Meningoencephalitis Syndrome Research Articles

Frequency, characteristics, predictors and treatment of relapsing myelin oligodendrocyte glycoprotein antibody–associated disease (MOGAD)

BackgroundMyelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) may have a monophasic or relapsing disease course. To date, factors that may predict a relapsing disease course remain largely unknown and only limited data exist regarding the efficacy of different utilized immunotherapy regimens at preventing or reducing relapses. ObjectivesTo assess the characteristics, predictors, and immunotherapy of relapsing MOGAD. MethodsThis multicenter retrospective analysis included all MOGAD cases at the University of Florida, Baylor College of Medicine and the University of California San Diego with minimum follow-up time of 6 months. Cox proportional hazards regression analyses, corrected for age and sex, were performed to evaluate hazard ratios (HR) of predictors of a relapsing disease course and to compare relapse hazards for utilized immunotherapies. ResultsThe majority of included participants (51/79 [64.6 %]) had a relapsing course, and of these individuals, 68.6 % (35/51) experienced their first relapse within the first year. However, 10/51 (19.6 %) participants experienced their first relapse ≥5 years (5–15 years) after the initial presentation. Predictors of a relapsing course were CSF pleocytosis (>150 cells/mm3; HR 3.3 [1.18 – 9.24]; p = 0.023), a pediatric disease onset at age < 9 years (HR 2.69 [1.07–6.75]; p = 0.035), and an initial presentation with the clinical syndrome of meningoencephalitis (HR 3.42 [1.28 – 9.17]; p = 0.015),. In participants with a relapsing course, 13/24 (54.2 %) patients remained relapse-free on rituximab, 4/8 (50 %) on mycophenolate mofetil, and 11/14 (78.6 %) on scheduled immunoglobulins. Patients treated with immunoglobulins had significantly fewer relapses compared to patients treated with other immunotherapies (HR: 0.1 [0.2 – 0.63]; p = 0.014). ConclusionsIn our cohort, the majority of MOGAD patients relapsed. The initial relapse occurred most frequently within the first year, but first relapses also took place over a decade after the initial presentation. Prepubertal onset, severe CSF pleocytosis, and the clinical syndrome of meningoencephalitis may be predictors of a relapsing course. Of the currently available off-label steroid-sparing treatments, scheduled immunoglobulins may be the most effective in relapse prevention.

Scrub Typhus in Children: A Prospective Observational Study in a Tertiary Care Hospital in Eastern India.

Background Scrub typhus is a reemerging, acute, undifferentiating febrile illness and one of the most neglected tropical diseases, calling for an in-depth investigation into its clinical diversity, complications, and mortality, which drives us to carry out this research work. Methods Over a year, prospective observational research was carried out after gaining parental consent and institutional ethical clearance, 206 children of either gender aged between one month and 12 years who had been hospitalized with a fever for at least five days and subsequently tested positive forOrientia​​​​tsutsugamushiwere included in the study. Basic demographic information, clinical characteristics, laboratory findings, complications, related coinfections, and results were gathered and analyzed.A P-value of 0.05 was set as the statistical benchmark. Results The current study found that boys outnumbered girls. The ratio of boys to girls was 1.22:1, and the average age was 5.18 years. All had a fever (100%), and the other most frequently occurring clinical signs and symptoms were abdominal pain (16.99%), vomiting (22.33%), hepatosplenomegaly (49.51%), facial puffiness (39.32%), edema (27.18%), lymphadenopathy (19.90%), eschar (19.90%), macular-erythematous rash (17.96%), cough (21.84%), conjunctival congestion (25.24%), and headache (13.59%). Anemia (81.55%), leucocytosis (20.39%), leucopenia (6.8%), thrombocytopenia (49.51%), thrombocytosis (2.43%), and elevated serum levels of alanine aminotransferase (ALT, 57.28%) and aspartate aminotransferase (AST, 63.59%) were characteristic laboratory results. The coinfections were dengue, enteric fever, urinary tract infections, and malaria.Children who also had dengue were more likely to develop thrombocytopenia, which was statistically significant (P-value = 0.008). With doxycycline medication, early defervescence of fever occurred earlier than with azithromycin, and it was statistically significant (P-value = 0.000). The complications were hepatitis (63.59%), lower respiratory tract infections (LRTIs, 22.82%),scrub typhus meningoencephalitis (STME, 3.88%), acute kidney injury (AKI, 2.91%), myocarditis (1.46%), and acute disseminated encephalomyelitis (ADEM, 0.49%). Except for one who had ADEM, everyone was sent back home after receiving the best care possible. The average duration of hospital stay was 6.89 days. Conclusions Even in the absence of eschar, scrub typhus should be suspected in any febrile child who experiences clinical signs of meningoencephalitis syndrome, capillary leakage, skin rash, conjunctival congestion, LRTI, AKI, lymphadenopathy, hepatosplenomegaly, thrombocytopenia, and liver dysfunction in the post-monsoon season. Strong clinical suspicion and prompt anti-scrub drug administration go a long way in preventing or decreasing the morbidity and mortality of the same.

