Japanese spotted fever (JSF) is a rickettsial disease caused by Rickettsia japonica. To the best of our knowledge, there have only been five reported cases of JSF involving the central nervous system. A 74-year-old man was admitted after 1 week of fever and maculopapular rash. JSF was definitively diagnosed by PCR; however, the patient showed mental disturbance and abnormal behavior. After intravenous immunoglobulin, his mental state and behavior improved. The findings of cerebrospinal fluid analysis, electroencephalography, and 99 mTcHM-PAO single photon computed emission tomography suggested post-infectious encephalitis. JSF causes post-infectious encephalitis and early treatment is recommended.

In autoimmune encephalitis, abnormalities of diffusion-weighted imaging (DWI), fluid-attenuated inversion recovery (FLAIR), arterial spin labeling (ASL) in magnetic resonance imaging (MRI), single-photon emission computed tomography (SPECT) and 18F-fluorodeoxyglucose-positron emission tomography (18F-FDG-PET) have been reported. However, there are few studies of long-term follow-up of imaging. We report a case of anti-leucine-rich glioma-inactivated 1 antibody encephalitis whose MRI (DWI, FLAIR and ASL), 99mTcHM-PAO SPECT (PAO-SPECT) and 18F-FDG-PET were evaluated through the clinical course. ASL, PAO-SPECT and 18F-FDG-PET consistently showed abnormalities in almost the same area. Serial assessment of these imaging modalities is useful in evaluating disease activity and efficacy of treatment.

Tetanus is an infectious disease induced by wound invasion of Clostridium tetani, which is ubiquitous among soil. Many more cases are reported in Japan than in other developed countries. In this study, we report 11 cases of tetanus experienced at our hospital and discuss the preceding trauma and treatment course. The mean age at onset was 68 years old (35-86 years) and 7 cases required intensive care. Some preceded injuries were clearly contaminated, and others were small and minor. Even minor injuries developed serious tetanus. Trauma was not identified in 2 cases yet both used their family garden every day and had a high risk of exposure to C tetani, suggesting that micro-wounds may have been a gateway to entry. The average length of stay in the intensive care unit was 28 days (4-73 days) and average total hospitalization was 55 days (13-114 days). Only 4 out of 11 cases were diagnosed correctly by the initial physician and others, especially when the trauma was minor or absent, were misdiagnosed even when presenting with characteristic symptoms like lockjaw and posterior neck stiffness. Tetanus should be diagnosed based on medical history and physical examination due to lack of high specific testing. Therefore, a detailed history taking is required, including hobbies in addition to the appropriate neurological examination, thereby facilitating a quick diagnosis and commencement of treatment as soon as possible.

Little is known about the mechanism of central nervous system (CNS) symptoms after human papillomavirus (HPV) vaccine, and there is no report on electroencephalographic (EEG) findings about these symptoms. This study shows postictal and interictal EEG findings of two girls with CNS symptoms after HPV vaccine. Case1: a 16-year-old girl. Her attack was left dominant dystonia followed by loss of consciousness. Her interictal EEG showed unilateral (the right side) loss of a photic driving response, B(I) RDs (Brief Potentially Ictal Rhythmic Discharges) on T6 electrode. Her postictal EEG showed asymmetric alpha rhythm amplitude (suppression of the left side; the left was less than 50% of the right). This asymmetry disappeared within 5 min EEG recordings. Case2: a 19-year-old girl. Her attack was right dominant dystonia followed by loss of consciousness. Her interictal EEG showed the left dominant incomplete alpha blocking, asymmetric alpha rhythm frequency (the left side was slower). Trihexyphenidyl was effective in reducing attacks of these patients. These EEG findings look like hemiplegic migraine, epilepsy, so the mechanism of CNS symptoms after HPV vaccine may be similar to these disorders. This study demonstrates objective findings about CNS symptoms (dystonia, loss of consciousness) after HPV vaccine, and that these symptoms are not functional/psychogenic disorders.

A 79-year-old woman was admitted with severe headache and fever lasting for 1 week amongst a mumps epidemic. She had no parotitis. Nuchal stiffness facilitated cerebrospinal fluid (CSF) study, which showed lymphocytic pleocytosis (985 cells/mm). Reverse transcription-PCR (RTPCR) test detected mumps virus RNA in the CSF. Mumps meningitis was strongly suspected, although serum mumpsspecific IgG or IgM was negative with paired serum samples. Unexpectedly, brain MRI on admission revealed an enlarged pituitary gland and stalk with contrast enhancement (Fig. 1a-c). Her visual field and serum levels of pituitary hormones were normal, without signs of polyuria or any other hormonal dysfunction. High-dose methylprednisolone (1000 mg/day for 3 days) for suspected hypophysitis resulted in clinical and radiological improvement within several days (Fig. 1d). No after therapy was required, and MRI findings almost normalized within a month except for empty sella turcica (Fig. 1e), without any sequelae or relapse for the following 16 months (Fig. 1f). Dramatic response to corticosteroid without any relapse indicates the transient inflammatory etiology of hypophyseal enlargement. Mumps-related hypophysitis is suspected, which seems a hitherto unrecognized association.

April 27, 2017April 18, 2017Free AccessExtreme delta brush in electroencephalogram may be nonspecific to the anti-NMDAR encephalitis. (P5.223)Kanako Namekawa, Hitoshi Mori, Hiromitsu Tabata, Hiroyuki Miyahara, Misako Minote, Akira Nishida, and Katsuro ShindoAuthors Info & AffiliationsApril 18, 2017 issue88 (16_supplement)https://doi.org/10.1212/WNL.88.16_supplement.P5.223 Letters to the Editor