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Dyckhoff-Shen S, Pfister HW, Koedel U, Klein M. PCR-positive meningococcal CSF infection without pleocytosis but high IL-6 and IL-8. Infection 2024:10.1007/s15010-024-02275-0. [PMID: 38678151 DOI: 10.1007/s15010-024-02275-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 04/16/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND Meningococcal meningitis is still a severe disease causing high mortality and morbidity rates. Early diagnosis is crucial to ensure prompt antibiotic therapy. However, identification of the pathogen can be challenging. CASE PRESENTATION A 32-year-old male patient with systemic lupus erythematosus (SLE) presented to the emergency room with fever, nausea, vomiting, headache and lower back pain as well as multiple petechial bleedings. On suspicion of meningococcal infection, the emergency doctor had already administered one dose of ceftriaxone before arrival to the clinic. Blood works showed massive inflammation due to bacterial infection. Cerebrospinal fluid (CSF) analysis showed normal cell count, protein and glucose levels but PCR was positive for Neisseria meningitis and IL-6 as well as IL-8 were elevated. On antibiotic therapy with ceftriaxone, the patient's condition improved quickly. CONCLUSIONS We present a rare case of meningococcal infection of the CSF in a SLE patient without further CSF abnormalities. We discuss the involvement of early antibiotic treatment and the role of the patient's immune status in the normal CSF findings of this case. Moreover, this case demonstrates the importance of early antibiotic therapy in bacterial meningitis for the clinical outcome.
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Affiliation(s)
- Susanne Dyckhoff-Shen
- Department of Neurology with Friedrich-Baur-Institute, LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | - Hans-Walter Pfister
- Department of Neurology with Friedrich-Baur-Institute, LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Uwe Koedel
- Department of Neurology with Friedrich-Baur-Institute, LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Matthias Klein
- Department of Neurology with Friedrich-Baur-Institute, LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- Emergency Department, LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
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2
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Mueller TT, Pilartz M, Thakur M, LangHeinrich T, Luo J, Block R, Hoeflinger JKL, Meister S, Karaj F, Perez LG, Öllinger R, Engleitner T, Thoss J, Voelkl M, Tersteeg C, Koedel U, Kohlmaier AZ, Teupser D, Wygrecka M, Ye H, Preissner KT, Radbruch H, Elezkurtaj S, Mack M, Von Hundelshausen P, Weber C, Massberg S, Schulz C, Rad R, Huber S, Ishikawa-Ankerhold H, Engelmann B. Mutual regulation of CD4+ T cells and intravascular fibrin in infections. Haematologica 2024. [PMID: 38572559 DOI: 10.3324/haematol.2023.284619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Indexed: 04/05/2024] Open
Abstract
Innate myeloid cells especially neutrophils and their extracellular traps are known to promote intravascular coagulation and thrombosis formation in infections and various other conditions. Innate myeloid cell dependent fibrin formation can support systemic immunity while its dysregulation enhances the severity of infectious diseases. Less is known about the immune mechanisms preventing dysregulation of fibrin homeostasis in infection. During experimental systemic infections local fibrin deposits in the liver microcirculation cause rapid arrest of CD4+ T cells. Arrested T helper cells mostly represent Th17 cells that partially originate from the small intestine. Intravascular fibrin deposits activate mouse and human CD4+ T cells which can be mediated by direct fibrin - CD4+ T cell interactions. Activated CD4+ T cells suppress fibrin deposition and microvascular thrombosis by directly counteracting coagulation activation by neutrophils and classical monocytes. T cell activation, which is initially triggered by IL- 12p40- and MHC-II dependent mechanisms, enhances intravascular fibrinolysis via LFA-1. Moreover, CD4+ T cells disfavor the association of the fibrinolysis inhibitor TAFI with fibrin whereby fibrin deposition is increased by TAFI in the absence but not presence of T cells. In human infections thrombosis development is inversely related to microvascular levels of CD4+ T cells. Thus, fibrin promotes LFA-1 dependent T helper cell activation in infections which drives a negative feedback cycle that rapidly restricts intravascular fibrin and thrombosis development.
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Affiliation(s)
- Tonina T Mueller
- Institut für Laboratoriumsmedizin, Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU), Munich, Germany; Medizinische Klinik I, Klinikum der Universität München, LMU, Munich.
| | - Mona Pilartz
- Institut für Laboratoriumsmedizin, Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU), Munich
| | - Manovriti Thakur
- Institut für Laboratoriumsmedizin, Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU), Munich
| | - Torben LangHeinrich
- Institut für Laboratoriumsmedizin, Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU), Munich
| | - Junfu Luo
- Institut für Laboratoriumsmedizin, Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU), Munich
| | - Rebecca Block
- Institut für Laboratoriumsmedizin, Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU), Munich
| | - Jonathan K L Hoeflinger
- Institut für Laboratoriumsmedizin, Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU), Munich
| | - Sarah Meister
- Institut für Laboratoriumsmedizin, Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU), Munich
| | - Flavio Karaj
- Institut für Laboratoriumsmedizin, Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU), Munich
| | - Laura Garcia Perez
- 1. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Rupert Öllinger
- Institut für Molekulare Onkologie und Funktionelle Genomik, Technische Universität München, Munich
| | - Thomas Engleitner
- Institut für Molekulare Onkologie und Funktionelle Genomik, Technische Universität München, Munich
| | - Jakob Thoss
- Institut für Laboratoriumsmedizin, Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU), Munich
| | - Michael Voelkl
- Institut für Laboratoriumsmedizin, Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU), Munich
| | - Claudia Tersteeg
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk
| | - Uwe Koedel
- Neurologische Klinik, Klinikum der Universität München,LMU, Munich
| | - Alexander Zigman Kohlmaier
- Institut für Laboratoriumsmedizin, Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU), Munich
| | - Daniel Teupser
- Institut für Laboratoriumsmedizin, Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU), Munich
| | - Malgorzata Wygrecka
- Center for Infection and Genomics of the Lung (CIGL), Justus-Liebig-Universität, Giessen
| | - Haifeng Ye
- Institute of Regenerative Biology and Medicine, Helmholtz-Zentrum München, Munich
| | | | - Helena Radbruch
- Institut für Neuropathologie, Charité - Universitätsmedizin, Berlin
| | | | - Matthias Mack
- Medizinische Klinik II, University of Regensburg, Regensburg
| | - Philipp Von Hundelshausen
- Institut für Prophylaxe und Epidemiologie der Kreislaufkrankheiten, Ludwig-Maximilians-Universität, Munich
| | - Christian Weber
- Institut für Prophylaxe und Epidemiologie der Kreislaufkrankheiten, Ludwig-Maximilians-Universität, Munich
| | - Steffen Massberg
- Medizinische Klinik I, Klinikum der Universität München, LMU, Munich
| | - Christian Schulz
- Medizinische Klinik I, Klinikum der Universität München, LMU, Munich
| | - Roland Rad
- Institut für Molekulare Onkologie und Funktionelle Genomik, Technische Universität München, Munich
| | - Samuel Huber
- 1. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | | | - Bernd Engelmann
- Institut für Laboratoriumsmedizin, Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU), Munich.
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Dyckhoff-Shen S, Bruegel M, Koedel U, Klein M. Author reply to "reporting standards for cerebrospinal fluid studies: more transparency of laboratory data is needed" by JL Frater. Infection 2024; 52:697-698. [PMID: 37947972 PMCID: PMC10954991 DOI: 10.1007/s15010-023-02134-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Susanne Dyckhoff-Shen
- Department of Neurology, Ludwigs Maximilians University (LMU) Hospital, Munich, Germany.
| | - Mathias Bruegel
- Institute of Laboratory Medicine, Ludwigs Maximilians University (LMU) Hospital, Munich, Germany
| | - Uwe Koedel
- Department of Neurology, Ludwigs Maximilians University (LMU) Hospital, Munich, Germany
| | - Matthias Klein
- Department of Neurology, Ludwigs Maximilians University (LMU) Hospital, Munich, Germany
- Emergency Department, Ludwigs Maximilians University (LMU) Hospital, Munich, Germany
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Dyckhoff-Shen S, Koedel U, Brouwer MC, Bodilsen J, Klein M. ChatGPT fails challenging the recent ESCMID brain abscess guideline. J Neurol 2024; 271:2086-2101. [PMID: 38279999 DOI: 10.1007/s00415-023-12168-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 01/29/2024]
Abstract
BACKGROUND With artificial intelligence (AI) on the rise, it remains unclear if AI is able to professionally evaluate medical research and give scientifically valid recommendations. AIM This study aimed to assess the accuracy of ChatGPT's responses to ten key questions on brain abscess diagnostics and treatment in comparison to the guideline recently published by the European Society for Clinical Microbiology and Infectious Diseases (ESCMID). METHODS All ten PECO (Population, Exposure, Comparator, Outcome) questions which had been developed during the guideline process were presented directly to ChatGPT. Next, ChatGPT was additionally fed with data from studies selected for each PECO question by the ESCMID committee. AI's responses were subsequently compared with the recommendations of the ESCMID guideline. RESULTS For 17 out of 20 challenges, ChatGPT was able to give recommendations on the management of patients with brain abscess, including grade of evidence and strength of recommendation. Without data prompting, 70% of questions were answered very similar to the guideline recommendation. In the answers that differed from the guideline recommendations, no patient hazard was present. Data input slightly improved the clarity of ChatGPT's recommendations, but, however, led to less correct answers including two recommendations that directly contradicted the guideline, being associated with the possibility of a hazard to the patient. CONCLUSION ChatGPT seems to be able to rapidly gather information on brain abscesses and give recommendations on key questions about their management in most cases. Nevertheless, single responses could possibly harm the patients. Thus, the expertise of an expert committee remains inevitable.
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Affiliation(s)
- Susanne Dyckhoff-Shen
- Department of Neurology with Friedrich-Baur-Institute, LMU University Hospital, LMU Munich (en.), Klinikum Grosshadern of the Ludwig Maximilians University of Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | - Uwe Koedel
- Department of Neurology with Friedrich-Baur-Institute, LMU University Hospital, LMU Munich (en.), Klinikum Grosshadern of the Ludwig Maximilians University of Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Matthijs C Brouwer
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
- European Society for Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Infections of the Brain (ESGIB), Basel, Switzerland
| | - Jacob Bodilsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
- European Society for Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Infections of the Brain (ESGIB), Basel, Switzerland
| | - Matthias Klein
- Department of Neurology with Friedrich-Baur-Institute, LMU University Hospital, LMU Munich (en.), Klinikum Grosshadern of the Ludwig Maximilians University of Munich, Marchioninistr. 15, 81377, Munich, Germany
- Emergency Department, LMU University Hospital, LMU Munich (en.), Munich, Germany
- European Society for Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Infections of the Brain (ESGIB), Basel, Switzerland
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5
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Dyckhoff-Shen S, Masouris I, Islam H, Hammerschmidt S, Angele B, Marathe V, Buer J, Völk S, Pfister HW, Klein M, Koedel U, Kirschning CJ. Combining antibiotic with anti-TLR2/TLR13 therapy prevents brain pathology in pneumococcal meningitis. JCI Insight 2024; 9:e165737. [PMID: 38358825 DOI: 10.1172/jci.insight.165737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 02/14/2024] [Indexed: 02/17/2024] Open
Abstract
Despite effective antibiotic therapy, brain-destructive inflammation often cannot be avoided in pneumococcal meningitis. The causative signals are mediated predominantly through TLR-recruited myeloid differentiation primary response adaptor 88 (MyD88), as indicated by a dramatic pneumococcal meningitis phenotype of Myd88-/- mice. Because lipoproteins and single-stranded RNA are crucial for recognition of Gram-positive bacteria such as Streptococcus pneumoniae by the host immune system, we comparatively analyzed the disease courses of Myd88-/- and Tlr2-/- Tlr13-/- mice. Their phenotypic resemblance indicated TLR2 and -13 as master sensors of S. pneumoniae in the cerebrospinal fluid. A neutralizing anti-TLR2 antibody (T2.5) and chloroquine (CQ) - the latter applied here as an inhibitor of murine TLR13 and its human ortholog TLR8 - abrogated activation of murine and human primary immune cells exposed to antibiotic-treated S. pneumoniae. The inhibitory effect of the T2.5/CQ cocktail was stronger than that of dexamethasone, the current standard adjunctive drug for pneumococcal meningitis. Accordingly, TLR2/TLR13 blockade concomitant with ceftriaxone application significantly improved the clinical course of pneumococcal meningitis compared with treatment with ceftriaxone alone or in combination with dexamethasone. Our study indicates the importance of murine TLR13 and human TLR8, besides TLR2, in pneumococcal meningitis pathology, and suggests their blockade as a promising antibiotic therapy adjunct.
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Affiliation(s)
| | - Ilias Masouris
- Department of Neurology, LMU University Hospital, LMU Munich, Germany
| | - Heba Islam
- Institute of Medical Microbiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Sven Hammerschmidt
- Department of Molecular Genetics and Infection Biology, Interfaculty Institute for Genetics and Functional Genomics, University of Greifswald, Greifswald, Germany
| | - Barbara Angele
- Department of Neurology, LMU University Hospital, LMU Munich, Germany
| | - Veena Marathe
- Institute of Medical Microbiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Jan Buer
- Institute of Medical Microbiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Stefanie Völk
- Department of Neurology, LMU University Hospital, LMU Munich, Germany
| | | | - Matthias Klein
- Department of Neurology, LMU University Hospital, LMU Munich, Germany
| | - Uwe Koedel
- Department of Neurology, LMU University Hospital, LMU Munich, Germany
| | - Carsten J Kirschning
- Institute of Medical Microbiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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6
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Dyckhoff-Shen S, Bewersdorf JP, Teske NC, Völk S, Pfister HW, Koedel U, Klein M. Characterization and diagnosis spectrum of patients with cerebrospinal fluid pleocytosis. Infection 2024; 52:219-229. [PMID: 37656347 PMCID: PMC10811117 DOI: 10.1007/s15010-023-02087-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 08/17/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE There is an overlap in the cerebrospinal fluid (CSF) characteristics of patients presenting with different etiologies of CSF pleocytosis. Here, we characterized patients with CSF pleocytosis treated in a large hospital. METHODS A retrospective cohort study of 1150 patients with an elevated CSF leukocyte count > 5 cells/µl treated at a university hospital in Germany from January 2015 to December 2017 was performed. Information on clinical presentation, laboratory parameters, diagnosis and outcome was collected. Clinical and laboratory features were tested for their potential to differentiate between bacterial meningitis (BM) and other causes of CSF pleocytosis. RESULTS The most common etiologies of CSF pleocytosis were CNS infections (34%: 20% with detected pathogen, 14% without), autoimmune (21%) and neoplastic diseases (16%). CSF cell count was higher in CNS infections with detected pathogen (median 82 cells/µl) compared to autoimmune (11 cells/µl, p = 0.001), neoplastic diseases (19 cells/µl, p = 0.01) and other causes (11 cells/µl, p < 0.001). The CHANCE score was developed to differentiate BM from other causes of CSF pleocytosis: Multivariate regression revealed that CSF cell count > 100 cells/µl, CSF protein > 100 mg/dl, CRP > 5 mg/dl, elevated white blood cell count, abnormal mental status and nuchal rigidity are important indicators. The CHANCE score identified patients with BM with high sensitivity (92.1%) and specificity (90.9%) (derivation cohort: AUC: 0.955, validation cohort: AUC: 0.956). CONCLUSION Overall, the most common causes for CSF pleocytosis include infectious, neoplastic or autoimmune CNS diseases in ~ 70% of patients. The CHANCE score could be of help to identify patients with high likelihood of BM and support clinical decision making.