Editorial introductions.

Editorial introductions.

Clinical Performance of FilmArray Meningitis/Encephalitis Multiplex Polymerase Chain Reaction Panel in Central Nervous System Infections.

IntroductionEarly identification of etiology is very important for initiating appropriate therapy promptly in patients with meningoencephalitis (ME). BioFire FilmArray® meningitis/encephalitis (FA-ME) panel is a fully automated multiplex polymerase chain reaction (PCR) that detects 14 pathogens simultaneously in an hour. There is a dearth of studies highlighting its usefulness in ME syndrome in Indian patients.Materials and methodsWe performed a retrospective analysis of patients, admitted to the Kerala Institute of Medical Sciences Hospital, Thiruvananthapuram, Kerala, South India, with meningitis/encephalitis syndrome who underwent the multiplex PCR test on cerebrospinal fluid (CSF) over a period of 2 years from 2016 to 2018. Patients presenting with clinical diagnosis of acute meningitis, encephalitis, or ME who underwent CSF FA-ME panel were studied. The performance of the FA-ME panel was compared to CSF bacterial culture.ResultsTwo-hundred and fifty-nine patients between December 2016 and December 2018 underwent the FA-ME test in CSF. FA-ME test detected pathogens in 61 (23.6%) out of 259 patients with ME syndrome. Among the pathogens detected by FA-ME panel, enterovirus was the commonest accounting for 29 cases (47.5%), followed by varicella in 11 patients (18%) and pneumococci in 9 (14.8%). CSF bacterial culture yield was low, positive only in 8 (3%) out of 259 cases, and matched with FA-ME panel in only one sample that grew Streptococcus pneumoniae. Bacterial culture yielded seven pathogens in those whose FA-ME panels were negative.ConclusionFA-ME panel improves diagnostic yield as compared to bacterial culture (26.3 vs 3%). FA-ME test helps in the early initiation of targeted antibiotic therapy and greater antibiotic de-escalation.How to cite this articleChandran S, Arjun R, Sasidharan A, Niyas VKM, Chandran S. Clinical Performance of FilmArray Meningitis/Encephalitis Multiplex Polymerase Chain Reaction Panel in Central Nervous System Infections. Indian J Crit Care Med 2022;26(1):67–70.

