To determine the diagnostic value of clinical factors and biochemical or microbiological measures for diagnosing a drain-associated ventriculitis, we summarized the available evidence.
We performed a systematic review and meta-analysis of studies of patients with external ventricular CSF drains who developed drain-associated ventriculitis by searching MEDLINE, EMBASE, and CENTRAL electronic database. We reported the occurrence of abnormal test results in patients with and without drain-associated ventriculitis. For continuous variables, we recalculated mean values presented in multiple studies.
We identified 42 articles published between 1984 and 2018 including 3,035 patients with external CSF drains of whom 697 (23%) developed drain-associated bacterial ventriculitis. Indications for drain placement were subarachnoid, intraventricular or cerebral hemorrhage or hemorrhage not further specified (69%), traumatic brain injury (13%), and obstructive hydrocephalus secondary to a brain tumor (10%). Fever was present in 116 of 162 patients with ventriculitis (72%) compared with 80 of 275 (29%) patients without ventriculitis. The CSF cell count was increased for 74 of 80 patients (93%) with bacterial ventriculitis and 30 of 95 patients (32%) without ventriculitis. CSF culture was positive in 125 of 156 episodes classified as ventriculitis (80%), and CSF Gram stain was positive in 44 of 81 patients (54%). In patients with ventriculitis, PCR on ribosomal RNA was positive on 54 of 78 CSF samples (69%).
Clinical factors and biochemical and microbiological measures have limited diagnostic value in differentiating between ventriculitis and sterile inflammation in patients with external CSF drains. Prospective well-designed diagnostic accuracy studies in drain-associated ventriculitis are needed.

BACKGROUND: Central nervous system (CNS) melioidosis is rare. Clinical presentations depend on the region of endemicity. Despite treatment, neurologic disease has relatively high mortality rates. Less than 80 cases of CNS involvement have been reported.
METHODS: A literature review was performed by searching online databases for melioidosis presenting as osteomyelitis or scalp/extra-axial abscess (OSEAA). In addition, 3 similar cases managed at my institute have been presented.
RESULTS: Including this report of 3 cases, 20 additional cases have been reported. Of these, 12 cases (60%) were from India. The mean age of patients was 45.5 years (range, 29-74 years), and none were in the pediatric age group. Patients in the fifth to sixth decades were most frequently affected. The male to female ratio was 5.3:1. Eleven patients had predisposing factors. Fever, headache, and scalp swelling were the most common features. Five cases had history of previous melioid infection. Seven cases had systemic disease. Debridement was performed in 11 cases. The average intensive phase treatment duration was 4.6 weeks (range, 2-8 weeks) and 5.5 months (range, 3-12 months) for the maintenance phase. Mean follow-up duration was 13.5 months (range, 2 weeks-40 months). Two deaths (10%) were reported, and 1 case of residual frontal abscess had relapse.
CONCLUSIONS: Cranial melioidosis presenting as OSEAA is associated with good outcome, in contrast with other neurologic presentations. Intensive phase for at least 2-3 weeks followed by maintenance phase for 3-6 months is the standard treatment, similar to other melioid presentations. A high degree of suspicion and accurate identification of the organism is crucial. Patients need to be monitored for recurrences, both clinically and radiologically.

BACKGROUND: Actinomycetes can rarely cause intracranial infection and may cause a variety of complications. We describe a fatal case of intracranial and intra-orbital actinomycosis of odontogenic origin with a unique presentation and route of dissemination. Also, we provide a review of the current literature.
METHODS: A 58-year-old man presented with diplopia and progressive pain behind his left eye. Six weeks earlier he had undergone a dental extraction, followed by clindamycin treatment for a presumed maxillary infection. The diplopia responded to steroids but recurred after cessation. The diplopia was thought to result from myositis of the left medial rectus muscle, possibly related to a defect in the lamina papyracea. During exploration there was no abnormal tissue for biopsy. The medial wall was reconstructed and the myositis responded again to steroids. Within weeks a myositis on the right side occurred, with CT evidence of muscle swelling. Several months later he presented with right hemiparesis and dysarthria. Despite treatment the patient deteriorated, developed extensive intracranial hemorrhage, and died. Autopsy showed bacterial aggregates suggestive of actinomycotic meningoencephalitis with septic thromboembolism. Retrospectively, imaging studies showed abnormalities in the left infratemporal fossa and skull base and bilateral cavernous sinus.
CONCLUSIONS: In conclusion, intracranial actinomycosis is difficult to diagnose, with potentially fatal outcome. An accurate diagnosis can often only be established by means of histology and biopsy should be performed whenever feasible. This is the first report of actinomycotic orbital involvement of odontogenic origin, presenting initially as bilateral orbital myositis rather than as orbital abscess. Infection from the upper left jaw extended to the left infratemporal fossa, skull base and meninges and subsequently to the cavernous sinus and the orbits.

