A Cluster of Fatal Tick-borne Encephalitis Virus Infection in Organ Transplant Setting.

Background: Tick-borne encephalitis virus (TBEV) infection has become a major health problem in Europe and is currently a common cause of viral brain infection in many countries. Encephalitis in transplant recipients, althrough rare, is becoming a recognized complication. Our study provides the first description of transmission of TBEV through transplantation of solid organs. Methods: Three patients who received solid organ transplants from a single donor (2 received kidney, and 1 received liver) developed encephalitis 17-49 days after transplantation and subsequently died. Blood and autopsy tissue samples were tested by next-generation sequencing (NGS) and reverse transcription polymerase chain reaction (RT-PCR). Results: All 3 recipients were first analyzed in autopsy brain tissue samples and/or cerebrospinal fluid by NGS, which yielded 24-52 million sequences per sample and 9-988 matched TBEV sequences in each patient. The presence of TBEV was confirmed by RT-PCR in all recipients and in the donor, and direct sequencing of amplification products corroborated the presence of the same viral strain. Conclusions: We demonstrated transmission of TBEV by transplantation of solid organs. In such a setting, TBEV infection may be fatal, probably due to pharmacological immunosuppression. Organ donors should be screened for TBEV when coming from or visiting endemic areas.

Sensitivity of Next-Generation Sequencing Metagenomic Analysis for Detection of RNA and DNA Viruses in Cerebrospinal Fluid: The Confounding Effect of Background Contamination.

Next-generation sequencing (NGS) followed by metagenomic enables the detection and identification of known as well as novel pathogens. It could be potentially useful in the diagnosis of encephalitis, caused by a variety of microorganisms. The aim of the present study was to evaluate the sensitivity of isothermal RNA amplification (Ribo-SPIA) followed by NGS metagenomic analysis in the detection of human immunodeficiency virus (HIV) and herpes simplex virus (HSV) in cerebrospinal fluid (CSF). Moreover, we analyzed the contamination background. We detected 102 HIV copies and 103 HSV copies. The analysis of control samples (two water samples and one CSF sample from an uninfected patient) revealed the presence of human DNA in the CSF sample (91 % of all reads), while the dominating sequences in water were qualified as 'other', related to plants, plant viruses, and synthetic constructs, and constituted 31 % and 60 % of all reads. Bacterial sequences represented 5.9 % and 21.4 % of all reads in water samples and 2.3 % in the control CSF sample. The bacterial sequences corresponded mainly to Psychrobacter, Acinetobacter, and Corynebacterium genera. In conclusion, Ribo-SPIA amplification followed by NGS metagenomic analysis is sensitive for detection of RNA and DNA viruses. Contamination seems common and thus the results should be confirmed by other independent methods such as RT-PCR and PCR. Despite these reservations, NGS seems to be a promising method for the diagnosis of viral infections.

[Listeriosis of the central nervous system: epidemiological and diagnostic aspects--own observations]. / Listerioza osrodkowego ukladu nerwowego: aspekty epidemiologiczne i diagnostyczne--obserwacje wlasne.

UNLABELLED: The aim of the study was to evaluate clinical and laboratory findings and predisposing factors for Listeria monocytogenes (Lm) meningitis. METHODS: 17 intensive care unit patients (12 M, 5 F), aged 54.4 +/- 15.3 yrs, were studied. CNS listeriosis was confirmed by culture of cerebrospinal fluid (CSF) or CSF pleocytosis coupled with Lm bacteriemia. RESULTS: The frequency of central nervous system (CNS) listeriosis among patients with bacterial meningitis was 5.5%. Meningeal signs were present in all patients. 15 patients had impaired level of consciousness. Possible predisposing factors occurred in 15 patients. The average CSF white blood cell count was 1034 +/- 1064 cells/microl. CONCLUSION: Symptoms and signs of patients with CNS listeriosis were not different from those usually found in other bacterial meningitis. A trend toward fewer WBC in CSF was revealed. Most patients with Lm meningitis were immunocompromised.

[Clinical manifestations, diagnosis and treatment of swine flu (A/H1N1) infection among patients hospitalized in the Hospital of Infectious Diseases in Warsaw in 2009]. / Objawy kliniczne, rozpoznanie i leczenie grypy wywolanej wirusem A/H1N1 u osób hospitalizowanych w Szpitalu Zakaznym w Warszawie w 2009 r.