Safety and immunogenicity of an inactivated eastern equine encephalitis virus vaccine

BackgroundEastern equine encephalitis virus (EEEV) is a mosquito borne alphavirus spread primarily in Atlantic and Gulf Coast regions of the United States. EEEV is the causative agent of a devastating meningoencephalitis syndrome, with approximately 30% mortality and significant morbidity. There is no licensed human vaccine against EEEV. An inactivated EEEV vaccine has been offered under investigational new drug (IND) protocols at the United States Army Medical Research Institute of Infectious Diseases (USAMRIID) since 1976. MethodsHealthy at-risk laboratory personnel received inactivated PE-6 strain EEEV (TSI-GSD 104) vaccine under two separate IND protocols. Protocol FY 99–11 (2002–2008) had a primary series consisting of doses on day 0, 7, and 28. Protocol FY 06–31 (2008–2016) utilized a primary series with doses on day 0 and 28, and month 6. Participants with an inadequate immune response, plaque reduction neutralization test with 80% cut-off (PRNT80) titer < 40, received booster vaccination. Volunteers with prior EEEV vaccination were eligible to enroll for booster doses based on annual titer evaluation. ResultsThe FY06-31 dosing schema resulted in significantly greater post-primary series immune response (PRNT80 ≥ 40) rates (84% vs 54%) and geometric mean titers (184.1 vs 39.4). The FY 06–31 dosing schema also resulted in significantly greater cumulative annual immune response rates from 1 to up to 7 years post vaccination (75% vs 59%) and geometric mean of titers (60.1 vs 43.0). The majority of probably or definitely related adverse events were mild and local; there were no probably or definitely related serious adverse events. ConclusionsInactivated PE-6 EEEV vaccine is safe and immunogenic in at-risk laboratory personnel. A prolonged primary series, with month 6 dose, significantly improved vaccine immunogenicity both post-primary series and longitudinally on annual titers. Despite decades of safe use under IND, full licensure is not planned due to manufacturing constraints, and ongoing development of alternatives.

Microbial Etiology of Community Acquired Meningoencephalitis In Adults: A Retrospective Review

Objectives: Meningoencephalitis (ME) is a well-recognized clinical entity with diverse infectious etiologies. Only a few studies in the Indian literature are available on this issue, especially in the adult population. The aim is to study the microbial etiology of ME presenting to a tertiary care center. Methods: A total of 97 cases labeled as ME were initially found on review of hospital records in a retrospective review over 5 years. Of these, only 62 were microbiologically confirmed and these were selected for this study. Results: Bacteria were the cause in 21(34%) cases. Pneumococcus was the predominant bacterial etiology, found in 17 cases (detected by PCR in 15 and by culture in 3 cases). Viruses were seen in 13 (21%) cases; Herpes simplex virus (HSV) was seen in 4 cases and enterovirus and varicella in 2 cases each (all were detected by PCR). We also had Arboviruses: Chikungunya (3 cases) and Dengue (2 cases) (serological diagnosis). TB was found in 15 (24%) cases (diagnosed by positive CSF Xpert Mtb in 11 cases and by AFB culture in 7 cases). Cryptococcus was seen in another 13 (21%) cases (detected by positive CSF CRAG in all cases and culture positivity in 7 cases). Conclusion: Pneumococcus and HSV are the commonest agents causing acute ME syndrome. Mycobacterium tuberculosis and Cryptococcus accounted for all cases of chronic ME. Multiplex PCR (in acute ME) and Xpert Mtb and cryptococcal antigen (in chronic ME) play an important role in the diagnosis of culture-negative ME. J Microbiol Infect Dis 2021; 11(1):15-20.

Disease Surveillance System of Bangladesh: Combating Public Health Emergencies

Disease Surveillance System of Bangladesh: Combating Public Health Emergencies

Protocolo diagnóstico del síndrome de meningoencefalitis importada

Imported meningoencephalitis syndrome encompasses aetiologies present in our geographical area and others that are unique to tropical/subtropical areas or countries in our hemisphere but which have other endemic microorganisms that are not present in Spain. Encephalitis can be differentiated clinically as acute or subacute/chronic and the list of pathogens that can cause these clinical symptoms is very long, and includes agents that predominantly cause encephalitis and others that cause clinical symptoms which, in addition to other manifestations, can include a reduced level of consciousness with or without neurological focus, seizures and/or meningeal syndrome.

