Bacterial Diseases of the Nervous System

C H A P T E R

19 Bacterial Diseases of the Nervous System Jean-Franc¸ois Faucher1 and Marie-Ce´cile Ploy2 1

Limoges University Medical Center, Limoges, France 2UMR 1092 University of Limoges, Limoges, France

O U T L I N E 19.1 Introduction

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19.2 BM/Encephalitis/Cerebral Abscess (Mycobacteria Excluded) 19.2.1 Neonatal Meningitis 19.2.2 BM in Children and Adults 19.2.3 Cerebral Abscess

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19.3 Mycobacterial Infections 19.3.1 TB of the CNS 19.3.2 Leprosy

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19.1 INTRODUCTION Bacterial diseases of the nervous system comprise a broad range of diseases with their related pathogens. Many bacterial infections can spread to the nervous system, most of them by the hematogenous route. Some of them, like bacterial meningitis (BM), represent a high disease burden worldwide, which disproportionately affect young children and deserve vigorous interventions for prevention by vaccination. As tuberculosis (TB) is still highly prevalent in tropical areas, tuberculous meningitis (TBM) will be presented separately.

19.2 BM/ENCEPHALITIS/CEREBRAL ABSCESS (MYCOBACTERIA EXCLUDED) BM, which is very common in many tropical areas, is a medical emergency. Large meningococcal epidemics have occurred in Brazil, China, and sub-Saharan Africa (SSA) and they still threaten populations in resourcepoor settings. In addition to a high mortality rate, a Neuroepidemiology in Tropical Health DOI: http://dx.doi.org/10.1016/B978-0-12-804607-4.00019-8

19.4 Other Bacterial Infections Involving the CNS 19.4.1 Neurosyphilis 19.4.2 Zoonotic BM 19.4.3 Mycoplasma pneumoniae 19.4.4 Tetanus

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References

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high risk of neurologic sequelae is associated with BM. Neonatal meningitis and meningitis occurring in children and adults will be detailed separately.

19.2.1 Neonatal Meningitis 19.2.1.1 Epidemiology and Physiopathology Early BM is usually part of a syndrome of sepsis neonatorum. A significant part of the mortality attributed to neonatal sepsis (which represents 7% of the mortality in under-five death worldwide1) is related to neonatal meningitis (NNM). The incidence of NNM is much higher in low-income areas than in other areas, from 0.8/1000 to 6.1/ 1000 live births.2,3 The epidemiology and microbiology of NNM is similar to neonatal sepsis.4 Neonatal meningitis has a high mortality rate, up to 58% in the tropical world.4 Mortality is higher in premature babies and specifically in low birth-weight neonates. Meningitis in neonates are divided into early- (#7 days of life) or late- (from 7 to 90 days) onset diseases. Different bacterial species have been isolated in neonates meningitis

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© 2018 Elsevier Inc. All rights reserved.

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TABLE 19.1 Main Etiologies of Bacterial Meningitis in Neonates in the Tropical World Early- (first 7 days of life) and late- (from 7 days to 3 months) onset meningitis

Bacterial species Group B Streptococcus (Streptococcus agalactiae)

Both

Escherichia coli

Mostly early

Streptococcus pneumoniae

Mostly late

Neisseria meningitidis

Late

Staphylococcus sp

Late

Haemophilus influenzae

Late

Gram-negative bacteria, including Salmonella enterica

Late

(Table 19.1).2,5 8 Bacteria involved in early-onset meningitis are mainly commensal of the vaginal flora of the mothers. Early-onset meningitis is due to bacteria transmitted from mother to newborn before or during delivery. Bloodstream infection with hematogenous spread to the meninges is the most common mechanism. The physiopathology of late-onset meningitis is less obvious, with both vertical and horizontal transmission. Risk factors for neonatal meningitis do not seem to differ between developing countries and the rest of the world:6 low birth weight and prematurity, premature rupture of membranes, prolonged rupture of membranes (.18 hours), maternal colonization with Group B Streptococcus (GBS), maternal chorioamnionitis, urinary tract infection, and low socioeconomic status. Group B Streptococcus (Streptococcus agalactiae) is a gram-positive cocci normally present in the rectovaginal flora but the prevalence differs according to the country9 and the socio-economic status.10 Neonates who have been colonized at birth can develop an infection (1% 3%11). There are 10 serotypes of Group B Streptococcus and serotypes I and III are predominant in invasive diseases in neonates and showed a high morbidity and mortality rates, with a higher risk of late-onset disease in human immunodeficiency virus (HIV)-exposed neonates.12 Escherichia coli is the second most prevalent bacteria found in early-onset meningitis. The mortality is higher for neonates infected with the strain expressing the K1 antigen.13 Salmonella species have been reported to be among the most prevalent gram-negative bacilli in reports from Africa.7 Contrary to what happens in more developed countries, Listeria monocytogenes is less prevalent in the

TABLE 19.2

Clinical Signs of Neonatal Meningitis2,14

Neurologic

Aspecific

Irritability or lethargy

Fever or hypothermia Feeding intolerance or vomiting Respiratory distress

Hypotonia

Apnea

Seizures

Bradycardia

Bulging anterior fontanel

Hypotension

Nuchal rigidity

Poor perfusion Jaundice Hypo- or hyperglycemia Diarrhea

tropical world, probably due to the low availability of the usual contaminated dietary sources.4 The likelihood of neonatal meningitis takes into account the above-mentioned risk factors and various clinical signs.14 Clinical presentation is often subtle and indistinguishable from that of sepsis without meningitis15 (Table 19.2). 19.2.1.2 Diagnosis As much as possible, blood cultures and a lumbar puncture (LP) should be performed to collect the cerebrospinal fluid (CSF), but the latter is frequently deferred due to the concern of exacerbating clinical deterioration in the infant with hemodynamic instability. Approaches in which only infants with confirmed bacteremia are evaluated for meningitis will result in missed diagnoses of meningitis.16 The current recommendation is to perform an LP (whenever possible, it should be performed prior to the administration of antibiotics) on all clinically stable infants suspected to have neonatal sepsis and who are exhibiting signs of infection.17 A cytologic analysis (red and white cells) of the CSF will be performed. For neonates, the normal white cell count can reach up to 30 cells/mm3. Above this threshold, a formula should be performed to distinguish neutrophils, lymphocytes and other nuclear cells. A Gram stain should be done systematically. The other parameters to be performed are the CSF protein (normal when ,0.4 g/L, but premterm neonates have higher values) and glucose (normally .50% of the glycemia) levels. There is great difficulty in predicting the diagnosis of meningitis solely based on CSF parameters due to overlaps of values between infants with and without confirmed meningitis.2,13 The CSF is normally sterile and the culture should be done systematically with

