Caracterización clínica de pacientes con infecciones del sistema nervioso central en un centro de atención terciaria / Clinical description of patients with central nervous system infections at a tertiary care center

Introducción: Las infecciones del sistema nervioso central constituyen un problema de salud a nivel mundial por la elevada morbimortalidad que produce. Objetivo: Caracterizar clínicamente a pacientes con infección del sistema nervioso central. Métodos: Estudio observacional, descriptivo y retrospectivo (2009-2018) en pacientes con infección del sistema nervioso central atendidos en el Hospital Hermanos Ameijeiras. Las variables estudiadas fueron: edad, sexo, tipo de infección, estado de inmunocompetencia, manifestaciones clínicas, complicaciones, agentes etiológicos, celularidad en el líquido cefalorraquídeo, estado al egreso, estadía hospitalaria. Resultados: Fueron incluidos 133 pacientes, 52,6 por ciento eran del sexo masculino y 45,9 por ciento tenían entre 40-59 años. Prevalecieron los pacientes con infecciones bacteriana en 58,6 por ciento, el staphylococcus sp fue el agente etiológico que más se identificó, la meningoencefalitis representó 36,8 por ciento, estaban inmunodeprimidos 56,4 por ciento, la cefalea y la fiebre estuvieron presente en 82,7 por ciento y la rigidez nucal en 15 por ciento. Las complicaciones respiratorias y la hidrocefalia representaron 21 por ciento y 12,8 por ciento respectivamente. El estado al egreso se asoció al estado de inmunocompetencia (p=0,002), la estadía hospitalaria (p=0,001) y el tipo de infección (p=0,002). Conclusiones: El principal tipo de infección según predominio de la celularidad fue la bacteriana, fue bajo el número de agentes etiológicos identificados. La meningoencefalitis fue la infección más frecuente. La cefalea, la fiebre y la rigidez nucal los síntomas y signos que predominaron, así como las complicaciones respiratorias y la hidrocefalia. Hubo asociación del estado al egreso con el tipo de infección, estado de inmunocompetencia y la estadía hospitalaria(AU)

Introduction: Central nervous system infections constitute a health problem worldwide due to the high morbidity and mortality that it produces. Objective: To clinically describe patients with central nervous system infection. Methods: An observational, descriptive and retrospective study was carried out from 2009 to 2018, in patients with central nervous system infection treated at Hermanos Ameijeiras Hospital. The variables studied were age, sex, type of infection, immunocompetence status, clinical manifestations, complications, etiological agents, cellularity in the cerebrospinal fluid, state at discharge, hospital stay. Results: One hundred thirty three patients were included, 52.6 percent were male and 45.9 percent aged between 40-59 years. Patients with bacterial infections prevailed in 58.6 percent, staphylococcus sp was the most identified etiological agent, meningoencephalitis accounted 36.8 percent, 56.4 percent were immunosuppressed, headache and fever were present in 82.7 percent and nuchal rigidity in 15 percent. Respiratory complications and hydrocephalus covered 21 percent and 12.8 percent respectively. Status at discharge was associated with immunocompetence status (p = 0.002), hospital stay (p = 0.001) and type of infection (p = 0.002). Conclusions: Bacterial infection was the main type of infection according to the cellularity predominance; the number of etiological agents identified was low. Meningoencephalitis was the most frequent infection. Headache, fever and nuchal stiffness were the predominant symptoms and signs, as well as respiratory complications and hydrocephalus. There was an association of the state at discharge with the type of infection, immunocompetence status and hospital stay(AU)

Utilidad de las técnicas de biología molecular en neuroinfecciones / Usefulness of molecular biology techniques in neuroinfectious diseases / Utilidade das técnicas de biologia molecular em neuroinfecções

