Cerebrospinal Fluid Examination Research Articles

Cerebrospinal fluid in Borna disease virus 1 (BoDV-1) encephalitis

Borna disease virus 1 (BoDV-1) has been recognized as a rare cause of very severe encephalitis with rapid onset in central Europe. Data on cerebrospinal fluid (CSF) analysis have not yet been analyzed in detail. Here, we present the first study on CSF changes in BoDV-1 encephalitis.We retrospectively analyzed CSFs from 18 BoDV-1 encephalitis cases from Bavaria, Germany, an endemic region, from 1996 to 2021. Data were obtained through review of medical records and institutional databases.We found that white blood cell count (WBC) in CSF is elevated in 13 of our 18 patients at first examination (average 83.2 ± 142.3 leukocytes/μl) and cytology showed predominance of lymphocytes. Patients with typical symptoms of meningoencephalitis had higher WBC in first CSF analyzation (133.5 ± 163.1 vs 4.0 ± 3.2/μl; p = 0.065). BoDV-1 PCR of CSF is not always positive when tested (7 of 9 cases). Four of five patients tested showed a polyvalent reaction against multiple viruses in the CSF suggesting that BoDV-1 may trigger autoimmune mechanisms.CSF changes in BoDV-1 encephalitis seem similar to those of other viral encephalitis and at the beginning WBC can be normal in up to 28%, making the diagnosis even more challenging. All in all, BoDV-1 should be included in the diagnostic workup of patients with rapidly evolving and/or severe encephalitis and patients with severe neuropathy and secondary encephalopathy with and without CSF changes. Repeated CSF examinations as well as BoDV-1 serology and CSF PCR have to be considered in endemic areas.

Woman with dyspnea after skin rash.

Woman with dyspnea after skin rash.

Severe Pulmonary Hemorrhage in Herpangina.

To the Editors: Herpangina is a common infectious disease of childhood caused by enteroviruses (EV): Coxsackievirus A2, 4, 5, 6, 8, 10, 16 and Enterovirus A71 (EV-A71).1 The clinical manifestations of herpangina include fever, sore throat and herpes in the pharynx and isthmus. The minority have serious complications, such as encephalitis, meningitis, pulmonary hemorrhage, pulmonary edema and cardiopulmonary failure.1,2 Although coxsackievirus A6 (CV-A6) has become the dominant pathogen of herpangina in some regions of China,2,3 severe cases caused by CV-A6 are rare. We present an extremely rare case of CV-A6 severe herpangina complicated with pulmonary hemorrhage. A 4-years and 7-months old boy was admitted to our hospital with a history of fever and vomiting for 1 day, cough and dyspnea for half a day, mechanical ventilation for 8 hours, and extracorporeal membrane oxygenation (ECMO) support for 3.5 hours. One day before admission, the child presented to a local hospital with high fever, vomiting, herpes in the isthmus and no rash on the hands, feet or hips. Thirteen hours before admission, the child developed a cough, pink frothy sputum and dyspnea. Nasal catheter oxygen, gamma globulin and methylprednisolone treatments did not work. Eight hours before admission, he developed severe dyspnea, pale complexion, unconsciousness, rapid heart rate, low blood pressure and poor peripheral circulation. Three hours before admission, the boy was placed on ECMO and transferred to our hospital. The patient received the EV71 vaccine. Blood tests revealed blood lactate (7.5 mmol/L), B-type natriuretic peptide precursor (21,768 pg/mL), creatine kinase isoenzyme (16.130 ng/mL) and troponin T (0.515 ng/mL). Echocardiography showed a large left ventricle, left ventricular ejection fraction 24%. Head magnetic resonance imaging and computed tomography, electroencephalogram and the cerebrospinal fluid examinations were normal. The CV-A6 nucleic acid test was positive. The diagnosis was CV-A6 severe herpangina, cardiopulmonary failure and pulmonary hemorrhage. After comprehensive treatment with ECMO, mechanically assisted ventilation, methylprednisolone anti-inflammatory agent, intravenous immunoglobulin shock therapy, anti-infection therapy, vasoactive drugs and other agents, cardiopulmonary function was restored, and the boy was discharged 14 days later. The specific mechanism of severe herpangina complicated with pulmonary hemorrhage is unclear, pulmonary hemorrhage is preceded by and closely associated with the central nervous system involvement. Severe herpangina with pulmonary hemorrhage may be related to neurogenic pulmonary edema, cardiac dysfunction, increased vascular permeability and cytokine storms.4 As an important part of modern pediatric intensive care, ECMO has been used to support gas exchange in children with severe acute respiratory failure who fail mechanical ventilation.5 ECMO for severe cardiopulmonary failure provides gas exchange and systemic circulation. In this case, when the patient developed severe pulmonary hemorrhage and routine mechanical ventilation could not maintain vital signs, the use of ECMO effectively avoided irreversible organ damage and saved the patient’s life.

