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Kim M, Choi Y, Kim SY, Cho A, Kim H, Chae JH, Kim KJ, Park D, Kwon YS, Kim MJ, Yum MS, Kong JH, Lee YJ, Lim BC. Severe Neurological Manifestation Associated With Coronavirus Disease 2019 in Children During the Omicron Variant-Predominant Period. Pediatr Neurol 2024; 156:17-25. [PMID: 38692086 DOI: 10.1016/j.pediatrneurol.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 11/13/2023] [Accepted: 04/02/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND The Omicron variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is known to be more infectious and less severe than the other variants. Despite the increasing number of symptomatic patients, severe neurological complications in children with the Omicron variant have been reported rarely, unlike with wild-type or Delta variants. This study aimed to investigate severe neurological complications in children with Omicron variant infection. METHODS We conducted a retrospective study of 17 pediatric patients with severe neurological manifestations associated with coronavirus disease 2019 in Korea during the Omicron variant prevalence, from January 1 to April 30, 2022. RESULTS Among the 17 patients, 11 had pre-existing neurological disabilities and nine met the criteria for multisystem inflammatory syndrome in children (MIS-C). Four of the five vaccine-eligible patients (12 years and older) were unvaccinated. Severe neurological manifestations included acute necrotizing encephalopathy, acute fulminant cerebral edema, acute disseminated encephalomyelitis, basal ganglia encephalitis, unclassified severe encephalopathy/encephalitis, and refractory status dystonicus. Patients with MIS-C and underlying neurological disabilities had longer median hospital and intensive care unit stays compared with those without these conditions. Five patients survived with new neurological deficits at the one-year follow-up, and three died, all of whom had underlying neurological disabilities. CONCLUSIONS This study shows that severe neurological complications in pediatric patients with the Omicron variant of SARS-CoV-2 occur infrequently but may lead to significant morbidity and mortality, especially among those with pre-existing neurological disabilities and unvaccinated individuals. Continued efforts are necessary to prevent and manage such complications in these vulnerable populations.
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Affiliation(s)
- Minhye Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University, College of Medicine, Seoul, Korea
| | - Younghun Choi
- Department of Radiology, Seoul National University Children's Hospital, Seoul National University, College of Medicine, Seoul, Korea
| | - Soo Yeon Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University, College of Medicine, Seoul, Korea
| | - Anna Cho
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Seoul National University College of Medicine, Seoul, Korea
| | - Hunmin Kim
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Seoul National University College of Medicine, Seoul, Korea
| | - Jong Hee Chae
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University, College of Medicine, Seoul, Korea
| | - Ki Joong Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University, College of Medicine, Seoul, Korea
| | - Dasom Park
- Department of Pediatrics, Inha University Hospital, Inha University, College of Medicine, Incheon, Korea
| | - Young Se Kwon
- Department of Pediatrics, Inha University Hospital, Inha University, College of Medicine, Incheon, Korea
| | - Min-Jee Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Mi-Sun Yum
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Ju Hyun Kong
- Department of Pediatrics, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, Korea
| | - Yoon Jin Lee
- Department of Pediatrics, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, Korea
| | - Byung Chan Lim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University, College of Medicine, Seoul, Korea.
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Lee EP, Lin JJ, Chang HP, Yen CW, Hsieh MS, Chan OW, Lin KL, Su YT, Mu CT, Hsia SH. Ferritin as an Effective Predictor of Neurological Outcomes in Children With Acute Necrotizing Encephalopathy. Pediatr Neurol 2024; 152:162-168. [PMID: 38295717 DOI: 10.1016/j.pediatrneurol.2023.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 04/26/2023] [Accepted: 12/31/2023] [Indexed: 02/20/2024]
Abstract
BACKGROUND Acute necrotizing encephalopathy (ANE) is a fulminant disease with poor prognosis. Cytokine storm is the important phenomenon of ANE that affects the brain and multiple organs. The study aimed to identify whether hyperferritinemia was associated with poor prognosis in patients with ANE. METHODS All patients with ANE had multiple symmetric lesions located in the bilateral thalami and other regions such as brainstem tegmentum, cerebral white matter, and cerebellum. Neurological outcome at discharge was evaluated by pediatric neurologists using the Pediatric Cerebral Performance Category Scale. All risk factors associated with poor prognosis were further analyzed using receiver operating characteristic curve analysis. RESULTS Twenty-nine patients with ANE were enrolled in the current study. Nine (31%) patients achieved a favorable neurological outcome, and 20 (69%) patients had poor neurological outcomes. results The group of poor neurological outcome had significantly higher proportion of shock on admission and brainstem involvement. Based on multivariate logistic regression analysis, ferritin, aspartate aminotransferase (AST), and ANE severity score (ANE-SS) were the predictors associated with outcomes. The appropriate cutoff value for predicting neurological outcomes in patients with ANE was 1823 ng/mL for ferritin, 78 U/L for AST, and 4.5 for ANE-SS. Besides, comparison analyses showed that higher level of ferritin and ANE-SS were significantly correlated with brainstem involvement (P < 0.05). CONCLUSIONS Ferritin may potentially be a prognostic factor in patients with ANE. Hyperferritinemia is associated with poor neurological outcomes in patients with ANE and ferritin levels more than 1823 ng/mL have about eightfold increased risk of poor neurological outcome.
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Affiliation(s)
- En-Pei Lee
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Han-Pi Chang
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chen-Wei Yen
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Nephrology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Shun Hsieh
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taoyuan Branch, Taoyuan, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Oi-Wa Chan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kuang-Lin Lin
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ya-Ting Su
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Ting Mu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Shao-Hsuan Hsia
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Lee VW, Kam KQ, Mohamed AR, Musa H, Anandakrishnan P, Shen Q, Palazzo AF, Dale RC, Lim M, Thomas T. Defining the Clinicoradiologic Syndrome of SARS-CoV-2 Acute Necrotizing Encephalopathy: A Systematic Review and 3 New Pediatric Cases. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200186. [PMID: 38086061 PMCID: PMC10758947 DOI: 10.1212/nxi.0000000000200186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 10/02/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND AND OBJECTIVES We characterize clinical and neuroimaging features of SARS-CoV-2-related acute necrotizing encephalopathy (ANE). METHODS Systematic review of English language publications in PubMed and reference lists between January 1, 2020, and June 30, 2023, in accordance with PRISMA guidelines. Patients with SARS-CoV-2 infection who fulfilled diagnostic criteria for sporadic and genetic ANE were included. RESULTS From 899 articles, 20 cases (17 single case reports and 3 additional cases) were curated for review (50% female; 8 were children). Associated COVID-19 illnesses were febrile upper respiratory tract infections in children while adults had pneumonia (45.6%) and myocarditis (8.2%). Children had early neurologic deterioration (median day 2 in children vs day 4 in adults), seizures (5 (62.5%) children vs 3 of 9 (33.3%) adults), and motor abnormalities (6 of 7 (85.7%) children vs 3 of 7 (42.9%) adults). Eight of 12 (66.7%) adults and 4 (50.0%) children had high-risk ANE scores. Five (62.5%) children and 12 (66.7%) adults had brain lesions bilaterally and symmetrically in the putamina, external capsules, insula cortex, or medial temporal lobes, in addition to typical thalamic lesions of ANE. Hypotension was only seen in adults (30%). Hematologic derangements were common: lymphopenia (66.7%), coagulopathy (60.0%), or elevated D-dimers (100%), C-reactive protein (91.7%), and ferritin (62.5%). A pathogenic heterozygous c/.1754 C>T variant in RANBP2 was present in 2 children: one known to have this before SARS-CoV-2 infection, and a patient tested because the SARS-CoV-2 infection was the second encephalopathic illness. Three other children with no prior encephalopathy or family history of encephalopathy were negative for this variant. Fifteen (75%) received immunotherapy (with IV methylprednisolone, immunoglobulins, tocilizumab, or plasma exchange): 6 (40.0%) with monotherapy and 9 (60.0%) had combination therapy. Deaths were in 8 of 17 with data (47.1%): a 2-month-old male infant and 7 adults (87.5%) of median age 56 years (33-70 years), 4 of whom did not receive immunotherapy. DISCUSSION Children and adults with SARS-CoV-2 ANE have similar clinical features and neuroimaging characteristics. Mortality is high, predominantly in patients not receiving immunotherapy and at the extremes of age.
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Affiliation(s)
- Vanessa W Lee
- From the Children's Neurosciences (V.W.L., M.L.), Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre; Infectious Disease Service (K.Q.K.), Department of Paediatrics, KK Women's and Children's Hospital; SingHealth Duke-NUS Paediatrics Academic Clinical Program (ACP) (K.Q.K., T.T.), KK Women's and Children's Hospital, Singapore; Paediatric Neurology Unit (A.R.M., H.M., P.A.), Hospital Tunku Azizah, Kuala Lumpur; Department of Paediatrics (H.M.), Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang; Department of Immunology (Q.S.), School of Basic Medical Sciences, Fujian Medical University; Department of Obstetrics (Q.S.), Fujian Maternity and Child Health Hospital, Fuzhou, China; Department of Biochemistry (A.F.P.), University of Toronto, Ontario, Canada; Kids Neuroscience Centre (R.C.D.), The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney; Clinical School (R.C.D.), The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia; Department Women and Children's Health (M.L.), School of Life Course Sciences (SoLCS), King's College London, United Kingdom; and Neurology Service (T.T.), Department of Paediatrics, KK Women's and Children's Hospital, Singapore
| | - Kai Qian Kam
- From the Children's Neurosciences (V.W.L., M.L.), Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre; Infectious Disease Service (K.Q.K.), Department of Paediatrics, KK Women's and Children's Hospital; SingHealth Duke-NUS Paediatrics Academic Clinical Program (ACP) (K.Q.K., T.T.), KK Women's and Children's Hospital, Singapore; Paediatric Neurology Unit (A.R.M., H.M., P.A.), Hospital Tunku Azizah, Kuala Lumpur; Department of Paediatrics (H.M.), Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang; Department of Immunology (Q.S.), School of Basic Medical Sciences, Fujian Medical University; Department of Obstetrics (Q.S.), Fujian Maternity and Child Health Hospital, Fuzhou, China; Department of Biochemistry (A.F.P.), University of Toronto, Ontario, Canada; Kids Neuroscience Centre (R.C.D.), The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney; Clinical School (R.C.D.), The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia; Department Women and Children's Health (M.L.), School of Life Course Sciences (SoLCS), King's College London, United Kingdom; and Neurology Service (T.T.), Department of Paediatrics, KK Women's and Children's Hospital, Singapore
| | - Ahmad R Mohamed
- From the Children's Neurosciences (V.W.L., M.L.), Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre; Infectious Disease Service (K.Q.K.), Department of Paediatrics, KK Women's and Children's Hospital; SingHealth Duke-NUS Paediatrics Academic Clinical Program (ACP) (K.Q.K., T.T.), KK Women's and Children's Hospital, Singapore; Paediatric Neurology Unit (A.R.M., H.M., P.A.), Hospital Tunku Azizah, Kuala Lumpur; Department of Paediatrics (H.M.), Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang; Department of Immunology (Q.S.), School of Basic Medical Sciences, Fujian Medical University; Department of Obstetrics (Q.S.), Fujian Maternity and Child Health Hospital, Fuzhou, China; Department of Biochemistry (A.F.P.), University of Toronto, Ontario, Canada; Kids Neuroscience Centre (R.C.D.), The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney; Clinical School (R.C.D.), The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia; Department Women and Children's Health (M.L.), School of Life Course Sciences (SoLCS), King's College London, United Kingdom; and Neurology Service (T.T.), Department of Paediatrics, KK Women's and Children's Hospital, Singapore
| | - Husna Musa
- From the Children's Neurosciences (V.W.L., M.L.), Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre; Infectious Disease Service (K.Q.K.), Department of Paediatrics, KK Women's and Children's Hospital; SingHealth Duke-NUS Paediatrics Academic Clinical Program (ACP) (K.Q.K., T.T.), KK Women's and Children's Hospital, Singapore; Paediatric Neurology Unit (A.R.M., H.M., P.A.), Hospital Tunku Azizah, Kuala Lumpur; Department of Paediatrics (H.M.), Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang; Department of Immunology (Q.S.), School of Basic Medical Sciences, Fujian Medical University; Department of Obstetrics (Q.S.), Fujian Maternity and Child Health Hospital, Fuzhou, China; Department of Biochemistry (A.F.P.), University of Toronto, Ontario, Canada; Kids Neuroscience Centre (R.C.D.), The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney; Clinical School (R.C.D.), The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia; Department Women and Children's Health (M.L.), School of Life Course Sciences (SoLCS), King's College London, United Kingdom; and Neurology Service (T.T.), Department of Paediatrics, KK Women's and Children's Hospital, Singapore
| | - Poorani Anandakrishnan
- From the Children's Neurosciences (V.W.L., M.L.), Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre; Infectious Disease Service (K.Q.K.), Department of Paediatrics, KK Women's and Children's Hospital; SingHealth Duke-NUS Paediatrics Academic Clinical Program (ACP) (K.Q.K., T.T.), KK Women's and Children's Hospital, Singapore; Paediatric Neurology Unit (A.R.M., H.M., P.A.), Hospital Tunku Azizah, Kuala Lumpur; Department of Paediatrics (H.M.), Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang; Department of Immunology (Q.S.), School of Basic Medical Sciences, Fujian Medical University; Department of Obstetrics (Q.S.), Fujian Maternity and Child Health Hospital, Fuzhou, China; Department of Biochemistry (A.F.P.), University of Toronto, Ontario, Canada; Kids Neuroscience Centre (R.C.D.), The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney; Clinical School (R.C.D.), The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia; Department Women and Children's Health (M.L.), School of Life Course Sciences (SoLCS), King's College London, United Kingdom; and Neurology Service (T.T.), Department of Paediatrics, KK Women's and Children's Hospital, Singapore
| | - Qingtang Shen
