Жамият
ва
инновациялар
–
Общество
и
инновации
–
Society and innovations
Journal home page:
https://inscience.uz/index.php/socinov/index
Etiological aspects of viral encephalitis explored using
PCR-based cerebrospinal fluid analysis, considering
patients’ HIV status
Janna NAZAROVA
1
, Munisa BAKHADIROVA
2
, Dilbar KHIDOYATOVA
3
Malika DUSHAEVA
4
Center for the Development of Professional Skills of Medical Personnel
Republican Scientific Center for Emergency Medical Care
ARTICLE INFO
ABSTRACT
Article history:
Received April 2023
Received in revised form
15 May 2023
Accepted 15 June 2023
Available online
25 June 2023
This study examined 124 patients suffering from acute viral
encephalitis who were admitted to the Center for the
Development of Professional Skills of Medical Personnel
between 2014 and 2019. The research focused on the outcomes
of cerebrospinal fluid PCR diagnostics in viral encephalitis
cases, taking into account patients’ HIV status. Findings
revealed that PCR testing offers a more reliable diagnosis and,
when lab resources permit, should be employed for CSF
analysis to more accurately identify the etiological agent
responsible for SVE. It is advised to repeat real-time PCR
diagnostics of CSF in cases where the cause of SVE remains
undetermined to improve detection rates of SVE’s causative
factors and enhance targeted therapy effectiveness, shifting
from empirical and symptomatic to etiotropic approaches.
2181-
1415/©
2023 in Science LLC.
https://doi.org/10.47689/2181-1415-vol4-iss3-pp9
This is an open access article under the Attribution 4.0 International
(CC BY 4.0) license (https://creativecommons.org/licenses/by/4.0/deed.ru)
Keywords:
HIV,
viral encephalitis,
PCR,
cerebrospinal fluid.
1
Assistant professor, Department of Neurorehabilitation, Center for the Development of Professional Skills of
Medical Personnel. E-mail: janna804@mail.ru
2
Assistant Professor, Neurorehabilitation Department, Center for the Development of Professional Skills of Medical
Personnel. E-mail: m.bakhadirova@mail.ru
3
Attending Physician, Department of Republican Scientific Center for Emergency Medical Care
4
Republican Scientific Center for Emergency Medical Care
Жамият
ва
инновациялар
–
Общество
и
инновации
–
Society and innovations
Issue
–
4
№
3 (2023) / ISSN 2181-1415
93
Patsyentov OIV STATUS hisobga olgan holda PCR asosida
miya omurilik suyuqligi tahlil foydalanish virusli ensefalit
etiolohycheskyh aspektlari o
‘
rganildi
ANNOTATSIYA
Kalit so‘zlar
:
OIV,
virusli ensefalit,
PCR,
miya omurilik suyuqligi.
Ushbu tadqiqot 2014 va 2019-
yillar oralig‘ida RSCEMCga
yotqizilgan o‘tkir virusli ensefalit bilan og‘rigan 124 bemorni
tekshirdi. Tadqiqot bemorlarning OIV holatini hisobga olgan
holda virusli ensefalit holatlarida miya omurilik suyuqligining
PCR diagnostikasi natijalariga qaratilgan. Topilmalar shuni
ko‘rsatdiki, PCR testi yanada ishonchli tashxisni taklif qiladi va
agar laboratoriya resurslari ruxsat bergan bo‘lsa, SVE uchun
javobgar bo‘lgan etiologik agentni aniqroq aniqlash uchun
CSF tahlilidan
foydalanish kerak. SVE qo‘zg‘atuvchi omillarini
aniqlash
tezligini
yaxshilash
va
maqsadli
terapiya
samaradorligini oshirish, empirik va simptomatik yondashuvdan
etiotropik yondashuvlarga o‘tish uchun, SVE sabablari noma’lum
bo‘lgan hollarda CSFning real va
qt rejimida PCR diagnostikasini
takrorlash tavsiya etiladi.
Этиологические аспекты вирусного энцефалита,
изученные
с
использованием
ПЦР
-
анализа
церевроспинной жидкости, с учетом ВИЧ
-
статуса
пациентов
АННОТАЦИЯ
Ключевые слова:
ВИЧ,
вирусный энцефалит,
ПЦР,
спинномозговая жидкость.
В работе обследовано 124 пациента с острым вирусным
энцефалитом, поступивших в РНЦЭМС в период с 2014 по
2019 г. Изучены результаты ПЦР
-
диагностики ликвора при
вирусных энцефалитах с учетом ВИЧ
-
статуса пациентов.
