Coinfection of Streptococcus suis and Nocardia asiatica in the human central nervous system: A case report

lNTRODUCTlON

() is a facultative anaerobic gram-positive bacterium located in the nasal cavity,tonsils, upper respiration tract and gastrointestinal tract of pigs. This microbe can be transmitted through contact, the respiratory tract and the digestive tract[1]. It enters the human body, spreads through the blood to the epithelial cells of the choroid plexus in the brain and crosses the blood-brain barrier, resulting in intracranial infection. The common complications ofinfection are hearing loss and vestibular dysfunction[2]. Since the first case in Denmark in 1968, over 1600 mankindinfections have been documented in 30 nations across the globe, especially in Southeastern Asian countries[3].is divided into 35 serotypes (Types 1-34 and Type 1/2), as per the different antigenicity of the capsular polysaccharide; the common serotypes with strong pathogenicity to pigs are Type 1, Type 2, Type 1/2, Type 7 and Type 9[4].

is a gram-positive aerobic bacterium and an opportunistic pathogen. It is widely distributed in soil and water and mainly invades the human body through respiratory tract inhalation and damaged skin. Infection byleads to abscesses of the respiratory system, skin and central nervous system as well as systemic disseminated infection. At least 100 species ofhave been identified; the medically relevant strains include,,,

On admission, the patient’s examination results were completely normal, including leukocyte count,hypersensitive C-reactive protein, procalcitonin, electrolytes, liver and kidney function tests and coagulation function tests. On the second day of hospitalization, cerebrospinal fluid examination showed 62.9 × 10white blood cells (WBCs)/μL, with a protein level of 8036 mg/L, glucose level of 3.8 mmol/L and chloride ion concentration of 139 mmol/L. The cerebrospinal fluid pressure was 270 mm HO; in routine examination of the cerebrospinal fluid, the appearance was light yellow and slightly muddy; the Pandy test was positive, with 2.4 × 10/L karyocytes, 51% neutrophils, and 69%lymphocytes. Biochemical examination of cerebrospinal fluid revealed a total protein content ＞ 1.07 g/L(normal, approximately 0.15-0.40 g/L), dextrose level of 1.87 mmol/L (normal, approximately 2.5-4.4 mmol/L), chloride level of 114.60 mmol/L (normal, approximately 120-132 mmol/L), body temperature of 38.5 °C, heart rate of 66 bpm, and blood pressure of 210/110 mmHg. The patient reported blurred consciousness and binaural hearing loss. He had signs of meningeal irritation in the form of neck stiffness and positive Kernig’s and Lesage’s signs.

Few cases of simultaneous infection withandhave been reported. The current case was an elderly male patient who hadmeningitis with abrain abscess, and metagenomic next-generation sequencing (mNGS) of cerebrospinal fluid confirmed the coinfection ofand. The present research was accepted by the Ethical Board of Liaocheng People’s Hospital, and the publication of clinical data was approved by the patient’s family[5,6].

CASE PRESENTATlON

Chief complaints

A 66-year-old hospitalized male who complained of dizziness.

History of present illness

Informed written consent was obtained from the patient for publication of this report and any accompanying images.

History of past illness

身負(fù)重任，于是私下我建議大家主動(dòng)與秦風(fēng)交往，但注意不要總問(wèn)他關(guān)于以前在農(nóng)村學(xué)校的事情，也不要在他面前表現(xiàn)出優(yōu)越感，讓他難堪……其實(shí)我也不知道要如何做才好，但總覺得，人與人之間相處，還是得互相尊重，真誠(chéng)相待。

每一段的防浪墻我們都進(jìn)行了單獨(dú)的深化設(shè)計(jì)，以契合每一段的主題，并與周圍環(huán)境進(jìn)行高度融合?？紤]到夜晚的效果，在異型防浪墻底部增設(shè)燈帶，使得其在夜晚也能形成一道優(yōu)美的景觀。左岸中大面積的景墻其實(shí)也屬于防浪墻的范疇，但由于景墻后部為居住區(qū)，因此作為防浪墻的景墻設(shè)置了2m多高，如何利用這2m多高的景墻，將其做的有特色，并能成為河對(duì)岸的視覺觀賞點(diǎn)是設(shè)計(jì)過(guò)程中的難點(diǎn)。因此，在這里也選用了可雕刻的異型混凝土，將滁河左岸“望山見水”景觀主題刻畫于此。

Physical examination

Body temperature 38.5 °C, heart rate 66 bpm, and blood pressure 210/110 mmHg. The patient reported blurred consciousness, binaural hearing loss, signs of meningeal irritation displayed by neck rigidity,positive Kernig’s and Lesage’s signs, normal muscular strength and limb muscle tension, and negative pathologic signs.

