- Email: [email protected]
Human encephalitis complicated with bilateral acute retinal necrosis associated with pseudorabies virus infection: A case report
Journal Pre-proof Human encephalitis complicated with bilateral Acute retinal necrosis associated with Pseudorabies Virus infection: a case report Yuwei Wang, Hong Nian, Ziwei Li, Wenjuan Wang, Xin Wang, Yan Cui
PII:
S1201-9712(19)30381-9
DOI:
https://doi.org/10.1016/j.ijid.2019.09.019
Reference:
IJID 3765
To appear in:
International Journal of Infectious Diseases
Received Date:
30 June 2019
Revised Date:
20 September 2019
Accepted Date:
20 September 2019
Please cite this article as: Wang Y, Nian H, Li Z, Wang W, Wang X, Cui Y, Human encephalitis complicated with bilateral Acute retinal necrosis associated with Pseudorabies Virus infection: a case report, International Journal of Infectious Diseases (2019), doi: https://doi.org/10.1016/j.ijid.2019.09.019
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.
TITLE PAGE Human encephalitis complicated with bilateral Acute retinal necrosis associated with Pseudorabies Virus infection: a case report Authors Yuwei Wang1, Hong Nian2, Ziwei Li1, Wenjuan Wang1, Xin Wang3, Yan Cui4 (Yuwei Wang and Hong Nian are co-first authors) Affiliations University Cheeloo College of Medicine, 44 West Wenhua Road,
Lixia District, Jinan, Shandong 250012, P.R.China. 2Tianjin
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1Shandong
Key Laboratory of Retinal Functions and Diseases, Tianjin Medical
-p
University Eye Hospital, School of Optometry and Ophthalmology & Eye
Institute, No.251 Fu Kang Road, Nankai District, Tianjin 300384, P.R.China. University of Traditional Chinese Medicine, 16369 Jingshi Road,
re
3Shandong
Lixia District, Jinan, Shandong 250014, P.R.China.
of Ophthalmology, Qilu Hospital of Shandong University,
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4Department
Shandong University, 107 West Wenhua Road, Lixia District, Jinan,
na
Shandong 250012, P.R.China. Authors’ email addresses
ur
Yuwei Wang E-mail: [email protected] Hong Nian E-mail: [email protected]
Jo
Ziwei Li E-mail: [email protected] Wenjuan Wang E-mail: [email protected] Xin Wang E-mail: [email protected] Yan Cui E-mail: [email protected] Corresponding author
Dr. Yan Cui, Department of Ophthalmology, Qilu Hospital of Shandong University, Shandong University, 107 West Wenhua Road, Jinan, Shandong 250012, People's Republic of China. E-mail address: [email protected]
Highlights: We report a case who was highly suspected infected with pseudorabies virus presented with viral encephalitis and bilateral acute retinal necrosis.
This is the first case pseudorabies virus sequence detected in both cerebrospinal fluid and vitreous humor by next-generation sequencing.
Swine herpesvirus could cause human infection and lead to serious consequences. Self-protection is of great importance while in contact with the animals.
-p
ro of
re
Abstract
We report a case of a patient presented viral encephalitis and pulmonary
lP
infection complicated with bilateral acute retinal necrosis (ARN) after direct contact with the diseased swine. Next-generation sequencing (NGS) of the cerebrospinal fluid and vitreous humor detected pseudorabies virus (PRV)
na
simultaneously. Intravenous acyclovir and dexamethasone treatment improved the symptoms of encephalitis, and vitrectomy surgery with silicone oil tamponade treated retinal detachment. This case implies that pseudorabies
ur
virus could infect humans, and thus, self-protection is imperative while in contact with the animals.
