Search

Forty one soldiers were examined in the acute period of the concussion of the brain, among which 22 were injured due to shock wave. All injured underwent neurological examination with the study of recommended pathological reflexes (from face, hands and feet). Pyramidal, cerebellar signs, symptoms of meningism were revealed in neurological status. The conducted research showed that in the acute period of brain concussion resulting from shock wave, a significant number of neurological symptoms were detected, namely pathological axial and symmetrical carpal and foot reflexes. The defined group of pathological reflexes is an indispensable feature of the concussion of the brain due to air blast. Clinical evaluation of neurological status emphasizes the importance of this affordable and simple method. Timely identification and recognition of pathological symptomatology may have an extremely valuable clinical significance. Therefore, injured persons with brain concussion require specialized in-patient treatment (level III–IV medical care) to provide them with neurovisual methods of investigation, dosage regimen of work and rest, medical supervision, modern medical and physiotherapeutic treatment, prophylaxis, including psychotherapeutic one, in order to prevent the development of post-traumatic stress and diencephalic disorders, epileptic seizures, the development of traumatic brain disease.

Forty one soldiers were examined in the acute period of the concussion of the brain, among which 22 were injured by the blast wave. All patients underwent neurological examination with the study of recommended pathological reflexes (related to face, hands and feet). Neurological status revealed pyramidal, cerebellar signs, symptoms of meningism. The conducted research showed that in the acute period of the concussion of the brain due the blast wave, a significant number of neurological symptoms were revealed, namely pathological axial and symmetrical carpal and foot reflexes. The defined group of pathological reflexes is an indispensable feature of the concussion of the brain as a result of the blast wave. Clinical evaluation of neurological status emphasizes the importance of this affordable and simple method. Timely identification and recognition of pathological symptomatology may have an extremely valuable clinical significance. Therefore, injured persons with concussion of the brain require specialized in-patient treatment in medical institutions level III–IV in order to provide them with neurovisual methods of investigation, dosage regimen of work and rest, medical supervision, modern medical and physiotherapeutic treatment, including psychotherapeutic one, to prevent the development of post-traumatic stress and diencephalic disorders, epileptic seizures, traumatic brain disease.

Background: Children comprise only 1–5% of COVID-19 cases. Recent studies have shown that COVID-19 associated multisystem inflammatory syndrome in children (MIS-C) can present with neurological signs and symptoms. In this systematic review and meta-analysis, we have reviewed neurological involvement in these patients. Methods: A comprehensive electronic literature search was done on PubMed, Google Scholar, Embase, Cochrane database, and SCOPUS for the published English language articles from December 1, 2019, to February 28, 2021. A meta-analysis of the proportion was expressed as a pooled proportion with a 95% confidence interval (CI). Representative forest plots showing individual studies and the combined effect size were generated to provide an overview of the results.Results: This systematic review and meta-analysis analyzed 15 published MIS-C studies with a total of 785 patients. Neurological manifestations in patients with MIS-C was found in 27.1%. We found that 27% developed headaches, 17.1% developed meningism/meningitis and 7.6 % developed encephalopathy. Other uncommon neurological manifestations of MIS-C includes anosmia, seizures, cerebellar ataxia, global proximal muscle weakness and bulbar palsy. In MIS-C patients with neurological feature, neuroimaging showed signal changes in the splenium of the corpus callosum. Electroencephalography showed slow wave pattern and nerve conduction studies and electromyography showed mild myopathic and neuropathic changes. Conclusions: Our study revealed that neurological manifestations are not uncommon in patients with MIS-C. Further large prospective studies are needed to better explore the disease spectrum and to unravel the underlying pathophysiology.Keywords: Children; COVID-19; kawasaki disease; MIS-C, neurology

Relevance. In 2020, children were hospitalized with fever and multisystem inflammation throughout the world during the COVID-19 pandemic. In the United States, this condition is called MIS-C (Multisystem Inflammatory Syndrome in Children). This syndrome is thought to be similar to the severe course of COVID-19 in adults (cytokine storm). The objective of the work is to evaluate the features of the course and pharmacotherapy of multisystem inflammatory syndrome in children. Materials and methods. The study included 17 children (10 boys and 7 girls) aged 3-16 years (on average – 9.5±3.4 years). Diagnosis of coronavirus infection was performed by polymerase chain reaction with real-time detection, determined the level of immunoglobulins M and G before coronavirus infection. Results. The duration of fever in patients was 5-21 days (average 8.1±4.0 days), the duration of inpatient treatment – 7-35 days (average 15.7±7.0 days). Blood albumin levels were reduced in 53.8% of children; the level of fibrinogen was increased in 88.2% of children, the level of C-reactive protein, ferritin, and D-dimer – in all patients. 15 (88.2%) children had pathology of the digestive system, 13 (76.5%) – cardiovascular system (7 children were diagnosed with carditis, 2 – dilation of coronary arteries, 7 – cardiac arrhythmia). Acute respiratory distress -syndrome was found in a 13-year-old girl, shock - in an 11-year-old boy, 11 children (64.7%) were diagnosed with the pathology of the respiratory system (pleurisy, pneumonia), skin and mucous membranes, and 4 children (23.5%) there were manifestations of central nervous system disorders (meningism, decreased reflexes, ataxia), in 2 (11.8%) – renal failure. On average, each patient had lesions of 3.9 ±1.2 systems. Conclusions. MIS-C was manifested by prolonged fever, high levels of laboratory markers of inflammation, hypoalbuminemia, hypercoagulation, often – pathological manifestations of the cardiovascular, digestive, respiratory systems, skin, and mucous membranes. The treatment included intravenous immunoglobulin, steroids, anticoagulant, and antibacterial therapy and was effective.

Acute cerebellitis is a rare condition with a highly heterogenous clinical course, ranging from self-limiting mild symptoms to a fulminant presentation. Symptoms include headache, vomiting, fever, ataxia, dysarthria, intention tremor, meningism, seizures, and altered level of consciousness. It warrants a high level of suspicion because of the risk of intracranial hypertension and acute hydrocephalus due to compression of the posterior fossa. We present the case of a 7-year-old boy who presented emergently with new-onset left head turn and horizontal nystagmus. Acute inflammation of a single cerebellar hemisphere (hemicerebellitis) in childhood is extremely rare, diagnosed in this case with magnetic resonance imaging. Symmetrical, diffuse cerebellar hemisphere involvement is more typical of cerebellitis. Our patient was unusual in that he presented initially with predominantly ophthalmological signs, with an otherwise normal neurological assessment. Subsequent positive serological Borrelia burgdorferi antibodies led to a diagnosis of Lyme neuroborreliosis.