- From the Children's Neurosciences (V.W.L., M.L.), Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre; Infectious Disease Service (K.Q.K.), Department of Paediatrics, KK Women's and Children's Hospital; SingHealth Duke-NUS Paediatrics Academic Clinical Program (ACP) (K.Q.K., T.T.), KK Women's and Children's Hospital, Singapore; Paediatric Neurology Unit (A.R.M., H.M., P.A.), Hospital Tunku Azizah, Kuala Lumpur; Department of Paediatrics (H.M.), Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang; Department of Immunology (Q.S.), School of Basic Medical Sciences, Fujian Medical University; Department of Obstetrics (Q.S.), Fujian Maternity and Child Health Hospital, Fuzhou, China; Department of Biochemistry (A.F.P.), University of Toronto, Ontario, Canada; Kids Neuroscience Centre (R.C.D.), The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney; Clinical School (R.C.D.), The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia; Department Women and Children's Health (M.L.), School of Life Course Sciences (SoLCS), King's College London, United Kingdom; and Neurology Service (T.T.), Department of Paediatrics, KK Women's and Children's Hospital, Singapore
| | - Alexander F Palazzo
- From the Children's Neurosciences (V.W.L., M.L.), Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre; Infectious Disease Service (K.Q.K.), Department of Paediatrics, KK Women's and Children's Hospital; SingHealth Duke-NUS Paediatrics Academic Clinical Program (ACP) (K.Q.K., T.T.), KK Women's and Children's Hospital, Singapore; Paediatric Neurology Unit (A.R.M., H.M., P.A.), Hospital Tunku Azizah, Kuala Lumpur; Department of Paediatrics (H.M.), Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang; Department of Immunology (Q.S.), School of Basic Medical Sciences, Fujian Medical University; Department of Obstetrics (Q.S.), Fujian Maternity and Child Health Hospital, Fuzhou, China; Department of Biochemistry (A.F.P.), University of Toronto, Ontario, Canada; Kids Neuroscience Centre (R.C.D.), The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney; Clinical School (R.C.D.), The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia; Department Women and Children's Health (M.L.), School of Life Course Sciences (SoLCS), King's College London, United Kingdom; and Neurology Service (T.T.), Department of Paediatrics, KK Women's and Children's Hospital, Singapore
| | - Russell C Dale
- From the Children's Neurosciences (V.W.L., M.L.), Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre; Infectious Disease Service (K.Q.K.), Department of Paediatrics, KK Women's and Children's Hospital; SingHealth Duke-NUS Paediatrics Academic Clinical Program (ACP) (K.Q.K., T.T.), KK Women's and Children's Hospital, Singapore; Paediatric Neurology Unit (A.R.M., H.M., P.A.), Hospital Tunku Azizah, Kuala Lumpur; Department of Paediatrics (H.M.), Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang; Department of Immunology (Q.S.), School of Basic Medical Sciences, Fujian Medical University; Department of Obstetrics (Q.S.), Fujian Maternity and Child Health Hospital, Fuzhou, China; Department of Biochemistry (A.F.P.), University of Toronto, Ontario, Canada; Kids Neuroscience Centre (R.C.D.), The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney; Clinical School (R.C.D.), The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia; Department Women and Children's Health (M.L.), School of Life Course Sciences (SoLCS), King's College London, United Kingdom; and Neurology Service (T.T.), Department of Paediatrics, KK Women's and Children's Hospital, Singapore
| | - Ming Lim
- From the Children's Neurosciences (V.W.L., M.L.), Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre; Infectious Disease Service (K.Q.K.), Department of Paediatrics, KK Women's and Children's Hospital; SingHealth Duke-NUS Paediatrics Academic Clinical Program (ACP) (K.Q.K., T.T.), KK Women's and Children's Hospital, Singapore; Paediatric Neurology Unit (A.R.M., H.M., P.A.), Hospital Tunku Azizah, Kuala Lumpur; Department of Paediatrics (H.M.), Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang; Department of Immunology (Q.S.), School of Basic Medical Sciences, Fujian Medical University; Department of Obstetrics (Q.S.), Fujian Maternity and Child Health Hospital, Fuzhou, China; Department of Biochemistry (A.F.P.), University of Toronto, Ontario, Canada; Kids Neuroscience Centre (R.C.D.), The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney; Clinical School (R.C.D.), The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia; Department Women and Children's Health (M.L.), School of Life Course Sciences (SoLCS), King's College London, United Kingdom; and Neurology Service (T.T.), Department of Paediatrics, KK Women's and Children's Hospital, Singapore
| | - Terrence Thomas
- From the Children's Neurosciences (V.W.L., M.L.), Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre; Infectious Disease Service (K.Q.K.), Department of Paediatrics, KK Women's and Children's Hospital; SingHealth Duke-NUS Paediatrics Academic Clinical Program (ACP) (K.Q.K., T.T.), KK Women's and Children's Hospital, Singapore; Paediatric Neurology Unit (A.R.M., H.M., P.A.), Hospital Tunku Azizah, Kuala Lumpur; Department of Paediatrics (H.M.), Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang; Department of Immunology (Q.S.), School of Basic Medical Sciences, Fujian Medical University; Department of Obstetrics (Q.S.), Fujian Maternity and Child Health Hospital, Fuzhou, China; Department of Biochemistry (A.F.P.), University of Toronto, Ontario, Canada; Kids Neuroscience Centre (R.C.D.), The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney; Clinical School (R.C.D.), The Children's Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia; Department Women and Children's Health (M.L.), School of Life Course Sciences (SoLCS), King's College London, United Kingdom; and Neurology Service (T.T.), Department of Paediatrics, KK Women's and Children's Hospital, Singapore
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Maejima N, Matsumoto S, Hayakawa I, Koike K, Abe Y. A Case of Acute Necrotizing Encephalopathy With Multiple Organ Failure Following COVID-19. Cureus 2024; 16:e51665. [PMID: 38313914 PMCID: PMC10838156 DOI: 10.7759/cureus.51665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 02/06/2024] Open
Abstract
Neurological complications are frequent non-respiratory complications associated with coronavirus disease 2019 (COVID-19), and acute encephalopathy (AE) has been reported to occur in 2.2% of patients. Among many phenotypes of AEs, acute necrotizing encephalopathy (ANE) is associated with multiple organ failure (MOF), leading to severe neurological morbidity and mortality. A previously healthy seven-year-old girl presented with a one-day history of fever followed by 12 hours of vomiting and altered consciousness. On arrival, the patient was in shock. Blood tests revealed severe acute liver failure and kidney injury, accompanied by coagulopathy. The serum interleukin-6 levels were also elevated. PCR testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was positive. A head CT scan showed heterogeneous low-density areas in the bilateral thalamus, without brainstem involvement. She was diagnosed as ANE complicated with MOF (ANE severity score = 6). Intravenous methylprednisolone and therapeutic plasma exchange (TPE) were initiated with neurocritical care. After the introduction of TPE, hemodynamics improved rapidly, followed by gradual improvement in neurological manifestations. Upon follow-up after two months, no neurological or systemic sequelae were noted. Although further studies are needed, our case suggests that early immunomodulatory therapy and TPE may have contributed to the improvement in ANE and MOF associated with COVID-19.
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Affiliation(s)
- Naohiko Maejima
- Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, JPN
| | - Shotaro Matsumoto
- Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, JPN
| | - Itaru Hayakawa
- Division of Neurology, National Center for Child Health and Development, Tokyo, JPN
| | - Kentaro Koike
- Division of Neurology, National Center for Child Health and Development, Tokyo, JPN
| | - Yuichi Abe
- Division of Neurology, National Center for Child Health and Development, Tokyo, JPN
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Fischell SZ, Fischell J, Kliot T, Tumulty J, Thompson SJ, Raees MQ. Case report: Acute necrotizing encephalopathy: a report of a favorable outcome and systematic meta-analysis of outcomes with different immunosuppressive therapies. Front Neurol 2023; 14:1239746. [PMID: 37745654 PMCID: PMC10512083 DOI: 10.3389/fneur.2023.1239746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/14/2023] [Indexed: 09/26/2023] Open
Abstract
Acute Necrotizing Encephalopathy (ANE) is a condition characterized by symmetric, bilateral lesions affecting the thalamus and potentially other areas of the brain following an acute febrile illness. It manifests clinically as abrupt development of encephalopathy, or alteration in mental status that often includes development of seizures and progression to coma. Treatment strategies combine immunosuppressive therapies and supportive care with varying levels of recovery, however there are no universally accepted, data-driven, treatment algorithms for ANE. We first report a case of a previously healthy 10-year-old female with acute onset diplopia, visual hallucinations, lethargy, and seizures in the setting of subacute non-specific viral symptoms and found to have bilateral thalamic and brainstem lesions on MRI consistent with ANE. She was treated with a combination of immunomodulatory therapies and ultimately had a good outcome. Next, we present a meta-analysis of 10 articles with a total of 158 patients meeting clinical and radiographic criteria for ANE. Each article reported immunosuppressive treatments received, and associated morbidity or mortality outcome for each individual patient. Through our analysis, we confirm the effectiveness of high-dose, intravenous, methylprednisolone (HD-IV-MP) therapy implemented early in the disease course (initiation within 24 h of neurologic symptom onset). There was no significant difference between patients treated with and without intravenous immunoglobulin (IVIG). There was no benefit of combining IVIG with early HD-IV-MP. There is weak evidence suggesting a benefit of IL-6 inhibitor tocilizumab, especially when used in combination with early HD-IV-MP, though this analysis was limited by sample size. Finally, plasma exchange (PLEX) improved survival. We hope this meta-analysis will be useful for clinicians making treatment decisions for patients with this potentially devastating condition.
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Affiliation(s)
- Stefanie Zaner Fischell
- Department of Pediatrics, University of Maryland Medical Center, Baltimore, MD, United States
| | - Jonathan Fischell
- Division of Pediatric Neurology, Department of Pediatrics and Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Tamara Kliot
- Department of Pediatrics, University of Maryland Medical Center, Baltimore, MD, United States
| | - Jamie Tumulty
- Division of Critical Care, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Stephen J. Thompson
- Division of Pediatric Neurology, Department of Pediatrics and Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Madiha Q. Raees
- Division of Critical Care, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, United States
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6
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Hosie PH, Lim C, Scott TRD, Cardamone M, Farrar MA, Frith C, Andrews PI, Pinner J, Pillai S. Treatment of severe acute necrotizing encephalopathy of childhood with interleukin-6 receptor blockade in the first 24 h as add-on immunotherapy shows favorable long-term outcome at 2 years. Brain Dev 2023; 45:401-407. [PMID: 36967317 DOI: 10.1016/j.braindev.2023.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/28/2023] [Accepted: 03/06/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Acute necrotizing encephalopathy (ANE) of childhood is a rare and devastating infection-associated acute encephalopathy. While there are no consensus treatments for ANE, recent case reports suggest a beneficial role for the use of tocilizumab, a recombinant humanized monoclonal antibody against the interleukin-6 (IL-6) receptor. The correlation of the timing of add-on tocilizumab in relation to long-term outcome has not been reported. METHODS We report on the timing of administration of tocilizumab in two patients classified as high-risk using the ANE severity score (ANE-SS) with respect to the long-term outcome at 2 years. RESULTS Case 1 was a 19-month-old previously well boy who presented to a tertiary children's hospital with seizures, evolving status dystonicus and shock. Case 2 was a three-year-old boy who presented to a peripheral hospital with fever, sepsis and encephalopathy. The patients were transferred to the tertiary intensive care unit and MRI confirmed ANE with extensive brainstem involvement. Case 1 received intravenous immunoglobulin (IVIg), methylprednisolone and tocilizumab at 21, 39 and 53 h respectively. His modified Rankin scale (mRS) at discharge and two years was unchanged at 5. The functional independence measure - for children (WeeFIM) at two years was very low (19/126). Case 2 received dexamethasone at 1 h, methylprednisolone at 21 h and IVIg and tocilizumab at 22 h. The mRS at discharge and two years was 4 and 3 respectively. The WeeFIM score at two years showed substantial improvement (96/126). CONCLUSION The very early use of interleukin-6 blockade as 'add-on' immunotherapy in the first 24 h demonstrates potential for improving the long-term outcome in patients classified as high-risk using the ANE-SS.
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Affiliation(s)
- Patrick H Hosie
- Department of Neurology, Sydney Children's Hospital, Randwick, Australia
| | - Carylyn Lim
- Rehab2Kids, Sydney Children's Hospital, Randwick, Australia
| | - Timothy R D Scott
- Rehab2Kids, Sydney Children's Hospital, Randwick, Australia; Discipline of Pediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Australia; Graduate School of Biomedical Engineering, UNSW Sydney, Australia
| | - Michael Cardamone
- Department of Neurology, Sydney Children's Hospital, Randwick, Australia; Discipline of Pediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Australia
| | - Michelle A Farrar
- Department of Neurology, Sydney Children's Hospital, Randwick, Australia; Discipline of Pediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Australia
| | - Catherine Frith
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, Australia
| | - Peter I Andrews
- Department of Neurology, Sydney Children's Hospital, Randwick, Australia
| | - Jason Pinner
- Centre for Clinical Genetics, Sydney Children's Hospital, Randwick, Australia
| | - Sekhar Pillai
- Department of Neurology, Sydney Children's Hospital, Randwick, Australia; Discipline of Pediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Australia.
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7
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Azmi A, Zainal Abidin AS. Good Outcome With Respect to Acute Necrotizing Encephalitis in Children Associated With Post-infectious SARS-CoV-2. Cureus 2023; 15:e43198. [PMID: 37692682 PMCID: PMC10486289 DOI: 10.7759/cureus.43198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 09/12/2023] Open
Abstract
This case report demonstrates an excellent outcome in a child with acute necrotizing encephalitis that was likely associated with the post-infectious SARS-CoV-2. The aim of this report is to emphasize that early diagnosis and initiation of immunotherapy treatment may yield good outcome, particularly with the use of tocilizumab and high-dose methylprednisolone. Post immunotherapy, significant neurological improvement was seen through the gradual improvement of Glasgow Coma Scale (GCS) score of 6 to GCS score of 12 within three weeks and subsequently acquired almost full neurological function with minimally dependent activity of daily living (ADL) at eight weeks in the post-treatment follow-up. It is interesting to identify that the possible causative factor could be the natural infection in a vaccinated patient. This was evidenced by the persistently high SARS-CoV-2 immunoglobulin G (IgG)-Spike antibodies titre in a patient vaccinated with two doses of BNT162b2, 11 months before presentation.
