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[Hypertrophic cranial pachymeningitis with propionibacterium acnes detected by dural biopsy]
Abstract:
A 30-year-old woman experienced recurrent dull headache and frequent partial motor seizure (Jacksonian type) that marched from right fingers. This motor seizure was uncontrollable with ordinary anticonvulsant therapy. Cerebrospinal fluid showed mild pleocytosis. Cranial CT examination was unremarkable, but MRI revealed thickened dural lesion on the left fronto-parietal site, giving diagnosis of hypertrophic cranial pachymeningitis. Dural biopsy showed nonspecific chronic granulomatous state without specific granuloma such as tuberculosis nor sarcoidosis. Anaerobic culture revealed Propionibacterium acnes, a rare causative agent of meningitis. We conclude that it is important to follow a case of unknown cause pachymeningitis carefully with MRI, and in some cases, is required a dural biopsy to make a diagnosis before steroid therapy.
Insights
A rare case of hypertrophic cranial pachymeningitis caused by Propionibacterium acnes was diagnosed in a woman with intractable seizures. Early MRI and biopsy are crucial for diagnosis before steroid treatment.
Area of Science:
- Neurology
- Infectious Diseases
- Radiology
Background:
- Hypertrophic cranial pachymeningitis is a rare condition characterized by thickening of the dura mater.
- Idiopathic hypertrophic cranial pachymeningitis is a diagnosis of exclusion, often requiring invasive procedures for definitive diagnosis.
- Cranial nerve deficits and seizures are among the neurological manifestations.
Observation:
- A 30-year-old woman presented with intractable partial motor seizures and headache, unresponsive to standard anticonvulsant therapy.
- Cerebrospinal fluid analysis revealed mild pleocytosis, while initial cranial CT scans were unremarkable.
- Magnetic resonance imaging (MRI) identified a thickened dural lesion in the left fronto-parietal region, suggestive of pachymeningitis.
Findings:
- Dural biopsy demonstrated a nonspecific chronic granulomatous inflammation.
- Anaerobic culture of the biopsy specimen isolated Propionibacterium acnes, an uncommon pathogen in meningitis.
- The patient's symptoms were attributed to Propionibacterium acnes-induced hypertrophic cranial pachymeningitis.
Implications:
- This case highlights the importance of advanced imaging like MRI in diagnosing obscure cases of pachymeningitis.
- Dural biopsy and microbiological analysis are essential for identifying specific causative agents, such as Propionibacterium acnes.
- Accurate diagnosis is critical to guide appropriate treatment, potentially avoiding empirical steroid therapy which could exacerbate infections.