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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.

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.

Spontaneous intracranial hypotension syndrome (SIH) is a rare condition. The main symptom is orthostatic headache, although other symptoms such as vegetative symptoms, meningism, or focal neurological deficits may appear. The most common cause is a cerebrospinal fluid leak, usually traumatic. Spontaneous cerebrospinal fluid leaks are rare and associated with the presence of meningeal cysts / diverticula or in the setting of connective tissue diseases. The diagnosis is based on imaging tests, both to detect intracranial complications and bilateral subdural hematomas and to locate the leak point at the intracranial or spinal level. The treatment of SIH is usually conservative: bed rest, caffeine and analgesics. Epidural blood patch is a good option when symptoms persist. Surgery is indicated in refractory cases or when there is an evident and accessible anatomic defect. This article describes three clinical cases with intracranial hypotension syndrome secondary to a spontaneous spinal cerebrospinal fluid leak.

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.

The diagnosis and management of the patient in coma demands rigorous clinical assessment that encompasses a meticulous approach to history-taking and systemic and neurological examination. Following immediate resuscitation and acute management, the level of consciousness must be assessed and evidence of meningism, brainstem or lateralizing neurological signs sought. The prognosis depends on the underlying cause and the appropriateness of acute management. The diagnosis of brain death depends on establishing the aetiology of irreversible brain damage, excluding reversible causes and establishing the absence of any brainstem reflexes.

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.

Background: Pituitary apoplexy (PA) is a rare but potentially life-threatening condition that may require urgent surgical intervention.Case Presentation: We report a case of a patient who was initially diagnosed with meningoencephalitis (ME) based on clinical presentation and cerebrospinal fluid (CSF) analysis, but was eventually diagnosed with PA. We present a summary of other cases reported in the literature of PA mimicking ME and analyze their clinical features and CSF findings.Results: Among all 22 PA cases reviewed, headache was the most commonly reported symptom. Hypopituitarism was seen in 94.4% of the cases; of these, panhypopituitarism was noted in 38.9%. The sensitivity of magnetic resonance image (MRI) for detecting PA was 94.7%, much higher than that of computed tomography (CT), which was only 31.6%. Neutrophil predominant pleocytosis was present in all cases with a neutrophil percentage ranging from 73% to 98%. CSF leukocyte count was less than 1000/ul in 86% of the cases. CSF erythrocytosis was seen in 92.9% of the cases with a count ranging from 15 to 2030/ul. Elevated CSF protein was present in all cases with a range of 69.8 to 239 mg/dl. CSF glucose level varied with a range between 12 and 136 mg/dl; the level was greater than 40 mg/dl in 73% of the cases.Conclusion: PA tends to be misdiagnosed as ME due to the similarities of semiology and CSF findings. PA should be considered in refractory acute headache cases, especially those with visual and endocrine abnormalities. Early recognition and treatment may lead to significant reduction in morbidity and mortality.Abbreviations: ACTH: adrenocorticotropic hormone; CSF: cerebrospinal fluid; CT: computed tomography; GRE: gradient echo; HRT: hormone replacement therapy;HSV: Herpes Simplex Virus; IV: intravenous; ME: meningoencephalitis; MRI: magnetic resonance image; PA: pituitary apoplexy; RBC: red blood cell; WBC: white blood cell.

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

Sepsis is a syndromic entity with high prevalence and mortality. The management of sepsis is standardized and exhibits time-dependent efficiency. However, the management of patients with sepsis is complex. The heterogeneity of the forms of presentation can make it difficult to detect and manage such cases, in the same way as differences in training, professional competences or the availability of health resources. The Advisory Commission for Patient Care with Sepsis (CAAPAS), comprising 7 scientific societies, the Emergency Medical System (SEM) and the Catalan Health Service (CatSalut), have developed the Interhospital Sepsis Code (CSI) in Catalonia (Spain). The general objective of the CSI is to increase awareness, promote early detection and facilitate initial care and interhospital coordination to attend septic patients in a homogeneous manner throughout Catalonia.