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Affiliation(s)
- Anayasmin Azmi
- Paediatrics and Child Health, Medical Faculty, Universiti Teknologi Mara, Sungai Buloh, MYS
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8
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AlQasim E, Alawfi A, Hamad A, Alghamdi F, Albaradi BA. Human Herpesvirus-6 Encephalitis Associated With Acute Necrotizing Encephalopathy in an Immunocompetent Child: A Case Report and Literature Review. Cureus 2023; 15:e39897. [PMID: 37404398 PMCID: PMC10316458 DOI: 10.7759/cureus.39897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2023] [Indexed: 07/06/2023] Open
Abstract
Human herpesvirus type 6 (HHV-6) is a DNA virus considered a member of the Herpesviridae family. HHV-6 is acquired early in life, when it may cause roseola infantum and nonspecific febrile illnesses which is usually a self-limiting disease before the age of two. Primary HHV-6 encephalitis and acute necrotizing encephalopathy (ANE) are rare diseases to occur in immunocompetent children. We describe an unusual case of HHV-6 encephalitis with mixed features of acute necrotizing encephalopathy and acute disseminated encephalomyelitis and contextualize it with a review of the literature on HHV-6 encephalitis in immunocompetent children. Although the incidence of primary HHV-6 encephalitis is rare in immunocompetent children, HHV-6 encephalitis associated with acute necrotizing encephalopathy is a devastating disease, highly fatal and neurologically damaging disease. Therefore, early testing and diagnosis are crucial as well as effective management of encephalitis with antiviral therapy is highly recommended.
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Affiliation(s)
- Esraa AlQasim
- Pediatric Infectious Diseases, King Fahad Specialist Hospital, Dammam, SAU
| | | | - Abdalazeem Hamad
- Pediatric Infectious Diseases, King Fahad Specialist Hospital, Dammam, SAU
| | - Fouad Alghamdi
- Pediatric Neurology, King Fahad Specialist Hospital, Dammam, SAU
| | - Bandar A Albaradi
- Pediatric Infectious Diseases, King Fahad Specialist Hospital, Dammam, SAU
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9
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Kumar Singh P, Sharma R, Saini C, Murray J, Parrish Winesett S. Acute Necrotizing Encephalitis Due to Influenza B in a Child: A Case Report. Cureus 2023; 15:e38573. [PMID: 37288218 PMCID: PMC10243387 DOI: 10.7759/cureus.38573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2023] [Indexed: 06/09/2023] Open
Abstract
Acute necrotizing encephalitis (ANE) is a rare and life-threatening form of encephalitis associated with influenza virus and other pathogens. It is characterized by a rapid onset of neurological symptoms and has been linked to a cytokine storm within the brain. We present a unique case of an eight-year-old female with influenza B-associated ANE, involving multiple brain areas including the cerebellum and brainstem and cauda equina involvement. The patient had a rapid neurological deterioration, and MRI findings revealed extensive multifocal areas of abnormal brain parenchyma and inflammation with Guillain-Barre appearance in the cauda equina. To the best of our knowledge, this is the first reported case of ANE with cauda equina involvement leading to neurological deficits. Despite treatment with oseltamivir, steroids, and intravenous immunoglobulins, the patient had poor neurological outcomes, similar to those reported in the literature.
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Affiliation(s)
| | - Rohit Sharma
- Internal Medicine, Geisinger Health System, Wilkes-Barre, USA
| | | | - John Murray
- Neurology, Geisinger Commonwealth School of Medicine, Scranton, USA
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10
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Mori A, Kawano Y, Hara S, Numoto S, Kurahashi H, Okumura A. A nationwide survey of human metapneumovirus-associated encephalitis/encephalopathy in Japan. Brain Dev 2023; 45:197-204. [PMID: 36702664 DOI: 10.1016/j.braindev.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 12/13/2022] [Accepted: 01/03/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND As there have been no comprehensive reports of human metapneumovirus-associated encephalopathy (hMPVE), this study examined the clinical features of hMPVE in children in Japan. METHOD A nationwide survey of children with hMPVE was conducted using a structured research form. An initial survey asked pediatricians about children with hMPVE treated between 2014 and 2018. A second survey obtained patient information from hospitals that responded to the initial survey and those identified as having treated cases from a literature search. We collected demographic data, symptoms of hMPV infection, neurological symptoms, laboratory data, treatment, and outcomes. Outcomes were determined using the Pediatric Cerebral Performance Category Score. RESULT Clinical information was available for 16 children. Their median age was 37 months. Six had preexisting neurological disorders. The interval between the onsets of infection and hMPVE was 4 days. Outcomes were good in 11 patients and poor in 5. There were no significant differences in demographic data, neurological symptoms, or laboratory data between the patients with good and poor outcomes. The encephalopathy subtypes were acute encephalopathy with biphasic seizures and late reduced diffusion in 3, clinically mild encephalitis/encephalopathy with a reversible splenial lesion in 3, hemorrhagic shock and encephalopathy syndrome in 2, and others in 8. CONCLUSION The outcomes of children with hMPVE were not very different from those of acute encephalopathy due to other viruses. We found no factors associated with poor outcomes.
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Affiliation(s)
- Ayumi Mori
- Department of Pediatrics, Toyota Memorial Hospital, Japan
| | | | - Shinya Hara
- Department of Pediatrics, Toyota Memorial Hospital, Japan
| | - Shingo Numoto
- Department of Pediatrics, Aichi Medical University, Japan
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11
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Lee VWM, Khoo TB, Teh CM, Heng HS, Li L, Yusof YLM, Yahaya NA, Dharshini S, Wong SW, Nickson T. Factors associated with outcomes of severe acute necrotizing encephalopathy: A multicentre experience in Malaysia. Dev Med Child Neurol 2023. [PMID: 36748407 DOI: 10.1111/dmcn.15536] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 11/30/2022] [Accepted: 01/10/2023] [Indexed: 02/08/2023]
Abstract
This case series compared clinical variables and various combinations of immunotherapy received with outcomes of patients with severe acute necrotizing encephalopathy (ANE). We performed a retrospective review of clinical variables, immunotherapy received, and outcomes (based on the modified Rankin Scale) in Malaysia between February 2019 and January 2020. Twenty-seven children (12 male), aged 7 months to 14 years (mean 4 years) at diagnosis were included. Of these, 23 had an ANE severity score of 5 to 9 out of 9 (high risk). Eleven patients received tocilizumab (four in combination with methylprednisolone [MTP], seven with MTP + intravenous immunoglobulin [IVIG]) and 16 did not (two received MTP alone, 14 received MTP + IVIG). Nine died. Among the survivors, six had good outcomes (modified Rankin Score 0-2) at 6 months follow-up. All patients who received tocilizumab in combination with MTP + IVIG survived. Twenty children received first immunotherapy within 48 hours of admission. No significant association was found between the timing of first immunotherapy with outcomes. Those with brainstem dysfunction (p = 0.016) were observed to have poorer outcomes. This study showed a trend towards better survival when those with severe ANE were treated with tocilizumab in combination with MTP + IVIG. However, larger studies will be needed to determine the effect of this regime on the long-term outcomes.
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Affiliation(s)
| | - Teik Beng Khoo
- Paediatric Neurology Unit, Hospital Tunku Azizah, Kuala Lumpur, Malaysia
| | - Chee Ming Teh
- Pediatric Neurology Unit, Hospital Pulau Pinang, Pulau Pinang, Malaysia
| | - Hock Sin Heng
- Pediatric Neurology Unit, Sabah Women and Children Hospital, Kota Kinabalu, Malaysia
| | - Limin Li
- Division of Pediatric Neurology, Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Yusma Lyana Md Yusof
- Pediatric Unit, Faculty of Medicine, Universiti Teknologi Mara, Selangor Darul Ehsan, Malaysia
| | - Nor Azni Yahaya
- Paediatric Neurology Unit, Hospital Raja Perempuan Zainab II, Kota Bharu, Malaysia
| | - Sangita Dharshini
- Pediatric Neurology Unit, Subang Jaya Medical Centre, Selangor Darul Ehsan, Malaysia
| | - Sau Wei Wong
- Paediatric Neurology Unit, Hospital Pakar Kanak-Kanak Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Tai Nickson
- Paediatric Unit, Hospital Umum Sarawak, Sarawak, Malaysia
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12
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Ho JH, Lee CY, Chiong YK, Aoyama R, Fan LJ, Tan AH, Han VX. SARS-CoV-2-Related Acute Necrotizing Encephalopathy of Childhood With Good Response to Tocilizumab in an Adolescent. Pediatr Neurol 2023; 139:65-69. [PMID: 36529001 PMCID: PMC9694347 DOI: 10.1016/j.pediatrneurol.2022.11.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/16/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Acute necrotizing encephalopathy of childhood (ANEC) is a rare parainfectious neurological disorder. ANEC is associated with a high mortality rate and poor neurological outcomes. ANEC is postulated to arise from immune-mediated or metabolic processes driven by viral infections. Although there have been some case reports of acute necrotizing encephalopathy with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) coinfection in adults, paediatric cases are rare. METHODS A single case report of SARS-CoV-2-related ANEC in an 11-year-old boy is presented through retrospective chart review. Literature search was performed using PubMed, Embase, Cochrane database, and Google Scholar to compare and analyze similar cases of parainfectious immune-mediated encephalopathies related to SARS-CoV-2 in children. RESULTS An 11-year-old boy with acute SARS-CoV-2 infection presented with ophthalmoplegia, ataxia, and aphasia. Neuroimaging findings demonstrated significant swelling and signal changes in bilateral thalami, brainstem, and cerebellar hemispheres, consistent with ANEC. His high ANEC Severity Score indicated poor neurological prognosis. Treatment with a combination of early steroid therapy, intravenous immunoglobulin therapy, and targeted interleukin 6 (IL-6) blockade yielded good neurological improvements. Literature search identified 19 parainfectious immune-mediated neurological disorders related to SARS-CoV-2 in children. The only other pediatric ANEC case identified was postinfectious and thus not included. CONCLUSIONS This is the first report of a pediatric case of SARS-CoV-2-related ANEC, which responded well to early immunotherapy, including IL-6 blockade. Early immunotherapy with IL-6 blockade can be considered as an adjunct in managing severe ANEC.
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Affiliation(s)
- Jasmine H.Y. Ho
- Khoo Teck Puat - National University Children's Medical Institute, National University Hospital, Singapore, Singapore
| | - Cheryl Y.M. Lee
- Khoo Teck Puat - National University Children's Medical Institute, National University Hospital, Singapore, Singapore
| | - Yee Keow Chiong
- Khoo Teck Puat - National University Children's Medical Institute, National University Hospital, Singapore, Singapore
| | - Rie Aoyama
- Khoo Teck Puat - National University Children's Medical Institute, National University Hospital, Singapore, Singapore
| | - Li Jia Fan
- Khoo Teck Puat - National University Children's Medical Institute, National University Hospital, Singapore, Singapore
| | - Amos H.S. Tan
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
| | - Velda X. Han
- Khoo Teck Puat - National University Children's Medical Institute, National University Hospital, Singapore, Singapore,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore,Communications should be addressed to: Dr. Han; Department of Paediatrics; Khoo Teck Puat - National University Children's Medical Institute; National University Hospital of Singapore; 5 Lower Kent Ridge Road; Singapore 119074, Singapore
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13
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Hwee TANGP, Koh Cheng THOON. Imaging of Congenital/Childhood Central Nervous System Infections. Neuroimaging Clin N Am 2023; 33:207-224. [DOI: 10.1016/j.nic.2022.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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14
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Forest C, Laudisi M, Malaventura C, Tugnoli V, Pellino G, Marangoni E, Baldi E, Borgatti L, Pugliatti M, Suppiej A. Pediatric recurrent acute necrotizing encephalomyelitis, RANBP2 genotype and Sars-CoV-2 infection: Diagnosis, pathogenesis and targeted treatments from a case study. Eur J Paediatr Neurol 2023; 42:117-121. [PMID: 36621064 DOI: 10.1016/j.ejpn.2022.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 12/18/2022] [Accepted: 12/29/2022] [Indexed: 01/05/2023]
Abstract
Acute necrotizing encephalopathy (ANE) is a rare disease not yet described in children with Covid-19. RANBP2 gene variations are implicated in recurrences in the genetic form of ANE, the so called ANE1. We report the first case of pediatric ANE1 following Sars-CoV-2 infection. She had a first episode at 2 years of age following influenza type A with full recovery, many other respiratory and non-respiratory febrile viral infections without recurrences and a severe recurrence following Sars-CoV-2 infection, suggesting a potentiation effect on cytokine cascade. Her MRI showed the typical pattern of injury resembling that of mitochondrial disorders, and supported the role of RANBP2 in mitochondrial homeostasis. This case rises attention on diagnostic challenges and offers several interesting tips for discussion about new perspectives in pathogenesis and targeted treatments.
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Affiliation(s)
- Cristina Forest
- Department of Medical Sciences-Pediatric Section, University of Ferrara, Ferrara, Italy
| | - Michele Laudisi
- Department of Neuroscience and Rehabilitation, University of Ferrara, Italy
| | - Cristina Malaventura
- Department of Medical Sciences-Pediatric Section, University of Ferrara, Ferrara, Italy
| | - Valeria Tugnoli
- S. Anna University Hospital, Department of Neuroscience and Rehabilitation, Ferrara, Italy
| | - Giuditta Pellino
- Department of Medical Sciences-Pediatric Section, University of Ferrara, Ferrara, Italy
| | - Elisabetta Marangoni
- Department of Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Eleonora Baldi
- S. Anna University Hospital, Department of Neuroscience and Rehabilitation, Ferrara, Italy
| | - Luca Borgatti
- Pediatric Neuroradiology, S. Anna University Hospital, Ferrara, Italy
| | - Maura Pugliatti
- Department of Neuroscience and Rehabilitation, University of Ferrara, Italy; S. Anna University Hospital, Department of Neuroscience and Rehabilitation, Ferrara, Italy
| | - Agnese Suppiej
- Department of Medical Sciences-Pediatric Section, University of Ferrara, Ferrara, Italy.