Результаты показали, что ПЦР
-
тестирование предлагает
более надежный диагноз и, когда позволяют лабораторные
ресурсы, его следует использовать для анализа
спинномозговой
жидкости,
чтобы
более
точно
идентифицировать этиологический агент, ответственный
за ЦСЖ. Для улучшения выявляемости причинных
факторов СВЭ и повышения эффективности таргетной
терапии, переходя от эмпирических и симптоматических
к этиотропным подходам, рекомендуется повторная
ПЦР
-
диагностика ЦСЖ в режиме реального времени в тех
случаях, когда причина СВЭ остается неустановленной.
Relevance:
Despite the availability of numerous diagnostic methods at the
beginning of the 21st century, the cause of encephalitis remains undetermined in 62% of
patients, and in 10% of cases, a non-infectious origin is diagnosed (3). According to
Lobzin Y.V. and Zhdanov K.V. in their
“
Manual of Infectious Diseases
”
, the following
Жамият
ва
инновациялар
–
Общество
и
инновации
–
Society and innovations
Issue
–
4
№
3 (2023) / ISSN 2181-1415
94
statistics are reported:
“
...out of confirmed or probable cases, 69% were viral, 20% were
bacterial, 7% were related to prions, 3% were parasitic, and 1% were fungal. It is crucial
to acknowledge that the inability to determine the cause in many instances may be due to
challenging diagnostic cases, as well as limited access to suitable samples and suboptimal
sample processing; despite extensive laboratory capabilities, the etiology of encephalitis
remained unclear in 64% of patients
”
(1).
Presently, scientific studies concentrate on the quality of inflammatory and
immune responses in cerebrospinal fluid (CSF) patients, drawing correlations between
local and systemic immune responses in central nervous system (CNS) infections (2,4).
Numerous publications explore neuroinfections during childhood or specifically address
the prevention, diagnosis, and treatment of tick-borne encephalitis (5,6). However, there
is a scarcity of research focusing on the clinical aspects, diagnosis, inflammatory
response, and immune response parameters of CSF in encephalitis among adults,
depending on the etiological factor.
The aim of the research
is to investigate the outcomes of PCR diagnostics in
cerebrospinal fluid for viral encephalitis, considering the HIV status of the patients
involved.
Data and Methods.
We examined 124 patients with severe viral encephalitis
(SVE). The diagnosis of SVE was based on general infectious, general cerebral and focal
neurological symptoms, and the detection of infectious agents. HIV infection was
diagnosed according to the national clinical protocols for HIV infection in Uzbekistan
according to the WHO classification of clinical stages of HIV infection in adults and
adolescents (2010). All patients with SVE were treated as inpatients at the RSCEMC from
2014 to 2019.
Based on HIV status, the patients were divided into 2 groups: Group I
–
72 (58.1%)
patients with SVE with HIV seronegative status (HIV-) and Group II
–
52 (41.9%) patients
with SVE with HIV seropositive status (HIV+). Out of the number of SVE patients with HIV
(+), 41 patients (33.1%) had injecting drug addiction.
In Group I, the average age of the patients was 49.82 ± 2.96 years old; there were
45 (62.5%) and 27 (37.5%) male and female patients, respectively. In Group 2, the
average age of patients was 42.28 ± 2.74 years. There were 29 (55.8%) men and
23 (44.2%) women. The age and sex distribution of Group 2 patients are shown in Table 1.
Table 1.
Distribution of patients by sex and age.
Group I
–
SVE, HIV (-) patients n=72 (58,1%)
Age
(Years)
men
women
all
n
%
n
%
n
%
18-44
21
29,20%
15
20,80%
36
50,00%
45-59
14
19,40%
9
12,50%
23
31,90%
60-74
10
13,90%
3
4,20%
13
18,10%
TOTAL
45
62,5%**
27
37,50%
72
100,00%
Group II
–
SVE, HIV (+) patients n=52 (41,9%)
Age
(Years)
men
women
all
n
%
n
%
n
%
18-44
19
36,50%
15
28,80%
34
65,40%
Жамият
ва
инновациялар
–
Общество
и
инновации
–
Society and innovations
Issue
–
4
№
3 (2023) / ISSN 2181-1415
95
45-59
8
15,40%
8
15,40%
16
30,80%
60-74
2
3,80%
0
0,00%
2
3,80%
total
29
55,8%*
23
44,20%
52
100,00%
TOTAL
74
59,7%
50
40,3%
124
100,00%
As it was shown in Table 1, the structure of patients in Group I was somehow
different from that in Group II. Thus, males prevailed in both groups (62.5% and 55.8%
in groups I and II, respectively). It should also be noted that there was a percentage shift
toward the younger age of patients in group I compared to group II.
