Positive Meningeal Signs Research Articles

Chronic Neutrophilic Meningitis in Tuberculous Infection: A Rare Case Presentation and review of the literature

Persistent neutrophilic pleocytosis syndrome is a rare form of tuberculous meningitis that is defined as the persistence of neutrophils in cerebrospinal fluid for more than 7 days, in association with the clinical features of meningitis (headache, fever, and positive meningeal signs).1 The exact pathogenesis of this syndrome is not well known yet, and it has many diverse etiologies, including infectious and noninfectious ones. among infectious ones: bacteria such as Nocardia and Actinomyces, and systemic mycoses such as Aspergillus and the zygomycetes, as well as mycobacterium.2 This entity is very rare in immunocompetent patients, and most of the cases are due to infectious causes in those who are immunocompromised. The usual scenario in such cases is initiating broad-spectrum antimicrobial agents without any improvement, therefore the diagnosis is difficult initially and often delayed. Therefore, the epidemiologic features and clinical profile may offer clues to the etiologic agent, especially in the immunocompromised host.3

Clinical characteristics and prognosis of pediatric Listeria monocytogenes meningitis based on 10-year data from a large children's hospital in China.

This study aims to summarize the clinical characteristics and prognosis of Listeria monocytogenes (LM) meningitis in children in Chongqing, China. A retrospective analysis of the clinical data and follow-up results of 20 LM meningitis patients admitted to the Children's Hospital of Chongqing Medical University (CHCMU) from January 2012 to December 2022 was performed. The LM meningitis incidence rate was between 0 and 14.3 per 100,000 persons. The median age at onset was 8.98 months. There were five neonate cases, which all had perinatal abnormalities. Seven non-neonatal cases (7/15, 46.7%) had a documented history of contaminated food intake. One case had primary immunodeficiency. The most common symptoms were fever (20/20), altered consciousness (19/20), and vomiting (15/20). Seven cases had seizures, eight cases had cranial nerve involvement, eight cases had positive Babinski sign, and 10 cases had positive meningeal signs. The most common complications were hyponatremia (6/20), hypokalemia (6/20), respiratory failure (5/20), subdural effusion (3/20), and hydrocephalus (2/20). Treatment primarily involved monotherapy or combination therapy with meropenem (15/20) and ampicillin (10/20). Fifteen cases were treated with monotherapy or combination therapy using vancomycin. Twelve cases were successfully followed up from 10 months to 9 years and 6 months, and all had favorable long-term outcomes. LM meningitis incidence in children is low and with nonspecific clinical manifestations. Strengthening food hygiene and safety education, and avoiding infections during pregnancy are important to prevent LM infection in neonates and high-risk individuals. Meropenem and ampicillin are the preferred treatments. Early diagnosis and treatment can improve prognosis.IMPORTANCEThe incidence of LM meningitis is extremely low, and there is currently no standardized treatment. We conducted a retrospective analysis of ten years of data from CHCMU regarding diagnosed LM meningitis cases, aiming to provide clinical evidence for the diagnosis and treatment.

Clinical characteristics of perioperative central fever and its relationship with anesthesia.

To analyze clinical characteristics and anesthesia-related factors influencing central fever during cranial neurosurgery. 31 central fever cases (observation) and 120 controls (no fever) underwent detailed investigation. Anaesthesia-related variables were analyzed using logistic regression. Observation group exhibited significantly elevated indicators-CSF white blood cells, protein, CRP, severe EEG abnormalities, abnormal imaging, positive meningeal signs, seizures, consciousness disorders, and status epilepticus (P < .05). Anesthesia plans showed no influence (P > .05). pH, PaCO2, PaO2, SaO2, MAP, ICP, CPP, and SjiO2 didn't impact central fever (P > .05). However, high HR, low Da-jvO2, and low CEO2 were independent risk factors (P < .05). Central fever, marked by CNS abnormalities, manifests with distinctive clinical features. Anesthesia plans have limited impact, while elevated HR, low Da-jvO2, and low CEO2 independently contribute to central fever. Understanding these factors is crucial for perioperative care optimization.

