Cerebrospinal Fluid Examination Research Articles

Clinical characteristics and ketogenic diet therapy of glucose transporter type 1 deficiency syndrome in children: a multicenter clinical study

Objective: To explore the clinical characteristics of pediatric glucose transporter type 1 deficiency syndrome (GLUT1 DS), evaluate the efficacy and safety of ketogenic diet therapy (KDT). Methods: Clinical data of 19 children with GLUT1 DS admitted to Children's Hospital of Fudan University, Tianjin Children's Hospital, Shenzhen Children's Hospital, Children's Hospital of Nanjing Medical University and Jiangxi Provincial Children's Hospital between 2015 and 2019 were collected retrospectively. The first onset symptom, main clinical manifestations, cerebrospinal fluid features and genetic testing results of patients were summarized, the efficacy and safety of ketogenic diet treatment were analyzed. Results: Among the 19 cases, 13 were males and 6 females. The age of onset was 11.0 (1.5-45.0) months,the age of diagnosis was 54.0 (2.8-132.0) months. Epilepsy was the first onset symptom of 13 cases. Different forms of tonic-clonic seizures were the most common types of epilepsy (7 cases with generalized tonic-clonic seizures, 5 cases with focal tonic or clonic seizures, 4 cases with generalized tonic seizures). Antiepileptic drugs were effective in 4 cases. Paroxysmal motor dysfunction was present in 12 cases and ataxia was the most common one. All patients had different degrees of psychomotor retardation. Among 17 patients received cerebrospinal fluid examination, cerebrospinal fluid (CSF) glucose level was lower than 2.2 mmol/L and CSF glucose/glycemic index was<0.45 in 16 cases, only 1 case presented normal CSF glucose level (2.3 mmol/L) and normal CSF glucose/glycemic index(0.47). SLC2A1 gene mutations were found in 16 patients, missense, frameshift and nonsense mutations were the common types with 5 cases, 5 cases and 3 cases respectively. All 19 patients were treated with ketogenic diet, which was effective in 18 cases in seizure control, 11 cases in dyskinesia improvement and 18 cases in cognitive function improvement. No serious side effects were reported in any stage of KDT. Conclusions: The diagnosis of GLUT1 DS is often late. It is necessary to improve the early recognition of the disease and perform CSF glucose detection and genetic testing as early as possible. The KDT is an effective and safe treatment for GLUT1 DS, but a small number of patients have not response to diet therapy.

Central nervous system aspergillosis in immunocompetent patients: Case series and literature review.

The aim of this study was to investigate the clinical characteristics of central nervous system (CNS) aspergillosis in immunocompetent patients.This study enrolled six immunocompetent patients diagnosed with CNS aspergillosis. Additionally, we reviewed the clinical profiles for 28 cases reported in the literature. The age, gender, etiology of Aspergillus infection, clinical manifestations, location of the lesion, treatment, and prognosis were analyzed.There were 19 men (average age, 54.6 ± 14.3 years) and 15 women (average age, 47.0 ± 19.4 years). The clinical manifestations included headache (55.9%; n = 19), visual impairment (32.4%; n = 11), diplopia (32.4%; n = 11), hemiplegia (20.6%; n = 7), fever (17.6%; n = 6), and epilepsy (8.8%; n = 3). According to the radiological features, CNS aspergillosis lesions were divided into two subtypes: parenchymal lesions in the cerebral lobes (n = 11), and meningeal lesions in the meninges (n = 23). The patients with meningeal lesions are easy to be complicated with more serious cerebrovascular diseases, such as subarachnoid hemorrhage and massive infarction. Most of the lesions in brain parenchyma were abscess formation, and magnetic resonance imaging showed ring enhancement. The clinical diagnosis of Aspergillus infection was mainly based on brain biopsy (n = 14), autopsy (n = 8), pathological examination of adjacent brain tissues (n = 7), cerebrospinal fluid (CSF) or tissue culture (n = 3), and second-generation sequencing analysis of the CSF (n = 3). Clinical improvement was achieved in 23 cases, and 11 patients succumbed to the disease. Voriconazole treatment was effective in 24 (70.6%) cases.Immunocompetent subjects are also at risk for Aspergillus infections. Concomitant cerebrovascular diseases are common in patients with CNS aspergillosis, especially in patients with meningeal aspergillosis. Parenchymal aspergillosis lesions are usually localized and manifest as brain abscesses with annular enhancement on magnetic resonance imaging. Biopsy, CSF culture, and next-generation sequencing are mainstream diagnostic modalities. Voriconazole is an effective treatment for Aspergillus infection, and early diagnosis and treatment should be highlighted.

