结核性脑膜炎患者脑脊液基质金属蛋白酶-9的检测意义

在脑膜炎的发展过程中,基质金属蛋白酶-9(MMP-9)对降解基底膜和损伤血脑屏障发挥重要作用,结核分枝杆菌能够刺激单核-巨噬细胞过度表达MMP-9.为检测结核性脑膜炎患者脑脊液MMP-9水平,评价其对结核性脑膜炎诊断及治疗的意义,应用ELISA方法检测12例结核性脑膜炎和9例病毒性脑膜炎患者脑脊液MMP-9水平,并选取5例非肿瘤非感染性头痛患者脑脊液作对照组.结果显示,结核性脑膜炎脑脊液MMP-9的水平显著增高,中枢神经系统并发症发生率与MMP-9的水平相关.结论为脑脊液MMP-9水平对结核性脑膜炎的诊断和预后有参考价值.     

Demonstration of Components of Antigen 85 Complex in Cerebrospinal Fluid of Tuberculous Meningitis Patients

Tuberculous meningitis (TBM) is the most common form of chronic infection of the central nervous system. Despite the magnitude of the problem, the general diagnostic outlook is discouraging. Specifically, there is no generally accepted early confirmative diagnosis protocol available for TBM. Various Mycobacterium tuberculosis antigens are now recognized as potential markers for diagnosis of TBM. However, their presence remains questionable, and many of these antigens are reported in the blood but not in the cerebrospinal fluid (CSF). This study identifies a specific protein marker in CSF which will be useful in early diagnosis of TBM. We have demonstrated the presence of a 30-kDa protein band in CSF of 100% (n = 5) of confirmed and 90% (n = 138) of suspected TBM patients out of 153 TBM patients. The 30-kDa band was excised from the gel, destained extensively, and digested with trypsin. The resulting peptides were analyzed by liquid chromatography-tandem mass spectrometry (LC-MS/MS). Partially purified proteins from CSF samples of TBM were analyzed by two-dimensional polyacrylamide gel electrophoresis and Western blotting. Immunoblotting and enzyme-linked immunosorbent assay (ELISA) were performed to confirm the presence of proteins in the 30-kDa protein band. The antigen 85 (Ag 85) complex was detected in CSF of TBM patients by indirect ELISA using antibodies against Ag 85 complex. The results of this study showed the 30-kDa protein band contained MTB proteins Rv3804c (Ag85A) and Rv1886c (Ag 85B), both members of the Ag85 complex. This was also confirmed by using immunotechniques such as indirect ELISA and the dot immunobinding assay. Detection of Ag85 complex was observed in CSF of 89% (71 out of 80) of suspected TBM patients that were 30-kDa protein positive. The observed 30-kDa protein in the CSF is comprised of the MTB Ag85 complex. This protein was earlier reported to be present in the blood of patients with extra-central nervous system tuberculosis. Therefore, this finding suggests that this protein can be used as a molecular marker for any type of tuberculous infection. It also provides a more sensitive immunoassay option for the early and confirmatory diagnosis of TBM.     

Serum and Cerebrospinal Fluid Neuron-Specific Enolase for Diagnosis of Tuberculous Meningitis

Purpose

Late diagnosis and treatment lead to high mortality and poor prognosis in tuberculous meningitis (TbM). A rapid and accurate diagnosis is necessary for a good prognosis. Neuron-specific enolase (NSE) has been investigated as a biochemical marker of nervous tissue damage. In the present study, the usefulness of NSE was evaluated, and a cut-off value for the differential diagnosis of TbM was proposed.

Materials and Methods

Patient charts were reviewed for levels of serum and cerebrospinal fluid (CSF) NSE, obtained from a diagnostic CSF study of samples in age- and gender-matched TbM (n=15), aseptic meningitis (n=28) and control (n=37) patients.

Results

CSF/serum NSE ratio was higher in the TbM group than those of the control and aseptic groups (p=0.001). In binary logistic regression, CSF white blood cell count and CSF/serum NSE ratio were significant factors for diagnosis of TbM. When the cut-off value of the CSF/serum NSE ratio was 1.21, the sensitivity was 86.7% and the specificity was 75.4%.

Conclusion

The CSF/serum NSE ratio could be a useful parameter for the early diagnosis of TbM. In addition, the authors of the present study suggest a cut-off value of 1.21 for CSF/serum NSE ratio.     