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19.2 BM/ENCEPHALITIS/CEREBRAL ABSCESS (MYCOBACTERIA EXCLUDED)

rich media incubated for at least 3 days to confirm that bacterial culture is negative. Bacterial antigens can also be detected directly from the CSF, as for Streptococcus pneumoniae for which an immunochromatographic test is available allowing detection of pneumococcal antigen in 15 minutes. Lastly, the detection of bacterial DNA by polymerase chain reaction (PCR) should be performed either with specific PCRs for bacterial agents or with a universal PCR (targeting the 16SRNA encoding DNA) and sequencing allowing the detection of any bacterial DNA. These tests require specialized technicians and different equipments and are not easy to implement in low-income countries. In-house multiplex molecular tests have recently been described and introduced18 with a higher detection rate of the etiological infectious agent than culture. Fully automated multiplex tests are being developed and some are already available as a matter of routine allowing the detection of different infectious agents (bacteria, virus, fungi, parasites) in one assay in less than 2 hours.19 These tests could be performed by non-specialized technicians as the technology includes all steps from DNA extraction to amplification detection. These tests are expensive but medico-economic studies including all the costs (diagnosis, treatment, hospital length of stay, complications, etc.) should be performed to address the added-value of such tests in meningitis. Recent studies underline the potential clinical impact of the reduction of the time-to-diagnosis20 induced by this approach. 19.2.1.3 Treatment Along with supportive care, parenteral antibiotics should be administered as a matter of emergency because delays in treatment are associated with increased mortality and morbidity.21 Empirical antibiotic therapy must be effective and achieve bactericidal activity in the CSF22 without toxicity. The World Health Organization (WHO) recommends ampicillin plus gentamicin combination or a third-generation cephalosporin.23 The areas most affected by bacteria which are resistant to the first-line antibiotics are resource-poor countries,24 where local data on antimicrobial resistance are generally lacking.25 The prevention of nosocomial infections in these children is a challenge, especially in low-income countries. Interventions like clustering of nursing care, implementing a simple algorithm for empirical therapy of suspected early-onset sepsis, minimal invasive care and promotion of early discharge proved to be effective for reducing the incidence of nosocomial infections in Senegal.26 There is evidence that mortality of neonatal meningitis is much higher in resource-poor

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countries (roughly 50%) than in wealthy countries (10% 15%).5,6,27 Survivors of neonatal meningitis are at considerable risk of long-term neurologic impairment.28,29 Taking into account the disease burden, there are very few data on disability in survivors from resource-limited countries in the literature.30 In many countries, the adoption of intrapartum antibiotic prophylaxis (IAP) and universal antenatal screening for GBS colonization lead to a reduction limited to early onset-GBS infections.31 In some areas of developing countries, early-onset GBS disease is sufficiently prevalent to justify the implementation of IAP (260). However, it is unclear whether IAP32 can reduce the incidence of neonatal sepsis in areas where the incidence of GBS early-onset sepsis is low.31,33 35 Maternal immunity to the most common serotypes of GBS can be transferred passively to the infant and protect against early- and late-onset infections.36 Surrogate markers for a prevention of early-onset GBS neonatal sepsis by vaccination have been defined and a GBS vaccine is currently in development.37

19.2.2 BM in Children and Adults BM is frequent in developing countries. Neisseria meningitidis, S. pneumoniae, and Haemophilius influenzae serotype b (Hib) are the main pathogens. Meningococcal disease is characterized by its association with large meningitis epidemics. However, microbiological diagnosis is rarely possible and presumptive treatment is the current standard of care in most care settings. Prevention of BM by vaccination is currently a critical issue. 19.2.2.1 Epidemiology Acute BM is found throughout the world, but the relative contributions of the three more common pathogens varies considerably. 19.2.2.1.1 MENINGOCOCCAL DISEASE

Neisseria meningitidis is a gram-negative cocci only found in humans. It can be found as a commensal bacteria of the oropharynx. In a study on the N. meningitides carriage in the African meningitis belt, the overall rate of acquisition of meningococci was 2.4% per month38 but the average duration of carriage was relatively short (3 4 months). Different N. meningitidis serogroups have been defined according to the composition of the capsule. In Africa, the serogroup A is the most prevalent. However, the global plan for vaccination in this part of the world allowed a decrease in the incidence of meningococcal meninigitis.39 However, other

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serogroups then emerged, mainly C and W.40 In the northern hemisphere, serogroups B and C predominate but serogroup Y incidence increased for few years. In tropical areas, meningococcal disease has a very high incidence in children and adults, and this is especially true for the meningitis belt, where more than 10,000 cases of meningococcal meningitis were recorded annually. A common feature for the occurrence of frequent epidemics is the 300 1100 mm mean annual rainfall isohyets. Thus, the area where meningitis epidemics frequently occur extends beyond the meningitis belt. The largest outbreaks, as defined by a case incidence superior to 10 cases per week/100,000 inhabitants, occur during Sahelian dry season (December May).41 Typically, epidemics occur in 5- to 10-year cycles and spread from the East (Red Sea) to the West (Atlantic). Epidemics in tropical areas were mostly related to serogroup A meningococci. 19.2.2.1.2 STREPTOCOCCUS PNEUMONIAE

In the absence of a major meningococcal epidemic, the incidence of S. pneumoniae meningitis in the meningitis belt and elsewhere, may be higher than the meningococcal meningitis incidence for persons less than 1 and over 20 years of age.42 Streptococcus pneumoniae (pneumococcus) is a gram-positive cocci which is a commensal of the oropharynx. The bacterial capsule is antigenic and lead to the description of 93 serotypes. The capsule is a major virulence factor allowing the bacteria to avoid the immune system and producing adhesion to epithelial cells.43 Moreover, the pneumococcus produces a lot of enzymes as pneumolysin involved in bacterial virulence. Some serotypes are frequent as commensals of the oropharynx, especially in children, and are frequently highly resistant to antibiotics. Other serotypes, less able to colonize the oropharynx for a long time and are often more susceptible to antibiotics. In Africa, the serotype 1 is the main serotype of the pneumococcus strains isolated from CSF or blood cultures from patients with a BM.44 Other serotypes are also described (19F, 4, 3, 9V, etc.). However, the recent introduction of conjugate pneumococcal vaccines in immunization programs might change the epidemiology of pneumococcal meningitis.45,46 Interestingly, it has been recently shown that the serotype 1 strains circulating in Africa lack the main virulence factors of the European Serotype 1 strains43 suggesting the specificity of the clones disseminating in Africa. Since 2000, there have been outbreaks of pneumococcal meningitis in the African belt with cumulative attack rates of 100/100,00047 and a mortality rate higher than for meningococcal meningitis.

19.2.2.1.3 OTHER PATHOGENS

Other pathogens can be involved in BM. Hib is a gram-negative bacteria mainly described in children below 5 years of age in all regions of the world where the conjugate vaccine is not used routinely. Streptococcus suis is an important zoonotic pathogen in South East Asia,48 and by far the first cause of BM in southern Vietnam.49 Non-typhoidal Salmonella meningitis has been described in South Africa, where it is associated with HIV infection in adults.8 Listeriosis in the developed world most commonly occurs at the extremes of life, during severe immune suppression and during pregnancy. This pattern may be different in developing countries, were cases have rarely been reported.50 19.2.2.2 Pathophysiology Patients usually develop a meningitis via hematogenous dissemination of the bacteria. Streptococcus pneumoniae is also responsible for meningitis via direct spread from the nasopharyngeal niche to the central nervous system (CNS). Direct entry through dural defects is possible. Bacterial components are recognized by receptors of brain cells. This leads to the release of proinflammatory cytokines. This inflammatory response allows granulocytes to go through the blood brain barrier. Lysis of the bacterial cells due to the antibiotic treatment or autolysis (S. pneumoniae) allows the release of bacterial components (lipoteichoic acids, lipopolysaccharide, peptidoglycan, etc.) increasing the inflammatory host response. Moreover, patients with deficiencies in the complement system are more susceptible to invasive diseases with capsulated bacteria.46 19.2.2.3 Clinical Features BM should be promptly considered, when symptoms and signs of infection or inflammation of the meninges are found. There may be signs of raised intracranial pressure (headache, bulging fontanelle). Purpura is reported more frequently with N. meningitidis meningitis, than with meningitis of other causes. There is little information on the incidence of purpura fulminans in the meningitis belt.51 Pneumococcal meningitis is more likely to be associated with focal signs on admission. As large meningitis epidemics occur in poorresource settings, surveillance in these areas is based on a simple case definition that can be implemented in any health care setting (Table 19.3, adapted from WHO/EMC/BAC/98.3).

