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Rash, severe constitutional symptoms, and arthritis developed in three persons who were bitten by ticks in Wisconsin. On comparison with other reports of arthritis related to tick bites, we found that the illness of our patients had clinical features consistent with Lyme arthritis. Lyme arthritis appears not to be restricted to New England as has been previously reported.

For a five year period 235 patients with a malignant lymphoma were studied in clinical conditions. In 20 of them (8.9%) the central nervous system was affected: 13 patients showed signs of spinal cord compression, 5 patients were with meningosis and 2 patients had cerebral infiltrations. The meningeal affection was found in patients presenting certain risk factors: young age, packages of lymph nodes localized retroperitoneally, lymphomas with a high degree of malignancy, extranodal localization. The patients with meningosis have a short longevity which implies meningeal prophylaxis in the risk groups. The spinal cord compression as a complication of the lymphoma does not determine the prognosis. The prognosis is related to the spread of the lymphoma. The knowledge of the early manifestations of these complications and the timely treatment lead to a favourable result. A very good therapeutic result can be achieved by the combined treatment--polychemotherapy and intrathecal administration of a cytostatic (cyclophosphamide and/or methotrexate).

Fourteen cases of subdural empyema seen in Oxford since the introduction of the CT scanner are reviewed; 11 were male and 12 survived. The clinical presentation was stereotyped and characterised by severe headache, fever and meningism followed after a few days by rapidly progressive drowsiness, focal signs, papilloedema and seizures. All had radiological evidence of paranasal sinus disease (particularly frontal) although this was not apparent clinically in the majority. Plain skull and sinus radiographs remain important early investigations. Over-reliance can be placed on the CT scan which initially may be normal or show only non-specific hemisphere swelling. Parafalcine collections are easily missed. The diagnosis of subdural empyema remains difficult and a high index of clinical suspicion is required. Outcome depends on prompt treatment with parenteral antibiotics and surgical drainage.

The OKA-MT pressure chamber was used. The course consisted of 6-15 sessions at a pressure of 1.6-2.0 at. abs. Hyperbaric oxygenation (HBO) was included in the complex of therapeutic measures applied in the postoperative period in patients with ruptured aneurysms of the cerebral vessels. From comparison of the course of the disease in 47 patients treated by HBO with that in 30 patients not subjected to HBO (control group) the authors conclude that the inclusion of HBO in the complex of measures applied after operations on the cerebral vessels for ruptured aneurysms has a positive effect on the course of the disease: the grave condition is less prolonged; the duration of the meningeal syndrome, headache, and temperature reaction is shorter by 6 days than in the control group; the number of patients with a good result of treatment increases by 18%; mental disorders in the absence of hematoma of the frontal area are prevented; the frequency of suppurations of the postoperative wound diminishes.

Eleven patients were referred to the infectious diseases wards of the Prince Henry Hospital, Sydney, between August and December, 1979, with acute infectious diarrhoea acquired within Australia. Nine of the 11 had infection with Campylobacter species as the sole pathogens. In contrast, a variety of pathogens was isolated from the stools of 13 patients referred to the hospital with enteritis acquired during overseas travel, including three Shigella species, but only one Campylobacter species. The patients with campylobacter enteritis suffered fever, abdominal discomfort and diarrhoea, often with some blood. Complications of campylobacter enteritis included colitis, severe abdominal pain, renal failure, severe muscle cramps, headache with meningism, myalgias and arthralgias. Campylobacter enteritis resolved with cessation of solid food intake, together with intravenous or oral fluid therapy. Some patients were treated with erythromycin, with prompt improvement, though a role for antibiotic therapy has not yet been established.

