Cerebrospinal Fluid Examination Research Articles

Recommendations for Cerebrospinal Fluid Cytology. A Review Article

The description of cytological findings in cerebrospinal fluid (CSF) is very inconsistent in the literature since no generally recognized uniform classification of these findings has been proposed to date. The need for developing such a classification system becomes quite obvious against the background of renaissance CSF cytology is currently experiencing in our country. A precondition sine qua non for developing a uniform classification system is its general applicability and recognition as well as a capacity to establish, using precisely formulated conclusions, the aetiological diagnosis, something quite impossible with today's terminology. Our draft classification is that used by a team of physicians working previously in the CSF Laboratory of the Department of Neurology of Charles University School of Medicine I in Prague. The classification employed there is based on monitoring pathology in the cytological picture both according to the presence of the prevailing cellular population in CSF and to the presence of activation in elements of lymphocyte and monocyte lines. We were able to combine both criteria into a single viable system expressing the current status of cellular response in CSF. The presence of a pathological cytological finding provides the basis for defining individual cytological CSF syndromes closely related to the etiological diagnosis of the patient, which in the great majority of cases make it possible to formulate the diagnostic conclusion. The classification employed allows to establish the diagnosis in diseases manifesting themselves by at least a mild alteration of the cytological picture. In general, it is useful for classifying inflammatory, neoplastic diseases, inter-meningeal haemorrhage and morphological manifestations of CNS tissue destruction. A distinct advantage is the plausible classification of cytological findings in oligo-cellular CSF specimens which to date has been difficult to make due to the low numbers of cellular elements detected in samples. In cytological examination of CSF, the parameters evaluated include, in addition to the number of elements, qualitative representation of individual cellular lines. (1-Monografie). When evaluating the monocyte-macrophage system and/or the reticuloendothelial system, attention is focused on the proportions of activated monocytes and, particularly, on the presence of macrophages showing a specific substrate of phagocytosis. It is according to this substrate that macrophages are further divided into erythron-phages, sidero-phages, lipo-phages, lympho-phages, leuko-phages or myco-phages, etc. To visualize a substrate, it is often necessary to use additional staining e.g., staining by Oil Red for lipids, Berlin Blue for iron, etc. If inter-meningeal haemorrhage is suspected, monitoring of the phagocytosis of red blood cells and haematogenic pigments allows us to determine the approximate age and course of the bleeding. Monitoring of lipo-phagocytosis visualizing the scavenging response on CNS parenchymal damage also has a number of potential applications. As the number of CSF examinations increases, proportionately increasing numbers of cells are being detected. This is true especially of diseases involving the presence of primary or secondary neoplastic processes right in the CNS or in the vicinity of CSF pathways. The currently employed cytological methods of CSF examination, whenever malignant elements were detected, have made it possible to establish the presence of a tumor disease in general only. For instance, monitoring of the functional status of nucleoli, PAS positivity, or the presence of adipose droplets in the cytoplasm suggest only indirectly an increased metabolic activity of the cells monitored. Other morphological markers of atypical cells (polymorphism of cells, nuclei, polynuclear elements, cytoplasm basophilia, atypical mitoses, etc.,) may only raise suspicion of the presence of a tumorous process, but not identify the cellular system the belong to. Another problem which by no means is negligible is the low number of cells detected. As a result, we started to study the mode of reaction of atypical elements with certain monoclonal antibody binding to individual antigens, tumor markers specific for the respective cellular populations. Moreover, the method can be used to determine the degree of their maturity, presence of individual receptors, state of activation in the course of their cellular cycle.

