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Fellner A, White S, Rockwell E, Giandomenico D, Diaz MM, Weber DJ, Miller MB, Boyce RM. The clinical epidemiology, management, and outcomes of patients diagnosed with encephalitis in North Carolina, 2015-2020. J Clin Microbiol 2023; 61:e0073123. [PMID: 38014985 PMCID: PMC10729753 DOI: 10.1128/jcm.00731-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/12/2023] [Indexed: 11/29/2023] Open
Abstract
IMPORTANCE Despite the relatively high mortality and the difficulty in diagnosis, nearly one-third of patients hospitalized with a documented diagnosis of encephalitis did not undergo a lumbar puncture (LP). When an LP was performed, pathogen-specific testing was greatly underutilized. Infectious etiologies were most common, but over 40% of cases were idiopathic at discharge. These findings suggest that there is a substantial opportunity to improve the quality of care through more accurate and timely diagnosis.
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Affiliation(s)
- Anuva Fellner
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Samuel White
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Emmanuel Rockwell
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Dana Giandomenico
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Monica M. Diaz
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - David J. Weber
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Melissa B. Miller
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ross M. Boyce
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Blanton LS. Murine Typhus: A Review of a Reemerging Flea-Borne Rickettsiosis with Potential for Neurologic Manifestations and Sequalae. Infect Dis Rep 2023; 15:700-716. [PMID: 37987401 PMCID: PMC10660532 DOI: 10.3390/idr15060063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/24/2023] [Accepted: 10/24/2023] [Indexed: 11/22/2023] Open
Abstract
Murine typhus is an acute febrile illness caused by Rickettsia typhi, an obligately intracellular Gram-negative coccobacillus. Rats (Rattus species) and their fleas (Xenopsylla cheopis) serve as the reservoir and vector of R. typhi, respectively. Humans become infected when R. typhi-infected flea feces are rubbed into flea bite wounds or onto mucous membranes. The disease is endemic throughout much of the world, especially in tropical and subtropical seaboard regions where rats are common. Murine typhus is reemerging as an important cause of febrile illness in Texas and Southern California, where an alternate transmission cycle likely involves opossums (Didelphis virginiana) and cat fleas (Ctenocephalides felis). Although primarily an undifferentiated febrile illness, a range of neurologic manifestations may occur, especially when treatment is delayed. Serology is the mainstay of diagnostic testing, but confirmation usually requires demonstrating seroconversion or a fourfold increase in antibody titer from acute- and convalescent-phase sera (antibodies are seldom detectable in the first week of illness). Thus, early empiric treatment with doxycycline, the drug of choice, is imperative. The purpose of this review is to highlight murine typhus as an important emerging and reemerging infectious disease, review its neurologic manifestations, and discuss areas in need of further study.
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Affiliation(s)
- Lucas S Blanton
- Department Internal Medicine, Division of Infectious Diseases, University of Texas Medical Branch, Galveston, TX 77555, USA
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Bloch KC, Glaser C, Gaston D, Venkatesan A. State of the Art: Acute Encephalitis. Clin Infect Dis 2023; 77:e14-e33. [PMID: 37485952 DOI: 10.1093/cid/ciad306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Indexed: 07/25/2023] Open
Abstract
Encephalitis is a devastating neurologic disease often complicated by prolonged neurologic deficits. Best practices for the management of adult patients include universal testing for a core group of etiologies, including herpes simplex virus (HSV)-1, varicella zoster virus (VZV), enteroviruses, West Nile virus, and anti-N-methyl-D-aspartate receptor (anti-NMDAR) antibody encephalitis. Empiric acyclovir therapy should be started at presentation and in selected cases continued until a second HSV-1 polymerase chain reaction test is negative. Acyclovir dose can be increased for VZV encephalitis. Supportive care is necessary for other viral etiologies. Patients in whom no cause for encephalitis is identified represent a particular challenge. Management includes repeat brain magnetic resonance imaging, imaging for occult malignancy, and empiric immunomodulatory treatment for autoimmune conditions. Next-generation sequencing (NGS) or brain biopsy should be considered. The rapid pace of discovery regarding autoimmune encephalitis and the development of advanced molecular tests such as NGS have improved diagnosis and outcomes. Research priorities include development of novel therapeutics.
