1
|
Huang Y, Zhou B, Hong S, Cai Y. A case report and literature review on tocilizumab-cured acute necrotizing encephalopathy caused by influenza A virus. Front Pediatr 2024; 12:1351478. [PMID: 38646514 PMCID: PMC11026575 DOI: 10.3389/fped.2024.1351478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/19/2024] [Indexed: 04/23/2024] Open
Abstract
Introduction Acute Necrotizing Encephalopathy (ANE), is a kind of severe Central Nervous System Disease. The commonest pathogen is the influenza virus. The pathogenesis of ANE is bound up to genetic susceptibility and cytokine storm. Interleukin-6 (IL-6) is deemed as the core function in cytokine storm of ANE and that plays a significant role in evaluating the severity of Influenza-Related ANE. Tocilizumab, an IL-6 antagonist, is known to be safe and effective in the treatment of ANE when used early and has an essential role in improving prognosis and preventing disability. Case report This case reports a 2 year 10 month old boy who developed ANE after being infected with influenza A virus (H1N1-2019). After treatment with Tocilizumab, the child's consciousness was clear, no convulsions occurred, the movement of limbs was improved, and the lesions of encephalopathy were significantly reduced. Conclusion The early use of Tocilizumab is safe and effective for the treatment of ANE caused by influenza virus.
Collapse
Affiliation(s)
| | - Bin Zhou
- Pediatric Intensive Care Unit, Xiamen Children's Hospital, Children's Hospital of Fudan University (Xiamen Branch), Xiamen, China
| | | | | |
Collapse
|
2
|
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.
Collapse
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.
| |
Collapse
|
3
|
Tang JW, Ritchie B, Taranath A, Mos K, Baulderstone M, Coppin B. Case of Acute Necrotising Encephalopathy of Childhood secondary to Severe Acute Respiratory Syndrome Coronavirus 2 infection. J Paediatr Child Health 2024; 60:28-30. [PMID: 37864394 DOI: 10.1111/jpc.16506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 05/07/2023] [Accepted: 10/01/2023] [Indexed: 10/22/2023]
Affiliation(s)
- Jonathan W Tang
- Department of General Medicine, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Brett Ritchie
- Department of Microbiology and Infectious Diseases, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Ajay Taranath
- South Australia Medical Imaging, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Krista Mos
- Department of Paediatric Critical Care Medicine, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Michaela Baulderstone
- Department of General Medicine, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Brian Coppin
- Department of General Medicine, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Fang Y, Gao Q, Jin W, Li J, Yuan H, Lin Z, Pan G, Lin W. Clinical characteristics and prognostic analysis of acute necrotizing encephalopathy of childhood: a retrospective study at a single center in China over 3 years. Front Neurol 2023; 14:1308044. [PMID: 38178890 PMCID: PMC10766426 DOI: 10.3389/fneur.2023.1308044] [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: 10/05/2023] [Accepted: 11/28/2023] [Indexed: 01/06/2024] Open
Abstract
Objective Acute Necrotizing Encephalopathy of Childhood (ANEC) is a rare, fulminant neurological disease in children with unknown mechanisms and etiology. This study summarized the clinical characteristics, treatment, and prognosis of ANEC through a retrospective analysis, providing insights into the ANEC early diagnosis and prognosis assessment. Methods Clinical data of children diagnosed with ANEC at the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University from July 1, 2020, to June 30, 2023, were retrospectively analyzed. Results There were 25 cases, 14 males and 11 females, with a median age of 3 years. Hospital admissions were mainly in the winter (14/25, 56%) and spring (9/25, 36%). All patients presented with varying degrees of fever and altered consciousness, with 92% (23/25) experiencing high body temperatures (>39.1°C) and 88% (22/25) having a Glasgow coma scale (GCS) score of ≤8. Seizures were observed in 88% (22/25) of patients. Laboratory findings indicated 100% B lymphocyte activation (14/14), and 78% (14/18) of patients showed cytokine storm (interleukin (IL)-6, IL-8, IL-10, interferon (IFN)-α). Neuroimaging showed symmetrical thalamus involvement, commonly involving basal ganglia and brainstem regions. Viral infection (23/24, 96%) was the predominant etiological finding, with 42% (10/24) of cases due to SARS-CoV-2 infection and 42% (10/24) to influenza A virus infection. Multi-organ dysfunction occurred in 68% (17/25) of patients, and 52% (13/25) died. Correlation analysis revealed the death group exhibited higher proportion of male, lower GCS scores, higher IL-6 level and a greater likelihood of associated brainstem impairment (p < 0.05). Conclusion ANEC is more prevalent in the winter and spring, and its etiology may be associated with B lymphocyte activation and cytokine storm following viral infections. Clinical manifestations lack specific features, with fever, consciousness disturbances, and seizures being the main presentations, particularly in cases of high fever and hyperpyrexia. ANEC progresses rapidly and has a high mortality rate. The child's gender, GCS score, IL-6 levels, and the presence of brainstem involvement can serve as important risk factors for assessing the risk of mortality.