Sympathetic ophthalmia after 27-G pars plana vitrectomy

BackgroundSympathetic ophthalmia (SO) is a bilateral diffuse uveitis that can arise after ocular trauma or ocular surgery in the inciting eye. Pars plana vitrectomy (PPV) is one of the risk factors for SO. Several reports have described SO developing after 23- and 25-G PPV, but none have described SO occurring after 27-G PPV. We describe herein a case of SO after 27-G PPV for rhegmatogenous retinal detachment.Case presentationA 42-year-old woman presented with visual disturbance in the right eye. Best-corrected visual acuity (BCVA) was 6/200 in the right eye. Fundus examination revealed off-macula retinal detachment with retinal tears at both ends of retinal lattice degeneration at the temporal-oven peripheral retina of the right eye. We therefore performed 27-G sutureless PPV on the right eye. After 12 days, the retina was reattached, and BCVA improved to 6/30 in the right eye. Fifteen days postoperatively, she experienced headache and reduced vision in both eyes. Symptoms gradually worsened, and she visited our hospital 21 days postoperatively. BCVA was 6/30 in the right eye and 6/15 in the left eye. Slit-lamp examination revealed uveitis in the anterior chambers of both eyes, and fundus examination showed papillitis and subretinal detachment at the posterior poles of both eyes. Optical coherence tomography revealed subretinal fluid in the maculae of both eyes and fluorescein angiography showed multiple hyperfluorescent leakage sites in the retinal pigment epithelium. Cerebrospinal fluid examination showed pleocytosis and human leukocyte antigen testing showed expression of the DR04 phenotype; therefore, the patient was diagnosed with SO. She was treated with steroid therapy, and her visual disturbance subsided and the subretinal fluid improved as well. Her BCVA was 6/15 for the right eye and 6/5 for the left eye 93 days after the initial surgery.ConclusionThe present case shows that even if the sclerotomy site of 27-G PPV is small, there is still a risk of SO occurring in the eyes of patients who underwent transconjunctival vitrectomy. Ophthalmologists should recognize SO as complication of 27-G PPV and carry out proper management as early as possible.

Symptoms: Sudden Hearing Loss and Facial Paralysis

Symptoms: Sudden Hearing Loss and Facial Paralysis

Pneumocystis jirovecii Pneumonia Mimicking COVID-19 Pneumonia In A Patient With Newly Diagnosed Advanced HIV Disease

During the pandemic, diagnosis of COVID-19 infection must be excluded in patients presenting with respiratory features, especially in the area where the incidence was high. This case report highlights a man who came with respiratory infection symptoms and the chest radiograph suspicious of COVID-19 pneumonia; however, his swab test for RT-PCR was negative for COVID-19. Later he was found to have a positive anti-HIV antibody and developed advanced HIV infection by multiple opportunistic infections. A 45-year-old man presented with chronic cough and dyspnea for three months which worsened five days before the presentation. It was associated with diarrhoea, dysphagia, weight loss, left lower limb weakness, with bowel and urinary incontinence. Chest auscultation revealed generalized crepitations. The first chest radiograph showed bilateral reticular opacities extending to the lung peripheries when the suspected diagnosis of COVID-19 pneumonia was made. The nasopharynx swab for RT-PCR for COVID-19 was negative, and the sputum was positive for Pneumocystis jirovecii. The contrast-enhanced CT (CECT) brain revealed changes consistent with brain abscess. The cerebrospinal fluid (CSF) examination was consistent with cryptococcal infection. He was initially treated in the Severe Acute Respiratory Infection (SARI) ward because of the initial impression of COVID-19. He was tested positive for Human Immunodeficiency Virus (HIV) rapid test and PCR, RPR and TPHA for syphilis. He was diagnosed with Pneumocystis jirovecii pneumonia, cryptococcal meningitis, brain abscess, oral and oesophageal candidiasis and syphilis. He was treated with co-trimoxazole, Amphotericin B, flucytosine, fluconazole, penicillin G and Nystatin. He initially improved upon treatment but later succumbed to his illnesses. Given the current situation of COVID-19, any patient with acute respiratory symptoms must be tested to rule out COVID-19 pneumonia. However, in a newly diagnosed advanced HIV patient presented with respiratory infection symptoms and extrapulmonary symptoms, opportunistic infections should be excluded along with COVID-19.

Emergency immune reconstitution inflammatory syndrome (IRIS) in HIV drug discontinued with tuberculous meningoencephalitis: a case report