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15
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Sun W, Fu C, Zhu X. Acute necrotizing encephalopathy associated with lymphoma-associated hemophagocytic lymphohistiocytosis: A case report and literature review. Front Oncol 2022; 12:986957. [DOI: 10.3389/fonc.2022.986957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/06/2022] [Indexed: 11/13/2022] Open
Abstract
Damage associated with lymphoma-associated hemophagocytic lymphohistiocytosis (LA-HLH) to the central nervous system (CNS) is not uncommon. However, the combination with brain damage resembling acute necrotizing encephalopathy (ANE) is rarely reported. Herein, we introduce the diagnosis and treatment of a case of ANE associated with LA-HLH in our hospital and review the relevant literature. After treatment, the child was discharged with only dysarthria and decreased sucking ability. The child is now discharged from the hospital for 6 months with regular follow-up. There were no disease recurrence signs. LA-HLH and ANE were related to cytokine storm. Therefore, early steroid application is essential for treating these diseases.
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16
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Chatur N, Yea C, Ertl-Wagner B, Yeh EA. Outcomes in influenza and RANBP2 mutation-associated acute necrotizing encephalopathy of childhood. Dev Med Child Neurol 2022; 64:1008-1016. [PMID: 35108406 DOI: 10.1111/dmcn.15165] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 12/22/2021] [Indexed: 12/17/2022]
Abstract
AIM To evaluate clinical and imaging features in patients with acute necrotizing encephalopathy of childhood (ANEC) to identify predictors of RANBP2 mutations, influenza association, and long-term outcomes. METHOD A retrospective chart review in patients with ANEC (2012-2020) seen at a tertiary pediatric center was performed. Children were included if they had acute inflammatory lesions in the basal ganglia and pons. Variables included presenting features, imaging characteristics, RANBP2 gene testing, nasopharyngeal swab findings, therapies, and long-term outcomes. RESULTS Twenty patients were included (average age at presentation 3y 6mo, interquartile range 3y 7mo, SD 2y 8mo; 14 females, six males). Three of the 20 experienced recurrences; one of the 20 died. Ten patients were influenza positive. Seven patients were RANBP2 mutation positive. A higher likelihood of hemorrhage was observed in patients who were influenza positive compared to influenza negative (p=0.048). Patients with influenza had a higher degree of thalamic hemorrhage (2, p=0.035) and greater extent of diffusion restriction (3, p=0.035) in semiquantitive analysis. INTERPRETATION Children with ANEC who are positive for influenza are more likely to have hemorrhage and greater thalamic swelling. RANBP2 status was predictive of relapse but not predictive of overall outcome.
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Affiliation(s)
- Nurin Chatur
- Department of Pediatrics, Division of Neurology, Hospital for Sick Children, Division of Neuroscience and Mental Health, SickKids Research Institute, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Carmen Yea
- Department of Pediatrics, Division of Neurology, Hospital for Sick Children, Division of Neuroscience and Mental Health, SickKids Research Institute, Toronto, Ontario, Canada
| | - Birgit Ertl-Wagner
- Division of Neuroradiology, Department of Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Division of Neuroscience and Mental Health, SickKids Research Institute, Toronto, Ontario, Canada
| | - E Ann Yeh
- Department of Pediatrics, Division of Neurology, Hospital for Sick Children, Division of Neuroscience and Mental Health, SickKids Research Institute, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
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17
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Early therapeutic plasma exchange may lead to complete neurological recovery in moderate to severe influenza-associated acute necrotizing encephalopathy. Brain Dev 2022; 44:492-497. [PMID: 35337691 DOI: 10.1016/j.braindev.2022.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 03/01/2022] [Accepted: 03/15/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Acute necrotizing encephalopathy (ANE) is a pediatric neurological disease, presumably caused by cytokine storms, with a poor prognosis. Immunomodulatory therapy, including therapeutic plasma exchange (TPE), could be an effective treatment. CASES Two patients with influenza-associated ANE were treated. The ANE severity scores were 3 and 8 in case 1 (a 3-y-old boy) and case 2 (a 7-y-old boy), respectively. In case 1, intravenous methylprednisolone and TPE were initiated at 8 and 16 h, respectively, after the onset of impaired consciousness. In case 2, multiple organ failure and septic shock persisted even after infusion of fluids and inotropic agents. Intravenous methylprednisolone and TPE were started at 5 and 9 h, respectively, after the onset of impaired consciousness, which improved the inotrope-refractory septic shock. Patient 1 and 2 achieved complete neurological recovery within 4 weeks and after 3 months, respectively. In both patients, cytokine levels were serially measured. There were increased serum interleukin (IL)-6 and IL-10 levels in both patients; patient 1 showed increased IL-6 levels in the initial cerebrospinal fluid sample. There was a post-treatment decrease in serum IL-6 levels in both cases. DISCUSSION Early intensive immunomodulatory therapy with TPE may improve neurological outcomes in pediatric influenza-associated ANE. Further studies are required to establish the efficacy of TPE for ANE.
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18
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Wu L, Peng H, Jiang Y, He L, Jiang L, Hu Y. Clinical features and imaging manifestations of acute necrotizing encephalopathy in children. Int J Dev Neurosci 2022; 82:447-457. [PMID: 35688614 DOI: 10.1002/jdn.10201] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/09/2022] [Accepted: 05/16/2022] [Indexed: 11/11/2022] Open
Abstract
PURPOSE We summarized the clinical features of acute necrotizing encephalopathy (ANE) in children. METHODS Clinical data of 14 children with ANE at one center from January 2017 to January 2020 were retrospectively analyzed. ANE severity score (ANE-ss) was used to assess ANE severity, and the Glasgow Outcome Scale-Extended was used to assess functional outcomes. RESULTS Peak incidence was between 1 and 3 years of age (71%), and a large percentage of males were affected (79%). The main manifestations included fever (100%), seizure (86%), and impaired consciousness (100%). Seven patients (58%) developed status epilepticus. The etiology was identified in 10 patients (71%) and mainly included H1N1 (36%) and Epstein-Barr virus (29%).Complications included multiple organ failure (MOF), predominantly liver (36%), heart (21%) and kidney (7%) failure, gastrointestinal hemorrhage (21%), hypernatremia (7%), hematuria (7%), disseminated intravascular coagulation (7%), and shock (7%). Pleocytosis was observed in two patients, and increased cerebrospinal fluid protein was found in 11 patients. A missense mutation in RANBP2 (c.1754C>T: p.Thr585Met) was observed in one patient. Magnetic resonance imaging revealed increased T2 and T1 signal density in multifocal and symmetric brain lesions (bilateral thalami, 100%) in all patients during the acute phase. There were no deaths. Nine children retained neurological sequelae affecting movement, cognition, speech, vision, and/or seizure. Four children recovered almost completely. There was a significant correlation between risk classification and outcome by ANE-ss. CONCLUSION ANE is a group of clinical and imaging syndromes. Most patients have severe neurological sequelae, and ANE may have lower mortality. And ANE-ss can assess prognosis.
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Affiliation(s)
- Lianhong Wu
- Department of Neurology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,National Clinical Research Center for Child Health and Disorders, Chongqing, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China.,Department of Neurosurgery, Chongqing Traditional Chinese Medicine Hospital, Chongqing, China
| | - Hailun Peng
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,National Clinical Research Center for Child Health and Disorders, Chongqing, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China.,Department of Radiology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yan Jiang
- Department of Neurology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,National Clinical Research Center for Child Health and Disorders, Chongqing, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Ling He
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,National Clinical Research Center for Child Health and Disorders, Chongqing, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China.,Department of Radiology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Li Jiang
- Department of Neurology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,National Clinical Research Center for Child Health and Disorders, Chongqing, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yue Hu
- Department of Neurology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,National Clinical Research Center for Child Health and Disorders, Chongqing, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China
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19
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Wang Y, Qian S, Li K, Yang Y, Fan C, Wang L. Association of O blood type with the prognosis of acute necrotizing encephalopathy in childhood: A single-center cohort study. Brain Dev 2022; 44:131-138. [PMID: 34563416 DOI: 10.1016/j.braindev.2021.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 09/01/2021] [Accepted: 09/13/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Acute necrotizing encephalopathy (ANE) of childhood is a rare but critical disease with global distribution. Few studies have focused on investigating the relationship between O blood type and the prognosis of ANE. METHODS We analyzed retrospectively the data of patients with ANE admitted to the Beijing Children's Hospital from March 2012 to February 2019. Baseline data, clinical characteristics, examination, treatment, and prognosis of O blood group were compared with those of the non-O blood group. Cox regression was used to observe the independent prognostic factors in ANE. RESULTS Thirty-one ANE patients were recruited, and 8 (25.8%) of these patients were in the O blood group. The rest (n = 23; 74.2%) were in the non-O blood group. No significant differences were found in the demographic characteristics, clinical features, examinations, and treatments between the two groups (p > 0.05). At 28 days after discharge, the overall survival rate of the O blood group was significantly higher than that of the non-O blood group (χ2 = 5.630, p = 0.018). At 1 year after discharge, the survival quality of the O blood group was higher than that of the non-O blood group (p = 0.006). After adjusting for the confounding factors, Cox regression analysis showed that O blood type might be a protective factor in ANE [hazard ratio = 0.283, 95% CI = 0.081-0.988; p = 0.048]. CONCLUSIONS O blood type may be a protective factor for patients with ANE.
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Affiliation(s)
- Yeqing Wang
- Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Suyun Qian
- Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
| | - Kenchun Li
- Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Ying Yang
- Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Chaonan Fan
- Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Lijuan Wang
- Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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20
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Shukla P, Mandalla A, Elrick MJ, Venkatesan A. Clinical Manifestations and Pathogenesis of Acute Necrotizing Encephalopathy: The Interface Between Systemic Infection and Neurologic Injury. Front Neurol 2022; 12:628811. [PMID: 35058867 PMCID: PMC8764155 DOI: 10.3389/fneur.2021.628811] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 12/02/2021] [Indexed: 12/17/2022] Open
Abstract
Acute necrotizing encephalopathy (ANE) is a devastating neurologic condition that can arise following a variety of systemic infections, including influenza and SARS-CoV-2. Affected individuals typically present with rapid changes in consciousness, focal neurological deficits, and seizures. Neuroimaging reveals symmetric, bilateral deep gray matter lesions, often involving the thalami, with evidence of necrosis and/or hemorrhage. The clinical and radiologic picture must be distinguished from direct infection of the central nervous system by some viruses, and from metabolic and mitochondrial disorders. Outcomes following ANE are poor overall and worse in those with brainstem involvement. Specific management is often directed toward modulating immune responses given the potential role of systemic inflammation and cytokine storm in potentiating neurologic injury in ANE, though benefits of such approaches remain unclear. The finding that many patients have mutations in the nucleoporin gene RANBP2, which encodes a multifunctional protein that plays a key role in nucleocytoplasmic transport, may allow for the development of disease models that provide insights into pathogenic mechanisms and novel therapeutic approaches.
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Affiliation(s)
- Priya Shukla
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Abby Mandalla
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Matthew J Elrick
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Arun Venkatesan
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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21
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Chang HP, Hsia SH, Lin JJ, Chan OW, Chiu CC, Lee EP. Early High-Dose Methylprednisolone Therapy Is Associated with Better Outcomes in Children with Acute Necrotizing Encephalopathy. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9020136. [PMID: 35204857 PMCID: PMC8870393 DOI: 10.3390/children9020136] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 12/27/2021] [Accepted: 01/18/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND The neurologic outcomes of acute necrotizing encephalopathy (ANE) are very poor, with a mortality rate of up to 40% and fewer than 10% of patients surviving without neurologic deficits. Steroid and immunoglobulin treatments have been the most commonly used options for ANE, but their therapeutic efficacy is still controversial. METHOD We retrospectively reviewed the medical records of 26 children diagnosed with ANE. We also divided these patients into two groups: 21 patients with brainstem involvement and 8 patients without brainstem involvement. Pulse steroid therapy (methylprednisolone at 30 mg/kg/day for 3 days) and intravenous immunoglobulin (2 g/kg for 2-5 days) were administered to treat ANE. RESULTS The overall mortality rate was 42.3%, and patients who did not survive had significantly higher initial lactate and serum ferritin levels, as well as higher rates of inotropic agent use with brainstem involvement. There were no significant differences in the outcomes of pulse steroid therapy or pulse steroid plus immunoglobulin between survivors and non-survivors. When analyzing the time between symptom onset and usage of pulse steroid therapy, pulse steroid therapy used within 24 h after the onset of ANE resulted in significantly better outcomes (p = 0.039). In patients with brainstem involvement, the outcome was not correlated with pulse steroid therapy, early pulse steroid therapy, or pulse steroid therapy combined with immunoglobulin. All patients without brainstem involvement received "early pulse methylprednisolone" therapy, and 87.5% (7/8) of these patients had a good neurologic outcome. CONCLUSION Pulse steroid therapy (methylprednisolone at 30 mg/kg/day for 3 days) administered within 24 h after the onset of ANE may be correlated with a good prognosis. Further studies are needed to establish a consensus guideline for this fulminant disease.
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Affiliation(s)
- Han-Pi Chang
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (H.-P.C.); (S.-H.H.); (J.-J.L.); (O.-W.C.); (C.-C.C.)
- College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Shao-Hsuan Hsia
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (H.-P.C.); (S.-H.H.); (J.-J.L.); (O.-W.C.); (C.-C.C.)
- College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Jainn-Jim Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (H.-P.C.); (S.-H.H.); (J.-J.L.); (O.-W.C.); (C.-C.C.)
- College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Oi-Wa Chan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (H.-P.C.); (S.-H.H.); (J.-J.L.); (O.-W.C.); (C.-C.C.)
- College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Chun-Che Chiu
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (H.-P.C.); (S.-H.H.); (J.-J.L.); (O.-W.C.); (C.-C.C.)
- College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - En-Pei Lee
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (H.-P.C.); (S.-H.H.); (J.-J.L.); (O.-W.C.); (C.-C.C.)
