Suspected Central Nervous System Infection Research Articles

Meningomyeloencephalitis secondary to Mycobacterium haemophilum infection in AIDS

Infections by opportunistic non-tuberculous mycobacteria (NTM) are rising in global incidence. One emerging, slowly growing NTM is Mycobacterium haemophilum, which can cause skin, lung, bone, and soft tissue infections in immunocompromised patients as well as lymphadenitis in immunocompetent individuals. Detection of this microorganism is difficult using conventional culture-based methods and few reports have documented involvement of this pathogen within the central nervous system (CNS).We describe the neuropathologic autopsy findings of a 39-year-old man with AIDS who died secondary to M. haemophilum CNS infection. He initially presented with repeated bouts of pyrexia, nausea and vomiting, and altered mental status that required numerous hospitalizations. CSF infectious workups were consistently negative. His most recent admission identified hyperintensities within the brainstem by MRI and despite antibiotic therapies for suspected CNS infection, he died. Autopsy revealed a swollen brain with marked widening of the brainstem. Microscopic examination of the brain and spinal cord showed focal lymphohistiocytic infiltrates, gliosis and neuronal loss that were associated with acid-fast bacilli (AFB). The brainstem was the most severely damaged and AFB were found to congregate along arterial territories lending support to the notion of hematogenous spread as a mechanism for the organisms’ dissemination. 16S rRNA sequencing on formalin-fixed paraffin-embedded tissue enabled post-mortem identification of M. haemophilum. This sequencing methodology may permit diagnosis on CSF intra-vitam.

Next-generation sequencing of cerebrospinal fluid for the diagnosis of neurocysticercosis

ObjectiveNeurocysticercosis (NCC) is the most common parasitic disease of the human central nervous system (CNS). However, a diagnosis of NCC may be hard to make if the specific clinical and routine neuroimaging manifestations are lacking, which hinders physicians from considering further immunodiagnostic tests. Patients and methodsSeven patients presented with fever, headache, nausea, cognitive decline, confusion, or progressive leg weakness. There were no pathogens found in the cerebrospinal fluid (CSF); patients were clinically suspected of meningoencephalitis or cerebrovascular disease. To clearly determine the etiology, next generation sequencing (NGS) of the CSF was used to detect pathogens in these seven patients. ResultsTaenia solium DNA sequences were detected in the seven patients, but not in the non-template controls (NTCs) or the other patients with clinically suspected CNS infections. Based on the patients' medical data and the diagnostic criteria for NCC, seven patients were diagnosed with probable NCC. The unique reads aligning to Taenia solium ranged from 6 to 261064, with genomic coverage ranging from 0.0003% to 14.8079%. The number of unique reads and genomic coverage dropped in three of the seven patients after antiparasitic treatment, consistent with the relief of symptoms. ConclusionThis study showed that NGS of the CSF might be an auxiliary diagnostic method for NCC patients. Larger studies are required.

Comparison of antibiotic and acyclovir usage before and after the implementation of an on-site FilmArray meningitis/encephalitis panel in an academic tertiary pediatric hospital: a retrospective observational study

BackgroundPrompt initiation of empiric therapy is common practice in case of suspected meningitis or encephalitis. However, in children the most common pathogens are viruses that usually do not require and are not covered by the applied anti-infective treatment. Novel multiplex PCR (mPCR) panels provide rapid on-site diagnostic testing for a variety of pathogens. This study compared empiric antibiotic and acyclovir usage before and after the introduction of an on-site FilmArray Meningitis/Encephalitis Panel (FA ME Panel).MethodsWe retrospectively compared data for empiric antibiotic and acyclovir usage between pediatric patients with suspected central nervous system (CNS) infection receiving mPCR testing and a matched historical control group. Patients were matched by age and suspected CNS infection. We included all patients for whom empiric antibiotics and/or acyclovir were prescribed.ResultsEach study group consisted of 46 patients with 29 (63.0%) infants and 17 (37.0%) older children. A viral pathogen was diagnosed in 5/46 (10.9%) patients in the control group (all enteroviruses) and in 14/46 (30.4%) patients in the mPCR group (enterovirus n = 9; human herpesvirus 6 (HHV-6) n = 5), (p = 0.038)). Length of Therapy (LoT) and Days of Therapy (DoT) for antibiotics were significantly lower for infants (4.0 vs. 3.0, p = 0.038 and 8.0 vs. 6.0, p = 0.015, respectively). Acyclovir therapy was significantly shorter for both, infants and older children (3.0 vs. 1.0 day, p < 0.001 for both age groups).ConclusionThe findings of our study suggest that the introduction of a FA ME Panel into clinical routine procedures is associated with a significantly reduced LoT and DoT of empiric anti-infective treatment in children with suspected meningoencephalitis. The largest effect was observed in infants.

