Pathogen-associated acute encephalitis syndrome: therapeutics and management

The Clinical Profile and Prognostic Factors Influencing Mortality in Patients With Acute Encephalitis Syndrome

Introduction Acute encephalitis syndrome (AES) is a significant global public health concern. AES is a disorder characterized by fever and altered mental status, and it is associated with considerable morbidity and mortality. There is a limited amount of existing literature on the clinical profile and prognostic markers that influence mortality in these patients. Our study seeks to comprehend the etiology, clinical characteristics, complications, and prognostic markers that impact mortality among patients with AES.  Methods The study was a prospective observational study conducted over 18 months, involving a sample size of 105 patients. Patients aged 12 years and older, who met the WHO case definition of Acute Encephalitis Syndrome (AES), were consecutively recruited for this study. The patients' details were recorded, including their medical history and physical and clinical examination findings upon admission. The extent of cognitive impairment was evaluated using the Glasgow Coma Scale (GCS). Additionally, the patient's presenting symptoms, any complications experienced during their hospital stay, and the mortality rate were documented. The etiology, MRI results of the brain, laboratory parameters, and the need for assisted ventilation were also recorded. In-hospital characteristics were analyzed using the t-test for continuous variables and the chi-square test for binary variables. The log-rank test was employed to identify the predictors with the most significant independent influence on prognosis. All participants were selected only after obtaining their written informed consent.  Results Most of the patients were in the age group of 21-30. 60% of the patients were male. Advanced age at presentation was associated with an increased risk of mortality (p-value=0.018). All patients presented to the hospital with symptoms of fever and altered sensorium. The most common agent isolated as the etiologic cause was HSV-1, found in 31.4% of the patients. 28.6% of the patients succumbed to death. The leading cause of death was raised intracranial pressure leading to hemorrhage in the brain. There was no significant correlation between the duration of symptoms and the primary outcome of death (p-value=0.498). The requirement for assisted ventilation was shown to increase the risk of death (p-value=0.001). A low GCS score at presentation was associated with a higher mortality rate (p-value=0.048).    Conclusions The factors that predict mortality in AES involve a complex interplay of patient demographics, viral etiology, clinical severity, neuroimaging findings, and the need for assisted ventilation. Integrating these factors into clinical practice would enable healthcare providers to make informed decisions regarding patient management and interventions. As our comprehension of AES continues to develop, forthcoming advancements in diagnostics and therapeutics could refine prognostic assessments further. These developments could open new avenues for enhancing outcomes and diminishing mortality rates in this complex neurological disorder.

Antiviral and anti-inflammatory activity of novel belladonna formulation against Japanese encephalitis virus via inhibition of p65 nuclear translocation and TNF-α mediated NF-kB signaling

Japanese encephalitis (JE) is a mosquito-borne flavivirus infection, a major cause of viral encephalitis in South-East Asia with a CFR of ~30% and no specific treatment. Therefore, a novel belladonna formulation (BCT) was prepared and its antiviral and anti-inflammatory activity was elucidated during Japanese encephalitis virus (JEV) infection. Anti-JEV role of BCT was investigated aiming to prevent the infection in the peripheral immune cells. Antiviral activity of BCT was evaluated by plaque reduction assay, cell survival and apoptosis assay. BCT-mediated reduction in JEV-envelope expression was measured by indirect immunofluorescence, RT-PCR and Western blot assays. NF-κB expression and p65 nuclear translocation assays were determined to explore the mechanism of the action of BCT. TNF-α level was measured to evaluate the anti-inflammatory role of BCT during JEV infection. Consequently, molecular docking was performed with the TRAF2-TRADD complex. Our data suggested that BCT treatment reduces the JEV-plaque formation, JEV-induced cytopathic effects and increases cell survival. The antiviral effect of BCT was confirmed by reduction in the JEV-envelope protein expression. Moreover, BCT treatment and prevents the NF-κB activation via preventing the nuclear translocation of p65 and reduces the TNF-α levels. Our molecular docking analysis suggested that belladonna alkaloids interfere with the TRAF2-TRADD complex that results in inhibition of TNF-induced NF-κB signaling. For the first time, our data suggested that BCT reduces JEV expression and interferes with TNF-induced NF-κB signaling, thereby increasing cell survival via preventing the p65 nuclear translocation and may be used for the treatment and prevention of JE.Abbreviation: CFR: Case fatality rate; CAM: Complementary and alternative medicines; COX-2: Cyclooxygenase-2; IκB: Inhibitor kappa B; JE: Japanese encephalitis; JEV: Japanese encephalitis virus; NF-κB: Nuclear factor kappa-light-chain-enhancer of activated B cells; ORF: Open reading frame; TNFR: Tumor necrosis factor receptor; TNF-α: Tumor necrosis factor-α; TRADD: TNFR1-associated death domain protein; TRAF2: TNF Receptor Associated Factor 2.

