Dual Invasive Fungal Infection Presenting with Cervical Myelopathy.

Disseminated fungal infections are often seen in immunocompromised patients. Here we present a case of a previously healthy woman presenting with cervical myeloradiculopathy found to have two separate fungal infections in the setting of depressed CD4 cell counts and a genetic mutation predisposing to invasive fungal infections.

Lyme Neuroborreliosis is a Severe and Frequent Neurological Disease in Mexico.

OBJECTIVE: To describe clinical cases with neurological manifestations associated with Borrelia burgdorferi infection in a large cohort of children and adults from Mexico. MATERIAL AND METHODS: Patients with neurological manifestation (cranial neuritis, radiculoneuritis, meningitis and encephalomyelitis) were recruited in one pediatric and two general hospitals, during January 2006-December 2015. Blood and cerebrospinal fluid (CSF) samples were drawn from each patient at inclusion. IgM and IgG antibodies against B. burgdorferi were detected using a commercial ELISA test, and confirmed by Western-Blot test (WB) using three different antigens from Borrelia burgdorferi complex. Following CDC criteria were considered true cases with both positive tests. RESULTS: Of 606 patients recruited, 403 (66.5%) were adults and 203 (33.4%) children, 50.5% were male. B. burgdorferi infection was diagnosed in 168 patients (27.7%), 97 adults, mean age 42 ± 14.7 years and 71 children, mean age 9.6 ± 5 years; early disseminated disease occurred in 130 cases (77.4 %) and chronic stage in 38 (22.6 %). A previous tick bite was reported by 21% cases, and 5% recalled an erythema migrans lesion. Polyradiculoneuropathy and encephalomyelitis were the most common manifestations, whereas 14.8% presented an initial Guillain-Barré Syndrome. B. burgdorferi sensu stricto was identified in 142 (84%) cases, B. garinii in 14 (8%), B. afzelii in three, and nine cases presented coinfection with two species. CONCLUSION: Lyme neuroborreliosis is a frequent condition in patients with neurological diseases in Mexico.

[Acute parainfectious transverse myelitis with radiculitis in a child with closed spinal dysraphism]. / Mielitis transversa parainfecciosa aguda con radiculitis en una niña con disrafismo espinal cerrado.

TITLE: Mielitis transversa parainfecciosa aguda con radiculitis en una niña con disrafismo espinal cerrado.

Ticking off diagnoses of abdominal pain: early neuroborreliosis with radiculopathy.

Lyme disease (LD) is the most common tick-borne illness. The diagnosis of LD is difficult because of the great variation in clinical manifestations. Although abdominal pain is generally not considered a sign of LD, in this case report we describe a patient with unexplained severe abdominal pain that eventually turned out to be LD due to radiculopathy. Since the incidence of LD is rising it is important to realise that severe abdominal pain could be the first clinical manifestation of early neuroborreliosis.

Iliacus abscess with radiculopathy mimicking herniated nucleus pulposus: Additional diagnostic value of magnetic resonance imaging.

An iliacus abscess is an extremely rare cause of low back pain. With an iliacus abscess, the classical signs seen with a psoas abscess are frequently absent. Therefore, a timely diagnosis at the initial visit is difficult and inadequate treatment usually results in high mortality. Here, we report the case of 19-year-old man who presented with acute low back pain with radiculopathy and was ultimately diagnosed with an iliacus muscle abscess.

Do bacteria play an important role in the pathogenesis of low back pain?

Considerable interest has been generated recently regarding an alternative hypothesis for the pathogenesis of low back pain and radiculopathy in the presence of intervertebral disc prolapse. Traditionally, back pain and radicular (sciatic) symptoms have been attributed to mechanical compression of neural tissue by herniated disc material and to inflammation caused by exposure of the nerve roots to disc tissue. Recent research however has suggested that low-grade infection within the intervertebral disc by anaerobic bacteria may be responsible. The development of Modic changes in the corresponding adjacent vertebral endplates has also been suggested as an indicator of infection. This article is a thorough review of the current literature regarding the hypothesis that low-grade anaerobic bacterial infection may be the cause of disabling low back pain and radiculopathy.

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.

Acute bilateral painless radiculitis with abnormal Borrelia burgdorferi immunoblot.

