- Email: [email protected]
2-04-05 Aspergillosis of the central nervous system: A case report
S72
Bacterial,
12-03-08
A. Tambussi,
Fungal & viral Infections of the Nervous System
1 Prognosis of loss of consciousness. Anaiisis of the syncope recurrence in patients with clinical neurocardiogenic syncope S. Kochen,
E. Fossa Olandini.
Centre of Epilepsy, Neurology and Cardiology Hospital, Buenos Aires, Argentina
Syncope Centre and Municipal Division, Ramos Mejfa
An overall oooulation of 397 patients (~1 from an Epilepsy Centre and Syncope Centre with diagnosis of syr&pe (.Si’&as regulaity f&wed up from i991 .to 1996. We have selected 70 p (M/F: 35/35) suffering from Neurocardiogenic Syncope (mean 30 f 16 yr).This group w& studied by means of a protocol which included history, physical examination, carotid sinus massage, blood pressure control (supine and orthostatic), neurologic and EEG evaluation, ECG, eohocardiogram, 24 hr-Holter monitoring and tilt-table test. The diagnosis was reached mainly based on a typical history of neurocardiogenic syncope in absence of another cause of syncope with or without a positive tilt-table test. Based on the interrogation of the patients and their close relatives, we managed to build the chronology of the syncopal episodes up to the first examination and with a further 4 year follow-up. No pharmacological treatment was indicated. Once the diagnosis was reached, the patient was given instructions as to how to avoid triggering factors or to recognise preceding symptoms in order to avoid the crisis. The Kaplan-Meier method was used to analyse the recurrence of episodes. In the four years previous to the first visit, 74% of the population had recurrences after the first historical episode. After making the diagnose, only 13% recurred in the same period of time, which resulted in a significant difference (p < 0.001). The natural history of patients with Neurocardiogenic Syncope has not yet been cleared up. Attention has been focused increasingly on how best to treat these patients. These findings suggest that the natural evolution of the disease could be modified by accurately diagnosing and indicating preventive attitudes, avoiding thus inappropriate treatments in these patients.
04
Bacterial, Fungal & Viral Infections of the Nervous System
2 04 01 I__I A. Aksamit,
Trends in CreutzfeidtJakob may0 clinic experience K. Chung.
Neurology
Dept.,
disease 1975-1995:
Federal
University
,y*=
resistance
of Bahia, Salvador
Objective: Description of S. pneumoniae’s response used antibiotics in treatment of bacterial meningitis.
sensitivity to the most commonly used antibiotics N 95 91 36
% of sensitlMty
76
100
66.3
83.5 97.4
16.69 p = 0.0007
Conclusion: Meningitis is a disease with an elevated morbidity in BahiaBrazil. Although Ceftriaxone is an expensive antibiotic, it may be considered the best choice for the treatment of infection caused by S. pneumoniae.
2-04-03 A. Caride, Buenas
HTLV-I associated myeiopathy/tropicai paraparesis (H.A.MJT.S.P.) J. Ferreiro,
E. Zevallos.
Hospital
de Clinicas
spastic
Jose De San Martin,
Aires, Argentina
H.A.M./T.S.P. is a chronic inflammatory and demyelinating myelopathy that can mimic progressive spinal forms of Multiple Sclerosis (M.S.). We report two cases, mairied between‘ them, Bolivian nationality, male ‘72 years old; female 61 years old. Both had high titles of seric Ig, G. Anti H.T.L.V.-I, with the following-characteristics: 1) Female H.A.M.TT.S.F. had an evolution of 5 years, she was politransfused with less than 20 years old. Time mediated to marriage: 5 years; Time mediated to initial symptoms of H.A.M.IT.S.P.: 31 years; cd4: elevated; cd6: diminish; P.P.D0.2 U.T.: 0 mm. No extraneurologic manifestations. 2) Male are Asintomatic, he infected by sexual transmission, cd4: diminish; cd6: diminish, P.P.D0.2 U.T.: 15 mm. 3) Neither one had Tuberculosis/H.T.V. nor Leukemia- Lymphoma. We concluded that the different H.L.A./&l-cdB ratios/l?P.D. reaction and sexs was deteninant of the diierent courses.
