Letters to Editor
to spinal aneurysms: Diagnosis and treatment paradigm. Neurosurg 2005;57:1127‑31. 4. Kurita M, Endo M, Kitahara T, Fujii K. Subarachnoid haemorrhage due to a lateral spinal artery aneurysm misdiagnosed as a posterior inferior cerebellar artery aneurysm: Case report and literature review. Acta Neurochir (Wien) 2009;151:165‑9. 5. Madhugiri VS, Ambekar S, Roopesh Kumar VR, Sasidharan GM, Nanda A. Spinal aneurysms: Clinicoradiological features and management paradigms. J Neurosurg Spine 2013;19:34‑48.
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Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.137003
Received: 23-07-2014 Review completed: 01-06-2014 Accepted: 01-06-2014
Cervical spine brucellosis presenting as fever with neck stiffness and cervical compressive myelopathy: A case report Sir, Osteoarticular brucellosis is the most common presentation of systemic brucellosis and most commonly affects lumbar spine, but isolated involvement of cervical region is very rare, 1.2–2.1%.[1] Cervical spine involvement can pose diagnostic difficulties due to its similarities with other conditions such as tuberculous spondylitis, metastases, and myeloma,[2] causing delay in diagnosis and treatment. A 60‑year‑old male farmer presented with moderate‑grade intermittent fever and restricted neck movements of one month and 9 days duration, respectively. There was no history of chronic cough, hemoptysis, altered sensorium, neck trauma, weight loss, or any medical illness. General examination was normal except for pallor. Neck stiffness and neck muscle spasm was present. Neurological examination was normal. Blood investigations revealed normocytic normochromic anemia, elevated erythrocyte sedimentation rate of 70 mm at 1 hour, and hyperglobulinemia (globulins ‑ 7.2 gm%). Cerebrospinal fluid examination was normal. Sputum for acid fast bacilli and Mantoux test was negative. Neurology India | May-Jun 2014 | Vol 62 | Issue 3
Magnetic resonance imaging (MRI) of cervical spine showed altered marrow signal intensities in cervical vertebrae C3-C5 indicating diffuse marrow infiltrative disorder [Figure 1a]. Bone marrow biopsy revealed normocellular marrow with plasmacytosis (plasma cells 1.1). For definitive
a
c
b
d
Figure 1: (a) MRI on 1st visit showing altered marrow signal intensities in cervical vertebrae C3-C5 s/o diffuse marrow infiltrative disorder, diffuse disc bulges and osteophytes (b) MRI cervical spine on subsequent admission showing progression of lesion with altered marrow signal C1, C2, C3, C6, C7, D1 vertebral body, discs, tip of clivus with partial collapse (c) Bone scan showing increased radionucleotide uptake in cervical region (d) Vertebral biopsy showing chronic non specific inflammation with plasma cells and russel bodies
313
Letters to Editor
diagnosis, CT‑guided biopsy was done from vertebral lesion, which showed chronic inflammatory lesion with moderate infiltration by plasma cells, with no features suggestive of tuberculosis. [Figure 1d]. In view of patient’s history, raised IgG for brucellosis and no evidence of tuberculosis on cervical lymphnode, bone marrow biopsy and local vertebral lesion biopsy, this chronic inflammatory lesion was reported as brucella infection. Thus, the final diagnosis was brucellosis of cervical spine (spondylitis) with cervical compressive myelopathy. The patient was not willing for operative intervention and was discharged on doxycycine 200 mg/day and streptomycin 1 gm/day. Three months after discharge, the patient was afebrile with symptomatic improvement, however, with persistent residual neurologic deficit. In this patient, the diagnosis of osteoarticular brucellosis is established based on the presence of criteria laid by Turgut et al.[3] Our case fulfilled 4 out of 5 criteria. Blood culture is the diagnostic test, but it is positive only in 20-30% of cases. ELISA IgG and IgM antibodies is now considered the most sensitive, specific, and rapid test for diagnosis of osteoarticular brucellosis.[4] Management of spinal brucellosis is mainly medical with doxycyclin along with streptomycin for 12 weeks. [5] Surgical treatment is reserved for biopsy purpose, advanced cases not responding to medical treatment, or severe neurological compromise. Difficulties in the diagnosis of cervical brucellosis spondylitis may cause a delay in treatment and may lead to devastating neurological consequences. Hence, brucellosis should be included in the differential diagnosis of fever with neck stiffness and spondylitis, particularly in countries like India, where brucellosis is still endemic.
