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$310 Wednesday, November 9, 2005 Poster Abstracts ,]ha, S. Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India Backgroumh A high level of suspicion is mandatory for diagnosis of Herpes Simplex Encephalitis (HSE), since acyclovir is known to reduce mortality and limit morbidity. We report our observations on clinical spectrum, pitfalls in diagnosis and therapeutic aspects in patients of HSE. Method: We selected 38 (126 male, 12 female) patients of HSE in age range of 6-72 years. Diagnosis was based on clinical assessment, cranial MRI, EEG and PCR in CSF. Results: Referral diagnosis were as; Japanese encephalitis (12 cases), cerebral malaria (7 cases), tuberculous meningitis (4 cases), only encephalitis (17 cases) and others or no diagnosis (18 cases). High fever, seizures, behavioral abnormality and encephalopathy were present in all cases. EEG, CSF and cranial MRI were abnormal in 100% cases. PCR for HSE virus was positive in 19 (79"/0) cases. Abnormality in CT was detected only in 4 out of 12 cases. Acyclovir was given to 26 patients along with carbamazepine and sodium valproate following which, 14 (55?,'8) recovered completely and 3 partially. There was no improvement in 5 patients while 4 expired. Among 9 patients who refused therapy of acyclovir, 6 expired and 3 remained in unaltered status. Three patients expired before therapy could be completed. Conclusion: HSE is under or misdiagnosed. This is important especially in India where Japanese encephalitis, tuberculous meningitis and cerebral malaria are extremely common. Important factors influencing mortality and morbidity were; delay or refusal in therapy, old age, poor immmne status, long duration of illness and deep coma before initiation of therapy. We suggest that acyclovir should be given to all patients as soon as suspected, while confirmatory investigations are in progress. O823 Cerebral air embolism associated with ptthimnary tuberculosis Park, JH, Kim, JY, Baik, JS, Han, SW. Department of Neurology, Sanggye Paik Hospital, Inje University, Seoul, Korea Background: Air embolism, entry of gas into vascular structure, is usually result of iatrogenic procedure like endoscopic procedure and can result in serious morbidity and mortality. Case Reports: A 47-year-old man was referred for the evaluation and management of sudden loss of consdousness and stupurous mentality. He had a history of pulmonary tuberculosis in his twenties. But it relapsed 2 months before admission and he have taken antituberculosis medications since then. Brain imaging obtained an hour after loss of consciousness revealed multiple small hypodense air bubbles at right MCA territory. Hyperbaric oxygen therapy was performed immedi- ately, but he did not respond. Follow up brain CT taken at 5 days after admission revealed severe brain edema. He expired 8 day after admission. Discussion: Cerebral air embolism is rare cause of cerebral infarction and is the result of entry of air into the pulmmmry veins or directly into cerebral arteries. Entry of the air in to brain can be caused by barotrauma, neurosurgical procedures. There also have been reports as the complication of cardiac surgery with cardiopulmonary bypass, mechanical ventilation and endoscopic procedures. But there have been no reports of cerebral air embolism associated with pulmonary tuberculosis. O824 Ability to penetrate the blood brain barrier of fluconazole for cryptocoecal meningitis umler the admitfislrafion of fosllueonazole Katsuo Khnura ~, Masanao Endo, Takehiko Nishiyama 2, Yasuhisa Baba e, Hiroyuki Toda e, Yume Suzuki e, Yoshiyuki Kuroiwa 2, Tamaki Nomiya 1, Megumi ~ Takahashi ~. 1Dept. of Shimamura, Tatsuya Neurology, Yokohama City University Medical Center, Yokohama, Japan.." 2Dept. of Neurology, Graduate School of Medicine, Yokohama City University, Yokohama, )'apart Background: Fosfluconazole is a phosphate prodrug of fluconazole that have been developed to reduce the volume of fluid required to administer fluconazole by the intravenous route. Fosfluconazole is soon hydrolyzed by alkaline phosphatase to fluconazole and phos- phoric add and effective against cryptococcus or candida infections. We adininistered fosfluconazole to a patient of cryptococcal meningitis, and exanffned both serum and cerebrospinal fluid (CSF) concentrations of fluconazole. Method: We administered fosfluconazole 800 mg/day by the intrave- nous route for 42 days to a cryptococcal meningitis patient using no-loading dose regimen. The administration of fosfluconazole was continued until the India ink exanffnation of CSF was negative. We exmnined both serum and CSF concentrations of fluconazole every 5 7 days. Results: Fhiconazole had high ability to penetrate to the blood brain barrier under the administration of fosfluconazole. The concentration of fluconazole in serum is significantly correlated with that in CSF (correlated coefficient _ 0.89). Condasion: Under the adininistration of fosfluconazole, a high concentration of fluconazole is obtained in CSF and a reduction of fluid volume to inject is possible. Thereafter fosfluconazole is appropriate to cryptococcus or candida meningitis the same as fluconazole. 0825 Clinical and Neuropathological Studies of Fulmninant Bacterial Meningoeneephalilis (SBNIE) with Severe Brain Edema Kobayashi, T. Nakano General Hospital, Nakano-R~, Tokyo, Japan Background: It is not certain whether or not to do emergency brain decompression operation at the clinical sign of brain herniation of SBME patients with severe brain edema. This study is conducted to clarify the clinical and neuropathological features of SBME to consider more suitable drug and/or neurosurgical therapies. Design/Methods: Clinical studies of Seven SBME cases and ncuro- pathological studies of two autopsied cases. Results: Four cases were due to Penicillin-resistant S. pneumoniae (PRSP). Two out of four SBME cases occurred after nine and forty years of frontal bone fractures. The repairment of dura matter and frontal skull base using Gclfoam bone wax and the fragments of frontal muscle with vessels were performed after antibiotic therapies. They have had good course without neurological deficits. Another two cases died by cerebral hemorrhage and multiple organ failure. Their autopsies showed prominent brain edema and herniation. One case due to Krebsiella pneumoniae with cerebral hemorrhage and multiple brain abscesses was cured by antibiotics. One case of other two cases due to gram-negative badlli had prominent brain edema and cpidural abscess. Emergency decompression operation of wide removal of skull and aspiration of epidural abscess was done at the beginning of brain herniation. Tiffs patient was saved with the disappearance of herniation after surgery. Condusious: The emergency brain decompression surgery must be considered at the time of herniation by severe brain edema although high doses of antibiotic and steroid therapies have been done. 0826 Neurological complications in AIDS patients: the two years retrospective study in HAART era Kongsaengdao Subsai ~, Samintarapanya Kanoksri 1, Chankraehang Siwaporn 1, Ling Helen 1, Oranratanachai Kanokporn e, Prapakorn Wantana 2. 1Division of Neurology, Department of Medicine; 2Division of Neuro-radiology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Thailand