Neurologic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can present with fever, headache, and meningism.

Introduction: Vogt–Koyanagi–Harada (VKH) disease is defined as an autoimmune disorder characterized by bilateral granulomatous panuveitis with systemic manifestations, such as tinnitus, vertigo, and meningism caused by melanocyte antigen-reactive T-cells. Majority of VKH patients present at the age between 20 and 50 years. VKH is uncommon in elderly and challenging to manage. VKH is one of the important differential diagnosis of bilateral pan uveitis Case: A 65 year/ female brought with chief complaint of sudden loss of vision in both eyes, headache and hearing problem for 1 month. She didn’t give any history of other systemic illness, ocular surgery, ocular trauma, chronic use of medicament. Her visual acuity was hand movement with accurate projection of rays (HM) in both eyes The intraocular pressure (IOP) was 12mmHg in both eye. Slit-lamp bio microscopy revealed features of Pan uveitis in both eye. Systemic work up revealed no any other abnormalities. A diagnosis of early phase VKH was made and treated with intravenous pulse steroid therapy followed by tapering dose of oral steroid along with immunemodulator resulting in a very good visual recovery. Conclusion: VKH can present in elderly. immunomodulator should be considered in elderly to prevent side effect of steroid along with recurrence of inflammation.

Summary Introduction Tuberculous meningitis accounts for 1–5% of tuberculosis cases. Diagnostic delay contributes to poor outcomes. We evaluated the performance of the new Xpert MTB/RIF Ultra (Xpert Ultra) for tuberculous meningitis diagnosis. Methods In this prospective validation study, we tested the cerebrospinal fluid (CSF) of adults presenting with suspected meningitis (ie, headache or altered mental status with clinical signs of meningism) to the Mulago National Referral Hospital and Mbarara Regional Referral Hospital in Uganda. We centrifuged the CSF, resuspended the cell pellet in 2 mL CSF, and tested 0·5 mL aliquots with Xpert Ultra, Xpert MTB/RIF (Xpert), and mycobacterial growth indicator tube (MGIT) culture. We quantified diagnostic performance against the uniform case definition of probable or definite tuberculous meningitis and a composite microbiological reference standard. Findings From Nov 25, 2016, to Jan 24, 2019, we screened 466 adults with suspected meningitis and tested 204 for tuberculous meningitis. Uniform clinical case definition classified 51 participants as having probable or definite tuberculous meningitis. Against this uniform case definition, Xpert Ultra had 76·5% sensitivity (95% CI 62·5–87·2; 39 of 51 patients) and a negative predictive value of 92·7% (87·6–96·2; 153 of 165), compared with 55·6% sensitivity (44·0–70·4; 25 of 45; p=0·0010) and a negative predictive value of 85·8% (78·9–91·1; 121 of 141) for Xpert and 61·4% sensitivity (45·5–75·6; 27 of 44; p=0·020) and negative predictive value of 85·2% (77·4–91·1; 98 of 115) for MGIT culture. Against the composite microbiological reference standard, Xpert Ultra had sensitivity of 92·9% (80·5–98·5; 39 of 42), higher than Xpert at 65·8% (48·6–80·4; 25 of 38; p=0·0063) and MGIT culture at 72·2% (55·9–86·2; 27 of 37; p=0·092). Xpert Ultra detected nine tuberculous meningitis cases missed by Xpert and MGIT culture. Interpretation Xpert Ultra detected tuberculous meningitis with higher sensitivity than Xpert and MGIT culture in this HIV-positive population. However, with a negative predictive value of 93%, Xpert Ultra cannot be used as a rule-out test. Clinical judgment and novel highly sensitive point-of-care tests are still required. Funding Wellcome Trust, National Institute of Health, National Institute of Neurologic Diseases and Stroke, Fogarty International Center, and National Institute of Allergy and Infectious Diseases.

Non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol are the common analgesics used in children who experience mild to moderate pain. NSAIDs-related case of aseptic meningitis or meningism in healthy adolescent is relatively uncommon. We report a case of an 11-year-old boy with underlying bronchial asthma who had recent intake of three doses of diclofenac (50 mg), presented with signs and symptoms mimicking acute meningism. The boy initially presented to the emergency department after he experienced throbbing headache, dizziness, nausea and persistent vomiting for about 15 times per day for the past 2 days. He did not report presence of any auditory or visual hallucination; however, he claimed to have a bit of photophobia. Signs and symptoms occurred soon after the second dose of diclofenac. Besides, he was also taking oral antibiotic Augmentin for his left epididymo-orchitis problem and famotidine for prevention of gastritis prescribed by general practitioner. Vital signs were normal, and review of systems did not find any abnormality. Neurological assessment found no significant deficit, no cerebellar sign, negative Babinski test and no sign of meningism. Patient did not have frequent fall, head trauma or any family history of neurological diseases. A provisional diagnosis of meningoencephalitis was made after review by specialist. The parents of the boy did not give consent to conduct spinal tap. Upon further examination, urgent contrast-enhanced computed tomography was done and clinical neurological assessment was not suggestive of meningoencephalitis. Antibiotics treatment for meningoencephalitis was stopped 12 h after hospitalization. Although this case was not diagnosed as aseptic meningitis, timeline of diclofenac intake, onset of symptoms, clinical manifestations and quick resolution symptoms after drug discontinuation were supportive of a temporal relationship between diclofenac and meningism. Paracetamol was given to relieve the headache, vomiting resolved after one dose of intravenous metoclopramide plus ranitidine, and patient was well throughout the 5 days in ward. This adverse effect of NSAIDs is very rare and continuous effort in pharmacovigilance can help to raise awareness among clinicians. Int J Clin Pediatr. 2020;9(1):20-23 doi: https://doi.org/10.14740/ijcp358

Introduction Acute primary bacterial ventriculitis in adults is a rare intracranial disease. It can be a complication of neurosurgical patients with ventricular stent insertions or in children. Objective This paper presents a case of acute otitis media in a 71-year-old diabetic male that progressed rapidly to acute ventriculitis, with a literature review of presentation, work up, management and patient outcomes. Methods A search using MEDLINE and EMBASE was carried out including “primary ventriculitis”, “bacterial ventriculitis” or “pyogenic ventriculitis” in the adult population. The cases were summarised. Results A total of 13 case reports were analysed. There was only one other case of pyogenic ventriculitis presenting with of sudden onset hearing loss, which turned out to be a complication of ventriculitis. Common presenting symptoms included agitation, depressed consciousness but no case reported any signs of meningism. This is the only known case of ventriculitis following acute otitis media. Conclusion Ventriculitis can result as a complication of otological disease; it can manifest as rapid neurological deterioration and is difficult to diagnose. A high index of suspicion should be held for ventriculitis in cases with rapid progression or severity. Optimal work up includes serial MRI and lumbar puncture, for prolonged, targeted antimicrobial therapy.