Multicenter Evaluation of the Implementation Status of Laboratory Tests in Korea and the Potential Usefulness of a Multiplex PCR Assay in Patients with Suspected Central Nervous System Infections.

The rapid diagnosis and treatment of central nervous system (CNS) infections are critical to minimizing morbidity and mortality. We evaluated the implementation status of laboratory tests in patients with suspected CNS infection, and the potential usefulness of a multiplex PCR assay for rapid and simultaneous detection in cerebrospinal fluid (CSF) of 14 targets capable of causing CNS infections. The study was conducted at 5 hospitals located in Daegu and Gyeongju over a period of 6 months. A total of 140 patients with suspected CNS infection were included. CSF samples were tested for 6 bacteria, 7 viruses, and 1 yeast using multiplex PCR (FilmArray Meningitis/Encephalitis Panel, BioFire Diagnostics/Biomerieux, Salt Lake City, UT, USA) and conventional diagnostic testing including chemistry tests, cell count, bacterial culture, antigen detection assay, and pathogen-specific PCR. The five conventional tests most commonly performed were the chemistry and cell count (100%), bacterial culture (94.3%), enterovirus PCR (52.9%), and herpes simplex virus PCR (25.7%). Among the 140 CSF samples, 27 (19.3%) and 42 (30.0%) tested positive by conventional and the FilmArray ME panel testing, respectively. The detection rate of pathogens for CNS infections increased using only one FilmArray test compared to all of the conventional methods actually performed in patients with suspected CNS infection.

Systematic review and validation of diagnostic prediction models in patients suspected of meningitis

ObjectivesDiagnostic prediction models have been developed to assess the likelihood of bacterial meningitis (BM) in patients presented with suspected central nervous system (CNS) infection. External validation in patients suspected of meningitis is essential to determine the diagnostic accuracy of these models. MethodsWe prospectively included patients who underwent a lumbar puncture for suspected CNS infection. After a systematic review of the literature, we applied identified models for BM to our cohort. We calculated sensitivity, specificity, predictive values, area under the curve (AUC) and, if possible, we evaluated the calibration of the models. ResultsFrom 2012-2015 we included 363 episodes. In 89 (24%) episodes, the patient received a final diagnosis of a CNS infection, of whom 27 had BM. Seventeen prediction models for BM were identified. Sensitivity of these models ranged from 37% to 100%. Specificity of these models ranged from 44% to 99%. The cerebrospinal fluid model of Oostenbrink reached the highest AUC of 0.95 (95% CI 0.91–0.997). Calibration showed over- or underestimation in all models. ConclusionNone of the existing models performed well enough to recommend as routine use in individual patient management. Future research should focus on differences between diagnostic accuracy of the prediction models and physician's therapeutic decisions.

652. Impact of FilmArray Meningitis Encephalitis Panel on HSV Testing and Acyclovir Use in Children Beyond the Neonatal Period