0826 Neurological complications in AIDS patients: the two years retrospective study in HAART era

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Page 1: 0826 Neurological complications in AIDS patients: the two years retrospective study in HAART era

$310 Wednesday, November 9, 2005 Poster Abstracts

,]ha, S. Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India

Backgroumh A high level o f suspicion is mandatory for diagnosis of Herpes Simplex Encephalitis (HSE), since acyclovir is known to reduce mortality and limit morbidity. We report our observations on clinical spectrum, pitfalls in diagnosis and therapeutic aspects in patients of HSE. Method: We selected 38 (126 male, 12 female) patients of HSE in age range of 6-72 years. Diagnosis was based on clinical assessment, cranial MRI, EEG and PCR in CSF. Results: Referral diagnosis were as; Japanese encephalitis (12 cases), cerebral malaria (7 cases), tuberculous meningitis (4 cases), only encephalitis (17 cases) and others or no diagnosis (18 cases). High fever, seizures, behavioral abnormality and encephalopathy were present in all cases. EEG, CSF and cranial MRI were abnormal in 100% cases. PCR for HSE virus was positive in 19 (79"/0) cases. Abnormality in CT was detected only in 4 out of 12 cases. Acyclovir was given to 26 patients along with carbamazepine and sodium valproate following which, 14 (55?,'8) recovered completely and 3 partially. There was no improvement in 5 patients while 4 expired. Among 9 patients who refused therapy of acyclovir, 6 expired and 3 remained in unaltered status. Three patients expired before therapy could be completed. Conclusion: HSE is under or misdiagnosed. This is important especially in India where Japanese encephalitis, tuberculous meningitis and cerebral malaria are extremely common. Important factors influencing mortality and morbidity were; delay or refusal in therapy, old age, poor immmne status, long duration of illness and deep coma before initiation of therapy. We suggest that acyclovir should be given to all patients as soon as suspected, while confirmatory investigations are in progress.

