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Kvam KA, Stahl JP, Chow FC, Soldatos A, Tattevin P, Sejvar J, Mailles A. Outcome and Sequelae of Infectious Encephalitis. J Clin Neurol 2024; 20:23-36. [PMID: 38179629 PMCID: PMC10782093 DOI: 10.3988/jcn.2023.0240] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 10/04/2023] [Accepted: 10/23/2023] [Indexed: 01/06/2024] Open
Abstract
Acute infectious encephalitis is a widely studied clinical syndrome. Although identified almost 100 years ago, its immediate and delayed consequences are still neglected despite their high frequency and possible severity. We reviewed the available data on sequelae and persisting symptoms following infectious encephalitis with the aim of characterizing the clinical picture of these patients at months to years after hospitalization. We searched PubMed for case series involving sequelae after infectious encephalitis. We carried out a narrative review of the literature on encephalitis caused by members of the Herpesviridae family (herpes simplex virus, varicella zoster virus, and human herpesvirus-6), members of the Flaviviridae family (West Nile virus, tick-borne encephalitis virus, and Japanese encephalitis virus), alphaviruses, and Nipah virus. We retrieved 41 studies that yielded original data involving 3,072 adult patients evaluated after infectious encephalitis. At least one of the five domains of cognitive outcome, psychiatric disorders, neurological deficits, global functioning, and quality of life was investigated in the reviewed studies. Various tests were used in the 41 studies and the investigation took place at different times after hospital discharge. The results showed that most patients are discharged with impairments, with frequent deficits in cognitive function such as memory loss or attention disorders. Sequelae tend to improve within several years following flavivirus or Nipah virus infection, but long-term data are scarce for other pathogens. Further research is needed to better understand the extent of sequelae after infectious encephalitis, and to propose a standardized assessment method and assess the rehabilitation efficacy in these patients.
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Affiliation(s)
- Kathryn A Kvam
- Department of Neurology & Neurological Sciences, Center for Academic Medicine, Stanford University, Stanford, CA, USA
| | | | - Felicia C Chow
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, CA, USA
| | - Ariane Soldatos
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Pierre Tattevin
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - James Sejvar
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alexandra Mailles
- Department of Infectious Diseases, Santé publique France, Saint-Maurice, France.
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2
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Lanni F, Antilus Sainte R, Hansen, M, Parigi P, Kaya F, LoMauro K, Siow B, Wilkinson RJ, Wasserman S, Podell BK, Gengenbacher M, Dartois V. A preclinical model of TB meningitis to determine drug penetration and activity at the sites of disease. Antimicrob Agents Chemother 2023; 67:e0067123. [PMID: 37966227 PMCID: PMC10720511 DOI: 10.1128/aac.00671-23] [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: 05/25/2023] [Accepted: 09/29/2023] [Indexed: 11/16/2023] Open
Abstract
Tuberculosis meningitis (TBM) is essentially treated with the first-line regimen used against pulmonary tuberculosis, with a prolonged continuation phase. However, clinical outcomes are poor in comparison, for reasons that are only partially understood, highlighting the need for improved preclinical tools to measure drug distribution and activity at the site of disease. A predictive animal model of TBM would also be of great value to prioritize promising drug regimens to be tested in clinical trials, given the healthy state of the development pipeline for the first time in decades. Here, we report the optimization of a rabbit model of TBM disease induced via inoculation of Mycobacterium tuberculosis into the cisterna magna, recapitulating features typical of clinical TBM: neurological deterioration within months post-infection, acid-fast bacilli in necrotic lesions in the brain and spinal cord, and elevated lactate levels in cerebrospinal fluid (CSF). None of the infected rabbits recovered or controlled the disease. We used young adult rabbits, the size of which allows for spatial drug quantitation in critical compartments of the central nervous system that cannot be collected in clinical studies. To illustrate the translational value of the model, we report the penetration of linezolid from plasma into the CSF, meninges, anatomically distinct brain areas, cervical spine, and lumbar spine. Across animals, we measured the bacterial burden concomitant with neurological deterioration, offering a useful readout for drug efficacy studies. The model thus forms the basis for building a preclinical platform to identify improved regimens and inform clinical trial design.