Background: Immune reconstitution inflammatory syndrome (IRIS) is a paradoxical condition in which the administration of ART (antiretroviral therapy) to human immune virus (HIV) patients causes a deterioration in clinical situations. This article describes IRIS in an HIV patient who discontinued the drugs and was accompanied by opportunistic infection with tuberculous meningoencephalitis.Case Presentation: A 40-year-old male complained of high fever and severe headache for 1 week, then the patient had general tonic-clonic seizures twice and less than 5 minutes. After seizure, patient experiences a loss of consciousness with the only response to pain stimuli. He was diagnosed with HIV since 3 years ago and only taking ART 2 months after being diagnosed. The physical examination revealed neck stiffness with a positive Brudzinski I and Kernig Sign, as well as lateralization to the right side. Oral candidiasis was found. HIV screening tests were reactive with CD4 65 cells/mm3. Cerebrospinal fluid (CSF) examination showed 172.8 mg/dL protein, 23 mg/dL glucose, MN 13/mm3 dominant cells, clear CSF fluid and colorless, supporting tuberculous meningoencephalitis (METB). Multi sliced CT-Scan (MSCT) head contrast shows enhancement of the basal cistern. The patient received the ART tenofovir-lamivudine-efavirenz. Then he has experienced a deterioration in clinical condition. He had ARDS, respiratory failure and was intubated, but failed resuscitation attempts.Conclusion: The patient was diagnosed with HIV 3 years ago but discontinued the treatment. HIV causes diffuse inflammation throughout the body including the cardiac, where myocarditis cannot be ruled out as a cause of death. IRIS may occur when the patient has risk factors for not getting previous ART (withdrawal of drugs) and has a low CD4 count. According to the criteria proposed by Robertson, there were worsening clinical symptoms, associated with initiation of ART administration, not explained by the presence of previously acquired infection, we suggest IRIS as causes of death in this patient.Â

Procalcitonin measurement using antibody-conjugated fluorescent microspheres distinguishes atypical bacterial meningitis from viral encephalitis in children

Examination of cerebrospinal fluid in atypical bacterial meningitis (ABM) is similar to that of viral encephalitis (VE), so ABM can easily be misdiagnosed as VE, which can delay diagnosis and treatment. We developed a simple, rapid hand-held lateral flow immunoassay detection system based on fluorescent microspheres (FMS) for procalcitonin (PCT) detection, which provides an indicator to differentiate between ABM and VE. With this novel method, the antigen-antibody reaction systems involve different species, making the test strips more stable than those utilizing one species. The strips exhibited a wide dynamic range (0.04–50 ng/mL) and good sensitivity (0.03 ng/mL). The function of PCT in the identification of ABM and VE in children was further studied. A significant difference in PCT levels was observed between the ABM and VE groups (P = 0.00) and between the ABM and the normal control groups (P = 0.00). PCT levels were not significantly different between the VE and normal control groups (P = 0.30). The area under the receiver operating characteristic curve of PCT for the diagnosis of ABM was 0.95. These findings collectively indicate the usefulness of the PCT detection method based on FMS for clinically differentiating between ABM and VE.

Blood, urine and cerebrospinal fluid analysis in TH and AADC deficiency and the effect of treatment

BackgroundAromatic L-amino acid decarboxylase (AADC) deficiency and tyrosine hydroxylase (TH) deficiency are rare inherited disorders of monoamine neurotransmitter synthesis which are typically diagnosed using cerebrospinal fluid examination of monoamine neurotransmitter metabolites. Until now, it has not been systematically studied whether analysis of monamine neurotransmitter metabolites in blood or urine has diagnostic value as compared to cerebrospinal fluid examination, or whether monoamine neurotransmitter metabolites in these peripheral body fluids is useful to monitor treatment efficacy. MethodsAssessment, both by literature review and retrospective analysis of our local university hospital database, of monoamine neurotransmitter metabolites in urine, blood and cerebrospinal fluid, and serum prolactin levels, before and during treatment in patients with AADC and TH deficiency. ResultsIn AADC deficiency, 3-O-methyldopa in serum or dried blood spots was reported in 34 patients and found to be (strongly) increased in all, serotonin in serum was decreased in 7/7 patients. Serum prolactin was increased in 34/37 and normal in 3 untreated patients. In urine, dopamine was normal or increased in 21/24 patients, 5-hydroxyindoleacetic acid was decreased in 9/10 patients, and vanillactic acid was increased in 19/20 patients. No significant changes were seen in monoamine neurotransmitter metabolites after medical treatment, except for an increase of homovanillic acid in urine and cerebrospinal fluid after levodopa therapy, sometimes even in absence of a clinical response. After gene therapy, cerebrospinal fluid homovanillic acid increased in most patients (8/12), but 5-hydroxyindoleacetic acid remained unchanged in 9/12 patients.In TH deficiency, serum prolactin was increased in 12/14 and normal in the remaining untreated patients. Urinary dopamine was decreased in 2/8 patients and normal in 6. Homovanillic acid concentrations in cerebrospinal fluid increased upon levodopa treatment, even in the absence of a clear treatment response. ConclusionsThis study confirms that cerebrospinal fluid is the most informative body fluid to measure monoamine neurotransmitter metabolites when AADC or TH deficiency is suspected, and that routine follow-up of cerebrospinal fluid measurements to estimate treatment response is not needed. 3-O-methyldopa in dried blood spots and vanillactic acid in urine are promising peripheral biomarkers for diagnosis of AADC deficiency. However, in many patients with TH or AADC deficiency dopamine in urine is normal or increased thereby not reflecting the metabolic block. The value of serum prolactin for follow-up of AADC and TH deficiency should be further studied.

