High Rates Of Neurological Sequelae Research Articles

Assessment of the Diagnostic Utility of GeneXpert Mycobacterium tuberculosis/Rifampicin (MTB/RIF) Assay in the Suspected Cases of Tuberculous Meningitis.

Tuberculous meningitis (TBM) is a manifestation of extrapulmonary tuberculosis (EPTB) caused by Mycobacterium tuberculosis (MTB). The central nervous system is involved in about 1%-2% of all current tuberculosis (TB) cases and about 7%-8% of all EPTB. if not treated early, TBM leads to a high rate of neurological sequelae and mortality. This study aimed to assess the diagnostic performance of the GeneXpert MTB/rifampicin (RIF) assay in patients with TBM. A total of 100 suspected TBM cases were enrolled from various departments at tertiary care hospital, Bhopal, Madhya Pradesh, India, and classified as definite, possible, or probable TBM. The clinical samples were tested for microbiological and other cerebrospinal fluid(CSF) testing. Out of 100 cases, 14 (14%) were classified as definite TBM, 15 (15%) were having probable TBM, and 71 (71%) were having possible TBM.Out of a total of 100 participants, all were negative for acid-fast bacilli (AFB) staining. Of the 100 cases, 11 (11%) were positive by mycobacterium growth indicator tube (MGIT) culture, of which only four (36.36%) were positive by GeneXpert MTB/RIF. GeneXpert MTB/RIF detected three (3%) cases that were negative by MGIT culture. Ten (90.9%) of the 11 MGIT-positive culture isolates were found to be RIFsensitive while one (9.1%) was found to be RIF resistant. Three cases tested positive/sensitive by the GeneXpert MTB/RIF but negative by MGIT culture. Six (85%) of the seven GeneXpert MTB/RIF positive cases were RIF sensitive while one (15%) was RIF resistant. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were 36.36% (95% Confidence Interval (CI) (10.93% to 69.21%)), 96.63% (95% CI (90.46% to 99.30%)), 57.14% (95% CI (25.50% to 83.85%)), 92.47% (95% CI (88.70% to 95.06%)) and 90% (95% CI (82.38% to 95.10%)) for GeneXpert MTB/RIF assay, compared with MGIT culture as the reference standard. Our study found that the sensitivity is lower when compared to culture, so using GeneXpert MTB/RIF alone is not recommended. Overall performance of GeneXpert MTB/RIF assay is noteworthy. The GeneXpert MTB/RIF assay is a potentially accepted test for obtaining an earlier diagnosis, and if it tested positive, the treatment should begin immediately. However, culture must be performed in GeneXpert MTB/RIF negative cases.

Peripheral nervous system involvement in Q fever.

Q fever is a zoonosis with a worldwide distribution caused by Coxiella burneti. Acute manifestations include a self-limited febrile illness which may associate headache, atypical pneumonia, or hepatitis. Neurological manifestations are rare, and they occur in less than half of the patients. Of these, approximately 1% present peripheral nervous system involvement, and, when present, it is difficult to diagnose because it has multiple manifestations such as mononeuritis multiplex, plexopathy or Guillain Barre syndrome. Due to the high rate of neurological sequelae, early diagnostic suspicion and appropriate treatment must be established. In this review, we have collected the patients with peripheral nervous system involvement due to Coxiella burnetii described so far. Our aim is to provide a concise description of the disease, its diagnosis and management that may be useful to clinicians treating such patients.

Encephalitis Related to Human Parechovirus Type 3

Human parechoviruses belong to the Picornaviridae family and are classified into 17 genotypes. Recently, it has been reported that human parechovirus genotype 3 is an important cause of severe infections, including sepsis-like illness and encephalitis, especially in newborns and infants younger than 3 months. There are also reports that human parechovirus genotype 3 infections with central nervous system symptoms lead to high rates of neurological sequelae and death. Here, we report a case of a previously healthy 1-month-old girl who developed encephalitis related to human parechovirus genotype 3 and had a favorable outcome. The patient presented septicemic symptoms, including fever, tachycardia, tachypnea with retractions and seizures without an elevated inflammatory response. She lacked cerebrospinal fluid pleocytosis but had hypercytokinemia. Brain magnetic resonance imaging and electroencephalography showed abnormal findings. Together, these findings strongly suggested acute encephalopathy. She underwent emergency intubation for respiratory failure and mechanical ventilation was started. Intravenous phenobarbital injection was performed to prevent convulsion. She was treated using intravenous immunoglobulin with methylprednisolone pulse therapy. As of 2 years after discharge, her growth development is equivalent to her age and she has had no clinical epileptic seizures. In this case, human parechovirus genotype 3 was detected from pharyngeal swabs, stool, cerebrospinal fluid and blood by polymerase chain reaction assay. The patient was diagnosed definitively with encephalitis related to human parechovirus genotype 3. The symptoms that we observed should be considered for the differential diagnosis of human parechovirus infection. When a patient is suspected of having encephalitis related to human parechovirus, treatment including intravenous immunoglobulin and corticosteroid must be started as soon as possible to prevent neurodevelopmental sequelae. Int J Clin Pediatr. 2019;8(2):37-40 doi: https://doi.org/10.14740/ijcp333

Continuous venovenous hemofiltration in neonates with hyperammonemia. A case series.

