P.031 A Rare Canadian Case of Cervical Pyomyosistis Presenting as Occipital Neuralgia

Background: Pyomyositis is an infectious disease usually encountered in tropical regions. It typically occurs in immunocompromised hosts and most commonly affects lower limb muscles. Our patient was a healthy Canadian with an atypical presentation of cervical pyomyositis. Methods: We report a case of a healthy 22-year old woman presenting to the emergency department with unprovoked severe bilateral cervico-occipital pain and nuchal rigidity. She remained afebrile. Review of the literature was conducted to search for similar presentations. Results: A Computed Tomography scan of the head and neck demonstrated the presence of a ring enhancing lesion in the semispinalis capitis muscle extending from the occiput to the C4 level. The abscess was surgically drained and cultures grew staphylococcus aureus. The patient rapidly improved on intravenous antibiotics. Literature review revealed this to be the first Canadian case of cervical pyomyositis. Conclusions: Cervical pyomyositis can be complicated by local destruction of the vertebrae, septic shock, endocarditis, septic emboli, brain abscess or rhabdomyolysis. Early diagnosis and source control is necessary to reduce the risk of morbidity. Therefore, it is important to consider this rare disease in the differential diagnosis of cervicalgia even in healthy immunocompetent patients.

Unusual presentation of meningococcal meningitis in the elderly and utility of CSF PCR testing

We present an unusual case of a previously healthy 74-year-old man who presented with diffuse weakness, severe myalgias, petechial palmar rash and hypotension, but without fever, altered mental status, nuchal rigidity or headache, who was ultimately found through PCR testing to have meningococcal meningitis.

MPC-16 RAPID PROGRESSIVE SPINAL DIFFUSE MIDLINE GLIOMA, A CASE REPORT

A 17-year-old boy presented with a 2-week history of lower back pain, progressive gait difficulty and sensory deficit of bilateral lower limbs. Magnetic resonance imaging of neuroaxis showed intramedullary tumor with spinal cord expansion from Th12 to L2 and irregular areas of enhancement. Emergent laminoplasty and biopsy was performed. Histopathological examination showed small atypical cells, but most cells had too much degeneration and necrosis to confirm the diagnosis definitively. Leptomeningeal dissemination caused conscious disturbance, nuchal rigidity and epilepsy. 2 weeks after decompression, we performed cordotomy again for advanced diagnosis, to be found diffuse midline glioma, H3K27M mutant by immunohistopathological examination and DAN sequence. He was treated with combination of whole brain and spine radiation therapy and chemotherapy with temozolomide and bevacizumab. He is still alive over 6 months. The clinical significance of H3K27M mutant in spinal gliomas is unclear. Further examinations are needed.

How to use clinical signs of meningitis

Meningitis is a critical diagnosis not to miss in children presenting with fever. Since the early 20th century, classical clinical signs have been used to aid the diagnosis of meningitis. These classical signs are nuchal rigidity, Kernig’s sign and Brudzinski’s sign. Each of these relies on the principle that stretching the inflamed meningeal membranes causes clinically detectable irritation. Several primary studies have quantified the diagnostic performance of clinical examination in detecting meningitis in children. The results of these studies vary significantly due to methodological differences, clinical heterogeneity and interobserver variability. However, their findings demonstrate that positive meningitic signs increase the likelihood of a diagnosis of meningitis, and the absence of meningitic signs reduces this probability. These signs have greatest utility when combined with other features in the history and examination to contribute to a comprehensive clinical assessment.

Acute Viral Meningitis

Acute viral meningitis refers to inflammation of the meninges of the brain in response to a viral pathogen. Viruses cause meningitis, encephalitis, myelitis, or a combination of these, meningoencephalitis or encephalomyelitis. Viral meningitis is typically a self-limited disorder with no permanent neurologic sequelae. This chapter reviews the epidemiology, etiology, diagnosis, differential diagnosis, treatment, complications, and prognosis. Tables describe Wallgren’s criteria for aseptic meningitis, important arboviral infections found in North America, herpes family viruses and meningitis, classic cerebrospinal fluid (CSF) abnormalities with viral meningitis, Centers for Disease Control and Prevention criteria for confirming arboviral meningitis, basic CSF studies for viral meningitis, and etiology of CSF pleocytosis. Figures depict common causes of viral meningitis, nuchal rigidity, examination for Kernig sign, and Brudzinski sign for meningeal irritation. This review contains 4 highly rendered figures, 8 tables, and 17 references.

