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mycoplasmal pneumonias or with serologic evidence of a recent infection (Westenfelder et al; Fisher et al; Rothstein and Kenny) We have observed several patients with striking cerebral, cerebellar, brainstem, or spinal syndromes incurred during or soon after a mycoplasmal pneumonia or tracheobronchitis In addition to the cerebellitis, which is clinically similar to the illness that follows varicella, unusual encephalitic syndromes of choreoathetosis, seizures, delirium, hemiparesis, and acute brain swelling (Reye syndrome) have each been reported in a few cases The incidence of these complications has been estimated as 1 in 1000 mycoplasmal infections, but it may approach 5 percent when more careful surveillance is carried out during epidemics A severe prodromal headache has occurred in most of our cases At the time of onset of the neurologic symptoms, there may be scant signs of pneumonia, and in some patients, only an upper respiratory syndrome occurs The mechanism of cerebral damage that complicates mycoplasmal infections has not been established, but recent evidence suggests that the organism is present in the CNS during the acute illness To our knowledge, the organism has been cultured from the brain in only one fatal case, but PCR techniques have detected fragments of mycoplasmal DNA in the spinal uid from several patients (Narita et al) In other instances, the nature of the neurologic complications and their temporal relationship to the mycoplasmal infection clearly suggest that secondary autoimmune factors are operative; ie, that these are instances of postinfectious encephalomyelitis (a type of acute disseminated encephalomyelitis described in Chap 36) Most of the patients with the infectious variety have recovered with few or no sequelae, but rare fatalities are reported The CSF usually contains small numbers of lymphocytes and other mononuclear cells and an increased protein content The diagnosis can be established by culture of the organism from the respiratory tract (which is dif cult), by rising serum titers of complement- xing IgG and IgM antibodies and cold agglutinin antibodies in the blood and CSF, or by specialized DNA detection techniques from the CSF Treatment Erythromycin and tetracycline derivatives reduce morbidity, mainly by eradicating the pulmonary infection, but the effects of antibiotics on the nervous system complications are not known Listeria monocytogenes Infections Meningoencephalitis from this organism is most likely to occur in immunosuppressed and debilitated individuals and is a well-known and occasionally fatal cause of meningitis in the newborn Meningitis is the usual neurologic manifestation, but there are numerous recorded instances of an isolated focal bacterial infectious encephalitis, rarely with a normal CSF, most cases showing a pleocytosis that may be initially polymorphonuclear Between 1929, when the organism was discovered, and 1962, when Gray and Killinger collected all the reported cases, it was noted that 35 percent of 467 patients had either meningitis or meningoencephalitis as the primary manifestation The infection may take the form of a brainstem, or rhombencephalitis more speci cally, several days of headache, fever, nausea, and vomiting followed by asymmetrical cranial nerve palsies, signs of cerebellar dysfunction, hemiparesis, quadriparesis, or sensory loss Respiratory failure has been reported Of 62 cases of Listeria brainstem encephalitis reported by Armstrong and Fung, 8 percent were in immunosuppressed patients, meningeal signs were present in only half the patients, and the spinal uid often showed, misleadingly mild abnormalities CSF cultures yielded.

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Listeria in only 40 percent of cases (blood cultures were even more often normal) Consistent with our experience, the early CT scan was often normal; MRI, however, has revealed abnormal signals in the parenchyma of the brainstem The monocytosis, which gives the organism its name, refers to the reaction in the peripheral blood in rabbits and has not been prominent in the blood or CSF of our cases One of the patients described by Lechtenberg and coworkers had a proven brain abscess; other patients have had multiple small abscesses (Uldry et al) Judging from the clinical signs in some cases, the infection appears to affect both the brainstem parenchyma and the extra-axial portion of cranial nerves Treatment The treatment is ampicillin (1 g intravenously every 4 h) in combination with tobramycin (5 mg/kg intravenously in three divided doses daily) If the condition of the host is compromised, the outcome is often fatal; but most of our patients without serious medical disease have made a full and prompt recovery with treatment Legionella This potentially fatal respiratory disease caused by the gram-negative bacillus Legionella pneumophila, rst came to medical notice in July 1976, when a large number of members of the American Legion fell ill at their annual convention in Philadelphia The fatality rate was high In addition to the obvious pulmonary infection, manifestations referable to the CNS and other organs were observed regularly Lees and Tyrrell described patients with severe and diffuse cerebral involvement, and Baker et al and Shetty et al described others with cerebellar and brainstem syndromes The clinical details have varied One constellation consisted of headache, obtundation, acute confusion or delirium with high fever, and evidence of pulmonary distress; another took the form of tremor, nystagmus, cerebellar ataxia, extraocular muscle and gaze palsies, and dysarthria Other neurologic abnormalities have been observed, such as inappropriate ADH secretion, or a syndrome of more diffuse encephalomyelitis or transverse myelitis, similar to that observed with Mycoplasma infections The CSF is usually normal and CT scans of the brain are negative, a circumstance that makes diagnosis dif cult The neuropathologic abnormalities have not been studied Suspicion of the disease, based on suspected exposure or on the presence of an atypical pneumonia, should prompt tests for serum antibodies to the bacillus, which rise to high levels in a week to 10 days In most patients the signs of CNS disorder resolve rapidly and completely, although residual impairment of memory and a cerebellar ataxia have been recorded To date, the Legionella bacillus has not been isolated from the brain or spinal uid Treatment Treatment in adults has consisted of erythromycin, 05 to 10 g intravenously q 6 h for a 3-week period The combination of the erythromycin analogue azithromycin and cipro oxacin (a quinolone) is believed to be more potent Cat-Scratch Encephalitis Reports of approximately 100 cases of encephalitis from cat-scratch disease have appeared in the medical literature The causative organism is a gram-negative bacillus now called Rochalimaea henselae (formerly Bartonella henselae) The illness begins as unilateral axillary or cervical adenopathy occurring after a seemingly innocuous scratch (rarely a bite) from an infected cat The cases with which we are familiar began with an encephalopathy and high fever (higher temperature than with most of the other organisms that are capable of causing a bacterial encephalitis), followed by seizures or status epilepticus The organism has also been implicated in causing a focal cerebral vasculitis in.

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