Study of Etiological Pattern of Acute Meningo-Encephalitis Syndrome

Background: Acute meningo-encephalitis syndrome is a medical emergency which claim urgent management. So the objectives of the present study was to find out aetiological factors and differentiating parameter between different types acute meningoencephalitis syndrome with minimum investigation. Methods: This hospital based observational study was carried out in medicine units of Chittagong Medical College. Fifty cases were studied who present with acute onset fever with central nervous system dysfunction. Results: In this study it reveals that hospital rate of bacterial meningitis was 26%, viral encephalitis was 34% and severe malaria was 26% among the patient with acute meningo-encephalitis syndrome. It shows that mean age (years) in viral encephalitis was 33.71, bacterial meningitis was 34.15 &amp; in severe malaria was 27.92. It reveals that all patients of this series presented with acute onset fever (n=50,100%), maximum patients present with sign of meningeal irritation (n=44, 88%) &amp; altered mental state (n=41,82%). Few patients was present with new onset seizure (n=11,22%) &amp; neurologic deficit (n=1,2%). In Bacterial meningitis most patient was with low CSF glucose (n=10, 76.9%). In viral meningitis there were normal CSF glucose level (n=17,100%). High protein content in bacterial (n=13,100%) &amp; Viral (n=15,88.2%) was found. It shows differential count of CSF WBC in different type of meningitis where in Bacterial meningitis it is neutrophils &amp; in other type of meningitis it is the lymphocyte. Conclusion: CSF findings are hallmark of diagnosing various type of meningitis. CSF glucose and protein content found in this study significantly correlate with different etiology (p value = 0.000). Bangladesh Journal of Neuroscience 2018; Vol. 34 (1): 45-51

Fungal and Parasitic CNS Infections.

Central nervous system fungal infections can be broadly divided into those that infect a healthy host such as Cryptococcus, Coccidioides, Histoplasma, Blastomyces, Sporothrix spp., and those that cause opportunistic infections in an immunocompromised host such as Candida, Aspergillus, Zygomycetes, Trichosporon spp. The clinical manifestations of central nervous system fungal infections commonly seen in children in clinical practice include a chronic meningitis or meningoencephalitis syndrome, brain abscess, rhino-cerebral syndrome and rarely, a fungal ventriculitis. Fungal central nervous system infections should be suspected in any child with subacute to chronic febrile encephalopathy or meningitis with or without raised intracranial pressure, seizures, orbital pain and/or sero-sanguinous nasal discharge. Diagnosis is corroborated by cerebrospinal fluid analysis, culture and PCR, special stains, serological tests and neuroimaging. Management of fungal central nervous system infections include specific antifungal therapy and supportive measures for associated problems, management of underlying predisposing condition and surgical intervention in cases with localized disease, abscess or presence of simultaneous foreign body such as intracranial shunts. In addition to the fungi, several parasitic infections can cause central nervous system infections in children. Of these, authors briefly discuss cerebral malaria, and amebic meningo-encephalitis.

Severe Human Illness Caused by Rift Valley Fever Virus in Mauritania, 2015.

Background.Rift Valley Fever epizootics are characterized by numerous abortions and mortality among young animals. In humans, the illness is usually characterized by a mild self-limited febrile illness, which could progress to more serious complications.Objectives. The aim of the present prospective study was to describe severe clinical signs and symptoms of Rift Valley Fever in southern Mauritania.Patients and methods.Suspected cases were enrolled in Kiffa (Assaba) and Aleg (Brakna) Hospital Centers from September 1 to November 7, 2015, based on the presence of fever, hemorrhagic or meningoencephalitic syndromes, and probable contact with sick animals. Suspected cases were confirmed by enzyme-linked immunosorbent assay (ELISA) and reverse transcriptase-polymerase chain reaction (RT-PCR).Results.There were thirty-one confirmed cases. The sex ratio M/F and the average age were 2.9 and 25 years old [range, 4-70 years old], respectively. Mosquito bites, direct contact with aborted or dead animals, and frequent ingestion of milk from these animals were risk factors observed in all patients. Hemorrhagic and neurological manifestations were observed in 81% and 13% of cases, respectively. The results of laboratory analysis showed high levels of transaminases, creatinine, and urea associated with thrombocytopenia, anemia, and leukopenia. All patients who died (42%) had a hemorrhagic syndrome and 3 of them had a neurological complication. Among the cured patients, none had neurologic sequelae.Conclusion.The hemorrhagic form was the most common clinical manifestation of RVF found in southern Mauritania and was responsible for a high mortality rate. Our results justify the implementation of a continuous epidemiological surveillance.