Anita Basavaraj, Rahul S. Kulkarni Department of Medicine, Byramjii‑Jeejeebhoy Government Medical College, Pune, Maharashtra, India E‑mail: [email protected]
References 1. Zormpala A, Skopelitis E, Thanos L, Artinopoulos C, Kordossis T, Sipsas NV. An unusual case of brucellar spondylitis involving both the cervical and lumbar spine. Clin Imaging 2000;24:273‑5. 2. Ozaksoy D, Yucesoy K, Yucesoy M, Kovanlikaya I, Yuce A, Naderi S. Brucellar spondylitis: MRI findings. Eur Spine J 2001;10:529‑33. 3. Turgut M, Turgut AT, Kosar U. Spinal brucellosis: Turkish experience based on 452 case published during the last century. Acta Neurochir (Wien) 2006;148:1033‑44. 4. Sathyanarayan MS, Suresh DR, Sonth SB, Krishna S, Mariraj J, Surekha YA, et al. A comparative study of agglutination tests, blood culture and ELISA in the laboratory diagnosis of human brucellosis. Int J Biol Med Res 2011;2:569‑72. 5. Vajramani GV, Nagmoti MB, Patil CS. Neurobrucellosis presenting as an intra‑medullary spinal cord abscess. Ann Clin Microbiol Antimicrob 2005;4:14‑8. 314
Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.137005
Received: 15-03-2014 Review completed: 30-03-2014 Accepted: 02-06-2014
Cryptococcal myelitis: A rare manifestation in immunocompetent patients Sir, Cryptococcus neoformans is the most common central nervous system fungal infection. Spinal cord syndrome as a presenting feature of cryptococcus is rare;[1] hence, we are presenting this report. Case 1: An 18‑year‑old male farmer presented with urinary complains in the form of hesitancy and increased frequency, followed by asymmetrical weakness of lower limbs, truncal weakness, and sensory loss up to umbilicus for 5 months. There was history of contact with pigeons. Neurological examination revealed flexor spasm of both lower limbs; muscle power 0/5 in left lower limb, right lower limb at knee and ankle joints, and 1/5 at right hip joint; exaggerated deep tendon reflexes in both lower limbs; and sensory impairment below umbilicus [right ˃ left]. Blood biochemistry was normal except raised aspartate transferase [92 IU/L]. Magnetic resonance imaging (MRI) of cervicodorsal spine with screening of whole spine showed long segment dorsal cord (D4–D13) patchy hyper intensity in T2‑weighted images [Figure 1a]. Cerebrospinal fluid examination (CSF) revealed protein 142 mg%, sugar 50 mg%, total cells 95 [5% polymorphs and 95% were lymphocytes]. India ink [Figure 2a] and Gram stain [Figure 2b] preparations showed budding yeast forms of cryptococcus and positive serology for cryptococcus antigen in 1:64 titers. Based on history, examination, and investigations, the diagnosis of Cryptococcus myelitis was made. He was started on intravenous fluconazole (200 mg) two times a day for 7 days, followed by oral fluconazole (400 mg daily for 8 weeks). At the time of discharge, the patient was able to walk by himself without assistance. The patient was followed up at regular intervals of one month up to 6 months from date of discharge; he is ambulatory, continent, and performing his daily activities independently. Neurology India | May-Jun 2014 | Vol 62 | Issue 3
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
to spinal aneurysms: Diagnosis and treatment paradigm. Neurosurg 2005;57:1127‑31. 4. Kurita M, Endo M, Kitahara T, Fujii K. Subarachnoid haemorrhage due to a lateral spinal artery aneurysm misdiagnosed as a posterior inferior cerebellar artery aneurysm: Case report and literature review. Acta Neurochir (Wien) 2009;151:165‑9. 5. Madhugiri VS, Ambekar S, Roopesh Kumar VR, Sasidharan GM, Nanda A. Spinal aneurysms: Clinicoradiological features and management paradigms. J Neurosurg Spine 2013;19:34‑48.
Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.137003
Received: 23-07-2014 Review completed: 01-06-2014 Accepted: 01-06-2014
Cervical spine brucellosis presenting as fever with neck stiffness and cervical compressive myelopathy: A case report Sir, Osteoarticular brucellosis is the most common presentation of systemic brucellosis and most commonly affects lumbar spine, but isolated involvement of cervical region is very rare, 1.2–2.1%.[1] Cervical spine involvement can pose diagnostic difficulties due to its similarities with other conditions such as tuberculous spondylitis, metastases, and myeloma,[2] causing delay in diagnosis and treatment. A 60‑year‑old male farmer presented with moderate‑grade intermittent fever and restricted neck movements of one month and 9 days duration, respectively. There was no history of chronic cough, hemoptysis, altered sensorium, neck trauma, weight loss, or any medical illness. General examination was normal except for pallor. Neck stiffness and neck muscle spasm was present. Neurological examination was normal. Blood investigations revealed normocytic normochromic anemia, elevated erythrocyte sedimentation rate of 70 mm at 1 hour, and hyperglobulinemia (globulins ‑ 7.2 gm%). Cerebrospinal fluid examination was normal. Sputum for acid fast bacilli and Mantoux test was negative. Neurology India | May-Jun 2014 | Vol 62 | Issue 3
Magnetic resonance imaging (MRI) of cervical spine showed altered marrow signal intensities in cervical vertebrae C3-C5 indicating diffuse marrow infiltrative disorder [Figure 1a]. Bone marrow biopsy revealed normocellular marrow with plasmacytosis (plasma cells 1.1). For definitive
a
c
b
d
Figure 1: (a) MRI on 1st visit showing altered marrow signal intensities in cervical vertebrae C3-C5 s/o diffuse marrow infiltrative disorder, diffuse disc bulges and osteophytes (b) MRI cervical spine on subsequent admission showing progression of lesion with altered marrow signal C1, C2, C3, C6, C7, D1 vertebral body, discs, tip of clivus with partial collapse (c) Bone scan showing increased radionucleotide uptake in cervical region (d) Vertebral biopsy showing chronic non specific inflammation with plasma cells and russel bodies
313
Letters to Editor
diagnosis, CT‑guided biopsy was done from vertebral lesion, which showed chronic inflammatory lesion with moderate infiltration by plasma cells, with no features suggestive of tuberculosis. [Figure 1d]. In view of patient’s history, raised IgG for brucellosis and no evidence of tuberculosis on cervical lymphnode, bone marrow biopsy and local vertebral lesion biopsy, this chronic inflammatory lesion was reported as brucella infection. Thus, the final diagnosis was brucellosis of cervical spine (spondylitis) with cervical compressive myelopathy. The patient was not willing for operative intervention and was discharged on doxycycine 200 mg/day and streptomycin 1 gm/day. Three months after discharge, the patient was afebrile with symptomatic improvement, however, with persistent residual neurologic deficit. In this patient, the diagnosis of osteoarticular brucellosis is established based on the presence of criteria laid by Turgut et al.[3] Our case fulfilled 4 out of 5 criteria. Blood culture is the diagnostic test, but it is positive only in 20-30% of cases. ELISA IgG and IgM antibodies is now considered the most sensitive, specific, and rapid test for diagnosis of osteoarticular brucellosis.[4] Management of spinal brucellosis is mainly medical with doxycyclin along with streptomycin for 12 weeks. [5] Surgical treatment is reserved for biopsy purpose, advanced cases not responding to medical treatment, or severe neurological compromise. Difficulties in the diagnosis of cervical brucellosis spondylitis may cause a delay in treatment and may lead to devastating neurological consequences. Hence, brucellosis should be included in the differential diagnosis of fever with neck stiffness and spondylitis, particularly in countries like India, where brucellosis is still endemic.