Background Recently, antibodies against the alpha isoform of the glial-fibrillary-acidic-protein (GFAPα) were identified in a small series of patients with encephalomyelitis. Coexisting autoantibodies (NMDA receptor, GAD65 antibodies) have been described in a few of these patients. We describe a patient with rapidly progressive encephalomyeloradiculitis and a combination of anti-ITPR1, anti-GFAP and anti-MOG antibodies. Case presentation and literature review A 44-year old caucasian woman with a flu-like prodrome presented with meningism, progressive cerebellar signs and autonomic symptoms, areflexia, quadriplegia and respiratory insufficiency. MRI showed diffuse bilateral T2w-hyperintense brain lesions in the cortex, white matter, the corpus callosum as well as a longitudinal lesion of the medulla oblongata and the entire spinal cord. Anti-ITPR1, anti-GFAP and anti-MOG antibodies were detected in cerebrospinal fluid along with lymphocytic pleocytosis. Borderline tumor of the ovary was diagnosed. Thus, the disease of the patient was deemed to be paraneoplastic. The patient was treated by surgical removal of tumor, steroids, immunoglobulins, plasma exchange and rituximab. Four months after presentation, the patient was still tetraplegic, reacted with mimic expressions to pain or touch and could phonate solitary vowels. An extensive literature research was performed. Conclusion Our case and the literature review illustrate that multiple glial and neuronal autoantibodies can co-occur, that points to a paraneoplastic etiology, above all ovarian teratoma or thymoma. Clinical manifestation can be a mixture of typically associated syndromes, e.g. ataxia associated with anti-ITPR1 antibodies, encephalomyelitis with anti-GFAPα antibodies and longitudinal extensive myelitis with anti-MOG antibodies.

Background Syphilis is increasing in prevalence in the community.1 2 Neurosyphilis has protean manifestations making recognition, diagnosis and early initiation of treatment challenging. Methods/Results We present a case of early syphilitic meningitis in a 37-year-old female presenting with multiple cranial neuropathies (V, VI, VII, VIII and XII) developing over the course of two weeks. This began with a sensation of disequilibrium and unsteady gait, and progressed to difficulty closing both eyes, right lip numbness, bilateral hearing impairment (right, followed by left), and dysarthria. She did not report headache, meningism, features of primary syphilis infection or risk factors for sexually transmitted infections (STIs). Examination confirmed the presence of right-sided trigeminal, bilateral abducens, facial, vestibulocochlear and hypoglossal nerve palsies. Cerebrospinal fluid (CSF) examination was inflammatory (protein 1.28 g/L, glucose 3.8mmol/L) with predominant lymphocytosis (76%, WCC 441 x 106/L). Magnetic resonance imaging (MRI) demonstrated post-contrast enhancement of the trigeminal nerve at the pons, as well as facial and vestibulocochlear nerves at the geniculate ganglion with no leptomeningeal enhancement. Our patient was diagnosed with neurosyphilis on serum and CSF serological testing (Serum Treponema pallidum particle agglutination assay (TPPA) positive, chemiluminescent microparticle immunoassay (CMIA) IgG and IgM positive, rapid plasma reagen 1:32. CSF TPPA positive, Venereal Disease Research Laboratory test titre of 1:8). She was treated with intravenous benzylpenicillin with rapid improvement in her cranial neuropathies. Conclusions This is the most extensive cranial neuropathy reported with syphilitic infections to date. Neurosyphilis should be considered as a differential in patients presenting with multiple cranial neuropathies. References Kojima N, Klausner J. An update on the global epidemiology of syphilis. Curr Epidemiol Rep 2018;5(1):24–38. Ghanem K, Ram S, Rice P. The modern epidemic of syphilis. N Engl J Med 2020;382(24):2379–80.

Aspergillus meningitis is a rare clinical entity that is much more frequently observed among immunocompetent patients. Here we present the case of a 28 year old immunocompetent lady with Aspergillus fumigatus meningitis possibly following spinal anaesthesia for her caesarean section. The diagnosis of Aspergillus meningitis is very difficult and challenging. Even after diagnosis, clinical outcomes remain poor with treatment. We wish to highlight the need for high index of suspicion for Fungal meningitis in patients presenting with meningism after Neurosurgeries and procedures involving invasion into the CSF compartment.

Background and purpose The purpose of this study was to elucidate the association between aseptic meningitis and jolt accentuation of headache (JAH) in adults. Subjects and method 87 patients with meningeal irritation (age; 35.6 ± 13.3 years old, 45 males) who were admitted to our hospital from 1st August 2013 to 31st August 2018 were included. The diagnosis was determined according to the following criteria:, aseptic meningitis was defined as cerebrospinal fluids (CSF) pleocytosis with no evidence of bacterial infection, fungal infection or carcinomatous findings; meningism was defined as the absence of CSF pleocytosis. None of these patients had consciousness disturbance and focal neurological abnormalities. The blood and CSF data were reviewed for analysis. Results 61 patients were in aseptic meningitis group, 26 patients were in meningism group. Multiple logistic regression analysis showed older age (OR 1.059, 95% Confidence interval (CI) 1.012-1.108, P = 0.013), lower CRP (OR 0.803, 95%CI 0.697-0.925, P = 0.002) and absence of JAH (OR 0.048, 95%CI 0.004-0.554, P = 0.015) were significantly associated with aseptic meningitis. The sensitivity and specificity of JAH in aseptic meningitis were 68.9%, 3.8%.

Shigella is a common cause of gastroenteritis and can also lead to serious complications such as dehydration, seizures, hemolytic uremic syndrome, and neurological complications. In this paper, we describe a case of a 39-year-old man who was admitted septic, with altered mental status and gastrointestinal symptoms. During the evaluation, he was found to have positive meningeal signs, non-anion gap metabolic acidosis, enteric panel positive for Shigella flexneri, positive IgG for Strongyloides, and pancolitis on computed tomography (CT) of the abdomen and pelvis. He was treated for infectious colitis and initially treated empirically for meningitis, but antibiotics were later discontinued due to rapid improvement of meningeal signs. To reduce the risk of disseminated infection, the patient was also treated for Strongyloides.

