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8Herpetic Lesionofthe Central NervousSystem in Children
Zabolotskikh T.V., GrigorenkoG.V., MishchenkoG.N., MarkinaT.A., KharchenkoM.V., MedvedevaS.V., SergaA.P.
Amur State Medical Academy, Blagoveshchensk, Russia Amur Regional Children s Hospital, Blagoveshchensk, Russia
Abstract. 50 patientsaged frombirth to 2years old,contaminatedin uteroHerpes simplex virus type1, 2 and. Cytomegalovirus type 5with varying degreesof brain damagein the form ofneuroinfectionsencephalopathiesormixed originandotherorganpathology were observed.The timely diagnosisand earlyadequate therapymay improveneurologicaloutcome.
Key words: herpeticneuroinfection, newborns, infants.
Intrauterine infections have significant socio-economic and demographic importance due to their steady rise in the structure of perinatal and infant morbidity and mortality in the formation of severe disease and disability in children in the older age groups. (5). In Perinatology there is a term "intrauterine infection," meaning the contamination of the fetus and newborn child a variety of infectious pathogens ante-or intrapartum, the outcome of which may become clinically manifest as a form of infection (in utero, congenital infection), and the formation of latent, persistent form of the disease (4) . Of all the TORCH-complex for babies have the greatest significance herpes infections (CMV, HSV 1 and 2). Celebrated their special tropism for the central nervous system and the immune system. Herpes viruses are widespread in the human population, they can attack virtually all organs and systems of the host, causing acute, chronic or latent TB infection. This can be considered as a common herpes systemic disease of the body (2). This may develop a direct herpetic lesion in the form of encephalitis and meningoencephalitis, however, recent studies indicate that hypoxia-mediated CNS involvement as a result of chronic fetal hypoxia, respiratory distress syndrome, general immaturity in neonates with herpes infections. It is shown that the exacerbation of herpes infection in pregnancy leads to gross morphological changes in the fetoplacental barrier and impaired respiratory function of the placenta (3).
The aim of this study was to investigate the characteristics of herpetic lesions of the central nervous system in newborns and children during the first two years of life.
Materials and methods
The peculiarities of the clinical course and outcome of 50 children: 32 of newborns from mothers with verified at various stages of pregnancy, using polymerase chain reaction (PCR) and enzyme-linked immunosorbent assay (ELISA), herpes infection types 1 and 2 (Herpes simplex virus type 1, 2 - HSV -1, HSV-2) and 18 children from women with CMV (. Cytomegalovirus type 5 - CMV). Most mothers (20) had recurrent HSV -1 - infection of 1 to 3 times during pregnancy, maternal verified in 9 HSV-2 infection, the mixed option (HSV -1 + HSV-2) was observed in three women. In 18 mothers identified chronic persistent CMV-infection.
The majority of children (44) were treated at the Department of Pathology of neonatal and perinatal neurology, 30 of them continued treatment in the neurological department of the Amur Oblast Children's Hospital (AODKB) for the last 10 years. In addition to clinical observations, conducted etiological verification using PCR to detect the virus genome in blood, cerebrospinal fluid, saliva, urine, vesicle contents, if any, and determine the nature of the pathological process by enzyme-linked immunosorbent determination of specific antibodies in children of classes M and G, and the extent of their avidity . Some of the children (11) defining the antigen HSV -1, HSV-2 in vesicle contents was conducted by direct immunofluorescence. At the same time children with
established HSV infection we measured parameters of cellular and humoral immunity and phagocytosis by conventional methods.
Neuroimaging techniques performed NSG, CT and MRI in the dynamics. All children underwent a standard neurological examination, the study of cerebrospinal fluid, the fundus, clinical and biochemical analyzes of blood and urine tests.
Results and discussion
The majority of infected infants (32) were full-term, 10 children were born at 36-37 weeks of gestation, 8 - at 32-34 weeks of gestation. In third term infants was observed prenatalnayagipotrofiya.