A 57-year-old woman with a history of hypertension and hypothyroidism presented with painless left arm weakness and numbness 2 weeks before evaluation. Nerve conduction studies of the left arm revealed normal motor and sensory responses. Needle examination revealed acute denervation changes in all myotomes of the affected extremity, including cervical paraspinals on the left, and several myotomes on the contralateral side. The laboratory evaluation revealed normal anti-GM1 antibodies and 3 IgM/5 IgG bands on Lyme Western Blot. The patient began treatment with 28 days of intravenous ceftriaxone. On follow-up, patient had regained full strength of her extremities with no sensory deficits. Inflammatory borrelia radiculitis usually presents with pain in the distribution of the affected nerves and nerve roots. The novelty of this case report rests on (1) the absence of primary borreliosis symptomatology preceding the radiculitis and (2) the painless and bilateral clinical presentation in a patient with suspected Lyme radiculitis.

Tuberculous radiculomyelitis presenting as urinary retention in a child with Down's syndrome.

Tuberculous radiculomyelitis (TBRM) is an uncommon complication of TB meningitis. The authors report the case of a 10-year-old Asian girl with trisomy 21, who presented with acute urinary retention and fever. She was initially treated for a urinary tract infection. After an acute neurological deterioration she was found to have evidence of TB meningitis with TBRM. She developed acute hydrocephalus requiring ventriculo-peritoneal shunt. She was treated with quadruple antituberculous therapy and high dose intravenous dexamethasone. She needed tracheostomy with continuous positive airway pressure (CPAP) support. Although she showed gradual neurological improvement in her cognitive functions, she persisted to have quadriparesis with the need for tracheostomy and CPAP support overnight and gastrostomy feeding. Acute urinary retention in children is uncommon, and should serve as a 'red flag' to consideration of further underlying neurological problems. This presentation and subsequent events should serve as a learning point to clinicians.

Bacteriologic culture of excised intervertebral disc from immunocompetent patients undergoing single level primary lumbar microdiscectomy.

STUDY DESIGN: A consecutive case series from a single center of patients undergoing primary microdiscectomy for lumbar herniated nucleus pulposus (HNP) who received microbiologic laboratory culture of excised disc material. OBJECTIVE: To determine the prevalence of positive bacterial cultures in the disc material of immunocompetent patients without diabetes mellitus or other immune compromise. SUMMARY OF BACKGROUND DATA: The intradiscal space is a physiologically tenuous environment in terms of oxygen tension, pH, and vascularity. This space may be susceptible to indolent infections with an unknown effect on the pathogenesis of HNP. METHODS: This case series included 52 patients with radiculopathy and magnetic resonance imaging positive for HNP who elected for lumbar microdiscectomy after failure of conservative management. All patients received primary surgery at a single spinal level in the absence of diabetes mellitus, systemic steroid use, chemotherapy, other immune compromise, or prior lumbar surgery. Excised disc material was sent for routine bacterial culture. No special culture techniques were used to improve the yield of positive cultures. RESULTS: Cultures were positive in 10 patients (19.2%). Propionibacterium acnes was the sole organism isolated in 7 (13.5%), with Peptostreptococcus and Staphylococcus species accounting for the remainder. There were 24 women (46.2%) and 28 men (53.8%) with a mean age of 43.9 years (SE 1.8). Duration of symptoms was greater than 12 weeks in 35 patients (67.3%). Onset of symptoms was insidious in 22 patients (42.3%), sudden in 16 (30.8%), and the history was unclear in the remainder. Prior epidural steroid injection was received by 17 patients (32.7%), and 11 patients had a history of smoking (21.2%). None of these variables was significantly different in patients with positive and negative cultures (P >0.05). CONCLUSIONS: P. acnes was isolated by routine laboratory culture of excised disc material in 13.5% of immunocompetent patients undergoing primary single level discectomy for radiculopathy with lumbar HNP; other organisms were isolated in 6% of patients. LEVEL OF EVIDENCE: Diagnostic level of evidence III.

Nervous system Lyme disease.

Lyme disease, the multi-system infection caused by the tick-borne spirochaete Borrelia burgdorferi, can involve the nervous system, most commonly causing, alone or in combination, lymphocytic meningitis or abnormalities of cranial or peripheral nerves, the latter most typically presenting as a painful radicular syndrome. Diagnosis is based on appropriately used, standard serological tests; in instances where the central nervous system is involved, cerebrospinal fluid assessment for organism-specific antibodies can be useful. Treatment with any of several standard regimens of oral or parenteral antimicrobials is highly effective. Prolonged treatment beyond four weeks is rarely if ever warranted, and carries significant risk.