Neurologic manifestations associated with Covid-19 are increasingly reported, especially stroke and acute cerebrovascular events. Beyond cardiovascular risk factors associated with age, some young adults without medical or cardiovascular history had stroke as a presenting feature of Covid-19. Suggested stroke mechanisms in this setting are inflammatory storm, subsequent hypercoagulability, and vasculitis. To date, a handful of pediatric stroke cases associated with Covid-19 have been reported, either with a cardioembolic mechanism or a focal cerebral arteriopathy. We report the case of an adolescent who presented with febrile meningism and stupor. Clinical, biological, and radiological features favored the diagnosis of Lemierre syndrome (LS), with Fusobacterium necrophorum infection (sphenoid sinusitis and meningitis) and intracranial vasculitis. The patient had concurrent SARS-CoV-2 infection. Despite medical and surgical antimicrobial treatment, stroke prevention, and venous thrombosis prevention, he presented with severe cerebrovascular complications. Venous thrombosis and stroke were observed, with an extension of intracranial vasculitis, and lead to death. As both F. necrophorum and SARS-CoV-2 enhance inflammation, coagulation, and activate endothelial cells, we discuss how this coinfection may have potentiated and aggravated the usual course of LS. The potentiation by SARS-CoV-2 of vascular and thrombotic effects of a bacterial infection may represent an underreported cerebrovascular injury mechanism in Covid-19 patients. These findings emphasize the variety of mechanisms underlying stroke in this disease. Moreover, in the setting of SARS-CoV-2 pandemic, we discuss in what extent sanitary measures, namely, lockdown and fear to attend medical facilities, may have delayed diagnosis and influenced outcomes. This case also emphasizes the role of clinical assessment and the limits of telemedicine for acute neurological condition diagnosis.

Pyogenic ventriculitis is an infection of the cerebral ventricles usually associated with neurosurgery or head trauma. There are less than 10 reported cases of community-acquired pyogenic ventriculitis in adults. We present the case of a 71-year-old man with a medical history of type 2 diabetes mellitus, hospitalized due to urosepsis caused by E. coli. Because he had a fluctuant level of consciousness, he underwent magnetic resonance imaging that diagnosed pyogenic ventriculitis. He was treated with ceftriaxone 2 g 12/12h for a total of 6 weeks and recovered without neurological deficits. Pyogenic ventriculitis is a clinical challenge due to its rarity, atypical presentation and variety of aetiological microorganisms. LEARNING POINTS Pyogenic ventriculitis is an infection of the cerebral ventricles usually associated with neurosurgery or head trauma; community-acquired primary pyogenic ventriculitis is very rare. Presentation is atypical (no meningism), multiple microorganisms can be involved, and it should be treated with prolonged antibiotic regimens. MRI is the most useful exam for diagnosis. Keywords: Pyogenic ventriculitis, urosepsis, E. coli CASE DESCRIPTION We present the case of a 71-year-old male patient, still professionally active, with a medical history of type 2 diabetes mellitus with poor metabolic control, who was admitted to the emergency department with symptoms of nausea, vomiting, dysuria and fever. A diagnosis of pyelonephritis was made and the patient was discharged with a prescription for amoxicillin-clavulanic acid. Over the next few days, in addition to the previous symptoms, a change in the patient’s behaviour and cognition was noticed, so he returned to hospital. At this second presentation, he was confused and had a fever (temperature 39oC), but there were no other abnormalities in his physical examination, as there was no alteration in his cardio-pulmonary auscultation, no neurological deficits and no meningeal signs. He denied any recent travel, head trauma or previous neurosurgery. His laboratory results revealed leucocytosis, elevated C-reactive protein, altered renal function and leukocyturia (Table 1). A renal CT scan showed kidneys with multiple simple cysts and inflammatory signs. While in the emergency department, the patient’s level of consciousness declined from a Glasgow Coma Scale (GCS) score of 14 to 7, so he was admitted to the internal medicine department with a diagnosis of urosepsis and was prescribed ceftriaxone 2 g, 24/24h. Table 1 Blood tests at admission to the emergency room

Behcet’s disease (BD) is a clinical syndrome characterised by systemic vasculitis commonly involving the central nervous system.[1][1] However, brain stem involvement is less pronounced.[2][2] The lack of definitive conclusive tests with prime dependence on clinical criteria led to low

A thorough examination of a comatose patient is essential given the spectrum of clinical diagnoses. The most immediate threat to patients is airway, breathing and circulation. All attending physician should employ a structured and focused approach in dealing with a comatose patient. It is important to recognise the urgent steps needed at the time to prevent further deterioration, followed by the final diagnosis of patient’s neurologic status. Here we provide the essential practical guide to the neurological exam of a comatose patient that would assist to determine the aetiology, location and nature of the neurological lesion.

Background Pneumococcus remains the most common cause of bacterial meningitis with high morbidity and mortality. Adjuvant corticosteroids with early antibiotics have been shown to reduce the neurological morbidity and mortality respectively and this is reflected in British Infection Society (BIS) guidance. Aim To assess how closely BIS guidelines were followed regarding antibiotic and adjuvant corticosteroid administration in management of pneumococcal meningitis. Methods Newcastle Upon Tyne Hospital case-notes of pneumococcal meningitis from a 7-year-period(2012-2019) were audited. Patients were identified using microbiological records and case-notes. Data was collected on intervals from initial-assessment to commencing antibiotics and corticosteroids. Results Eighteen cases were identified of whom three(17%) presented with the classic triad (fever, meningism, reduced GCS). All patients received appropriate antibiotics: 3/18(17%) within first hour of assessment. The median time to antibiotics was 5h 8mins (range:21-7129min). Eight patients(44%) received antibiotics >6h after assessment. Twelve patients(67%) received corticosteroids; only six(33%) at the recommended dose and duration. Mean time from antibiotics to corticosteroids was 6h1min. Five deaths occurred in the cohort with three attributable to pneumococcal sepsis (all had late presentations). 6/18 had significant neurological sequelae, irrespective of whether they received corticosteroids. Discussion The significant morbidity and mortality of pneumococcal meningitis demands a high index of suspicion. BIS guideline targets are repeatedly not met; long delays exist between assessment and antibiotic and corticosteroid administration. Integrated electronic prescribing and clinical Early Warning Systems have potential to ameliorate this with meningitis-tailored order sets to prompt consideration of meningitis and guide correct prescribing.

