Ruptured long intramedullary spinal cord abscess successfully treated with antibiotic treatment.

Intramedullary spinal cord abscess (ISCA) is an extremely rare infection of the central nervous system. We report a 17-year old man with ISCA that suggested rupture confirmed by magnetic resonance imaging (MRI). The patient presented with meningeal signs, severe paraplegia, sensory impairment with a sensory level, and urinary retention. The cerebrospinal fluid (CSF) study showed pleocytosis with polymorphonuclear cells and a decreased glucose level suggesting bacterial meningitis. Computed tomography showed maxillary sinusitis and a lower respiratory tract infection. Spinal MRI showed an ISCA from Th5 to Th12. Part of the abscess seemed to have ruptured into the medullary cavity. Streptococcus intermedius was cultured from CSF, sputum, and the maxillary sinus abscess. It appeared that Streptococcus intermedius transferred from the respiratory tract to the spinal cord hematogenously, formed the ISCA, and the ISCA ruptured. The patient was treated with ampicillin, vancomycin, and meropenem. After 56 days of treatment, he could walk with a walker. In the present case, the MRI findings were helpful for early diagnosis and follow-up of the pathogenic condition. Although the present case suggested rupture of ISCA, he recovered with antibiotic therapy alone. This suggested earlier diagnosis with MRI and aggressive antibiotic therapy appear to be critical factors that determine the prognosis of patients with ISCA.

Association of outcomes in acute flaccid myelitis with identification of enterovirus at presentation: a Canadian, nationwide, longitudinal study.

BACKGROUND: Acute flaccid myelitis (AFM) is characterised by rapid onset of limb weakness with spinal cord grey-matter abnormalities on MRI scan. We aimed to assess whether detection of enterovirus in respiratory or other specimens can help predict prognosis in children with AFM. METHODS: In this nationwide, longitudinal study, we evaluated the significance of detection of enterovirus in any sample in predicting outcomes in a cohort of Canadian children younger than 18 years presenting with AFM to tertiary paediatric hospitals in Canada in 2014 and 2018. All patients fulfilled the 2015 US Centers for Disease Control and Prevention case definition for definite AFM or probable AFM. Clinical data, laboratory findings, treatment, and neuroimaging results were collected (follow up period up to 5 years). We assessed neurological function and motor outcomes using Kurtzke's Expanded Disability Status Scale (EDSS) and a Weakest Limb Score. FINDINGS: 58 children with AFM (median age 5·1 years, IQR 3·8-8·3) were identified across five of Canada's ten provinces and three territories. 25 (43%) children had enterovirus detected in at least one specimen: 16 (64%) with EV-D68, two (8%) with EV-A71, two (8%) with coxsackievirus, 10 (40%) with untyped enterovirus. Children who were enterovirus positive were more likely than those that were negative to have had quadriparesis (12 [48%] of 25 vs four [13%] of 30; p=0·028), bulbar weakness (11 [44%] of 25 vs two [7%] of 30; p=0·028), bowel or bladder dysfunction (14 [56%] of 25 vs seven [23%] of 30; p=0·040), cardiovascular instability (nine [36%] of 25 vs one [3%] of 30; p=0·028), and were more likely to require intensive care unit admission (13 [52%] of 25 vs 5 [17%] of 30; p=0·028). On MRI, most children who were enterovirus positive showed brainstem pontine lesions (14 [61%] of 23), while other MRI parameters did not correlate with enterovirus status. Median EDSS of enterovirus positive (EV+) and enterovirus negative (EV-) groups was significantly different at all timepoints: baseline (EDSS 8·5, IQR 4·1-9·5 vs EDSS 4·0, IQR 3·0-6·0; p=0·0067), 3 months (EDSS 4·0, IQR 3·0-7·4 vs EDSS 3·0, IQR 1·5-4·3; p=0·0067), 6 months (EDSS 3·5, IQR 3·0-7·0 vs EDSS 3·0, IQR 1·0-4·0; p=0·029), and 12 months (EDSS 3·0, IQR 3·0-6·9 vs EDSS 2·5 IQR 0·3-3·0; p=0·0067). Kaplan-Meier survival analysis of a subgroup of patients showed significantly poorer motor recovery among children who tested positive for enterovirus than for those who tested negative (p=0·037). INTERPRETATION: Detection of enterovirus in specimens from non-sterile sites at presentation correlated with more severe acute motor weakness, worse overall outcomes and poorer trajectory for motor recovery. These results have implications for rehabilitation planning as well as counselling of families of children with these disorders. The findings of this study support the need for early testing for enterovirus in non-CNS sites in all cases of AFM. FUNDING: None.

