Cerebrospinal Fluid Polymerase Chain Reaction Research Articles

Listeria monocytogenes: a rare cause of rhomboencephalitis in an immunocompetent patient

We present an unusual case of Listeria monocytogenes rhomboencephalitis in a young, healthy patient. Although L. monocytogenes meningitis is usually associated with immunodeficiency, rhomboencephalitis is more commonly seen in immunocompetent patients. The wide differential for rhomboencephalitis can create a diagnostic challenge. Without prompt pathogen identification and appropriate antibiotic regimen, L. monocytogenes central nervous system infections can be fatal. Cerebro-Spinal Fluid (CSF) Polymerase Chain Reaction (PCR) aided a prompt diagnosis and adjustment of therapy to achieve a good patient outcome.

Whole-Blood PCR Preferred for Timely Diagnosis of Neuroinvasive West Nile Virus Infections: Lessons From the 2021 Arizona Outbreak.

In 2021, the state of Arizona experienced the largest focal outbreak of West Nile virus (WNV) in US history. Timely and accurate diagnostic testing remains a challenge for WNV due to transient viremia and limited immunoassay specificity. Recent studies have identified whole blood (WB) and urine as more sensitive specimen types for the detection of WNV RNA. We evaluated ordering practices, test performance, and patient characteristics of probable and confirmed cases. In total, we identified 190 probable and proven cases, including 127 patients (66.8%) with neuroinvasive disease. Among all cases, only 29.5% had WNV polymerase chain reaction (PCR) testing ordered on WB, of which 80.3% resulted as positive, including 7 cases in which WNV serologic testing was negative and 5 cases for which serologic testing was not ordered. In comparison, only 23.7% of cases that had cerebrospinal fluid (CSF) PCR ordered had a positive result, including 3 cases that were negative by PCR on WB. In contrast, WNV PCR on WB detected 12 neuroinvasive cases that were CSF PCR negative. WNV PCR testing in urine was only ordered on 2 patients, both of whom were positive. Crossing cycle threshold (Ct) values were not significantly different between WB and CSF specimen types, nor was there a correlation between Ct value and days from symptom onset at the time of sample collection; all specimen types and time points had Ct values, with 98% above 30. WB was positive by WNV PCR in several patients for >7 days (range, 7-25 days) after symptom onset, as was the CSF PCR. Taken together, these findings indicate that WNV PCR testing on WB may be the best initial test for timely diagnosis of WNV infection, irrespective of clinical manifestation; however, if negative in patients with suspected neuroinvasive disease, WNV PCR testing on CSF should be ordered.

Treponema pallidum PCR with blood and cerebrospinal fluid of newborns exposed and not exposed to syphilis during pregnancy.

Congenital syphilis (CS) has severe adverse outcomes, including abortion and death. Diagnosis of CS in asymptomatic newborns remains difficult. This study aims to evaluate an in-house polymerase chain reaction (PCR) on cerebrospinal fluid (CSF) and blood samples (BS) to identify T. pallidum DNA in newborns. We performed an exploratory cross-sectional study that included newborns exposed to syphilis during pregnancy (SEG) and non-exposed (SNEG) newborns, between 2019 and 2020. In-house conventional PCR for T. pallidum targeting the tpp47 gene was used to analyze CSFS and dried blood spots. BS was obtained from 54 newborns (33 SEG/21 SNEG) and CSF from 55 newborns (33 SEG/22 SNEG). Twenty-five (71.4%) SEG newborns had reactive BS rapid plasmatic reagins (RPR), and all of them had RPR titers less than or equal to the corresponding maternal titers. All RPR CSF tests were negative. PCR for T. pallidum DNA was positive in 19/33 (57.6%) BS, and in 22/33 CSF. The only SEG newborn with clinical signs of early CS had a positive CSF PCR and a negative BS PCR. Conversely, among SNEG newborns, PCR was positive in 2/21 BS and 5/22 (22.7%) CSF. T. pallidum DNA was identified using our PCR tests. The exposed group did not present abnormalities that would indicate CS. This prevented conclusions regarding sensitivity and specificity. Dried spot permitted bedside collection, easy transportation, and storage. Further research is needed to evaluate and improve the accuracy of CS low-cost PCR tests, especially for limited resource settings.