Twenty-four university or hospital departments of neurosurgery took part in the cooperative study on acute, non-traumatic intracranial hemorrhage during the years 1978, 1979 and 1980. In three instances the data from two clinics with a common group of patients were combined. With the help of an extensive questionnaire, data were gathered on the causes of the hemorrhage, when and how the diagnosis and treatment was carried out, the patient’s condition on admission to hospital and to what extent his condition influenced the diagnostic procedure (computed tomography and angiography), the therapy and — where indicated — the time of the operation. A division into six grades of severity was made, using the International Cooperative Study on Timing of Aneurysm Surgery as a model: Grade I: No symptoms Grade II: Slight symptoms (headache, meningism, diplopia) Grade III: Neurological focal symptoms with full retention of consciousness Grade IV: Reduced consciousness, defensive reactions retained Grade V: Weak defensive reactions together with stable vital signs Grade VI: No reaction to shouting or shaking, no reaction to pain stimuli and increasing instability of vital signs.

To study the nature of the multiple sclerosis (MS) central nervous system (CNS) immune reaction, cytarabine (ara-C) was administered intravenously to three patients and intrathecally to another seven. Although intravenous administration severely suppressed circulating leukocytes derived fom the bone marrow, there was no change in de novo CNS IgG synthesis (rate or presence of CSF IgG oligoclones). Therefore, the MS CNS immune reaction can persist in the presence of severe granulocytopenia and severe monocytopenia of one to two weeks' duration. In four patients who were given ara-C intrathecally, cytotoxic levels (> 10 micrograms/ml) were present for a least 24 hours. A brief elevation in CSF albumin indicated transient damage to the blood-brain barrier. Leukopenia did not result in the seven patients treated intrathecally, and de novo CNS IgG synthesis did not change or was transiently increased. Assuming that cytotoxic levels in CSF diffused to the CNS sites responsible for synthesizing IgG, results indicate that CNS IgG synthesis does not depend on in situ rapid turnover of immune cells. None of the ten patients demonstrated neurological improvement or persistent adverse effects.

Nuchal rigidity, which may be a sign of meningitis, was found in 35 per cent of geriatric patients on acute-care and rehabilitation wards and in 13 per cent of younger patients on an acute-care ward. It was significantly associated with cerebrovascular disease, confusion, abnormal plantar responses, and primitive reflexes. Elderly patients who have nuchal rigidity with no history of neurologic or cognitive disorders should be investigated for meningitis.

Seven adults with multiple brain abscesses were successfully treated with antibiotic therapy alone at The George Washington University Medical Center, Washington, D.C., during 1976-1981. Fever, meningismus, and focal neurologic signs were common presenting features. No patient presented with coma or obtundation. Etiologic agents were identified in only three cases. Computerized tomographic (CT) scans were valuable in diagnosing and monitoring the response to therapy. Decrease in the size of the lesions was noted two to nine weeks after initiation of antibiotic therapy. In all patients, clinical signs of improvement preceded evidence of resolution of lesions on CT scan. These results indicate that, in carefully selected patients in whom surgical drainage is not feasible because of the anatomic location and/or multiplicity of lesions, a prolonged course of high-dose intravenous antibiotics alone can lead to a successful outcome.

Apart from the most essential aspects of the diagnosis and differential diagnosis of acute leukaemias concerning the early diagnosis of leukaemias the author deals with the so-called praeleukaemia. On the basis of a survey of international literature the modern polychemotherapy and its successes are characterized as well as the necessary supportive haemotherapy) are dealt with. Despite the improved frequency of remissions the survival time of acute leukaemias could only little be prolonged, that of the first remission could not be prolonged. Perhaps it is possible by an in future improved immunotherapy and by allogenic transplantation of the bone-marrow after supralethal total body irradiation to set new measures in the treatment of acute leukaemias.

Summary A case of spinal subarachnoid haemorrhage with progressive spinal cord compression and without any evidence of meningism is described. Spinal block was demonstrated by myelography and computerized tomography and surgical decompression of the subarachnoid blood clot resulted in almost complete recovery. A diagnosis of spinal subarachnoid haemorrhage should be considered in any patient who presents with acute back pain and slowly or rapidly progressive neurological signs in the limbs, even when meningism is absent.

