RESUMEN
Bacterial meningitis is a life-threatening condition that is mainly caused by Streptococcus pneumoniae and Neisseria meningitis. Although Streptococcus gallolyticus subsp. pasteurianus (Sgp) is also known to cause meningitis, its frequency is quite low, especially in adults. We herein report the first immunocompetent Japanese adult patient (20-year-old woman) with bacterial meningitis caused by Sgp. The patient showed dramatic improvement after antibiotic treatment. Although previous reports have described an association between Sgp infection and an immunosuppressive status, bowel and hepatobiliary diseases, or strongyloidiasis, our case did not demonstrate any of these conditions, suggesting that Sgp can cause meningitis even in young immunocompetent adults.
Asunto(s)
Meningitis Bacterianas , Infecciones Estreptocócicas , Femenino , Humanos , Adulto Joven , Adulto , Streptococcus gallolyticus , Infecciones Estreptocócicas/complicaciones , Infecciones Estreptocócicas/diagnóstico , Infecciones Estreptocócicas/tratamiento farmacológico , Streptococcus , Meningitis Bacterianas/diagnóstico , Meningitis Bacterianas/tratamiento farmacológico , Meningitis Bacterianas/microbiologíaRESUMEN
An 80-year-old woman underwent pancreatoduodenectomy. Post-operation, she experienced a fever, and a culture of blood revealed metallo-beta-lactamase-producing Raoultella ornithinolytica. For treatments with aminoglycoside antimicrobial agents, a therapeutic drug monitoring-based dosing design can lower the risk of adverse events and enable appropriate treatment. Key Clinical Message. When aminoglycoside antimicrobial agents are administered for MBL-producing bacteremia, prescription suggestions based on TDM by antimicrobial stewardship team can reduce the occurrence of adverse events and enable appropriate treatment.
RESUMEN
A 56-year-old woman with a history of connective tissue disease developed fever, and Bacillus cereus (B. cereus) was detected in blood cultures. Therefore, treatment with vancomycin (VCM) was initiated. Since her blood cultures persistently detected B. cereus despite peripheral intravenous catheter replacement and VCM treatment, concomitant treatment with gentamicin (GM) was started. Blood cultures then became negative. Persistent B. cereus bacteremia responded to combination therapy with VCM and GM. This combination therapy may increase the risk of developing renal dysfunction, but the risk can be mitigated by appropriate therapeutic drug monitoring (TDM) and dose adjustments to achieve successful treatment.
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Neurotoxicity is one of the more serious immune-related adverse events (irAEs) linked to immune checkpoint inhibitors and calls for prompt diagnosis and treatment. We describe a case of posttreatment anti-programmed death-1 immune checkpoint inhibitor pembrolizumab-induced oculomotor, optic, and trigeminal neuropathy in an 84-year-old female patient with recurrent pulmonary adenocarcinoma. After she received 13 cycles of pembrolizumab, she experienced hyponatremia, anorexia, and right ptosis. There were signs of the suspected irAEs of pembrolizumab, including trigeminal neuropathy, optic neuropathy, and oculomotor neuropathy. Steroid pulse therapy had good results for her neurological findings. We reported this case despite reports of pembrolizumab-induced mononeuropathy of the oculomotor and optic nerves because multiple cranial neuropathies like orbital apex syndrome are thought to be uncommon.
RESUMEN
We herein report a 63-year-old rippling muscle disease (RMD) patient who presented with painless stiffness, muscle hypertrophy and muscle contractions elicited by mechanical stimulation. He also showed irregular toe jerks and a slightly elevated level of anti-acetylcholine receptor antibody (AChR-Ab). Since he had a mediastinal mass mimicking thymoma, which was later revealed to be a bronchial cyst, he underwent extended thymectomy. The irregular toe jerks disappeared within a week after the operation. The other muscle symptoms completely remitted 27 months after the onset. This is the first report of a sporadic case of RMD with irregular toe jerks that resolved after extended thymectomy.