Case Report: Histiocytic Necrotizing Lymphadenitis (Kikuchi–Fujimoto Disease) Concurrent With Aseptic Meningitis

Kikuchi–Fujimoto disease (KFD), also known as histiocytic necrotizing lymphadenitis, is a rare, benign, self-limiting disease characterized by local lymphadenopathy. Central nervous system involvement in KFD is extremely rare and remains a diagnostic challenge. Only 41 cases of aseptic meningitis associated with KFD have been reported worldwide, with just four cases (including our case) of KFD with meningitis as the first symptom. We report a case of KFD accompanied by aseptic meningitis with severely high intracranial pressure (400 mmH2O), increased white blood cell count (56 × 106/L), and moderately elevated protein level (0.52 g/L). This case is unique in the delayed appearance of lymphadenopathy. After 1 month of treatment with steroids, fever, headache, and lymphadenopathy gradually disappeared, and the result of cerebrospinal fluid examination gradually became normal. In conclusion, based on our case findings and our literature review on KFD with aseptic meningitis, a diagnosis of KFD should be considered when delayed appearance of lymphadenopathy is observed in patients with aseptic meningitis.

Predictive value of neurological symptoms in persons with suspected neurosyphilis

Treponema pallidum is detected in the cerebrospinal fluid (CSF) in up to 30% of individuals with early syphilis.1 An ongoing challenge in accurate diagnoses of neurosyphilis (NS) is variable symptomatology...

Comparison of Clinical, Laboratory and Immune Characteristics of the Monophasic and Biphasic Course of Tick-Borne Encephalitis.

The biphasic course of tick-borne encephalitis (TBE) is well described, but information on the monophasic course is limited. We assessed and compared the clinical presentation, laboratory findings, and immune responses in 705 adult TBE patients: 283 with monophasic and 422 with biphasic course. Patients with the monophasic course were significantly (p ≤ 0.002) older (57 vs. 50 years), more often vaccinated against TBE (7.4% vs. 0.9%), more often had comorbidities (52% vs. 37%), and were more often treated in the intensive care unit (12.4% vs. 5.2%). Multivariate logistic regression found strong association between the monophasic TBE course and previous TBE vaccination (OR = 18.45), presence of underlying illness (OR = 1.85), duration of neurologic involvement before cerebrospinal fluid (CSF) examination (OR = 1.39), and patients’ age (OR = 1.02). Furthermore, patients with monophasic TBE had higher CSF levels of immune mediators associated with innate and adaptive (Th1 and B-cell) immune responses, and they had more pronounced disruption of the blood–brain barrier. However, the long-term outcome 2–7 years after TBE was comparable. In summary, the monophasic course is a frequent and distinct presentation of TBE that is associated with more difficult disease course and higher levels of inflammatory mediators in CSF than the biphasic course; however, the long-term outcome is similar.

An autopsy case of Nocardia meningitis patient presenting with multiple folliculitis

