Comparison of Clinical, Immunological And Radiological Characteristics In Autoimmune GFAP Astrocytopathy, MOGAD And AQP4-Igg +NMOSD Mimicking Infectious Meningitis As The Initial Manifestation

Objective: Several autoimmune CNS inflammatory diseases, including autoimmune glial fibrillary acidic protein astrocytopathy (A-GFAP-A), myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) and aquaporin-4-immunoglobulin-G-positive neuromyelitis optica spectrum disorders (AQP4-IgG+ NMOSD) often presented initially with similar infectious meningitis-like symptoms. However, it was not easy to differentiate them at disease onset without antibody detection. The present study aimed to compare the clinical, immunological and radiological features among the three diseases. Methods: In our single-center cohorts, 9 A-GFAP-A, 17 MOGAD and 11 AQP4-IgG+ NMOSD patients mimicking infectious meningitis as initial symptoms were retrospectively included. The autoantibodies were detected with cell-based assays. The clinical, immunological and radiological characteristics of the three groups were summarized. Results: AQP4-IgG+ NMOSD patients were statistically more often in men (10, 90.9%, P=0.003). Tremor was predominated in A-GFAP-A (4, 44.4%) over MOGAD (1, 5.9%, P= 0.034) and never found in AQP4-IgG+NMOSD (0, P=0.026). The Modified Rankin Score (mRS) at the clinical nadir of diseases was lower in AQP4-IgG+NMOSD (2.2 [IQR, 1-3]) compared to A-GFAP-A (3.7 [IQR, 3-5], P=0.04). On CSF examination, white blood cell count (WBC) was higher in A-GFAP-A (median, 272×106/L [range, 0-1600]) compared to AQP4-IgG+NMOSD (median, 12×106/L [range, 0-48], P=0.049). Significant increase in CSF protein (1490.7±871.2 mg/L), lactic acid (3.43±0.81 mmol/L), IgG (130.9±60.4 mg/L), IgM (8.6±6.1mg/L) and IgA (23.0±11.4mg/L) levels in A-GFAP-A was found compared to MOGAD (CSF protein: 606.7±379.4 mg/L, P<0.001; lactic acid: 2.15 ± 0.62mmol/L, P<0.001; IgG: 77.9±71.3 mg/L, P=0.043; IgM, 2.7±2.9mg/L, P=0.002; IgA, 11.3±12.1mg/L, P=0.012) and AQP4-IgG+NMOSD (CSF protein: 441.8±178.0 mg/L, P<0.001; lactic acid: 2.40 ± 0.66 mmol/L, P=0.003; IgG, 53.2±30.3 mg/L, P=0.01; IgM, 2.1±3.9mg/L, P=0.003; IgA, 5.2±5.0mg/L, P=0.001). Over half of the A-GFAP-A patients (5/8, 62.5%) showed small (<2 cm), symmetrical lesions in ganglia and thalamus (5/8, 62.5%), but never in MOGAD (0%, P=0.001) and AQP4-IgG+NMOSD (0%, P=0.026). Diffuse meningeal enhancement was common in A-GFAP-A (8, 88.9%) compared to MOGAD (5, 29.4%, P=0.011) and AQP4-IgG+NMOSD (1/6, 16.7%, P=0.011). Acute disseminated encephalomyelitis (ADEM) -like lesions occurred frequently in MOGAD (6/16, 37.5%) but never in A-GFAP-A and AQP4-IgG+NMOSD (P=0.02). Conclusion: Our study demonstrated that several signs including the symptom of tremor, a more severe disease course, higher CSF immunological profiles and ganglia bilateral symmetrical lesions, diffuse meningeal enhancement were distinct features in A-GFAP-A, and ADEM-like lesions occurred only in MOGAD mimicking infectious meningitis as initial symptoms, providing possible clinical implications for patient differential diagnosis.

Autoimmune diseases in HIV-negative cryptococcal meningitis

Aim: The purpose of our study was to assess the differences between HIV-negative cryptococcal meningitis (CM) patients with and without autoimmune diseases. Methods: A total of 43 CM patients with autoimmune diseases and 67 without autoimmune diseases were enrolled for analysis. Results: CM patients with autoimmune diseases had higher fever, modified Rankin Scale scores, C-reactive protein and erythrocyte sedimentation rate, but had lower rates of visual and hearing symptoms, ventriculoperitoneal shunts, MRI meningeal enhancement and amphotericin B treatment, as well as lower cerebrospinal fluid pressure and fungal counts. When divided according to gender, each group had lower intracranial pressure and higher inflammation indicators. No differences in outcomes, sequelae and mortality hazard were found. Fluconazole treatment was a prognostic factor for CM without autoimmune diseases. Conclusions: Both antifungal and anti-inflammatory therapy should be considered in CM patients with autoimmune diseases.