Asunto(s)
Miastenia Gravis , Timoma , Neoplasias del Timo , Autoanticuerpos , Humanos , Masculino , Persona de Mediana Edad , Enfermedades Musculares , Miastenia Gravis/diagnóstico , Miastenia Gravis/cirugía , Receptores Colinérgicos , Timectomía , Timoma/diagnóstico , Timoma/cirugía , Neoplasias del Timo/complicaciones , Neoplasias del Timo/diagnóstico , Neoplasias del Timo/cirugía , Dedos del PieRESUMEN
This is the first report of tocilizumab-associated meningitis-retention syndrome in a patient with idiopathic multicentric Castleman disease. A 57-year-old man presented with headache, nuchal rigidity, impaired consciousness, pyramidal tract signs and urinary retention. A cerebrospinal fluid examination revealed increased cell counts and protein levels. These symptoms were improved by intravenous methylprednisolone. Tocilizumab-associated meningoencephalitis has been reported in patients with rheumatoid arthritis and juvenile idiopathic arthritis but not with multicentric Castleman disease. This case presents evidence of the increased probability of meningitis as a neurological complication of tocilizumab administration.
Asunto(s)
Enfermedad de Castleman , Meningitis Aséptica , Anticuerpos Monoclonales Humanizados/efectos adversos , Enfermedad de Castleman/complicaciones , Enfermedad de Castleman/tratamiento farmacológico , Humanos , Masculino , Meningitis Aséptica/inducido químicamente , Meningitis Aséptica/diagnóstico , Meningitis Aséptica/tratamiento farmacológico , Metilprednisolona/uso terapéutico , Persona de Mediana EdadRESUMEN
Lymphomatosis cerebri (LC) is a variant of primary central nervous system lymphoma, which demonstrates diffuse white matter infiltrates without showing definite enhanced mass lesions on MR scans. We present a case of seventy-one year-old immunocompetent male who manifested with progressive truncal ataxia and drowsiness. The MRI exhibited diffuse white matter lesions from brainstem to cerebral hemispheres with minimum enhanced lesions at the first presentation. Because the diagnosis of LC was suspected, we performed a brain biopsy from the enhanced lesion near the right thalamus, which revealed diffuse large B cell lymphoma. After he underwent methylprednisolone pulse therapy and methotrexate chemotherapy, he obtained remission. Making a diagnosis of LC is often difficult because image findings resemble those of inflammatory or autoimmune diseases. LC is an important differential diagnosis to be considered in patients presenting with diffuse white matter disease. Performing a brain biopsy at the early phase is essential for the correct diagnosis and the favorable prognosis.
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Biopsia/métodos , Neoplasias Encefálicas/diagnóstico , Encéfalo/patología , Linfoma de Células B Grandes Difuso/diagnóstico , Anciano , Antimetabolitos Antineoplásicos/administración & dosificación , Encéfalo/diagnóstico por imagen , Neoplasias Encefálicas/diagnóstico por imagen , Neoplasias Encefálicas/tratamiento farmacológico , Neoplasias Encefálicas/patología , Diagnóstico Diferencial , Humanos , Linfoma de Células B Grandes Difuso/diagnóstico por imagen , Linfoma de Células B Grandes Difuso/tratamiento farmacológico , Linfoma de Células B Grandes Difuso/patología , Imagen por Resonancia Magnética , Masculino , Metotrexato/administración & dosificación , Resultado del TratamientoRESUMEN
The case is a 64-year-old male who had a past history of herpes simplex virus encephalitis (HSE) two years prior to his admission. He was admitted to our hospital due to severe pneumonia and sepsis. Several days later, he developed HSE again. It has been known that immunosuppressive state called immune paralysis occurs in the patient with sepsis due to the amplification of anti-inflammatory responses after the initial hyper-inflammatory phase, which increases the susceptibility to various latent viruses including herpes simplex virus. In the present case, we consider that the severe infection may trigger the recurrence of HSE through the viral reactivation due to immune paralysis. When we see a patient suffering from severe infection who had a past history of HSE, we should keep in mind that such a patient may have a risk of the recurrence of HSE.
