Tricuspid valve infective endocarditis associated with aseptic meningitis: a rare presentation in a child. / Endocarditis infecciosa de la válvula tricúspide asociada con meningitis aséptica: presentación infrecuente en una niña.

Infective endocarditis (IE) is a rare but a potentially life-threatening infectious disease. Atypical presentations cause delays in the diagnosis. Neurological involvement such as meningitis or meningismus, are especially common in mitral valve endocarditis, but unusual in tricuspid valve endocarditis. Although few cases of right-sided IE have been reported with neurological symptoms in adults, children have not been described in literature. A nine-year-old girl with congenital ventricular septal defect (VSD) was admitted with fever, headache and neck stiffness. Her clinical symptoms and cerebrospinal fluid findings supported the aseptic meningitis. On ceftriaxone therapy day 3, her complaints were resolved; nine days later she was admitted with fever and neck stiffness again. Further investigation for fever source with echocardiogram revealed a tricuspid valve endocarditis. Antibiotic therapy was completed after 6 weeks. Cardiac surgery was performed for VSD and tricuspid valvular insufficiency.

La endocarditis infecciosa es infrecuente pero potencialmente mortal. Las presentaciones atípicas retrasan el diagnóstico. El compromiso neurológico es habitual en la endocarditis de la válvula mitral, aunque infrecuente en la endocarditis de la válvula tricúspide. Si bien se han informado algunos casos e el del lado derecho con síntomas neurológicos en adultos, en la bibliografía no se ha descripto en niños. Se presenta una niña de 9 años con comunicación interventricular (CIV) congénita con fiebre, cefalea y rigidez de nuca. Sus síntomas clínicos y los hallazgos en el líquido cefalorraquídeo respaldaron el diagnóstico de meningitis aséptica. El día 3 del tratamiento con ceftriaxona, se resolvieron los síntomas; tras nueve días, reingresó con fiebre y rigidez de nuca. Un ecocardiograma mostró endocarditis de la válvula tricúspide. Recibió tratamiento antibiótico durante 6 semanas. Se realizó una cirugía cardíaca para la CIV y la insuficiencia de la válvula tricúspide.

Síndrome de meningitis y retención urinaria / Meningitis-retention syndrome. Report of one case

The Meningitis-Retention Syndrome associates aseptic meningitis and neurogenic bladder, with a vesical dysfunction that outlasts meningitis widely. Urodynamic assessment shows a detrusor palsy with normal function of the external sphincter. We report a 24-year-old male admitted for headache, fever, myalgias and acute urinary retention, which was diagnosed as a urinary tract infection. Worsening of symptoms and slight meningeal signs prompted for a lumbar puncture that yielded a cerebrospinal fluid with 94 lymphocytes, in which etiological evaluation was inconclusive. Meningeal syndrome and myalgia subsided by the fifth day, while urinary retention persisted. A magnetic resonance imaging of the brain and spinal cord done at the fifth day, showed high intensity signals in basal ganglia and central spinal cord, not altered by contrast. These images disappeared in the imaging control performed two months later. Bladder dysfunction lasted at least until the second month of follow up.

[Meningitis-retention syndrome. Report of one case]. / Síndrome de meningitis y retención urinaria.

The Meningitis-Retention Syndrome associates aseptic meningitis and neurogenic bladder, with a vesical dysfunction that outlasts meningitis widely. Urodynamic assessment shows a detrusor palsy with normal function of the external sphincter. We report a 24-year-old male admitted for headache, fever, myalgias and acute urinary retention, which was diagnosed as a urinary tract infection. Worsening of symptoms and slight meningeal signs prompted for a lumbar puncture that yielded a cerebrospinal fluid with 94 lymphocytes, in which etiological evaluation was inconclusive. Meningeal syndrome and myalgia subsided by the fifth day, while urinary retention persisted. A magnetic resonance imaging of the brain and spinal cord done at the fifth day, showed high intensity signals in basal ganglia and central spinal cord, not altered by contrast. These images disappeared in the imaging control performed two months later. Bladder dysfunction lasted at least until the second month of follow up.

Clinical characteristics and outcomes of the meningitides in systemic lupus erythematosus.