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19.2 BM/ENCEPHALITIS/CEREBRAL ABSCESS (MYCOBACTERIA EXCLUDED)

TABLE 19.3

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Standard Case Definition of Meningococcal Meningitis

1. Suspected case of acute meningitisa • sudden onset of fever ( . 38.5 C rectal or 38.0 C axillary) WITH • stiff neck In patients under 1 year of age, a suspected case of meningitis occurs when fever is accompanied by a bulging fontanelle 2. Probable case of bacterial meningitisb • suspected case of acute meningitis as defined above WITH • turbid cerebrospinal fluid 3. Probable case of meningococcal meningitisb • suspected case of either acute or bacterial meningitis as defined above WITH • Gram stain showing gram-negative diplococcus OR • ongoing epidemic OR • petechial or purpural rash 4. Confirmed casec • suspected or probable case as defined above WITH EITHER • positive cerebrospinal fluid antigen detection for Neisseria meningitidis OR • positive culture of cerebrospinal fluid or blood with identification of N. meningitidis a

Often the only diagnosis that can be made in dispensaries (peripheral level of health care). Diagnosed in health centers where lumbar punctures and cerebrospinal fluid examination are feasible (intermediate level). Diagnosed in well-equipped hospitals (provincial or central level).

b c

The HIV status, as far as possible, should be quickly determined when the etiology has HIV infection as a risk factor (S. pneumoniae, non-typhoidal Salmonella), and also in meningitis of unknown etiology since there are specific etiologies of meningitis in these patients. The differential diagnosis with cerebral malaria in malaria endemic areas is complicated by the fact that BM can occur in a patient who asymptomatically harbors malaria parasites, in which case meningitis can easily (malaria rapid diagnostic tests (mRDT) have been widely implemented in the recent years) be misdiagnosed as cerebral malaria. In a study performed in Kenya in children with encephalopathy, Histidin-Rich Protein 2 was detectable in the blood of children with meningitis, epilepsy and severe sepsis.52 In children with meningitis, this pittfall is likely to delay a prompt administration of an adequate treatment. As cerebral malaria is associated with a high (partially sequestered) parasite biomass, attempts to identify a more specific marker of cerebral malaria than malaria infection, in patients with encephalopathy in malaria endemic areas are underway.52 54 19.2.2.4 Diagnosis The diagnosis is identical to the one described for neonates. However, for children and adults, the white cell normal count is less than 10 white cells per mm3

and the protein and glucose parameters are more discriminant. When patients have petechial or purpural rash, it can be helpful to sample the petechiae either for bacterial culture or molecular diagnosis by PCR. This can also be helpful for a post-mortem diagnosis.55 19.2.2.5 Treatment Whatever the care setting, a patient suspected of meningitis should be urgently referred for hospitalization. For patients with a history of clinically overt meningitis, an inappropriate delay in commencing therapy incrementally increases the risk of permanent injury.56 Therefore, BM treatment is an emergency. Penicillin and other β-lactams are effective against the most common pathogens and the CSF concentration tends to be close to the minimum inhibitory concentrations for moderately susceptible bacteria. Penicillin-resistant pneumococci have been reported from all parts of the world25 and their impact on mortality has been established.57 However, epidemiological data on the etiologies of BM and antimicrobial resistance of etiologic agents, which could inform rationale guidelines on the management of BM, are scarce or absent in many parts of the world. Vancomycin is widely recommended when penicillin-resistant pneumococci might be present, but because it crosses the blood brain barrier poorly it

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should be used in conjunction with another antimicrobial, often a cephalosporin. Antibiotics to be recommended may vary according to national guidelines, but high-dose third-generation cephalosporins have become the cornerstone of BM therapy worldwide. In the meningitis belt, during the meningitis epidemics, the recommend regimens depend on the age group:58 intravenous or intramuscular ceftriaxone (100 mg/kg per day in one dose) for 7 days in children below 2 months of age, intravenous or intramuscular ceftriaxone (100 mg/kg per day in one dose) for 5 days in children from 2 months to 14 years of age, intravenous or intramuscular ceftriaxone (2 g/day in one dose) for 5 days in children above 14 years of age and in adults. Out of meningitis epidemic periods, WHO recommends 7- to 10-day treatment with intravenous or intramuscular ceftriaxone, whatever the age group. Chloramphenicol is not recommended any more. In many settings, corticosteroids administered before or at the same time as the first dose of antibiotics are recommended in children as well as in adults on the basis of the results of randomized trials. In children, the risk of hearing loss following meningitis can be reduced with corticosteroids, as confirmed by a recent metanalysis.59 There is a strong negative correlation between (1) severity of illness at the time of presentation, and (2) delay in the initiation of appropriate antibiotic therapy and hearing outcome.60,61 This may explain why studies of dexamethasone therapy in children with BM from low-income countries found no beneficial effects.59 In adults, likewise, mortality and neurologic disabilities were reduced with corticosteroids in a doubleblind trial in a resource-rich setting62 but not confirmed in adults, 90% of whom were HIV-positive with high rates of malnutrition.49,63 In Vietnam, however, treatment with dexamethasone was associated with reduced hearing loss in S. suis meningitis patients.49

Mortality in S. suis BM in Vietnam was below 5%.71 Global and regional risks of disabling sequelae from BM (children and adults) have been reviewed.72 The risk of at least one major sequela (cognitive deficit, bilateral hearing loss, motor deficit, seizures, visual impairment, hydrocephalus) was 12% and of at least one minor sequela (behavioral problems, learning difficulties, unilateral hearing loss, hypotonia, diplopia) was 8%. The risk of at least one major sequela was 24% in pneumococcal meningitis, 9% in Hib, and 7% in meningococcal meningitis. The most common major sequela was hearing loss (33%), and 19% had multiple impairments. All-cause risk of a major sequela was twice as high in the African (25%) and southeast Asian regions (21%) as in the European region (9%). In a systematic literature review on sequelae due to BM among African children,70 about a quarter of children surviving pneumococcal meningitis and Hib meningitis had neuropsychological sequelae by the time of hospital discharge, a risk higher than in meningococcal meningitis cases (7%). In Vietnam, 6 months after randomization, 42% of adults with definite meningitis were disabled.49 Deafness was observed in 9% of those who had received dexamethasone. Hearing loss was a common sequel occurring in 53% of patients with S. suis BM.73 These data suggest that in some parts of the world, a substantial part of intellectual impairment and hearing loss is related to BM.74 However, there is little data describing intellectual disability or hearing loss geographically and across population and age groups, with their etiologies.75 These data are needed, especially in resource-poor countries, in order to plan for and meet the needs of patients who survive with sequelae.

19.2.2.6 Outcome Many factors influence mortality: age,64 underlying diseases,65 etiologic agent66 and clinical status at admission.67 Mortality with S. pneumoniae meningitis is higher than with N. meningitidis meningitis, but broadly varies according to care setting, with mortality rates as high as 54% in Malawi,68 whereas it was estimated at 17% in the Netherlands64 and below 10% in Vietnam.49 In Malawi, nearly 90% of patients were HIV-positive (5% of whom received antiretrovirals). Impaired consciousness at admission and HIV infection increase the odds of death from BM in Malawian children, in whom mortality was 28%.69 Some data indicate that in resource-poor settings, a substantial part (10%; range 5 0% 18%) of mortality occurs within weeks after discharge.70

Chemoprophylaxis is effective in preventing subsequent cases of meningococcal disease in household contacts of a case of meningococcal disease.76 The number needed to treat to prevent one subsequent case is 200. Drugs recommended for chemoprophylaxis are the following: rifampicin, ceftriaxone, ciprofloxacine.77 Chemoprophylaxis is however not promoted, unlike vaccination, as a preventive tool in response to meningitis epidemics in the meningitis belt.58

19.2.2.7 Prevention 19.2.2.7.1 CHEMOPROPHYLAXIS

19.2.2.7.2 VACCINATION

A high burden of sequelae could be averted by vaccination with Hib, pneumococcal, and meningococcal vaccines.70,72 Conjugate vaccines are immunogenic in infants and can prevent transmission by their activity on carriage.

