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Purpose: To investigate the clinical characteristics, laboratory features and prognostic factors of elderly patients with postneurosurgical bacterial meningitis., Methods: Five hundred and forty patients with adult bacterial meningitis (ABM) were collected from 1986-2015, of whom 167 were ≥ 65 years. Of these 167 elderly patients, 82 had postneurosurgical infections and 85 had spontaneous infections. Clinical, laboratory and therapeutic data of these two groups were compared., Results: The 82 elderly ABM patients with postneurosurgical infections included 48 men and 34 women with a median age of 71 years (range: 65-84 years). In addition to the postneurosurgical condition, the other most common underlying conditions included diabetes mellitus (29.3%) and hydrocephalus (29.3%). The major clinical presentations were fever (80.5%), altered consciousness (50.0%), hydrocephalus (43.9%), seizure (24.4%) and septic shock (15.9%). Of the implicated pathogens, staphylococcal species (spp.) were the most common (31.7%), followed by Acinetobacter spp. (12.2%), Enterobacter spp. (7.3%), Pseudomonas spp. (7.3%), Enterococcus faecalis (7.3%) and Escherichia coli (6.1%). The implicated staphylococcal spp. had a high rate of non-susceptibility to methicillin (84.6%), and the implicated Acinetobacter spp. and Enterobacter spp. had non-susceptible rates to ceftazidime of 60% and 50%, respectively. The mortality rate was 28.1%, and septic shock was the most significant prognostic factor. Compared with the clinical characteristics of the other 85 elderly patients with spontaneous ABM, there were significant differences in underlying condition, clinical and laboratory features and therapeutic outcomes., Conclusions: Elderly patients accounted for 30.9% of all cases of ABM, of whom 49.1% had postneurosurgical ABM. The clinical characteristics of the elderly patients with postneurosurgical ABM were non-specific, and cerebrospinal fluid studies were needed to confirm the diagnosis. The mortality rate of this group of patients was high, and septic shock was an important prognostic factor. The clinical and laboratory features and therapeutic outcomes were different between the elderly patients with postneurosurgical and spontaneous ABM.

Klebsiella (K.) pneumoniae infections, including adult bacterial meningitis (ABM), are a distinct syndrome in Taiwan, which may consist of diabetes mellitus and multiple septic metastatic lesions such as liver abscess, endophthalmitis, and focal suppuration of other internal organs. In this review article, the authors will discuss the protean clinical manifestations and the complexity of the clinical course of this specific central nervous system infectious disease in Taiwan. The clinical and laboratory data of 49 K. pneumoniae ABM cases diagnosed at Chang Gung Memorial Hospital-Kaohsiung, collected over a period of 11 years (2000-2010), were included for analysis. This review may help clinical physicians, especially first-line, primary- care physicians, to have a better understanding of this critical CNS infection.

Purpose: Silent brain infarctions (SBI) commonly go unnoticed due to the subtlety of their neurological signs. However, there is the risk of subsequent symptomatic stroke and dementia. A better understanding of the risk factors of SBI may help accurately predict those who will require treatment., Methods: This one-year retrospective study enrolled 199 adult healthy Taiwanese. Multiple logistic regression analysis was used to evaluate the relationships between baseline clinical factors and the presence of SBI during the study period., Results: Fifteen (7.5%) healthy subjects had SBI, including 4.9% (5/103) males and 10.4% (10/96) females. Multiple logistic regression analysis revealed that both mean age and hypertension were independently associated with SBI, such that any increase of one year in mean age increased the SBI rate by 7.3%., Conclusion: In the present study, there is a close relationship between elderly patients and SBI and any increase of one year in mean age increases the SBI rate by 7.3%. Aside from age, hypertension is by far the strongest modifiable risk factor identified to date. Prospective, longitudinal observational studies are warranted to evaluate the relationship between control of hypertension and SBI in this specific population to determine how to prevent subsequent symptomatic stroke.