Collapse
Affiliation(s)
- Yu Fang
- Department of Pediatrics, The Second School of Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
- Key Laboratory of Perinatal Medicine of Wenzhou, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Qiqi Gao
- Department of Pediatrics, The Second School of Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
- Key Laboratory of Perinatal Medicine of Wenzhou, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Wenwen Jin
- Department of Pediatrics, The Second School of Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
- Key Laboratory of Perinatal Medicine of Wenzhou, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jianshun Li
- Department of Pediatrics, The Second School of Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
- Key Laboratory of Perinatal Medicine of Wenzhou, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Hao Yuan
- Department of Pediatrics, The Second School of Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
- Key Laboratory of Perinatal Medicine of Wenzhou, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Zhenlang Lin
- Department of Pediatrics, The Second School of Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
- Key Laboratory of Perinatal Medicine of Wenzhou, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
- Key Laboratory of Structural Malformations in Children of Zhejiang Province, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Guoquan Pan
- Department of Pediatrics, The Second School of Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
- Key Laboratory of Perinatal Medicine of Wenzhou, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Wei Lin
- Department of Pediatrics, The Second School of Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
- Key Laboratory of Perinatal Medicine of Wenzhou, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| |
Collapse
|
7
|
Li J, Huo F, Wang S, Fan Y, Wu J, Zhang Z, Liu S, Wang Q. Recurrent infection triggered encephalopathy syndrome in a pediatric patient with RANBP2 mutation and severe acute respiratory syndrome coronavirus 2 infection. Pediatr Investig 2023; 7:290-296. [PMID: 38050538 PMCID: PMC10693665 DOI: 10.1002/ped4.12406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 10/31/2023] [Indexed: 12/06/2023] Open
Abstract
Introduction Acute necrotizing encephalopathy (ANE), a fatal subtype of infection-triggered encephalopathy syndrome (ITES), can be triggered by many systemic infections. RANBP2 gene mutations were associated with recurrent ANE. Case presentation Here we report a 1-year-old girl with recurrent ITES and RANBP2 mutation. She was diagnosed with influenza-associated encephalopathy and made a full recovery on the first episode. After severe acute respiratory syndrome coronavirus 2 infection, the patient presented with seizures and deteriorating mental status. Brain magnetic resonance imaging revealed necrotic lesions in bilateral thalami and pons. Methylprednisolone, immunoglobulin, and interleukin 6 inhibitors were administered. Her consciousness level was improved at discharge. Nineteen cases of 2019 coronavirus disease-related ANE have been reported, of which 22.2% of patients died and 61.1% had neurologic disabilities. RANBP2 gene mutation was found in five patients, two of whom developed recurrent ITES. Conclusion Patients with RANBP2 mutations are at risk for recurrent ITES, may develop ANE, and have a poor prognosis after relapse.
Collapse
Affiliation(s)
- Jiaqi Li
- Emergency DepartmentBeijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Feng Huo
- Emergency DepartmentBeijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Shuo Wang
- Emergency DepartmentBeijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Yimu Fan
- Emergency DepartmentBeijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Jie Wu
- Emergency DepartmentBeijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Zhezhe Zhang
- Emergency DepartmentBeijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Shuangjun Liu
- Emergency DepartmentBeijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Quan Wang
- Emergency DepartmentBeijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
- Pediatric Intensive Care UnitBeijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| |
Collapse
|
8
|
Aslam K, Uldin H, Smith L. Possible Toxin-Induced Acute Necrotising Encephalitis (ANE) With Secondary Vasculopathy and Paroxysmal Autonomic Instability With Dystonia (PAID) Syndrome. Cureus 2023; 15:e50100. [PMID: 38192966 PMCID: PMC10771933 DOI: 10.7759/cureus.50100] [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: 12/07/2023] [Indexed: 01/10/2024] Open
Abstract
Acute necrotising encephalitis (ANE) is a rare and life-threatening disorder typically associated with viral pathogens triggering an inflammatory response. It is characterised by rapid neurological deterioration linked to a cytokinetic storm which radiologically manifests with cerebral radiological changes. We present a unique case not previously documented of an immunocompetent 23-year-old male who survived the course of ANE, with widespread involvement of the brain including the deep white matter, cortex, superior frontal gyrus, occipital lobe and cerebellum. His disease course was complicated by a ventilator-associated empyema, paroxysmal autonomic instability with dystonia (PAID) syndrome) and livedo reticularis which cumulatively resulted in a poor neurological outcome.