BackgroundTesting and empiric use of acyclovir for herpes simplex virus (HSV) in children beyond the neonatal period undergoing lumbar puncture for suspected central nervous system (CNS) infection doubled in the past decade, while the incidence of HSV CNS infection is unchanged. A new syndromic multiplex PCR panel (FilmArray Meningitis Encephalitis Panel [MEP]) rapidly detects 14 pathogens in cerebrospinal fluid (CSF), including HSV. The impact of MEP implementation on HSV testing and acyclovir use is unknown.MethodsWe retrospectively compared CSF testing and acyclovir use in the pre-MEP era January 1, 2007–January 22, 2017 to post-implementation era of MEP January 23, 2017–December 31, 2017 amongst children >60 days with a CSF specimen sent to the Children’s Hospital Colorado microbiology laboratory. HSV singleplex PCR testing was available in both the pre-MEP and MEP eras.ResultsThe proportion of CSF specimens from children with suspected CNS infection undergoing HSV testing (MEP or HSV PCR) doubled from 25% in the pre-MEP era to 54% in the MEP era (P < 0.01; Figure 1). In the MEP era, HSV testing was conducted by MEP in 96% of cases and HSV PCR in 8% of cases. In both eras, a majority of CSF specimens undergoing HSV testing had no pleocytosis (63% vs. 59%, P = 0.27). Children with negative HSV testing by MEP were less likely to be started on acyclovir than those with negative HSV testing by singleplex PCR (18% vs. 50%, P < 0.01) and, amongst those started, acyclovir was discontinued sooner, after a median 3 vs 5 doses (P = 0.05). Overall, however, a similar proportion of children with suspected CNS infection received acyclovir in the MEP and pre-MEP eras (13% vs. 12%), despite a low rate of HSV positivity (0.5% vs. 0%).ConclusionImplementation of MEP for syndromic CSF testing in children >60 days with suspected CNS infection doubled HSV testing without affecting the rate of empiric acyclovir initiation. Patients with negative HSV testing on MEP were less likely to be started on acyclovir, and if started, received fewer doses than those who tested negative on HSV singleplex PCR, likely due to more rapid turnaround time. However, increased MEP testing offset this, suggesting increased use of newer rapid syndromic tests will not cure creeping empiricism. Diagnostic stewardship targeting MEP use toward children with pleocytosis to decrease unnecessary test utilization are warranted. Disclosures All authors: No reported disclosures.

1399. A Prospective Cohort Study Regarding the Impact of Biofire® FilmArray® Meningitis/Encephalitis (FA) Panel in Children with Suspected Central Nervous System Infection

BackgroundRapid detection of pathogens involved in central nervous system (CNS) infections could be important for the optimal patient management and overall hospitalization cost. The aim of the study was to evaluate the possible benefits with the use of BioFire® FilmArray® meningitis/encephalitis (FA) panel in children with suspected CNS infection.MethodsA prospective cohort study, was performed on children admitted to a tertiary pediatric hospital, over a period of 1 year (April 2018–April 2019), with possible CNS infection and cerebrospinal fluid (CSF) pleocytosis (>15 cells/mm3). For each child that FA was used for the diagnosis, an age-matched control was selected, and separate molecular CSF microbiological tests were sent according to pediatrician’s discretion. Conventional microbiological procedures were performed in all children. Length of hospital stay, duration of antimicrobials, and total cost of hospitalization were compared between groups. FA enables rapid automated cerebrospinal fluid testing for 14 common viral, bacterial and yeast pathogens that cause CNS infections. The cost was estimated according to ICD-10 diagnosis standard cost, adding additional daily hospitalization cost, FA or other molecular microbiological tests costs.ResultsA total of 142 children were included in the study (71 cases). The median age of cases and controls was 2.5 months (IQR: 1–72) and 2 months (IQR: 0.7–36) respectively (P = 0.157). A pathogen was detected in 38/71 (53.5%) children with the use of FA and in 16/71 (22.5%) in the control group (P < 0.001). In aseptic meningitis cases a virus was detected in 27/60 (45%) and in 11/64 (16.4%) controls (P < 0.001). Length of stay in cases and controls with aseptic meningitis was 5 days (IQR: 4–8) and 8 (IQR: 6–10) respectively (P < 0.001). The median duration of antimicrobials in cases was 4 days (IQR: 2–5.7) and 7 (IQR: 5–10) respectively (P < 0.001). The hospitalization cost was calculated in cases and controls 1,042 (IQR: 932–1372€) and 1,522 (IQR: 1,302–1,742€) respectively (P < 0.001).ConclusionThe use of FA was able to reduce significantly the hospitalization days and the total cost comparing to the control group in children with suspected CNS infection.Disclosures All authors: No reported disclosures.