Early-Onset Neonatal listeriosis –A Case Report

A 25-year-old primigravida in her 30 weeks of gestation presented with fever and some flu-like symptoms. There was minimal vaginal discharge. Keeping in view the possibility of chorioamnionitis a prompt intravenous infusion of antibiotics was instituted with continuous external monitoring of fetal heart rate. An emergency cesarean section was performed 3 hours later for persistent fetal tachycardia suggestive of fetal distress. A preterm baby girl was born with evidence of respiratory distress requiring ventilatory support. Listeria monocytogenes was isolated from newborn’s blood culture, tracheal secretions and the placental swab, confirming neonatal listeriosis. Cerebro-spinal fluid examination did not reveal evidence of meningitis. Prompt laboratory diagnosis and aggressive antibiotic treatment led to complete recovery of the infant from septicemia. This represents the first reported case of early-onset neonatal listeriosis in Malaysia

Neuronal intranuclear inclusion disease with mental abnormality: a case report

BackgroundNeuronal intranuclear inclusion disease (NIID) is a chronic progressive neurodegenerative disease that is characterized by the discovery of eosinophilic hyaline intranuclear inclusions in the central and peripheral nervous systems and visceral organs. In this paper, we report a case of an adult-onset neuronal intranuclear inclusion disease presenting with mental abnormality in China.Case presentationA 62-year-old woman presented with mental abnormality and forgetfulness for 3 months before she was admitted to our hospital. There were prodromal symptoms of fever before she had the mental disorder. Encephalitis was first suspected, and the patient underwent lumbar puncture and brain magnetic resonance imaging (MRI). A cerebrospinal fluid (CSF) examination indicated normal pressure, a normal white blood cell count, and slightly elevated protein and glucose levels. Coxsackie B virus, enterovirus, and cytomegalovirus tests showed normal results. Bacterial culture and Cryptococcus neoformans test results were negative. The contrast-enhanced MRI of the brain was normal. The brain diffusion-weighted imaging (DWI) showed a symmetrically distributed strip-shaped hyperintensity signal of the corticomedullary junction in the bilateral frontal, parietal, and temporal lobes. We considered the diagnosis of the NIID, and therefore, skin biopsy was performed. The electron microscopy revealed that intranuclear inclusions in the nucleus of fibrocytes existed and were composed of filaments.ConclusionsNIID is a rare neurodegenerative disease with diverse clinical manifestations. In clinical work, when a patient presents with abnormal mental behavior and exhibits hyperintensity signals on DWI images of the corticomedullary junction, it is crucial to consider the diagnosis of NIID.

Study on biochemical and radiological profile in children clinically diagnosed as tubercular meningoencephalitis: a prospective study from a tertiary care centre in Rajasthan

