Impact of Multiplex Polymerase Chain Reaction Test in Patients With Meningitis or Encephalitis.

Background: The objective of this study was to evaluate the impact of the FilmArray meningitis/encephalitis panel (FAME) on length of stay (LOS) and duration of antimicrobial treatment in children and adults in a Japanese community hospital. Methods: This retrospective cohort study was conducted in Japan between January 2016 and December 2022. We included hospitalized patients with cerebrospinal fluid (CSF) samples and those aged <2 months or who had 5 or more white blood cells/µL in the CSF. To compare the days of therapy (DOT) and LOS between the pre-FAME and FAME periods, multivariate Poisson regression analyses were conducted without an offset term. Results: The number of cases undergoing pathogen-specific polymerase chain reaction increased from 3.7% in the pre-FAME period to 57.5% in the FAME period (P < .001). The pathogen identification rate also increased during the FAME period, from 0.4% to 18.7% (P < .001). While the antibacterial DOT was not statistically different between the 2 periods (adjusted rate ratio [aRR], 1.06 [95% confidence interval {CI}, 1.00-1.13]; P = .063]), the antiviral DOT was significantly shorter in the FAME period (aRR, 0.80 [95% CI, .71-.89]; P < .001). Conclusions: This study revealed a significant reduction in antiviral use during the FAME period, whereas LOS and antibacterial use did not decrease. Given the possibility of factors (eg, the COVID-19 pandemic) affecting the epidemiology of meningitis and encephalitis, the indications and impact of the FAME test should be evaluated with continuous monitoring of the epidemiology of meningitis and encephalitis and its clinical impact.

Lidocaine as a potential therapeutic option for super-refractory status epilepticus: A case report.

New-onset refractory status epilepticus (NORSE) is a rare and devastating condition and the prognosis is often poor, with half to two-thirds of survivors experiencing drug-resistant epilepsy, residual cognitive impairment, or functional disability, and the mortality rate is 16% to 27% for adults. We describe a patient with cryptogenic NORSE and favorable recovery from drug-resistant super-refractory SE after the use of intravenous lidocaine. The patient experienced fever and presented with refractory generalized tonic-clonic seizures. The cause was not found by performing extensive examinations, including cell surface autoantibodies and rat brain immunohistochemistry evaluations. The refractory SE with unresponsiveness to multiple anti-epileptic and prolonged sedative medications, which are necessary for prolonged mechanical ventilation, were ameliorated by additive treatment with intravenous lidocaine initiating at 1 mg/kg/h and maintaining at 2 mg/kg/h for 40 days, which led to freedom from intravenous sedative medication and mechanical ventilation. The patient was able to return to school. Lidocaine may be an optional treatment for cryptogenic NORSE.

Recurrent Guillain-Barré Syndrome Associated with the Second Episode of Campylobacter jejuni Infection.

Guillain-Barré syndrome (GBS) cases are generally monophasic, and recurrence is rare. However, the pathogenesis and pathophysiology of recurrent GBS remain to be fully elucidated. There are few detailed reports of patients who have been infected twice with Campylobacter jejuni and have developed GBS twice. We herein report a case of recurrent GBS in a 21-year-old man with a history of GBS caused by C. jejuni infection at 19 years old. Although our patient was reinfected with C. jejuni, several different anti-ganglioside antibodies were identified, and the clinical manifestations were more severe than those in the first GBS episode. We compared the anti-ganglioside antibodies and nerve conduction studies findings between the two GBS episodes. This case suggested that different antibodies are involved and produce different symptoms even when C. jejuni infection is the trigger in recurrent episodes.

Comparison of comfortable and maximum walking speed in the 10-meter walk test during the cerebrospinal fluid tap test in iNPH patients: A retrospective study.