Antiviral Activity of Belladonna During Japanese Encephalitis Virus Infection via Inhibition of Microglia Activation and Inflammation Leading to Neuronal Cell Survival

Japanese encephalitis virus (JEV) is the main cause of viral encephalitis resulting in more than 68 000 clinical cases every year with case fatality rate as high as 30-40% for which no specific treatments are available. We have recently exhibited belladonna may be widely applicable for the treatment of various neurological disorders. Therefore, we developed a hydroalcoholic formulation of belladonna (B200) consisting of atropine and scopolamine and showed its antiviral efficacy against JEV infection. B200 treatment increases neuronal cell survival by reducing JEV induced cytopathic effects which were evident from significant reduction in necrotic cell population by flow-cytometry analysis and caspase 3 and 8 enzymatic activities. B200 treatment was found to reduce the intracellular JEV level observed by significant reduction in JEV-fluorescein isothiocyanate (FITC) expression in both neurons and microglia. Because microglia plays a crucial role in JEV pathogenesis, we further investigated the anti-JEV effects of B200 on human microglia cells and elucidated the mechanism of action by performing whole-transcriptome sequencing. Gene expression analysis revealed that B200 reduces the pro-apoptotic and inflammatory gene expression observed by significant reduction in BAD, BAX, CASP3, CASP8, IL1B, and CXCL10 and increase in IL10 responsive gene expression. Interestingly, our molecular docking analysis revealed that atropine and scopolamine interact with the His288 residue of NS3 protein, a crucial residue for RNA unwinding and ATPase activity that was further confirmed by degradation of NS3 protein. Drug likeness, ADME (absorption, distribution, metabolism, and excretion), and toxicity analysis further suggests that atropine and scopolamine both cross the blood-brain barrier, which is crucial for effective treatment of Japanese encephalitis (JE).

Dark Classics in Chemical Neuroscience: An Evidence-Based Systematic Review of Belladonna

Belladonna has diverse pharmacotherapeutic properties with a shadowy history of beauty, life, and death. Alkaloids present in belladonna have anti-inflammatory, anticholinergic, antispasmodic, mydriatic, analgesic, anticonvulsant, and antimicrobial activities, which makes it widely applicable for the treatment of various diseases. However, because of its associated toxicity, the medicinal use of belladonna is debatable. Therefore, an evidence-based systematic review was planned to elucidate the pharmacotherapeutic potential of belladonna. A comprehensive literature search was performed in PubMed, MEDLINE, the Cochrane database, Embase, and ClinicalTrials.gov using the keywords "belladonna", "belladonna and clinical trials", and "safety and efficacy of belladonna". Articles published from 1965 to 2020 showing the efficacy of belladonna in diverse clinical conditions are included. The quality of evidence was generated using the GRADE approach, and 20 studies involving 2302 patients were included for the systematic review. Our analyses suggest that belladonna treatment appears to be safe and effective in various disease conditions, including acute encephalitis syndrome, urethral stent pain, myocardial ischemia injury, airway obstructions during sleep in infants, climacteric complaints, irritable bowel syndrome, and throbbing headache. However, better understanding of the dosage and the toxicity of tropane alkaloids of belladonna could make it an efficient remedy for treating diverse medical conditions.

Calcarea carbonica treatment rescues lipopolysaccharide-induced inflammatory response in human mononuclear cells via downregulation of inducible cyclooxygenase pathway

OBJECTIVE

Prolonged use of nonsteroidal anti-inflammatory drugs is associated with severe side effects and toxicity. Therefore, we studied the anti-inflammatory role of Calcarea carbonica which had minimal toxicity at the low doses.

METHODS

THP-1 human mononuclear cells were treated with C. carbonica to evaluate the 50% cytotoxicity concentration (CC₅₀) and 50% effective concentration (EC₅₀). Cell survival was evaluated in lipopolysaccharide-stimulated C. carbonica-treated cells. Nitric oxide (NO) and tumor necrosis factor-α (TNF-α) were measured to evaluate the anti-inflammatory activity of C. carbonica. Cyclooxygenase-2 (COX-2) protein expression was determined by Western blotting analysis, and the interaction of C. carbonica with the COX-2 protein was evaluated using molecular docking simulation.

RESULTS

The CC₅₀ and EC₅₀ of C. carbonica were found to be 43.26 and 11.99 µg/mL, respectively. The cell survival assay showed a 1.192-fold (P = 0.0129), 1.443-fold (P = 0.0009) and 1.605-fold (P = 0.0004) increase in cell survival at 24, 48 and 72 h after initiating C. carbonica treatment, respectively. C. carbonica-treated cells showed a reduction in NO levels by 2.355 folds (P = 0.0001), 2.181 folds (P = 0.0001) and 2.071 folds (P = 0.0001) at 24, 48 and 72 h, respectively. The treated cells also showed a reduction in TNF-α levels by 1.395 folds (P = 0.0013), 1.541 folds (P = 0.0005) and 1.550 folds (P = 0.0005) at 24, 48 and 72 h, respectively. In addition, a 1.193-fold reduction (P = 0.0126) in COX-2 protein expression was found in C. carbonica-treated cells. The molecular docking showed interaction of C. carbonica with the phenylalanine 367 residue present in active site of Cox-2.

CONCLUSION

C. carbonica exhibited anti-inflammatory properties in lipopolysaccharide-stimulated cells by significantly reducing NO production and TNF-α level through downregulation of the COX-2 protein. This effect is probably mediated through interaction of C. carbonica with the phenylalanine 367 residue present in active site of Cox-2.