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Encefalitis por Herpes Simple/etiología , Huésped Inmunocomprometido , Neumonía/complicaciones , Sepsis/complicaciones , Encéfalo/diagnóstico por imagen , Encefalitis por Herpes Simple/diagnóstico por imagen , Encefalitis por Herpes Simple/virología , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Neuroimagen , Recurrencia , Índice de Severidad de la Enfermedad , Simplexvirus/fisiología , Activación ViralAsunto(s)
Axones , Encéfalo/diagnóstico por imagen , Listeriosis/diagnóstico por imagen , Imagen por Resonancia Magnética , Anciano , Biomarcadores/sangre , Biomarcadores/líquido cefalorraquídeo , Diagnóstico Precoz , Humanos , Listeriosis/tratamiento farmacológico , Listeriosis/metabolismo , Listeriosis/psicología , MasculinoRESUMEN
OBJECTIVE: We aimed to analyze the clinical and histopathologic features of cancer-associated myositis (CAM) in relation to anti-transcriptional intermediary factor 1 γ antibody (anti-TIF1-γ-Ab), a marker of cancer association. METHODS: We retrospectively studied 349 patients with idiopathic inflammatory myopathies (IIMs), including 284 patients with pretreatment biopsy samples available. For the classification of IIMs, the European Neuromuscular Center criteria were applied. Patients with CAM with (anti-TIF1-γ-Ab[+] CAM) and without anti-TIF1-γ-Ab (anti-TIF1-γ-Ab[-] CAM) were compared with patients with IIM without cancers within and beyond 3 years of myositis diagnosis. RESULTS: Cancer was detected in 75 patients, of whom 36 (48%) were positive for anti-TIF1-γ-Ab. In anti-TIF1-γ-Ab(+) patients with CAM, cancers were detected within 1 year of myositis diagnosis in 35 (97%) and before 1 year of myositis diagnosis in 1. All the anti-TIF1-γ-Ab(+) patients with CAM satisfied the dermatomyositis (DM) criteria, including 2 possible DM sine dermatitis cases, and were characterized histologically by the presence of perifascicular atrophy, vacuolated fibers (VFs), and dense C5b-9 deposits on capillaries (dC5b-9). In contrast, 39 anti-TIF1-γ-Ab(-) patients with CAM were classified into various subgroups, and characterized by a higher frequency of necrotizing autoimmune myopathy (NAM). Notably, all 7 patients with CAM classified into the NAM subgroup were anti-TIF1-γ-Ab(-) and exhibited no dC5b-9 or VFs. CONCLUSIONS: CAM includes clinicohistopathologically heterogeneous disease entities. Among CAM entities, anti-TIF1-γ-Ab(+) CAM has characteristically shown a close temporal association with cancer detection and the histopathologic findings of dC5b-9 and VFs, and CAM with NAM is a subset of anti-TIF1-γ-Ab(-) CAM.
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Proteínas Reguladoras de la Apoptosis/inmunología , Autoanticuerpos/inmunología , Miositis/complicaciones , Miositis/inmunología , Neoplasias/complicaciones , Neoplasias/inmunología , Proteínas Nucleares/inmunología , Autoanticuerpos/sangre , Biomarcadores/sangre , Femenino , Humanos , Masculino , Miositis/sangre , Miositis/diagnóstico , Neoplasias/sangre , Neoplasias/diagnóstico , Estudios RetrospectivosRESUMEN
Vitamin deficiency is one of the major causes of treatable dementia. Specifically, patients suffering from dementia frequentry display low serum levels of vitamin B(12). There is a close metabolic interaction between folate and vitamin B(12). Folate deficiency causes various neuropsychiatric symptoms, which resemble those observed in vitamin B(12) deficiency. This review summarizes, the basic pathophysiology of vitamin B(12) and folate deficiency, its clinical diagnosis, associated neuropsychiatric symptoms such as subacute combined degeneration and dementia, and epidemiological studies of cognitive decline and brain atrophy.