BACKGROUND: The meningitides are rare but well-identified complications in patients with systemic lupus erythematosus (SLE). AIMS: To determine the clinical characteristics, risk factors, prevalence and outcomes of the meningitides (septic and aseptic) in patients with SLE. PATIENTS AND METHODS: From January 1988 to December 2006, we identified patients with SLE and septic or aseptic meningitis. RESULTS: We identified 25 episodes of meningitis in 23 patients with SLE, from a total of 1,411 SLE patients (1.63%); in 15 out of 25 episodes, a microorganism was identified. Mycobacterium tuberculosis, Listeria monocytogenes and Criptococcus neoformans represented the main microorganisms. In 10 episodes, aseptic meningitis was diagnosed. Lymphopenia, steroid use, chronic damage and systemic activity of SLE were frequent in both kinds of meningitis. Although the clinical presentation did not differ significantly, patients with septic meningitis had more residual neurological deficits (p = 0.04). CONCLUSIONS: Meningitis was observed in about 1.6% of the patients with SLE; in 40% of the cases, no microorganism could be isolated. A residual neurological deficit was more common in patients with septic meningitis.

Cat scratch disease complicated with aseptic meningitis and neuroretinitis.

Cat scratch disease (CSD) is a self limited condition characterized by fever, lymph node enlargement and less often eye involvement. Central nervous system involvement by Bartonella henselae infection is possibly an important cause of morbidity; its role as an agent of aseptic meningitis is unknown. We report a case of a 40 years-old man with CSD accompanied by aseptic meningitis and neuroretinitis. Serum indirect immmunofluorescence (IFI) assays for B. henselae were positive and the cerebrospinal fluid (CSF) analysis showed mononuclear pleocytosis and increased level of protein. Serological tests for other etiologies were negative. The patient responded well to antibiotic therapy with oral doxycicline plus rifampin and in the 12th day of hospitalization evolved to total regression of the headache and partial regression of the visual loss. Clinicians should consider CSD as a differential diagnosis when assessing previously healthy patients with aseptic meningitis associated with regional lymphadenopathy and epidemiological history of feline contact.

¿Es necesaria la punción lumbar en la evaluación del recién nacido febril sin signos de focalización? / ¿Is it necessary to perform a lumbar puncture in the evaluation of the febrile newborn infant without source?

La evaluación del RN febril incluye efectuar una punción lumbar para detectar un foco meníngeo. Objetivo: Evaluar la utilidad de este procedimiento al ingreso del paciente al hospital y, eventualmente, en una segunda instancia si se justifica clínicamente. Pacientes y Método: Estudiamos 1.841 recién nacidos febriles sin signos de focalización que consultaron en la Unidad de Emergencia entre enero 1992 y diciembre 2000. Todos se sometieron a una evaluación para pesquisa de sepsis. Calculamos la tasa de incidencia de meningitis, y analizamos la frecuencia de meningitis diagnosticada en la evaluación inicial y en una re-evaluación. Resultados: Hubo 206 pacientes con diagnóstico de meningitis (incidencia de 11,2 por ciento), de las cuales 20 fueron bacterianas (1,1 por ciento) y 186 meningitis asépticas (10,1 por ciento). En la evaluación inicial se detectaron 155 pacientes con meningitis (155/ 1.774 = 8,7 por ciento) y en la reevaluación (media de 39,5 ± 25,2 horas más tarde) se diagnosticaron 51 casos más (51/ 135 = 37,8 por ciento). Conclusiones: La meningitis fue un diagnóstico frecuente en recién nacidos febriles sin signos de focalización, predominando la meningitis aséptica. En casi 25 por ciento de los casos se llegó a este diagnóstico mediante la ejecución de la punción lumbar al ser re-evaluados(AU)

Lumbar puncture to detect bacterial meningitis is a recommended screening procedure to be performed in febrile newborn infants at admission to hospital. Objective: To evaluate the usefulness of this procedure performed at admission and eventually, in a second look if clinically justified. Patients and method: There were studied 1,841 febrile newborns consulting at the Emergency Department from January 1992 to December 2000 without source. All of them underwent a sepsis workup. The rate of meningitis incidence was calculated, and we analyzed the frequency of meningitis diagnosed in the initial evaluation and reappraisal. Results: There were 206 febrile patients with diagnosis of meningitis for an incidence of 11.2 percent, which 20 were bacterial (1.1percent) and 186 aseptic meningitis (10.1 percent). In the initial evaluation 155 patients were diagnosed with meningitis (155/ 1.774 = 8.7 percent) and in reappraisal (mean 39,5 ± 25,2 hours after) there were diagnosed another 51 cases (51/ 135 = 37.8 percent). Conclusions: The meningitis was a common diagnosis in febrile newborns without source, with prevalence of aseptic meningitis. In almost 25percent of cases we reached to this diagnosis by means of performing lumbar puncture after a reappraisal(AU)

[Is it necessary to perform a lumbar puncture in the evaluation of the febrile newborn infant without source?]. / Es necesaria la punción lumbar en la evaluación del recién nacido febril sin signos de focalización?