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Affiliation(s)
- Karen C Bloch
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carol Glaser
- California Department of Public Health, Richmond, California, USA
| | - David Gaston
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Arun Venkatesan
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland, USA
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Cente M, Danchenko M, Skultety L, Filipcik P, Sekeyova Z. Rickettsia Deregulates Genes Coding for the Neurotoxic Cell Response Pathways in Cerebrocortical Neurons In Vitro. Cells 2023; 12:cells12091235. [PMID: 37174635 PMCID: PMC10177168 DOI: 10.3390/cells12091235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/15/2023] Open
Abstract
Rickettsial infections of the central nervous system (CNS) are manifested by severe neurological symptoms and represent a serious life-threatening condition. Despite the considerable health danger, only a few studies have been conducted focusing on the pathogenesis induced by Rickettsia sp. in CNS. To investigate the signaling pathways associated with the neurotoxic effects of rickettsiae, we employed an experimental model of cerebrocortical neurons combined with molecular profiling and comprehensive bioinformatic analysis. The cytopathic effect induced by Rickettsia akari and Rickettsia slovaca was demonstrated by decreased neuronal viability, structural changes in cell morphology, and extensive fragmentation of neurites in vitro. Targeted profiling revealed the deregulation of genes involved in the neuroinflammatory and neurotoxic cell response pathways. Although quantitative analysis showed differences in gene expression response, functional annotation revealed that the biological processes are largely shared between both Rickettsia species. The identified enriched pathways are associated with cytokine signaling, chemotaxis of immune cells, responses to infectious agents, interactions between neurons, endothelial and glial cells, and regulation of neuronal apoptotic processes. The findings of our study provide new insight into the etiopathogenesis of CNS infection and further expand the understanding of molecular signaling associated with neuroinvasive Rickettsia species.
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Affiliation(s)
- Martin Cente
- Institute of Neuroimmunology, Slovak Academy of Sciences, Dubravska cesta 9, 845 10 Bratislava, Slovakia
| | - Monika Danchenko
- Department of Rickettsiology, Biomedical Research Center, Slovak Academy of Sciences, Dubravska cesta 9, 845 05 Bratislava, Slovakia
| | - Ludovit Skultety
- Department of Rickettsiology, Biomedical Research Center, Slovak Academy of Sciences, Dubravska cesta 9, 845 05 Bratislava, Slovakia
| | - Peter Filipcik
- Institute of Neuroimmunology, Slovak Academy of Sciences, Dubravska cesta 9, 845 10 Bratislava, Slovakia
| | - Zuzana Sekeyova
- Department of Rickettsiology, Biomedical Research Center, Slovak Academy of Sciences, Dubravska cesta 9, 845 05 Bratislava, Slovakia
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Imaging of Uncommon Bacterial, Rickettsia, Spirochete, and Fungal Infections. Neuroimaging Clin N Am 2023; 33:83-103. [DOI: 10.1016/j.nic.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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A Vaccine for Canine Rocky Mountain Spotted Fever: An Unmet One Health Need. Vaccines (Basel) 2022; 10:vaccines10101626. [PMID: 36298491 PMCID: PMC9610744 DOI: 10.3390/vaccines10101626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/22/2022] [Accepted: 09/25/2022] [Indexed: 11/17/2022] Open
Abstract
Outbreaks of life-threatening Rocky Mountain spotted fever in humans and dogs associated with a canine-tick maintenance cycle constitute an important One Health opportunity. The reality of the problem has been observed strikingly in Mexico, Brazil, Colombia, and Native American tribal lands in Arizona. The brown dog tick, Rhipicephalus sanguineus sensu lato, acquires the rickettsia from bacteremic dogs and can maintain the bacterium transtadially to the next tick stage. The subsequent adult tick can then transmit infection to a new host, as shown by guinea pig models. These brown dog ticks maintain spotted fever group rickettsiae transovarially through many generations, thus serving as both vector and reservoir. Vaccine containing whole-killed R. rickettsii does not stimulate sufficient immunity. Studies of Rickettsia subunit antigens have demonstrated that conformationally preserved outer-membrane autotransporter proteins A and B are the leading vaccine candidates. The possibility of a potentially safe and effective live attenuated vaccine has only begun to be explored as gene knockout methods are applied to these obligately intracellular pathogens.
