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0824 Ability to penetrate the blood brain barrier of fluconazole for cryptococcal meningitis under the administration of fosfluconazole
$310
Wednesday, November 9, 2005
,]ha, S. Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India Backgroumh A high level o f suspicion is mandatory for diagnosis of Herpes Simplex Encephalitis (HSE), since acyclovir is known to reduce mortality and limit morbidity. We report our observations on clinical spectrum, pitfalls in diagnosis and therapeutic aspects in patients of HSE. Method: We selected 38 (126 male, 12 female) patients of HSE in age range of 6-72 years. Diagnosis was based on clinical assessment, cranial MRI, EEG and P C R in CSF. Results: Referral diagnosis were as; Japanese encephalitis (12 cases), cerebral malaria (7 cases), tuberculous meningitis (4 cases), only encephalitis (17 cases) and others or no diagnosis (18 cases). High fever, seizures, behavioral abnormality and encephalopathy were present in all cases. EEG, CSF and cranial MRI were abnormal in 100% cases. PCR for HSE virus was positive in 19 (79"/0) cases. Abnormality in CT was detected only in 4 out of 12 cases. Acyclovir was given to 26 patients along with carbamazepine and sodium valproate following which, 14 (55?,'8) recovered completely and 3 partially. There was no improvement in 5 patients while 4 expired. Among 9 patients who refused therapy of acyclovir, 6 expired and 3 remained in unaltered status. Three patients expired before therapy could be completed. Conclusion: HSE is under or misdiagnosed. This is important especially in India where Japanese encephalitis, tuberculous meningitis and cerebral malaria are extremely common. Important factors influencing mortality and morbidity were; delay or refusal in therapy, old age, poor immmne status, long duration of illness and deep coma before initiation of therapy. We suggest that acyclovir should be given to all patients as soon as suspected, while confirmatory investigations are in progress.
Poster Abstracts Neurology, Yokohama City University Medical Center, Yokohama, Japan.." 2Dept. of Neurology, Graduate School of Medicine, Yokohama City University, Yokohama, )'apart Background: Fosfluconazole is a phosphate prodrug of fluconazole that have been developed to reduce the volume of fluid required to administer fluconazole by the intravenous route. Fosfluconazole is soon hydrolyzed by alkaline phosphatase to fluconazole and phosphoric add and effective against cryptococcus or candida infections. We adininistered fosfluconazole to a patient of cryptococcal meningitis, and exanffned both serum and cerebrospinal fluid (CSF) concentrations o f fluconazole. Method: We administered fosfluconazole 800 mg/day by the intravenous route for 42 days to a cryptococcal meningitis patient using no-loading dose regimen. The administration of fosfluconazole was continued until the India ink exanffnation of CSF was negative. We exmnined both serum and CSF concentrations of fluconazole every 5 7 days. Results: Fhiconazole had high ability to penetrate to the blood brain barrier under the administration of fosfluconazole. The concentration of fluconazole in serum is significantly correlated with that in CSF (correlated coefficient _ 0.89). Condasion: Under the adininistration of fosfluconazole, a high concentration of fluconazole is obtained in CSF and a reduction of fluid volume to inject is possible. Thereafter fosfluconazole is appropriate to cryptococcus or candida meningitis the same as fluconazole. 0825 Clinical and Neuropathological Studies of Fulmninant Bacterial Meningoeneephalilis (SBNIE) with Severe Brain Edema Kobayashi, T. Nakano General Hospital, Nakano-R~, Tokyo, Japan
O823 Cerebral air embolism associated with ptthimnary tuberculosis Park, JH, Kim, JY, Baik, JS, Han, SW. Department of Neurology,
Sanggye Paik Hospital, Inje University, Seoul, Korea Background: Air embolism, entry of gas into vascular structure, is usually result o f iatrogenic procedure like endoscopic procedure and can result in serious morbidity and mortality. Case Reports: A 47-year-old man was referred for the evaluation and management of sudden loss o f consdousness and stupurous mentality. He had a history of pulmonary tuberculosis in his twenties. But it relapsed 2 months before admission and he have taken antituberculosis medications since then. Brain imaging obtained an hour after loss of consciousness revealed multiple small hypodense air bubbles at right M C A territory. Hyperbaric oxygen therapy was performed immediately, but he did not respond. Follow up brain CT taken at 5 days after admission revealed severe brain edema. He expired 8 day after admission. Discussion: Cerebral air embolism is rare cause of cerebral infarction and is the result of entry of air into the pulmmmry veins or directly into cerebral arteries. Entry o f the air in to brain can be caused by barotrauma, neurosurgical procedures. There also have been reports as the complication of cardiac surgery with cardiopulmonary bypass, mechanical ventilation and endoscopic procedures. But there have been no reports of cerebral air embolism associated with pulmonary tuberculosis.
