Method for evaluating the degree of meningococcal and viral meningitis in children

FIELD: medicine, juvenile infectious diseases.

SUBSTANCE: in a patient's peripheral blood on the 1^st-6^th and 10^th-15^th d of the disease one should detect the concentration of interleukin-10. In case of severe flow of meningitis the concentration of IL-10 on the 1^st-6^th d corresponds to about 4.24-4.58 pkg/ml by increasing up to about 4.94-5.56 pkg/ml on the 10^th-15^th d. In case of light and average flow of meningococcal meningitis the concentration of IL-10 on the 1^st-6^th d corresponds to about 7.21-7.75 pkg/ml by decreasing up to about 3.76-4.5 pkg/ml on the 10^th-15^th d. In case of light and average flow of viral meningitis the concentration of IL-10 on the 1^st-6^th d corresponds to about 3.61-3.89 pkg/ml, and on the 10^th-15^th d - about 4.25-4.81 pkg/ml, not higher. Application of the present method enables to increase the accuracy of evaluation.

EFFECT: higher efficiency of therapy.

6 ex, 3 tbl

The invention relates to medicine, in particular to children infectious diseases, and can be used in the treatment of meningococcal and viral meningitis in children.

In the structure of General pathology of the nervous system, the share of infectious diseases is about 40%. Every year an increasing number of reported viral meningitis and encephalitis, 75% of affected children (Wavin et al., 2001). The emergence of new pathogens of meningitis dictates the need for their early etiological decryption identify the flow characteristics and predict disease outcome.

The urgency of the problem is determined by the occurrence of severe and complicated disease, high mortality rates in some entities, the increase of resistance of the main pathogens of bacterial meningitis the most common antibiotics, the lack of effective antiviral drugs. Despite actively used antibacterial therapy, as well as attempts to use antiviral drugs, there is often an unfavorable course of meningitis. If further medical observation for 2 years or more healthy can be considered no more than 38-40% of children (Skripchenko NV and others, 2000). Remote adverse effects associated with the development of cerebros ticheskogo, hypertension-hydrocephalic syndrome, neurotic conditions, hypothalamic dysfunction, focal " soft " signs, epilepsy and other manifestations.

The lack of clear criteria for assessing the severity especially viral meningitis, where the level of the liquor is often changed, leads to inadequate treatment or early termination of treatment. Children are issued in the early period of convalescence modified, according to our data, immunological parameters.

The most common way of assessing the severity of meningitis is the study of the liquor with the definition of lymphocytosis, pleocytosis, protein concentration, glucose and chloride ("Acute neuroinfections in children" edited by Zinchenko A.P. - Moscow, 1986, p.45).

From the practice of medicine known way to assess severity of meningitis (job A.S. "Ultrasonography in neuropediatrics". - M.: Medicine, 1997 s), based on the sonographic changes of indicators in the cerebrospinal fluid hypertension.

There is a method of estimating the viscosity of the liquor (the METHOD for the DIAGNOSIS of PATHOLOGICAL CHANGES in the BRAIN AND SPINAL cord./ Alexandrov Y.A., Larionov, S., Gray, NV, Onysko OV - Patent RF №94027310), which characterizes the increase of the protein level in severe inflammatory diseases.

The known method fractionarea the Oia centrifugate liquor (METHOD of PREDICTING the COURSE AND OUTCOME of BACTERIAL PURULENT MENINGITIS IN CHILDREN./ Alekseeva L.A., Sorokin M.N., Karasev V.V. - RF Patent №2141668) determination of concentrations of high and low molecular weight components having diagnostic value in infectious lesions.

Known methods of assessing the degree of severity and viral meningococcal meningitis have the following disadvantages:

- Need repeated lumbar puncture, which is undesirable in children of early age and requires General anesthesia.

- Indicators of lymphocytosis, pleocytosis and glucose CSF are minor due to the low predictive value, especially with viral meningitis.

- Assessment of the glucose concentration of the liquor requires simultaneous determination of the blood - diabetes, hypoglycemia, and other metabolic changes, and febrile patients adequate interpretation of the results is almost impossible.

- Getting blood from the soft tissues during the lumbar puncture dramatically distorts the results.

- Normal concentrations of protein in the cerebrospinal fluid is created by the weight fraction that falls from the blood plasma, and vary widely, thereby reducing the specificity of the results in pathological conditions.

- Not less than 75% of children with meningitis have a change of pressure of the liquor to the period of "clinical recovery", complicating interpretation is not roseogrisea indicators.