脑胶质瘤患者脑脊液白细胞介素6和血小板衍化生长因子水平的变化

检测了２７例脑胶质瘤病人手术前、后不同时期脑脊液（ＣＳＦ）中白细胞介素６（ＩＬ－６）和血小板衍化生长因子（ＰＤＧＦ）水平，发现脑胶质瘤病人ＣＳＦ中ＩＬ－６、ＰＤＧＦ水平升高，与对照组相比，差异非常显著。术后一周ＣＳＦ中ＩＬ－６水平较术前升高，ＰＤＧＦ水平较术前下降。术后３０天时，ＣＳＦ中ＩＬ－６、ＰＤＧＦ水平均明显低于术前水平，但并没有达到对照组水平。对１６例次全切除术病人进行随访，发现复发组病人ＣＳＦ中的ＩＬ－６、ＰＤＧＦ水平要明显高于未复发组病人和对照组，而且要比临床发现肿瘤复发的时间早３～６个月。因此，动态检测脑胶质瘤病人ＣＳＦ中ＩＬ－６、ＰＤＧＦ水平对判断手术疗效、估计预后、及早发现肿瘤复发均有重要的临床意义。     

YKL-40 Is Elevated in Cerebrospinal Fluid from Patients with Purulent Meningitis

YKL-40, a member of the family 18 glycosyl hydrolases, is secreted by activated neutrophils and macrophages. It is a growth factor for connective tissue cells and a potent migration factor for endothelial cells and may function in inflammation and tissue remodeling. YKL-40 was determined in 134 cerebrospinal fluid (CSF) samples taken on admission from patients suspected of having meningitis (48 with purulent meningitis, 49 with lymphocytic meningitis, 5 with encephalitis, and 32 without evidence of meningitis). YKL-40 levels in CSF were significantly higher in patients with purulent meningitis (median, 663 μg/liter [range, 20 to 8,960]) and encephalitis (5,430 μg/liter [620 to 11,600]) than in patients with lymphocytic meningitis (137 μg/liter [41 to 1,865]) or patients without meningitis (167 μg/liter [24 to 630]) (Kruskal-Wallis and Dunn multiple comparison tests, P < 0.001). CSF YKL-40 levels were also determined for 26 patients with purulent meningitis having a repuncture, and patients who died (n = 5) had significantly higher YKL-40 levels than patients who survived (n = 21) (2,100 μg/liter [1,160 to 7,050] versus 885 μg/liter [192 to 15,400], respectively; Mann-Whitney test, P = 0.018). YKL-40 was most likely locally produced, since patients with infections of the central nervous system had CSF YKL-40 levels that were at least 10-fold higher than the corresponding levels in serum (2,033 μg/liter [470 to 11,600] versus 80 μg/liter [19 to 195]). The CSF neopterin level was the biochemical parameter in CSF and blood that correlated best with CSF YKL-40 levels, indicating that YKL-40 may be produced by activated macrophages within the central nervous system. In conclusion, high levels of YKL-40 in CSF are found in patients with purulent meningitis.     

神经外科手术后颅内感染早期脑脊液中IL-6、IL-8和TNF-α水平变化的意义

目的通过研究神经外科手术后颅内感染患者脑脊液中的IL-6、IL-8和TNF-α的水平变化,探讨其在术后颅内感染中的诊断价值。方法选取我院神经外科手术后颅内感染患者46例,非颅内感染患者34例,所有病例均于手术后1～7天内和7～14天取脑脊液进行IL-6、IL-8和TNF-α的检测,并进行统计分析。结果神经外科手术后颅内感染组患者1～7天内的脑脊液中IL-6、IL-8和TNF-α的含量显著高于非感染组患者,差异有统计学意义(P<0.05);颅内感染患者7～14天的脑脊液中IL-6、IL-8和TNF-a的含量虽高于非感染组患者,但差异没有统计学意义(P>0.05)。结论结合临床症状和有效的检查脑脊液中IL-6、IL-8和TNF-α水平,可明显提高神经外科术后颅内感染早期的诊断价值和准确性,值得临床推广。     

Levels of Gamma Interferon and Interleukin-4 Are Inversely Related to the Levels of Their Corresponding Autoantibodies in Patients with Lower Respiratory Tract Infection