- College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
- Correspondence:
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22
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Fan X, Huang L, Li S, Yang S, Song Y, Chen Q, Xiong Y, Peng Q, Ma W, Hu D, Li P. Clinical evaluation of acute necrotizing encephalopathy in children. Front Pediatr 2022; 10:947693. [PMID: 36090552 PMCID: PMC9455778 DOI: 10.3389/fped.2022.947693] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/11/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Acute necrotizing encephalopathy (ANE) is a rare but severe encephalopathy and is associated with a high morbidity and mortality. We aimed to analyze and compare the clinical features and predictive indicators of pediatric ANE. MATERIALS AND METHODS This retrospective study included children with ANE diagnosed at Guangzhou Women and Children's Medical Center between November 2018 and January 2020. Pediatric patients' information, including clinical characteristics, laboratory tests, neuroelectrophysiology and brain magnetic resonance imaging (MRI) findings, MRI score, brainstem auditory evoked potential (BAEP) grades, ANE severity scores (ANE-SS), and modified Rankin scale (mRS), were collected. RESULTS Twelve ANE patients were included. Among them, one patient (8.3%) died from brainstem dysfunction, one (8.3%) recovered and 10 (83.3%) experienced neurological sequelae. All patients had an initial viral infection and neurological symptoms such as acute disturbance of consciousness (ADOC) or seizure, and the interval from onset of the disease to neurological manifestations was 3 (1.25-3) days. MRI score-I ranged from 1 to 3 (1.8 ± 0.7), MRI score-II ranged from 1 to 4 (2.5 ± 1.1). ANE-SS varied from 1 to 6 (3.9 ± 1.3). The scores of mRS were from 0 to 6 (2.9 ± 1.7). Higher MRI score were associated with worse outcomes, while the BAEP grade and ANE-SS score were not significantly associated with mRS. CONCLUSION ANE is a severe encephalopathy syndrome with rapid progression, resulting in serious neurological sequelae. Compared with BAEP grade and ANE-SS, brain MRI shows more comprehensive advantages in predicting the prognosis of ANE patients. More in-depth research and better indicators are still needed to support the evaluation and treatment of ANE.
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Affiliation(s)
- Xiaowei Fan
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Li Huang
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Suyun Li
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Sida Yang
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Yongling Song
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Qinglian Chen
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Yumei Xiong
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Qiuyan Peng
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Wencheng Ma
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Dandan Hu
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Peiqing Li
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
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23
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Chen Y, Fang B, Hu X, Guo R, Guo J, Fang K, Ni J, Li W, Qian S, Hao C. Identification and functional analysis of novel SLC25A19 variants causing thiamine metabolism dysfunction syndrome 4. Orphanet J Rare Dis 2021; 16:403. [PMID: 34587972 PMCID: PMC8480130 DOI: 10.1186/s13023-021-02028-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 09/19/2021] [Indexed: 11/10/2022] Open
Abstract
Background Thiamine metabolism dysfunction syndrome 4 (THMD4, OMIM #613710) is an autosomal recessive inherited disease caused by the deficiency of SLC25A19 that encodes the mitochondrial thiamine pyrophosphate (TPP) transporter. This disorder is characterized by bilateral striatal degradation and progressive polyneuropathy with the onset of fever of unknown origin. The limited number of reported cases and lack of functional annotation of related gene variants continue to limit diagnosis. Results We report three cases of encephalopathy from two unrelated pedigrees with basal ganglia signal changes after fever of unknown origin. To distinguish this from other types of encephalopathy, such as acute necrotizing encephalopathy, exome sequencing was performed, and four novel heterozygous variations, namely, c.169G>A (p.Ala57Thr), c.383C>T (p.Ala128Val), c.76G>A (p.Gly26Arg), and c.745T>A (p.Phe249Ile), were identified in SLC25A19. All variants were confirmed using Sanger sequencing. To determine the pathogenicity of these variants, functional studies were performed. We found that mitochondrial TPP levels were significantly decreased in the presence of SLC25A19 variants, indicating that TPP transport activities of mutated SLC25A19 proteins were impaired. Thus, combining clinical phenotype, genetic analysis, and functional studies, these variants were deemed as likely pathogenic. Conclusions Exome sequencing analysis enables molecular diagnosis as well as provides potential etiology. Further studies will enable the elucidation of SLC25A19 protein function. Our investigation supplied key molecular evidence for the precise diagnosis of and clinical decision-making for a rare disease.
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Affiliation(s)
- Yuanying Chen
- Beijing Key Laboratory for Genetics of Birth Defects, Beijing Pediatric Research Institute, MOE Key Laboratory of Major Diseases in Children, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China.,Henan Key Laboratory of Pediatric Inherited and Metabolic Diseases, Henan Children's Hospital, Zhengzhou Hospital of Beijing Children's Hospital, Zhengzhou, China
| | - Boliang Fang
- Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Xuyun Hu
- Beijing Key Laboratory for Genetics of Birth Defects, Beijing Pediatric Research Institute, MOE Key Laboratory of Major Diseases in Children, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China.,Henan Key Laboratory of Pediatric Inherited and Metabolic Diseases, Henan Children's Hospital, Zhengzhou Hospital of Beijing Children's Hospital, Zhengzhou, China
| | - Ruolan Guo
- Beijing Key Laboratory for Genetics of Birth Defects, Beijing Pediatric Research Institute, MOE Key Laboratory of Major Diseases in Children, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China.,Henan Key Laboratory of Pediatric Inherited and Metabolic Diseases, Henan Children's Hospital, Zhengzhou Hospital of Beijing Children's Hospital, Zhengzhou, China
| | - Jun Guo
- Beijing Key Laboratory for Genetics of Birth Defects, Beijing Pediatric Research Institute, MOE Key Laboratory of Major Diseases in Children, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China.,Henan Key Laboratory of Pediatric Inherited and Metabolic Diseases, Henan Children's Hospital, Zhengzhou Hospital of Beijing Children's Hospital, Zhengzhou, China
| | - Kenan Fang
- Pediatric Intensive Care Unit, Luoyang Maternal and Child Health Hospital, Luoyang, China
| | - Jingwen Ni
- Pediatric Intensive Care Unit, Luoyang Maternal and Child Health Hospital, Luoyang, China
| | - Wei Li
- Beijing Key Laboratory for Genetics of Birth Defects, Beijing Pediatric Research Institute, MOE Key Laboratory of Major Diseases in Children, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China.,Henan Key Laboratory of Pediatric Inherited and Metabolic Diseases, Henan Children's Hospital, Zhengzhou Hospital of Beijing Children's Hospital, Zhengzhou, China
| | - Suyun Qian
- Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China.
| | - Chanjuan Hao
- Beijing Key Laboratory for Genetics of Birth Defects, Beijing Pediatric Research Institute, MOE Key Laboratory of Major Diseases in Children, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China. .,Henan Key Laboratory of Pediatric Inherited and Metabolic Diseases, Henan Children's Hospital, Zhengzhou Hospital of Beijing Children's Hospital, Zhengzhou, China.
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24
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Wang Y, Younce JR, Perlmutter JS, Mar SS. Excellent Outcome of Acute Necrotizing Encephalopathy in an Adult With Bacterial Infections, Case Report. Neurohospitalist 2021; 11:351-355. [PMID: 34567397 DOI: 10.1177/1941874421991370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Acute necrotizing encephalopathy (ANE) is a rare para-infectious encephalopathy that classically occurs in children. However, ANE should be considered in the differential diagnosis of adults with symmetric brain lesions after a prodromal illness given recent reports of coronavirus disease of 2019 (COVID-19) to presumably cause ANE in adults. We report a case of a 29-year-old male presenting with fever, malaise, and rapid deterioration into coma. Brain magnetic resonance imaging revealed multifocal symmetric areas of diffusion restriction and surrounding vasogenic edema involving bilateral thalami, pons and cerebellar hemispheres with a core of susceptibility artifact, and minimal thalamic contrast enhancement, most consistent with ANE. Extensive infectious workup revealed isolated Escherichia coli and Neisseria gonorrhoeae in his urine. Despite the severe encephalopathy on initial presentation, the patient improved with intravenous antibiotics and supportive management with minimal residual deficits at 9 months follow-up. We aim to provide an overview of the radiological features, differential diagnosis, treatment and prognosis of ANE. Becoming familiarized with this rare but devastating disease will improve detection, treatment, and ultimately prognosis, especially in the era of a new pandemic.
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Affiliation(s)
- Yan Wang
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO, USA
| | - John R Younce
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Joel S Perlmutter
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO, USA.,Department of Radiology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Soe S Mar
- Department of Pediatric Neurology, Washington University School of Medicine, Saint Louis, MO, USA
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25
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Recurrent acute necrotizing encephalopathy in a boy with RANBP2 mutation and thermolabile CPT2 variant: The first case of ANE1 in Japan. Brain Dev 2021; 43:873-878. [PMID: 34059398 DOI: 10.1016/j.braindev.2021.04.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 03/24/2021] [Accepted: 04/26/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Acute necrotizing encephalopathy (ANE) is a severe encephalopathy associated with acute viral infection. While most ANE cases are sporadic, pathogenic variants in the gene RAN binding protein 2 (RANBP2) have been identified as a major cause of familial or recurrent ANE (ANE1). Although sporadic ANE predominantly affects Asian children, ANE1 is very rare in east Asia. CASE REPORT A 1-year-7-month-old boy, born to unrelated Japanese parents, presented with a seizure and impaired consciousness after 3 days of fever. Brain magnetic resonance imaging (MRI) showed a characteristic involvement of the bilateral thalami, external capsules, insular cortices, and brainstem, suggesting ANE. He received intravenous steroids. Two months later, he had another episode of acute encephalopathy during respiratory syncytial virus infection, from which he recovered relatively well. The recurrent encephalopathic episodes and the characteristic MRI suggested ANE1. Genetic analyses revealed two variants: a rare heterozygous missense variant of RANBP2 [c.1754C>T; p.Thr585Met], and a thermolabile polymorphism in carnitine palmitoyltransferase 2 (CPT2) [c. 1055T>G; p.Phe352Cys]. CONCLUSION This is the first case of recurrent ANE with an RANBP2 mutation in Japan. The patient also harbored a CPT2 polymorphism that is linked to acute encephalopathy in Japanese patients. Thus, he had a genetic background with two susceptibility variants for acute encephalopathy, RANBP2 (frequent in the Caucasians), and CPT2 (frequent in the Japanese). Further studies are needed to fully discover the genetic predisposition to familial or recurrent ANE in the Asian population.
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26
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Holla VV, Gohel AB, Kartik N, Netravathi M. Acute Necrotizing Encephalopathy as a Complication of Chikungunya Infection. Neurol India 2021; 69:490-492. [PMID: 33904484 DOI: 10.4103/0028-3886.314525] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Acute necrotizing encephalopathy (ANE) is a rapidly progressive encephalopathy seen commonly in children triggered by various prodromal viral infections, most common being influenza virus and Human herpes virus-6. Objective We report two rare cases of ANE preceded by Chikungunya infection. Cases A 13-year old girl presented with a three-day history of headache, fever, seizures, and altered sensorium. Another 42-year old man presented with two days history of fever and altered sensorium. Both were suspected to have viral encephalitis. Evaluation revealed serum positivity for Chikungunya virus. In both cases, diagnosis was clinched by characteristic bilateral symmetrical thalamic lesions with central necrosis and hemorrhage along with lesions in cerebral white matter, brainstem, and cerebellum. Conclusions ANE is reported to have high morbidity and mortality. To the best of our knowledge, this is the first report of ANE post-Chikungunya infection. Apart from being rare etiologically, the patients had excellent response to steroids.
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Affiliation(s)
- V V Holla
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS) Bengaluru, Karnataka, India
| | - Abhishek B Gohel
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS) Bengaluru, Karnataka, India
| | - N Kartik
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS) Bengaluru, Karnataka, India
| | - M Netravathi
- Department of Neuroimaging and Interventional Neuroradiology (NIIR), National Institute of Mental Health and Neurosciences (NIMHANS) Bengaluru, Karnataka, India
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27
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Li K, Zhang T, Liu G, Jin P, Wang Y, Wang L, Xu M, Liu C, Liu Y, Zhou T, Xu Y, Yang Y, Fang B, Yang X, Liu C, Qian S. Plasma exchange therapy for acute necrotizing encephalopathy of childhood. Pediatr Investig 2021; 5:99-105. [PMID: 34179705 PMCID: PMC8212728 DOI: 10.1002/ped4.12280] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 05/20/2021] [Indexed: 02/02/2023] Open
Abstract
IMPORTANCE Acute necrotizing encephalopathy (ANE) is a rare disease with high mortality. Plasma exchange (PLEX) has recently been reported to treat ANE of childhood (ANEC), but its efficacy is uncertain. OBJECTIVE This study aimed to investigate the effectiveness of PLEX on ANEC. METHODS A retrospective study was conducted in four pediatric intensive care units from December 2014 to December 2020. All patients who were diagnosed with ANEC were included; however, these patients were excluded if their length of stay was less than 24 h. Participants were classified into PLEX and non-PLEX groups. RESULTS Twenty-nine patients with ANEC were identified, 10 in the PLEX group and 19 in the non-PLEX group. In the PLEX group, C-reactive protein, procalcitonin, alanine aminotransferase, and aspartate aminotransaminase levels were significantly lower after 3 days of treatment than before treatment (13.1 vs. 8.0, P = 0.043; 9.8 vs. 1.5, P = 0.028; 133.4 vs. 31.9, P = 0.028; 282.4 vs. 50.5, P = 0.046, respectively). Nine patients (31.0%, 9/29) died at discharge, and a significantly difference was found between the PLEX group and non-PLEX group [0 vs. 47.4% (9/19), P = 0.011]. The median follow-up period was 27 months, and three patients were lost to follow-up. Thirteen patients (50.0%, 13/26) died at the last follow-up, comprising three (33.3%, 3/9) in the PLEX group and ten (58.8%, 10/17) in the non-PLEX group, but there was no significant difference between the two groups (P = 0.411). Three patients (10.3%, 3/29) fully recovered. INTERPRETATION PLEX may reduce serum C-reactive protein and procalcitonin levels and improve liver function in the short term. PLEX may improve the prognosis of ANEC, and further studies are needed.
