Kernig's Sign Research Articles

結核菌とポリオウイルス2型の混合感染

A 5-year-old female who fell ill with fever on 21st, Nov., 1980 showed vomiting and headache and then was diagnosed as aseptic meningitis. On 2nd Dec. she was admitted to this hospital. Thereafter she had intermittent fever and showed a positive Kernig's sign, stiffness of the neck, stupor, light paresis in left extremities and pain in the abdomen and other parts of body.Cerebrospinal fluid (C.S.F) showed pleocytosis and increment of protein contents. Bacteriological cultures of 3 C.S.F. were found positive for Mycobacterium tuberculosis and the complement fixing serum antibodies against poliovirus type 2 also appeared at the stage between the 27 and 48 days of disease and she showed the rise of the neutralizing antibody titer of serum against this virus strain in the course of the disease. Therefore, she was diagnosed as a complication of tuberculous meningitis and poliomyelitis due to poliovirus type 2.The origin of Mycobacterium tuberculosis was suspected her aunt who had had pulmonary tuberculosis. The origin of poliovirus type 2, however, could not be clarified because she had not received the live vaccine of poliovirus and nobody was suffered from poliomyelitis in her neighborhood. It was tried without effects to isolate the virus from her materials. Then, biological characters of the poliovirus type 2 with which she was infected could not be studied.

Aseptic Meningitis Associated With Ibuprofen

To the Editor. —Three patients with systemic lupus erythematosus (SLE) in whom aseptic meningitis developed during ibuprofen therapy and again with rechallenge have been described. 1-3 We report an additional case in a patient whose course was remarkable for severe lethargy and grossly elevated CSF protein and WBC counts. Report of a Case. —A 23-year-old woman with SLE, manifested by serositis, polyarthritis, Raynaud's phenomenon, high-titer antinuclear antibody with antibodies to double-stranded DNA, and hypocomplementemia, experienced headaches within two hours of taking a 400-mg tablet of ibuprofen. As the ibuprofen therapy was continued during the following 48 hours, the headache progressively worsened and became associated with neck stiffness, nausea, vomiting, and lethargy. Physical examination showed a somnolent young woman who became totally unarousable within four hours of admission. Temperature was 40 °C. Kernig's and Brudzinski's signs were present. Findings from serial CSF analyses are displayed in the Table; CSF smears, cultures,

Eosinophilic Meningitis Following Myelography

<h3>To the Editor.—</h3> If the recently reported case of eosinophilic meningitis following myelography (242:2432, 1979) is only the third reported such case, it appears reasonable to report a fourth case. <h3>Report of a Case.—</h3> Our patient was a 32-year-old woman who had undergone an uneventful iophendylate injection (Pantopaque) myelogram and an L5-S1 diskectomy. Her postoperative course was uneventful until 30 days after the myelogram was performed. She then had an acuteonset of headache and anterior thigh pain. She was afebrile and exhibited a positive Kernig sign, and the straight-leg raising test was normal bilaterally at 20 degrees. Analysis of CSF showed an elevated eosinophil count and an increased protein level (Table). Culture yields for bacteria, viruses, and fungi were all negative. Her blood sample showed a WBC count of 5,500/cu mm, with 45% segmented neutrophils, 6% eosinophils, and 49% lymphocytes. An unsuccessful attempt to remove a small amount of

Neutral involvement in kawasaki disease.

Neurological findings and histopathology of the nervous system were studied in 30 patients with Kawasaki disease. As neurological manifestations, irritability, lethargy, meningeal signs such as nuchal rigidity, Kernig's sign, and opisthotonus, and facial nerve paralysis were present in 8 patients. In 9 out of 11 patients who had examination of cerebrospinal fluid, pleocytosis mainly consisting of lymphocytes and mononuclear cells was seen. Protein and glucose concentrations were within normal range. On histopathological investigation, aseptic chorio and/or leptomeningitis were present in 7 out of 14 patients. Severe edema, edema necrosis and localized status spongiosus were frequently observed. Atrophy, nonspecific degeneration and loss of neurons were detected, but pathognomonic changes were not evident. Marginal gliosis in the subpendimal region and superficial cerebral cortex and glial nodule formation surrounding the degenerated neurons were occasionally seen. Vascular changes such as endoarteritis, periarteritis and perivascular cuffing were present in 5 out 14 patients, though such lesions were geneally mild. Ganglionitis and neuritis in the various areas were seen in 13 patients.