- Evaluation of disorders of CSF dynamics is difficult when your child is compensated hydrocephalus.

Closest to the proposed method is a method of determining the concentration of proinflammatory cytokine interleukin - 6 (IL-6) in the peripheral blood as a criterion of severe viral meningitis (pahunov's Russian I.I., ruby L.K. "cytokines and acute phase proteins as prognostic criteria of the flow of meningitis and meningoencephalitis"//proceedings of the 6th Russian Congress of infectiologists. - SPb., 2003, s.293).

However, the latter method also has several disadvantages that affect the results of the evaluation of the severity of the disease:

- IL-6 is constantly present in the blood in healthy children and its level varies widely.

The level of IL-6 in the blood increases more with viral meningitis and may not be an indicator of severity of meningococcal meningitis;

- IL-6 has pleiotropism (performs both proinflammatory and anti-inflammatory functions, triggers of acute-phase response) and is a nonspecific indicator, which complicates the explanation of the results;

- IL-6 is a cytokine of the "first generation"exists only in the first hours of the disease, quickly falling within 4-6 hours prior to the original level due to the suppression by interleukine-10 (IL-10).

These deficiencies in itivity and are eliminated in the present invention.

The aim of the invention is a more accurate assessment of the severity of meningococcal and viral meningitis in children.

The goal of the invention is achieved by the fact that determine the concentration of interleukin-10 in peripheral blood of the patient on 1-6 and 10-15 day of the disease: in severe meningitis concentration of interleukin-10 1-6 day is 4,24-4,58 PCG/ml, increasing to 10-15 days before 4,94-5,56 PCG/ml; with mild and moderate for meningococcal meningitis concentration of interleukin-10 1-6 day is 7,21-7,75 PCG/ml, reduced by 10-15 days to 3.76-4,5 PCG/ml; with mild and moderate for viral meningitis concentration of interleukin-10 on 1-6 day is 3,61-3,89 PCG/ml and 10-15 day - not more than 4,25-4,81 PCG/ml

IL-10 is anti-inflammatory mediator acts as a universal inhibitor of the synthesis of all cytokines. Suppresses the effector functions of macrophages, T-cells, NK-cells. IL-10 regulates the proliferation of b-cells and thymocytes. Inhibits the synthesis of interferon, cellular immune response, acute-phase response. IL-10 is a low molecular weight protein with a molecular mass of 18 kDa. Produces T-cells, macrophages, keratinocytes and In human lymphocytes. Increased concentration of this cytokine registered in newborns with sepsis, patients with acute peritonitis, infectious-toxic the sky shock (Assemblies et al., 2003). Typically, viruses activate macrophages to the production of cytokines by lymphocytes TX-1, whereas the antigens of the bacteria to the production of cytokines by lymphocytes TX-2. In this regard, a range of cytokines in patients with viral and bacterial infection will be different.

This can explain the different concentrations of IL-10 in the first days of the disease in patients with viral and meningococcal meningitis.

Endotoxin meningococcus stimulates macrophages and neutrophils to the production of proinflammatory group of mediators, but their system products does not always mean high efficiency anti-infective immunity. On the contrary, excessive and generalized production of proinflammatory cytokines leads to the development of bacterial-toxic shock, which is a cause of early mortality, including patients with meningococcal infection. To avoid excessive systemic inflammation in the body include the mechanisms of negative control, mediated by the production of inflammatory cytokines. Sometimes the production of IL-10 in viral infections is rapidly increasing, such action on macrophages exert immune complexes. While an excess of IL-10 in 10 to 15 days of the disease leads to a decrease in anti-infective protection and development of prolonged or chronic forms of infection. Today we know that VI is Yu role in the pathogenesis of viral lesions of the Central nervous system perform immune complexes (Assemblies et al., 2004).

The main cause of secondary immunodeficiency induced by a viral infection, is in violation of the interactions between the major immunoregulatory subpopulations of lymphocytes. Suppression of Th-1 lymphocytes and activation of Th-2-subpopulation (producers of IL-10) leads to decreased production of proinflammatory cytokines by inhibition of more effective cellular immune response and, consequently, to a more "sluggish" during the inflammatory response.

We found a significant increase in serum concentrations of IL-10 to the period of early recovery in patients with severe viral meningitis, which corresponded to a clinically significant asthenic syndrome and prolonged course of infection with the subsequent formation of the residual effects or complications (tables 1 and 2).