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19.3 MYCOBACTERIAL INFECTIONS

Consequently conjugate vaccines are a more appropriate tool for effective prevention strategies than polysaccharide vaccines in SSA as well as in other parts of the world. Immunization based on a meningococcal serogroup A polysaccharide/tetanus toxoid conjugate vaccine (PsA-TT) is being implemented in countries of the African meningitis belt.78 Getting developing countries the best vaccines beyond protection of meningococcal A disease (other meningococcal serogroups, Hib, S. pneumoniae), at affordable prices is a critical global health governance issue.79 Immunization strategies in Southeast Asia, where S. suis is highly prevalent, have to be determined.46

19.2.3 Cerebral Abscess Relatively few studies from poor-resource countries are available in the literature on this subject, as shown in a recent meta-analysis.80 Although opportunistic infections related to AIDS involve more frequently parasites or fungi than bacteria, HIV screening is the rule as far as a cerebral abscess is suspected or diagnosed. In a monocentric study from Burkina Faso, where the abscess etiologic agents were isolated in 16% of patients, HIV seroprevalence was 5%.81 Data on cerebral abscess incidence are scarce. The incidence of cerebral abscesses was estimated to be 1/100,000 per year in a part of South Africa.82 They arise from direct dissemination of adjacent infection (of odontogenic origin, sinusitis, otitis, meningitis), hematogenous spread, head trauma. Several bacteria may be isolated in cerebral abcesses, anaerobes (Fusobacterium, Bacteroides, Propionibacterium acnes), Streptococcus of the buccal flora, Actinomyces and Nocardia, Aggregatibacter, Staphylococcus aureus, and Enterobacteriaceae. The etiology depends on the origin of infection.82,83 Although disseminated nocardiosis with cerebral abscess infection has been well described in immunodeficient patients including AIDS patients,84 very few case reports have been published from Africa, where most patients with AIDS live,85 probably due to the lack of means of diagnosis. Mortality can be estimated at 10% 20%.86 Although a global trend to a better prognosis with as much as 70% of patients with full recovery has been found in a broad study,80 it may not reflect the outcome in many settings, with up to 50% of patients living with sequelae.81

19.3 MYCOBACTERIAL INFECTIONS 19.3.1 TB of the CNS Three main types of CNS tuberculous infection are seen: TBM, solitary lesions in the brain or the spinal

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cord (tuberculoma) and spinal tuberculous arachnoiditis. These three types can overlap.87 CNS TB by postprimary dissemination of TB is frequent in children and encountered in regions where TB incidence is high. CNS TB is also diagnosed in immunocompromised adults as a result of reactivation bacillemia. TBM may be seen at any age, although it disproportionately affects young children.88 It is the most common form of CNS TB, and one of the most severe forms of TB. The meningeal inflammation typically leads to a rhombencephalitis. 19.3.1.1 Epidemiology In the USA, TBM represents 1% of all cases of TB and 5% of extrapulmonary meningitis.89 There is a preponderance of the disease type in children and in HIVpositive individuals. All patients with any form of TB should be proposed for HIV screening. In a review devoted to CNS TB in children, CNS TB represented 10% of all TB cases.90 TBM could be the second leading cause of meningitis in African patients living with HIV.91 TBM among HIV-positive patients was associated with advanced HIV-infection, as evidenced by the median CD4 count at admission, significantly lower with TBM than with pulmonary TB.92 It is therefore expected that broad access of HIV-positive patients to antiretrovirals can reduce the incidence of TBM. 19.3.1.2 Pathophysiology Mycobacterium tuberculosis belongs to the M. tuberculosis complex which includes several species with nearly identical sequences. This group contains the human pathogens M. tuberculosis, Mycobacterium africanum, and Mycobacterium canetti. Five major lineages of M. tuberculosis have been described in the different regions of the world, lineage 1 (East Africa, Philippines, in the region of the Indian Ocean), lineage 2 (East Asia), lineage 3 (East Africa, Central Asia), lineage 4 (Europe, America, Africa) and lineage 7 (Ethiopia93). The precise mechanism of how M. tuberculosis invades the brain is still unknown. There is probably a hematogenous dissemination that occurs early in the disease, before the control by the immune system. Indeed, patients co-infected by HIV or patients with polymorphisms of innate immune response (TLR2) are more susceptible to developing TBM. A possible role for vitamin D has been also proposed. Furthermore, it seems that some strain lineages (Indo-Oceanic or East Asian Beijing) are more susceptible to causing TBM. Lastly, the Rv0931c gene (also known as pknD), that encodes a serine/threonine protein kinase is necessary for brain endothelial invasion and thus enable bacteria to cross blood brain barrier.94

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19.3.1.3 Clinical Features Patients with TBM present with a subacute illness combining fatigue and most of the times fever, meningeal signs (headache, neck stiffness, vomiting), alterations of mental status (personality change, lethargy, confusion, coma), focal signs (cranial nerves alterations, long-tract signs), and seizures. A categorization in three stages of increasing severity has been proposed:95 (1) stage I patients are lucid with no focal neurologic signs or evidence of hydrocephalus; (2) stage II patients exhibit lethargy, confusion; they may have mild focal signs, such as cranial nerve palsy or hemiparesis; (3) stage III represents advanced illness with delirium, stupor, coma, seizures, multiple cranial nerve palsies, and/or dense hemiplegia. Abnormalities on chest radiographs may be seen in half of cases, ranging from focal lesions to a miliary pattern. Papilloedema is a common feature of raised intacranial pressure, which can complicate TBM. There is an overlap between TBM and miliary TB. Miliary TB should therefore be suspected in case of TBM and vice versa. Tuberculomas present like symptomatic intracranial mass lesions: headache, seizures, focal signs and signs of raised intracranial pressure.96 Occasionally, tuberculomas can present like intramedullary mass lesions: subacute spinal cord compression with the appropriate motor and sensory findings, depending on the level of the lesion.97 With spinal tuberculous arachnoiditis, symptoms develop and progress slowly over weeks to months. Patients present with the subacute onset of nerve root and cord compression signs: spinal or radicular pain, hyperesthesia or paresthesias; lower motor neuron paralysis; and bladder or rectal sphincter dysfunction.98 Neurological symptoms can occur in the course of spinal TB, as compression of the spinal cord can complicate Pott’s disease.99,100 19.3.1.4 Diagnosis Diagnosis of TBM will combine CSF cytology, microscopy, culture and molecular techniques. That means that a volume of CSF .1 mL has to be sampled. The examination of the CSF in case of TBM usually reveals a clear appearance and white cells count .500 mm23 with a mixture of neutrophils and lymphocytes, with less than 50% neutrophils. The protein level is increased and the ratio of CSF to plasma glucose level is less than 0.5. The sensitivity of the CSF Ziehl Neelsen staining and microscopy does not exceed 60% and highly depends on the volume of CSF used. Culture must be performed but give final results in 8 weeks as M. tuberculosis is a slow-growing bacteria.

