Karen L. Roos

Practice Guidelines for the Management of Bacterial Meningitis

Allan R. Tunkel, Barry J. Hartman, Sheldon L. Kaplan, Bruce A. Kaufman, Karen L. Roos, W. Michael Scheld, and Richard J. Whitley Drexel University College of Medicine, Philadelphia, Pennsylvania; Weill Cornell Medical Center, New York, New York; Baylor College of Medicine, Houston, Texas; Medical College of Wisconsin, Milwaukee; Indiana University School of Medicine, Indianapolis; University of Virginia School of Medicine, Charlottesville; and University of Alabama at Birmingham

The Management of Encephalitis: Clinical Practice Guidelines by the Infectious Diseases Society of America

Guidelines for the diagnosis and treatment of patients with encephalitis were prepared by an Expert Panel of the Infectious Diseases Society of America. The guidelines are intended for use by health care providers who care for patients with encephalitis. The guideline includes data on the epidemiology, clinical features, diagnosis, and treatment of many viral, bacterial, fungal, protozoal, and helminthic etiologies of encephalitis and provides information on when specific etiologic agents should be considered in individual patients with encephalitis.

Evidence-based guideline: Treatment of parenchymal neurocysticercosis Report of the Guideline Development Subcommittee of the American Academy of Neurology

Objective: To review the evidence base for different treatment strategies in intraparenchymal neurocysticercosis in adults and children. Method: A literature search of Medline, EMBASE, LILACS, and the Cochrane Database from 1980 to 2008, updated in 2012, resulted in the identification of 10 Class I or Class II trials of cysticidal drugs administered with or without corticosteroids in the treatment of neurocysticercosis. Results: The available data demonstrate that albendazole therapy, administered with or without corticosteroids, is probably effective in decreasing both long-term seizure frequency and the number of cysts demonstrable radiologically in adults and children with neurocysticercosis, and is well-tolerated. There is insufficient information to assess the efficacy of praziquantel. Recommendations: Albendazole plus either dexamethasone or prednisolone should be considered for adults and children with neurocysticercosis, both to decrease the number of active lesions on brain imaging studies (Level B) and to reduce long-term seizure frequency (Level B). The evidence is insufficient to support or refute the use of steroid treatment alone in patients with intraparenchymal neurocysticercosis (Level U).

Subacute Sclerosing Panencephalitis Manifesting as Viral Retinitis: Clinical and Histopathologic Findings

PURPOSE AND METHODS To describe the clinical and histopathologic features of a patient with viral retinitis secondary to subacute sclerosing panencephalitis. RESULTS The patient was a human immunodeficiency virus-negative intravenous drug abuser with an acute retinitis that later progressed to encephalitis despite aggressive treatment for possible viral, protozoal, bacterial, and rickettsial infections. The patient had many of the characteristic findings of subacute sclerosing panencephalitis, including a history of measles in early childhood, myoclonus, periodic complexes on electroencephalographic testing, persistently elevated serum and cerebrospinal fluid antimeasles immunoglobulin G (IgG) titers, and a cerebrospinal fluid oligoclonal IgG gammopathy. Ultrastructural examination demonstrated numerous filamentous microtubular intranuclear viral inclusions in the nuclear layers of the retina consistent with the measles virus. This case is unusual in that our patient developed subacute sclerosing panencephalitis later in life and because there was an 8-year period between presumed viral infections in the two eyes. CONCLUSIONS An acute retinitis in an intravenous drug abuser is not always caused by human immunodeficiency virus-related infections; not all viral retinitis responds to therapy; and mortality as well as the usual morbidity may be associated with viral retinitis. One might consider the diagnosis of subacute sclerosing panencephalitis in a young person with an acute retinitis with little or no vitreal inflammation and lack of response to anticytomegalovirus and antitoxoplasmosis therapy.

Antibacterial therapy of neurosyphilis: Lack of impact of new therapies

Neurosyphilis is caused by the spirochete Treponema pallidum. These organisms divide slowly, requiring long exposure to antibacterials for treatment success. In order for an antibacterial to be effective in the therapy of neurosyphilis, it must achieve treponemicidal concentrations in the CSF, have a long half-life and be given in a treatment regimen that favours compliance. Penicillin was first introduced for the treatment of syphilis in 1943, and despite interest in the use of amoxicillin, erythromycin, tetracycline, doxycycline, ceftriaxone and azithromycin, penicillin remains the only recommended antibacterial agent for neurosyphilis.

Reversible Cortical Blindness (Anton's Syndrome) Associated with Bilateral Occipital EEG Abnormalities

A 50-year-old woman with systemic lupus erythematosus was admitted in an obtunded state. An EEG recorded while she was unconscious demonstrated one episode of rhythmic sharp wave activity in the left occipital area that lasted for 5 minutes and was followed later in the same recording by an episode of high amplitude sharp wave discharges in the right posterior temporal and occipital areas. When the patient regained consciousness, she had an Antons syndrome of cortical blindness with denial. When she recovered light perception only, the EEG demonstrated synchronous and independent right and left occipital-posterior temporal periodic lateralized epileptiform discharges (PLEDs). Cortical blindness (Antons syndrome) associated with abnormal electrical activity in the occipital areas has only rarely been reported. Our case is significant for the following reasons: 1) PLEDs maximal right and left occipital areas associated with bilateral visual loss has not previously been observed; 2) abnormal electrical activity in the occipital lobes may be a reversible cause of Antons syndrome.

Neurology in the Tropics

edited by J. S. Chopra and I. M. S. Sawhney, 602 pp., ill., New Delhi, India, Churchill Livingstone, 1999,

Chapter 94 - Encephalitis

85.00 This textbook should be quite useful to physicians practicing medicine in tropical and subtropical areas of the world. The editors and authors are very pragmatic about the practice of neurology in the tropics. The textbook describes how to diagnose neurologic diseases in regions of the world where “neuroimaging facilities such as CT and MRI are rarely available or accessible,” “a good history is all that is required to make the diagnosis,” and “empiric treatment is based on clinical suspicion.” The therapeutic discussions are realistic, based on what is available and affordable in the tropics. There …

Chapter 4 - Bacterial meningitis

Encephalitis is an infectious or inflammatory disorder of the brain that presents with fever, headache, and an altered level of consciousness. There may also be focal or multifocal neurologic deficits, and focal or generalized seizure activity. Of the infectious etiologies, herpesviruses are the most common and some of the few treatable viral causative agents of encephalitis. The etiology, clinical presentation, diagnosis, and treatment of viral encephalitis is discussed in this chapter.

Primary intravascular lymphomatosis associated with Mycobacterium marinum.

Bacterial meningitis is a neurological emergency. Empiric antimicrobial and adjunctive therapy should be initiated as soon as a single set of blood cultures has been obtained. Clinical signs suggestive of bacterial meningitis include fever, headache, meningismus, vomiting, photophobia, and an altered level of consciousness. The peripheral white blood cell count with a left shift, an elevated serum procalcitonin and C-reactive protein, and a cerebrospinal fluid pleocytosis with a predominance of polymorphonuclear leukocytes, and a decreased glucose concentration are predictive of bacterial meningitis. Patients with documented bacterial meningitis and those in whom the diagnosis is a strong possibility should be admitted to the intensive care unit. Timely recognition of bacterial meningitis and initiation of therapy are critical to outcome.