Clinicopathology conference: 41‐year‐old woman with chronic relapsing meningitis

Beck, Erin; Ramachandran, Prashanth; Khan, Lillian M.; Zorn, Kelsey C.; O’Connell, Elise M.; Nash, Theodore E.; Reich, Daniel S.; Venkatesan, Arun; DeRisi, Joseph L.; Nath, Avindra; Wilson, Michael R.

doi:10.1002/ana.25400

Cited by 18 publications

(18 citation statements)

References 81 publications

(171 reference statements)

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“…Importantly, mNGS can detect unsuspected pathogens that clinicians may fail to consider because of atypical clinical manifestations. Many cases of neurological infections have been unexpectedly diagnosed by mNGS of CSF 11,22,29,30 similar to the present study for the cases of L. monocytogenes , Brucella and T. solium 12–14 . In addition, as demonstrated in previous studies 10,20,21 and in the present study for the case of encephalitis caused by Suid herpesvirus 1 31 , mNGS of CSF has the ability to identify novel aetiologies of CNS infections.…”

Section: Discussionsupporting

confidence: 88%

Metagenomic Next-generation Sequencing of Cerebrospinal Fluid for the Diagnosis of Central Nervous System Infections: A Multicentre Prospective Study

Fan

Wang

et al. 2019

Preprint

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BackgroundInfectious encephalitis and meningitis are often treated empirically without identification of the causative pathogen. Metagenomic next-generation sequencing (mNGS) is a high throughput technology that enables the detection of pathogens independent of prior clinical or laboratory information.MethodsThe present study was a multicentre prospective evaluation of mNGS of cerebrospinal fluid (CSF) for the diagnosis of suspected central nervous system infections.ResultsA total of 276 patients were enrolled in this study between Jan 1, 2017 and Jan 1, 2018. Identification of an etiologic pathogen in CSF by mNGS was achieved in 101 patients (36.6%). mNGS detected 11 bacterial species, 7 viral species, 2 fungal species, and 2 parasitic species. The five leading positive detections were varicella-zoster virus (17), Mycobacterium tuberculosis (14), herpes simplex virus 1 (12), Epstein-Barr virus (12), and Cryptococcus neoformans (7). False positives occurred in 12 (4.3%) patients with bacterial infections known to be widespread in hospital environments. False negatives occurred in 16 (5.8%) patients and included bacterial, viral and fungal aetiologies.ConclusionsmNGS of CSF is a powerful diagnostic method to identify the pathogen for many central nervous system infections.

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Section: Discussionsupporting

confidence: 88%

Metagenomic Next-generation Sequencing of Cerebrospinal Fluid for the Diagnosis of Central Nervous System Infections: A Multicentre Prospective Study

Fan

Wang

et al. 2019

Preprint

View full text Add to dashboard Cite

show abstract

“…Importantly, mNGS can detect unsuspected pathogens that clinicians may fail to consider because of atypical clinical manifestations. Many cases of neurological infections have been unexpectedly diagnosed by mNGS of CSF [11,22,29,30] similar to the present study for the cases of L. monocytogenes, Brucella and T. solium [12][13][14]. In addition, as demonstrated in previous studies [10,20,21] and in the present study for the case of encephalitis caused by Suid herpesvirus 1 [31], mNGS of CSF has the ability to identify novel aetiologies of CNS infections.…”

Section: Discussionsupporting

confidence: 90%

Metagenomic Next-generation Sequencing of Cerebrospinal Fluid for the Diagnosis of Central Nervous System Infections: A Multicentre Cohort Study

