CSF Polymerase Chain Reaction Research Articles

An 11-month-old boy with tuberculous meningitis presenting as progressive limb weakness, fever, developmental retardation, and loss of consciousness: a case report

BackgroundTuberculous meningitis (TBM) accounts for about 1% of all tuberculosis cases and about 5% of extrapulmonary tuberculosis cases. However, it poses major importance because approximately half of those affected die or become severely disabled. Herein, the successful treatment of an 11-month-old boy with progressive limb weakness, fever, developmental retardation, and loss of consciousness due to tuberculosis, was reported.Case presentationAn 11-month-old (Iranian Turk) boy was referred to Loghman Hakim hospital for progressive limb weakness and loss of previously attained developmental milestones for the past 2 months. He also had persistent fever and loss of consciousness for about 14 to 21 days. Before being referred to our center, the patient had been diagnosed with hydrocephalus at another center due to possible acute bacterial meningitis based on a CT scan and MRI imaging. On physical examination, anterior fontanel bulging and neck stiffness were observed on the admission. His body temperature and heart rate were 38.1 C and 86 beats per minute (bpm), respectively. He had left 6 cranial nerve palsy and spastic quadriparesis with a power of grade 3/5. Other systemic examinations were normal. Endoscopic third ventriculostomy (ETV) (and leptomeningeal biopsy) revealed diffuse thickening of the floor and lateral walls of the 3rd ventricle and also a cobblestone appearance in the form of multiple white patchy lesions was detected on the floor of the 3rd ventricle. CSF analysis and polymerase chain reaction confirmed the TB meningitis. During hospitalization, a temporary EVD (external ventricular drain) was initially inserted. Eventually, defervescence was denoted 5–6 days after initiation of anti-TB medications, and a permanent ventriculoperitoneal shunt was inserted due to hydrocephalus. Gradually his truncal and limb tone and motor function improved, as did his emotional responses to his parents and ability to eat. The patient can walk without help in the 15th month following the operation and resolved hydrocephalus demonstrated on follow-up imaging.ConclusionOver half of treated TB meningitis patients die or suffer severe neurological sequelae, mainly due to late diagnosis. Hence, early diagnosis and prompt initiation of TB treatment offer the best chance of a good neurological outcome.

1324. Impact of Implementation of CSF PCR Panel in Patients with Meningitis

Abstract Background Cerebrospinal fluid (CSF) Polymerase chain reaction (PCR) panel is routinely used for etiologic diagnosis of meningitis. While its role in this setting has been proven, there is no data on its benefits on duration of antibiotic use and hospital length of stay. Methods Retrospective cohort study was performed to compare meningitis patients who received the CSF PCR panel versus those who did not in a large database of HCA hospitals across the United States. Data was collected from January 2014 to May 2022 on all patients diagnosed with meningitis with a CSF WBC greater than 10. Using logistic regression and negative binomial regression, the study compared utility of CSF PCR panel use versus non-use with regards to length of stay, antibiotic duration, resolution of fever and leukocytosis, and hospital readmission rate. Demographics by Panel Use A total of 4895 patients were included in the study, of which 379 received the CSF PCR Meningitis Panel. Results A total of 4895 distinct patient encounters were included, of whom 379 patients had the CSF PCR panel. CSF PCR use was associated with a significant decrease in readmission rates within 30 days (x2 5.64, p< 0.05) and had decreased log count days of antibiotic duration (x2 17.56, p< 0.0001) with a mean duration of antibiotic use of 73.91 hours in CSF PCR panel patients versus 82.05 hours. Panel use was not significantly associated with length of stay (x2 0.96, p 0.328). The likelihood of fever resolution and leukocytosis resolution was the same for those who received the CSF PCR Panel versus those who did not. Antimicrobial Medications Received by Panel Use Antimicrobial Duration and Clinical Presentation by Panel Use There was a decrease in antibiotic use of 73.91 hours in CSF PCR panel patients versus 82.05 hours. There was also a significant decrease in hospital readmission rates within 30 days Conclusion CSF PCR panel benefits included reduced antibiotic duration of use and reduced 30-day readmission rates. Fever resolution and leukocytosis or leukopenia resolution was not impacted by CSF PCR panel use. Disclosures All Authors: No reported disclosures

Clinical progress note: Evaluation and management of neonatal herpes simplex virus disease.