Jo
Keywords: pseudorabies virus, acute retinal necrosis, viral encephalitis, nextgeneration sequencing Introduction PRV, also known as Suid herpesvirus and Aujeszky’s disease virus, primarily infects the members of the Suidae family and can potentially infect different hosts, such as horses, dogs, and cattle(Ehlers, B et al 2007). Although the
susceptibility of man to PRV has not been confirmed(Wozniakowski, G et al 2015), previous reports indicated that the infection could lead to viral encephalitis or endophthalmitis(Ai, J. W. et al 2018; Mravak, S et al 1987; H.N. Yang et al 2019). Acute retinal necrosis (ARN) is a rare viral retina disease characterized by well-demarcated areas of retinal necrosis in the peripheral retina, occlusive vasculopathy, and vitreous inflammation(Holland, G. N 1994). ARN in most of the reported cases has been caused by varicella-zoster virus (VZV) or herpes simplex virus (HSV)-1; PRV infection is rare. Herein, we report a human case of viral encephalitis combined with bilateral retinal
ro of
necrosis that was suspected to be caused by PRV infection. Case report
A 44-year-old male was admitted to Qilu Hospital of Shandong University (Jinan, China) with fever lasting 11 days and unconsciousness with
-p
convulsions for 3 days.His daily work was to dispose of diseased swine and sell pork. Chest computed tomography (CT) at other hospital indicated
re
bilateral pulmonary inflammation. The magnetic resonance imaging (MRI) of the brain showed high signal intensity on T2-weighted MR image (T2WI),
lP
T1WI hypointensity, hyperintense foci on the T2- FLAIR sequences and DWI in the bilateral temporal lobe and hippocampus; the left lesion was more severe than that on the right side(Figure.1A). Polymerase chain reaction
na
using blood tested negative for JC polyomavirus (JCV), Epstein-Barr virus (EBV), human cytomegalovirus (CMV), herpes simplex virus type 1(HSV-1), And about 5ml cerebrospinal fluid sample was obtained by lumbar puncture
ur
for next-generation sequencing (NGS) detection(see the detailed steps of NGS test in the supplementary material) and the result showed 72
Jo
pseudorabies virus reads, covering 3.35% of the nucleotide sequences (Figure. 1B Table.1A). Therefore, he was diagnosed as viral encephalitis and pulmonary infection(see the diagnostic details of pulmonary infection in the supplementary material), and hospitalized in ICU for the treatment of the virus infection using intravenous acyclovir, intravenous mannitol to adjust intracranial pressure, dexamethasone and gamma globulin for antiinflammation and immune support treatment. After the condition stabilized, the patient was transferred to the Neurology Department for further treatment.
After treatment for 3 months, the size of the lesion was smaller than that observed previously on the cranial MRI. During these 3 months, he developed blurred vision in both eyes (OU) gradually, but did not focus on the condition due to weak health. Due to the progressive visual loss of the left eye, the patient was transferred to Department of Ophthalmology. The examination revealed that his bestcorrected visual acuity was 5/20 in the right eye and hand movement/30cm in the left eye, and the pupillary direct light reflex was negative in both eyes. The intraocular pressure was 11.2 and 9.7 mmHg in the right and left the eye,
ro of
respectively. The vitreous opacity of the left eye prevented visualization of the
detail of retina, but fundus examination could distinguish funnel-shaped retinal detachment, as well as, atrophied and thinned peripheral retina. The vitreous of the right eye was mildly opaque, and the fundus examination showed the
-p
pallor optic disc with clear border and loss of the foveal reflex. The retinal
detachment in the left eye and the scar stage of acute retinal necrosis was
re
diagnosed clinically in both eyes.
The left eye underwent pars plana vitrectomy with silicone oil tamponade. The
lP
vitreous opacity and complete retinal detachment were observed during surgery, and the peripheral retina was thinned and bugbite-like broken(Figure.1C), even some parts of retinal neurepithelium layer were
na
almost completely destroyed, all of these was consistent with retinal necrosis. It was also found that lesion progressively aggravated from the periphery to the posterior pole. Approximately, 5 ml of the vitreous humor sample was
ur
collected for pathogenic examination(see the detailed steps of NGS test in the supplementary material). NGS of the vitreous humor detected 2 sequences of
Jo
PRV type-1, covering 0.0286% of the nucleotide sequences (Figure.1D Table.1B). Considering PRV positive in both CSF and vitreous humor, patient’s contact history of diseased swine, and clinical symptoms, we thought PRV infection probably led to encephalitis complicated with bilateral retinal necrosis. After the vitrectomy of left eye, retinal holes of retinal necrosis with discrete borders in the peripheral retina were distinctly visible. Four months after
vitrectomy of left eye, retinal detachment of right eye and recurrent detachment of left eye with silicone oil tamponade occurred Both eyes underwent surgery for retinal reattachment. We speculated that retinal detachment in the right eye also probably because of PRV infection. Therefore, during the operation of right eye, 5 ml of vitreous cavity fluid was extracted for NGS detection, but PRV was not found. Then, the patient was followed-up for 6 months. The visual acuity decreased to 2/20 in right eye owing to the complicated cataract.
ro of
Discussion Previously, PRV was thought to be transmitted only in swine. However, in
2017, Li et al. reported a case of endophthalmitis caused by PRV, which was highly homologous to three highly pathogenic PRV variants in China.