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Affiliation(s)
- Susanne Dyckhoff-Shen
- Department of Neurology, LMU University Hospital, LMU Munich (en.), Marchioninistr. 15, 81377, Munich, Germany.
| | - Jan P Bewersdorf
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nina C Teske
- Department of Neurosurgery, LMU University Hospital, LMU Munich (en.), Munich, Germany
| | - Stefanie Völk
- Department of Neurology, LMU University Hospital, LMU Munich (en.), Marchioninistr. 15, 81377, Munich, Germany
| | - Hans-Walter Pfister
- Department of Neurology, LMU University Hospital, LMU Munich (en.), Marchioninistr. 15, 81377, Munich, Germany
| | - Uwe Koedel
- Department of Neurology, LMU University Hospital, LMU Munich (en.), Marchioninistr. 15, 81377, Munich, Germany
| | - Matthias Klein
- Department of Neurology, LMU University Hospital, LMU Munich (en.), Marchioninistr. 15, 81377, Munich, Germany
- Emergency Department, LMU University Hospital, LMU Munich (en.), Munich, Germany
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Teske NC, Dyckhoff-Shen S, Beckenbauer P, Bewersdorf JP, Engelen-Lee JY, Hammerschmidt S, Kälin RE, Pfister HW, Brouwer MC, Klein M, Glass R, van de Beek D, Koedel U. Pericytes are protective in experimental pneumococcal meningitis through regulating leukocyte infiltration and blood-brain barrier function. J Neuroinflammation 2023; 20:267. [PMID: 37978545 PMCID: PMC10655320 DOI: 10.1186/s12974-023-02938-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 10/27/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Brain pericytes participate in the regulation of cerebral blood flow and the maintenance of blood-brain barrier integrity. Because of their perivascular localization, their receptor repertoire, and their potential ability to respond to inflammatory and infectious stimuli by producing various cytokines and chemokines, these cells are also thought to play an active role in the immune response to brain infections. This assumption is mainly supported by in vitro studies, investigations in in vivo disease models are largely missing. Here, we analysed the role of brain pericytes in pneumococcal meningitis, in vitro and in vivo in two animal models of pneumococcal meningitis. METHODS Primary murine and human pericytes were stimulated with increasing concentrations of different serotypes of Streptococcus pneumoniae in the presence or absence of Toll-like receptor inhibitors and their cell viability and cytokine production were monitored. To gain insight into the role of pericytes in brain infection in vivo, we performed studies in a zebrafish embryo model of pneumococcal meningitis in which pericytes were pharmacologically depleted. Furthermore, we analyzed the impact of genetically induced pericyte ablation on disease progression, intracranial complications, and brain inflammation in an adult mouse model of this disease. RESULTS Both murine and human pericytes reacted to pneumococcal exposure with the release of selected cytokines. This cytokine release is pneumolysin-dependent, TLR-dependent in murine (but not human) pericytes and can be significantly increased by macrophage-derived IL-1b. Pharmacological depletion of pericytes in zebrafish embryos resulted in increased cerebral edema and mortality due to pneumococcal meningitis. Correspondingly, in an adult mouse meningitis model, a more pronounced blood-brain barrier disruption and leukocyte infiltration, resulting in an unfavorable disease course, was observed following genetic pericyte ablation. The degree of leukocyte infiltration positively correlated with an upregulation of chemokine expression in the brains of pericyte-depleted mice. CONCLUSIONS Our findings show that pericytes play a protective role in pneumococcal meningitis by impeding leukocyte migration and preventing blood-brain barrier breaching. Thus, preserving the integrity of the pericyte population has the potential as a new therapeutic strategy in pneumococcal meningitis.
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Affiliation(s)
- Nina C Teske
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany.
- ESCMID Study Group for Infections of the Brain, Basel, Switzerland.
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands.
- Department of Neurosurgery, LMU University Hospital, LMU Munich, Munich, Germany.
| | | | - Paul Beckenbauer
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | | | - Joo-Yeon Engelen-Lee
- ESCMID Study Group for Infections of the Brain, Basel, Switzerland
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Sven Hammerschmidt
- Department Genetics of Microorganisms, Interfaculty Institute of Genetics and Functional Genomics, University of Greifswald, Greifswald, Germany
| | - Roland E Kälin
- Neurosurgical Research, Department of Neurosurgery, LMU University Hospital, LMU Munich, Munich, Germany
- Walter Brendel Center of Experimental Medicine, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Hans-Walter Pfister
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
- ESCMID Study Group for Infections of the Brain, Basel, Switzerland
| | - Matthijs C Brouwer
- ESCMID Study Group for Infections of the Brain, Basel, Switzerland
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Matthias Klein
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
- ESCMID Study Group for Infections of the Brain, Basel, Switzerland
| | - Rainer Glass
- Neurosurgical Research, Department of Neurosurgery, LMU University Hospital, LMU Munich, Munich, Germany
| | - Diederik van de Beek
- ESCMID Study Group for Infections of the Brain, Basel, Switzerland
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Uwe Koedel
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
- ESCMID Study Group for Infections of the Brain, Basel, Switzerland
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8
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Masouris I, Klein M, Angele B, Groß B, Goswami N, Mashood F, Gesell Salazar M, Schubert S, Pfister HW, Koedel U, Schmidt F. Quantitative proteomic analysis of cerebrospinal fluid from patients with idiopathic facial nerve palsy. Eur J Neurol 2023; 30:1048-1058. [PMID: 36504168 DOI: 10.1111/ene.15663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/17/2022] [Accepted: 11/23/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Idiopathic facial palsy (IFP) accounts for over 60% of peripheral facial palsy (FP) cases. The cause of IFP remains to be determined. Possible etiologies are nerve swelling due to inflammation and/or viral infection. In this study, we applied an integrative mass spectrometry approach to identify possibly altered protein patterns in the cerebrospinal fluid (CSF) of IFP patients. METHODS We obtained CSF samples from 34 patients with FP. In four patients, varicella-zoster virus was the cause (VZV-FP). Among the 30 patients diagnosed with IFP, 17 had normal CSF parameters, five had slightly elevated CSF cell counts and normal or elevated CSF protein, and eight had normal CSF cell counts but elevated CSF protein. Five patients with primary headache served as controls. All samples were tested for viral pathogens by PCR and subjected to liquid chromatography tandem mass spectrometry and bioinformatics analysis and multiplex cytokine/chemokine arrays. RESULTS All CSF samples, except those from VZV-FP patients, were negative for all tested pathogens. The protein composition of CSF samples from IFP patients with normal CSF was comparable to controls. IFP patients with elevated CSF protein showed dysregulated proteins involved in inflammatory pathways, findings which were similar to those in VZV-FP patients. Multiplex analysis revealed similarly elevated cytokine levels in the CSF of IFP patients with elevated CSF protein and VZV-FP. CONCLUSIONS Our study revealed a subgroup of IFP patients with elevated CSF protein that showed upregulated inflammatory pathways, suggesting an inflammatory/infectious cause. However, no evidence for an inflammatory cause was found in IFP patients with normal CSF.
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Affiliation(s)
- Ilias Masouris
- Department of Neurology, University hospital, Ludwig Maximilian University, Munich, Germany
| | - Matthias Klein
- Department of Neurology, University hospital, Ludwig Maximilian University, Munich, Germany
| | - Barbara Angele
- Department of Neurology, University hospital, Ludwig Maximilian University, Munich, Germany
| | - Birgit Groß
- Virology Department, Max-von-Pettenkofer-Institute, Ludwig Maximilian University, Munich, Germany
| | - Neha Goswami
- Proteomics Core, Weill Cornell Medicine-Qatar, Qatar Foundation-Education City, Doha, Qatar
| | - Fathima Mashood
- Proteomics Core, Weill Cornell Medicine-Qatar, Qatar Foundation-Education City, Doha, Qatar
| | - Manuela Gesell Salazar
- Interfaculty Institute for Genetics and Functional Genomics, University Medicine Greifswald, Greifswald, Germany
| | - Sören Schubert
- Virology Department, Max-von-Pettenkofer-Institute, Ludwig Maximilian University, Munich, Germany
| | - Hans-Walter Pfister
- Department of Neurology, University hospital, Ludwig Maximilian University, Munich, Germany
| | - Uwe Koedel
- Department of Neurology, University hospital, Ludwig Maximilian University, Munich, Germany
| | - Frank Schmidt
- Proteomics Core, Weill Cornell Medicine-Qatar, Qatar Foundation-Education City, Doha, Qatar
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Völk S, Dobler F, Koedel U, Pfister HW, Bruegel M, Schubert S, Klein M. Cerebrospinal fluid analysis in emergency patients with suspected infection of the central nervous system. Eur J Neurol 2023; 30:702-709. [PMID: 36398479 DOI: 10.1111/ene.15638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/11/2022] [Accepted: 11/14/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND PURPOSE Meningitis and encephalitis are potentially life-threatening diseases that require fast and accurate diagnostics and therapy. The value of polymerase chain reaction (PCR) multiplex testing in clinical practice is still a matter of debate. This study aims to evaluate its benefits and limitations in emergency patients. METHODS We assessed the value of a meningoencephalitis PCR array in the clinical routine of an emergency department. RESULTS Of 1578 emergency patients who received a lumbar puncture, 43% received it for a clinically suspected central nervous system (CNS) infection. After initial workup for cerebrospinal fluid (CSF) cell count, protein and glucose, a CNS infection was still considered likely in 307 patients. In these patients, further microbiologic workup was performed. A total of 230 samples were examined by PCR and a pathogen was detected in 66 of these samples. In the case of a positive microbiologic result, a comparison between PCR array and standard method was available for 59 samples, which demonstrated an overcall agreement of 80% (n = 47/59). Of interest, exclusively array-positive results were observed for patients with meningitis found to be positive for Streptococcus pneumoniae; four out of five patients had been treated with antibiotics before the lumbar puncture. In samples with normal CSF cell count only two positive array results were obtained, both for human herpesvirus 6, and these were not clinically relevant. CONCLUSION Our data suggest that the array substantially contributes to a detection of pathogens in patients with suspected CNS infection and seems of particular interest in patients with acute bacterial meningitis under empiric antibiotic treatment. In CSF samples with normal cell count, it might be dispensable.
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Affiliation(s)
- Stefanie Völk
- Department of Neurology, University Hospital, LMU, Munich, Germany
| | - Fabian Dobler
- Department of Neurology, University Hospital, LMU, Munich, Germany
| | - Uwe Koedel
- Department of Neurology, University Hospital, LMU, Munich, Germany
| | | | - Mathias Bruegel
- Institute of Laboratory Medicine, University Hospital, LMU, Munich, Germany
| | - Sören Schubert
- Max von Pettenkofer-Institute, Faculty of Medicine, LMU, Munich, Germany
| | - Matthias Klein
- Department of Neurology, University Hospital, LMU, Munich, Germany
- Emergency Department, University Hospital, LMU, Munich, Germany
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10
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Teske NC, Engelen-Lee JY, Dyckhoff-Shen S, Pfister HW, Klein M, van de Beek D, Kirschning CK, Koedel U, Brouwer MC. The role of plasminogen activator inhibitor-2 in pneumococcal meningitis. Acta Neuropathol Commun 2022; 10:155. [DOI: 10.1186/s40478-022-01461-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 10/12/2022] [Indexed: 11/10/2022] Open
Abstract
AbstractPneumococcal meningitis is associated with dysregulation of the coagulation cascade. Previously, we detected upregulation of cerebral plasminogen activator inhibitor-2 (PAI-2) mRNA expression during pneumococcal meningitis. Diverse functions have been ascribed to PAI-2, but its role remains unclear. We analyzed the function of SERPINB2 (coding for PAI-2) in patients with bacterial meningitis, in a well-established pneumococcal meningitis mouse model, using Serpinb2 knockout mice, and in vitro in wt and PAI-2-deficient bone marrow-derived macrophages (BMDMs). We measured PAI-2 in cerebrospinal fluid of patients, and performed functional, histopathological, protein and mRNA expression analyses in vivo and in vitro. We found a substantial increase of PAI-2 concentration in CSF of patients with pneumococcal meningitis, and up-regulation and increased release of PAI-2 in mice. PAI-2 deficiency was associated with increased mortality in murine pneumococcal meningitis and cerebral hemorrhages. Serpinb2−/− mice exhibited increased C5a levels, but decreased IL-10 levels in the brain during pneumococcal infection. Our in vitro experiments confirmed increased expression and release of PAI-2 by wt BMDM and decreased IL-10 liberation by PAI-2-deficient BMDM upon pneumococcal challenge. Our data show that PAI-2 is elevated during in pneumococcal meningitis in humans and mice. PAI-2 deficiency causes an inflammatory imbalance, resulting in increased brain pathology and mortality.
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11
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Völk S, Koedel U, Horster S, Bayer A, D'Haese JG, Pfister HW, Klein M. Patient disposition using the Emergency Severity Index: a retrospective observational study at an interdisciplinary emergency department. BMJ Open 2022; 12:e057684. [PMID: 35551090 PMCID: PMC9109098 DOI: 10.1136/bmjopen-2021-057684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Early patient disposition is crucial to prevent crowding in emergency departments (EDs). Our study aimed to characterise the need of in-house resources for patients treated in the ED according to the Emergency Severity Index (ESI) and the presenting complaint at the timepoint of triage. DESIGN A retrospective single-centre study was conducted. SETTING Data of all patients who presented to the interdisciplinary ED of a tertiary care hospital in Munich, Germany, from 2014 to 2017 were analysed. PARTICIPANTS n=113 694 patients were included. MEASURES ESI Score, medical speciality according to the chief complaint, mode of arrival, admission rates and discharge destination from the ED were evaluated. RESULTS Patient disposition varied according to ESI scores in combination with the chief complaint. Patients with low ESI scores were more likely to be admitted after treatment in the ED than patients with high ESI scores. Highly prioritised patients (ESI 1) mainly required admission to an intensive care unit (ICU, 27%), intermediate care unit (IMC, 37%) or immediate intervention (11%). In this critical patient group, 30% of patients with neurological or medical symptoms required immediate intensive care, whereas only 17% of patients with surgical problems were admitted to an ICU. A significant number of patients (particularly with neurological or medical problems) required hospital (and in some cases even ICU or IMC) admission despite high ESI scores. CONCLUSIONS Overall, ESI seems to be a useful tool to anticipate the need for specialised in-hospital resources on arrival. Patients with symptoms pointing at neurological or medical problems need particular attention as ESI may fail to sufficiently predict the care facility level for this patient group.