The proposed method was successfully tested in 45 patients with meningococcal meningitis and viral etiology in the Department of childhood CNS regional infectious diseases hospital, Astrakhan from 2003 to 2004 the Following are the results of testing.

Example 1. Patient P., age 6 (and a/b No. 5715), received on the first day of illness. Ill acutely, in the midst of perfect health: chills, temperature rose to 39.8°appeared headache zero, repeated vomiting. The state of heavy, lethargic, photophobia. Moderate rigidity Stylo the different muscles, a positive symptom of Cernica, abdominal and cremasteric reflexes weakened. Lumbar puncture for admission: transparency incomplete, lymphocytosis - 143 cells, neutrophils - 90%, lymphocytes 10%, protein - 0,198 g/l, reaction Pandi(++), glucose - 2.5 µmol/l, chlorides - 75 µmol/l complete blood count: leukocytes 4,6×10⁹/l, ESR 15 mm/h IL-10 on day 2 of the disease - 7,815 PCG/ml Lumbar puncture on the 10th day of the disease: the cerebrospinal fluid is clear, lymphocytosis - 8 cells, lymphocytic, protein 0,224 g/L. General analysis of blood without pathological changes. IL-10 on day 10 of disease - 3,879 PCG/ml Clinical diagnosis of meningococcal disease, meningitis, mild form. The diagnosis was confirmed bacteriologically. When the seeding of the cerebrospinal fluid and blood derived growth meningococcus type "C"; RIGA with meningococcal antigen group "C" is positive. The further course of the disease is favorable, the improvement has come to the 4th day of the disease, was discharged on the 11th day of hospital stay.

Example 2. Freestyle W., 7 years (and a/b No. 5126), received on the first day of illness with complaints of sudden headache, fever up to 39°, repeated vomiting. When viewed in the receiving Department of a state of moderate severity, fever up to 38°complains of headache, vomiting. Shows rigidity of occipital muscles, slabopolozhitelnym symptom of Cernica, abdominal reflexes quick history which are stated. For diagnostic purposes conducted lumbar puncture: the color of the liquor is clear, flows under pressure, lymphocytosis - 986 cells, neutrophils 69%, protein - 0.33 g/l, reaction Pandi(-), glucose 3.5 µm/l complete blood count: leukocytes - 7,3×10⁹/l, erythrocyte sedimentation rate of 14 mm/h IL-10 on day 1 of the disease 7,212 PCG/ml of the Child was conducted under conventional therapy, the improvement came on the 6th day of the disease. Control puncture on the 11th day of the disease: transparent liquor, lymphocytosis 3 lymphocyte. Protein 0.33 g/l, total blood without pathological changes. The concentration of IL-10 on the 11th day of the disease 4,422 PCG/ml Clinical diagnosis of meningococcal disease, meningitis. The intermediate form. The diagnosis was confirmed bacteriologically: liquor sown meningococcus group "A". Discharged with full clinical recovery on the 14th day of hospital stay.

Example 3. Patient S., 2 years and 8 months. (and a/b No. 6248), came on the second day of the disease with complaints of headache, fever up to 38°S, repeated vomiting, lethargy. When inspecting the condition of the heavy, sluggish, well-marked neck stiffness, positive symptom of Cernica. Lumbar puncture: color cerebrospinal fluid whitish, lymphocytosis - 2135 cells, neutrophils and 96%, lymphocytes - 4%, protein - 0.25 g/l, reaction Pandi(+), glucose - 2.3 µmol/l complete blood count: leukocytes 15,1×10⁹/the, Erythrocyte sedimentation rate of 18 mm/h IL-10 on day 2 of the disease - 4,311 PCG/ml Lumbar puncture on the 10th day of the disease: the cerebrospinal fluid is clear, lymphocytosis - 968 cells, neutrophils - 31%, lymphocytes - 68%, macrophages - 1%, the reaction Pandi(+), protein - 0.35 g/l complete blood count: leukocytes 5,6×10⁹/l, erythrocyte sedimentation rate of 16 mm/h IL-10 on day 10 of disease - 5,470 PCG/ml Lumbar puncture for 21 days disorders: lymphocytosis - 6 cells in field of view, protein 0,165 g/L. Clinical diagnosis of meningococcal disease, meningitis. A severe form. A protracted course. Hypertension-hydrocephalic syndrome. The diagnosis was confirmed serologically: found in the blood of antibodies to meningococcal group "A" in the diagnostic titer. The patient was discharged on day 34 of hospital stay with the elements of the residual phenomena.