Moreover, they discovered that PRV could interact with both human and
-p
swine cellular receptor nectin-1 via the envelope glycoprotein D (gD) on the viral surface(Li, A et al 2017). This discovery might explain the possibility of
re
zoonosis caused by PRV variants and stressed the necessity for researchers and workers in the breeding industry to increase awareness of self-protection.
lP
To the best of our knowledge, up to Jun 2019, seven cases reported PRV infection in humans, including suspected and confirmed cases(Ai, J. W. et al 2018; Mravak, S et al 1987; H.N. Yang et al 2019). Of these, only one of them
na
reported that PRV led to endophthalmitis; NGS detected PRV only in the vitreous humor, not in the CSF(Ai, J. W. et al 2018). We reported the first intraocular infection case, wherein the PRV sequence was detected in both
ur
CSF and vitreous humor by NGS. Besides, the intraocular inflammation of our patient still progressed after a series of drug treatment and surgery. Though,
Jo
NGS test showed PRV was negative in right eye vitreous humor, the visual of right eye was impaired gradually and continuously, owing to retinal detachment and complicated cataract, meanwile, retinal detachment recurred in the left eye after vitrectomy. Hafidi et al found that numerous and prolonged antiviral intravitreal injections, used as ajdunctive therapy, could improve the prognosis of ARN patients by decreasing the risk of retinal detachment and improving visual acuity(Hafidi, M et al 2019). This discovery provides a new idea for our further treatment.
Although the pathogenicity of the detected PRV in our patient can not be determined, we consider that there is a strong correlation between PRV infection and our patient’s diseases. First of all, PRV was the only virus detected in both cerebrospinal fluid and vitreous cavity fluid by NGS, though the sequence reads are as low as 72 and 2. The antiviral treatment before detection might be the main reason of a limited number of virus sequences. Secondly, Antiviral therapy was effective in controlling infection of nervous system and respiratory system. Futhermore, viral encephalitis may be a risk factor for retinal necrosis. The mechanism of ARN has yet to be elucidated;
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however, it has been indicated that the virus may be transmitted via the brainoptic nerve axon-retina pathway(Gaynor, B et al 2001; Liang, Z. G et al 2015).And after PRV infects rat retina, the virus can invade the central
nervous system (CNS) via anterograde transynaptic spread through axons in the optic nerve, also maybe via retrograde transport through the oculomotor
-p
nucleus that innervates extraocular muscles of the eye(Rassnick, S et al
re
1998).
The detection of virus DNA sequences allows early antiviral treatment, which can reduce the risk of complications and limit disease progression. NGS is
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based on high throughput sequencing technology. Microbial nucleic acid sequences in samples were analyzed and compared to those of existing
na
microorganisms in the database, so as to identify microorganisms. Therefore, NGS does not only offer the possibility of pathogen detection without prior knowledge of the target but also rapidly makes an accurate diagnosis. In 2015,
ur
Guan et al. highlighted the feasibility of using NGS of CSF as a tool to diagnose the CNS viral infection(Guan, H. et al 2015). And in a recent study,
Jo
NGS of CSF obtained from patients with meningitis or encephalitis improved diagnosis of neurologic infections(Wilson M. R. et al 2019). However, if we verified PRV defection by PCR or sanger sequencing in time, it would be further support our patient’s infection of PRV. In conclusion, PRV infection perhaps can cause encephalitis and acute retinal necrosis in human with serious consequences and ocular inflammation is hard to control, so protective measures for animal contacts are much needed. In
addition, sensitive and accurate technique of virus detection is of great significance for early diagnosis and treatment of PRV infection. Author contributions Wenjuan Wang, Xin Wang and Ziwei Li collected the patient data and images. Yuwei Wang wrote the original manuscript with support from Hong Nian. Yan Cui was responsible for revising the draft. All authors contributed to the final manuscript and agreed to submit. Funding source
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This work was supported by the Natural Science Foundation of Shandong
Province [grant number ZR2016HM14]; the Jinan Science and Technology
Project [grant number 201805050];the National Natural Science Foundation of
-p
China [No. 81100658 and No.81570834] Ethical approval
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Approval was given by the patient for the reporting of his case details.