Neonatal hyperammonemia secondary due to inborn errors of metabolism is a rare condition with a high rate of neurological sequelae and mortality. Initial medical management is often insufficient to stop the progressive increase of ammonia, with the consequent deterioration of the patient. For this reason, depurative techniques have been implemented, including peritoneal dialysis, intermittent hemodialysis and continuous renal replacement therapy (CRRT). To describe our experience with continuous extracorporeal dialysis in severely ill neonates with hyperammonemia. Retrospective review of clinical records of neonates with hyperammonemia due to congenital errors of metabolism undergoing CRRT admitted in our institution in the last 6 years. Demographic data, chronological and gestational age, gender, anthropometric and laboratory data (creatininemia, ammonemia), and severity index PIM-II where collected. It was analyzed the CRRT: modality, duration and complications. The stard of therapy depended on the response to medical management in the first 24 hours, progressive neurological involvement, or increased blood ammonia (> 400 qg/dl) at the time of admission. CRRTs were performed using the Prisma Flex system and M100 and/or HF20 filters. 6 neonates, 4 males, half of them with a history of prematurity, all with severe acute neurological involvement and severe ammonemias (> 1,000 qg/dl). The average age and weight at the start of the CRRT were 10 days and 2798 g, respectively, ammonia (median) 1,663 qg/dl (range 1,195 - 3,097). The PIM-II score had a median of 53 (range 13.4 - 87.4). On average, patients were 49.5 hours in continuous therapy. In four neonates, a mixed convective and diffusive technique (hemodiafiltration) was used, and only convective one (hemofiltration) in the 2 remaining. Mortality was 33%, and one of the survivors had permanent moderate neurological damage in clinical follow-up. The results obtained in this extremely ill group of neonates encourage us to propose this dialytic therapy as an excellent alternative in the management of this type of patients.

Aetiology and Outcomes of Suspected Infections of the Central Nervous System in Children in Mbarara, Uganda

Infections of the central nervous system (CNS) are severe conditions, leading to neurological sequelae or death. Knowledge of the causative agents is essential to develop guidelines for case management in resource-limited settings. Between August 2009 and October 2012, we conducted a prospective descriptive study of the aetiology of suspected CNS infections in children two months to 12 years old, with fever and at least one sign of CNS involvement in Mbarara Hospital, Uganda. Children were clinically evaluated on admission and discharge, and followed-up for 6 months for neurological sequelae. Pathogens were identified from cerebrospinal fluid (CSF) and blood using microbiological and molecular methods. We enrolled 459 children. Plasmodium falciparum (36.2%) and bacteria in CSF (13.3%) or blood (3.3%) were the most detected pathogens. Viruses were found in 27 (5.9%) children. No pathogen was isolated in 207 (45.1%) children. Patterns varied by age and HIV status. Eighty-three (18.1%) children died during hospitalisation, and 23 (5.0%) during follow-up. Forty-one (13.5%) children had neurological sequelae at the last visit. While malaria remains the main aetiology in children with suspected CNS infections, no pathogen was isolated in many children. The high mortality and high rate of neurological sequelae highlight the need for efficient diagnosis.

Research progress of pediatric mycoplasma pneumoniae encephalitis

Mycoplasma pneumoniae is a common cause of pediatric community-acquired pneumonia.It has been associated with various extrapulmonary manifestations.Pediatric mycoplasma pneumoniae encephalitis is the most common neurologic manifestations.Direct invasion, an immune-mediated mechanism, or neurotoxin production has been proposed.Because mycoplasma pneumoniae encephalitis has a high mortality and a high rate of neurological sequelae, improving the clinicians awareness of the disease, minimizing misdiagnosis and missed diagnosis, have important significance. Key words: Mycoplasma pneumoniae; Children; Community-acquired pneumonia

Characteristics and Costs of Ladder Fall Injuries: A Report from a Single Emergency Center in Okayama.

We sought to identify the incidence, injury patterns, and financial burden of ladder fall injuries to provide a reference for reinforcing guidelines on the prevention of such injuries. We enrolled the patients who were injured in a ladder-related fall and required intensive care between April 2012 and March 2014 at Okayama University Hospital, a tertiary care hospital in Okayama City:9 patients injured in 7 stepladder falls and 2 straight ladder falls. The median patient age was 69 years, and 8 were males. Six falls occurred in non-occupational settings. Head injuries predominated, and the injury severity score ranged from 2 to 35 (mean＝21±12). At the time of discharge from the intensive care unit, one patient had died and 5 patients had some neurological disabilities. The case fatality rate was 11%. The total cost of care during the review period was ￥16,705,794, with a mean cost of ￥1,856,199 per patient. Ladder fall injuries are associated with a high rate of neurological sequelae and pose a financial burden on the health insurance system. A prevention education campaign targeting at older-aged males in non-occupational settings may be a worthwhile health service investment in this community.

