RU2339039C1 - Method of differential diagnostics of meningococcus and serous meningitis of enterovirus of etiology on basis of studying of free-radikal status of liquor at children - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: by means of high-strung chemiluminescent (CML) the liquor analysis define an illuminated sum of spontaneous CML (S1) for 1 minute And an illuminated sum of a luminol-dependent luminescence also for 1 minutes (S3). At value S1 within 1.5±0.12 CU and S3 1.98±0.19 CU, diagnose a purulent meningitis, and at value S1 within 1,1±0.07 CU and S3 1,1±0.07 CU - serous meningitis.

EFFECT: carrying out of differential diagnostics in short terms at an early stage of disease and appointment of adequate therapy.

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Description

The invention relates to medicine, specialty pediatrics, to the section of childhood infectious diseases.

The leading place in the structure of neuroinfections in children is occupied by meningitis, which account for up to 70-80% of the total number of CNS infections [Lobzin Yu.V. Meningitis and encephalitis, 2003. - 128 p., Sorokina M.N. Bacterial meningitis in children, 2003. - 320 p., Sorokina M.N. Viral encephalitis and meningitis in children, 2004. - 416 p.]. Among purulent meningitis, meningococcal meningitis (MM) is most common, among serous - enterovirus (EM).

According to the materials of the Children's Infectious Diseases Hospital named after A.K. Piotrovich, Khabarovsk, from 2001 to 2006 in the etiological structure of patients with neuroinfections, meningococcal infection (MI) was the leading one, the specific gravity of which was 42% of the total number of patients with CNS infectious lesions. Enterovirus etiology meningitis, which is the leading form of enterovirus infection (EVI), was recorded annually, while for the period we studied, patients with EM accounted for 39% of the total structure of neuroinfection.

Despite the fact that at present many aspects of the diagnosis and clinical manifestations of these diseases have been well studied, the problems of early differential diagnosis of purulent and serous meningitis, not only at the prehospital stage, but also in stationary conditions remain largely unresolved.

The similarity of the clinical manifestations of MM and EM in the initial period of the disease, hemogram indicators and cerebrospinal fluid examination cause difficulties for practical doctors in establishing an etiological diagnosis of meningitis. So, neutrophilic pleocytosis is typical for MM, but in the first hours from the onset of the disease, it can be mixed (half, 1: 1) and even lymphocytic in the case of the development of the serous variant of MM. For EM, on the contrary, lymphocytic pleocytosis is characteristic, however, in the first three days of the disease, it can be mixed or neutrophilic. The etiological diagnosis of MM and EM is often retrospective. Therefore, in order to prescribe adequate timely treatment (the approaches to the treatment of MM and EM are different), it is necessary to search for additional criteria for the early differential diagnosis of purulent and serous meningitis.

As is known, an acute infectious process, along with specific disorders of homeostasis due to the properties of specific pathogens, is also characterized by a number of nonspecific reactions due to the response of the metabolic systems of the macroorganism to infectious stress.

There is information in the literature on the activation of free radical oxidation (SRO) processes in the brain in various non-infectious cerebral disorders (V. Zhelev. Activity of superoxide dismutase, glutathione peroxidase and the level of malondialdehyde in premature infants with hypoxic damage to the central nervous system, 2004 - No. 12. - P.13-16, Pedachenko EG Free radical peroxidation reactions in the acute period of traumatic brain injury, 1999. - P.54., Vasiliev EM. Lipid peroxidation with no rologicheskoy pathology in children, 2005. - №2 -. S.8-12). In this case, most authors studied the processes of SRO with neurological pathology only at the systemic level - in the blood. With neuroinfections, in particular with MM and EM, these processes at the local level (in the cerebrospinal fluid) have not been studied.

When conducting an information search, we met only one work characterizing the processes of SRO in bacterial meningitis in children, which was chosen as an analogue (prototype) - L. Lvovsky. The state of the system lipid peroxidation is an antioxidant system for severe bacterial meningitis in children, 2003. - P. 105 - 106. However, in this work, the group of children examined was children with bacterial meningitis, regardless of their etiology, while bacterial meningitis in children can occur with both purulent and serous inflammation. The material for the study was the blood of patients, i.e. oxidative processes were studied at the systemic, and not at the local (in the cerebrospinal fluid) level. In addition, an insufficiently sensitive spectrophotometric research method was used to study the SRO processes.

As the closest analogue (prototype), we used a method for differential diagnosis of purulent and serous meningitis by determining the activity of alkaline phosphatase in cerebrospinal fluid, including in children, described in SU 1406482, published on 06.30.1988.

In this invention, in order to improve the accuracy of diagnosis, it is recommended to study the activity of alkaline phosphatase in cerebrospinal fluid. The proposed method improves the accuracy of the differential diagnosis of purulent and serous meningitis compared with previously known by 27%.

As a prototype can also be used the method of differential diagnosis of bacterial and viral meningitis, described in SU 1534396 A1, publ. 07.01.1990. This invention relates to medical microbiology and is based on the determination of lysozyme in cerebrospinal fluid by diffusion in agar with a test culture of M. Lysodeikticus. Using the proposed method can increase the sensitivity of diagnosis of meningitis by 30%.