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Affiliation(s)
- Stefanie Völk
- Department of Neurology, University Hospital, Ludwig Maximilians University, Munich, Germany
| | - Uwe Koedel
- Department of Neurology, University Hospital, Ludwig Maximilians University, Munich, Germany
| | - Sophia Horster
- Emergency Department, University Hospital, Ludwig Maximilians University, Munich, Germany
| | - Andreas Bayer
- Department of Anaesthesiology, University Hospital, Ludwig Maximilians University, Munich, Germany
| | - Jan G D'Haese
- Department of General, Visceral and Transplantation Surgery, University Hospital, Ludwig Maximilians University, Munich, Germany
| | - Hans-Walter Pfister
- Department of Neurology, University Hospital, Ludwig Maximilians University, Munich, Germany
| | - Matthias Klein
- Department of Neurology, University Hospital, Ludwig Maximilians University, Munich, Germany
- Emergency Department, University Hospital, Ludwig Maximilians University, Munich, Germany
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12
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van de Beek D, Brouwer MC, Koedel U, Wall EC. Steroid use in non-pneumococcal and non-Haemophilus bacterial meningitis - Authors' reply. Lancet 2022; 399:718. [PMID: 35183295 DOI: 10.1016/s0140-6736(21)02662-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 11/16/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Diederik van de Beek
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam 1105 AZ, Netherlands.
| | - Matthijs C Brouwer
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam 1105 AZ, Netherlands
| | - Uwe Koedel
- Department of Neurology, Ludwig-Maximilians-University, Munich, Germany
| | - Emma C Wall
- Research Department of Infection, University College London, London, UK; Francis Crick Institute, London, UK
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13
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Abstract
Progress has been made in the prevention and treatment of community-acquired bacterial meningitis during the past three decades but the burden of the disease remains high globally. Conjugate vaccines against the three most common causative pathogens (Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae) have reduced the incidence of disease, but with the replacement by non-vaccine pneumococcal serotypes and the emergence of bacterial strains with reduced susceptibility to antimicrobial treatment, meningitis continues to pose a major health challenge worldwide. In patients presenting with bacterial meningitis, typical clinical characteristics (such as the classic triad of neck stiffness, fever, and an altered mental status) might be absent and cerebrospinal fluid examination for biochemistry, microscopy, culture, and PCR to identify bacterial DNA are essential for the diagnosis. Multiplex PCR point-of-care panels in cerebrospinal fluid show promise in accelerating the diagnosis, but diagnostic accuracy studies to justify routine implementation are scarce and randomised, controlled studies are absent. Early administration of antimicrobial treatment (within 1 hour of presentation) improves outcomes and needs to be adjusted according to local emergence of drug resistance. Adjunctive dexamethasone treatment has proven efficacy beyond the neonatal age but only in patients from high-income countries. Further progress can be expected from implementing preventive measures, especially the development of new vaccines, implementation of hospital protocols aimed at early treatment, and new treatments targeting checkpoints of the inflammatory cascade.
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Affiliation(s)
- Diederik van de Beek
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Meibergdreef, Amsterdam, Netherlands.
| | - Matthijs C Brouwer
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Meibergdreef, Amsterdam, Netherlands
| | - Uwe Koedel
- Department of Neurology, Ludwig-Maximilians-University, Munich, Germany
| | - Emma C Wall
- Research Department of Infection, University College London, London, UK; Francis Crick Institute, London, UK
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14
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Masouris I, Manz K, Pfirrmann M, Dreyling M, Angele B, Straube A, Langer S, Huber M, Koedel U, Von Baumgarten L. CXCL13 and CXCL9 CSF Levels in Central Nervous System Lymphoma-Diagnostic, Therapeutic, and Prognostic Relevance. Front Neurol 2021; 12:654543. [PMID: 33841320 PMCID: PMC8032970 DOI: 10.3389/fneur.2021.654543] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 03/03/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Diagnostic delay and neurologic deterioration are still a problem for the treatment of rapidly progressing CNS lymphoma (CNSL); there is an unmet need for a diagnostic test with a high diagnostic yield and limited risk, minimizing the time to the initiation of effective treatment. Methods: In this prospective monocentric study, we analyzed the utility of CXCL13 and CXCL9 as diagnostic, therapeutic and prognostic biomarkers for CNSL. Cerebrospinal fluid (CSF) from 155 consecutive patients admitted with brain lesions of various origins was collected. Levels of CXCL13 and CXCL9 were analyzed by ELISA. Additionally, CSF was analyzed during CNSL disease course (relapse, remission, progress) in 17 patients. Results: CXCL13 and CXCL9 CSF levels were significantly increased in patients with CNSL compared to control patients with lesions of other origin. Using logistic regression and a minimal-p-value approach, a cut-off value of 80 pg/ml for CXCL13 shows high sensitivity (90.7%) and specificity (90.1%) for the diagnosis of active CNSL. CXCL9 at a cut-off value of 84 pg/ml is less sensitive (61.5%) and specific (87.1%). Both cytokines correlate with the clinical course and response to therapy. Conclusions: Our results confirm the excellent diagnostic potential of CXCL13 and introduce CXCL9 as a novel albeit less powerful marker for PCNSL.
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Affiliation(s)
- Ilias Masouris
- Department of Neurology, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Kirsi Manz
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig Maximilian University, Munich, Germany
| | - Markus Pfirrmann
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig Maximilian University, Munich, Germany
| | - Martin Dreyling
- Department of Medicine III, Ludwig Maximilian University, Munich, Germany
| | - Barbara Angele
- Department of Neurology, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Andreas Straube
- Department of Neurology, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Sigrid Langer
- Department of Neurology, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Marion Huber
- Max Planck Institute of Psychiatry, Munich, Germany
| | - Uwe Koedel
- Department of Neurology, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Louisa Von Baumgarten
- Department of Neurology, University Hospital, Ludwig Maximilian University, Munich, Germany.,Department of Neurosurgery, University Hospital, Ludwig Maximilian University, Munich, Germany
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15
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Dyckhoff-Shen S, Koedel U, Pfister HW, Klein M. SOP: emergency workup in patients with suspected acute bacterial meningitis. Neurol Res Pract 2021; 3:2. [PMID: 33499920 PMCID: PMC7791806 DOI: 10.1186/s42466-020-00098-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/25/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction Despite antibiotic therapy, adjunctive treatment with dexamethasone, and care on modern intensive care units, bacterial meningitis remains a life-threatening disease with a high mortality and morbidity. One of most critical factors that influences outcome is a targeted quick but profound workup and early initiation of therapy in the Emergency Department. This standardized operating procedure was designed to guide physicians through the workup of patients with suspected acute bacterial meningitis. First steps In patients with suspected community-acquired bacterial meningitis, the first steps aim at establishing a diagnosis and at starting empiric therapy without delay. Therefore, physicians need to seek for an early lumbar puncture that can be done safely without prior imaging if clinical signs that point at contraindications of a lumbar puncture are absent. Immediately after lumbar puncture, empiric therapy with ceftriaxone, ampicillin and dexamethasone should be started. In regions with a critical resistance rate of pneumococci against third generation cephalosporines, vancomycin or rifampicin need to be added. Comments Clinical signs that are associated with intracranial conditions that are a contraindication for a lumbar puncture are severely decreased consciousness, new onset focal neurological signs, and epileptic seizures. If any of these clinical signs are present, cerebral imaging is recommended before lumbar puncture. Whenever lumbar puncture is delayed, empiric therapy needs to be begun before cerebrospinal fluid is obtained. Conclusion Suspected acute bacterial meningitis is an emergency and requires attention with high priority in the emergency department to ensure a quick workup and early start of therapy.
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Affiliation(s)
- Susanne Dyckhoff-Shen
- Department of Neurology, LMU Klinikum, Ludwig Maximilians University Munich, Marchioninistr 15, 81377, Munich, Germany
| | - Uwe Koedel
- Department of Neurology, LMU Klinikum, Ludwig Maximilians University Munich, Marchioninistr 15, 81377, Munich, Germany
| | - Hans-Walter Pfister
- Department of Neurology, LMU Klinikum, Ludwig Maximilians University Munich, Marchioninistr 15, 81377, Munich, Germany
| | - Matthias Klein
- Department of Neurology, LMU Klinikum, Ludwig Maximilians University Munich, Marchioninistr 15, 81377, Munich, Germany. .,Emergency Department, LMU Klinikum, Ludwig Maximilians University Munich, Marchioninistr 15, 81377, Munich, Germany.
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16
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Ricci S, Grandgirard D, Masouris I, Braccini T, Pozzi G, Oggioni MR, Koedel U, Leib SL. Combined therapy with ceftriaxone and doxycycline does not improve the outcome of meningococcal meningitis in mice compared to ceftriaxone monotherapy. BMC Infect Dis 2020; 20:505. [PMID: 32660552 PMCID: PMC7359289 DOI: 10.1186/s12879-020-05226-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 07/03/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Meningococcal meningitis (MM) is a life-threatening disease associated with approximately 10% case fatality rates and neurological sequelae in 10-20% of the cases. Recently, we have shown that the matrix metalloproteinase (MMP) inhibitor BB-94 reduced brain injury in a mouse model of MM. The present study aimed to assess whether doxycycline (DOX), a tetracycline that showed a neuroprotective effect as adjuvant therapy in experimental pneumococcal meningitis (PM), would also exert a beneficial effect when given as adjunctive therapy to ceftriaxone (CRO) in experimental MM. METHODS BALB/c mice were infected by the intracisternal route with a group C Neisseria meningitidis strain. Eighteen h post infection (hpi), animals were randomised for treatment with CRO [100 mg/kg subcutaneously (s.c.)], CRO plus DOX (30 mg/kg s.c.) or saline (control s.c.). Antibiotic treatment was repeated 24 and 40 hpi. Mouse survival and clinical signs, bacterial counts in cerebella, brain damage, MMP-9 and cyto/chemokine levels were assessed 48 hpi. RESULTS Analysis of bacterial load in cerebella indicated that CRO and CRO + DOX were equally effective at controlling meningococcal replication. No differences in survival were observed between mice treated with CRO (94.4%) or CRO + DOX (95.5%), (p > 0.05). Treatment with CRO + DOX significantly diminished both the number of cerebral hemorrhages (p = 0.029) and the amount of MMP-9 in the brain (p = 0.046) compared to untreated controls, but not to CRO-treated animals (p > 0.05). Levels of inflammatory markers in the brain of mice that received CRO or CRO + DOX were not significantly different (p > 0.05). Overall, there were no significant differences in the parameters assessed between the groups treated with CRO alone or CRO + DOX. CONCLUSIONS Treatment with CRO + DOX showed similar bactericidal activity to CRO in vivo, suggesting no antagonist effect of DOX on CRO. Combined therapy significantly improved mouse survival and disease severity compared to untreated animals, but addition of DOX to CRO did not offer significant benefits over CRO monotherapy. In contrast to experimental PM, DOX has no adjunctive activity in experimental MM.
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Affiliation(s)
- Susanna Ricci
- Department of Medical Biotechnologies, Laboratory of Molecular Microbiology and Biotechnology (LA.M.M.B.), Ospedale Santa Maria alle Scotte, University of Siena, Siena, Italy. .,ESCMID Study Group for Infectious Diseases of the Brain (ESGIB), Basel, Switzerland.
| | - Denis Grandgirard
- ESCMID Study Group for Infectious Diseases of the Brain (ESGIB), Basel, Switzerland.,Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Ilias Masouris
- Department of Neurology, Ludwig-Maximilians University, Munich, Germany
| | - Tiziana Braccini
- Department of Medical Biotechnologies, Laboratory of Molecular Microbiology and Biotechnology (LA.M.M.B.), Ospedale Santa Maria alle Scotte, University of Siena, Siena, Italy
| | - Gianni Pozzi
- Department of Medical Biotechnologies, Laboratory of Molecular Microbiology and Biotechnology (LA.M.M.B.), Ospedale Santa Maria alle Scotte, University of Siena, Siena, Italy
| | - Marco R Oggioni
- ESCMID Study Group for Infectious Diseases of the Brain (ESGIB), Basel, Switzerland.,Department of Genetics and Genome Biology, University of Leicester, Leicester, UK
| | - Uwe Koedel
- ESCMID Study Group for Infectious Diseases of the Brain (ESGIB), Basel, Switzerland.,Department of Neurology, Ludwig-Maximilians University, Munich, Germany
| | - Stephen L Leib
- ESCMID Study Group for Infectious Diseases of the Brain (ESGIB), Basel, Switzerland.,Institute for Infectious Diseases, University of Bern, Bern, Switzerland
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17
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Koedel U, Klein M, Pfister HW. Neurological infections in 2019: challenges, solutions, and open questions. Lancet Neurol 2020; 19:19-20. [PMID: 31839242 DOI: 10.1016/s1474-4422(19)30436-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 10/22/2019] [Indexed: 12/27/2022]
Affiliation(s)
- Uwe Koedel
- Department of Neurology, Klinikum Grosshadern, Ludwig-Maximilians-University, 81377 Munich, Germany
| | - Matthias Klein
- Department of Neurology, Klinikum Grosshadern, Ludwig-Maximilians-University, 81377 Munich, Germany
| | - Hans Walter Pfister
- Department of Neurology, Klinikum Grosshadern, Ludwig-Maximilians-University, 81377 Munich, Germany.
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18
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Klein M, Koedel U, Pfister HW. Update wichtige ZNS-Infektionen. Dtsch Med Wochenschr 2020; 145:155-160. [DOI: 10.1055/a-0968-1063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Was ist neu?
Herpes-simplex-Virus (HSV)-Enzephalitis Bei Verdacht auf eine HSV-Enzephalitis sollte unabhängig von der Zellzahl im Liquor eine PCR zum Nachweis von Viruskopien durchgeführt werden. Im Fall einer autoimmunvermittelten sekundären Verschlechterung innerhalb der ersten 2 Monate nach Aciclovir-Behandlung einer HSV-Enzephalitis sollte eine unverzügliche Therapie mit Immunsuppression und/oder Plasmapherese eingeleitet werden.
