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Spontaneous intracranial hypotension (SIH) is recognized with increasing frequency. A throbbing headache occurring or worsening in the upright position and improving after lying down, a so-called 'orthostatic headache', low cerebrospinal fluid (CSF) pressure, and diffuse pachymeningeal enhancement on brain magnetic resonance imaging (MRI) are the major features of the classic syndrome. These patients, who are admitted with fever, headache, and CSF findings revealing lymphocytic pleocytosis, elevated protein concentration, normal glucose levels, and negative culture results, are prone to be misdiagnosed with aseptic meningitis. The aims of this single-centre retrospective study were to determine the epidemiological, clinical, laboratory, and radiological features of patients initially evaluated as having aseptic meningitis but subsequently diagnosed with SIH, and to touch upon the key points of the differential diagnosis in daily infectious diseases practice.Patients referred to Cerrahpasa Medical School with a presumed diagnosis of aseptic meningitis or viral meningitis between 1 January 2006 and 1 January 2011 were reviewed. Epidemiological, clinical, laboratory, radiological, and follow-up data obtained from the hospital database were processed. Patients confirmed to have SIH syndrome were included for evaluation.Eleven cases of SIH syndrome were diagnosed during the study period (8 male and 3 female, median age 30 y, range 21-44 y). All had headache, hearing changes, and nausea. Vomiting (10/11) and posterior neck pain (9/11) were also frequent. Seven had fever and 5 had a stiff neck. Four cases had lymphocytic pleocytosis, 4 cases had elevated CSF protein concentrations (1.5 times the upper limit of normal), and 2 cases had slightly lower CSF glucose levels. Polymerase chain reaction (PCR) analyses of the CSF for Mycobacterium tuberculosis complex, herpes simplex viruses 1 and 2, and enteroviruses were negative in all cases. MRI of the 11 cases revealed signs of spontaneous CSF leaks with diffuse pachymeningeal gadolinium enhancement (11/11), sagging of the brain (9/11), enlargement of the pituitary (6/11), engorgement of the venous structures (5/11), and subdural fluid collections (2/11). CSF leaks were demonstrated by intrathecal magnetic resonance or computed tomography myelography at different levels along the thoracic spine (7/11), cervico-thoracic junction (2/11), and thoraco-lumbar junction (2/11). Autologous blood injection into the spinal epidural space ('blood patch') was performed for treatment. Strict bed rest followed, and all patients recovered fully within a week; no recurrence or complication was observed during the follow-up periods, which ranged from 6 months to 5 y.Findings of fever, headache, and meningeal irritation are generally accepted as the clinical features of meningitis. When CSF findings are not characteristically compatible with bacterial meningitis and particularly when the headache is orthostatic in nature, SIH should also be included in the differential diagnosis. MRI findings are characteristic and clearly contribute to the differential diagnosis between viral meningitis and SIH.

(2002). Cutaneous Tuberculosis: An Evaluation of 7 Cases. Scandinavian Journal of Infectious Diseases: Vol. 34, No. 7, pp. 552-554.

Fungal infection after total joint arthroplasty is a very rare but serious complication and a challenge to the treating and consulting physicians. The literature includes little information about the treatment protocol for Aspergillus infection after total knee arthroplasty, since only 3 cases have been reported. We describe the case of a non-immunocompromised patient who lacked predisposing risk factors and presented with pain and swelling. An aspiration under sterile conditions revealed Aspergillus fumigatus. The patient was treated successfully with a 2-stage exchange reimplantation and 6-week course of liposomal amphotericin B. At 4 y after reimplantation, the patient had no evidence of infection or pain.

