Risk of dementia in patients with toxoplasmosis: a nationwide, population-based cohort study in Taiwan.

BACKGROUND: Approximately 25-30% of individuals worldwide are infected with Toxoplasma gondii (T. gondii), which is difficult to detect in its latent state. We aimed to evaluate the association between toxoplasmosis, the risk of dementia, and the effects of antibiotics in Taiwan. METHODS: This nationwide, population-based, retrospective cohort study was conducted using the Longitudinal Health Insurance Database containing the records of 2 million individuals retrieved from Taiwan's National Health Insurance Research Database. Fine-Gray competing risk analysis was used to determine the risk for the development of dementia in the toxoplasmosis cohort relative to the non-toxoplasmosis cohort. A sensitivity analysis was also conducted. The effects of antibiotics (sulfadiazine or clindamycin) on the risk of dementia were also analyzed. RESULTS: We enrolled a total of 800 subjects, and identified 200 patients with toxoplasmosis and 600 sex- and age-matched controls without toxoplasmosis infection in a ratio of 1:3, selected between 2000 and 2015. The crude hazard ratio (HR) of the risk of developing dementia was 2.570 [95% confidence interval (CI) = 1.511-4.347, P < 0.001]. After adjusting for sex, age, monthly insurance premiums, urbanization level, geographical region, and comorbidities, the adjusted HR was 2.878 (95% CI = 1.709-4.968, P < 0.001). Sensitivity analysis revealed that toxoplasmosis was associated with the risk of dementia even after excluding diagnosis in the first year and the first 5 years. The usage of sulfadiazine or clindamycin in the treatment of toxoplasmosis was associated with a decreased risk of dementia. CONCLUSIONS: This finding supports the evidence that toxoplasmosis is associated with dementia and that antibiotic treatment against toxoplasmosis is associated with a reduced risk of dementia. Further studies are necessary to explore the underlying mechanisms of these associations.

Randomized controlled trial of a six-week spiritual reminiscence intervention on hope, life satisfaction, and spiritual well-being in elderly with mild and moderate dementia.

OBJECTIVE: Reminiscence therapy has been reported to improve the well-being in patients with dementia. However, few studies have examined the effects of spiritual reminiscence, which emphasizes on reconnecting and enhancing the meaning of one's own experience, on patients with dementia. Therefore, this study aimed to investigate the effects of spiritual reminiscence on hope, life satisfaction, and spiritual well-being in elderly Taiwanese with mild or moderate dementia. METHODS: A randomized controlled trial was conducted on 103 patients with mild or moderate dementia recruited from a medical center in central Taiwan. The patients were randomly assigned to either a 6-week spiritual reminiscence group (n = 53) or control group (n = 50). The Herth Hope Index, the Life Satisfaction Scale, the Spirituality Index of Well-Being were administered before and after the 6-week period. RESULTS: The interaction terms between group and time for the three outcome measures were found to be significant (P < 0.001), indicating that the changes over time in them were different between the intervention and control groups. CONCLUSIONS: Findings of this randomized controlled trial showed that hope, life satisfaction, and spiritual well-being of elderly patients with mild or moderate dementia could significantly be improved with a 6-week spiritual reminiscence intervention.

Dementia and neurocysticercosis.

OBJECTIVE: Cysticercosis is a parasitic infestation that can be seen in developing countries with poor sanitation. The infection at brain, called neurocysticercosis, is a serious form. The neurocysticercosis can manifest neuropsychiatric presentations including dementia. METHODS: In this short review, the author briefly summarizes on neurocysticercosis and dementia. RESULTS: In clinical practice, neurocysticercosis can manifest several neuropsychiatric symptoms. Dementia is an important neuropsychiatric manifestation to be mentioned. Many dementia patients have neurocysticercosis as underlying etiology. The problem might be unrecognized by practitioner and this can result in a delayed diagnosed, hence, the concern of the practitioner is required. CONCLUSION: Since the recovery after treatment of parasitic infection is very good, early diagnosis is a critical step determining success of patient management.

Infectious causes of rapidly progressive dementia.

Infections represent an uncommon but important to recognize cause of rapidly progressive dementia, as diagnosis and treatment may produce a favorable outcome in selected instances. This article reviews infectious causes of rapidly progressive dementia, including selected viruses, bacteria, fungi, parasites, and prion diseases. Epidemiology, clinical manifestations, imaging characteristics, laboratory diagnosis, and treatment options are discussed.

Alzheimer's disease - a neurospirochetosis. Analysis of the evidence following Koch's and Hill's criteria.

