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MAJOR CATEGORIES OF NEUROLOGIC DISEASE
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intravenous drugs For late abnormalities, no treatment has proved to be effective However, most of the symptoms tend to regress regardless of the type of treatment given
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This systemic spirochetal infection, caused by Leptospira interrogans, is characterized primarily by hepatitis but may include an aseptic meningitis during the second part of a biphasic illness Initially there is high fever, tender muscles, chest and abdominal pain, and cough An extreme form (Weil disease) comprises hepatic and renal failure Prominent conjunctival suffusion and photophobia are typical of leptospirosis and should draw attention to the diagnosis The CSF during the meningitic stage contains approximately 100 lymphocytes per milliliter, but cell counts in excess of 10,000 have been reported and the protein concentration may reach high levels Subarachnoid and intracerebral bleeding, probably from in amed blood vessels, are known to occur The diagnosis is made by serologic methods (complement xation screening followed by speci c agglutination tests) Antibiotic treatment seems to be effective only if implemented during the initial febrile phase The meningitis is usually self-limited
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Figure 32-6 Encephalitis in Lyme disease High-signal areas in the white matter in a patient with Lyme disease arthritis (Reproduced by permission from Bisese JH: Cranial MRI New York, McGraw-Hill, 1991)
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be an understatement to indicate that a number of patients are persuaded that various symptoms are the result of Lyme infection and seek and receive unnecessary treatment Serologic tests are of great value but again must be interpreted with caution if there has not been an inciting clinical syndrome of erythema chronicum migrans or arthritis or a well-documented tick bite The most valuable initial screening is performed by the enzyme-linked immunosorbent assay (ELISA); if both acute and convalescent sera are tested, about 90 percent of patients have a positive IgM response After the rst few weeks, most patients have elevated IgG antibody responses to the spirochete (Berardi et al); a positive test of this nature may simply re ect prior exposure False-positive tests do occur in some of the conditions that react to syphilitic reagin B burgdorferi speci c antibodies can also be demonstrated in the CSF Positive ELISA testing should be pursued further with Western blot or immunoblot analysis or other more speci c serologies in clinically uncertain cases Although these latter tests are dif cult to carry out and have not been standardized, the presence of both IgG and IgM antibodies is strongly supportive of a recent infection, whereas the IgG is useful in later cases These complex laboratory issues are discussed and put in perspective by Golightly In about 30 percent of cases, the organism can be detected in the spinal uid using PCR techniques In the chronic phase of the disease, CT and MRI in cases of encephalopathy may display multifocal and periventricular cerebral lesions (Fig 32-6), but these are by no means indicative alone of Lyme disease, as they also appear in numerous other conditions Treatment The recommended treatment in the rst stage of the disease is oral tetracycline (250 mg qid) or doxycycline (100 mg bid) CNS cardiac and arthritic disease can thereby be prevented Once the meninges and nervous system are implicated, high-dose penicillin, 20 million units daily for 10 to 14 days, or, probably more effective, ceftriaxone, 2 g daily, must be given intravenously for a similar period Tetracycline, 500 mg four times a day for 30 days, is recommended by Reik for patients who are allergic to these
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FUNGAL INFECTIONS OF THE NERVOUS SYSTEM
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Described in the following pages are a number of infectious diseases, much less common than bacterial ones, in which a systemic infection may secondarily involve the CNS For the neurologist, the diagnosis rests on two lines of clinical information one, evidence of infection in the skin, lungs, or other organs, and two, the appearance of a subacute meningeal or multifocal encephalitic disorder Once demonstrated, the nature of the neurologic disorder is determined by identifying the infective agent in the CSF, by appropriate immunologic tests, and by the biopsy of nonneurologic tissue or brain Although a large number of fungal diseases may involve the nervous system, only a few do so with any regularity Of 57 cases assembled by Walsh and coworkers, there were 27 of candidiasis, 16 of aspergillosis, and 14 of cryptococcosis Among the opportunistic mycoses (see below), 90 to 95 percent are accounted for by species of Aspergillus and Candida Mucormycosis and coccidioidomycosis are far less frequent, and blastomycosis and actinomycosis (Nocardia) occur only in isolated instances However, all of these infections, particularly cryptococcal meningitis, are being seen more frequently, mainly in association with AIDS
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