Sepsis-like HPeV encephalitis in young infants – case series

Human parechovirus is the most common underrecognised aetiological agent of encephalitis in children younger than 90 days. The aim of this study is to describe the clinical manifestation, laboratory features, and potential risk factors for severe parechovirus-related sepsis-like encephalitis. The case series included five infants aged below three months diagnosed with sepsis-like parechovirus encephalitis. The diagnosis was based on the patients’ neurological symptoms, the criteria of sepsis defined by the National Institute for Health and Care Excellence, and parechovirus-positive cerebrospinal fluid polymerase chain reaction (PCR). The majority of patients presented with irritability, fever, abnormal muscle tone, mottling, decreased activity, tachycardia, abdominal distension, and absence of neonatal developmental reflexes. No abnormalities in the cerebrospinal fluid were identified. Abnormal blood laboratory measurements included lymphopaenia, leukopaenia, and anaemia. The case series highlights the necessity to perform cerebrospinal fluid PCR for parechovirus in infants with sepsis-like illness and neurological signs but without cerebrospinal fluid signs of inflammation.

Intravascular Lymphoma-Associated Stroke: A Systematic Review of Case Studies.

Intravascular lymphoma (IVL) is an aggressive systemic large B-cell lymphoma that is a rare cause of stroke. The clinical characteristics of stroke associated with IVL remain underexplored, contributing to diagnostic complexities and a high mortality rate. This study endeavors to elucidate the salient clinical and investigative features of stroke linked to this condition. A systematic review was performed using the PubMed database from the incident to August 2023 including search categories for IVL and stroke. All studies, excluding review articles, were included in this study. There were 58 cases with a confirmed diagnosis of IVL associated with stroke, with a mean age of 62.9 ± 9.6 years (female 50%). Classical lateralizing stroke symptoms were noted in only 69% of cases. Other clinical syndromes included altered sensorium (31%), rapidly progressive cognitive impairment (23%), seizures (22%), and gait disturbances (19%). Common hematological abnormalities included elevated lactate dehydrogenase (LDH, 97%), erythrocyte sedimentation rate (ESR, 79%), C-reactive protein (CRP, 61%), interleukin-2, microglobulins, and cerebrospinal fluid (CSF) protein. CSF flow cytometry was not diagnostic, and cytology was mostly negative. The dynamic pattern for DWI/T2 lesions was predominant and primarily located in the subcortical regions. Diffuse background slowing (64%) was a major finding in the electroencephalogram. Seventy-one percent of cases died (n=45) mostly due to delayed diagnosis. Only 31% were treated with first-line R-CHOP (rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine, prednisone) chemotherapy, among whom 25% died. This study suggests that IVL-associated strokes carry a high mortality rate, largely due to challenges in timely diagnosis and therapy. Unlike classical stroke syndrome, key indicators to aid in early diagnosis include a clinical syndrome of multiple non-lateralizing neurological symptoms, dynamic MRI DWI/T2-lesions primarily located in subcortical regions, elevated serum LDH, ESR, CRP, interleukins, microglobulin, CSF protein, and CSF polymerase chain reaction analysis, apart from tissue examination. Larger studies should be performed to establish diagnostic and predictive scores.

Two Cases of Varicella Zoster Virus Meningitis without Fever and Rash: An Unexpected Clinical Presentation

Aseptic meningitis caused by Varicella-Zoster virus (VZV) is a rare phenomenon in the healthy population. Immunocompromised patients are predominantly affected by viral reactivation, characterized by rash and neurological symptoms, and meningitis as a rare complication. Herein, we report two cases of VZV meningitis in adult patients without rash and fever over a 4-month period. The first case was an immunocompetent 37-year-old male who presented with persistent headache, agitation and unclear speech. The second case was an immunocompromised 76-year-old male who was admitted to the emergency department with confusion, disorientation, dizziness, loss of consciousness, pain in the lower left extremities and difficulty in walking. Cerebrospinal fluid (CSF) analysis in both patients revealed a high leukocyte cell count with 97% lymphocytes. CSF gram staining and culture were negative. CSF polymerase chain reaction (PCR) analysis indicated VZV infection. Both patients were administered acyclovir for 14 days and were discharged without any neurological sequela. This case report series highlight the presentation of VZV as aseptic meningitis in both immunocompetent and immunocompromised patients without the typical clinical symptoms and should always be considered by the clinicians.