By forms of herpes infection patients were as follows: in 10 symptomatic children from the first days of life neonatal herpes occur in the form of meningoencephalitis with a typical cerebral and focal symptoms and severe progressive chronic. 4 children the clinical picture of generalized neonatal herpes developed by 8-10 days after birth with a combination of skin herpes sores and meningoencephalitis followed by the addition polirgannoy pathology (pneumonia, enterocolitis, cardiomyopathy, etc.).
In 11 children in the neonatal period, there was no clinical herpes infection, but 5 of them developed purulent meningitis and ventriculitis, and at 6 - septic tank with a progressive process that is difficult to conventional methods of treatment course (1).
In the study of CSF by PCR in only half of cases the virus HSV 1 or 2, and for septic lesions of herpes virus group to be identified. At the same time, all children with herpetic neuroinfection observed diagnostically significant increase in IgG antibodies in paired sera.
Of the remaining 7 children have developed three clinic localized cutaneous herpes infection in the first days after birth, the four - later, at 3, 5 and 7 months, indicating that they formirovaniiu chronic persistent infection was confirmed by PCR and ELISA.
All children with herpetic infections were treated with Zovirax (acyclovir), both systemic and topical, immunomodulators (viferon, likopid).
In addition to the manifest neuroinfections, almost all children with neonatal herpes a marked disorders of the central nervous system from the first days of life in the form of a perinatal encephalopathy syndrome of mixed origin, among which prevailed syndrome CSF hypertension secondary to severe and severe (9), motor syndromes (4) and vegetative-visceral (21) disorders, as well as subarachnoid hemorrhage (5), and intraventricular (3) hemorrhage. By the end of the first year of life was formed in 9 patients resistant hypertension-hydrocephalic syndrome, in 2 -hydrocephalus, confirmed neurosonographic research in dynamics with the other children up to 2 years of formation of the defining features of hyperactivity and attention deficit disorder. The most significant outcomes observed in children who had herpetic meningoencephalitis in spite of the subsequent rehabilitation therapy in specialized neurological departments in 7 of them were formed disabling residual - organic state in the form of cerebral palsy, epilepsy, hearing loss, the rest - rough delay static-motor and mental development. In two patients with herpetic encephalitis and three with septic complications observed death. The features of the CNS in 18 newborn infants of mothers with chronic persistent CMV-infection were: non-specific initial symptoms neuroinfections, the lack of clear serological markers of infection (high avidity anti-CMV-class antibodies Ig G at baseline child and mother), the prevalence of early neonatal period of severe organ manifestations in the form of respiratory distress syndrome, plevmopatii, pneumonia, posthypoxic cardiomyopathy in conjunction with perinatal encephalopathy syndrome without the characteristic changes in the cerebrospinal fluid, leading to late diagnosis and delayed the appointment of specific therapy, morbidity and high mortality. Of those in the neurology department AODKB were observed in age from 1 month to 6 months, 10 people from 6 to 12 months. - 6 people, from 12 to 24 months. -2 Person. At the same Manifest signs of meningoencephalitis had 14 children between the ages of 1 and 7 months, active infection was confirmed by detection of CMV genome in blood, urine, in 6 children - in the cerebrospinal fluid.
Serologically detected by ELISA specific anti - CMV-class antibodies Ig M - y 6 children, Ig G-low avidity in 5 children, increased titers of antibodies Ig G-3 - 4 times in paired sera at intervals of 2 - 3 weeks. - Y 3 kids. Still have 4 children had motor impairment in the form of bulbar, pseudobulbar disorders, paresis, paralysis, delayed motor development, they are defined serologically vysokoavidnye anti-CMV-class antibodies Ig G with negative PCR results. The characteristic early and long-lasting symptom CMV-meningoencephalitis in the study of cerebrospinal fluid - a protein greater than 1.0 g / l at low or moderate or mixed lymphocyte cell count of character. All children with active CMV-infection received combined therapy: antiviral drugs (viroleks) intravenously, specific immunoglobulins (neotsitotekt) pentaglobin, immunomodulators (genferon, viferon, likopid, izoprinozin). The criterion for the efficiency of the treatment was the disappearance of markers of viral replication. Despite ongoing therapy, outcomes CMV-neuroinfections children were serious enough: the transition to the latent chronic form of the disease (all patients was determined by CMV genome in saliva and / or urine), epilepsy - 12 children, hydrocephalus replacement - at 13, motor disorders - Y14, delayed psycho - speech development - in 13 children. Pictured 1-4 presents the neuroimaging by magnetic resonance imaging disabling outcomes CMV-neuroinfections in infants.