O823 Cerebral air embolism associated with ptthimnary tuberculosis

Park, JH, Kim, JY, Baik, JS, Han, SW. Department of Neurology, Sanggye Paik Hospital, Inje University, Seoul, Korea

Background: Air embolism, entry of gas into vascular structure, is usually result o f iatrogenic procedure like endoscopic procedure and can result in serious morbidity and mortality. Case Reports: A 47-year-old man was referred for the evaluation and management of sudden loss of consdousness and stupurous mentality. He had a history of pulmonary tuberculosis in his twenties. But it relapsed 2 months before admission and he have taken antituberculosis medications since then. Brain imaging obtained an hour after loss of consciousness revealed multiple small hypodense air bubbles at right MCA territory. Hyperbaric oxygen therapy was performed immedi- ately, but he did not respond. Follow up brain CT taken at 5 days after admission revealed severe brain edema. He expired 8 day after admission. Discussion: Cerebral air embolism is rare cause of cerebral infarction and is the result of entry of air into the pulmmmry veins or directly into cerebral arteries. Entry of the air in to brain can be caused by barotrauma, neurosurgical procedures. There also have been reports as the complication of cardiac surgery with cardiopulmonary bypass, mechanical ventilation and endoscopic procedures. But there have been no reports of cerebral air embolism associated with pulmonary tuberculosis.

O824 Ability to penetrate the blood brain barrier of fluconazole for cryptocoecal meningitis umler the admitfislrafion of fosllueonazole

Katsuo Khnura ~, Masanao E n d o , Takehiko Nishiyama 2, Yasuhisa Baba e, Hiroyuki Toda e, Yume Suzuki e, Yoshiyuki Kuroiwa 2, Tamaki Nomiya 1, Megumi ~ Takahashi ~. 1Dept. of Shimamura , Tatsuya

Neurology, Yokohama City University Medical Center, Yokohama, Japan.." 2Dept. of Neurology, Graduate School of Medicine, Yokohama City University, Yokohama, )'apart

Background: Fosfluconazole is a phosphate prodrug of fluconazole that have been developed to reduce the volume of fluid required to administer fluconazole by the intravenous route. Fosfluconazole is soon hydrolyzed by alkaline phosphatase to fluconazole and phos- phoric add and effective against cryptococcus or candida infections.

We adininistered fosfluconazole to a patient of cryptococcal meningitis, and exanffned both serum and cerebrospinal fluid (CSF) concentrations of fluconazole. Method: We administered fosfluconazole 800 mg/day by the intrave- nous route for 42 days to a cryptococcal meningitis patient using no-loading dose regimen. The administration of fosfluconazole was continued until the India ink exanffnation of CSF was negative. We exmnined both serum and CSF concentrations of fluconazole every 5 7 days. Results: Fhiconazole had high ability to penetrate to the blood brain barrier under the administration of fosfluconazole. The concentration of fluconazole in serum is significantly correlated with that in CSF (correlated coefficient _ 0.89). Condasion: Under the adininistration of fosfluconazole, a high concentration of fluconazole is obtained in CSF and a reduction of fluid volume to inject is possible. Thereafter fosfluconazole is appropriate to cryptococcus or candida meningitis the same as fluconazole.