Neuromyelitis optica (Devic disease)_following varicella infection

A 5-year-old white girl was admitted to Milwaukee Children's Hospital with a four-day history of inability to walk. Eleven days prior to admission she developed a febrile illness associated with a vesicular eruption, which was diagnosed as varicella. Two siblings developed a similar exanthem simultaneously. Five days after the onset of her exanthem the patient complained of burning feet. The next day she refused or was unable to walk. Two days later she was noted to have decreased strength in her lower extremities, a stiff neck, incontinence, and blurred vision. There was no history of loss of consciousness or ataxia. Physical examination re~{ealed a well-developed, wellnourished, afebrile white girl covered with crusted lesions. Positive physical findings included posterior cervical lymphadenopathy and positive Kernig and Brudzinski signs. Papilledema was absent. Her abdomen was distended but there was no organomegaly, The patient was alert and well oriented. The optic fundi were normal and cranial nerve dysfunction was not observed. There was a flaccid paralysis of the lower extremities. Rectal sphincter tone was normal. There was loss of pain, pin, and light touch sensations below T~,. Position sensation could not be reliably tested. Deep tendon reflexes were absent in the lower extremities and the Babinski sign was present bilaterally.

Subdural Empyema in an Infant Due to Group B β-Hemolytic Streptococcus

Subdural empyema is a rare infection in children, and its association with group BStreptococcushas not been previously reported. This case is of further interest in that the pathogenesis is best explained by hematogenous infection of subdural hemato Report of a Case.—A 4-month-old male infant born at 36 weeks' gestation had normal development until one day prior to admission to hospital, when fever, irritability, and poor feeding developed. A gradual increase in head size had been noted. The temperature was 39.7 C; head circumference, 45 cm (> 97th percentile); and height, 60 cm (tenth percentile). The fontanelle was full and tense, with slight separation of the sutures and right occipital flattening. Transillumination of the skull was normal. Fundi were normal. Nuchal rigidity was present with positive Kernig and Brudzinski signs. Deep tendon reflexes were symmetrical and slightly increased. There was no evidence of sensory or motor dysfunction. Laboratory

Case of human listeriosis in Kochi--the 1st report in the Shikoku area

Patient: 39 year-old male.Personal and family history: Nothing particular.On the night of 10th January 1970 he was taken ill with high fever, headache and vomiting. On 17th January, the seventh day after the onset, he was admitted to the hospital.The clinical findings at the time of admission were as follows. Temperature 39.6°C, he was in dreamy state and agony. Nuchal rigidity and Kernig's sign was positive.Gram positive short rod was isolated from the cerebrospinal fluid. Its morphological findings and biochemical properties are identical with those of Listeria monocytogenes, i. e. it caused monocytosis in rabbit by its i. v. inoculation and conjunctivitis by its eye smering. Serologically, i. e. by cross agglutination test and absorption test, this strain was identified as Listeria monocytogenes type 1 and named as “Yorimitsu strain” by the authors.The epidemiology of this case has not been clear yet.By adding this case, the total number of human listeriosis cases in this country counts 41. The summary of these 41 cases is indicated in Table 6-9.

Meningeal Irritation : A Review

Cases of meningeal irritation are prevalent worldwide and much Infectious and non-infectiousaetiology exist for this condition. Sub-arachnoid haemorrhage (SAH), central nervous systemsarcoidosis(neuro-sarcoidosis) . systemic lupus erythematosus (SLE), drugs and chemicals arethe non-infectious causes of meningeal irritation. But much is focused on infectious causesbecause infection of the central nervous system (CMS) is a medical emergency. The clinicalconstellation of fever, headache and neck-stiffness is diagnostic of meningitis. Other clinicalfindings like Kernig's sign, Brudzinski's sign and extensor plantar responses support thediagnosis of meningitis and / or meningo-encephalitis. The clinical onset of sudden severeheadache, vomiting and unconsciousness is diagnostic of SAH. Neck rigidity, positive Kernig'ssign and sub-hyaloid haemorrhage on fundoscopic examination support the diagnosis.However, diagnosis of meningitis and its treatment is very much important and critical inparticular. A patient presenting with fever and unconsciousness with no substantial pre-existingillness eg. HTN, DM, endocrinopathy and.' or history of traveling from a malarial epidemic areashould be differentially considered meningo-encephalitis for once at least.doi: 10.3329/taj.v15i2.3922TAJ December 2002; Vol.15(2): 108-114

The signs of Kernig and Brudzinski.