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Conflict of interest
All authors declare no potential conflict of interest.
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Acknowledgements
Jo
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We would like to express our thank to the patient and our colleagues.
Reference 1.
Ehlers, B., J. Kuchler, N. Yasmum, G. Dural, S. Voigt, J. Schmidt-Chanasit, T. Jakel, F. R. Matuschka, D. Richter, S. Essbauer, D. J. Hughes, C. Summers, M. Bennett, J. P. Stewart, and R. G. Ulrich. Identification of novel rodent herpesviruses, including the first gammaherpesvirus of Mus musculus. Journal of virology 2007;81: 8091-8100. https://doi.org/10.1128/JVI.00255-07.
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Wozniakowski, G., and E. Samorek-Salamonowicz. Animal herpesviruses and their zoonotic potential for cross-species infection. Annals of agricultural and environmental medicine 2015;AAEM 22: 191-194. https://doi.org/10.5604/12321966.1152063. Ai, J. W., S. S. Weng, Q. Cheng, P. Cui, Y. J. Li, H. L. Wu, Y. M. Zhu, B. Xu,
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and W. H. Zhang. Human Endophthalmitis Caused By Pseudorabies Virus Infection, China, 2017. Emerging infectious diseases 2018;24: 1087-1090. https://doi.org/10.3201/eid2406.171612.
Mravak, S., U. Bienzle, H. Feldmeier, H. Hampl, and K. O. Habermehl.
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Pseudorabies in man. Lancet 1987;1: 501-502.
https://doi.org/10.1016/S0140-6736(87)92105-2.
H.N. Yang, H. Han, H. Wang, Y. Cui, H. Liu, S.F. Ding. A Case of Human Viral
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Encephalitis Caused by Pseudorabies Virus Infection in China. Front. Neurol
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2019;10:534. https://doi.org/10.3389/fneur.2019.00534 Holland, G. N. Standard diagnostic criteria for the acute retinal necrosis syndrome. Executive Committee of the American Uveitis Society. American
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journal of ophthalmology 1994;117: 663-667. https://doi.org/10.1016/S00029394(14)70075-3. 7.
Li, A., G. Lu, J. Qi, L. Wu, K. Tian, T. Luo, Y. Shi, J. Yan, and G. F. Gao.
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Structural basis of nectin-1 recognition by pseudorabies virus glycoprotein D. PLoS pathogens 2017;13: e1006314. https://doi.org/10.1371/journal.ppat.1006314.. Gaynor, B. D., N. K. Wade, and E. T. Cunningham, Jr. Herpes simplex virus
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type 1 associated acute retinal necrosis following encephalitis. Retina 2001;21: 688-690. https://doi.org/10.1097/00006982-200112000-00028.
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Liang, Z. G., Z. L. Liu, X. W. Sun, M. L. Tao, and G. P. Yu. Viral encephalitis complicated by acute retinal necrosis syndrome: A case report. Experimental and therapeutic medicine 2015;10: 465-467. https://doi.org/10.3892/etm.2015.2557.