Central nervous system (CNS) melioidosis is rare. However, delayed diagnosis and treatment could lead to fatality. To identify knowledge of CNS melioidosis, we systematically review case reports and case series.
We searched through PubMed, Web of Science and Thai-Journal Citation Index databases as well as Google Scholar with the last date on July 10, 2018. The diagnosis of CNS melioidosis had to be confirmed with culture, serology or polymerase chain reaction. We excluded the animal cases and the studies that the clinical data were not available. We identified 1170 relevant studies, while 70 studies with a total of 120 patients were analyzed. Ninety-three percent of patients were reported from the endemic area of melioidosis. Median age was 40 years (IQR 18-53), and 70% were men. A total of 60% had one or more risk factors for melioidosis. The median duration from clinical onset to diagnosis was ten days (IQR 5-25). Fever (82%), headache (54%), unilateral weakness (57%) and cranial nerve deficits (52%) are among the prominent presentation. Most patient (67%) had at least one extraneurological organ involvement. The CSF profile mostly showed mononuclear pleocytosis (64%), high protein (93%) and normal glucose (66%). The rim-enhancing pattern (78%) is the most frequent neuroimaging finding in encephalomyelitis and brain abscess patients. Both brainstem (34%) and frontal lobe (34%) are the most affected locations. Mortality rate was 20%.
This study is the most extensive systematic review of case reports and case series of CNS melioidosis in all age groups. However, the results should be cautiously interpreted due to the missing data issue. The propensity of brainstem involvement which correlates with prominent cranial nerve deficits is the characteristic of CNS melioidosis especially encephalomyelitis type. The presenting features of fever and neurological deficits (especially cranial nerve palsies) along with the mononuclear CSF pleocytosis in a patient who lives in the endemic area and also has the risk factor for melioidosis should raise the CNS melioidosis as the differential diagnosis.

BACKGROUND: Pseudomonas aeruginosa is an unusual pathogen in community-acquired pneumonia, especially in previously healthy adults, but often indicates poor prognosis.
METHODS: We report a previously healthy patient who developed severe community-acquired pneumonia (CAP) caused by P. aeruginosa. He deteriorated to septic shock and multiple organ dysfunction syndrome (MODS) quickly, complicated by secondary hematogenous central nervous system (CNS) infection. After 1 month of organ support and antipseudomonal therapy, he had significant symptomatic improvement and was discharged from hospital. During treatment, the pathogen developed resistance to carbapenems quickly and the antibiotic regimen was adjusted accordingly.
CONCLUSIONS: According to our case and related literature review, we conclude that more attention should be paid to community-acquired Pseudomonas aeruginosa pneumonia, because of its rapid progression and poor prognosis.

BACKGROUND: Nocardial spinal epidural abscess is rare. The diagnosis is often difficult to make and, if delayed, poses a high risk of long-term disability. Nocardial spinal epidural abscess with severe lumbar disc herniation has not previously been reported.
METHODS: A 50-year-old man presented with progressive lumbago and leg pain for 6 weeks after receiving acupuncture therapy, and then the patient suddenly occurred urine retention after walking.
METHODS: Clinical examination revealed sign of cauda equina syndrome. Magnetic resonance imaging (MRI) revealed a Lumbar(L)4 to L5 disc herniation, L3 to Sacrum(S)1 epidural abscess, and L2 to S1 paravertebral abscess. The causative organism was Nocardia farcinica.
METHODS: An urgent paravertebral abscess debridement and right L4 to L5 laminectomy were performed. Simultaneously, the disc tissue protruding into the spinal canal was removed, as well as irrigation and drainage. And antimicrobial treatment was continued for 12 months.
RESULTS: Fortunately, the patient was able to walk with a cane and urinate autonomously without a catheter, although this remained difficult 7 days after surgery. After 1 year of treatment, the patient has recovered completely and returned to work.
CONCLUSIONS: Nocardial spinal epidural abscess with severe lumbar disc herniation is extremely rare. Pain from spinal degenerative diseases often masks the early symptoms of spinal infection. It\'s worth noting that invasive treatment of spine is a way of causing spinal nocardial infection.

