Gene/Protein Disease Symptom Drug Enzyme Compound
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Children with partially treated (PT) meningitis present diagnostic and therapeutic dilemmas. Since the approach to these children is not uniform, both in the literature and in daily practice, we conducted a survey among leading Israeli pediatricians from various hospitals to learn about their opinions and practices relating to this problem. Twenty-eight of 30 senior pediatricians responded to a questionnaire encompassing the various aspects of PT meningitis. The results of the survey highlighted the confusion and lack of clear policy regarding the definition, diagnostic approach and treatment of these children. Fifty percent of the pediatricians stated that even one dose of an antimicrobial agent, regardless of the type of drug, is sufficient for the definition of PT meningitis; 43% of the responders did not require any threshold parameter in CSF findings for the definition of probable bacterial meningitis among PT children and 52% did not think that a second lumbar puncture was useful as a diagnostic aid in PT meningitis. Epidemiological circumstances played a role in the diagnostic and therapeutic approach of infectious disease specialists mainly, but less so in the other groups of pediatricians. Finally, more than half the responders did not use throat cultures to identify potential carriers among PT meningitis patients and did not consider the use of prophylactic treatment in close contacts. These data clearly indicate the need for guidelines regarding the various aspects of PT meningitis.
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PMID:A survey of current Israeli practices and approach to partially treated meningitis in children. 759 92

Regulation of circulating iron is important in bacterial, yeast, and fungal infections. In the present study, cerebrospinal fluid levels of ferritin, an iron-binding protein, were determined in controls and in patients with central nervous system pyogenic and viral infections. Among 441 controls, cerebrospinal fluid ferritin level was higher than 18 ng/mL in two relapsed patients with central nervous system leukemia, 12 with bacteremia or pneumonia, and one with hemorrhagic herpes simplex encephalitis. Cerebrospinal fluid ferritin levels were more than 18 ng/mL in 13 of 63 patients diagnosed with nonhemorrhagic aseptic meningitis/ventriculitis, when defined solely by negative cerebrospinal fluid culture. Conversely, cerebrospinal fluid ferritin exceeded 18 ng/mL in culture-proven meningitis (46 of 47 cases) and ventriculitis (five of five cases). Cases of indolent cryptococcus and tuberculous meningitis showed modest increases despite traditional cerebrospinal fluid markers, at times, being normal. Cerebrospinal fluid ferritin levels did not correlate with cerebrospinal fluid neutrophil count, cerebrospinal fluid protein concentration, serum ferritin level, or patient age. In 16 of 19 cases monitored sequentially during ongoing antibiotic treatment, levels remained over 18 ng/mL (average, 15.0 days; range, 1 to 54 days). This observation suggests that obtaining cerebrospinal fluid ferritin levels is helpful whenever traditional laboratory benchmarks normalize, as during acute or chronic antibiotic therapy, or create confusion with positive cultures stemming from sample contamination.
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PMID:A persistent biochemical marker for partially treated meningitis/ventriculitis. 778 15

Three patients with antibiotic induced meningitis, one following penicillin with seven episodes, are reported on--the first well documented description of penicillin induced meningitis. In this patient episodes of headache and nuchal rigidity appeared with and without CSF pleocytosis. Two patients had a total of five episodes of antibiotic induced meningitis after trimethoprim-sulphamethoxazole (co-trimoxazole) administration. The features common to all three patients were myalgia, confusion and low CSF glucose. CSF analysis was not a reliable method to differentiate antibiotic induced meningitis from partially treated bacterial meningitis.
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PMID:Antibiotic induced meningitis. 800 51

We present a systematic review of meningitis associated with transsphenoidal surgery. Patients present within the first 4 days after surgery with symptoms of headache, fever, and confusion. Overt cerebrospinal rhinorrhea or nuchal rigidity at the time of presentation is an infrequent finding. Although postoperative aseptic meningitis may be difficult to distinguish from early bacterial meningitis, the findings of hypoglycorrhachia, pleocytosis, and hyperproteinemia in the setting of fever and neurological deficit strongly suggest bacterial infection. The preponderance of cases of gram-negative meningitis observed in this series and in previous reports related to posttraumatic CSF leaks indicates that empirical regimens should include agents suitable for treating infections caused by nosocomial pathogens. In general, patients with uncomplicated meningitis in this setting can be expected to recover and do well. Questions remain as to the role of prophylactic antibiotics in the development of gram-negative meningitis in the setting of transsphenoidal surgery. A multicenter trial might be better able to define this role.
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PMID:Gram-negative meningitis associated with transsphenoidal surgery: case reports and review. 803 9

The authors report the results of a retrospective review, between January 1986 and December 1991, of the results of early surgery and intrathecal thrombolytic therapy in 111 patients with aneurysmal subarachnoid hemorrhage. Effects on clot lysis, angiographic and symptomatic vasospasm, cerebral infarction, and clinical outcome were compared in 60 patients treated with urokinase (UK) 60,000 IU/d for 7 days (UK group), 22 patients treated with 0.042 to 1 mg tissue plasminogen activator (tPA) every 6 to 8 hours for 5 days (tPA group), and 29 patients who did not receive treatment with either thrombolytic agent (no-treatment group). The no-treatment group consisted of all patients treated before July 1986 and of patients in whom thrombolytic therapy was attempted but failed to start or in whom the therapy was not used intentionally because of small subarachnoid clot. Treatment with UK was employed between July 1986 and March 1991, and tPA was employed during the remainder of the study for patients at a higher risk for vasospasm. The severity of angiographic vasospasm and the incidence of infarction in the UK and the tPA groups were less than those of the no-treatment group (P < 0.01), in spite of a larger amount of initial subarachnoid blood clot in both thrombolytic groups. This appears to be the result of the more rapid clearance of cisternal clot in the thrombolytic groups than the no-treatment group (P < 0.01). Only tPA therapy reduced the incidence of symptomatic vasospasm (P < 0.05). No serious complications were observed, although in the tPA group, asymptomatic intraventricular hemorrhage occurred in one patient, and transient confusion in another. Both received 4 mg tPA/d. Meningitis was suspected in 16 patients of the UK group. However, in this relatively small retrospective series, there were no differences among the three groups in overall outcome at 3 months. This study indicates that postoperative intrathecal thrombolytic therapies, especially with less than 4 mg/d of tPA, are effective in lysing subarachnoid clot and preventing vasospasm and infarction safely.
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PMID:Vasospasm prevention with postoperative intrathecal thrombolytic therapy: a retrospective comparison of urokinase, tissue plasminogen activator, and cisternal drainage alone. 817 83