Meningoencephalitis Secondary To Cerebrospinal Fluid Leakage From Nasopharyngeal COVID-19 Swab (P6-10.006)

<h3>Objective:</h3> NA <h3>Background:</h3> The WHO regarded the novel coronavirus as an outbreak on January 2020. The preferable initial testing to detect SARS-CoV-2 RNA was from the upper respiratory tract using nucleic acid amplification testing (NAAT) through nasopharyngeal, oropharyngeal, nasal mid-turbinate, or anterior nasal specimen. Although specimen collection is considered safe and adverse events are rare, some reported cases of cerebrospinal fluid leakage were attributed to pharyngeal swab procedures. Therefore, increased awareness of nasal and pharyngeal swab complications is necessary. <h3>Design/Methods:</h3> A 36 years old female known to have chronic idiopathic intracranial hypertension brought to the emergency department with a history of fever, altered level of consciousness, and generalized tonic-clonic seizure. She had unilateral rhinorrhea for three months following a nasopharyngeal COVID-19 swab as part of an in-vitro fertilization workup. Upon assessment in the ED, she was stuporous due to sedation effect. There was no clear rhinorrhea, no papilledema on the fundus exam, and the remaining cranial nerves examination was unremarkable. She had positive meningeal signs. A cloudy cerebrospinal fluid analysis revealed findings of bacterial meningitis with high WBC and protein. She was started on empirical antimeningeal coverage. MRI brain showed a small CSF containing space at the left inferior frontal in the olfactory groove, which is continuous with the adjacent sulci concerning for the CSF leak site. Beta-transferrin was requested by the otolaryngology team and came back positive. After fourteen days of antibiotics, she regained her baseline cognitive and functional status then was discharged in stable condition with close follow-up with neurology, otolaryngology, and MRI cisternography. <h3>Results:</h3> NA <h3>Conclusions:</h3> Our case emphasizes that awareness of potential adverse events related to nasopharyngeal swabs that became part of daily clinical practice and hospital policies must be improved. It also supports existing scattered evidence that an existing idiopathic intracranial hypertension can be associated with cerebrospinal fluid leakage. <b>Disclosure:</b> Dr. Alnafisah has nothing to disclose. Dr. Altowairqi has nothing to disclose.

Varicella Zoster Virus Aseptic Meningitis: A Misleading Clinical And Laboratory Presentation: Three Case Reports

Background: A septic meningitis caused by varicella zoster virus (VZV) reactivation was less described in the literature, Varicella-zoster virus is a neurotropic virus that remain dormant in dorsal root ganglion after primary infection, usually manifested as chickenpox which gets reactivated in immunocompromized state presented usually with vesicular rash complicated with multi-organ affection such as central nervous system. Rarely this characteristic skin rash can be absent initially requiring high clinical suspicion for diagnosis. When no skin lesions are present, a high clinical suspicion is required to reach the diagnosis. In this report we described three clinical of varicella-zoster virus reactivation presented in atypical way in terms of clinical presentation and cerebrospinal fluid analysis. Case presentation: Three patients otherwise healthy were admitted to the hospital with a chief complaint of headache, nausea, vomiting and symptoms suggestive of increased intracranial pressure (IIH). Resembling IIH but due to acute presentation and positive meningeal signs this was unlikely. The clinical examination did not show any neurological deficits or rash except lately in the first case. Lumbar puncture unexpectedly showed high opening pressure with markedly elevated CSF total and high total cell count with lymphocytic predominance which was misleading raising suspicion of tuberculous meningitis. Further CSF analysis, including polymerase chain reaction (PCR) and detection of intrathecal synthesis of antibodies, showed a VZV infection. Clinical follow-up examinations later on proved successful antiviral treatment. Conclusion: In conclusion, absence of typical vesicular rash of varicella zoster initially as well as high opening CSF pressure with high CSF protein even young and previously healthy patients should not rule out consideration of varicella zoster meningitis.

A Little Neutrophil Predominance May Not Be a Harbinger of Death: Clinical and Laboratory Characteristics of Meningitis in Jordan.

