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LETTERS TO THE EDITOR
In the present clinical case, the variation in CSF biomarkers levels probably indicates brain tissue damage associated with the inflammatory process. If this raises interest in measuring CSF biomarkers for the diagnosis of rapidly progressing non-Alzheimer’s dementia syndromes, further studies are necessary to better interpret value variations in Ab1–40, Ab1–42, Tau and PhosphoTau-181 proteins, although the measurement of CSF biomarkers would never replace pathological analysis of the brain tissue to confirm the origin of cognitive disorders. Michele Kiesmann, MD Department of Geriatrics, H^ opital de la Robertsau University Hospitals of Strasbourg, Strasbourg, France Pierre Oliver Lang, MD, MPH, PD, PhD Health and Wellbeing Academy, Anglia Ruskin University Cambridge, UK Raphael Clere, MD Department of Geriatrics, H^ opital de la Robertsau University Hospitals of Strasbourg, Strasbourg, France Olivier Bousiges, MD Department of Biochemistry and Molecular Biology H^ opital de Hautepierre, University Hospitals of Strasbourg, Strasbourg, France Thomas Vogel, MD, PhD Georges Kaltenbach, MD Department of Geriatrics, H^ opital de la Robertsau University Hospitals of Strasbourg, Strasbourg, France
ACKNOWLEDGMENTS Conflict of Interest: None of the authors has any conflict of interest to declare. Author Contributions: MK, POL, RC, OB, TV, and GK wrote the manuscript. Sponsor’s Role: There was no sponsor for this manuscript.
REFERENCES 1. Amin EN, Closser DR, Crouser ED. Current best practice in the management of pulmonary and systemic sarcoidosis. Ther Adv Respir Dis 2014;8:111–132. 2. Cordingley G, Navarro C, Brust JC et al. Sarcoidosis presenting as senile dementia. Neurology 1981;31:1148–1151. 3. Zajicek JP, Scolding NJ, Foster O et al. Central nervous system sarcoidosis-diagnosis and management. Q J Med 1999;92:103–117. 4. Winkler G, Von Sattel JP. Case records of the Massachusetts General Hospital. N Engl J Med 1990;322:388–397. 5. Schielke E, Nolte C, M€ uller W et al. Sarcoidosis presenting as rapidly progressive dementia: Clinical and neuropathological evaluation. J Neurol 2001;248:522–524. 6. O’Dwyer JP, Al-Moyeed BA, Farrell MA et al. Neurosarcoidosis-related intracranial haemorrhage: Three new cases and a systematic review of the literature. Eur J Neurol 2013;20:71–78. 7. Gilles E, Patterson K, Hodges JR. Performance on the Boston Cookie theft picture description task in patient with early dementia of the Alzheimer’s type: Missing information. Aphasiology 1996;4:395–408. 8. Genius J, Klafkih H, Benninghoff J et al. Current application of neurochemical biomarkers in the prediction and differential diagnosis of Alzheimer’s disease and other neurodegenerative dementias. Eur Arch Psychiatry Clin Neurosci 2012;(Suppl 2):571–577.
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9. Pawate S, Moses H, Sriram S. Presentations and outcomes of neurosarcoidosis: A study of 54 cases. Q J Med 2009;102:449–460. 10. Tabaraud F, Leman JP, Milor AM et al. Alzheimer CSF biomarkers in routine clinical setting. Acta Neurol Scand 2012;125:416–423. 11. Grossman M, Farmer J, Leight S et al. Cerebrospinal fluid profile in frontotemporal dementia and Alzheimer’s disease. Ann Neurol 2005;57:721–910.
HIDDEN IN A HEADACHE: CRYPTOCOCCAL MENINGITIS IN A SEPTUAGENARIAN To the Editor: New-onset headaches in adults aged 65 and older are rare, accounting for only 5.4% of all headaches but conveying a 10-fold risk of serious conditions, such as strokes or malignancy, compared to those under 65.1 Cryptococcal meningitis, with only 3.3% occurring in adults aged 70 and older, is rarely suspected in elderly adults.2 We report a septuagenarian with headache as the only presenting symptom of cryptococcal meningitis, resulting in a delayed diagnosis.
