Bang-Hoon Cho

Meningitis Caused by Streptococcus suis: Case Report and Review of the Literature

Background Human infection with Streptococcus suis (S. suis), a zoonotic pathogen, has been reported mainly in pig-rearing and pork-consuming countries. Meningitis is the most-common clinical manifestation and is often associated with deafness and vestibular dysfunction. Case Report A 57-year-old man was referred to the hospital with headaches, fevers, chills, and hearing impairment. Meningitis was confirmed and S. suis was isolated from the cerebrospinal fluid. Spondylodiscitis occurred after 2 weeks of antibiotic treatment, and was successfully treated with a prolonged course of antibiotics for another 4 weeks. His hearing loss was irreversible despite the improvement of other symptoms. Conclusions We report the first human case of S. suis infection in Korea. In patients presenting with meningitis, S. suis should be considered if the characteristic features of prominent and early hearing loss are present.

Prediction of hemorrhagic transformation in acute ischaemic stroke by micro‐ and macroalbuminuria after intravenous thrombolysis

Hemorrhagic transformation (HT) is one of the most problematic complications to arise from intravenous thrombolysis (IVT). This study was conducted to assess whether micro‐ and macroalbuminuria could be associated with HT after IVT in patients with acute ischaemic stroke, and to investigate whether the value of urinary albumin‐to‐creatinine ratios would correlate with the degree of HT.

Adenosine deaminase activity in cerebrospinal fluid and serum for the diagnosis of tuberculous meningitis.

OBJECTIVE To evaluate the usefulness of serum and CSF adenosine deaminase (ADA) activity for the diagnosis of tuberculous meningitis (TBM) from other meningitis. METHODS We studied CSF and serum ADA activity for 83 cases of TBM, 148 of bacterial meningitis (BM), and 262 of viral or aseptic meningitis. RESULTS The mean ADA activities (IU/L) in CSF and serum were higher in TBM (11.80 ± 2.50, 30.28 ± 7.30) than in other types of meningitis (8.52 ± 3.60, 17.90 ± 9.20 in BM; 5.26 ± 1.90, 8.56 ± 5.9 in viral or aseptic meningitis). When we accepted a serum ADA activity cut-off value of 15 IU/L for the differential diagnosis of TBM and non-TBM with ROC analysis, the sensitivity was 84% and specificity was 82%. Combining CSF (≥ 10) and serum (≥ 15) ADA activity significantly increased overall specificity from 92% to 97% for the diagnosis of TBM. CONCLUSIONS The determination of CSF and serum ADA activity is a simple and reliable test for differentiating TBM from other types of meningitis.

Right-to-left shunts as a cause of juxtacortical spots in patients with migraine.

Backgrounds:  Juxtacortical spots on fluid‐attenuated inversion recovery (FLAIR) images can be frequently detected in patients with migraine. However, the origins of the cerebral lesions (including juxtacortical spots on FLAIR images) found in the previous studies are not known. We sought to investigate the association between juxtacortical spots on FLAIR images and right‐to‐left shunt (RLS) in migraine patients.

Central positional nystagmus associated with cerebellar tumors: Clinical and topographical analysis

PURPOSE Positional nystagmus is usually caused by peripheral vestibular disorder, mostly benign paroxysmal positional vertigo (BPPV). However, positional nystagmus is also encountered in central lesions. We aimed to determine clinical characteristics of the structures responsible for central positional nystagmus (CPN) associated with brain tumors. METHODS All four patients (3 men; range=19-77years) had an evaluation of spontaneous and positional nystagmus using video-oculography. Brain MRIs were performed in all patients. RESULTS All patients showed apogeotropic positional nystagmus during supine roll tests, and had an initial diagnosis of BPPV. Except for the positional nystagmus, findings of neurological examination were normal. Because all subjects were initially diagnosed with BPPV, canalith repositioning maneuvers were applied repeatedly but without a success. Brain MRI finally disclosed brain tumors involving the midline cerebellar structures around the fourth ventricle and the nodulus. The pathological diagnosis was hemangioblastoma in two and metastatic tumor in the others. CONCLUSIONS An apogeotropic type of CPN may be an isolated finding in patients with a cerebellar tumor. Even in patients with isolated apogeotropic positional nystagmus, a central lesion should be sought especially when refractory to repeated canalith repositioning maneuvers.