We report a case of disseminated cryptococcosis in a 42-year old immunocompetent female. Prior to admission at Bugando Medical Center, the patient was attended at three hospitals for hypertension and clinically diagnosed malaria. Following diagnosis of disseminated Cryptococcus at our center, she was successfully treated with fluconazole but remained with visual loss. Blood cultures should be considered in the management of any adult presenting with fever to enable early detection of the least expected differentials like in this case. Keywords: Disseminated cryptococcosis, C. gattii, Meningism, Cryptococcus deuterogattii, HIV negative

Introdução: Meningite de Mollaret consiste em uma forma de meningite asséptica, sendo considerada uma patologia rara, haja visto a revisão literária mundial apresentar aproximadamente 50 casos descritos até o momento. Objetivo: Descrição de caso de meningite asséptica decorrente de lesão expansiva epidermóide. Método: Mulher submetida à ressecção retrossigmoidéia de tumor epidermóide em ângulo ponto-cerebelar a direita evoluindo sem déficits no pós-operatório imediato, mas evoluindo, no pós-operatório tardio, com meningismo e deficit de nervos cranianos contralaterais à lesão primária. Exames de propedêutica liquórica evidenciaram meningite sem crescimento de microorganismos. Discussão: A cascatainflamatória sistêmica desencadeada por essa patologia pode gerar um estado toxêmico, assemelhando-se clinicamente a meningite bacteriana. O estudo liquórico não evidencia agente causador, a despeito da elevação de polimorfonucleares e a redução da glicorraquia. O risco de desenvolver meningite asséptica pode ser reduzido, evitando-se contaminação do conteúdo cístico no espaço subaracnóide, removendo cuidadosamente todo tecido cístico e administrando corticoterapia no perioperatório. Conclusão: Meningite asséptica é uma patologia rara, sem consenso a respeito de seu manejo, justificando a necessidade de acúmulo de conhecimentos a partirde relatos de casos em todo o mundo

A obstrução da drenagem venosa cerebral é uma entidade pouco conhecida na prática clínica podendo, no entanto estar implicada na etiopatogenia de situações como Pseudotumor cerebrii, enxaqueca, ou mesmo esclerose múltipla. Quando sintomática, apresenta-se com sinais e sintomas de hipertensão intracraniana crônica, isto é, cefaleias, papiledema e, mais raramente, zumbidos pulsáteis, consequência da estase venosa cerebral. As causas mais comuns são trombose venosa cerebral, compressão extrínseca por lesão tumoral, fratura afundada com comprometimento do sistema venoso e, raramente, a compressão da veia jugular por uma apófise etilóidea do osso temporal hipertrófica. Estão descritas inúmeras variações anatômicas desta apófise, condicionando manifestações clínicas diversas de acordo com a estrutura anatômica por ela afetada. Os autores relatam um caso clínico singular de compressão unilateral da veia jugular interna na região cervical superior (entre uma apófise estilóidea redundante e a massa lateral de C1), que se apresentou por cefaleia súbita e meningismo, mimetizando uma hemorragia subaracnóideia (HSA). Revêem-se as possíveis implicações desta variação anatômica sobre a circulação venosa cerebral, suas eventuais consequências patológicas e opções terapêuticas. Segundo os autores, situações de drenagem venosa deficiente por compressões extrínsecas da veia jugular interna na base do crânio devem ser investigadas sempre que existam queixas de hipertensão intracraniana idiopática ou evidências de hemorragias intracranianas de etiologia não esclarecida.

Salmonella bacilli are the most common cause of bacterial foodborne diseases in Poland. Due to heterogeneous clinical course, they may cause an essential problem during differential diagnosis. In this paper we aimed to present a case report of a 14-year-old patient infected with Salmonella enteritidis , in whom the disease initially imitated the symptoms of bacterial meningitis. We described the difficulties within the diagnostic process and the chosen treatment. This case report demonstrates that Salmonella infection, due to its heterogeneous clinical course, may cause an important diagnostic and therapeutic problem.

Cerebrospinal fluid (CSF) rhinorrhoea results from anatomical breach between the subarachnoid space and air sinus cavities of the skull base and traumatic CSF rhinorrhoea accounts for 80% - 90% of all cases of CSF leaks. We sought to report the case of a 16-year-old patient with a history of head injury following a fall from a tree, who developed a post-traumatic CSF rhinorrhoea after an onset of meningitis. The patient sustained a fall from a 6-meter tree in 2008, and was reviewed by our neurosurgical team in February 2016 for a 1-month history of progressive headaches associated with fever, asthenia and left CSF rhinorrhoea. Clinical examination revealed frank meningism and abundant CSF leak from the left nostril. CT scanning showed fractures of the left frontal bone and sinus wall associated with a massive pneumocephalus. The patient benefited from surgical repair of the tear and post-operative lumbar punctures at day 15. The patient’s guardian was informed that non-identifiable information from the case would be submitted for publication and he provided consent.

A case of Streptococcus gallolyticus subsp. pasteurianus meningitis, unusually occurring in a splenectomized patient and complicated by cerebral venous thrombosis, is described. Following presentation with meningism and diagnosis and management of S. gallolyticus meningitis, the patient presented again with a further 4 days of fevers and subsequently developed left-sided paresthesias. Cerebral imaging revealed a venous thrombus in the right frontal cortical veins and left sigmoid sinus. The patient recovered following 4 weeks of intravenous ceftriaxone and anticoagulation with enoxaparin and then warfarin. Apart from the splenectomy, no underlying cause was found. The patient was commenced on life-long prophylactic amoxicillin, given appropriate vaccinations, and anticoagulated with warfarin. After initial difficulties, identification of the causative organism to the subspecies level was confirmed by analysis of short-read whole genome sequencing data. This case demonstrates two features that have not previously been reported for S. gallolyticus subsp. pasteurianus infections: splenectomy as a potential risk factor and that infection may be complicated by cerebral venous thrombosis. The resolution provided by whole genome sequencing was valuable in accurately identifying the bacterial subspecies.