Abstract Rationale: Nocardia is widespread in the soil and causes life-threatening infections in the central nervous system, such as meningitis. Nocardia infection can develop in immunocompetent individuals, not just in immunocompromised persons. Nocardia is a slow-growing bacterium, which makes its detection difficult during routine microbial examinations, resulting in a delayed diagnosis and poor prognosis. Patient concerns: A 64-year-old Japanese man was admitted with fever, headache with meningeal irritation, and multiple folliculitis on his face and neck. Cerebrospinal fluid revealed neutrophilic pleocytosis. All cultures, including cerebrospinal fluid examination, were negative, and serum procalcitonin levels were normal. Diagnoses: The tentative diagnosis was culture-negative bacterial meningitis or meningeal neuro-Behçet disease. Intervention: Meropenem was administered for 12 days, along with corticosteroids. His symptoms were temporarily relieved but worsened again, and finally, he died suddenly on the 37th day of hospitalization. An autopsy revealed extensive infiltration of inflammatory cells in the subarachnoid space, especially the brain stem, cerebellum, whole spinal cord, and cerebral base, where Nocardia species were detected. The final diagnosis was Nocardia meningitis. Lessons: Given the very close timing of the onset of signs of meningitis and multiple folliculitis, the most reasonable and probable idea is that the patient had disseminated nocardiosis. In patients with meningitis with multiple skin infection lesions, such as folliculitis, nocardiosis should be considered a differential diagnosis.

Venous hypertension caused by a meningioma involving the sigmoid sinus: case report

BackgroundIntracranial venous hypertension has been associated with a few cases of meningioma secondary to compression of the venous sinus. This is the rare case of small meningioma involving the sigmoid sinus leading to intracranial venous hypertension mimicking venous thrombosis.Case presentationA 39-year-old woman suffered visual dysfunction due to bilateral papilledema. Noncontrast head computed tomography (CT) showed no intracranial space-occupying lesions or hydrocephalus. Cerebrospinal fluid examination revealed high opening pressure. Various image inspections such as three-dimensional CT angiography, magnetic resonance imaging, and cerebral angiography demonstrated a small 2.5-cm lesion causing subtotal occlusion of the dominant right sigmoid sinus. No improvement of clinical manifestations was observed after medical treatment for 6 months, so right presigmoid craniectomy was performed. Operative findings revealed that the tumor was located predominantly involving the sigmoid sinus. The pathological diagnosis was fibrous meningioma. Postoperative fundoscopic examination showed improvement of bilateral papilledema.ConclusionsWe treated a patient presenting with intracranial hypertension due to a small meningioma involving the sigmoid sinus. This unusual case suggests that early surgical strategies should be undertaken to relieve the sinus obstruction.

Early multiple sclerosis: diagnostic challenges in clinically and radiologically isolated syndrome patients.

With the introduction of new diagnostic criteria, the sensibility for multiple sclerosis (MS) diagnosis increased and the number of cases with the clinically isolated syndrome (CIS) decreased. Nevertheless, a misdiagnosis might always be around the corner, and the exclusion of a 'better explanation' is mandatory.There is a pressing need to provide an update on the main prognostic factors that increase the risk of conversion from CIS or from radiologically isolated syndrome (RIS) to MS, and on the potential 'red flags' to consider during the diagnostic workup. We discuss diagnostic challenges when facing patients presenting with a first demyelinating attack or with a RIS, with a focus on recently revised diagnostic criteria, on other neuroinflammatory conditions to be considered in the differential diagnosis and on factors distinguishing patients at risk of developing MS.A correct definition of a 'typical' demyelinating attack, as well as a correct interpretation of MRI findings, remains crucial in the diagnostic process. The cerebrospinal fluid examination is warmly recommended to confirm the dissemination in time of the demyelinating process and to increase the diagnostic accuracy. An early and accurate diagnosis of MS requires careful consideration of all clinical, paraclinical and radiological data, as well the reliable exclusion of other mimicking pathological conditions. This is advocated to promptly initiate an appropriate disease-modifying therapy, which can impact positively on the long-term outcome of the disease.

The clinical profiles and outcomes of HIV-negative cryptococcal meningitis patients in type II diabetes mellitus

