Objective:To analyze the clinical diagnosis, treatment ，and surgical timing of otogenic intracranial complications. Methods:The clinical data of 11 patients with intracranial complications with ear symptoms as the first manifestation in Department of Otorhinolaryngology Head and Neck Surgery, Qilu Hospital of Shandong University（Qingdao） from December 2014 to June 2022 were collected, including 8 males and 3 females, aged from 4 to 69 years. All patients had complete otoendoscopy, audiology, imaging and etiology examination, and the diagnosis and treatment plan was jointly developed through multidisciplinary consultation according to the critical degree of clinical symptoms and imaging changes. Among the 11 patients, 5 cases were treated with intracranial lesions first in neurosurgery department and middle ear lesions later in otolaryngology, 3 cases of meningitis, were treated with middle ear surgery after intracranial infection control, 1 case was treated with middle ear lesions and intracranial infection simultaneously, and 2 cases were treated with sigmoid sinus and transverse sinus thrombosis conservatively. They were followed up for 1-6 years. Descriptive statistical methods were used for analysis. Results:All the 11 patients had ear varying symptoms, including ear pain, pus discharge and hearing loss, etc, and then fever appeared, headache, disturbance of consciousness, facial paralysis and other intracranial complication. Otoendoscopy showed perforation of the relaxation of the tympanic membrane in 5 cases, major perforation of the tension in 3 cases, neoplasia in the ear canal in 1 case, bulging of the tympanic membrane in 1 case, and turbidity of the tympanic membrane in 1 case. There were 4 cases of conductive hearing loss, 4 cases of mixed hearing loss and 3 cases of total deafness. Imaging examination showed cholesteatoma of the middle ear complicated with temporal lobe brain abscess in 4 cases, cerebellar abscess in 2 cases, cholesteatoma of the middle ear complicated with intracranial infection in 3 cases, and sigmoid sinus thrombophlebitis in 2 cases. In the etiological examination, 2 cases of Streptococcus pneumoniae were cultured in the pus of brain abscess and cerebrospinal fluid, and 1 case was cultured in streptococcus vestibularis, Bacteroides uniformis and Proteus mirabilis respectively. During the follow-up, 1 patient died of cardiovascular disease 3 years after discharge, and the remaining 10 patients survived. There was no recurrence of intracranial and middle ear lesions. Sigmoid sinus and transverse sinus thrombosis were significantly improved. Conclusion:Brain abscess, intracranial infection and thrombophlebitis are the most common otogenic intracranial complications, and cholesteatoma of middle ear is the most common primary disease. Timely diagnosis, multidisciplinary collaboration, accurate grasp of the timing in the treatment of primary focal and complications have improved the cure rate of the disease.
Female ; Humans ; Male ; Brain Abscess/therapy* ; Cholesteatoma ; Deafness/etiology* ; Hearing Loss/etiology* ; Lateral Sinus Thrombosis/therapy* ; Retrospective Studies ; Thrombophlebitis/therapy* ; Child, Preschool ; Child ; Adolescent ; Young Adult ; Adult ; Middle Aged ; Aged ; Cholesteatoma, Middle Ear/therapy* ; Central Nervous System Infections/therapy* ; Sinus Thrombosis, Intracranial/therapy* ; Ear Diseases/therapy*

Central Nervous System Infections/drug therapy* ; Child ; Humans ; Nervous System Malformations