Clinical progress note: Evaluation and management of neonatal herpes simplex virus disease.

Delayed Diagnosis of West Nile Meningoencephalitis in a Patient Receiving Rituximab for Rheumatoid Arthritis

West Nile virus (WNV) neuroinvasive disease is associated with substantial morbidity and mortality. Clinical suspicion is usually confirmed with cerebrospinal (CSF) immunoglobulin M (IgM) detection using enzyme-linked immunoassay (ELISA) techniques. CSF polymerase chain reaction (PCR) is rarely used to confirm the disease and is not widely available. We present a detailed report offalse-negative WNV IgM in a patient receiving rituximab therapy for rheumatoid arthritis. She was exposed to the virus during peak immunosuppression and strong clinical suspicion was confirmed with WNV PCR, illustrating the importance of such consideration with the recent incremental use of rituximab therapy.Despite the lack of specific anti-viral treatment for WNV, delayed consideration and diagnosis of WNV in those who are immunosuppressed would expose them to a wide panel of testing, with a subsequent increase in the cost of medical care.

Seropositive Neuromyelitis Optica in a Case of Undiagnosed Ankylosing Spondylitis: A Neuro-Rheumatological Conundrum

Seropositive Neuromyelitis Optica in a Case of Undiagnosed Ankylosing Spondylitis: A Neuro-Rheumatological Conundrum

Clinical features and management strategies of Meningitis in adult patients: A hospital based study from Kuwait

Introduction: High mortality rate of meningitis has been reported in Kuwait, however, limited data is available describing this disease in adult patients. With this background, we conducted a prospective study on patients admitted with meningitis, with an objective to describe the risk factors, clinical presentation, disease course and outcome; focus given on diagnostic problems and consequent management difficulties.
 Methods: Our team diagnosed, managed and documented hospital records of patients (n=44) admitted with suspected meningitis at a referral hospital during 2010-12. Detailed information was collected regarding clinical presentation, CSF analysis, treatment, hospital course and outcome as per Glasgow Outcome Scale (GOS). Results: Bacterial, viral, and tuberculosis (TB) meningitis were seen in 22.8%, 52.3%, and 15.9% of patients. Clinical features of our cohort were consistent with available literature. Positive identification of organism by culture, gram stain, or antigen test was possible in only 6 patients i.e. Streptococcus pneumonae-(n=3), Streptococcus agalactiae-(n=2), Neisseria meningitides-(n=1). CSF polymerase chain reaction was detected positive for Enterovirus RNA, and Herpes simplex virus DNA for one patient each. Empirical antimicrobial treatment directed against common causative organisms was the mainstay of management of bacterial meningitis. Viral meningitis was managed symptomatically. TB meningitis patients were administered anti-tubercular treatment. As per GOS, 38(85.4%) patients recovered with no neurological deficit. Six patients recovered with mild to moderate deficit. Conclusion: Low positive culture rates and inability to identify pathogens have been a diagnostic challenge faced by our team. Strong clinical suspicion, early empiric antibiotic and dexamethasone therapy perhaps contributed to very good recovery in our study.
 Keywords: Meningitis, Kuwait, Clinical Suspicion, Antibiotic, Dexamethasone