Background: Objective of the current study was to assess biochemical profile and neuroimaging findings in children diagnosed with neurotuberculosis in a tertiary care centre in Southern Rajasthan, India.Methods: A prospective randomized controlled trial was conducted in Department of Pediatrics, tertiary care centre in Southern Rajasthan, India from July 2017 to June 2018. Total 110 children of age group of 6 months to 18 years with the diagnosis of tubercular meningoencephalitis (TBME) on the basis of clinical evaluation, cerebrospinal fluid (CSF) examination and neuroimaging were included in the study.Results: Among 110 children included in the study, CSF lymphocytic pleocytosis was seen in all. Majority of children (56.36%) cell counts were in the range of 101-500 cells/µl and mean CSF cell count was 198.09±177.86 per µl. CSF protein ranges from 100 to 400 mg/dl in 68.2% children and 19 children had CSF protein &gt;400 mg/dl with mean of 230.98±167.73 mg/dl. In majority of patients (40%) CSF glucose level was in range of 20-40 mg/dl and in 31.82% children CSF glucose was &lt;20 mg/dl. Mean CSF sugar level was 33.86±18.22 mg/dl. None of them demonstrated acid fast bacillus (AFB) on Ziehl-Neelsen staining of CSF sample. Chest radiographic abnormality was found in 41.82% cases. Mantoux test was positive in 16.36% (18) children admitted with TBME. Common abnormalities noted on neuroimaging were: Communicating hydrocephalus (77.27%), meningeal enhancement (40%), infarction (27.27%), cerebral oedema (11.82%) and 9.09% has tuberculoma on neuroimaging. CSF and gastric aspirate were examined by cartridge based nuleic acid amplification test (CBNAAT) for Mycobacterium Tuberculosis (MTB), among them 5 (4.55%) children had positive in CSF and 16 (14.55%) had gastric aspirate positive for MTB by CBNAAT.Conclusions: Clinical, biochemical and radiological parameters is sufficient enough to diagnose TBME in children.

The meaning of blood and cerebrospinal fluid biomarkers in early diagnosis of Alzheimer's disease

Introduction and purpose: Alzheimer's disease (AD) belongs to the group of neurodegenerative diseases and is the leading cause of dementia worldwide. Its development includes the impact of genetic, metabolic and environmental factors. Despite high prevalence of Alzheimer’s disease and dynamic development of medical science, there is currently no clinically proven causal treatment. The proposed therapies are only symptomatic. However, there is a wide set of substances known as biomarkers that are detected in the blood or in the cerebrospinal fluid (CSF) in the stages preceding full-blown Alzheimer's disease.Brief description of the state of knowledge: In order to obtain material for CSF examination, a lumbar puncture must be performed. It is an invasive procedure, with the risk of complications such as bleeding into the spinal cord, infection or even nerve damage. Obtaining a blood sample for testing specific indicators is less invasive and more widely available. Currently, the diagnostic significance of commonly known markers arising in the progress of the AD pathological process, such as amyloid β, tau protein and its phosphorylated form or β-secretase, is being investigated. As the knowledge on the pathogenesis of AD grows, further markers such as ubiquitin, micro RNA or plasma neurofilament light are tested.Conclusions: There is a collection of biomarkers that can perform a diagnostic function for Alzheimer's disease. Due to the advantages of blood and plasma testing, basing the diagnosis of early forms of AD on these tests seems to be particularly interesting. However, the use of biomarkers on a global scale requires further research and test standardization, as well as the development of guidelines for their interpretation.

3‐T MRI of protothecosis encephalic lesions in a Scottish shepherd dog

A four‐year‐old Scottish Shepherd dog was referred for acute onset of disorientation, blindness and chronic diarrhoea. The neurological examination was consistent with a multifocal neurolocalisation involving the prosencephalon and the brainstem. The ophthalmological exam showed bilateral chorioretinitis with retinal detachment. The brain MRI showed periventricular and left caudate nucleus lesions, increased thickness of the left III, IV, VI and opthalmic branch of V cranial nerves and bilateral multifocal lesions in the temporal and masseter muscles. Cerebrospinal fluid examination showed mild mixed pleocytosis. Faecal and urine cultures were positive for Prototheca zopfii genotype 2. Despite starting itraconazole therapy, the dog's conditions deteriorated and the owner elected euthanasia. Protothecosis should be suspected in young dogs with multifocal neurological signs, blindness and chronic diarrhoea.MRI study of the central nervous system (CNS), together with blood exam, cytology and cultures, is a useful tool to evaluate the CNS in disseminated form of Prototheca infection.