A-308 The Molecular Diagnosis of Varicella Zoster Virus (VZV): A Validation of a Real-Time PCR (qPCR) Assay for the Qualitative Detection

Abstract Background Varicella zoster virus (VZV) is the etiological agent of chicken pox and herpes zoster. After the primary infection, which usually occurs in childhood, VZV remains latent in sensory nerve roots for life. When reactivation occurs, especially in immunocompromised patients, the virus migrates to the skin and causes painful rashes that can evolute to a dermatome. Even after the end of the viral acute infection, some individuals may experience continued pain. Furthermore, VZV reactivation can lead to a wide spectrum of clinical manifestations such as self-limited radicular pain and central nervous system involvement. During acute illness, 90% of patients experience pain and 12% have symptoms similar to influenza infection (influenza-like). Immunocompromised patients may have an unfavorable course with disseminated infection, pneumonitis, hepatitis, and encephalitis. The cerebrospinal fluid polymerase chain reaction (PCR) test is indicated for suspected involvement of the central nervous system and complications of ocular or periocular lesions. Compared to other diagnostic methods, real-time PCR has great advantages as its high throughput, efficiency, and sensitivity. Therefore, the detection of VZV by real-time PCR presents great importance for the diagnosis and monitoring of the disease due to its precision and agility. Thus, we intended to validate a qualitative method for VZV detection by real-time PCR. Methods We evaluated the performance of the inventoried TaqMan assay (Vi06439647_s1) (Thermo Fisher Scientific). For this validation, we used 64 samples - whole blood (n = 31), cerebrospinal fluid (n = 32), vaginal lesion scraping (n = 1) - from the Genetics sector of the Pardini Group, previously tested by in-house PCR for the qualitative detection of VZV. Samples were extracted using the MagNA Pure 24 System platform (Roche Diagnostics) with the MagNA Pure 24 Total NA Isolation Kit, according to the manufacturer's instructions. All assays were performed using Taqman Universal Master Mix (Thermo Fisher Scientific). The inventoried B-actin Assay (assay ID: Hs01060665_g1) (Thermo Fisher Scientific) was used as endogenous control. Assay verification tests, evaluation of reaction efficiency, and determination of the detection limit (LOD) were performed using a synthetic control of known concentrations and a pool of negative samples (healthy volunteers). At the end of the tests, were made a comparison of the previous results with the results obtained in the ThermoFisher Real-Time PCR Assay. Results The Inventoriad Taqman Assay (VZV) had a limit of detection of 10 copies/µL and the Cq > 35 was defined as a cut-off to consider a sample as positive. Whole blood samples had higher Cts than cerebrospinal fluid samples, indicating lower viremia. Whitin all evaluated samples, 11 samples had positive results detected by in-house PCR (9 from whole blood and 2 from cerebrospinal fluid). Of these, 10 had a result detected in Real-time PCR and the agreement with the positive results between compared methodologies was 91.0%. The divergent sample was whole blood and can be related to DNA degradation. The 47 negative samples evaluated were concordant in both methods. Conclusion The inventoried TaqMan Assay with Taqman Universal Master Mix protocol evaluated was sensitive, fast, and applicable as a tool for the qualitative detection of VZV.

