Publish Time: 2022-12-14 Origin: 迪飞医学
/ guide /
In October 2022, the team of Professor Lu Guoping and Professor Yan Gangfeng from the Children's Hospital of Fudan University will cooperate with Difei Medicine in Frontiers in Public Health (IF=6.461) magazine published a case report,This paper describes the diagnosis and treatment process of a case of severe eosinophilic meningitis caused by Angiostrongylus cantonensis in children, and explores the value of mNGS technology in the early diagnosis and course monitoring of Angiostrongylus infection.
/ background /
Angiostrongylus cantonensis, also known as rat lungworm, is transmitted through primary hosts (rats) and intermediate hosts (snails and slugs).Humans become infected through accidental ingestion of infected intermediate hosts or contaminated raw vegetables.Canton round line is the most common infectious cause of eosinophilic meningitis.
Angiostrongylus eosinophilic meningitis (AEM)Mainly in the Asia-Pacific region, globalization and travel-related exposures have spread to Europe and the United States.The presence of infiltrating eosinophils and Angiostrongylus cantonensis larvae in CSF are the main pathological features.The incubation period of AEM is generally 2 weeks, and the clinical manifestations of adults and children are different, and the incidence of nausea, vomiting, fever, lethargy, muscle twitching and convulsions is higher in children.
The diagnosis of AEM mainly relies on traditional detection methods, such as blood routine, cerebrospinal fluid cell count, serological antibody detection, qPCR and MRI.However, these techniques often have unsatisfactory detection rates due to limitations such as low throughput and lack of angiostrongylus antibodies in the early stage.In addition, atypical symptoms in children may lead to a misdiagnosis of viral meningitis, especially if the patient has no clear history of parasite exposure.mNGS is an emerging etiological diagnostic tool, which is superior to traditional detection methods in terms of no prediction and comprehensive pathogen detection.
/ Case introduction /
Figure 1 Clinical examination and treatment timeline
—— ✦ Local hospital diagnosis and treatment process✦ ——
An 8-year-old male, on February 23, 2021 (day 0 after the onset of symptoms, DAY 0), developed symptoms such as low-grade fever, paroxysmal headache, mental fatigue, and loss of appetite. He was admitted to a local hospital on DAY 8 because the symptoms continued without improvement.He denied history of hepatitis, tuberculosis, or genetic/metabolic disease.Complete clinical examination and laboratory examination on the day of admission (Table 1).Analysis of blood and cerebrospinal fluid revealed leukocytosis, and EEG and MRI of the brain were abnormal.Autoimmune antibody testing was negative, ruling out autoimmune encephalitis.The patient was diagnosed with viral meningitis and treated symptomatically.
—— ✦ Pediatric hospital diagnosis and treatment process✦ ——
Admission diagnosis and treatment:
On DAY 15, the patient's condition deteriorated, with disturbance of consciousness, no response to painful stimuli, and a Glasgow Coma Scale (GCS) score of 6.He was transferred to the PICU of the Children's Hospital Affiliated to Fudan University due to his critical condition.The patient's condition worsened after antiviral treatment.Knowing that the patient had a history of contact with snails, clinical and laboratory tests were further improved to clarify the pathogen (Table 1).The total number of white blood cells and eosinophils were significantly increased, the appearance of cerebrospinal fluid was turbid, leukocytes and protein were elevated, the culture of cerebrospinal fluid was negative, and the HSV-1/2 DNA test was negative.At the same time, the cerebrospinal fluid was sent to mNGS for examination, and 22 Guangzhou tube-round line-specific sequences were detected.It is worth mentioning that the detection of Angiostrongylus cantonensis by mNGS was earlier than the positive serological antibody report of Angiostrongylus, which was negative and weakly positive on DAY 24 and DAY 35, respectively.At the same time, PCR-Sanger sequencing also confirmed the existence of the Guangzhou Guanyuan line.In summary, the patient was finally diagnosed as AEM, and the treatment plan of albendazole and methylprednisolone was initiated.
Further examination and treatment:
After standard treatment with AEM, the patient's body temperature dropped, but he remained in a coma.On DAY 24, a new round of laboratory tests was performed, and cerebrospinal fluid was taken for mNGS testing.Peripheral blood eosinophils and cerebrospinal fluid leukocytes (Table 1) decreased rapidly, and cerebrospinal fluid was clear (Fig. 2B).Peripheral blood WBC was still high, and cerebrospinal fluid mNGS results showed that there were still 399 Guangzhou tube round line sequences.Based on the serious condition of the patient, experts from the Department of Infectious Diseases, Pediatric Neurology, and Antibiotic Research Institute were invited to participate in the MDT consultation.Considering that doxycycline can be used to treat filarial infection and the patient has lung infection, doxycycline treatment was added on DAY 29.On DAY30, the blood routine showed that the eosinophils tended to be normal, and the GCS score was 12.On DAY30, albendazole was withdrawn, and doxycycline and methylprednisolone were continued.On DAY 42, the eosinophils in peripheral blood increased slightly, but 374 Guangzhou canal lines were still detected by mNGS in cerebrospinal fluid.Albendazole treatment was resumed, and the patient's symptoms were relieved.
Outcome and Prognosis:
On DAY 51, the patient's body temperature returned to normal, and he was transferred from the PICU to the Department of Neurology for further treatment.On DAY 65, the patient had no neurological symptoms, and the GCS score was 14. Except for the slightly elevated WBC levels in peripheral blood and cerebrospinal fluid, the rest of the indicators returned to the reference range, and he was discharged from the hospital.The mNGS test results of cerebrospinal fluid showed that the number of Guangzhou tube circle line sequence dropped to 35.After discharge, the patient continued to take prednisone for 20 days.A follow-up one year later showed that the patient had fully recovered without any neurological sequelae.
Table 1 Laboratory examination results of peripheral blood and cerebrospinal fluid during hospitalization
Figure 2 Clinical test results during treatment
/ Summarize /
The diagnosis of AEM is difficult, and it is easy to cause sequelae such as blindness and limb paralysis, and the mortality rate of children is as high as 10%. Therefore, early accurate diagnosis and timely clinical intervention are crucial for the treatment of AEM.
2. In this case,mNGS has fully demonstrated its ability to quickly and accurately identify pathogens, 11 days earlier than serological antibody detection, to buy time for the initiation of symptomatic treatment, and to monitor the changes of pathogens in real time during the treatment process of more than 2 months, to adjust the anti-infection treatment plan Provide evidence.
3. mNGS combined with multidisciplinary MDT will provide new ideas for the diagnosis and treatment of complicated and difficult infections.
references
Gu L, Liu W, Ru M, Lin J, Yu G, Ye J, Zhu ZA, Liu Y, Chen J, Lai G, Wen W. The application of metagenomic next-generation sequencing in diagnosing Chlamydia psittaci pneumonia: a report of five cases. BMC Pulm Med. 2020 Mar 17;20(1):65. doi: 10.1186/s12890-020-1098-x. PMID: 32178660; PMCID: PMC7077129.
Author: Yamana Review: Xue Lengjia Typesetting: Moro