Collapse
Affiliation(s)
- Kasim Aslam
- Rehabilitation Medicine, Moseley Hall Hospital, Birmingham, GBR
| | - Hasaam Uldin
- Radiology, University Hospitals Coventry and Warwickshire, Coventry, GBR
| | - Laura Smith
- Rehabilitation Medicine, Moseley Hall Hospital, Birmingham, GBR
| |
Collapse
|
9
|
Gouy B, Decorsière A, Desgraupes S, Duan W, Ouyang H, Wang YE, Yeh EA, Palazzo AF, Moraes TJ, Nisole S, Arhel NJ. Rapid and inexpensive bedside diagnosis of RAN binding protein 2-associated acute necrotizing encephalopathy. Front Neurol 2023; 14:1282059. [PMID: 38046586 PMCID: PMC10690583 DOI: 10.3389/fneur.2023.1282059] [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: 08/23/2023] [Accepted: 11/01/2023] [Indexed: 12/05/2023] Open
Abstract
Acute necrotizing encephalopathy 1 (ANE1) is a very rare disorder associated with a dominant heterozygous mutation in the RANBP2 (RAN binding protein 2) gene. ANE1 is frequently triggered by a febrile infection and characterized by serious and irreversible neurological damage. Although only a few hundred cases have been reported, mutations in RANBP2 are only partially penetrant and can occur de novo, suggesting that their frequency may be higher in some populations. Genetic diagnosis is a lengthy process, potentially delaying definitive diagnosis. We therefore developed a rapid bedside qPCR-based tool for early diagnosis and screening of ANE1 mutations. Primers were designed to specifically assess RANBP2 and not RGPD (RANBP2 and GCC2 protein domains) and discriminate between wild-type or mutant RANBP2. Nasal epithelial cells were obtained from two individuals with known RANBP2 mutations and two healthy control individuals. RANBP2-specific reverse transcription followed by allele-specific primer qPCR amplification confirmed the specific detection of heterozygously expressed mutant RANBP2 in the ANE1 samples. This study demonstrates that allele-specific qPCR can be used as a rapid and inexpensive diagnostic tool for ANE1 using preexisting equipment at local hospitals. It can also be used to screen non-hospitalized family members and at risk-population to better establish the frequency of non-ANE-associated RANBP2 mutations, as well as possible tissue-dependent expression patterns. Systematic review registration The protocol was registered in the international prospective register of systematic reviews (PROSPERO- CRD42023443257).
Collapse
Affiliation(s)
- Benoît Gouy
- Institut de Recherche en Infectiologie de Montpellier, University of Montpellier, Montpellier, France
- Master de Biologie, École Normale Supérieure de Lyon, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Adrien Decorsière
- Institut de Recherche en Infectiologie de Montpellier, University of Montpellier, Montpellier, France
| | - Sophie Desgraupes
- Institut de Recherche en Infectiologie de Montpellier, University of Montpellier, Montpellier, France
| | - Wenming Duan
- Program in Translational Medicine, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Hong Ouyang
- Program in Translational Medicine, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Yifan E. Wang
- Department of Biochemistry, University of Toronto, Toronto, ON, Canada
| | - E. Ann Yeh
- Department of Pediatrics, Division of Neurology, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Division of Neuroscience and Mental Health, The Hospital for Sick Children Research Institute, University of Toronto, Toronto, ON, Canada
| | | | - Theo J. Moraes
- Program in Translational Medicine, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
- Department of Pediatrics, Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Sébastien Nisole
- Institut de Recherche en Infectiologie de Montpellier, University of Montpellier, Montpellier, France
| | - Nathalie J. Arhel
- Institut de Recherche en Infectiologie de Montpellier, University of Montpellier, Montpellier, France
| |
Collapse
|
10
|
Geng C, Zhao W, Wang Z, Wu J, Jiang D, Jiang N, Liu M, Yao M, Guan H. Acute necrotizing encephalopathy associated with COVID-19: case series and systematic review. J Neurol 2023; 270:5171-5181. [PMID: 37695531 DOI: 10.1007/s00415-023-11915-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 09/12/2023]
Abstract
Acute necrotizing encephalopathy (ANE) is a rare neurological complication related to COVID-19. Here we present a case series of six Chinese cases with ANE associated with COVID-19 and review all reported cases in the literature. A total of six cases with ANE related to COVID-19 were enrolled in this study. Clinical manifestations, neuroimaging data, treatment and outcomes of these patients were analyzed. A literature review was performed in Pubmed and Embase and 25 cases with clinical and neuroimaging data were collected and analyzed. Among our six cases, the age of onset ranged from 15 to 56 years, with a male-to-female ratio of nearly 1:1. All patients presented with reduced consciousness. Elevated interleukin 6 in serum and/or cerebrospinal fluid (CSF) was detected in four patients. Two patients improved clinically after intravenous methylprednisolone and intravenous immunoglobulin (IVIG). Based on the literature review, the majority of cases were from Europe and the United States (60%). Two age peaks at 10-20 years (20%) and 50-60 years (28%) were observed. Two cases were found with a heterozygous Thr585Met mutation. The mortality of ANE caused by COVID-19 was 42%. The use of IVIG in combination with other immunotherapies was related to better outcome (P = 0.041) and both two patients who received Tocilizumab survived. This is the first Chinese case series about ANE associated with COVID-19. Elevated serum and CSF interlukin-6 were found in certain cases. The mortality and morbidity rates remained high although prompt immunotherapy could improve the outcomes.
