trimethoprim--sulfamethoxazole-drug-combination and Brain-Diseases

Melioidosis is an infection caused by Burkholderia pseudomallei, which is more prevalent in the tropics and leads to significant morbidity and mortality. It characteristically produces widespread caseous lesions and abscesses, and can present with varied clinical manifestations. Melioidosis involving the central nervous system is uncommon.. A 42-year-old Sri Lankan male with type 2 diabetes presented with a febrile illness of 6 days with headache and constitutional symptoms. Clinical examination was unremarkable. Four days later, he developed focal seizures involving the left leg and numbness of the left side. Initial laboratory investigations were suggestive of a bacterial infection. Blood culture was reported as positive for a Pseudomonas species, which was resistant to gentamicin. Contrast enhanced CT and MRI scans of the brain showed a subdural collection in the right fronto-temporo-parietal region with possible abscess formation. Melioidosis antibody testing using indirect hemagglutination method was reactive with a titre more than 1/10,240. He was treated with intravenous meropenem and oral co-trimoxazole for 8 weeks (Intensive phase). The subdural collection was managed conservatively, and seizures were treated with oral antiepileptics. At 7 weeks, follow-up contrast enhanced MRI showed improvement of the subdural collection, and inflammatory markers had normalized. He was discharged after 8 weeks, and treated with oral co-trimoxazole and doxycycline for 6 months (eradication phase). At 6 months follow-up, the patient is asymptomatic.. Cerebral melioidosis is an unusual presentation of melioidosis where the diagnosis can be easily missed. Knowledge of the protean manifestations of melioidosis is of paramount importance in order to detect and treat this potentially fatal infection appropriately, especially in tropical countries where the disease is endemic.

Topics: Adult; Anti-Bacterial Agents; Brain; Brain Diseases; Burkholderia pseudomallei; Diabetes Complications; Diabetes Mellitus, Type 2; Doxycycline; Gentamicins; Humans; Magnetic Resonance Imaging; Male; Melioidosis; Meropenem; Subdural Space; Trimethoprim, Sulfamethoxazole Drug Combination

Nocardia is a genus of gram-positive Actinomycetes that are ubiquitous in decaying organic material, soil, and water. Some Nocardia species can infect humans, mainly by airborne transmission. Several reports describe disseminated infections, which are rare and mostly affect strongly immunocompromised patients because intact T-cell-mediated immunity is the major protective mechanism.. We report a case of disseminated pulmonary, cerebral, and cutaneous infection with Nocardia farcinica in a 66-year-old kidney transplant recipient treated with low-dose triple immunosuppression. The patient was initially admitted because of severe hyponatremia and pneumonia with radiologic signs of pleural effusion. The infectious agent was isolated when cutaneous lesions developed. Oral trimethoprim/sulfamethoxazole treatment led to severe hyponatremia; therefore, long-term treatment with parenteral amikacin and minocycline was initiated. After 7 months of consistent intravenous treatment, the lesions completely resolved and treatment was stopped, against some expert suggestions. The patient had remained free of relapse at the time of writing.. Disseminated Nocardia infection in immunocompromised patients is a rare but life-threatening disease. Owing to its infrequency, the variety of clinical patterns, antimicrobial resistance, and often fatal complications of standardized therapy, the diagnosis and treatment of this infection remain challenging and protracted.

Topics: Administration, Intravenous; Aged; Brain Diseases; Female; Humans; Hyponatremia; Immunocompromised Host; Immunosuppressive Agents; Kidney Transplantation; Male; Nocardia; Nocardia Infections; Opportunistic Infections; Pleural Effusion; Pneumonia, Bacterial; Postoperative Complications; Skin Diseases, Bacterial; Trimethoprim, Sulfamethoxazole Drug Combination

