| Abstract | Neuroinvazivna West Nile virusna (NI WNV) bolest predstavlja rijetko, ali teško očitovanje WNV infekcije. Na ovaj način oboli manje od 1% bolesnika. Rizični čimbenici za pojavu NI WNV infekcije su starija životna dob, kronične bolesti (šećerna bolest, hipertenzija) te imunosupresija (najčešće zbog transplantacije solidnih organa). NI WNV infekcija najčešće se očituje sindromom meningoencefalitisa, mijelitisa ili flakcidne pareze. Kako je u Hrvatskoj 2018. godine zabilježena do sada najveća epidemija WNV bolesti, u ovom radu želimo prezentirati ključne značajke bolesnika s teškim oblikom NI WNV infekcije koji su liječeni u Zavodu za intenzivno liječenje i neuroinfektologiju Klinike za infektivne bolesti „Dr. Fran Mihaljević“ u Zagrebu tijekom navedenog epidemijskog razdoblja. Liječeno je 12 bolesnika, od toga 8 muškaraca, medijan dobi iznosio je 73 (minimum 59, maksimum 84) godine. Pet bolesnika bili su iz Grada Zagreba, 2 iz Zagrebačke, te po jedan bolesnik iz Karlovačke, Međimurske, Koprivničko-križevačke, Varaždinske i Virovitičke županije. Polovica bolesnika su stanovnici prigradskih naselja, dok su polovica bili stanovnici gradova. Za dvojicu bolesnika je bilo poznato da su 4 tjedna ranije putovali (iz Ohio, SAD i u Bosansku Gradišku, BIH). Niti jedan bolesnik nije imao podatak o prethodnom cijepljenju protiv krpeljnog meningoencefalitisa i/ili žute groznice. Većina bolesnika su naveli komorbiditete, od kojih su najčešći bili arterijska hipertenzija (11/12), šećerna bolest (4/12) i hiperlipidemija (3/12). Dvojica bolesnika su imali transplantiran bubreg (4 tjedna ranije i 5 godina ranije) te su primali imunosupresiju. Vrijeme od pojave prvih simptoma do hospitalizacije iznosilo je medijan 5 (minimum 1, maksimum 13) dana. Najčešći klinički simptomi bili su vrućica (12/12), kvantitativni poremećaj svijesti (6/12), gastrointestinalni simptomi (6/12), glavobolja (4/12) te opća slabost (4/12). Svi bolesnici su se prezentirali kliničkom slikom meningoencefalitisa. Tijekom liječenja u intenzivnoj jedinici 8 bolesnika su intubirani i mehanički ventilirani, medijan trajanja mehaničke ventilacije bio je 14.5 dana (minimum 5, maksimum 73 dana). Medijan trajanja hospitalizacije u JIL-u iznosio je 24.5 dana (minimum 4, maksimum 73 dana), dok je medijan trajanja ukupne hospitalizacije iznosio 51.5 dan (minimum 19, maksimum 97 dana). Dva bolesnika su preminula tijekom liječenja u JIL-u. Medijan Glasgow outcome score (GOS) kod otpusta iz JIL-a iznosio 3 (minimum 3, maksimum 4). Karnofsky performance score iznosio je median je 40% (minimum 30% do 70%).
Zaključno se može reći da je u RH, NI WNV bolest rijetka, uglavnom pogađa bolesnike starije životne dobi sa značajnim komorbiditetima (arterijska hipertenzija, šećerna bolest, stanje nakon transplantacije bubrega). Ovi bolesnici često imaju potrebu za intenzivnim liječenjem, intubacijom, produženom mehaničkom ventilacijom, dugim boravkom u JIL-u i dugotrajnom hospitalizacijom te kasnijom medicinskom rehabilitacijom. Dakle, radi se o životno ugrožavajući bolesti koja pacijentima može teško narušiti zdravlje, te predstavlja veliki izazov za liječenje. |
| Abstract (english) | Neuroinvasive West Nile viral (NI WNV) disease is a rare but difficult manifestation of WNV infection. Less than 1% of infected patients will be affected with neuroinvasive disease. The risk factors for NI WNV infection are older age, chronic illness (diabetes, hypertension) and immunosuppression (most commonly due to organ transplantation). NI WNV infection is most often manifested by meningoencephalitis syndrome, myelitis, or flaccid paresis. The largest epidemic of WNV infection ever recorded in Croatia was in 2018. In this paper, we will present the key features of the severe form of NI WNV infection that has been treated at the Department for intensive medicine and neuroinfections of the University Hospital for Infectious Diseases "Dr. Fran Mihaljević ", Zagreb during 2018 epidemic period. Of the 12 patients treated, 8 were males, the median patient age was 73 (minimum 59, maximum 84) years. Five patients were from the Grad Zagreb County, 2 from Zagrebačka County and one from Karlovačka, Međimurska, Koprivničko-križevačka, Varaždinska and Virovitička County. Half of the patients were residents of suburb areas, while half of them were town residents. Two patients reported traveling 4 weeks earlier (from Ohio, USA and Bosanska Gradiška, BIH). None of the patients provided any information on previous vaccination against tick-borne encephalitis and/or yellow fever. Most patients reported comorbidities, most commonly arterial hypertension (11/12), diabetes (4/12) and hyperlipidemia (3/12). Two patients had transplanted kidney (4 weeks earlier and 5 years earlier) and received immunosuppression. The time period from first symptoms onset to hospitalization was median 5 (minimum 1, maximum 13) days. The most common clinical symptoms were fever (12/12), altered mental status (6/12), gastrointestinal symptoms (6/12), headache (4/12) and general weakness (4/12). All patients presented with a clinical feature of a meningoencephalitis. During treatment in the Intensive care unit (ICU), 8 patients were intubated and mechanically ventilated, the median duration of mechanical ventilation was 14.5 days (minimum 5, maximum 73 days). The median duration of hospitalization in ICU was 24.5 days (minimum 4, maximum 73 days), while the median duration of total hospitalization was 51.5 days (minimum 19, maximum 97 days). Two patients died during treatment at ICU. Median Glasgow score (GOS) at the time of release from the ICU was 3 (minimum 3, maximum 4). Karnofsky performance score averaged 40% (minimum 30% to 70%).
To conclude, NI WNV disease in Croatia is rare, mainly affects elderly patients with significant comorbidities (arterial hypertension, diabetes mellitus, kidney transplant status). These patients often require intensive treatment, intubation, extended mechanical ventilation, long stay in ICU, long-term hospitalization and medical rehabilitation. NI WNV infection is a life-threatening disease that can severely affect patient’s health and it presents a great therapeutic challenge. |