A NEW clinical sign, like a new treatment, often seems to have its greatest value in the hands of its promulgator. Josef Brudzinski (1874-1917), a Polish pediatrician,1claimed that his neck sign for meningitis was present in a higher percentage of cases than Kernig's sign, which had been described earlier for the same condition.2,3The usefulness of Brudzinski's test has been well documented by later observers, but its superiority to Kernig's sign has not been established.4 In 1884, Vladimir Kernig (1840-1917), a Russian physician,1described a sign consisting of limitation in passive extension at the knee because of spasm of the hamstring muscles.3Kernig preferred to elicit his sign with the patient in the sitting position, though the test is rarely done this way now. It is more convenient to allow the patient to remain in the supine position and attempt to extend the knee

An outbreak among children of aseptic meningitis caused by Echovirus type 9. A clinical and serological study.

SummaryAn outbreak of aseptic meningitis broke out in a limited residential area of Jerusalem, Israel, in the early summer of 1967. The patients, whose ages varied from 15 months to 10 years, presented a clinical picture of acute meningitis. Nuchal rigidity, positive Kernig's and Brudzinski's signs and high temperature were noted in all cases.Examination of the CSF revealed pleocytosis, mostly of mononuclear cells.Echovirus 9 was isolated from the CSF of 5 patients and from a throat swab and rectal swab taken from the sixth patient.The outbreak lasted for 5 weeks, and all the patients recovered completely.

Paragonimus meningitis

Meningitic episodes occurring in the histories of patients with known cerebral paragonimiasis appear to be common, but reports of such cases observed and studied in hospital are scarce. It has only been possible to find 6 cases reported in the literature. At the National Medical Center, Seoul, Korea, 6 cases of meningitis associated with cerebral paragonimiasis have been observed and at the Seoul National University Hospital, Seoul, Korea, an additional 2 cases have been observed. A detailed description of the history and clinical findings in these 8 cases is given, and the 6 cases previously reported are reviewed. Based on a review of the literature and upon our own observations the following points are stressed. 1. (1) Meningitis may be the only manifestation of paragonimiasis in the nervous system or it may occur in association with parenchymatous manifestations of the disease. 2. (2) The onset is acute with fever, vomiting, and headache of variable degree. Neck stiffness and Kernig's sign are usually present but may not be severe. In the reported cases and in our 8 patients, such symptoms as headache, irritability, poor general condition and mental confusion are sometimes mild or absent, contrary to the picture seen in other forms of meningitis. This point is valuable in the differential diagnosis from other meningitides, especially from tuberculous meningitis. 3. (3) The spinal fluid findings are similar to those seen in bacterial meningitis. The sugar content of the fluid is usually decreased. The chlorides may be within normal limits or slightly decreased. In a number of cases there is an excess of eosinophils in the fluid. The importance of a careful search for eosinophilia in the spinal fluid is stressed. Paragonimus ova are rarely found in the fluid. 4. (4) In our experience paragonimus meningitis has often been misdiagnosed as tuberculous meningitis. Points of differential diagnostic significance are that in the latter condition the onset is more gradual with a moderate initial rise of the temperature, both the sugar and chloride values are low in the spinal fluid, the general condition of the patient and the conscious level are more severely affected. In paragonimus meningitis the onset is acute with moderate fever and the chloride in the spinal fluid may be normal or only slightly lowered. In suspected cases the CSF should be examined for eosinophils and the skin test for paragonimus should be performed. 5. (5) Bithionol appears to be effective in the treatment of paragonimus meningitis and should be given to all cases.