Laboratory examinations

大型工業(yè)立體倉(cāng)庫(kù)的貨位分配問(wèn)題主要考慮貨物數(shù)量、質(zhì)量、出/入庫(kù)頻率等因素。為兼顧立體倉(cāng)庫(kù)的存儲(chǔ)效率及其結(jié)構(gòu)穩(wěn)定性，主要采用的貨位分配原則有存儲(chǔ)效率優(yōu)先原則和結(jié)構(gòu)穩(wěn)定性原則。

After 5 d, cerebrospinal fluid was extracted by lumbar puncture and subjected to mNGS. The result revealed(with 1884 detected sequences), and the relative abundance was 93.27%. No pathogens were found by routine methods such as cerebrospinal fluid culture or blood culture.

We then performed lumbar puncture every week to extract cerebrospinal fluid and examined inflammatory indices, with cerebrospinal fluid culture and blood culture performed.

A1組(濃度為1. 25%的大豆卵磷脂稀釋液)低溫保存綿羊精液精子活率均高于其他濃度組(P<0. 05)；A1組低溫保存綿羊精液精子活率第9 d(0. 53±0. 06)、12 d(0. 46±0. 09)與C組第9 d(0. 55±0. 03)、12 d(0. 49±0. 07)差異不顯著(P﹥0. 05)，且頂體完整率相當(dāng)(P﹥0. 05)；A1組低溫保存第9 d的精液進(jìn)行人工授精,受胎率64. 3%與C組65. 6%差異不顯著(P>0. 05)。表明1. 25%濃度的大豆卵磷脂稀釋液能夠進(jìn)行綿羊精液低溫長(zhǎng)時(shí)間有效保存。

After 37 d, the patient’s condition worsened. We repeated mNGS of cerebrospinal fluid, and the results revealed(the number of detected sequences was 130) and(the number of detected sequences was 31598). The results of the seven cerebrospinal fluid examinations are shown in Table 1, and the etiological examination of the cerebrospinal fluid is shown in Table 2.

(1)CT平掃禁忌癥:近半年內(nèi)有生育計(jì)劃或處于妊娠期的女性。(2)CT增強(qiáng)掃描需應(yīng)用高壓注射器進(jìn)行靜脈團(tuán)注,即在短時(shí)間快速注射大量的造影劑,這會(huì)導(dǎo)致部分患者出現(xiàn)碘過(guò)敏或腎損害等不良反應(yīng),故為保證CT受檢者的安全,存在以下情況的受檢者需謹(jǐn)慎進(jìn)行CT檢查:伴有糖尿病腎病、腎功能不全;具有藥物、海鮮等過(guò)敏史;有癲癇、酒精中毒等急性神經(jīng)系統(tǒng)疾病病史;惡性腫瘤晚期;存在自身免疫性疾病或伴有哮喘、心衰、肺動(dòng)脈高壓等嚴(yán)重心肺疾病者。(3)禁止CT增強(qiáng)掃描檢查:妊娠期婦女或?qū)τ诤喜⒓卓骸⒅匕Y肌無(wú)力,對(duì)含碘對(duì)比劑過(guò)敏的患者。

FlNAL DlAGNOSlS

The initial diagnosis on admission was intracranial infection. Coinfection ofandinfection was the final diagnosis.