It is established that chronic spirochetal infection can cause slowly progressive dementia, brain atrophy and amyloid deposition in late neurosyphilis. Recently it has been suggested that various types of spirochetes, in an analogous way to Treponema pallidum, could cause dementia and may be involved in the pathogenesis of Alzheimer's disease (AD). Here, we review all data available in the literature on the detection of spirochetes in AD and critically analyze the association and causal relationship between spirochetes and AD following established criteria of Koch and Hill. The results show a statistically significant association between spirochetes and AD (P = 1.5 × 10-17, OR = 20, 95% CI = 8-60, N = 247). When neutral techniques recognizing all types of spirochetes were used, or the highly prevalent periodontal pathogen Treponemas were analyzed, spirochetes were observed in the brain in more than 90% of AD cases. Borrelia burgdorferi was detected in the brain in 25.3% of AD cases analyzed and was 13 times more frequent in AD compared to controls. Periodontal pathogen Treponemas (T. pectinovorum, T. amylovorum, T. lecithinolyticum, T. maltophilum, T. medium, T. socranskii) and Borrelia burgdorferi were detected using species specific PCR and antibodies. Importantly, co-infection with several spirochetes occurs in AD. The pathological and biological hallmarks of AD were reproduced in vitro by exposure of mammalian cells to spirochetes. The analysis of reviewed data following Koch's and Hill's postulates shows a probable causal relationship between neurospirochetosis and AD. Persisting inflammation and amyloid deposition initiated and sustained by chronic spirochetal infection form together with the various hypotheses suggested to play a role in the pathogenesis of AD a comprehensive entity. As suggested by Hill, once the probability of a causal relationship is established prompt action is needed. Support and attention should be given to this field of AD research. Spirochetal infection occurs years or decades before the manifestation of dementia. As adequate antibiotic and anti-inflammatory therapies are available, as in syphilis, one might prevent and eradicate dementia.

Cognitive impairment and dementia in neurocysticercosis: a cross-sectional controlled study.

OBJECTIVES: Neurocysticercosis (NCYST) is the most frequent CNS parasitic disease worldwide, affecting more than 50 million people. However, some of its clinical findings, such as cognitive impairment and dementia, remain poorly characterized, with no controlled studies conducted so far. We investigated the frequency and the clinical profile of cognitive impairment and dementia in a sample of patients with NCYST in comparison with cognitively healthy controls (HC) and patients with cryptogenic epilepsy (CE). METHODS: Forty treatment-naive patients with NCYST, aged 39.25 +/- 10.50 years and fulfilling absolute criteria for definitive active NCYST on MRI, were submitted to a comprehensive cognitive and functional evaluation and were compared with 49 HC and 28 patients with CE of similar age, educational level, and seizure frequency. RESULTS: Patients with NCYST displayed significant impairment in executive functions, verbal and nonverbal memory, constructive praxis, and verbal fluency when compared with HC (p < 0.05). Dementia was diagnosed in 12.5% patients with NCYST according to DSM-IV criteria. When compared with patients with CE, patients with NCYST presented altered working and episodic verbal memory, executive functions, naming, verbal fluency, constructive praxis, and visual-spatial orientation. No correlation emerged between cognitive scores and number, localization, or type of NCYST lesions on MRI. CONCLUSIONS: Cognitive impairment was ubiquitous in this sample of patients with active neurocysticercosis (NCYST). Antiepileptic drug use and seizure frequency could not account for these features. Dementia was present in a significant proportion of patients. These data broaden our knowledge on the clinical presentations of NCYST and its impact in world public health.

Unusual cause of dementia in an immunocompetent host: toxoplasmic encephalitis.

A 69-year-old male was presented with a 2-month history of cognitive decline. The most profound deficit was observed in short-term verbal and visual memory and recognition. He was otherwise healthy, apart from atrial fibrillation diagnosed 5 months before. Brain MRI revealed T2 hyperintensities in the left thalamus, right pulvinar thalami, both putamina and right head of caudate nucleus without diffusion restriction on DWI sequences. CSF examination revealed elevated proteins. He was HIV negative. The course of the disease was complicated with gram negative sepsis and the patient died 14 days later. Autopsy revealed the brain lesions to have been caused by toxoplasmic encephalitis. Toxoplasmic encephalitis is an extremely rare cause of rapidly progressive dementia in immunocompetent patients. In patients with multiple lesions, hyperintense on T2 and hypointense on T1 weighted sequences, without diffusion restriction and some expansive effect, infectious causes should be considered, even in the absence of classical signs of infectious diseases and CSF pleocythosis.

Pleomorphism of the clinical manifestations of neurocysticercosis.

Neurocysticercosis (NCC) remains a major public health problem in developing countries as it is the most common helminthic infection of the central nervous system. Clinical manifestations are non-specific and pleomorphic. Case reports on uncommon presentations of NCC are few. We report six interesting cases of NCC with unusual clinical presentation that demonstrate this spectrum of pleomorphism. These include extrapyramidal disease (parkinsonism and focal dystonia), Kluver-Bucy syndrome, Weber's syndrome, dementia and cortical blindness. The clinical details and possible mechanisms for the uncommon presentations are also discussed. Thus, a high level of suspicion should be kept for NCC, especially in endemic zones and developing countries.