Abstracts

A 62‐year‐old woman with a long history of neurotic depression and vertex headaches had been taking trifluoperazine (Stelazine), 1 mg. twice a day for 3% years. This medication was stopped and a mixture of tranylcypromine (Parnate) and trifluoperazine, 1 tablet twice a day, was substituted because of the depression. On the sixth day the customary headaches became worse and localized in the occipital area. The medication was stopped the next day. Five days later there was nuchal rigidity, positive Kernig's signs, and fever. Blood pressure was 170/110. Lumbar puncture showed xanthochromic fluid. The subject's condition improved with bed rest, but the former headaches returned.

Clinical paralytic poliomyelitis due to Coxsackie virus group A, type 7.

THE following case represents apparently the first clinical confirmation, outside Russia, of paralytic disease caused by Coxsackie virus Group A, Type 7.Case ReportA 3-year-old boy entered Children's Hospital, Louisville, on July 9, 1956, because of stiff neck, vomiting and walking "stiff legged" for a day. He was noted to have a temperature of 103°F., nuchal rigidity and positive Kernig and Brudzinski signs, without any paresis. The clear spinal fluid revealed 245 white cells per cubic millimeter (68 per cent polymorphonuclear leukocytes and 32 per cent lymphocytes), with a total protein of 32 mg. and sugar of 56 mg. . . .

Pulmonary Cryptococcosis

It is becoming increasingly evident that Cryptococcus infections must be considered in the differential diagnosis of certain types of pulmonary lesions. The causative organism Cryptococcus neoformans (Torula histolytica) is a single budding fungus of world-wide distribution. It can be distinguished from non-pathogenic Cryptococci occurring in the oropharynx by certain cultural methods and by tissue invasion on animal inoculation. In a review of the English literature on cryptococcosis, it was found that at least 75 cases in which the lungs were affected were recorded prior to 1953. Seven additional cases are presented here, bringing the total to 82. This number is approximately one-third of the total of more than 250 cases of cryptococcal infection reported. It is probable that the lung is involved more often than these figures indicate, since it is believed that the causative organism gains access to the body through the respiratory tract. The infection may remain localized there or may spread to adjacent lymph nodes or other organs. The initial pulmonary lesion may heal with or without dissemination of the disease. Case Reports Case I: E. H., a 28-year-old colored male, complained of headaches, experienced over a period of six months, and gradually developing drowsiness. Three days before admission to Lawson Veterans Administration Hospital, he had a generalized clonic convulsion followed by stupor. On admission he was comatose, his neck was stiff, and his reflexes were increased. Roentgenograms showed multiple small, rounded, nodular densities throughout both lung fields (Fig. 1). Death occurred about ten weeks later. A postmortem examination revealed Cryptococcus meningitis with dissemination of miliary granulomata throughout the lungs, liver, and spleen. Case II: B. S. F., a 58-year-old white female, was admitted to Georgia Baptist Hospital in a stuporous condition in May 1949. Kernig and Brudzinski's signs were positive. The liver and spleen were enlarged. Cryptococci were identified in the spinal fluid in an India ink preparation. Roentgenograms of the chest disclosed linear infiltrations and small nodulations throughout the right lung and similar infiltrates with large confluent areas of consolidation in the left lung (Fig. 2). Similar but less extensive infiltrates had been present since 1947, when the patient had been observed in a tuberculosis sanitarium. At that time, numerous smears, cultures, and animal inoculations of the sputum failed to reveal acid-fast bacilli. During the present admission, tuberculin, blastomycin, coccidioidin, and histoplasmin skin tests were negative. The patient's condition improved while she was hospitalized, but she died later at home. Permission for postmortem examination was not obtained.

Escherichia coli meningitis in five-day-old infant; report of a case with complete recovery.