MN, USA
to
Amanda Almeida, Adriana Cardoso, Rog&fo SantosJesus, Luciana Hughes, Tania Maia, Marco Antonio Novaes, Luciana Nunes, Ricardo Peixoto, Mutilo Souza, Rita Lucena, lrenio Gomes, Ailton Melo. Neurohfectology and Ditision,
Antibiotic Ampiciline Peniciline Cloramphsnicol Ceftriaxone
I 2-04-04
Mayo Clinic, Rochester,
1 Pyogenic meningitis: S. pneumoniae antibiotics in Bahia-Brazil
Neurcepidemiobgy Brasil
Table 1: S. pneumonia&
The
This retrospective review of Creutzfeldt-Jakob disease (CJD) was performed to identify evolving trends over time in neurologic presentation. For the years 1976-1995, patients were identified by final diagnosis in the Mayo Clinic record system. Review using previously published criteria revealed 40 patients classified as definite, 63 as probable, and 53 as possible. 59 patients did not fulfill the criteria for CID. Peak occurrence was in the 7th decade of life, with a range from the 4th to 10th decade. 30% of pathologically proven patients had a course longer than 12 months. 22% of all patients had behavioral or psychiatric manifestations as the presenting symptom complex without overt dementia or neurologic motor signs. The major clinical findings were dementia, myoclonus, ataxia, cortical blindness, and extrapyramidal findings. Other common clinical manifestations included frontal release signs or visual blurring without frank cortical blindness. Aphasia was the presenting neurologic sign in 3%. MRI scans of the head showed T2 signal abnormalities involving gray matter structures in recent patients. Young patients affected by Creutzfeldt-Jakob disease of the type associated with transmissible bovine spongioform encephalopathy were not identified. Psychiatric manifestations were nonetheless common. The spectrum of clinical features of CJD were invariant over time. MRI head scan abnormalities using newer protocols may be a useful noninvasive adjunct for diagnosis.
12-04-02
Setting: Hospital Couto Maia, a large reference center for the treatment of infectious disease in Bahia-Brazil. Study’s Design: Cross-sectional descriptive study. Patients: All patientes, admitted to HCMaia between 1969 and 1996, who had meningitis and a positive CSF culture for S. pneumoniae. Analysis: Patients with meningitis caused by S. pneumoniae were enrolled in this study. The response of S. pneumoniae to ampiciline, peniciline, cloramphenicol and ceftriaxone were analysed. Chi-square test was used in order to detenine the statistical significance. Results: Between January 1969 and December 1996 there were 101 positive cultures for S. pneumoniae. This agent was most sensitive to ceftriaxone and and less sensitive to peniciline, respectively (Table 1).
Bahia,
to the most commonly
1 Myeiopathy associated with HTLV-I and chronic dacryosiaiadenitis: A common association
L.M. Cartier,
E. Lopez, C. Vergara,
Neurological
Science,
University
L. Garcia,
J.G. Cea. Department
of Chile, Salvador
Hospital,
of Santiago, Chile
Chronic dactyosialadenitis associated with HTLV-I associated myelopathy (HAM) has been described as a disease of viral origin distinct from Sj6gren syndrome. Between 1991 and 1996 we studied 45 patients with HAM and dacryosialadenitis. Other myelopathies were excluded by clinical, radiological and electrophysiological studies and immunological test for collagen disease. The HTLV-I status was established using ELISA, indirect immunofluorescence and Western-blot, and in most with proviral DNA from circulating lymphocytes. The sicca syndrome was established clinically using the Schirmer test and confirmed by a salivary gland biopsy. Forty five patients (33 women and 12 men) with average age of 52 years and an average time of paraparesis of 7.6 years were found to have a chronic dacryosialadenitis. According to Chisholm and Mason their salivary gland biopsies were Grade II, Ill and IV in 12, 22 and 11 patients respectively. The extractable nuclear antibodies (Ro and La) were negative in all cases. The severity of the sicca syndrome had no relation to the severity of the paraparesis which ranged from independent walk, aided gate, wheelchair to bedridden (22, 11, 5 and 7 patients respectively). Fifteen patients presented sensory symptoms without detectable peripheral nerve involvement and 12 had other central neurological involvement (parkinsonian syndrome, pseudobulbar palsy and intellectual impairment). We concluded that chronic dacryosialadenitis is a common association with HAM and that they probably have the same viral origen.