UNLABELLED: Lumbar puncture to detect bacterial meningitis is a recommended screening procedure to be performed in febrile newborn infants at admission to hospital. OBJECTIVE: To evaluate the usefulness of this procedure performed at admission and eventually, in a second look if clinically justified. PATIENTS AND METHOD: There were studied 1,841 febrile newborns consulting at the Emergency Department from January 1992 to December 2000 without source. All of them underwent a sepsis workup. The rate of meningitis incidence was calculated, and we analyzed the frequency of meningitis diagnosed in the initial evaluation and reappraisal. RESULTS: There were 206 febrile patients with diagnosis of meningitis for an incidence of 11.2%, which 20 were bacterial (1.1%) and 186 aseptic meningitis (10.1%). In the initial evaluation 155 patients were diagnosed with meningitis (155/ 1.774 = 8.7%) and in reappraisal (mean 39,5 +/- 25,2 hours after) there were diagnosed another 51 cases (51/ 135 = 37.8%). CONCLUSIONS: The meningitis was a common diagnosis in febrile newborns without source, with prevalence of aseptic meningitis. In almost 25% of cases we reached to this diagnosis by means of performing lumbar puncture after a reappraisal.

¿Es necesaria la punción lumbar en la evaluación del recién nacido febril sin signos de focalización? / ¿Is it necessary to perform a lumbar puncture in the evaluation of the febrile newborn infant without source?

La evaluación del RN febril incluye efectuar una punción lumbar para detectar un foco meníngeo. Objetivo: Evaluar la utilidad de este procedimiento al ingreso del paciente al hospital y, eventualmente, en una segunda instancia si se justifica clínicamente. Pacientes y Método: Estudiamos 1.841 recién nacidos febriles sin signos de focalización que consultaron en la Unidad de Emergencia entre enero 1992 y diciembre 2000. Todos se sometieron a una evaluación para pesquisa de sepsis. Calculamos la tasa de incidencia de meningitis, y analizamos la frecuencia de meningitis diagnosticada en la evaluación inicial y en una re-evaluación. Resultados: Hubo 206 pacientes con diagnóstico de meningitis (incidencia de 11,2 por ciento), de las cuales 20 fueron bacterianas (1,1 por ciento) y 186 meningitis asépticas (10,1 por ciento). En la evaluación inicial se detectaron 155 pacientes con meningitis (155/ 1.774 = 8,7 por ciento) y en la reevaluación (media de 39,5 ± 25,2 horas más tarde) se diagnosticaron 51 casos más (51/ 135 = 37,8 por ciento). Conclusiones: La meningitis fue un diagnóstico frecuente en recién nacidos febriles sin signos de focalización, predominando la meningitis aséptica. En casi 25 por ciento de los casos se llegó a este diagnóstico mediante la ejecución de la punción lumbar al ser re-evaluados.

Lumbar puncture to detect bacterial meningitis is a recommended screening procedure to be performed in febrile newborn infants at admission to hospital. Objective: To evaluate the usefulness of this procedure performed at admission and eventually, in a second look if clinically justified. Patients and method: There were studied 1,841 febrile newborns consulting at the Emergency Department from January 1992 to December 2000 without source. All of them underwent a sepsis workup. The rate of meningitis incidence was calculated, and we analyzed the frequency of meningitis diagnosed in the initial evaluation and reappraisal. Results: There were 206 febrile patients with diagnosis of meningitis for an incidence of 11.2 percent, which 20 were bacterial (1.1 percent) and 186 aseptic meningitis (10.1 percent). In the initial evaluation 155 patients were diagnosed with meningitis (155/ 1.774 = 8.7 percent) and in reappraisal (mean 39,5 ± 25,2 hours after) there were diagnosed another 51 cases (51/ 135 = 37.8 percent). Conclusions: The meningitis was a common diagnosis in febrile newborns without source, with prevalence of aseptic meningitis. In almost 25 percent of cases we reached to this diagnosis by means of performing lumbar puncture after a reappraisal.