Asunto(s)
Encéfalo/patología , Demencia/terapia , Deficiencia de Ácido Fólico/metabolismo , Médula Espinal/patología , Deficiencia de Vitamina B 12/terapia , Vitamina B 12/metabolismo , Anciano , Encéfalo/fisiopatología , Demencia/diagnóstico , Demencia/genética , Demencia/fisiopatología , Femenino , Deficiencia de Ácido Fólico/diagnóstico , Deficiencia de Ácido Fólico/fisiopatología , Deficiencia de Ácido Fólico/terapia , Humanos , Vitamina B 12/genética , Deficiencia de Vitamina B 12/complicaciones , Deficiencia de Vitamina B 12/diagnóstico , Deficiencia de Vitamina B 12/fisiopatologíaRESUMEN
A 62-year-old man was admitted to our hospital because of fever and disturbed consciousness. He suffered from persistent constipation due to diabetic autonomic neuropathy. On admission, neck stiffness and weakness of the lower extremities were observed. Cerebrospinal fluid (CSF) pleocytosis and decreased CSF glucose concentration showed the presence of meningitis. Bacterial culture of CSF was negative. One week after admission, he suddenly suffered from massive bleeding from the rectum, where a hemorrhagic ulcer caused by severe persistent constipation was observed. Contrast-enhanced CT scans and gadolinium-enhanced MR scans demonstrated a lumbar spinal epidural abscess, paraspinal muscle abscess, and cervical osteomyelitis. Streptococcus agalactiae, a bacterial species belonging to the group B streptococci, was isolated from pus obtained by needle puncture of the paraspinal muscle abscess. His entire condition was treated successfully with ampicillin and cefotaxime. Group B streptococci normally colonize the mucous membrane of the genital or lower gastrointestinal regions and rarely cause a spinal epidural abscess. However, in this case, the existence of a rectal ulcer probably made it possible for S. agalactiae to cause an infection of the epidural space or paraspinal muscles via the spinal valveless venous system named Batson's plexus communicating with the sacral, pelvic, and prostatic venous plexus. Our case indicated the importance of Batson's plexus in group B streptococcus infections surrounding the spinal canal and the necessity to explore for intrapelvic lesions including a rectal ulcer.
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Neuropatías Diabéticas/complicaciones , Meningitis Bacterianas/etiología , Enfermedades del Recto/microbiología , Canal Medular , Infecciones Estreptocócicas/microbiología , Streptococcus agalactiae , Úlcera/microbiología , Estreñimiento/etiología , Humanos , Masculino , Persona de Mediana Edad , Streptococcus agalactiae/aislamiento & purificaciónRESUMEN
We report a 62-year-old woman with intravascular lymphomatosis (IVL) which presented as subacute encephalopathy. She was admitted to our hospital because of loss of consciousness in the middle of February, 2006. Laboratory tests indicated elevated serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and cerebrospinal fluid protein. Magnetic resonance imaging (MRI) of the brain revealed multiple infarct-like lesions mainly in the white matter. After admission, her consciousness was soon improved, but the inflammatory response did not disappear with any antibiotics or virucides. Her consciousness was not exacerbated, and she was discharged in the middle of March, although the reason for loss of consciousness remained unknown. After discharge she developed an abnormal behavior and mental deterioration, and therefore she was readmitted late in March. On second admission, her consciousness was drowsy. Neurological examinations revealed conjugate deviation of her eyes to the left, left hemiparesis, and generalized hyporeflexia. Laboratory tests showed more elevated CRP than that of the last time, and raised soluble IL-2 receptor (sIL-2R). The repeated MRI of the brain disclosed that initial lesions of the white matter progressively enlarged and increased in number. To make an appropriate diagnosis of the lesions on the brain MRI, the open brain biopsy was performed. Microscopic examination showed that many small vessels were occluded by lymphoma cells (B-lymphocytes) with hemorrhage, and IVL was diagnosed. She was treated with regimens of combined chemotherapy with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone). After chemotherapy her consciousness and left hemiparesis were gradually improved and the levels of CRP were normalized. The infarcts-like lesions detected on the brain MRI became reduced and decreased. IVL is a rare disease, and the prognosis is generally poor, with a rapidly fatal outcome, leading to a postmortem diagnosis. In the present report, we successfully treated the patient by rituximab in addition to standard CHOP therapy. Rituximab may play an important role in the treatment of IVL.