Long-term observations of feline meningoencephalitis of unknown etiology: clinical, CSF, and MRI findings

A 4-year-old neutered female Turkish Angora cat presented with acute onset of obtundation, right-sided head turn, and rolling. On neurologic examination, postural reactions were found either absent or decreased in all four limbs. Cranial nerve examination, such as menace response, pupillary light, and oculocephalic reflex, showed absent or decreased results. Magnetic resonance imaging (MRI) demonstrated demarcated lesions in the thalamus and brainstem, which were marked hyperintense on T2-weighted and FLAIR images and isointense on T1-weighted images. Cerebrospinal fluid (CSF) nucleated cell count was markedly elevated (258 cells/µl) with a neutrophilic pattern. The CSF polymerase chain reaction for infectious agents was negative. Based on these results, a diagnosed of feline meningoencephalitis of unknown etiology (FMUE) was made. The cat was treated with prednisolone (3 mg/kg, twice a daily), which was gradually tapered off. The follow-up of clinical signs, MRI, and CSF analysis was performed at 33, 118, and 611 days after the initial therapy. At 33 days, abnormalities of clinical signs, MRI, and CSF almost disappeared. At 139 days, because all examinations showed normal findings, the treatment was stopped. At 611 days, the final examinations showed no remarkable findings. This is the first case describing changes in the clinical signs, MRI findings, and CSF analysis of FMUE with long-term follow-up.

Meta-analysis of Cerebrospinal Fluid Cell Count and Biochemistry to Diagnose Meningitis in Infants Aged < 90 Days.

Cerebrospinal fluid (CSF) white blood cell (WBC) count, protein, and glucose (cytochemistry) are performed to aid in the diagnosis of meningitis in young infants. However, studies have reported varying diagnostic accuracies. We assessed the diagnostic accuracy of CSF cytochemistry in infants below 90 days and determined the certainty of evidence. We searched PubMed, Embase, Cochrane Library, Ovid, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus databases in August 2021. We included studies that evaluated the diagnostic accuracy of CSF cytochemistry compared with CSF culture, Gram stain, or polymerase chain reaction in neonates and young infants <90 days with suspected meningitis. We pooled data using the hierarchical summary receiver operator characteristic (ROC) model. Of the 10,720 unique records, 16 studies were eligible for meta-analysis, with a cumulative sample size of 31,695 (15 studies) for WBC, 12,936 (11 studies) for protein, and 1,120 (4 studies) for glucose. The median (Q1, Q3) specificities of WBC, protein, and glucose were 87 (82, 91), 89 (81, 94), and 91% (76, 99), respectively. The pooled sensitivities (95% confidence interval [CI]) at median specificity of WBC count, protein, and glucose were 90 (88, 92), 92 (89, 94), and 71% (54, 85), respectively. The area (95% CI) under ROC curves were 0.89 (0.87, 0.90), 0.87 (0.85, 0.88), and 0.81 (0.74, 0.88) for WBC, protein, and glucose, respectively. There was an unclear/high risk of bias and applicability concern in most studies. Overall certainty of the evidence was moderate. A bivariate model-based analysis to estimate the diagnostic accuracy at specific thresholds could not be conducted due to a paucity of data. CSF WBC and protein have good diagnostic accuracy for the diagnosis of meningitis in infants below 90 days of age. CSF glucose has good specificity but poor sensitivity. However, we could not identify enough studies to define an optimal threshold for the positivity of these tests. · Median specificity of CSF leucocyte count, protein and glucose are similar in young infants.. · At median specificity, CSF leukocyte count and protein are more sensitive than glucose.. · Owing to inadequate data, bivariate modelling to suggest optimal diagnostic thresholds is not possible..

Neuroimaging Features and Outcomes of Progressive Multifocal Leukoencephalopathy (PML): A Single-Center Experience (P13-10.003)