Acute Viral Meningitis

Acute viral meningitis refers to inflammation of the meninges of the brain in response to a viral pathogen. Viruses cause meningitis, encephalitis, myelitis, or a combination of these, meningoencephalitis or encephalomyelitis. Viral meningitis is typically a self-limited disorder with no permanent neurologic sequelae. This chapter reviews the epidemiology, etiology, diagnosis, differential diagnosis, treatment, complications, and prognosis. Tables describe Wallgren’s criteria for aseptic meningitis, important arboviral infections found in North America, herpes family viruses and meningitis, classic cerebrospinal fluid (CSF) abnormalities with viral meningitis, Centers for Disease Control and Prevention criteria for confirming arboviral meningitis, basic CSF studies for viral meningitis, and etiology of CSF pleocytosis. Figures depict common causes of viral meningitis, nuchal rigidity, examination for Kernig sign, and Brudzinski sign for meningeal irritation. This review contains 4 highly rendered figures, 8 tables, and 17 references.

Infections of the CNS: Meningitis and Encephalitis (DRAFT)

The video in this chapter discusses infections of the central nervous system (CNS), meningitis including its symptoms (fever, headache, nuchal rigidity, altered level of consciousness), its causes (bacterial, fungal, viral, or aseptic), and how the CSF profile provides clues to the etiology. The chapter also discusses encephalitis, its symptoms (seizures, other focal neurologic symptoms). Patients with Herpes Simplex Encephalitis may show T2 hyperintensities in the anterior temporal lobes and limbic structures on MRI. CSF may show xanthochromia and positive PCR for HSV1 or HSV2.

Retropharyngeal tendinitis: Hydroxyapatite deposition driven headache and nuchal rigidity resolves with prednisone

We present a case of a 42-year-old woman who presented with sudden onset severe headache, neck pain, and nuchal rigidity associated with dysphagia. The initial differential in this patient included meningitis or retropharyngeal abscess, and an extracranial neck CT showed an ill-defined hypo-attenuated lesion within the retropharyngeal space. However, the neck pain and dysphagia were unresponsive to empirical antibiotic treatment and pain management. Further CT with contrast identified acute calcific tendonitis of the longus colli tendon, also known as retropharyngeal tendonitis (RCT). Although RCT is already known as a rare, self-limiting inflammatory condition, we present a new case of RCT, with the uncommon features of headache and nuchal rigidity in an aseptic patient, while providing a diagnostic flow chart to guide the clinical work-up of similar presentations to also include RCT.

Microsurgical treatment for arteriovenous malformation of the corpus callosum and choroidal fissure

The management of arteriovenous malformations (AVMs) of the corpus callosum and choroidal fissure is challenging because they commonly receive arterial feeders from the anterior and posterior circulation, and drain to deep veins. In this video the authors present the case of a 20-year-old man who presented with acute onset of headache, loss of consciousness, and nuchal rigidity. Computed tomography, MRI, and cerebral angiography performed in tandem revealed a ruptured, large, Grade IV AVM of the corpus callosum and choroidal fissure with two groups of arterial feeders: one from the pericallosal artery and the other from the medial and lateral posterior choroidal arteries. The treatment strategy included two stages. The first stage involved preoperative embolization of the arterial feeders from the posterior circulation, which promoted reduction of the nidus flow of the AVM. The second involved a microsurgical resection, using the interhemispheric approach, with the patient in the prone position, which allowed accessing the anterior circulation feeders and the complete resection of the AVM, without associated morbidity.The video can be found here: https://youtu.be/5wcYKhcJtls.