UNLABELLED: The aim of this paper was the evaluation of clinical characteristics, demographics and therapeutic response for oseltamivir, among patients with swine flu confirmed, hospitalized in the Hospital For Infectious Diseases in Warsaw, Poland. MATERIAL: We have observed infection A/H1N1 occurrence in 109 patients (Female-64, Male-45, aged 17-71 y), hospitalized between August and December 2009. The influenza specific test PCR (TaqMan A/H1N1) were used to pandemic flu confirmation. RESULTS: Out of 109 analyzed patients, 67% were young, before 40 y. old. The largest infected group were patients between 20 and 29 years. Among multiple acute symptoms we observed high temperature, cough, myalgia and neurological manifestations, very frequent. In 42 patients (38%) the interstitial pneumonia were observed. Eight patients developed severe respiratory insufficiencies -ARDS (7%) and one died. We observed also 10 infections A/H1N1 influenza during pregnancy, with good oseltamivir tolerance and without recent perinathal complications. CONCLUSIONS: Among 109 individuals with swine flu influenza, 67% have not complicated clinical manifestation and they recovered during 3-4 days. Eight patients developed ARDS and one of them died. Test PCR for influenza A/H1N1 was the basis in diagnostics procedures of the new pandemic influenza confirmation. Oseltamivir safety and tolerability were verified in patients with new variant infection A/H1N1.

[Influence of concomitant illness on clinical manifestations and severity of A/H1N1 influenza infection among patients hospitalized in the Hospital of Infectious Diseases in Warsaw--clinical cases]. / Wplyw chorób towarzyszacych na przebieg kliniczny grypy wywolanej przez wirus A/H1N1 u osób hospitalizowanych w Szpitalu Zakaznym w Warszawie--opis przypadków.

UNLABELLED: Many cases of swine flu is mild or even asymptomatic. The recent cases have been much more severe, and many patients have presented pneumonia, respiratory failure and acute respiratory distress syndrome (ARDS). Illness-related fatalities have been recorded among individuals hospitalized in The Hospital For Infectious Diseases in Warsaw, Poland. There were 109 patients (age: 17-71y), with A/H1N1 infection confirmed by PCR. In this article have shown cases of H1N1 influenza - related complications. We observed bacterial superinfections associated with swine flu, ARDS and shock syndrome, secondary bacterial pneumonia and neurological complications. Severe hypoxemia, multilobar pneumonia, and dramatic signs and symptoms progression, were reported in 8 individuals. All patients required admission to intensive care unit and the mechanical ventilation. One patient died due to ARDS and encephalitis. Many people have experienced risk factors, e.g.: asthma, sarcoidosis, or chronic bronchitis and other pulmonary illness. One patient after renal transplant with immunosuppressive therapy recovered, as well as two patients with chronic lymphatic leucaemia in remission. Two woman with clinically-relevant obesity have developed rapid progression of respiratory insufficiency and were still on mechanical ventilation. Influenza A/H1N1 were observed in 10 pregnant women, without co-morbidities. Three of them developed interstitial pneumonia. Consequently pregnant women with confirmed pandemic A/H1N1 infection received treatment with oseltamivir. IN CONCLUSION: Among 109 hospitalized individuals with A/H1N1 infection, eight (7%) developed severe pulmonary complications, and one of this patient died. The risk factors of progression to acute respiratory distress syndrome (ARDS) have all of this group patients.

[Burkholderia cepacia: a new pathogen causing nosocomial infections]. / Burkholderia cepacia--nowy patogen wywolujacy zakazenia wsród pacjentów szpitalnych.

UNLABELLED: Burkholderia cepacia is an opportunistic gram-negative, inherently resistant to multiple antibiotics and highly transmissible bacteria found in the soil and moist environments. The bacteria is known as a cause of severe lung infections in cystic fibrosis and immunocompromised patients. The authors observed a nosocomial outbreak of B. cepacia, the strains were isolated from five patients. In one case occurred colonization of the decubitus and in the other four severe pneumonia or sepsis. Four patients developed respiratory failure and septic shock and were admitted to intensive care unit. The infections led to death of two patients. The aim of the study was to evaluate the possibility that the hospital environment or cross-infection were the source of pathogen. The authors discussed the influence of previously used antibiotics on B. cepacia selection and drug susceptibility data as well, as the influence of obtained microbiological data on therapeutic decision making process. We were not able to confirm origin of B. cepacia strains, but in our opinion the hospital environment was the most probable source of pathogen. Increasing multidrug resistance were observed during the time of outbreak. In a case of the last patient we observed only weak susceptibility to imipenem. CONCLUSIONS: B. cepacia may be an etiologic agent of severe hospital acquired pneumonia and sepsis among immunocompromised patients. Clinically infection develops picture of superinfection and usually is life-threatening condition.