Collapse
Affiliation(s)
- Chang Geng
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No 1, Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Weili Zhao
- Department of Neurology, Chifeng Hospital, Inner Mongolia, China
| | - Zhijun Wang
- Department of Neurology, Shanxi Baiqiuen Hospital, Shanxi, China
| | - Jin Wu
- Department of Neurology, Ordos Central Hospital, Inner Mongolia, China
| | - Dongxiao Jiang
- Department of Neurology, Weihai Central Hospital Affiliated to Medical College of Qingdao University, Shandong, China
| | - Nan Jiang
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No 1, Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Mange Liu
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No 1, Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Ming Yao
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No 1, Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
| | - Hongzhi Guan
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No 1, Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Nagase H, Yamaguchi H, Tokumoto S, Ishida Y, Tomioka K, Nishiyama M, Nozu K, Maruyama A. Timing of therapeutic interventions against infection-triggered encephalopathy syndrome: a scoping review of the pediatric literature. Front Neurosci 2023; 17:1150868. [PMID: 37674514 PMCID: PMC10477367 DOI: 10.3389/fnins.2023.1150868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 08/07/2023] [Indexed: 09/08/2023] Open
Abstract
Our goal was to conduct a scoping review of the literature on the treatment of infection-triggered encephalopathy syndrome/acute encephalopathy in children, focusing on treatment targets and treatment initiation timing. We performed literature searches using PubMed for articles reporting treatments of infection-triggered encephalopathy syndrome/acute encephalopathy. We included articles describing specific treatments for acute encephalopathy with control groups. For the purpose of searching new therapies only experimentally tried in the case series, we also included case series studies without control groups in this review, if the studies contained at least two cases with clear treatment goals. Therapies were classified based on their mechanisms of action into brain protection therapy, immunotherapy, and other therapies. We operationally categorized the timing of treatment initiation as T1 (6-12 h), T2 (12-24 h), T3 (24-48 h), and T4 (>48 h) after the onset of seizures and/or impaired consciousness. Thirty articles were included in this review; no randomized control study was found. Eleven retrospective/historical cohort studies and five case-control studies included control groups with or without specific therapies or outcomes. The targeted conditions and treatment timing varied widely across studies. However, the following three points were suggested to be effective in multiple studies: (1) Careful seizure management and targeted temperature management within 12 h (T1) of onset of febrile seizure/prolonged impaired consciousness without multiple organ failure may reduce the development of acute encephalopathy with biphasic seizures and late reduced diffusion; (2) immunotherapy using corticosteroids, tocilizumab, or plasma exchange within 24 h (T1-T2) of onset of acute necrotizing encephalopathy may reduce sequelae; and (3) anakinra therapy and ketogenic diet demonstrate little evidence of neurologic sequelae reduction, but may reduce seizure frequency and allow for weaning from barbiturates, even when administered weeks (T4) after onset in children with febrile infection-related epilepsy syndrome. Although available studies have no solid evidence in the treatment of infection-triggered encephalopathy syndrome/acute encephalopathy, this scoping review lays the groundwork for future prospective clinical trials.
Collapse
Affiliation(s)
- Hiroaki Nagase
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Yamaguchi
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shoichi Tokumoto
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yusuke Ishida
- Department of Neurology, Hyogo Prefectural Kobe Children’s Hospital, Kobe, Japan
- Department of Emergency and General Pediatrics, Hyogo Prefectural Kobe Children’s Hospital, Kobe, Japan
| | - Kazumi Tomioka
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masahiro Nishiyama
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
- Department of Neurology, Hyogo Prefectural Kobe Children’s Hospital, Kobe, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Azusa Maruyama
- Department of Neurology, Hyogo Prefectural Kobe Children’s Hospital, Kobe, Japan
| |
Collapse
|
13
|
Hoshino A, Takahashi N, Oka A, Mizuguchi M. Association of IL6 and IL10 gene promotor polymorphisms with susceptibility to acute necrotizing encephalopathy. Front Neurosci 2023; 17:1231957. [PMID: 37600000 PMCID: PMC10435083 DOI: 10.3389/fnins.2023.1231957] [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: 05/31/2023] [Accepted: 07/18/2023] [Indexed: 08/22/2023] Open
Abstract
Objective Acute necrotizing encephalopathy (ANE) is a severe complication of infectious diseases affecting the brain and systemic organs. The main pathogenesis is cytokine storm, in which interleukin-6 (IL-6) and interleukin-10 (IL-10) are candidates for key cytokines. To further elucidate their roles in the etiology and pathogenesis of ANE, we studied polymorphisms in the promotor regions of the IL6 and IL10 genes by genetic and functional analyses. Methods We first conducted a case-control association study of four IL6 and three IL10 polymorphisms. We genotyped 31 Japanese ANE cases and compared the results with those of approximately 200 Japanese controls. For the two polymorphisms showing a possible association, we next studied whether the polymorphisms alter the production of IL-6 or IL-10 by lymphoblasts upon phorbol 12-myristate 13-acetate (PMA) stimulation. Results The frequencies of IL6 rs1800796G allele and IL10 rs1800871/rs1800872 CC/CC diplotype were significantly higher in ANE cases than in controls. The IL10 CC/CC diplotype was associated with low IL-10 production, whereas the IL6 GG genotype was not associated with IL-6 production. Conclusion IL10 rs1800871/rs1800872 CC/CC diplotype may predispose Japanese children to ANE by altering IL-10 production in the early phase of infection. Etio-pathogenetic significance of IL6 rs1800796G remains to be elucidated.
Collapse
Affiliation(s)
- Ai Hoshino
- Department of Developmental Medical Sciences, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
- Department of Neuropediatrics, Tokyo Metropolitan Neurological Hospital, Fuchu, Japan
| | - Naoto Takahashi
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Akira Oka
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
- Department of Neurology, Saitama Children's Medical Center, Saitama, Japan
| | - Masashi Mizuguchi
- Department of Developmental Medical Sciences, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Pediatrics, National Rehabilitation Center for Children with Disabilities, Tokyo, Japan
| |
Collapse
|
14
|
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.
