Hepatitis B virus in cerebrospinal fluid of a patient with purulent bacterial meningitis detected by multiplex-PCR:A case report

BACKGROUND Bacterial meningitis(BM)is a common central nervous system inflammatory disease.BM may cause serious complications,and early diagnosis is essential to improve the prognosis of affected patients.CASE SUMMARY A 37-year-old man was hospitalized with purulent meningitis because of worsening headache for 12 h,accompanied by vomiting,fever,and rhinorrhea.Head computed tomography showed a lesion in the left frontal lobe.Infectious disease screening showed positivity for hepatitis B surface antigen,hepatitis B e antigen,and hepatitis B core antigen.Cerebrospinal fluid(CSF)leak was suspected based on clinical history.Streptococcus pneumoniae(S.pneumoniae)was detected in CSF by metagenomic next-generation sequencing(mNGS)technology,confirming the diagnosis of purulent BM.After treatment,multiplex PCR indicated the presence of hepatitis B virus(HBV)DNA and absence of S.pneumoniae DNA in CSF samples.CONCLUSION We report a rare case of HBV in the CSF of a patient with purulent BM.Multiplex PCR is more sensitive than mNGS for detecting HBV DNA.

An Investigation and Suggestions for the Improvement of Brain Death Determination in China

Background: Brain death is the irreversible cessation of the function of the brain including the brainstem. In 2013, the Brain Injury Evaluation Quality Control Centre (BQCC) of the National Health and Family Planning Commission issued criteria and practical guidelines for the determination of brain death. This study aimed to evaluate whether the institutions have adopted these guidelines and to make suggestions for the improvement of the current criteria and practical guidelines for brain death determination in China. Methods: Consecutive brain death cases from 44 hospitals were evaluated for summary statistics for the following data: the performance of BQCC criteria and practical guidelines, clinical examination, apnea testing, ancillary testing, and the number of examinations as well as the waiting periods between examinations and details of who determined brain death. Data analysis was conducted from January 2013 to December 2017. Results: A total of 550 cases were obtained. All patients were determined to have deep coma and met the prerequisites for clinical testing. The performance rates of four brainstem reflex examinations (except cough reflex) ranged from 97.5% to 98.0%, and the completion rate as well as the coincidence rate were both 100.0%. The 238 cases (50.7%) completed apnea testing, and 231 cases (42.0%) had to stop apnea testing during the examination because of instability. The performance rates of the three ancillary tests, including electroencephalogram, short-latency somatosensory evoked potential, and transcranial Doppler, were 89.5%, 67.5%, and 79.5%, respectively;furthermore, the coincidence rates were 98.6%, 96.5%, and 99.5%, respectively. The combination of two ancillary tests was more accurate than one single ancillary test. A total of 401 (72.9%) cases successfully underwent two separate examinations to determine brain death with at least a 12-h waiting period. All brain death cases were determined by at least two qualified physicians. Conclusion: This study might provide suggestions for brain death determination in China.

Study of Simplified Coma Scales： Acute Stroke Patients with Tracheal Intubation

Background： Whether the Glasgow Coma Scale （GCS） can assess intubated patients is still a topic of controversy. We compared the test performance of the GCS motor component （GCS-M）/Simplified Motor Score （SMS） to the total of the GCS in predicting the outcomes of intubated acute severe cerebral vascular disease patients. Methods： A retrospective analysis of prospectively collected observational data was performed. Between January 2012 and October 2015, 106 consecutive acute severe cerebral vascular disease patients with intubation were included in the study. GCS, GCS-M, GCS eye-opening component, and SMS were documented on admission and at 24, 48, and 72 h after admission to Neurointensive Care Unit （NCU）. Outcomes were death and unfavorable prognosis （modified Rankin Scale： 5-6） at NCU discharge. The receiver operating characteristic （ROC） curve was obtained to determine the prognostic performance and best cutoff value for each scoring system. Comparison of the area under the ROC curves （AUCs） was performed using the Z-test.Results： Of 106 patients included in the study, 41 （38.7%） patients died, and 69 （65.1%） patients had poor prognosis when discharged from NCU. The four time points within 72 h of admission to the NCU were equivalent for each scale＇s predictive power, except that 0 h was the best for each scale in predicting outcomes of patients with right-hemisphere lesions. Nonsignificant difference was found between GCS-M AUCs and GCS AUCs in predicting death at 0 h （0.721 vs. 0.717, Z = 0.135, P = 0.893） and 72 h （0.730 vs. 0.765, Z = 1.887, P = 0.060）, in predicting poor prognosis at 0 h （0.827 vs. 0.819, Z = 0.395, P = 0.693）, 24 h （0.771 vs. 0.760, Z = 0.944, P = 0.345）, 48 h （0.732 vs. 0.741, Z= 0.593, P= 0.590）, and 72 h （0.775 vs. 0.780, Z= 0.302, P= 0.763）. AUCs in predicting death for patients with left-hemisphere lesions ranged from 0.700 to 0.804 for GCS-M and from 0.700 to 0.824 for GCS, in predicting poor prognosis ranged from 0.841 to 0.969 for GCS-M and from 0.875 to 0.969 for GCS, with no significant difference between GCS-M AUCs and GCS AUCs within 72 h （P 〉 0.05）. No significant difference between GCS-M AUCs and GCS AUCs was found in predicting death （0.964 vs. 0.964, P = 1.000） and poor prognosis （ 1.000 vs. 1.000, P = 1.000） for patients with right-hemisphere lesions at 0 h. AUCs in predicting death for patients with brainstem or cerebella were poor for GCS-M （〈0.700）, in predicting poor prognosis ranged from 0.727 to 0.801 for GCS-M and from 0.704 to 0.820 for GCS, with no significant difference between GCS-M AUCs and GCS AUCs within 72 h （P 〉 0.05）. The SMS AUCs （〈0.700） in predicting outcomes were poor. Conclusions： The GCS-M approaches the same test performance as the GCS in assessing the prognosis ofintubatcd acute severe cerebral vascular disease patients. The GCS-M could be accurately and reliably applied in patients with hemisphere lesions, but caution must be taken for patients with brainstem or cerebella lesions.