SURG-09. REACTIVATION OF HERPES SIMPLEX VIRUS AFTER NEUROLOGIC SURGERY

BACKGROUNDHerpes simplex virus encephalitis (HSVE) is a rare complication after neurosurgery, and its clinical picture mimics features of other most frequent infectious complications of bacterial origin. Probable triggering factors are manipulation and surgical stress, since most cases occur due to reactivation rather than primary infection. The main symptoms include fever and altered consciousness. DNA identification of HSV by PCR has accuracy. Even with adequate treatment, HSVE is associated with a mortality of 30%, and potential neurologic sequelae such as cognitive and motor. CASE REPORT: An 18-year-old male patient presented with loss of vision due to cystic craniopharyngioma. We inserted an Omaya catheter and drained the cyst. On the third day, he presented with fever, seizures, and decreased consciousness. Magnetic resonance imaging (MRI) showed high signal intensity on T2-weighted and FLAIR images in the left frontal and temporal lobe, cingulate gyrus, and corpus callosum, with mass effect. He was submitted to decompressive craniectomy and empirical antibiotic therapy. CSF and blood cultures were negative. Due to inexpressive clinical improvement after 48 hours, CSF was collected for polymerase chain reaction (PCR), and we performed a brain biopsy and started intravenous acyclovir. Histology and PCR confirmed HSVE type 1 and 2. He received antiviral for two weeks and was discharged after CSF PCR negative.CONCLUSIONClinical suspicion, CSF PCR, and imaging are of paramount importance for early diagnosis of HSVE, which should be considered in the differential diagnosis of recent postoperative neurologic surgery in cases of unexplained postoperative fever with altered consciousness.

Author response: Miller Fisher syndrome and polyneuritis cranialis in COVID-19.

We thank Drs. Ni and Xu for their letter on our study.1 We think that our 2 patients developed Miller Fisher syndrome and polyneuritis cranialis because of an aberrant immunologic response to COVID-19. As we previously commented in the article, oropharyngeal swab test for SARS-CoV-2 by qualitative real-time reverse transcriptase polymerase chain reaction (PCR) assay was positive in both patients and negative in the CSF. We did not examine the presence of antibodies for SARS-CoV-2 in CSF because that technique had not been validated. In the patient who acutely presented with Miller Fisher syndrome, CSF PCR for enterovirus, herpes simplex virus type 1 and 2, and varicella zoster virus were negative as well as CSF-VDRL test. On the other hand, in the patient with polyneuritis cranialis, these tests could not be performed because of the extreme circumstances of the University Hospital “Príncipe de Asturias,” Alcala de Henares, Madrid, at the peak of this pandemic. Notwithstanding, considering the temporal relationship, we feel that SARS-CoV-2 infection was responsible for the development of these 2 neurologic pictures.

Progressive multifocal leukoencephalopathy (PML) presenting as focal seizures in a filipino male with aids a case report

A 38-year old male, health care worker presented one month PTA with myoclonic jerks of the left upper extremity lasting approximately one minute associated with left hemiparesis. He was initially managed as cerebrovascular disease (CVD) infarct at a local hospital. Brain plain CT scan and MRI were both unremarkable. Patient was discharged with noted improvement of his motor strength. A week after he developed intermittent fever and recurrence of myoclonic seizures. MRI of the brain plain and contrast showed a non-specific and non - enhancing T2W and FLAIR hyperintensities in the right and left parietal white matter due to small vessel ischemic change or foci of demyelination and temporal lobe volume loss (Fig. 1). His social history revealed MSM (male having sex with male). HIV ELISA was positive and CD4 T-cell count was of 22 cells/ul. Blood Cultures, serum electrolytes and Chest X-ray taken were all unremarkable. Patient was started on combination antiretroviral drug therapy, Azithromycin and Cotrimoxazole and Levetiracetam and discharged. He developed recurrent fever, headache, left sided hemiparesis, blurring of vision, focal seizures and progressive deterioration of sensorium and was readmitted. Empiric Ceftriaxone, IV Valproic Acid and Levetiracetam were started.CSF samples were sent for cultures and film array ®assay for meningitis and encephalitis, India ink and TB gene Expert were all negative (Table 1). CSF Polymerase Chain Reaction (PCR) for JC virus was positive. He deteriorated, became comatose and eventually succumbed on the 3rdweek of admission.