1774. Impact of a Multiplex Polymerase Chain Reaction Assay on the Clinical Management of Adults Undergoing a Lumbar Puncture for Suspected Community-Onset Central Nervous System Infections

BackgroundPatients admitted from the community with a suspected central nervous system (CNS) infection require prompt antimicrobial treatment and diagnostic evaluation. Our health network recently implemented a multiplex polymerase chain reaction (PCR) assay in-house.MethodsThis was a pre-/post-intervention study evaluating the impact that a multiplex PCR assay had on the clinical management of patients ≥18 years of age admitted from the community with a lumbar puncture (LP) performed for a suspected CNS infection. The primary outcome was Herpes Simplex Virus (HSV) PCR turnaround time (TAT). Secondary outcomes included inpatient length of stay (LOS), total antimicrobial days of therapy (DOT), and antiviral DOT. Patients were excluded if an LP was performed after hospital day 3, if they were on a systemic antimicrobial for a non-CNS indication, if they were a neurosurgical patient, and if they had a fungal CNS infection.ResultsThe pre- and post-intervention groups each had 57 patients. The average age was 51 and 52 years in the pre- and post-intervention groups, respectively. Four patients (7%) in the pre-intervention group were immunocompromised, compared with 9 (16%) in the post-intervention group. Four patients in the pre-intervention group had a positive PCR assay for either HSV or Varicella Zoster Virus (VZV), compared with 5 patients in the post-intervention group. Neither group had a positive cerebrospinal fluid culture, bacterial antigen assay, or bacterial PCR assay. The median (IQR) HSV PCR TAT was significantly longer in the pre-intervention group, 85 (78, 96) vs. 3.9 hours (2.9, 4.7), P < 0.001. The mean LOS was numerically greater in the pre-intervention arm (7 vs. 4.7 days, P = 0.069), as were the total antimicrobial DOT (9 vs. 7.4 days, P = 0.279) and antiviral DOT (3.9 vs. 2.7 days, P = 0.136). Pre-intervention antiviral DOT was significantly greater (3.1 vs. 1.6 days, P = 0.011) in patients without a positive HSV or VZV PCR.ConclusionImplementing a multiplex PCR assay for adults undergoing an LP for a suspected CNS infection significantly reduced the HSV PCR turnaround time. Antiviral DOT was significantly shorter in patients with a negative PCR result post-intervention. We also found a non-significant reduction in LOS, total antimicrobial DOT, and antiviral DOT.Disclosures All authors: No reported disclosures.

Cranial Imaging and Lumbar Puncture in Patients With Suspected Central Nervous System Infection.

BackgroundPerforming cranial imaging prior to lumbar punctures (LPs) in patients with suspected central nervous system (CNS) infections has been associated with delayed treatments and poor outcomes. Various guidelines provide different criteria for cranial imaging prior to LP.MethodsWe describe the use of cranial imaging in a cohort of adult patients with suspected CNS infections, and evaluated adherence to the recommendations made in the Infectious Disease Society of America (IDSA), European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Swedish, and Dutch guidelines. We also analyzed the association between cranial imaging and the time between emergency department entrance and intravenous antibiotic administration.ResultsFrom 2012–2015, 203 patients with suspected CNS infections were included, of whom 56 (27%) were diagnosed with CNS infections and 16 were diagnosed with bacterial meningitis (8%). Cranial imaging, in all cases computed tomography (CT), was performed in 130 patients (64%) and led to the deferral of LPs in 7 (5%). Criteria by the IDSA, ESCMID, Swedish, and Dutch guidelines showed indications for imaging in 64%, 39%, 39%, and 40% of patients, respectively. The times between emergency department arrivals and the start of antibiotic therapy between patients with and without CT before LP were similar (median 134 [interquartile range (IQR) 58–292] vs. 141 minutes [IQR 52–227], respectively; Mann-Whitney U P = .74).ConclusionsA cranial CT prior to LP was done in the majority of patients with a suspected CNS infection, irrespective of guideline indications. The ESCMID, Swedish, and Dutch guidelines were more restrictive in advising imaging, compared to the IDSA guidelines. Performing cranial imaging prior to LP was not associated with treatment delays in this Dutch cohort study.

Clinical features of central nervous system infections and experience in differential diagnosis from neuropsychiatric lupus erythematosus in a cohort of 8491 patients with systemic lupus erythematosus

