Behavioural disturbances following Japanese B encephalitis

A systematic review of modified electroconvulsive therapy (ECT) to treat delirium

BACKGROUND

Delirium is costly for patients, carers, and healthcare systems. In addition, non-pharmacological and pharmacological management of delirium is challenging. Electroconvulsive therapy (ECT) has been proposed and used as an anecdotal treatment of delirium in clinical practice. However, the efficacy and safety of this approach are not well understood.

OBJECTIVE

To synthesise and review the evidence relating to the safety and efficacy of ECT as a treatment for delirium.

METHODS

A systematic review was completed according to PRISMA guidelines using the PubMed, CINAHL, Cochrane Library, and PsycINFO databases. Studies were eligible for inclusion if modified ECT was used to treat delirium symptoms. ECT for delirium in people with neuroleptic malignant syndrome, catatonia, or confusional states associated with acute primary psychiatric conditions were excluded. All included records were first ranked using the hierarchy of evidence-based medicine; quality was then assessed using the Joanna Briggs critical appraisal checklists. Pooled data across the cases identified were analysed using descriptive statistics.

RESULTS

Of 1226 records screened, 10 studies met inclusion criteria: six case reports, three case series, and one quasi-experimental study. The literature base was of mixed quality. A single quasi-experimental study was assessed to be of 'fair' quality, the remainder of the case series and case reports were rated as 'poor' to 'fair' quality. A total of only 40 individual people with delirium who were treated with ECT were identified. In 33/40 cases, the aetiology of delirium was substance withdrawal. The number of ECT treatments administered ranged from 1 to 13. ECT was reported to positively contribute towards treatment of delirium in all cases, although objective measures of improvement were reported in only 6/13 patient cases from case reports and case series (46%). The singular quasi-experimental study reported a statistically significant decrease in duration of delirium, time spent in physical restraint, and in benzodiazepine requirement when ECT was used as an adjunct in benzodiazepine withdrawal delirium. When adverse events were described these included mild confusion and memory deficits; all were reported as time limited and reversible. Considerable limitations in the quality of the evidence base were identified, including the risk of selection, publication and reporting bias. Much data reporting on safety and efficacy of ECT in delirium was missing.

CONCLUSION

There is insufficient literature to support modified ECT as a clinical treatment for delirium. The few studies identified were generally of weak evidence lacking important data on safety and objective outcome measures, and not including populations with broad delirium aetiologies. Further research using more robust methodologies and broader populations (age, aetiology) of people with delirium treated with ECT is needed.

Arboviral Infections in Neurological Disorders in Hospitalized Patients in São José do Rio Preto, São Paulo, Brazil

Arbovirus infections are increasingly important causes of disease, whose spectrum of neurological manifestations are not fully known. This study sought to retrospectively assess the incidence of arboviruses in cerebrospinal fluid samples of patients with neurological symptoms to inform diagnosis of central and peripheral nervous system disorders. A total of 255 cerebrospinal fluid (CSF) samples collected from January 2016 to December 2017 were tested for dengue virus (DENV 1-4), Zika virus (ZIKV), and Chikungunya virus (CHIKV) in addition to other neurotropic arboviruses of interest, using genetic and serologic assays. Of the 255 CSF samples analyzed, 3.53% (09/255) were positive for arboviruses presenting mainly as meningitis, encephalitis, and cerebrovascular events, of which ZIKV was detected in 2.74% (7/255), DENV in 0.78% (2/255), in addition to an identified ILHV infection that was described previously. All the cases were detected in adults aged 18 to 74 years old. Our findings highlight the scientific and clinical importance of neurological syndromes associated with arboviruses and demonstrate the relevance of specific laboratory methods to achieve accurate diagnoses as well as highlight the true dimension of these diseases to ultimately improve public health planning and medical case management.

The Spectrum of Repetitive Behaviors Associated With Subacute Sclerosing Panencephalitis

BACKGROUND

Repetitive behaviors refer to a broad class of responses ranging from stereotypic body movements to impulsive/compulsive behaviors. They may be associated with neurological disorders.

METHODS

This is a case series of six subacute sclerosing panencephalitis (SSPE) patients who presented with a wide spectrum of repetitive motor behaviors and vocalizations.