0825 Clinical and Neuropathological Studies of Fulmninant Bacterial Meningoeneephalilis (SBNIE) with Severe Brain Edema

Kobayashi, T. Nakano General Hospital, Nakano-R~, Tokyo, Japan

Background: It is not certain whether or not to do emergency brain decompression operation at the clinical sign of brain herniation of SBME patients with severe brain edema. This study is conducted to clarify the clinical and neuropathological features of SBME to consider more suitable drug and/or neurosurgical therapies. Design/Methods: Clinical studies of Seven SBME cases and ncuro- pathological studies of two autopsied cases. Results: Four cases were due to Penicillin-resistant S. pneumoniae (PRSP). Two out of four SBME cases occurred after nine and forty years of frontal bone fractures. The repairment of dura matter and frontal skull base using Gclfoam bone wax and the fragments of frontal muscle with vessels were performed after antibiotic therapies. They have had good course without neurological deficits. Another two cases died by cerebral hemorrhage and multiple organ failure. Their autopsies showed prominent brain edema and herniation. One case due to Krebsiella pneumoniae with cerebral hemorrhage and multiple brain abscesses was cured by antibiotics. One case of other two cases due to gram-negative badlli had prominent brain edema and cpidural abscess. Emergency decompression operation of wide removal of skull and aspiration of epidural abscess was done at the beginning of brain herniation. Tiffs patient was saved with the disappearance of herniation after surgery. Condusious: The emergency brain decompression surgery must be considered at the time of herniation by severe brain edema although high doses of antibiotic and steroid therapies have been done.

0826 Neurological complications in AIDS patients: the two years retrospective study in HAART era

Kongsaengdao Subsai ~, Samintarapanya Kanoksri 1, Chankraehang Siwaporn 1, Ling Helen 1, Oranratanachai Kanokporn e, Prapakorn Wantana 2. 1Division of Neurology, Department of Medicine; 2Division of Neuro-radiology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Thailand

Page 2: 0826 Neurological complications in AIDS patients: the two years retrospective study in HAART era

Poster Abstracts Wednesday, November 9, 2005 $311

Background: Neurological complications in AIDS patients who receiving Highly Active Anti Retroviral Treatment (HAART) had been reported worldwide. Most of these were Neurological Inmmne Restoration Infianmmtory Syndrome (NIRIS) and non- NIRIS neurological complications. However, the incidences of NIRIS and non-NIRIS neurological complications had not been reported by comparison with previous incidence of AIDS defining disease. In Northern Thailand, GPO-vir (Stavudine-D4T+Lamivudine-3TC+ Nevirapine-NVP), has been promoted in AIDS patients since April 2002, under supervision of Government Pharmaceutical Organiza- tion's guideline. Therefore, these seem to be changing in incidence throughout the last two years. Objective: To identify the incidence change of Neurological Complica- tions in AIDS patients in HAART era. Method: We have conducted a retrospective study to review the incidence of NIRIS and non-NIRIS neurological complications in AIDS patients, who were treated with GPO-vir, in Chiang Mai University Hospital, Thailand during the period that runs from April 2002 to 2004. These incidences were used to compare with pre- HAART era. Results: There were 506 patients who received GPO-vir during this specified period, 255 of which were male and 251 female, aged between 14 and 73. There were 10 patients (1.97%) adi~fftted to hospital with neurological complications after treated with GPO-vir. The incidence of neurological complications in the patients treated with GPO-vir were 0.59 in the first 12 months and 4.70 in the next 12 months. The incidence of NIRIS were 0.59 and 1.17 per 100 person-years and the incidence of non-NIRIS neurological complications were 0.29 and 3.52 per 100 person-years in May 2002 to April 2003 and May 2003 to April 2004 respectively. Incidence of cerebral toxoplasmosis-NIRIS account for 0.29 and 0.59 per 100 person-years, CMV retiniris-NIRIS account for 0.29 and 0 per 100 person-years, PML account for 0 and 0.59 per 100 p erson-years, CNS lymphoma-non NIRIS and hemorrhagic stroke account for 0 and 1.17 per 100 person-years, and ischemic stroke account for 0 and 2.35 per 100 person-years in May 2002 to April 2003 and May 2003 to April 2004 respectively. Conclusion: The incidence of PML, cerebral toxoplasmosis and CMV retinitis were decreased in HAART era. However, incidence of ischemic stroke, hemorrhagic stroke, and primary CNS lymphoma were increased during the past two years after the promotion of HAART in The northern Thai AIDS patients.

0827 Tetanus in adult: 7-year retrospective study in Suratthani Hospital

Krittayapoositpot, P. Department of medicine, Suratthani Hospital, Thailand

Tetanus is still important public health problem. Even we have vaccine which completely prevents tetanus but we are continued found tetanus patients. The objective of this study was to describe the epidemiology, patients' data, treatment and factors that associated with mortality rate in tetanus patients. We collected data from medical record and found 32 tetanus patients from 1 October 1997 to 30 September 2004. There were 19 male (59.4%) and 13 female (140.6%) patients, average age 53.1 years. Most cases received Clostridium tetani from wound at foot (50°,5). There were generalized tetanus patients more than localised tetanus patients (184.4',/o/15.6"/o) and diabetic patients trend to be severe tetanus. The mortality in tiffs study was 28.1% which related to diabetic patients (P - 0.046) and patients with pneumonia (P -- 0.017). Because tetanus is severe and high mortality disease so prevention with tetanus vaccination to all population is important.

