Intracranial caseating granulomas with no infectious organism detected.

BACKGROUND: Caseating granuloma is a classic histopathological feature of mycobacterial infections. Occasionally, no infectious organism is demonstrated despite extensive examination of intracranial caseating granulomas. The pathogenesis and optimal management strategy for patients with such intracranial caseating granulomas with no detectable infectious organism (ICGNs) remain unclear. METHODS: The study was a retrospective case-series design in a referral hospital setting. Patients with intracranial caseating granulomas in whom no infectious etiology was identified after appropriate investigations were reviewed. RESULTS: Eight patients with ICGN (four females and four males) were identified in an eight-year-period. Average age on presentation was 46 years (range 21-69 years). Cerebrospinal fluid showed lymphocytic pleocytosis, elevated protein and decreased glucose. Neuroimaging showed multiple or single intraparenchymal and meningeal enhancements. Intracranial ICGN were demonstrated on biopsy. Immunomodulation was tried and resulted in improvement in five out of eight patients. In four patients, anti-mycobacterial treatment resulted in no improvement or worsening of clinical or radiological features. CONCLUSIONS: The response to therapy of intracranial caseating granulomas where no organism is identified after thorough investigations hints to non-infectious causes, and suggests current dogma regarding the significance of necrosis in granulomatous diseases should be re-evaluated. Our retrospective series suggests that patients may benefit from an early trial of immunomodulation therapy, a hypothesis to be tested in a randomized trial.

First case of granulomatous amebic encephalitis caused by Acanthamoeba castellanii in Taiwan.

We report the first case of granulomatous amebic encephalitis caused by Acanthamoeba in a previously healthy farmer in Taiwan who fell into a ditch. The DNA amplicons of amebas identified by polymerase chain reaction in the cerebrospinal fluid specimen and the ditch water specimens were identical and shared strong homology with A. castellanii . He survived after treatment with amphotericin B, rifampin, and corticosteroids.

Inflammatory cerebrospinal fluid analysis in cats: clinical diagnosis and outcome.

The medical records of 62 cats with clinical signs of central nervous system disease and accompanying inflammatory cerebrospinal fluid (CSF) analysis were examined retrospectively to determine if signalment, clinical signs, CSF analysis and ancillary testing could accurately predict the type of central nervous system disease that was present. An inflammatory CSF was defined as one in which a total nucleated cell count was greater than 5 cells/microl or one in which the total nucleated cell count was normal but the nucleated cell differential count was abnormal. Sex, degree of CSF inflammation, neuroanatomical location and systemic signs provided little contributory information to the final diagnosis. In 63% of the cases a presumptive diagnosis could be made based on a combination of clinical signs, clinicopathological data and ancillary diagnostic tests. CSF analysis alone was useful only in the diagnosis of cats with feline infectious peritonitis, Cryptococcus species infection, lymphoma and trauma. Overall, despite extensive diagnostic evaluation, a specific diagnosis could not be made in 37% of cats. The prognosis for cats with inflammatory CSF was poor with 77% of cats surviving less than 1 year.

Pyogranulomatous meningoencephalitis due to Actinomyces sp. in a dog.

Actinomyces sp. are commensal, filamentous, gram-positive, acid-fast-negative bacteria that can cause pyogranulomatous inflammation in animals and humans. Central nervous system (CNS) disease is a rare presentation of actinomycosis and is usually due to extension from infected wounds or seeding from distant sites. A dog with progressive, poorly localized neurologic signs had primary CNS actinomycosis without history or evidence of previous trauma or other organ involvement. Histologically, there was a severe pyogranulomatous meningoencephalitis with intralesional filamentous bacteria that were also visible on cytology of the cerebral spinal fluid (CSF) postmortem. Actinomyces sp. was cultured postmortem from the CSF, confirming the diagnosis. This case demonstrates that Actinomyces sp. can be a causative agent of primary CNS disease in dogs.

Idiopathic granulomatous angiitis of the central nervous system. Diagnostic challenges.

OBJECTIVE: Granulomatous angiitis of the central nervous system (CNS) is a rare cause of vasculitis involving the brain and spinal cord and is included in lists of disorders causing strokes. To determine the frequency of strokes (eg, sudden onset of focal symptoms) as a presenting complication and to determine the sensitivity of angiography and other technologies in detecting vasculitis in histologically proved cases of idiopathic granulomatous angiitis of the CNS (IGANS), we reviewed the published literature. DATA SOURCES: A biopsy-proved case of IGANS in a patient presenting without strokes and with a normal angiogram is reported. Additional cases of pathologically proved IGANS where results of angiography or other neuroimaging procedures were available were found by search of MEDLINE and bibliographies of pertinent articles and books. DATA EXTRACTION: We compared our case with 39 reported cases of histologically proved granulomatous angiitis of the CNS not associated with Hodgkin's disease, herpes zoster, sarcoidosis, or other proximate cause. We included only those cases that had been evaluated with angiography or other neuroimaging techniques before death or biopsy. DATA SYNTHESIS: Analysis of these cases shows that strokes as presenting complications are rare in IGANS. Most patients present with a diffuse encephalopathy and, when focal symptoms develop, they tend to develop gradually. Including our case, 56% of 41 angiograms performed in 31 reported patients with histologically proved IGANS were abnormal, but only 27% were diagnostic for vasculitis. CONCLUSIONS: We conclude that stroke is uncommon as a presenting complaint in IGANS and angiography is insensitive as a screening test for these patients.

Characteristics of cerebrospinal fluid associated with canine granulomatous meningoencephalomyelitis: a retrospective study.

Cerebrospinal fluid of 22 dogs with histologically confirmed granulomatous meningoencephalomyelitis was analyzed, retrospectively. Seventeen dogs had cisternal CSF analysis, 4 dogs had lumbar CSF analysis, and 1 dog had both. For cisternal CSF, the mean +/- SEM total WBC count was 800.8 +/- 300.9 cells/microliter. The WBC differential count was predominantly lymphoplasmacytic cells, but 13 of the 18 cisternal CSF had polymorphonuclear (PMN) cells, and the mean +/- SEM PMN cell percentage was 18.6 +/- 5.3%. The mean +/- SEM total protein content of cisternal CSF was 255.8 +/- 98 mg/dl. Of 5 cisternal CSF pressures measured, 4 were within the normal range. The mean +/- SEM total WBC count and total protein content of lumbar CSF were 533.4 +/- 256.5 cells/mu/microliter and 163.2 +/- 25 mg of protein/dl, respectively. As with cisternal CSF, the WBC differential count of lumbar CSF was predominantly lymphoplasmacytic cells. Of 5 lumbar CSF, 4 contained PMN cells, but the percentage was less than the PMN cell percentage of cisternal CSF. Although variable, the general pattern of CSF abnormality associated with granulomatous meningoencephalomyelitis was different from the CSF abnormalities commonly seen with viral, bacterial, or mycotic encephalitides.

Systemic Candida albicans infection with cerebral abscess and granulomas.

This study reports the case of a 19-year-old Turkish woman who was suffering from a cerebral abscess and granuloma formation caused by Candida albicans. The diagnosis of her illness was established by cytologic analysis of the cerebrospinal fluid. Combined application of amphotericin B and 5-fluorocytosine cured the patient's disorder. Its remission was documented over a period of 2 years by the use of computed tomography.