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Infarto Cerebral/etiología , Linfoma de Células B/complicaciones , Inconsciencia/etiología , Neoplasias Vasculares/complicaciones , Enfermedad Aguda , Anticuerpos Monoclonales/administración & dosificación , Anticuerpos Monoclonales de Origen Murino , Protocolos de Quimioterapia Combinada Antineoplásica/administración & dosificación , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Biomarcadores/análisis , Proteína C-Reactiva/análisis , Ciclofosfamida/administración & dosificación , Doxorrubicina/administración & dosificación , Femenino , Humanos , Linfoma de Células B/diagnóstico , Linfoma de Células B/terapia , Imagen por Resonancia Magnética , Persona de Mediana Edad , Prednisolona/administración & dosificación , Receptores de Interleucina-2/análisis , Rituximab , Neoplasias Vasculares/diagnóstico , Neoplasias Vasculares/terapia , Vincristina/administración & dosificaciónRESUMEN
A slightly obtunded 59-year-old man admitted for headache and consciousness disturbance after two weeks of fever, sore throat, and general malaise. His cerebrospinal fluid showed a slight increase in the white cell count and protein content. T2-weighted MRI demonstrated high signal intensity of the bilateral globus pallidus. Cerebrospinal fluid culture was negative for fungi and bacteria, including mycobacterium tuberculosis. Negative results for PCR and ELISA made herpes simplex virus encephalitis unlikely. We treated him empirically with aciclovir and cefpirome, conducting further tests because a HIV serological test was positive on admission. HIV RNA was 2.9 x 10(5) copies/ml in the blood. Western blot analysis demonstrated positive bands at gp160, p24, p55, and p68, but negative at gp120, p52, gp41, p40, p34, and p18. These results yielded a definitive diagnosis of acute primary HIV infection presenting as meningoencephalitis. His clinical condition improved over the next few days. Repeated MRI showed a new lesion in the pons on T2-weighted images. No MRI abnormality has reported previously in acute primary HIV infection with meningoencephalitis. High signal intensity in the bilateral globus pallidus and the pons in patients with meningoencephalitis may thus be a useful indicator for acute primary HIV infection.
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Globo Pálido/patología , Infecciones por VIH , Angiografía por Resonancia Magnética , Meningoencefalitis/patología , Meningoencefalitis/virología , Enfermedad Aguda , Biomarcadores/sangre , Western Blotting , VIH/genética , VIH/inmunología , Anticuerpos Anti-VIH/sangre , Humanos , Aumento de la Imagen , Masculino , Meningoencefalitis/diagnóstico , Persona de Mediana Edad , ARN Viral/sangreRESUMEN
A 17-year-old boy with high fever, headache, and neck stiffness was admitted to our hospital. Spinal fluid showed a protein level of 215 mg/dL with myelin basic protein (579 pg/mL), 347/ microl cells (330 mononuclear cells), and a glucose level of 53 mg/dL. One week later, urinary retention, flaccid paraplegia, and sensory disturbance below the 10th thoracic level developed. MRI of the spinal cord revealed swelling and T2-high intensity area in the cord at the 11th and 12th thoracic level. Although high-dose of methylprednisolone was administered, consciousness disturbance and respiratory failure that required mechanical ventilation occurred. Bilateral abducens nerve palsy, nystagmus, and flaccid tetraparesis also occurred. Brain MRI revealed T2-high intensity area in the midbrain and pons. Nerve conduction study showed diminished amplitudes and prolonged latencies or absence of F waves. The patient was administered a combination of intravenous immunoglobulin and a high-dose of methylprednisolone. He showed improvement within one week after the treatment. Two weeks later, he recovered from respiratory failure and weakness of the upper limbs. He remained paraplegic, but gradually improved and was able to walk with support one and a half years later. We suggest the combination therapy of intravenous immunoglobulin and a high-dose of methylprednisolone is effective for patients with combined ADEM and peripheral neuropathy.