P84-T Neuromyositis associated with cytomegalovirus infection in an immunocompetent patient with antineutrophil cytoplasmic antibodies-associated vasculitis

The role of CMV in ANCA-positive vasculitis is controversial. A 40-year-old man, with an unremarkable medical history, presented with progressive muscle weakness of all four limbs, accompanied by diffuse myalgia, arthralgia, and a 10 kg weight loss 2 months before admission to the Neurology Department of our hospital. Clinical examination revealed a flaccid tetraparesis with absent reflexes on the lower limbs and marked muscle atrophy. Electrophysiological investigations were consistent with a demyelinating motor polyradiculoneuropathy. Laboratory data showed AST = 1137 IU/L (normal < 37 IU/L), ALT = 582 IU/L (normal < 41 IU/L), C-reactive protein (CRP) = 19 mg/L (normal < 8 mg/L), CPK = 13779 IU/L (normal < 397). and LDH = 911 IU/L (normal < 192). CMV ELISA (serum) was strongly positive and CMV DNA by polymerase chain reaction (PCR) in blood and CSF also was positive. Immunologic screening revealed positive anti-myeloperoxidase antibodies anti-MPO = 56,9 IU/mL (normal < 9 IU/mL; ELISA). The inflammatory process involving the vessel walls and muscle fibers was histologically found in biopsy specimen of the muscle, with positive staining for CMV. The patient was treated initially with corticosteroids and intravenous immunoglobulins, but these therapies had very poor effect. Immunosuppressive therapy was instituted, resulting in a progressive partial recovery of all four limb weakness without relapses. We hypothesize that the CMV infection triggered an ANCA-positive vasculitis and its particular severe neurological involvement. An awareness of the association between CMV infection and vasculitis may have important therapeutic consequences.

AN UNCOMMON PRESENTATION, AN UNUSUAL ASSOCIATION: A STROKE, DEMYELINATING DISORDER, OR AN INFECTION?

SESSION TITLE: Critical Care 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Rhombencephalitis, a rare manifestation of listeria is seen in immunocompetent young adults. Reverse takotsubo(r-TTC) is an unusual association described with listeria rhombencephalitis (LRE). CASE PRESENTATION: A 42-year-old Brazilian female with medical history of migraine presented with headache, nausea, vomiting, photophobia, left facial numbness and fevers for four days. Physical findings remarkable for bilateral horizontal nystagmus, left facial numbness and left upper extremity dysdiadochokinesia. Multiple lower cranial nerves were involved subsequently leading to compromised airway, hypoxia, orotracheal intubation and mechanical ventilation. She was treated with ceftriaxone, vancomycin and acyclovir initially. Later ampicillin and double strength trimethoprim/sulfamethoxazole (DS-TMP/SMZ) were added based on the magnetic resonance imaging (MRI) brain results. MRI revealed a ring-enhancing central T1 hypointense lesion in the left cerebral peduncle with extension to posterolateral pons and medulla suspicious for LRE. Chest computerized tomography (CT) was suggestive of pulmonary edema. Echocardiography revealed left ventricular global hypokinesis sparing the apex suggestive of r-TTC. Given her worsening hemiparesis and altered mentation, dexamethasone was initiated on day 4 and continued for seven days. Blood and cerebrospinal fluid culture (CSF) were negative. However, CSF polymerase chain reaction (PCR) confirmed the diagnosis of listeria. Subsequently all antimicrobials were discontinued except ampicillin and DS-TMP/SMZ. A gradual recovery of mentation and hemiparesis was evident. Echocardiography on day 9 showed improvement in the ejection fraction (50-55%). She underwent tracheostomy and subsequently weaned from mechanical ventilation. She was then discharged to acute rehabilitation where she completed 6 weeks of DS-TMP/SMZ and ampicillin. DISCUSSION: Mortality with LRE is high and approaches 51%. CSF culture is the gold standard for diagnosis. Real time PCR, a reliable diagnostic modality is relatively new but not widely available. MRI brain is the preferred radiological investigation. Prognosis depends on timely diagnosis and therapy. rTTC, a form of stress-induced myocardial injury is reversible with recovery from the inciting illness. The role of dexamethasone is controversial and lacks supporting evidence except as reported in case series. In retrospect, corticosteroid was probably beneficial in our patient. Increased penetration into the meninges and bactericidal properties of the ampicillin plus DS-TMP/SMZ combination is an effective therapy for LRE. CONCLUSIONS: LRE is a life-threatening illness and warrants early diagnosis and management in order prevent adverse outcomes and minimize morbidity. Stress related cardiomyopathy, a well-known entity needs prompt identification and supportive therapy. Reference #1: Armstrong RW, Fung PC. Brainstem encephalitis (rhombencephalitis) due to Listeria monocytogenes: case report and review. Clinical Infectious Diseases. The University of Chicago Press; 1993;16(5):689–702. Reference #2: Ruggieri F, Cerri M, Beretta L. Infective rhomboencephalitis and inverted Takotsubo: neurogenic-stunned myocardium or myocarditis? The American journal of emergency medicine. Elsevier; 2014;32(2):191–e1. Reference #3: Merle-Melet M, Dossou-Gbete L, Maurer P, Meyer P, Lozniewski A, Kuntzburger O, et al. Is amoxicillin-cotrimoxazole the most appropriate antibiotic regimen for listeria meningoencephalitis? Review of 22 cases and the literature. Journal of Infection. Elsevier; 1996;33(2):79–85. DISCLOSURES: No relevant relationships by Ricardo de la Villa, source=Web Response No relevant relationships by Alejandro Diaz Chavez, source=Web Response No relevant relationships by Raymonde Jean, source=Web Response No relevant relationships by Sathish Pondaiah, source=Web Response No relevant relationships by Christine Stavropoulos, source=Web Response