Cat scratch disease complicated with aseptic meningitis and neuroretinitis

Cat scratch disease (CSD) is a self limited condition characterized by fever, lymph node enlargement and less often eye involvement. Central nervous system involvement by Bartonella henselae infection is possibly an important cause of morbidity; its role as an agent of aseptic meningitis is unknown. We report a case of a 40 years-old man with CSD accompanied by aseptic meningitis and neuroretinitis. Serum indirect immmunofluorescence (IFI) assays for B. henselae were positive and the cerebrospinal fluid (CSF) analysis showed mononuclear pleocytosis and increased level of protein. Serological tests for other etiologies were negative. The patient responded well to antibiotic therapy with oral doxycicline plus rifampin and in the 12th day of hospitalization evolved to total regression of the headache and partial regression of the visual loss. Clinicians should consider CSD as a differential diagnosis when assessing previously healthy patients with aseptic meningitis associated with regional lymphadenopathy and epidemiological history of feline contact.

An outbreak of eosinophilic meningitis caused by Angiostrongylus cantonensis in travelers returning from the Caribbean.

BACKGROUND: Outbreaks of eosinophilic meningitis caused by the roundworm Angiostrongylus cantonensis are rarely reported, even in regions of endemic infection such as Southeast Asia and the Pacific Basin. We report an outbreak of A. cantonensis meningitis among travelers returning from the Caribbean. METHODS: We conducted a retrospective cohort study among 23 young adults who had traveled to Jamaica. We used a clinical definition of eosinophilic meningitis that included headache that began within 35 days after the trip plus at least one of the following: neck pain, nuchal rigidity, altered cutaneous sensations, photophobia, or visual disturbances. RESULTS: Twelve travelers met the case definition for eosinophilic meningitis. The symptoms began a median of 11 days (range, 6 to 31) after their return to the United States. Eosinophilia was eventually documented in all nine patients who were hospitalized, although on initial evaluation, it was present in the peripheral blood of only four of the nine (44 percent) and in the cerebrospinal fluid of five (56 percent). Repeated lumbar punctures and corticosteroid therapy led to improvement in symptoms in two of three patients with severe headache, and intracranial pressure decreased during corticosteroid therapy in all three. Consumption of one meal (P=0.001) and of a Caesar salad at that meal (P=0.007) were strongly associated with eosinophilic meningitis. Antibodies against an A. cantonensis--specific 31-kD antigen were detected in convalescent-phase serum samples from 11 patients. CONCLUSIONS: Among travelers at risk, the presence of headache, elevated intracranial pressure, and pleocytosis, with or without eosinophilia, particularly in association with paresthesias or hyperesthesias, should alert clinicians to the possibility of A. cantonensis infection.

Nested PCR for rapid detection of mumps virus in cerebrospinal fluid from patients with neurological diseases.

In this study, we have developed a reverse transcription (RT)-nested polymerase chain reaction (n-PCR) for the detection of mumps virus RNA in cerebrospinal fluid (CSF) from patients with neurological infections. A specific 112-bp fragment was amplified by this method with primers from the nucleoprotein of the mumps virus genome. The mumps virus RT-n-PCR was capable of detecting 0.001 PFU/ml and 0.005 50% tissue culture infective dose/ml. This method was found to be specific, since no PCR product was detected in each of the CSF samples from patients with proven non-mumps virus-related meningitis or encephalitis. Mumps virus RNA was detected in all 18 CSF samples confirmed by culture to be infected with mumps virus. Positive PCR results were obtained for the CSF of 26 of 28 patients that were positive for signs of mumps virus infection (i.e., cultivable virus from urine or oropharyngeal samples or positivity for anti-mumps virus immunoglobulin M) but without cultivable virus in their CSF. Overall, mumps virus RNA was detected in CSF of 96% of the patients with a clinical diagnosis of viral central nervous system (CNS) disease and confirmed mumps virus infection, while mumps virus was isolated in CSF of only 39% of the patients. Furthermore, in a retrospective study, we were able to detect mumps virus RNA in 25 of 55 (46%) CSF samples from patients with a clinical diagnosis of viral CNS disease and negative laboratory evidence of viral infection including mumps virus infection. The 25 patients represent 12% of the 236 patients who had a clinical diagnosis of viral CNS infections and whose CSF was examined at our laboratory for a 2-year period. The findings confirm the importance of mumps virus as a causative agent of CNS infections in countries with low vaccine coverage rates. In summary, our study demonstrates the usefulness of the mumps virus RT-n-PCR for the diagnosis of mumps virus CNS disease and suggests that this assay may soon become the "gold standard" test for the diagnosis of mumps virus CNS infection.

Detection of Leptospira DNA in patients with aseptic meningitis by PCR.

