Preventing infections post-transplantation has been shown to greatly improve outcomes in KT patients. [1][2][3]5 The number of KTs performed has been rising gradually this decade. In 2019, 23 400 KTs were performed in the United States, which is 6300 more than the number of KTs recorded just 5 years ago. 6 As these numbers increase, care providers must be proactive in optimizing immunity against vaccine-preventable diseases since they are associated with high rates of morbidity and mortality post-transplantation. 7,8 Live attenuated vaccines, including the MMR vaccination, are not generally recommended in post-KT recipients since patients are on lifelong immunosuppression and are contraindicated. The AST Clinical Practice Guidelines advise that live virus vaccine serologic screening for MMR be conducted for all pre-KT candidates and MMR vaccinations be given if required as early as possible before KT procedure. 4
The COVID-19 pandemic continues to overwhelm global healthcare systems. While the disease primarily causes pulmonary complications, reports of central nervous system (CNS) involvement have recently emerged ranging from encephalopathy to stroke. This raises a practical dilemma for clinicians as to when to pursue neuroimaging and lumbar tap with cerebrospinal fluid (CSF) analysis in COVID-19 patients with neurological symptoms. We present a case of an encephalopathic patient infected with SARS-CoV-2 with no pulmonary symptoms. We propose a three-tier risk stratification for CNS COVID-19 aiming to help clinicians to decide which patients should undergo CSF analysis. The neurological examination remains an integral component of screening and evaluating patients for COVID-19 considering the range of emerging CNS complications.
Introduction
Post-operative meningitis (POM) is a life-threatening complication of neurosurgery. Diagnosis is often difficult due to pre-existing inflammation and antecedent antimicrobial use. Bacterial cerebrospinal fluid (CSF) cultures may reveal no growth, but empiric antibiotics are typically given due to the high morbidity and mortality associated with POM. 16S rRNA gene PCR/sequencing is a molecular methodology that can identify the presence of bacteria regardless of viability for culture.
Case Presentation
A patient presented with a rapid onset of fever associated with headache, neck pain, nausea and altered mental status 11 days after undergoing laser interstitial thermal therapy for treatment of recurrent astrocytoma at another hospital. Based on clinical presentation and imaging, POM was suspected, and empiric antibacterial therapy was started. Microbiological stains and cultures of CSF were negative. Due to persistent fevers, 16S rRNA gene PCR/sequencing was done on CSF; it detected a member of the order
Enterobacteriales
most closely resembling
Serratia
species. All antimicrobials were stopped except for cefepime, which was given for 2 weeks. The patient’s mental status fully recovered.
Conclusion
The application of 16S rRNA gene PCR/sequencing in the setting of POM is of value by improving the quality of patient care and decreasing costs by antimicrobial de-escalation. Further studies regarding the positive and negative predictive values of this test are required.
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