To study the involvement of cytokines and their corresponding autoantibodies (Aabs) in inflammatory mechanisms in patients with lower respiratory tract infections, blood samples were taken from patients at the time of admission to the hospital and before treatment. Cell-released capturing enzyme-linked immunosorbent assay was used to measure the levels of gamma interferon (IFN-gamma) and interleukin-4 (IL-4) produced spontaneously by peripheral mononuclear cells (PMNC). ELISA was used to measure Aabs to these cytokines in sera. The levels of both cytokines were inversely related to the levels of their corresponding Aabs. While a high level of IFN-gamma was observed together with a low level of anti-IFN-gamma Aab, decreased IL-4 levels were observed with increased levels of Aabs to IL-4. Immunoglobulins were purified, digested to obtain Fab fragments, and tested for specificity and cross-reactivity. The Aabs and their Fab fragments were tested in cytokine biological assays and showed neutralizing effects. Our data demonstrated increased levels of the proinflammatory cytokine IFN-gamma and decreased release of the anti-inflammatory cytokine IL-4 during early presentation of lower respiratory tract infection. The levels of these cytokines were inversely related to the levels of their corresponding Aabs that exhibited regulatory effects on the cytokine biological function in vitro.     

颅内肿瘤与功能性头痛病人脑脊液神经降压素含量的比较

本实验采用放射免疫分析法测定了１０例伴头痛颅内肿瘤病人，１１例功能性头痛病人及８例正常人脑脊液内神经降压素含量。结果表明：（１）常见伴头痛的颅内肿瘤病人脑脊液神经降压素含量与正常人相比无明显改变。（２）功能性头痛病人头发病作时，脑脊液内神经降压素含量较正常人显著降低（Ｐ＜０．００１）。（３）颅内肿瘤与功能性头痛二组间脑脊液中神经降压素含量相比较呈非常显著差别（Ｐ＜０．００１），后者比前者明显降低。     

Limits of Detection of Mycobacterium tuberculosis in Spiked Cerebrospinal Fluid Using the Polymerase Chain Reaction in Tuberculous Meningitis

 The limit of detection of Mycobacterium tuberculosis in spiked cerebrospinal fluid (CSF) using polymerase chain reaction (PCR) was compared to that of a radiometric liquid culture. Serial dilutions of clinical isolates of Mycobacterium tuberculosis were prepared in CSF (n=3) or broth (n=11) with estimated concentrations of 0–550 cfu/ml. Each dilution was examined concurrently by PCR and radiometric culture. PCR and radiometric culture detected Mycobacterium tuberculosis DNA in all dilutions with an estimated 2 cfu/ml in the CSF. At lower concentrations (estimated <2 cfu/ml), PCR and radiometric culture were positive in three of five (60%) and five of five (100%) CSF samples, respectively. In comparison to PCR in broth dilutions, no evidence of inhibition or interference was noted. These results imply that PCR can provide a rapid and reliable diagnosis of tuberculous meningitis, although there is a potential for false-negative results to occur in samples containing very few organisms (<2 cfu/ml).     

Multicenter Evaluation of the Amplicor Enterovirus PCR Test with Cerebrospinal Fluid from Patients with Aseptic Meningitis

The Amplicor Enterovirus PCR test was compared with viral culture for the detection of enteroviruses in cerebrospinal fluid (CSF) specimens. In a multicenter study in which nine laboratories participated, a total of 476 CSF specimens were collected from patients with suspected aseptic meningitis. Sixty-eight samples were positive by PCR (14.4%), whereas 49 samples were positive by culture (10.4%), demonstrating that the Amplicor Enterovirus PCR test was significantly more sensitive than culture (P < 0.001). After discrepancy analysis the sensitivity and specificity of the Amplicor Enterovirus PCR test obtained by using viral culture as the “gold standard” were 85.7 and 93.9%, respectively. Our results with the CSF specimens collected in different countries demonstrate that the Amplicor test is capable of detecting a large variety of enterovirus serotypes and epidemiologically unrelated isolates in CSF specimens from patients with aseptic meningitis. The Amplicor Enterovirus PCR test is a rapid assay which can be routinely performed with CSF samples and is an important improvement for the rapid diagnosis of enteroviral meningitis.     

Interferon Alpha Treatment of Patients with Impaired Interferon Gamma Signaling

Patients with deficiency in the interferon gamma receptor (IFN-γR) are unable to respond properly to IFN-γ and develop severe infections with nontuberculous mycobacteria (NTM). IFN-γ and IFN-α are known to signal through STAT1 and activate many downstream effector genes in common. Therefore, we added IFN-α for treatment of patients with disseminated mycobacterial disease in an effort to complement their IFN-γ signaling defect. We treated four patients with IFN-γR deficiency with adjunctive IFN-α therapy in addition to best available antimicrobial therapy, with or without IFN-γ, depending on the defect. During IFN-α treatment, ex vivo induction of IFN target genes was detected. In addition, IFN-α driven gene expression in patients’ cells and mycobacteria induced cytokine response were observed in vitro. Clinical responses varied in these patients. IFN-α therapy was associated with either improvement or stabilization of disease. In no case was disease exacerbated. In patients with profoundly impaired IFN-γ signaling who have refractory infections, IFN-α may have adjunctive anti-mycobacterial effects.     