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Affiliation(s)
- Kechun Li
- Department of Pediatric Intensive Care UnitBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthChina
| | - Tao Zhang
- Department of PediatricsShengjing Hospital of China Medical UniversityShenyangLiaoningChina
| | - Gang Liu
- Department of Pediatric Intensive Care UnitHebei Children’s HospitalHebei Medical UniversityShijiazhuangHebeiChina
| | - Ping Jin
- Department of Pediatric Intensive Care UnitBao’an Maternity & Child Health HospitalShenzhenGuangdongChina
| | - Yeqing Wang
- Department of Pediatric Intensive Care UnitBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthChina
| | - Lijie Wang
- Department of PediatricsShengjing Hospital of China Medical UniversityShenyangLiaoningChina
| | - Meixian Xu
- Department of Pediatric Intensive Care UnitHebei Children’s HospitalHebei Medical UniversityShijiazhuangHebeiChina
| | - Chunyi Liu
- Department of Pediatric Intensive Care UnitBao’an Maternity & Child Health HospitalShenzhenGuangdongChina
| | - Yingchao Liu
- Department of Pediatric Intensive Care UnitBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthChina
| | - Tao Zhou
- Department of Pediatric Intensive Care UnitBao’an Maternity & Child Health HospitalShenzhenGuangdongChina
| | - Yan Xu
- Department of Pediatric Intensive Care UnitBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthChina
| | - Ying Yang
- Department of Pediatric Intensive Care UnitBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthChina
| | - Boliang Fang
- Department of Pediatric Intensive Care UnitBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthChina
| | - Xin Yang
- Department of Pediatric Intensive Care UnitBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthChina
| | - Chunfeng Liu
- Department of PediatricsShengjing Hospital of China Medical UniversityShenyangLiaoningChina
| | - Suyun Qian
- Department of Pediatric Intensive Care UnitBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthChina
- Research Unit of Critical infection in ChildrenChinese Academy of Medical Sciences2019RU016
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Appavu B, Foldes S, Fox J, Shetty S, Oh A, Bassal F, Marku I, Mangum T, Boerwinkle V, Neilson D, Kruer M. Treatment Timing, EEG, Neuroimaging, and Outcomes After Acute Necrotizing Encephalopathy in Children. J Child Neurol 2021; 36:517-524. [PMID: 33393838 DOI: 10.1177/0883073820984063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Acute necrotizing encephalopathy (ANE) is a rare condition associated with rapid progression to coma and high incidence of morbidity and mortality. METHODS Clinical, electroencephalographic (EEG), and brain magnetic resonance imaging (MRI) characteristics and immunomodulatory therapy timing were retrospectively analyzed in children with ANE. ANE severity scores (ANE-SS) and MRI scores were also assessed. The associations of patient characteristics with 6-month modified Rankin scale (mRS) and length of hospitalization were determined using either univariate linear regression or one-way analysis of variance. RESULTS 7 children were retrospectively evaluated. Normal EEG sleep spindles (P = .024) and early treatment (R2 = .57, P = .030) were associated with improved outcomes (ie, decreased mRS). Higher ANE-SS (R2 = .79, P = .011), higher age (R2 = .62, P = .038), and presence of brainstem lesions (P = .015) were associated with longer length of hospitalization. Other patient characteristics were not significantly associated with mRS or length of hospitalization. CONCLUSION Early immunomodulatory therapy and normal sleep spindles are associated with better functional outcome in children with ANE.
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Affiliation(s)
- Brian Appavu
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Stephen Foldes
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Jordana Fox
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Sheetal Shetty
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Ann Oh
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Freddy Bassal
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Iris Marku
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Tara Mangum
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Varina Boerwinkle
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Derek Neilson
- Department of Genetics, Phoenix Children's Hospital, 42283University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Michael Kruer
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
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Li S, Hu D, Li P, Xiao W, Li H, Liu G, Song Y, Ning S, Peng Q, Zhao D, Situ M, Li W, Wu P, Zheng J, Liu Y, Hu L, Wang P, Hu Z, Ma W, Shen J, Yang S. Parameters Indicating Development of Influenza-Associated Acute Necrotizing Encephalopathy: Experiences from a Single Center. Med Sci Monit 2021; 27:e930688. [PMID: 33934098 PMCID: PMC8101270 DOI: 10.12659/msm.930688] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Influenza-associated acute necrotizing encephalopathy (IANE) can be lethal and disabling and have a sudden onset and deteriorate rapidly but lacks early diagnostic indicators. We aimed to examine the early clinical diagnostic indicators in children with IANE. Material/Methods Acute influenza patients were grouped according to their clinical manifestations: flu alone (FA), flu with febrile seizure (FS), influenza-associated encephalopathy (IAE), and IANE. The clinical features, biomarkers, neuroelectrophysiological results, and neuroimaging examination results were compared. Results A total of 31 patients were included (FA (n=4), FS (n=8), IAE (n=14), and IANE (n=5)). The IANE group, whose mean age was 3.7 years, was more likely to show rapid-onset seizure, acute disturbance of consciousness (ADOC), Babinski’s sign, and death/sequela. More patients in the IANE group required tracheal intubation mechanical ventilation and received intravenous immunoglobulins (IVIG) and glucocorticoids. The alanine aminotransferase (ALT), aspartate transaminase (AST), and lactate dehydrogenase (LDH) levels in the IANE group were significantly higher than in the FS and IAE groups. The aquaporin-4 (AQP-4) antibody and malondialdehyde (MDA) levels in the serum and cerebrospinal fluid (CSF) were notably higher in IANE patients in the acute stage compared with FS and IAE patients. All patients in the IANE group had positive neuroimaging findings. Conclusions Early clinical warning factors for IANE include rapid-onset seizures in patients under 4 years of age, ADOC, and pathological signs. Increased AQP-4 antibodies and MDA levels in CSF might contribute to early diagnosis. Early magnetic resonance venography (MRV) and susceptibility-weighted imaging (SWI) sequences, or thrombelastography to identify deep vein thrombosis, might indicate clinical deterioration.
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Affiliation(s)
- Suyun Li
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Dandan Hu
- Department of Pediatric Neurology, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Peiqing Li
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Weiqiang Xiao
- Department of Radiology, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Huixian Li
- Data Statistics Center, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Guangming Liu
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Yongling Song
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Shuyao Ning
- Department of Pediatric Neurology, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Qiuyan Peng
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Danyang Zhao
- Department of Disease Control and Prevention, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Minxiong Situ
- Department of Disease Control and Prevention, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Wanqi Li
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Peiqun Wu
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Jipeng Zheng
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Yueting Liu
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Lin Hu
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Pengfei Wang
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Zhengbin Hu
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Wencheng Ma
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Jun Shen
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Sida Yang
- Department of Pediatric Neurology, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
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Nishiyama M, Ishida Y, Yamaguchi H, Tokumoto S, Tomioka K, Hongo H, Toyoshima D, Maruyama A, Kurosawa H, Tanaka R, Nozu K, Iijima K, Nagase H. Prediction of AESD and neurological sequelae in febrile status epilepticus. Brain Dev 2021; 43:616-625. [PMID: 33563484 DOI: 10.1016/j.braindev.2021.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/19/2020] [Accepted: 01/22/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The clinical prediction rule (CPR) for acute encephalopathy with biphasic seizures and late reduced diffusion (AESD) was developed with an area under the receiver operating characteristic curve (AUC) of 0.95 - 0.96. Our objective was to verify the AESD CPR in a new cohort and compare the utilities of three CPRs of acute encephalopathy: the Tada, Yokochi, and Nagase criteria. METHODS We reviewed the clinical data and medical charts of 580 consecutive patients (aged < 18 years) with febrile convulsive status epilepticus lasting for ≥ 30 min in 2002 - 2017 and measured the performance of the CPRs in predicting AESD and sequelae. RESULTS The CPRs predicted AESD with an AUC of 0.84 - 0.88. The Tada criteria predicted AESD with a positive predictive value (PPV) of 0.25 and a negative predictive value (NPV) of 0.99. The Yokochi criteria predicted AESD with a PPV and NPV of 0.20 and 0.95, respectively, after 12 h. The Nagase criteria predicted AESD with a PPV and NPV of 0.14 and 1.00, respectively, after 6 h. The PPVs of the Tada, Yokochi, and Nagase criteria for sequelae were 0.28, 0.28, and 0.17, respectively; the corresponding NPVs were 0.97, 0.95, and 0.98, respectively. CONCLUSIONS The effectiveness of the AESD CPR in a new cohort was lower than that in the derivation study. CPRs are not sufficient as diagnostic tests, but they are useful as screening tests. The Nagase criteria are the most effective for screening among the three CPRs due to their high NPV and swiftness.
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Affiliation(s)
- Masahiro Nishiyama
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan.
| | - Yusuke Ishida
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Hyogo, Japan
| | - Hiroshi Yamaguchi
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Shoichi Tokumoto
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan; Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Hyogo, Japan
| | - Kazumi Tomioka
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Hiroto Hongo
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Hyogo, Japan
| | - Daisaku Toyoshima
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Hyogo, Japan
| | - Azusa Maruyama
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Hyogo, Japan
| | - Hiroshi Kurosawa
- Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Hyogo, Japan
| | - Ryojiro Tanaka
- Department of Emergency and General Pediatrics, Hyogo Prefectural Kobe Children's Hospital, Hyogo, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Hiroaki Nagase
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan
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Aksoy E, Öztoprak Ü, Çelik H, Özdemir FMA, Özkan M, Kayılıoğlu H, Danış A, Kucur Ö, Kesici S, Uysal Yazıcı M, Azapağası E, Taşcı Yıldız Y, Ceylan N, Şenel S, Yüksel D. Acute necrotizing encephalopathy of childhood: a single-center experience. Turk J Med Sci 2021; 51:706-715. [PMID: 33754655 PMCID: PMC8203168 DOI: 10.3906/sag-2102-47] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/20/2021] [Indexed: 11/03/2022] Open
Abstract
Background/aim Acute necrotizing encephalopathy is a rare type of acute encephalopathy characterized by multi-ocal brain lesions
and associated severe neurological findings and various organ dysfunctions may accompany it. Materials and Methods Patients with acute necrotizing encephalopathy of childhood diagnosed by pediatric neurology and pediatric intensive care at Sami Ulus Maternity, Child Health and Diseases Training and Research Hospital between 2007 and 2020 were included in this study. Results Nine patients (six females, three males) with a mean age of 4.05 ± 1.94 years (age range 1–6.5) were included in this study. The interval range between fever and encephalopathy in patients was 1–4 days. Influenza A (3H1N1, one untyped) was detected in four patients, influenza B in three patients, and no cause was found in two patients. Major clinical findings other than febrile encephalopathy in all patients were a hemodynamic shock in seven patients, seizures in six patients, vomiting in five patients, dystonia in three patients, and flaccid paralysis in the upper extremity in one patient. Despite all our treatment approaches, including plasmapheresis, moderate to severe neurological sequelae was observed in all of our patients, who survived even with significant radiological improvement. Three patients for whom we could not perform plasmapheresis died. Conclusion Our study revealed that thalamic involvement increased as the interval shortened, and brainstem involvement increased in patients over four years of age. The presence of persistent vomiting accompanying encephalopathy during the parainfectious period and plasmapheresis treatment being a treatment option that could prevent mortality were cautionary for our study.
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Affiliation(s)
- Erhan Aksoy
- Department of Pediatric Neurology, Faculty of Medicine, Dr Sami Ulus Maternity Child Health and Diseases Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Ülkü Öztoprak
- Department of Pediatric Neurology, Faculty of Medicine, Dr Sami Ulus Maternity Child Health and Diseases Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Halil Çelik
- Department of Pediatric Neurology, Faculty of Medicine, Dr Sami Ulus Maternity Child Health and Diseases Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Fatih Mehmet Akif Özdemir
- Department of Pediatric Neurology, Faculty of Medicine, Dr Sami Ulus Maternity Child Health and Diseases Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Mehbare Özkan
- Department of Pediatric Neurology, VM Medical Park Pendik Hospital, İstanbul, Turkey
| | - Hülya Kayılıoğlu
- Department of Pediatric Neurology, Faculty of Medicine, Muğla Sıtkı Koçman University, Muğla, Turkey
| | - Ayşegül Danış
- Department of Pediatric Neurology, Faculty of Medicine, Abant İzzet Baysal University, Bolu, Turkey
| | - Özge Kucur
- Department of Pediatric Neurology, Faculty of Medicine, Dr Sami Ulus Maternity Child Health and Diseases Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Selman Kesici
- Department of Pediatric Intensive Care, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Mutlu Uysal Yazıcı
- Department of Pediatric Intensive Care, Faculty of Medicine, Dr Sami Ulus Maternity Child Health and Diseases Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Ebru Azapağası
- Department of Pediatric Intensive Care, Faculty of Medicine, Dr Sami Ulus Maternity Child Health and Diseases Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Yasemin Taşcı Yıldız
- Department of Pediatric Radiology, Faculty of Medicine, Dr Sami Ulus Maternity Child Health and Diseases Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Nesrin Ceylan
- Department of Pediatric Neurology, Faculty of Medicine, Dr Sami Ulus Maternity Child Health and Diseases Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Saliha Şenel
- Department of Pediatrics, Faculty of Medicine, Dr Sami Ulus Maternity Child Health and Diseases Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Deniz Yüksel
- Department of Pediatric Neurology, Faculty of Medicine, Dr Sami Ulus Maternity Child Health and Diseases Training and Research Hospital, University of Health Sciences, Ankara, Turkey
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Fong CY, Saw MT, Li L, Lim WK, Ong LC, Gan CS. Malaysian outcome of acute necrotising encephalopathy of childhood. Brain Dev 2021; 43:538-547. [PMID: 33358123 DOI: 10.1016/j.braindev.2020.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/17/2020] [Accepted: 12/06/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Describe the outcome of a Malaysian cohort of children with acute necrotising encephalopathy (ANE). METHOD Retrospective study of children with ANE seen at University of Malaya Medical Centre from 2014 to 2019. All clinical details including ANE-severity score (ANE-SS), immunomodulation treatment and neurodevelopmental long-term outcome were collected. RESULTS Thirteen patients had ANE and brainstem death occurred in 5. In 10 patients (77%) viruses were isolated contributing to ANE: 8 influenza virus, 1 acute dengue infection, and 1 acute varicella zoster infection. The ANE-SS ranged 2-7: 9 were high risk and 4 were medium risk. Among the 8 survivors; 1 was lost to follow-up. Follow-up duration was 1-6 years (median 2.2). At follow-up among the 4 high-risk ANE-SS: 2 who were in a vegetative state, 1 remained unchanged and 1 improved to severe disability; the other 2 with severe disability improved to moderate and mild disability respectively. At follow-up all 3 medium-risk ANE-SS improved: 2 with severe disability improved to moderate and mild disability respectively, while 1 in a vegetative state improved to severe disability. Early treatment with immunomodulation did not affect outcome. CONCLUSION Our ANE series reiterates that ANE is a serious cause of encephalopathy with mortality of 38.5%. All survivors were in a vegetative state or had severe disability at discharge. Most of the survivors made a degree of recovery but good recovery was seen in 2. Follow-up of at least 12 months is recommended for accurate prognostication. Dengue virus infection needs to be considered in dengue endemic areas.