Early clinical implications of microalbuminuria in patients with acute ischaemic stroke

Background Microalbuminuria is thought to be independently associated with an increased risk of, and mortality from, stroke. However, no studies have shown whether microalbuminuria is associated with the early clinical outcomes of acute ischaemic stroke. Therefore we investigated whether this. We also looked at radiological outcomes in stroke patients with microalbuminuria. Methods This was a retrospective study of patients with ischaemic stroke (within 72 h of symptom onset) who had been consecutively admitted to the Cerebrovascular Center at Chonnam National University Hospital between May 2010 and February 2011. Early clinical outcomes were assessed by early neurological deterioration (END) and modified Rankin Scale score >2 at discharge. In addition, early radiological outcomes were assessed from haemorrhagic transformation (HT) and lesion changes on follow-up diffusion-weighted imaging. We categorised a urine albumin/creatinine ratio of ≤30 mg albumin/g creatinine as normal and 30–300 mg albumin/g creatinine as microalbuminuria. Results 139 of 361 patients (38.5%) had microalbuminuria. In multivariate analysis, microalbuminuria was independently associated with END and HT. Furthermore, there were significant relationships between urinary albumin/creatinine ratio and white matter hyperintensity (WMH) grades (31.78 mg albumin/g creatinine for no WMH, 48.41 for grade 1, 64.29 for grade 2, and 44.16 for grade 3; p=0.004) and the types of HT (37.43 mg albumin/g creatinine for no HT, 71.41 for HI, and 131.63 for PH; p<0.001). Conclusion In the early phase of ischaemic stroke, patients with microalbuminuria were associated with worse clinical and radiological outcomes (END, HT and lesion changes on follow-up diffusion-weighted imaging) than those without.

Lobar cerebral microbleeds associated with transient focal neurological symptoms followed by symptomatic intracerebral hemorrhage.

Cerebral microbleeds (CMBs) are defined as all discrete round-shaped hypointense areas on T2*-weighted magnetic resonance images (MRIs) with a gradient-echo (GRE) sequence [11]. CMBs can be regarded as a marker of vessel wall disorders with a higher tendency for intracerebral hemorrhage (ICH) [11]. It has been suggested that microbleeds increase the risk of ICH following antithrombotic administration for acute ischemic stroke [9, 14], though this issue remains controversial. In addition, there have been few reports of symptomatic ICH that has occurred at the site of microbleeds in the literature [2, 13]. However, these lesions themselves have been considered asymptomatic. We present a case of CMBs presenting with transient neurologic symptoms that developed into subsequent ICH. A 65-year-old man with no previous neurological history visited our hospital because of incoherent speech and headache. He had a history of diabetes mellitus and chronic hepatitis B. He had been diagnosed with hepatocellular carcinoma prior to this presentation. Neurological examination revealed that he had language disturbances with jargon speech and abnormal comprehension. These symptoms fluctuated and persisted for about half an hour after symptom onset. The results of other physical examinations were normal. Electroencephalography showed that there were no epileptiform discharges or abnormal inherent rhythms. There were also no acute ischemic brain lesions or hemorrhages on initial brain MRI (Fig. 1a). GRE images showed multiple CMBs in the left temporo-parieto-occipital lobe relevant to language disturbance (Fig. 1b). However, there were no CMBs in the deep subcortical area and brainstem. There were no CMBs on previous GRE images obtained at a local clinic 1 month prior to this presentation as well (Supplemental Figure). While he had no symptoms at this time, he underwent brain MRI as part of a medical check-up. All laboratory tests, including coagulation profiles, were normal. He was tentatively diagnosed with (1) recurrent transient ischemic attacks and (2) mood disorder associated with medical condition. During admission, he was treated with antihypertensive agents and 100 mg of aspirin for prevention of secondary ischemic stroke. On the fourth day of admission, he suddenly developed global aphasia and right hemiparesis. Follow-up GRE images showed a large lobar hematoma with perilesional edema in the left temporo-parietal lobe where the CMBs were previously seen (Fig. 1c). Although he was referred to the Department of Neurosurgery for surgical management, he was discharged with a modified Rankin scale of 5. Our case illustrates that localized CMBs can be related to transient neurological symptoms and subsequent ICH. Although this is a single case that represents a causal relationship between CMBs and transient neurological symptoms, the association between CMBs and subsequent ICH could not be clarified, suggesting that transient Electronic supplementary material The online version of this article (doi:10.1007/s00415-012-6504-8) contains supplementary material, which is available to authorized users.