Early-onset and late-onset group B streptococcal disease in Japan: a nationwide surveillance study, 2004–2010

To clarify the incidence and prognosis of early-onset (EOD) and late-onset (LOD) GBS disease in Japan. To evaluate the influence of national guidelines issued in 2008 on the epidemiology of GBS disease. Retrospective nationwide questionnaire surveillance on culture-confirmed GBS infections between 2004 and 2010. Eighty-eight EOD and 162 LOD cases were reported from 152 participating hospitals. The case fatality of EOD was 13.6% and of LOD was 8.0%. Premature birth <37 weeks (p<0.001) and low birth weight <2500 g (p<0.001) were significantly associated with EOD mortality. A high rate of neurological sequelae was noted in meningitis in EOD (8/24) and LOD (29/85) cases. Based on a live-birth number of 438359 and inborn case numbers of 36 EOD and 42 LOD, the incidence of EOD and LOD were estimated to be 0.08 (95% confidence interval (CI) 0.06-0.11)/1000 and 0.10 (95% CI 0.07-0.12)/1000 live-births, respectively. Before (2004-2008) and after (2009-2010) the issue of guidelines, the mortality of EOD (from 14.8% to 11.8%) and LOD (from 9.8% to 2.5%) improved, but the incidence was unchanged. The incidence of EOD and LOD is apparently low in Japan, but the mortality and morbidity rates remain substantial. The issue of national guidelines did not affect the incidence.

Pneumococcal meningitis: clinical course and resource use in Western Australian children.

Paediatric pneumococcal meningitis causes high rates of neurological sequelae and is presenting challenges due to the emergence of antibiotic resistance. Diagnosis can be difficult and management is frequently complicated and resource intensive. This population-based study outlines the diagnosis, clinical course and initial resource use of Western Australian (WA) children diagnosed between 1990 and 2000. The charts of all rural and metropolitan children discharged from all WA hospitals with International Classification of Disease 9 and 10 codes of pneumococcal or streptococcal meningitis from the Health Department's Hospital Morbidity Data System were reviewed retrospectively. Ninety-four episodes of pneumococcal meningitis were confirmed (median age 12.4 months). Initial diagnosis was often difficult with a suggestive prodrome in less than one quarter of cases and a median of two reviews until diagnosis (range 1-7). The median duration of hospitalization was 11.6 days, 41.5% were admitted to the Intensive Care Unit (ICU), and 47.9% had seizures. There were eight related deaths and neurological sequelae occurred in 24. Initial hospitalization cost on average $A 19,900. Penicillin resistance was first noted in 1993 and occurred in 4.6% of isolates. Most cases (84.5%) were caused by serotypes contained in the currently available seven-valent conjugate vaccine. Pneumococcal meningitis is often difficult to diagnose, necessitates long and frequently complicated in-patient stays and has high rates of neurological sequelae. It is possible to prevent most cases with new conjugate vaccines.

Pneumococcal meningitis in Western Australian children: epidemiology, microbiology and outcome.

Pneumococcal meningitis is now vaccine-preventable but continues to cause high rates of neurological sequelae internationally. Population-based epidemiology, outcome and microbiology data are necessary to target vaccination strategies. This study outlines these key areas for Western Australian children diagnosed 1990-2000. The charts of all rural and metropolitan children with International Classification of Disease 9 and 10 discharge codes of pneumococcal or streptococcal meningitis from the Health Department's Hospital Morbidity Data System were reviewed. Over 10.5 years, 94 episodes were confirmed. The average annual incidence for children under 2 years was 13.45 per 100 000 and 0.66 per 100 000 for children 2 years or older. Indigenous children had an almost seven-fold increased risk compared to non-Indigenous (with 78.55 per 100 000 in the under two-year Indigenous group). Eight children died and 24 of the survivors had neurological sequelae. Penicillin resistance occurred in four of 87 isolates. One quarter of the cohort qualify under the current Australian policy of vaccination of high-risk children with seven-valent conjugate (7vPCV) vaccine. Most isolates (49/58) were 7vPCV serotypes, however, Indigenous populations were less well-covered (58.3% covered vs 91.3% of isolates from non-Indigenous children). Indigenous coverage would be improved to 75% with 11-valent conjugate vaccine. Indigenous children and those under 2 years are most affected by pneumococcal meningitis and remain primary vaccination targets. Three quarters of these children would not be protected by a policy of vaccination of only high-risk children with 7vPCV--improved protection requires higher valencies for Indigenous populations and universal infant vaccination.