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Case Report: Para-infectious cranial nerve palsy after bacterial meningitis

A 27-year-old woman was admitted to our hospital for fever, associated with headache, nausea, and vomiting, and she rapidly developed mild left facial nerve palsy and diplopia. Neurological examination revealed mild meningitis associated with bilateral VI cranial nerve palsy and mild left facial pal...

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Autores principales: Zanotelli, Giovanni, Bresciani, Lorenzo, Anglani, Mariagiulia, Miscioscia, Alessandro, Rinaldi, Francesca, Puthenparampil, Marco
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Frontiers Media S.A. 2022
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9582131/
https://www.ncbi.nlm.nih.gov/pubmed/36275763
http://dx.doi.org/10.3389/fimmu.2022.1000912
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author Zanotelli, Giovanni
Bresciani, Lorenzo
Anglani, Mariagiulia
Miscioscia, Alessandro
Rinaldi, Francesca
Puthenparampil, Marco
author_facet Zanotelli, Giovanni
Bresciani, Lorenzo
Anglani, Mariagiulia
Miscioscia, Alessandro
Rinaldi, Francesca
Puthenparampil, Marco
author_sort Zanotelli, Giovanni
collection PubMed
description A 27-year-old woman was admitted to our hospital for fever, associated with headache, nausea, and vomiting, and she rapidly developed mild left facial nerve palsy and diplopia. Neurological examination revealed mild meningitis associated with bilateral VI cranial nerve palsy and mild left facial palsy. As central nervous system (CNS) infection was suspected, a diagnostic lumbar puncture was performed, which revealed 1,677 cells/μl, 70% of which were polymorphonuclear leukocytes. Moreover, multiplex PCR immunoassay was positive for Neisseria meningitidis, supporting the diagnosis of bacterial meningitis. Finally, IgG oligoclonal bands (IgGOB) were absent in serum and cerebrospinal fluid (CSF). Therefore, ceftriaxone antibiotic therapy was started, and in the following days, the patient’s signs and symptoms improved, with complete remission of diplopia and meningeal signs within a week. On the contrary, left facial nerve palsy progressively worsened into a severe bilateral deficit. A second lumbar puncture was therefore performed: the CSF analysis revealed a remarkable decrease of pleocytosis with a qualitative modification (only lymphocytes), and oligoclonal IgG bands were present. A new brain MRI was performed, showing a bilateral gadolinium enhancement of the intrameatal VII and VIII cranial nerves bilaterally. Due to suspicion of para-infectious etiology, the patient was treated with oral steroid (prednisolone 1 mg/kg/day), with a progressive and complete regression of the symptoms. We suggest that in this case, after a pathogen-driven immunological response (characterized by relevant CSF mixed pleocytosis and no evidence of IgGOB), a para-infectious adaptive immunity-driven reaction (with mild lymphocyte pleocytosis and pattern III IgGOB) against VII and VIII cranial nerves started. Indeed, steroid administration caused a rapid and complete restoration of cranial nerve function.
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spelling pubmed-95821312022-10-21 Case Report: Para-infectious cranial nerve palsy after bacterial meningitis Zanotelli, Giovanni Bresciani, Lorenzo Anglani, Mariagiulia Miscioscia, Alessandro Rinaldi, Francesca Puthenparampil, Marco Front Immunol Immunology A 27-year-old woman was admitted to our hospital for fever, associated with headache, nausea, and vomiting, and she rapidly developed mild left facial nerve palsy and diplopia. Neurological examination revealed mild meningitis associated with bilateral VI cranial nerve palsy and mild left facial palsy. As central nervous system (CNS) infection was suspected, a diagnostic lumbar puncture was performed, which revealed 1,677 cells/μl, 70% of which were polymorphonuclear leukocytes. Moreover, multiplex PCR immunoassay was positive for Neisseria meningitidis, supporting the diagnosis of bacterial meningitis. Finally, IgG oligoclonal bands (IgGOB) were absent in serum and cerebrospinal fluid (CSF). Therefore, ceftriaxone antibiotic therapy was started, and in the following days, the patient’s signs and symptoms improved, with complete remission of diplopia and meningeal signs within a week. On the contrary, left facial nerve palsy progressively worsened into a severe bilateral deficit. A second lumbar puncture was therefore performed: the CSF analysis revealed a remarkable decrease of pleocytosis with a qualitative modification (only lymphocytes), and oligoclonal IgG bands were present. A new brain MRI was performed, showing a bilateral gadolinium enhancement of the intrameatal VII and VIII cranial nerves bilaterally. Due to suspicion of para-infectious etiology, the patient was treated with oral steroid (prednisolone 1 mg/kg/day), with a progressive and complete regression of the symptoms. We suggest that in this case, after a pathogen-driven immunological response (characterized by relevant CSF mixed pleocytosis and no evidence of IgGOB), a para-infectious adaptive immunity-driven reaction (with mild lymphocyte pleocytosis and pattern III IgGOB) against VII and VIII cranial nerves started. Indeed, steroid administration caused a rapid and complete restoration of cranial nerve function. Frontiers Media S.A. 2022-10-06 /pmc/articles/PMC9582131/ /pubmed/36275763 http://dx.doi.org/10.3389/fimmu.2022.1000912 Text en Copyright © 2022 Zanotelli, Bresciani, Anglani, Miscioscia, Rinaldi and Puthenparampil https://creativecommons.org/licenses/by/4.0/This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
spellingShingle Immunology
Zanotelli, Giovanni
Bresciani, Lorenzo
Anglani, Mariagiulia
Miscioscia, Alessandro
Rinaldi, Francesca
Puthenparampil, Marco
Case Report: Para-infectious cranial nerve palsy after bacterial meningitis
title Case Report: Para-infectious cranial nerve palsy after bacterial meningitis
title_full Case Report: Para-infectious cranial nerve palsy after bacterial meningitis
title_fullStr Case Report: Para-infectious cranial nerve palsy after bacterial meningitis
title_full_unstemmed Case Report: Para-infectious cranial nerve palsy after bacterial meningitis
title_short Case Report: Para-infectious cranial nerve palsy after bacterial meningitis
title_sort case report: para-infectious cranial nerve palsy after bacterial meningitis
topic Immunology
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9582131/
https://www.ncbi.nlm.nih.gov/pubmed/36275763
http://dx.doi.org/10.3389/fimmu.2022.1000912
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