Toxoplasmosis and infections by other opportunistic agents such as Pneumocystis jirovecii constitute life-threatening risks for patients after allogeneic hematopoietic stem cell transplantation. Trimethoprim/sulfamethoxazole (TMP-SMX) has been well established for post-transplant toxoplasmosis and pneumocystis prophylaxis, but treatment may be limited due to toxicity. We explored atovaquone as an alternative and compared it with TMP-SMX regarding toxicity and efficacy during the first 100 days after transplantation in 155 consecutive adult stem cell recipients. Eight patients with a prior history of TMP-SMX intolerance received atovaquone as first-line prophylaxis. TMP-SMX was used for 141 patients as first-line strategy, but 13 patients (9.2%) were later switched to atovaquone due to TMP-SMX toxicity or gastrointestinal symptoms. No active toxoplasmosis or active P. jirovecii infection developed under continued prophylaxis with either TMP-SMX or atovaquone. However, for reasons of TMP-SMX and/or atovaquone toxicity, 7 patients were unable to tolerate any efficacious toxoplasmosis prophylaxis and therefore obtained inhalative pentamidine as P. jirovecii prophylaxis but no toxoplasmosis prophylaxis. Importantly, 2 of these patients developed severe toxoplasmosis. In summary, atovaquone appears as a valid alternative for at least some post-transplant patients who cannot tolerate TMP-SMX. This should be further confirmed by multicenter trials.

Topics: Adolescent; Adult; Aged; Anti-Infective Agents; Atovaquone; Brain Diseases; Female; Hematologic Diseases; Hematopoietic Stem Cell Transplantation; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Retrospective Studies; Toxoplasmosis; Transplantation, Homologous; Trimethoprim, Sulfamethoxazole Drug Combination; Young Adult

Nocardiosis of the central nervous system is a challenging and difficult diagnosis for the clinician. The combination of infections of the brain and spinal cord is even more rare. The authors report on a patient with multiple lesions in the brainstem and cervical spinal cord. This 81-year-old immunocompetent woman presented with symptoms of progressive walking difficulty and ataxia. The results of an extensive workup with laboratory investigation, MRI, lumbar puncture, positron emission tomography (PET), and bone marrow biopsy remained inconclusive. Only after an open biopsy of a cervical lesion by an anterior approach through a partial central corpectomy of the cervical spine, was the diagnosis of nocardiosis made, allowing for specific antibiotic treatment.

Topics: Anti-Infective Agents; Brain Abscess; Brain Diseases; Brain Stem; Central Nervous System Bacterial Infections; Cervical Vertebrae; Female; Humans; Magnetic Resonance Imaging; Nocardia; Nocardia Infections; Spinal Cord Diseases; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

Topics: Anti-Bacterial Agents; Brain Diseases; Ceftriaxone; Cerebrospinal Fluid; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Polymerase Chain Reaction; Spinal Puncture; Trimethoprim, Sulfamethoxazole Drug Combination; Tropheryma; Whipple Disease

Neuroparacoccidioidomycosis is the central nervous system involvement by Paracoccidioides brasiliensis, a condition that may be underdiagnosed and has been scarcely reported. We describe a case of neuroparacoccidioidomycosis in a diabetic male with antecedent of heavy cigarette smoking and alcohol abuse. Thirty years before, he lived in the Amazon area and exerted rural activities in more recent years. The patient's main complaints were headache, visual deficit, hemiparesis, and weight loss. Imaging studies detected changes in the lungs and right adrenal gland, in addition to brain lesions. Paracoccidioides brasiliensis was found in tissue samples collected by the lung and brain biopsies. The patient is under ambulatory surveillance and in use of trimethoprim-sulfamethoxazole.