Subacute presentation of herpes simplex virus-1 encephalitis: A rare case report

Herpes simplex encephalitis (HSE) is a potentially fatal infectious disease with high mortality if undiagnosed. HSE mostly presents with acute features such as a headache, fever, and altered sensorium. The combination of clinical history and examination, brain computed tomography scan, magnetic resonance imaging (MRI), and cerebrospinal fluid analysis (CSF) analysis have been used to establish the diagnosis. Uncommonly, HSE presents as a mild and slowly evolving disease and clinical relapse is rare. Here, we are presenting a rare case of HSE with subacute course presenting as forgetfulness and disorientation with abnormal CSF analysis and typical MRI findings consistent with HSE and CSF polymerase chain reaction positive for herpes simplex virus-1 DNA, who responded well to Acyclovir therapy with recovery.

TRC4 Gene Based PCR Assay in Diagnosis of Tuberculous Meningitis

The prevalence of Tuberculous meningitis remains largely underestimated due to nonspecific clinical manifestation at early stages. A total of 20 CSF samples were studied from clinically suspected cases of tuberculous meningitis. All the samples were processed for ZN staining, TB culture on LJ media and TB-PCR using IS6110 and TRC4 primers by standard protocols. Of the total 20 CSF samples, 12 cases were diagnosed as TB meningitis. Most of the tuberculous meningitis cases were found positive by PCR using TRC4 primers (83.33%) followed by IS6110 primer (66.67%) and culture on L-J media(8.33%). None were found positive by ZN staining. TB-PCR usingTRC4 primer showed higher positivity than using IS6110 in detecting tuberculous meningitis, since some strains of MTB may lack the IS6110 element in their genome. PCR assay using TRC4 primer is superior in diagnosing tuberculous meningitis. This study was aimed to evaluate the diagnostic potentials of CSF polymerase chain reaction (PCR) by using TRC4 and IS6110 primers. Further the results were also compared with culture on Lowenstein-Jensen (LJ) media and AFB smear by Zeihl-Nelson (ZN) staining.Bangladesh J Med Microbiol 2014; 08 (02): 19-22

ANNA-1 Paraneoplastic Encephalomyelitis Presenting as Rapidly Progressing Dementia in a Man With Undiagnosed Small Cell Lung Cancer

ANNA-1 Paraneoplastic Encephalomyelitis Presenting as Rapidly Progressing Dementia in a Man With Undiagnosed Small Cell Lung Cancer

Post-operative Herpes Simplex Virus Encephalitis after Surgical Resection of Meningioma: A Case Report and Review of the Literature