2 04 05
Aspergiiiosis
l-l..d
report
G. D’Andrea, A. Farruggio.
R. Amerio,
The Aspergillus not uncommon
Department
of the central nervous system: A case
L. Pistollato. of Neurology
L. Pasqui, M. Castagna, T. Balbi, and Patolog)! Este Hospital, /ta/y
infections of central nervous among immunocompromised
system (CNS), once rare, now are patients and/or after prolonged
Bacterial,
Fungal & viral Infections of the Nervous System
antibiotic treatments. Very few reports are available about CNS Aspergillosis in a subject otherwise healthy. We describe a 58year-old-man, who in September 1995 presented a suddenly diminution of visus in both eyes and papilledema. An Angie-MNR demonstrated thrombosis of left transverse sinus. He was treated with heparin i.v. and ameliorated. After three months of good health he had vertigo, disartna and paresis of right arm. A cerebral CT and MNR showed three ipodense lesions in the white matter of right frontal, right temporo-occipital and left fronto-temporal regions. Cerebral spinal fluid examination was normal (not cells present). A month later the neurological signs get worse and a cerebral stereotassic biopsy was made. Pathological examination showed some inflammatory cells but not possible aetiological agents. In February 1996 he started antifunginal treatment wfth fluconazolum without improvement. A CT of the skull showed bilateral cholesteatoma of the ear. He underwent intervention at the left middle ear. Cellular culture showed presence of Aspargillus flavus. In few months, despite antifunginal treatment, after progressive neurological deterioration, the patient died. Pathological examination showed numerous areas of infarction and pseudocistis in cerebral white matter. Numerous colonies of Aspergillus were found in small blood vessels of brain and lung. We think that chronic infection of the ear by Aspergillus determined the thrombosis of left transverse sinus. From cerebral vein Aspergillus disseminated in blood stream and reached lung tissue and cerebral blood vessels and caused brain infarcts. In conclusion our case suggests that probably Aspergillus infection is less uncommon than previously reported in non immunocompromised hosts. The progression of the symptoms may be stepwise and proteifomt. The treatment of this fungal infection remains problematic.
2-04-06
Syringomyelia developing tuberculous meningitis
AK. Daif, S. Al Rajeh, A. Awada, Riyadh, Saudi Arabia
A. Boukhai.
as acute complication King Khalid University
of
Hospital,
Tuberculosis of the nervous system has protean manifestations and may be associated with severe sequelae or death. Syrtngomyelia, though an uncommon complication of it, is usually of late onset. We report 2 interesting cases of TBM who developed sytingomyelia acutely. The clinical diagnosis was supported by neuroimagtng and findings at laminectomy. The 2 cases developed syringomyelia between 11 days and 6 weeks of the onset of their illnesses diagnosed as tuberculous meningitis. They both had evidence of cord swelling and softening. Acute-onset syrtngomyelia may not be rare and should be suspected in any patient being treated for TBM who subsequently develops limb weakness andlor sphincteric dysfunction. Inflammatory edema and cord ischemia appeared to be the underlying mechanisms in these early onset cases rather than arachnoiditis which is important in the late-onset cases.
2-04-07
Levels of HSV-1 DNA in cetebrospinal acyclovir treatment
R.B. Domingues’, Scio Paul0 Medical USA
fluid during
F.D.Lakeman2,M.S. Mayo2,R.J. Whitley*.‘Universifyof School, Bra&/, *University of Alabama at Birmingham,
There were no studies analyzing the response of HSV-1 levels to antiviral treatment in herpes encephalitis (HSE) patients. In this study, the levels of HSV-1 DNA in 6 HSE cases during Acyclovir treatment were prospectively detemined by competitive PCR. An internal standard with an internal 25 bp deletion was constructed. Two hundred copies of internal standard were co-amplified with serial dilutions of HSV-1 DNA. The number of copies of HSV-1 DNA was determined by interpoiating the log of the ratio of amplified products from the standard curve. The initial HSV-1 DNA levels ranged from 1.5 x 10s to 1.8 x 1O4 copiea!pL. Five patients had a progressive decline in HSV-1 DNA levels. All these patients had clinical improvement and remained with no, mild, or moderate neurologic deficit. One patient had higher HSV-1 DNA levels in the second CSF. This patient had no response to Acyclovir therapy and died after 9 days of treatment. This study suggests that the HSV-1 DNA quantitation in CSF samples can be used for monitoring antiviral treatment of patients with HSE.
2-04-06
Prognostic evaluation of herpes simplex encephalitis using competitive potymerase reaction assay of cerebrospinal fluid
tients with herpes encephalitis (HSE). Sixteen patients with HSV-1 encephalitis were divided into two groups according to the amount of HSV-1 DNA being above or below 100 copies/pL. Dichotomous variables were compared with Fisher’s Exact Two-Tailed test and continuous variables were compared with Wilcoxon Rank-Sum test. Time of Acyclovir administration was not significantly different between these groups (P = 0.869). The group of patients with more than 100 HSV DNA copies had a higher age (P = 0.0221), a longer disease (P = 0.0624) a more severe disease (P = 0.019) and more CT lesions (P = 0.0008). Six (85.7%) patients with low DNA levels regained normal neurologic examination after 3 months while all patients with high DNA level remained with neurological deficit or died. The competitive PCR for HSV-1 DNA quantification is efficient for prognostic evaluation of HSE patients.