<h3>Objective:</h3> To summarize the clinical and imaging features of progressive multifocal leukoencephalopathy (PML) and highlight the importance of a timely diagnosis. <h3>Background:</h3> PML is a rare but fatal demyelinating disease of the central nervous system caused by the reactivation of the John Cunningham (JC) virus (JCV). It has an exceedingly high mortality rate and exhibits significant cerebrospinal fluid (CSF) and neuroimaging features, which can be identified early in the disease course. <h3>Design/Methods:</h3> We conducted a single-center retrospective cohort study of patients recruited at the Department of Neurology, West Virginia University, between January 2014 and December 2021. Of the 37 enrolled patients, 12 were included based on our selection criteria. Magnetic resonance imaging (MRI) and confirmation of PML through JCV polymerase chain reaction of CSF were done in all cases. <h3>Results:</h3> Eleven out of the 12 patients (92%) had predisposing risk factors, such as hematologic malignancies (n=5) and human immunodeficiency virus (HIV) infection (n=4). Symptoms included altered mental status (n=5), seizure-like activity (n=4), unilateral weakness/paresthesia (n=3), and visual deficits (n=3). MRI revealed bihemispheric (n=7) and unilateral (n=5) lesions within the fronto-parietal (8/12) and temporo-parietal (4/12) lobes. Subcortical U-fibers were involved, and lesions were predominantly confluent (9/12) with irregular borders and without mass effect. These demonstrated hyperintensities on fluid-attenuated inversion recovery, with corresponding hypo-intensity on T1-weighted imaging and restricted diffusion. A single faint contrast-enhanced punctate lesion was reported in 3 patients; seven had no documented contrast studies. Nine (75%) received treatment, and only four cases (33.3%) survived; the mean time from diagnosis to death was 1.4 months (±0.69), and all eight patients died within three months of diagnosis. <h3>Conclusions:</h3> PML should immediately be considered in immunocompromised patients presenting with new-onset neurological symptoms and typical imaging findings. Physicians must familiarize themselves with these presentations since a rapid diagnosis and targeted intervention are critical to reducing overall mortality. <b>Disclosure:</b> Dr. Yu has nothing to disclose. Dr. Sharma has nothing to disclose. Dr. R has nothing to disclose. Dr. Sriwastava has nothing to disclose.

MRI of neurosyphilis with mesiotemporal lobe lesions of "knife-cut sign” on MRI: A case report and literature review

Neurosyphilis with mesiotemporal lobe lesions remains a difficult entity to diagnose, especially when it mimics herpes simplex encephalitis (HSE). Here, we report what appeared to be the first case of mesiotemporal imaging of neurosyphilis presenting as a “knife-cut” sign and mimicking HSE pathological hallmarks on imaging. The magnetic resonance imaging (MRI) changes in neurosyphilis and HSE were indistinguishable in the initial diagnosis because of the common involvement of the mesiotemporal lobe. Neurosyphilis was diagnostically confirmed by positive readings in the treponema pallidum hemagglutination assay (TPHA), rapid plasma reagin (RPR) and cerebrospinal fluid-polymerase chain reaction (CSF-PCR) tests for Treponema pallidum infection. Neurosyphilis and HSE had similar clinical features and signs on MRI, except the knife-cut sign which is a common diagnosis in HSE. Therefore, neurosyphilis with mesiotemporal changes and knife-cut signs on MRI should be evaluated in the differential diagnosis in all patients, as similar changes may also occur in HSE patients. The literature review of published articles between 1997 and 2020 was conducted to further validate our clinical observations and discuss diagnostic and treatment options for neurosyphilis with mesiotemporal lobe lesions.

Late-Onset Sepsis Mortality among Preterm Infants: Beyond Time to First Antibiotics.

Objective: To investigate the impact of timing, in vitro activity and appropriateness of empirical antimicrobials on the outcome of late-onset sepsis among preterm very low birth weight infants that are at high risk of developing meningitis. Study design: This retrospective study included 83 LOS episodes in 73 very low birth weight infants born at ≤32 weeks' gestation with positive blood and/or cerebrospinal fluid culture or polymerase chain reaction at >72 h of age. To define the appropriateness of empirical antimicrobials we considered both their in vitro activity and their ideal delivery through the blood-brain barrier when meningitis was confirmed or not ruled out through a lumbar puncture. The primary outcome was sepsis-related mortality. The secondary outcome was the development of brain lesions. Timing, in vitro activity and appropriateness of empirical antimicrobials, were compared between fatal and non-fatal episodes. Uni- and multi-variable analyses were carried out for the primary outcome. Results: Time to antibiotics and in vitro activity of empirical antimicrobials were similar between fatal and non-fatal cases. By contrast, empirical antimicrobials were appropriate in a lower proportion of fatal episodes of late-onset sepsis (4/17, 24%) compared to non-fatal episodes (39/66, 59%). After adjusting for Gram-negative vs. Gram-positive pathogen and for other supportive measures (time to volume administration), inappropriate empirical antimicrobials remained associated with mortality (aOR, 10.3; 95% CI, 1.4-76.8, p = 0.023), while timing to first antibiotics was not (aOR 0.9; 95% CI, 0.7-1.2, p = 0.408; AUC = 0.88). The association between appropriate antimicrobials and brain sequelae was also significant (p = 0.024). Conclusions: The risk of sepsis-related mortality and brain sequelae in preterm very low birth weight infants is significantly associated with the appropriateness (rather than the timing and the in vitro activity) of empirical antimicrobials. Until meningitis is ruled out through lumbar puncture, septic very low birth weight infants at high risk of mortality should receive empiric antimicrobials with high delivery through the blood-brain barrier.