Bakterielle Meningitis Zur Erregerdiagnostik kann seit einigen Jahren neben Gramfärbung, Liquorkultur und PCR ein Multiplex-PCR-Verfahren zur simultanen Testung der häufigsten Meningitis- und Enzephalitiserreger eingesetzt werden. Bei positivem Nachweis von HHV6 ist die klinische Relevanz jedoch infrage zu stellen. Bei unveränderter Resistenzlage in Deutschland wird nach wie vor als Initialtherapie Ceftriaxon i. v. und Ampicillin i. v. empfohlen, bei ambulant erworbener Meningitis mit Verdacht auf Pneumokokkeninfektion zusätzlich adjuvant Dexamethason i. v.
Frühsommer-Meningo-Enzephalitis (FSME) 2019 wurden in Deutschland 5 zusätzliche Risikogebiete definiert. Einen zuverlässigen Schutz bietet die Impfung, die allerdings auch in den Risikogebieten nicht konsequent durchgeführt wird. Hier besteht noch großer Aufklärungsbedarf.
Neuroborreliose Als zusätzlicher diagnostischer Parameter bei früher Neuroborreliose wurde in den vergangenen Jahren das Chemokin CXCL13 identifiziert. CXCL13 aus Liquor kann ein hilfreicher Parameter für die Diagnosestellung einer Neuroborreliose sein, wenn in der Frühphase der Borrelien-spezifische Liquor-Serum-Antikörper-Index noch negativ ist.
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Affiliation(s)
- Matthias Klein
- Neurologische Klinik und Poliklinik, Klinikum der Ludwig-Maximilians-Universität München
| | - Uwe Koedel
- Neurologische Klinik und Poliklinik, Klinikum der Ludwig-Maximilians-Universität München
| | - Hans-Walter Pfister
- Neurologische Klinik und Poliklinik, Klinikum der Ludwig-Maximilians-Universität München
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19
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Mulazzani M, Huber M, Borchard S, Langer S, Angele B, Schuh E, Meinl E, Dreyling M, Birnbaum T, Straube A, Koedel U, von Baumgarten L. APRIL and BAFF: novel biomarkers for central nervous system lymphoma. J Hematol Oncol 2019; 12:102. [PMID: 31615554 PMCID: PMC6792247 DOI: 10.1186/s13045-019-0796-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 09/25/2019] [Indexed: 12/22/2022] Open
Abstract
Background Early diagnosis of CNS lymphoma (CNSL) is essential for successful therapy of this rapidly progressing brain tumor. However, in patients presenting with focal brain lesions, fast and reliable diagnosis of PCNSL remains a challenge. A proliferation-inducing ligand (APRIL) and B cell activating factor (BAFF) are important factors in the pathophysiology, diagnosis, and prognosis of systemic B cell malignancies. However, their utility as biomarkers for the diagnosis of CNSL and their effects on CNSL cells remain unclear. Methods In this prospective study, we analyzed the levels of APRIL and BAFF in the cerebrospinal fluid (CSF) of 116 patients with suspected focal brain lesions, including 53 CNSL patients. Additionally, we serially measured their levels during chemotherapy and relapse. Furthermore, we analyzed the effect of APRIL and BAFF on two B cell lymphoma cell lines using proliferation, viability, and chemotaxis assays. Results CSF levels of APRIL and BAFF reliably differentiated CNSL from other focal brain lesions (including primary and metastatic brain tumors, autoimmune-inflammatory lesions, and neuroinfectious lesions) with a specificity of 93.7% (APRIL, BAFF) and a sensitivity of 62.3% (APRIL) and 47.1% (BAFF). Serial CSF analysis of CNSL patients during chemotherapy and relapse demonstrates a close correlation of APRIL CSF levels and the course of this disease. In vitro, APRIL and BAFF showed anti-apoptotic effects during MTX treatment and mediated chemotaxis of malignant B cells. Conclusion This study extends the spectrum of valuable diagnostic biomarkers in CNSL. In patients with focal brain lesions, measurement of APRIL in CSF could help accelerating the diagnosis of CNSL. Moreover, our results highlight an important role of APRIL and BAFF in the pathophysiology of CNSL.
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Affiliation(s)
| | - Marion Huber
- Department of Neurology, University Hospital, LMU, Munich, Germany
| | - Sabine Borchard
- Department of Neurology, University Hospital, LMU, Munich, Germany
| | - Sigrid Langer
- Department of Neurology, University Hospital, LMU, Munich, Germany
| | - Barbara Angele
- Department of Neurology, University Hospital, LMU, Munich, Germany
| | - Elisabeth Schuh
- Institute for Clinical Neuroimmunology, University Hospital, LMU, Munich, Germany
| | - Edgar Meinl
- Institute for Clinical Neuroimmunology, University Hospital, LMU, Munich, Germany
| | - Martin Dreyling
- Department of Oncology, University Hospital, LMU, Munich, Germany
| | - Tobias Birnbaum
- Department of Neurology, HELIOS Amper-Hospital Dachau, Dachau, Germany
| | - Andreas Straube
- Department of Neurology, University Hospital, LMU, Munich, Germany
| | - Uwe Koedel
- Department of Neurology, University Hospital, LMU, Munich, Germany
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20
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O'Connor T, Zhou X, Kosla J, Adili A, Garcia Beccaria M, Kotsiliti E, Pfister D, Johlke AL, Sinha A, Sankowski R, Schick M, Lewis R, Dokalis N, Seubert B, Höchst B, Inverso D, Heide D, Zhang W, Weihrich P, Manske K, Wohlleber D, Anton M, Hoellein A, Seleznik G, Bremer J, Bleul S, Augustin HG, Scherer F, Koedel U, Weber A, Protzer U, Förster R, Wirth T, Aguzzi A, Meissner F, Prinz M, Baumann B, Höpken UE, Knolle PA, von Baumgarten L, Keller U, Heikenwalder M. Age-Related Gliosis Promotes Central Nervous System Lymphoma through CCL19-Mediated Tumor Cell Retention. Cancer Cell 2019; 36:250-267.e9. [PMID: 31526758 DOI: 10.1016/j.ccell.2019.08.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 06/05/2019] [Accepted: 08/05/2019] [Indexed: 10/26/2022]
Abstract
How lymphoma cells (LCs) invade the brain during the development of central nervous system lymphoma (CNSL) is unclear. We found that NF-κB-induced gliosis promotes CNSL in immunocompetent mice. Gliosis elevated cell-adhesion molecules, which increased LCs in the brain but was insufficient to induce CNSL. Astrocyte-derived CCL19 was required for gliosis-induced CNSL. Deleting CCL19 in mice or CCR7 from LCs abrogated CNSL development. Two-photon microscopy revealed LCs transiently entering normal brain parenchyma. Astrocytic CCL19 enhanced parenchymal CNS retention of LCs, thereby promoting CNSL formation. Aged, gliotic wild-type mice were more susceptible to forming CNSL than young wild-type mice, and astrocytic CCL19 was observed in both human gliosis and CNSL. Therefore, CCL19-CCR7 interactions may underlie an increased age-related risk for CNSL.
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Affiliation(s)
- Tracy O'Connor
- Institute of Virology, Technical University of Munich, 81675 Munich, Germany; Helmholtz Center Munich, 85764 Neuherberg, Germany; Institute of Molecular Immunology and Experimental Oncology, Technical University of Munich, Ismaningerstraße 22, 81675 Munich, Germany; Division of Chronic Inflammation and Cancer, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 242, 69120 Heidelberg, Germany.
| | - Xiaolan Zhou
- Department of Neurology, Ludwig-Maximilians-University Hospital Munich, 81377 Munich, Germany; Department of Rehabilitation, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Jan Kosla
- Institute of Virology, Technical University of Munich, 81675 Munich, Germany; Helmholtz Center Munich, 85764 Neuherberg, Germany; Division of Chronic Inflammation and Cancer, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 242, 69120 Heidelberg, Germany
| | - Arlind Adili
- Institute of Virology, Technical University of Munich, 81675 Munich, Germany; Helmholtz Center Munich, 85764 Neuherberg, Germany
| | - Maria Garcia Beccaria
- Division of Chronic Inflammation and Cancer, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 242, 69120 Heidelberg, Germany
| | - Elena Kotsiliti
- Institute of Virology, Technical University of Munich, 81675 Munich, Germany; Helmholtz Center Munich, 85764 Neuherberg, Germany; Division of Chronic Inflammation and Cancer, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 242, 69120 Heidelberg, Germany
| | - Dominik Pfister
- Institute of Virology, Technical University of Munich, 81675 Munich, Germany; Helmholtz Center Munich, 85764 Neuherberg, Germany; Division of Chronic Inflammation and Cancer, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 242, 69120 Heidelberg, Germany
| | - Anna-Lena Johlke
- Institute of Virology, Technical University of Munich, 81675 Munich, Germany; Helmholtz Center Munich, 85764 Neuherberg, Germany
| | - Ankit Sinha
- Experimental Systems Immunology, Max Planck Institute of Biochemistry, Munich, Germany
| | - Roman Sankowski
- Institute of Neuropathology, Medical Faculty, University of Freiburg, 79085 Freiburg, Germany
| | - Markus Schick
- III. Medical Department, Technical University of Munich, 81675 Munich, Germany
| | - Richard Lewis
- III. Medical Department, Technical University of Munich, 81675 Munich, Germany
| | - Nikolaos Dokalis
- Institute of Neuropathology, Medical Faculty, University of Freiburg, 79085 Freiburg, Germany
| | - Bastian Seubert
- Institute of Virology, Technical University of Munich, 81675 Munich, Germany; Helmholtz Center Munich, 85764 Neuherberg, Germany
| | - Bastian Höchst
- Institute of Molecular Immunology and Experimental Oncology, Technical University of Munich, Ismaningerstraße 22, 81675 Munich, Germany
| | - Donato Inverso
- Division of Vascular Oncology and Metastasis, German Cancer Research Center Heidelberg (DKFZ-ZMBH Alliance), 69120 Heidelberg, Germany
| | - Danijela Heide
- Division of Chronic Inflammation and Cancer, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 242, 69120 Heidelberg, Germany
| | - Wenlong Zhang
- Department of Neurology, Ludwig-Maximilians-University Hospital Munich, 81377 Munich, Germany
| | - Petra Weihrich
- Institute for Physiological Chemistry, University of Ulm, 89081 Ulm, Germany
| | - Katrin Manske
- Institute of Molecular Immunology and Experimental Oncology, Technical University of Munich, Ismaningerstraße 22, 81675 Munich, Germany
| | - Dirk Wohlleber
- Institute of Molecular Immunology and Experimental Oncology, Technical University of Munich, Ismaningerstraße 22, 81675 Munich, Germany
| | - Martina Anton
- Institute of Molecular Immunology and Experimental Oncology, Technical University of Munich, Ismaningerstraße 22, 81675 Munich, Germany
| | - Alexander Hoellein
- III. Medical Department, Technical University of Munich, 81675 Munich, Germany
| | - Gitta Seleznik
- Institute of Neuropathology, University Hospital of Zurich, 8091 Zurich, Switzerland
| | - Juliane Bremer
- Institute of Neuropathology, University Hospital of Zurich, 8091 Zurich, Switzerland
| | - Sabine Bleul
- Department of Hematology, Oncology and Stem Cell Transplantation, Freiburg University Medical Center, Albert-Ludwigs University, 79106 Freiburg, Germany
| | - Hellmut G Augustin
- Division of Vascular Oncology and Metastasis, German Cancer Research Center Heidelberg (DKFZ-ZMBH Alliance), 69120 Heidelberg, Germany; European Center for Angioscience (ECAS), Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany; German Cancer Consortium (DKTK), 69120 Heidelberg, Germany
| | - Florian Scherer
- Department of Hematology, Oncology and Stem Cell Transplantation, Freiburg University Medical Center, Albert-Ludwigs University, 79106 Freiburg, Germany
| | - Uwe Koedel
- Department of Neurology, Ludwig-Maximilians-University Hospital Munich, 81377 Munich, Germany
| | - Achim Weber
- Department of Pathology and Molecular Pathology, University Hospital of Zurich, 8091 Zurich, Switzerland
| | - Ulrike Protzer
- Institute of Virology, Technical University of Munich, 81675 Munich, Germany; Helmholtz Center Munich, 85764 Neuherberg, Germany
| | - Reinhold Förster
- Institute of Immunology, Hannover Medical School, 30625 Hannover, Germany
| | - Thomas Wirth
- Institute for Physiological Chemistry, University of Ulm, 89081 Ulm, Germany
| | - Adriano Aguzzi
- Institute of Neuropathology, University Hospital of Zurich, 8091 Zurich, Switzerland
| | - Felix Meissner
- Experimental Systems Immunology, Max Planck Institute of Biochemistry, Munich, Germany
| | - Marco Prinz
- Institute of Neuropathology, Medical Faculty, University of Freiburg, 79085 Freiburg, Germany; Signalling Research Centres BIOSS and CIBSS, University of Freiburg, Freiburg, Germany; Center for Basics in NeuroModulation (NeuroModulBasics), Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bernd Baumann
- Institute for Physiological Chemistry, University of Ulm, 89081 Ulm, Germany
| | - Uta E Höpken
- Max Delbrück Center for Molecular Medicine, 13092 Berlin, Germany
| | - Percy A Knolle
- Institute of Molecular Immunology and Experimental Oncology, Technical University of Munich, Ismaningerstraße 22, 81675 Munich, Germany
| | - Louisa von Baumgarten
- Department of Neurology, Ludwig-Maximilians-University Hospital Munich, 81377 Munich, Germany
| | - Ulrich Keller
- III. Medical Department, Technical University of Munich, 81675 Munich, Germany; German Cancer Consortium (DKTK), 69120 Heidelberg, Germany; Hematology and Oncology, Charité - Universitätsmedizin Campus Benjamin Franklin, 12200 Berlin, Germany
| | - Mathias Heikenwalder
- Institute of Virology, Technical University of Munich, 81675 Munich, Germany; Helmholtz Center Munich, 85764 Neuherberg, Germany; Institute of Molecular Immunology and Experimental Oncology, Technical University of Munich, Ismaningerstraße 22, 81675 Munich, Germany; Division of Chronic Inflammation and Cancer, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 242, 69120 Heidelberg, Germany.