Successful Treatment of Mycoplasma hominis Meningitis, Diagnosed Using Real-Time Polymerase Chain Reaction, with Ciprofloxacin in a Neonate

Mycoplasma hominis can cause life-threatening central nervous system infections in neonates following intrauterine infection or during delivery. In newborns, the diagnosis and treatment of M. hominis meningitis are challenging, because cultures are often negative and the bacterium is not susceptible to empirical antibiotics. Herein, we describe a case of neonatal M. hominis meningitis diagnosed using real-time polymerase chain reaction (RT-PCR) and treated with ciprofloxacin. The patient was a 3-day-old female hospitalized for a fever and lethargy. Her blood laboratory findings were non-specific; cerebrospinal fluid (CSF) examination showed a white blood cell count of 580/μL and indicated meningitis. Her symptoms could not be controlled with empirical antibiotics. Urine culture on a special medium revealed ciprofloxacin-susceptible M. hominis. Furthermore, the RT-PCR performed with the CSF sample revealed M. hominis. Therefore, the patient was administered ciprofloxacin; after 2 days, the fever subsided. The patient was discharged on day 30 without complications. Keywords: Mycoplasma hominis; Meningitis; Infant, newborn; Real-time polymerase chain reaction; Ciprofloxacin

Two Cases of Acute Isolated Sphenoid Sinusitis in Children

Acute isolated sphenoid sinusitis is a rare disease, and accounts for less than 3% of all sinusitis, especially in young children. Delayed diagnosis or misdiagnosis can occur frequently due to atypical clinical presentations. This can lead to serious complications because of the involvement of anatomically related intracranial structures. Therefore, nasal endoscopy, computed tomography (CT), and magnetic resonance imaging (MRI) are important diagnostic tools to confirm the diagnosis. We report two cases of a previously healthy 6-year-old girl and a 13-year-old boy, whose chief complaints were uncontrolled headache and high fever over 38°C. Physical examination and initial laboratory test results of blood, urine, and cerebrospinal fluid were normal. The diagnosis was made after a brain MRI revealed isolated sphenoid sinusitis. The girl was treated with third generation cephalosporins intravenously. The boy, however, had to undergo an emergent endoscopic sinus surgery as his headache and eyeball-pain symptoms did not resolve by medical treatment alone. Both cases had good outcomes, without neurological sequelae.

Delirium and encephalopathy in severe COVID-19: a cohort analysis of ICU patients

BackgroundNeurotropism of SARS-CoV-2 and its neurological manifestations have now been confirmed. We aimed at describing delirium and neurological symptoms of COVID-19 in ICU patients.MethodsWe conducted a bicentric cohort study in two French ICUs of Strasbourg University Hospital.All the 150 patients referred for acute respiratory distress syndrome due to SARS-CoV-2 between March 3 and May 5, 2020, were included at their admission. Ten patients (6.7%) were excluded because they remained under neuromuscular blockers during their entire ICU stay. Neurological examination, including CAM-ICU, and cerebrospinal fluid analysis, electroencephalography, and magnetic resonance imaging (MRI) were performed in some of the patients with delirium and/or abnormal neurological examination. The primary endpoint was to describe the incidence of delirium and/or abnormal neurological examination. The secondary endpoints were to describe the characteristics of delirium, to compare the duration of invasive mechanical ventilation and ICU length of stay in patients with and without delirium and/or abnormal neurological symptoms.ResultsThe 140 patients were aged in median of 62 [IQR 52; 70] years old, with a median SAPSII of 49 [IQR 37; 64] points. Neurological examination was normal in 22 patients (15.7%). One hundred eighteen patients (84.3%) developed a delirium with a combination of acute attention, awareness, and cognition disturbances. Eighty-eight patients (69.3%) presented an unexpected state of agitation despite high infusion rates of sedative treatments and neuroleptics, and 89 (63.6%) patients had corticospinal tract signs. Brain MRI performed in 28 patients demonstrated enhancement of subarachnoid spaces in 17/28 patients (60.7%), intraparenchymal, predominantly white matter abnormalities in 8 patients, and perfusion abnormalities in 17/26 patients (65.4%). The 42 electroencephalograms mostly revealed unspecific abnormalities or diffuse, especially bifrontal, slow activity. Cerebrospinal fluid examination revealed inflammatory disturbances in 18/28 patients, including oligoclonal bands with mirror pattern and elevated IL-6. The CSF RT-PCR SARS-CoV-2 was positive in one patient. The delirium/neurological symptoms in COVID-19 patients were responsible for longer mechanical ventilation compared to the patients without delirium/neurological symptoms. Delirium/neurological symptoms could be secondary to systemic inflammatory reaction to SARS-CoV-2.Conclusions and relevanceDelirium/neurological symptoms in COVID-19 patients are a major issue in ICUs, especially in the context of insufficient human and material resources.Trial registrationNA.