Increased Levels of Cytokines in Cerebrospinal Fluid of Children with Aseptic Meningitis Caused by Mumps Virus and Echovirus 30

We measured levels of pro‐inflammatory cytokines in the cerebrospinal fluid (CSF) of patients with mumps meningitis, enteroviral echovirus 30 meningitis and children without central nervous system infection to investigate whether these molecules were involved in the pathogenesis of viral meningitis. The CSF was obtained from 62 children suspected with meningitis. These patients were classified to the mumps meningitis (n = 19), echovirus 30 meningitis (n = 22) and non‐meningitis (n = 21) groups. The concentrations of interleukin‐1 (IL‐1), interleukin‐1 soluble receptor type 2 (IL‐1R2), interleukin‐8 (IL‐8), human interferon gamma (IFN‐γ) and human tumour necrosis factor alpha (TNF‐α) were determined by immunoassay. A significant increase was noted in the levels of IL‐8, TNF‐α and IL‐1R2 in the CSF of both meningitis groups as compared to controls. The concentrations of IFN‐γ and IL‐1 differed significantly only between the mumps group and control. The levels of IL‐1, IFN‐γ and TNF‐α were significantly higher in mumps meningitis when compared to the echovirus 30 group. Of all cytokines examined, only IFN‐γ correlated with pleocytosis (r = 0.58) in the mumps meningitis group. The increased CSF cytokine levels are markers of meningeal inflammation, and each virus may cause a specific profile of the cytokine pattern.     

Elevation of Cerebrospinal Fluid Interleukin-6 Activity in Patients with Vasculitides and Central Nervous System Involvement

The pathogenesis of central nervous system (CNS) involvement in vasculitides remains unclear. We evaluated cerebrospinal fluid (CSF) interleukin-6 (IL-6) activity in relation to the CNS disease activity in vasculitides. Three patients with vasculitides of different categories who showed CNS manifestations were studied, including polyarteritis nodosa, temporal arteritis, and Behcet's disease. All three patients showed marked elevation of CSF IL-6 activity in parallel with the CNS disease activity. In one of the three patients, cerebral vasculitis was demonstrated histologically. All these patients also showed elevation of serum IL-6 activity in parallel with systemic symptoms, such as fever and/or elevation of C-reactive protein and erythrocyte sedimentation rate. These results strongly suggest that elevation of CSF IL-6 activity may underly the common pathogenetic mechanism of CNS involvement of vasculitides irrespective of their category. Taken together with the histopathological findings in one patient, the data also suggest that inflammation might not be restricted within the CNS blood vessels, but rather be extended to brain parenchyma to promote IL-6 production presumably by glial cells.     

颅内压及腰区脑脊液压的脉动值与平均值关系

颅内压由于心博、呼吸、以及神经调节等的影响而出现波动。传统的颅内压(Intracranialpressure,ICP)研究多停留在静态压及相关因素的分析,注重于对颅内压平均值的监护,对其脉动成分的变化及规律研究很少。本研究工作由两部分组成动物实验和理论分析。在动物实验中,以狗为实验对象,研究在不同颅内压水平下颅内压波形的变化及其规律。通过14条狗安置硬膜外球囊并注液制成颅高压模型,通过改变球囊内液体量改变颅压和颅内容积,由压力传感器持续记录脑室内压和腰区脑脊液压(Lumbarcerebrospinalfluidpressure,LCP)。结果发现随着颅内压平均值的持续增高,颅内压脉动值也相应增高,两者间呈线性关系。当排空球囊内液体后再次注入液体时,颅内压脉动值和平均值线性关系的斜率比第一次大。腰区脑脊液压的情况与颅内压一致。由此可见,颅内压及腰区脑脊液压脉动值和平均值两者间呈线性关系,且其斜率反映了颅内自调节功能的程度高低。     

Diagnosis of Meningococcal Meningitis by Broad-Range Bacterial PCR with Cerebrospinal Fluid

