Coinfection of Streptococcus suis and Nocardia asiatica in the human central ner

lNTRODUCTlON

() is a facultative anaerobic gram-positive bacterium located in the nasal cavity,tonsils, upper respiration tract and gastrointestinal tract of pigs. This microbe can be transmitted through contact, the respiratory tract and the digestive tract[1]. It enters the human body, spreads through the blood to the epithelial cells of the choroid plexus in the brain and crosses the blood-brain barrier, resulting in intracranial infection. The common complications ofinfection are hearing loss and vestibular dysfunction[2]. Since the first case in Denmark in 1968, over 1600 mankindinfections have been documented in 30 nations across the globe, especially in Southeastern Asian countries[3].is divided into 35 serotypes (Types 1-34 and Type 1/2), as per the different antigenicity of the capsular polysaccharide; the common serotypes with strong pathogenicity to pigs are Type 1, Type 2, Type 1/2, Type 7 and Type 9[4].

is a gram-positive aerobic bacterium and an opportunistic pathogen. It is widely distributed in soil and water and mainly invades the human body through respiratory tract inhalation and damaged skin. Infection byleads to abscesses of the respiratory system, skin and central nervous system as well as systemic disseminated infection. At least 100 species ofhave been identified; the medically relevant strains include,,,

On admission, the patient’s examination results were completely normal, including leukocyte count,hypersensitive C-reactive protein, procalcitonin, electrolytes, liver and kidney function tests and coagulation function tests. On the second day of hospitalization, cerebrospinal fluid examination showed 62.9 × 10white blood cells (WBCs)/μL, with a protein level of 8036 mg/L, glucose level of 3.8 mmol/L and chloride ion concentration of 139 mmol/L. The cerebrospinal fluid pressure was 270 mm HO; in routine examination of the cerebrospinal fluid, the appearance was light yellow and slightly muddy; the Pandy test was positive, with 2.4 × 10/L karyocytes, 51% neutrophils, and 69%lymphocytes. Biochemical examination of cerebrospinal fluid revealed a total protein content ＞ 1.07 g/L(normal, approximately 0.15-0.40 g/L), dextrose level of 1.87 mmol/L (normal, approximately 2.5-4.4 mmol/L), chloride level of 114.60 mmol/L (normal, approximately 120-132 mmol/L), body temperature of 38.5 °C, heart rate of 66 bpm, and blood pressure of 210/110 mmHg. The patient reported blurred consciousness and binaural hearing loss. He had signs of meningeal irritation in the form of neck stiffness and positive Kernig’s and Lesage’s signs.

Few cases of simultaneous infection withandhave been reported. The current case was an elderly male patient who hadmeningitis with abrain abscess, and metagenomic next-generation sequencing (mNGS) of cerebrospinal fluid confirmed the coinfection ofand. The present research was accepted by the Ethical Board of Liaocheng People’s Hospital, and the publication of clinical data was approved by the patient’s family[5,6].

CASE PRESENTATlON

Chief complaints

A 66-year-old hospitalized male who complained of dizziness.

History of present illness

Informed written consent was obtained from the patient for publication of this report and any accompanying images.

History of past illness

身负重任，于是私下我建议大家主动与秦风交往，但注意不要总问他关于以前在农村学校的事情，也不要在他面前表现出优越感，让他难堪……其实我也不知道要如何做才好，但总觉得，人与人之间相处，还是得互相尊重，真诚相待。

每一段的防浪墙我们都进行了单独的深化设计，以契合每一段的主题，并与周围环境进行高度融合。考虑到夜晚的效果，在异型防浪墙底部增设灯带，使得其在夜晚也能形成一道优美的景观。左岸中大面积的景墙其实也属于防浪墙的范畴，但由于景墙后部为居住区，因此作为防浪墙的景墙设置了2m多高，如何利用这2m多高的景墙，将其做的有特色，并能成为河对岸的视觉观赏点是设计过程中的难点。因此，在这里也选用了可雕刻的异型混凝土，将滁河左岸“望山见水”景观主题刻画于此。

Physical examination

Body temperature 38.5 °C, heart rate 66 bpm, and blood pressure 210/110 mmHg. The patient reported blurred consciousness, binaural hearing loss, signs of meningeal irritation displayed by neck rigidity,positive Kernig’s and Lesage’s signs, normal muscular strength and limb muscle tension, and negative pathologic signs.

Laboratory examinations

大型工业立体仓库的货位分配问题主要考虑货物数量、质量、出/入库频率等因素。为兼顾立体仓库的存储效率及其结构稳定性，主要采用的货位分配原则有存储效率优先原则和结构稳定性原则。

After 5 d, cerebrospinal fluid was extracted by lumbar puncture and subjected to mNGS. The result revealed(with 1884 detected sequences), and the relative abundance was 93.27%. No pathogens were found by routine methods such as cerebrospinal fluid culture or blood culture.

We then performed lumbar puncture every week to extract cerebrospinal fluid and examined inflammatory indices, with cerebrospinal fluid culture and blood culture performed.