Correlation of Alzheimer Disease Neuropathologic Staging with Amyloid and Tau Scintigraphic Imaging Biomarkers.

PET neuroimaging of amyloid-β (Aβ) provides an in vivo biomarker for pathologic changes associated with Alzheimer disease (AD). Aβ-targeted agents have been approved by the Food and Drug Administration, with additional agents, most notably targeting tau, currently under clinical investigation and one approved in May 2020. These agents, along with nonscintigraphic biomarkers from blood and cerebrospinal fluid, have provided an opportunity to investigate the pathogenesis, prodromal changes, and time course of the disease in living individuals. The current understanding is that the neuropathologic changes of the AD continuum begin up to 25 y before the onset of clinical symptomatology. The opportunities afforded by in vivo biomarkers of AD, whether by serum, cerebrospinal fluid examination or PET, have transformed the design of AD therapeutic trials by shifting focus to the preclinical stages of disease. Future disease-modifying therapies, should they be forthcoming, will rely heavily on the use of approved biomarkers or biomarkers currently under investigation to confirm the presence of target pathology. Understanding the progressive neuropathologic changes that occur in AD-and how scintigraphic findings relate to these changes-will help the interpreting physician to fully appreciate the implications of the scintigraphic findings and provide a basis to interpret the examinations. The recently adopted National Institute on Aging-Alzheimer Association guidelines define postmortem AD neuropathologic changes as a composite score based on 3 elements. These elements are the extent of involvement (spread) by cerebral Aβ based on the progression model defined by the Thal Aβ phases, the extent of involvement (spread) by neurofibrillary tangles (composed of hyperphosphorylated tau proteins) based on the progression model defined by Braak, and the Consortium to Establish a Registry for Alzheimer's Disease score, which describes the density of neuritic plaques based on certain key locations in the neocortex. This paper will review the 3 elements that define the National Institute on Aging-Alzheimer's Association scoring system and discusses current evidence on how these elements relate to findings based on Aβ and tau PET scintigraphy.

Canine meningoencephalitis and meningitis: retrospective analysis of a veterinary hospital population

Characterization of the etiology of meningoencephalitis and meningitis in dogs through an analysis of a veterinary hospital population. Retrospective study (2011-2016) with evaluation of clinical and diagnostic data of dogs with cerebrospinal fluid (CSF) pleocytosis (> 5/µl). Only dogs with cytological evaluation of CSF or pathological examination of CNS were included. Results of CSF cytology and examination for infectious diseases were reviewed. A total of 62 dogs met the inclusion criteria. 14.5 % (n = 9) were classified as reactive CSF pleocytosis due to other structural CNS disease, such as neoplasia or infarct. Meningoencephalitis or meningitis of unknown origin was diagnosed in 56.5 % (n = 35). In 29.0 % (n = 18), investigations for infectious diseases or presence of bacteria in CSF cytology (n = 5) indicated an infectious etiology. This infectious etiology appeared reliable in 6 dogs (9.7 %) based on the examination findings, in 9 dogs (14.5 %), there was only a suspicion of infectious meningoencephalitis or meningitis and in 3 dogs (4.8 %), the findings were of uncertain significance. The most common cause of CSF pleocytosis was meningoencephalitis or meningitis of unknown origin. Nevertheless, there was evidence of a possible infectious etiology in 29 % of the dogs. For a reliable diagnosis, it is important to assess the CSF cytology and to conduct investigations for infectious diseases. Meningoencephalitis or meningitis of unknown origin requires immunosuppressive therapy. Therefore, CSF cytology and investigations for infectious diseases are important for an exclusion of infectious meningoencephalitis or meningitis.