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.

We welcome the study by Martinez-Hernandez et al.1 reporting antibody coexistence in anti-n-methyl-d-aspartate receptor (NMDA-R) encephalitis. The authors confirmed coexistence of aquaporin-4-IgG or myelin oligodendrocyte glycoprotein (MOG)-IgG as predictors of co-occurrence of anti-NMDA-R encephalitis and autoimmune CNS demyelination. By contrast, it was concluded that coexisting GFAP-IgG is “clinicoradiologically nonspecific.”1 The diagnosis of autoimmune GFAP astrocytopathy—AGA, a clinical-radiological-serological entity, characterized by an inflammatory steroid-responsive meningoencephalomyelitis—requires adherence to a 2-step CSF evaluation2–5 (figure): (1) detection—by optimized rodent tissue-based immunohistochemistry—of an astrocytic filamentous-appearing pattern of IgG staining of all of midbrain (meningeal, subpial, and periventricular), cerebellar white—but not gray—matter, hippocampal, and cortical brain regions, and myenteric plexus and (2) positivity by GFAPα isoform-transfected HEK293 CBA (figure). Serum testing is insensitive and generates nonspecific results, as occasionally does CSF if both tissue and cell-based assays steps are not followed. Two patients with coexisting GFAP-IgG reported by Martinez-Hernandez et al.1 had meningeal enhancement on MRI, but the authors attribute this to anti-NMDA-R encephalitis alone, although the question of these 2 IgGs coexisting was not addressed systematically. Deviations from published methods may explain the paucity of cases found by Martinez-Hernandez et al.—10 of 846 anti-NMDA-R encephalitis patients total, 1.2%.2 Since test “go-live” in June 2019, we have detected GFAP-IgG coexisting in 6% of NMDA-R-IgG positive CSF specimens. Martinez-Hernandez et al. reported universal nondetection of coexisting GFAP-IgG by immunohistochemistry.2 The authors did not state whether fixation and permeabilization were optimized for detection of IgGs reactive with cytoplasmic proteins, such as GFAP. Furthermore, the authors used a “live” GFAP-specific cell-based assay (CBA) to identify 10 patients with coexisting GFAP-IgG, yet the intracellular location of GFAP should preclude detection in live cells. Additional details pertaining to the GFAP isoform expressed, and the specimen types tested—CSF or serum—were lacking. All of these factors can impact the sensitivity and specificity of GFAP-IgG testing and frequency of coexistence with NMDA-R-IgG.2,6 To address the question of neurologic phenotype further, we reviewed data for 248 unique patients in whom CSF GFAP-IgG was detected and confirmed by our 2-step laboratory protocol2,6 over the course of 4.5 years (January 1, 2015–June 30, 2019). Median GFAP-IgG endpoint titer was 1:64 (range 4–512; normal

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.

Clinical case A 31-year-old right-handed man was transferred by ambulance after falling out of bed. His wife reported that he was agitated, not moving his left side, appeared ‘blue in the face’ and complained that he could not see properly. He had a history of seronegative inflammatory arthritis and keratitis. On arrival at the emergency department, he was significantly agitated and required anaesthetic support for sedation and intubation. Further collateral history found that in the 10 days before admission, he had reported increasing joint pain and swelling, neck stiffness and general malaise. His regular medications were paracetamol and naproxen. Combination therapy for his seronegative inflammatory arthritis in the form of methotrexate and sulfasalazine had been stopped 2 weeks before due to routine blood monitoring identifying deranged liver function tests. On neurological examination, he was encephalopathic and could not follow commands. He had normal pupillary responses and funduscopic appearances. There was no gaze preference, facial weakness or meningism. His muscle tone was normal, and strength testing in the context of poor cooperation found no lateralising weakness. Limb reflexes were symmetrically present, and plantar responses were bilaterally extensor. ### What is the most likely clinical syndrome? We suspected that he had experienced a generalised seizure, given the description of central cyanosis and altered mental state with agitation. The initial witness account of left-sided weakness suggested either a right hemispheric lesion or a Todd’s phenomenon. The prodromal symptoms of neck stiffness and altered mental state with suspected seizure made meningoencephalitis the most likely diagnosis. We started ceftriaxone and acyclovir promptly in the emergency department, …

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.