A1组(浓度为1. 25%的大豆卵磷脂稀释液)低温保存绵羊精液精子活率均高于其他浓度组(P<0. 05)；A1组低温保存绵羊精液精子活率第9 d(0. 53±0. 06)、12 d(0. 46±0. 09)与C组第9 d(0. 55±0. 03)、12 d(0. 49±0. 07)差异不显著(P﹥0. 05)，且顶体完整率相当(P﹥0. 05)；A1组低温保存第9 d的精液进行人工授精,受胎率64. 3%与C组65. 6%差异不显著(P>0. 05)。表明1. 25%浓度的大豆卵磷脂稀释液能够进行绵羊精液低温长时间有效保存。

After 37 d, the patient’s condition worsened. We repeated mNGS of cerebrospinal fluid, and the results revealed(the number of detected sequences was 130) and(the number of detected sequences was 31598). The results of the seven cerebrospinal fluid examinations are shown in Table 1, and the etiological examination of the cerebrospinal fluid is shown in Table 2.

(1)CT平扫禁忌症:近半年内有生育计划或处于妊娠期的女性。(2)CT增强扫描需应用高压注射器进行静脉团注,即在短时间快速注射大量的造影剂,这会导致部分患者出现碘过敏或肾损害等不良反应,故为保证CT受检者的安全,存在以下情况的受检者需谨慎进行CT检查:伴有糖尿病肾病、肾功能不全;具有药物、海鲜等过敏史;有癫痫、酒精中毒等急性神经系统疾病病史;恶性肿瘤晚期;存在自身免疫性疾病或伴有哮喘、心衰、肺动脉高压等严重心肺疾病者。(3)禁止CT增强扫描检查:妊娠期妇女或对于合并甲亢、重症肌无力,对含碘对比剂过敏的患者。

FlNAL DlAGNOSlS

The initial diagnosis on admission was intracranial infection. Coinfection ofandinfection was the final diagnosis.

TREATMENT

The sufferer was hospitalized and finished routine examination, and he received lumbar puncture on the second day after admission. The routine culture, staining and bacterial examinations of cerebrospinal fluid were negative. According to the biochemical results of cerebrospinal fluid, we considered bacterial meningitis and empirically gave the patient ceftriaxone 2 g once a day. After 5 d of treatment, the patient’s condition did not improve significantly, and he still had dizziness, nausea and vomiting. Physical examination revealed a clear mind, poor spirit, positive meningeal stimulation sign,normal muscular strength and limb muscle tension, and negative pathologic signs on both sides. The outcomes showed that thesequence was detected; the number of sequences identified was 1884,and the relative abundance was 93.27%. The patient was diagnosed with suppurative meningoencephalitis caused byinfection. The treatment plan was adjusted as follows: ceftriaxone 2 g q12h plus penicillin sodium 4 million units q6h intravenous drip, combined with the hormone dexamethasone 10 mg qd andextract 70 mg bid to improve the patient’s hearing. The patient’s temperature gradually returned to normal, and the patient had no symptoms other than binaural hearing loss. After 37 d of treatment, the patient had a fever again, the body temperature reached 38.8 °C, and severe headache occurred. Laboratory examination showed that the WBC count registered 7.8 × 10/L(referential range: 4-10 × 10/L), and the neutrophil percentage registered 73.5% (referential range: 40%-75%). Subsequently, considering that the patient had drug resistance or that the patient's condition was repeated, we continued to apply the antibiotics ceftriaxone 2 g q12h and penicillin sodium 4 million units q6h. Nevertheless, his body temperature increased persistently, and our team discovered that he displayed neck stiffness again. Therefore, our team finished lumbar puncture. Cerebrospinal fluid test revealed a WBC content of 34 × 10WBC/μL, a protein content of 4470 mg/L, a GLU content of 2.48 mmol/L, and a chloride ion level of 124.40 mmol/L.was identified in the cerebrospinal fluidmNGS on day 2. At the time, our team thought thatmeningitis was rare, that the probability ofendocranial infection was low, and that the probability of contamination was high.Therefore, our team didn’t modify the therapeutic regimen. Subsequently, his body temperature still presented a fluctuation between 38 °C and 39 °C. Just when we were overwhelmed, we discussed with neurologists, infectious disease specialists and hematologists, considering that the patient's central nervous system was reinfected with, and developed a treatment plan: ceftriaxone, penicillin sodium, and compound sulfamethoxazole oxazole tablets combined with anti-infective therapy. His body temperature restored to normal on the 2day posterior to the modification of the therapeutic regimen. After 65 d, his clinical symptoms improved. The patient was discharged from the hospital.After returning home, he continued to take compound sulfamethoxazole tablets trimethoprimsulfamethoxazole (TMP-SMX), with TMP 80 mg and SMX 400 mg 2 tablets/time, 2 times/d for a total of 12 mo until the 1-year follow-up.

OUTCOME AND FOLLOW-UP

At the 1-year follow-up, the patient had left hearing loss in both ears and could work normally.

