Why is the recurrent high fever? Dial the clouds to see the moon and the moon is brighter!

preface

Ureaplasma urealytica is the smallest prokaryotic organism between bacteria and viruses, mainly colonized on the surface of urethral and genital mucosal epithelial cells, and sexual contact is the main transmission route

This article reports a case of middle-aged and elderly men undergoing bone flap decompression and two hematoma removal due to head trauma, and was transferred to our hospital

Case passed

Patient, male, 57 years old

Past history: The patient has a previous history of syphilis infection, has been treated in an informal procedure in a local community hospital, and has no follow-up follow-up

The patient had high postoperative fever and poor antibiotic efficacy after many adjustments (Table 1), and was transferred to our hospital

Table 1 Summary of medication during treatment in the outer hospital

Admission diagnosis: (1) closed head injury (severe); (2) After left subdural and epidural hematoma clearance + cerebral hematoma clearance + decompression of bone flaps; (3) Intracranial infection (pathogenic bacteria to be investigated); (4) Lung infection; (5) Leukocyte decline (drug-based?) ）； (6) Syphilis

Laboratory tests: (1) Blood routine examination: WBC0.

Imaging examination: cranial CT scan and enhancement: after intracranial surgery, the left frontal parietal bone is absent, intracranial gas accumulation, the corresponding meningeal parenchyma is bulging outward, the left frontotemporal parietal lobe is seen with a large low-density shadow, a little slightly high-density shadow is seen inside, the left ventricle is slightly compressed, the midline structure is basically centered, which is a postoperative change of intracranial surgery; CT scan of the chest: double pneumonia with exudation, bilateral pleural effusion;

After the patient was admitted to the hospital, the infection-related examination was improved, especially the content related to intracranial infection, and the cerebrospinal fluid bacterial culture was continuously sent for examination

On November 5, the patient suddenly developed high fever, the body temperature reached up to 40 ° C, and the antibiotics were adjusted to meropenem + amikacin + fluconazole

On November 8, the body temperature improved from the previous one, and the blood routine was: WBC10.

On November 17, considering that the patient still had recurrent high fever, no pathogen was cultured in ordinary culture of cerebrospinal fluid, intracranial infection was still unclear, antibiotics combined with medium- and long-term external drainage coordinated therapy, and "OMMAYA implantation" was performed after preoperative preparation, and cerebrospinal fluid

Since the patient has clinical manifestations of intracranial infection, but no pathogen is found in culture, CSF PCR+NGS testing

On November 24, according to the NGS results of clinical returns, the bacteriological department of our hospital immediately used urea-arginine broth to culture cerebrospinal fluid, cultured positive ureaplasma urealytica, and gave the corresponding drug susceptibility results, adjusted the antibiotics to amikacin + moxifloxacin + meropenem anti-infection therapy, the patient's intracranial infection gradually improved, the number of cerebrospinal fluid cells improved, the body temperature and infection indicators improved, and the number of NGS sequences followed up was stable

November 27, the patient's vital signs were stable, CSF-WBC4×106/L, CSF-IL662.

On December 4, due to the sputum culture of carbapenem-resistant Pseudomonas aeruginosa and Acinetobacterium baumangis, it was treated with meropenem anti-infection treatment through consultation of the infectious disease department, and esmolol and metoprolol were given to control the heart rate

On 9 December, he checked the positive rapid plasma reagin test (RPR) for syphilis cerebrospinal fluid syphilis and positive for treponemal-specific antibodies to exclude syphilis

On 12 December, the patient continued to have recurrent fever, so moxifloxacin was changed to levofloxacin anti-infective therapy
.

On December 15, the patient was removed from Ommaya and drained, and the follow-up CT found that the patient's ventricles were enlarged, accompanied by intercerebral attack and deboned flap skin swelling
.

On 20 December, the antibiotic regimen was adjusted to doxycycline + ceftadine + levofloxacin
.

On December 27, the urine routine white blood cell count > 900/ul, urine culture Candida, plus fluconazole anti-infection therapy, follow-up urine routine and urine fungal culture
.

On December 29, ventricles and lumbar puncture of cerebrospinal fluid
.

On 31 December, a ventriculoperitoneal shunt was performed with a pressure of 2.
0
.
After follow-up cranial CT ventricular structure can be transferred to the rehabilitation hospital for continued treatment
.

On January 5 (2022), the patient was transferred to the rehabilitation hospital to continue treatment, followed by levofloxacin + doxycycline anti-infection therapy, the patient's body temperature and infection indicators were further stabilized, and on January 28, the number of NGS sequences of the follow-up shunt cerebrospinal fluid was significantly reduced compared with before, and the patient's GCS score was 4-5-T
.

On January 28, ventriculoperitoneal shunt cerebrospinal fluid - rehabilitation hospital follow-up

Case studies

Clinical case analysis

The patient was treated with two craniotomy surgeries in the emergency department of the local hospital after trauma, although the condition was basically stable after ICU treatment and transferred to the general ward, but the body temperature, blood examination and cerebrospinal fluid examination all showed the possibility of intracranial infection, and all the local bacterial cultures were not cultured to the pathogenic bacteria, and the local competent physician said that the local hospital culture positive rate was very low, so the culture results were not consistent with the clinical manifestations
.

Immediately after the patient is transferred to our department, the infection related screening is carried out, and the cerebrospinal fluid specimen is retained through the lumbar pool, and the cerebrospinal fluid is sent for routine cerebrospinal fluid, biochemistry, culture (injected into the blood culture flask), PCR, and the blood, sputum, urine and routine biochemical indicators
are improved.
After screening, the patient's admission blood routine WBC reported critical value, considering the infection and previous drug factors, further improvement of the relevant examination, and the treatment of Ruibai and other symptomatic treatments, the patient's WBC quickly rose to normal in a short period of time, and can be maintained for a period of time
.