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Hafidi, M., Janin-Manificat, H., Denis, P., Charleux, B., Rabilloud, M., Boibieux,
A., Burillon, C., Kodjikian, L., Frobert, E. Acute retinal necrosis: virological features using quantitative PCR, therapeutic management, and clinical outcomes. Am. J. Ophthalmol 2019, Aug 23. https://doi.org/10.1016/j.ajo.2019.08.007 11
Rassnick, S. , Enquist, L. W. , Sved, A. F. , & Card, J. P. Pseudorabies virusinduced leukocyte trafficking into the rat central nervous system. Journal of Virology, 1998;72(11),9181-9191. https://doi.org/10.1016/S0166-0934(98)00117-7
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Guan, H., Shen, A., Lv, X., Yang, X., Cui, L. Detection of virus in CSF from the cases with meningoencephalitis by next-generation sequencing. Journal of
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NeuroVirology 2015; 22(2): 240-245. https://doi.org/10.1007/s13365-0150390-7 13
Wilson M. R., Sample H. A., Zorn K. C., Arevalo S., Yu G., Neuhaus J.,
Federman S., Stryke D., Briggs B., Langelier C., Berger A., Douglas V., Josephson S. A., Chow F. C., Fulton B. D., DeRisi J. L., Gelfand J. M.,
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Naccache S. N., Bender J., Dien B. J., Murkey J., Carlson M., Vespa P. M., Vijayan T., Allyn P. R., Campeau S., Humphries R. M., Klausner J. D.,
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Ganzon C. D., Memar F.., Ocampo N. A., Zimmermann L. L., Cohen S. H., Polage C. R., DeBiasi R. L., Haller B., Dallas R., Maron G., Hayden R.,
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Messacar K., Dominguez S. R., Miller S., Chiu C. Y. Clinical Metagenomic Sequencing for Diagnosis of Meningitis and Encephalitis. N. Engl. J. Med
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2019; 380, 2327-2340. https://doi.org/10.1056/NEJMoa1803396
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Fig 1. A) Cranial MRI of initial visit (before antiviral therapy) showed T2-flair abnormal hyperintensity signals in bilateral medial temporal lobe and hippocampus. B) Sequencing of Suid herpesvirus 1 (pseudorabies virus) yielded a total coverage of 3.35% in cerebrospinal fluid sample. C) Peripheral retinal necrosis and retinal detachment were observed during the vitrectomy of left eye. D) Sequencing of Suid herpesvirus 1 (pseudorabies virus) yielded a total coverage of 0.0286% in vitreous humor sample. And the GenBank number of the PRV whole genome sequence used as the source for comparison is BK001744.1
Table 1A.Pathogens detected by using next-generation sequencing in cerebrospinal fluid Pathogen Coverage,% Depth Unique reads Virus 3.35 1 72 Suid herpesvirus 1 Bacteria 0.13 1 22 Staphylococcus warneri 0.03 1 11 Staphylococcus cohnii 0.08 1 8 Corynebacterium tuberculostearicum 0.08 1 7 Corynebacterium pseudogenitalium 0.05 1 20 Prevotella intermedia 0.04 1 15 Prevotella corporis
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na
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re
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Fungi, parasite, mycobacterium tuberculosis complex, mycoplasma, chlamydia were all negative, and no viruses other than PRV were detected.
Jo
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na
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Table 1B. Pathogens detected by using next-generation sequencing in vitreous humor Pathogen Coverage,% Depth Unique reads Virus 0.03 1 2 Suid herpesvirus 1 Bacteria 0.12 1 14 Staphylococcus pasteuri 0.005 1 7 Gordonia polyisoprenivorans 0.007 1 5 Leptospira noguchii 0.005 1 3 Rhodoferax ferrireducens Fungi, parasite, mycobacterium tuberculosis complex, mycoplasma, chlamydia were all negative, and no viruses other than PRV were detected.
PII:
S1201-9712(19)30381-9
DOI:
https://doi.org/10.1016/j.ijid.2019.09.019
Reference:
IJID 3765
To appear in:
International Journal of Infectious Diseases
Received Date:
30 June 2019
Revised Date:
20 September 2019
Accepted Date:
20 September 2019
Please cite this article as: Wang Y, Nian H, Li Z, Wang W, Wang X, Cui Y, Human encephalitis complicated with bilateral Acute retinal necrosis associated with Pseudorabies Virus infection: a case report, International Journal of Infectious Diseases (2019), doi: https://doi.org/10.1016/j.ijid.2019.09.019
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.
TITLE PAGE Human encephalitis complicated with bilateral Acute retinal necrosis associated with Pseudorabies Virus infection: a case report Authors Yuwei Wang1, Hong Nian2, Ziwei Li1, Wenjuan Wang1, Xin Wang3, Yan Cui4 (Yuwei Wang and Hong Nian are co-first authors) Affiliations University Cheeloo College of Medicine, 44 West Wenhua Road,
Lixia District, Jinan, Shandong 250012, P.R.China. 2Tianjin
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1Shandong
Key Laboratory of Retinal Functions and Diseases, Tianjin Medical
-p
University Eye Hospital, School of Optometry and Ophthalmology & Eye
Institute, No.251 Fu Kang Road, Nankai District, Tianjin 300384, P.R.China. University of Traditional Chinese Medicine, 16369 Jingshi Road,
re
3Shandong
Lixia District, Jinan, Shandong 250014, P.R.China.