Fan

Wang

et al. 2019

Preprint

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Background: Infectious encephalitis and meningitis are often treated empirically without identification of the causative pathogen, even if comprehensive conventional diagnostic technologies are applied. Metagenomic next-generation sequencing (mNGS) is a high throughput technology that enables the detection of pathogens independent of prior clinical or laboratory information.Methods: The present study was a multicentre prospective evaluation of mNGS of cerebrospinal fluid (CSF) for the diagnosis of suspected central nervous system infections in China, where routine PCR was not widely used. Results: A total of 276 patients were enrolled in this study between Jan 1, 2017 and Jan 1, 2018. Identification of an aetiologic pathogen in CSF by mNGS was achieved in 101 patients (36.6%). mNGS detected 11 bacterial species, 7 viral species, 2 fungal species, and 2 parasitic species. The leading positive detections were Mycobacterium tuberculosis (14), Listeria monocytogenes (8), Brucella (7), varicella-zoster virus (17), herpes simplex virus 1 (12), Epstein-Barr virus (12), and Cryptococcus neoformans (7). False positives occurred in 12 (4.3%) patients with bacterial infections known to be widespread in hospital environments. False negatives occurred in 16 (5.8%) patients and included bacterial, viral and fungal aetiologies. Conclusions: This study shows that mNGS of CSF is a powerful diagnostic method to identify the pathogen for many central nervous system infections. The result of mNGS should be interpreted with clinical information sometimes.

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“…Patient 28, who migrated to the United States from India (Supplemental Figure 4), was undiagnosed for 15 years, despite multiple clinical flares and evaluations at referral institutions/ hospitals for spinal symptoms in the setting of lymphocytic pleocytosis. 25 Other NCC involvement. Half of the cohort had one or more other disease manifestations of NCC (Table 2).…”

Section: Resultsmentioning

confidence: 99%

“…Anakinra, an interleukin 1 receptor antagonist, was prescribed only in patient 28 before the diagnosis of NCC and continued after the diagnosis in an attempt to better control spinal nerve pain. 25 Consideration to stop therapy occurred when MRI imaging was improved with moderation and stabilization of enhancement, decreased or serial decreases in cestode antigen concentrations to low or undetectable levels, successive decrease in CSF WBC counts, and improved or stable clinical state of the patient.…”

Section: Resultsmentioning

confidence: 99%

Natural History of Treated Subarachnoid Neurocysticercosis

Nash

O’Connell

Hammoud

et al. 2020

The American Journal of Tropical Medicine and Hygiene

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Subarachnoid neurocysticercosis (SUBNCC) is usually caused by an aberrant proliferative form of Taenia solium causing mass effect and arachnoiditis. Thirty of 34 SUBNCC patients were treated with extended cysticidal and anti-inflammatory regimens and followed up a median of 4.2 years posttreatment (range: 15 for ³ 4 years, 20 ³ 2 years, 26 > 1 year, and 3 < 1 year). The median ages at the time of first symptom, diagnosis, and enrollment were 29.7, 35.6, and 37.9 years, respectively; 58.8% were male and 82.4% were Hispanic. The median time from immigration to symptoms (minimum incubation) was 10 years and the estimated true incubation period considerably greater. Fifty percent also had other forms of NCC. Common complications were hydrocephalus (56%), shunt placement (41%), infarcts (18%), and symptomatic spinal disease (15%). Thirty patients (88.2%) required prolonged treatment with albendazole (88.2%, median 0.55 year) and/or praziquantel (61.8%; median 0.96 year), corticosteroids (88.2%, median 1.09 years), methotrexate (50%, median 1.37 years), and etanercept (34.2%, median 0.81 year), which led to sustained inactive disease in 29/30 (96.7%) patients. Three were treated successfully for recurrences and one has continuing infection. Normalization of cerebral spinal fluid parameters and cestode antigen levels guided treatment decisions. All 15 patients with undetectable cestode antigen values have sustained inactive disease. There were no deaths and moderate morbidity posttreatment. Corticosteroid-related side effects were common, avascular necrosis of joints being the most serious (8/33, 24.2%). Prolonged cysticidal treatment and effective control of inflammation led to good clinical outcomes and sustained inactive disease which is likely curative.

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Clinicopathology conference: 41‐year‐old woman with chronic relapsing meningitis

Cited by 18 publications

References 81 publications

Metagenomic Next-generation Sequencing of Cerebrospinal Fluid for the Diagnosis of Central Nervous System Infections: A Multicentre Prospective Study

Metagenomic Next-generation Sequencing of Cerebrospinal Fluid for the Diagnosis of Central Nervous System Infections: A Multicentre Prospective Study

Metagenomic Next-generation Sequencing of Cerebrospinal Fluid for the Diagnosis of Central Nervous System Infections: A Multicentre Cohort Study

Natural History of Treated Subarachnoid Neurocysticercosis

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