Persistent psychotic symptoms following COVID-19 infection.

To date, there have been no detailed reports of patients developing persistent psychotic symptoms following Coronavirus disease 2019 (COVID-19) infection. There have been reports of patients developing transient delirium (with and without hypoxia) after COVID-19 infection as well as other neurological manifestations. We report on a female patient who, post-COVID-19 infection, developed an initial delirium followed by persistent and florid psychotic symptoms consisting of persecutory delusion, complex visual and auditory hallucinations and Capgras phenomenon in the absence of hypoxia but elevated tumour necrosis factor (TNF)-α. The psychotic symptoms persisted for about 40 days. Her magnetic resonance imaging brain scan, electroencephalogram, cerebrospinal fluid examination and extensive autoimmune panel did not show any abnormalities. The cause of the psychotic symptoms in this patient were not ascertained but we propose either an inflammatory state, characterised by the patient's elevated TNF-alpha levels as a possible contributing mechanism for her psychosis in line with the proinflammatory changes observed in some cases of psychosis. Or, an alternative, but unproven, hypothesis is one of an antibody-mediated encephalitic event induced by viral infection.

Meningitis with Normal Cerebrospinal Fluid: Lactate and FilmArray Can Save my Life? Case Report

Cytological and biochemical examination from cerebrospinal fluid are key essentials in the diagnosis of bacterial meningitis. In most cases, cerebrospinal fluid (CSF) yields white cell counts > 100 mm3, hyperproteinorachia, and hypoglycorrhachia. However, in some patients, these findings do not appear especially in the elderly, pediatric, and the immunocompromised. A 78-year-old immunocompromised woman was admitted for fever and headache. Despite typical meningeal clinical signs, lumbar puncture showed absence of pleiocytosis, normal glycorrhachia, and normal proteinorachia. The lactate level in CSF was high (3.8 mmol/L). The FilmArray ® Meningitis/Encephalitis (ME) panel was positive for Human Herpesvirus 6 (HHV6). Gram staining was negative. In front of a high probability of bacterial meningitis, a second lumbar puncture was performed and showed normal cell counts and high lactate level (4.4 mmol/L). The FilmArray ® ME panel was positive for HHV6 and Streptococcus pneumoniae. The antimicrobial therapy was conducted for 14 days. She was treated with cefotaxime then amoxicillin. This case indicates the importance of repeating a lumbar puncture even if the examination of CSF is normal, whereas the patient has typical meningeal clinical signs. Lactate levels in CSF with a diagnostic cutoff value of 3.8 mmol/L and the FilmArray ® ME panel could help physicians in this situation in order to decrease a poor outcome.

Elevation of Cerebrospinal Fluid Light and Heavy Neurofilament Levels in Symptomatic Neurosyphilis.