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Affiliation(s)
- Choong Yi Fong
- Division of Paediatric Neurology, Department of Paediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| | - Mon Thandar Saw
- Division of Paediatric Neurology, Department of Paediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Paediatric Neurology Unit, Yangon Children Hospital, Yangon, Myanmar
| | - Limin Li
- Division of Paediatric Neurology, Department of Paediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Wei Kang Lim
- Division of Paediatric Neurology, Department of Paediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Lai Choo Ong
- Division of Paediatric Neurology, Department of Paediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chin Seng Gan
- Division of Paediatric Intensive Care, Department of Paediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Song Y, Li S, Xiao W, Shen J, Ma W, Wang Q, Yang H, Liu G, Hong Y, Li P, Yang S. Influenza-Associated Encephalopathy and Acute Necrotizing Encephalopathy in Children: A Retrospective Single-Center Study. Med Sci Monit 2021; 27:e928374. [PMID: 33388740 PMCID: PMC7789050 DOI: 10.12659/msm.928374] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background Although influenza primarily affects the respiratory system, it can cause severe neurological complications, especially in younger children, but knowledge about the early indicators of acute necrotizing encephalopathy (ANE) is limited. The main purpose of this article is to summarize the clinical characteristics, diagnosis, and treatment of neurological complications of influenza in children, and to identify factors associated with ANE. Material/Methods This was a retrospective study of children with confirmed influenza with neurological complications treated between 01/2014 and 12/2019 at Guangzhou Women and Children’s Medical Center. A receiver operating characteristics curve analysis was performed to determine the prognostic value of selected variables. Results Sixty-three children with IAE (n=33) and ANE (n=30) were included. Compared with the IAE group, the ANE group showed higher proportions of fever and acute disturbance of consciousness, higher alanine aminotransferase, higher aspartate aminotransferase, higher creatinine kinase, higher procalcitonin, higher cerebrospinal fluid (CSF) protein, and lower CSF white blood cells (all P<0.05). The areas under the curve (AUCs) for procalcitonin and CSF proteins, used to differentiate IAE and ANE, were 0.790 and 0.736, respectively. The sensitivity and specificity of PCT >4.25 ng/ml to predict ANE were 73.3% and 100.0%, respectively. The sensitivity and specificity of CSF protein >0.48 g/L to predict ANE were 76.7% and 69.7%, respectively. Thirteen (43.3%) children with ANE and none with IAE died (P<0.0001). Conclusions High levels of CSF protein and serum procalcitonin might be used as early indicators for ANE. All children admitted with neurological findings, especially during the influenza season, should be evaluated for influenza-related neurological complications.
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Affiliation(s)
- Yongling Song
- Pediatric Emergency Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Suyun Li
- Pediatric Emergency Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Weiqiang Xiao
- Pediatric Radiology Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Jun Shen
- Suspected Screening Wards, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Wencheng Ma
- Pediatric Emergency Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Qiang Wang
- Pediatric Emergency Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Haomei Yang
- Pediatric Emergency Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Guangming Liu
- Pediatric Emergency Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Yan Hong
- Suspected Screening Wards, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Peiqing Li
- Pediatric Emergency Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Sida Yang
- Pediatric Neurology Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
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Zhu HM, Zhang SM, Yao C, Luo MQ, Ma HJ, Lei T, Yuan CH, Wu GF, Hu JS, Cai CQ, Liu ZS. The Clinical and Imaging Characteristics Associated With Neurological Sequelae of Pediatric Patients With Acute Necrotizing Encephalopathy. Front Pediatr 2021; 9:655074. [PMID: 34046375 PMCID: PMC8144495 DOI: 10.3389/fped.2021.655074] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/22/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Acute necrotizing encephalopathy of childhood (ANE) is a rare but rapidly progressing encephalopathy. Importantly, the exact pathogenesis and evidence-based treatment is scarce. Thus, we aimed to identify the clinical, imaging, and therapeutic characteristics that associated with prognosis of pediatric ANE patients. Methods: A retrospective study was conducted on pediatric patients with ANE who were admitted to Wuhan Children's Hospital between January 2014 and September 2019. All cases met the diagnostic criteria for ANE proposed by Mizuguchi in 1997. The clinical information and follow-up data were collected. The prognostic factors were analyzed by trend chi-square test and Goodman-Kruskal gamma test. Results: A total of 41 ANE patients ranging in age from 8.9 to 142 months were included in this study. Seven cases (17%) died, and the other 34 survivors had different degrees of neurological sequelae. Factors tested to be significantly correlated with the severity of neurological sequelae were the intervals from prodromal infection to acute encephalopathy (G = -0.553), conscious disturbance (r = 0.58), endotracheal intubation (r = 0.423), elevation of alanine aminotransferase (r = 0.345), aspartate aminotransferase (r = 0.393), and cerebrospinal fluid protein (r = 0.490). In addition, dynamic magnetic resonance imaging (MRI) evaluation on follow-up revealed that the total numbers of brain lesion location (χ2 = 6.29, P < 0.05), hemorrhage (r = 0.580), cavitation (r = 0.410), and atrophy (r = 0.602) status were significantly correlated with the severity of neurological sequelae, while early steroid therapy (r = -0.127 and 0.212, respectively) and intravenous immunoglobulin (IVIG) (r = 0.111 and -0.023, respectively) within 24 h or within 72 h after onset showed no association. Conclusions: Intervals from prodromal infection to acute encephalopathy (≤1 day), total numbers of brain lesion location (≥3), the recovery duration of hemorrhage and atrophy (>3 months), and the presence of cavitation predict severe neurological sequelae in pediatric patients with ANE. Early treatments, including steroid therapy and IVIG, had no correlation with better outcomes. Further studies are needed to establish a consensus guideline for the management of ANE.
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Affiliation(s)
- Hong-Min Zhu
- Pediatric Clinical College of Tianjin Medical University, Tianjin, China.,Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Si-Min Zhang
- Department of Emergency, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Cong Yao
- Health Care Department, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Meng-Qing Luo
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hui-Jing Ma
- Department of Radiology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tao Lei
- Department of Rehabilitation, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chun-Hui Yuan
- Department of Laboratory Medicine, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ge-Fei Wu
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jia-Sheng Hu
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chun-Quan Cai
- Pediatric Clinical College of Tianjin Medical University, Tianjin, China.,Tianjin Children's Hospital (Children's Hospital of Tianjin University), Tianjin, China.,Tianjin Pediatric Research Institute, Tianjin Children's Hospital (Children's Hospital of Tianjin University), Tianjin, China.,Tianjin Key Laboratory of Birth Defects for Prevention and Treatment, Tianjin, China
| | - Zhi-Sheng Liu
- Department of Neurology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Ibrahim RSM, Elzayat W, Seif HM, El-Kiki HA, Emad-Eldin S, Shahin M, Kamel SM, Osama R, Zakaryia R, Fatouh M, Hachem RH. Multi-parametric magnetic resonance imaging in acute necrotizing encephalopathy of children: validity and prognostic value. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2020. [DOI: 10.1186/s43055-020-00214-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Acute necrotizing encephalopathy of children (ANEC) is a rare fulminant type of acute encephalopathy that mainly occurs in children with a characteristic clinico-radiological pattern. It is commonly preceded by viral infections. The condition carries a poor prognosis with high morbidity and mortality rates. We highlight the relationship between diagnostic multi-parametric magnetic resonance imaging (MRI) findings and correlate them with the clinical outcome of children with ANEC by enrollment of MRI scoring.
Results
The thalami were involved in all 30 patients, brain stem in 80%, basal ganglia (13.3%), cerebral white matter (WM) in 73%, and cerebellar WM in 33%. Hemorrhage was present in 86.7% patients, edema 80%, and necrosis in 13.3%. We found that the patients having the highest MRI scores were in the poor outcome category; whereas the patients with lower MR score (1 or 2) had better outcomes. Statistically positive correlation (r= 0.1198) was found between the multi-parametric MR score and the outcome category.
Conclusion
An extended multi-parametric MRI should be performed in ANEC, allowing early detection and scoring of the disease for better prognosis. There is a positive correlation between the clinical outcome and the MR scoring.
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Vanjare HA, Selvi BT, Karuppusami R, Manesh A, Gunasekaran K, Prabhakar AT, Mannam P, Jasper A. Clinical and Radiologic Findings of Acute Necrotizing Encephalopathy in Young Adults. AJNR Am J Neuroradiol 2020; 41:2250-2254. [PMID: 33122207 DOI: 10.3174/ajnr.a6803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 07/15/2020] [Indexed: 12/23/2022]
Abstract
Acute necrotizing encephalopathy after an acute febrile illness, although initially described exclusively in the pediatric age group, has been recently shown to have an adult onset as well. In this study, we describe 10 patients (16 years of age or older) with acute necrotizing encephalopathy. In our study, bilateral thalamic involvement with the trilaminar pattern of diffusion restriction on MR imaging was the predominant finding seen in all of the patients reviewed. Ancillary findings of cerebral white matter, brain stem, and cerebellum involvement with sparing of the basal ganglia were also noted. A poorer outcome was observed in patients with a higher degree of thalamic involvement. The cause of an underlying infection was identified in 4 patients (dengue in 3 and influenza in 1). Overall, a sizeable portion of young adults with acute necrotizing encephalopathy have shown a poorer outcome, with dengue being an important underlying trigger in an endemic region.
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Affiliation(s)
- H A Vanjare
- From the Christian Medical College and Hospital, Tamil Nadu, India
| | - B T Selvi
- From the Christian Medical College and Hospital, Tamil Nadu, India
| | - R Karuppusami
- From the Christian Medical College and Hospital, Tamil Nadu, India
| | - A Manesh
- From the Christian Medical College and Hospital, Tamil Nadu, India
| | - K Gunasekaran
- From the Christian Medical College and Hospital, Tamil Nadu, India
| | - A T Prabhakar
- From the Christian Medical College and Hospital, Tamil Nadu, India
| | - P Mannam
- From the Christian Medical College and Hospital, Tamil Nadu, India
| | - A Jasper
- From the Christian Medical College and Hospital, Tamil Nadu, India
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Chow CK, Ma CKL. Presentation and Outcome of Acute Necrotizing Encephalopathy of Childhood: A 10-Year Single-Center Retrospective Study From Hong Kong. J Child Neurol 2020; 35:674-680. [PMID: 32493103 DOI: 10.1177/0883073820927915] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Acute necrotizing encephalopathy (ANE) is a rare disease in childhood. We reviewed the 10-year data from a local pediatric department, reported the clinical characteristics, laboratory tests, neuroimaging findings, and outcome of the acute necrotizing encephalopathy cases and identified the potential factors affecting the outcome. Eight episodes of acute necrotizing encephalopathy among 7 patients were recorded, in which all of them had an initial presentation of fever and seizure. We identified that acute necrotizing encephalopathy patients with a severe score of Glasgow Coma Scale (GCS) on presentation, brainstem involvement in magnetic resonance imaging (MRI) of the brain, and higher MR imaging scores were associated with worse outcome. Association of outcome with acute necrotizing encephalopathy severity score, platelet count, and serum alanine aminotransferase level did not reach a statistically significant level. These results highlight the importance of combined clinical, laboratory, and neuroimaging findings in determining the prognostic outcome of acute necrotizing encephalopathy patients.
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Affiliation(s)
- Chit Kwong Chow
- Department of Paediatrics and Adolescent Medicine, United Christian Hospital, Kwun Tong, Kowloon, Hong Kong SAR
| | - Che Kwan Louis Ma
- Department of Paediatrics and Adolescent Medicine, United Christian Hospital, Kwun Tong, Kowloon, Hong Kong SAR
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38
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Huber JN, Berg AD, Bula-Rudas F. Acute Necrotizing Encephalopathy due to Streptococcus pneumoniae: An Uncommon Pathogen in a Devastating Disease. Pediatr Neurol 2020; 108:126-127. [PMID: 32299747 DOI: 10.1016/j.pediatrneurol.2020.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/02/2020] [Accepted: 03/01/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Jody N Huber
- Sanford Children's Hospital, Sanford Medical Center, Sioux Falls, South Dakota; University of South Dakota, Sanford School of Medicine, Vermillion, South Dakota.
| | - Aaron D Berg
- University of South Dakota, Sanford School of Medicine, Vermillion, South Dakota; Sanford Medical Center, Sioux Falls, South Dakota
| | - Fernando Bula-Rudas
- Sanford Children's Hospital, Sanford Medical Center, Sioux Falls, South Dakota; University of South Dakota, Sanford School of Medicine, Vermillion, South Dakota
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39
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Larsh T, Hsich G. Temporal Course of Imaging and Laboratory Findings in a Child with Fulminant Acute Necrotizing Encephalopathy. Pediatr Neurol 2020; 102:74-75. [PMID: 31178236 DOI: 10.1016/j.pediatrneurol.2019.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/14/2019] [Accepted: 05/05/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Travis Larsh
- Cleveland Clinic, Neurological Institute, Center for Pediatric Neurology, Cleveland, Ohio.
| | - Gary Hsich
- Cleveland Clinic, Neurological Institute, Center for Pediatric Neurology, Cleveland, Ohio
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Hayakawa I, Okubo Y, Nariai H, Michihata N, Matsui H, Fushimi K, Yasunaga H. Recent treatment patterns and variations for pediatric acute encephalopathy in Japan. Brain Dev 2020; 42:48-55. [PMID: 31522789 DOI: 10.1016/j.braindev.2019.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 08/15/2019] [Accepted: 08/22/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Treatments for pediatric acute encephalopathy are largely empiric with limited evidence to support. This study investigated recent trends in clinical practice patterns for pediatric acute encephalopathy at a national level. METHOD Discharge records were extracted for children with acute encephalopathy for the fiscal years 2010-2015 using a national inpatient database in Japan. We ascertained the secular trends in medications, diagnostic and therapeutic procedures, healthcare costs, in-hospital mortality, and length of hospital stays (LOS), using mixed effect linear or logistic regression models. We also ascertained variations and clustering of the practice patterns across different hospitals using hierarchical cluster analyses. RESULTS A total of 4692 eligible inpatients were identified. From 2010 to 2015, we observed increasing trends in hospitalization costs, corticosteroid and edaravone use and a decreasing trend in LOS. Despite changes in treatments, the rates of home respiratory support and in-hospital mortality were constant during the study period. Hierarchical cluster analyses showed that 6 hospital groups showed largely different therapeutic strategies to the same disease regardless of mortality rates. Hospitals with more intensive treatment practices were likely to have higher mortality, while hospitals with less intensive treatment practices were likely to have the lower mortality. However, hospitals in one group (group 1) had less intensive treatment practice even though they had the highest mortality. CONCLUSIONS We provided novel insights into the recent trends in treatments for pediatric acute encephalopathy. Therapeutic strategies varied between hospitals, suggesting the importance of pursuing evidence-based treatment strategy and promoting standardized practices to pediatric acute encephalopathy.