Treating dementia patients with vascular lesions with donepezil: a preliminary analysis.

Sixteen patients with Alzheimer's disease (AD) and 15 patients with vascular dementia (VaD) associated with subcortical white matter lesions or subcortical cardiovascular accidents (CVAs) were treated with donepezil for 16 weeks. Within-group analyses for the AD group revealed significant improvement on some tests of working memory, and marginal improvement on the Mini-Mental State Examination and on tests of immediate free recall from a serial list-learning task. Identical analyses for the VaD group revealed substantial gains on tests of working memory and delayed recognition memory. These data suggest that medication such as donepezil may act to improve the working memory deficits known to be associated with dementia patients with subcortical vascular lesions. The clinical implications of these findings are discussed.

The serological surveillance of several groups of patients using antigens of Encephalitozoon hellem and E. cuniculi antibodies to microsporidia in patients.

This study was undertaken to attempt to identify correlations between microsporidial seroprevalence data in man, clinical diseases and groups of people at the risk of HIV/AIDS infection. Groups of patients were selected according to the predilection of members of the genus Encephalitozoon for nervous and kidney tissue. Female prostitutes and alcohol and intravenous drug abusers were selected as groups at risk of HIV/AIDS infections. A total of 401 samples of human sera were examined for the presence of antimicrosporidial IgG antibodies by ELISA test with a titre of 600 considered borderline positivity. The highest occurrence of antimicrosporidial antibodies was found in the groups of alcohol abusers (16% from 43 patients), intravenous drug abusers (11% from 9 patients) and prostitutes (10% from 80 women) for E. cuniculi antigen and in the groups of psychiatric patients (14% from 44 patients), malaria patients (11% from 38 patients) and alcohol abusers (7% from 43 patients) for E. hellem antigen. The occurrence of specific antibodies of the six examined diagnostic units (glomerulonephritis chronica, pyelonephritis chronica, schizophrenia, dementia, multiple sclerosis and cerebral stroke) was statistically significant only in patients with pyelonephritis chronica and dementia (p < 0.05). No cases of microsporidial infection were found among the female prostitutes by parasitological examination, although one case of giardiasis was identified. Sera of patients with high anti-E. cuniculi and anti-E. hellem antibodies (titres in ELISA of 600 and above) were confirmed by Western blot using E. cuniculi and E. hellem polypeptides, respectively. These results suggest that the examined patients could show residual antibodies from past or latent infections.

Perceptual attention in aging and dementia measured by Gottschaldt's Hidden Figure Test.

Gottschaldt's Hidden Figure Test (GHFT) calls for figure-ground discrimination abilities. The aim of this study was to provide a perceptual attention test for the cognitive assessment of demented patients. In Experiment 1, GHFT normal baselines on 190 healthy controls are achieved, and age-education score correction as well as transformation of the original scores into "Equivalent Scores" is established. On the inferential percentile allocation of 45 mildly-moderately deteriorated DAT patients, 65% of them performed in the critically low range of the score distribution. In Experiment 2, the discriminant power of GHFT between DAT patients and healthy controls matched by age and Experiment 2, the discriminant power of GHFT between DAT patients and healthy controls matched by age and education is assessed. Overall correct classification reached 90%. This experiment shows that GHFT in demented patients works chiefly as an attentional task. The discussion is based largely on methodological and statistical issues.

Cysticercosis--review of 230 patients.

Two hundred thirty patients with cysticercosis were reviewed. Investigation with CT scan has led to a more detailed understanding of the natural history of human infestation which is essential to the evaluation of new pharmacological and neurosurgical treatments. In contrast to reports emphasizing the need to extirpate all intraventricular cysts, many of our patients needed only ventricular shunt implantation. The ability to evaluate and reevaluate hydrocephalus by CT scan permitted comfortable use of ventricular shunt insertion as the only treatment. Nevertheless, cysts in the fourth ventricle should nearly always be extirpated, because these cysts, by their mass effect, may cause herniation even after shunt implantation. Serious morbidity and death occur chiefly in patients who develop hydrocephalus from intraventricular and basilar infestation. It is unlikely that praziquantel will be effective in patients who present with symptoms of hydrocephalus.

CNS cysticercosis--a problem of differential diagnosis.

Although a well-known disease worldwide, cerebral cysticercosis in European countries is a rare event. Due to increased travel to East-Asian and Latin American countries it is possible that the occurrence of brain cysticercosis will become more frequent. These facts should remind us of the possibility of cysticercosis of the nervous system. A case of cerebral and spinal cord cysticercosis is presented, causing symptoms of progressive dementia with ventricular occlusion and hydrocephalus. Differential diagnosis causes a major problem. It is shown that myelography may demonstrate characteristic features of the disease.