BackgroundThe clinical profiles and outcomes of cryptococcal meningitis have been shown to vary depending on the underlying condition. The aim of this study was to investigate clinical characteristics and outcomes in patients with and without type II diabetes mellitus.MethodsA retrospective study was performed. Clinical data of HIV-negative cryptococcal meningitis patients with type II diabetes mellitus (n = 26) and without type II diabetes mellitus (n = 52) referring to the Jiangxi Chest Hospital between January 2012 to December 2018 were analyzed. The data were analyzed using chi square, none-parametric tests, and logistic regression. P-values < 0.05 were considered significant.ResultsIn this study, cryptococcal meningitis patients suffering from type II diabetes mellitus had a higher mortality (23.08% vs. 7.69%; P = 0.055), and required longer hospitalization (59.58 vs. 42.88 days; P = 0.132). Moreover, cerebrospinal fluid examinations revealed that cryptococcal meningitis patients with type II diabetes mellitus had higher opening pressure (271.54 vs. 234.23 mmH2O; P = 0.125).The results of multivariate regression analysis revealed that cryptococcal meningitis patients with type II diabetes were more often presented with visual disorders (28.54% vs. 11.54%; [95% CI 0.056–0.705]; p = 0.012), and had higher cerebrospinal fluid protein levels (1027.62 ± 594.16 vs. 705.72 ± 373.88 mg/l; [95% CI 1.000–1.002]; p = 0.016). Among patients with type II diabetes mellitus, nausea and vomiting was more frequent at the initial visit in those died (100% vs. 50%; p = 0.027), and 66% of died type II diabetes mellitus patients were poorly controlled blood glucose level, compared with 30% in survival type II diabetes mellitus patients.ConclusionThis study suggests that cryptococcal meningitis patients with type II diabetes mellitus differ significantly from cryptococcal meningitis patients without type II diabetes mellitus with respect to clinical symptoms such as visual disorders and cerebrospinal fluid examination. The presence of nausea and vomiting among type II diabetes mellitus patients could have implication in mortality.

A mechanic with confusion and right-sided weakness

A 47-year-old man presented as a thrombolysis call. A family member had visited that morning, finding him confused with difficulty speaking and dragging his right leg and arm. There had...

Neurosyphilis presenting as herpes simplex virus encephalitis

AbstractA 63‐year‐old woman was admitted to our hospital complaining of sudden slow response and irrelevant answer for three days. The brain magnetic resonance imaging revealed a left‐sided hyperintense lesion and moderate expansiveness involving the hippocampus, insular cortex, and temporal lobe, which mimicking herpes simplex virus encephalitis. Her cerebrospinal fluid examination disclosed the Treponema pallidum particle agglutination assay and rapid plasma regain test were both positive. A diagnosis of neurosyphilis was made, and the patient was benefited from penicillin therapy.

Plasma Exchange in Refractory Acute Disseminated Encephalomyelitis Associated with COVID-19: Technical Challenges in a Developing Country

AbstractEvaluation of acquired demyelinating syndrome (ADS) without diagnostic biomarkers results in diagnostic and therapeutic challenges in pediatric population. Immune-mediated ADS of childhood responds well to steroid and intravenous immunoglobulin (IVIg) and in refractory cases with plasma exchange. Novel coronavirus disease 2019 (COVID-19) coinfection in such cases imposes technical challenges in management. An 11-year-old girl with quadriparesis and loss of vision and a magnetic resonance imaging (MRI) brain showing acute demyelinating encephalomyelitis (ADEM) and cerebrospinal fluid examination being noncontributory responded well with plasma exchange after failing steroid and IVIg is described. Coinfection with COVID-19 mandating personal protection in a temperate country imposed technical challenges in her management.

Shunt Nephritis: A Rare and Forgotten Diagnosis

Shunt nephritis is a rare complication of ventriculoatrial and ventriculoperitoneal shunt infection. The clinical manifestations are nonspecific and include asthenia, arthralgias, anorexia, weight loss, hematuria, proteinuria, and progressive renal impairment. Therefore, diagnosis can be delayed up for to several years after the first clinical manifestations, which increases the risk of progressive renal impairment and neurological dysfunction. A 57-year-old woman who had undergone ventriculoperitoneal shunt placement in 1990 was admitted to the nephrology department to perform an elective kidney biopsy due to hematuria, proteinuria, and rapidly progressive renal failure. The patient presented with asthenia and weight loss with a duration of one year. No other symptoms were reported. The kidney biopsy was suggestive of infection associated glomerulonephritis, particularly a subacute infection, as a membranoproliferative pattern was seen in light microscopy, and IgM staining was predominant in immunofluorescence imaging. During the hospital stay, the patient developed neurological symptoms. Cerebrospinal fluid examination showed pleocytosis. Shunt nephritis was suspected, and antibiotic treatment was initiated. Due to the patient’s worsening neurological status, an urgent surgical shunt removal was performed. Two months later, her renal function was normal, and the urinalysis result was unremarkable, even though her neurological status did not improve. Although rare, shunt nephritis should be considered in patients that have a history of ventriculoperitoneal shunt placement and present with a proliferative or membranoproliferative glomerulonephritis and prominent IgM deposits in immunofluorescence imaging. Early diagnosis and shunt removal are critical for improving the neurological and renal prognosis.