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Affiliation(s)
- Faye Lanni
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | | | - Mark Hansen,
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Paul Parigi
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Firat Kaya
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Katherine LoMauro
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
| | - Bernard Siow
- The Francis Crick Institute, London, United Kingdom
| | - Robert J. Wilkinson
- The Francis Crick Institute, London, United Kingdom
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Brendan K. Podell
- Mycobacteria Research Laboratories, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Martin Gengenbacher
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Véronique Dartois
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey, USA
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
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3
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Ardiansyah E, Avila-Pacheco J, Nhat LTH, Dian S, Vinh DN, Hai HT, Bullock K, Alisjahbana B, Netea MG, Estiasari R, Tram TTB, Donovan J, Heemskerk D, Chau TTH, Bang ND, Ganiem AR, Ruslami R, Koeken VACM, Hamers RL, Imran D, Maharani K, Kumar V, Clish CB, van Crevel R, Thwaites G, van Laarhoven A, Thuong NTT. Tryptophan metabolism determines outcome in tuberculous meningitis: a targeted metabolomic analysis. eLife 2023; 12:e85307. [PMID: 37158692 PMCID: PMC10181821 DOI: 10.7554/elife.85307] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 05/01/2023] [Indexed: 05/10/2023] Open
Abstract
Background Cellular metabolism is critical for the host immune function against pathogens, and metabolomic analysis may help understand the characteristic immunopathology of tuberculosis. We performed targeted metabolomic analyses in a large cohort of patients with tuberculous meningitis (TBM), the most severe manifestation of tuberculosis, focusing on tryptophan metabolism. Methods We studied 1069 Indonesian and Vietnamese adults with TBM (26.6% HIV-positive), 54 non-infectious controls, 50 with bacterial meningitis, and 60 with cryptococcal meningitis. Tryptophan and downstream metabolites were measured in cerebrospinal fluid (CSF) and plasma using targeted liquid chromatography-mass spectrometry. Individual metabolite levels were associated with survival, clinical parameters, CSF bacterial load and 92 CSF inflammatory proteins. Results CSF tryptophan was associated with 60-day mortality from TBM (hazard ratio [HR] = 1.16, 95% confidence interval [CI] = 1.10-1.24, for each doubling in CSF tryptophan) both in HIV-negative and -positive patients. CSF tryptophan concentrations did not correlate with CSF bacterial load nor CSF inflammation but were negatively correlated with CSF interferon-gamma concentrations. Unlike tryptophan, CSF concentrations of an intercorrelating cluster of downstream kynurenine metabolites did not predict mortality. These CSF kynurenine metabolites did however correlate with CSF inflammation and markers of blood-CSF leakage, and plasma kynurenine predicted death (HR 1.54, 95% CI = 1.22-1.93). These findings were mostly specific for TBM, although high CSF tryptophan was also associated with mortality from cryptococcal meningitis. Conclusions TBM patients with a high baseline CSF tryptophan or high systemic (plasma) kynurenine are at increased risk of death. These findings may reveal new targets for host-directed therapy. Funding This study was supported by National Institutes of Health (R01AI145781) and the Wellcome Trust (110179/Z/15/Z and 206724/Z/17/Z).