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21
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Colicchio R, Pagliuca C, Ricci S, Scaglione E, Grandgirard D, Masouris I, Farina F, Pagliarulo C, Mantova G, Paragliola L, Leib SL, Koedel U, Pozzi G, Alifano P, Salvatore P. Virulence Traits of a Serogroup C Meningococcus and Isogenic cssA Mutant, Defective in Surface-Exposed Sialic Acid, in a Murine Model of Meningitis. Infect Immun 2019; 87:e00688-18. [PMID: 30718288 PMCID: PMC6434112 DOI: 10.1128/iai.00688-18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 01/29/2019] [Indexed: 12/17/2022] Open
Abstract
In serogroup C Neisseria meningitidis, the cssA (siaA) gene codes for an UDP-N-acetylglucosamine 2-epimerase that catalyzes the conversion of UDP-N-acetyl-α-d-glucosamine into N-acetyl-d-mannosamine and UDP in the first step in sialic acid biosynthesis. This enzyme is required for the biosynthesis of the (α2→9)-linked polysialic acid capsule and for lipooligosaccharide (LOS) sialylation. In this study, we have used a reference serogroup C meningococcal strain and an isogenic cssA knockout mutant to investigate the pathogenetic role of surface-exposed sialic acids in a model of meningitis based on intracisternal inoculation of BALB/c mice. Results confirmed the key role of surface-exposed sialic acids in meningococcal pathogenesis. The 50% lethal dose (LD50) of the wild-type strain 93/4286 was about four orders of magnitude lower than that of the cssA mutant. Compared to the wild-type strain, the ability of this mutant to replicate in brain and spread systemically was severely impaired. Evaluation of brain damage evidenced a significant reduction in cerebral hemorrhages in mice infected with the mutant in comparison with the levels in those challenged with the wild-type strain. Histological analysis showed the typical features of bacterial meningitis, including inflammatory cells in the subarachnoid, perivascular, and ventricular spaces especially in animals infected with the wild type. Noticeably, 80% of mice infected with the wild-type strain presented with massive bacterial localization and accompanying inflammatory infiltrate in the corpus callosum, indicating high tropism of meningococci exposing sialic acids toward this brain structure and a specific involvement of the corpus callosum in the mouse model of meningococcal meningitis.
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Affiliation(s)
- Roberta Colicchio
- Department of Molecular Medicine and Medical Biotechnology, Federico II University, Naples, Italy
| | - Chiara Pagliuca
- Department of Molecular Medicine and Medical Biotechnology, Federico II University, Naples, Italy
| | - Susanna Ricci
- Laboratory of Molecular Microbiology and Biotechnology (LAMMB), Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Elena Scaglione
- Department of Molecular Medicine and Medical Biotechnology, Federico II University, Naples, Italy
| | - Denis Grandgirard
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Ilias Masouris
- Department of Neurology, Ludwig Maximilians University of Munich, Munich, Germany
| | - Fabrizio Farina
- Department of Law, Economics, Management and Quantitative Methods, University of Sannio, Benevento, Italy
| | | | - Giuseppe Mantova
- Department of Molecular Medicine and Medical Biotechnology, Federico II University, Naples, Italy
| | - Laura Paragliola
- Department of Integrated Activity of Laboratory Medicine and Transfusion, Complex Operative Unit of Clinical Microbiology, University Hospital Federico II, Naples, Italy
| | - Stephen L Leib
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Uwe Koedel
- Department of Neurology, Ludwig Maximilians University of Munich, Munich, Germany
| | - Gianni Pozzi
- Laboratory of Molecular Microbiology and Biotechnology (LAMMB), Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Pietro Alifano
- Department of Biological and Environmental Sciences and Technologies, University of Salento, Lecce, Italy
| | - Paola Salvatore
- Department of Molecular Medicine and Medical Biotechnology, Federico II University, Naples, Italy
- Department of Integrated Activity of Laboratory Medicine and Transfusion, Complex Operative Unit of Clinical Microbiology, University Hospital Federico II, Naples, Italy
- CEINGE, Biotecnologie Avanzate s.c.ar.l., Naples, Italy
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22
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Völk S, Koedel U, Pfister HW, Schwankhart R, Op den Winkel M, Mühlbauer K, Klein M. Impaired Consciousness in the Emergency Department. Eur Neurol 2018; 80:179-186. [PMID: 30541008 DOI: 10.1159/000495363] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 11/12/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND The approach to unconscious patients in the emergency department (ED) is difficult, often depends on local resources and interests, and workup strategies often lack standardization. One reason for this is that data on causes, management, and outcome of patients who present to the ED with sudden onset unconsciousness of unknown cause is limited. OBJECTIVES This study was performed to analyze the causes of acute impaired consciousness in patients in an interdisciplinary ED. METHODS Here, we analyzed all patients who were admitted to the ED of a tertiary care hospital with the dominating symptom of "sudden onset unconsciousness" within 1 year (September 2014 until August 2015). Patients with a clear diagnosis at arrival that explained the altered state of consciousness or other dominating symptoms at the time of arrival were not included. RESULTS A total of 212 patients were analyzed. In 88% of the patients, a final diagnosis could be established in the ED. Most common causes for unconsciousness were cerebrovascular diseases (24%), infections (14%), epileptic seizures (12%), psychiatric diseases (8%), metabolic causes (7%), intoxications (7%), transient global amnesia (5%), and cardiovascular causes (4%). The diagnoses were predominantly established by physical examination in combination with computed tomography (23%) and by the results of laboratory testing (25%). In-hospital mortality was 11%, and 59% of all patients were discharged with a Glasgow Outcome Score of 2-4. CONCLUSIONS This analysis demonstrates a large variety of etiologies in patients with unknown unconsciousness of acute onset who are admitted to an ED. As neurological diagnoses are among the most common etiologies, neurological qualification is required in the ED, and availability of diagnostics such as cerebral imaging is indispensable and recommended as an early step in a standardized clinical approach.
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Affiliation(s)
- Stefanie Völk
- Department of Neurology, Hospital of the Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Uwe Koedel
- Department of Neurology, Hospital of the Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Hans-Walter Pfister
- Department of Neurology, Hospital of the Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Roland Schwankhart
- Emergency Department, Hospital of the Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Mark Op den Winkel
- Emergency Department, Hospital of the Ludwig-Maximilians-University (LMU), Munich, Germany.,Department of Medicine II, Hospital of the Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Konstanze Mühlbauer
- Department of Anaesthesiology, Hospital of the Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Matthias Klein
- Department of Neurology, Hospital of the Ludwig-Maximilians-University (LMU), Munich, Germany, .,Emergency Department, Hospital of the Ludwig-Maximilians-University (LMU), Munich, Germany,
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23
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Knier B, Hiltensperger M, Sie C, Aly L, Lepennetier G, Engleitner T, Garg G, Muschaweckh A, Mitsdörffer M, Koedel U, Höchst B, Knolle P, Gunzer M, Hemmer B, Rad R, Merkler D, Korn T. Myeloid-derived suppressor cells control B cell accumulation in the central nervous system during autoimmunity. Nat Immunol 2018; 19:1341-1351. [PMID: 30374128 PMCID: PMC6241855 DOI: 10.1038/s41590-018-0237-5] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 09/13/2018] [Indexed: 01/25/2023]
Abstract
Polymorphonuclear myeloid-derived suppressor cells (PMN-MDSCs) have been characterized in the context of malignancies. Here we show that PMN-MDSCs can restrain B cell accumulation during central nervous system (CNS) autoimmunity. Ly6G+ cells were recruited to the CNS during experimental autoimmune encephalomyelitis (EAE), interacted with B cells that produced the cytokines GM-CSF and interleukin-6 (IL-6), and acquired properties of PMN-MDSCs in the CNS in a manner dependent on the signal transducer STAT3. Depletion of Ly6G+ cells or dysfunction of Ly6G+ cells through conditional ablation of STAT3 led to the selective accumulation of GM-CSF-producing B cells in the CNS compartment, which in turn promoted an activated microglial phenotype and lack of recovery from EAE. The frequency of CD138+ B cells in the cerebrospinal fluid (CSF) of human subjects with multiple sclerosis was negatively correlated with the frequency of PMN-MDSCs in the CSF. Thus PMN-MDSCs might selectively control the accumulation and cytokine secretion of B cells in the inflamed CNS.
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Affiliation(s)
- Benjamin Knier
- Department of Experimental Neuroimmunology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Hiltensperger
- Department of Experimental Neuroimmunology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christopher Sie
- Department of Experimental Neuroimmunology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Lilian Aly
- Department of Experimental Neuroimmunology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gildas Lepennetier
- Department of Experimental Neuroimmunology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Thomas Engleitner
- Institute of Molecular Oncology and Functional Genomics, TranslaTUM Cancer Center, Technical University of Munich, Munich, Germany.,Department of Medicine II, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Garima Garg
- Department of Experimental Neuroimmunology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Andreas Muschaweckh
- Department of Experimental Neuroimmunology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Meike Mitsdörffer
- Department of Experimental Neuroimmunology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Uwe Koedel
- Department of Neurology, Klinikum Grosshadern, Ludwig Maximilians University Munich, Munich, Germany
| | - Bastian Höchst
- Institute of Molecular Immunology and Experimental Oncology, Technical University of Munich, Munich, Germany
| | - Percy Knolle
- Institute of Molecular Immunology and Experimental Oncology, Technical University of Munich, Munich, Germany
| | - Matthias Gunzer
- Institute for Experimental Immunology and Imaging, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Bernhard Hemmer
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Roland Rad
- Institute of Molecular Oncology and Functional Genomics, TranslaTUM Cancer Center, Technical University of Munich, Munich, Germany.,Department of Medicine II, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Doron Merkler
- Department of Pathology and Immunology, Division of Clinical Pathology, University of Geneva, Geneva, Switzerland
| | - Thomas Korn
- Department of Experimental Neuroimmunology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany. .,Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany. .,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany.
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24
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Rupprecht TA, Manz KM, Fingerle V, Lechner C, Klein M, Pfirrmann M, Koedel U. Diagnostic value of cerebrospinal fluid CXCL13 for acute Lyme neuroborreliosis. A systematic review and meta-analysis. Clin Microbiol Infect 2018; 24:1234-1240. [PMID: 29674128 DOI: 10.1016/j.cmi.2018.04.007] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 04/04/2018] [Accepted: 04/04/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVES The utility of cerebrospinal fluid (CSF) CXCL13 for diagnosis of acute Lyme neuroborreliosis (LNB) has been debated and the test is not yet routinely performed. This study's aim was to evaluate its overall diagnostic accuracy through meta-analysis. METHODS Electronic searches in PubMed MEDLINE and Web of Science were performed to identify relevant articles published before January 2018. A summary receiver operating characteristic curve and an optimal cut-off were estimated modelling multiple cut-offs. Publication bias was evaluated using a funnel plot and the associated regression test. RESULTS A total of 18 studies involving 618 individuals with acute LNB and 2326 individuals with other neurological disorders meeting the eligibility criteria were identified. The pooled sensitivity for CSF CXCL13 was 89% (95% CI 85%-93%) and the pooled specificity was 96% (95% CI 92%-98%), using the identified optimal cut-off value of 162 pg/mL. There was marked heterogeneity between studies, caused by differences in the designs of the study populations and age distribution. The optimal cut-off in the seven studies with a cross-sectional design was 91 pg/mL (sensitivity 96%, 95% CI 92%-98%; specificity 94%, 95% CI 86%-97%) and in the 11 case-control studies it was 164 pg/mL (sensitivity 85%, 95% CI 78%-91%; specificity 95%, 95% CI 90%-98%). CSF CXCL13 values above the optimal cut-off level (determined in this meta-analysis) were also detectable in some other central nervous system disorders, namely neurosyphilis and central nervous system lymphoma. CONCLUSIONS Our meta-analysis shows that CSF CXCL13 has the potential to become a useful adjunct in the diagnosis of acute LNB.
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Affiliation(s)
- T A Rupprecht
- Department of Neurology, HELIOS-Clinic Munich West, Munich, Germany
| | - K M Manz
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - V Fingerle
- Bavarian Health and Food Safety Authority, Munich, Oberschleissheim, Germany
| | - C Lechner
- Department of Neurology, HELIOS-Clinic Munich West, Munich, Germany
| | - M Klein
- Department of Neurology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - M Pfirrmann
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - U Koedel
- Department of Neurology, Ludwig-Maximilians-University Munich, Munich, Germany.
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25
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Klein M, Höhne C, Angele B, Högen T, Pfister HW, Tüfekci H, Koedel U. Adjuvant non-bacteriolytic and anti-inflammatory combination therapy in pneumococcal meningitis: an investigation in a mouse model. Clin Microbiol Infect 2018; 25:108.e9-108.e15. [PMID: 29649601 DOI: 10.1016/j.cmi.2018.03.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 03/05/2018] [Accepted: 03/28/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Therapy with antibiotics, dexamethasone, and supportive intensive care has improved the prognosis of pneumococcal meningitis, but mortality remains high. Here, we investigated an adjunctive combination therapy of the non-bacteriolytic antibiotic daptomycin plus several anti-inflammatory agents to identify the currently most promising adjunctive combination therapy for pneumococcal meningitis. METHODS C57BL/6 mice were infected by injection of pneumococci into the cisterna magna. Treatment was begun 21 h after infection, and consisted of ceftriaxone plus (a) dexamethasone, (b) dexamethasone plus daptomycin, (c) daptomycin, (d) daptomycin plus an anti-IL1 antibody, (e) daptomycin plus roscovitine, or (f) daptomycin plus an anti-C5 antibody. Animals were followed until 45 h after infection. Furthermore, adjunctive daptomycin plus anti-C5 antibodies were assessed in a long-term follow-up. RESULTS Adjunctive treatment with daptomycin and an anti-C5 antibody was superior to adjunctive dexamethasone and reduced disease symptoms (clinical score 1.1 ± 1.1 versus 5.0 ± 2.7, p < 0.0083), improved explorative activity (open field test 17.8 ± 8.2 versus 7.4 ± 4.3 crossed fields/2 minutes, p < 0.0083), and reduced hearing impairment (thresholds for click stimulus 96.1 ± 14.7 versus 114.8 ± 9.3 dB SPL, p < 0.0083) in the acute stage. Furthermore, explorative activity (14.4 ± 7.3 crossed fields/2 minutes versus 6.3 ± 7.2, p < 0.05) and cognitive function (t-maze test, exploration time previously unknown alley 72.4 ± 14.3 versus 48.7 ± 25.6%, p < 0.05) was improved at 2 weeks after infection. Treatment with daptomycin plus an anti-IL-1β antibody or roscovitine was not of significant benefit in comparison to adjunctive therapy with dexamethasone. CONCLUSIONS An adjunctive combination of the non-lytic antibiotic daptomycin plus an anti-C5 antibody was superior to standard therapy with adjunctive dexamethasone in the treatment of pneumococcal meningitis.