2-04-09
Correlation between neurodiagnostic tests and pofymerase chain reaction for herpes encephalitis (HSE) diagnosis
R.B. Domingues’, A.M.C. Tsanaclis’, C.S. Pannuti’, M.C.D. Fink’, MS. Mayo 2, F.D. Lakeman 2. ’ University of S,%ioPaul0 Medical School, * UniveMy of Alabama at Birmingham, USA
Brazil,
The aim of this study was to correlate electrcencephalography (EEG), computed tomography (CT), and magnetic resonance imaging (MRI) findings with CSF polvmerase chain reaction (PCR) in 49 HSE suspected cases. Eiahteen patients-(36.7%) were PCR positive. Temporal abnormalities at CT were significantly correlated with positive PCR (P = 0.00783) and increased 20 times the probability of PCR+;-however, 33.3% of PCR+.patients had normal CT. The probability of PCR+ increased 10.5 times if temporal abnormalities at EEG were found; however, five (19.2%) PCR- patients had similar abnormalities. The presence of MRI temporal lesion was highly associated with PCR+ (P = 0.00178). One PCR- patient had MRI abnormalities at temporal lobe. There was a high correlation between temporal abnormalities and positive PCR results. CT was not a very sensitive test. Although EEG was more sensitive than CT scan, the specificity of EEG was low. MRI was the more sensitive and specific test. All these tests (EEG, CT scan, and MRI) were susceptible to error when comparing to PCR.
2-04-l 0
Acute bacterial
Irenio Gomes, Rita Lucena, Gout0 Maia, Brasi/
meningitis
Ailton Melo. Federal
in adults University
of Bahia/Hospital
Objective: To report the clinical and demographic characteristics of acute bacterial meningitis in adults. Design: cross-sectional study. Setting: Hospital Couto Maia (HCMaia), a referral center to infectious disease in Northeastern, Brazil. Patients: One hundred seventy-six adult patients, admitted at HCMaia with a diagnosis of acute bacterial meningitis from January 1992 to December 1993. Analysis: Data was collected by the examiners, and all information entered in a computer file, to be analysed with the help of SPSS for Windows. Results: All patients had community-acquired meningitis. Sixty seven percent were males. Mean age was 32.6 (SD: 15.4). In 120 patients we could identify the causative agent on Gram’ staining and culture. The most common pathogens were Streptococcus pneumoniae (37.5%) and Neisseria meningitidis (56.7%). The overall lethality rate was 19.8% and the lethality was greater in the group with Streptococcus meningitis (31.8%). Mean age and leukocyte count in the peripheral blood were greater in the group with S. pneumoniae meningitis than in the meningowccai group. Cutaneous hemorrhagic lesions were considered an excellent predictor of meningococcal meningitis. As we could determine in children, the incidence of meningitis in adults was equally distributed along the year. Conclusions: Although more frequent in children, acute bacterial meningitis continues to be prevalent and an important cause of morbidity and lethality in adults of developing countries.
2-04-l 1 The predictive value of gram stain in the diagnosis of acute bacterial meningitis Luciana Hughes, Rogorio SantosJesus, Tania Maia, Marco Antonio Novaes, Luciana Nunes. Rica& Peixoto, Murilo Souza, Amanda Almeida, Adriana Cardoso, Rita Lucena, lrenio Gomes, Ailton Melo. Neuroinfectology/Neuroepidemiology Division, Federal University of Bahia, Salvador. Bahia, Bras4
chain
R.B. Domingues ‘, F.D. Lakeman *, M.S. Mayo 2, R.D. Whitleya. ’ University Sao Paul0 Medical School, Brazil, *University of Alabama at Birmingham, USA
s13
of
The aim of this study was to correlate the amount of HSV DNA in cerebrospinal fluid with age, time of symptoms, severity of disease, and clinical outcome of pa-
Objective: To establish the predictive value of the initial gram-stained CSF smear in the diagnosis of acute bacterial meningitis (ABM). !Mtlng: Hospital Couto Maia, a large infectious disease hospital in Salvador, Northeast of Brazil. HCMaia treats almost all cases of community meningitis from the city and nearly 50% from the state countryside hospital.