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Affiliation(s)
- Edwin Ardiansyah
- Research Center for Care and Control of Infectious Diseases, Universitas PadjadjaranBandungIndonesia
- Department of Internal Medicine and Radboud Center of Infectious Diseases (RCI), Radboud University Medical CenterNijmegenNetherlands
| | | | | | - Sofiati Dian
- Research Center for Care and Control of Infectious Diseases, Universitas PadjadjaranBandungIndonesia
- Department of Neurology, Hasan Sadikin Hospital, Faculty of Medicine, Universitas PadjadjaranBandungIndonesia
| | - Dao Nguyen Vinh
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
| | - Hoang Thanh Hai
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
| | - Kevin Bullock
- The Broad Institute of MIT and HarvardCambridgeUnited States
| | - Bachti Alisjahbana
- Research Center for Care and Control of Infectious Diseases, Universitas PadjadjaranBandungIndonesia
- Department of Internal Medicine, Hasan Sadikin Hospital, Faculty of Medicine, Universitas PadjadjaranBandungIndonesia
| | - Mihai G Netea
- Department of Internal Medicine and Radboud Center of Infectious Diseases (RCI), Radboud University Medical CenterNijmegenNetherlands
| | - Riwanti Estiasari
- Department of Neurology, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas IndonesiaJakartaIndonesia
| | | | - Joseph Donovan
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of OxfordOxfordUnited Kingdom
- London School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Dorothee Heemskerk
- Department of Medical Microbiology and Infection Prevention, Amsterdam University Medical CentreAmsterdamNetherlands
| | - Tran Thi Hong Chau
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
- Hospital for Tropical DiseasesHo Chi Minh CityViet Nam
| | - Nguyen Duc Bang
- Pham Ngoc Thach Hospital for Tuberculosis and Lung DiseaseHo Chi Minh CityViet Nam
| | - Ahmad Rizal Ganiem
- Research Center for Care and Control of Infectious Diseases, Universitas PadjadjaranBandungIndonesia
- Department of Neurology, Hasan Sadikin Hospital, Faculty of Medicine, Universitas PadjadjaranBandungIndonesia
| | - Rovina Ruslami
- Research Center for Care and Control of Infectious Diseases, Universitas PadjadjaranBandungIndonesia
- Department of Biomedical Science, Faculty of Medicine, Universitas PadjadjaranBandungIndonesia
| | - Valerie ACM Koeken
- Department of Internal Medicine and Radboud Center of Infectious Diseases (RCI), Radboud University Medical CenterNijmegenNetherlands
- Department of Computational Biology for Individualised Infection Medicine, Centre for Individualised Infection Medicine (CiiM) & TWINCORE, joint ventures between the Helmholtz-Centre for Infection Research (HZI) and the Hannover Medical School (MHH)HanoverGermany
| | - Raph L Hamers
- Oxford University Clinical Research Unit Indonesia, Faculty of Medicine Universitas IndonesiaJakartaIndonesia
| | - Darma Imran
- Department of Neurology, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas IndonesiaJakartaIndonesia
| | - Kartika Maharani
- Department of Neurology, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas IndonesiaJakartaIndonesia
| | - Vinod Kumar
- Department of Internal Medicine and Radboud Center of Infectious Diseases (RCI), Radboud University Medical CenterNijmegenNetherlands
| | - Clary B Clish
- The Broad Institute of MIT and HarvardCambridgeUnited States
| | - Reinout van Crevel
- Department of Internal Medicine and Radboud Center of Infectious Diseases (RCI), Radboud University Medical CenterNijmegenNetherlands
| | - Guy Thwaites
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of OxfordOxfordUnited Kingdom
| | - Arjan van Laarhoven
- Department of Internal Medicine and Radboud Center of Infectious Diseases (RCI), Radboud University Medical CenterNijmegenNetherlands
| | - Nguyen Thuy Thuong Thuong
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of OxfordOxfordUnited Kingdom
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Mason S, Solomons R. CSF Metabolomics of Tuberculous Meningitis: A Review. Metabolites 2021; 11:661. [PMID: 34677376 PMCID: PMC8541251 DOI: 10.3390/metabo11100661] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/20/2021] [Accepted: 09/24/2021] [Indexed: 02/07/2023] Open
Abstract
From the World Health Organization's global TB report for 2020, it is estimated that in 2019 at least 80,000 children (a particularly vulnerable population) developed tuberculous meningitis (TBM)-an invariably fatal disease if untreated-although this is likely an underestimate. As our latest technologies have evolved-with the unprecedented development of the various "omics" disciplines-a mountain of new data on infectious diseases have been created. However, our knowledge and understanding of infectious diseases are still trying to keep pace. Metabolites offer much biological information, but the insights they permit can be difficult to derive. This review summarizes current metabolomics studies on cerebrospinal fluid (CSF) from TBM cases and collates the metabolic data reported. Collectively, CSF metabolomics studies have identified five classes of metabolites that characterize TBM: amino acids, organic acids, nucleotides, carbohydrates, and "other". Taken holistically, the information given in this review serves to promote the mechanistic action of hypothesis generation that will drive and direct future studies on TBM.