Emergence of human West Nile Virus infection in Sri Lanka.

BackgroundWest Nile virus (WNV) has emerged as one of the most common causes of epidemic meningoencephalitis worldwide. Most human infections are asymptomatic. However, neuroinvasive disease characterized by meningitis, encephalitis and/or acute flaccid paralysis is associated with significant morbidity and mortality. Although outbreaks have been reported in Asia, human WNV infection has not been previously reported in Sri Lanka.MethodsSera and cerebrospinal fluid (CSF) from 108 consecutive patients with a clinical diagnosis of encephalitis admitted to two tertiary care hospitals in Colombo, Sri Lanka were screened for WNV IgM antibody using enzyme-linked immunosorbent assay. Positive results were confirmed using plaque reduction neutralization test (PRNT). Patient data were obtained from medical records and by interviewing patients and care-givers.ResultsThree of the 108 patients had WNV IgM antibody in serum and one had antibody in the CSF. The presence of WNV neutralizing antibodies was confirmed in two of the three patients using PRNT. Two patients had presented with the clinical syndrome of meningoencephalitis while one had presented with encephalitis. One patient had CSF lymphocytic pleocytosis, one had neutrophilic pleocytosis while CSF cell counts were normal in one. CSF protein showed marginal increase in two patients.ConclusionsThis is the first report of human WNV infection identified in patients presenting with encephalitis or meningoencephalitis in Sri Lanka. There were no clinical, routine laboratory or radiological features that were distinguishable from other infectious causes of meningoencephalitis.

Atypical Presentation of West Nile Virus in a Newly Diagnosed Human Immunodeficiency Virus Patient in New York City

Central nervous system manifestations of West Nile virus (WNV) infection include meningitis, encephalitis, and poliomyelitis-like syndrome. We describe a 44-year-old man with no past medical history who presented with a meningoencephalitic syndrome and spastic paralysis bilaterally in the upper and lower extremities, hyperreflexia, and myoclonus and was ultimately diagnosed as being infected with HIV and WNV.

Inaugural severe vaso-occlusive retinopathy in systemic lupus erythematosus

Purpose To report the case of a patient with an inaugural severe bilateral vaso-occlusive retinopathy due to systemic lupus erythematosus. Method Clinical examination, fundus pictures and fluorescein angiography were performed. Results A 26-year-old, healthy, African man presented with a meningo-encephalitic syndrome and a severe bilateral visual impairment. The fundus examination revealed multiple retinal vascular occlusions, and a fluorescein angiography showed retinal and choroidal ischemia bilaterally. In addition, based on the neurologic disorders, a pleuritis, a renal disorder and a hematologic disorder, systemic lupus erythematosus, was diagnosed. Conclusions Severe vaso-occlusive retinopathy in a 26-year-old man resulting in a significant visual loss as the initial manifestation of systemic lupus erythematosus. Central nervous system involvement during lupus might be more frequent in patients when serious retinal changes occur.

The spectrum of central nervous system infections in an adult referral hospital in Hanoi, Vietnam.