Collapse
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.
| |
Collapse
|
15
|
Dale RC, Thomas T, Patel S, Han VX, Kothur K, Troedson C, Gupta S, Gill D, Malone S, Waak M, Calvert S, Subramanian G, Andrews PI, Kandula T, Menezes MP, Ardern‐Holmes S, Mohammad S, Bandodkar S, Yan J. CSF neopterin and quinolinic acid are biomarkers of neuroinflammation and neurotoxicity in FIRES and other infection-triggered encephalopathy syndromes. Ann Clin Transl Neurol 2023; 10:1417-1432. [PMID: 37340737 PMCID: PMC10424664 DOI: 10.1002/acn3.51832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 05/28/2023] [Accepted: 06/05/2023] [Indexed: 06/22/2023] Open
Abstract
OBJECTIVE Infection-triggered encephalopathy syndromes (ITES) are potentially devastating neuroinflammatory conditions. Although some ITES syndromes have recognisable MRI neuroimaging phenotypes, there are otherwise few biomarkers of disease. Early detection to enable immune modulatory treatments could improve outcomes. METHODS We measured CSF neopterin, quinolinic acid, kynurenine and kynurenine/tryptophan ratio using a liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS) system. The CSF of 18 children with ITES were compared with acute encephalitis (n = 20), and three control groups, namely epilepsy (n = 20), status epilepticus (n = 18) and neurogenetic controls (n = 20). RESULTS The main ITES phenotypes in 18 patients were acute encephalopathy with biphasic seizures and late restricted diffusion (AESD, n = 4), febrile infection-related epilepsy syndrome (FIRES n = 4) and other ITES phenotypes. Influenza A was the most common infectious trigger (n = 5), and 50% of patients had a preceding notable neurodevelopmental or family history. CSF neopterin, quinolinic acid and kynurenine were elevated in ITES group compared to the three control groups (all p < 0.0002). The ROC (area under curve) for CSF neopterin (99.3%, CI 98.1-100) was significantly better than CSF pleocytosis (87.3% CI 76.4-98.2) (p = 0.028). Elevated CSF neopterin could discriminate ITES from other causes of seizures, status epilepticus and febrile status epilepticus (all p < 0.0002). The elevated CSF metabolites normalised during longitudinal testing in two patients with FIRES. INTERPRETATION CSF neopterin and quinolinic acid are neuroinflammatory and excitotoxic metabolites. This CSF metabolomic inflammatory panel can discriminate ITES from other causes of new onset seizures or status epilepticus, and rapid results (4 h) may facilitate early immune modulatory therapy.
Collapse
Affiliation(s)
- Russell C. Dale
- Kids Neuroscience Centre, The Children's Hospital at Westmead, Faculty of Medicine and HealthUniversity of SydneyWestmeadNew South WalesAustralia
- Clinical School, The Children's Hospital at Westmead, Faculty of Medicine and HealthUniversity of SydneyWestmeadNew South WalesAustralia
| | - Terrence Thomas
- Department of Paediatrics, Neurology ServiceKK Women's and Children's HospitalSingaporeSingapore
| | - Shrujna Patel
- Kids Neuroscience Centre, The Children's Hospital at Westmead, Faculty of Medicine and HealthUniversity of SydneyWestmeadNew South WalesAustralia
- Clinical School, The Children's Hospital at Westmead, Faculty of Medicine and HealthUniversity of SydneyWestmeadNew South WalesAustralia
| | - Velda X. Han
- Khoo Teck Puat‐National University Children's Medical InstituteNational University Health SystemSingaporeSingapore
| | - Kavitha Kothur
- Kids Neuroscience Centre, The Children's Hospital at Westmead, Faculty of Medicine and HealthUniversity of SydneyWestmeadNew South WalesAustralia
- Clinical School, The Children's Hospital at Westmead, Faculty of Medicine and HealthUniversity of SydneyWestmeadNew South WalesAustralia
- TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at WestmeadThe University of SydneyWestmeadNew South WalesAustralia
| | - Christopher Troedson
- TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at WestmeadThe University of SydneyWestmeadNew South WalesAustralia
| | - Sachin Gupta
- TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at WestmeadThe University of SydneyWestmeadNew South WalesAustralia
| | - Deepak Gill
- Kids Neuroscience Centre, The Children's Hospital at Westmead, Faculty of Medicine and HealthUniversity of SydneyWestmeadNew South WalesAustralia
- TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at WestmeadThe University of SydneyWestmeadNew South WalesAustralia
| | - Stephen Malone
- Department of NeuroscienceQueensland Children's HospitalSouth BrisbaneQueenslandAustralia
| | - Michaela Waak
- Department of NeuroscienceQueensland Children's HospitalSouth BrisbaneQueenslandAustralia
| | - Sophie Calvert
- Department of NeuroscienceQueensland Children's HospitalSouth BrisbaneQueenslandAustralia
| | - Gopinath Subramanian
- Department of PaediatricsJohn Hunter Children's HospitalNewcastleNew South WalesAustralia
| | - P. Ian Andrews
- Department of NeurologySydney Children's Hospital NetworkSydneyNew South WalesAustralia
| | - Tejaswi Kandula
- Department of NeurologySydney Children's Hospital NetworkSydneyNew South WalesAustralia
| | - Manoj P. Menezes
- Kids Neuroscience Centre, The Children's Hospital at Westmead, Faculty of Medicine and HealthUniversity of SydneyWestmeadNew South WalesAustralia
- TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at WestmeadThe University of SydneyWestmeadNew South WalesAustralia
| | - Simone Ardern‐Holmes
- TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at WestmeadThe University of SydneyWestmeadNew South WalesAustralia
| | - Shekeeb Mohammad
- Kids Neuroscience Centre, The Children's Hospital at Westmead, Faculty of Medicine and HealthUniversity of SydneyWestmeadNew South WalesAustralia
- Clinical School, The Children's Hospital at Westmead, Faculty of Medicine and HealthUniversity of SydneyWestmeadNew South WalesAustralia
- TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at WestmeadThe University of SydneyWestmeadNew South WalesAustralia
| | - Sushil Bandodkar
- Clinical School, The Children's Hospital at Westmead, Faculty of Medicine and HealthUniversity of SydneyWestmeadNew South WalesAustralia