Purpose: Nontuberculous bacterial spinal epidural abscess (SEA) is a serious infectious disease of spines. Despite proper management, SEA remains a disease of high morbidity. The epidemiological data in southern Taiwan is still lacking., Methods: We analyzed the clinical features, laboratory data, magnetic resonance imaging findings, and therapeutic results of 45 bacterial SEA patients, collected during a study period of six years (2003- 2008)., Results: The 45 adult SEA patients, 32 were men and 13 women, aged 17-81 years (mean = 62 years). Thoracic and lumbosacral spines were the most commonly affected segments. Staphylococcus aureus was the most commonly implicated pathogen, accounting for infections in 67% (29/43) of the culture-proven cases, and 41% (12/29) of the S. aureus strains were oxacillin resistant. Gram-negative pathogens were implicated in 30% (13/43) of the culture-proven cases. Of the 45 patients, 19 underwent antibiotic treatment alone and 26 underwent medical and surgical treatments. The therapeutic results showed that 28 patients had a good prognosis and 17 had a poor prognosis. The significant prognostic factors included higher age, presence of diabetes mellitus and chronic heart disease, and initial presentation of altered consciousness., Conclusion: S. aureus was the most commonly implicated pathogen of adult SEA, and most S. aureus strains were oxacillin resistant. A relatively high incidence of Gram-negative infection was observed in this study. The epidemiological characteristics of the implicated pathogens must receive special consideration when selecting the empirical antibiotics. Despite adequate management, many adults with bacterial SEA had a high incidence of poor prognosis.

Purpose: Dizziness/vertigo are important public heath care issues especially in elderly patients. Isolated dizziness/vertigo without neurological deficits has seldom been considered a symptom/sign due to vascular origin. Recently, some studies have suggested that vascular origin should be considered in cases of positional vertigo and isolated vertigo or dizziness when the etiology remains unclear. In this study, we tried to delineate the correlation of dizziness/vertigo and risk factors of stroke., Methods: We collected adult subjects receiving health screening of the brain at their own expense. All subjects had undergone brain magnetic resonance imaging (MRI), magnetic resonance angiography (MRA) and carotid duplex. The chief complaints, body height, body weight, waist circumference and blood pressure of all subjects were recorded. Most received blood tests including fasting sugar, total cholesterol, low density lipoprotein, high density lipoprotein (HDL), triglycerides, and uric acid (UA). The relationships between dizziness/vertigo and blood test data, blood pressure, body mass index (BMI), waist circumference, metabolic syndrome, carotid duplex, silent brain infarction, leukoaraiosis and MRA were analyzed., Results: After exclusion, a total of 170 out of 210 subjects were collected. The analysis revealed that dizziness/ vertigo had a significant correlation to age, UA , BMI, male HDL and female waist circumference. Among them, female waist circumference had the highest statistical significance (P = 0.001). Leukoaraiosis on brain MRI also had a close relationship with dizziness/vertigo., Conclusion: After careful examination and approach, a vascular origin should be considered in dizzy patients of unknown etiology.

Purpose: To analyze the clinical characteristics and therapeutic outcome of patients with solely cerebellar bacterial brain abscess (BBA)., Case Report: Eight patients with solely cerebellar BBA, collected during a period of 23 years from 210 BBA patients, were included in this study. The eight patients were five men and three women, aged 5-54 years (mean, 36.6 years). Six of them were adults, one was a child, and one was an adolescent. Six patients had underlying medical/surgical problems. Of the clinical presentations, dizziness was the most common (87.5%, 7/8), followed by headache (62.5%, 5/8), altered consciousness (62.5%, 5/8), fever (50%, 4/8), ataxia (25%, 2/8), hearing impairment (12.5%, 1/8), dysarthria (12.5%, 1/8), and hemiparesis (12.5%, 1/8). The Image Severity Index (ISI) scores of these eight patients ranged from 6 to 12 points. All eight patients received both medical and surgical treatment. One patient died owing to a complication in the neurosurgical procedure and the remaining patients survived. The therapeutic outcome was quantified one month after discharge by modified Rankin scale (mRS) and the result showed six of the seven survivors had good outcomes, while the other one had a poor outcome (ataxic gait)., Conclusion: Cerebellar BBA accounted for 3.8% (8/210) of the overall BBA. In cerebellar BBA, dizziness is a frequent symptom. Early diagnosis and a combination of antimicrobial and neurosurgical intervention is important for its treatment. The small case number is a limitation of this study; therefore, further large-scale study of cerebellar BBA is needed for better delineation of the clinical characteristics, therapeutic outcome, and prognostic factors.

Purpose: To report on the findings of a series of cranial computed tomography (CT) and magnetic resonance (MR) imaging studies of a 57-years-old woman with Klebsiella (K.) pneumoniae infection., Case Report: The patient had fever, consciousness disturbance and left hemiplegia as the initial presentations of K. pneumoniae infection. Initial blood culture grew K. pneumoniae, and a delayed purulent cerebrospinal fluid profile was found later. The serial neuroimaging studies showed cerebral hemorrhage, cerebritis and subsequent multiple abscess formations. In the meanwhile hepatic and pulmonary abscess were also discovered by imaging studies. With a 77- days intravenous ceftriaxone treatment (4 gm/day), the abscess formations of brain, lung and liver were all resolved., Conclusion: This study showed the protean neuroimage features of a woman with K. pneumoniae infection and the confirmation of multiple brain abscesses was made by follow-up neuroimaging studies. These sequential neuroimage findings in one patient are uncommon but deserved special clinical note by the first-line, primary-care physicians including neurologists.