Clinical characteristic of myelin oligodendrocyte glycoprotein antibody associated cortical encephalitis in adults and outcomes following glucocorticoid therapy.

To describe the clinical and radiological features, as well as outcomes following glucocorticoid therapy and recurrence in adults suffering from cortical encephalitis associated with myelin oligodendrocyte glycoprotein (MOG) antibody. The clinical information of nine adult patients suffering from cortical encephalitis associated with MOG antibody admitted to the Affiliated Brain Hospital of Nanjing Medical University from 2020 to 2022 was systematically reviewed. The clinical symptoms, laboratory data, imaging results, outcomes following glucocorticoid therapy and recurrence were evaluated. A total of 9 patients positive for MOG antibody and suffering from cortical encephalitis were included in our study (55.6% men, median age 29 years, 15-57 years). The most common clinical symptoms included headache (77.8%), fever (66.7%), and generalized seizures (55.6%). Some patients also experienced limb shaking (22.2%), leg numbness (22.2%), transient motor aphasia (11.1%), and vision loss (11.1%). The main features of cerebrospinal fluid () examination were increased intracranial pressure, pleocytosis, and elevated cerebrospinal fluid (CSF) protein. In addition, N-methyl-D-aspartate receptor (NMDAR) and MOG antibodies were found in the CSF of 3 patients, and NMDAR, MOG, and glial fibrillary acidic protein antibodies were found in the CSF of 1 patient. All patients were subjected to magnetic resonance imaging (MRI) and the images of eight of them showed T2 and/flair image hyperintense lesions, three showed meningeal or lesion enhancement and four showed white matter lesions, which were mostly located in the midline structures (75%). All patients received glucocorticoid therapy in the acute phase and in remission, and eight of them received an intravenous high dose of methylprednisolone, including one patient who received a simultaneous immunoglobulin therapy. One patient was treated with low-dose prednisolone tablets. Seven (77.8%) patients were wholly recovered at discharge, and 2 (22.2%) patients were left with slight symptoms. During the median 9-month follow-up (range: 2-36 months), 2 (22.2%) patients developed recurrence. The clinical manifestations of adult MOG antibody-associated cortical encephalitis were significantly different from those of the typical MOG antibody-associated disease (MOGAD). Patients in the acute phase of the disease were prone to show signs similar to central nervous system infection, requiring clinicians to have the ability to recognize the disease to avoid misdiagnosis. In addition, seizures were common in MOG antibody-related encephalitis, and the type of seizures was age-related. Brain MRI results showed that the distribution of cerebral cortex lesions was closely related to the classification of cortical encephalitis. Based on the patient's response to the treatment, glucocorticoid therapy was effective against MOG antibody-associated cortical encephalitis, which is consistent with the treatment response and clinical prognosis of MOGAD. Therefore, our opinion was that MOG antibody might be the "responsible antibody" in MOG antibody-associated cortical encephalitis, although further studies are needed to confirm this hypothesis.

A case of ataxic gait disturbance due to 1-bromopropane neurotoxicity

A 55-year-old man presented a slowly progressive sensory disorder, predominantly in both lower limbs, and gait disturbance. Neurological examinations revealed abnormal sensation and spasticity in both lower limbs, and a wide-based gait. Although examination revealed mild hyperchloremia and decreased motor conduction velocity in the peroneal nerve, head and whole spine MRI, and spinal fluid examination were normal. His job history revealed he had been engaged in metal cleaning work using 1-bromopropane (1-BP) for three years. His serum bromide concentration was increased to 175.6mg/l (standard value: 5 or less), so we diagnosed him as having 1-BP neurotoxicity. The serum bromide concentration decreased after avoidance of exposure to 1-BP, but the gait disturbance remained. It was considered that we should obtain a detailed job history and measure the serum bromide concentration in patients with a sensory disorder in the extremities and gait disturbance of unknown origin.