Bacterial,
12-03-08
A. Tambussi,
Fungal & viral Infections of the Nervous System
1 Prognosis of loss of consciousness. Anaiisis of the syncope recurrence in patients with clinical neurocardiogenic syncope S. Kochen,
E. Fossa Olandini.
Centre of Epilepsy, Neurology and Cardiology Hospital, Buenos Aires, Argentina
Syncope Centre and Municipal Division, Ramos Mejfa
An overall oooulation of 397 patients (~1 from an Epilepsy Centre and Syncope Centre with diagnosis of syr&pe (.Si’&as regulaity f&wed up from i991 .to 1996. We have selected 70 p (M/F: 35/35) suffering from Neurocardiogenic Syncope (mean 30 f 16 yr).This group w& studied by means of a protocol which included history, physical examination, carotid sinus massage, blood pressure control (supine and orthostatic), neurologic and EEG evaluation, ECG, eohocardiogram, 24 hr-Holter monitoring and tilt-table test. The diagnosis was reached mainly based on a typical history of neurocardiogenic syncope in absence of another cause of syncope with or without a positive tilt-table test. Based on the interrogation of the patients and their close relatives, we managed to build the chronology of the syncopal episodes up to the first examination and with a further 4 year follow-up. No pharmacological treatment was indicated. Once the diagnosis was reached, the patient was given instructions as to how to avoid triggering factors or to recognise preceding symptoms in order to avoid the crisis. The Kaplan-Meier method was used to analyse the recurrence of episodes. In the four years previous to the first visit, 74% of the population had recurrences after the first historical episode. After making the diagnose, only 13% recurred in the same period of time, which resulted in a significant difference (p < 0.001). The natural history of patients with Neurocardiogenic Syncope has not yet been cleared up. Attention has been focused increasingly on how best to treat these patients. These findings suggest that the natural evolution of the disease could be modified by accurately diagnosing and indicating preventive attitudes, avoiding thus inappropriate treatments in these patients.
04
Bacterial, Fungal & Viral Infections of the Nervous System
2 04 01 I__I A. Aksamit,
Trends in CreutzfeidtJakob may0 clinic experience K. Chung.
Neurology
Dept.,
disease 1975-1995:
Federal
University
,y*=
resistance
of Bahia, Salvador
Objective: Description of S. pneumoniae’s response used antibiotics in treatment of bacterial meningitis.
sensitivity to the most commonly used antibiotics N 95 91 36
% of sensitlMty
76
100
66.3
83.5 97.4
16.69 p = 0.0007
Conclusion: Meningitis is a disease with an elevated morbidity in BahiaBrazil. Although Ceftriaxone is an expensive antibiotic, it may be considered the best choice for the treatment of infection caused by S. pneumoniae.
2-04-03 A. Caride, Buenas
HTLV-I associated myeiopathy/tropicai paraparesis (H.A.MJT.S.P.) J. Ferreiro,
E. Zevallos.
Hospital
de Clinicas
spastic
Jose De San Martin,
Aires, Argentina
H.A.M./T.S.P. is a chronic inflammatory and demyelinating myelopathy that can mimic progressive spinal forms of Multiple Sclerosis (M.S.). We report two cases, mairied between‘ them, Bolivian nationality, male ‘72 years old; female 61 years old. Both had high titles of seric Ig, G. Anti H.T.L.V.-I, with the following-characteristics: 1) Female H.A.M.TT.S.F. had an evolution of 5 years, she was politransfused with less than 20 years old. Time mediated to marriage: 5 years; Time mediated to initial symptoms of H.A.M.IT.S.P.: 31 years; cd4: elevated; cd6: diminish; P.P.D0.2 U.T.: 0 mm. No extraneurologic manifestations. 2) Male are Asintomatic, he infected by sexual transmission, cd4: diminish; cd6: diminish, P.P.D0.2 U.T.: 15 mm. 3) Neither one had Tuberculosis/H.T.V. nor Leukemia- Lymphoma. We concluded that the different H.L.A./&l-cdB ratios/l?P.D. reaction and sexs was deteninant of the diierent courses.
