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A wide range of pathogens can cause meningitis or meningoencephalitis.Guiding symptoms of meningitis are headache, fever, nausea, vomiting and meningism.Guiding symptoms of meningoencephalitis are headache, fever, qualitative or quantitative disturbances of consciousness, signs of meningism are possible, optional focal neurological signs can occur.Crucial prognostic factor in treatment of acute meningitis and meningoencephalitis is rapid diagnosis and early initiation of therapy. An early start of therapy is crucial. In addition to rapid pathogen-specific treatment, specialized neurological intensive care medicine is life-saving.

Cerebral diseases such as epileptic seizures, cerebral hemorrhages or meningoencephalitis are the primary cause of approximately 50 % of non-traumatic acute disorders of consciousness. For the differential diagnosis, history and other symptoms are important such as hemiplegia, signs of brain stem dysfunction, meningism or headache. Metabolic, endocrinologic, toxicologic or electrolytic causes of coma usually can be diagnosed by laboratory examinations. Anamnestic informations, body inspection, clinical neurological examination as well as laboratory and imaging findings have to be added and categorized by a multilevel composition to establish a conclusive diagnosis. Simultaneously therapeutic measures for suspected primary cerebral diseases must be initiated, for example a rapid antibiotic treatment in case of a possible bacterial meningitis. A fast and structured diagnostic approach is crucial for ensuring a good prognosis and helps to miss relevant diagnostic steps. Potential diagnostic and therapeutic pitfalls must be kept in mind.

A 19-year-old boy developed paravertebral muscular pain in the lumbar region after an episode of extremely arduous sporting activity, with fever followed by meningism. The cerebrospinal fluid showed a reactive pleocytosis. Initially, no acute inflammatory changes were present on serum and blood analysis, although the erythrocyte sedimentation rate was moderately increased to 25/60 mm. Pyrexia of up to 38.5 degrees C developed 6 days after admission. Because Borrelia IgM and IgG titres were positive, the diagnosis was at first thought to be atypical borreliosis and the patient was treated with antibiotics. However, after a further episode of fever. Salmonella antibody titres, which had initially been normal, rose to 1: 3200 (Salmonella typhi O and H antigens) and 1: 12800 (Salmonella enteritidis, H antigen). At this stage, the erythrocyte sedimentation rate rose to 86/120 mm and the C-reactive protein to 77 mg/dl. The white cell count remained normal throughout. Blood cultures grew Salmonella enteritidis. Abnormalities on bone scintigraphy were confirmed by CT and MRI scans, showing spondylodiscitis of lumbar vertebrae 1 and 2 with limited osteolysis. The lesion resolved completely on 6 week's treatment with ciprofloxacin (200 mg twice a day intravenously) and conservative supportive treatment. Spondylodiscitis is an uncommon complication of salmonellosis and may occur long after the diarrhoea. Cross reactions with Borrelia flagellin antigens may lead to the wrong diagnosis being made.

Six months after an attack of pyelonephritis, adnexitis and candida colpitis an 18-year-old girl developed some clouding of consciousness. On neurological examination she showed organic behavioural changes, discrete anisocoria and possible meningism. Computed tomography revealed hydrocephalus and signs of increased cerebrospinal fluid (CSF) pressure. CSF contained 2336/3 cells, while total protein was raised to 7.0 g/l and lactate concentration to 6.85 mmol/l. Glucose concentration in CSF was 51 mg/dl and 75 mg/dl in serum. As tuberculous meningitis was suspected, treatment was started with four tuberculostatic drugs, but there was no improvement. Five weeks later microscopic CSF examination showed fungal spores and nonbranching hyphae. The maximal candida haemagglutination titre in CSF was 1:2048. CSF culture grew Candida albicans. The further course was complicated by side effects to the antimycotic drugs (amphotericin B between 4.5 and 45 mg daily; flucytosine 1.7 g four times daily) and recurrent obstruction in the ventricular system requiring repeated neurosurgical interventions. However, full cure was achieved after seven months' hospital treatment.