of Ophthalmology, Qilu Hospital of Shandong University,
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4Department
Shandong University, 107 West Wenhua Road, Lixia District, Jinan,
na
Shandong 250012, P.R.China. Authors’ email addresses
ur
Yuwei Wang E-mail: [email protected] Hong Nian E-mail: [email protected]
Jo
Ziwei Li E-mail: [email protected] Wenjuan Wang E-mail: [email protected] Xin Wang E-mail: [email protected] Yan Cui E-mail: [email protected] Corresponding author
Dr. Yan Cui, Department of Ophthalmology, Qilu Hospital of Shandong University, Shandong University, 107 West Wenhua Road, Jinan, Shandong 250012, People's Republic of China. E-mail address: [email protected]
Highlights: We report a case who was highly suspected infected with pseudorabies virus presented with viral encephalitis and bilateral acute retinal necrosis.
This is the first case pseudorabies virus sequence detected in both cerebrospinal fluid and vitreous humor by next-generation sequencing.
Swine herpesvirus could cause human infection and lead to serious consequences. Self-protection is of great importance while in contact with the animals.
-p
ro of
re
Abstract
We report a case of a patient presented viral encephalitis and pulmonary
lP
infection complicated with bilateral acute retinal necrosis (ARN) after direct contact with the diseased swine. Next-generation sequencing (NGS) of the cerebrospinal fluid and vitreous humor detected pseudorabies virus (PRV)
na
simultaneously. Intravenous acyclovir and dexamethasone treatment improved the symptoms of encephalitis, and vitrectomy surgery with silicone oil tamponade treated retinal detachment. This case implies that pseudorabies
ur
virus could infect humans, and thus, self-protection is imperative while in contact with the animals.
Jo
Keywords: pseudorabies virus, acute retinal necrosis, viral encephalitis, nextgeneration sequencing Introduction PRV, also known as Suid herpesvirus and Aujeszky’s disease virus, primarily infects the members of the Suidae family and can potentially infect different hosts, such as horses, dogs, and cattle(Ehlers, B et al 2007). Although the
susceptibility of man to PRV has not been confirmed(Wozniakowski, G et al 2015), previous reports indicated that the infection could lead to viral encephalitis or endophthalmitis(Ai, J. W. et al 2018; Mravak, S et al 1987; H.N. Yang et al 2019). Acute retinal necrosis (ARN) is a rare viral retina disease characterized by well-demarcated areas of retinal necrosis in the peripheral retina, occlusive vasculopathy, and vitreous inflammation(Holland, G. N 1994). ARN in most of the reported cases has been caused by varicella-zoster virus (VZV) or herpes simplex virus (HSV)-1; PRV infection is rare. Herein, we report a human case of viral encephalitis combined with bilateral retinal
ro of
necrosis that was suspected to be caused by PRV infection. Case report
A 44-year-old male was admitted to Qilu Hospital of Shandong University (Jinan, China) with fever lasting 11 days and unconsciousness with
-p
convulsions for 3 days.His daily work was to dispose of diseased swine and sell pork. Chest computed tomography (CT) at other hospital indicated
re
bilateral pulmonary inflammation. The magnetic resonance imaging (MRI) of the brain showed high signal intensity on T2-weighted MR image (T2WI),
lP
T1WI hypointensity, hyperintense foci on the T2- FLAIR sequences and DWI in the bilateral temporal lobe and hippocampus; the left lesion was more severe than that on the right side(Figure.1A). Polymerase chain reaction
na
using blood tested negative for JC polyomavirus (JCV), Epstein-Barr virus (EBV), human cytomegalovirus (CMV), herpes simplex virus type 1(HSV-1), And about 5ml cerebrospinal fluid sample was obtained by lumbar puncture
ur
for next-generation sequencing (NGS) detection(see the detailed steps of NGS test in the supplementary material) and the result showed 72
Jo
pseudorabies virus reads, covering 3.35% of the nucleotide sequences (Figure. 1B Table.1A). Therefore, he was diagnosed as viral encephalitis and pulmonary infection(see the diagnostic details of pulmonary infection in the supplementary material), and hospitalized in ICU for the treatment of the virus infection using intravenous acyclovir, intravenous mannitol to adjust intracranial pressure, dexamethasone and gamma globulin for antiinflammation and immune support treatment. After the condition stabilized, the patient was transferred to the Neurology Department for further treatment.