BACKGROUND: The 10-meter walking test (10 MWT) is widely used during a cerebrospinal fluid tap test (CSFTT) for idiopathic normal-pressure hydrocephalus (iNPH). However, various previous studies and guidelines do not specify whether to adopt a comfortable walking speed or maximum walking speed when implementing the 10 MWT. In this study, we analyzed the values of comfortable and maximum walking speeds during the CSFTT in patients who underwent shunt surgery to determine which walking form is desirable for evaluation. METHODS: The patients were 29 consecutive cases in which a CSFTT was performed, followed by shunting, between October 2012 and April 2019. Data on the 10 MWT comfortable walking speed and maximum walking speed were collected, as were data on the timed up and go (TUG) test and Mini-Mental State Examination (MMSE). We analyzed the rate of change in comfortable walking speed and maximum walking speed before CSFTT and on the first day after CSFTT, and the amount of improvement compared to baseline ability. In addition, diagnostic performance was compared using a receiver operating characteristic (ROC) analysis. RESULTS: Twenty-eight patients who underwent shunt surgery improved their symptoms and were designated as shunt responders. The remaining patient who underwent surgery was considered a non-responder with no improvement in symptoms. The parameters of the shunt responders that changed were muscle strength, the 10 MWT, and the TUG test, and there was no significant change in cognitive function. The rate of change, amount of change, and sensitivity were large at a comfortable walking speed, but ROC analysis showed that the maximum walking speed had a large area under the curve and excellent specificity. The higher the preoperative gait function, the lower the improvement rate of gait function. DISCUSSION: The comfortable walking speed is easy to measure, but its specificity is inferior to the maximum walking speed. However, the maximum walking speed may be affected by the ceiling effect and measurement errors. Despite this, we concluded that the maximum walking speed had a better diagnostic performance. Because the causes of gait disturbance in iNPH include decreased muscle output, postural instability, and gait rhythm disorder, and maximum walking speed is strongly related to each of these factors, this accounts for the changes in maximum walking speed. CONCLUSION: In conclusion, although comfortable walking speed was easy to measure in terms of changes and had high sensitivity, the maximum walking speed had the highest specificity and comprehensive diagnostic performance. It is recommended that maximum walking speed be evaluated when making a definitive diagnosis of iNPH.

Intracranial varicella zoster virus infection may elicit an unusual hyperkinetic volitional tremor.

Central nervous system manifestations of varicella zoster virus (VZV) infection are uncommon, and associated involuntary movement is rare. Herein, we describe a patient with VZV induced encephalopathy who presented with an unusual hyperkinetic volitional tremor.

Characteristics of cognitive function evaluation using the Montreal cognitive assessment in a cerebrospinal fluid tap test in patients with idiopathic normal pressure hydrocephalus.

OBJECTIVES: Though the Japanese version of the Montreal Cognitive Assessment (MoCA-J) scores change after a cerebrospinal fluid tap test (CSFTT), their characteristics remain unclear. To compare patient response rate to changes in cognitive function observed in the cerebrospinal fluid tap test, and to determine which group of patients were good responders. PATIENTS AND METHODS: This study included 32 patients who were suspected of having idiopathic normal pressure hydrocephalus (iNPH) between May 2017 and October 2018. Cases were divided into, following a CSFTT, a gait responder group and a non-responder group. Scores of the MoCA-J were compared and examined before, one day after, and one week after the CSFTT. RESULTS: Significant changes in MoCA-J scores were observed 1 day and 1 week after the CSFTT in the gait responder group. The change in scores was larger, and had a larger effect size, one week after the CSFTT. On assessment, MoCA-J sub-items began to show changes in attention and abstract items one day after the CSFTT, and significant changes were noted in attention and abstract items in addition to executive functions and orientation one week after the CSFTT. The degree of cognitive function before the CSFTT was less closely related to the amount of change. Changes in cognitive function can be assessed at each time point after the CSFTT, and changes in cognitive function are measured regardless of the level of cognitive function. CONCLUSION: These results suggest that evaluating patients with the MoCA-J may potentially support a more accurate iNPH diagnosis.

Changes in Cognitive Function Scores After Cerebrospinal Fluid Tap Testing in Patients with Suspected Idiopathic Normal-Pressure Hydrocephalus.

BACKGROUND: In patients suspected of having idiopathic normal-pressure hydrocephalus (iNPH), improvement in impaired cognition is common after a diagnostic cerebrospinal fluid tap test (CSFTT). Measures used to evaluate cognitive function before and after a CSFTT include the Mini-Mental State Examination (MMSE), Frontal Assessment Battery (FAB), and Trail Making Test (TMT). However, the time point at which cognitive function should be reevaluated after a CSFTT remains controversial. OBJECTIVE: To investigate differences in cognitive function 1 day and 1 week after a CSFTT (versus baseline) in patients with suspected iNPH. METHODS: This retrospective study, conducted between October 2012 and January 2017, involved 39 patients with suspected iNPH. We analyzed their MMSE, FAB, and TMT scores on tests conducted before and 1 day and 1 week after the CSFTT. RESULTS: Changes in MMSE scores were negligible 1 day after the CSFTT but began to appear 1 week later. Changes in FAB scores were observed from 1 day to 1 week after the CSFTT. Although no statistically significant differences in TMT scores were observed at either time point, the execution time for the test tended to be shorter on the day after the CSFTT. Changes in cognitive function were not associated with demographic or morphological parameters. More severe impairments at baseline, however, were associated with greater changes in cognitive function. CONCLUSIONS: Performing several reevaluations using each test may enable more accurate assessment of cognitive function in patients with suspected iNPH. Our results highlight the need for long-term follow-up, regardless of the severity of cognitive impairment.