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Mastroianni A, Greco S, Urso F, Mauro MV, Vangeli V. Does Tigecycline Have a Place in Therapy for Rickettsial Infection of the Central Nervous System? Infect Chemother 2022; 54:165-172. [PMID: 35384427 PMCID: PMC8987170 DOI: 10.3947/ic.2021.0070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 01/21/2022] [Indexed: 01/04/2023] Open
Abstract
This brief report documents the safety and efficacy of high-dose tigecycline as a salvage-therapy in in a case series of five patients with serious central nervous system (CNS) rocky mountain spotted fever (RMSF). These severily ill patients were unable to take any oral drug therapy, parenteral doxycycline was unavailable and absorption of oral doxycycline was a concern in these critically ill patients. As far as we know, we report the successfull use of tigecycline for the treatment of rickettsial meningitis for the first time in Italy. We suggest more studies on tigecycline in severe CNS infections from Rickettsia species and multi-drug resistant bacteria, especially the use of tigecycline at higher than standard doses in these life-threathening infectious diseases.
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Affiliation(s)
- Antonio Mastroianni
- Infectious & Tropical Diseases Unit, Annunziata Hub Hospital, Cosenza, Italy
| | - Sonia Greco
- Infectious & Tropical Diseases Unit, Annunziata Hub Hospital, Cosenza, Italy
| | - Filippo Urso
- Hospital Pharmacy, Annunziata Hub Hospital, Cosenza, Italy
| | | | - Valeria Vangeli
- Infectious & Tropical Diseases Unit, Annunziata Hub Hospital, Cosenza, Italy
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Schmidt WP, Devamani CS, Elangovan D, Alexander N, Rose W, Prakash JAJ. Clinical characteristics of and antibody response to spotted fever group rickettsial infections in South India: Case series and serological cohort study. Trop Med Int Health 2021; 26:1616-1623. [PMID: 34597443 DOI: 10.1111/tmi.13682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The clinical and serological characteristics of spotted fever group rickettsial (SFGR) infections in South Asia are poorly understood. We studied the clinical presentation and the IgM/IgG response in cases enrolled at two health care centres in South India. METHOD We enrolled 77 patients. Fifty-seven of these patients were recruited at a tertiary care centre, the remaining 20 at a community hospital (secondary care level). Diagnostic tests included IgM and IgG enzyme-linked immunosorbent assay and polymerase chain reaction. Over a period of 1 year, 41 cases were followed up for repeated sero-analysis. RESULTS Median age was 9 years (range 1-79). A rash was present in 74% of cases (57/77). In cases aged <15 years, rash was present in 94% (44/47) vs. 43% (13/30) in cases aged ≥15 years. An eschar was found in two cases (3%). Severe infection or complications occurred in 10 cases (13%). These included central nervous system infection (6/77, 8%), kidney injury (3/77, 4%), shock (3/77, 4%), lung involvement (2/77, 3%) and peripheral gangrene (2/77, 3%). IgM antibody levels increased faster after fever onset than IgG antibodies, peaking at 50 and 60 days, respectively. After the peak, IgM and IgG levels showed a slow decline over one year with less than 50% of cases showing persistent IgG antibody levels. CONCLUSION Spotted fever group rickettsial infections in South India may be under-diagnosed, as many cases may not develop a rash. The proportion of cases developing severe infection seems lower than for scrub typhus in this region. IgG seroprevalence may substantially underestimate the proportion in a population with past SFGR infection.