Background This study aims to evaluate the clinical features, laboratory findings, and outcomes of children and adults diagnosed with meningitis in Jordan. Methodology This is a retrospective chart review study that targeted patients diagnosed with meningitis at King Abdullah University Hospital, a tertiary care center in Northern Jordan, from March 21, 2015, to March 31, 2019. Patients were included in this study if they were older than 28 days and had no risk factors for meningitis. Results A total of 169 patients met the inclusion criteria. Males were overrepresented (67%) and were significantly younger than females (6 vs. 17 years, p = 0.01). Positive meningeal signs were not predictive of greater cerebrospinal fluid leukocytosis (p = 0.348), and they did not provide sufficient sensitivity to be used as screening tools. The most common etiology was aseptic (49%), followed by enterovirus (43%), while bacterial meningitis was an uncommon diagnosis (3.5%). Nearly half of the patients took antibiotics prior to their hospital presentation. During in-hospital admission, six patients died, four of whom had bacterial and two had aseptic meningitis. Enteroviral meningitis showed neutrophil predominance in 44% of cases on lumbar puncture and had a higher neutrophil proportion compared to aseptic meningitis (p = 0.026). Streptococcus pneumoniae was the most common bacterial etiology identified. Conclusions Meningitis in Jordan is most commonly of aseptic and enteroviral origin, and these etiologies carry significantly more favorable outcomes compared to bacterial meningitis. Enteroviral meningitis displays a higher percentage of neutrophils in cerebrospinal fluid compared to aseptic meningitis. S. pneumoniae is the leading cause of bacterial meningitis.Slight neutrophil predominance above halfis a weak predictor of bacterial meningitis due to the small contribution of bacteria asa cause among enteroviruses and aseptic etiologies.

Varicella Zoster Virus Aseptic Meningitis: A Misleading Clinical and Laboratory Presentation: Three Cases Reports

Background: A septic meningitis caused by varicella zoster virus (VZV) reactivation was less described in the literature, Varicella-zoster virus is a neurotropic virus that remain dormant in dorsal root ganglion after primary infection, usually manifested as chickenpox which gets reactivated in immunocompromized state presented usually with vesicular rash complicated with multi-organ affection such as central nervous system. Rarely this characteristic skin rash can be absent initially requiring high clinical suspicion for diagnosis. When no skin lesions are present, a high clinical suspicion is required to reach the diagnosis. In this report we described three clinical of varicella- zoster virus reactivation presented in atypical way in terms of clinical presentation and cerebrospinal fluid analysis. Case presentation: Three patients otherwise healthy were admitted to the hospital with a chief complaint of headache, nausea, vomiting and symptoms suggestive of increased intracranial pressure (IIH). Resembling IIH but due to acute presentation and positive meningeal signs this was unlikely. The clinical examination did not show any neurological deficits or rash except lately in the first case. Lumbar puncture unexpectedly showed high opening pressure with markedly elevated CSF total and high total cell count with lymphocytic predominance which was misleading raising suspicion of tuberculous meningitis. Further CSF analysis, including polymerase chain reaction (PCR) and detection of intrathecal synthesis of antibodies, showed a VZV infection. Clinical follow-up examinations later on proved successful antiviral treatment.

A Rare Case of Guillain–Barré Syndrome with Signs of Meningeal Irritation and Treatment-Related Fluctuations/Relapse

Abstract Guillain–Barré Syndrome is an acute inflammatory demyelinating polyradiculoneuropathy that can present at any age. The presentation of Guillain–Barré syndrome may be variable as the classic symptoms of areflexia and flaccid paralysis may or may not be present. Here we reported a case of a 15-year-old male patient who presented with complaints of weakness in bilateral lower limbs with inability to sit along with slurred speech and drooling of saliva with positive meningeal signs like neck stiffness and Kernig's sign. His symptoms improved with immunoglobulin therapy. Five days later, the child again had pain and increased weakness with increased work of breathing for which repeat dose and course of immunoglobulins were given. As patients with signs of meningeal irritation may suggest other diseases such as meningitis, it is important to consider atypical cases of Guillain–Barré syndrome along with treatment-related fluctuations as observed in our patient.