Meningitis is uncommon during the first weeks of life. The mortality incidence of meningitis has changed for the better as a consequence of the introduction and availability of newer and more effective antibiotics, such as chlortetracycline (Aureomycin), oxytetracycline (Terramycin), and chloramphenicol (Chloromycetin). By way of example, before the advent of these antibiotics, of 74 infants less than 2 weeks of age with primary bacterial meningitis, only 7 survived. The morbidity incidence, in the form of impaired cerebral function as a result of meningitis, persists. The high morbidity is partly attributable to poor resistance of the infant to infection and partly to delayed diagnosis. DIAGNOSIS It is well known that, in some cases, the diagnosis of meningitis in the young infant may be extremely difficult, mainly because of the absence of the characteristic signs: the bulging anterior fontanel; nuchal rigidity; projectile vomiting; and positive Brudzinskis and Kernig's signs. Cyanosis, fever, vomiting,

Acute interstitial myocarditis in an infant: Report of a case with autopsy findings

Hivtory.--H. T., a 1-year-old white girl, was admitted to the Jewish Hospital Pediatric Service on March 31, 1935, with the complaint of rapid breathing with grunting expiration, which had begun ten days previously and had become progressively worse. Her appetite failed, and she lost 5 pounds. For the previous two days she had been irritable and drowsy. Birth and developmental history were normal. The child had begun to walk two weeks bes the onset of this illness. There had been no previous illnesses of note. The child had played with toys, the paint on which which was found to contain lead. Fa~n~ly His~o~y.--Both maternal grandparents had arteriosclerotic heart disease. Physical Exa~nimation.--Examination showed a well-developed and nourished child, irritable, but alert. The temperature was 99 ~ (rectal) ; pulse, 160; respirations, 60. There was a mucoid nasal discharge. Breathing was almost entirely diaphragmatic, with grunting expiration. The percussion note was resonant, and the breath sounds were normal. No rMes were heard. The heart was not enlarged. The sounds were of good quality. A systolic murmur was heard best over the mitral area and was transmitted into the left axilla. The murmur was less intense over the aortic area. The liver could be felt 1 cm. below the costal margin in the midclavicular line. The spleen was not palpable. The child assumed a gun-hammer position. The patellar reflexes were hyperactive. The biceps and abdominal reflexes were not elicited. Babinski 's, Kernig 's , and Brudzlnski 's signs were negative. Laboratory Data.--On admission acetone and a trace of albumen were present in the urine, but these disappeared during the hospital stay. Dr. Robert :Kehoe reported no increase of lead in the urine. Repeated counts showed a red blood count of about 3,500,000, with hemoglobin 60 to 65 per cent. The white blood counts varied between 14,000 on admission to 10,000 later on, with the differential count showing 47.5 per cent polymorphonuclears and 48 per cent lymphoeytes. There were moderate anisocytosis, slight poikiloeytosis~ and on one occasion ] per cent eosinophiles and 2.5 per cent reticulocytes. There was no stippling. Blond calcium was 11.2 per cent. The lead content of the stool, determined by Dr. Kehoe, was normal. Spinal fluid pressure was normal. Globulin in the spinal fluid was negative. There were four cells per cubic millimeter. Lead content was at the upper level of normal. Sugar was 86 mg. per cent. The Wassermann test was negative. The Schick test was negative. Tuberculin tests with P.P.D. No. 2 were negative. Cultures from nose and throat showed staphylococci. No ]~lebs-L~ffier organisms were found. The mother 's blood Wassermann test was negative. l~oentgen Exam~nations.--On April 1, 1935, the ulna and radius showed no lead line. On April 2, 1935, lung films were interpreted as follows: Both lungs showed diffuse parenchymatous infiltration along the bronchial tree, apparently due to a bronchitis. The heart was normal in position, size, a~d shape. Teleoroentgenograms of the chest on April 11, ]935, showed the same findings as above. On April 23, 1935, the heart was deviated to the right, and in addition to the previous findings, there was a triangular dense shadow at the base of the right lung, possibly produced by atelectasis of the right lower lobe.

PNEUMOCOCCIC MENINGITIS SUCCESSFULLY TREATED WITH SULFAPYRIDINE

Two reports 1 of the successful treatment of pneumococcic meningitis with 2-( p -aminobenzenesulfonamido) pyridine (sulfapyridine) have recently appeared from England. In view of the rarity of recovery from this disease and the apparent effectiveness of this new drug 2 in the condition, the following case is presented: B. A., a white girl aged 14 years, admitted to the Charles V. Chapin Hospital Nov. 16, 1938, had had a nonproductive cough for two weeks but did not feel sick until three days before admission. At this time headache, projectile vomiting, increasing restlessness and a rise in temperature suddenly developed. She was delirious on admission. The temperature was 103.6 F., the pulse 104, the respiratory rate 26. The blood pressure was 98 systolic, 62 diastolic. Her neck was stiff and the Kernig sign was present. Physical examination showed no other abnormalities. In particular the lungs were clear, and no origin of the infection