Commercial real-time PCR tests have been developed enabling the diagnosis of M. tuberculosis complex in less than 2 hours. Some studies showed that these commercial tests are less sensitive than culture but more sensitive than microscopy. As for microscopy, the sensitivity depends on the volume of CSF available. Rapid detection of multidrug resistant (MDR) strains (resistant to rifampin and isoniazid) must be performed directly from the CSF. Commercial molecular techniques allow detection of at least rifampicin or rifampicin and isoniazid resistance. Indeed, the management of patients infected with MDR strains is different than for patients infected with susceptible strains. The new cases of TB occur mainly in Asia and Africa. MDR and XDR (resistant to rifampin and isoniazid and at least one fluoroquinolone, and any of the second-line injectable treatments (amikacin, capreomycin, kanamycin)) strains are increasing in these countries. MDR strains are highly prevalent in the tropical world, especially in the BRICS countries (Brazil, Russia, India, China, South Africa). Around 3% of new cases of TB are due to MDR strains (20% for patients who have already received a treatment for TB). In central Asia, South Africa and Eastern Europe, the proportion of MDR and XDR cases increases dramatically.101 Few studies have analyzed the value of interferongamma release assay performed on CSF and concluded that sensitivity and specificity will be acceptable only for CSF volumes of 5 10 mL. In patients with TBM, computed tomography and magnetic resonance imaging can define the presence and extent of basilar arachnoiditis, cerebral edema, infarction, and hydrocephalus.102 In patients with tuberculoma, LP is usually avoided because of concerns for raised intracranial pressure and risk of brainstem herniation; in the occasional reported case where CSF has been examined, the findings are normal or nonspecific. On contrast CT imaging, early-stage lesions are low density or isodense, often with edema out of proportion to the mass effect and little encapsulation. Laterstage tuberculomas are well encapsulated, isodense or hyperdense, and have peripheral ring enhancement.102 19.3.1.5 Treatment Anti-tuberculous therapy is based on a combination of four drugs. It generally combines isoniazide, rifampin, pyrazinamide, and ethambutol. Some experts advise treating TBM with a fluoroquinolone (moxifloxacin or levofloxacine),103 instead of ethambutol which poorly penetrates into meninges. Intensive therapy is advised for 2 months, with a further continuation phase (isoniazide plus rifampin) of 10 months. In many areas, however, treatment and prevention of TB has become more complex because of resistance

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to commonly used antituberculous drugs. Hence, multiresistant TBM is predictive of an increased risk of death.104,105 Management of drug-resistant TB can be difficult and may necessitate the use of second-line drugs and/or surgical resection. Duration of therapy should be extended to 18 24 months. It is widely acknowledged than adding glucocorticoids to anti-tuberculous therapy reduces mortality, at least in children and adults patients who are HIV negative, with no effect on the number of people who survive TBM with disabling neurological deficit.106 Dexamethasone or prednisone should be used in this indication. In HIV-positive patients, initiation of antiretroviral therapy (ART) within 2 weeks of antituberculous therapy was associated with increased mortality in patients with TBM.107 Thus, for ART-naı¨ve HIV patients with CNS TB, initiation of ART should be delayed for the first 4 8 weeks of antituberculous therapy, regardless of CD4 count.108,109 Patients with hydrocephalus may require surgical decompression of the ventricular system in order to manage the complications of raised intracranial pressure.110 Unlike other CNS mass lesions, medical management is preferred for clinical tuberculomas unless the lesion produces obstructive hydrocephalus or compression of the brainstem. When the diagnosis is in doubt, surgery is also required to obtain tissue for culture and sensitivity studies.110 19.3.1.6 Outcome In a recent meta-analysis, mortality of TBM in children is estimated at 19% and the probability of surviving without neurological sequelae at 36%, which means that the risk of neurological sequelae is slightly above 50% in survivors.88 Mortality was estimated to be 10% in children with pooled early stages, whereas it was 34% in children with the most advanced disease stage. In a study performed in south Africa, drug resistance was more likely encountered in children with HIV, and multiresistance was independently associated with a higher risk of death.111 The influence of drug resistance on the risk of death in TBM is dramatic in HIV-infected adults,112 with a mortality up to 100% with multiresistant TBM. Mortality in adults with TBM is high, but certainly varies among care settings and populations of patients. It is estimated to be at 25% in HIV-negative adults, and 67% for HIV-positive adults.107,113 Mortality in adults with TBM in Africa, as reflected by literature, is as high as 60% and seems to have remained stagnant over the past half century.114

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Stroke can complicate MTB, early in the course of disease as a consequence of vasospasms. Later strokes involve proliferative intimal disease.115 Stroke complicates approximately one-third of TBM cases.116 An open label randomized study in adults with TBM, on the role of aspirin showed a beneficial effect on mortality.117 However, patients selectively received corticosteroids, which may have biased the results.118 19.3.1.7 Prevention 19.3.1.7.1 CHEMOPROPHYLAXIS

Treating latent M. tuberculosis in persons at risk for TB is recommended in low TB burden control.119 In high-burden countries, HIV-positive patients are clearly at risk for TB. The Temprano study, which was performed in HIV1 positive patients with a CD41 between 200 and 800 cells/μL, has shown that immediate 6 months of isoniazide preventive therapy (IPT) and ART independently led to lower rates of severe illness than did deferred ART and no IPT, both overall and among patients with CD41 counts of at least 500 cells per cubic millimeter.120 19.3.1.7.2 VACCINATION: BACILLE CALMETTE GUE´RIN

Newborns and infants are the demographic group with greatest potential benefit from Bacille Calmette Gue´rin (BCG) vaccination, and this intervention has been adopted for prevention of TB worldwide. BCG protects children both against infection and against disease.121 In countries where the prevalence of TB is moderate to high, neonatal vaccination is recommended by the WHO and is administered routinely. BCG vaccination is not appropriate for infants or adults with known immunodeficiency (including HIV infection) nor for infants with symptoms consistent with HIV infection in the absence of laboratory confirmation of actual HIV infection.122

19.3.2 Leprosy Mycobacterium leprae, the agent of Hansen’s disease, is a slow-growing mycobacterium and has a tropism for the skin, and for peripheral nerves (Schwann cells). The reservoir of leprosy is human, although anecdotal cases acquired by contact with armadillos have been reported. The main dissemination route of leprosy seems to be aerosol/droplets,123 which occurs through repeated contact with untreated infected individuals, is favored by a long asymptomatic or paucisymptomatic incubation period (more than 5 years most of the time). Living in close contact with a patient is therefore a major risk factor for leprosy. Multibacillary forms and

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multilesional forms of leprosy are more contagious than paucibacillary forms with a single lesion.124 19.3.2.1 Epidemiology Leprosy is endemic in Asia, Africa, South America, Middle-East, South Pacific, and the Carribean. In 2014, 213,899 new cases were recorded. Patients from India, Brazil and Indonesia represent 81% of incident cases. The trend in terms of leprosy prevalence was marked by a dramatic decrease between 1980 and 2005, after the approval and wide use of a multidrug therapy but it has reached a plateau for 10 years (between 200,000 and 250,000 yearly cases).125 19.3.2.2 Pathophysiology Mycobacterium leprae belongs to the Mycobacteriaceae family. The respiratory tract seems to be the potential portal of entry for M. leprae and transmission probably occurs through nasal or sputum excretions. Mycobacterium leprae has a very long doubling time (14 days) compared to M. tuberculosis (24 hours). Leprosy has thus a slow evolution with various incubation periods, from very short in young children to very long in adults (up to 30 years). The mechanisms of transmission from the latent infection to symptomatic infection are still unknown. On the other hand, host immunity plays an important role in the evolution of the disease. Tuberculoid leprosy is associated with a Th1 response and lepromatous leprosy involves a predominant Th2 response leading to an inadequate immune response to an intracellular bacterium and thus the uncontrolled multiplication of the bacteria.126

hand), the common peroneal nerve (foot drop), the posterior tibial nerve (claw toes and plantar insensitivity), the facial nerve (lagophthalmos), the radial cutaneous nerve, and the great auricular nerve. Pure neurologic forms of the disease occur in less than 10% of cases.127 They should be suspected in persons exposed to leprosy, with an asymmetrical neuropathy of unknown origin. 19.3.2.4 Diagnosis Mycobacterium leprae cannot be cultured in vitro and the diagnosis will thus be based mainly on optical microscopy from skin lesion samples (punch biopsy). A rapid diagnosis can also be performed from a tissue fluid smear test on the earlobe. PCR methods have also been developed. Pathological analysis of the skin biopsies must also be performed. The infiltrations observed are specific to the tuberculoid or lepromatous leprosy states. 19.3.2.5 Treatment Treatment may be prescribed in the setting of a national program, following the WHO guidelines, or as an individualized treatment. The WHO advise a combination of dapsone plus rifampicin for 6 months in paucibacillary TB, and a combination of dapsone plus rifampicin (intermittent) plus clofazimine (intermittent) for 12 months128 in multibacillary TB. The same drugs can be prescribed to be administered on a daily basis in individualized therapy. Alternatives (ofloxacin, minocycline, clarithromycin) can be necessary either because of poor tolerance/ toxicity, or because of (rarely observed) resistance to the standard regimen.