Effects of high-dose docosahexaenoic acid supplementation as an add-on therapy for canine idiopathic epilepsy: A pilot study.

The anti-epileptic effects of docosahexaenoic acid (DHA) in dogs and humans remain controversial. The dosage and efficacy of DHA were various in the previous reports. The effects of high-dose DHA supplementation as add-on therapy for idiopathic epilepsy in dogs were evaluated. An open-label clinical trial was designed in this pilot study. Six dogs (median age: 6 years) with idiopathic epilepsy were included. All the patients were diagnosed with idiopathic epilepsy using magnetic MRI and cerebrospinal fluid examination (median: 2.0 years before the trial). They had 5-45 seizures and/or auras (median: 9.0) in the month before starting DHA supplementation. DHA was adjunctively administered at doses of 69-166 mg/kg/day without changing other prescriptions. Four of the six patients completed the 6-month observation period. All the patients showed a decrease in seizure frequency of 50% or more within 2-3 months after the start of the administration, and three patients decreased to a frequency of 0-1 per month after 5-6 months. No clear adverse events were observed in the general condition or blood test results in any patients. Although the sample size was small and the study was not a randomized controlled trial, the data suggest that add-on supplementation of DHA could be useful in reducing the frequency of seizures in canine idiopathic epilepsy.

Chapter 5 - Transverse myelitis in children and adults

Transverse myelitis is a noncompressive myelopathy of inflammatory origin. The causes are broad, ranging from infective or toxic to immuno-mediated etiology. They can be manifestations of systemic diseases, such as sarcoidosis and systemic lupus erythematous, or phenotypes of neuroinflammation; in a portion of cases, the etiology remains unknown, leading to the designation idiopathic. The clinical presentation of transverse myelitis depends on the level of spinal cord damage and may include sensorimotor deficits and autonomic dysfunction. The age of onset of the disorder can impact the symptoms and outcomes of affected patients, with differences in manifestation and prognosis between children and adults. Spinal cord magnetic resonance imaging and cerebrospinal fluid examination are the main diagnostic tools that can guide clinicians in the diagnostic process, even though the search for antibodies that target the structural components of the neural tissue (anti-aquaporin4 antibodies and anti-myelin-oligodendrocyte antibodies) helps in the distinction among the immune-mediated phenotypes. Management and outcomes depend on the underlying cause, with different probabilities of relapse according to the phenotypes. Hence, immunosuppression is often recommended for the immune-mediated diseases that may have a higher risk of recurrence. Age at onset has implications for the choice of treatment.

Importance of Serosal Fluid Cytology as an Aid to Primary Diagnosis: A Descriptive Cross-sectional Study

Cytological study of fluids is an inexpensive, simple procedure and has significant utility in diagnosingneoplastic and non neoplastic lesions. The cytological examination of fluids in combination with physicalexamination helps identify aetiologic agents, follow the natural process of the disease and monitor the responseto the treatment.Aim: To determine the diagnostic utility of serosal fluid cytology and analyse the incidence of neoplastic and nonneoplastic lesions using serous fluid cytology.Materials and Methods: This was a descriptive cross-sectional study comprising 311 cases conducted in a tertiarycare hospital. Purposive sampling was used to recruit the participants. All the patients with pleural effusions,ascites or in whom Cerebral Spinal Fluid (CSF), pericardial and synovial fluids examination was indicated wereincluded. The provisional diagnosis was obtained from case sheets, including relevant clinical information. Smearswere prepared from freshly tapped specimens without adding anticoagulants and were processed by routine,conventional smear technique. The data were analysed using the SPSS version 22.0 for Windows. Numericalvariables were reported as frequency and percentage. The chi-square test was used wherever necessary, and thep-value less than 0.05 were considered significant.Results: The peritoneal fluid was the most common fluid collected in the present study, followed by pleural fluidand CSF. The malignancy rate in the present study was 19 (10.4%) of peritoneal fluid, 6 (5.9%) for pleural fluid,and 2 (4.1%) for CSF.Conclusion: Adenocarcinoma was the most common malignancy found in this study, which was in concordancewith the research conducted earlier, where gold standard investigations confirmed the findings. In the peritonealfluid, most of the patients had cirrhosis and tuberculosis. In pleural fluid and cerebrospinal fluid, most of them hadtuberculosis and chronic inflammatory conditions, respectively. Previous researchers confirmed similar findingsin their studies. It is seen that malignant and benign conditions like tuberculosis can be diagnosed well witheffusion cytology.