TREATMENT

The sufferer was hospitalized and finished routine examination, and he received lumbar puncture on the second day after admission. The routine culture, staining and bacterial examinations of cerebrospinal fluid were negative. According to the biochemical results of cerebrospinal fluid, we considered bacterial meningitis and empirically gave the patient ceftriaxone 2 g once a day. After 5 d of treatment, the patient’s condition did not improve significantly, and he still had dizziness, nausea and vomiting. Physical examination revealed a clear mind, poor spirit, positive meningeal stimulation sign,normal muscular strength and limb muscle tension, and negative pathologic signs on both sides. The outcomes showed that thesequence was detected; the number of sequences identified was 1884,and the relative abundance was 93.27%. The patient was diagnosed with suppurative meningoencephalitis caused byinfection. The treatment plan was adjusted as follows: ceftriaxone 2 g q12h plus penicillin sodium 4 million units q6h intravenous drip, combined with the hormone dexamethasone 10 mg qd andextract 70 mg bid to improve the patient’s hearing. The patient’s temperature gradually returned to normal, and the patient had no symptoms other than binaural hearing loss. After 37 d of treatment, the patient had a fever again, the body temperature reached 38.8 °C, and severe headache occurred. Laboratory examination showed that the WBC count registered 7.8 × 10/L(referential range: 4-10 × 10/L), and the neutrophil percentage registered 73.5% (referential range: 40%-75%). Subsequently, considering that the patient had drug resistance or that the patient's condition was repeated, we continued to apply the antibiotics ceftriaxone 2 g q12h and penicillin sodium 4 million units q6h. Nevertheless, his body temperature increased persistently, and our team discovered that he displayed neck stiffness again. Therefore, our team finished lumbar puncture. Cerebrospinal fluid test revealed a WBC content of 34 × 10WBC/μL, a protein content of 4470 mg/L, a GLU content of 2.48 mmol/L, and a chloride ion level of 124.40 mmol/L.was identified in the cerebrospinal fluidmNGS on day 2. At the time, our team thought thatmeningitis was rare, that the probability ofendocranial infection was low, and that the probability of contamination was high.Therefore, our team didn’t modify the therapeutic regimen. Subsequently, his body temperature still presented a fluctuation between 38 °C and 39 °C. Just when we were overwhelmed, we discussed with neurologists, infectious disease specialists and hematologists, considering that the patient's central nervous system was reinfected with, and developed a treatment plan: ceftriaxone, penicillin sodium, and compound sulfamethoxazole oxazole tablets combined with anti-infective therapy. His body temperature restored to normal on the 2day posterior to the modification of the therapeutic regimen. After 65 d, his clinical symptoms improved. The patient was discharged from the hospital.After returning home, he continued to take compound sulfamethoxazole tablets trimethoprimsulfamethoxazole (TMP-SMX), with TMP 80 mg and SMX 400 mg 2 tablets/time, 2 times/d for a total of 12 mo until the 1-year follow-up.

OUTCOME AND FOLLOW-UP

At the 1-year follow-up, the patient had left hearing loss in both ears and could work normally.

DlSCUSSlON

The current patient frequently consumed pork and was infected withafter eating contaminated pork. His drinking history and diabetes history are risk factors forinfection[7].infection can occur in patients taking immunosuppressant hormones and by, which destroys the bloodbrain barrier. Brain computed tomography scan of the brain of the patient led to the diagnosis ofinfection of the central nervous system. During infection, the pathogen enters the brain tissue through the lumbar puncture wound, resulting in brain abscess[8].

用SPSS 19.0和EXCEL 2010對(duì)數(shù)據(jù)進(jìn)行統(tǒng)計(jì)分析和繪圖，數(shù)據(jù)以平均值±標(biāo)準(zhǔn)差表示，p<0.05認(rèn)為有統(tǒng)計(jì)學(xué)差異。

There was no improvement in binaural hearing impairment at the 1-year follow-up. Animal studies have shown that hearing impairment is related to suppurative labyrinthitis caused by the invasion ofin the subarachnoid space to the external lymph through the cochlear aqueduct, which leads to the disturbance of inner ear microcirculation and the direct invasion of the cochlear nerve by[9].Hearing impairment affects the daily life of patients, and questions regarding how to predict, prevent and treat hearing impairment are urgent problems that remain to be solved.