After treatment for 3 months, the size of the lesion was smaller than that observed previously on the cranial MRI. During these 3 months, he developed blurred vision in both eyes (OU) gradually, but did not focus on the condition due to weak health. Due to the progressive visual loss of the left eye, the patient was transferred to Department of Ophthalmology. The examination revealed that his bestcorrected visual acuity was 5/20 in the right eye and hand movement/30cm in the left eye, and the pupillary direct light reflex was negative in both eyes. The intraocular pressure was 11.2 and 9.7 mmHg in the right and left the eye,
ro of
respectively. The vitreous opacity of the left eye prevented visualization of the
detail of retina, but fundus examination could distinguish funnel-shaped retinal detachment, as well as, atrophied and thinned peripheral retina. The vitreous of the right eye was mildly opaque, and the fundus examination showed the
-p
pallor optic disc with clear border and loss of the foveal reflex. The retinal
detachment in the left eye and the scar stage of acute retinal necrosis was
re
diagnosed clinically in both eyes.
The left eye underwent pars plana vitrectomy with silicone oil tamponade. The
lP
vitreous opacity and complete retinal detachment were observed during surgery, and the peripheral retina was thinned and bugbite-like broken(Figure.1C), even some parts of retinal neurepithelium layer were
na
almost completely destroyed, all of these was consistent with retinal necrosis. It was also found that lesion progressively aggravated from the periphery to the posterior pole. Approximately, 5 ml of the vitreous humor sample was
ur
collected for pathogenic examination(see the detailed steps of NGS test in the supplementary material). NGS of the vitreous humor detected 2 sequences of
Jo
PRV type-1, covering 0.0286% of the nucleotide sequences (Figure.1D Table.1B). Considering PRV positive in both CSF and vitreous humor, patient’s contact history of diseased swine, and clinical symptoms, we thought PRV infection probably led to encephalitis complicated with bilateral retinal necrosis. After the vitrectomy of left eye, retinal holes of retinal necrosis with discrete borders in the peripheral retina were distinctly visible. Four months after
vitrectomy of left eye, retinal detachment of right eye and recurrent detachment of left eye with silicone oil tamponade occurred Both eyes underwent surgery for retinal reattachment. We speculated that retinal detachment in the right eye also probably because of PRV infection. Therefore, during the operation of right eye, 5 ml of vitreous cavity fluid was extracted for NGS detection, but PRV was not found. Then, the patient was followed-up for 6 months. The visual acuity decreased to 2/20 in right eye owing to the complicated cataract.
ro of
Discussion Previously, PRV was thought to be transmitted only in swine. However, in
2017, Li et al. reported a case of endophthalmitis caused by PRV, which was highly homologous to three highly pathogenic PRV variants in China.
Moreover, they discovered that PRV could interact with both human and
-p
swine cellular receptor nectin-1 via the envelope glycoprotein D (gD) on the viral surface(Li, A et al 2017). This discovery might explain the possibility of
re
zoonosis caused by PRV variants and stressed the necessity for researchers and workers in the breeding industry to increase awareness of self-protection.
lP
To the best of our knowledge, up to Jun 2019, seven cases reported PRV infection in humans, including suspected and confirmed cases(Ai, J. W. et al 2018; Mravak, S et al 1987; H.N. Yang et al 2019). Of these, only one of them
na
reported that PRV led to endophthalmitis; NGS detected PRV only in the vitreous humor, not in the CSF(Ai, J. W. et al 2018). We reported the first intraocular infection case, wherein the PRV sequence was detected in both
ur
CSF and vitreous humor by NGS. Besides, the intraocular inflammation of our patient still progressed after a series of drug treatment and surgery. Though,
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NGS test showed PRV was negative in right eye vitreous humor, the visual of right eye was impaired gradually and continuously, owing to retinal detachment and complicated cataract, meanwile, retinal detachment recurred in the left eye after vitrectomy. Hafidi et al found that numerous and prolonged antiviral intravitreal injections, used as ajdunctive therapy, could improve the prognosis of ARN patients by decreasing the risk of retinal detachment and improving visual acuity(Hafidi, M et al 2019). This discovery provides a new idea for our further treatment.