Topics: Antifungal Agents; Brain; Brain Diseases; Central Nervous System Fungal Infections; Humans; Male; Middle Aged; Paracoccidioides; Paracoccidioidomycosis; Tomography, X-Ray Computed; Trimethoprim, Sulfamethoxazole Drug Combination

We report a series of four cases presented with transient ischemic attacks (TIA) or ischemic stroke as the predominant manifestation of neurobrucellosis (NB). Three of the patients were 20-28 years of age, and one patient was 53 years old. They all used to consume unpasteurized milk or its products. Two patients had systemic brucellosis in the past and received antibiotic treatment. Other causes of TIA including cardiac embolism, hypercoagulability, vascular malformations, systemic vasculitis, and infective endocarditis were excluded. NB was diagnosed with serological tests or cultures for Brucella in the cerebrospinal fluid. None of the patients had any further TIA after the initiation of specific treatment. NB should always be sought in young patients with TIA or ischemic stroke, especially if they have no risk factors for stroke and live in an endemic area for brucellosis, even if they do not have other systemic signs of brucellosis.

Topics: Adult; Anti-Bacterial Agents; Brain Diseases; Brucellosis; Humans; Immunoglobulins; Ischemic Attack, Transient; Male; Middle Aged; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

Patients with End-stage Renal Disease being immunocompromised; are prone to a variety of infections, sometimes, rare ones, more than the general population. This fact should alert the physicians to be more vigilant and have a broader scope when considering the etiology of infections in such patients. We report the case of a 65-year-old man who had a very stormy hospital stay secondary to cerebral nocardiosis with multiple brain abscesses, prolonged unconsciousness and neurological deficits. However, the patient was treated successfully, surgically and chemotherapeutically. He was discharged home in a good condition.

Topics: Aged; Amikacin; Brain Abscess; Brain Diseases; Brain Edema; Ceftriaxone; Humans; Kidney Failure, Chronic; Male; Nocardia Infections; Trimethoprim, Sulfamethoxazole Drug Combination; Unconsciousness; Vancomycin

We report on a 36 years-old man that had been at the Amazon forest four years before. Six months before the admission he had developed a progressive quadriparesis, gait ataxia, dysphagia, dysarthria, difficulty in breathing and hiccup. The gadolinium-enhanced T1-weighted MRI showed a lesion into the right parietoccipital area and another into the medulla, that was the largest. There was any evidence of tuberculosis or AIDS. The patient was submitted to microsurgical approach to the medulla. Pathological examination revealed paracoccidioidomycosis. Treatment with anphotericin B till 2100 mg was administered followed by sulfamethoxazole-trimetoprim for three months plus physical therapy. The patient went back to his activities six months after the end of the treatment. Comments are presented about the participation of the immunological system and of the cytokines (interleukines).

Topics: Adult; Amphotericin B; Antifungal Agents; Brain Diseases; Combined Modality Therapy; Humans; Magnetic Resonance Imaging; Male; Paracoccidioidomycosis; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

The central nervous system (CNS) may be affected in up to 50% of patients with Whipple's disease and this can occur even with little or no gastrointestinal involvement. We describe a 63-year-old patient in whom CNS involvement with Whipple's disease had the clinical and imaging features of a brain infarction. Treatment with aspirin and ceftriaxone followed by trimethoprim-sulfamethoxazole resulted in a good neurological recovery and complete remission of the malabsorption syndrome. Cerebral Whipple's disease resembling a stroke syndrome has so far been reported in only two other patients and in both cases it represented the first presentation of the disease. Arterial or arteriolar fibrosis, thrombosis and thickening associated with the inflammation of adjacent brain parenchyma and leptomeninges, and cerebral vasculitis caused by the hematogenous spread of Tropheryma whippelii to the brain may all be important triggers of brain infarction in patients with Whipple's disease. Our case report highlights the important point that cerebral Whipple's disease with the features of a stroke syndrome, if recognized early and treated aggressively with antibiotics, could have a favorable course with no long-term disability sequelae.