Resumen: Introducción: un porcentaje de las infecciones del sistema nervioso central permanece sin diagnóstico etiológico. Las técnicas de amplificación de ácidos nucleicos mediante reacción en cadena de la polimerasa en tiempo real pueden disminuir este porcentaje. Objetivo: describir la etiología de las neuroinfecciones y valorar la utilidad de las técnicas de biología molecular en el diagnóstico y su impacto en el tratamiento antimicrobiano. Metodología: estudio observacional, descriptivo, retrospectivo a partir de registros clínicos. Se incluyeron mayores de 18 años asistidos en un hospital público de Montevideo durante un período de 32 meses, a quienes que se les realizaron técnicas de biología molecular en líquido cefalorraquídeo por sospecha clínica de neuroinfección. Resultados: se incluyeron 109 pacientes. En pacientes sin infección por VIH ni antecedentes neuroquirúrgicos (67%), se identificó microorganismo responsable en 16 casos, 8 bacterias y 9 virus. Todos identificados por técnicas de biología molecular modificando el tratamiento antimicrobiano empírico en 25 casos (34,2%). En portadores de VIH (25,7%), se detectaron microorganismos en 14 pacientes (50%). Seis virus, 5 bacterias y 7 hongos (Cryptococcus neoformans). El estudio por técnicas de biología molecular determinó el diagnóstico de 17 microorganismos y modificó el plan antimicrobiano inicial en 12 casos (42,9%). En pacientes con antecedente de neurocirugía reciente (7,3%), se aislaron seis microorganismos, tres de ellos exclusivamente mediante cultivo. Se modificó el tratamiento en tres casos (37,5%). Conclusiones: las técnicas de biología molecular deben considerarse complementarias. El impacto que generan en el diagnóstico y tratamiento justifica el uso de estas técnicas a pesar de su mayor costo.

Summary: Introduction: a certain percentage of infections of the central nervous system have no etiological diagnosis. Nucleic acids amplification techniques by means of a polymerase chain reaction in real time may reduce this percentage. Objective: to describe etiology of neuroinfectious diseases and assess the usefulness of molecular biology techniques in their diagnosis, as well as its impact on antimicrobial treatment. Method: observational, descriptive, retrospective study based on clinical records which included patients older than 18 years old, who had been assisted in a public hospital in Montevideo for over 32 months and had undergone molecular biology techniques with cerebrospinal fluid (CSF) given the clinical suspicion of neuroinfection. Results: 109 patients were included in the study. Among non-HIV infected patients who had not undergone neurosurgeries the responsible microorganism was identified in 16 cases (8 bacteria and 9 virus). They were all identified by molecular biology techniques by modifying the empiric antimicrobial therapy in 25 cases (34.2%). In carriers of HIV (25.7%), microorganisms were identified in 14 patients (50%). Six virus, 5 bacteria and 7 fungi (Cryptococcus neoformans). Molecular biology techniques defined the diagnosis of 17 microorganisms and modified the initial antimicrobial plan in 12 cases (42.9%). In patients with a history of recent neurosurgery (7.3%), 6 microorganisms were isolated, 3 of them exclusively through cultures. Treatment was modified in 3 cases (37.5%). Conclusions: molecular biology techniques need to be regarded as a complement. The impact that have in diagnosis and therapy justify their use despite its higher cost.

Resumo: Introdução: uma proporção das infecções do sistema nervoso central permanece sem diagnóstico etiológico. As técnicas de ampliação de ácidos nucléicos por reação em cadeia da polimerase em tempo real, podem diminuir esta proporção. Objetivo: descrever a etiologia das neuro infecções e avaliar a utilidade das técnicas de biologia molecular no diagnóstico e seu impacto no tratamento antimicrobiano. Metodologia: estudo observacional, descritivo, retrospectivo de prontuários de pacientes. Foram incluídos pacientes maiores de 18 anos, atendidos em um hospital público de Montevidéu, durante um período de 32 meses. Foram realizadas técnicas de biologia molecular ao líquido cefalorraquidiano por suspeita clínica de neuroinfecção. Resultados: foram incluídos 109 pacientes. Em pacientes sem infecção por VIH e sem antecedentes neurocirúrgicos (67%), o microrganismo responsável em 16 casos, sendo 8 bactérias e 9 vírus. Todos foram identificados por técnicas de biologia molecular modificando el tratamento antimicrobiano empírico em 25 casos (34,2%). Em portadores de VIH (25,7%), foram detectados microrganismos em 14 pacientes (50%). Seis vírus, 5 bactérias e 7 leveduras (Cryptococcus neoformans). O estudo por técnicas de biologia molecular permitiu o diagnóstico de 17 microrganismos e modificou o tratamento antimicrobiano inicial em 12 casos (42,9%). Em pacientes com antecedentes de neurocirurgia recente (7,3%), foram isolados 6 microrganismos, em 3 casos exclusivamente por cultura. O tratamento foi modificado em 3 casos (37,5%). Conclusões: as técnicas de biologia molecular devem ser consideradas como complementares. O impacto que causam sobre o diagnóstico e o tratamento justifica seu uso apesar de seu maior custo.