The patient has repeated high fever during treatment, which clinically excludes blood, urine and lung infection, and routine culture of cerebrospinal fluid + PCR cannot find the pathogen, so the cerebrospinal fluid is sent to NGS for testing, and the results are reported as ureaplasma ureaplasma
.
After the pathogen was identified as ureaplasma), the number of NGS sequences was significantly reduced and the condition gradually improved
after repeatedly adjusting the anti-infection regimen according to the susceptibility results.

Although the final therapeutic effect of this case is possible, there is a delay in definitive diagnosis, mainly due to the patient's specific pathogen
.
In the future, if the patient has a high clinical suspicion of intracranial infection, PCR or NGS can be carried out in advance to assist in diagnosis, and the pathogen diagnosis method and clinical treatment plan can be adjusted according to this result, and early diagnosis and treatment
can be sought.

Test case analysis

This case is a rare case of central nervous system infection caused by Ureaplasma urealytica, the patient has a previous history of syphilis + two times of craniotomy + a history of lumbar large pool drainage, postoperative immunity is low, therefore, the common pathogen colonized in the urinary tract - Ureaplasma urealytica is most likely caused by hand hygiene caused by intracranial infection
。 However, after admission, despite the uninterrupted alternate day to test the cerebrospinal fluid ordinary culture, still did not develop any pathogen, after November 24 NGS report of positive ureaplasma urea), immediately borrowed urea-arginine broth special medium from the outer hospital for culture, the culture result was positive and provided the corresponding drug susceptibility results, clinicians combined with the patient's medical history, clinical symptoms, laboratory and imaging results to determine the central nervous system infection of ureaplasma.
The infection of the patient is controlled
after the antibiotics are gradually adjusted according to the susceptibility results.

As an inspector, from the case, we have deeply realized that we must take the initiative to help clinicians find the real pathogen, to break the existing culture conditions, you can use different methods, and even continue to carry out new projects, such as PCR, second-generation sequencing, etc.
, these more rapid and accurate methods, for patients to identify pathogens as soon as possible, early recovery to provide corresponding help
.

Knowledge development

Ureaplasma urea is a common reproductive tract parasite in
humans.
It can use its own urease to break down urea to provide energy
.
In addition to causing genital tract infections and infertility, it is also associated with adverse pregnancy and neonatal diseases (chronic lung disease and retinopathy of prematurity), in which pregnant women produce cytokines in the amniotic fluid after infection, which triggers preterm birth, and occasionally in
kidney stones and purulent arthritis.

Laboratory test methods: morphological examination, mycoplasma culture, antigen detection, serological methods and molecular biology methods, and suitable culture methods and polymerase chain reaction (PCR) are currently the main methods
of diagnosis.
Looking at the relevant literature, the top three antibiotics associated with ureaplasma resistance are ofloxacin, sparfloxacin, and levofloxacin
.
Doxycycline, crosamycin, and minocycline are preferred because they have the lowest
drug resistance.
Ureaplasma has no cell wall and is therefore insensitive
to antimicrobial drugs (eg, penicillin, cephalosporins) that inhibit cell wall synthesis.
The problem of antibiotic resistance of Ureaplasma urea has attracted everyone's attention, and some experts have called for the treatment of the pathogen to use 2 to 3 different types of antibiotic combination therapy to prevent or reduce the emergence
of resistant strains.

Case summary

Central nervous system infection is a common complication of neurosurgery postoperative complications, clinical can be sent to the cerebrospinal fluid routine, biochemical, culture, PCR and NGS and so on to be clear, due to the different degrees of difficulty of culture of special pathogenic bacteria, clinical in the high suspicion of special pathogenic bacteria need to fully communicate with the microbial laboratory, choose the appropriate way (conventional culture, PCR and NGS) for the identification of pathogenic microorganisms, in order to improve the detection rate
of pathogenic bacteria.

In this case, the central nervous system urease ureaplasma is a rare central nervous system infection, and the commonly used central nervous system infection antibiotics are not effective
due to the relationship of special pathogenic bacteria.
When the pathogen is identified and the antibiotic infection control is gradually adjusted according to the susceptibility results, the ventriculoperitoneal shunt is successfully carried out, and the clinical results
are relatively satisfactory.

Expert reviews

In this case, the patient had repeated high fever during treatment, which clinically ruled out the possibility of blood, urine and lung infection, and routine culture of cerebrospinal fluid + PCR could not find the pathogenic bacteria, so the cerebrospinal fluid was sent to NGS for testing, and the results were reported as plasma
urealytica.
After the pathogen was identified as ureaplasma), the number of NGS sequences was significantly reduced and the condition gradually improved
after repeatedly adjusting the anti-infection regimen according to the susceptibility results.

Central nervous system infection caused by Plasma urea urea is a relatively rare central nervous system infection, due to the relationship between special pathogenic bacteria, clinical manifestations are non-specific, clinical diagnosis is difficult, microbial testing and clinical is very easy to miss diagnosis and misdiagnosis
.
The treatment of ureaplasma urea infection is different from common bacterial infections, which is easy to cause poor
anti-infection efficacy.
In this case, the pathogen was finally discovered through mNGS, and then targeted culture was used to obtain the pathogenic diagnosis basis and drug susceptibility results
.
Case description The diagnosis and treatment and microbial testing process are complete, clear and the diagnosis is clear
.
Therefore, the report of this case has high value
for microbial testing and clinical diagnosis and treatment.

Thanks

In the process of revising this article, Professor Jiang Xiaofei of the Department of Clinical Laboratory, Huashan Hospital Affiliated to Fudan University has been carefully guided and commented, and I hereby thank you!

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