Intracranial Arterial Aneurysms

Case 1. A young white male, 30 years of age, whose past medical history was entirely irrelevant to the present condition, was hospitalized in a state of extreme nervousness, complaining of frontal headache, nausea, and vomiting. On the evening prior to the day of admission, while fixing a radio aerial on the roof of his home, he suddenly became dizzy and apparently was unconscious for about fifteen minutes. When he finally recovered consciousness, he was able to make his way to his apartment downstairs, where he complained of a rightsided pounding headache and a sense of exhaustion. His wife noticed him to be extremely pale. Within the next hour he vomited several times. Late that night he had a chill, or at least felt chilly. Within a few hours after admission to the hospital he became semi-stuporous. His rectal temperature was 100 degrees; pulse 84 per minute; blood pressure 160/90. Physical examination failed to reveal any evidence of trauma, and the entire physical examination did not disclose any abnormalities. A tentative diagnosis of an acute gastrointestinal disturbance was made. The eyegrounds were clear. There was no evidence of cranial nerve palsies, and all reflexes were of normal activity. The pupils were regular and equal and reacted smartly to light. The following day he became irrational. His respirations were labored. The blood pressure was now 142/76, pulse 70, temperature 99.4 degrees, and respirations 22. He vomited frequently. There appeared to be signs of meningeal irritation, since he now complained of pain and stiffness in the neck. Kernig's sign was not present. On the following day there was extreme restlessness, irritability, and periods of disorientation and irrationalism. Some stiffness of the neck was still present. During this day the blood pressure ranged from 120 to 140 systolic and 60 diastolic. The rectal temperature ranged just below 100 degrees. On the third day after admission to the hospital, he was somewhat more rational and coherent, complaining of stiffness of the neck. The left pupil was now noted to be slightly larger than the right and reacted better to light. No abnormal reflexes were observed but normal reflexes were not obtained. Biceps and triceps reflexes were diminished. Areas of anesthesia or paresthesia were not found. On the fourth day after admission to the hospital, the right pupil was definitely smaller than the left, and there was a paralysis of the right external rectus muscle. He now complained of some diplopia. Fundus exam-

ACUTE LYMPHOCYTIC MENINGITIS

Scant attention has been paid in America to a symptom-complex which has been widely discussed in Europe in recent years. Especially from France, Germany and Scandinavia have come reports of cases designated by various authors as acute benign idiopathic serous meningitis,1acute aseptic meningitis,2benign aseptic purulent meningitis,3and epidemic meningitis serosa.4Only recently have reports emanated from this country.5 In the syndrome to be discussed there is a prodromal period of one or two weeks, as a rule, during which the patient may have the symptoms of an infection of the upper respiratory tract. Then there is a sudden onset of headache, general malaise, vomiting, mild fever, a varying degree of rigidity of the neck and a mild Kernig sign. Signs in the pyramidal tract are unusual (Kecht6). Blurring of the disks is fairly common in adults. Rarely does involvement of the cranial

Bacteriological Observations on a Case of Meningo-Encephalitis.

On December 12, 1933, a nurse became suddenly ill and repeatedly vomited bile stained material. The following morning she had a severe chill, a temperature of 101 °F., severe headache, some rigidity of the neck and a doubtful Kernig's sign. A day later her temperature reached 105.3°F. and the meningeal symptoms were more marked. During the first 10 days of her illness the more prominent symptoms were: fever, headache, occipital tenderness, rigidity of the neck, strabismus, ptosis of left eyelid, diplopia, twitching muscle fasciculi and lethargy from which she could be fairly easily roused. There was gradual improvement after about the tenth day. Ten weeks after the onset there remained some speech defect, difficulty in feeding herself, dysmetria, sprawling gait, slight nodding of head, emotional instability and impaired memory.Spinal fluid obtained December 15 was hazy and contained 812 cells per cu. mm. (95% small lymphocytes). The sugar content was 37 mg. per 100 cc. and the gold curve 0023321111. Subse...