Purpose: Supratentorial deep-seated bacterial brain abscess (BBA) in adults is rarely examined solely in the literature. This retrospective study is conducted to examine the clinical characteristics and therapeutic outcome of this specific group of BBA., Methods: Eight adult patients with supratentorial deep-seated BBA, collected during a study period of 14 years (1994-2007), were enrolled. Their microbiological data derived from cerebrospinal fluid (CSF), blood or pus cultures, clinical features and therapeutic outcome were analyzed., Results: The eight adult cases were six men and two women, aged 41 to 80 years (mean=61). Preceding medical conditions were found in five of these eight cases, while preceding neurosurgical event was found in one. Of the clinical presentations, hemiparesis (6) was the most common, followed by fever (5), altered consciousness (4), headache (3), septic shock (1), and seizure (1). The main locations of the BBA were the left basal ganglia in five, the left thalamus in two, and the right basal ganglia in one. Causative pathogens were found in six cases and the isolated pathogens were all cultured from CSF specimens. Positive bacteremia which grew K. pneumoniae was found in one case. Seven of these eight cases contracted the infection in a community-acquired state. Besides antibiotic treatment, seven of them received a neurosurgical intervention (stereotactic aspiration and/or ventriculoperitoneal shunt). The therapeutic result showed six cases survived and two expired. Five of the six survivors had variable degree of neurologic deficits., Conclusions: Besides the common clinical features of BBA, supratentorial deep-seated BBA has a high incidence of hemiparesis in the early stages of disease. Most of the involved patients have community-acquired infections and are preceded by a medical condition. Stereotactic aspiration for therapeutic and diagnostic purposes, as well as shunting surgery, is the most common neuro-surgical procedures used for treatment. But despite therapeutic efforts, high mortality and morbidity remain.

Purpose: Seizures originating in the occipital areas are relatively uncommon. They are usually characterized by visual hallucinations and illusions or other symptoms related to the eyes and vision., Case Report: In a 54-year-old woman with occipital lobe epilepsy, complex visual hallucinations, illusions, and migraine-like headache constitute the major clinical manifestations. During focal status epilepticus, ictal electroencephalography revealed rhythmic focal spikes in the right occipital region, rapidly propagating to the right parietal and contralateral occipital areas. Ictal brain single-photon emission computed topography revealed hyperperfusion of the right occipital region. Using a full-field pattern-shift visual evoked potential (VEP) study, we found that the P100 responses on both sides were markedly attenuated in amplitude during occipital focal status epilepticus, whereas the latencies of the VEPs were normal. The amplitude and morphology of P100 responses on both sides, however, returned to the normal range 7 days after cessation of the seizures., Conclusion: In addition to clinical seizure semiology, scalp EEG, SPECT and neuroimaging studies, VEP studies may be used as a supplementary examination tool to provide further information in the patients with occipital lobe seizures or epilepsies.

Objectives: To analyze the correlation between brainstem-auditory evoked potentials (BAEP) and nerve conduction (NC) studies in patients with diabetes mellitus (DM)., Methods: We retrospectively reviewed the results from the subjects who received our neurological screening test including BAEP and NC studies. A DM group and a control group were applied. The DM group was subdivided 4 subgroups including neuropathy, non-neuropathy, infarct and non-infarct., Results: A total of 43 DM patients and 43 control subjects were included. The inter-peak latencies (IPL) IIII and IPL I-V of the BAEP showed a statistical significance between the DM and control groups. In the IPL I-III study, the DM neuropathy subgroup showed a statistical significance in either the DM non-neuropathy or control subgroup. The IPL I-III showed moderate correlation (correlation coefficient- 0.334) with tibial motor NC velocity., Conclusion: Patients with DM have a prolongation in IPL I-III, especially in the neuropathy subgroup. This prolongation in IPL I-III would best be explained by acoustic neuropathy. The tibial motor, median sensory, and sural NC velocities correlated with the acoustic neuropathy in patients with DM.