BackgroundIn clinical practice, discrimination between central nervous system (CNS) infections in patients with systemic lupus erythematosus (SLE) and neuropsychiatric lupus erythematosus (NPSLE) could be urgent and critical yet extremely challenging. Given this, this study aimed to investigate the clinical features and outcomes of infections in the CNS in patients with SLE and to establish a simplified scoring system for guiding the discrimination of CNS infections from NPSLE.MethodsA total of 95 patients who were identified as having CNS infections among 8491 SLE patients between January 1992 and January 2018 were included in this retrospective study. NPSLE patients admitted at the same period were randomly selected for comparison. Key factors either clinically valuable or statistically significant for discriminating CNS infections from NPSLE were integrated to build a simplified scoring system. Another group of 22 SLE patients complicated with suspected newly onset of CNS infections or NPSLE admitted after January 2018 was enrolled to verify the utility of the scoring system.ResultsSixty-three positive pathogens were identified in 59 patients of the total 95 CNS infection cases. Compared with the NPSLE group, the CNS infections group had a longer disease duration (21.0 [3.0–50.0] vs. 1.0 [0–22.0] months, P < 0.05), exhibited more fever (96.8% vs. 23.2%, P < 0.001) and polymorphonuclear leukocyte leukocytosis in the cerebrospinal fluid (CSF) (45.6% vs. 0.5%, P < 0.05), and had significantly decreased CSF glucose (2.0 ± 1.3 vs. 3.3 ± 0.9 mmol/L, P < 0.01), whereas hypocomplementemia seemed to be a strong hint of NPSLE (44.6% vs. 77.4%, P < 0.001). A simplified scoring system integrated with 8 key factors was established for guiding clinical differential diagnosis. By setting the cutoff value at 4 and verifying in a group of SLE patients complicated with newly occurred suspected CNS infection or NPSLE, a sensitivity of 85.7% and specificity of 93.3% with the area under the curve (AUC) being 0.93 (95%CI 0.80–1.00) were obtained.ConclusionsCNS infections are a fatal complication of SLE and can be difficult to discriminate from NPSLE. A simplified scoring system may help to make preliminary discrimination of CNS infections from NPSLE.

Diagnostic Testing in Central Nervous System Infection.

Patients with central nervous system (CNS) infection experience very high levels of morbidity and mortality, in part because of the many challenges inherent to the diagnosis of CNS infection and identification of a causative pathogen. The clinical presentation of CNS infection is nonspecific, so clinicians must often order and interpret many diagnostic tests in parallel. This can be a daunting task given the large number of potential pathogens and the availability of different testing modalities. Here, we review traditional diagnostic techniques including Gram stain and culture, serology, and polymerase chain reaction (PCR). We highlight which of these are recommended for the pathogens most commonly tested among U.S. patients with suspected CNS infection. Finally, we describe the newer broad-range diagnostic approaches, multiplex PCR and metagenomic sequencing, which are increasingly used in clinical practice.

Blood and cerebrospinal fluid characteristics in neonates with a suspected central nervous system infection.

Clinical signs and symptoms of central nervous system (CNS) infections in neonates are often nonspecific. Therefore, cerebrospinal fluid (CSF) analysis is performed to diagnose CNS infections. Data on combined microbiological results and their correlation with biochemical characteristics in CSF and blood in infants younger than 90 days are limited. This study provides an overview of microbiological test results, CSF- and hematological characteristics among infants with a clinically suspected CNS infection.This retrospective study included infants younger than 90 days, with a clinically suspected CNS infection who underwent a diagnostic lumbar puncture between January 2012 and January 2014. Data on the presence of microbiological pathogens in CSF, CSF inflammation markers (white blood cell [WBC] counts, protein levels and glucose CSF/serum ratio) and blood inflammatory responses (WBC count, C-reactive protein [CRP], neutrophil percentage) were collected by reviewing patient files.We included data from 576 infants (median age 12.5 days, interquartile range, 6-27 days) of whom 383 (66.5%) were born prematurely. In total, 16 bacterial pathogens (3.0%) and 21 viruses (5.5%) were detected in CSF. Escherichia coli was detected in 5 cases (1.0%), Enterovirus was detected in 12 cases (3.1%). Leucocytosis in CSF was associated with identification of a pathogen in CSF. Increased CRP was associated with the identification of a bacterial pathogen in CSF.Bacterial or viral pathogens were only identified in a small proportion of infants with a clinically suspected CNS infection. Leucocytosis in CSF was associated with CNS infection in infants. An increased CRP was indicative of bacterial meningitis.

Management of Central Nervous System Infections, Vientiane, Laos, 2003-2011.