RESULTS

Repetitive motor behaviors involved the upper limbs in all patients and lower limbs in 3 patients. The repetitive movements in the upper limbs were clapping, finger-clicking, hand rubbing, flailing, and dystonic posturing. In the lower limbs, the repetitive movements were rubbing with the heel, pelvic thrusting with flexion extension of the leg, and foot tapping. The spectrum of vocalizations included palilalia, whistling, grunting with spitting, and pathological crying. Repetitive behaviors were the presenting features in 2 patients.

CONCLUSIONS

This case series expands the spectrum of repetitive behaviors seen in neurological disorders associated with brain infections. © 2020 International Parkinson and Movement Disorder Society.

Delirium in Meningitis and Encephalitis: Emergence and Prediction in a 6-Year Cohort

BACKGROUND/OBJECTIVE

Data regarding delirium in patients presenting with infections of the central nervous system, such as meningitis and/or encephalitis (ME), are scarce. We aimed to determine the frequency and early predictors of delirium in the acute phase of ME.

METHODS

We assessed clinical, radiologic, and laboratory data of patients with ME at a Swiss academic medical center from 2011 to 2017. The highest Intensive Care Delirium Screening Checklist (ICDSC) score was assessed within 24 hours around lumbar puncture. Multivariable logistic regression was performed to identify predictors of delirium (ICDSC ≥4).

RESULTS

Among 330 patients with ME, infectious pathogens were identified in 41%. An ICDSC >1 was found in 28% with and 19% without identified infectious pathogens. Delirium was diagnosed in 18% with and 14% without infectious pathogens and significantly associated with prolonged in-hospital treatment and mechanical ventilation, more frequent administration of neuroleptics and anesthetics (in 96% with delirium vs 35% without), complications, and less recovery to premorbid functional baseline. Low serum albumin at presentation was the only independent predictor of delirium (area under the receiver-operating curve [AUROC] = 0.792) in patients with pathogens. In patients with infections, the AUROC was smallest for encephalitis (AUROC = 0.641) and larger for patients with meningeal infections (meningitis AUROC = 0.807; meningoencephalitis AUROC = 0.896).

CONCLUSIONS

Delirium in the context of ME is seen in almost every fifth patient and linked to prolonged treatment, complications, and incomplete recovery. Among clinical, radiologic, and laboratory parameters, the good calibration and discrimination of low albumin serum concentrations for the prediction of delirium in patients with ME seem promising, especially if meninges are affected.

Clinical analysis of psychiatric symptoms of Japanese encephalitis during the convalescent Period: A single center study in Chongqing, China

BACKGROUND

This study aimed to analyze clinical and imaging features of children with severe Japanese encephalitis (JE), and to analyze causes and solutions for psychiatric symptoms of JE during the convalescent period.

METHODS

We analyzed clinical information for 78 children with severe JE at the Department of Neurology, Department of Infection, and Department of Rehabilitation in our hospital during 2014-2016. Seventy-eight cases of severe JE were divided into patients with psychiatric symptoms and no psychiatric symptoms groups. We focused on analysis of the patients with psychiatric symptoms group.

RESULTS

The incidence of psychiatric symptoms during the convalescent period was 46.15% (36/78). Antipsychotic drugs can effectively control psychiatric symptoms and shorten duration of symptoms. Seventy-one patients underwent reexamination with a head MRI. Of these, 8 cases (8/36 = 22.22%) in patients with psychiatric symptoms group showed new lesions in the basal ganglia, insula, and hippocampus. During the 12-month follow-up, two cases showed reappearance of psychiatric symptoms that had been relieved previously.

CONCLUSION

This study found that severe JE cases revealed a considerable proportion with psychiatric symptoms during the convalescent period.