BACKGROUND: Central nervous system (CNS) symptoms after efavirenz (EFV) treatment in people living with human immunodeficiency virus (HIV) could persist and impact their quality of life. We assessed the impact of EFV-based regimen replacement with elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide (E/C/F/TAF), which is considered an alternative option for subjects who do not tolerate EFV. Most specifically, we assessed the safety and the efficacy of E/C/F/TAF and its effects on the participants' neuropsychiatric toxicity symptoms in a real-life setting. METHODS: A prospective cohort study was conducted among virologic suppressed HIV-positive participants receiving EFV-based regimens with ongoing CNS toxicity ≥ grade 2. The participants were switched to single-pill combination regimens E/C/F/TAF and followed up for 48 weeks. The neuropsychiatric toxicity symptoms were measured using a CNS side effects questionnaire, as well as the Hospital Anxiety and Depression Scale and the Pittsburgh Sleep Quality Index. The primary outcome measure was the proportion of participants experiencing grade 2 or higher CNS toxicity after EFV switch off at weeks 12, 24, and 48. Secondary endpoints included virologic and immunological responses and the effect on fasting lipids at week 48 after switch. RESULTS: One hundred ninety-six participants (96.9% men, median age: 37.5 years, median: 3.7 years on prior EFV-containing regimens) were included in the study. Significant improvements in anxiety and sleep disturbance symptoms were observed at 12, 24, and 48 weeks after switching to E/C/F/TAF (P < 0.05). No significant change in depression symptom scores was observed. At 48 weeks after switch, HIV viral load <50 copies/mL was maintained in all of the participants, median fasting lipid levels were moderately increased (total cholesterol [TC]: 8.2 mg/dL, low-density lipoprotein cholesterol [LDL-C]: 8.5 mg/dL, high-density lipoprotein cholesterol [HDL-C]: 2.9 mg/dL, and triglyceride (TG): 1.6 mg/dL, and the TC:HDL-C ratio remained stable. CONCLUSIONS The single-pill combination regimens E/C/F/TAF is safe and well tolerated. This study reveals that switching from EFV to E/C/F/TAF significantly reduces neuropsychiatric toxicity symptoms in people living with HIV with grade 2 or higher CNS complaints.
Adenine/therapeutic use* ; Adult ; Alanine ; Alkynes ; Anti-HIV Agents/adverse effects* ; Benzoxazines ; Central Nervous System ; Cobicistat/therapeutic use* ; Cyclopropanes ; Drug Combinations ; Emtricitabine/therapeutic use* ; Female ; HIV Infections/drug therapy* ; Humans ; Male ; Prospective Studies ; Quality of Life ; Quinolones ; Sleep Quality ; Tenofovir/analogs & derivatives*

Enterovirus 71 frequently involves the central nervous system and may present with a variety of neurologic manifestations. Here, we aimed to describe the clinical features, magnetic resonance imaging (MRI) findings, and cerebrospinal fluid (CSF) profiles of patients presenting with neurologic complications of enterovirus 71 infection. We retrospectively reviewed the records of 31 pediatric patients hospitalized with acute neurologic manifestations accompanied by confirmed enterovirus 71 infection at Ulsan University Hospital between 2010 and 2014. The patients' mean age was 2.9 ± 5.5 years (range, 18 days to 12 years), and 80.6% of patients were less than 4 years old. Based on their clinical features, the patients were classified into 4 clinical groups: brainstem encephalitis (n = 21), meningitis (n = 7), encephalitis (n = 2), and acute flaccid paralysis (n = 1). The common neurologic symptoms included myoclonus (58.1%), lethargy (54.8%), irritability (54.8%), vomiting (48.4%), ataxia (38.7%), and tremor (35.5%). Twenty-five patients underwent an MRI scan; of these, 14 (56.0%) revealed the characteristic increased T2 signal intensity in the posterior region of the brainstem and bilateral cerebellar dentate nuclei. Twenty-six of 30 patients (86.7%) showed CSF pleocytosis. Thirty patients (96.8%) recovered completely without any neurologic deficits; one patient (3.2%) died due to pulmonary hemorrhage and shock. In the present study, brainstem encephalitis was the most common neurologic manifestation of enterovirus 71 infection. The characteristic clinical symptoms such as myoclonus, ataxia, and tremor in conjunction with CSF pleocytosis and brainstem lesions on MR images are pathognomonic for diagnosis of neurologic involvement by enterovirus 71 infection.
Acute Disease ; Brain/diagnostic imaging ; Central Nervous System Diseases/etiology/*pathology ; Child ; Child, Preschool ; Encephalitis/pathology ; Enterovirus A, Human/genetics/*isolation & purification ; Enterovirus Infections/drug therapy/*pathology/virology ; Feces/virology ; Female ; Humans ; Immunoglobulins/administration & dosage ; Infant ; Injections, Intravenous ; Leukocytes/cytology ; Leukocytosis/cerebrospinal fluid/pathology ; Magnetic Resonance Imaging ; Male ; RNA, Viral/genetics/metabolism ; Real-Time Polymerase Chain Reaction ; Republic of Korea ; Retrospective Studies ; Seasons

Adult ; Anti-Bacterial Agents ; therapeutic use ; Brucellosis ; diagnosis ; drug therapy ; pathology ; Central Nervous System Bacterial Infections ; diagnosis ; drug therapy ; pathology ; Female ; Humans ; Male ; Middle Aged ; Retrospective Studies