O824 Ability to penetrate the blood brain barrier of fluconazole for cryptocoecal meningitis umler the admitfislrafion of fosllueonazole
Katsuo Khnura ~, Masanao E n d o , Takehiko Nishiyama 2, Yasuhisa Baba e, Hiroyuki Toda e, Yume Suzuki e, Yoshiyuki Kuroiwa 2, Tamaki Nomiya 1, Megumi Shimamura,~ Tatsuya Takahashi ~. 1Dept. of
Background: It is not certain whether or not to do emergency brain decompression operation at the clinical sign of brain herniation of SBME patients with severe brain edema. This study is conducted to clarify the clinical and neuropathological features of SBME to consider more suitable drug and/or neurosurgical therapies. Design/Methods: Clinical studies of Seven SBME cases and ncuropathological studies o f two autopsied cases. Results: Four cases were due to Penicillin-resistant S. pneumoniae (PRSP). Two out of four SBME cases occurred after nine and forty years of frontal bone fractures. The repairment of dura matter and frontal skull base using Gclfoam bone wax and the fragments of frontal muscle with vessels were performed after antibiotic therapies. They have had good course without neurological deficits. Another two cases died by cerebral hemorrhage and multiple organ failure. Their autopsies showed prominent brain edema and herniation. One case due to Krebsiella pneumoniae with cerebral hemorrhage and multiple brain abscesses was cured by antibiotics. One case of other two cases due to gram-negative badlli had prominent brain edema and cpidural abscess. Emergency decompression operation of wide removal of skull and aspiration of epidural abscess was done at the beginning of brain herniation. Tiffs patient was saved with the disappearance of herniation after surgery. Condusious: The emergency brain decompression surgery must be considered at the time of herniation by severe brain edema although high doses of antibiotic and steroid therapies have been done. 0826 Neurological complications in AIDS patients: the two years retrospective study in H A A R T era Kongsaengdao Subsai ~, Samintarapanya Kanoksri 1, Chankraehang Siwaporn 1, Ling Helen 1, Oranratanachai Kanokporn e, Prapakorn Wantana 2. 1Division of Neurology, Department of
Medicine; 2Division of Neuro-radiology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Thailand
Wednesday, November 9, 2005
,]ha, S. Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India Backgroumh A high level o f suspicion is mandatory for diagnosis of Herpes Simplex Encephalitis (HSE), since acyclovir is known to reduce mortality and limit morbidity. We report our observations on clinical spectrum, pitfalls in diagnosis and therapeutic aspects in patients of HSE. Method: We selected 38 (126 male, 12 female) patients of HSE in age range of 6-72 years. Diagnosis was based on clinical assessment, cranial MRI, EEG and P C R in CSF. Results: Referral diagnosis were as; Japanese encephalitis (12 cases), cerebral malaria (7 cases), tuberculous meningitis (4 cases), only encephalitis (17 cases) and others or no diagnosis (18 cases). High fever, seizures, behavioral abnormality and encephalopathy were present in all cases. EEG, CSF and cranial MRI were abnormal in 100% cases. PCR for HSE virus was positive in 19 (79"/0) cases. Abnormality in CT was detected only in 4 out of 12 cases. Acyclovir was given to 26 patients along with carbamazepine and sodium valproate following which, 14 (55?,'8) recovered completely and 3 partially. There was no improvement in 5 patients while 4 expired. Among 9 patients who refused therapy of acyclovir, 6 expired and 3 remained in unaltered status. Three patients expired before therapy could be completed. Conclusion: HSE is under or misdiagnosed. This is important especially in India where Japanese encephalitis, tuberculous meningitis and cerebral malaria are extremely common. Important factors influencing mortality and morbidity were; delay or refusal in therapy, old age, poor immmne status, long duration of illness and deep coma before initiation of therapy. We suggest that acyclovir should be given to all patients as soon as suspected, while confirmatory investigations are in progress.