A 58 year old man presented with one week of progressive right sided weakness and headache. He drank approximately 7 units of alcohol a week and had stopped smoking cigarettes 20 years ago (10 pack year history). He had no recent head injuries and took no medications or recreational drugs. He had no fever, weight loss, or night sweats and was fully alert. He had no signs of meningism or papilloedema and was afebrile with normal observations. Power in his right upper and lower limbs was of Medical Research Council grade 4/51 and he had …

Context: Endodermal cysts are rare benign developmental cysts lined by mucin-secreting and/or ciliated, cuboidal, or columnar epithelium of probably endodermal origin. Aims: Endodermal cysts are rarely intracranial, frequently located in the posterior fossa. Supratentorial location is the most infrequent and only few cases are reported in the literature, included our case. Settings and Design: The authors report a case of intracranial supratentorial endodermal cyst with a review of the literature. Subjects and Methods: A 40-year-old woman was admitted to our department because of progressive gait disorder for 3 months due to right brachial and crural motor deficit associated to right crural sensory disorder (tactile hypesthesia) and right Babinski response at neurological examination due to an endodermal cyst located in the left frontoparietal convexity. Discussion: Total resection of endodermal cysts is recommended, despite their location and adhesion to the surrounding structures, due to its high risk of recurrence. Fenestration of the cystic content into the subarachnoid cistern may cause obstructive hydrocephalus or chemical meningism. Results: Although rare, surgeons should be aware that these lesions must be differentiated clinically, radiologically, and histologically from other supratentorial cystic lesions.

Background Bacillus cereus sometimes causes central nervous system infection, especially in compromised hosts. In cases of meningitis arising during neutropenia, CSF abnormalities tend to be subtle and can be easily overlooked, and mortality rate is high. We report a survived case of B. cereus meningitis/brain abscess in severe neutropenia, presenting as immune reconstitution syndrome. Case presentation A 54-year-old Japanese female with acute myelogenous leukemia developed B. cereus bacteremia and meningitis during consolidation chemotherapy. At the onset, she presented with mild meningism. She had marked leukocytopenia (WBC Conclusions With early diagnosis and prompt initiation and of antibiotics, the case was successfully treated without any sequelae. It is important to remember that, even under optimal antimicrobial therapy, bone marrow recovery can cause transient reaggravation of the disease. In such cases, timely and appropriate evaluation should be done to make the clinical decision to change, continue, or intensify treatment.

Background The symptoms of meningitis which include fever, headache, photophobia and irritability along with abducens nerve palsy pose a diagnostic dilemma requiring urgent attention. Here we report how such a dilemma was methodically and sequentially resolved using anatomical knowledge supported by neuroimaging and the eventual diagnosis of Gradenigo syndrome was made. Case presentation A 6-year-old previously healthy boy from Sri Lanka presented with high grade fever, headache, photophobia and left eye pain for 10 days and diplopia for 2 days duration. Neurological examination was unremarkable except for left sided abducens nerve palsy. He had high inflammatory markers and white blood cell count. A tentative differential diagnosis of acute bacterial meningitis complicated by cerebral oedema, acute hydrocephalus or cerebral abscess was made. However, non-contrast CT brain, cerebrospinal fluid analysis and electroencephalogram were normal leading to a diagnostic dilemma. MRI brain with contrast performed 3 days later due to limited resources revealed left mastoiditis extending to petrous temporal bone confirming Gradenigo syndrome. Conclusion This case report highlights the importance of a thorough physical examination in children presenting with unrelated neurological symptoms and signs. Unilateral abducens nerve palsy raises the suspicion of increased intracranial pressure and neuroimaging is vital in diagnostic uncertainties. Gradenigo syndrome emphasises the importance of incorporating anatomical knowledge into clinical practice.

Background: In the pre-antiretroviral era, the frequency of neurologic complications was associated with low baseline CD4+ T-cell counts. Introduction of antiretroviral therapy (ART) has largely decreased the incidence of opportunistic infections and CNS neoplasia in the recent two decades; however, virus replication persists in the cerebrospinal fluid (CSF) and neuronal tissues due to variable drug penetration as well as development of drug resistance. Although many previous studies have addressed the presence of neurologic manifestations in the course of HIV infection; an update on the type of neurologic involvement, presenting signs and symptoms, radiologic findings, and response to treatment is essential. Methods: In a case series, we recruited 42 patients presenting with neurologic symptoms/signs and concomitant HIV infection in 12 months during 2015 and 2016 at a tertiary academic hospital. Information regarding the course of diagnosis, laboratory findings, radiologic findings, and final diagnosis were documented and analyzed in relation to the survival status of each patient during up to one month of hospitalization. Results: The mean age of the patients was 39.7; 25 were men, 19 were newly diagnosed. Thirteen patients (31%) died during treatment; from them, six were newly diagnosed. Median CSF white blood cell counts were significantly higher in nonsurvivors; the most common diagnosis was focal brain lesions; toxoplasmosis and tuberculosis were the first common etiologies; 79% recovered with the intended treatment regimen. History of drug abuse, not receiving antiretrovirals, low baseline CD4 counts, and loss of consciousness at the time of admission has been seen more among deceased patients. Conclusions: Neurologic presentations or complications of HIV infection lead to high mortality rates. Early diagnosis of infection and improvement of patient compliance with antiretroviral treatment can reduce the mortality associated with neurologic diseases.

Lyme disease is the most common vector-borne disease in the northern hemisphere. Neurological complications usually manifest in patients who do not receive treatment for Lyme disease. Neurological involvement may be early or late, depending on the duration of the symptoms. Early neuroborreliosis presents with symptoms such as headache and meningism; late neuroborreliosis can present with signs and symptoms of encephalopathy and stroke-like symptoms. The diagnosis is based on clinical manifestations and lumbar puncture finding. Treatment consists of intravenous antibiotics for a period of three to four weeks. Patients who receive early treatment usually have an excellent prognosis, with very few patients developing post-treatment Lyme disease syndrome. Here, we report an unusual case of Lyme disease with extremely high cerebrospinal fluid protein level and devastating neurological sequelae. The diagnosis of neuroborreliosis is based on neurological symptoms and lumbar puncture findings.