CASE REPORT A 79-year-old mentally intact, petless woman presented to the emergency department (ED) with 1 week of frontal headache and rhinorrhea. She denied fever, confusion, or prior headaches. Past medical history included postpartum panhypopituitary syndrome resulting in hypothyroidism and adrenal insufficiency, for which she takes 5 mg of prednisone daily along with levothyroxine. She denied sick contacts or recent travel. Physical examination revealed a non-toxic-appearing woman without fever, neck stiffness, or altered mental status. In the ED on Day 1, she was diagnosed with sinusitis and discharged home with fluticasone. No laboratory work or imaging was ordered. On Day 3, she followed up with her outpatient physician. She had a new symptom of mixing up her medications but did not mention her headache to the physician. Physical examination was normal except for a temperature of 37.8°C. Because her white blood cell count (WBC) was 8.0 9 103 cells/lL, no interventions were performed other than recommending a pillbox for her medications. On Day 6, patient returned to the ED with lethargy and confusion. She had a fever to 38.5°C and was oriented only to person. Her WBC was 9.4 9 103 cells/lL, with otherwise normal laboratory tests. Head computed tomography (CT) was normal, and lumbar puncture showed clear cerebrospinal fluid (CSF) with negative India ink and GRAM stain, glucose less than 20 mg/dL, protein 298 mg/dL, and WBC 350/ mm3 with 90% polymorphonuclear predominance. CSF cryptococcal antigen and opening pressure were not ordered. She was diagnosed with subacute bacterial meningitis and started on vancomycin, ceftriaxone, and ampicillin. On Day 8, she became agitated, and serum cryptococcal antigen, sent as a result, returned positive. Human immunodeficiency virus (HIV) test was negative. She was diagnosed with cryptococcal meningitis and started on amphotericin and flucytosine. On Day 9, she became more delirious, and due to concerns of increased intracranial pressure, she underwent repeat lumbar puncture, which showed an opening pressure of 16 cm. CSF cryptococcal antigen and culture were sent and returned positive, confirming the diagnosis.
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JANUARY 2015–VOL. 63, NO. 1
On Day 10, her mental status improved, but her creatinine increased from 1.3 to 1.9 mg/dL, likely due to kidney injury from amphotericin and flucytosine. She was switched to fluconazole intravenously and discharged home 4 days later on chronic oral fluconazole, to be continued while she is on prednisone.
LETTERS TO THE EDITOR
201
and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Both authors contributed to the preparation of this manuscript. Sponsor’s Role: None.
REFERENCES DISCUSSION New-onset headaches in adults aged 65 and older are rare, accounting for only 5.4% of all new-onset headaches, but elderly adults with new-onset headaches have a risk of serious conditions, such as stroke, malignancy, infection, or temporal arteritis (15% ≥65 vs 1.6%
LETTERS TO THE EDITOR
In the present clinical case, the variation in CSF biomarkers levels probably indicates brain tissue damage associated with the inflammatory process. If this raises interest in measuring CSF biomarkers for the diagnosis of rapidly progressing non-Alzheimer’s dementia syndromes, further studies are necessary to better interpret value variations in Ab1–40, Ab1–42, Tau and PhosphoTau-181 proteins, although the measurement of CSF biomarkers would never replace pathological analysis of the brain tissue to confirm the origin of cognitive disorders. Michele Kiesmann, MD Department of Geriatrics, H^ opital de la Robertsau University Hospitals of Strasbourg, Strasbourg, France Pierre Oliver Lang, MD, MPH, PD, PhD Health and Wellbeing Academy, Anglia Ruskin University Cambridge, UK Raphael Clere, MD Department of Geriatrics, H^ opital de la Robertsau University Hospitals of Strasbourg, Strasbourg, France Olivier Bousiges, MD Department of Biochemistry and Molecular Biology H^ opital de Hautepierre, University Hospitals of Strasbourg, Strasbourg, France Thomas Vogel, MD, PhD Georges Kaltenbach, MD Department of Geriatrics, H^ opital de la Robertsau University Hospitals of Strasbourg, Strasbourg, France
ACKNOWLEDGMENTS Conflict of Interest: None of the authors has any conflict of interest to declare. Author Contributions: MK, POL, RC, OB, TV, and GK wrote the manuscript. Sponsor’s Role: There was no sponsor for this manuscript.
REFERENCES 1. Amin EN, Closser DR, Crouser ED. Current best practice in the management of pulmonary and systemic sarcoidosis. Ther Adv Respir Dis 2014;8:111–132. 2. Cordingley G, Navarro C, Brust JC et al. Sarcoidosis presenting as senile dementia. Neurology 1981;31:1148–1151. 3. Zajicek JP, Scolding NJ, Foster O et al. Central nervous system sarcoidosis-diagnosis and management. Q J Med 1999;92:103–117. 4. Winkler G, Von Sattel JP. Case records of the Massachusetts General Hospital. N Engl J Med 1990;322:388–397. 5. Schielke E, Nolte C, M€ uller W et al. Sarcoidosis presenting as rapidly progressive dementia: Clinical and neuropathological evaluation. J Neurol 2001;248:522–524. 6. O’Dwyer JP, Al-Moyeed BA, Farrell MA et al. Neurosarcoidosis-related intracranial haemorrhage: Three new cases and a systematic review of the literature. Eur J Neurol 2013;20:71–78. 7. Gilles E, Patterson K, Hodges JR. Performance on the Boston Cookie theft picture description task in patient with early dementia of the Alzheimer’s type: Missing information. Aphasiology 1996;4:395–408. 8. Genius J, Klafkih H, Benninghoff J et al. Current application of neurochemical biomarkers in the prediction and differential diagnosis of Alzheimer’s disease and other neurodegenerative dementias. Eur Arch Psychiatry Clin Neurosci 2012;(Suppl 2):571–577.