- Department of BiochemistryThe Children's Hospital at WestmeadWestmeadNew South WalesAustralia
| | - Jingya Yan
- Kids Neuroscience Centre, The Children's Hospital at Westmead, Faculty of Medicine and HealthUniversity of SydneyWestmeadNew South WalesAustralia
- Clinical School, The Children's Hospital at Westmead, Faculty of Medicine and HealthUniversity of SydneyWestmeadNew South WalesAustralia
- Department of BiochemistryThe Children's Hospital at WestmeadWestmeadNew South WalesAustralia
| |
Collapse
|
16
|
Qin N, Wang J, Peng X, Wang L. Pathogenesis and Management of Acute Necrotizing Encephalopathy. Expert Rev Neurother 2023; 23:641-650. [PMID: 37309119 DOI: 10.1080/14737175.2023.2224503] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/08/2023] [Indexed: 06/14/2023]
Abstract
INTRODUCTION During the COVID-19 pandemic, many cases of acute necrotizing encephalopathy (ANE) secondary to COVID-19 have been reported. ANE is characterized by a rapid onset, a fulminant course, and low morbidity and fatality rates. Therefore, clinicians need to be vigilant for such disorders, especially during the influenza virus and COVID-19 epidemics. AREAS COVERED The authors summarize the most recent studies on the clinical spectrum and treatment essentials of ANE to provide references for prompt diagnosis and improved treatment of this rare but fatal disease. EXPERT OPINION ANE is a type of necrotizing lesion of the brain parenchyma. There are two major types of reported cases. One is isolated and sporadic ANE, which is primarily caused by viral infections, particularly influenza and HHV-6 virus. The other type is familial recurrent ANE, which is caused by RANBP2 gene mutations. ANE patients have rapid progression and a very poor prognosis, with acute brain dysfunction occurring within days of viral infection and requiring admission to the intensive care unit. Clinicians still need to investigate and find solutions for the problems of early detection and treatment of ANE.
Collapse
Affiliation(s)
- Ningxiang Qin
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jing Wang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xi Peng
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Liang Wang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
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.
Collapse
Affiliation(s)
| | - Rohit Sharma
- Internal Medicine, Geisinger Health System, Wilkes-Barre, USA
| | | | - John Murray
- Neurology, Geisinger Commonwealth School of Medicine, Scranton, USA
| | | |
Collapse
|
19
|
Goetz V, Yang DD, Abid H, Roux CJ, Levy R, Kossorotoff M, Desguerre I, Angoulvant F, Aubart M. Neurological features related to influenza virus in the pediatric population: a 3-year monocentric retrospective study. Eur J Pediatr 2023:10.1007/s00431-023-04901-9. [PMID: 36947244 DOI: 10.1007/s00431-023-04901-9] [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: 10/23/2022] [Revised: 02/22/2023] [Accepted: 02/24/2023] [Indexed: 03/23/2023]
Abstract
Influenza virus is generally characterized by fever, myalgia, and respiratory symptoms. Neurological entities have already been described, such as acute necrotizing encephalitis (ANE). We aimed to highlight the non-exceptional nature and explore the clinical spectrum and evolution of neurological features related to influenza virus in children. This monocentric observational study included patients under 18 years old, positive for influenza virus, between January 2017 and April 2019 in a pediatric university hospital. Patients were classified into two groups: those with or without a previous significant neurological or metabolic disorder. Two hundred eighty-nine children were identified with influenza infection. Thirty seven had a neurological manifestation: 14 patients who had previous significant neurological or metabolic disorder and 23 patients with no medical history. We identified several clinical patterns: 22 patients had seizures, 7 behavior disorders, 5 disturbances of consciousness, and 3 motor deficits. Four were diagnosed with a known influenza-associated neurological syndrome: 1 ANE, 1 cytotoxic lesion of the corpus callosum, 1 hemiconvulsion-hemiplegia-epilepsia syndrome, and 1 recurrent encephalitis in the context of a RANBP2 mutation. The neurological outcome was favorable in most cases. None of the patients with previous significant disorder retained sequalae or had a recurrence. Two patients had a fatal outcome, and both had a predisposing disorder. CONCLUSION Various neurological manifestations can be associated with influenza virus. Certain entities led to a poor prognosis, but in most cases, symptoms improved within a few days. The severity of the neurological manifestations correlated with previous neurological or metabolic disorders. WHAT IS KNOWN • Influenza viruses are well known pathogens with a seasonal epidemic evolution, particularly affecting children. These viruses cause acute fever with respiratory symptoms, associated with myalgia and headaches. Neurological presentation in influenza-virus infection is a well-established possibility as influenza virus is considered to be responsible for 27 to 36% of childhood encephalitis. Some specific and severe entity as acute necrotizing encephalitis, cytotoxic lesion of the corpus callosum, or Hemiconvulsion-hemiplegia-epilepsy syndrome are well described. WHAT IS NEW • In a French monocentric cohort of 37 children with influenza-related neurologic manifestations, the majority of these manifestations, including seizure, drowsiness, motor deficiency, hallucination… are self limiting and do not lead to after-effects. In rare cases (4/37), they may reveal severe encephalitis requiring rapid and appropriate treatment. Otherwise, comparison of a group of 14 children with underlying neurological or metabolic disorder with a group of 23 children free of any significant disorder show that the severity of the neurological manifestations was largely related to previous neurological or metabolic disorders highlighting the importance of vaccination in this population.