Our proposed method is a modern, highly sensitive method that allows you to determine highly reactive, short-lived radicals that are not identifiable by other methods. It is an additional criterion for early differential diagnosis of purulent and serous inflammation of the meninges in children. The proposed method is more economical in the use of biological material (analysis requires 0.3 ml of cerebrospinal fluid), which is important for pediatric practice. The method is quite operational, making it possible to obtain a result on the day of the puncture, which allows you to timely diagnose purulent or serous meningitis and prescribe adequate therapy for patients with neuroinfection.

The objective of the invention is to conduct a comparative analysis of the processes of free radical oxidation in the cerebrospinal fluid in children with MM and EM in the acute period of the disease.

The technical result is to identify additional criteria for the differential diagnosis of MM and EM in the acute period of the disease to prescribe adequate therapy.

The technical result is achieved by examining 114 children with neuroinfections. The first group (group I) included 71 children with MM, the second (group II) - 43 children with EM. The diagnosis in all children was established on the basis of clinical and epidemiological data and confirmed using bacteriological, virological and serological methods. When verifying the diagnosis of MM, it was revealed that meningococci of serotypes B and C, nonagglutinable antigenic strains predominated in the etiological structure, and viruses ECHO ₆ and ECHO ₃₀ prevailed for enterovirus infection.

The control group (group III) included 23 children who underwent lumbar puncture according to strict clinical indications, however, inflammatory changes in the cerebrospinal fluid were not detected, which was regarded as meningism that arose during ARVI.

The average age of the examined children was: in the I group - 2.5 ± 0.5 years, in the II - 3.2 ± 0.16 years and in III - 2.9 ± 0.3 years.

The highly sensitive method of chemiluminescence (CML) according to V. Vladimirov was used as the main method for assessing free radical oxidation processes. Free radicals in living systems, 1991. - P.147. In this case, the light sum for 1 min of spontaneous CML (S ₁ ), the magnitude of which correlates with the intensity of free radical processes, and the light sum of the luminescent luminescence for one minute (S ₃ ), the magnitude of which is proportional to the content of hydroxyl radicals, were determined. CML intensity was expressed in relative units. CML was recorded on an LS-50B luminescent spectrometer (PERKIN ELMER, Switzerland). Signal standardization and mathematical processing of the curves were performed using the built-in Finlab program.

, средней ошибки средней арифметической (m), оценка достоверности показателей (p), вычисление коэффициента парной корреляции Пирсона (r). Сравнение показателей между сравнительной группами осуществляли с использованием критерия Стьюдента (t). Вычисления производились на ПЭВМ в операционной среде Windows XP с использованием пакета программ Microsoft Office (Excel, Word) и с применением пакета прикладных программ «STATISTICA» (версия 5.0).For static processing of the obtained materials, statistical methods were used: calculation of the arithmetic mean (M), standard deviation

, the arithmetic mean error (m), the reliability of indicators (p), the calculation of the Pearson pair correlation coefficient (r). Comparison of indicators between the comparative groups was carried out using Student's criterion (t). The calculations were performed on a PC in the Windows XP operating environment using the Microsoft Office software package (Excel, Word) and using the STATISTICA application software package (version 5.0).

The data obtained are presented in the table. As can be seen from the results presented in table 1, in the cerebrospinal fluid of children with MM and EM, unidirectional changes are noted. It was found that an increase in the production of free radicals (SR): the value of S ₁ in children with MM exceeded that of children in the control group by a factor of 3.7 (P ₁ <0.001). In children with EM, the value of S ₁ exceeded the same indicator found in children in the control group by 2.6 times. The content of hydroxyl radicals in the cerebrospinal fluid in children with MM was significantly higher than that found in children without inflammatory processes of the meninges, as evidenced by an excess of S _{3 by} 2.9 times (P <0.001). In children with EM, S ₃ was 2.4 times higher than in the control group. However, in children with MM, these changes were more pronounced than in patients with EM. The value of S ₁ in patients with MM exceeds the rate obtained in patients with EM by 1.4 times (P ₃ <0.01). The value of S ₃ in children with MM exceeds the same indicator obtained in children with EM by 1.8 times (P ₃ <0.001).

Therefore, upon receipt in liquor indicator S ₁ within 1.5 ± 0.12 srvc. units, one should assume the presence of purulent, and within 1.1 ± 0.07 srvc. units - serous meningitis. The indicator S ₃ in the cerebrospinal fluid in the range of 1.98 ± 0.19 srvc. units characteristic of purulent meningitis, within 1.1 ± 0.07 srvc. units - for serous inflammation of the meninges.

Advantages of the proposed method:

- high sensitivity;

- the possibility of determining highly reactive, short-lived radicals that are not identifiable by other methods;

- profitability in the use of biological material (analysis requires 0.3 ml of liquor);

- efficiency, the possibility of obtaining a result on the day of puncture, which is especially important for early differential diagnosis of MM and EM;

- is an additional differential diagnostic criterion for purulent and serous inflammation of the meninges in children.