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Affiliation(s)
- M Klein
- Department of Neurology, Klinikum der Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377 München, Germany.
| | - C Höhne
- Department of Neurology, Klinikum der Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377 München, Germany
| | - B Angele
- Department of Neurology, Klinikum der Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377 München, Germany
| | - T Högen
- Department of Neurology, Klinikum der Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377 München, Germany
| | - H W Pfister
- Department of Neurology, Klinikum der Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377 München, Germany
| | - H Tüfekci
- Department of Neurology, Klinikum der Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377 München, Germany
| | - U Koedel
- Department of Neurology, Klinikum der Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377 München, Germany
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26
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Fritscher J, Amberger D, Dyckhoff S, Bewersdorf JP, Masouris I, Voelk S, Hammerschmidt S, Schmetzer HM, Klein M, Pfister HW, Koedel U. Mast Cells Are Activated by Streptococcus pneumoniae In Vitro but Dispensable for the Host Defense Against Pneumococcal Central Nervous System Infection In Vivo. Front Immunol 2018; 9:550. [PMID: 29616039 PMCID: PMC5867309 DOI: 10.3389/fimmu.2018.00550] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 03/05/2018] [Indexed: 01/01/2023] Open
Abstract
Mast cells reside on and near the cerebral vasculature, the predominant site of pneumococcal entry into the central nervous system (CNS). Although mast cells have been reported to be crucial in protecting from systemic bacterial infections, their role in bacterial infections of the CNS remained elusive. Here, we assessed the role of mast cells in pneumococcal infection in vitro and in vivo. In introductory experiments using mouse bone marrow-derived mast cells (BMMC), we found that (i) BMMC degranulate and release selected cytokines upon exposure to Streptococcus pneumoniae, (ii) the response of BMMC varies between different pneumococcal serotypes and (iii) is dependent on pneumolysin. Intriguingly though, apart from a slight enhancement of cerebrospinal fluid (CSF) pleocytosis, neither two different mast cell-deficient Kit mutant mouse strains (WBB6F1-KitW/Wv and C57BL/6 KitW-sh/W-sh mice) nor pharmacologic mast cell stabilization with cromoglycate had any significant impact on the disease phenotype of experimental pneumococcal meningitis. The incomplete reversal of the enhanced CSF pleocytosis by local mast cell engraftment suggests that this phenomenon is caused by other c-Kit mutation-related mechanisms than mast cell deficiency. In conclusion, our study suggests that mast cells can be activated by S. pneumoniae in vitro. However, mast cells do not play a significant role as sentinels of pneumococcal CSF invasion and initiators of innate immunity in vivo.
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Affiliation(s)
- Johanna Fritscher
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Daniel Amberger
- Department of Internal Medicine III (Oncology), University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Susanne Dyckhoff
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Jan Philipp Bewersdorf
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Ilias Masouris
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Stefanie Voelk
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Sven Hammerschmidt
- Department of Molecular Genetics and Infection Biology, Interfaculty Institute for Genetics and Functional Genomics, Center for Functional Genomics of Microbes, Ernst Moritz Arndt University Greifswald, Greifswald, Germany
| | - Helga Maria Schmetzer
- Department of Internal Medicine III (Oncology), University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Matthias Klein
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Hans-Walter Pfister
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Uwe Koedel
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
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Masouris I, Klein M, Dyckhoff S, Angele B, Pfister HW, Koedel U. Inhibition of DAMP signaling as an effective adjunctive treatment strategy in pneumococcal meningitis. J Neuroinflammation 2017; 14:214. [PMID: 29096648 PMCID: PMC5669003 DOI: 10.1186/s12974-017-0989-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 10/27/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pneumococcal meningitis remains a potentially lethal and debilitating disease, mainly due to brain damage from sustained inflammation. The release of danger-associated molecular patterns (DAMPs), like myeloid-related protein 14 (MRP14) and high mobility group box 1 protein (HMGB1), plays a major role in persistence of inflammation. In this study, we evaluated if paquinimod, an MRP14-inhibitor, and an anti-HMGB1 antibody can improve clinical outcome as adjunctive therapeutics in pneumococcal meningitis. METHODS We tested the adjuvant administration of paquinimod and the anti-HMGB1 antibody in our pneumococcal meningitis mouse model assessing clinical (clinical score, open-field-test, temperature) and pathophysiological parameters (intracranial pressure, white blood cell count in CSF, bleeding area) as well as bacterial titers in blood and brain 24 h after administration and 48 h after infection. Furthermore, we explored the interactions of these two agents with dexamethasone, the standard adjuvant treatment in pneumococcal meningitis (PM), and daptomycin, a non-bacteriolytic antibiotic preventing pathogen-associated molecular pattern (PAMP) release. RESULTS Adjunctive inhibition of MRP14 or HMGB1 reduced mortality in mice with PM. This effect was lost when the two anti-DAMP agents were given simultaneously, possibly due to excessive immunosuppression. Combining anti-PAMP (daptomycin) and anti-DAMP treatments did not produce synergistic results; instead, the anti-DAMP treatment alone was sufficient and superior. The combination of anti-HMGB1 with dexamethasone did not diminish the effect of the former. CONCLUSIONS DAMP inhibition possesses good potential as an adjuvant treatment approach in PM, as it improves clinical outcome and can be given together with the standard adjuvant dexamethasone without drug effect loss in experimental PM.
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Affiliation(s)
- Ilias Masouris
- Department of Neurology, University Hospital, LMU Munich, 81377, Munich, Germany. .,Department of Neurology, Klinikum Grosshadern of the Ludwig Maximilians University, Marchioninistraße 15, 81377, Munich, Germany.
| | - Matthias Klein
- Department of Neurology, University Hospital, LMU Munich, 81377, Munich, Germany
| | - Susanne Dyckhoff
- Department of Neurology, University Hospital, LMU Munich, 81377, Munich, Germany
| | - Barbara Angele
- Department of Neurology, University Hospital, LMU Munich, 81377, Munich, Germany
| | - H W Pfister
- Department of Neurology, University Hospital, LMU Munich, 81377, Munich, Germany
| | - Uwe Koedel
- Department of Neurology, University Hospital, LMU Munich, 81377, Munich, Germany
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Abstract
Meningitis is an inflammation of the meninges and subarachnoid space that can also involve the brain cortex and parenchyma. It can be acquired spontaneously in the community - community-acquired bacterial meningitis - or in the hospital as a complication of invasive procedures or head trauma (nosocomial bacterial meningitis). Despite advances in treatment and vaccinations, community-acquired bacterial meningitis remains one of the most important infectious diseases worldwide. Streptococcus pneumoniae and Neisseria meningitidis are the most common causative bacteria and are associated with high mortality and morbidity; vaccines targeting these organisms, which have designs similar to the successful vaccine that targets Haemophilus influenzae type b meningitis, are now being used in many routine vaccination programmes. Experimental and genetic association studies have increased our knowledge about the pathogenesis of bacterial meningitis. Early antibiotic treatment improves the outcome, but the growing emergence of drug resistance as well as shifts in the distribution of serotypes and groups are fuelling further development of new vaccines and treatment strategies. Corticosteroids were found to be beneficial in high-income countries depending on the bacterial species. Further improvements in the outcome are likely to come from dampening the host inflammatory response and implementing preventive measures, especially the development of new vaccines.
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Affiliation(s)
- Diederik van de Beek
- Department of Neurology, Center of Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, P.O. BOX 22660, 1100DD Amsterdam, The Netherlands
| | - Matthijs Brouwer
- Department of Neurology, Center of Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, P.O. BOX 22660, 1100DD Amsterdam, The Netherlands
| | - Rodrigo Hasbun
- Department of Internal Medicine, UT Health McGovern Medical School, Houston, Texas, USA
| | - Uwe Koedel
- Department of Neurology, Clinic Grosshadern of the Ludwig-Maximilians University of Munich, Munich, Germany
| | - Cynthia G Whitney
- Respiratory Diseases Branch, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Eelco Wijdicks
- Division of Critical Care Neurology, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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Buchholz G, Koedel U, Pfister HW, Kastenbauer S, Klein M. Dramatic reduction of mortality in pneumococcal meningitis. Crit Care 2016; 20:312. [PMID: 27716447 PMCID: PMC5045860 DOI: 10.1186/s13054-016-1498-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 09/19/2016] [Indexed: 12/28/2022]
Abstract
Background Acute bacterial meningitis is still a life threatening disease. Methods We performed a retrospective observational study on the clinical characteristics of consecutively admitted patients with acute pneumococcal meningitis in a single tertiary care center in central Europe (from 2003 until 2015). Data were compared with a previously published historical group of 87 patients treated for pneumococcal meningitis at the same hospital (from 1984 until 2002). Results Fifty-five consecutive patients with microbiologically proven pneumococcal meningitis were included. Most striking, mortality was down to 5.5 %, which was significantly lower than in the historical group where 24.1 % of the patients did not survive. Intracranial complications during the course of the disease were common and affected half of the patients. Unlike in the historic group, most of the intracranial complications (except ischemic stroke) were no longer associated with a low Glasgow Outcome Score at discharge. Conclusion The drastic reduction of mortality proves there have been important advances in the treatment of pneumococcal meningitis. Nevertheless, the fact that only 44.2 % of survivors had a full recovery indicates that the search for new adjunctive treatment options must be ongoing.
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Affiliation(s)
- Grete Buchholz
- Department of Neurology, Klinikum Grosshadern, Ludwig Maximilians University, Marchioninistr. 15, 81377, Munich, Germany
| | - Uwe Koedel
- Department of Neurology, Klinikum Grosshadern, Ludwig Maximilians University, Marchioninistr. 15, 81377, Munich, Germany
| | - Hans-Walter Pfister
- Department of Neurology, Klinikum Grosshadern, Ludwig Maximilians University, Marchioninistr. 15, 81377, Munich, Germany
| | | | - Matthias Klein
- Emergency Department, Klinikum Grosshadern, Ludwig Maximilians University, Marchioninistr, 15, 81377, Munich, Germany.
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30
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Abstract
Lyme disease, caused by the Borrelia burgdorferi bacterium, is the most common vector-borne disease in the northern hemisphere. The clinical presentation varies with disease stage, and neurological manifestations (often referred to as Lyme neuroborreliosis) are reported in up to 12% of patients with Lyme disease. Most aspects of the epidemiology, clinical manifestation and treatment of Lyme neuroborreliosis are well known and accepted; only the management of so-called chronic Lyme disease is surrounded by considerable controversy. This term is used for disparate patient groups, including those who have untreated late-stage infection (for example, late neuroborreliosis), those with subjective symptoms that persist after treatment (termed 'post-treatment Lyme disease syndrome' [PTLDS]), and those with unexplained subjective complaints that may or may not be accompanied by positive test results for B. burgdorferi infection in serum (here called 'chronic Lyme disease'). The incidence of PTLDS is still a matter of debate, and its pathogenesis is unclear, but there is evidence that these patients do not have ongoing B. burgdorferi infection and, thus, do not benefit from additional antibiotic therapy. Chronic Lyme disease lacks an accepted clinical definition, and most patients who receive this diagnosis have other illnesses. Thus, a careful diagnostic work-up is needed to ensure proper treatment.
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Affiliation(s)
- Uwe Koedel
- Clinic Grosshadern of the Ludwig-Maximilians University of Munich, Department of Neurology, Marchioninistrasse 15, D-81377 Munich, Germany
| | - Volker Fingerle
- Bavarian Health and Food Safety Authority &German National Reference Centre for Borrelia, Veterinärstrasse 2, 85764 Oberschleissheim, Germany
| | - Hans-Walter Pfister
- Clinic Grosshadern of the Ludwig-Maximilians University of Munich, Department of Neurology, Marchioninistrasse 15, D-81377 Munich, Germany
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31
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Pruenster M, Kurz ARM, Chung KJ, Cao-Ehlker X, Bieber S, Nussbaum CF, Bierschenk S, Eggersmann TK, Rohwedder I, Heinig K, Immler R, Moser M, Koedel U, Gran S, McEver RP, Vestweber D, Verschoor A, Leanderson T, Chavakis T, Roth J, Vogl T, Sperandio M. Extracellular MRP8/14 is a regulator of β2 integrin-dependent neutrophil slow rolling and adhesion. Nat Commun 2015; 6:6915. [PMID: 25892652 PMCID: PMC4411303 DOI: 10.1038/ncomms7915] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 03/13/2015] [Indexed: 12/16/2022] Open
Abstract
Myeloid-related proteins (MRPs) 8 and 14 are cytosolic proteins secreted from myeloid cells as proinflammatory mediators. Currently, the functional role of circulating extracellular MRP8/14 is unclear. Our present study identifies extracellular MRP8/14 as an autocrine player in the leukocyte adhesion cascade. We show that E-selectin–PSGL-1 interaction during neutrophil rolling triggers Mrp8/14 secretion. Released MRP8/14 in turn activates a TLR4-mediated, Rap1-GTPase-dependent pathway of rapid β2 integrin activation in neutrophils. This extracellular activation loop reduces leukocyte rolling velocity and stimulates adhesion. Thus, we identify Mrp8/14 and TLR4 as important modulators of the leukocyte recruitment cascade during inflammation in vivo. MRP8/14 are actively secreted by myeloid cells during inflammation. Here the authors show that MRP8/14 play an important role in leukocyte recruitment to the inflammatory site, triggering an autocrine cascade that promotes neutrophil adhesion to the endothelium.