Steroids in neuroinfection / Esteroides em neuroinfeccao

The consequences of inflammatory response are primarily responsible for morbimortality in bacterial meningitis. Early use of steroids in these cases can reduce mortality and hearing loss and improve functional outcome without causing significant side effects. The formal recommendation towards pneumoccocal meningitis is being extended to other forms of Bacterial Meningitis. The same thought can be applied to tuberculous meningitis. In neurocysticercosis and neuroschistosomiasis steroids are more useful than parasiticides in most cases. Despite the evidence favoring the use of steroids in herpes simplex encephalitis, it is not sufficient to definitely support such indication. Among the opportunistic infections that affect AIDS patients, neurotoxoplasmosis and progressive multifocal leukoencephalopaty are those most often considered for the use of steroids; steroids are safe to use, but no definite benefit could be demonstrated in both conditions.

As consequências da resposta inflamatória são as grandes responsáveis pela morbimortalidade das meningites bacterianas. O uso precoce de esteróides nestes casos pode reduzir a mortalidade e a perda auditiva, além de atenuar as consequências a longo prazo deste grupo de doenças, sem causar efeitos colaterais importantes. A recomendação formal de seu uso na meningite pneumocócica tem sido ampliada para outras formas de meningite bacteriana. O mesmo raciocínio pode ser aplicado para a Meningite tuberculosa. Na neurocisticercose e na neuroesquistossomose, os esteróides são mais úteis que as drogas parasiticidas na maior parte dos casos. Apesar de evidências a favor do seu uso na Encefalite Herpética, não existe ainda suporte definitivo para esta recomendação. Entre as infecções oportunísticas que ocorrem nos pacientes com AIDS, a Neurotoxoplasmose e a leucoencefalopatia multifocal progressiva são as mais frequentemente relacionadas com o uso dos esteróides; seu uso tem se mostrado seguro, mas seus benefícios não parecem bem estabelecidos em ambas as condições.

Central nervous system infectious diseases mimicking multiple sclerosis: recognizing distinguishable features using MRI / Doencas infecciosas do sistema nervoso central mimetizando esclerose multipla: reconhecendo as caracteristicas de imagem por RM que as distinguem

The current diagnostic criteria for multiple sclerosis (MS) confirm the relevant role of magnetic resonance imaging (MRI), supporting the possibility of characterizing the dissemination in space (DIS) and the dissemination in time (DIT) in a single scan. To maintain the specificity of these criteria, it is necessary to determine whether T2/FLAIR visible lesions and the gadolinium enhancement can be attributed to diseases that mimic MS. Several diseases are included in the MS differential diagnosis list, including diseases with exacerbation, remitting periods and numerous treatable infectious diseases, which can mimic the MRI features of MS. We discuss the most relevant imaging features in several infectious diseases that resemble MS and examine the primary spatial distributions of lesions and the gadolinium enhancement patterns related to MS. Recognizing imaging "red flags" can be useful for the proper diagnostic evaluation of suspected cases of MS, facilitating the correct differential diagnosis by assessing the combined clinical, laboratory and MR imaging information.

Os critérios diagnósticos atuais para a esclerose múltipla (EM) destacam a ressonância magnética (RM) e reforçam a caracterização de disseminação no espaço e no tempo, mesmo em um único exame. Para preservar a especificidade desses critérios é necessário determinar se as lesões identificadas em T2/FLAIR e o realce pelo gadolínio não são devidos a doenças que mimetizam EM. Várias doenças compõem a lista de diagnósticos diferenciais da EM, incluindo algumas com períodos de exacerbação e remissão, além de doenças infecciosas tratáveis, que podem imitar suas características de RM. Discutiremos as características de imagem mais relevantes de diversas neuroinfecções que mimetizam EM, examinando a distribuição espacial das lesões e os padrões de realce pelo gadolínio. O reconhecendo dos sinais de alerta por imagem pode ser útil para a avaliação diagnóstica de casos suspeitos de EM, conduzindo ao diagnóstico diferencial correto através de uma avaliação combinada da clínica, laboratório e imagem.

Cerebrospinal fluid analysis in infectious diseases of the nervous system: when to ask, what to ask, what to expect / O exame do liquido cefalorraquidiano em doencas infecciosas do sistema nervoso: quando pedir, o que pedir, o que esperar

Cerebrospinal fluid (CSF) analysis very frequently makes the difference to the diagnosis, not only in relation to infections but also in other diseases of the nervous system such as inflammatory, demyelinating, neoplastic and degenerative diseases. The authors review some practical and important features of CSF analysis in infectious diseases of the nervous system, with regard to acute bacterial meningitis, herpetic meningoencephalitis, neurotuberculosis, neurocryptococcosis, neurocysticercosis and neurosyphilis.