Collapse
Affiliation(s)
- Violette Goetz
- Pediatric Neurology Department, Necker-Enfants malades Hospital, APHP, Université de Paris Cité, Paris, France
| | - David-Dawei Yang
- Pediatric Emergency Department, Necker-Enfants alades Hospital, APHP, Université de Paris Citém, Paris, France
| | - Hanene Abid
- Virology Laboratory, Necker-Enfants alades Hospital, APHP, Université de Paris Citém, Paris, France
| | - Charles-Joris Roux
- Paediatric Radiology Department, Necker-Enfants malades Hospital, APHP, Université de Paris Cité, Paris, France
| | - Raphael Levy
- Paediatric Radiology Department, Necker-Enfants malades Hospital, APHP, Université de Paris Cité, Paris, France
| | - Manoelle Kossorotoff
- Pediatric Neurology Department, Necker-Enfants malades Hospital, APHP, Université de Paris Cité, Paris, France
| | - Isabelle Desguerre
- Pediatric Neurology Department, Necker-Enfants malades Hospital, APHP, Université de Paris Cité, Paris, France
| | - François Angoulvant
- Pediatric Emergency Department, Necker-Enfants alades Hospital, APHP, Université de Paris Citém, Paris, France.
- INSERM, Centre de Recherche des Cordeliers, UMRS 1138, Sorbonne Université, Université de Paris, Paris, France.
| | - Mélodie Aubart
- Pediatric Neurology Department, Necker-Enfants malades Hospital, APHP, Université de Paris Cité, Paris, France.
- INSERM U1163 Institut HU Imagine, Laboratory of Human Genetics of Infectious Disease, Paris, France.
| |
Collapse
|
20
|
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.
Collapse
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
| | | |
Collapse
|
21
|
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.
Collapse
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
| |
Collapse
|
22
|
Mizuguchi M, Shibata A, Kasai M, Hoshino A. Genetic and environmental risk factors of acute infection-triggered encephalopathy. Front Neurosci 2023; 17:1119708. [PMID: 36761411 PMCID: PMC9902370 DOI: 10.3389/fnins.2023.1119708] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 01/09/2023] [Indexed: 01/25/2023] Open
Abstract
Acute encephalopathy is a constellation of syndromes in which immune response, metabolism and neuronal excitation are affected in a variable fashion. Most of the syndromes are complex disorders, caused or aggravated by multiple, genetic and environmental risk factors. Environmental factors include pathogenic microorganisms of the antecedent infection such as influenza virus, human herpesvirus-6 and enterohemorrhagic Escherichia coli, and drugs such as non-steroidal anti-inflammatory drugs, valproate and theophylline. Genetic factors include mutations such as rare variants of the SCN1A and RANBP2 genes, and polymorphisms such as thermolabile CPT2 variants and HLA genotypes. By altering immune response, metabolism or neuronal excitation, these factors complicate the pathologic process. On the other hand, some of them could provide promising targets to prevent or treat acute encephalopathy.