Topics: Anti-Infective Agents; Anti-Inflammatory Agents, Non-Steroidal; Aspirin; Brain Diseases; Ceftriaxone; Cerebral Infarction; Drug Therapy, Combination; Humans; Male; Middle Aged; Stroke; Trimethoprim, Sulfamethoxazole Drug Combination; Whipple Disease

Topics: Actinomycetales Infections; Adult; Anti-Infective Agents; Bacterial Infections; Brain Diseases; Female; Granuloma; Humans; Radiography; Scalp; Trimethoprim, Sulfamethoxazole Drug Combination

Whipple's disease (WD) is an uncommon multisystem condition caused by the bacillus Tropheryma whipplei. Central nervous system involvement is a classical feature of the disease observed in 20 to 40% of the patients. We report the case of a 62 year old man with WD that developed neurological manifestations during its course, and discuss the most usual signs and symptoms focusing on recent diagnostic criteria and novel treatment regimens.

Topics: Biopsy; Brain Diseases; Diarrhea; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Polyneuropathies; Tomography, X-Ray Computed; Trimethoprim, Sulfamethoxazole Drug Combination; Whipple Disease

Topics: Bone Marrow Transplantation; Brain Diseases; Drug Therapy, Combination; Humans; Magnetic Resonance Imaging; Male; Meropenem; Middle Aged; Minocycline; Nocardia asteroides; Nocardia Infections; Thienamycins; Transplantation, Homologous; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

Topics: Anti-Infective Agents; Brain Diseases; Drug Combinations; Female; Humans; Immunosuppression Therapy; Kidney Failure, Chronic; Kidney Transplantation; Lung Diseases; Magnetic Resonance Imaging; Middle Aged; Nocardia Infections; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

To describe an atypical case of central nervous system and ocular paracoccidioidomycoses simulating ocular toxoplasmosis in a pregnant woman with acquired immunodeficiency syndrome (AIDS).. Interventional case report.. Case report.. A 25-year-old pregnant woman with AIDS, presented with a severe ocular inflammation in the right eye involving the choroid, retina, and the optic disk, which rapidly progressed to retinal detachment, iris neovascularization, and neovascular glaucoma. The left eye was normal. Magnetic resonance imaging (MRI) showed a focal hypodense contrast-enhanced ring lesion in the brain. Serum antibody titers were negative for Toxoplasma gondii, but the polymerase chain reaction was positive for the parasite in the vitreous sample. The patient responded partially to specific treatment for toxoplasmosis, and there was a small reduction in size of the brain lesion. She progressed to a blind painful eye, which was enucleated. Paracoccidioides brasiliensis was found in the histopathological studies of the eye and oropharynx. With the diagnosis of disseminated ocular paracoccidioidomycoses, the patient was treated with trimethoprim-sulfamethoxazole with a satisfactory outcome and reduction in size of the brain lesion.. Although ocular infection with ocular paracoccidioidomycoses is rare, this diagnosis should be considered when investigating ocular inflammation in a patient with AIDS.

Topics: Acquired Immunodeficiency Syndrome; Adult; Anti-Infective Agents; Brain Diseases; Eye Enucleation; Eye Infections, Fungal; Female; Humans; Magnetic Resonance Imaging; Paracoccidioides; Paracoccidioidomycosis; Pregnancy; Pregnancy Complications, Infectious; Trimethoprim, Sulfamethoxazole Drug Combination

Central nervous system involvement by brucellosis is infrequent and usually presents as acute meningoencephalitis. Neurobrucellosis presenting as a focal brain mass has rarely been demonstrated on imaging studies. We describe the imaging and pathologic findings in a child affected by neurobrucellosis with focal cortico-subcortical involvement.

Topics: Adolescent; Anti-Bacterial Agents; Brain; Brain Diseases; Brucellosis; Drug Therapy, Combination; Humans; Magnetic Resonance Imaging; Male; Rifampin; Trimethoprim, Sulfamethoxazole Drug Combination

Whipple's disease is a rare, generalized inflammatory disorder due to the recently described bacterium Tropheryma whippelii. We report an unusual, successfully treated case of a 32-year-old woman, who presented with a 25 month history of large abdominal lymphomas, polyserositis and cachexia. The diagnosis of Whipple's disease was confirmed by duodenoscopy, lymph node and duodenal histology and polymerase chain reaction analysis of biopsy material and cerebrospinal fluid. A prolonged convulsive seizure with a subsequent 5 day period of coma were interpreted as signs of cerebral involvement. Under antibiotic treatment with trimethoprim-sulfamethoxazole (co-trimoxazole) the patient recovered completely, CT scans showed a complete regression of abdominal lymphomas. The therapy was continued over 18 months without the occurrence of a relapse.