Purpose: To analyze the clinical characteristics of hepatocellular carcinoma (HCC) with spinal metastasis., Methods: During a period of 14 years, 42 HCC patients with cranial and/or spinal metastasis were identified. Among them, 12 had spinal involvement and thus were included for study. The clinical, laboratory and neuroimaging data of these 12 cases were analyzed., Results: The 12 cases were all male, aged 36-65 years. The time interval from the diagnosis of HCC to the finding of spinal involvement was 0-38 months. Among these 12 cases, four had the features of spinal involvement in the initial presentation of their HCC. Low back pain was the most common symptom followed by weakness and numbness in the lower limbs. A serum biochemical study did not show unique findings. All 12 cases died within nine months after the diagnosis of the HCC spinal involvement., Conclusions: 28.6% (12/42) of the HCC patients with nervous system metastasis had spinal involvement and the exact incidence rate can be increased by more extensive neuroimaging studies. Viral hepatitis and liver cirrhosis are common preceding events in patients with HCC with spinal involvement. T- and L-spine are the most commonly involved segments and back pain is the most common complaint in patients with HCC with spinal metastasis. The prognosis in this group of patients is grave and most of the patients died soon after the development the HCC's spinal involvement. No specific biomarker can predict the development of spinal involvement in HCC patients and diagnostic consideration can only be emphasized, especially in HCC hyperendemic areas such as Taiwan.

Background: Different methods in performing nerve conduction studies (NCS) yield different results. The results of NCS can also be affected by factors such as gender, age, height, and weight. This study aimed (1) to survey the effects of such factors, (2) to determine the importance of these factors, and (3) to analyze them for building equations in NCS and late response studies., Methods: NCS from the neurological screening tests of 101 individuals without spinal cord, root, nerve, neuro-muscular junction, muscular, or systemic diseases were collected and analyzed., Results: Subjects with older age had longer latencies, smaller amplitudes, and slower velocities compared with those in the younger age group. The change with age was greater in the median than in the ulnar nerve. Female subjects or those with lower weight had higher median and ulnar sensory amplitude. Females had shorter latency in the upper limbs and longer latency in the lower limbs by F-wave studies than males did. Height was an important factor by F-wave studies, with approximately 0.1 ms/cm and 0.3 ms/cm increase in the upper and lower limbs, respectively. Height and age were the most significant factors in the H reflex study with an increase of 0.18 ms/cm in height and 0.07 ms/year in age., Conclusion: Without adjustment for these factors, the sensitivity and specificity of NCS will decrease when using the same reference data in patients with different gender, age, height, and weight.

Acute intermittent porphyria (AIP) is an inherited metabolic disease that can affect the autonomic, peripheral and central nervous systems. Pancreatic diseases assocated with AIP is rarely reported. We report here a 60-year-old non-alcoholic male who had typical manifestations of AIP, including abdominal pain, constipation, tachycardia, hypertension, mental disturbances, psychiatric manifestations, seizures, peripheral neuropathy, and excessive excretion of porphyrin precursors in urine. Increases of serum amylase and lipase, as well as mild pancreatic edema on ultrasonography, were noted during the acute attack of AIP, suggesting concomitant acute pancreatitis. In this patient, brain magnetic resonance imaging revealed reversible multifocal cerebral lesions resembling a posterior reversible encephalopathy syndrome (PRES) during the acute attack of AIP. Because the clinical manifestations of acute pancreatitis could be present with an acute attack of AIP, early confirmation of diagnosis is mandatory to effectively manage the attack and avoid inappropriate treatment.

Exercise test was reported to be useful for some patients with periodic paralysis. We report here the results of exercise test in three cases of thyrotoxic periodic paralysis, for whom the exercise test was all positive. Exercise test could be one of the diagnostic tools in the "inter-attack" state of the probable cases with thyrotoxic periodic paralysis. However, the case number of this study is small and larger-scale studies may be warranted in the future.