Although the pathogenicity of the detected PRV in our patient can not be determined, we consider that there is a strong correlation between PRV infection and our patient’s diseases. First of all, PRV was the only virus detected in both cerebrospinal fluid and vitreous cavity fluid by NGS, though the sequence reads are as low as 72 and 2. The antiviral treatment before detection might be the main reason of a limited number of virus sequences. Secondly, Antiviral therapy was effective in controlling infection of nervous system and respiratory system. Futhermore, viral encephalitis may be a risk factor for retinal necrosis. The mechanism of ARN has yet to be elucidated;
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however, it has been indicated that the virus may be transmitted via the brainoptic nerve axon-retina pathway(Gaynor, B et al 2001; Liang, Z. G et al 2015).And after PRV infects rat retina, the virus can invade the central
nervous system (CNS) via anterograde transynaptic spread through axons in the optic nerve, also maybe via retrograde transport through the oculomotor
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nucleus that innervates extraocular muscles of the eye(Rassnick, S et al
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1998).
The detection of virus DNA sequences allows early antiviral treatment, which can reduce the risk of complications and limit disease progression. NGS is
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based on high throughput sequencing technology. Microbial nucleic acid sequences in samples were analyzed and compared to those of existing
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microorganisms in the database, so as to identify microorganisms. Therefore, NGS does not only offer the possibility of pathogen detection without prior knowledge of the target but also rapidly makes an accurate diagnosis. In 2015,
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Guan et al. highlighted the feasibility of using NGS of CSF as a tool to diagnose the CNS viral infection(Guan, H. et al 2015). And in a recent study,
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NGS of CSF obtained from patients with meningitis or encephalitis improved diagnosis of neurologic infections(Wilson M. R. et al 2019). However, if we verified PRV defection by PCR or sanger sequencing in time, it would be further support our patient’s infection of PRV. In conclusion, PRV infection perhaps can cause encephalitis and acute retinal necrosis in human with serious consequences and ocular inflammation is hard to control, so protective measures for animal contacts are much needed. In
addition, sensitive and accurate technique of virus detection is of great significance for early diagnosis and treatment of PRV infection. Author contributions Wenjuan Wang, Xin Wang and Ziwei Li collected the patient data and images. Yuwei Wang wrote the original manuscript with support from Hong Nian. Yan Cui was responsible for revising the draft. All authors contributed to the final manuscript and agreed to submit. Funding source
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This work was supported by the Natural Science Foundation of Shandong
Province [grant number ZR2016HM14]; the Jinan Science and Technology
Project [grant number 201805050];the National Natural Science Foundation of
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China [No. 81100658 and No.81570834] Ethical approval
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Approval was given by the patient for the reporting of his case details.
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Conflict of interest
All authors declare no potential conflict of interest.
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Acknowledgements
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We would like to express our thank to the patient and our colleagues.
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Fig 1. A) Cranial MRI of initial visit (before antiviral therapy) showed T2-flair abnormal hyperintensity signals in bilateral medial temporal lobe and hippocampus. B) Sequencing of Suid herpesvirus 1 (pseudorabies virus) yielded a total coverage of 3.35% in cerebrospinal fluid sample. C) Peripheral retinal necrosis and retinal detachment were observed during the vitrectomy of left eye. D) Sequencing of Suid herpesvirus 1 (pseudorabies virus) yielded a total coverage of 0.0286% in vitreous humor sample. And the GenBank number of the PRV whole genome sequence used as the source for comparison is BK001744.1
Table 1A.Pathogens detected by using next-generation sequencing in cerebrospinal fluid Pathogen Coverage,% Depth Unique reads Virus 3.35 1 72 Suid herpesvirus 1 Bacteria 0.13 1 22 Staphylococcus warneri 0.03 1 11 Staphylococcus cohnii 0.08 1 8 Corynebacterium tuberculostearicum 0.08 1 7 Corynebacterium pseudogenitalium 0.05 1 20 Prevotella intermedia 0.04 1 15 Prevotella corporis
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Fungi, parasite, mycobacterium tuberculosis complex, mycoplasma, chlamydia were all negative, and no viruses other than PRV were detected.
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Table 1B. Pathogens detected by using next-generation sequencing in vitreous humor Pathogen Coverage,% Depth Unique reads Virus 0.03 1 2 Suid herpesvirus 1 Bacteria 0.12 1 14 Staphylococcus pasteuri 0.005 1 7 Gordonia polyisoprenivorans 0.007 1 5 Leptospira noguchii 0.005 1 3 Rhodoferax ferrireducens Fungi, parasite, mycobacterium tuberculosis complex, mycoplasma, chlamydia were all negative, and no viruses other than PRV were detected.