The patient’s condition initially improved after the initial treatment forand then deteriorated.We speculated that the patient was not sensitive to the current treatment and that there might be drugresistant strains of. Therefore, we repeated mNGS and found that the counts ofdeoxyribonucleic acid (DNA) decreased (from 1884 to 130), which confirmed that our treatment was effective. We also identified 31598sequences by mNGS. Therefore, we concluded that the deterioration of the patient’s condition was caused by intracranial infection with, and the patient was diagnosed with coinfection ofand. After the treatment plan was adjusted to penicillin sodium combined with ceftriaxone and sulfamethoxazole, the patient’s systemic and nervous system symptoms improved within a few weeks. The number of leukocytes decreased gradually, and the proportion of multiple nuclei cells decreased significantly, as observed in the re-examination of cerebrospinal fluid. The patient’s condition improved, and the mNGS results obtained at the time were consistent with the clinical situation.

那么，琴曲是如何有意境，即如何“遠(yuǎn)”的呢？一言以蔽之，以氣貫通。而此氣是由生理之氣、琴曲之氣組成，并非單一而就的。

There were no pathogenic bacteria found in the multiple evaluations of blood culture, cerebrospinal fluid culture and smears, which may be related to the extensive use of cephalosporins in the early stage of treatment. mNGS quickly and accurately diagnoses pathogens without the influence of antibiotic treatment[10]. mNGS detects pathogenic pathogens, including rare pathogens, more appropriately than traditional detection methods. mNGS also determines all DNA/RNA genome information in a sample in a single run and allows for the identification and typing of all pathogens without specific primers,which can play an important role in the diagnosis and treatment of complex and mixed infectious diseases with repeated negative clinical routine examinations. Rapid detection and identification offer the opportunity for treatment at early stages of disease, which helps control the condition, shorten recovery time, improve the prognosis and shorten the hospital stay duration. Therefore, mNGS can provide reliable and effective evidence for the diagnosis and treatment of CNS infectious diseases, with certain clinical application value[7].

The man was healthy, with no specific diseases.

CONCLUSlON

In the case of intracranial infection with rare pathogens, if the disease continues during treatment,clinicians should also consider coinfection more than the possibility of drug resistance. mNGS of cerebrospinal fluid can accurately and quickly diagnose pathogen infection in the nervous system in rare cases of infections of multiple pathogens. Based on the number of reads and relative abundance,mNGS could be used for semiquantitative detection, which can evaluate the therapeutic effect to a certain extent in addition to its important diagnostic value.

ACKNOWLEDGEMENTS

The authors are very grateful to the patient for participating in this study.

FOOTNOTES

Chen YY reviewed the literature, analyzed the patient data and wrote the manuscript; Xue XH and Chen YY were responsible for data collection; All the authors read and approved the final manuscript.

mNGS is a multi-faceted technique which can determine pathogenic agents more quickly and accurately in contrast to conventional approaches and can even offer novel enlightenment regarding illness propagation, virulence, and antibiotic tolerance. In contrast to conventional identification approaches which can merely identify some target pathogenic agents, mNGS is a shotgun sequence identification approach of ribonucleic acids (RNAs) and DNAs from clinic specimens, in which the entire DNAs or RNAs of the specimen to be examined are blended and subjected to sequencing, and the data are afterwards contrasted with the pathogenic agent data base to acquire pathogen categorization data. Such approach can identify substantial pathogenic agents in a run in 48 h. The pathogenic agent profiles involve nearly every virus, bacterium, fungus, and parasite which is capable of infecting sufferers. The detailed description of the materials and approaches for mNGS were presented by supplemental material.

The patient developed dizziness, nausea, and vomiting 4 d prior. The vomit was non-brown-colored stomach contents, accompanied by confusion, headache, and hearing loss in both ears. One day prior,his dizziness aggravated, and he presented to the hospital.

The authors declare that they have no conflicts of interest.

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

China

Ying-Ying Chen 0000-0002-0668-4285; Xin-Hong Xue 0000-0003-0034-3831.

Chang KL

A

4.藥材規(guī)范化種植面積和認(rèn)證情況。種植面積甘肅最大，達(dá)100萬(wàn)畝，其他?。▍^(qū)）幾十萬(wàn)畝不等，GAP認(rèn)證基地陜西最多，為7個(gè)。

Chang KL