Although clinical manifestations of symptomatic and asymptomatic neurosyphilis are different, few laboratory tests could reflect the difference. A total of 92 non-HIV-infected patients with syphilis were enrolled in this study, including 23 with symptomatic neurosyphilis, 51 with asymptomatic neurosyphilis, and 18 with latent syphilis, which were excluded neurosyphilis because they were found to have no symptom and normal cerebrospinal fluid (CSF) tests and served as the control group. The concentrations of neurofilament light subunit (NF-L) and phosphorylated neurofilament heavy subunit (pNF-H) in the CSF were measured and compared among these groups, as well as before and after treatment in the symptomatic and asymptomatic groups. The median concentrations of NF-L in the symptomatic neurosyphilis, asymptomatic neurosyphilis, and control groups were 5806, 218, and 266 pg/mL, respectively (P < 0.001), and the median concentrations of pNF-H were 986, 43, and 49 pg/mL, respectively (P < 0.001). A subgroup of 15 symptomatic neurosyphilis and 10 asymptomatic neurosyphilis patients were followed up and underwent CSF examination 6 months after the antineurosyphilis treatment. The median concentration of NF-L in the symptomatic neurosyphilis group decreased from baseline 6420 to 2914 pg/mL after the treatment (P = 0.03), and the median concentration of pNF-H in the symptomatic neurosyphilis group decreased from baseline 1399 to 246 pg/mL after the treatment (P = 0.03). Neurofilament light subunit and pNF-H were significantly elevated in the symptomatic neurosyphilis patients, not in asymptomatic neurosyphilis, which was an implication of the different pathogeneses in neurosyphilis.

Cerebro spinal fluid pleocytosis: A clinicopathologic analysis

Background: Cerebro Spinal Fluid (CSF) examination is very useful in patients of suspected CNS disease and the necessity of correlating it with the clinico-pathologic findings which will help in early diagnosis of CNS diseases and guide the further management of the disease. CSF examination with quantification of leukocytes and differential count of cellular subsets in the cerebrospinal fluid is a standard procedure in cases of suspected infectious conditions. Present study emphasises pleocytosis in the cerebrospinal fluid along with other laboratory parameters. Materials and Methods: The study is consisting of 295 CSF samples from patients with clinically suspected CNS infections. The CSF findings were evaluated in all age group patients in relation to cell counts and pleocytosis. Results: In Physical examination of CSF colour, appearance and received quantity were evaluated. Maximum specimen was received in 1 year to 18 year age group. CSF pleocytosis (>5cells/µl) was present maximum (48%) in 1 month to less than 1 year age. Pleocytosis >5 leucocytes/µl was found in 121 (41%) samples out of 295 samples. Conclusion: CSF cell count examination is very common and useful investigation done for suspected various CNS diseases. Infectious and non-infectious diseases of CNS can cause pleocytosis of the cerebrospinal fluid. The type of cells depends mainly on the clinical scenario. However it seems to vary with total cell count also, such as lymphocytes predominating at lower total cell counts while neutrophils are at higher total counts.

A systematic review of neurological manifestations of SARS-CoV-2 infection: the devil is hidden in the details.

Background and purposeWe systematically reviewed available evidence for reports of neurological signs and symptoms in patients with COVID‐19 to identify cases with severe acute respiratory syndrome coronavirus (SARS‐CoV)‐2 infection or immune‐mediated reaction in the nervous system.MethodsWe followed PRISMA guidelines and used the MEDLINE, EMBASE, Google Scholar, MedRxiv and ChinaXiv databases to search for articles on COVID‐19 and nervous system involvement that were published from 1 January to 24 April 2020. Data on design, sample size, neurological assessment and related work‐up were extracted. Biases were assessed with the Newcastle–Ottawa scale.ResultsWe analysed 27 publications on potential neuroinvasive or parainfectious neurological complications of COVID‐19. The reports focused on smell and taste (n = 5) and evaluation of neurological symptoms and signs in cohorts (n = 5). There were cases of Guillain‐Barré syndrome/Miller‐Fisher syndrome/cranial neuropathy (seven cases), meningitis/encephalitis (nine cases) and various other conditions (five cases). The number of patients with examination of cerebrospinal fluid and, in particular, SARS‐CoV‐2 polymerase chain reaction was negligible. Two had a positive SARS‐CoV‐2 polymerase chain reaction examination of cerebrospinal fluid specimen. Study of potential parenchymal involvement with magnetic resonance imaging was rare. Only four reports received a rating of the highest quality standards.ConclusionsThis systematic review failed to establish comprehensive insights into nervous system manifestations of COVID‐19 beyond immune‐mediated complications in the aftermath of respiratory symptoms. The authors therefore provide guidance for more careful clinical, diagnostic and epidemiological studies to characterize the manifestations and burden of neurological disease caused by SARS‐CoV‐2 on behalf of the Infectious Disease Panel of the European Academy of Neurology.