ObjectiveThe aim of this study was to better characterise clinical presentation, management and outcome in infants and children with brain abscess.MethodsThe authors conducted a retrospective, multicentre study in two national reference centres over a 25-year period (1992–2017). During this period, 116 children and 28 infants (age ResultsThe median age at diagnosis was 101.5 (range: 13–213) months in children and 1 (0–11) month in infants. Significant differences were observed between children and infants. The most common predisposing factor was meningitis in infants (64% of cases vs 3% in children), while it was otolaryngology-related infection in children (31% of cases vs 3.6% in infants). Infants presented more frequently with fever and meningism compared with children. 115 patients were treated with aspiration and 11 with excision. Reoperation was required in 29 children vs 1 infant. The overall mortality rate was 4% (3.4% for children, 7.1% for infants). At 3-month follow-up, the outcome was favourable in 86% of children vs in 68% of infants.ConclusionThere is a clear difference between children and infants with brain abscess in terms of predisposing factors, causative organisms and outcome. Despite surgical drainage and directed antibiotic therapy, 25% of patients with brain abscess require reoperation. Mortality is improved compared with historical series; however, long-term morbidity is significant particularly in the infant population.

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.

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.

A 46-year-old right-handed man presented to the emergency department with a 1-week history of headache. The headache was bilateral, predominantly posterior, worsened transiently on Valsalva manoeuvre and was refractory to simple analgesia. It did not vary with posture or time of day. He felt nauseated but had not vomited. There were no visual symptoms and specifically no blurring, obscuration or diplopia. A few hours before presenting, there had been an unwitnessed collapse without prodrome, and he sustained a soft tissue injury to his neck. His partner had found him confused and drowsy and so called an ambulance. He had previous episodic migraine, depression and gastro-oesophageal reflux. Borderline hypertension (143/90 mmHg) had been found at a neurology consultation for headache 18 months before; an MR scan of the brain at this time was normal. He smoked 20 cigarettes per day and drank alcohol excessively (100 units per week). He did not use recreational substances. On examination, his blood pressure was significantly elevated, averaging 210–245 mmHg systolic. He had a mild encephalopathy with a Glasgow Coma Scale score of 14/15 but no meningism. There was a left-sided partial ptosis (without anisocoria) and extensive bruising to the left side of the neck, sustained during the collapse. His pupils appeared and responded normally. Fundal examination (and later fundal photographs) was normal. Pursuit and saccadic eye movements were normal but there was upbeat nystagmus on upgaze. Muscle tone, strength and deep tendon reflexes were normal in all four limbs. The left plantar response was extensor and the right equivocal. His blood tests were normal except for elevated serum creatine 209 µmol/L (45–84). The …

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

Background The neurological effects of Lyme borreliosis in children are varied and their clinical progression is not widely reported in the French literature. We carried out a retrospective study to describe the clinical characteristics of Lyme neuroborreliosis in children in southwest France and their clinical progression at 6 months. Methods This study was carried out at Toulouse University Hospital during the period 2006–2017 using patient records. Case definition was based on the combined French clinical and laboratory diagnostic criteria. Results In total, 26 children were included. The median age was 8 years (4–14 years). The different neurological symptoms reported were: meningoradiculitis (62%), which was usually associated with facial palsy (54%); isolated facial palsy (15%); isolated meningitis (8%); polyradiculoneuritis (4%); benign intracranial hypertension (4%) and myelomeningoradiculitis (4%). The most common functional symptoms were headaches (54%), the perception of asthenia (42%), neck pain (27%), and a loss of appetite (19%). Patients with laboratory meningitis (84%) often had no signs of meningism or headaches (38%). Conclusion The majority of the cases involved meningoradiculitis but other, less common, neurological conditions have been described. The clinical signs suggestive of meningitis are not very marked and might delay the diagnosis.