Topics: Abdominal Neoplasms; Adult; Anti-Infective Agents; Brain Diseases; Coma; Female; Humans; Lymphoma; Seizures; Tomography, X-Ray Computed; Trimethoprim, Sulfamethoxazole Drug Combination; Whipple Disease

Infection with Toxoplasma gondii was studied in 600 patients with AIDS, diagnosed in the eastern part of Denmark from 1980 up to and including 1990. The median age was 38 years, and 223 (44%) had anti-T. gondii IgG antibodies. Of the patients seropositive to T. gondii 61 (27%) developed toxoplasma encephalitis (TE). Few patients received prophylactic treatment with sulfamethoxazole-trimetoprim. In total, 66 patients were diagnosed with TE. One had no serological test performed, and of the remaining 65, 4 (6%) had no anti-T. gondii IgG antibodies. The predictive value of a negative Sabin-Feldman dye test was 99%. The geometric mean dye test titer was higher in patients with TE than in patients without TE. Of the patients with TE 34% had serological reactivation of their T. gondii infection at the time of TE diagnosis, and 34% had detectable T. gondii-specific antibodies in the cerebrospinal fluid. Specific IgM antibodies were found to have little value in the diagnosis of TE, as only 3% had detectable IgM antibodies. Acute toxoplasmosis was the AIDS-defining diagnosis for 23 (35%) of the patients with TE. The median CD4 count at the time of TE was 30 x 10(6)/l, and the median survival time from diagnosis of TE was 9 months.

Topics: Acquired Immunodeficiency Syndrome; Adolescent; Adult; Aged; Animals; Anti-Infective Agents; Antibodies, Protozoan; Brain Diseases; CD4 Lymphocyte Count; Child; Child, Preschool; Denmark; Female; Humans; Immunocompromised Host; Immunoglobulin G; Immunoglobulin M; Infant; Male; Middle Aged; Retrospective Studies; Toxoplasma; Toxoplasmosis; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

In a case of pediatric Whipple disease confined to the central nervous system, white matter lesions initially appeared as areas of very low signal intensity on T1-weighted MR images and as areas of hyperintensity on proton density-weighted and T2-weighted images, and showed slight peripheral enhancement on delayed contrast-enhanced T1-weighted images. On MR studies obtained 3 and 6 months after antibiotic therapy, the lesions had decreased in size and no longer enhanced. They became progressively less hypointense on T1-weighted images and less hyperintense on T2-weighted images.

Topics: Anti-Bacterial Agents; Anti-Infective Agents; Brain Diseases; Cerebellar Diseases; Child, Preschool; Chloramphenicol; Contrast Media; Follow-Up Studies; Gliosis; Humans; Image Enhancement; Magnetic Resonance Imaging; Male; Necrosis; Trimethoprim, Sulfamethoxazole Drug Combination; Whipple Disease

Topics: Acquired Immunodeficiency Syndrome; Brain Diseases; Humans; Pentamidine; Retrospective Studies; Toxoplasmosis; Trimethoprim, Sulfamethoxazole Drug Combination

Nocardiosis is an opportunistic infection that often occurs in patients who are in an immunosuppressive state. It is often difficult to treat and the mortality is high. We report on an immunocompromised patient who suffered from cerebral nocardiosis with multiple brain abscesses which was successfully treated with trimethoprim-sulfamethoxazole (TMP-SMX) for a period of 6 months. The resolution of the brain abscesses with this treatment was documented by serial CT scans. Our experience indicates that a short course of TMP-SMX in a low dose may not be effective in preventing the spread of nocardiosis to the central nervous system (CNS). We recommend a prolonged course of a high dose of TMP-SMX in the treatment of CNS nocardiosis.