Background: Herpes Simplex Virus (HSV) encephalitis is a rare but life threatening complication in neurosurgical patients. Diagnosis of Herpes Simplex Encephalitis (HSVE) is based on the detection of the herpes simplex virus (HSV) DNA in patient`s CSF samples. A low threshold for both investigations with CSF PCR and empirical treatment with intravenous acyclovir is warranted. Methods and materials: In this case we discussed a 55- year-old man with HSVE after surgical resection of meningioma. We represent a rare case of HSV encephalitis. The appearance of a high grade fever (40°C) and altered consciousness and spastic quadriparesia complicated the post-operative course in a 55-year-old man who underwent surgical removal of a meningioma on the second postoperative day. Brain MRI detected brain abnormalities on the fourth day after onset of symptoms, and polymerase chain reaction (PCR) identification of HSV 1 DNA confirmed the diagnosis. Result: A positive prognosis was achieved due to the decision to start specific, high-dose antiviral therapy based on clinical suspicion, before a firm diagnosis was established. . Treatment with acyclovir was maintained for 8 weeks and patient die after severe sepsis. Conclusion: There are only few case reports of postoperative HSV1 encephalitis. These reports suggest that this rare postoperative complication is associated with a poor prognosis, with high mortality and morbidity. Neurosurgical interventions involving peripheral nerve root or ganglia have been reported to cause re-activation of cutaneous herpes simplex infection. Factors compromising the immune system may also increase susceptibility to herpes simplex infection.

P65 – 2865: Basal ganglia inflammation and a severe dystonic-akinetic syndrome after mycoplasma pneumonia infection in a 6 years old boy

Objective Severe CNS diseases like encephalitis, myelitis or radiculitis are described frequently associated with mycoplasma pneumonia (Mp) infections. There are some case reports of patients with post-infectious bilateral basal ganglia necrosis. In most cases, polymerase chain reaction (PCR) in CSF for Mp is negative. Standard treatments are mostly restricted to antibiotics and symptomatic therapies. Results A 6 years old boy was admitted to our hospital two weeks after a mild respiratory infection because of mutism and swallowing problems. He was alert, compliant and able to walk unaided. The movements were slowly and dystonic, deep tendon reflexes were augmented. Cerebral MRT revealed bilateral signal alteration of the striatum. Within the next days his state deteriorated. He lay in bed without spontaneous movements, with rigor on all extremities, unable to speak nor to swallow. Under the initial suspicion of a thiamine transporter defect, high doses of thiamine and biotine were given without visible impact within the following days. Mp serology showed up to be positive. So we decided to start an immune modulating therapy with corticoids and intravenously immunoglobulins (IVIG). The PCR for Mp in CSF was negative. For the next days, the neurological condition of the boy did not change. Although autoantibodies could not be found, an autoimmune disease was postulated and plasmaexchange (PE) was performed six times followed by four rituximab administrations. The day after the last PE the boy started to move and within a week, he was able to speek and walk unaided again. Conclusion Because of the prompt clinical recovery after PE we postulate an autoimmune aetiology of this postinfectious neurological disease after mycoplasma pneumonia infection although we could not find autoantibodies. Immunmodulatory therapy with corticosteroids and IVIG was not enough to alter the clinical state, only serial plasma exchanges led to fast improvements of the neurological condition.

Neuromyositis Associated with Cytomegalovirus Infection in an Immunocompetent Patient with Antineutrophil Cytoplasmic Antibodies-Associated Vasculitis

The role of CMV in ANCA-positive vasculitis is controversial. A 40-year-old man, with an unremarkable medical history, presented with progressive muscle weakness of all four limbs, accompanied by diffuse myalgia, arthralgia, and a 10 kg weight loss 2 months before admission to the Neurology Department of our hospital. Clinical examination revealed a flaccid tetraparesis with absent reflexes on the lower limbs and marked muscle atrophy. Electrophysiological investigations were consistent with a demyelinating motor polyradiculoneuropathy. Laboratory data showed AST=1137 IU/L (normal<37 IU/L), ALT=582 IU/L (normal<41 IU/L), C-reactive protein (CRP)=19 mg/L (normal<8 mg/L), CPK=13779 IU/L (normal<397). and LDH=911 IU/L (normal<192). CMV ELISA (serum) was strongly positive and CMV DNA by polymerase chain reaction (PCR) in blood and CSF also was positive. Immunologic screening revealed positive anti-myeloperoxidase antibodies anti-MPO=56,9 IU/mL (normal <9 IU/mL; ELISA). The inflammatory process involving the vessel walls and muscle fibers was histologically found in biopsy specimen of the muscle, with positive staining for CMV. The patient was treated initially with corticosteroids and intravenous immunoglobulins, but these therapies had very poor effect. Immunosuppressive therapy was instituted, resulting in a progressive partial recovery of all four limb weakness without relapses. We hypothesize that the CMV infection triggered an ANCA-positive vasculitis and its particular severe neurological involvement. An awareness of the association between CMV infection and vasculitis may have important therapeutic consequences.