Intracranial infections are one of the most common neurological diseases in children and are associated with high mortality and morbidity. Intracranial hypertension and hydrocephalus are the common, fatal complications of intracranial infections, so early diagnosis and timely treatment are the keys to saving patients' lives and reducing neurological sequelae. This paper introduces the progress in the etiology, diagnosis, and treatment of intracranial hypertension and hydrocephalus in children with intracranial infections.
Central Nervous System Infections ; complications ; Child ; Humans ; Hydrocephalus ; diagnosis ; etiology ; therapy ; Intracranial Hypertension ; diagnosis ; etiology ; therapy

OBJECTIVETo summarize the clinical features, imaging characteristics, diagnosis and treatment of a case with central nervous system infection caused by Exophiala dermatitidis, as well as to review the related literature.

METHODAssociated literature and clinical data of an 8-year-old boy who was diagnosed as central nervous system infection caused by Exophiala dermatitidis in Beijing Children's Hospital Affiliated to Capital Medical University and hospitalized twice from 2012 to 2014 were analyzed retrospectively.

RESULTThe boy was 8 years old with the chief complaint of dizziness for 2 months, intermittent fever for 1 month accompanied with spasm twice. He was diagnosed as bile ducts space-occupying lesions 2 years ago, when the pathological diagnosis was fungal infection. The boy was treated with irregular anti-fungal therapy. Then the boy developed nervous symptoms, impaired consciousness and abnormal physical activity that developed gradually. After hospitalization the cerebral MRI of the boy showed space-occupying lesions accompanied with edema of surrounding area. Filamentous fungi was found by brain biopsy, which was culture positive for Exophiala dermatitidis. After diagnosis the boy was treated with amphotericin B (AMB), voriconazole and 5-Fu, as well as symptomatic treatment. The state of the boy was improved gradually. Two months later, the boy could communicate with others normally and move personally. The lesions and edema seen on the MRI was decreased moderately. Accordingly, the boy was treated with oral voriconazole maintenance treatment for about 1 year and 4 months after discharge. During this period, the state of him was stable without symptoms. The lesions shown by MRI did not disappear but decreased on regular examination. However, recently the disease of the boy progressed again, with dizziness, neck pain, headache and progressive nervous symptoms (intermittent spasm, inability to cough, and impaired consciousness). The boy died at last, even with the active treatment at the second hospitalization. Exophiala dermatitidis was culture-positive again in his CSF, and was confirmed by PCR successfully.

CONCLUSIONThe central nervous system infection caused by Exophiala dermatitidis is rare. Clinical features of this disease were similar to those of other fungal CNS infection, cerebral MRI of which could show the similar lumpy lesions. Diagnosis of the disease should be based on pathology and culture.

Amphotericin B ; administration & dosage ; Antifungal Agents ; administration & dosage ; Brain ; diagnostic imaging ; microbiology ; pathology ; Central Nervous System Infections ; diagnosis ; drug therapy ; microbiology ; Cerebrospinal Fluid ; microbiology ; Child ; Drug Therapy, Combination ; Exophiala ; isolation & purification ; Fatal Outcome ; Fluorouracil ; administration & dosage ; Humans ; Magnetic Resonance Imaging ; Male ; Mycoses ; diagnosis ; drug therapy ; microbiology ; Radiography ; Voriconazole ; administration & dosage

Secondary opportunistic central nervous system infections occur in approximately one-third of patients with acquired immune deficiency syndrome. With the introduction of highly active antiretroviral therapy, the number of opportunistic infection cases has significantly decreased. However, the number of progressive multifocal leukoencephalopathy (PML) cases caused by opportunistic human JC polyomavirus has not decreased at a noticeable rate. In this report, seven patients with PML were evaluated at the infectious disease unit of the National Medical Center. Six of the 7 patients were not on antiretroviral therapy at the time of diagnosis. The mean patient age of the 6 men and 1 woman was 39 years. The individual CD4 cell counts were 58, 6, 18, 73, 90, 252, and 94 cells/microliter. The mean CD4 cell count was 84 cells/microliter. The most common clinical manifestation was focal weakness and the temporal lobe was mainly involved. Two of the patients died 52 days after the diagnosis was made. Three patients survived for more than 1 year without disease progression. We conclude that one must take a careful patient history, perform a neurological examination, and examine brain magnetic resonance images in patients with human immunodeficiency virus who show neurological symptoms.
Acquired Immunodeficiency Syndrome ; Antiretroviral Therapy, Highly Active ; Brain ; CD4 Lymphocyte Count ; Central Nervous System Infections ; Communicable Diseases ; Disease Progression ; Female ; HIV ; Humans ; JC Virus ; Leukoencephalopathy, Progressive Multifocal ; Magnetic Resonance Spectroscopy ; Male ; Neurologic Examination ; Opportunistic Infections ; Temporal Lobe