A case of primary central nervous system lymphoma with marked cauda equina enlargement

An 80-year-old woman presented with subacute right lower limb pain and bilateral lower limb weakness. MRI of the spine showed marked cauda equina enlargement with contrast enhancement. Cerebrospinal fluid (CSF) examination showed elevated cell count, decreased glucose, and elevated protein. Cytology of the CSF showed class V, which together with B-cell clonality by flow cytometry, led to the diagnosis of primary central nervous system lymphoma (PCNSL). The patient was treated with steroid, radiation, and chemotherapy. Despite the reduction in lesion size, her neurological symptoms revealed no improvement. PCNSL with cauda equina lesions are rare and often require highly invasive cauda equina biopsy for diagnosis. In recent years, some studies reported useful CSF biomarkers, but they may have some problems. Therefore, as in this case, the combination of cytology, flow cytometry and, CSF biomarkers could be a substitute method for invasive biopsies, and contribute to the early treatment of PCNSL.

Myélinolyse centropontine réversible sans hyponatrémie chez un enfant atteint de leucémie aigue lymphoblastique: à propos d’un cas

Central pontine myelinolysis is a demyelinating disorder mainly affecting the central pons. In some cases, it is associated with extrapontine myelinolysis. It is usually caused by rapid correction of hyponatremia and osmotic shock. We here report the case of a 3.5-year-old girl diagnosed with acute lymphoblastic leukemia admitted to our Oncology Unit with neutropenic fever and diarrhea. Laboratory tests showed mild neutropenia, normochromic normocytic anemia. Electrolyte tests were normal without hyponatremia. She received antibiotic therapy with Metronidazole. Five days later, she developed flaccid quadriparesis with mutism. Computerized tomography (CT) scan was normal, cerebrospinal fluid (CSF) examination was normal (there was no evidence of leukemic cells) and ophthalmological examination did not show any abnormalities. Brain MRI found hyperintense signal in the pons. The child improved without specific treatment, and clinical and complete neurological recovery was noted. This case highlights that myelinolysis can occur under some circumstances not related with hyponatremia such as malignancy, chemotherapy.

Microbial signatures of neonatal bacterial meningitis from multiple body sites.

As a common central nervous system infection in newborns, neonatal bacterial meningitis (NBM) can seriously affect their health and growth. However, although metagenomic approaches are being applied in clinical diagnostic practice, there are some limitations for whole metagenome sequencing and amplicon sequencing in handling low microbial biomass samples. Through a newly developed ultra-sensitive metagenomic sequencing method named 2bRAD-M, we investigated the microbial signatures of central nervous system infections in neonates admitted to the neonatal intensive care unit. Particularly, we recruited a total of 23 neonates suspected of having NBM and collected their blood, cerebrospinal fluid, and skin samples for 2bRAD-M sequencing. Then we developed a novel decontamination method (Reads Level Decontamination, RLD) for 2bRAD-M by which we efficiently denoised the sequencing data and found some potential biomarkers that have significantly different relative abundance between 12 patients that were diagnosed as NBM and 11 Non-NBM based on their cerebrospinal fluid (CSF) examination results. Specifically, we discovered 11 and 8 potential biomarkers for NBM in blood and CSF separately and further identified 16 and 35 microbial species that highly correlated with the physiological indicators in blood and CSF. Our study not only provide microbiological evidence to aid in the diagnosis of NBM but also demonstrated the application of an ultra-sensitive metagenomic sequencing method in pathogenesis study.

