoma mansoni eggs were positive. The patient underwent surgery, the intramedullary mass was partially resected, and the diagnosis of spinal cord infection by Schistosoma mansoni was confirmed. After surgery, the patient was treated with praziquantel and oxamniquine. He was discharged with partial improvement of the lower extremity weakness and bowel/bladder function. The clinical and imaging features of spinal cord schistosomiasis are reviewed.

MRI of cerebral alveolar echinococcosis.

Cerebral alveolar echinococcosis is rare. We report a case with multiple intracranial masses which show cauliflower-like contrast enhancement pattern on MRI. The lesions originated from hepatic involvement with invasion of the inferior vena cava.