Poster Abstracts Neurology, Yokohama City University Medical Center, Yokohama, Japan.." 2Dept. of Neurology, Graduate School of Medicine, Yokohama City University, Yokohama, )'apart Background: Fosfluconazole is a phosphate prodrug of fluconazole that have been developed to reduce the volume of fluid required to administer fluconazole by the intravenous route. Fosfluconazole is soon hydrolyzed by alkaline phosphatase to fluconazole and phosphoric add and effective against cryptococcus or candida infections. We adininistered fosfluconazole to a patient of cryptococcal meningitis, and exanffned both serum and cerebrospinal fluid (CSF) concentrations o f fluconazole. Method: We administered fosfluconazole 800 mg/day by the intravenous route for 42 days to a cryptococcal meningitis patient using no-loading dose regimen. The administration of fosfluconazole was continued until the India ink exanffnation of CSF was negative. We exmnined both serum and CSF concentrations of fluconazole every 5 7 days. Results: Fhiconazole had high ability to penetrate to the blood brain barrier under the administration of fosfluconazole. The concentration of fluconazole in serum is significantly correlated with that in CSF (correlated coefficient _ 0.89). Condasion: Under the adininistration of fosfluconazole, a high concentration of fluconazole is obtained in CSF and a reduction of fluid volume to inject is possible. Thereafter fosfluconazole is appropriate to cryptococcus or candida meningitis the same as fluconazole. 0825 Clinical and Neuropathological Studies of Fulmninant Bacterial Meningoeneephalilis (SBNIE) with Severe Brain Edema Kobayashi, T. Nakano General Hospital, Nakano-R~, Tokyo, Japan
O823 Cerebral air embolism associated with ptthimnary tuberculosis Park, JH, Kim, JY, Baik, JS, Han, SW. Department of Neurology,
Sanggye Paik Hospital, Inje University, Seoul, Korea Background: Air embolism, entry of gas into vascular structure, is usually result o f iatrogenic procedure like endoscopic procedure and can result in serious morbidity and mortality. Case Reports: A 47-year-old man was referred for the evaluation and management of sudden loss o f consdousness and stupurous mentality. He had a history of pulmonary tuberculosis in his twenties. But it relapsed 2 months before admission and he have taken antituberculosis medications since then. Brain imaging obtained an hour after loss of consciousness revealed multiple small hypodense air bubbles at right M C A territory. Hyperbaric oxygen therapy was performed immediately, but he did not respond. Follow up brain CT taken at 5 days after admission revealed severe brain edema. He expired 8 day after admission. Discussion: Cerebral air embolism is rare cause of cerebral infarction and is the result of entry of air into the pulmmmry veins or directly into cerebral arteries. Entry o f the air in to brain can be caused by barotrauma, neurosurgical procedures. There also have been reports as the complication of cardiac surgery with cardiopulmonary bypass, mechanical ventilation and endoscopic procedures. But there have been no reports of cerebral air embolism associated with pulmonary tuberculosis.
O824 Ability to penetrate the blood brain barrier of fluconazole for cryptocoecal meningitis umler the admitfislrafion of fosllueonazole
Katsuo Khnura ~, Masanao E n d o , Takehiko Nishiyama 2, Yasuhisa Baba e, Hiroyuki Toda e, Yume Suzuki e, Yoshiyuki Kuroiwa 2, Tamaki Nomiya 1, Megumi Shimamura,~ Tatsuya Takahashi ~. 1Dept. of
Background: It is not certain whether or not to do emergency brain decompression operation at the clinical sign of brain herniation of SBME patients with severe brain edema. This study is conducted to clarify the clinical and neuropathological features of SBME to consider more suitable drug and/or neurosurgical therapies. Design/Methods: Clinical studies of Seven SBME cases and ncuropathological studies o f two autopsied cases. Results: Four cases were due to Penicillin-resistant S. pneumoniae (PRSP). Two out of four SBME cases occurred after nine and forty years of frontal bone fractures. The repairment of dura matter and frontal skull base using Gclfoam bone wax and the fragments of frontal muscle with vessels were performed after antibiotic therapies. They have had good course without neurological deficits. Another two cases died by cerebral hemorrhage and multiple organ failure. Their autopsies showed prominent brain edema and herniation. One case due to Krebsiella pneumoniae with cerebral hemorrhage and multiple brain abscesses was cured by antibiotics. One case of other two cases due to gram-negative badlli had prominent brain edema and cpidural abscess. Emergency decompression operation of wide removal of skull and aspiration of epidural abscess was done at the beginning of brain herniation. Tiffs patient was saved with the disappearance of herniation after surgery. Condusious: The emergency brain decompression surgery must be considered at the time of herniation by severe brain edema although high doses of antibiotic and steroid therapies have been done. 0826 Neurological complications in AIDS patients: the two years retrospective study in H A A R T era Kongsaengdao Subsai ~, Samintarapanya Kanoksri 1, Chankraehang Siwaporn 1, Ling Helen 1, Oranratanachai Kanokporn e, Prapakorn Wantana 2. 1Division of Neurology, Department of
Medicine; 2Division of Neuro-radiology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Thailand