Atypical posterior reversible encephalopathy syndrome associated with Sjögren'‍s syndrome: a case report.

Sjögren'‍s syndrome (SJS) is a common autoimmune disease. Generally, posterior reversible encephalopathy syndrome (PRES) is often concomitant with autoimmune disease; however, PRES rarely complicates SJS. Thus, the detailed clinical course of cases with SJS and PRES remains unknown. We present the case of a 71-year-old female patient with primary SJS, whose magnetic resonance (MR) images showed bilateral vasogenic edema in the basal ganglia, brainstem, and cerebellum. Cerebrospinal fluid (CSF) examination revealed increased IgG index and higher interleukin-6 and anti-SSA-autoantibody levels. Management of her blood pressure combined with corticosteroid therapy improved her neurological symptoms, including abnormal CSF and MR imaging findings.

Chasing shadows: Cytologically detected shadow cells in the cerebrospinal fluid of patients with multiple sclerosis.

Pathophysiology of multiple sclerosis (MS) is dominated by both inflammation and neurodegeneration. A correlation between inflammation and regulated cell death has been suggested previously. Shadow cells in the cerebrospinal fluid (CSF) are considered apoptotic cells. To assess the occurrence of shadow cells in MS patients in comparison to other neurological diseases (OND). We conducted cytological examination of CSF in 114 MS patients and 125 patients with OND, who had diagnostic lumbar puncture at the Department of Neurology, Medical University of Innsbruck, with time to laboratory processing ≤0.5h, showed a CSF white blood cell (WBC) count ≤50/µl and a red blood cell (RBC) count ≤500/µl. Shadow cells were counted by two blinded, independent, experienced investigators, using a standardized approach on microscopic slides. The number of shadow cells did not statistically significantly differ between patients with MS (median: 12, IQR: 0-85) and OND (median 6, IQR: 0-94; p=0.106). Multivariable regression analysis including age, sex, time to laboratory processing, CSF WBC and RBC count, CSF/serum glucose ratio, CSF/serum albumin quotient and disease group as independent variables, identified WBC count as significant predictor of shadow cells (β [ln WBC count]=0.73, p<10-9), whereas the disease group had no impact (p=0.466). Occurrence of shadow cells in the CSF seems to depend on the extent of inflammatory cells rather than MS disease-specific mechanisms.

A case of multiple sclerosis with a tumefactive lesion during long-term treatment with fingolimod, leading to decompressive craniotomy

We report a 57-year-old man with multiple sclerosis since his 30s who was treated with fingolimod for 9 years. He developed left hemiparesis and consciousness disturbance. Brain MRI revealed a mass lesion in the right frontal lobe with gadolinium enhancement. Cerebrospinal fluid examination showed no pleocytosis. The lesion continued to expand after admission, and on the 9th day after admission, decompressive craniectomy and brain biopsy were performed. Brain pathology revealed demyelination in the lesion, leading to the diagnosis of a tumefactive demyelinating lesion. Corticosteroid therapy ameliorated the brain lesion, and we inducted natalizumab. Tumefactive demyelinating lesions requiring decompressive craniotomy are rare, and we report this case for the further accumulation of similar cases.

Viral encephalitis: A mere evil doppelganger or a mini-me of glioblastoma

Background: Viral encephalitis and glioblastomas can have a very variable clinical and radiological presentation. Although they are both relatively rare, they are known to mimic each other.Methods: In this study, we retrospectively analysed the radiology databank from 2010 to 2020 to find cases which were initially suspected to be viral encephalitis based on their imaging and clinical parameters but were later diagnosed with glioblastomas on final histopathology. The initial imaging at the time of presentation was reviewed by three radiologists having experience of 18, 15 and 6 years in neuroimaging, and the follow-up imaging data were also reviewed by the same set of radiologists, and the results were recorded. Age- and sex-matched controls of confirmed viral encephalitis were also extracted from the same database.Results: We found three such cases which were initially diagnosed with viral encephalitis but rapidly progressed to glioblastoma in the region of suspected encephalitis. The average age of these patients was 60 years and all of them were males. All these cases had a very short history and the cerebrospinal fluid examination of all of these patients had tested negative for herpes simplex virus at the time of initial presentation.Conclusions: The development of glioma exactly at the site of initial encephalitic abnormality suggests an association between these two entities, which needs further prospective studies for validation and correlation with post-mortem histopathology. Furthermore, the fact that these glioma patients showed initial clinical improvement with antiviral drugs suggests a strong point towards such an association.