DlSCUSSlON

The current patient frequently consumed pork and was infected withafter eating contaminated pork. His drinking history and diabetes history are risk factors forinfection[7].infection can occur in patients taking immunosuppressant hormones and by, which destroys the bloodbrain barrier. Brain computed tomography scan of the brain of the patient led to the diagnosis ofinfection of the central nervous system. During infection, the pathogen enters the brain tissue through the lumbar puncture wound, resulting in brain abscess[8].

用SPSS 19.0和EXCEL 2010对数据进行统计分析和绘图，数据以平均值±标准差表示，p<0.05认为有统计学差异。

There was no improvement in binaural hearing impairment at the 1-year follow-up. Animal studies have shown that hearing impairment is related to suppurative labyrinthitis caused by the invasion ofin the subarachnoid space to the external lymph through the cochlear aqueduct, which leads to the disturbance of inner ear microcirculation and the direct invasion of the cochlear nerve by[9].Hearing impairment affects the daily life of patients, and questions regarding how to predict, prevent and treat hearing impairment are urgent problems that remain to be solved.

The patient’s condition initially improved after the initial treatment forand then deteriorated.We speculated that the patient was not sensitive to the current treatment and that there might be drugresistant strains of. Therefore, we repeated mNGS and found that the counts ofdeoxyribonucleic acid (DNA) decreased (from 1884 to 130), which confirmed that our treatment was effective. We also identified 31598sequences by mNGS. Therefore, we concluded that the deterioration of the patient’s condition was caused by intracranial infection with, and the patient was diagnosed with coinfection ofand. After the treatment plan was adjusted to penicillin sodium combined with ceftriaxone and sulfamethoxazole, the patient’s systemic and nervous system symptoms improved within a few weeks. The number of leukocytes decreased gradually, and the proportion of multiple nuclei cells decreased significantly, as observed in the re-examination of cerebrospinal fluid. The patient’s condition improved, and the mNGS results obtained at the time were consistent with the clinical situation.

那么，琴曲是如何有意境，即如何“远”的呢？一言以蔽之，以气贯通。而此气是由生理之气、琴曲之气组成，并非单一而就的。

There were no pathogenic bacteria found in the multiple evaluations of blood culture, cerebrospinal fluid culture and smears, which may be related to the extensive use of cephalosporins in the early stage of treatment. mNGS quickly and accurately diagnoses pathogens without the influence of antibiotic treatment[10]. mNGS detects pathogenic pathogens, including rare pathogens, more appropriately than traditional detection methods. mNGS also determines all DNA/RNA genome information in a sample in a single run and allows for the identification and typing of all pathogens without specific primers,which can play an important role in the diagnosis and treatment of complex and mixed infectious diseases with repeated negative clinical routine examinations. Rapid detection and identification offer the opportunity for treatment at early stages of disease, which helps control the condition, shorten recovery time, improve the prognosis and shorten the hospital stay duration. Therefore, mNGS can provide reliable and effective evidence for the diagnosis and treatment of CNS infectious diseases, with certain clinical application value[7].

The man was healthy, with no specific diseases.

CONCLUSlON

In the case of intracranial infection with rare pathogens, if the disease continues during treatment,clinicians should also consider coinfection more than the possibility of drug resistance. mNGS of cerebrospinal fluid can accurately and quickly diagnose pathogen infection in the nervous system in rare cases of infections of multiple pathogens. Based on the number of reads and relative abundance,mNGS could be used for semiquantitative detection, which can evaluate the therapeutic effect to a certain extent in addition to its important diagnostic value.

ACKNOWLEDGEMENTS

The authors are very grateful to the patient for participating in this study.

FOOTNOTES

Chen YY reviewed the literature, analyzed the patient data and wrote the manuscript; Xue XH and Chen YY were responsible for data collection; All the authors read and approved the final manuscript.

mNGS is a multi-faceted technique which can determine pathogenic agents more quickly and accurately in contrast to conventional approaches and can even offer novel enlightenment regarding illness propagation, virulence, and antibiotic tolerance. In contrast to conventional identification approaches which can merely identify some target pathogenic agents, mNGS is a shotgun sequence identification approach of ribonucleic acids (RNAs) and DNAs from clinic specimens, in which the entire DNAs or RNAs of the specimen to be examined are blended and subjected to sequencing, and the data are afterwards contrasted with the pathogenic agent data base to acquire pathogen categorization data. Such approach can identify substantial pathogenic agents in a run in 48 h. The pathogenic agent profiles involve nearly every virus, bacterium, fungus, and parasite which is capable of infecting sufferers. The detailed description of the materials and approaches for mNGS were presented by supplemental material.

The patient developed dizziness, nausea, and vomiting 4 d prior. The vomit was non-brown-colored stomach contents, accompanied by confusion, headache, and hearing loss in both ears. One day prior,his dizziness aggravated, and he presented to the hospital.

The authors declare that they have no conflicts of interest.

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

China

Ying-Ying Chen 0000-0002-0668-4285; Xin-Hong Xue 0000-0003-0034-3831.

Chang KL

A

4.药材规范化种植面积和认证情况。种植面积甘肃最大，达100万亩，其他省（区）几十万亩不等，GAP认证基地陕西最多，为7个。

Chang KL