Cluster-like Headache Secondary to Focal Cervical Myelitis

Background: Cluster headache (CH) is characterized by attacks of severe periorbital pain associated with autonomic symptoms. As with other forms of primary headache, structural lesions should be excluded, particularly if the headache presents with an atypical pattern. Case: We report a 41-year-old woman who had no previous history of primary headache and showed a poor response to medication for CH. The patient was finally diagnosed as secondary headache with CH feature due to focal myelitis at the cervical level of the spinal cord. A strong positive Enzyme-linked Immunosorbent Assay test for Toxocara canis antibodies helped us to make a diagnosis of cervical Toxocara myelitis. After starting treatment with intravenous methylprednisolone and albendazole, her headache gradually improved with abortive and preventive treatment for CH. Conclusions: We suggest that neuroimaging of the upper cervical cord as well as the brain is important when CH is showing an atypical clinical course. Cervical Toxocara myelitis might be a possible cause of secondary headache with CH feature.

Association of coffee consumption and non-motor symptoms in drug-naïve, early-stage Parkinson's disease

OBJECTIVE Coffee consumption has an inverse association with the risk of Parkinsons disease (PD). The aim of this study was to investigate the association between coffee consumption and non-motor symptoms (NMSs) in patients with PD. METHODS In this cross-sectional study, we included 196 early-stage, treatment-naïve PD patients. Coffee consumption history was obtained via semi-structured interviews. NMSs were assessed using the Non-Motor Symptom assessment scale (NMSS). RESULTS Of the 196 patients with PD, 136 (69.3%) were categorized as coffee drinkers and 60 (30.6%) were non-drinkers. Coffee drinkers were younger, predominantly male, were younger in age at symptom onset, had lower Unified Parkinsons Disease Rating Scale motor and Beck Depression Inventory scores, and higher Mini-Mental State Examination scores than non-coffee drinkers. After adjustment, coffee drinking was significantly inversely associated with the prevalence of lack of motivation, anhedonia, and lack of pleasure, which were less frequent in coffee drinkers. Total NMSS scores were lower in coffee drinkers than in non-drinkers (p = 0.047). In particular, coffee drinking was significantly associated with a reduced severity of the mood/cognition domain of NMSS (p = 0.003). After correcting for multiple testing, there were no significant differences in the prevalence of NMSs, but there were significant differences in the severity of NMSs between coffee drinkers and non-drinkers. CONCLUSION There is a negative association between coffee consumption and the severity of the mood/cognition domain of NMSS in patients with PD. Clinicians should consider the history of coffee consumption in the assessment of NMSs in PD.

Comparison of two motor subtype classifications in de novo Parkinson's disease

BACKGROUND Clinical subtypes of Parkinsons disease (PD) have been empirically defined based on the prominent motor symptoms. The aim of this study was to compare the prevalence of non-motor symptoms across PD motor subtypes in patients with PD. METHODS A total of 192 patients with de novo PD were included. The patients were classified into the tremor-dominant/mixed/akinetic-rigid (TD/mixed/AR) and tremor-dominant/mixed/postural instability and gait disturbance (TD/mixed/PIGD) subtypes, according to previous reports. RESULTS In the TD/mixed/AR classification, scores for scales related to motor symptoms and activities of daily living (ADL) were significantly different among the groups, and patients with the AR subtype demonstrated more severe scores than patients with the TD subtype. In the TD/mixed/PIGD classification, age, age at symptom onset, scores on motor-related scales, ADL, and non-motor symptoms were significantly different among the groups. Scores including the modified Hoehn and Yahr stages, the motor and ADL subscores of the Unified Parkinsons Disease Rating Scale, the Beck Depression Inventory, and the Non-Motor Symptom Assessment Scale were significantly different after adjustments for age and age at symptom onset, and patients with the PIGD subtype obtained more severe scores than patients with the TD subtype. CONCLUSION The TD/mixed/PIGD classification seems to be more suitable for identifying non-motor abnormalities than the TD/mixed/AR classification.