Lethal outcomewas observed in4 children, pathologicallyatautopsyfoundspecificcellsinthe form of "owl eyes" in parenchymal organsand salivaryglands.
We can not ignorefeatures ofimmunity in childrenwithherpeticinfections.A cleardecrease inthe immunoregulatoryindexdue to the predominanceof subpopulations ofT-cytotoxic cells/suppressorgipoimmunoglobulinemiyaM& G,lowabsorptionanddigestiveabilityof
neutrophilphagocytosis, which undoubtedlyunderliesa weakimmune defensein thesechildren, the formation of the latentandpersistentformsof infection,and also affects theexpression ofspecificserologicalmarkers inthe diagnosis ofELISA.
Conclusions
Thus, analysis ofmedical history, clinicalmanifestationsandparaklinik, neuroimagingdata, the results of followgivea clear ideaaboutthe nature and volumeof brain damageinchildrenintrauterineherpesinfections,the formation ofdisablingconditions.We need to developa road map, comprehensive measuresfor prevention,early diagnosis, early andadequate therapy, the etiologicalandserological monitoringnot only inthe neonatal period, but also in its infancy, and effective rehabilitation measures, which will undoubtedly reduce thenumberof adverse outcomesand the degree ofdisability ofchildren.
References:
1. GrigorenkoG.V., Zabolotskikh T.V., Serga A.P. Peculiaritiesofthesepsiscourseinnewborns.-CurrentPediatrics: ProceedingsoftheXCongressofPediatriciansofRussia. - 2006. - T. .5, № 1.-P. 128.
2. IsakovV.A., ArkhipovE.I.,IsakovD.Herpesvirusinfection in humans: a guide for physicians- St, Petersburg.: SpetsLit2006. - 303p.
3. Lutsenko M.T., AndriyevskayaI.A.,DovzhikovaI.V.,IshutinaN.A.Morphologicalpatterns ofimpairment of respiratoryfunction of the placentain pregnancies complicated byherpes viralinfection.- VladivostokDal'nauka, 2012. - 143p.
4. Minutes ofthe diagnosis, treatmentand preventionof intrauterine infectionsin newborn infants. Moscow, SEI BYNMCHealth Ministry,2002, 96 p.
5. RyabchukF.I.,AleksandrovV.A.,PirogovZ.I.gPersistentinfection in childrenprenatal, neonatalandpostnatalorigin.Textbook.St. Petersburg,2012.65.
Photo number 1
Child 1month. CMVmeningoencephalitis: the formation of external hydrocephalus, mostpronouncedin the fronto-parietal areas
Photonumber3 Child 6 months. The outcome of CMV meningoencephalitis with the defeat of the paraventricular areas, the formation of substitution of hydrocephalus and cystic transformation of the brain.
Photonumber 3 Child 9 months. The outcome of CMV meningoencephalitis as external and internal hydrocephalus
Photonumber4
Child 3 months. The outcome of CMV meningoencephalitis with late onset of causal treatment: cystic transforming the brain, secondary asymmetric ventriculomegaly
Morphological potentialities of external jugular vein in surgery of vertebro-
basillar insufficiency
ZavaruevA.V.
Amur State Medical Academy, Blagoveshchensk, Russia
Abstracts: Vein shunting of brachiocephalic arteries in affection of a vertebral and subclavial zone and hypodermic veins of extremities practically isn't carried out today. It is caused by several reasons: time lengthening of operation, additional operational trauma, cosmetic defect, rather good results of endovascular treatment and using synthetic artificial prosthesises. However these researches of the postoperative period after shunting and endovascular operations on vertebral and