ObjectivesTo determine prospectively the causative pathogens of central nervous system (CNS) infections in patients admitted to a tertiary referral hospital in Hanoi, Vietnam.MethodsFrom May 2007 to December 2008, cerebrospinal fluid (CSF) samples from 352 adults with suspected meningitis or encephalitis underwent routine testing, staining (Gram, Ziehl-Nielsen, India ink), bacterial culture and polymerase chain reaction targeting Neisseria meningitidis, Streptococcus pneumoniae, S. suis, Haemophilus influenzae type b, Herpes simplex virus (HSV), Varicella Zoster virus (VZV), enterovirus, and 16S ribosomal RNA. Blood cultures and clinically indicated radiology were also performed. Patients were classified as having confirmed or suspected bacterial (BM), tuberculous (TBM), cryptococcal (CRM), eosinophilic (EOM) meningitis, aseptic encephalitis/meningitis (AEM), neurocysticercosis and others.Results352 (male: 66%) patients were recruited: median age 34 years (range 13–85). 95/352 (27.3%) diagnoses were laboratory confirmed and one by cranial radiology: BM (n = 62), TBM (n = 9), AEM (n = 19), CRM (n = 5), and neurocysticercosis (n = 1, cranial radiology). S. suis predominated as the cause of BM [48/62 (77.4%)]; Listeria monocytogenese (n = 1), S. pasteurianus (n = 1) and N. meningitidis (n = 2) were infrequent. AEM viruses were: HSV (n = 12), VZV (n = 5) and enterovirus (n = 2). 5 patients had EOM. Of 262/352 (74.4%) patients with full clinical data, 209 (79.8%) were hospital referrals and 186 (71%) had been on antimicrobials. 21 (8%) patients died: TBM (15.2%), AEM (10%), and BM (2.8%).ConclusionsMost infections lacked microbiological confirmation. S. suis was the most common cause of BM in this setting. Improved diagnostics are needed for meningoencephalitic syndromes to inform treatment and prevention strategies.

Toscana meningoencephalitis: A comparison to other viral central nervous system infections

BackgroundToscana virus (TOSV) is an emerging pathogen causing central nervous system (CNS) infection in Mediterranean countries, mostly during summer season. ObjectivesTo compare the clinical and laboratory characteristics of Toscana CNS infections to the most common viral pathogens seen in the United States. Study designWe performed a case series of patients with 41 TOSV infection and compared the clinical characteristics, laboratory findings, imaging results and clinical outcomes to the most commonly recognized viral causes of meningoencephalitis in the US [enterovirus (n=60), herpes simplex virus (n=48), and West Nile virus (n=30)] from our multi-center study of patients with aseptic meningoencephalitis syndromes in the Greater Houston area. ResultsTOSV infection occurs in different age groups compared to enterovirus, HSV, and WNV. All infections most frequently occur during summer–fall except HSV which distributes throughout the year. All patients with TOSV had history of travel to endemic areas. There are differences in clinical presentation and CSF findings comparing TOSV and enterovirus, HSV, and WNV infection. There are no significant differences in outcomes of each infection except WNV meningoencephalitis which had a poorer outcome compared to TOSV infection. ConclusionsTOSV is an emerging pathogen that should be considered in the differential diagnosis of patients with CNS infections and a recent travel history to endemic areas.

A Novel Low-Cost Approach to Estimate the Incidence of Japanese Encephalitis in the Catchment Area of Three Hospitals in Bangladesh

Acute meningoencephalitis syndrome surveillance was initiated in three medical college hospitals in Bangladesh in October 2007 to identify Japanese encephalitis (JE) cases. We estimated the population-based incidence of JE in the three hospitals' catchment areas by adjusting the hospital-based crude incidence of JE by the proportion of catchment area meningoencephalitis cases who were admitted to surveillance hospitals. Instead of a traditional house-to-house survey, which is expensive for a disease with low frequency, we attempted a novel approach to identify meningoencephalitis cases in the hospital catchment area through social networks among the community residents. The estimated JE incidence was 2.7/100,000 population in Rajshahi (95% confidence interval [CI] = 1.8-4.9), 1.4 in Khulna (95% CI = 0.9-4.1), and 0.6 in Chittagong (95% CI = 0.4-0.9). Bangladesh should consider a pilot project to introduce JE vaccine in high-incidence areas.