Bioinformatics Analysis of Gut Microbiota and CNS Transcriptome in Virus-Induced Acute Myelitis and Chronic Inflammatory Demyelination; Potential Association of Distinct Bacteria With CNS IgA Upregulation.

Virus infections have been associated with acute and chronic inflammatory central nervous system (CNS) diseases, e.g., acute flaccid myelitis (AFM) and multiple sclerosis (MS), where animal models support the pathogenic roles of viruses. In the spinal cord, Theiler's murine encephalomyelitis virus (TMEV) induces an AFM-like disease with gray matter inflammation during the acute phase, 1 week post infection (p.i.), and an MS-like disease with white matter inflammation during the chronic phase, 1 month p.i. Although gut microbiota has been proposed to affect immune responses contributing to pathological conditions in remote organs, including the brain pathophysiology, its precise role in neuroinflammatory diseases is unclear. We infected SJL/J mice with TMEV; harvested feces and spinal cords on days 4 (before onset), 7 (acute phase), and 35 (chronic phase) p.i.; and examined fecal microbiota by 16S rRNA sequencing and CNS transcriptome by RNA sequencing. Although TMEV infection neither decreased microbial diversity nor changed overall microbiome patterns, it increased abundance of individual bacterial genera Marvinbryantia on days 7 and 35 p.i. and Coprococcus on day 35 p.i., whose pattern-matching with CNS transcriptome showed strong correlations: Marvinbryantia with eight T-cell receptor (TCR) genes on day 7 and with seven immunoglobulin (Ig) genes on day 35 p.i.; and Coprococcus with gene expressions of not only TCRs and IgG/IgA, but also major histocompatibility complex (MHC) and complements. The high gene expression of IgA, a component of mucosal immunity, in the CNS was unexpected. However, we observed substantial IgA positive cells and deposition in the CNS, as well as a strong correlation between CNS IgA gene expression and serum anti-TMEV IgA titers. Here, changes in a small number of distinct gut bacteria, but not overall gut microbiota, could affect acute and chronic immune responses, causing AFM- and MS-like lesions in the CNS. Alternatively, activated immune responses would alter the composition of gut microbiota.

Infección espinal por una cepa defectiva de Streptococcus intermedius diagnosticada mediante PCR multiplex / Spinal infection caused by a defective strain of Streptococcus intermedius diagnosed by multiplex-PCR

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Tick-borne encephalitis virus vaccination breakthrough infections in Germany: a retrospective analysis from 2001 to 2018.

OBJECTIVES: There are few data available regarding the clinical course of tick-borne encephalitis virus (TBEV) vaccination breakthrough infections. The published studies suggest that vaccination breakthrough infections may have a more severe course than native TBEV infection in unvaccinated individuals-potentially due to antibody-dependent enhancement. Here we report a large analysis of vaccination breakthrough infections. METHODS: This retrospective analysis was based on a national surveillance dataset spanning the years 2001-2018. Variables reflecting disease severity, such as 'CNS symptoms', 'myelitis', 'fatal outcome' and 'hospitalization' were analysed as well as general epidemiological variables. Cases were categorized as 'unvaccinated' or 'ever vaccinated', the latter category including cases with at least one dose of a TBEV vaccine. RESULTS: A total of 6073 notified TBEV infection cases were included in our analysis. Sufficient data on vaccination status were available for 95.1% of patients (5777/6073); of these, 5298 presented with a native infection. A total of (334/5777) cases developed an infection despite having been vaccinated at least once. Comparing unvaccinated patients with those with at least one vaccination, we find an odds ratio (OR) 2.73, (95% confidence interval (CI) 0.79-9.50) regarding the variable fatal outcome that did not reach statistical significance. Analysing the clinical variables 'CNS symptoms' and 'myelitis', there is no difference between these groups (OR 0.86, 95% CI 0.68-1.08; and OR 1.30, 95% CI 0.74-2.27 respectively). Patients who were vaccinated and had an assumed protection at symptom onset (n = 100) had a higher risk for the development of myelitic symptoms (OR 2.21, 95% CI 1.01-4.86]) than unvaccinated patients. CONCLUSION: Our findings could neither verify that vaccination breakthrough infections might cause a more severe disease than native infections nor prove a clear antibody-dependent enhancement phenomenon. It remains unclear whether the increased myelitis risk in a subgroup of vaccinated patients is a true effect or confounded.