MN, USA
to
Amanda Almeida, Adriana Cardoso, Rog&fo SantosJesus, Luciana Hughes, Tania Maia, Marco Antonio Novaes, Luciana Nunes, Ricardo Peixoto, Mutilo Souza, Rita Lucena, lrenio Gomes, Ailton Melo. Neurohfectology and Ditision,
Antibiotic Ampiciline Peniciline Cloramphsnicol Ceftriaxone
I 2-04-04
Mayo Clinic, Rochester,
1 Pyogenic meningitis: S. pneumoniae antibiotics in Bahia-Brazil
Neurcepidemiobgy Brasil
Table 1: S. pneumonia&
The
This retrospective review of Creutzfeldt-Jakob disease (CJD) was performed to identify evolving trends over time in neurologic presentation. For the years 1976-1995, patients were identified by final diagnosis in the Mayo Clinic record system. Review using previously published criteria revealed 40 patients classified as definite, 63 as probable, and 53 as possible. 59 patients did not fulfill the criteria for CID. Peak occurrence was in the 7th decade of life, with a range from the 4th to 10th decade. 30% of pathologically proven patients had a course longer than 12 months. 22% of all patients had behavioral or psychiatric manifestations as the presenting symptom complex without overt dementia or neurologic motor signs. The major clinical findings were dementia, myoclonus, ataxia, cortical blindness, and extrapyramidal findings. Other common clinical manifestations included frontal release signs or visual blurring without frank cortical blindness. Aphasia was the presenting neurologic sign in 3%. MRI scans of the head showed T2 signal abnormalities involving gray matter structures in recent patients. Young patients affected by Creutzfeldt-Jakob disease of the type associated with transmissible bovine spongioform encephalopathy were not identified. Psychiatric manifestations were nonetheless common. The spectrum of clinical features of CJD were invariant over time. MRI head scan abnormalities using newer protocols may be a useful noninvasive adjunct for diagnosis.
12-04-02
Setting: Hospital Couto Maia, a large reference center for the treatment of infectious disease in Bahia-Brazil. Study’s Design: Cross-sectional descriptive study. Patients: All patientes, admitted to HCMaia between 1969 and 1996, who had meningitis and a positive CSF culture for S. pneumoniae. Analysis: Patients with meningitis caused by S. pneumoniae were enrolled in this study. The response of S. pneumoniae to ampiciline, peniciline, cloramphenicol and ceftriaxone were analysed. Chi-square test was used in order to detenine the statistical significance. Results: Between January 1969 and December 1996 there were 101 positive cultures for S. pneumoniae. This agent was most sensitive to ceftriaxone and and less sensitive to peniciline, respectively (Table 1).
Bahia,
to the most commonly
1 Myeiopathy associated with HTLV-I and chronic dacryosiaiadenitis: A common association
L.M. Cartier,
E. Lopez, C. Vergara,
Neurological
Science,
University
L. Garcia,
J.G. Cea. Department
of Chile, Salvador
Hospital,
of Santiago, Chile
Chronic dactyosialadenitis associated with HTLV-I associated myelopathy (HAM) has been described as a disease of viral origin distinct from Sj6gren syndrome. Between 1991 and 1996 we studied 45 patients with HAM and dacryosialadenitis. Other myelopathies were excluded by clinical, radiological and electrophysiological studies and immunological test for collagen disease. The HTLV-I status was established using ELISA, indirect immunofluorescence and Western-blot, and in most with proviral DNA from circulating lymphocytes. The sicca syndrome was established clinically using the Schirmer test and confirmed by a salivary gland biopsy. Forty five patients (33 women and 12 men) with average age of 52 years and an average time of paraparesis of 7.6 years were found to have a chronic dacryosialadenitis. According to Chisholm and Mason their salivary gland biopsies were Grade II, Ill and IV in 12, 22 and 11 patients respectively. The extractable nuclear antibodies (Ro and La) were negative in all cases. The severity of the sicca syndrome had no relation to the severity of the paraparesis which ranged from independent walk, aided gate, wheelchair to bedridden (22, 11, 5 and 7 patients respectively). Fifteen patients presented sensory symptoms without detectable peripheral nerve involvement and 12 had other central neurological involvement (parkinsonian syndrome, pseudobulbar palsy and intellectual impairment). We concluded that chronic dacryosialadenitis is a common association with HAM and that they probably have the same viral origen.