HISTORY AND CLINICAL FINDINGS Two months after the onset of mainly frontal headaches a 25-year-old man of Turkish descent additionally developed double vision. Fundoscopy revealed bilateral choked discs and right trochlear paralysis. Computed tomography and digital subtraction angiography demonstrated thrombosis of the superior sagittal sinus. On admission to hospital the patient was fully conscious but had marked meningism, bilaterally positive Lasegue's sign (painful straight leg raising) at a 50 degree angle, and multiple oral aphthous ulcers. The sinus thrombosis suggested a chronic inflammatory process, while the oral ulcers pointed to Behcet's syndrome. INVESTIGATIONS Inflammatory parameters (erythrocyte sedimentation rate, C-reactive protein and white blood cell count) were increased and the HLA-B27 test was positive. Other laboratory tests, cerebrospinal fluid, chest radiogram and ECG were unremarkable. TREATMENT AND COURSE Despite intravenous administration of heparin nad cefuroxim for one week the sagittal sinus thrombosis spread to the straight sinus. In the third week scrotal ulcerations were noted and taken to confirm Behcet's syndrome. Immunosuppressive treatment with methylprednisolone (initially 80 mg daily) and 2 weeks later together with chlorambucil (0.1 mg/kg daily) was started. Four weeks later the patient was free of symptoms and discharged. CONCLUSION Neurological signs are not adequately stressed by the International Study Group for Behcet's Disease among its listed diagnostic criteria.

A 19-year-old man with acute lymphoblastic leukaemia developed fever, general deterioration and somnolence 3 days after a cycle of cytostatic treatment. He had anaemia (haemoglobin 6.6 g/dl), leukopenia (100/microliters) and thrombocytopenia (7,000/microliters). As an acute septicaemia was suspected he received broad spectrum antibiotic therapy, together with two units of red cell and platelet concentrates. However, his condition worsened rapidly over the next 5 hours (meningism, seizures, fever to 41.1 degrees C, dyspnoea). Another blood count revealed severe haemolysis. Computed tomography of the skull demonstrated multilocular intraparenchymal gas formation. Although the antibiotic treatment was extended the patient died several hours later. Retrospective examination for suspected transfusion mismatch provided no evidence for erythrocyte incompatibility. But there was liberation of T-antigen as sign of a bacterial cause of erythrocyte damage. An anaerobic blood culture grew Clostridium perfringens. This case demonstrates that acute intravascular haemolysis in septicaemia should be considered in the differential diagnosis of transfusion mismatch.

HISTORY AND CLINICAL FINDINGS A 23-year-old woman suddenly had the sensation of a foreign body in her right eye. On looking into the mirror she saw what looked like a moving worm-like structure in the lateral angle of the eye. The patient had visited Cameroon 2 years previously. TESTS On ophthalmological examination with a slit-lamp a transparent worm, 6-7 cm long, was seen. Laboratory tests showed an eosinophilia of 13%, C-reactive protein slightly raised to 1.25 mg/dl and IgG of 2100 mg/dl (IgE was normal at 33 U/ml). Giemsa staining of a whole-blood drop contained numerous microfilaria typical of Loa loa (2000/ml). Filaria serology with antigen of Dipetalonema vitae (Acanthocheilonema) gave a positive response. TREATMENT AND COURSE The worm was removed surgically and, after a test dose, diethylcarbamazine, 6 mg/kg daily), was administered. Although methylprednisolone (initially 20 mg daily) was given concurrently, a fever of 38,5 degrees C developed on the 4th day. At the same time, streaky cutaneous eruptions were noted over the left lower arm and left knee bond. These two signs, which were due to two adult worms, disappeared within 2 days. On the 5th day the patient complained of headache, nausea and sensitivity to light, and she had meningism. The symptoms were treated with paracetamol and diazepam and quickly improved. The patient was discharged after 3 weeks. Further treatment cycles with diethylcarbamazine are planned.

History and clinical findings Two weeks after returning from a trip to Thailand a 79-year-old man developed a higher fever, pain in the right flank and progressive clouding of consciousness. She had meningism on admission. Investigations There was a marked leukocytosis (WBC count 17,700/microliter) and raised C-reactive protein (6.5 mg/dl). Cerebrospinal fluid was clear, containing 119 cells/mm3 and elevated protein (90 mg/dl). Abdominal sonography demonstrated segmental pyelonephritis, and blood culture grew Pseudomonas pseudomallei. Treatment and course On the basis of sensitivity tests imipenem was chosen as the antibiotic and was given for 6 weeks. Because of an inadequate response and a right renal abscess a right nephrectomy was performed. After marked improvement the septicaemia recurred one week after antibiotic treatment had been discontinued, and the patient died. Conclusion Efficacious treatment of melioidosis (a glanders-like disease) presupposes diagnosis of the causative microorganism and testing of its antibiotic sensitivity. As Pseud. pseudomallei may encapsulate and persist intracellularly, the selection of antibiotic and the duration of treatment are crucial.