Example 4. Patient A., 13 years (and a/b No. 4424), came on the second day of the disease with complaints of sudden headache, fever up to 38°With vomiting. When inspecting the condition of heavy, lethargic, severe neck stiffness, positive symptom Brudzinskogo. Lumbar puncture: transparency incomplete, lymphocytosis - 589 cells, neutrophils - 100%, protein - 0,186 g/l, glucose - 3,5 mmol/l complete blood count: leukocytes 7,8×10⁹/l, erythrocyte sedimentation rate of 17 mm/h, IL-10 on day 2 of the disease - 3,770 PCG/ml Lumbar puncture on the 12th day of the disease: colorless cerebrospinal fluid lymphocytosis - 10 of lymphocytes in the OLE of view. Complete blood count within normal limits. IL-10 on day 12 of illness - 4,316 PCG/ml Clinical diagnosis: Viral meningitis unspecified etiology. The intermediate form. Acute course.

Example 5. Patient D., age 13 (and/b No. 5900), and entered on the first day of illness with complaints of headache, fever, lethargy, vomiting. When inspecting the condition of heavy, lethargic, severe neck stiffness, positive symptoms of Cernica, Brudzinskogo, abdominal reflexes weakened. Lumbar puncture: full transparency, lymphocytosis - 137 cells in field of view, neutrophils - 100, lymphocytes - 37, protein 0.2 g/l, glucose 3.5 µmol/l complete blood count: leukocytes 7,1×10⁹/l, erythrocyte sedimentation rate of 7 mm/h IL-10 on day 1 of the disease - 4,370 LCG/ml Lumbar puncture for 12 hours: liquid colourless, lymphocytosis - 120 lymphocytes. Complete blood count within normal limits. IL-10 on day 12 of illness - 5,016 PCG/ml Lumbar puncture on the 17th day: the cerebrospinal fluid is clear, lymphocytosis - 85 cells, lymphocytic, protein 0.2 g/L. General analysis of blood without pathological changes. The duration of meningeal symptoms 21 days. Fever up to subfebrile figures, wavy. CSF detected enterovirus Echo-33 (PCR). Clinical diagnosis of Enteroviral infection, serous meningitis. A severe form. A protracted course. Hypertension-hydrocephalic syndrome.

Example 6. Patient S., age 12 (and/b No. 4089), ustupila on the second day of the disease with complaints of sudden headache, the temperature rise up to 38°With vomiting. When inspecting the condition of heavy, lethargic, severe neck stiffness, positive symptoms Brudzinskogo, Cernica. Lumbar puncture: transparency incomplete, lymphocytosis - 279 cells, neutrophils - 95%, lymphocytes - 5%, protein - 0/286 g/l, glucose - 3,5 mmol/l, the reaction Pandi (opalestiruet). IL-10 on day 2 of the disease 3,870 PCG/ml Lumbar puncture on the 10th day of the disease: colorless cerebrospinal fluid lymphocytosis - 6 infusion. General analysis of blood without pathological changes. IL-10 on day 10 of disease 4,316 PCG/ml In the CSF by PCR detected West Nile virus. Clinical diagnosis of West Nile Fever, serous meningitis. A mild form. Acute course. The duration of meningeal symptoms 6 days. The patient was discharged on the 15th day stay in the hospital in satisfactory condition.

The proposed method for the determination of IL-10 in peripheral blood, along with the conventional methods of assessing the severity of the disease, allows you to more accurately detect the activity of the inflammatory process, to monitor the effectiveness of therapy, predict the outcome of the disease (table 3). The advantages of the test is the possibility of using it in emergency clinical situations in the intensive therapy and as a prognostic marker in the Denia patients with infectious-toxic shock. A sharp decrease in the concentration of IL-10 in infectious-toxic shock indicates mild shock and implies the possibility of early assignment of bactericidal antibiotics, especially if meningococcemia with meningitis (bactericidal antibiotics increase the depth of the shock with subsequent adverse outcome). High stability of IL-10 in the blood, the resistance at room temperature and freeze a constant presence in the plasma within 24 hours. One of the advantages of the test is that IL-10 is virtually undetectable in healthy children. The essential advantage of the method is the relative ease of execution. There is no need for frequent studies of the liquor to monitor the effectiveness of treatment. The claimed method is reproducible, informative and accurate, since it uses high-affinity monoclonal antibodies in the reaction assay. The proposed method can be used in the practice of pediatric infectious hospitals and intensive care units.