We used broad-range bacterial PCR combined with DNA sequencing to examine prospectively cerebrospinal fluid (CSF) samples from patients with suspected meningitis. Fifty-six CSF samples from 46 patients were studied during the year 1995. Genes coding for bacterial 16S and/or 23S rRNA genes could be amplified from the CSF samples from five patients with a clinical picture consistent with acute bacterial meningitis. For these patients, the sequenced PCR product shared 98.3 to 100% homology with the Neisseria meningitidis sequence. For one patient, the diagnosis was initially made by PCR alone. Of the remaining 51 CSF samples, for 50 (98.0%) samples the negative PCR findings were in accordance with the negative findings by bacterial culture and Gram staining, as well as with the eventual clinical diagnosis for the patient. However, the PCR test failed to detect the bacterial rRNA gene in one CSF sample, the culture of which yielded Listeria monocytogenes. These results invite new research efforts to be focused on the application of PCR with broad-range bacterial primers to improve the etiologic diagnosis of bacterial meningitis. In a clinical setting, Gram staining and bacterial culture still remain the cornerstones of diagnosis.     

牙周炎患者龈沟液中白细胞介素-8水平的变化

研究牙周炎患者龈沟液（GCF）中白细胞介素-8（IL-8）的变化及其临床意义。采用RIA检测了成人牙周炎患者（AP组）52例67个牙,快速进展性牙周炎患者（RPP组）23例37个牙和牙周健康对照组（H组）31名49个牙的龈沟液（GCF）中的IL-8水平的变化并记录受检牙的牙周破坏指数PD、AL。结果表明AP组、RPP组患者GCF中IL-8水平明显高于对照组（P〈0.01）且与PD、AL呈显著正相关（P〈0.01）。提示IL-8是参与牙周炎发生发展及其牙周破坏重要的细胞因子之一。     

Microscopic Examination and Broth Culture of Cerebrospinal Fluid in Diagnosis of Meningitis

We reviewed the results of microscopic Gram stain examination and routine culture for 2,635 cerebrospinal fluid (CSF) samples processed in an adult hospital microbiology laboratory during 55 months. There were 56 instances of bacterial or fungal meningitis (16 associated with central nervous system [CNS] shunt infection), four infections adjacent to the subarachnoid space, four cases of sepsis without meningitis, and an additional 220 CSF specimens with positive cultures in which the organism isolated was judged to be a contaminant. Because 121 of these contaminants were isolated in broth only, elimination of the broth culture would decrease unnecessary work. However, 25% of the meningitis associated with CNS shunts would have been missed by this practice. The most common cause of meningitis was Cryptococcus neoformans, followed by Streptococcus pneumoniae and Neisseria meningitidis. In 48 of 56 (88%) of cases, examination of the Gram-stained specimen revealed the causative organism. If patients who had received effective antimicrobial therapy prior to lumbar puncture are excluded, the CSF Gram stain is 92% sensitive. Microscopic examination incorrectly suggested the presence of organisms in only 3 of 2,635 (0.1%) CSF examinations. Thus, microscopic examination of Gram-stained, concentrated CSF is highly sensitive and specific in early diagnosis of bacterial or fungal meningitis.     

Accuracy of Lipoarabinomannan and Xpert MTB/RIF Testing in Cerebrospinal Fluid To Diagnose Tuberculous Meningitis in an Autopsy Cohort of HIV-Infected Adults

Point-of-care tests for tuberculous meningitis (TBM) are needed. We studied the diagnostic accuracy of the lipoarabinomannan (LAM) lateral flow assay (LFA), LAM enzyme-linked immunosorbent assay (ELISA), and Xpert MTB/RIF in cerebrospinal fluid (CSF) in an autopsy cohort of Ugandan HIV-infected adults. We obtained written informed consent postmortem from the next of kin. A complete autopsy was done and CSF obtained. We performed LAM LFA (on unprepared and supernatant CSF after heating and spinning), LAM ELISA, and Xpert MTB/RIF on the CSF samples. Accuracy parameters were calculated for histopathological TBM and also for the composite standard, including Xpert MTB/RIF-positive cases. We tested CSF of 91 patients. LAM LFA had a sensitivity of 75% for definite histopathological TBM, ELISA a sensitivity of 43%, and Xpert MTB/RIF a sensitivity of 100% and specificities of 87%, 91%, and 87%, respectively. LAM LFA had a sensitivity of 50% for definite and probable histopathological TBM, ELISA a sensitivity of 38%, and Xpert MTB/RIF a sensitivity of 86% and specificities of 70%, 91%, and 87%, respectively. LAM LFA had a sensitivity of 68% for the composite standard and ELISA a sensitivity of 48% and specificities of 78% and 98%, respectively. The rapid diagnostic tests detected TBM in 22% to 78% of patients not on anti-TB treatment. Point-of-care tests have high accuracy in diagnosis of TBM in deceased HIV-infected adults. LAM LFA in CSF is a useful additional diagnostic tool.