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Affiliation(s)
- Itaru Hayakawa
- Division of Neurology, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan; Department of Pediatrics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yusuke Okubo
- Department of Epidemiology, UCLA Fielding School of Public Health, LA, CA, USA; Department of Social Medicine, National Research Institute for Child Health and Development, Tokyo, Japan; Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Japan.
| | - Hiroki Nariai
- Division of Pediatric Neurology, Department of Pediatrics, UCLA Medical Center, LA, CA, USA
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Japan
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41
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Neuropsychological outcomes of childhood acute necrotizing encephalopathy. Brain Dev 2019; 41:894-900. [PMID: 31376945 DOI: 10.1016/j.braindev.2019.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 06/07/2019] [Accepted: 07/10/2019] [Indexed: 11/21/2022]
Abstract
Acute necrotizing encephalopathy (ANE) is a rare form of acute encephalopathy, predominantly occurring in childhood, which has a typical radiological phenotype including bilateral, symmetrical, diffusion-restricted lesions of the thalami; posterior putamen; cerebellum; and brainstem. To date, no study has systematically examined the long-term cognitive and psychological impact of ANE. The current study describes the neuropsychological outcomes of three paediatric cases of ANE, ranging from 18 months to 10 years post ANE. All three cases displayed inattention, fine motor difficulties and anxiety. Social difficulties were also reported in all cases. The severity of long-term impairment was associated with acute presentation, as well as convalescent neuroimaging. These findings highlight the need for detailed neuropsychological assessment and long-term rehabilitation.
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Koh JC, Murugasu A, Krishnappa J, Thomas T. Favorable Outcomes With Early Interleukin 6 Receptor Blockade in Severe Acute Necrotizing Encephalopathy of Childhood. Pediatr Neurol 2019; 98:80-84. [PMID: 31201070 DOI: 10.1016/j.pediatrneurol.2019.04.009] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/16/2019] [Accepted: 04/18/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Outcome in severe acute necrotizing encephalopathy of childhood is poor, with high mortality (30%) and moderate to severe disability in survivors despite the use of intravenous corticosteroids or immunoglobulins. Increased blood interleukin 6 level correlates with poor outcome. METHODS We report the early use of tocilizumab, a monoclonal antibody against the interleukin 6 receptor, in three patients (aged five, eight, and 10 years) with severe acute necrotizing encephalopathy. RESULTS All three patients experienced a rapid neurological deterioration associated with febrile viral illnesses and met criteria for severe acute necrotizing encephalopathy with a high risk for death or severe disability. Intravenous methylprednisolone and tocilizumab were administered at 18 to 32 hours of encephalopathy in addition to supportive medical therapy. No side effects were observed with this therapeutic strategy. The two patients with influenza A(H1N1)pdm09 virus-related acute necrotizing encephalopathy had a short illness with excellent clinical and radiological recovery. The patient with influenza B virus-related acute necrotizing encephalopathy and florid hemorrhagic brain lesions had a slow recovery with eventual mild disability despite focal encephalomalacia on follow-up neuroimaging. CONCLUSIONS The early use of interleukin 6 blockade in acute necrotizing encephalopathy is safe and may have a role in improving outcomes and preventing disability.
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Affiliation(s)
- Janine Cynthia Koh
- Paediatric Neurology Service, KK Women's and Children's Hospital, Singapore
| | - Aaron Murugasu
- School of Medicine, Dentistry & Nursing, University of Glasgow, United Kingdom
| | | | - Terrence Thomas
- Paediatric Neurology Service, KK Women's and Children's Hospital, Singapore.
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43
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Oba C, Kashiwagi M, Tanabe T, Nomura S, Ogino M, Matsuda T, Murata S, Nakamura M, Shirasu A, Inoue K, Okasora K, Tamai H. Prognostic factors in the early phase of acute encephalopathy. Pediatr Int 2018; 60:270-275. [PMID: 29280262 DOI: 10.1111/ped.13492] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 11/18/2017] [Accepted: 12/20/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Neurological sequelae occur in 40% of patients with acute encephalopathy (AE). The early prediction of poor outcomes is critical to the initiation of appropriate treatment. The aim of the present study was therefore to elucidate prognostic factors that can be quickly and feasibly evaluated on hospital admission in patients with AE. METHODS We analyzed data from 51 AE patients admitted to Hirakata City Hospital between January 2005 and December 2014. Age at onset, sex, underlying disease, status epilepticus (SE), presence of benzodiazepine-resistant SE (BZD-resistant SE), and basic blood serum parameters on admission were evaluated in relation to each patient's outcome. RESULTS On univariate analysis age at onset, BZD-resistant SE, and serum aspartate aminotransferase (AST), alanine aminotransferase, lactate dehydrogenase, and platelet count varied significantly according to outcome. On multivariate analysis age at onset (≤21 months), presence of BZD-resistant SE, and AST (≥46 IU/L) were identified as independent variables associated with poor outcome. CONCLUSION Age at onset, presence of BZD-resistant SE, and AST are associated with a poor prognosis in AE.
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Affiliation(s)
- Chizu Oba
- Department of Pediatrics, Hirakata City Hospital, Hirakata, Osaka, Japan
| | - Mitsuru Kashiwagi
- Department of Pediatrics, Hirakata City Hospital, Hirakata, Osaka, Japan
| | - Takuya Tanabe
- Department of Child Neurology, Tanabe Children's Clinic, Hirakata, Osaka, Japan
| | - Shohei Nomura
- Department of Pediatrics, Hirakata City Hospital, Hirakata, Osaka, Japan
| | - Motoko Ogino
- Department of Pediatrics, Hirakata City Hospital, Hirakata, Osaka, Japan
| | - Takuya Matsuda
- Department of Pediatrics, Hirakata City Hospital, Hirakata, Osaka, Japan
| | - Shinya Murata
- Department of Pediatrics, Hirakata City Hospital, Hirakata, Osaka, Japan
| | - Michiko Nakamura
- Department of Pediatrics, Hirakata City Hospital, Hirakata, Osaka, Japan
| | - Akihiko Shirasu
- Department of Pediatrics, Hirakata City Hospital, Hirakata, Osaka, Japan
| | - Keisuke Inoue
- Department of Pediatrics, Hirakata City Hospital, Hirakata, Osaka, Japan
| | - Keisuke Okasora
- Department of Pediatrics, Hirakata City Hospital, Hirakata, Osaka, Japan
| | - Hiroshi Tamai
- Department of Pediatrics, Osaka Medical College, Takatsuki, Osaka, Japan
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Lim HY, Ho VPY, Lim TCC, Thomas T, Chan DWS. Serial outcomes in acute necrotising encephalopathy of childhood: A medium and long term study. Brain Dev 2016; 38:928-936. [PMID: 27256511 DOI: 10.1016/j.braindev.2016.05.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 05/13/2016] [Accepted: 05/13/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Acute necrotising encephalopathy (ANEC) is a severe, debilitating childhood disorder. We used the ANEC scoring system (ANE-ss) and standardised neurodevelopmental scores to objectively characterise medium and long term outcomes. METHODS Retrospective review of children with ANEC at KK Women's and Children's Hospital, Singapore, from 2005 to 2012. ANE-ss was determined from clinical features and neuroimaging, and neurodevelopmental scores (Pediatric Glasgow Outcome Scale Extended, Pediatric Cerebral Performance Category scale and Pediatric Overall Performance Category scale) were applied at 1, 6, 12 and 24months post diagnosis. RESULTS Seven patients with ANEC were studied. All had a viral prodrome with fever, and encephalopathy at presentation, and received immunotherapy (steroids or immunoglobulin). ANE-ss scores were medium risk in 4 patients and high risk in 3 patients. One died (high risk ANE-ss) and outcome was determined in the 6 survivors. At 1month post diagnosis, 3 patients (50%) were mildly affected and 3 (50%) were severely affected. Morbidity rates improved by 12months, with 67% and 33.3% scoring in the mildly affected and severely affected ranges, respectively. Medium risk patients did well with majority having little or no neurological deficits and good outcome scores. CONCLUSION Mortality and severe morbidity correlated well with high risk ANE-ss. However, our patients with medium risk ANE-ss had good neurodevelopmental sequelae. Serial disability scoring is useful in evaluating the progress of ANEC patients on follow up. Assessment at 1month post diagnosis can aid prognostication of long term outcome.
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Affiliation(s)
- Hwee Ying Lim
- Department of Paediatric Medicine, KK Women and Children Hospital, Singapore
| | | | | | - Terrence Thomas
- Paediatric Neurology, Department of Paediatrics, KK Women and Children Hospital, Singapore
| | - Derrick Wei Shih Chan
- Paediatric Neurology, Department of Paediatrics, KK Women and Children Hospital, Singapore.
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Short and long-term outcomes in children with suspected acute encephalopathy. Brain Dev 2016; 38:731-7. [PMID: 26952815 DOI: 10.1016/j.braindev.2016.02.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 02/21/2016] [Accepted: 02/22/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND The time-dependent changes that occur in children after acute encephalopathy are not clearly understood. Therefore, we assessed changes in brain function after suspected acute encephalopathy over time. METHODS We created a database of children admitted to the pediatric intensive care unit at Kobe Children's Hospital because of convulsions or impaired consciousness with fever between 2002 and 2013. Clinical courses and outcomes were reviewed and patients who met the following criteria were included in the study: (1) 6months to 15years of age, (2) no neurological abnormality before onset, (3) treated for suspected acute encephalopathy, and (4) followed after 1 (0-2) month and 12 (10-17) months of onset. Outcomes were assessed using the Pediatric Cerebral Performance Category (PCPC) scale, with a score of 1 representing normal performance; 2, mild disability; 3, moderate disability; 4, severe disability; 5, vegetative state; and 6, brain death. RESULTS A total of 78 children (32 male) with a median (range) age at onset of 20 (6-172) months were enrolled. Fifty-one cases scored 1 on the PCPC, 13 scored 2, three scored 3, five scored 4, one scored 5, and five cases scored 6 at discharge. Whereas seven of the 13 cases that scored a 2 on the PCPC recovered normal brain function after 12months, none of the nine cases that scored a 3-5 on the PCPC recovered normal function. CONCLUSIONS Our findings suggest moderate to severe disability caused by acute encephalopathy had lasting consequences on brain function, whereas mild disability might result in improved function.
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Yoganathan S, Sudhakar SV, James EJ, Thomas MM. Acute necrotising encephalopathy in a child with H1N1 influenza infection: a clinicoradiological diagnosis and follow-up. BMJ Case Rep 2016; 2016:bcr-2015-213429. [PMID: 26759402 DOI: 10.1136/bcr-2015-213429] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Acute necrotising encephalopathy of childhood (ANEC) is a fulminant disorder with rapid progressive encephalopathy, seizures and poor outcome. It has been reported in association with various viral infections. We describe the clinicoradiological findings and short-term follow-up in a child with H1N1 influenza-associated ANEC. Laminar, target or tricolour pattern of involvement of the thalami was seen on apparent diffusion coefficient images. Our patient had significant morbidity at discharge despite early diagnosis and management with oseltamivir and immunoglobulin. Repeat imaging after 3 months had shown significant resolution of thalamic swelling, but there was persistence of cytotoxic oedema involving bilateral thalami. She was pulsed with intravenous steroids and maintained on a tapering schedule of oral steroids. This report emphasises the need for a high index of suspicion to establish early diagnosis, promotion of widespread immunisation strategies to prevent influenza outbreak, and more research to establish standard treatment protocols for this under-recognised entity.
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Affiliation(s)
- Sangeetha Yoganathan
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamilnadu, India
| | - Sniya Valsa Sudhakar
- Department of Radiodiagnosis, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ebor Jacob James
- Department of Pediatrics, Christian Medical College, Vellore, Tamilnadu, India
| | - Maya Mary Thomas
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamilnadu, India
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Acute necrotizing encephalopathy: an underrecognized clinicoradiologic disorder. Mediators Inflamm 2015; 2015:792578. [PMID: 25873770 PMCID: PMC4385702 DOI: 10.1155/2015/792578] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 10/13/2014] [Indexed: 01/02/2023] Open
Abstract
Acute necrotizing encephalopathy (ANE) is a rare but distinctive type of acute encephalopathy with global distribution. Occurrence of ANE is usually preceded by a virus-associated febrile illness and ensued by rapid deterioration. However, the causal relationship between viral infections and ANE and the exact pathogenesis of ANE remain unclear; both environmental and host factors might be involved. Most cases of ANE are sporadic and nonrecurrent, namely, isolated or sporadic ANE; however, few cases are recurrent and with familial episodes. The recurrent and familial forms of ANE were found to be incompletely autosomal-dominant. Further the missense mutations in the gene encoding the nuclear pore protein Ran Binding Protein 2 (RANBP2) were identified. Although the clinical course and the prognosis of ANE are diverse, the hallmark of neuroradiologic manifestation of ANE is multifocal symmetric brain lesions which are demonstrated by computed tomography (CT) or magnetic resonance imaging (MRI). The treatment of ANE is still under investigation. We summarize the up-to-date knowledge on ANE, with emphasis on prompt diagnosis and better treatment of this rare but fatal disease.
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