Finding positive SARS-CoV-2 RT-PCR in cerebrospinal fluid of two pediatric patients with severe COVID-19: a brief case report

BackgroundThere is growing evidence of nervous system involvement and related complaints in children with coronavirus disease 2019 (COVID-19). However, it seems that attempts to track of the virus in the nervous system have so far been unsuccessful.Case presentationHere we describe two pediatric cases of severe COVID-19 who had positive cerebrospinal fluid (CSF) and nasopharyngeal polymerase chain reaction (PCR) tests for severe acute respiratory syndrome coronavirus disease 2019 (SARS-CoV-2). A 36-month-old girl who presented with fever, diarrhea, mild left ventricular dysfunction and bizarre movements, and a five-month-old boy who presented with fever, watery diarrhea, severe dehydration, mottling, and two episodes of seizure. Their CSF analyses and cultures were normal. They admitted in intensive care unit (ICU) for near four days and discharged after ten days without any complaint.ConclusionThis is one of the first reports of the presence of coronavirus in the central nervous system in COVID-19 pediatric patients, emphasizing the neurotropism and neuroinvasion characteristics of the virus.

Two cases of Ramsay-Hunt syndrome following varicella zoster viral meningitis in young immunocompetent men: case reports

BackgroundRamsay-Hunt syndrome (RHS) due to varicella zoster virus (VZV) infection is commonly reported in individuals aged at least 50 years or immunocompromised individuals. VZV infection may invade the central nervous system (CNS) and cause meningitis or encephalitis, which are more likely to occur in patients with chronic diseases such as diabetes and chronic renal failure. However, cases with VZV-induced concurrent RHS and CNS infections are rare.Case presentationTwo young male patients, aged 32 and 43 years, with no underlying disease developed VZV meningitis, followed by RHS involving cranial nerves VII and VIII. Both patients presented with symptoms of peripheral facial palsy, and dizziness accompanied by tinnitus and hearing loss, which appeared several days after the onset of fever and headache. These symptoms were documented as facial neuropathy and sensorineural hearing loss in the electrophysiologic studies. Lymphocyte-dominant pleocytosis and VZV positivity were confirmed from cerebrospinal fluid examination and polymerase chain reaction, respectively. The patients were treated with intravenous acyclovir and oral steroids simultaneously. Following the treatment completion, both patients were relieved of their headaches and fever; however, facial palsy, dizziness, and tinnitus persisted. They were followed up at the outpatient clinic.ConclusionThese cases confirmed that RHS and CNS infections can co-exist even in young adults with normal immune function and more importantly, that CNS infection can precede RHS. Since early detection and treatment of RHS improve the prognosis, it is critical to closely monitor patients with VZV meningitis or encephalitis considering the possible superimposition of RHS.

Role of cerebrospinal fluid lactate in diagnosing meningitis in critically ill patients.