Japanese Encephalitis Vaccine: Recommendations of the Advisory Committee on Immunization Practices

This report updates the 2010 recommendations from the CDC Advisory Committee on Immunization Practices (ACIP) regarding prevention of Japanese encephalitis (JE) among U.S. travelers and laboratory workers (Fischer M, Lindsey N, Staples JE, Hills S. Japanese encephalitis vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2010;59[No. RR-1]). The report summarizes the epidemiology of JE, describes the JE vaccine that is licensed and available in the United States, and provides recommendations for its use among travelers and laboratory workers.JE virus, a mosquitoborne flavivirus, is the most common vaccine-preventable cause of encephalitis in Asia. JE occurs throughout most of Asia and parts of the western Pacific. Approximately 20%-30% of patients die, and 30%-50% of survivors have neurologic, cognitive, or behavioral sequelae. No antiviral treatment is available.Inactivated Vero cell culture-derived JE vaccine (Ixiaro [JE-VC]) is the only JE vaccine that is licensed and available in the United States. In 2009, the U.S. Food and Drug Administration (FDA) licensed JE-VC for use in persons aged ≥17 years; in 2013, licensure was extended to include children aged ≥2 months.Most travelers to countries where the disease is endemic are at very low risk for JE. However, some travelers are at increased risk for infection on the basis of their travel plans. Factors that increase the risk for JE virus exposure include 1) traveling for a longer period; 2) travel during the JE virus transmission season; 3) spending time in rural areas; 4) participating in extensive outdoor activities; and 5) staying in accommodations without air conditioning, screens, or bed nets. All travelers to countries where JE is endemic should be advised to take precautions to avoid mosquito bites to reduce the risk for JE and other vectorborne diseases. For some persons who might be at increased risk for JE, the vaccine can further reduce the risk for infection. The decision about whether to vaccinate should be individualized and consider the 1) risks related to the specific travel itinerary, 2) likelihood of future travel to countries where JE is endemic, 3) high morbidity and mortality of JE, 4) availability of an effective vaccine, 5) possibility (but low probability) of serious adverse events after vaccination, and 6) the traveler's personal perception and tolerance of risk.JE vaccine is recommended for persons moving to a JE-endemic country to take up residence, longer-term (e.g., ≥1 month) travelers to JE-endemic areas, and frequent travelers to JE-endemic areas. JE vaccine also should be considered for shorter-term (e.g., <1 month) travelers with an increased risk for JE on the basis of planned travel duration, season, location, activities, and accommodations and for travelers to JE-endemic areas who are uncertain about their specific travel duration, destinations, or activities. JE vaccine is not recommended for travelers with very low-risk itineraries, such as shorter-term travel limited to urban areas or outside of a well-defined JE virus transmission season.

Encephalitic Arboviruses: Emergence, Clinical Presentation, and Neuropathogenesis

Arboviruses are arthropod-borne viruses that exhibit worldwide distribution, contributing to systemic and neurologic infections in a variety of geographical locations. Arboviruses are transmitted to vertebral hosts during blood feedings by mosquitoes, ticks, biting flies, mites, and nits. While the majority of arboviral infections do not lead to neuroinvasive forms of disease, they are among the most severe infectious risks to the health of the human central nervous system. The neurologic diseases caused by arboviruses include meningitis, encephalitis, myelitis, encephalomyelitis, neuritis, and myositis in which virus- and immune-mediated injury may lead to severe, persisting neurologic deficits or death. Here we will review the major families of emerging arboviruses that cause neurologic infections, their neuropathogenesis and host neuroimmunologic responses, and current strategies for treatment and prevention of neurologic infections they cause.

Abrogated inflammatory response promotes neurogenesis in a murine model of Japanese encephalitis

Background

Japanese encephalitis virus (JEV) induces neuroinflammation with typical features of viral encephalitis, including inflammatory cell infiltration, activation of microglia, and neuronal degeneration. The detrimental effects of inflammation on neurogenesis have been reported in various models of acute and chronic inflammation. We investigated whether JEV-induced inflammation has similar adverse effects on neurogenesis and whether those effects can be reversed using an anti-inflammatory compound minocycline.

Methodology/Principal Findings

Here, using in vitro studies and mouse models, we observed that an acute inflammatory milieu is created in the subventricular neurogenic niche following Japanese encephalitis (JE) and a resultant impairment in neurogenesis occurs, which can be reversed with minocycline treatment. Immunohistological studies showed that proliferating cells were replenished and the population of migrating neuroblasts was restored in the niche following minocycline treatment. In vitro, we checked for the efficacy of minocycline as an anti-inflammatory compound and cytokine bead array showed that production of cyto/chemokines decreased in JEV-activated BV2 cells. Furthermore, mouse neurospheres grown in the conditioned media from JEV-activated microglia exhibit arrest in both proliferation and differentiation of the spheres compared to conditioned media from control microglia. These effects were completely reversed when conditioned media from JEV-activated and minocycline treated microglia was used.