Myeloradiculitis with meningoencephalopathy and optic neuritis in a case of previous Chlamydia psittaci infection.

We present a case of optic neuritis and myelo-radiculopathy as a late association following Chlamydia psittaci infection. A 45-year-old female patient with a prior history of C psittaci pneumonia and subsequent reactive arthritis presented to the neurology unit with severe headache, constitutional symptoms and monocular disturbance in vision. Clinical examination revealed focal signs with brisk upper limb reflexes compared to lower limbs and mild left-sided pyramidal signs. Systemic inflammatory markers were raised and serological studies showed no evidence of re-infection. MRI showed multiple high signal foci within the brain parenchyma and pachymeningeal thickening and enhancement. There was marked clinical and haematological improvement with high dose corticosteroids.

Uncommon manifestations of neuroborreliosis in children.

Lyme borreliosis is a tick-borne spirochetal infection which affects the skin, joints, heart and nervous system. Children with a neuroborreliosis usually present with a facial nerve palsy or aseptic meningitis, but the spectrum also includes other rare manifestations. We report four unusual cases of childhood neuroborreliosis and show that seizures with regional leptomeningeal enhancement, acute transverse myelitis, meningoradiculitis with pain and paraesthesia and cranial nerve palsies other than facial nerve palsy can be the leading symptoms of children with neuroborreliosis. All children had serological evidence of an acute infection with Borrelia burgdorferi, a pleocytosis in the cerebrospinal fluid and a complete response to antibiotic treatment. An intrathecal synthesis of IgG antibodies was detected in three children. Thus, diagnostic work up in children with unusual neurological symptoms should include cerebrospinal fluid studies with determination of the white blood cell count and calculation of the antibody index against B. burgdorferi.

Possible role of glial cells in the onset and progression of Lyme neuroborreliosis.

BACKGROUND: Lyme neuroborreliosis (LNB) may present as meningitis, cranial neuropathy, acute radiculoneuropathy or, rarely, as encephalomyelitis. We hypothesized that glia, upon exposure to Borrelia burgdorferi, the Lyme disease agent, produce inflammatory mediators that promote the acute cellular infiltration of early LNB. This inflammatory context could potentiate glial and neuronal apoptosis. METHODS: We inoculated live B. burgdorferi into the cisterna magna of rhesus macaques and examined the inflammatory changes induced in the central nervous system (CNS), and dorsal root nerves and ganglia (DRG). RESULTS: ELISA of the cerebrospinal fluid (CSF) showed elevated IL-6, IL-8, CCL2, and CXCL13 as early as one week post-inoculation, accompanied by primarily lymphocytic and monocytic pleocytosis. In contrast, onset of the acquired immune response, evidenced by anti-B. burgdorferi C6 serum antibodies, was first detectable after 3 weeks post-inoculation. CSF cell pellets and CNS tissues were culture-positive for B. burgdorferi. Histopathology revealed signs of acute LNB: severe multifocal leptomeningitis, radiculitis, and DRG inflammatory lesions. Immunofluorescence staining and confocal microscopy detected B. burgdorferi antigen in the CNS and DRG. IL-6 was observed in astrocytes and neurons in the spinal cord, and in neurons in the DRG of infected animals. CCL2 and CXCL13 were found in microglia as well as in endothelial cells, macrophages and T cells. Importantly, the DRG of infected animals showed significant satellite cell and neuronal apoptosis. CONCLUSION: Our results support the notion that innate responses of glia to B. burgdorferi initiate/mediate the inflammation seen in acute LNB, and show that neuronal apoptosis occurs in this context.

Multiple cranial nerve involvement in Bannwarth's syndrome.

Bannwarth's syndrome is a tick-transmitted neurological disease caused by spirochetes of the Borrelia burgdorferi group. Neurological manifestations of the disease occur after skin erythema and include: neuritic pain, lymphocytic pleocytosis without headache and sometimes cranial neuritis. We present the case of a man who complained of a neurological syndrome without evidence of tick bite and concurrent manifestation of the infection, for whom serological analysis only revealed the infection after testing repetitive specimens. We discuss the need to start early therapy when clinical manifestations are suggestive of the disease in endemic areas.