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Affiliation(s)
- Shayne Mason
- Human Metabolomics, Faculty of Natural and Agricultural Sciences, North-West University, Potchefstroom 2531, South Africa
| | - Regan Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg 7505, South Africa;
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Tucker EW, Marais S, Seddon JA, van Crevel R, Ganiem AR, Ruslami R, Zhang W, Sun F, Zhou X, Solomons RS, Cresswell FV, Wilmshurst J, Rohlwink U. International Survey Reveals Opportunities to Improve Tuberculous Meningitis Management and the Need for Standardized Guidelines. Open Forum Infect Dis 2020; 7:ofaa445. [PMID: 33209947 PMCID: PMC7652100 DOI: 10.1093/ofid/ofaa445] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/17/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Tuberculous meningitis (TBM) is a medical emergency, yet there are no standardized treatment guidelines for the medical or neurosurgical management of these patients and little data on neurocritical care. We conducted an international survey to understand current medical and neurosurgical TBM management and resource availability to provide baseline data needed for future multicenter trials addressing unanswered clinical research questions and the establishment of standardized guidelines. METHODS An online survey of 77 questions covering medical and neurosurgical TBM management aimed at clinicians/nurses treating TBM was distributed as an anonymous link through email invitation, international organizations' membership distribution, and direct links on organizational webpages or social media. The survey remained open for 5 months. Data were summarized with frequencies and percentages. RESULTS The survey had 222 responses from 43 countries representing 6 continents. Most respondents were from tertiary care facilities, with broad access to medical and neurosurgical resources. There was significant heterogeneity in general supportive care, and TBM-specific management demonstrated considerable divergence from current standard-of-care practices. The lack of standardized guidelines was identified as a major challenge in TBM management. General and neurocritical care were largely absent. Resources for bedside supportive care and noninvasive monitoring were broadly accessible. CONCLUSIONS These findings suggest that current TBM management could be improved by the establishment of internationally accepted treatment guidelines based on available evidence, and that numerous centers have resources available to participate in future multicenter trials, even for basic interventions, that may further improve patient outcomes globally.
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Affiliation(s)
- Elizabeth W Tucker
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Pediatric Critical Care, Johns Hopkins All Children’s Hospital, St. Petersburg, Florida, USA
| | - Suzaan Marais
- Division of Neurology, Department of Medicine and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - James A Seddon
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Reinout van Crevel
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Ahmad Rizal Ganiem
- Department of Neurology, Hasan Sadikin Hospital, Faculty of Medicine Universitas Padjadjaran, Bandung, Indonesia
| | - Rovina Ruslami
- Department of Neurology, Hasan Sadikin Hospital, Faculty of Medicine Universitas Padjadjaran, Bandung, Indonesia
| | - Wenhong Zhang
- Departments of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Feng Sun
- Departments of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Xian Zhou
- Departments of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Regan S Solomons
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Fiona V Cresswell
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Infectious Disease Institute, Mulago College of Health Sciences, Kampala, Uganda
- MRC-UVRI LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Jo Wilmshurst
- Neuroscience Institute and Department of Paediatric Neurology, University of Cape Town, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
| | - Ursula Rohlwink
- Division of Neurosurgery, Department of Surgery and Neuroscience Institute, University of Cape Town, Faculty of Health Sciences, Cape Town, South Africa
- The Francis Crick Institute, London, United Kingdom
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