Conclusion/Significance

This study provides conclusive evidence that JEV-activated microglia and the resultant inflammatory molecules are anti-proliferative and anti-neurogenic for NSPCs growth and development, and therefore contribute to the viral neuropathogenesis. The role of minocycline in restoring neurogenesis may implicate enhanced neuronal repair and attenuation of the neuropsychiatric sequelae in JE survivors.

Viral infection and neural stem/progenitor cell's fate: implications in brain development and neurological disorders

Viral infections in the prenatal (during pregnancy) and perinatal period have been a common cause of brain malformation. Besides the immediate neurological dysfunctions, virus infections may critically affect CNS development culminating in long-term cognitive deficits. Most of these neurotropic viruses are most damaging at a critical stage of the host, when the brain is in a dynamic stage of development. The neuropathology can be attributed to the massive neuronal loss induced by the virus as well as lack of CNS repair owing to a deficit in the neural stem/progenitor cell (NSPC) pool or aberrant formation of new neurons from NSPCs. Being one of the mitotically active populations in the post natal brain, the NSPCs have emerged as the potential targets of neurotropic viruses. The NSPCs are self-renewing and multipotent cells residing in the neurogenic niches of the brain, and, therefore, hampering the developmental fate of these cells may adversely affect the overall neurogenesis pattern. A number of neurotropic viruses utilize NSPCs as their cellular reservoirs and often establish latent and persistent infection in them. Both HIV and Herpes virus infect NSPCs over long periods of time and reactivation of the virus may occur later in life. The virus infected NSPCs either undergoes cell cycle arrest or impaired neuronal or glial differentiation, all of which leads to impaired neurogenesis. The disturbances in neurogenesis and CNS development following neurotropic virus infections have direct implications in the viral pathogenesis and long-term neurobehavioral outcome in infected individuals.

Japanese encephalitis in travelers from non-endemic countries, 1973-2008

Japanese encephalitis (JE) is a severe disease and a risk for travelers who visit JE-endemic countries. We reviewed all published JE cases in travelers from non-endemic areas from 1973 through 2008, and assessed factors related to risk of infection. There were 55 cases that occurred in citizens of 17 countries. Age range of case-patients was 1-91 years (median = 34 years). Ten (18%) persons died and 24 (44%) had mild to severe sequelae. In a detailed risk assessment of 37 case-patients, 24 (65%) had spent > or = 1 month in JE-endemic areas, and most had factors identified that may have increased infection risk. The estimate of overall JE risk was low, < 1 case/1 million travelers to JE-endemic countries. Nonetheless, for each traveler, a careful assessment of itinerary and activities, a decision on vaccination, and information on mosquito precautions are needed to reduce the risk of this disease.

Neurocognitive and functional outcomes in persons recovering from West Nile virus illness

Long-term neurocognitive and functional impairments following West Nile virus (WNV) disease are poorly understood. We assessed quality-of-life indices and neurocognitive performance in a cohort of 54 persons recovering from one of three WNV disease syndromes (fever [WNF], meningitis [WNM], or encephalitis [WNE]) approximately 1.5 years following acute illness. We compared findings between the three syndromic groups; the study cohort and a demographically similar group of 55 controls from a study of chronic fatigue syndrome (CFS); and the study cohort and a 'normative' control population based on cognitive test data. Persistent symptoms, diminished quality of life, and functional impairment were reported by 50% of WNF patients, and 75% each of WNM and WNE patients. Overall, objective neurocognitive performance did not differ significantly between the three syndromic groups, or between the study cohort and the CFS controls or the normative controls. In some neurocognitive subtests, the study cohort scored below the 15th percentile when compared with normative control data. Most persons who returned to independent living following hospitalization for WNV illness had persistent subjective complaints, but had normal cognitive function. However, a minority displayed subtle neurocognitive deficits more than 18 months following acute disease.

