Reilly Eileen, Hwang Justin
UW School of Medicine and Public Health, Madison, WI, USA.
Case Rep Infect Dis. 2020 Apr 24;2020:4901562. doi: 10.1155/2020/4901562. eCollection 2020.
is historically a central nervous system pathogen of consideration in the very young, very old, and immune suppressed. Diagnosis of is based on positive bodily fluid culture or PCR testing. Cerebral edema is nonspecific and can be a manifestation of vasculitis, trauma, anoxia, ischemia, infarction, malignancy, or an infectious process. A main mechanism of immune protection against is tumor necrosis factor (TNF). Lenalidomide, an immunosuppressant, inhibits TNF. A 61-year-old female with diabetes mellitus 2 and multiple myeloma treated with stem cell transplant and immunosuppressant (lenalidomide) was found to have cerebral edema after presenting with headache for 3 weeks and new focal neurologic deficits. Vitals signs were stable, with no meningeal exam findings and unremarkable initial serum testing. Blood cultures on days 0 and 2 of hospitalization as well as cerebral spinal fluid cultures were negative for infectious organisms. PCR testing of CSF was also negative for microorganisms. Brain biopsy was scheduled but postponed due to outstanding prion testing. The patient's focal neurologic deficits worsened prompting administration of dexamethasone after extensive negative infectious disease workup. By day 6, gross neurologic function deteriorated prompting transfer to higher level of care where the patient spiked a fever and one set of blood cultures revealed Gram-positive bacillus. Aggressive antimicrobial therapy was initiated, excluding ampicillin; however, this was later added. Blood culture further identified . By day 17, the patient suffered demise. Autopsy revealed brain microabscess lesions consistent with .
Clinicians should employ prophylactic antimicrobial treatment for when caring for those patients presenting with cerebral edema who are immune suppressed with TNF inhibition no matter the initial exam findings, serum testing, and/or radiologic interpretation. If initial workup is negative and brain biopsy is needed to determine the next course of action in the patient with cerebral edema, transfer the patient to a higher level of care if unable to complete biopsy at your facility in an expedient fashion.
从历史上看，它是极年幼、极年老者以及免疫抑制人群中枢神经系统病原体的考虑对象。其诊断基于体液培养阳性或聚合酶链反应（PCR）检测。脑水肿是非特异性的，可能是血管炎、创伤、缺氧、缺血、梗死、恶性肿瘤或感染过程的表现。针对它的主要免疫保护机制是肿瘤坏死因子（TNF）。来那度胺是一种免疫抑制剂，可抑制TNF。一名61岁患有2型糖尿病且接受干细胞移植和免疫抑制剂（来那度胺）治疗的多发性骨髓瘤女性，在出现头痛3周并伴有新的局灶性神经功能缺损后被发现患有脑水肿。生命体征稳定，脑膜检查无异常发现，初始血清检测无异常。住院第0天和第2天的血培养以及脑脊液培养均未发现感染性生物体。脑脊液的PCR检测也未发现微生物。脑部活检已安排但因朊病毒检测未完成而推迟。在广泛的传染病检查均为阴性后，患者的局灶性神经功能缺损恶化，于是给予地塞米松治疗。到第6天，总体神经功能恶化，促使患者转至更高水平的护理机构，在那里患者发热，一组血培养显示革兰氏阳性杆菌。开始积极的抗菌治疗，不包括氨苄西林；然而，后来又加用了氨苄西林。血培养进一步鉴定出它。到第17天，患者死亡。尸检显示脑微脓肿病变与它相符。
临床医生在护理那些因TNF抑制而免疫抑制且出现脑水肿的患者时，无论初始检查结果、血清检测和/或影像学解释如何，都应采用预防性抗菌治疗。如果初始检查为阴性且需要脑部活检以确定脑水肿患者的下一步治疗方案，而你所在机构无法及时完成活检，则应将患者转至更高水平的护理机构。