In this study, we investigated clinical features, aetiology, prospective follow-up results and also factors favouring secondary erythema nodosum (EN) in patients with EN. A total of 50 patients (mean age 38 y) with a diagnosis of EN between 1993 and 2002 in our clinic were included in the study prospectively. A biopsy was performed in 30 of the patients. Patients were considered to have secondary EN when an underlying condition was found, and to have primary (or idiopathic) EN when no such condition was found. For the diagnosis of the underlying diseases, diagnostic criteria and/or diagnostic methods were used. Categorical variables were compared by using chi2 test. The majority of the patients were female (6F/1M) and 54% of cases had a determined aetiology. The foremost aetiology was primary tuberculosis (18%) followed in decreasing order by a poststreptococcal (16%), sarcoidosis (12%), inflammatory bowel diseases (IBD) (4%), Behçet's disease (2%), and pregnancy (2%). All the patients were followed for a mean duration of 7 y. The nodosities relapsed every y in 74% of idiopathic EN patients but in only 1 (Behçet's disease) of the secondary ones. Factors favouring secondary EN were as follows: prolonged fever, cough, sore throat, not relapsing EN, abnormal chest X-ray, leukocytosis, an erythrocyte sedimentation rate of higher than 50 mm/h and a CRP value of higher than 6 times the upper limit of normal. All the patients had bed rest and the majority was given naproxen. The outcomes were usually favourable within 7 d. The patients with an underlying disease were given specific treatment. EN has been associated with numerous diseases. In order to reduce cost and duration of diagnosis, every centre should determine its own most frequent aetiological factors. Factors favouring secondary EN should also be determined. Our study revealed primary tuberculosis, streptococcal pharyngitis, sarcoidosis, IBD, and Behçet's syndrome as the main aetiologies of EN.

Brucellosis is an infectious disease with multisystemic involvement caused by the genus Brucella. Neurological complications, including meningitis, meningoencephalitis, myelitis-radiculoneuritis, brain abscess, epidural abscess and meningovascular syndromes, are rarely encountered. We present a patient with epileptic seizures and aggressive mood due to chronic neurobrucellosis of 2.5 y duration, which was misdiagnosed as bacterial meningitis and epilepsy. This form of presentation has not previously been reported in the English language literature. We conclude that the diagnosis of neurobrucellosis should be considered in patients presenting with recurrent or chronic meningitis syndromes with or without seizure from endemic areas for brucellosis.

Although mild proteinuria is commonly observed during the course of brucellosis, biopsy-proven glomerulonephritis (GN) is quite rare. We present the first case of mesangiocapillary glomerulonephritis (MCGN) associated with brucellosis and summarize all cases of Brucella GN published to date. Our patient, who had a congenital bicuspid aortic valve, also had heart failure, fever, urinary abnormalities and proteinuria. Renal biopsy revealed MCGN. Although the clinical features raised the possibility of GN associated with endocarditis, transesophageal echocardiography did not show any vegetations.

Although rare, paradoxical subcutaneous abscesses may develop during appropriate treatment of miliary tuberculosis. While the pathogenesis of this phenomenon is not clear, some theories have been postulated. A case of a 37-y-old woman diagnosed as having miliary tuberculosis who developed subcutaneous abscesses within the 5 months of antituberculous treatment is described and all 6 similar cases published in English from 1954 to 1999 are discussed.

(100%), mucosal hyperaemia (55%), renal failure (70%), hepatic involvement (70%), gastrointestinal involvement (55%), muscle involvement (25%), cardiopulmonary involvement (25%), anaemia (100%), leukocytosis (85%), thrombocytopenia (45%), hypocalcaemia (70%), hypoalbuminaemia (85%), pyuria (90%), haematuria (55%) and proteinuria (55%). The leukocyte and eosinophil counts of the patients are given in Table I. The first leukocyte and eosinophil counts which were done during the initial days of hospitalization showed that 10:20 patients had blood eosinophil counts ranging between 1.16‐10.54 10 9 cells:l (8‐31% of leukocytes). The mean interval between the onset of the first symptom (fever) and admittance to the hospital was 7.89 3.2 SD d (range 5‐14). Methicillinsensitive S. aureus was isolated from the 9 patients (4 from the throat, 2 from the nose, 3 from the abscess) and methicillin-resistant S. aureus was isolated from 3 patients (2 from the nose, 1 from the abscess). Blood cultures were negative in all the patients. Four patients died with a clinical picture of adult respiratory distress syndrome. All surviving patients became afebrile within 7 d after the initiation of therapy. Blood eosinophil counts returned to normal levels following clinical improvement. To conclude, we have observed 50% frequency of eosinophilia in our 20 patients with TSS. Recovery was associated with the disappearance of eosinophilia. We suspect that eosinophilia may be a feature of TSS. A possible explanation for this finding might be the production of IL-5, a cytokine involved in the formation and differentiation of eosinophils, by TSST-1 activated TH2 CD4 cells (3). Prospective studies on TH2 CD4cells and serum IL-5 in the patients with TSS will further clarify this subject.

Spondylitis is one of the more frequent osteoarticular complications of Brucella infection, but cervical spine involvement is rare. We report here a case of cervical Brucella spondylitis with paravertebral anterior epidural abscess which resulted in neurological deficits. The diagnosis is based on clinical history supported by Brucella serology, radiological findings and histological evidence.