Topics: Adult; Brain Diseases; Humans; Male; Nocardia Infections; Trimethoprim, Sulfamethoxazole Drug Combination

Two infants with human immunodeficiency virus (HIV) infection, encephalopathy, intrathecal anti-HIV IgG antibody production and (in one case) the presence of HIV antigen received monthly doses of intravenous gammaglobulin (IVGG) and daily antimicrobial prophylaxis starting at the ages of 6 and 9 months respectively. The follow-up over 15 and 12 months revealed a favourable course with remarkable improvement in visuo-spatial functions, receptive language, play behaviour and fine motor skills, as well as in muscle tone, pyramidal tract signs and vigilance in case 1, and near normalization in case 2. Viability of HIV in peripheral blood mononuclear cells, antigen in serum and cellular immunodeficiency, however, all remained unchanged. We suggest that neurological complications of encephalopathy in paediatric acquired immunodeficiency syndrome may have a slower progression when IVGG treatment plus antimicrobial prophylaxis is started early.

Topics: Acquired Immunodeficiency Syndrome; Brain Diseases; Drug Combinations; Drug Therapy, Combination; HIV Antibodies; HIV Antigens; Humans; Immunoglobulin G; Immunoglobulins, Intravenous; Infant; Infant, Newborn; Ketoconazole; Male; Neurologic Examination; Opportunistic Infections; Sulfamethoxazole; Trimethoprim; Trimethoprim, Sulfamethoxazole Drug Combination

A mouse model of cerebral nocardiosis was used to determine the efficacy of synergistic antimicrobial combinations in reducing bacterial colony counts per gram of brain tissue. The combinations of imipenem-cefotaxime and imipenem-trimethoprim/sulphamethoxazole (TMP/SMP) were compared with each other and with each agent used alone. A saline treated control group was also included. At the completion of 72 h of therapy the combinations of imipenem-cefotaxime and imipenem-TMP/SMX were the most effective in reducing bacterial colony counts. These were statistically superior to cefotaxime and TMP/SMX used alone but not statistically superior to imipenem alone. TMP/SMX was not effective in this model and was inferior to all other antibiotic treatments.

Topics: Animals; Brain Diseases; Cefotaxime; Colony Count, Microbial; Drug Combinations; Drug Synergism; Drug Therapy, Combination; Female; Imipenem; Mice; Microbial Sensitivity Tests; Nocardia asteroides; Nocardia Infections; Sulfamethoxazole; Trimethoprim; Trimethoprim, Sulfamethoxazole Drug Combination

A mouse model of cerebral nocardiosis was used to determine relative antibiotic efficacy by reducing bacterial colony counts per gram of brain tissue. The antimicrobial agents employed were demonstrated in vitro to be inhibitory to most strains of Nocardia asteroides at very low concentrations. The agents used in this study were imipenem-cilastatin, amikacin, trimethoprim-sulfamethoxazole, and minocycline. Antibiotics were administered every 4 h for 72 h before animal sacrifice. Bacterial colony counts were assayed at various time points before the completion of therapy. Imipenem-cilastatin and amikacin were the most effective agents tested. Trimethoprim-sulfamethoxazole was less effective than imipenem and amikacin but more effective than minocycline. Minocycline did not eradicate intracerebral organisms and was similar to saline (control) in its effects.

Topics: Amikacin; Animals; Brain Diseases; Drug Combinations; Female; Imipenem; Kinetics; Mice; Minocycline; Nocardia asteroides; Nocardia Infections; Sulfamethoxazole; Tetracyclines; Thienamycins; Trimethoprim; Trimethoprim, Sulfamethoxazole Drug Combination