During 2003–2011, we recruited 1,065 patients of all ages admitted to Mahosot Hospital (Vientiane, Laos) with suspected central nervous system (CNS) infection. Etiologies were laboratory confirmed for 42.3% of patients, who mostly had infections with emerging pathogens: viruses in 16.2% (mainly Japanese encephalitis virus [8.8%]); bacteria in 16.4% (including Orientia tsutsugamushi [2.9%], Leptospira spp. [2.3%], and Rickettsia spp. [2.3%]); and Cryptococcus spp. fungi in 6.6%. We observed no significant differences in distribution of clinical encephalitis and meningitis by bacterial or viral etiology. However, patients with bacterial CNS infection were more likely to have a history of diabetes than others. Death (26.3%) was associated with low Glasgow Coma Scale score, and the mortality rate was higher for patients with bacterial than viral infections. No clinical or laboratory variables could guide antibiotic selection. We conclude that high-dependency units and first-line treatment with ceftriaxone and doxycycline for suspected CNS infections could improve patient survival in Laos.

Viral Metagenomics on Cerebrospinal Fluid.

Identifying the causative pathogen in central nervous system (CNS) infections is crucial for patient management and prognosis. Many viruses can cause CNS infections, yet screening for each individually is costly and time-consuming. Most metagenomic assays can theoretically detect all pathogens, but often fail to detect viruses because of their small genome and low viral load. Viral metagenomics overcomes this by enrichment of the viral genomic content in a sample. VIDISCA-NGS is one of the available workflows for viral metagenomics, which requires only a small input volume and allows multiplexing of multiple samples per run. The performance of VIDISCA-NGS was tested on 45 cerebrospinal fluid (CSF) samples from patients with suspected CNS infections in which a virus was identified and quantified by polymerase chain reaction. Eighteen were positive for an RNA virus, and 34 for a herpesvirus. VIDISCA-NGS detected all RNA viruses with a viral load >2 × 104 RNA copies/mL (n = 6) and 8 of 12 of the remaining low load samples. Only one herpesvirus was identified by VIDISCA-NGS, however, when withholding a DNase treatment, 11 of 18 samples with a herpesvirus load >104 DNA copies/mL were detected. Our results indicate that VIDISCA-NGS has the capacity to detect low load RNA viruses in CSF. Herpesvirus DNA in clinical samples is probably non-encapsidated and therefore difficult to detect by VIDISCA-NGS.

Pattern and Outcome of Central Nervous System Infections in Suez Governorate

Background and study aim: Egypt is an endemic area with Central nervous system (CNS) infections, which associated with high complications and death rates so it is considered a medical emergency. In spite of emerging of new potent antibiotics and availability of specific vaccination accompanied with improving of medical care, morbidity rates accompanied with CNS infection remains unacceptably high. There is dramatic change in the epidemiology of CNS infection that leads to incomplete understanding of its pathogenesis which interferes with the initiation of effective empirical antimicrobial treatment. There is a growing need for more researches to uncover these changes.The aim of the study is to assess the pattern of CNS infections, identify the causative organisms, course and outcome of the CNS infections to implement standard management approaches and improve outcome. Patients and Methods: One hundred twenty-four patients, recruited from Suez Fever and General Hospitals with suspected CNS infection, were enrolled in this study. CNS infection was confirmed by cerebrospinal fluid results supported by clinical diagnosis and in some patients brain imaging was performed. Results: In our study streptococcus pneumonia was the main cause of septic meningitis; males infected more than females, children were the most vulnerable group; among children Haemophilus influenzae was the commonest cause of septic meningitis. Mycobacterium meningitis was the leading cause of death among studied patient and deafness was the main neurological complication. Conclusion: Early clinical suspicion of CNS infection and immediate management are crucial factors in reduction of the still high morbidity and mortality rates. The changes in the pattern of causative organisms must be considered when starting empiric antibiotic.

Viral RNA Degradation Makes Urine a Challenging Specimen for Detection of Japanese Encephalitis Virus in Patients With Suspected CNS Infection.