HISTORY AND ADMISSION FINDINGS A 37-year-old woman was admitted with total loss of vision of the left eye within 24 hours. Additionally, she complained about fatigue, headache, chills, fever, muscle pain and neck stiffness since 4 days. At admission, the body temperature was 38.7 degrees C. Neurological examination revealed papilledema and meningism. INVESTIGATIONS Ophthalmologic findings were consistent with a papillitis. The vision was lost, the pattern-shift checkerboard visual evoked potentials were not measurable. MRI of the brain and the optical nerve was without pathological findings, meningeal or cerebral Gadolinium enhancement was not present. The CSF analysis yielded a lymphocytic meningitis with 249 cells/mm (3), the glucose ratio of cerebrospinal fluid and serum was normal. DIAGNOSIS, TREATMENT AND COURSE The papillitis was treated unsuccessfully with high-dose methylprednisolone, the left eye remained blind. Persistence of the pleocytosis under initial treatment with aciclovir and ceftriaxone, reduction of the glucose ratio of cerebrospinal fluid and serum and intrathecal immunoglobuline A -- synthesis required a change of the diagnostic and therapeutic regimen. Various common and rare differential diagnoses were considered and ruled out, a chronic meningitis of unclear aetiology with the complication of amaurosis was diagnosed. In consideration of the most probable diagnosis, a tuberculostatic therapy was initiated. A prolonged reduction of the pleocytosis and normalization of cerebrospinal fluid parameters could be observed. CONCLUSIONS A large number of aetiologies can cause chronic meningitis; this case report reviews the most important differential diagnoses and highlights the limitations of the diagnostic work-up although various methods are available. Clinical course and symptoms of chronic meningitis are mild to moderate and may even be absent, but it can cause severe complications.

BACKGROUND: Guillain-Barre syndrome (GBS) is an acute inflammatory demyelinating disease of peripheral nerves. Antibodies acting against antigens on the myelin or the axons seem to play a causative role. In up to 80 % the onset of GBS follows an antecedent respiratory or gastrointestinal infection. CASE REPORT: An 20 month old boy was referred to our hospital because of meningism and aspiration pneumonia. 10 days earlier the patient had experienced a period of fever. Because of respiratory insufficiency the patient was intubated, sedated and received mechanical ventilation. That's why a major neurological examination was not possible. The patient demonstrated a flaccid tetraplegic paralysis and autonomic dysfunction with elevated blood pressure, tachycardia, elevated ADH level and hyperglycaemia. Decreased motor nerve conduction and an increased CSF protein with normal CSF cell count confirmed diagnosis of GBS. Active CMV infection was diagnosed by PCR as the possible trigger factor. Intravenous immunoglobulins were given and the patient reached a complete remission except a slight disturbance of peroneal nerve. CONCLUSIONS: IVIG and PP therapy are equally effective in GBS. In contrast corticosteroids are not of benefit. Prognosis of childhood GBS is good. Only 4 % of affected children demonstrate persistent muscular weakness. The long interval between admission and diagnosis in the reported case emphasized the importance of neurological examination especially in sedated patients.

Background Enterovirus infections are among the most common causes of aseptic meningitis. Worldwide there are reports about recurring outbreaks, especially during the summer. They are favoured by conditions of bad hygiene and contaminated water, transmission is predominantly through the faeco-oral route or by droplet infection. The most common species are Coxsackie B and ECHO (Enteric Cytopathogenic Human Orphan) virus. ECHO viruses have a worldwide distribution and usually occur as "summer flu" or aseptic meningitis and meningoencephalitis in toddlers and infants. Type 30 caused an outbreak of aseptic meningitis in the Rhein-Main region in summer 1997. During five months 63 children younger than 16 years were reported. Patients and methods During this outbreak 18 children with prooved enterovirus infections were treated at the Frankfurt/Main University Children's Hospital. Standardized infectiological diagnostic procedures were performed and risc factors, clinical symptoms, inflammatory marker, neurophysiological findings (electroencephalography, evoked potentials) and outcome were assessed. Results The affected children were between 3 and 11 years old. Clinical symptoms were cephalgia, nausea, vomiting, meningism and seizures with fever. Virus isolation from faecal and cerebrospinal fluid (CSF) samples and the use of polymerase chain reaction (PCR) was superior to serological methods. Erythrocyte sedimentation rates showed more significant increase than C-reactive protein (CRP) and blood leukocytes. CSF pleocytosis showed high variation. Clinical course as well as prognosis and outcome were favourable. Conclusion Virusisolation in stool and CSF is most promising in the diagnostic of cerebral enterovirus infections. Usually the outcome is favourable, encephalitis can occur as serious complication.