CASE REPORT Background Varicella zoster virus (VZV) causes chicken pox and shingles. Neurological manifestations occur in both illnesses. An exanthem is usually present except in the immunocompromised and elderly. Case A 14 year old girl presented with headache, fever, vomiting and photophobia, though no meningism or altered consciousness. She was febrile, Glasgow Coma Scale was 15, she was fully orientated and conversing freely. Neurological exam revealed brisk deep tendon reflexes of all 4 limbs and ankle clonus bilaterally. The remainder of her examination was normal. There was no significant past medical history. Her vaccinations were up to date. Baseline bloods reported normal complete blood count, renal and hepatic profile, thyroid function tests and inflammatory markers. CT brain was normal. Lumbar puncture revealed a CSF protein of 1.4 g/L, glucose of 2.3 mmol/L, 356×10^9/L WBC, 99% of which lymphocytes. MRI brain and spine and EEG were normal. The patient underwent an extensive infectious diseases work up for viral, bacterial and fungal etiologies, autoimmune work up and flow cytometry of CSF in order to outrule a primary CNS malignancy. She received acyclovir and cefotaxime as empiric treatment for infectious meningoencephalitis. Given anamnestic potential for TB exposure, antimycobacterial combination therapy also was commenced. Subsequently, AFB stain and Mtb PCR on CSF were negative, as were bacterial and fungal PCRs and cultures. A chest XR, tuberculin skin test and IGRA all yielded a negative result. CSF virology identified varicella zoster virus positive PCR. The patient was treated for VZV meningoencephalitis most likely due to VZV reactivation following primary infection in early childhood. Flow cytometry of CSF leukocytes identified a high proportion (12%) of double negative T cells, with normal flow cytometry of peripheral blood. Her recovery was complicated by bilateral anterior uveitis two months after initial presentation which resolved on topical steroids. She completed a 21 day course of Aciclovir and recovered fully. Conclusion We present a rare case of aseptic meningitis caused by VZV reactivation without exanthem in an immunocompetent patient. This case is instructive in posing a wide differential diagnosis including the possibility of viral meningoencephalitis, an evolving autoimmune process, postviral complications or treatment related adverse effects; and illustrates the need for a better understanding of the role of certain lymphocyte subsets in infectious and autoimmune disorders involving the central nervous system.

Objectives: Hantavirus infection and leptospirosis are infectious diseases transmitted by rodents. The clinical picture is nonspecific, often involving the kidneys but other organs can be affected too. Clinical and biochemical clues to make a difference between these two entities will be described.Methods: A retrospective analysis was performed on a database of patients presenting between January 2012 and September 2017 at the emergency department of the university hospital Leuven, Belgium. Patients were selected on the basis of a compatible clinical picture, biochemistry, and microbiological evidence. Presenting complaints and clinical examination were compared. Blood, taken at presentation, was used for hematological and biochemical analysis.Results: Sixteen patients with hantavirus infection and eight patients with leptospirosis were identified. All patients complained about general malaise and fever. Other frequent complaints were myalgia and a headache. Patients with leptospirosis often experienced photo- or sonophobia.Looking for neck stiffness and eye lesions might help to diagnose leptospirosis.Differences in biochemistry between viral and bacterial disease could be recognized; high C-reactive protein (CRP) and leukocytosis with left shift favor leptospirosis, elevated lactate dehydrogenase (LDH) favors viral infection. Abnormal liver function with raised total bilirubin is often seen in cases with leptospirosis.Conclusion: This study demonstrates some subtle clues that may help to differentiate between hantavirus infection and leptospirosis in patients presenting to a hospital in a nonendemic region of the world. Because of small number of patients, we could not identify significant clinical or biochemical tests. Serology remains the gold standard.

Background: Multisystem inflammatory syndrome in children (MIS-C) is a new serious emerging disease that is temporally related to previous exposure to coronavirus infection disease (COVID-19). Aim: To describe the clinical features, laboratory findings, therapies and outcomes for the first Tunisian cluster admissions of critically ill children with severe MIS-C. Methods: Retrospective study conducted between 01 November and 30 November 2020 We included 8 children aged less than 15 years who were admitted to our pediatric intensive care and met the criteria for MIS-C according to the WHO definition case. We reviewed the medical records of all patients to collect demographic and clinical data, severity scores, laboratory test results, echocardiographic findings, treatment, and outcomes. Results: All children were previously fit and well. Seven patients were boys. Known exposure to COVID-19 was reported in 4 cases. Fever and gastrointestinal symptoms were reported in all cases. Five patients had marked abdominal pain and were examined by the surgeon for a possible appendicitis. Seven patients had diarrhea. On examination, we found a rash (n=7), a conjunctivitis (n=7), a cheilitis (n=5) and a meningism (n=3). We reported cardiac dysfunction in 7 cases and a shock with hypotension in 3 cases. All patients received immunoglobulins, methyl prednisolone and a low dose of aspirine. No deaths occurred. Conclusion: We reported here the first Tunisian cluster admissions of 8 critically ill children with MIS-C to highlight the increase of a new severe emerging disease with an evidence of prior COVID-19 infection in older children.

Patient: Female, 44 Final Diagnosis: McArdle disease Symptoms: Exercise intolerance • muscle contracture • myalgia • myoglobinuria • recurrent rhabdomyolysis Medication: — Clinical Procedure: — Specialty: Neurology Objective: Rare disease Background: McArdle disease is a glycogen storage disorder mainly characterized by exercise intolerance. Prolonged muscle contracture is also a feature of this condition and may lead to rhabdomyolysis (RM), which is a serious event characterized by acute skeletal muscle damage. Case Report: A 44-year-old female patient presented with an acute contracture of the posterior neck muscles, causing severe nuchal rigidity. The contracture was induced during a dental extraction as she held her mouth open for a prolonged period, with her neck in a rigid position. She presented with severe pain in her ear and head, as well as fever, vomiting, and confusion. Based on her symptoms, she was initially misdiagnosed with bacterial meningitis and experienced an acute allergic reaction to the systemic penicillin she was subsequently administered. Lumbar puncture results were normal. High serum creatine kinase (CK) levels, recurrent exercise-related muscle symptoms, and a previous history of recurrent myoglobinuria raised the suspicion of an underlying neuromuscular condition. McArdle disease was confirmed by muscle biopsy and a genetic test, which revealed that the patient was homozygous for the R50X mutation in the PYGM gene. Conclusions: This case illustrates that even seemingly innocuous movements, if rapid isotonic or prolonged isometric in nature, can elicit a muscle contracture in McArdle disease patients. Here, we highlight the need for careful management in this patient population even during routine healthcare procedures. The allergic reaction to antibiotics emphasises that misdiagnoses may result in iatrogenic harm.