Frequency Of Common CT Scan Findings In Children With Tuberculous Meningitis

Aim: To determine the frequency of common CT scan findings in children with Tuberculous meningitis Setting: Department of Pediatrics, Khyber Teaching Hospital, Peshawar. Study design: descriptive cross-sectional study. Duration: 6 months (3/7/2015 to 3/1/2016) Methodology: In this study, 178 patients were selected. Non probability sampling technique was used for sample collection. Results: In this study, mean age was 9 years with SD ± 2.54. 55% patients were male and 45% patients were female. Common CT scan findings among 178 patients were analyzed. 40% patients had hydrocephalous, 72% patients had meningeal enhancement, 3% patients had infraction, 5% patients had tuberculoma. Conclusion: Most common CT scan findings of Tuberculosis meningitis in children were meningeal enhancement 72% followed by hydrocephalous 40%. Keywords: hyponatremia, tuberculous meningitis

A Patient of Neurocysticercosis Misdiagnosed as Tuberculous Meningitis for 26 Years: a Case Report

Background: Neurocysticercosis (NCC) is a neurological infection caused by the larval stage of the tapeworm Taenia solium (T. solium). The diagnosis of NCC can be challenging because of heterogeneity in clinical manifestation. Neurocysticercosis is easily misdiagnosed as tuberculous meningitis (TBM).Case presentation: We describe a case of subarachnoid neurocysticercosis with 28 years illness course misdiagnosed as TBM for 26 years. The patient presented with symptoms of repeated headache, fever, serious low back and legs pain, and vomiting, occasional seizure and lose of consciousness. The neurological assessments revealed stiff neck and right plantar and saddle numbness. Lumbar puncture results revealed obvious intracranial hypertension, pleocytosis, elevated protein level, and decreased glucose level. Magnetic resonance imaging showed meningeal enhancement of brain, cystlike structure in the lumbosacral sac and the clumping of the nerve roots of the cauda equina. Five recurrent episodes occurred in twenty-eight years. TBM was considered as a probable etiology and was treated for tuberculosis empirically with adjunctive corticosteroids for 26 years. In the first three hospitalizations, During this period, the patient was hospitalized three times. In 2016, The local hypertrophic pachymeningitis were considered as a probable etiology. She was treated with steroid pulse therapy. At her fifth relapse, in 2018, next-generation sequencing of cerebrospinal fluid (CSF) identified the patient was NCC, T. solium infection. Her symptoms and CSF examination were relieved after etiological treatment. Conclusions: Neurocysticercosis is easily misdiagnosed as TBM. Meanwhile, adjunctive corticosteroids therapy can alleviate the symptom of TBM and NCC. So we suggest that NCC should be considered in the differential diagnosis of TBM. NGS of CSF is a promising tool for the diagnosis of NCC.

Spontaneous dissolution of a cyst located within the septum pellucidum in a patient with sarcoidosis: a case report

Sarcoidosis is a granulomatous multisystem disease of unknown etiology. Typically, the disease affects the lungs, causing enlargement of the mediastinal lymph nodes, but other organs can be affected. Neurosarcoidosis is reported in 5–10% of the patients. This case represents a 39-year-old male patient diagnosed with lung sarcoidosis. Due to neurological symptoms, a contrast-enhanced cerebral magnetic resonance imaging was performed. Neurosarcoidosis was presented with meningeal enhancement adjacent to a cyst located within the cavum septum pellucidum. The cyst dissolved spontaneously within six months. The finding of a cyst located within the septum pellucidum is rare.

Neurotuberculosis with intracerebral tuberculoma and PCR for detectable Mycobacterium in CSF

Introduction: Neurotuberculosis is the most serious form of extrapulmonary tuberculosis. The main clinical presentation is meningoencephalitis, which may be associated with tuberculomas. The detection of Mycobacterium tuberculosis by CSF in CSF is still a diagnostic challenge. Objectives: To report a clinical case of neurotuberculosis associated with intracranial tuberculoma with detection of Mycobacterium tuberculosis by CSF in CSF. Methods: Neurotuberculosis is the most serious form of extrapulmonary tuberculosis. The main clinical presentation is meningoencephalitis, which may be associated with tuberculomas. The detection of Mycobacterium tuberculosis by CSF in CSF is still a diagnostic challenge. Results: C. A. G., 45 years old, female, admitted to the hospital in January 2020, presenting holocranial, pulsatile headache, which had worsened for 5 days, with little response to analgesics, associated with an episode of tonic-clonic seizure crisis, without other clinical signs. Previous diagnosis of asthma, using continuously salbutamol and beclomethasone. Examinations were requested - BAAR search for positive sputum, rapid molecular sputum test revealing Mycobacterium tuberculosis, clear-looking CSF, detectable CRP for Mycobacterium tuberculosis, glucose 63, protein 56.3, total cytology 74 (35% neutrophils, 19% lymphocytes , 46% macrophages). The cranial tomography showed a nodular lesion in the corticosubcortical region of the left frontal lobe, with annular enhancement by means of contrast, measuring 3.9 x 3.9 cm, in addition to accentuated meningeal enhancement. Chest tomography showed hollowed-out lesions with thickened walls, with the appearance of a sprouting tree, predominating in the lower lobe of the right lung. The diagnoses of neurotuberculosis (cerebral tuberculoma and meningitis) and pulmonary tuberculosis were then established. Referred to the infectious disease referral hospital using RHZE associated with dexamethasone and phenytoin. After 48 hours of hospitalization, the patient evolved with confusion and mental disorientation, suspecting complex subentrant partial seizures with a confused post-ictal state. A new skull tomography was requested, which showed an expansive lesion with an ovoid aspect 4.5 x 3.3 cm with liquefied content and ring impregnation by means of contrast in the upper left frontal region with mass effect and significant perilesional edema. Electroencephalogram showed disorganized base activity, periodically, sometimes with three-phase morphology, sometimes acute, in both hemispheres, with greater projection to the left and epileptiform activity also in the frontal- temporal region, bilaterally and independently. After therapeutic adjustment, the patient remained clinically stable and was discharged from the hospital with outpatient followup due to infectious diseases and neurology. Conclusion: The case addressed draws attention to the different neurological manifestations observed in neurotuberculosis, such as headache, seizures, confusion and disorientation. Early diagnosis and treatment is important to achieve a favorable outcome.