BackgroundJapanese encephalitis virus (JEV) is a leading cause of central nervous system (CNS) infections in Asia and results in significant morbidity and mortality. JEV RNA is rarely detected in serum or cerebrospinal fluid (CSF), and diagnosis of JEV infection is usually based on serological tests that are frequently difficult to interpret. Unlike serum or CSF, urine is relatively easy to obtain, but, to date, there has been minimal work on the feasibility of testing urine for JEV RNA.MethodsWe investigated the use of lysis buffer and a Microsep device to optimize urine storage for detection of JEV RNA by reverse transcription real-time polymerase chain reaction (RT-qPCR). The best of the studied methods was then evaluated in consecutive patients admitted to the hospital with suspected CNS infections in Laos.ResultsWe demonstrated degradation of JEV RNA in urine after even short storage periods at 4°C or –80°C. Although there was no advantage in using a Microsep concentration device alone, immediate addition of lysis buffer to fresh urine improved the detection of JEV RNA at the limit of detection.ConclusionsIn 2 studies of 41 patients with acute encephalitis syndrome, 11 (27%) were positive for JEV IgM in CSF and/or serum, and 2 (4.9%) were JEV RT-qPCR positive from throat swabs. JEV RNA was not detected in any of these patients’ urine samples. However, lysis buffer was only used during a prospective study, that is, for only 17/41 (41%) patient urine samples. Our findings suggest a need for larger studies testing urine for JEV RNA, with urine collected at different times from symptom onset, and using lysis buffer, which stabilizes RNA, for storage.

326. Malaria vs. Bacterial Meningitis in Children With Spinal Tap in the Luanda Children’s Hospital, Angola

BackgroundIn Sub-Saharan Africa, both malaria (M), and bacterial meningitis (BM) cause fever and central nervous system (CNS) disturbance. We studied their prevalence, characteristics, outcome, and risk factors for poor outcome to better understand the clinical impact of suspected CNS infection in children.MethodsWe conducted a prospective study in the Children’s Hospital (HPDB) in the capital of Angola which attends 300 new patients daily. Spinal tap (ST) was performed for children presenting with altered consciousness, convulsions, prostration, or meningism. The analysis included children aged 3 month to 15 years with confirmed discharge diagnosis in 2016–2017.ResultsOf 941 children, the diagnosis was M in 56% (525), BM in 12% (116), epilepsy/convulsions in 9% (88), and other infections in 6% (60). Of all children, 16% (150/941) died, 6% (45/733) had severe, 14% (93/655) any neurological sequelae, and 27% (243/897) either died or had neurological sequelae. In children with M, the corresponding figures were 7% (35/525), 1.5% (7/476), 4% (19/443), and 11% (54/514). In children with BM, the figures were 41% (47/116), 15% (8/54), 33% (11/33), and 55% (58/105), respectively. Comparing with M, children with BM were younger (median age (IQR) 28 (61) vs. 60 (68) months, P < 0.0001), had an underlying illness (23/97 vs. 19/374, P < 0.0001), like sickle-cell disease (18/96 vs. 9/372, P < 0.0001), longer duration of illness (4 (4) vs. 3 (3) days, P < 0.0001, dyspnea (70/119 vs. 210/463, P = 0.009), were dehydrated (36/113 vs. 67/441, P < 0.0001), or malnourished (38/115 vs. 75/447, P = 0.0001). Multivariate analysis revealed as independent risk factors for death or neurological sequelae age <12 months (OR 1.71, 95% CI 1.02–2.88, P < 0.0001), duration of illness >3 days (2.48, 1.68–3.64, P < 0.0001), malnutrition (1.92, 1.20–3.05, P = 0.006), and dehydration (1.92, 1.16–3.14, P = 0.01). When BM vs. M was included in the analysis, BM appeared as the most important risk factor (OR 8.06, 4.44–14.65, P < 0.0001) and age lost its significance.ConclusionIn suspected CNS infection, M was the final diagnosis of most children. However, BM caused more deaths and neurological sequelae. Amendable factors, such as delay in treatment, dehydration, and malnutrition, appeared as risk factors for poor outcome.Disclosures T. Pelkonen, sanofi pasteur: Investigator, Sanofi Paster funded this study. Paediatric Research Foundation, Helsinki, Finland: Grant Investigator, Grant recipient. Päivikki and Sakari Sohlberg Foundation, Helsinki, Finland: Grant Investigator, Grant recipient

Next-Generation Sequencing of Cerebrospinal Fluid for the Diagnosis of Neurocysticercosis.

