Xie Yirui, Ruan Bing, Lang Guanjing, Zhu Biao
State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The Department of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
Front Med (Lausanne). 2021 Oct 28;8:736064. doi: 10.3389/fmed.2021.736064. eCollection 2021.
Streptococcus suis has been recognized as a zoonotic pathogen that may cause infections in humans. Although rarely described, it is not surprising that both cryptococcal and streptococcus suis meningitis infections can co-exist in a HIV-infected patient with a low CD4 count. However, a fast and accurate diagnose of meningitis of multipathogenic infections is challenging. In this report, we describe such a case of a HIV-infected patient with meningitis of multipathogenic infections. The patient was a 34-year-old Chinese male who was diagnosed with cryptococcal meningitis and HIV at the same time about 1 year ago. During the same time period, he had received (with good compliance) fluconazole and tenofovir-lamivudine- dolutegravir based antiretroviral therapy (ART). However, symptom of progressively worsening occipital headache appeared after he was exposed to a truck which was used for transporting pigs. Initial workup indicated an increase of the cerebrospinal fluid (CSF) opening pressure (OP) and an increase in the number of lymphocytes and proteins in CSF. A magnetic resonance imaging (MRI) scan revealed that partial cerebellar surface enhancement. The cryptococcus capsular antigen test of CSF was positive. The results of the India Ink microscopy for cryptococcus, nucleic acid of CMV and EBV and mycobacterium tuberculosis (MTB) tests of CSF were negative. The results of the bacteria and fungi smear and culture of CSF were also negative. Eventually, streptococcus suis was detected using next-generation sequencing (NGS) in CSF. The diagnosis of Streptococcus suis meningitis was made based on the patient's contact history with carrier pigs and the clinical findings addressed above. The treatment of 2 weeks of intravenous ceftriaxone and 1 week of oral moxifloxacin resulted in improvement of the condition of CSF. The anti-fungal treatment using fluconazole continued until the CFS OP went down to a normal level and the cryptococcus capsular antigen test of CSF was negative 6 months later. This case highlights that NGS might be beneficial to HIV-infected patients who have meningitis with negative CSF culture results. Multiple etiologies for such condition in the immunocompromised patients must be taken into consideration and early stage NGS is recommended.
猪链球菌已被确认为一种可导致人类感染的人畜共患病原体。虽然鲜有描述，但在一名CD4计数较低的HIV感染患者中，隐球菌性脑膜炎和猪链球菌性脑膜炎感染同时存在并不奇怪。然而，快速准确地诊断多重病原体感染所致的脑膜炎具有挑战性。在本报告中，我们描述了这样一例HIV感染患者发生多重病原体感染所致脑膜炎的病例。该患者为一名34岁的中国男性，约1年前同时被诊断为隐球菌性脑膜炎和HIV。在此期间，他接受了（依从性良好）基于氟康唑和替诺福韦-拉米夫定-多替拉韦的抗逆转录病毒治疗（ART）。然而，在接触一辆用于运输猪的卡车后，他出现了枕部头痛逐渐加重的症状。初步检查显示脑脊液（CSF）开放压（OP）升高，CSF中淋巴细胞和蛋白质数量增加。磁共振成像（MRI）扫描显示小脑表面部分强化。CSF隐球菌荚膜抗原检测呈阳性。CSF的隐球菌墨汁负染、巨细胞病毒和EB病毒核酸以及结核分枝杆菌（MTB）检测结果均为阴性。CSF的细菌和真菌涂片及培养结果也为阴性。最终，通过下一代测序（NGS）在CSF中检测到猪链球菌。根据患者与携带猪的接触史及上述临床表现，诊断为猪链球菌性脑膜炎。静脉注射头孢曲松2周和口服莫西沙星1周的治疗使CSF状况得到改善。使用氟康唑的抗真菌治疗持续至CFS OP降至正常水平且6个月后CSF隐球菌荚膜抗原检测呈阴性。该病例突出表明，NGS可能对CSF培养结果为阴性的HIV感染脑膜炎患者有益。对于免疫功能低下患者的此类情况，必须考虑多种病因，建议早期进行NGS检测。