Brain MRI findings in relation to clinical characteristics and outcome of tuberculous meningitis

Neuroradiological abnormalities in tuberculous meningitis (TBM) are common, but the exact relationship with clinical and inflammatory markers has not been well established. We performed magnetic resonance imaging (MRI) at baseline and after two months treatment to characterise neuroradiological patterns in a prospective cohort of adult TBM patients in Indonesia. We included 48 TBM patients (median age 30, 52% female, 8% HIV-infected), most of whom had grade II (90%), bacteriologically confirmed (71%) disease, without antituberculotic resistance. Most patients had more than one brain lesion (83%); baseline MRIs showed meningeal enhancement (89%), tuberculomas (77%), brain infarction (60%) and hydrocephalus (56%). We also performed an exploratory analysis associating MRI findings to clinical parameters, response to treatment, paradoxical reactions and survival. The presence of multiple brain lesion was associated with a lower Glasgow Coma Scale and more pronounced motor, lung, and CSF abnormalities (p-value <0.05). After two months, 33/37 patients (89%) showed worsening of MRI findings, mostly consisting of new or enlarged tuberculomas. Baseline and follow-up MRI findings and paradoxical responses showed no association with six-month mortality. Severe TBM is characterized by extensive MRI abnormalities at baseline, and frequent radiological worsening during treatment.

NIMG-61. UNUSUAL PRESENTATION OF NEUROSARCOIDOSIS: A CASE SERIES

INTRODUCTION Neurosarcoidosis is a rare diagnosis, and even with known systemic disease or history, often remains a diagnosis of exclusion. Typical imaging findings of neurosarcoidosis include white matter lesions coupled with meningeal enhancement, or “sugarcoating” near the skull base. Occasionally, imaging can be quite unusual and mimic other entities. Other diagnoses to rule out include neoplastic, autoimmune, or infectious pachymeningitis, neoplastic lesions, neurosyphilis or tuberculosis. METHODS Our neuropathology database was queried for neurosarcoidosis from January 2008 until December 2019. These cases were then reviewed for cases with unusual presentations for further review and discussion. RESULTS Here we present 16 cases of neurosarcoidosis with histories and/or imaging that did not conform to the typical appearance of neurosarcoidosis. Along with a rare radiographic presentation, these cases also lacked CSF, laboratory, or systemic findings to suggest a diagnosis of neurosarcoidosis. 15 of these cases presented intracranially while 1 case presented within the spinal cord. CONCLUSIONS Neurosarcoidosis presentations can vary greatly. A better understanding of some unique patient presentations can help improve noninvasive diagnosis, although biopsy often remains necessary for confirmation.

Postcontrast Fluid-Attenuated Inversion Recovery (FLAIR) Sequence MR Imaging in Detecting Intracranial Pathology

Background. Imaging sequences for detection of meningeal and parenchymal lesions are critical in intracranial pathology. Our study analysed FLAIR MRI sequence for evaluating postcontrast enhancement. Objectives. FLAIR imaging sequences have been used in evaluation of enhancement in the brain. We conducted a study of FLAIR imaging sequences to better delineate postcontrast enhancement. Materials and Methods. In this prospective hospital-based observational study, postcontrast T1 MTC and delayed postcontrast T2 FLAIR and T1 FLAIR images of 66 patients with intracranial pathology were assessed by experienced radiologists from November 2017 to November 2019. Results. 28 cases of meningeal enhancement were identified in delayed postcontrast T2 FLAIR images. Low-grade gliomas included in the study showed postcontrast enhancement on postcontrast T1 MTC images. Multiple sclerosis lesions were better seen on postcontrast T1 FLAIR. In extraaxial lesions of 11 cases of meningioma, brighter enhancement was seen on delayed postcontrast T2 FLAIR images. Conclusion. We found that delayed postcontrast T2 FLAIR was better in detection of meningeal enhancement in infectious meningitis and in meningitis carcinomatosis than T1 MTC images. In delayed postcontrast T2 FLAIR images, intra-axial parenchyma lesions appeared more conspicuous or similar to T1 MTC images. Delayed postcontrast T1 FLAIR images provided better anatomic delineation of intra-axial lesions.