O exame de líquido cefalorraquidiano (LCR) é frequentemente o elemento determinante para o diagnóstico não somente de infecções mas também de outras doenças do sistema nervoso, tais como doenças inflamatórias, desmielinizantes, neoplásicas e degenerativas. Os autores reveem alguns aspectos práticos e importantes quanto ao papel do exame de LCR em meningites bacterianas agudas, meningoencefalite herpética, neurotuberculose, neurocriptococose, neurocisticercose e neurossífilis.

Polyoma BK virus: an emerging opportunistic infectious agent of the human central nervous system

BK virus, a double-stranded DNA virus, is a member of the Polyomaviridae family which is known to infect humans. Clinical evidence of disease is mostly encountered in immunosuppressed individuals such as AIDS patients or those who undergo renal or bone marrow transplantation where complications associated with BKV infection manifest commonly as a polyomavirus nephropathy or hemorrhagic cystitis, respectively. Recent evidence suggests that in addition to the JC virus (the other member of the same family known to be strongly neurotropic and responsible for the progressive multifocal leukoencephalopathy), BK virus can infect and cause clinically relevant disease in the human central nervous system. In this mini-review, an analysis of the literature is made. A special focus is given to alert clinicians to the possibility of this association during the differential diagnosis of infections of the central nervous system in the immunocompromised host.

Diagnostic utility of squash (smear) technique in the inflammatory lesions of central nervous system.

Smears of histologically verified inflammatory lesions of central nervous system (CNS) during 12 years were analysed to determine the diagnostic utility and accuracy of squash (smear) technique. Two hundred and sixteen (216) lesions were analysed. Smears could not be interpreted in 72 lesions (33.33%) as the tissue could not be spread or not representative. Tuberculosis was the commonest etiology (70.83%) followed by bacterial, fungal and parasitic infections. To conclude, smear technique is a useful modality in establishing diagnosis in inflammatory lesions of CNS, but its usefulness is limited by difficulties in spreading tissue.

Dengue virus infection of the central nervous system (CNS): a case report from Brazil.

Dengue infection that is accompanied by unusual complications has been described in Brazil. We report on the presence of dengue virus in the central nervous system (CNS) of a patient who died in 1998 in Rio Grande do Norte, northeast Brazil. DEN-2 viruses were isolated from the brain liver, and lymphnode tissue of a 67-year-old man whose signs and symptoms were those of dengue infection and a secondary immune response. A postmortem revealed nose bleeds a liver that was brownish with yellow areas, and pulmonary and cerebrae congestion. Immunoperoxidase staining showed a dengue antigen-specific positive reaction in the gray matter cells of the cerebrall cortex; a granular citoplasmatic reaction was seen in the neurons. Dengue infection should always be considered as a cause encephalitis in tropical countries, especially in those where the disease is endemic.

Cerebral infection by candida albicans

We present a case of cerebral infection by candida albicans in a previously healthy 64-year-old man who had symptoms indicative of raised intracranial pressure without fever. Computed tomography scan and magnetic resonance imaging revealed multiple cerebral granulomas. Diagnosis was made after stereotactic biopsy. The patient's symptoms improved progressively with decrease in the size of lesions after antifungal therapy. No lesions were detected outside the central nervous system. However, he died 3 weeks later from pulmonary embolism. Candida albicans of the central nervous system is uncommon and occurs rarely in immunocompetent patients. As the neurologic sings and symptoms are vague, most cases of cerebral candidiasis are diagnosed just before death or during postmortem study. We have reviewed the main clinico-pathologic features of neurocandidiasis

Symptomatic hydrocephalus in newborn infected with Listeria monocytogenes

Central nervous system infections caused by Listeria monocytogenes produce a wide range of clinical symptoms wich include cerebral abscesses, meningitis and nonmeningitic parenchymal cerebritis. A case study is presented of early listeriosis with signs of meningitis accompanied with septicemia and complicated with severe hydrocephalus.

Esquistossomose do sistema nervoso central / Schistosomiasis mansonic case report of the central nervous system

A esquistossomose do Sistema Nervoso Central é relativamente pouco diagnosticada. Relatamos o caso de um paciente procedente de área näo endêmica, com manifestaçöes meningorradiculares da esquistosomose mansônica, comprovada por reaçäo de imunofluorescência no líquido cefalorraquidiano, tratado com praziquantel associado à corticoterapia. Ressaltamos a necessidade do diagnóstico etiológico específico e a instituiçäo precoce do tratamento com drogas antiinflamatórias e drogas específicas para a melhor recuperaçäo do paciente.

Infecciones del sistemas mervioso central

La gravedad que implica toda infección del sistema nervioso central, hace indispensable el conocimiento de sus signos, síntomas y tratamiento