Central nervous system infections, which are rarely seen in systemic lupus erythematosus (SLE), have considerably high mortality but they are difficult to distinguish from neuropsychiatric manifestation of lupus. This article reports the case of a patient with SLE with brain abscess which developed during immunosuppressive therapy for lupus nephritis. The patient completely recovered without neurological sequelae by open surgical drainage and 12-week antibiotic therapy. It is recommended that CNS infections must be excluded in patients with SLE, particularly who are receiving immunosuppressive therapy.

Meningitis and encephalitis are medical emergencies. Patients need prompt evaluation and immediate empiric therapy to reduce the likelihood of fatal outcomes and chronic neurological sequelae. Conjugate bacterial vaccines have significantly reduced the incidence of bacterial meningitis, especially in children. As the results of changes in patterns of bacterial drug sensitivity, ceftriaxone is now part of the recommended empiric treatment for bacterial meningitis and should be administered as early as possible. Neuroimaging delays the treatment of meningitis and is not needed in most cases. Adjunctive corticosteroid therapy is of benefit for many patients with meningitis and should be initiated in most adults before antibiotic therapy. Molecular testing can assist the specific diagnosis of encephalitis and should be based on the exposure history and geographic risk factors relevant to the patient, but non-infectious causes of encephalitis are also common. Empiric therapy for encephalitis should be directed at the most frequently identified infectious pathogen, herpes simplex virus type 1 (ie, intravenous aciclovir). Vaccines can protect against the major pathogens of childhood infections (measles, mumps, rubella, polio, varicella viruses), influenza viruses, and exotic pathogens that cause meningitis and encephalitis (rabies, Japanese encephalitis, dengue, yellow fever, tick-borne encephalitis viruses, Mycobacterium tuberculosis).

Infectious disease and pharmacokinetic textbooks indicate that vancomycin has poor penetration into the central nervous system due to its hydrophilic nature and high molecular weight. Recent literature suggests that penetration of vancomycin into cerebrospinal fluid (CSF) is higher than previously reported; therefore, we conducted a systematic review to assess the penetration of vancomycin into CSF.
We searched the MEDLINE, EMBASE, and CENTRAL electronic databases for English-language human studies evaluating serum and CSF concentrations of intravenous vancomycin.
In 13 identified studies, the CSF-to-serum ratio of vancomycin varied from 0.00 to 0.81. CSF penetration ranged 0.06-0.81 in patients with meningitis, 0.05-0.17 in ventriculitis, 0.00-0.36 in other infections, and 0-0.13 in patients without infection. Despite variable CSF penetration, 83% of patients with meningitis and 100% of patients with ventriculitis achieved clinical cure. No factor predicted vancomycin CSF penetration.
Contrary to prior belief, studies included in our review did not show universally low penetration of vancomycin into CSF. CSF vancomycin levels were variable and did not predict clinical cure.

OBJECTIVE: Melioidosis is a potentially fatal infectious disease caused by Burkholderia pseudomallei. Neurologic involvement in pediatric age group is very rare, and only a handful of cases have been reported in literature. We sought to provide a systematic review of pediatric neurologic melioidosis.
METHODS: Literature review was performed to analyze reported cases of pediatric neurologic melioidosis (≤16 years) by searching online database (PubMed/MEDLINE).
RESULTS: Twenty-seven cases were analyzed. Mean age was 6.7 years (range 2 days-14 years) and around 50% were older children (>5 years). Cranial nerve palsies and fever were most common presenting features. Major manifestations were meningoencephalitis in 16 (59%) and cerebral abscesses in eight (29%) cases. Abscesses were mostly located in parietal lobe. Among older children, abscesses were common than meningeal disease, while being converse for neonates. Mean follow-up duration was 11.5 months. Ten cases showed good to excellent outcome, while eight cases had fair (incomplete recovery) outcomes. The overall mortality rate was 18.5% (5/27) and tends to decrease with age. Among the five deaths, 4 (80%) had septicemia or pneumonia.
CONCLUSIONS: Pediatric neurologic melioidosis is very rare. Meningoencephalitis is the most common presentation. Mortality is the highest in neonates. Ceftazidime appears to be the drug of choice in intensive phase, although the best drug in maintenance phase cannot be commented upon, especially in very young children.