JANUARY 2015–VOL. 63, NO. 1
JAGS
9. Pawate S, Moses H, Sriram S. Presentations and outcomes of neurosarcoidosis: A study of 54 cases. Q J Med 2009;102:449–460. 10. Tabaraud F, Leman JP, Milor AM et al. Alzheimer CSF biomarkers in routine clinical setting. Acta Neurol Scand 2012;125:416–423. 11. Grossman M, Farmer J, Leight S et al. Cerebrospinal fluid profile in frontotemporal dementia and Alzheimer’s disease. Ann Neurol 2005;57:721–910.
HIDDEN IN A HEADACHE: CRYPTOCOCCAL MENINGITIS IN A SEPTUAGENARIAN To the Editor: New-onset headaches in adults aged 65 and older are rare, accounting for only 5.4% of all headaches but conveying a 10-fold risk of serious conditions, such as strokes or malignancy, compared to those under 65.1 Cryptococcal meningitis, with only 3.3% occurring in adults aged 70 and older, is rarely suspected in elderly adults.2 We report a septuagenarian with headache as the only presenting symptom of cryptococcal meningitis, resulting in a delayed diagnosis.
CASE REPORT A 79-year-old mentally intact, petless woman presented to the emergency department (ED) with 1 week of frontal headache and rhinorrhea. She denied fever, confusion, or prior headaches. Past medical history included postpartum panhypopituitary syndrome resulting in hypothyroidism and adrenal insufficiency, for which she takes 5 mg of prednisone daily along with levothyroxine. She denied sick contacts or recent travel. Physical examination revealed a non-toxic-appearing woman without fever, neck stiffness, or altered mental status. In the ED on Day 1, she was diagnosed with sinusitis and discharged home with fluticasone. No laboratory work or imaging was ordered. On Day 3, she followed up with her outpatient physician. She had a new symptom of mixing up her medications but did not mention her headache to the physician. Physical examination was normal except for a temperature of 37.8°C. Because her white blood cell count (WBC) was 8.0 9 103 cells/lL, no interventions were performed other than recommending a pillbox for her medications. On Day 6, patient returned to the ED with lethargy and confusion. She had a fever to 38.5°C and was oriented only to person. Her WBC was 9.4 9 103 cells/lL, with otherwise normal laboratory tests. Head computed tomography (CT) was normal, and lumbar puncture showed clear cerebrospinal fluid (CSF) with negative India ink and GRAM stain, glucose less than 20 mg/dL, protein 298 mg/dL, and WBC 350/ mm3 with 90% polymorphonuclear predominance. CSF cryptococcal antigen and opening pressure were not ordered. She was diagnosed with subacute bacterial meningitis and started on vancomycin, ceftriaxone, and ampicillin. On Day 8, she became agitated, and serum cryptococcal antigen, sent as a result, returned positive. Human immunodeficiency virus (HIV) test was negative. She was diagnosed with cryptococcal meningitis and started on amphotericin and flucytosine. On Day 9, she became more delirious, and due to concerns of increased intracranial pressure, she underwent repeat lumbar puncture, which showed an opening pressure of 16 cm. CSF cryptococcal antigen and culture were sent and returned positive, confirming the diagnosis.
JAGS
JANUARY 2015–VOL. 63, NO. 1
On Day 10, her mental status improved, but her creatinine increased from 1.3 to 1.9 mg/dL, likely due to kidney injury from amphotericin and flucytosine. She was switched to fluconazole intravenously and discharged home 4 days later on chronic oral fluconazole, to be continued while she is on prednisone.
LETTERS TO THE EDITOR
201
and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Both authors contributed to the preparation of this manuscript. Sponsor’s Role: None.
REFERENCES DISCUSSION New-onset headaches in adults aged 65 and older are rare, accounting for only 5.4% of all new-onset headaches, but elderly adults with new-onset headaches have a risk of serious conditions, such as stroke, malignancy, infection, or temporal arteritis (15% ≥65 vs 1.6%