Using clinical and a series of additional methods of examination, including computer-aided tomography, the authors studied 46 cases of limited (without breakthrough of blood into the CSF) intracerebral hematomas (LIH) which constituted 22% of the total number of the examined patients with brain hemorrhages. It has been established that in the majority of the cases of LIH (87%) the diagnosis of the stroke nature was difficult to make without computer-aided tomography. It was shown that the characteristics of the clinical picture and course of LIH were determined by the absence of breakthrough of blood into the CSF system, a relatively small size of hematoma, a mild degree of dislocational manifestations and their slow evolution. Three main variants of the clinical course of LIH were identified. The course of the disorder was usually favourable; the lethal outcome occurred in only 15.2% of the cases. The authors draw attention to the expediency of conducting computerized tomography over time and to the necessity of taking into account the status of the homeostasis system in the treatment of such patients.

The use of lumbar puncture (LP) and cerebrospinal fluid (CSF) analysis in the routine, initial evaluation of patients with dementia continues to be questioned. This is especially true in the investigation of infectious causes of dementia. To explore this question further, the authors performed a retrospective analysis of 672 hospitalized patients specifically evaluated for dementia. LP and CSF analysis were performed on 402 patients (60 per cent); routine bacteriologic, acid-fast, and fungal cultures were also obtained for 333 of these patients. Most patients were white (64 per cent) and male (63 per cent), their mean age being 66 +/- 11 years. Four patients were diagnosed as having meningitis--two with Cryptococcus neoformans, one with apparent Mycobacterium tuberculosis, and one with coagulase-positive Staphylococcus aureus. These patients were characterized by a subacute change in mental status, fever or meningismus, and CSF pleocytosis with abnormal CSF chemistries. None of the patients were found to have newly diagnosed neurosyphilis. The authors conclude that LP and CSF analysis should not be part of the routine evaluation of patients with dementia and should be performed only in the presence of such indications as a subacute duration of dementia, fever, and signs of meningeal irritation.

The clinical features, investigative profiles and outcome of 46 patients with biopsy or autopsy-proven herpes simplex encephalitis admitted to the Institute of Neurological Sciences, Glasgow between 1962 and 1985 were analysed retrospectively. The protean presenting symptoms and signs included a history of a prodromal influenza-like illness (48 per cent), rapid onset of headache, clouding of consciousness and confusion (52 per cent), meningism (65 per cent), raised intracranial pressure (33 per cent), deep coma (35 per cent), mutism or aphasia (46 per cent), focal neurological signs (89 per cent), and seizures (61 per cent). When seizures occurred they were almost always focal. The electroencephalogram was the most useful diagnostic test being abnormal in all cases, the majority showing focal changes in one or other hemisphere. Of the neuroradiological procedures employed, computerized tomographic and isotope brain scanning most frequently demonstrated localizing abnormalities in one or both temporal and/or frontal lobes. Midline shift was seen in half the cases. The cerebrospinal fluid was abnormal in every case but was not diagnostic. Cerebral biopsy of one temporal lobe was performed in 40 cases and a positive diagnosis of acute necrotizing encephalitis was made in 37 of these. Herpes simplex virus was isolated from the brains of 29 of the 40 cases in which the procedure was attempted, but immunofluorescence assays for antigens to herpes simplex virus were only positive in 11 out of 25 cases. Serological assays showed a greater than four-fold rise in the anti-herpes simplex virus antibody titre in 13 out of 22 patients tested.(ABSTRACT TRUNCATED AT 250 WORDS)

On the basis of a clinico-anatomical comparison in 70 cases of complicated infarctions and 77 observations of white infarctions the author elaborated computing tables. It was established that the following signs have certain diagnostic significance: the degree of changed consciousness, meningeal symptoms, symptoms indicating a secondary lesion of the brain stem and symptoms characterizing the degree of focal neurological disturbances. Among the supplementary methods of special significance is CSF analysis.

