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Diagnostic Practices for Suspected Community-Acquired Central Nervous System Infection in the Post-Conjugate Vaccine
Natalie Banniettis1, Saumya Joshi, Shubhi Kaushik
1From the Department of Pediatrics, State University of New York, Downstate Medical Center, Brooklyn, NY.
Insights
Pediatric central nervous system (CNS) infection diagnostics reveal bacterial cultures are often contaminated, while viral infections are underestimated. Enhanced testing, including N-methyl-D-aspartate receptor antibody (NMDAR ab) testing, is needed for accurate diagnosis.
Area of Science:
- Pediatric Infectious Diseases
- Neuroimmunology
- Clinical Diagnostics
Background:
- Community-acquired central nervous system (CNS) infections are a significant concern in pediatric populations.
- Current diagnostic practices for CNS infections in children may not align with evolving epidemiological data.
- The underdiagnosis of viral CNS infections and autoimmune encephalitis is a potential issue.
Purpose of the Study:
- To evaluate the diagnostic approaches for suspected community-acquired CNS infections in urban pediatric patients.
- To analyze the frequency and yield of cerebrospinal fluid (CSF) studies, including bacterial and viral diagnostics.
- To assess the incidence of N-methyl-D-aspartate receptor antibody (NMDAR ab) encephalitis.
Main Methods:
- Retrospective observational review of CSF studies in pediatric patients (1 month to 21 years) from 2004-2014.
- Exclusion of suspected nosocomial meningitis cases.
- Analysis of NMDAR ab encephalitis frequency from 2010-2014.
Main Results:
- Bacterial cultures were frequently performed but rarely identified pathogens (0.42%), with a high rate of contaminants (1.9%).
- Viral CNS infections were significantly more common (7.5 times) than bacterial infections; enterovirus was the sole virus identified.
- Five cases of NMDAR ab encephalitis were identified since 2010.
Conclusions:
- Diagnostic practices for pediatric CNS infections require modification to improve accuracy and reflect current epidemiology.
- Increased accessibility to molecular diagnostics, such as polymerase chain reaction (PCR), is crucial for viral detection.
- Early consideration of NMDAR ab encephalitis in children with suggestive symptoms is recommended.
Objective:
The aim of this study was to evaluate diagnostic practices for suspected community-acquired central nervous system (CNS) infection in an urban pediatric population.
Methods:
This is an observational, retrospective single-center review of cerebrospinal fluid (CSF) studies in children, 1 month to 21 years old, evaluated for suspected CNS infection from 2004 to 2014. Cases of suspected nosocomial meningitis were excluded. The frequency of N-methyl-D-aspartate receptor antibody (NMDAR ab) encephalitis was analyzed from 2010 to 2014.
Results:
A total of 940 unique patient visits with CSF studies were included in the final analysis. There were 940 bacterial cultures sent; 4 (0.42%) grew suspected CSF bacterial pathogens, and 18 (1.9%) grew organisms that were suspected contaminants. Bacterial pathogens included late-onset group B Streptococcus in 3 infants younger than 3 months and Streptococcus pneumoniae in an unvaccinated 9-year-old child. Viral CNS infection was 7.5 times more frequent than bacterial infection. Enterovirus was the only virus isolated. Five cases positive for NMDAR ab were identified since 2010.
Conclusions:
Bacterial studies were performed more frequently than viral and other studies. Cerebrospinal fluid bacterial culture was nearly 5 times more likely to yield a contaminant than a pathogen. The frequency of viral infection was likely underestimated as only 20% were tested, mainly by culture, which is suboptimal. These data suggest diagnostic practices for the evaluation of suspected community-acquired CNS infections in children need to be modified to reflect current epidemiology and highlight the need for greater accessibility to polymerase chain reaction for viral diagnostics. Furthermore, NMDAR ab-mediated encephalitis should be considered early in children presenting with suggestive symptoms.
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