Samples of cerebrospinal fluid from 103 patients with aseptic meningitis were tested by PCR for detection of leptospires, and the results were compared with those of the microscopic agglutination test (MAT) and an enzyme-linked immunosorbent assay for detection of immunoglobulin M (ELISA-IgM). Of these samples, 39.80% were positive by PCR and 8.74 and 3.88% were positive by MAT and ELISA-IgM, respectively.

Hipernatremia grave em paciente portadora de provável meningite asséptica / Acute hypernatremia in patient with probable asseptic meningitis

Nós descrevemos o caso de uma paciente que desenvolveu níveis séricos de sódio de 196 meq/L na véspera do óbito, e 202 meq/L nas amostras de sangue colhidas na manhä do óbito.

Manifestaçöes meníngeas na endocardite infecciosa / Maningeal manifestatious with infectious endocarditis

Säo apresentados três casos fatais de endocardite infecciosa tendo, entre os sintomas iniciais, manifestaçöes meníngeas clínicas e liquóricas que trouxeram dúvidas de interpretaçäo. No primeiro, havia pleocitose no líquor compatível com "meningite asséptica"; na realidade, esse caso foi uma endocardite subaguda no qual foi angiograficamente identificado aneurisma micótico de artéria cerebral média direita, que rompeu posteriormente. No segundo, as manifestaçöes clínicas foram de meningoencefalite piogênica e de hemorragia subaracnóide concomitantes. O terceiro paciente exibiu desde o início alteraçöes clínicas e liquóricas de meningite piogênica e, no segundo exame de líquor, o aspecto era de hemorragia subaracnóidea. Os estudos de necrópsia possibilitaram uma análise clinico-patológica correlata. Faz-se revisäo da literatura sobre as lesöes neurológicas na endocardite infecciosa, recebendo ênfase as alteraçöes meníngeas e os aneurismas micóticos

Inestabilidad ventilatoria en infecciones agudas del sistema nervioso central / Ventilatory inestability in acute infections of the central nervous system

Se evaluaron en forma retrospectiva 114 pacientes egresados del Hospital "Dr. F.J. Muñiz" con diagnóstico de infecciones agudas del sistema nervioso central. Se utilizó como criterio de inclusión, ausencia de patología pleuropulmonar concomitante, que se interpreta como posible factor desencadenante de un cuadro de insuficiencia respiratoria. Todos los pacientes fueron sometidos a asistencia respiratoria mecánica, por distintos criterios y con diferentes parámetros gasométricos previos. La tasa de letalidad global fue del 44,75 por ciento, hallándose en los pacientes ventilados, gasométricamente normales, previa asistencia respiratoria, el menor índice de letalidad, 13,63 por ciento en contraste con aquellos que fueron sometidos a ventilación mecánica con criterios de insuficiencia respiratoria, cuya mortalidad alcanzó el 61,76 por ciento. A pesar de tratarse de un estudio retrospectivo, se desea hacer hincapié en la necesidad de considerar los mecanismos compensatorios ante la hipertensión endocraneana, la hiperventilación, como una inestabilidad ventilatoria en sí, extremando las precauciones para indicar una asistencia ventilatoria precoz, para asegurar una ventilación alveolar efectiva (AU)

Inestabilidad ventilatoria en infecciones agudas del sistema nervioso central / Ventilatory inestability in acute infections of the central nervous system

Se evaluaron en forma retrospectiva 114 pacientes egresados del Hospital "Dr. F.J. Muñiz" con diagnóstico de infecciones agudas del sistema nervioso central. Se utilizó como criterio de inclusión, ausencia de patología pleuropulmonar concomitante, que se interpreta como posible factor desencadenante de un cuadro de insuficiencia respiratoria. Todos los pacientes fueron sometidos a asistencia respiratoria mecánica, por distintos criterios y con diferentes parámetros gasométricos previos. La tasa de letalidad global fue del 44,75 por ciento, hallándose en los pacientes ventilados, gasométricamente normales, previa asistencia respiratoria, el menor índice de letalidad, 13,63 por ciento en contraste con aquellos que fueron sometidos a ventilación mecánica con criterios de insuficiencia respiratoria, cuya mortalidad alcanzó el 61,76 por ciento. A pesar de tratarse de un estudio retrospectivo, se desea hacer hincapié en la necesidad de considerar los mecanismos compensatorios ante la hipertensión endocraneana, la hiperventilación, como una inestabilidad ventilatoria en sí, extremando las precauciones para indicar una asistencia ventilatoria precoz, para asegurar una ventilación alveolar efectiva