HISTORY AND CLINICAL FINDINGS A 38-year-old man presented with acute low back pain and paraesthesia in dermatome S1. 4 hours before onset of symptoms he had finished the last of three scuba dives with a maximum depth of 30 m and a total diving time of 3 hours. No alcoholic beverages were taken during or before diving. The patient was complaining of local pain in the thoracic and lumbar spine and showed a 3/5 weakness of the big toe and impaired sensitivity in the S1 dermatome. 90 minutes later the patient developed a hemiparesis of the right side including hypaesthesia and additional meningism (stiff neck). INVESTIGATIONS The X-rays of the thoracic and lumbar spine in two standard planes, cerebrospinal fluid examination, a cranial spiral-computer tomographie (CCT) and laboratory investigations showed no pathologic values. DIAGNOSIS Acute decompression sickness (DCS) type II. TREATMENT AND COURSE The patient received an intravenous infusion, antiinflammatory prophylaxis with dexamethasone and an immediate submission to hyperbaric oxygenation therapy. Complete recovery of neurological symptoms appeared after 4 decompression sessions in a hyperbaric chamber. CONCLUSIONS In patients presenting low back pain as common symptoms the differential diagnosis needs to be worked out and DCS should be included especially if progressive neurologic deficits are present. Only emergency hyperbaric oxygen therapy can compromise a sufficient therapy of these patients.

HISTORY AND ADMISSION FINDINGS: A 42-year-old man was admitted to hospital because of headache and fever for two days and showing signs of meningism. As a butcher he had had frequent cuts on his hands and forearms. INVESTIGATIONS AND DIAGNOSIS: Analysis of the cerebrospinal fluid revealed an elevated leukocyte count (81% segmented neutrophils). Large numbers of Gram-positive bacteria were found in both cerebrospinal fluid and blood culture, which were subsequently identified as Streptococcus suis (S. suis) by biochemical methods. The hypothesis of bacterial meningitis was thus confirmed. TREATMENT AND CLINICAL COURSE: The patient was treated with ampicillin, initially combined with ceftriaxone. Hearing impairment and vestibular dysfunction - a frequent complication after infection with S. suis - were observed as sequelae, indicating involvement of the vestibulocochlear nerve. CONCLUSION: Infections caused by S. suis are rare in Europe but must be taken into account if an occupational exposition to pigs is established.

Sixty-seven patients with brain abscess were managed over 19 years (1975-1993). Our series had a 2.5 to 1 male predominance; the age distribution was from 3 days to 81 years. The underlying conditions of hematogenic brain abscesses (n = 33; 49%) included lung infections (n = 16), heart disease (n = 4), sepsis (n = 10), and other foci (n = 3). Otolaryngologic infections led to the abscess in 10 cases; there were 9 traumatic abscesses. The causes remained unknown in 15 cases. There were 47 solitary abscesses (70%) and 20 multiple abscesses. The most frequent presenting signs and symptoms were neurologic deficits (n = 17), disturbances of consciousness (n = 14), seizures (n = 6), and headaches, meningism and vomiting (n = 13). Causative organisms were isolated in 39 cases (58%) and included staphylococci (n = 6), streptococci (n = 6), enterobacteriae (n = 2), and anaerobic pathogens (n = 9). The most reliable laboratory sign of inflammation was an elevated ESR (52/59 patients). With the advent of computed tomography, burr hole aspiration of the abscess with or without drainage was possible in 30 cases; the mortality in this subgroup was 9%. All 4 patients with surgical excision in the pre CT-era died. The mortality of patients treated with antibiotics only was 62% (18/29). Overall mortality was 37% (25/67), including 5 cases with post mortem-diagnosis of brain abscess. Good recovery was achieved in 29/42 survivors. Predictors of a poor outcome were the patient's age, the level of consciousness, multiple abscesses, polybacterial cultures, and a hematogenic etiology, but not the size of the abscess.

Lyme borreliosis is currently suspected to be capable of mimicking nearly all known neurologic symptoms and disease entities. The goal of our study is to define the associated anamnestic, clinical and laboratory findings in aseptic meningitis and Lyme borreliosis in childhood by a meta-analysis of recent literature and of our own data. We defined by means of 63 cases derived of 10 publications and own data a list of mainly rather unspecific parameters like insidious onset, fever, mild meningism, encephalitic symptoms and cranial nerve involvement. Mere neurologic presentation without ECM, arthritis or even an anamnestic insect-bite seems to be most frequent. Retrospective studies, however, can not sufficiently characterize the clinical picture of aseptic meningitis in Lyme borreliosis.

A 30-year old pregnant woman, who received an embryo transfer, suffered since the 12th week of pregnancy from therapy-resistant attacks of fever for several weeks. With progressive deterioration, the increasingly somnolent patient showed by now clear signs of meningism and acid-fast bacilli were found in the cerebrospinal fluid. NMR showed a finding consistent with bacterial meningoencephalitis. During therapy with INH, Rifa and EMB, the clinical course and the CSF findings showed rapid improvement. Nevertheless, spontaneous abortion occurred in the 23rd week of pregnancy. Previous history revealed, that granulomatous salpingitis had been diagnosed several years earlier as the reason for infertility.