Anita Basavaraj, Rahul S. Kulkarni Department of Medicine, Byramjii‑Jeejeebhoy Government Medical College, Pune, Maharashtra, India E‑mail: [email protected]
References 1. Zormpala A, Skopelitis E, Thanos L, Artinopoulos C, Kordossis T, Sipsas NV. An unusual case of brucellar spondylitis involving both the cervical and lumbar spine. Clin Imaging 2000;24:273‑5. 2. Ozaksoy D, Yucesoy K, Yucesoy M, Kovanlikaya I, Yuce A, Naderi S. Brucellar spondylitis: MRI findings. Eur Spine J 2001;10:529‑33. 3. Turgut M, Turgut AT, Kosar U. Spinal brucellosis: Turkish experience based on 452 case published during the last century. Acta Neurochir (Wien) 2006;148:1033‑44. 4. Sathyanarayan MS, Suresh DR, Sonth SB, Krishna S, Mariraj J, Surekha YA, et al. A comparative study of agglutination tests, blood culture and ELISA in the laboratory diagnosis of human brucellosis. Int J Biol Med Res 2011;2:569‑72. 5. Vajramani GV, Nagmoti MB, Patil CS. Neurobrucellosis presenting as an intra‑medullary spinal cord abscess. Ann Clin Microbiol Antimicrob 2005;4:14‑8. 314
Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.137005
Received: 15-03-2014 Review completed: 30-03-2014 Accepted: 02-06-2014
Cryptococcal myelitis: A rare manifestation in immunocompetent patients Sir, Cryptococcus neoformans is the most common central nervous system fungal infection. Spinal cord syndrome as a presenting feature of cryptococcus is rare;[1] hence, we are presenting this report. Case 1: An 18‑year‑old male farmer presented with urinary complains in the form of hesitancy and increased frequency, followed by asymmetrical weakness of lower limbs, truncal weakness, and sensory loss up to umbilicus for 5 months. There was history of contact with pigeons. Neurological examination revealed flexor spasm of both lower limbs; muscle power 0/5 in left lower limb, right lower limb at knee and ankle joints, and 1/5 at right hip joint; exaggerated deep tendon reflexes in both lower limbs; and sensory impairment below umbilicus [right ˃ left]. Blood biochemistry was normal except raised aspartate transferase [92 IU/L]. Magnetic resonance imaging (MRI) of cervicodorsal spine with screening of whole spine showed long segment dorsal cord (D4–D13) patchy hyper intensity in T2‑weighted images [Figure 1a]. Cerebrospinal fluid examination (CSF) revealed protein 142 mg%, sugar 50 mg%, total cells 95 [5% polymorphs and 95% were lymphocytes]. India ink [Figure 2a] and Gram stain [Figure 2b] preparations showed budding yeast forms of cryptococcus and positive serology for cryptococcus antigen in 1:64 titers. Based on history, examination, and investigations, the diagnosis of Cryptococcus myelitis was made. He was started on intravenous fluconazole (200 mg) two times a day for 7 days, followed by oral fluconazole (400 mg daily for 8 weeks). At the time of discharge, the patient was able to walk by himself without assistance. The patient was followed up at regular intervals of one month up to 6 months from date of discharge; he is ambulatory, continent, and performing his daily activities independently. Neurology India | May-Jun 2014 | Vol 62 | Issue 3
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