Acute effects of endurance exercise on nocturnal autonomic functions in sedentary subjects: a pilot study.

Nocturnal heart rate variability (HRV) is thought to reflect healthy recovery function of the autonomic nervous system. Although exercise is recommended for health promotion, exercise itself decreases HRV. We studied acute effect of daytime exercise on nocturnal HRV in 5 healthy adults (age, 22-40 years; 2 female subjects) without regular exercise habit. Using a treadmill, they performed 30-min walking at 4 km/hr and 30-min running at 9 km/hr from 11 a.m. on different days at an interval of 2 weeks. On these days and a day without exercise (control), Holter electrocardiograms were recorded from 9 a.m. for 24 hr. The amplitudes of low-frequency (LF, 0.04-0.15 Hz) and high-frequency (HF, 0.15-0.45 Hz) components of HRV were measured continuously by complex demodulation and were averaged over periods of 11:00-11:30 a.m., 3 hr after going to bed, and time in bed at night. Exercise intensities of the walking and running were at 10% to 44% and 55% to 67% of heart rate reserve, respectively. During exercise, heart rate increased and LF and HF amplitudes decreased with exercise intensity. Nocturnal heart rate and LF and HF amplitude, however, showed no consistent changes with exercise intensity and their averages on the days of walking and running did not differ significantly from those of the control day. In conclusion, 30-min walking and running exercises performed in the morning had no significant acute effects on nocturnal heart rate or HRV.

Investigation and clinical applications of muscle strength change in cerebrospinal fluid tap test in cases of idiopathic normal pressure hydrocephalus: A retrospective study.

The cerebrospinal fluid tap test (CSFTT) is widely used to diagnose idiopathic normal pressure hydrocephalus (iNPH) and predict the therapeutic effectiveness of shunting. However, the ability to walk cannot be quantified for patients who are unable to walk. Therefore, we examined whether the iNPH diagnostic aid is possible using dynamometry, even for patients who are unable to walk. In this study, 45 patients underwent grip strength assessment, quadriceps strength assessment, 10-m walk test, and 3-m Timed Up and Go test before and after CSFTT. Our investigation of physical functions indicated that the CSFTT-positive group demonstrated significant improvements in grip and bilateral quadriceps muscle strength. The results of the receiver operating characteristic analysis indicated that leg muscle strength measurement reliability was high and that the area under the curve was 0.754-0.811. Our investigation of the clinically effective cutoff point for the rate of change indicated that it was 13.6% for right quadriceps muscle strength and 15.3% for left quadriceps muscle strength. Comparing CSFTT results in cases of iNPH with the observed rate of change in muscle strength can aid in the diagnosis of iNPH.

An assessment of urea-formaldehyde fertilizer on the diversity of bacterial communities in onion and sugar beet.

The impact of a urea-formaldehyde (UF) fertilizer on bacterial diversity in onion bulbs and main roots of sugar beet were examined using a 16S rRNA gene clone library. The UF fertilizer markedly increased bacterial diversity in both plants. The results of principal coordinates analysis (PCoA) revealed that nearly 30% of the variance observed in bacterial diversity in both the onion and sugar beet was attributed to the fertilization conditions and also that the community structures in both plants shifted unidirectionally in response to the UF fertilizer.

Renin-angiotensin system blockers affect cognitive decline and serum adipocytokines in Alzheimer's disease.