[Lyme carditis--a bitter lesson or a delayed diagnostic success--a case report]. / Borelioza serca - gorzka lekcja czy spózniony sukces diagnostyczny? Opis przypadku.

Lyme carditis is a well known disorder; however, its diagnosis still remains a challenge because of varied clinical picture, low incidence rate and difficulties in detection of the aetiological agent (Borrelia burgdorferi). We report a case of a 60-year-old man with a 2.5-year history of dilated cardiomyopathy, recurring episodes of acute heart failure and arrhythmias which finally were diagnosed as Lyme carditis. The diagnosis was confirmed by endomyocardial biopsy that revealed spirochetes as well as by serological tests which showed complexed Borrelia antibodies. The patient responded to treatment with ceftriaxone and doxycycline.

Viral etiologies in adult patients with encephalitis in Poland: A prospective single center study.

Encephalitis is a severe neurological syndrome associated with high morbidity and mortality as well as long-term neurological sequelae. Despite being an important public health problem, very few extensive population-based studies were conducted so far in the world and none in Central Europe. Altogether 114 consecutive patients meeting the initial criteria for encephalitis were enrolled at the Warsaw Hospital for Infectious Diseases between June 2012 and July 2015. Eighteen patients were secondarily excluded from the analysis due to incomplete data or noinfectious cause. Potential pathogen sequences were searched for by molecular methods in the cerebrospinal fluid (CSF) and specific antibodies were detected in CSF and sera. An infectious agent was identified in 41 patients (42.7%). The most frequently diagnosed infections were Human herpesvirus 1 (HHV-1) (22 cases, 24%) followed by Enterovirus (6 cases, 6.3%), Varicella zoster virus (VZV) (5 cases, 5.2%), Tick-borne encephalitis virus (TBEV) (6 cases, 6.3%) and Cytomegalovirus (CMV) (2 cases, 2.1%). There were no cases of human adenovirus, Human herpesvirus 6 (HHV-6) or West Nile virus (WNV) infection identified. In 55 cases (57.3%) the cause of encephalitis remained unknown. Compared to patients in whom the diagnosis was determined the latter group contained more women, was less likely to manifest fever and had lower CSF pleocytosis (p < 0.05) In summary, we identified HHV-1 followed by Enterovirus, VZV and TBEV as the most common causes of encephalitis among adult patients in Poland. In a large proportion of patients the cause of encephalitis remained unknown.

Higher level of NT-proCNP in cerebrospinal fluid of patients with meningitis.

Aminoterminal pro-C type natriuretic peptide (NT-proCNP) as an active form of CNP, has been recently proven to be a potential marker of sepsis and to be linked to inflammatory diseases. So far, there are no studies describing the level of NT-proCNP in meningitis. The purpose of this study was to evaluate the diagnostic value of NT-proCNP in cerebrospinal fluid (CSF) in patients with meningitis and to compare it with the serum level of CRP and procalcitonin (PCT) in this group of patients. The results were compared to serum levels of CRP, PCT and CSF levels of cytosis, protein and lactate. NT-proCNP levels were statistically significant between the control group and the meningitis groups (p=0.02; R=0.3). We also noted a correlation between the level of NT-proCNP in the CSF of all of the study groups (controls and meningitis patients) and the CSF levels of cytosis (p<0.5; R=0.43), protein (p<0.05; R=0.39) and lactate (p<0.05; R=0.34), and also the serum level of CRP (p<0.05; R=0.30), but not serum PCT (p>0.05; R=0.11). These results suggest that NT-proCNP could be a potential marker of meningitis, but it cannot be used to distinguish between the types of meningitis.

Next-generation sequencing (NGS) in the identification of encephalitis-causing viruses: Unexpected detection of human herpesvirus 1 while searching for RNA pathogens.