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Affiliation(s)
- Monika Pruenster
- Institute of Cardiovascular Physiology and Pathophysiology, Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians Universität, Munich, Germany
| | - Angela R M Kurz
- Institute of Cardiovascular Physiology and Pathophysiology, Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians Universität, Munich, Germany
| | - Kyoung-Jin Chung
- Department of Clinical Pathobiochemistry, Institute for Clinical Chemistry and Laboratory Medicine, Technische Universität Dresden, Dresden, Germany
| | - Xiao Cao-Ehlker
- Institute of Cardiovascular Physiology and Pathophysiology, Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians Universität, Munich, Germany
| | - Stephanie Bieber
- Institute of Cardiovascular Physiology and Pathophysiology, Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians Universität, Munich, Germany
| | - Claudia F Nussbaum
- Institute of Cardiovascular Physiology and Pathophysiology, Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians Universität, Munich, Germany
| | - Susanne Bierschenk
- Institute of Cardiovascular Physiology and Pathophysiology, Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians Universität, Munich, Germany
| | - Tanja K Eggersmann
- Institute of Cardiovascular Physiology and Pathophysiology, Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians Universität, Munich, Germany
| | - Ina Rohwedder
- Institute of Cardiovascular Physiology and Pathophysiology, Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians Universität, Munich, Germany
| | - Kristina Heinig
- Institute of Cardiovascular Physiology and Pathophysiology, Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians Universität, Munich, Germany
| | - Roland Immler
- Institute of Cardiovascular Physiology and Pathophysiology, Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians Universität, Munich, Germany
| | - Markus Moser
- Department of Molecular Medicine, Max Planck Institute for Biochemistry, Martinsried, Germany
| | - Uwe Koedel
- Department of Neuroinflammation, Ludwig-Maximilians Universität, Munich, Germany
| | - Sandra Gran
- Institute of Immunology, University of Muenster, Muenster, Germany
| | - Rodger P McEver
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | | | - Admar Verschoor
- Institute for Medical Microbiology, Immunology and Hygiene, Technische Universität, Munich, Germany
| | | | - Triantafyllos Chavakis
- Department of Clinical Pathobiochemistry, Institute for Clinical Chemistry and Laboratory Medicine, Technische Universität Dresden, Dresden, Germany
| | - Johannes Roth
- Institute of Immunology, University of Muenster, Muenster, Germany
| | - Thomas Vogl
- Institute of Immunology, University of Muenster, Muenster, Germany
| | - Markus Sperandio
- Institute of Cardiovascular Physiology and Pathophysiology, Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians Universität, Munich, Germany
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32
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Wache C, Klein M, Ostergaard C, Angele B, Häcker H, Pfister HW, Pruenster M, Sperandio M, Leanderson T, Roth J, Vogl T, Koedel U. Myeloid-related protein 14 promotes inflammation and injury in meningitis. J Infect Dis 2015; 212:247-57. [PMID: 25605866 DOI: 10.1093/infdis/jiv028] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 01/06/2015] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Neutrophilic inflammation often persists for days despite effective antibiotic treatment and contributes to brain damage in bacterial meningitis. We propose here that myeloid-related protein 14 (MRP14), an abundant cytosolic protein in myeloid cells, acts as an endogenous danger signal, driving inflammation and aggravating tissue injury. METHODS The release pattern of MRP14 was analyzed in human and murine cerebrospinal fluid (CSF), as well as in isolated neutrophils. Its functional role was assessed in a mouse meningitis model, using MRP14-deficient mice. RESULTS We detected large quantities of MRP14 in CSF specimens from patients and mice with pneumococcal meningitis. Immunohistochemical analyses and a cell-depletion approach indicated neutrophils as the major source of MRP14. In a meningitis model, MRP14-deficient mice showed a better resolution of inflammation during antibiotic therapy, which was accompanied by reduced disease severity. Intrathecal administration of MRP14 before infection reverted the phenotype of MRP14-deficient mice back to wild type. Moreover, intrathecal injection of MRP14 alone was sufficient to induce meningitis in a Toll-like receptor 4 (TLR4)-CXCL2-dependent manner. Finally, treatment with the MRP14 antagonist paquinimod reduced inflammation and disease severity significantly, reaching levels comparable to those achieved after genetic depletion of MRP14. CONCLUSIONS The present study implicates MRP14 as an essential propagator of inflammation and potential therapeutic target in pneumococcal meningitis.
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Affiliation(s)
- Christina Wache
- Department of Neurology, Klinikum Grosshadern of the Ludwig Maximilians University
| | - Matthias Klein
- Department of Neurology, Klinikum Grosshadern of the Ludwig Maximilians University
| | - Christian Ostergaard
- Department of Clinical Microbiology, Copenhagen University Hospital Hvidovre, Denmark
| | - Barbara Angele
- Department of Neurology, Klinikum Grosshadern of the Ludwig Maximilians University
| | - Hans Häcker
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Hans-Walter Pfister
- Department of Neurology, Klinikum Grosshadern of the Ludwig Maximilians University
| | - Monika Pruenster
- Walter Brendel Center of Experimental Medicine, Ludwig Maximilians University, München
| | - Markus Sperandio
- Walter Brendel Center of Experimental Medicine, Ludwig Maximilians University, München
| | | | - Johannes Roth
- Institute of Immunology, Westfälische Wilhelms-Universität Münster, Germany
| | - Thomas Vogl
- Institute of Immunology, Westfälische Wilhelms-Universität Münster, Germany
| | - Uwe Koedel
- Department of Neurology, Klinikum Grosshadern of the Ludwig Maximilians University
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33
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Ricci S, Grandgirard D, Wenzel M, Braccini T, Salvatore P, Oggioni MR, Leib SL, Koedel U. Inhibition of matrix metalloproteinases attenuates brain damage in experimental meningococcal meningitis. BMC Infect Dis 2014; 14:726. [PMID: 25551808 PMCID: PMC4300156 DOI: 10.1186/s12879-014-0726-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 12/18/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Approximately 7% of survivors from meningococcal meningitis (MM) suffer from neurological sequelae due to brain damage in the course of meningitis. The present study focuses on the role of matrix metalloproteinases (MMPs) in a novel mouse model of MM-induced brain damage. METHODS The model is based on intracisternal infection of BALB/c mice with a serogroup C Neisseria meningitidis strain. Mice were infected with meningococci and randomised for treatment with the MMP inhibitor batimastat (BB-94) or vehicle. Animal survival, brain injury and host-response biomarkers were assessed 48 h after meningococcal challenge. RESULTS Mice that received BB-94 presented significantly diminished MMP-9 levels (p < 0.01), intracerebral bleeding (p < 0.01), and blood-brain barrier (BBB) breakdown (p < 0.05) in comparison with untreated animals. In mice suffering from MM, the amount of MMP-9 measured by zymography significantly correlated with both intracerebral haemorrhage (p < 0.01) and BBB disruption (p < 0.05). CONCLUSIONS MMPs significantly contribute to brain damage associated with experimental MM. Inhibition of MMPs reduces intracranial complications in mice suffering from MM, representing a potential adjuvant strategy in MM post-infection sequelae.
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Woehrl B, Linn J, Lummel N, Pfefferkorn T, Koedel U, Pfister HW, Klein M. Pneumococcal meningitis-associated pyogenic ventriculitis. J Infect 2014; 70:311-4. [PMID: 25452044 DOI: 10.1016/j.jinf.2014.10.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 10/29/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Bianca Woehrl
- Department of Neurology, Klinikum Grosshadern, Ludwig-Maximilians-Universität, Munich, Germany
| | - Jennifer Linn
- Department of Neuroradiology, Carl Gustav Jarus University Hospital, University of Dresden, Dresden, Germany
| | - Nina Lummel
- Department of Neuroradiology, Klinikum Grosshadern, Ludwig-Maximilians-Universität, Munich, Germany
| | | | - Uwe Koedel
- Department of Neurology, Klinikum Grosshadern, Ludwig-Maximilians-Universität, Munich, Germany
| | - Hans-Walter Pfister
- Department of Neurology, Klinikum Grosshadern, Ludwig-Maximilians-Universität, Munich, Germany
| | - Matthias Klein
- Department of Neurology, Klinikum Grosshadern, Ludwig-Maximilians-Universität, Munich, Germany.
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35
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Klein M, Brouwer MC, Angele B, Geldhoff M, Marquez G, Varona R, Häcker G, Schmetzer H, Häcker H, Hammerschmidt S, van der Ende A, Pfister HW, van de Beek D, Koedel U. Leukocyte attraction by CCL20 and its receptor CCR6 in humans and mice with pneumococcal meningitis. PLoS One 2014; 9:e93057. [PMID: 24699535 PMCID: PMC3974727 DOI: 10.1371/journal.pone.0093057] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 02/28/2014] [Indexed: 01/10/2023] Open
Abstract
We previously identified CCL20 as an early chemokine in the cerebrospinal fluid (CSF) of patients with pneumococcal meningitis but its functional relevance was unknown. Here we studied the role of CCL20 and its receptor CCR6 in pneumococcal meningitis. In a prospective nationwide study, CCL20 levels were significantly elevated in the CSF of patients with pneumococcal meningitis and correlated with CSF leukocyte counts. CCR6-deficient mice with pneumococcal meningitis and WT mice with pneumococcal meningitis treated with anti-CCL20 antibodies both had reduced CSF white blood cell counts. The reduction in CSF pleocytosis was also accompanied by an increase in brain bacterial titers. Additional in vitro experiments showed direct chemoattractant activity of CCL20 for granulocytes. In summary, our results identify the CCL20-CCR6 axis as an essential component of the innate immune defense against pneumococcal meningitis, controlling granulocyte recruitment.
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MESH Headings
- Adult
- Aged
- Animals
- Antibodies, Monoclonal/pharmacology
- Blotting, Western
- Brain/immunology
- Brain/metabolism
- Brain/microbiology
- Case-Control Studies
- Cells, Cultured
- Chemokine CCL20/antagonists & inhibitors
- Chemokine CCL20/immunology
- Chemokine CCL20/metabolism
- Chemotaxis, Leukocyte/immunology
- Enzyme-Linked Immunosorbent Assay
- Female
- Flow Cytometry
- Humans
- Immunoenzyme Techniques
- Male
- Meningitis, Pneumococcal/cerebrospinal fluid
- Meningitis, Pneumococcal/immunology
- Meningitis, Pneumococcal/metabolism
- Meningitis, Pneumococcal/microbiology
- Mice
- Mice, Inbred C57BL
- Mice, Knockout
- Prognosis
- Prospective Studies
- Receptors, CCR6/physiology
- Survival Rate
- Tumor Cells, Cultured
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Affiliation(s)
- Matthias Klein
- Department of Neurology, Ludwig-Maximilians-University, Munich, Germany
- * E-mail:
| | - Matthijs C. Brouwer
- Department of Neurology, University of Amsterdam, Amsterdam, The Netherlands
- Center of Infection and Immunity Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - Barbara Angele
- Department of Neurology, Ludwig-Maximilians-University, Munich, Germany
| | - Madelijn Geldhoff
- Department of Neurology, University of Amsterdam, Amsterdam, The Netherlands
- Center of Infection and Immunity Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Rosa Varona
- Departamento de Immunologia y Oncologia, Centro National de Biotecnologia, Madrid, Spain
| | - Georg Häcker
- Institute for Medical Microbiology and Hygiene, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Helga Schmetzer
- Medical Department III, Ludwig-Maximilians-University, Munich, Germany
| | - Hans Häcker
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Sven Hammerschmidt
- Department Genetics of Microorganisms, University of Greifswald, Greifswald, Germany
| | - Arie van der Ende
- Center of Infection and Immunity Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
- Department of Medical Microbiology, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Diederik van de Beek
- Department of Neurology, University of Amsterdam, Amsterdam, The Netherlands
- Center of Infection and Immunity Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - Uwe Koedel
- Department of Neurology, Ludwig-Maximilians-University, Munich, Germany
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36
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Gerlini A, Colomba L, Furi L, Braccini T, Manso AS, Pammolli A, Wang B, Vivi A, Tassini M, van Rooijen N, Pozzi G, Ricci S, Andrew PW, Koedel U, Moxon ER, Oggioni MR. The role of host and microbial factors in the pathogenesis of pneumococcal bacteraemia arising from a single bacterial cell bottleneck. PLoS Pathog 2014; 10:e1004026. [PMID: 24651834 PMCID: PMC3961388 DOI: 10.1371/journal.ppat.1004026] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 02/10/2014] [Indexed: 01/27/2023] Open
Abstract
The pathogenesis of bacteraemia after challenge with one million pneumococci of three isogenic variants was investigated. Sequential analyses of blood samples indicated that most episodes of bacteraemia were monoclonal events providing compelling evidence for a single bacterial cell bottleneck at the origin of invasive disease. With respect to host determinants, results identified novel properties of splenic macrophages and a role for neutrophils in early clearance of pneumococci. Concerning microbial factors, whole genome sequencing provided genetic evidence for the clonal origin of the bacteraemia and identified SNPs in distinct sub-units of F0/F1 ATPase in the majority of the ex vivo isolates. When compared to parental organisms of the inoculum, ex-vivo pneumococci with mutant alleles of the F0/F1 ATPase had acquired the capacity to grow at low pH at the cost of the capacity to grow at high pH. Although founded by a single cell, the genotypes of pneumococci in septicaemic mice indicate strong selective pressure for fitness, emphasising the within-host complexity of the pathogenesis of invasive disease.
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Affiliation(s)
- Alice Gerlini
- LAMMB, Department of Biotechnology, University of Siena, Siena, Italy
| | - Leonarda Colomba
- LAMMB, Department of Biotechnology, University of Siena, Siena, Italy
| | - Leonardo Furi
- LAMMB, Department of Biotechnology, University of Siena, Siena, Italy
| | - Tiziana Braccini
- LAMMB, Department of Biotechnology, University of Siena, Siena, Italy
| | - Ana Sousa Manso
- LAMMB, Department of Biotechnology, University of Siena, Siena, Italy
| | - Andrea Pammolli
- Department of Pathophysiology, Experimental Medicine and Public Health, University of Siena, Siena, Italy
| | - Bo Wang
- Department of Mathematics, University of Leicester, Leicester, United Kingdom
| | | | | | - Nico van Rooijen
- Department of Molecular Cell Biology, Vrije Universiteit Medical Center, Amsterdam, The Netherlands
| | - Gianni Pozzi
- LAMMB, Department of Biotechnology, University of Siena, Siena, Italy
- UOC Batteriologia, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Susanna Ricci
- LAMMB, Department of Biotechnology, University of Siena, Siena, Italy
| | - Peter W. Andrew
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, United Kingdom
| | - Uwe Koedel
- Department of Neurology, Ludwig-Maximilians University of Munich, München, Germany
| | - E. Richard Moxon
- Division of Medical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Marco R. Oggioni
- LAMMB, Department of Biotechnology, University of Siena, Siena, Italy
- UOC Batteriologia, Azienda Ospedaliera Universitaria Senese, Siena, Italy
- Department of Genetics, University of Leicester, Leicester, United Kingdom
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Buchholz G, Ormanns S, Pfister HW, Koedel U, Klein M. Neuroinfectious diseases at a European neurological tertiary care center: one-third of patients require treatment in the neurological intensive care unit. Eur J Neurol 2014; 21:1500-3. [PMID: 24506319 DOI: 10.1111/ene.12379] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2013] [Accepted: 12/30/2013] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND PURPOSE Studies on the impact of infectious diseases affecting the nervous system are sparse. METHODS All patients with neuroinfectious diseases (NIDs) who were treated at our Department of Neurology from 2005 until 2009 were retrospectively analyzed. RESULTS Patients with NIDs required treatment at the intensive care unit in 34.8%. The mortality rate of patients with NIDs was significantly higher than that of other inpatients with neurological diseases (5.1% vs. 3.0%, respectively, P = 0.018). CONCLUSION In summary, this study shows that patients with NIDs are severely ill and mortality is high.