Phylodynamics, vectorial competence and genetic diversity of West Nile virus in Africa: implications for global emergence of West Nile

West Nile virus (WNV) is a flavivirus (Flaviviridae family) and its transmission cycle involves Culex spp. mosquitoes and birds as reservoirs host whereas humans and horses are dead-end hosts. Clinical symptoms of WN human infections range from asymptomatic or mild influenza like disease to severe neurological and meningoencephalitis syndromes. West Nile is a neglected emerging disease with major breakthrough in 1999 with the introduction of WN virus (WNV) in New York City and the subsequent spread to whole northern America over the last decade causing massive human and animals infection leading to some fatal cases. In Eastern Europe, circulation of WNV with recurrent emergences impacting human and animal health since 1996 is similar to the situation in the USA. Strikingly, in Africa WN appears to have a minor effect despite regular isolations from mosquitoes and vertebrates hosts. In addition, WNV exhibited a great diversity with eight different lineages among which only one (lineage 1) is found worldwide and 4 are present in Africa. In order to understand factors underlying the different patterns of transmission and processes involved in the emergence of WN in the different contexts, genetic diversity, phylodynamics and vectorial competence of WNV have been studied in Africa. Phylogenetic analysis based on partial and complete genome suggests an interconnection of zoonotic amplifications in Africa with emergence in Europe as well as replacement between lineages over time. Vectorial competence of lineages circulating in Africa for a domestic mosquitoes Culex quinquefasciatus showed significant differences between strains of various lineages tested for infections, dissemination and transmission rates. Indeed the different strains can be classified as low, intermediary and high infection profile. Analysis of the transmission patterns with sequences of the strains suggest that glysoylation of the envelope protein of WNV, a key player in the virus entry in the cell, may play an important role. The implications of our findings are discussed in the context of global emergence of WN.

Central Nervous System Infections in Cancer Patients

With improved treatments, patients with many types of cancer survive longer. However, both the acute adverse effects of more intensive therapies and the risks of chronic immunosuppression have led to a diverse and evolving spectrum of central nervous system (CNS) infections. The presentation and course of CNS infections in cancer patients may be different from those in patients without cancer, complicating and delaying accurate diagnosis. New syndromes related both to the underlying malignancies and to their treatment continue to emerge. Noninfectious disorders such as adverse drug effects, vascular lesions, and radiation effects can mimic CNS infections. The two major clinical presentations of CNS infections are meningoencephalitic syndromes and focal deficits due to mass lesions. The range of pathogens can be narrowed by considering the type of immune deficit present, local nosocomial trends, and the specific vulnerabilities created by the underlying disease and treatment regimen. Patients undergoing neurosurgical procedures and those receiving hematopoietic cell transplants (HCT) account for the majority of cancer patients with CNS infections. Significant recent changes reviewed here include evolving patterns of bacterial meningitis, current treatment recommendations for fungal infections, special infectious risks associated with immunomodulatory therapies, and neuroimaging techniques to distinguish infection from other intracranial processes.

Insuffisance rénale aiguë lors d’un traitement par aciclovir

The antiviral molecule acyclovir can be responsible of severe renal dysfunction. Intratubular crystal precipitation of the drug may represent a major pathogenetic mechanism. ObservationA 30-year old, immunocompetent woman was admitted in the neurology unit for a viral meningo-encephalitic syndrome. Intravenous acyclovir was delivered at the dose of 45mg/kg per day. Despite a neurological improvement, she developed an acute renal insufficiency with the serum creatinine increasing from 63 to 385μmol/L within 12 days. The urine study revealed great amounts of birefringent crystals which were typical of acyclovir derived crystals according to the spectrophotometric examination. Withdrawal of acyclovir treatment in combination with oral and parenteral hydration resulted in a complete recovery of the renal function. The conditions favouring acyclovir-induced nephrotoxicity are discussed.