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Encefalomielitis Aguda Diseminada/complicaciones , Inmunoglobulinas Intravenosas/administración & dosificación , Metilprednisolona/administración & dosificación , Enfermedades del Sistema Nervioso Periférico/complicaciones , Adolescente , Quimioterapia Combinada , Encefalomielitis Aguda Diseminada/tratamiento farmacológico , Humanos , Masculino , Enfermedades del Sistema Nervioso Periférico/tratamiento farmacológicoRESUMEN
Polyglutamine diseases are inherited neurodegenerative diseases caused by the expanded polyglutamine proteins (polyQs). We have identified a novel guanosine triphosphatase (GTPase) named CRAG that contains a nuclear localization signal (NLS) sequence and forms nuclear inclusions in response to stress. After ultraviolet irradiation, CRAG interacted with and induced an enlarged ring-like structure of promyelocytic leukemia protein (PML) body in a GTPase-dependent manner. Reactive oxygen species (ROS) generated by polyQ accumulation triggered the association of CRAG with polyQ and the nuclear translocation of the CRAG-polyQ complex. Furthermore, CRAG promoted the degradation of polyQ at PML/CRAG bodies through the ubiquitin-proteasome pathway. CRAG knockdown by small interfering RNA in neuronal cells consistently blocked the nuclear translocation of polyQ and enhanced polyQ-mediated cell death. We propose that CRAG is a modulator of PML function and dynamics in ROS signaling and is protectively involved in the pathogenesis of polyglutamine diseases.
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GTP Fosfohidrolasas/metabolismo , Cuerpos de Inclusión Intranucleares/metabolismo , Proteínas de Neoplasias/metabolismo , Proteínas Nucleares/metabolismo , Péptidos/metabolismo , Factores de Transcripción/metabolismo , Proteínas Supresoras de Tumor/metabolismo , Secuencia de Aminoácidos , Animales , Proteína 7 Relacionada con la Autofagia , Proteínas Relacionadas con la Autofagia , Células Cultivadas , GTP Fosfohidrolasas/genética , Células HeLa , Humanos , Ratones , Datos de Secuencia Molecular , Proteínas de Neoplasias/genética , Señales de Localización Nuclear/genética , Señales de Localización Nuclear/metabolismo , Proteínas Nucleares/genética , Proteína de la Leucemia Promielocítica , Ratas , Factores de Transcripción/genética , Proteínas Supresoras de Tumor/genética , Enzimas Activadoras de Ubiquitina/metabolismo , Enzimas Ubiquitina-Conjugadoras/metabolismo , Rayos UltravioletaRESUMEN
Protein misfolding is considered a key event in the pathogenesis of polyglutamine disease such as Machado-Joseph disease (MJD). Overexpression of chaperone proteins and the application of chemical chaperones are reported to suppress polyglutamine induced cytotoxicity in vitro and in vivo. The effects of compatible solutes, which are osmoprotectants in bacteria and possess the action in stabilizing proteins under stress, have not, to our knowledge, been studied. We explored the protective effects of the compatible solutes ectoine, hydroxyectoine, and betaine on apoptotic cell death produced by the truncated MJD gene product with an expanded polyglutamine tract in cultured neuro2a cells. Ectoine, but not hydroxyectoine or betaine, decreased large cytoplasmic inclusions and increased the frequency of nuclear inclusions. Immunoblot analysis showed that ectoine reduced the total amount of aggregates. Despite the presence of nuclear inclusions, apoptotic features were less frequently observed after ectoine application. Our findings suggest that ectoine, a natural osmoprotectant in bacteria, may function as a novel molecule protecting cells from polyglutamine-induced toxicity.