http://www.familypracticenews.com/news/infectious-diseases/single-article/fungal-meningitis-can-masquerade-as-ischemic-stroke/bd6ab4dab41dd9db1a5b3f81edfd7c14.html
The recent
outbreak of fungal meningitis caused by spinal injections of
contaminated methylprednisolone illustrates that the disease can present
as ischemic stroke, according to a report published online July 22 in
JAMA Neurology.
Three such cases occurred in elderly patients who
had clear risk factors for stroke and no fever or meningeal signs; whose
exposure to the contaminated injection was as remote as 4 weeks
earlier; and whose early MRI scans indicated stroke rather than
infection, said Dr. Kirk Kleinfeld and his associates at Vanderbilt
University Medical Center, Nashville, Tenn.
The
investigators described these cases in detail so as to alert clinicians
to this confusing presentation, which would enable them to initiate
antifungal therapy as soon as possible. In two of these cases, the
diagnosis was delayed and the patients died. In the third case, once
clinical suspicion of fungal meningitis had been aroused, empiric
antifungal therapy appears to have saved the patient’s life, they noted.
"An awareness of the presentation and vascular
sequelae of fungal meningitis in immunocompetent patients should lead to
earlier treatment and improved outcomes prior to a definitive
diagnosis," Dr. Kleinfeld and his colleagues wrote.
In the first case, a 78-year-old man presented with
acute-onset, left-sided weakness and dysarthria. He was afebrile and had
no meningeal signs, and his laboratory workup showed only mild
leukocytosis. He had hyperlipidemia, hypertension, and atrial
fibrillation, and an MRI scan showed a small-vessel ischemic infarct of
the right anterior superior pons/lower midbrain.
The patient failed to improve with standard
poststroke care. When his left-sided weakness worsened on day 3, another
MRI showed that the infarct had extended and a new one had formed in
the right thalamus. The next day he became unresponsive, and repeated
imaging showed enlargement and evolution of those infarcts plus
formation of an occlusion of the right superior cerebellar artery. The
patient died on day 6.
An autopsy was performed when it was noted that the
patient had received an epidural steroid injection 2 weeks earlier to
treat low-back pain. It "revealed small areas of focal cortical and
pontine subarachnoid hemorrhage, as well as fungal cerebral vasculitis
with aneurysm formation."
Infection with Exserohilum species was identified, the investigators reported (JAMA Neurol. 2013 July 22 [doi: 10.1001/jamaneurol.2013.3586]).
In the second case, a 78-year-old woman presented
with subacute vertigo, nausea, and headache, and was found on
examination to have one-sided dysmetria and mild ataxia. Her medical
history included hypertension, hyperlipidemia, and coronary artery
disease, and the initial laboratory workup revealed type 2 diabetes. The
authors noted that an MRI scan showed "ischemic infarcts of the left
lateral pons, superior cerebellar peduncle, and superior cerebellum
suggestive of a large-vessel (superior cerebellar artery) etiology."
A hypercoagulable panel revealed lupus anticoagulant
and elevated antiphospholipid protein antibodies. Anticoagulation
therapy was given. The patient failed to improve, and on day 4 she
developed a low-grade fever and mild encephalopathy. A repeat MRI showed
a new ischemic pontine stroke.
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