BACKGROUND: Encephalitis is a severe neurological syndrome usually caused by viruses. Despite significant progress in diagnostic techniques, the causative agent remains unidentified in the majority of cases. The aim of the present study was to test an alternative approach for the detection of putative pathogens in encephalitis using next-generation sequencing (NGS). METHODS: RNA was extracted from cerebrospinal fluid (CSF) from a 60-year-old male patient with encephalitis and subjected to isothermal linear nucleic acid amplification (Ribo-SPIA, NuGen) followed by next-generation sequencing using MiSeq (Illumina) system and metagenomics data analysis. RESULTS: The sequencing run yielded 1,578,856 reads overall and 2579 reads matched human herpesvirus I (HHV-1) genome; the presence of this pathogen in CSF was confirmed by specific PCR. In subsequent experiments we found that the DNAse I treatment, while lowering the background of host-derived sequences, lowered the number of detectable HHV-1 sequences by a factor of 4. Furthermore, we found that the routine extraction of total RNA by the Chomczynski method could be used for identification of both DNA and RNA pathogens in typical clinical settings, as it results in retention of a significant amount of DNA. CONCLUSION: In summary, it seems that NGS preceded by nucleic acid amplification could supplement currently used diagnostic methods in encephalitis.

[Unclassified cardiomyopathy or Lyme carditis? A three year follow-up].

Lyme carditis can be a clinical manifestation of the early disseminated stage of Lyme disease caused by the tick-transmitted pathogen Borrelia burgdorferi. We present the case of a 41 year-old Caucasian woman referred to our hospital with symptoms of fatigue, progressive exertional dyspnoea, supraventricular cardiac arrhythmia, and an enlarged heart revealed on chest radiography. Following an untypical result of transthoracic echocardiography, cardiac magnetic resonance was performed. This showed structural cardiac changes and focus of late gadolinium enhancement in the midwall of the apex region. Further diagnostic processes, including endomyocardial biopsy and serology tests, made it possible to diagnose Lyme carditis. Clinical observation was followed-up for three years.

New endemic foci of tick-borne encephalitis (TBE) identified in districts where testing for TBE was not available before 2009 in Poland.

BACKGROUND: Tick-borne encephalitis (TBE) is found in limited endemic foci in Poland. Lack of diagnosis limits disease detection in non-endemic provinces. METHODS: In 2009, we enhanced TBE surveillance to confirm the location of endemic foci and inform vaccination policy. In 105 hospitals located in 11/16 provinces, we identified suspected TBE cases through admission ICD-10 codes indicating aseptic meningo-encephalitis or from specimens tested for TBE. The National Reference Laboratory confirmed cases at no cost, by testing serum and/or cerebrospinal fluid using ELISA method. We calculated TBE reported rates as the number of confirmed TBE cases per 100,000 inhabitants. Adjusting to neighbouring districts, we classified districts as non-endemic (<0.1 cases per 100,000 inhabitants), low endemic (> = 0.1 to <1), moderately endemic (> = 1 to <5) and highly endemic (> = 5). We compared surveillance data obtained in 2009 with 2004-2008 baseline data. RESULTS: Among 166,099 admissions, we identified 1,585 suspected TBE cases of which 256 were confirmed. Physicians reported more suspected cases among patients <40 years old (12 cases per 1,000 admissions) than among older patients (8 cases per 1,000 admissions). However, patients <40 years of age were confirmed less frequently (16%), than older patients (35%). Physicians reported more suspected cases in districts classed as endemic during 2004-2008 (12 cases per 1,000 admissions, 77% tested for TBE) than in districts classed as non-endemic (7 cases per 1,000 admissions, 59% tested). Of the 38 newly identified endemic districts, 31 were adjacent to 2004-2008 endemic districts and 7 were isolated. CONCLUSIONS: Enhanced surveillance detected 38 new endemic districts to be considered for TBE vaccination. However, lack of consistent testing in districts believed to be TBE-free remained an obstacle for mapping TBE risk. Although the disease affects mostly older adults and the elderly, more attention is given to the diagnosis of TBE in young patients. Solutions need to be identified to sustain sensitive, acceptable and affordable TBE surveillance in all districts of Poland. Also, higher attention should be given to the diagnosis of TBE in the elderly.