The epidemiologic landscape of causative pathogens and clinical characteristics of bacterial meningitis varies with several clinical factors including preceding/pre-existent medical and/or surgical conditions, modes of contraction, geographic distributions, status of vaccinations, the study time periods and differences among age groups. In order to delineate the epidemiology of bacterial meningitis in senior adults (ages > or =60 y/o) in southern Taiwan, we analyzed the clinical characteristics and therapeutic outcomes of 64 senior adults (42 men and 22 women, aged 60-80 years) with bacterial meningitis collected over a period of 13 years at our hospital. The prognostic factors between fatal and non-fatal groups of patients were compared. Twenty-seven of the 64 patients belonged to a nosocomial infection group, and the other 37 comprised a community-acquired infection group. Sixty percent (39/64) of the patients had a post-neurosurgical state as the most preceding event prior to infection. Liver disease (13) and diabetes mellitus (6) were the most common underlying conditions of the other 25 patients with spontaneous meningitis. Of these 64 patients, Klebsiella (K.) pneumoniae (18), Acinetobacter baumannii (5), Escherichia coli (5), and Enterobacter species (5) were the most commonly implicated Gram-negative pathogens. Staphylococcus (S.) aureus infection was increasing during the study period. The therapeutic results of this group of patients showed a mortality rate of 38% (24/64). The presence of septic shock was the most significant prognostic factor. In conclusion, for this study group, a post-neurosurgical state was the single most important preceding event for senior adults developing bacterial meningitis. Of the implicated pathogens, K. pneumoniae and S. aureus were the most common gram-negative and gram-positive pathogens, respectively. The therapeutic result of this specific group of patients showed a high mortality rate; however, the small case number and possible bias of case selection have limited the analytical conclusions of this study.

The neurologic manifestations of organophosphate intoxication are many, and different pathophysiologic mechanisms are responsible for the different presentations occurring at different stages of the disease process. Movement disorders constitute one of the neurologic manifestations, which may include Parkinsonism or other dyskinetic movements. However, involuntary coital-like movements have not been reported as one of the organophosphate intoxication-related movement disorders. In this case report, we describe a 71-year-old man who developed involuntary coital-like movements about one and a half months after an event of organophosphate intoxication in an attempt to commit suicide. The involuntary movements were to-and-fro pelvic thrusting and back-rocking movements. The patient was able to suppress the involuntary movements for a short period of time, although they usually persisted all day long. The involuntary movements occurred in all postures including standing, sitting and in supine postures, resulting in great embarrassment. These involuntary movements also interfered with the initiation of sleep, although they discontinued while asleep. With clonazepam and piracetam therapy, the involuntary coital-like movements of this patient decreased in amplitude, although remaining to a degree even after one year of follow-up.

Between January 1999 and December 2003, 81 cases of single pathogen-related culture-proven Gram-negative adult bacterial meningitis were identified at Chang Gung Memorial Hospital-Kaohsiung. Of these 81 cases, Acinetobacter infection was found in 13 cases. Clinical and laboratory data of these Acinetobacter meningitis patients were studied and were compared with those of other 68 non-Acinetobacter Gram-negative bacterial meningitis (GNBM) patients. Of the 13 implicated Acinetobacter strains, A. baumannii was the most common (12), and the other was A. lwoffii (1). Eleven of these 13 cases were due to a post-neurosurgical infection. The results of the antibiotic susceptibility test of the 13 Acinetobacter strains from cerebrospinal fluid included ceftriaxone, (1/13, 8%), ciprofloaxin (6/13, 46%), ceftazidime (6/13, 46%), cefepime (7/13, 54%), ampicillin-subtactam (7/13, 54%), imipenem (12/13, 92%) and meropenem (12/13, 92%). One strain with pan-drug resistant A. baumannii (PDRAB) emerged in 2003. A statistically significant difference between Acinetobacter meningitis and non-Acinetobacter GNBM included hydrocephalus and ceftazidime-resistance. A mortality rate was 30% (4/13), and 7 of the other 9 survivals had severe neurologic deficits. The emergence of Acinetobacter infections in adult post-neurosurgical infections, multiple antibiotic resistant characteristics, and the emergence of PDRAB strain remained a challenge of the initial management of this specific meningitis. Use of carbapenem, especially meropenem, could be considered as one of the initial empiric antibiotics chosen for the management of adult post-neurosurgical meningitis.

Cerebrovascular stroke due to Candida (C.) parapsilosis native valve endocarditis (NVE) is rarely reported. Herein, we report a 53-year man with C. parapsilosis NVE and acute ischemic stroke. Diabetes mellitus and recent dental manipulation were the preceding events. Cranial magnetic resonance imaging study revealed occlusion of left common carotid artery, and infarcts of the pons and territory of the branch of left middle cerebral artery. With a total of 4,051 mg amphotericin B therapy and aortic valve replacement, the patient survived with right hemiplegia and dysarthria. In the English literature, there have been 12 patients with C. parapsilosis NVE including our patient over the past 25 years. Intravenous drug abuse was the most common predisposing factor for this infective disorder, followed by hematological malignancy and central venous catheterization. Fever and ischemic phenomenon of lower legs were the common clinical manifestations. Cerebrovascular stroke was present only in our case. Of these 12 patients, one administered fluconazole and miconazole therapy died, while 11 with amphotericin B therapy and one patient with fluconazole monotherapy survived.