Patients were examined according to the following algorithm: complaints, medical
history; general clinical tests; biochemical tests; diagnostic lumbar puncture (LP) with
the clinical and biochemical examination; cerebrospinal fluid, diagnostic LP with PCR;
MRI of the brain.
Statistical processing of clinical and instrumental materials in accordance with the
recommendations for processing the results of biomedical research at the significance
level of p<0.05 was carried out using a practical statistical package STATISTICA.
Results and discussion.
Diagnostic lumbar puncture is one of the first and
indicative methods for early diagnosis of meningoencephalitis. When performing a
diagnostic lumbar puncture, pleocytosis was determined in all patients under study. With
increasing duration of SVE (according to anamnesis) initially neutrophilic or mixed
pleocytosis became lymphocytic in 4-5 days, the number of cells decreased, and in some
patients there was observed the formation of single erythrocytes in the CSF (Table 2).
Table 2.
CSF study indicators in patients with SVE, (M±σ
)
Studied indicator
Group I (n=72)
Group II (n=52)
Pressure (mm. of water column) (M±σ
)
198,2±12,6
187,9±16,4*
Cytosis (in 1
μl) (M±σ
)
4285±173,6
4762±189,2*
Cellular composition (M±σ)
Lymphocytes
68,2±12,3%
63,8±17,4%
Monocytes
26,7±9,2%
31,6±11,3%*
Erythrocytes
3,2±1,3%
5,4±1,7%
Protein (g/l) (M±σ
)
2,64±0,76
3,17±0,79*
D-Dimer of fibrin mg/
ml (M±σ
)
8,3±1,6
11,4±2,3
Lactate (mmol/l) (M±σ
)
8,7±1,4
10,1±1,6*
Glucose (mmol/l) (M±σ
)
2,5±0,6
2,2±0,8
Note: * significant differences between groups p<0.005.
The cerebrospinal fluid pressure was measured using a U-shaped manometer tube
filled with water in the supine position of the patient. As can be seen from Table 2,
the pressure of CSF in group I was higher than in group II
–
198.2 mm. of the water
column and 187.9 mm. of the water column, respectively.
Жамият
ва
инновациялар
–
Общество
и
инновации
–
Society and innovations
Issue
–
4
№
3 (2023) / ISSN 2181-1415
96
Fig. 1. Etiological factors of SVE in patient groups according to the first
PCR-diagnostics of CSF (abs; %).
The severity of reactive changes in the CSF was stronger in the HIV-negative group
compared to the HIV-positive group, while the overall neurological status and clinical
manifestations were stronger in the HIV-positive group. Thus, in the study of CSF, block
content values were higher in group II patients by 18.7%, D-dimer of fibrin prevailed by
27.2%, and lactate was up by 13.9% compared with group I.
To determine the causative agent of SVE, we used PCR diagnostics of CSF to detect
genetic material of HSV-1, HSV-2, VZV, enteroviruses, and CMV. PCR testing of CSF was
performed in the laboratory of the Research Institute of Virology, in the reference
laboratory of the Republic of Uzbekistan.
Жамият
ва
инновациялар
–
Общество
и
инновации
–
Society and innovations
Issue
–
4
№
3 (2023) / ISSN 2181-1415
97
Table 3.
Etiological factors of SVE depending on the presence of HIV infection
Pathogen
Group I (n=72)
p<
Group II (n=52)
n
%
n
%
HSV-1
42
58,3%
0,005
7
13,5%
HSV-2
0
0,0%
0,001
11
21,2%
Enteroviruses
6
8,3%
3
5,8%
VVZ
6
8,3%
5
9,6%
CMV
0
0,0%
0,005
14
26,9%
Non defined
18
25,0%
12
23,1%
PCR diagnostics of cerebrospinal fluid revealed that in Group I HSV-1 prevailed
–
in 42 patients (58.3%), the pathogen could not be detected in 18 patients (25.0%),
VVZ and enteroviruses were detected in 6 patients (8.3%) in each case. In Group II, CMV
was found in 14 patients (26.9%), which was significantly more frequent than in Group
I patients. In Group II, the frequent causative agents of CVE were also HSV-2 and HSV-1,
in 21.2% and 13.5% of patients, respectively. And in 23.1% of patients, the pathogen
agent of SVE was not identified (Fig. 1, Table 3).