Japanese encephalitis vaccines--needs, flaws and achievements

Japanese encephalitis causes serious health problems in countries in Southeast Asia, where the causative virus is endemic. Whereas most adults living in this region have acquired immunity, children are at high risk of infection. Childhood mass immunization programs with first-generation mouse brain-derived vaccines efficiently reduced Japanese encephalitis incidence in affected countries, but immunization recommendations have mostly been abolished in Japan owing to the occurrence of severe side effects. Thus, there is a pressing need for safer vaccines to keep the disease under control. The safety profile of the current vaccines, together with the relatively low incidence, makes the risk/benefit ratio unfavorable for immunization of travelers to Southeast Asia, despite the high mortality once the clinical disease has developed. As Asian countries become increasingly popular travel destinations, the availability of well-tolerated vaccines would likely shift the ratio towards immunization. Currently, there is one second-generation inactivated cell-culture-grown vaccine in late-stage clinical development that is approaching licensing in developed countries.

Safety and immunogenicity of a Vero-cell-derived, inactivated Japanese encephalitis vaccine: a non-inferiority, phase III, randomised controlled trial

BACKGROUND

Japanese encephalitis virus (JEV) is the leading cause of viral encephalitis in southeast Asia. Although no treatment is currently available, vaccination effectively prevents the disease. In a non-inferiority study, we aimed to compare the safety and immunogenicity of a novel, second-generation, inactivated candidate vaccine for JEV with a licensed, mouse-brain-derived vaccine.

METHODS

We included 867 adults in a multicentre, multinational, observer-blinded, randomised controlled phase III trial. Study sites were located in the USA, Germany, and Austria. Volunteers received either the JEV test vaccine intramuscularly on a two-dose schedule (on days 0 and 28; n=430) or the licensed vaccine subcutaneously according to its recommended three-dose schedule (on days 0, 7, and 28; n=437). The primary endpoint was immunogenicity, with respect to neutralising JEV-specific antibodies assessed by a plaque-reduction neutralisation test, which was assessable in 725 patients in the per-protocol population. This trial is registered as a clinical trial, EudraCT number 2004-002474-36.

FINDINGS

The safety profile of the test vaccine was good, and its local tolerability profile was more favourable than that of the licensed vaccine. Frequency of adverse events was similar between treatment groups, and vaccine-related adverse events were generally mild. The seroconversion rate of the test vaccine was 98% compared with 95% for the licensed vaccine on day 56 (95% CI for the difference -1.33 to 3.43). Geometric mean titre for recipients of the test vaccine was 244 (range 5-19 783), compared with 102 (5-1864) for the licensed vaccine (ratio 2.3 [95% CI 1.967-2.75]).

INTERPRETATION

The test JEV vaccine has a promising immunogenicity and safety profile.

Neuropsychological and psychiatric profiles in acute encephalitis in adults

Acute encephalitis is an inflammation of brain tissue that can result from activity in the central nervous system (CNS) of a number of viruses. Although the neurological and psychiatric effects of encephalitis in the acute phase of the illness are well-known (Caroff, Mann, Gliatto, Sullivan, & Campbell, 2001), larger scale studies of the pattern of neuropsychological and psychiatric impairment following recovery from the acute inflammatory phase are less apparent. This paper reports the results of neuropsychological testing with a range of standardised cognitive measures in a case series of long-term post-acute participants. Psychiatric abnormality is examined using the SCL-90-R self-report scale of distress (Derogatis, 1983). We also examined the role of emerging insight in the aetiology of depression in this population. Two clusters of cognitive dysfunction were observed, one group of primarily herpes simplex cases showing a severe generalised deficit across a number of cognitive domains and a second cluster showing a variety of more isolated disorders of executive function. Abnormally high levels of distress were reported by participants, with depression, obsessive-compulsive symptoms, interpersonal sensitivity and phobic anxiety most significantly increased. Depression was found to be least severe in those with most accurate insight into their problems. Examining the correlations between cognitive and psychiatric test results demonstrates a relationship between depression and interpersonal anxiety and specific cognitive measures. Obsessive-compulsive behaviour and phobic anxiety, however, appear to exist independently of the assessed cognitive deficits.

Long-term neurological and functional outcome in Nipah virus infection

OBJECTIVE

Nipah virus (NiV) is an emerging zoonosis. Central nervous system disease frequently results in high case-fatality. Long-term neurological assessments of survivors are limited. We assessed long-term neurologic and functional outcomes of 22 patients surviving NiV illness in Bangladesh.