The incidence of CNS infection is common in developing countries such as ours, a common complication of which is elevated intraaanial pressure. The deleterious effects of increased ICP in may manifest as severe headache, visual impairment and mortality. Several modalities have been suggested for the management of ICP either medical or surgical. However, for developing countries surgical procedures is not always feasible in most clinical centers due to lack of facilities or experts and as such medical management of ICP becomes the primary mode of treatment. Acetazolamide is an inexpensive, widely available drug that in theory can lower elevated ICP. There are also some anecdotal evidence on its efficacy. This paper aims to assess the efficacy of using acetazolamide in the management of increased ICP. Intensive search of the online medical journals were done using the following keywords: "Acetazolamide", "intracranial pressure", "hydrocephalus", "acetazolamide and increased intraaanial pressure", "cryptococcal meningitis". Five citations were obtained and based on the set inclusion and exclusion criteria, two trials were deemed appropriate for this review. Critical appraisal was done which validated the trials. Overall, the two studies analyzed showed conflicting data regarding the use of acetazolamide in the management of inereased intracranial pressure. The data available from this meta-analysis shows little or no effect in giving acetazolamide for the treatment of increased ICP. This meta-analysis, however is based only on 2 RCTs with a total of 40 patients. There is still a need to conduct studies with bigger sample sizes to provide more conclusive evidence on the utility or non-utility ofacetazolamied in ICP.

Human ; Male ; Female ; Acetazolamide ; Intracranial Pressure ; Musculoskeletal And Neural Physiological Phenomena ; Nervous System Physiological Phenomena ; Cerebrospinal Fluid Pressure ; Hydrocephalus ; Nervous System Diseases ; Central Nervous System Diseases ; Brain Diseases ; Meningitis, Cryptococcal ; Bacterial Infections And Mycoses ; Mycoses ; Central Nervous System Fungal Infection ; Meningitis, Fungal ; Therapeutics ; Therapy ; Treatment Outcome

Intracranial epidural abscess is a rare occurrence due the fact that the epidural space is tightly adherent to the overlying cranial vault, thus making it difficult for microorganisms to enter this potential space. Of the occasional reported cases of intracranial epidural abscess, most occurred in the adults, and is exceedingly rare in children less than 12 years. The mainstay of treatment in these reported cases I were combination of surgery and prolonged antibiotic coverage. This is a case of a 5 month old baby girl who was referred to the Neurology Service due to 5 day history of fever and irritability. The Patient was initially brought to hospital where she was managed with paracetamol and cotrimoxazole, which afforded no relief. No laboratory work up was requested. Due to persistence of fever, the patient was brought to a pediatrician where an unrecalled antibiotic was prescribed. On follow up, nuchal rigidity as well as bulging of anterior fontanel were noted. Hence, patient was referred to our Institution where she was subsequently admitted. On examination, there was fullness of the anterior fontanelle. The rest of the physical, as well as the dermatologic findings were unremarkable. The neurologic findings were likewise normal except for the presence of meningeal irritation. The initial impression was bacterial meningitis for which patient was started on penicillin. The CSF examination was normal with no growth on culture media. The blood culture, on the other hand, showed heavy growth of Staphylococcus aureus. A cranial ultrasound was done which revealed a 2x5 an cystic mass over the right fronto-parietal area.A cranial CT scan was consequently requested which showed a heterogeneously enhancing cystic mass over the right frontoparietal convexity which was lentiform in shape with intense enhancement of the rim. With these findings, an intracranial epidural abscess was entertained. She was started on oxacillin and was referred to the neurosurgery service for possible drainage. The patient was just managed medically after the parents declined the surgical intervention In the ward, the patient remained afebrile and was stable for the rest of the hospital stay. A repeat CT scan was done after three weeks which showed markedly decrease in size of the abscess. The patient was discharged improved after 6 weeks with no neurologic sequelae.
Female ; Infant ; Infant Newborn ; Epidural Abscess ; Bacterial Infections And Mycoses ; Bacterial Infections ; Central Nervous System Bacterial Infections ; Therapeutics ; Therapy