Clinical Metagenomic Sequencing for Diagnosis of Meningitis and Encephalitis.

BACKGROUND: Metagenomic next-generation sequencing (NGS) of cerebrospinal fluid (CSF) has the potential to identify a broad range of pathogens in a single test. METHODS: In a 1-year, multicenter, prospective study, we investigated the usefulness of metagenomic NGS of CSF for the diagnosis of infectious meningitis and encephalitis in hospitalized patients. All positive tests for pathogens on metagenomic NGS were confirmed by orthogonal laboratory testing. Physician feedback was elicited by teleconferences with a clinical microbial sequencing board and by surveys. Clinical effect was evaluated by retrospective chart review. RESULTS: We enrolled 204 pediatric and adult patients at eight hospitals. Patients were severely ill: 48.5% had been admitted to the intensive care unit, and the 30-day mortality among all study patients was 11.3%. A total of 58 infections of the nervous system were diagnosed in 57 patients (27.9%). Among these 58 infections, metagenomic NGS identified 13 (22%) that were not identified by clinical testing at the source hospital. Among the remaining 45 infections (78%), metagenomic NGS made concurrent diagnoses in 19. Of the 26 infections not identified by metagenomic NGS, 11 were diagnosed by serologic testing only, 7 were diagnosed from tissue samples other than CSF, and 8 were negative on metagenomic NGS owing to low titers of pathogens in CSF. A total of 8 of 13 diagnoses made solely by metagenomic NGS had a likely clinical effect, with 7 of 13 guiding treatment. CONCLUSIONS: Routine microbiologic testing is often insufficient to detect all neuroinvasive pathogens. In this study, metagenomic NGS of CSF obtained from patients with meningitis or encephalitis improved diagnosis of neurologic infections and provided actionable information in some cases. (Funded by the National Institutes of Health and others; PDAID ClinicalTrials.gov number, NCT02910037.).

Infectious Myelopathies.

Infectious diseases are an important cause of spinal cord dysfunction. Infectious myelopathies are of growing concern given increasing global travel and migration and expanding prevention and treatment with vaccinations, antibiotics, and antiretrovirals. Clinicians must recognize these pathologies because outcomes can dramatically improve with prompt diagnosis and management. We provide a complete review of the most frequent infectious agents that can affect the spinal cord. For each pathogen we describe epidemiology, pathophysiology, anatomic location, characteristic clinical syndromes, diagnostic approach, treatment, and prognosis. The review includes spinal imaging from selected cases.

Acute myelitis of children with positive anti-GM1 antibody: Case series and literature review.

RATIONALE: To explore the clinical features, treatment, and prognosis of acute myelitis (AM) of children with positive blood anti- ganglioside (GM1) antibodies. PATIENT CONCERNS: Two cases of AM of children with positive anti-GM1 antibody were retrospectively collected and followed up for 6 months. Two cases had positive helicobacter pylori IgG antibody, and Case 2 also had positive mycoplasma IgM antibody. DIAGNOSES: Two cases had typical symptoms of myelitis, abnormal spinal magnetic resonance imaging (MRI), and positive serum anti-GM1 IgM. INTERVENTIONS: They were treated with steroid, immunoglobulin and rehabilitation. OUTCOMES: Symptoms of AM were relieved after treatment. After 6 months of follow-up, case 1 was fully recovered and case 2 was partially recovered. Summarizing previous reports in literature and our 2 cases, AM with positive anti-GM1 antibody can be induced by multiple pathogen infections. About 35.7% were fully recovered, 42.9% had mild sequelae, and 21.4% had severe sequelae. LESSONS: Post-infection immune injury plays an important role in the pathogenesis of AM with positive anti-GM1 antibody. H pylori and Mycoplasma pneumoniae infection may also induce AM with positive anti-GM1 antibody. Screening and treatment of pathogens were required and only 21.4% patients had severe sequelae after treatment.

Spinal Tuberculosis: Clinicoradiological Findings in 274 Patients.