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Affiliation(s)
- G Buchholz
- Department of Neurology, Klinikum Grosshadern, Ludwig Maximilians University, Munich, Germany
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38
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Höhne C, Wenzel M, Angele B, Hammerschmidt S, Häcker H, Klein M, Bierhaus A, Sperandio M, Pfister HW, Koedel U. High mobility group box 1 prolongs inflammation and worsens disease in pneumococcal meningitis. Brain 2013; 136:1746-59. [DOI: 10.1093/brain/awt064] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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39
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Recher M, Malipiero U, Schaer DJ, Koedel U, Pfister HW, Birchler T, Petrausch U, Claus H, Gast H, Fontana A. Inhibition of meningitis-associated neutrophil apoptosis by TNF-α depends on functional PI3-kinase in monocytes. J Leukoc Biol 2012; 93:259-66. [PMID: 23139429 DOI: 10.1189/jlb.0511218] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
In bacterial meningitis, neutrophils cope with bacterial infection but also lead to tissue damage. The balance of beneficial and harmful effects may depend on the lifespan of the neutrophils in the CNS. Here, we show that CSF of patients with meningococcal meningitis contains a neutrophil apoptosis-inhibiting capacity that correlates with TNF-α content. In vitro experiments show that Neisseria meningitidis as well as LPS derived from these bacteria regulated neutrophil apoptosis mainly by stimulating TNF-α production in monocytes. Whereas LPS-induced PI3K-dependent survival signals in monocytes are critical for neutrophil survival, PI3K signaling in granulocytes did not contribute to the increased lifespan of neutrophils. We conclude that LPS-driven PI3K signaling in monocytes regulates neutrophil apoptosis and thereby, may be crucial in the initiation of secondary brain damage in bacterial meningitis.
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Affiliation(s)
- Mike Recher
- Clinical Immunology, University Hospital, Zürich, Switzerland.
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40
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Oldenburg M, Krüger A, Ferstl R, Kaufmann A, Nees G, Sigmund A, Bathke B, Lauterbach H, Suter M, Dreher S, Koedel U, Akira S, Kawai T, Buer J, Wagner H, Bauer S, Hochrein H, Kirschning CJ. TLR13 recognizes bacterial 23S rRNA devoid of erythromycin resistance-forming modification. Science 2012; 337:1111-5. [PMID: 22821982 DOI: 10.1126/science.1220363] [Citation(s) in RCA: 291] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Host protection from infection relies on the recognition of pathogens by innate pattern-recognition receptors such as Toll-like receptors (TLRs). Here, we show that the orphan receptor TLR13 in mice recognizes a conserved 23S ribosomal RNA (rRNA) sequence that is the binding site of macrolide, lincosamide, and streptogramin group (MLS) antibiotics (including erythromycin) in bacteria. Notably, 23S rRNA from clinical isolates of erythromycin-resistant Staphylococcus aureus and synthetic oligoribonucleotides carrying methylated adenosine or a guanosine mimicking a MLS resistance-causing modification failed to stimulate TLR13. Thus, our results reveal both a natural TLR13 ligand and specific mechanisms of antibiotic resistance as potent bacterial immune evasion strategy, avoiding recognition via TLR13.
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Affiliation(s)
- Marina Oldenburg
- Institute of Medical Microbiology, University of Duisburg-Essen, Essen, Germany
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41
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Woehrl B, Klein M, Grandgirard D, Koedel U, Leib S. Bacterial meningitis: current therapy and possible future treatment options. Expert Rev Anti Infect Ther 2012; 9:1053-65. [PMID: 22029523 DOI: 10.1586/eri.11.129] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Despite targeted therapy, case-fatality rates and neurologic sequelae of bacterial meningitis remain unacceptably high. The poor outcome is mainly due to secondary systemic and intracranial complications. These complications seem to be both a consequence of the inflammatory response to the invading pathogen and release of bacterial components by the pathogen itself. Therefore, within the last decades, research has focused on the mechanism underlying immune regulation and the inhibition of bacterial lysis in order to identify new targets for adjuvant therapy. The scope of this article is to give an overview on current treatment strategies of bacterial meningitis, to summarize new insights on the pathophysiology of bacterial meningitis, and to give an outlook on new treatment strategies derived from experimental models.
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Affiliation(s)
- Bianca Woehrl
- Department of Neurology, Klinikum Grosshadern, Ludwig Maximilians University, Munich, Germany
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42
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Klein M, Koedel U, Pfefferkorn T, Zeller G, Woehrl B, Pfister HW. Arterial cerebrovascular complications in 94 adults with acute bacterial meningitis. Crit Care 2011; 15:R281. [PMID: 22112693 PMCID: PMC3388646 DOI: 10.1186/cc10565] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Revised: 08/08/2011] [Accepted: 11/23/2011] [Indexed: 11/24/2022]
Abstract
Introduction Intracranial vascular complications are an important complication of acute bacterial meningitis. Ischemic stroke in meningitis is reported as a result of vasculitis, vasospasm, endocarditis or intraarterial thrombosis. The aim of the study was to identify the value of measuring cerebral blood flow velocity (CBFv) on transracranial doppler (TCD) in the identification of patients at risk for meningitis-associated stroke. Methods We retrospectively studied patients with acute bacterial meningitis who were treated in our university hospital from 2000 to 2009. Data were analyzed with the main focus on the incidence of an increase of CBFv on TCD, defined as peak systolic values above 150 cm/s, and the development of stroke. Results In total, 114 patients with acute bacterial meningitis were treated, 94 of them received routine TCD studies during their hospital stay. 41/94 patients had elevated CBFv values. This increase was associated with an increased risk of stroke (odds ratio (95% confidence intervall) = 9.15 (1.96-42.67); p < 0.001) and unfavorable outcome (Glasgow Outcome Score < 4; odds ratio (95% confidence intervall) = 2.93 (1.23-6.98); p = 0.018). 11/32 (34.4%) patients with an increase of CBFv who received nimodipine and 2/9 (22.2%) patients with an increase of CBFv who did not receive nimodipine developed stroke (p = 0.69). Conclusions In summary, TCD was found to be a valuable bedside test to detect arterial alterations in patients with bacterial meningitis. These patients have an increased risk of stroke.
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Affiliation(s)
- Matthias Klein
- Department of Neurology, Klinikum Grosshadern, Ludwig Maximilians University, Marchioninistr, 15, D-81377 Munich, Germany.
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Hoegen T, Tremel N, Klein M, Angele B, Wagner H, Kirschning C, Pfister HW, Fontana A, Hammerschmidt S, Koedel U. The NLRP3 inflammasome contributes to brain injury in pneumococcal meningitis and is activated through ATP-dependent lysosomal cathepsin B release. J Immunol 2011; 187:5440-51. [PMID: 22003197 DOI: 10.4049/jimmunol.1100790] [Citation(s) in RCA: 164] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Streptococcus pneumoniae meningitis causes brain damage through inflammation-related pathways whose identity and mechanisms of action are yet unclear. We previously identified caspase-1, which activates precursor IL-1 type cytokines, as a central mediator of inflammation in pneumococcal meningitis. In this study, we demonstrate that lack of the inflammasome components ASC or NLRP3 that are centrally involved in caspase-1 activation decreases scores of clinical and histological disease severity as well as brain inflammation in murine pneumococcal meningitis. Using specific inhibitors (anakinra and rIL-18-binding protein), we further show that ASC- and NLRP3-dependent pathologic alterations are solely related to secretion of both IL-1β and IL-18. Moreover, using differentiated human THP-1 cells, we demonstrate that the pneumococcal pore-forming toxin pneumolysin is a key inducer of IL-1β expression and inflammasome activation upon pneumococcal challenge. The latter depends on the release of ATP, lysosomal destabilization (but not disruption), and cathepsin B activation. The in vivo importance of this pathway is supported by our observation that the lack of pneumolysin and cathepsin B inhibition is associated with a better clinical course and less brain inflammation in murine pneumococcal meningitis. Collectively, our study indicates a central role of the NLRP3 inflammasome in the pathology of pneumococcal meningitis. Thus, interference with inflammasome activation might be a promising target for adjunctive therapy of this disease.
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Affiliation(s)
- Tobias Hoegen
- Department of Neurology, Clinic of the University of Munich, D-81377 Munich, Germany
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44
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Woehrl B, Brouwer MC, Murr C, Heckenberg SGB, Baas F, Pfister HW, Zwinderman AH, Morgan BP, Barnum SR, van der Ende A, Koedel U, van de Beek D. Complement component 5 contributes to poor disease outcome in humans and mice with pneumococcal meningitis. J Clin Invest 2011; 121:3943-53. [PMID: 21926466 DOI: 10.1172/jci57522] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 08/03/2011] [Indexed: 01/05/2023] Open
Abstract
Pneumococcal meningitis is the most common and severe form of bacterial meningitis. Fatality rates are substantial, and long-term sequelae develop in about half of survivors. Disease outcome has been related to the severity of the proinflammatory response in the subarachnoid space. The complement system, which mediates key inflammatory processes, has been implicated as a modulator of pneumococcal meningitis disease severity in animal studies. Additionally, SNPs in genes encoding complement pathway proteins have been linked to susceptibility to pneumococcal infection, although no associations with disease severity or outcome have been established. Here, we have performed a robust prospective nationwide genetic association study in patients with bacterial meningitis and found that a common nonsynonymous complement component 5 (C5) SNP (rs17611) is associated with unfavorable disease outcome. C5 fragment levels in cerebrospinal fluid (CSF) of patients with bacterial meningitis correlated with several clinical indicators of poor prognosis. Consistent with these human data, C5a receptor-deficient mice with pneumococcal meningitis had lower CSF wbc counts and decreased brain damage compared with WT mice. Adjuvant treatment with C5-specific monoclonal antibodies prevented death in all mice with pneumococcal meningitis. Thus, our results suggest C5-specific monoclonal antibodies could be a promising new antiinflammatory adjuvant therapy for pneumococcal meningitis.
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Affiliation(s)
- Bianca Woehrl
- Department of Neurology, Klinikum Grosshadern, Ludwig Maximilians University, Munich, Germany
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Abstract
Despite effective antimicrobial therapy, mortality and morbidity from bacterial meningitis remain unacceptably high. Meningitis deaths occur as a consequence of intracranial and systemic complications. The neurologic and otologic sequelae reflect structural injury to brain and cochlear tissues. Over the past decade, experimental studies have demonstrated that meningitis-related vascular and cortical injury is largely caused by the massive neutrophilic inflammatory reaction, whereas hippocampal and cochlear injury is driven by both the host response and bacterial toxins. The benefit of adjunctive corticosteroid therapy proves the principle that the key to improve clinical outcome is combining antibiotics with drugs directed against pathophysiologically relevant targets; its limitations in efficacy and applicability highlight the need for novel adjunctive therapies. Promising targets were identified recently through animal studies, and include limiting the release of toxic bacterial products (by using nonbacteriolytic antibiotics) and interfering with the generation of host-derived cytotoxins (by using neutrophil apoptosis-inducing agents).
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Affiliation(s)
- Uwe Koedel
- Department of Neurology, Klinikum Grosshadern, Ludwig Maximilians University, Munich, Germany,
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Schmidt C, Plate A, Angele B, Pfister HW, Wick M, Koedel U, Rupprecht TA. A prospective study on the role of CXCL13 in Lyme neuroborreliosis. Neurology 2011; 76:1051-8. [DOI: 10.1212/wnl.0b013e318211c39a] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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47
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Demel C, Hoegen T, Giese A, Angele B, Pfister HW, Koedel U, Klein M. Reduced spiral ganglion neuronal loss by adjunctive neurotrophin-3 in experimental pneumococcal meningitis. J Neuroinflammation 2011; 8:7. [PMID: 21261959 PMCID: PMC3038911 DOI: 10.1186/1742-2094-8-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Accepted: 01/24/2011] [Indexed: 12/20/2022] Open
Abstract
Background Hearing loss is a frequent long-term complication of pneumococcal meningitis (PM). Its main pathological correlate is damage to the organ of Corti and loss of spiral ganglion neurons. The only current treatment option is cochlear implants which require surviving neurons. Here, we investigated the impact of systemically applied neurotrophin-3 (NT-3) on long-term hearing loss and the survival of neurons. Methods Eighteen hours after infection with S. pneumoniae, C57BL/6 mice were treated with a combination of ceftriaxone with NT-3 or dexamethasone or placebo. Hearing, cochlear damage, and brain damage were assessed by audiometry and histology. Results The main findings from immunohistochemical visualization of neurotrophins (NT-3, BDNF) and their receptors (TrkB, TrkC, and p75) in the cochlea were (i) enhanced staining for the cell survival-promoting receptor TrkB and (ii) increased NT-3 staining in NT-3 treated mice, showing that systemically applied NT-3 reaches the cochlea. The major effects of adjunctive NT-3 treatment were (i) a reduction of meningitis-induced hearing impairment and (ii) a reduction of spiral ganglion neuronal loss. The efficacy of NT-3 therapy was comparable to that of dexamethasone. Conclusion Systemically applied NT-3 might be an interesting candidate to improve hearing outcome after pneumococcal meningitis.
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Affiliation(s)
- Cornelia Demel
- Department of Neurology, Klinikum Grosshadern, Ludwig Maximilians University Munich, Marchioninistrasse 15, 81377 Munich, Germany
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Woehrl B, Klein M, Rupprecht T, Schmetzer H, Angele B, Häcker H, Häcker G, Pfister H, Koedel U. CXCL16 Contributes to Neutrophil Recruitment to Cerebrospinal Fluid in Pneumococcal Meningitis. J Infect Dis 2010; 202:1389-96. [DOI: 10.1086/656532] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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49
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Klein M, Koedel U, Kastenbauer S, Pfister HW, van de Beek D, Schut ES, Brouwer MC, Steiner I. Delayed cerebral thrombosis after initial good recovery from pneumococcal meningitis: past as prologue: delayed stroke as a parainfectious process of bacterial meningitis? Neurology 2010; 75:193; author reply 193-4. [PMID: 20625175 DOI: 10.1212/wnl.0b013e3181e00e8e] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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50
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Blaser C, Klein M, Grandgirard D, Wittwer M, Peltola H, Weigand M, Koedel U, Leib SL. Adjuvant glycerol is not beneficial in experimental pneumococcal meningitis. BMC Infect Dis 2010; 10:84. [PMID: 20353584 PMCID: PMC2861059 DOI: 10.1186/1471-2334-10-84] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2010] [Accepted: 03/30/2010] [Indexed: 11/21/2022] Open
Abstract
Background Bacterial meningitis in children causes high rates of mortality and morbidity. In a recent clinical trial, oral glycerol significantly reduced severe neurological sequelae in paediatric meningitis caused by Haemophilus influenzae type b, and a tendency towards a benefit of adjunctive glycerol was seen in pneumococcal meningitis. Methods Here we examined the effects of glycerol in pneumococcal meningitis of infant rats and adult mice. All animals received ceftriaxone, and glycerol or placebo. Brain damage, hearing loss, and inflammatory parameters were assessed. Results Clinically and by histopathology, animals treated with glycerol or placebo did not differ. While both groups showed equally high levels of matrix metalloproteinase-9 at 24 h after infection, a significant difference in favour of glycerol was observed at 40 h after infection. However, this difference in matrix metalloproteinase-9 in late disease did not result in an improvement of histopathologic parameters. Conclusion No benefit of adjunctive glycerol was found in these models of pneumococcal meningitis.
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Affiliation(s)
- Cornelia Blaser
- Institute for Infectious Diseases, University of Bern, 3010 Bern, Switzerland
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