19.3.2.3 Clinical Features

19.3.2.6 Outcome

Paucibacillary (or tuberculoid) leprosy is the most frequent form of the disease. Most of the time, only the skin (hypochromic macules with loss of sensation within the lesions) is involved, but peripheral nerve enlargement and/or tenderness, including the ulnar nerve at the elbow, median and superficial radial cutaneous nerve at the wrist, great auricular nerve in the neck, and common peroneal nerve at the popliteal fossa may be associated. Typically, sensory and/or motor loss generally occurs in the distribution of nerves in the vicinity of the skin lesion. Mutibacillary (or lepromatous) leprosy skin lesions are usually generalized and consist of erythematous macules, papules, and/or nodules. A diffuse infiltration of the nose and ear lobes can lead to the leonine facies in extreme forms. Nerve damage may become bilateral and generalized. Commonly, the nerve trunks involved include the ulnar and median nerves (claw

Type 1 reaction is known as reversal reaction and type 2 reaction as erythema nodosum leprosum (ENL). They are defined by severe activation/reactivation of the immune and inflammatory systems and primarily affect peripheral nerves. Fifteen to 65% of leprosy patients present with irreversible nerve damage during the course of the disease, mainly during leprosy reactions.129 Patients can present with leprosy reactions before being diagnosed with leprosy, during treatment, or once an adequate treatment has been completed. Loss of nerve function can be dramatic. The peak time for type 1/reversal reactions is in the first 2 months of treatment, but they can continue to occur for 12 months, and occasionally after multidrug therarpy (MDT) is completed. Corticosteroids (starting at 40 60 mg daily), prolonged for several months, are the treatment of choice for type 1 reactions.

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The expected recovery rate for nerve function is 60% 70%. Recovery is less in patients with preexisting impairment of nerve function or with chronic or recurrent reactions. ENL (type 2 reactions) occur in about 20% of lepromatous forms. Patients are febrile with erythema nodosum; other signs are iritis, neuritis, lymphadenitis, orchiitis, bone pain, dactylitis, arthritis, and proteinuria. ENL can start during the first or second year of antimicrobial therapy and can relapse intermittently over several years. Thalidomide (400 mg daily) is better than steroids in controlling ENL and is the drug of choice when not contraindicated. Clofazimine has a useful anti-inflammatory effect in ENL and can be used (300 mg daily) for several months. The disabilities associated with leprosy are secondary to nerve damage. A patient with an anesthetic hand or foot needs to understand the importance of protection when undertaking potentially dangerous tasks, and inspection for trauma. Plantar ulcers should be treated with rest; weightbearing should not be permitted until the ulcer has healed. More complicated ulcers require surgical management. Likewise, surgery can be indicated in the following situations: contractures of hands, and feet, foot drop, lagophthalmos, entropion, and ectropion. 19.3.2.7 Prevention BCG gives variable protective efficacy against leprosy in different countries, ranging from 34% to 80%.129 Rifampicin has been proposed as a postexposure prophylaxis among contacts in non-endemic areas,129 but it’s efficacy is unknown.

19.4 OTHER BACTERIAL INFECTIONS INVOLVING THE CNS 19.4.1 Neurosyphilis In the context of syphilis resurgence in rich-resource countries, much remains to be known on the consequences of the disease in poor-resource countries. Neurosyphilis is a well-known and possibly severe form of syphilis, for which a CSF analysis is mandatory in order to establish a diagnosis. Thus, in poorresource countries, limited access to care is an obstacle to a proper estimation of neurosyphilis incidence. The rapid expansion of antibiotics consumption in poorresource countries, prescribed or purchased for any reason, may also interfere in the disease in an unknown manner, since the agent of neurosyphilis is sensitive to many widely available antibiotics.

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19.4.1.1 Epidemiology In 2012, an estimated 5.6 million new cases of syphilis occurred among 15- to 49-year-olds worldwide. There are an estimated 18 million prevalent cases of syphilis.130 Syphilis is transmitted through sexual contact with infectious lesions of the mucous membranes or abraded skin. Oral unprotected sex is an important way of sexual transmission. Syphilis can also be transmitted via blood transfusion, or transplacentally from a pregnant woman to her fetus. Mother-to-child transmission of syphilis (congenital syphilis) is usually devastating to the fetus if maternal infection is not detected and treated sufficiently early in pregnancy. The burden of morbidity and mortality due to congenital syphilis responsible for adverse pregnancy outcomes (early fetal deaths/stillbirths, neonatal deaths, preterm/low-birthweight babies, and infected infants) is still high.130 Most untreated primary and secondary syphilis infections in pregnancy result in severe adverse pregnancy outcomes. Latent (asymptomatic) syphilis infections in pregnancy also cause serious adverse pregnancy outcomes in more than half of cases. Mother-to-child transmission of syphilis is declining globally due to increased efforts to screen and treat pregnant women for syphilis,131 while a resurgence of syphilis, which primarily affects men who have sex with men, has clearly been identified in rich-resource countries,132 but not exclusively.133,134 Neurosyphilis is a rare but severe form of the disease.130 19.4.1.2 Physiopathology/Microbiology Syphilis is a chronic disease, strictly encountered in humans. This is a multistage disease with diverse manifestations. The etiological agent is Treponema pallidum subsp. pallidum, a bacterium belonging to the Spirochaetaceae family, spiral-shaped bacteria. It is able to invade a wide variety of tissues from the initial site of infection with a rapid dissemination rate. Treponema pallidum is able to recognize different cell types allowing the attachment to various tissues through a wide variety of adhesins able to attach to the extracellular matrix components (fibronectin, laminin). The high motility of T. pallidum is also a virulence factor enabling the rapid dissemination of the bacteria. Due to these different characteristics, T. pallidum gains access to deeper tissues and the bloodstream. Then T. pallidum is able to activate endothelial cells, macrophages and dendritic cells via TLR2 receptors, and to induce migration of inflammatory cells, leading to cytokine production.135 The bacterium is able to evade the immune system to survive. The organisms can survive in different tissues (CNS, eye, placenta) where they grow slowly and are able to reseed other tissues.