GRAVES’ ENCEPHALOPATHY – A CASE OF STEROID-RESPONSIVE ORGANIC PSYCHOSIS

Thyroid disorders are frequently associated with neurological manifestations affecting either the central or peripheral nervous system. We present the case of a 35-year-old female patient presenting with acute onset neuropsychiatric manifestations in the form of abusiveness, aggressiveness, hallucinations, and disorientation. Further, imaging of the brain was normal and cerebrospinal fluid examination showed normal cellularity, protein, and glucose composition and an absence of common autoimmune and paraneoplastic antibodies. Additional testing in this young, thin female revealed showed a marked imbalance in thyroid function test with thyroid-stimulating hormone level 1300 U/ml of thyroid peroxidase antibody (Anti-TPO). A diagnosis of Encephalopathy Associated with Autoimmune Thyroid Disease (EAATD) was considered, with newly diagnosed Graves’ disease (GD). She was promptly started on high dose steroid therapy and recovered dramatically. Classically, EAATD is thought to be associated with Hashimoto’s thyroiditis, but patients with GD can also present with it, with almost similar clinical, immunological, radiological, electrophysiological, and therapeutic manifestations. Our case and subsequent discussion highlight this rare neurological presentation in a patient with previously undiagnosed GD.

Lower Extremity Shingles Complicated by Varicella Zoster Viral Meningitis

Varicella zoster viral infection commonly presents as “chickenpox” in children and “shingles” in adults which may be complicated by meningitis in the immunocompromised but very rarely in the immunocompetent. Also, most reported cases of zoster meningitis were associated with the development of crops of vesicular rash at the cranial or cervical dermatomal levels. Here, we present a case of a 55-year-old African man with history of chronic low back pain who presented with frontal headache, fever and rash of the left lower extremity of two days’ duration. He had no neck stiffness, neck pain or mental status changes on presentation. Brain imaging revealed no significant findings but Cerebrospinal fluid (CSF) examination showed lymphocytic pleocytosis and patient was promptly started on IV acyclovir. Biofire CSF analysis detected presence of Varicella Zoster virus (VZV). In this clinical encounter, leg rash and non-specific symptoms of fever and headache in the absence of meningism, confusion or focal neurologic deficits is an unusual presentation of VZV meningitis which may delay diagnosis. Hence, a high index of suspicion and early treatment for neurologic complications of VZV like meningitis is required in order to prevent lethal or severe long-term neurologic deficits in patients.

MENINGOENCEFALITE CAUSADA POR ENTEROCOCCUS FAECALIS - UM RELATO DE CASO

Meningoencefalite bacteriana (MEB) é uma doença de baixa incidência e de extrema importância médica, com elevada morbimortalidade se não diagnosticada e tratada precocemente. Relata-se o caso de uma paciente de 49 anos, admitida com queixas gastrointestinais, plegia de membros inferiores, parestesia de membros superiores e cefaleia. Investigações realizadas através de exames de imagem e exame do líquido cefalorraquidiano (LCR) confirmaram MEB, sendo posteriormente identificado Enterococcus faecalis na cultura do LCR. O tratamento foi realizado com antibióticos sistêmicos e corticoterapia, apresentando boa resposta. O prognóstico da doença é reservado, levando geralmente a sequelas graves. A paciente do caso descrito encontra-se paraplégica, estado esse decorrente da rápida e grave evolução da doença.