BACKGROUND: Accumulating evidence indicates an association of Alzheimer's disease (AD) with the metabolic syndrome (MetS), characterized by visceral fat accumulation with insulin resistance and altered secretion of adipocytokines such as adiponectin and leptin. The renin-angiotensin system (RAS) regulates blood pressure and insulin resistance. Recent studies suggest that the RAS plays crucial roles in cognitive functions and that adipocytokines exert neuroprotective activity in the brain. We investigated whether RAS blockers (RASB) affect adipocytokines and cognitive function in patients with AD. METHODS: We studied 78 patients with a diagnosis of probable AD according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition and 106 nondemented control subjects who visited our clinic with a main complaint of headache or dizziness. We examined retrospectively the effects of RASB on adipocytokines and cognitive decline in patients with AD who were divided into three groups: hypertension treated with RASB (HT-RASB; n = 17), hypertension treated with other antihypertensive drugs (HT-other; n = 34), and no hypertension (non-HT; n = 27). RESULTS: The HT-RASB group had a significantly higher serum leptin level and a relatively larger visceral fat area than the other groups, because of the bias toward patients with MetS in this group. The HT-RASB group also had a significantly lower immunoreactive insulin level, a relatively low homeostasis model assessment as an index of insulin resistance, and a relatively high serum adiponectin level among the three groups. Cognitive decline, estimated on the basis of the mean annual decline using the Hasegawa Dementia Scale score was significantly low in the HT-RASB group. CONCLUSION: Treatment with RASB might modulate serum adipocytokines and glucose homeostasis, potentially slowing cognitive decline in patients with AD.

Clinical analysis and outcomes of amyotrophic lateral sclerosis with demyelinating polyneuropathy.

Abnormalities of both motor and sensory nerve action potentials, similar to those found in demyelinating polyneuropathy, may occur in patients with amyotrophic lateral sclerosis (ALS). We analyzed the clinical features of unusual ALS patients with demyelinating polyneuropathy (DPN) to delineate the characteristics and outcomes of this rare condition. We reviewed three ALS patients with DPN who were confirmed to meet the electrophysiological nerve conduction criteria for DPN among 157 patients with ALS. At the initial neurological examination, one patient had both subjective sensory symptoms and abnormal results of sensory examinations, and one patient had sensory symptoms. Motor weakness of the limbs was present in all patients, and fasciculation was present in two patients. Anti-GalNAc-GD1a IgG antibodies were evident in one. Sural nerve biopsy showed a moderate, marginal reduction in myelin thickness, and teased fiber analysis revealed segmental demyelination and remyelination, but axonal degeneration was found in one patient. The mean interval from disease onset to respiratory failure or death in our three patients and seven previously documented ALS patients with DPN was 43.1 ± 18.7 months. Our findings suggest that survival in ALS with DPN is similar to that in classic ALS.

Painful abdominal contractions in patients with Parkinson disease.

We hypothesized that the unusual and painful abdominal contractions in two of our patients with Parkinson disease (PD) were linked to abdominal muscle hypertrophy. The abdominal pain was aggravated by sitting, standing, or walking, and was characterized by a powerful pulling sensation associated with palpable contractions of the rectus abdominis. When the pain decreased, the camptocormia abated. The thickness of the rectus abdominis and the relative muscle thickness ratio were greater in the two patients with abdominal contractions than in the control patients with PD without abdominal contractions. Palpable painful abdominal contractions could be associated with the presence of hypertrophy of the rectus abdominis visible on CT scan. The abdominal muscle contractions probably contribute to the development a stooped posture.

Infarction limited to both middle cerebellar peduncles.

BACKGROUND: The middle cerebellar peduncle (MCP) is supplied mainly by the anterior inferior cerebellar artery and partly by the superior cerebellar artery. The bilateral MCP infarctions in previous patients were attributed to alternations of two vessels, such as the unilateral vertebral artery and basilar artery or both vertebral arteries. METHODS: We describe a case of bilateral acute infarction of the MCP and the stroke was apparently caused by occlusion of only one vertebral artery. RESULTS: A 63-year-old man presented with vertigo and auditory distortion, accompanied by difficulty in speaking and walking. Neurological examinations revealed bilateral horizontal nystagmus, scanning speech, and ataxia of the trunk and all four limbs. Brain MRI showed high signal intensity in the both MCPs on diffusion-weighted and T2-weighted images. Enhanced computed tomographic angiography showed fusiform dilatation at the V4 level of the right vertebral artery; a false lumen was evident in the dilatation. Right vertebral angiography showed occlusion from the C1 level to the foramen magnum. Left vertebral angiography revealed a hypoplastic vertebral artery with a maximum diameter of 2.5 mm. CONCLUSIONS: Alternations of the vertebral artery should be considered as a possible cause of MCP infarction, particularly when such anomalies are suggested.

Characteristic neuroimaging in patients with tumefactive demyelinating lesions exceeding 30 mm.