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19.4.1.3 Clinical Features The primary chancre, which usually develops 14 21 days after sexual contact, may go unnoticed by patients. If untreated, the disease progresses to the secondary stage, characterized by generalized mucocutaneous lesions affecting both skin, mucous membranes and lymph nodes. The rash of secondary syphilis can vary widely and mimic other infectious and noninfectious conditions, but characteristically affects the palms and soles. The multisystemic involvement of secondary syphilis can affect the CNS: meningitis, uveitis, cranial nerve palsies, and otitis. Early neurosyphilis can be the only symptoms of infection. This is why all patients with unexplained meningitis, uveitis, and sudden deafness should be screened for syphilis.136 Symptoms and signs of secondary syphilis spontaneously resolve, even without treatment, and if left untreated, the patient enters the latent stage. Tertiary (or late) syphilis may appear at any time between 1 and 30 years after primary infection and includes neurosyphilis, cardiovascular syphilis, and gummatous syphilis (among which intracranial forms mimicking meningiomas have been described). Late neurosyphilis includes meningovascular (cerebral and medullar) and parenchymatous (general paresis, tabes dorsalis) forms of the disease, as well as ocular and auricular manifestations. 19.4.1.4 Diagnosis There is no consensus for diagnosis of neurosyphilis. The invasion of the CNS by T. pallidum occurs relatively early in infection. However, not all patients will have a symptomatic neurosyphilis. It is thus not recommended to perform LPs in all patients with syphilis. The value of exploring asymptomatic neurosyphilis in HIV-coinfected patients remains controversial. Although these patients are more likely to develop neurosyphilis, the Center for Disease Control does not recommend performing LP in these patients, since the management based on CSF examination does not improve the clinical outcome.137 The usual parameters taken into account are a high white cell count and a high protein level in CSF, and non-treponemal (venereal disease research laboratory, VDRL) and treponemal tests performed in both the CSF and serum, together with clinical symptoms (neurological or ophtamological). The diagnosis will be based on a non-treponema test (VDRL,) performed in CSF. This test is highly specific but has a poor sensitivity (around 50%). A negative result should not rule out the diagnosis of neurosyphilis. Moreover, as rare falsepositives occur, a higher-sensitivity test (fluorescent Treponema antibody absorption, FTA-Abs), a treponemal test, could be used as a confirmatory test. Besides the CSF analysis, a serological assay must be performed.

The usefulness of PCR in the diagnosis of neurosyphilis was controversial. Different studies found diverse sensitivity rates, probably due to a transient presence of T. pallidum in CSF. As for serological tests, the PCR should be used only when clinical symptoms are present. A recent study showed that a nested PCR targeting the tpp47 gene (encoding a major lipoprotein of T. pallidum) seemed more sensitive in CSF from patients with clinical symptoms of neurosyphilis than CSF VDRL.138 A chest radiograph should be performed to exclude asymptomatic cardiovascular syphilis. When a repeat treatment of syphilis is considered (recurrence of symptoms/signs of active syphilis, increase in the titer of a non-treponemal test), the WHO recommends a CSF analysis in order to evaluate the possible presence of asymptomatic neurosyphilis before repeat treatment, unless reinfection and a diagnosis of early syphilis can be established.139 19.4.1.5 Treatment The recommended regimen of neurosyphilis is aqueous benzylpenicillin, 12 24 million IU by intravenous injection, administered daily in doses of 2 4 million IU, every 4 hours for 14 days. Procaine benzylpenicillin, 1.2 million IU by intramuscular injection, once daily, and probenecid, 500 mg orally, four times daily, both for 10 14 days have been proposed as an alternative regimen; in this case, the regimen should be used only for patients whose outpatient compliance can be assured. For penicillin-allergic non-pregnant patients, doxycycline, 200 mg orally, twice daily for 30 days or tetracycline, 500 mg orally, four times daily for 30 days have been proposed, but for some experts, however, there is no alternative to penicillin, and penicillinallergic patients should undergo penicillin desenzitisation before intravenous penicillin therapy. Although their efficacy is not yet well documented, third-generation cephalosporins may be useful in the treatment of neurosyphilis. The European guidelines on the management of syphilis advise 1 2 g intravenous ceftriaxone/day for 10 14 days.140 Corticosteroids (20 60 mg/day) as prevention of Jarisch Herxheimer reaction, are advised the first 3 days of treatment.136 19.4.1.6 Outcome CSF analysis should be checked 6 12 months after therapy.136 A decrease in protein level, white cells count and VDRL test should be seen. However, if the initial VDRL titer was high, the return to negative can take years.

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19.4.1.7 Prevention136 A routine test for syphilis should be taken in all pregnant women or those people who are donating blood, and the following groups are at higher risk of syphilis: all patients who are newly diagnosed with sexually transmitted infection (STI); persons with HIV; patients with hepatitis B; patients with hepatitis C; patients suspected of early neurosyphilis (i.e., unexplained sudden visual loss (uveitis), unexplained sudden deafness (otitis) or meningitis); patients who engage in sexual behavior that puts them at risk (e.g., men who have sex with men, sex workers) and all those individuals at higher risk of acquiring STIs.

19.4.2 Zoonotic BM 19.4.2.1 Leptospirosis, Brucellosis and Q Fever The zoonotic BM most prevalent in tropical areas and less-developed countries are leptospirosis, brucellosis, and Q fever. However, they represent less than 1% of episodes of BM, and have a strong regional distribution.141 19.4.2.1.1 EPIDEMIOLOGY

Infection by direct contact with infected animals is most likely with brucellosis, to which farmers and veterinarians are highly exposed. Leptospirosis occurs predominantly in tropical and sub-tropical parts of the world. Leptospirosis meningitis often follows exposition to fresh water sources contaminated with animal urine (mainly rodents and marsupials). Dairy unpasteurized products are a source of infection for brucellosis and Q fever. Outbreaks of Q fever have also been related to airborne dispersion.142 19.4.2.1.2 PHYSIOPATHOLOGY

Leptospira is a spirochete, living as a saprophyte in freshwater and soil. There are 20 species and hundreds of serovars. Leptospira interrogans serovar Icterohaemorragiae is mainly found in severe human disease. Portals of entry include skin (cuts and abrasions) and mucous membranes (conjunctival or oral). The bacteria then cross the tissue barriers and reach the bloodstream. The level of bacteremia is very high (.104 CFU/mL) due to the persistence of the Leptospira in the blood during the first week of the acute illness. This could be explained by the inability of TLR4 to recognize leptospiral lipopolysaccharide (LPS). This high level of bacteremia leads to a cytokinic storm and severe sepsis. Severe leptospirosis is characterized by dysfunction of multiple organs including the liver, kidneys, lungs, and brain.143

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Brucella are gram-negative rods. Among the 10 species described, Brucella melitensis followed by Brucella suis are the main species involved in human diseases. Q fever is due to Coxiella burnetii, a coccobacillus non-stainable with the Gram technique. It grows very slowly and is an intracellular pathogen in eukaryotic cells. It is able to survive in the phagolysosome through production of basic proteins and transporters for osmoprotectants, leading to a persistent infection.144 Different virulence factors have been described (secretion systems, adhesins, LPS, detoxification mechnisms, etc.). The pathogenicity depends on the route of infection, the C. burnetii strain and the inoculum size. 19.4.2.1.3 CLINICAL FEATURES

About 5% of patients with brucellosis have CNS involvement.145,146 The most common presentation of neurobrucellosis is acute or chronic meningitis or meningoencephalitis. In leptospirosis, 20% of patients with fever and headache have meningitis.147 In a study performed in Laos, leptospirosis was diagnosed in 3% of patients whose clinical signs lead to an LP.148 A variety of other neurologic complications may also occur including hemiplegia, transverse myelitis, and Guillain Barre´ syndrome. Only 1% of acute Q fever patients have meningitis/ meningoencephalitis.149 Myelitis and peripheral neuropathy have occasionally been described in acute Q fever.150 19.4.2.1.4 DIAGNOSIS

In neurological leptospirosis, CSF examination includes a white cell count up to 500 mm23 with predominance of lymphocytes, an increased protein level and a normal glucose level. Bacterial culture is possible but needs specialized media, takes time and could be falsely negative. CSF must be cultured the first week of the disease, urine from the beginning of the second week and blood cultures as soon as possible. PCR methods have been developed and increase the sensitivity of the diagnosis. A serological test must also be performed systematically by microscopy agglutination test (MAT). Immunoglobulin M (IgM) appears during the first week of infection. The diagnosis of neurobrucellosis includes bacterial culture of the CSF and a serological test. A PCR can also be performed.143 In Q fever with neurological signs (mainly meningoencephalitis), CSF examination shows a predominance of lymphocytes. As C. burnetii does not grow on culture media used in routine, the detection of the bacteria is performed by PCR techniques. Besides the molecular detection, a serological test should be performed.