Fatality Case in a Tuberculous Meningoencephalitis Patient Coinfected with COVID-19

: Tuberculous meningoencephalitis (TBM) is the most severe, life-threatening form of tuberculosis that contributes to as much as 5% of cases of extrapulmonary tuberculosis. Emerging at the end of 2019, COVID-19 has been shown to affect various organs, including the brain. In this case report, a 21-year-old woman diagnosed with TBM, being in the intensive phase of tuberculous therapy, came with dysphagia and dysphonia as new complaints felt one day before admission accompanied by a positive meningeal sign, diplopia, and cephalgia, which became heavier after previously getting better. Cough and fever followed this complaint two days before admission. About the laboratory results, the PCR was positive for COVID-19, and CT scans showed increased leptomeningeal enhancement when compared with CT scan one month earlier. The patient received intravenous dexamethasone, anti-tuberculosis drugs, phenytoin, aspirin, oseltamivir, and hydroxychloroquine. The patient died four days after being hospitalized due to respiratory failure. This case report shows the coinfection of COVID-19 and TBM resulting in a poor tuberculosis treatment response and outcome.

Subarachnoid Hemorrhage: A Case Report

We reported a case report of a 50-year-old woman with stroke hemorrhage due to subarachnoid hemorrhage with hypertensive urgency, left ventricular hypertrophy, and dyslipidemia. Subarachnoid hemorrhage indicates the presence of blood in the subarachnoid space between the pia mater and arachnoid mater which usually results from a ruptured cerebral aneurysm or arteriovenous malformation. The patient presents with decreased consciousness preceded by severe headache and projectile vomiting. In physical examination, we found hypertensive emergencies and positive meningeal signs, neck stiffness, and positive Brudzinski. CT scan shows bleeding in the pontocerebellar cistern and ventricular system. The patient was diagnosed with subarachnoid hemorrhage, intraventricular hemorrhage, and emergency hypertensive. The patient was hospitalized in the neurology ward of Ulin Hospital for 20 days with the management of antihypertensive, neuroprotectant, other symptomatic medications, and ventriculoperitoneal shunt surgery. The patient was then discharged home in a stable condition.

Disseminated Glioneuronal Tumor: A rare presentation in children

Gliomas, though most common pediatric central nervous system tumor, can manifest as disseminated glio-neuronal tumor, a rare variant in children. Clinical presentation depends on its location, type and age of child. We are presenting 8 years old male child with fever, projectile vomiting and severe headache which woke him up from deep sleep for 1 month. He had positive meningeal signs and raised intracranial tension with cerebrospinal fluid picture suggestive of partially treated meningitis. There was no improvement even on adequate duration of intravenous antibiotics and had appearance of new onset false localizing signs, MRI brain showed features of cryptococcal meningitis for which India ink staining was negative. As clinical picture was unlike of meningitis, repeat 3 tesla MRI brain was done. Expert neuro-radiologist’s opinion was in favor of disseminated glio-neuronal tumor which was confirmed on histopathological examination. Child underwent laminectomy in TATA memorial hospital and advised palliative care. Child succumbed at home within 6 months of illness.

Pseudomonas Pseudoalcaligenes Caused Otogenic Cerebellar Brain Abscess In Indonesian Child

Otogenic brain abscess is a common intracranial complication from chronic supurative otitis media.Pseudomonas pseudoalcaligenes is a rare cause of brain abscess. Prompt diagnosis and decision making issignificant in order to decrease the mortality rate from this type of abscess. We described A 13-year-old boypresented with decreased consciousness, positive meningeal signs, and pathological reflexes. There was ahistory of chronic suppurative otitis media. A head CT scan revealed multiple left cerebellar abscesses andbrain edema. The abscess wall culture revealed P. pseudoalcaligenes. After being managed with surgicalabscess drainage, mastoidectomy, ear flushing, and antimicrobial therapy for six weeks, his consciousnesslevel improved. Cerebellar neurological impairment was still observed. Physical and neurologicalrehabilitation was performed in order to improve the patient’s condition.