Meningitis is a life-threatening clinical condition associated with high mortality and morbidity. Early diagnosis and specific treatment may improve outcomes. Lack of specific clinical signs or tests make the diagnosis challenging. To assess the efficacy of cerebrospinal fluid (CSF) lactate in diagnosing meningitis in critically ill patients. A prospective, observational cohort study was carried out in a neuro-medical intensive care unit (ICU) over a 22 mo period. Adult patients, with suspected meningitis admitted in ICU, were serially recruited. Patients who refused consent, those with peripheral sensorineural deficit, or with any contraindication to lumber puncture were excluded. CSF cytology, bio-chemistry, lactates, culture and polymerase chain reaction based meningo-encephalitis panel were evaluated. Patients were divided in two groups based on clinical diagnosis of meningitis. The efficacy of CSF lactate in diagnosing meningitis was evaluated and compared with other tests. Seventy-one patients were included and 23 were diagnosed with meningitis. The mean values of CSF total leucocyte count (TLC), proteins and lactates were significantly higher in meningitis group. There was a significant correlation of CSF lactate levels with CSF cultures and meningo-encephalitis panel. CSF lactate (> 2.72 mmol/L) showed good accuracy in diagnosing meningitis with an area under the curve of 0.81 (95% confidence interval: 0.69-0.93), sensitivity of 82.6%, and specificity 72.9%. These values were comparable to those of CSF TLC and protein. Twelve patients with bacterial meningitis had significantly higher CSF lactate (8.9 ± 4.7 mmol/L) than those with non-bacterial meningitis (4.2 ± 3.8 mmol/L), P = 0.006. CSF lactate may be used to aid in our diagnosis of meningitis in ICU patients. CSF lactate (> 2.72 mmol/L) showed good accuracy, sensitivity, and specificity in diagnosing meningitis and may also help to differentiate between bacterial and non-bacterial meningitis.

Cerebrovascular accident in a child with precursor B-cell acute lymphoblastic leukemia and coronavirus disease 2019: a case report

BackgroundCoronavirus disease 2019 can lead to rare but severe and life-threatening diseases in susceptible high-risk populations, including patients with immunodeficiency. A rare event in this report is stroke following COVID-19 disease in a patient with an immunocompromised background due to leukemia and anti-cancer treatments.Case presentationA 6-year-old iranian girl with precursor B-cell leukemia receiving vincristine therapy presented with fever and absolute neutrophil count < 500. Her severe acute respiratory syndrome coronavirus 2 polymerase chain reaction test was positive. During hospitalization, she had abrupt onset tachypnea, reduced O2 saturation, and generalized tonic–clonic seizures treated with phenytoin and levetiracetam. Right parietal lobe ischemia was found on a brain computed tomography scan, and the cerebrospinal fluid polymerase chain reaction test was positive for severe acute respiratory syndrome coronavirus 2. Several days later, she developed lower extremity paralysis and speech impairment, so speech therapy and physiotherapy were initiated. The patient also received dexamethasone, mannitol, heparin, and remdesivir. She was discharged with enoxaparin and levetiracetam. Chemotherapy resumed 2 weeks following discharge. Her speech and walking improved after 10 months of follow-up, and bone marrow aspiration showed total remission.ConclusionOwing to the link between coronavirus disease 2019 and hematologic cancers with hypercoagulopathy and the tendency of patients with leukemia to have coronavirus disease 2019 complications, children with leukemia as well as suspected coronavirus disease 2019 must be hospitalized to prevent blood clot formation.

A case of new-onset refractory status epilepticus (NORSE) due to Herpes Simplex Virus-1 encephalitis

In the medical literature, the term of "new-onset refractory status epilepticus" (NORSE) is a novel term. Herpes Simplex Virus-1 and other viral infections can be cause to NORSE. Seizures are a rare sign of HSV encephalitis, but they can occur as the first symptom. Herein, we present a case of NORSE triggered by HSV-1 encephalitis, which had been diagnosed via cerebrospinal fluid polymerase chain reaction (PCR) method and magnetic resonance imaging findings.

The spectrum of central nervous system involvement in Whipple's disease.