Studded Brainstem Tuberculoma Presenting with Bilateral Inter-Nuclear Ophthalmoplegia.

Sir, A 17-year-old male with a history of low-grade fever for 2 months, headache for 15 days, and diplopia and drooping of the right upper eyelid for 10 days, was admitted to our hospital. There was no history of altered sensorium, convulsion, weakness, paresthesia, weight loss, or cough. There was no history of trauma, joint pain, rash, and high-risk behavior. His general examination was normal. Nervous system examination revealed a Glasgow Coma Scale of 15, normal visual acuity with bilateral Grade 2 papilledema, bilateral restriction of adduction movement of the eyeball with ptosis of the right eye, and dilated fixed right pupil [Figure 1a]. The rest of cranial nerve examination was unremarkable. He had bilateral upper motor neuron quadriparesis with power of 4+/5 with bilateral extensor plantars. Sensory and cerebellar functions were intact. Meningeal signs were present. Rest of the systemic examination was unremarkable.Figure 1: (a) On presentation, clinical image showing right-sided ptosis with restriction of bilateral adduction. MRI brain (i-iv) showing multiple T2 hypointense/FLAIR hyperintense signal changes in midbrain with ring enhancement in gadolinium contrast along with hydrocephalus. (b) At 1 month of follow-up, clinical image showing improvement in right-sided ptosis with reduced restriction of bilateral adduction. MRI brain (i-iv) showing reduction of midbrain lesions and resolving hydrocephalus. MRI: Magnetic resonance imaging, FLAIR: Fluid-attenuated inversion recoveryHis laboratory blood parameters showed normal hemogram with normal renal, liver, and thyroid functions with normal glucose and electrolytes. Serological examination was negative for HIV, hepatitis B and C, Leptospira, and Listeria. His cerebrospinal fluid examination revealed lymphocytic pleocytosis with elevated protein level, CBNAAT negative state, negative for Gram stain, fungal stain, and culture sensitivity. Magnetic resonance imaging (MRI) brain revealed multiple coalesced ring enhancing lesions of the midbrain with extension to upper pons with hydrocephalus [Figure 1a]. He was started on standard antitubercular treatment and corticosteroid. He showed improvement clinically within 10 days in the form of partial recovery in ptosis and adduction movements of the eyeball [Figure 1b]. Headache and fever resolved within 2 weeks. MRI brain was repeated at 1 month, which showed resolving hydrocephalus and reduction in size of the brainstem tuberculomas [Figure 1b]. The entity of the brainstem tuberculoma is a rare phenomenon in tuberculosis of central nervous system with incidence of 2.5%–8%.[1] The clinical presentation of the brainstem tuberculoma is pleomorphic. The site, size, and morphology of the lesions determine this versatility of manifestation.[2] Nuclear gaze palsy, ocular motor palsy, facial palsy, bulbar palsy, ataxia, and long tract signs are some important features of brainstem involvement.[3] A multitude of etiology can have similar presentation of brainstem encephalitis including infections, autoimmune disorders, neoplastic (gliomas), and vascular. Brainstem lesions are notorious for complications in the form of hydrocephalus, respiratory insufficiency, fatal arrhythmias, and brain herniation.[4] A thorough workup and aggressive management is prudent for correct diagnosis and better outcome. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Femoral Nerve Injury during Neuroborreliosis — Nursing Care. Case Report