2 04 05
Aspergiiiosis
l-l..d
report
G. D’Andrea, A. Farruggio.
R. Amerio,
The Aspergillus not uncommon
Department
of the central nervous system: A case
L. Pistollato. of Neurology
L. Pasqui, M. Castagna, T. Balbi, and Patolog)! Este Hospital, /ta/y
infections of central nervous among immunocompromised
system (CNS), once rare, now are patients and/or after prolonged
Bacterial,
Fungal & viral Infections of the Nervous System
antibiotic treatments. Very few reports are available about CNS Aspergillosis in a subject otherwise healthy. We describe a 58year-old-man, who in September 1995 presented a suddenly diminution of visus in both eyes and papilledema. An Angie-MNR demonstrated thrombosis of left transverse sinus. He was treated with heparin i.v. and ameliorated. After three months of good health he had vertigo, disartna and paresis of right arm. A cerebral CT and MNR showed three ipodense lesions in the white matter of right frontal, right temporo-occipital and left fronto-temporal regions. Cerebral spinal fluid examination was normal (not cells present). A month later the neurological signs get worse and a cerebral stereotassic biopsy was made. Pathological examination showed some inflammatory cells but not possible aetiological agents. In February 1996 he started antifunginal treatment wfth fluconazolum without improvement. A CT of the skull showed bilateral cholesteatoma of the ear. He underwent intervention at the left middle ear. Cellular culture showed presence of Aspargillus flavus. In few months, despite antifunginal treatment, after progressive neurological deterioration, the patient died. Pathological examination showed numerous areas of infarction and pseudocistis in cerebral white matter. Numerous colonies of Aspergillus were found in small blood vessels of brain and lung. We think that chronic infection of the ear by Aspergillus determined the thrombosis of left transverse sinus. From cerebral vein Aspergillus disseminated in blood stream and reached lung tissue and cerebral blood vessels and caused brain infarcts. In conclusion our case suggests that probably Aspergillus infection is less uncommon than previously reported in non immunocompromised hosts. The progression of the symptoms may be stepwise and proteifomt. The treatment of this fungal infection remains problematic.
2-04-06
Syringomyelia developing tuberculous meningitis
AK. Daif, S. Al Rajeh, A. Awada, Riyadh, Saudi Arabia
A. Boukhai.
as acute complication King Khalid University
of
Hospital,
Tuberculosis of the nervous system has protean manifestations and may be associated with severe sequelae or death. Syrtngomyelia, though an uncommon complication of it, is usually of late onset. We report 2 interesting cases of TBM who developed sytingomyelia acutely. The clinical diagnosis was supported by neuroimagtng and findings at laminectomy. The 2 cases developed syringomyelia between 11 days and 6 weeks of the onset of their illnesses diagnosed as tuberculous meningitis. They both had evidence of cord swelling and softening. Acute-onset syrtngomyelia may not be rare and should be suspected in any patient being treated for TBM who subsequently develops limb weakness andlor sphincteric dysfunction. Inflammatory edema and cord ischemia appeared to be the underlying mechanisms in these early onset cases rather than arachnoiditis which is important in the late-onset cases.
2-04-07
Levels of HSV-1 DNA in cetebrospinal acyclovir treatment
R.B. Domingues’, Scio Paul0 Medical USA
fluid during
F.D.Lakeman2,M.S. Mayo2,R.J. Whitley*.‘Universifyof School, Bra&/, *University of Alabama at Birmingham,
There were no studies analyzing the response of HSV-1 levels to antiviral treatment in herpes encephalitis (HSE) patients. In this study, the levels of HSV-1 DNA in 6 HSE cases during Acyclovir treatment were prospectively detemined by competitive PCR. An internal standard with an internal 25 bp deletion was constructed. Two hundred copies of internal standard were co-amplified with serial dilutions of HSV-1 DNA. The number of copies of HSV-1 DNA was determined by interpoiating the log of the ratio of amplified products from the standard curve. The initial HSV-1 DNA levels ranged from 1.5 x 10s to 1.8 x 1O4 copiea!pL. Five patients had a progressive decline in HSV-1 DNA levels. All these patients had clinical improvement and remained with no, mild, or moderate neurologic deficit. One patient had higher HSV-1 DNA levels in the second CSF. This patient had no response to Acyclovir therapy and died after 9 days of treatment. This study suggests that the HSV-1 DNA quantitation in CSF samples can be used for monitoring antiviral treatment of patients with HSE.
2-04-06
Prognostic evaluation of herpes simplex encephalitis using competitive potymerase reaction assay of cerebrospinal fluid
tients with herpes encephalitis (HSE). Sixteen patients with HSV-1 encephalitis were divided into two groups according to the amount of HSV-1 DNA being above or below 100 copies/pL. Dichotomous variables were compared with Fisher’s Exact Two-Tailed test and continuous variables were compared with Wilcoxon Rank-Sum test. Time of Acyclovir administration was not significantly different between these groups (P = 0.869). The group of patients with more than 100 HSV DNA copies had a higher age (P = 0.0221), a longer disease (P = 0.0624) a more severe disease (P = 0.019) and more CT lesions (P = 0.0008). Six (85.7%) patients with low DNA levels regained normal neurologic examination after 3 months while all patients with high DNA level remained with neurological deficit or died. The competitive PCR for HSV-1 DNA quantification is efficient for prognostic evaluation of HSE patients.