Two patients with inflammatory meningeal masses were studied. Lesions in both patients showed varying proportions of meningothelial and inflammatory components. The non-neoplastic nature of the inflammation was confirmed in one case by lymphocyte surface marker study, which showed T and B cells in one to four ratio, and by immunohistochemistry, which revealed polyclonal plasma cells. The abundant histiocytes contained muramidase and often enclosed intact lymphocytes or plasma cells within their cytoplasm, i.e., emperipolesis. Their surfaces bore slender interdigitating pseudopodia, intercellular junctions, and subplasmalemmal linear densities. The derivation of these histiocytes is uncertain: mononuclear phagocytes, meningothelial cells, and multipotential meningeal cells are all possible progenitors. A comparison with eleven similar reported cases reveals a tendency for inflammatory meningeal masses to occur in the young, as well as a predilection for posterior fossa involvement. They resemble the extranodal lesions of sinus histiocytosis with massive lymphadenopathy, as well as plasma cell granulomas or inflammatory pseudotumors of lung and other tissues. However, it is possible that these lesions represent a variant of meningioma in which an unusual immunological response has been evoked.

Summary A highly sensitive and specific immunoradiometric assay, based upon a monoclonal antibody, was used to measure interferon-alpha (IFN- α ) in the cerebrospinal fluid (CSF) of patients with central nervous system infections and in controls with non-infectious neurological disorders. IFN- α was detected in all 21 patients with viral meningitis but in only one of four patients with non-viral aseptic meningitis. It was also present in the CSF of three of four patients with herpes encephalitis and five of seven patients with acute bacterial meningitis. By contrast, IFN- α was present in the CSF in low concentrations in only five (7%) of 71 neurological controls. This rapid test is positive in viral meningitis and may help in distinguishing viral infection from other causes of aseptic meningitis. It is usually negative in non-infective disorders but will not distinguish between viral and bacterial infections.

Seven patients with SSPE aged from 10 to 19 years received beta interferon intrathecally one million units every second day during one month (in all, 15 million units for one course of treatment. During the treatment signs were observed of irritation of the meninges which regressed after treatment completion. The neurological status of the patients was not significantly changed during the treatment. Control investigations carried out 3 to 10 months after the treatment demonstrated worsening with progression to a further phase of SSPE in 4 cases, and evidence of disease progression within the previous phase in 3 cases.

A retrospective survey was made of 57 consecutive patients referred for myelography by one neurological team. Reactions occurred in patients with multiple sclerosis significantly more often than in all other patients (P=0·02). This finding appears to support the belief that demyelination may be associated with more severe reactions to iophendylate myelography.

Several biochemical markers in the cerebrospinal fluid (CSF) of 120 patients with serous meningoencephalitis (SM) of viral origin were compared with those of 74 patients with viral or bacterial infections accompanied by neck stiffness but no CSF abnormality (i.e., meningism). CSF adenylate kinase was higher (P less than 0.025) in SM and correlated with lactate concentration (r = 0.37; P less than 0.01). CSF hypoxanthine was lower (P less than 0.001) in SM, whereas CSF xanthine was similar in the two conditions. The xanthine/hypoxathine ratio correlated with the CSF leukocyte count (r = 0.32; P less than 0.01), and especially with the mononuclear cell count (r = 0.45; P less than 0.001). CSF adenylate kinase correlated with fever in SM (r = 0.28; P less than 0.01). CSF urate and protein displayed a mutual correlation in both conditions (r = 0.26 and P less than 0.05 for SM; r = 0.55 and P less than 0.001 for meningism). These results support the hypothesis of impaired brain cell metabolism, probably of ischemic nature, in viral meningoencephalitis, causing leakage of adenylate kinase into the CSF, where hypoxanthine may be reutilized by mononuclear leukocytes.