Introduction. Neuroborreliosis is an insidious disease. It is often confused with other neurological diseases. Diagnosis is possible when the following are present: neurological symptoms indicative of neuroborreliosis, pleocytosis in CSF, and production of antibodies to Borrelia burgdorferi in CSF.&#x0D; Aim. To assess the health situation and determine the nursing needs of a patient with femoral nerve damage during neuroborreliosis.&#x0D; Case Report. A 31-year-old woman was admitted to the Department of Neurology as an elective patient. On the basis of the clinical picture, elevated levels of protein and lymphocytic cells in the examination of cerebrospinal fluid and the demonstrated intrathecal synthesis of antibodies against Borrelia diagnosed neuroborreliosis with damage to the left femoral nerve. Observation, interview, and analysis of medical records were used to identify nursing problems correctly. The scales used were: the NRS Rating Scale (pain intensity), Lovett Scale (muscle strength assessment), Hospital Anxiety and Depression Scale Questionnaire (a modified version of the HADS scale to assess anxiety and depression), AIS Scale (to assess insomnia), Baxter Scale (to monitor and assess the risk of complications associated with venous cannulation).&#x0D; Conclusions. Dorothea Orem’s nursing theory is appropriate for a patient with neuroborreliosis. The patient’s main problems are: experiencing pain, difficulty in movement, and mental deterioration. The disease and related treatment and hospitalization influence bio-psycho-social deterioration. Holistic nursing management should be adapted to the patient’s changing condition. Care includes activities aimed at nullifying the effects of the disease, providing emotional support, and education regarding proper rehabilitation management and prevention of Lyme disease. (JNNN 2022;11(4):174–179)

Efficacy of intensive antibiotic regimens on postcraniotomy fever and cerebrospinal fluid examination results in patients with infratentorial surgeries

Postcraniotomy fever is a common complication in patients undergoing infratentorial surgeries. There are few studies about it and the efficacy of intensive antibiotic regimens, which remain to be studied. We carried out a retrospective study in patients undergoing infratentorial surgeries to analyze the factors associated with postcraniotomy fever and further investigated the efficacy of different antibiotic regimens on fever and abnormal cerebrospinal fluid (CSF) results. Among the 115 patients, 74 (64.3%) had fever after craniotomy. Univariate analysis results showed that disease type, drainage tube placement, duration of drainage tube, and intraoperative bleeding volume were associated with postcraniotomy fever in patients undergoing infratentorial surgeries (P < .05). The multivariate analysis results showed that the duration of drainage tube (odds ratio = 1.010, 95% confidence interval: 1.232-6.178, P = .014) and duration of surgery (odds ratio = 1.010, 95% confidence interval: 1.002-1.017, P = .013) were associated with postcraniotomy fever in these patients. After treatment with different antibiotic regimens, the changes of white blood cells, sugar, chlorine and protein in CSF in patients with intensive antibiotic regimens were -638.48 × 106/L, 0.25 mmol/L, -0.76 mmol/L and -0.16 g/L respectively, which did not show significant differences when compared with ordinary antibiotic regimens (P > .05). Most cases of fever at the early stage after craniotomy in patients with infratentorial surgeries were nonintracranial infectious. Intensive antibiotic regimens did not show obvious advantages in improving the body temperature and CSF examination results. It is not necessary to use intensive antibiotic regimens too early, such as carbapenems or linezolids.

Diagnostic Accuracy of Urinary Reagent Strip to Determine CSF Chemistry and Cellularity

Background: Cerebrospinal Fluid (CSF) examination is a common investigation to diagnose and evaluate different neurological diseases. The gold standard method of CSF examination is microscopy, biochemistry and culture in a standard laboratory, which require an experienced microscopist and laboratory support. Urinary reagent strip can be a point of care test in such condition. The study aimed to document the diagnostic accuracy of urinary reagent strip for the semi-quantitative analysis of CSF chemistry and cellularity.&#x0D; Materials and methods: One hundred hospitalized patients from the Department of Neurology, Chittagong Medical College Hospital were included in this study. CSF samples of the patients were subjected for the de nitive test (CSF microscopy and laboratory biochemical values) and the index test [Combur-10 urinary reagent strip was used as the index test for protein, glucose, leukocytes and erythrocytes. The diagnostic accuracy of each index test was calculated using different cut-off levels (Glucose 1+ vs. CSF glucose &gt;50 mg/dL, protein 1+ vs. CSF protein &gt;30 mg/dL, leukocyte esterase 1+ positivity vs. &gt;10 granulocytes/mm3 and erythrocyte 1+ positivity versus &gt;5 RBC/mm3 in CSF sample).&#x0D; Results: The diagnostic accuracy of protein estimation by reagent strip shows 100% sensitivity, 84.21% specificity for detection of CSF protein at level 30mg/dl. Glucose reagent strip positivity had 98.8% sensitivity and 75% specificity for detection of CSF glucose at level 50 mg/dl. Leukocyte esterase positivity by test strip had sensitivity of 60% and specificity of 100% for the detection of CSF granulocyte of &gt;10 granulocytes/mm3. The diagnostic accuracy of erythrocyte estimation by reagent strip show 92% sensitivity, 92% specificity for detection of CSF RBC &gt;5 cells/mm3.&#x0D; Conclusion: Urinary reagent strip can be used routinely for rapid analysis of CSF.A resource-limited hospital might find it useful as a point-of-care laboratory workup of CSF.&#x0D; Chatt Maa Shi Hosp Med Coll J; Vol.21 (2); July 2022; Page 9-13

