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AIDS patients as well as neuroretinitis in both immunocompromised and immune-competent patients Demonstration of elevated complement- xing titers and detection of the organism by PCR or by silver staining from an excised lymph node are diagnostic A single high antibody titer is inadequate for this purpose Treatment Erythromycin, chloramphenicol, or doxycycline seem to eradicate the infection; macrolide antibiotics have been recommended in recalcitrant cases Most patients recover completely, but one of our patients and a few reported by others have died Anthrax This rare form of meningoencephalitis is included here because of the current interest in Bacillus anthracis as a weapon of warfare Lanska was able to collect from the literature 70 patients with meningeal infection, most of whom were encephalopathic He has estimated that fewer than 5 percent of infected individuals will acquire a meningoencephalitis; in the 2001 US outbreak, only 1 of 11 cases with anthrax pneumonitis developed this complication Re ecting the main site of natural infection, the majority of cases originated in cutaneous anthrax In addition to a typically fulminating course after a prodrome of one or several days, the exceptional feature was a hemorrhagic and in ammatory spinal uid formula Subarachnoid hemorrhage was prominent in autopsy material, re ecting presumably necrosis of the vessel wall as a toxic effect of B anthracis Although natural isolates are sensitive to penicillin, bioengineered strains are resistant; therefore combined treatment with rifampin, vancomycin, and either cipro oxacin or doxycycline has been recommended initially The bene t of speci c antitoxin is uncertain once meningoencephalitis has occurred Brucellosis This worldwide disease of domesticated livestock is frequently transmitted to humans in areas where the infection is enzootic In the United States, it is distinctly rare, with 200 cases or less being reported annually since 1980 During the 1950s it was a fashionable explanation for chronic fatigue In the Middle East, infection with Brucella is still frequent, attributable to the ingestion of raw milk In Saudi Arabia, for example, al Deeb and coworkers reported on a series of 400 cases of brucellosis, of which 13 presented with brain involvement (acute meningoencephalitis, papilledema and increased intracranial pressure, and meningovascular manifestations) The CSF showed a lymphocytic pleocytosis and increased protein content Blood and CSF antibody titers to the organism were greater than 1/640 and 1/128, respectively Prolonged treatment with rifampin, cotrimoxazole, and doxycycline suppressed the infection Whipple Disease This is a rare but often discussed disorder, predominantly of middle-aged men Weight loss, fever, anemia, steatorrhea, abdominal pain and distention, arthralgias, lymphadenopathy, and hyperpigmentation are the usual systemic manifestations Less often, infection is associated with a number of neurologic syndromes It is now known to be caused by a gram-positive bacillus, Tropheryma whippelii, which resides predominantly in the gut Biopsy of the jejunal mucosa, which discloses macrophages lled with the periodic acid Schiff (PAS)-positive organisms, is diagnostic PAS-positive histiocytes have also been identi ed in the CSF as well as in periventricular regions, in the hypothalamic and tuberal nuclei, or diffusely scattered in the brain The neurologic manifestations most often take the form of a slowly progressive memory loss or dementia of subacute or early chronic evolution Supranuclear ophthalmoplegia, ataxia, seizures,.

14:

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Figure 14-10