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[Solved] What Causes Pachymeningitis?

An assessment was made on a 45-year old woman for progressive visual loss caused by psychosis. Before her admission, she was in good health. However, within four years of being admitted, she developed acute nasal obstruction. This was accompanied with purulent nasal drainage and progressive deformity. The septum then became severely damaged. At another hospital, she was referred for surgical treatment of her nose deformity. She was discharged with chronic rhinitis. The nasal congestion continued with non-purulent discharge and did not improve with treatment with anti-histaminic or local corticosteroids. She was scanned with CT to examine her orbit and paranasal sinuses three years later. When she was first diagnosed with psychosis in her late teens, she’s beginninginning experiencing psychiatric symptoms. She experienced hyperactivity and hallucinations as well as euphoria. She’s also beginninginning to experience anosmia, progressive visual loss and dilated pupils in her left eye. No headaches were reported. The magnetic resonance imaging (MRI), which was performed next, revealed a linear gadolinium-enhanced lesion at the’s leaving basal frontal lobe as well as the interhemispheric fracture consistent with meningeal thickening. (Fig 1). A lumbar puncture showed a 13 cmH2O opening pressure and clear cerebrospinal liquid (CSF). There were 6 cells/ mm3 (63% lymphocytes, 31% monocytes, 3% neutrophils, 3% plasmocytes) 🙈 Total protein was 45 mg/dL and glucose was 59 mg/dL 🤓 Protein electrophoresis revealed an increase of gamma globulins 👍 Microscopy and culture were ineffective for the detection of infectious agents. The results of immunological tests were negative for varicella zoster virus and herpes simplex virus. [1]
An assessment was made on a 45-year old woman for progressive visual loss caused by psychosis. Before her admission, she was in good health. However, within four years of being admitted she developed acute nasal obstruction. This was accompanied with purulent nasal drainage and progressive deformities that eventually led to the destruction of her nasal septum. At another hospital, she was referred for surgical treatment of her nose deformity. She was discharged with chronic rhinitis. The nasal congestion continued with non-purulent discharge and did not improve with treatment with anti-histaminic or local corticosteroids. She was scanned with CT to examine her orbit and paranasal sinuses three years later. She’s beginninginning to experience psychiatric symptoms. This included hyperactivity, euphoria and hallucinations. She’s also beginninginning to experience anosmia, progressive visual loss and dilated pupils in her left eye. No headaches were reported. The magnetic resonance imaging (MRI), which was performed next, revealed a linear gadolinium-enhanced lesion at the’s leaving basal frontal lobe as well as the interhemispheric fracture consistent with meningeal thickening. (Fig 1). A lumbar puncture showed a 13 cmH2O opening pressure and clear cerebrospinal liquid (CSF). 6 cells/mm3 (65% lymphocytes (31% monocytes), 3% neutrophils and 3% plasma cells) were detected. Glycerol was 59 mg/dL while total protein was 45 mg/dL. A protein electrophoresis showed an increase in the number of gammaglobulins. Microscopy was ineffective for detecting infectious agents. The results of immunological tests were negative for varicella zoster virus and herpes simplex virus. [2]
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Alice Mims says at hindawi.com, background. Tuberculous Pachymeningitis, a rare type of extrapulmonary tuberculosis, is usually diagnosed by thickening dura using contrast-enhanced magnet resonance imaging. Nature of progressive disease can lead to chronic Compression from thickened dura can cause headaches and other neurological problems. Case report. Report on a case of a 40 year-old woman who suffered from chronic headaches for a decade. She was suffering from hemisensory loss and migraines. The’s patient doing not respond to steroids initially, but she developed a progressive course. Investigating further, it’s was finding that she’s havingaving a diffused thickening of the dural wall on contrast MRI and a strong positive Mantoux test for caseating necrotizing granulomatous swelling on hertology. After the patient was able to respond well to antituberculous steroids, her condition significantly improved. The medication for tuberculosis continued for one year without any problems. Conclusion. A patient with a persistent headache and focal neurological signs should be diagnosed as primary tuberculous pachymeningitis. This is when MRI evidence of dural thickening can be detected. The diagnosis can be confirmed by image-guided, dural biopsy. [3]
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Results: These were the main features of 11 patients who presented with headaches, vision loss (7 cases), diplopia (4 instances), papilledema (3 cases), other brain involvement (3 cases), seizures (1 instance), ataxia (2 causes), and ataxia (2). A correlation was found between the location and the severity of dura mater abnormalities on the initial MRI. Clinical findings and the sphenoid wing area was affected in all patients. Five cases had a higher sedimentation rate. Six cases had higher levels of protein and four had lymphocytosis. In five cases, the dura mater was biopsied, while the orbital soft tissues in one case revealed infiltrates from plasma cells and small mature lymphocytes. There were no signs of neoplasia or vasculitis. Cultures of CSF and biopsy material were not sterile. The vision was improved in seven of eight cases. Corticosteroid therapy also controlled the headaches in ten of eleven cases. Five patients showed partial improvements in other neurological symptoms or signs. Six cases experienced recurrence after steroid tapering. One of the cases suffered progressive deterioration, and eventually died. Four cases had progressive deterioration and died. In these four cases, methotrexate was administered or azathioprine added to reduce the dose of steroid. A follow-up MRI was performed on 11 patients and showed a correlation of 80% to the clinical condition (p = 0.01). (last updated by William Bustamante of Rasht in Iran 59 days ago) [4]
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Marguita Burks n.neurology.orgHere are the details: According to the initial MRI findings, abnormal enhancements of the dura matrix were found in the majority of patients. The sphenoid wing was also affected. Five cases had a higher sedimentation rate. Six cases had higher levels of protein and four had lymphocytosis. In five cases, the dura mater was biopsied, while the orbital soft tissues in one case revealed infiltrates from plasma cells and small mature lymphocytes. There were no signs of neoplasia or vasculitis. Cultures of CSF and biopsy material were not sterile. In 7 cases, the corticosteroid treatment improved vision and managed headaches in 11 of 11. Five patients showed partial improvements in other neurological symptoms or signs. Six cases experienced recurrence after steroid tapering. One of the cases suffered progressive deterioration, and eventually died. Four cases had progressive deterioration and died. In these four cases, methotrexate was administered or azathioprine added to reduce the dose of steroid. The clinical status was correlated 80% by follow-up MRI in eleven patients (p = 0.01). Yanique Donahue, Hosur (India) for the revisions. [5]
Jnnp.bmj.com Also, he mentions the case of a 37-year-old man who presented with persistent bifrontal headaches over one year in 1984. His history included right mastoidectomy and chronic otitis media in 1977. He was then symptom free. The neurological exam in 1984 was normal. Also, brain CT, chest radiography and laboratory studies, including complete blood count, erythrocyte segregation rate (ESR) and blood chemical were all normal. The normal CSF pressure was measured at the lumbar puncture. CSF analysis showed that there was a mononuclear accumulation of lymphocytes at 168 cells/mm3. This is normal (last edited by Arvind McNair, Durban, South Africa). [6]

Refer to Article

  1. https://www.scielo.br/j/anp/a/6LVL9jkpjwxsdjf6zmLhZpN/?lang=en
  2. http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0004-282X2003000100021&lng=es&nrm=iso&tlng=es
  3. https://www.hindawi.com/journals/criid/2018/3012034/
  4. https://n.neurology.org/content/neurology/62/5/686.full-text.pdf
  5. https://n.neurology.org/content/62/5/686
  6. https://jnnp.bmj.com/content/64/3/408
Mae Chow

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