CNS-related symptoms and inflammation in the CSF are common in acute NE. Genetic properties of the host may predispose to CNS involvement. It does seem that pituitary injury and subsequent hormonal insufficiency may complicate the recovery.

Ocular symptoms and disturbances are common in acute NE, and the symmetry of the ocular changes reflects the systemic nature of the disease. A decrease in IOP and myopic shift mainly due to thickening of the lens are evident in acute disease. The myopic shift only partially explains the visual disturbances supporting the possible multifactorial origin of the ocular findings in patients with NE.

BackgroundOur aim was to characterize clinical properties and laboratory parameters in patients with or without cerebrospinal fluid (CSF) findings suggestive of central nervous system (CNS) involvement, and especially those who developed serious CNS complications during acute nephropathia epidemica (NE) caused by Puumala hantavirus (PUUV) infection.MethodsA prospective cohort of 40 patients with acute NE and no signs of major CNS complications was analyzed. In addition, 8 patients with major CNS complications associated with NE were characterized. We collected data of CNS symptoms, CSF analysis, brain magnetic resonance imaging (MRI) results, electroencephalography (EEG) recordings, kidney function, and a number of laboratory parameters. Selected patients were evaluated by an ophthalmologist.ResultsPatients with a positive CSF PUUV IgM finding or major CNS complications were more often males (p < 0.05) and they had higher plasma creatinine values (p < 0.001) compared to those with negative CSF PUUV IgM. The degree of tissue edema did not explain the CSF findings. Patients with major CNS complications were younger than those with negative CSF PUUV IgM finding (52.9 vs. 38.5 years, p < 0.05). Some patients developed permanent neurological and ophthalmological impairments.ConclusionsCNS and ocular involvement during and after acute NE can cause permanent damage and these symptoms seem to be attributable to true infection of the CNS rather than increased tissue permeability. The possibility of this condition should be borne in mind especially in young male patients.

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A 56-year-old male was admitted to the hospital after a bear attack. A wounded brown bear (Ursus arctos) had attacked the patient. The patient had several bite wounds. The most serious wound was a deep penetrating bite wound in his left thigh. This wound needed immediate debridement, and ceftriaxone prophylaxis was commenced. The wound penetrated the fascial planes. All necrotic tissues and foreign material were surgically removed, and the wound was left open. The patient's wounds required redebridements on the 7th and 12th days after the patient was admitted to the hospital due to necrotic residual tissue and a hematoma. After the first operation, he received 4 g of piperacillin-tazobactam three times a day, which was subsequently changed to amoxicillin-clavunate (875 mg of amoxicillin and 125 mg of clavunate) twice a day (b.i.d.). Bacterial specimens were collected in all of the operations and cultured.Direct examination of the specimen revealed leukocytes, but no bacteria. Cultures of bacteria from the deep wound in the thigh grew Streptococcus sanguis (identified by using RapID 32 Strep; bioMérieux, Marcy l'Etoile, France), Neisseria sicca (identified by RapID NH system; Remel, Inc., Lenexa, Kans.), and Bacillus spp. After 7 days of incubation, cultures on chocolate plate agar grew rough, white colonies. Gram staining revealed acid-fast gram-positive rods. The bacterium was identified as Mycobacterium fortuitum by PCR (GenoType Mycobacterium; Hain Lifescience GmbH, Nehren, Germany). The strain was in vitro multiply resistant. It was not susceptible to all cephalosporins, pyrazinamide, streptomycin, trimethoprimsulfamethoxazole, rifabutin, and tetracyclines tested. The strain was susceptible to clarithromycin (MIC of 0.25 g/ml), ciprofloxacin, levofloxacin, amikacin, tobramycin, meropenem, and vancomycin.The patient was treated with clarithomycin (500 mg b.i.d.) and ciprofloxacin (500 mg b.i.d.) orally once the culture results were available. The wound was covered with autologous split thin skin grafts. The bacterial sample taken before the application of skin grafts was still M. fortuitum. The patient tolerated the medication well with no major adverse events. The wound in the thigh healed within 2 months. Medication was continued for 6 months.The bacteriology of a grizzly bear bite was recently published (3). The cultures grew Serratia fonticola, Serratia marcescens, Aeromonas hydrophila, Bacillus cereus, and Enterococcus durans but no anaerobes and no atypical mycobacteria. Atypical mycobacterial infections after animal bites are probably rare.M. fortuitum is an atypical mycobacterium. It is classified as a rapid-growing mycobacteria (Runyon group IV). It has been found in sewage and also in natural waters (1). Atypical mycobacteria are environmental bacteria that rarely cause infections in immunocompetent hosts. Clinical infections, mostly skin and soft tissue infections, have been reported after surgery or trauma, particularly after cardiothoracic surgery (2). To our knowledge, this is the first report o...