A repeated real-time PCR diagnosis of CSF was performed to clarify the etiological
factor among the unspecified cases of SVE in both groups. The dynamics of the indicators
in the pathogen profiles are shown in Figure 2 and Table 4.
As can be seen from Figures 1 and 2, after a repeated PCR study of CSF for the
presence of viruses, 14 more cases of SVE were identified overall, 9 cases in Group I and
5 cases in Group II.
Dynamics of pathogen profile in group I after repeated PCR diagnostics of
CSF testing of unspecified cases of SVE
Жамият
ва
инновациялар
–
Общество
и
инновации
–
Society and innovations
Issue
–
4
№
3 (2023) / ISSN 2181-1415
98
Dynamics of pathogen profile in group II after repeated PCR diagnostics of
CSF testing of unspecified cases of SVE
Figure 2. The dynamics of the profiles of etiological factors of SVE in the groups of
patients after repeated PCR-diagnostics of CSF (abs; %).
As can be seen from Tables 3 and 4, the structure of the etiological factors of SVE in
both groups slightly changed. In group I, repeated PCR diagnostics of CSF additionally
revealed 4 cases of HSV-1, and 4 cases of ZZV, in group II one patient with CMV and one
patient with enterovirus.
Also, in group II, opportunistic infections were detected: cryptococcus
–
8 cases
(15.3%) and toxoplasma
–
5 cases (9.6%), Epstein-Barr virus
–
22 cases (42.3%).
Table 4.
Etiological factors of SVE depending on the presence of HIV infection after repeated
PCR examination of CSF
Pathogen
Group I (n=72)
p<
Group II (n=52)
n
%
n
%
HSV-1
48
66,7%
0,0005
7
13,5%
HSV-2
0
0,0%
0,005
11
21,2%
Enteroviruses
6
8,3%
4
7,7%
VVZ
10
13,9%
5
9,6%
CMV
0
0,0%
0,005
15
28,8%
Non defined
8
11,1%
10
19,2%
In conclusion, PCR-based diagnostics are more dependable, and when lab
resources permit, employing PCR analysis of cerebrospinal fluid is recommended to more
accurately identify the etiological agent responsible for SVE. In cases where the cause of
SVE remains uncertain, repeating real-time PCR diagnostics of CSF is advised to enhance
Жамият
ва
инновациялар
–
Общество
и
инновации
–
Society and innovations
Issue
–
4
№
3 (2023) / ISSN 2181-1415
99
detection rates of SVE’s causative factors and subsequently improve the efficacy of
targeted therapy, transitioning from an empirical and symptomatic approach to an
etiotropic one.
REFERENCES:
1.
Rukovodstvo po infeksionnim boleznyam. [Handbook of Infectious Diseases.
In 2 vols. 2 / ed. by Acad. V. Lobzin, Prof. K.V. Zhdanov.
–
4-th edition, updated and
revised.
–
Saint-Petersburg: Publishing House Foliant, 2011.
–
744 p.]
2.
Ensefaliti v klinicheskoy praktike
–
tak li vse prosto? // Klinicheskaya
mikrobiologiya i antimikrobnaya ximioterapiya [Karpov I.A., Kachanko E.F., Vasilenko
A.I., Y.L. et al. Encephalitis in clinical practice
–
is it that simple? // Clinical Microbiology
and Antimicrobial Chemotherapy, 2011, Vol. 13, No. 2, pp.104-133.]
3.
Obshaya nevrologiya. [Nikiforov A.S., Gusev E.I. General neurology.
–
Moscow:
GEOTAR-Media. 2013.]
4.
Sovremenniye aspekti rasprostranennosti i etiologii razvitiya virusnix
ensefalitov // Sovremenniye problemi nauki i obrazovaniya. [Reveguk E.A., Karpov S.M.,
Zavodnova O.S. Modern aspects of prevalence and etiology of viral encephalitis //
Modern problems of science and education.
–
2018.
–
№ 4. –
P.249-254.]
5.
Molecular Virology / S. Modrow, D. Falke, U. Truyen, H. Schätzl. –
B. etc.:
Springer, 2013.
–
1013 p.
6.
Spatola M, Du Pasquier RA. Immune system’s role in viral encephalit
is. Rev
Neurol (Paris). 2014; 170:577
–
83.