2-04-09
Correlation between neurodiagnostic tests and pofymerase chain reaction for herpes encephalitis (HSE) diagnosis
R.B. Domingues’, A.M.C. Tsanaclis’, C.S. Pannuti’, M.C.D. Fink’, MS. Mayo 2, F.D. Lakeman 2. ’ University of S,%ioPaul0 Medical School, * UniveMy of Alabama at Birmingham, USA
Brazil,
The aim of this study was to correlate electrcencephalography (EEG), computed tomography (CT), and magnetic resonance imaging (MRI) findings with CSF polvmerase chain reaction (PCR) in 49 HSE suspected cases. Eiahteen patients-(36.7%) were PCR positive. Temporal abnormalities at CT were significantly correlated with positive PCR (P = 0.00783) and increased 20 times the probability of PCR+;-however, 33.3% of PCR+.patients had normal CT. The probability of PCR+ increased 10.5 times if temporal abnormalities at EEG were found; however, five (19.2%) PCR- patients had similar abnormalities. The presence of MRI temporal lesion was highly associated with PCR+ (P = 0.00178). One PCR- patient had MRI abnormalities at temporal lobe. There was a high correlation between temporal abnormalities and positive PCR results. CT was not a very sensitive test. Although EEG was more sensitive than CT scan, the specificity of EEG was low. MRI was the more sensitive and specific test. All these tests (EEG, CT scan, and MRI) were susceptible to error when comparing to PCR.
2-04-l 0
Acute bacterial
Irenio Gomes, Rita Lucena, Gout0 Maia, Brasi/
meningitis
Ailton Melo. Federal
in adults University
of Bahia/Hospital
Objective: To report the clinical and demographic characteristics of acute bacterial meningitis in adults. Design: cross-sectional study. Setting: Hospital Couto Maia (HCMaia), a referral center to infectious disease in Northeastern, Brazil. Patients: One hundred seventy-six adult patients, admitted at HCMaia with a diagnosis of acute bacterial meningitis from January 1992 to December 1993. Analysis: Data was collected by the examiners, and all information entered in a computer file, to be analysed with the help of SPSS for Windows. Results: All patients had community-acquired meningitis. Sixty seven percent were males. Mean age was 32.6 (SD: 15.4). In 120 patients we could identify the causative agent on Gram’ staining and culture. The most common pathogens were Streptococcus pneumoniae (37.5%) and Neisseria meningitidis (56.7%). The overall lethality rate was 19.8% and the lethality was greater in the group with Streptococcus meningitis (31.8%). Mean age and leukocyte count in the peripheral blood were greater in the group with S. pneumoniae meningitis than in the meningowccai group. Cutaneous hemorrhagic lesions were considered an excellent predictor of meningococcal meningitis. As we could determine in children, the incidence of meningitis in adults was equally distributed along the year. Conclusions: Although more frequent in children, acute bacterial meningitis continues to be prevalent and an important cause of morbidity and lethality in adults of developing countries.
2-04-l 1 The predictive value of gram stain in the diagnosis of acute bacterial meningitis Luciana Hughes, Rogorio SantosJesus, Tania Maia, Marco Antonio Novaes, Luciana Nunes. Rica& Peixoto, Murilo Souza, Amanda Almeida, Adriana Cardoso, Rita Lucena, lrenio Gomes, Ailton Melo. Neuroinfectology/Neuroepidemiology Division, Federal University of Bahia, Salvador. Bahia, Bras4
chain
R.B. Domingues ‘, F.D. Lakeman *, M.S. Mayo 2, R.D. Whitleya. ’ University Sao Paul0 Medical School, Brazil, *University of Alabama at Birmingham, USA
s13
of
The aim of this study was to correlate the amount of HSV DNA in cerebrospinal fluid with age, time of symptoms, severity of disease, and clinical outcome of pa-
Objective: To establish the predictive value of the initial gram-stained CSF smear in the diagnosis of acute bacterial meningitis (ABM). !Mtlng: Hospital Couto Maia, a large infectious disease hospital in Salvador, Northeast of Brazil. HCMaia treats almost all cases of community meningitis from the city and nearly 50% from the state countryside hospital.