Purpose In 2015, an outbreak of group B streptococcal (GBS) infection caused by Streptococcus agalactiae Serotype III, multilocus sequence type 283, related to consuming infected raw freshwater fish, affected more than 200 patients in Singapore. We describe the clinical, laboratory, and neuroimaging features of a subgroup of adults with central nervous system (CNS) infections caused by GBS. Materials and Methods The database of the Singapore Neurologic Infections Program (SNIP), a national multicenter study for surveillance of infectious neurologic disease, was reviewed to select patients with GBS CNS infection during the outbreak. Cases were diagnosed on the basis of clinical features, cerebrospinal fluid (CSF) findings and identification or isolation of Streptococcus agalactiae in the blood or CSF. Demographic, clinical and neuroradiological information was obtained prospectively and retrospectively abstracted. Results Fourteen patients (6 male, 8 female; median age, 58 years) presented with fever, meningism, headache, encephalopathy, focal neurological deficits, and/or seizures. All except two were previously healthy. Diffusion-weighted imaging (DWI) on admission was abnormal in 13 patients, showing tiny hyperintensities in the subarachnoid space (7 patients), ventricles (6 patients) and brain parenchyma (8 patients); 5 patients had cerebellar abnormalities. Conclusion Among healthy non-pregnant adults infected with Serotype III, multilocus sequence type 283 GBS meningitis linked to eating infected raw freshwater fish, DWI detected small pus collections and unusual cerebellar involvement. A collaborative national surveillance system that includes MRI can be helpful during unusual food-borne zoonotic infectious disease outbreaks. Level of Evidence: 4 J. Magn. Reson. Imaging 2017;45:507–514.

Acquired central hypoventilation syndrome (CHS) is a rare cause of respiratory failure. We report a case of acquired CHS, diagnosed several years after Listeria monocytogenes (LM) rhombencephalitis. In 1993, a 46-year-old woman presented to our Sleep Clinic with poor sleep, nocturnal choking episodes and daytime fatigue. She denied habitual snoring and hypersomnolence. Her medical history was unremarkable except for severe LM rhombencephalitis in 1977. At that time, the patient had been hospitalised in the intensive care unit following the acute onset of fever, influenza-like symptoms, meningism, facial palsy and nystagmus. Blood and cerebral spinal fluid samples were positive for LM on direct microscopic exam as well cultures. Treatment was initiated but the patient acutely deteriorated, exhibiting tetra paresis, bilateral pontomedullary syndrome, impairment of vigilance, and experienced a cardiac arrest. She was successfully resuscitated and remained in the intensive care unit with gradual and slow recovery. After a lengthy hospital stay, she was eventually discharged from the hospital and resumed a normal life, with few neurological sequelae such as dysphagia and mild facial palsy. To investigate the patient's sleep complaints, an in-laboratory full polysomnography was obtained and revealed central sleep apnoeas and hypopnoeas (Apnoea–Hypopnoea index (AHI)=50 events/hour) with severe nocturnal hypoxaemia. Morning arterial blood gases revealed alveolar hypoventilation with partial pressure of arterial CO2 or PaCO2 of 6.7 kPa and PaO2 of 9.5 kPa. The patient refused further investigations and therapy but agreed to return to clinic for a follow-up in 1 year. In 1994, polysomnography and arterial blood gases showed persistent sleep apnoea and daytime hypoventilation but the patient continued to decline treatment. The patient was then lost to follow-up until 2011, when she presented for the third time to the Sleep Clinic complaining of daytime fatigue, unrefreshing sleep, choking episode during sleep and …

We report a case of sympathetic ophthalmia 1 month following trauma in a 71-year-old immunocompetent female patient of Indian origin. The patient was hospitalized with signs and symptoms of meningism, ataxia, and neurosensory deafness. We explore and provide further clinical evidence in supporting the hypothesis of antigen cross-reactivity derived from tissues with common neural crest embryological background such as the uvea and cells of the labyrinth. The patient was human leukocyte antigen-A2 positive and treatment with oral steroids and cyclosporine has managed to have favorable results and control the inflammation.

Investigations were carried out in 24 patients in order to evaluate information value of the data of clinical, laboratory, neuroradiological methods of research and develop the diagnostic algorithm in case of cerebral venous thrombosis (CVT). The main group consisted of 11 patients (7 male, 4 female, average age 49,1±4,3) with CVT. The comparison group included 13 patients (6 male, 7 female; average age 68,1±9,5) with ischemic stroke (IS) of moderate severity. There were revealed changes in blood and cerebrospinal fluid (CSF) as form of leukocytosis of blood and moderately increased cell count with elevated protein in CSF and blood in case of CTV. The authors noted an elevated protein in CSF and blood and leukocytosis with predominant lymphopenia in blood and neurophilic predominance in CSF within the reference range of CSF in patient with ischemic stroke. The epileptic attacks, meningeal syndromes, headaches were more often among clinical syndromes at CTV than in case of ischemic stroke. The algorithm of neuroimaging research methods and modes of MRI were determined and allowed an effective diagnostics of damages of venous sinuses, superficial and deep cerebral veins in case of urgent hospitalization of patients. It was possible to suggest the venous pathology in 7 (63,6%) cases due to SKT (without contrast) and in case of application of MR venography (2D TOFmode), there were revealed 100% of cases.

Background Defined by an infection of the ventricular system of the brain, ventriculitis is usually known as a health-care associated infection. In contrast, primary pyogenic ventriculitis complicating community-acquired meningitis is uncommon, and mainly described in infants. Only seven cases that have occured in adults have been found in the international literature. Case presentation We report here a new case due to Neisseria meningitidis occurring in an 85 year-old-man. The comparison with previous reports allows to drawn several conclusions: (i) cases occurred in relatively old adults (median age: 65 years); (ii) Streptococcus pneumoniae, N. meningitiditis and Staphylococcus aureus are the leading responsible pathogens; (iii) atypical clinical presentation seems the rule in which meningism often lacks; (iv) in absence of clinical or biological specific parameters, modern brain imaging such as magnetic resonance imaging with gadolinium enhancement is of utmost importance for the diagnosis, leading to anticipate an increase of the diagnosis in the near future, thanks to easier access to such exploration; (v) death or serious sequelae commonly occurred; (vi) prolonged antibiotic courses (6 weeks to 3 months) have been used, without strong rational. In the given case, the patient presented with a lack of meningeal irritation signs. The diagnosis was made by MRI considering a lasting confused state. A four-week antibiotic regimen was successful, combining two weeks of intravenous cefotaxime followed by two weeks of oral levofloxacin much easier to administrate and allowing early rehabilitation. Conclusion Primary bacterial ventriculitis is a real diagnosis challenge. Larger indications of MRI for bacterial meningitis, particularly in cases with an atypical presentation or poor evolution would certainly increase the number of diagnosis.