2018 年 35 巻 5 号 p. 593-597
Herein we describe recent advances in the treatment of neurological infections, as described on reports published in 2017.
Examination of a cohort of Dutch adults with community–acquired bacterial meningitis (BM) revealed that male sex and a history of alcoholism were an independent risk factors for adverse outcomes. Examinations of a Spanish cohort of patients with BM revealed that patients with meningitis and cancer had more subtle clinical manifestations than patients without cancer. Listeria monocytogenes was the predominant pathogen among patients with cancer. The ESCMID guidelines for community–acquired BM were updated, with new recommendations to start empiric treatment within one–hour of arrival for all suspected cases. Follow–up of surviving patients should include evaluations for hearing loss and pneumococcal vaccinations to prevent recurrence.
In Taiwan, the overall incidence of brain abscess (BA) was 1.88 per 100,000 person–years. Age and infectious diseases were important factors associated with in–hospital mortality.
Clinical outcomes of patients with drug–resistant tuberculous meningitis (TbM) were reported by a UK study group. Multidrug resistance was an independent predictor of death. Intensified treatments were significantly associated with improved survival in patients with isoniazid–resistant (INH–R) TBM, although INH–R was significantly associated with the combined outcome of new neurological events or death.
Outcomes of HIV–positive patients with cryptococcal meningitis (CM) in the United States were reported ; here, HIV–positive patients with CM exhibited high mortality, particularly those diagnosed after antiretroviral therapy initiation. An established multicenter retrospective cohort study out of the United States also showed that patients with coccidioidal meningitis who received adjunctive corticosteroids experienced significant reductions in secondary cerebrovascular events.
The clinical guidelines for herpes simplex virus encephalitis (HSVE) in Japan were revised, with recommendations to commence intravenous acyclovir within six–hours of arrival were added, applicable to all cases with suspected encephalitis. The revised guidelines also recommended continuation of acyclovir for at least 14 to 21 days in immunocompetent individuals if HSV–DNA was found within cerebrospinal fluid. For patients with acyclovir–resistant HSVE, a combination therapy that included acyclovir plus intravenous foscarnet or vidarabine was also recommended.
The main syndromes and clinical features of encephalitis associated with the antibodies against dipeptidyl–peptidase–like protein–6 (DPPX) gamma–aminobutyric acid type A receptor (GABAAR), and IgLON5 were reported. DPPX antibodies (predominantly IgG1 and IgG4) were associated with cognitive–mental deficits and symptoms of CNS hyperexcitability that were usually preceded by diarrhea, other gastrointestinal symptoms, and weight loss. Anti–GABAAR encephalitis was characterized by frequent seizures and distinctive multifocal cortical–subcortical MRI abnormalities, which provided important clues for diagnosis. Although the disorder is severe, most patients responded to treatment. Patients with IgLON5 antibodies, associated with the HLA–DRB1*10:01 allele, developed sleep disorder symptoms which preceded or were accompanied by bulbar symptoms, gait abnormalities, and oculomotor problems.
A proposed algorithm for the treatment of anti–LGI1 encephalitis was published, and rituximab was recommended as a second–line immunotherapy for patients who failed first–line immunotherapies, until B–cell depletion was achieved. Oral–prednisolone, in combination with immunosuppressants like azathioprine or mycophenolate mofetil, was also recommended as a maintenance therapy.