As an example of using the proposed method in a clinical laboratory examination of patients with neuroinfection, we provide extracts from medical records.

Example 1. The medical history No. 3557. Patient I. Maxim, 2 years old, was admitted to the hospital on 10/26/2006 on the second day from the onset of the disease. He became acutely ill when the body temperature increased to 37.9 ° C, repeated vomiting, headache appeared. The child was taken to hospital by ambulance with a diagnosis of Suspected enterovirus infection, serous-viral meningitis. Upon receipt, a moderate condition due to intoxication, meningeal syndromes. In the mind. The skin is clean, pale. In the oropharynx bright hyperemia, no raids. Heart sounds are loud, rhythmic, heart rate 108 per minute. HELL 90/60 mm Hg The vesicular breathing, no wheezing. BH 22 per minute. The abdomen is soft, painful on palpation in the right and left iliac region. Of the meningeal symptoms, stiff neck and upper Brudzinsky symptom were noted. Blood test at admission: Hb - 125 g / l, er. - 3.96 · 10 ¹² / l; col. pok. - 0.94; leukocytes - 17.8 · 10 ⁹ / l; PO Box - 7%; s / s - 77%; lymph - 13%; mon - 3%; ESR - 18 mm / hour. General cerebrospinal fluid analysis: cytosis of 976 cells (567 neutrophils, 409 lymphocytes), protein 0.27 g / l. In a chemiluminescent study of S ₁ - 1.57 Rel. units; S ₃ - 2.03 rel. units

Subsequently, during bacteriological examination of cerebrospinal fluid on the 4th day of illness, a culture of N. meningitidis, a nonagglutinable strain, was isolated. Clinical diagnosis: Meningococcal infection, purulent meningitis, moderate severity.

Example 2. The medical history No. 3557. Patient K. Alexey 3 years old was admitted to the clinic on September 19, 2006 on the third day from the onset of the disease. The disease began with a rise in temperature to subfebrile numbers, vomiting 1-3 times a day, headache. The child was taken to hospital by ambulance with a diagnosis of Suspected enterovirus infection, serous-viral meningitis. Upon admission, the condition was regarded as moderate due to intoxication, meningeal syndromes. The skin is clean. Facial hyperemia, injection of scleral vessels. The mucous oropharynx is pale pink, clear. Heart sounds are loud, rhythmic, heart rate 110 per minute. Vesicular breathing, no rales. BH 28 per min. The abdomen is soft, painless on palpation. Meningeal symptoms were noted: stiff neck, Kernig symptom. Blood test at admission: Hb - 115 g / l, er. - 3.72 · 10 ¹² / l; col. pok. - 0.84; white blood cells - 15.8 · 10 ⁹ / l; PO Box - 7%; s / s - 77%; lymph - 13%; mon - 3%; ESR - 15 mm / h. General cerebrospinal fluid analysis: cytosis of 520 cells (340 neutrophils, 180 lymphocytes), protein 0.21 g / l. In a chemiluminescent study, S ₁ - 1.08 Rel. units; S ₃ - 1.13 rel. units

During virological examination of the cerebrospinal fluid, ESO-6 virus was isolated. Clinical diagnosis: Enterovirus infection. Serous viral meningitis, moderate severity.

Thus, the determination of free radical parameters can serve as an additional differential diagnostic criterion for purulent and serous inflammatory processes in the membranes of the brain in children with MM and EM.

Indicators of free radical status of cerebrospinal fluid in children with meningococcal and enteroviral meningitis in the acute period of the disease (M ± m) Indicators Groups of children examined Group I patients with meningococcal meningitis n = 71 Group II patients with enteroviral meningitis n = 43 III group control group n = 25 S ₁ (rel. Units) 1.5 ± 0.12 1.1 ± 0.07 0.4 ± 0.04 P ₁ <0.001 P ₂ <0.001 P ₃ <0.01 S ₃ (rel. Units) 1.98 ± 0.19 1.1 ± 0.07 0.7 ± 0.05 P ₁ <0.001 P ₂ <0.001 P ₃ <0.001 Note:
n is the number of children examined;
P ₁ - significance of differences between indicators obtained in I and III gr .;
P ₂ - significance of differences between the indicators obtained in II and III gr .;
P ₃ - significance of differences between the indicators obtained in I and II gr.

Claims (1)

A method for the differential diagnosis of meningococcal (purulent) and enterovirus (serous) meningitis in children, including the study of the free radical status of cerebrospinal fluid, characterized in that they use a highly sensitive chemiluminescent analysis (CML) of cerebrospinal fluid, which allows to determine the light sum of spontaneous CML (S1) for 1 min of light and light sum also for 1 min (S3), with S1 values within 1.5 ± 0.12 srvc. units and S3 1.98 ± 0.19 conv. units diagnosed with purulent meningitis, and with S1 values within 1.1 ± 0.07 conv. units and S3 1.1 ± 0.07 conv. units - serous meningitis.