BACKGROUND AND PURPOSE: Features of tumefactive demyelinating lesion (TDL) on magnetic resonance imaging (MRI) can facilitate the differential diagnosis of TDL and neoplastic lesions, but vary considerably among patients. The larger TDL grows, the more difficult it becomes to differentiate TDL from neoplastic lesions. The purpose of this study was to elucidate typical MRI features in 12 patients with large TDL (>30 mm in diameter). METHODS: We identified 12 patients with large TDL (six men, six women; age range 17-64 years, median age 27 years) and studied the clinical histories and the results of laboratory and various radiological studies in these patients. All cases of clinically definite multiple sclerosis were diagnosed in accordance with McDonald's revised criteria. RESULTS: Common MRI features of large TDLs included variable degrees of mass effect (71%) and edema (100%), a T2 hypointense rim (79%), venular enhancement (57%), and peripheral restriction on diffusion-weighted images (50%). Ring enhancement (38%), open-ring enhancement (31%), or decreased N-acetylaspartate ratios on magnetic resonance spectroscopy (22%) were less frequently observed. Brain angiography demonstrated venous dilatations on and around the TDL. CONCLUSIONS: The diagnosis of large TDL is challenging. Our findings suggest that multiple venous dilatations on and around TDLs on angiography can facilitate diagnosis.

A successfully treated case of herpes simplex encephalitis complicated by subarachnoid bleeding: a case report.

INTRODUCTION: Histopathologically, herpes simplex virus type 1 causes hemorrhagic necrosis. Overt hemorrhage is infrequent in herpes simplex virus encephalitis but can lead to poor outcomes. This report describes a successfully treated case of herpes simplex virus encephalitis associated with subarachnoid bleeding in which real-time polymerase chain reaction was useful for diagnosis. CASE PRESENTATION: A 30-year-old previously healthy Japanese woman who had fever and headache for five days presented with disorganised speech, unusual behavior and delusional thinking. Real-time polymerase chain reaction amplification of herpes simplex virus type 1 in cerebrospinal fluid was positive (38,000 copies/mL) and antivirus treatment was started. During the course of her illness, the level of her consciousness decreased in association with desaturation and tachycardia. Thrombosis of the right pulmonary artery trunk with pulmonary embolism was evident on enhanced chest computed tomography. In addition, cranial computed tomography revealed subarachnoid and intraventricular bleeding. Intravenous heparin (12,000 U/day) was started and the dose was adjusted according to the activated partial thromboplastin time for about a month (maximum dose of heparin, 20,400 U/day). After the treatments, her Glasgow coma score increased and the thrombosis of the pulmonary artery trunk had disappeared. CONCLUSIONS: The present case raises the question of whether anticoagulant treatment is safe in patients with herpes simplex virus encephalitis complicated by subarachnoid bleeding.

Biphasic paraneoplastic brainstem encephalitis associated with anti-Ri antibody.

Brainstem encephalitis is not a classic paraneoplastic syndrome and usually involves monophasic neurological deterioration and has negative magnetic resonance imaging (MRI) findings. We describe a patient with brainstem encephalitis who had elevated anti-Ri antibody levels and double-step neurological deterioration associated with different abnormal lesions on MRI. Immunosuppression with steroids and intravenous immune globulin combined with aggressive treatment of the tumor successfully led to the resolution of brainstem symptoms and MRI lesions. In patients with unusual signs and symptoms of paraneoplastic encephalitis mimicking multiple sclerosis, onconeural antibody studies are recommended.

Ehrlichia chaffeensis infection of sika deer, Japan.

To determine whether Ehrlichia chaffeensis exists in Japan, we used PCR to examine blood from sika deer in Nara, Japan. Of 117 deer, 36 (31%) were infected with E. chaffeensis. The E. chaffeensis 16S rRNA base and GroEL amino acid sequences from Japan were most closely related to those of E. chaffeensis Arkansas.

Subthalamic nucleus stimulation in Parkinson's disease is associated with a risk of fixed epiglottis.

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) alleviates motor disability of patients with Parkinson's disease (PD). Mental changes and other adverse events are common, but typically transient. Severe complications such as intracerebral haemorrhage or infection are rare, but 6 of 73 patients who underwent STN-DBS died of pneumonia, cardiac failure or pulmonary embolism. We describe a patient with PD who had sudden respiratory difficulty due to a fixed epiglottis after STN-DBS. This symptom was confirmed to be related to STN stimulation on fibre-optic examination of the larynx.