An unusual presentation of neurosyphilis with complicated pulmonary involvement in a patient without HIV infection

Background: Neurosyphilis could develop at any time in the course of syphilis; with an annual incidence of 0.7 per 100,000 men. Homosexual and HIV were risk factors. Here we report an unusual case of neurosyphilis in non-HIV patient with complicated pulmonary involvement. Case description: A fifty-six-year-old promiscuity, heterosexual man, active smoker presented with a three-month history of pruritic maculopapular rashes on his body associated with low-grade fever, and a two-week history of productive cough with dyspnea. On physical examination, he was tachypnea, with crackles on the base of the right lung. There was plaque hyperpigmentation on his malar area and multiple maculopapular, erythematous lesions on his trunk, extremities including palms of the hands, and scrotal area. No ulcer was found on his penis. Laboratory results revealed leukocytosis (19.9 × 103/μl), non-reactive HIV test, with high titer of serum VDRL (1/8) and TPHA (1/1280). Chest X-ray showed infiltrate on right perihilar area. Patient was diagnosed as pneumonia with secondary syphilis. The patient was treated with a single dose of benzathine penicillin G 2.4 million units intramuscular and azithromycin 500 mg tablet OD. During observation, he had altered mental status, generalized tonic seizure, high-grade fever with respiratory distress. He had Argyll Robertson pupil, left central facial and hypoglossal nerve paralysis, and positive meningeal signs, with normal brain CT scan result, non-reactive CSF-VDRL and TPHA, with high leucocyte (17 cells/μl) and protein (54 mg/dl). He was diagnosed neurosyphilis with hospital-acquired pneumonia and treated with ceftriaxone and vancomycin, 2 g OD and 750 mg OD intravenous, respectively. The patient showed no significant improvement and unfortunately, he progressed to death caused by multiple organ dysfunctions due to septic shock. Discussion: There is no single, highly sensitive and specific diagnostic test exists for neurosyphilis. The diagnosis of neurosyphilis is based on clinical findings and the results of serologic tests and CSF examination. The CSF-VDRL has sensitivity 30–70%, non-reactive test does not exclude neurosyphilis. Neurosyphilis in a patient without HIV infection could be diagnosed by a high WBC or protein in CSF with symptoms or signs of neurosyphilis even with non-reactive CSF-VDRL. Conclusion: Neurosyphilis could be considered even with a non-reactive CSF-VDRL result in non-HIV patient.

Alien sign as bad prognostic factor in basilar tip aneurysm

A 44-year-old pregnant women presented with sudden onset coma. Upon arrival, GCS was E2V2M4 with positive meningeal sign. CT showed massive subarachnoid haemorrhage around the basal cisterns and co...

The occurrence of acute demyelinating encephalomyelitis after respiratory viral infection (clinical observation)

This article examines the development of acute demyelinating encephalomyelitis against a background of a viral infection in a clinical case. Based on the literature review, it is known that acute disseminated encephalomyelitis is an immuno-mediated single-phase inflammatory demyelinating disorder of white matter of the brain and spinal cord. It is noted that one of the proposed mechanisms of pathogenesis is that myelin autoantigens, such as myelin main protein, proteolipid protein and myelin oligodendrocyte protein, have antigenic determinants with the infecting agent. Antiviral antibodies or cell-mediated cross-reacting pathogens respond to myelin autoantigens, resulting in acute demyelinating encephalomyelitis. Acute demyelinating encephalomyelitis has been found to be associated with increased vascular permeability and accumulation of circulating immune complexes or other humoral factors that develop after exposure to a foreign antigen introduced by infection or vaccination. This process then leads to infiltration of the walls of the vessels by mononuclear cells with subsequent swelling and periodic hemorrhage. Microglia, lymphocytes, and phagocytes appear throughout the day, ultimately leading to demyelination and possible gliosis and necrosis. The degree of demyelination and subsequent glial and neural changes explain the difference between clinical features and disease prognosis. In clinical case, we have demonstrated the appearance of this disease, which developed in close temporal connection with infectious disease. Positive meningeal signs, tenderness and limited movements of the eyeballs, diplopia when viewed sideways, decreased convergence, horizontal nystagmus when viewed sideways, symptoms of oral automatism, decreased muscle strength diffuse, tendons and tendons = D, average liveliness; from the feet S&gt; = D, average liveliness, tremor of the hands. The MRI findings, in addition to the clinical picture, helped to establish the diagnosis. As a result of this, a cure for the disappearance of a neurological deficit was achieved. Thus, this clinical case proves that disseminated encephalomyelitis proceeds by type of acute disease with rapid increase of symptoms and their subsequent regression.