Background: Mycobacterium tuberculosis is a major cause of myelopathy and radiculopathy in settings with a high prevalence of tuberculosis/human immunodeficiency virus (HIV) coinfection. However, a paucity of publications exists on the spectrum of neurological and magnetic resonance (MR) imaging findings of spinal tuberculosis in these populations. Methods: We conducted a retrospective study of adults with spinal tuberculosis at a referral center in South Africa for patients with spinal disease without bony involvement seen at plain film radiography. We report the clinical, laboratory and spinal MR imaging findings, compare HIV-infected and HIV-uninfected patients, and correlate clinical and cerebrospinal fluid findings with those of MR imaging. Results: Of 274 patients, 209 (76%) were HIV infected and 49 (18%) were HIV uninfected. Radiculomyelitis occurred in 77% (n = 210), and spondylitis in 39% (n = 106). Subdural abscess (n = 42) and intramedullary tuberculoma (n = 33) were common. In 24% of HIV-infected and 14% of HIV-uninfected patients, spinal disease manifested as a paradoxical tuberculosis reaction, frequently following tuberculous meningitis. The triad of neurological deficit, fever, and back pain was similar in patients with spondylitis (24%), epi/subdural abscess without bony disease (14%), meningoradiculitis (17%), and isolated myelitis (17%) . Conclusions: Radiculomyelitis is a common manifestation of spinal tuberculosis in settings with high tuberculosis/HIV prevalence, often presenting as a paradoxical reaction. We describe a high frequency of rarely reported spinal tuberculosis manifestations, suggesting that these are more common than implied by the literature.

Rare and unusual presentation of Cladophialophora infection in a pulmonary transplant cystic fibrosis patient.

A 35-year-old woman with severe cystic fibrosis was admitted for sudden loss of strength in both legs, revealing a myelitis. The medullary lesion biopsy revealed phaeohyphomycosis caused by Cladophialophora species. Myelitis caused by Cladophialophora bantiana is a rare disease associated with high mortality.

Toxocara canis myelitis involving the lumbosacral region: a case report.

CONTEXT: Toxocara canis is a parasite known to cause visceral larva migrans. The infection rarely affects the central nervous system but there have been several reports of myelitis caused by visceral larva migrans due to Toxocara canis. In previous reported cases, the lesions were located in the thoracic or cervical spinal cord. To the best of our knowledge, this is the first report of a lesion involving the lumbosacral region. FINDINGS: A 60-year-old man developed weakness and dysesthesia in the lower limbs. The symptoms resolved spontaneously, but recurred after five months. One month later, the patient developed pollakiuria and constipation. He was a dog owner and frequently ate raw chicken meat and beef liver. Sagittal T2-weighted image (T2WI) showed swelling and hyperintensity in the spinal cord from T10 to the lumbosacral region and focal nodular enhancement on the posterior segment of the lumbar spinal cord. Blood cell counts showed slight eosinophilia and elevated serum immunoglobulin E level. Cerebrospinal fluid examination showed slight pleocytosis with eosinophilia. Enzyme-linked immunosorbent assay showed high levels of anti-Toxocara antibodies in the serum and cerebrospinal fluid. In addition, confirmatory test by Western blot was positive. The patient was initially treated with intravenous methylprednisolone with slight improvement in muscle weakness. Albendazole was added with a second course of intravenous methylprednisolone. The muscle weakness in the lower limbs improved considerably, and swelling and hyperintensity on T2WI almost disappeared. CONCLUSION: Our results suggest that Toxocara canis myelitis cannot be discounted even if the myelitis involves the lumbosacral region.

[Extensive Myelitis as a Manifestation of Neuroborreliosis]. / Mielite Extensa como Manifestação de Neuroborreliose.

Neurological manifestations of Lyme disease are reported in 3% - 12% of patients, with the most common form of presentation being meningoradiculitis. Other symptoms involving the central nervous system, such as myelitis or encephalitis, are rare (< 5 %). We report a case of a 66-year-old male, with a subacute extensive transverse myelitis, secondary to Borrelia burgdorferi infection. The patient underwent antibiotic therapy filed for neuroborreliosis with a good clinical outcome. The rareness in clinical symptoms and imaging presentation, based on a treatable infectious disease, highlights the importance of the inclusion of neuroborreliosis in the differential diagnosis of longitudinally extensive transverse myelitis.