Background: Neurocysticercosis (NCC) is the most common helminthic infection of the central nervous system (CNS). The diagnosis of NCC is sometimes challenging due to its heterogenous clinical manifestations and the variable sensitivity and specificity of neuroimaging and serological tests.Methods: Next-generation sequencing (NGS) of cerebrospinal fluid (CSF) was used to detect pathogens in patients with clinically suspected CNS infections. A series of patients diagnosed with NCC is reviewed here.Results: Using NGS of CSF, four patients were diagnosed with NCC. The reads corresponding to Taenia solium ranged from 478 to 117,362, with genomic coverage of 0.0564–11.15%. Reads corresponding to T. solium were not found in non-template controls and far exceeded those of the background microorganisms in patients with NCC, facilitating the interpretation of the NGS results.Conclusions: This case series demonstrates that NGS of CSF is promising in the diagnosis of NCC in difficult to diagnose cases. Larger studies are needed in the future.

Next-generation sequencing of the cerebrospinal fluid in the diagnosis of neurobrucellosis

BackgroundBrucellosis is the most common zoonotic infection in the world. Brucellosis with nervous system involvement is known as ‘neurobrucellosis’ (NB). The diagnosis of NB is difficult because its clinical manifestations are non-specific and the sensitivity of routine culture tests is low. MethodsNext-generation sequencing (NGS) of cerebrospinal fluid (CSF) was used to detect pathogens in patients with clinically suspected central nervous system (CNS) infections at a tertiary referral center in China between June 1, 2016 and June 1, 2017. The clinical characteristics and NGS results of patients with the diagnosis of NB were reviewed in this study. ResultsFour patients were rapidly diagnosed with NB using NGS of the CSF in patients with clinically suspected CNS infections, although the clinical manifestations varied dramatically between these patients. NGS of the CSF revealed that the sequence reads identified that corresponded to Brucella species ranged from 11 to 104, with genomic coverage ranging from 0.043% to 0.4%. Rapid diagnosis led to prompt treatment with the appropriate antibiotics. ConclusionsThis study demonstrates the power of NGS of the CSF coupled with a bioinformatic pipeline in the diagnosis of NB.

EAN consensus review on prevention, diagnosis and management of tick-borne encephalitis.

Tick-borne encephalitis (TBE) is an infection of the central nervous system (CNS) caused by tick-borne encephalitis virus (TBEV) and transmitted by ticks, with a variety of clinical manifestations. The incidence of TBE in Europe is increasing due to an extended season of the infection and the enlargement of endemic areas. Our objectives are to provide recommendations on the prevention, diagnosis and management of TBE, based on evidence or consensus decisions. For systematic evaluation, the literature was searched from 1970 to 2015 (including early online publications of 2016), and recommendations were based on evidence or consensus decisions of the Task Force when evidence-based data were not available. Vaccination against TBE is recommended for all age groups above 1 year in highly endemic areas (≥5 cases/100 000/year), but also for individuals at risk in areas with a lower incidence. Travellers to endemic areas should be vaccinated if their visits will include extensive outdoor activities. Post-exposure prophylaxis after a tick bite is not recommended. A case of TBE is defined by the presence of clinical signs of meningitis, meningoencephalitis or meningoencephalomyelitis with cerebrospinal fluid (CSF) pleocytosis (>5 × 106 cells/l) and the presence of specific TBEV serum immunoglobulin M (IgM) and IgG antibodies, CSF IgM antibodies or TBEV IgG seroconversion. TBEV-specific polymerase chain reaction in blood is diagnostic in the first viremic phase but it is not sensitive in the second phase of TBE with clinical manifestations of CNS inflammation. Lumbar puncture should be performed in all patients with suspected CNS infection unless there are contraindications. Imaging of the brain and spinal cord has a low sensitivity and a low specificity, but it is useful for differential diagnosis. No effective antiviral or immunomodulating therapy is available for TBE; therefore the treatment is symptomatic. Patients with a potentially life threatening meningoencephalitis or meningoencephalomyelitis should be admitted to an intensive care unit. In the case of brain oedema, analgosedation should be deepened; osmotherapy and corticosteroids are not routinely recommended. If intracranial pressure is increased, therapeutic hypothermia or decompressive craniectomy might be considered. Seizures should be treated as any other symptomatic epileptic seizures. Tick-borne encephalitis is a viral CNS infection that may result in long-term neurological sequelae. Since its incidence in Europe is increasing due to broadening of endemic areas and prolongation of the tick activity season, the health burden of TBE is enlarging. There is no effective antiviral treatment for TBE, but the disease may be effectively prevented by vaccination.