Accuracy of cerebrospinal fluid and serum S100B protein in the diagnosis of bacterial meningitis in children

Background: The diagnosis of bacterial meningitis is very difficult because of the vague clinical presentation primarily in infants and children. The S100B protein is a brain neurochemistry that may a biomarkers of inflammatory process in the brain and it is thought to have relationship with neuron damage and oxidative stress in bacterial meningitis.Methods: In this study, we measured the levels of S100B protein in CSF and serum by using ELISA method, in children with suspected bacterial meningitis. The diagnosis of proven bacterial meningitis based on positive culture that confirmed the causing bacteria. We analyzed the data by using MedCalc-version 17.6 programe.Results: Eighty patients suspected bacterial meningitis included in this study, 47 (58.8%) male, and mean of age was 29.8 months (SD+32.1). Prevalence of proven bacterial meningitis were 21/80 (26.25%). The main clinical symptoms were seizures, decreased of consciousness, clinically sepsis, positive meningeal sign, vomiting and focal neurologic deficits. The comparison of S100BCSF levels between positive culture and negative culture were 31.4 (SD+32.81) and 29.2 (SD+27.13). A comparison of S100Bserum levels between positive culture and negative culture 114.1 (SD+95.67) dan 74.9 (SD+75.84). Area under curve (AUC) of S100BCSF dan S100Bserum were 0.523 and 0.655, respectively. Levels of S100BCSF protein &gt;54 ng/L and S100Bserum &gt;177 ng/L were optimal criteria for diagnosis bacterial meningitis with sensitivity 29% and 19%, specificity 98% and 98%, respectively.Conclusion:  Levels of S100BCSF and S100Bserum protein have prospective value with high specificity to confirm the diagnosis of bacterial meningitis in children. We can use S100Bserum as addition test for the diagnosis of bacterial meningitis in children if there is contraindication for lumbal puncture.

Acute Bacterial Meningitis Complicated by Brain Herniation Shortly after Lumbar Puncture: A Case Report

INTRODUCTION: Brain herniation is a known complication of acute bacterial meningitis. Brain CT is requested before the lumbar puncture to rule out increased intracranial pressure. Delay antibiotic administration, secondary to brain CT leads to a poor clinical outcome.CASE PROFILE: 10 year old boy had previous history of skull fracture and pneumococcal meningitis, presented to ER with history of fever, headache and vomiting for 2 days. Clinically, he was fully conscious and vitally stables with positive meningeal signs and normal other examinations. Brain CT was normal before the lumbar puncture. The lumbar puncture came suggestive of meningitis in the form of leukocytosis with low glucose and high protein. Antibiotics were given after the lumbar puncture. Two hours after the lumbar puncture, the patient had deteriorations in the level of consciousness and respiratory arrest followed by a coma. Brain CT was repeated which showed cerebellar herniation and subarachnoid hemorrhage. Neuroprotective strategy was performed without improvements. Blood and CSF cultures showed pneumococcal growth. After onne week, brain death was confirmed.CONCLUSION: Brain herniation is a severe complication of bacterial meningitis. Clinical findings are the best indicators to delay the LP and to predict the risk of herniation. Normal brain CT doesn’t necessarily mean LP is safe. Early antibiotics administrations improve the mortality and morbidity. Unnecessary CT before the LP lead to a delay of antibiotic administration and poor outcome.

A report of two children with fever, headache, and purpura

In this study, two school-aged children had an acute onset in spring and had the manifestations of fever, headache, vomiting, disturbance of consciousness, purpura and ecchymosis, and positive meningeal irritation sign. There were increases in peripheral white blood cells and neutrophils, but reductions in the hemoglobin level and platelet count in the two children. They had a significant increase in C-reactive protein. There were hundreds or thousands of white blood cells in the cerebrospinal fluid, mainly neutrophils. Increased protein contents but normal levels of glucose and chloride in the cerebrospinal fluid were found. Head CT scan showed multiple hematomas in the right cerebellum and both hemispheres in one child. Bone marrow cytology indicated infection in the bone marrow, and both blood culture and bone marrow culture showed methicillin-resistant Staphylococcus aureus (MRSA). Both patients had cardiac murmurs and progressive reductions in the hemoglobin level and platelet count during treatment, and echocardiography showed the formation of vegetation in the aortic valve. Therefore, the patients were diagnosed with infectious endocarditis (IE). Vancomycin was used as the anti-infective therapy based on the results of drug sensitivity test. One child was cured after 6 weeks, and the other child was withdrawn from the treatment and then died. Dynamic monitoring of cardiac murmurs should be performed for children with unexplained fever, and echocardiography should be performed in time to exclude IE. IE should also be considered for children with purulent meningitis and skin and mucosal bleeding which cannot be explained by the reduction in platelet count.