0828 Fatal Meningoencephalitis caused by disseminated Strongyloidiasis

Shung-Lon, Lai l, Hsien-Hsueh, Chiu l'a. 1Department of NeurMogy; 2Department of Chinese Medicine, Chang Gung Memorial Hospital, Kaohsiung

Objective: Strongyloidiasis caused by strongyloides stercoralis is usually asymptomatic or mildly symptomatic in the gastrointestinal system; it can persist for many years and occasionally progresses to a disseminated state, with a resultant high mortality rate. We report herein a case of meningoencephalitis caused by strongyloidiasis occurring in Taiwan. Case Report: A 60-year-old right-handed aboriginal man, who had a history of alcoholism and gastrectomy, was transferred to our hospital because of irrelevant speech in late September 2004. He was diagnosed as having bacterial meningoencephalitis based on the typical clinical pictures, laboratory findings, and treatment response. During the recovery stage, consciousness change with seizure, severe diarrhea, and respiratory failure pushed us to search for other possibilities. The eosinophilia and repeated stool exanffnations helped us to diagnose disseminated strogyloides stercoralis. The patient had initial bacterial meningitis followed by S. stercoralis hyperinfection. Despite treatment with antimicrobial agents, the patient died. This case is a strong reminder to physicians to be alert for strongyloidiasis superimposed on bacterial meningitis. Conclusions: Disseminated strongyloidiasis mostly occurs in inmmno- suppressed patients, and can present with abdominal pain, distension, shock, pulmonary and neurological complications, and septicemia. We emphasize the importance of not overlooking the assodation of strongyloidiasis in bacterial meningitis.

0830 Antiepflectic Drugs in Patients {pts) with Human Immunodefidency Virus inl~ction (HIV)

Locatelli P~, Moretti F 2, Casari S 2, Zollo G 2, Quiros-Roldan E 2, Costarelli S 2, Carosi G 2. 2Department of Neurology, 2Department of Infectious and Tropical Diseases, Spedali Civili General Hospital, University of Brescia, Italy

Background: HIV-infection is frequently associated with neurological disorders. The introduction of HAART has brought a considerable reduction in the incidence of the most opportunistic infections. Objective: i) to study the clirfical and epidemiological aspects of seizures in HIV-pts; ii) to value the reason of antiepileptic therapy in our patients. Methods: We studied the patients who assumed antiepilectic drugs from a cohort of 1800 HIV-pts and we analyzed the reason for drugs prescription. Results: 90 HIV-pts with antiepilectic drugs were adi~fftted (5"/0). In 12/90 pts (113.3%) epilepsy was present before HIV-infection diagnosis and in 78/90 pts (186.7%) had seizures or antiepilecptic prescription after HIV-infection diagnosis. Antiepilectic drugs were prescribed for: cerebral toxoplasmosis (NTX) in 7/78 pts (18.97"/o), bacterial meningitis in 1/78 pt (1.3%), viral encephalitis in 1/78 pt (1.3%), cerebrovascular disease and cerebral trauma in 5/78 pts (6.4',/0), AIDS dementia complex (ADC) in 16/78 pts (20.5%), intravenous drug use in 1/78 pt (1.3%), meningioma in 1/78 pt (1.3%) and progressive muhifocal leucoencephalopathy (LEMP) in 2/78 pts (2.6%). Three pts presented multiple cerebral infections: 1 pt NTX-LEMP, 1 pt NTX- ADC, 1 pt ADC-NTX-LEMP. Peripheral neuropathy in 11/78 pts (14.1), psychiatric disorder in 29/78 pts (37.20,5). In 1/78 pt (11.3',/o) seizures were not associated with any cause. Levetiracetam, fenobar- bital, carbamazepine, clonazepan, gabapentin and oxcarbazepina were used for control of neurologic and psychiatric disorders during the period of follow up. Conclusion: In our setting of HIV-pts, cerebral infections and psychiatric disorders are the main cause for the prescription of antiepilep tic drugs.