Management of primary CNS lymphomas including vitreoretinal lymphomas

AbstractPrimary CNS lymphomas (PCNSL) are represented in almost all cases by diffuse large B‐cell lymphomas (DLBCL). WHO 2017 defines “Primary DLBCL of CNS as DLBCL arising within the brain, spinal cord, leptomeninges or eye”. Those sites together with testes are characterized as “immune sanctuaries”. CNS DLBCL accounts &lt;1% of all lymphomas and 2–3% of brain tumours. Approximately 15% of patients (pts) have ocular involvement and approximately 75% of pts with vitreoretinal lymphomas (VRL) develop contralateral and/or parenchymal CNS lesions. The aetiology in immunocompetent patients is unknown. The majority of DLBCL cases shows nongerminal center immunophenotype. The significant proportion reveals MYD88 and CD79b mutations. Copy number gains at chromosome 9p24.1 lead to PD‐L1/2 overexpression are frequently found. Cognitive dysfunction, psychomotor slowing, different neurological symptoms including seizures are among the leading symptoms. The median age at diagnosis is around 60 years and significant proportion of patients have worse performance status based on ECOG scale. The diagnosis is established on immunohistochemical examination of biopsy. Corticosteroid administration leads to the lymphoma regression and biopsy is therefore recommended before it. MRI, eye and cerebrospinal fluid (CSF) examination is recommended as essential for the staging. The neurosurgical tumour removal is generally not recommended. The CNS DLBCL is usually chemosensitive and combined immunochemotherapy consisted of rituximab and high dose methotrexate (HD MTX) up to 8 g/m2 (usually 3.5 g/m2) based chemotherapy is recommended. Several combinations are used, especially for younger patients, combine HD MTX with HD cytarabine and thiotepa, or procarbazine, lomustine. Intrathecal administration of methotrexate is omitted if the CSF is negative. The therapy goal is to achieve complete remission. The relapse rate is, however, high and consolidation therapy is necessary. The radiation therapy is a standard with the dose of 40Gy, but it seems to cause long‐term cognitive impairment especially in elderly patients with the age above 60 years. The dose reduction and even radiotherapy omitting has been tested in patient with complete remission at the end of induction. The high dose therapy with autologous stem cell transplantation is increasingly used in younger population. The prognosis has been significantly improved during last 10–15 years. At the time of relapse immunochemotherapy with radiotherapy (if it was not part of 1st line treatment) could be used. The targeted therapy or immunotherapy based on molecular biological findings is tested. Brutone tyrosine kinase inhibitor ibrutinib (active in lymphoproliferations dependent on BCR signalling and presence of MYD88 mutations) is tested. Immune checkpoint inhibitors nivolumab and pembrolizumab (active in lymphoproliferations with PD1/PDL‐1,2 axis activation) are tested in prospective trials and results awaited. Imids (lenalidomide, pomalidomide), mTOR inhibitors (temsirolimus) among others are tested. VRL is considered to be CNS DLBCL subtype as mentioned above. The diagnosis is challenging because the tumour tissue is usually not available and it is established on morphology, flow cytometry and currently on mutations of MYD88 and other genes. The same systemic therapy is recommended as in classical CNS DLBCL, intraocular methotrexate administration is used in some centers. A new drugs are tested in the relapse setting.