METHODS

During August 2005 and May 2006, we administered a questionnaire on persistent symptoms and functional difficulties to 22 previously identified NiV infection survivors. We performed neurologic evaluations and brain magnetic resonance imaging (MRI).

RESULTS

Twelve (55%) subjects were male; median age was 14.5 years (range 6-50). Seventeen (77%) survived encephalitis, and 5 survived febrile illness. All but 1 subject had disabling fatigue, with a median duration of 5 months (range, 8 days-8 months). Seven encephalitis patients (32% overall), but none with febrile illness had persistent neurologic dysfunction, including static encephalopathy (n = 4), ocular motor palsies (2), cervical dystonia (2), focal weakness (2), and facial paralysis (1). Four cases had delayed-onset neurologic abnormalities months after acute illness. Behavioral abnormalities were reported by caregivers of over 50% of subjects under age 16. MRI abnormalities were present in 15, and included multifocal hyperintensities, cerebral atrophy, and confluent cortical and subcortical signal changes.

INTERPRETATION

Although delayed progression to neurologic illness following Nipah fever was not observed, persistent fatigue and functional impairment was frequent. Neurologic sequelae were frequent following Nipah encephalitis. Neurologic dysfunction may persist for years after acute infection, and new neurologic dysfunction may develop after acute illness. Survivors of NiV infection may experience substantial long-term neurologic and functional morbidity.

Clonic perseveration in the subacute stage of Japanese encephalitis

We report a very rare case of Japanese encephalitis (JE) presenting with reversible stereotyped movement in the subacute stage. A 58-year-old woman presented with high fever, headache, nausea, vomiting, and consciousness disturbance. Cranial magnetic resonance imaging (MRI) of fluid attenuated inversion recovery (FLAIR) and T2-weighted image (WI) showed high intensity areas in the bilateral thalamus, caudate nucleus and hippocampus. She developed coma, convulsion, and ballism in the acute stage. One month after onset, she showed rhythmic, stereotyped, repetitive movements with hypoperfusion in the thalamus and frontal cortex on single photon emission computed tomography (SPECT). Three months later, her stereotyped movement improved accompanied by recovery of hypoperfusion in the thalamus and frontal cortex on SPECT. We speculated that her stereotyped movement was clonic perseveration due to frontal dysfunction induced by thalamofrontal disconnection.

Long-term clinical and neuropsychological outcomes of West Nile virus infection

BACKGROUND

Since its introduction in 1999, West Nile virus has rapidly become the most common arboviral infection in North America. Little is known about the long-term clinical sequelae of West Nile virus infection.

METHODS

A total of 49 patients with laboratory-confirmed West Nile virus infection were identified through state-based surveillance. Stratification for disease severity was based on hospitalization during the infection episode. Assessment occurred a mean of 13 months after diagnosis. Medical records were reviewed, and a complete neurologic examination was performed. Standardized surveys for quality of life, functional ability, fatigue, and depression were performed for all subjects. An extensive battery of neuropsychological tests was performed to assess cognitive function.

RESULTS

Self-reported fatigue, memory problems, extremity weakness, word-finding difficulty, and headache were common complaints. Standardized survey data confirmed an overall sense of poor physical health, fatigue, depression, and moderate-to-severe disability in 24 (49%), 24 (49%), 12 (24%), and 4 (8%) patients, respectively. New tremor was seen or reported for 10 (20%) of the patients. Neuropsychological testing showed abnormalities of motor skills, attention, and executive functions. Univariate analysis of multiple risk factors did not identify any predictors of adverse outcomes.

CONCLUSIONS

Multiple somatic complaints, tremor, and abnormalities in motor skills and executive functions are common long-term problems among patients who have had West Nile virus infection. Patients with milder illness are just as likely as patients with more-severe illness to experience adverse outcomes.

Psychotropic viruses

Viruses are increasingly being recognized as important factors in the pathogenesis of acute and chronic mental illness. Here we review clinical and epidemiologic data concerning viral infection and mental illness, as well as animal models that provide insight into the myriad of mechanisms by which infection can cause brain dysfunction.