Clinical Study of Autonomic Dysfunction in Patients With Anti-NMDA Receptor Encephalitis.

Objectives: Autonomic dysfunction is a common symptom of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis; however, it has been poorly researched. The purpose of this study was to compare the clinical features, tumor occurrence, intensive care unit (ICU) admission, mechanical ventilation, imaging assessment, cerebrospinal fluid examination, disease severity, and immunotherapy in patients with anti-NMDAR encephalitis with or without autonomic dysfunction.Methods: A retrospective study of anti-NMDAR encephalitis patients diagnosed between January 2016 and April 2020 was performed at the First Affiliated Hospital of Zhengzhou University. Patients were divided into two groups according to whether they had autonomic dysfunction, and their clinical features, treatment, and prognosis were compared.Results: A total of 119 patients with anti-NMDAR encephalitis were included in this study. Seventy-three patients (61.3%) had autonomic dysfunction, while the remaining 46 (38.7%) did not. Sinus tachycardia (69.9%) was the autonomic dysfunction with the highest incidence, while the incidences of symptoms including constipation, central hypopnea, and others gradually decreased. Compared to the group without autonomic dysfunction, the prevalence of the main clinical symptoms such as epileptic seizure (P = 0.003), involuntary movement (P = 0.028), and decreased consciousness (P < 0.001) were higher in the group with autonomic dysfunction, which also more frequently presented with complications such as pulmonary infection (P < 0.001) and abnormal liver function (P = 0.001). Moreover, the rates of ICU admission (P < 0.001) and mechanical ventilation (P = 0.001), as well as the modified Rankin scale (mRS) scores at admission (P < 0.001), maximum mRS scores during the course of disease (P < 0.001), and mRS scores at discharge (P < 0.001) were higher in the patients with autonomic dysfunction than in those without. The number of patients in the autonomic dysfunction group who underwent ≥2 immunotherapies was also higher than that in the group without autonomic dysfunction (P < 0.001).Conclusion: Sinus tachycardia is the most common type of autonomic dysfunction in anti-NMDAR encephalitis. Compared to patients without autonomic dysfunction, those with autonomic dysfunction had a higher incidence of epilepsy, involuntary movements, decreased consciousness, pulmonary infections, abnormal liver function, ICU admissions, and mechanical ventilation; moreover, the severity of the disease was greater, and their prognosis worse. Therefore, such patients require intensive immunotherapy.

Clinical features of children with Guillain-Barré syndrome and the significance of Brighton criteria

OBJECTIVE To study the clinical features of children with Guillain-Barre syndrome (GBS) and the significance of Brighton criteria in childhood GBS. METHODS A retrospective analysis was performed on the medical data of 72 children with GBS. Brighton criteria were used for the grading of diagnostic certainty (level 1 as the highest level, and level 4 as the lowest level). A Spearman's rank correlation analysis was used to evaluate the correlation of auxiliary examinations with the level of diagnostic certainty of Brighton criteria. RESULTS A total of 72 children with GBS were enrolled, with a mean age of onset of (98±32) months. All children (100%, 72/72) had weakness of bilateral limbs and disappearance or reduction of tendon reflex, and limb weakness reached the highest level of severity within 4 weeks. Of all the 72 children, 68 (94%) had positive results of neural electrophysiological examination and 51 (71%) had positive results of cerebrospinal fluid (CSF) examination, and the positive rate of neural electrophysiological examination was significantly higher than that of CSF examination (P < 0.01). The median interval time from disease onset to neural electrophysiological examination was significantly shorter than from disease onset to CSF examination (11 days vs 14 days, P < 0.01). Of all the 72 children, 49 (68%) met Brighton criteria level 1 and 21 (29%) met Brighton criteria level 2. Neural electrophysiological examination and CSF examination were positively correlated with the level of diagnostic certainty of Brighton criteria (rs=0.953 and 0.420 respectively, P < 0.01). CONCLUSIONS Most of the children with GBS meet Brighton criteria level 1, and the positive results of CSF examination and neural electrophysiological examination play an important role in improving the level of diagnostic certainty of Brighton criteria. Neural electrophysiological examination has a higher positive rate than CSF examination in the early stage of the disease.