神経感染症の治療の進歩

抄録

Recent advances in the treatment of neurological infections are described based on reports published in 2016.

According to the European cohort study of community–acquired bacterial meningitis, the incidence of adult bacterial meningitis has decreased substantially, which is partly explained by herd protection by pediatric conjugate vaccines. Also, adjunctive dexamethasone treatment was associated with substantially improved outcome. Streptococcus pneumonia is the most common pathogen in adult. Patients with active cancer, however, present with lower CSF leukocyte counts, are more likely to be infected with Listeria monocytogenes, and are at high risk of unfavorable outcome.

The plasma–cell–depleting proteasome inhibitor bortezomib could be useful for severe and therapy–refractory cases of anti–NMDAR encephalitis. Bortezomib treatment showed clinical improvement or disease remission in 5 severely affected patients with anti–NMDAR encephalitis with resistance to standard immunosuppressive therapy (corticosteroids, IVIG, plasma exchange, immunoadsorption, rituximab, cyclophosphamide). Autoimmune encephalitis including anti–NMDAR encephalitis often poses a therapeutic challenge. The Korea study reported the efficacy and safety of rituximab treatment as a second–line immunotherapy treatment for autoimmune limbic encephalitis. Functional improvement occurred more frequently in the rituximab group compared to the control group, regardless of autoantibody status. In a prospective observational case control study, treatment effects of plasma exchange and immunoadsorption were evaluated in 21 patients with autoimmune encephalitis associated with NMDAR, LGI1, CASPR2, GAD, mGluR5 and Hu antibodies. Apheresis is well tolerated and effective also as first–line therapy in autoimmune encephalitis, particularly in patients with antibodies targeting neuronal surfaces.

Cochrane Database Systemic Review reported the effect of adjuvant corticosteroid therapy in tuberculous meningitis. There is high quality evidence of the benefit of corticosteroids in preventing death in people with tuberculous meningitis. For HIV–positive people with TB meningitis, there is uncertainty about whether or not corticosteroids are beneficial due to the lack of direct evidence in this group. However, corticosteroids may not be associated with increased risk of adverse events. On the other hand, adjuvant corticosteroid therapy did not reduce mortality among patients with HIV–associated cryptococcal meningitis and was associated with more adverse events and disability than was placebo.