To assess the clinical spectrum of central nervous system (CNS) involvement as well as cerebrospinal fluid (CSF) and neuroimaging findings in patients with Whipple's disease (WD) and to analyze the association of neurological symptoms with CSF and imaging findings. Neurological involvement was retrospectively analyzed in a series of 36 patients diagnosed with WD at a single center between 1992 and 2019. Findings of 81 comprehensive CSF examinations from 36 patients, including polymerase chain reaction (PCR) tests for Tropheryma whipplei (TW) in CSF from 35 patients, were systematically evaluated. The prevalence of ischemic stroke in patients with WD was compared to a matched control cohort. Neurological symptoms occurred in 23 of 36 (63.9%) patients, with cognitive, motor, and oculomotor dysfunction being most frequent. TW was detected by PCR in CSF of 13 of 22 (59.1%) patients with and four of 13 (30.8%, p=0.0496) patients without neurological symptoms. Total CSF protein (p=0.044) and lactate (p=0.035) were moderately elevated in WD with neurologic symptoms compared with WD without. No intrathecal immunoglobulin synthesis was observed. Three of 36 (8.3%) patients had hydrocephalus due to aqueductal stenosis. Patients with WD had an unexpectedly high prevalence of ischemic stroke (10/36, 27.7%) compared to matched controls (10/360, 3.2%). Neurological involvement in patients with WD is common. Detection of TW DNA in CSF is only partly associated with neurological symptoms. Elevated CSF parameters suggest CNS parenchymal infection. Stroke is a hitherto underrecognized manifestation of WD. These findings suggest that mechanisms beyond CNS infection contribute to the spectrum of CNS involvement in WD.

Uncommon cause of trigeminal neuritis and central nervous system involvement by herpes labialis: a case report

BackgroundTrigeminal neuropathy is characterized by numbness in the region innervated by the trigeminal nerves, with or without neuropathic weakness in the muscles of mastication. Trigeminal neuritis is a form of trigeminal neuropathy in which the lesion is caused by an inflammation. Herein, we report a patient with trigeminal neuritis due to central nervous system (CNS) involvement of herpes labialis (HL) infection, which was successfully treated with anti-viral and anti-inflammatory agents.Case presentationA young healthy female presented with numbness in the left hemiface for two weeks. She had a preceding typical HL infection on left facial lip one week before the sensory symptom onset. Brain magnetic resonance imaging revealed high signal intensities and asymmetrical thickening with enhancement along the cisternal segment of the left trigeminal nerve. Additionally, brain MR angiography showed multifocal stenoses in the M1 segment of the middle cerebral artery and the cavernous portion of the internal carotid artery. Cerebrospinal fluid (CSF) examination showed mild pleocytosis with normal protein level, glucose ratio, but CSF polymerase chain reaction assay for specific anti-viral antibodies including herpes simplex virus was negative, and CSF culture also did not identify a specific pathogen. The results of serologic testing including tumor markers and autoimmune markers were all unremarkable. A tentative diagnosis of trigeminal neuritis as a complication of HL involving the CNS was made considering the clinical, neuroradiological, and laboratory findings of the patient. Therefore, the patient was treated with intravenous methylprednisolone and acyclovir for 10 days. After the treatments, her sensory disturbance was markedly improved. Brain MRI at the 3-month follow-up also demonstrated improvement of previously identified high signal intensity lesions and multifocal intracerebral artery stenoses.ConclusionHL is usually a self-limiting, benign disease without complications, but rarely presents as trigeminal neuritis due to CNS involvement. Therefore, meticulous evaluation may be necessary if trigeminal neuritis or CNS involving symptoms occur after HL.

Correlation between magnetic resonance imaging and histological lesions in a case of meningoencephalomyelitis secondary to Neospora caninum infection in a greyhound

AbstractAn 11‐year‐old, male, neutered raw fed greyhound was presented for a 2‐week history of progressive non‐lateralised, non‐painful ambulatory paraparesis, deteriorating acutely to non‐ambulatory tetraparesis. Magnetic resonance imaging, cerebrospinal fluid analysis and polymerase chain reaction tests confirmed the diagnosis of meningoencephalomyelitis secondary to Neospora caninum infection. Despite treatment, the patient deteriorated and was euthanased. Postmortem examination revealed diffuse areas of necrotising encephalomyelitis, multifocal non‐suppurative encephalomyelitis and areas of necrotising non‐suppurative cerebellitis. N. caninum parasitic cysts could also be identified. This is the first case report of correlated histological features and magnetic resonance imaging of meningoencephalomyelitis secondary to N. caninum. This case report was presented as an online poster presentation at the online 33rd ESVN‐ECVN symposium.