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Affiliation(s)
- Wolf-Peter Schmidt
- Department of Emergency Medicine, Christian Medical College, Vellore, India.,Department for Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Carol S Devamani
- Rural Unit for Health & Social Affairs, Christian Medical College, Vellore, India
| | - Divyaa Elangovan
- Department of Clinical Microbiology, Christian Medical College, Vellore, India
| | - Neal Alexander
- MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Winsley Rose
- Department of Pediatrics and Pediatric Infectious Diseases, Christian Medical College, Vellore, India
| | - John A J Prakash
- Department of Clinical Microbiology, Christian Medical College, Vellore, India
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Abstract
PURPOSE OF REVIEW This article reviews infections of the brain parenchyma and includes an overview of the epidemiology, pathogenesis, diagnostic approach, and management of infectious encephalitis and brain abscess. RECENT FINDINGS The epidemiology of infectious encephalitis and brain abscess has changed in recent years. Vaccination has reduced the incidence of certain viruses associated with encephalitis, while a decrease in fulminant otogenic infections has led to fewer brain abscesses associated with otitis media. However, changes in climate and human population density and distribution have enabled the emergence of newer pathogens and expanded the geographic range of others, and greater adoption of intensive immunosuppressive regimens for autoimmune conditions has increased the risk of opportunistic infections of the brain. The widespread use of early neuroimaging, along with improved diagnostic methodologies for pathogen detection, newer antimicrobial therapies with better brain penetration, and less invasive neurosurgical techniques, has resulted in better outcomes for patients with infectious encephalitis and brain abscess. Novel technologies including metagenomic next-generation sequencing are increasingly being applied to these conditions in an effort to improve diagnosis. Nevertheless, both infectious encephalitis and brain abscess continue to be associated with substantial mortality. SUMMARY Infectious encephalitis and brain abscess can present as neurologic emergencies and require rapid assessment, thorough and appropriate diagnostic testing, and early initiation of empiric therapies directed against infectious agents. Close clinical follow-up, proper interpretation of diagnostic results, and appropriate tailoring of therapeutic agents are essential to optimizing outcomes. Diagnosis and management of parenchymal brain infections are complex and often best achieved with a multidisciplinary care team involving neurologists, neurosurgeons, neuroradiologists, infectious disease physicians, and pathologists.
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Au CC, Hon KL, Leung AKC, Torres AR. Childhood Infectious Encephalitis: An Overview of Clinical Features, Investigations, Treatment, and Recent Patents. RECENT PATENTS ON INFLAMMATION & ALLERGY DRUG DISCOVERY 2020; 14:156-165. [PMID: 33238854 DOI: 10.2174/1872213x14999201124195724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 10/14/2020] [Accepted: 10/19/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Infectious encephalitis is a serious and challenging condition to manage. This overview summarizes the current literature regarding the etiology, clinical manifestations, diagnosis, management, and recent patents of acute childhood infectious encephalitis. METHODS We used PubMed Clinical Queries as a search engine and used keywords of "encephalitis" AND "childhood" Patents were searched using the key term "encephalitis" in google.patents.- com and patentsonline.com. RESULTS Viral encephalitis is the most common cause of acute infectious encephalitis in children. In young children, the clinical manifestations can be non-specific. Provision of empiric antimicrobial therapy until a specific infectious organism has been identified, which in most cases includes acyclovir, is the cornerstone of therapy. Advanced investigation tools, including nucleic acid-based test panel and metagenomic next-generation sequencing, improve the diagnostic yield of identifying an infectious organism. Supportive therapy includes adequate airway and oxygenation, fluid and electrolyte balance, cerebral perfusion pressure support, and seizure control. Recent patents are related to the diagnosis, treatment, and prevention of acute infectious encephalitis. CONCLUSION Viral encephalitis is the most common cause of acute infectious encephalitis in children and is associated with significant morbidity. Recent advances in understanding the genetic basis and immunological correlation of infectious encephalitis may improve treatment. Third-tier diagnostic tests may be incorporated into clinical practice. Treatment is targeted at the infectious process but remains mostly supportive. However, specific antimicrobial agents and vaccines development is ongoing.
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Affiliation(s)
- Cheuk C Au
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Kowloon Bay, Kowloon, Hong Kong
| | - Kam L Hon
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Kowloon Bay, Kowloon, Hong Kong
| | - Alexander K C Leung
- Department of Pediatrics, The University of Calgary and The Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Alcy R Torres
- Department of Pediatrics, Division of Pediatric Neurology, Pediatric Traumatic Brain Injury Program, Associate Professor of Pediatrics and Neurology, Boston University, School of Medicine, Boston, MA, United States
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