Epidemics of the central nervous system infections caused by West Nile virus in the territory of the South Backa District, Vojvodina, Serbia.

West Nile virus (WNV) is a neurotropic RNA virus particle which belongs to the Flaviviidae family, genus Flavivirus. It is sustained in arthropods within the transmission cycle between the mosquitoes and birds. Most commonly (80% of cases) WNV infections are asymptomatic among people. Less than 1% of patients develop neuroinvasive forms of the disease--meningitis, encephalitis, or acute flaccid paralysis. The aim of the research was to determine most common clinical and laboratory manifestations, to emphazise the presence of comorbidities and outcomes of treatment among patients with WNV infection. This retrospective study, which was conducted in the period from January 1, 2012 to December 31, 2013, evaluated 32 patients who were diagnosed with WNV infection based on clinical findings, laboratory, and serological tests. To assess statistical significance we used χ2, and t-test. The study involved 22 (69%) males and 10 (31%) females aged from 31 to 65 years. On admission, there were 16 (50%) febrile individuals, 27 (84.4%) with positive meningeal signs, 17 (53.2%) with pathological neurological signs, and 10 (31.3%) with consciousness disorders. WNV infection was confirmed by the method enzyme linked immuno sorbent assay (ELISA) in all the patients, while Reverse Transcription Polymerase Chain Reaction (RT-PCR) test was positive in 3 (30%) of the tested patients. Cardiovascular comorbidities dominated in 7 (21.9%) of the cases. Full recovery was accomplished in 87.5% of the cases. The results of our study show that the absence of meningeal signs and fever on the day 7 of hospital treatment are indicators of good course and prognosis of neuroinvasive forms of WNV infection. Comorbidities do not increase the risk of disease. ELISA test is a sovereign diagnostic method. In most cases, after the administered symptomatic therapy, the complete recovery of patients was achieved.

Disseminated Rhodococcus equi infection in a patient with Hodgkin’s lymphoma

Rhodococcus (R) equi is an opportunistic, uncommon human pathogen that causes mainly infection in immunocompromised hosts. The disease is usually presented as subacute pneumonia that is mostly cavitary and sometimes bacteremic. We reported the extremly rare case of a 43-year-old woman with Hodgkin lymphoma, who developed R equi pulmonary infection after recieving multiple courses of chemotherapy. Secondary, the patient developed bacteremia, leading to sepsis and dissemination of R equi infection in many extrapulmonary sites. At addmission the patient was febrile, tachypnoic, tachycardic, hypotensive, with fa cial edema, splenomegaly, positive meningeal signs, left hemiparesis and paraparesis. Laboratory data included erythrocyte sedimentation rate (ESR) > 140 mm/h, C-reactive protein (CRP) 143.0 mg/L, red blood cells (RBC) 2.14 x 10(12)/L, whyite blood cells (WBC) 2.8 x 10(9)/L, lactate dehydrogenase (LDH) 706 U/L, serum albumin 26 g/L, sodium 127 mmol/L and potassium 2.7 mmol/L. Blood culture and culture of sputum and empyema were positive for R equi. Imaging studies demonstrated a large right cavitary pneumonia and abscess, empyema, pericarditis, mediastinal and intra-abdominal lymphadenopathy, brain and psoas abscesses, osteomyelitis and spondylodiscitis. The patient recovered completely after a 12-month treatment with combinations of parenteral and oral antibiotics (meropenem, vancomycin, teicoplanin, ciprofloxacin, rifampicin, macrolides etc), including drainage of abscesses and empyema. Eight years after completition of the treatment the patient was without recurrence of R equi infection and lymphoma. Since the eradication od R equi is very difficult, it is very important to make the diagnosis and initiate appropriate antibiotic therapy as soon as possible.