As manifestações neurológicas na doença de Lyme ocorrem em 3% - 12% dos doentes, sendo a forma de apresentação mais comum a meningorradiculite. Outros sintomas de envolvimento do sistema nervoso central, como encefalomielite ou mielite são raros (< 5%). Descreve-se um caso clínico de um homem de 66 anos com uma mielite transversa extensa, de instalação subaguda, secundária a infeção por Borrelia burgdorferi. O doente foi submetido a terapêutica antibiótica dirigida, com uma boa evolução clínica. A raridade na forma de apresentação clínica e imagiológica deste caso, tendo como base uma doença infecciosa tratável, destaca a importância da sua inclusão no diagnóstico diferencial da mielite transversa longitudinalmente extensa.

[Methicillin resistant Staphylococcus aureus community acquired meningitis: a case report]. / Meningitis por Staphylococcus aureus meticilino resistente proveniente de la comunidad: a propósito de un caso.

Community-acquired Staphylococcus aureus (CA-SA) infections are becoming more frequent. Most cases present an infection of skin and soft tissue, and the most invasive forms observed are osteoarticular and pleuropulmonary infections. Meningitis is a rare manifestation of Staphylococcus aureus infections. We describe an unusual case of CA-MRSA infection. An infant of eight months presented with signs of irritability and 4 days duration fever, with alternating sensory and abdomen pain. Acute abdomen surgery was discarded and hospitalization was decided with diagnosis of sepsis due to probable enteral focus; antibiotics were indicated. Blood cultures and cerebrospinal fluid culture were positive for MRSA. Sepsis with meningitis by MRSA was diagnosed. On the 7th day of hospitalization the infant presented neurological signs and symptoms. On the resolution computed tomography and the magnetic resonance, images compatible with myelitis were observed. The patient complied with the 21 day endovenous treatment, and showed positive results, being discharged from hospital a month after the appearance of the symptoms.

Encefalitis del tallo cerebral y mielitis por Listeria monocytogenes / Brainstem encephalitis and myelitis due to Listeria monocytogenes : a case report and literature review

La romboencefalitis por Listeria monocytogenes es una presentación poco común de la listeriosis del sistema nervioso central; sin embargo, es la presentación más común en personas inmunocompetentes. Aun más rara es la combinación de romboencefalitis con mielitis causada por L. monocytogenes ; no obstante, en este artículo se reporta un caso de encefalitis del tallo y mielitis grave en un paciente sin compromiso del sistema inmunitario. Se presenta un paciente de 21 años de edad, sin deficiencias del sistema inmunitario, que consumió productos lácteos no pasteurizados y, posteriormente, presentó un cuadro de cefalea, vómito, deterioro de su estado general y, finalmente, alteración del estado de conciencia y muerte. Consultó al Instituto Neurológico de Colombia y se hizo diagnóstico de encefalitis del tallo y mielitis por L. monocytogenes . Se discuten las diferencias entre el caso presentado y los reportados en la literatura científica. Ante un paciente con signos de compromiso del tallo cerebral, de posible origen infeccioso, es prudente iniciar tratamiento antibiótico para L. monocytogenes y, en caso de poca respuesta, escalar rápidamente en dicho tratamiento. También lo es extender el estudio radiológico hacia la columna vertebral, con el fin de descartar compromiso de la médula espinal.

Brainstem encephalitis caused by Listeria monocytogenes is an uncommon form of central nervous system listeriosis; however, it is the most common presentation in immunocompetent individuals. Here, we describe an even more rare combination of rhombencephalitis with severe myelitis caused by L. monocytogenes in an immunocompetent patient. We report the case of a 21-year-old immunocompetent patient who consumed unpasteurized dairy products and experienced headache and vomiting that progressed to an impaired general condition, altered consciousness and ultimately death. The patient had presented to the Neurological Institute of Colombia (INDEC in Spanish) for consultation and was diagnosed with brainstem encephalitis and myelitis caused by Listeria monocytogenes . The differences between this particular case and those reported in the literature will be discussed. It is advisable to initiate antibiotic treatment for Listeria monocytogenes if a patient shows signs of brainstem compromise of possible infectious origin and quickly intensify treatment if there is no or minimal response. It is also necessary to extend radiological assessment to include the spinal column to rule out spinal cord involvement.

Tuberculous radiculomyelitis presenting in a toddler with lower extremity weakness and seizure.

Tuberculous radiculomyelitis is an uncommon but serious complication of tuberculosis that can lead to considerable morbidity and mortality. We present the case of a 21-month-old male Congolese refugee diagnosed with tuberculous radiculomyelitis who presented with gradual motor and speech regression, and likely an infection-related seizure 2 months before diagnosis.