Index of Suspicion in The Nursery

A 4-day-old male infant presents in late November to the pediatrics clinic with decreased activity and poor feeding. The mother reports that he had been feeding and acting well until 1 day before presentation. The mother states that he has not had any rhinorrhea, nasal congestion, cough, vomiting, diarrhea, rash, or any atypical movements that could be seizures. She had not taken his temperature, and she states that he has not felt hot. The pediatrician becomes immediately concerned as she recognizes a lethargic infant in respiratory distress. A code is called, and the resuscitation is begun. The infant was a 3,083-g product of a 38+1 week gestation to a 28-year-old G2P1 woman. The pregnancy was only complicated by a positive group B streptococcus screen at 35 weeks' gestation and a history of herpes simplex virus in the past, but no lesions were noted before or during delivery. On presentation to labor and delivery, the fetus was noted to be tachycardic and the mother had mild abdominal tenderness, leading to initiation of ampicillin and gentamicin 16 hours before delivery. The duration of rupture of membranes was 4 hours. The infant was born via spontaneous vaginal delivery and was vigorous, with Apgar scores of 9 and 9 at 1 and 5 minutes. Because the mother was neither febrile nor tachycardic, it was decided that she did not have chorioamnionitis, so the infant received no further laboratory evaluation or antibiotics. The mother and infant were discharged from the hospital after 2 uneventful days. In the clinic, the 4-day-old infant has initial vital signs that included a temperature of 98.9°F, a heart rate of 170 beats per minute, a respiratory rate of 71 breaths per minute, an oxygen saturation (SaO2) of 80% on room air, and blood pressure 84/35 mm …

Current Concepts in the Management of Tuberculosis

Tuberculosis (TB) poses a serious threat to public health throughout the world but disproportionately afflicts low-income nations. Persons in close contact with a patient with active pulmonary TB and those from endemic regions of the world are at highest risk of primary infection, whereas patients with compromised immune systems are at highest risk of reactivation of latent TB infection (LTBI). Tuberculosis can affect any organ system. Clinical manifestations vary accordingly but often include fever, night sweats, and weight loss. Positive results on either a tuberculin skin test or an interferon-γ release assay in the absence of active TB establish a diagnosis of LTBI. A combination of epidemiological, clinical, radiographic, microbiological, and histopathologic features is used to establish the diagnosis of active TB. Patients with suspected active pulmonary TB should submit 3 sputum specimens for acid-fast bacilli smears and culture, with nucleic acid amplification testing performed on at least 1 specimen. For patients with LTBI, treatment with isoniazid for 9 months is preferred. Patients with active TB should be treated with multiple agents to achieve bacterial clearance, to reduce the risk of transmission, and to prevent the emergence of drug resistance. Directly observed therapy is recommended for the treatment of active TB. Health care professionals should collaborate, when possible, with local and state public health departments to care for patients with TB. Patients with drug-resistant TB or coinfection with human immunodeficiency virus should be treated in collaboration with TB specialists. Public health measures to prevent the spread of TB include appropriate respiratory isolation of patients with active pulmonary TB, contact investigation, and reduction of the LTBI burden.

Going viral: fusiform vertebrobasilar and internal carotid aneurysms with varicella angiitis and common variable immunodeficiency

Intracranial aneurysms in the pediatric population are relatively rare entities. Immunocompromised patients (often from HIV/AIDS or pharmacological immunosuppression) represent a significant fraction of children with cerebral aneurysms. One proposed mechanism of aneurysm formation in these patients is from direct infection of the affected arteries. In this study, the authors report on a case of a 14-year-old girl with common variable immunodeficiency with T-cell dysfunction and a CSF polymerase chain reaction test positive for varicella-zoster virus who underwent evaluation for carotid and basilar artery fusiform aneurysms.