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19.4.2.1.5 TREATMENT

19.4.2.3 Relapsing Fever

Leptospirosis meningitis should be treated like any case of leptospirosis. Among the antibiotics studied in clinical trials, penicillin, ceftriaxone, doxycycline, and azithromycin are effective.151,152 Q fever meningitis should be treated with doxycycline. In brucellosis, a combination of at least two drugs which cross the blood brain barrier has been recommended.153 The primary drugs of choice are doxycycline, rifampin, trimethoprim-sulfamethoxazole (SXT), ciprofloxacin, and ceftriaxone. Data from a large retrospective study favored 1 month of parenteral ceftriaxone treatment in combination with doxycycline and rifampin for treating neurobrucellosis.154

Among 11 travelers diagnosed with Borellia crocidurae relapsing fever, four had a lymphocytic meningitis.159 The earliest neurologic signs occurred during the second febrile episode, confirming previous studies reporting the onset of neurologic complications after the first episode.160 All four patients had traveled to Senegal and had a lymphocytic meningitis. The diagnosis was established on Giemsa-stained blood smear; molecular diagnosis was positive for all patients in blood and for three patients in CSF. All were cured with doxycycline or ceftriaxone.

19.4.2.1.6 OUTCOME

While only 0.1% would complicate Mycoplasma pneumoniae infections,161 it is one of the major causes (5% 10%) of encephalitis in children in some areas. Meningitis, meningoencephalitis, cerebellitis, myelitis, polyneuropathy, acute disseminated encephalomyelitis, and Guillain-Barre´ syndrome are the most common neurological manifestations.162 Myasthenia gravis has also been described.163

The Istanbul study found sequelae in 19% of patients with neurobrucellosis: (in decreasing order) walking difficulty, hearing loss, urinary incontinence, visual disturbance, and amnesia.154 19.4.2.1.7 PREVENTION

Doxycycline might be effective as a pre-exposure or post-exposure prophylaxis in leptospirosis, but evidence of this is still lacking.155 Human vaccines are available for infection with Leptospira and Q fever but none of these vaccines has been widely implemented. 19.4.2.2 Rickettsiosis The proportion of patients with meningitis is estimated at 5% among patients with scrub typhus,156 with a mortality comparable to patients without meningitis. In scrub typhus, the presence of pneumonitis is associated with the occurrence of scrub typhus meningitis/encephalitis.157 Scrub typhus and Rickettsia typhi infections are prevalent in parts of South-East Asia.158 A study performed in Laos showed that the prevalence of these infections in patients whose clinical signs lead to an LP, was 6% (3% for each etiology).148 The mortality was 27% among the 28 patients with R. typhi meningitis, and 14% among the 31 patients with scrub typhus. The recommended treatment for both infections is doxycycline. However, observations have been made of meningitis developing in the course of scrub typhus while doxycycline had been started early in the management of infection,157 making it an issue to add rifampicin to doxycycline for treating rickettsiosis meningitis, for which penetration in the CSF is good, in order to treat scrub typhus meningitis more effectively.

19.4.3 Mycoplasma pneumoniae

19.4.3.1 Physiopathology162,164 and Diagnosis It seems that there are two ways for CSF infection, one of early onset via a direct invasion of the CSF and one of late onset via an immune-mediated mechanism. In this latter case, the PCR in CSF is rarely positive. Mycoplasma pneumoniae expresses adhesion proteins and glycolipids that share structural homology with host cells, leading to autoimmune responses. The CSF shows a pleocytosis and an increased protein level. A serological test in the blood will be also performed. However, the serology has some limitations. Indeed, IgM can be detectable for several months and their detection has poor sensitivity. The full interpretation of a serological test needs a fourfold increase in antibody titer between two sera. However, a convalescent serum is not very useful in clinical practice as it is time-consuming and does not allow initiation of early treatment. The diagnosis of a neurological infection will be based on a positive serology (IgM detection) and molecular detection of M. pneumoniae in CSF and/ or in respiratory tract. However, the results have to be interpreted with caution as asymptomatic carriage is observed in children, inducing a positive serological test and even positive PCR in the respiratory tract. 19.4.3.2 Treatment Macrolides, doxycycline, and fluoroquinolones are the antibiotics of choice. However, resistance to macrolides seems highly prevalent in Asia,165 and

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REFERENCES

prescriptions of alternatives to macrolides in children is an unresolved issue in these areas. Methylprednisolone usage along with antibiotics has been proposed on the basis of sporadic observations.166 Sequels of neurological manifestations of M. pneumoniae infections can be observed several years after the disease.167

19.4.4 Tetanus Tetanus is a nervous system disorder characterized by muscle spasms that is caused by the toxinproducing anaerobe Clostridium tetani, which is found in the soil. Neonatal tetanus reporting to the WHO notifiable surveillance system has very low notification efficiency, ranging from 3% to 11%168 and non-neonatal tetanus is not a reportable condition. Along with the Maternal and Neonatal Tetanus Elimination Initiative, global deaths from neonatal tetanus was reduced by more than 90% between 1987 and 2010.169 The highest reported number of non-neonatal tetanus cases is in the African Region, at 4.0 per million population, followed by the South-East Asia Region at 1.9 per million population.170 19.4.4.1 Physiopathology Tetanus is due to a gram-positive anaerobic sporulating bacteria, C. tetani, whose spores persist in the soil. Infection occurs after inoculation of the spores from the soil into a soft tissue wound. The spores will then germinate in vivo and the bacteria will produce a neurotoxin that can be disseminated via the bloodstream. This neurotoxin binds the neuromuscular junctions of the peripheral motor neurons and is then transported to the CNS.171 19.4.4.2 Diagnosis Diagnosis relies mainly on the clinical symptoms. A PCR can be used to detect the neurotoxin.

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19.4.4.4 Outcome in Survivors In neonatal tetanus, complications reflecting brain damages (microcephaly and mild neurological, developmental, or behavioral problems) have been observed in about one-third of neonates.174 Cerebral palsy, cognitive delay, and deafness have also been reported.169 In non-neonatal tetanus, serious sequelae following unequivocally linked to the disease are observed in less than 10% of survivors.175,176 Persistent vegetative state, limb amputations, and gait abnormality have been described,176 as well as residual muscle rigidity.177 19.4.4.5 Treatment Management of maternal and neonatal tetanus involves toxin neutralization (parenteral, intrathecal), bacterial elimination (penicillin, metronidazole), and symptomatic control.169 19.4.4.6 Prevention Neonatal tetanus can be prevented by immunizing pregnant women and women of childbearing age with tetanus toxoid. The WHO advocates the use of six clean measures to improve birth hygiene: clean birth surface, clean hands, clean perineum, cord cutting, cord tying, and cord care. Non-neonatal tetanus can be prevented with universal immunization. More than two-thirds of adults hospitalized for tetanus across Africa and elsewhere are men, which suggests that there is an underlying burden of tetanus among adolescent and adult men who have been largely missed by vaccination programs.170 Tetanus toxoid does not induce immunity immediately; after the second dose, it takes approximately 2 4 weeks to exceed the minimum level required for short-term protection. For post-exposure prophylaxis, human antitetanus immunoglobulin (TIG) is indicated for all persons at risk of contracting tetanus after being wounded if they are not (fully) vaccinated or are immunocompromised.

References 19.4.4.3 Mortality Mortality from maternal and neonatal tetanus is high. Neonatal mortality ranges from 3% to 88% in Asia and Africa.169 Maternal tetanus arising from internal entry sites (postpartum, postabortional, or intramuscular injection) are associated with higher mortality than tetanus arising from other entry sites.172 Adult mortality rates up to 52% are reported in Asia and Africa.169,173

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