Our team was referred a 14-year-old, previously healthy, immunised aboriginal boy from a remote community in northern Western Australia. He had been admitted to the local community hospital 10 days previously and while there developed haemoptysis, fever and epigastric abdominal pain so was transferred to our care at the regional hospital for ongoing investigation and management. Haemoptysis is an uncommon presentation in adolescence. It can be caused by infection (eg, bronchiectasis, pneumonia, lung abscess or tuberculosis), trauma (eg, lung contusion, foreign body or inhalation injury), vascular disorders (eg, pulmonary embolus, arteriovenous malformation or haemangioma), late complications of congenital lung malformations, coagulopathy or one of the diffuse alveolar haemorrhage syndromes.1 Additionally, bleeding from the upper airway or gastrointestinal tract can mimic haemoptysis. Demographic considerations are important in this case. Bronchiectasis and rheumatic heart disease, both of which may present with haemoptysis, have increased prevalence in aboriginal children in Australia. In addition, Burkholderia pseudomallei is endemic and pulmonary infection can mimic tuberculosis. An infectious aetiology is favoured here in view of the history of fever. He had initially been admitted to the local hospital with presumed bacterial meningitis following presentation with headache, fever and meningism 10 days prior. Cerebrospinal fluid (CSF) prior to antibiotics demonstrated elevated white cell count (WCC) 550/mm3 (90% neutrophils) and protein (0.84 g/L), with negative microscopy and culture for bacteria, and negative PCR testing for bacteria and viruses. Intravenous ceftriaxone (ongoing) and dexamethasone 0.15 mg/kg four times a day (total 4 days) had been administered, with rapid resolution of symptoms. Following transfer to our care (day 1), examination showed normal respiratory rate and oxygen saturations (SaO2=98%); a productive cough with a moderate amount of blood-stained sputum was noted. The respiratory examination (including upper airway) was otherwise unremarkable. There was mild right upper quadrant abdominal tenderness …

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.

We diagnosed varicella zoster virus (VZV) meningitis in a healthy adolescent boy who presented without a rash or fever. We aim to compare VZV reactivation meningitis in children after primary VZV infection and VZV vaccination. We reviewed the literature up until June 2020 using Pubmed/MEDLINE and EMBASE databases using 'varicella zoster', 'meningitis' and 'children' as keywords. Only English articles were included. Twenty-five cases were included in this review. Children who had VZV reactivation meningitis after vaccination were younger (7 ± 3.4 years vs. 11.9 ± 3.6 years, P = 0.0038), had a shorter interval between first exposure to reactivation (5.6 ± 2.9 years vs. 8.8 ± 3.2 years, P = 0.018) and more likely to have a rash (100% vs. 55%, P = 0.04). VZV reactivation meningitis occurs after both primary VZV infection and VZV vaccination. The absence of exanthem, fever or meningism does not rule out VZV meningitis.

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.

Pituitary apoplexy is an uncommon event, occurring due to the infarction and/or haemorrhage usually of a previously unknown pituitary adenoma. It can occur in all adenoma subtypes but is more common in nonfunctioning pituitary adenomas. The physiopathology is not completely clear, and precipitating factors, such as major surgeries, anticoagulant use or pituitary dynamic tests, can be found in up to 40% of patients. The clinical presentation is characterized by a rapid onset with a headache as the main symptom, but visual disturbances can also be present as well as meningism and intracranial hypertension. The diagnosis is based on imaging evaluations, mainly using magnetic resonance imaging, which can show various patterns depending on the timeframe following the occurrence of the apoplectic event. Pituitary hormonal deficits are also common, and the evaluation of hormonal levels is mandatory. Pituitary apoplexy can be managed by surgery or conservative treatment, and a multidisciplinary team is essential for the decision-making process. The outcome is usually positive with both surgical and conservative approaches, but surveillance is needed due to the risk of re-bleeding or tumour recurrence.