This community-based study analyzed 54 patients with definite or probable tuberculous meningitis (TBM) in New Mexico from 1970 through 1990. Patients ranged in age from 4 months to 86 years. The highest age-specific incidence occurred in the elderly, but 22% of patients were less than 10 years old. Native American patients were overrepresented. Patients were as likely to live in small towns as in large urban cities. Symptoms were present for a median of 13 days before admission. The majority of patients had fevers, headache, stiff neck, and mental changes, such as confusion or lethargy. No patient was admitted comatose. Focal neurologic signs were present in 33%. Laboratory testing found hyponatremia in 79%, pulmonary infiltrates on chest x-ray in 40%, ventricular dilatation on CT or MRI in 52%, and tuberculomas in 16%. PPD skin tests were positive in 64%. CSF cultures grew Mycobacterium tuberculosis in 50%, but colony counts were always lower than 10(2)/ml. As a consequence, acid-fast stains of CSF sediment were reported as positive in only 4%. Six patients were not diagnosed during the hospitalization and died of complications. Twenty-three percent of patients who were appropriately treated also died of complications during the initial hospitalization. Tuberculous meningitis continues to be an important disease in small communities, and affects all ages and ethnic and socioeconomic backgrounds.
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PMID:Tuberculous meningitis in the southwest United States: a community-based study. 841 30

We describe 2 patients with tuberculous meningitis who exhibited unusual changes of their cerebrospinal fluid (CSF) which led to confusion in their management. Patient 1 was a 25-year-old man who displayed persistent polymorphonuclear dominant pleocytosis in his CSF. Autopsy revealed marked hypoplasia of the thymus and T cell areas of the lymph nodes, consistent with the Nezelof syndrome, as well as disseminated tuberculosis. Patient 2 was a 39-year-old woman who demonstrated, during appropriate antituberculous chemotherapy, an atypical exacerbation consisting of prolonged fever, polymorphonuclear dominant pleocytosis in her CSF and multiple cerebral infarcts. The neurological abnormalities in the patient underwent marked improvement following oral prednisolone therapy.
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PMID:Atypical manifestations of tuberculous meningitis. 846 25

Several problems are presented in differential diagnosis between cerebral tuberculomas and other brain lesions. Eight cases of cerebral tuberculomas diagnosed in our hospital between 1962 and 1992 were studied. Data about age, sex, HIV antibodies, clinical manifestation, tomographic images, non cerebral locations, diagnostic method, evolution and treatment resolution were collected. Eight cases were diagnosed, seven men and one woman, age 40.75 +/- 10 HIV antibodies in three patients were positive. Meningitis (4 cases) and weight loss (4 cases) were the first clinical features. Confusional state, fever and seizures were presented in three cases one (37.5%), ataxia in two cases (25%) and headache in one (12.5%). Lesions were sole in 62.5% of cases, and several in 37.5%. Were high density in 25.9% and low density in 75%. All patients presented a other localization of tuberculosis. Mycobacterium tuberculosis was isolated in sputum in 75% of cases. After six month, most of the lesions improved.
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PMID:[Clinico-radiologic characteristics of 8 cases of brain tuberculoma]. 851 37

Although infrequent, one of the etiological causes of aseptic meningoencephalitis is drug-induced. In our patient, two cases of meningocephalitis took place over a period of six years, together with a meningismus following consumption of trimetroprim-sulphametoxazol (cotrimoxazol). Features of the cases were mental confusion, fever, alterations in the CSF and a benign clinical course, with a high degree of doubt regarding diagnosis, given the similarity of anomalies in the CSF to those present in partially treated bacterian meningitis.
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PMID:[Recurrence of meningoencephalitis induced by cotrimoxazole]. 854 10

Chronic lymphocytic leukemia is the most common human leukemia but infrequently causes neurologic symptoms. We have reviewed all previously reported cases of chronic lymphocytic leukemia in the CNS along with three new cases; one patient was diagnosed antemortem and treated with immediate improvement and 4-year survival. In addition, we reviewed all autopsy cases since 1972 and available lumbar puncture data on patients with chronic lymphocytic leukemia admitted to the Massachusetts General Hospital. Invasion of the CNS by chronic lymphocytic leukemia often leads to confusional state, meningitis with cranial nerve abnormalities, optic neuropathy, or cerebellar dysfunction. Lumbar puncture shows a lymphocytosis consisting of monoclonal B cells, but CSF cytology studies are of limited value in establishing the diagnosis. Long-term survival may be related to the stage of chronic lymphocytic leukemia at the time of CNS disease and may be associated with intrathecal chemotherapy. A mild, asymptomatic infiltration of the brain, frequently noted in late-stage chronic lymphocytic leukemia in autopsy series, may explain the CSF lymphocytosis in some patients with late-stage chronic lymphocytic leukemia.
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PMID:Chronic lymphocytic leukemia and the central nervous system: a clinical and pathological study. 879 4


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