Collapse
Affiliation(s)
- Masashi Mizuguchi
- Department of Developmental Medical Sciences, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan,Department of Pediatrics, National Rehabilitation Center for Children With Disabilities, Tokyo, Japan,*Correspondence: Masashi Mizuguchi,
| | - Akiko Shibata
- Department of Developmental Medical Sciences, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan,Laboratory for Brain Development and Disorders, RIKEN Center for Brain Science, Tokyo, Japan
| | - Mariko Kasai
- Department of Developmental Medical Sciences, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan,Department of Pediatrics, Saitama Citizens Medical Center, Saitama, Japan
| | - Ai Hoshino
- Department of Developmental Medical Sciences, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan,Department of Neuropediatrics, Tokyo Metropolitan Neurological Hospital, Fuchu, Japan
| |
Collapse
|
23
|
Nguyen KL, McGurty D, Innes EA, Goetti R, Thomas T, Dal S, Bandodkar S, Yan J, Wong M, Dale RC, Mohammad SS. Acute encephalopathy with biphasic seizures and restricted diffusion. J Paediatr Child Health 2022; 58:1688-1690. [PMID: 35426454 PMCID: PMC9545931 DOI: 10.1111/jpc.15981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Khoa L Nguyen
- TY Nelson Department of Neurology and NeurosurgeryThe Children's Hospital at WestmeadSydneyNew South WalesAustralia
| | - Daniel McGurty
- TY Nelson Department of Neurology and NeurosurgeryThe Children's Hospital at WestmeadSydneyNew South WalesAustralia
| | - Emily A Innes
- Department of NeurologySydney Children's HospitalSydneyNew South WalesAustralia,Kids Neuroscience CentreThe Children's Hospital at WestmeadSydneyNew South WalesAustralia
| | - Robert Goetti
- Medical ImagingThe Children's Hospital at WestmeadSydneyNew South WalesAustralia,University of Sydney Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health Clinical SchoolUniversity of SydneySydneyNew South WalesAustralia
| | - Terrence Thomas
- Department of Paediatrics, Neurology ServiceKK Women's and Children's HospitalSingaporeSingapore
| | - Sameer Dal
- Neurology DepartmentThe Royal Children's HospitalMelbourneVictoriaAustralia
| | - Sushil Bandodkar
- University of Sydney Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health Clinical SchoolUniversity of SydneySydneyNew South WalesAustralia,Department of BiochemistryThe Children's Hospital at WestmeadSydneyNew South WalesAustralia
| | - Jingya Yan
- University of Sydney Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health Clinical SchoolUniversity of SydneySydneyNew South WalesAustralia,Department of BiochemistryThe Children's Hospital at WestmeadSydneyNew South WalesAustralia
| | - Melanie Wong
- Department of ImmunologyThe Children's Hospital at WestmeadSydneyNew South WalesAustralia
| | - Russell C Dale
- TY Nelson Department of Neurology and NeurosurgeryThe Children's Hospital at WestmeadSydneyNew South WalesAustralia,University of Sydney Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health Clinical SchoolUniversity of SydneySydneyNew South WalesAustralia
| | - Shekeeb S Mohammad
- TY Nelson Department of Neurology and NeurosurgeryThe Children's Hospital at WestmeadSydneyNew South WalesAustralia,University of Sydney Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health Clinical SchoolUniversity of SydneySydneyNew South WalesAustralia
| |
Collapse
|
24
|
Neilson DE. Systematic studies in acute necrotizing encephalopathy of childhood: The way forward. Dev Med Child Neurol 2022; 64:937-938. [PMID: 35156197 DOI: 10.1111/dmcn.15180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 01/24/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Derek E Neilson
- Division of Genetics and Metabolism, Phoenix Children's Hospital, Phoenix, Arizona, USA
| |
Collapse
|
25
|
Khan M, Bhattarai S, Boyce TG, Hayek RA, Zhadanov SI, Hooper EE, Fernandez EG, Koehn MA. Acute Necrotizing Encephalopathy Associated with Coronavirus Disease 2019 in an Infant. J Pediatr 2022; 247:160-162. [PMID: 35447125 PMCID: PMC9015721 DOI: 10.1016/j.jpeds.2022.04.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 04/14/2022] [Accepted: 04/15/2022] [Indexed: 11/23/2022]
Abstract
A 5-week-old infant born at term was diagnosed with acute necrotizing encephalopathy associated with severe acute respiratory syndrome coronavirus 2 as evidenced by clinical presentation, neuroimaging, and cerebrospinal fluid studies. Our patient was treated with high-dose intravenous methylprednisolone, tocilizumab, and intravenous immunoglobulin with significant short-term clinical improvement but long-term sequelae.
Collapse
Affiliation(s)
- Mariha Khan
- Department of Pediatrics, Marshfield Clinic Health System, Marshfield, WI
| | - Samhita Bhattarai
- Department of Pediatrics, Marshfield Clinic Health System, Marshfield, WI
| | - Thomas G. Boyce
- Department of Pediatrics, Marshfield Clinic Health System, Marshfield, WI
| | - Reyaad A. Hayek
- Department of Radiology, Marshfield Clinic Health System, Marshfield, WI
| | - Sergey I. Zhadanov
- Department of Radiology, Marshfield Clinic Health System, Marshfield, WI
| | | | | | - Monica A. Koehn
- Department of Neurology, Marshfield Clinic Health System, Marshfield, WI,Reprint requests: Reprint requests: Monica Koehn, MD, Department of Neurology, Marshfield Clinic Health System, 1000 N Oak Ave, Marshfield, WI 54449
| |
Collapse
|
26
|
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.
Collapse
|
27
|
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.
Collapse
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
| |
Collapse
|
28
|
Abstract
Dominant missense mutations in RanBP2/Nup358 cause Acute Necrotizing Encephalopathy (ANE), a pediatric disease where seemingly healthy individuals develop a cytokine storm that is restricted to the central nervous system in response to viral infection. Untreated, this condition leads to seizures, coma, long-term neurological damage and a high rate of mortality. The exact mechanism by which RanBP2 mutations contribute to the development of ANE remains elusive. In November 2021, a number of clinicians and basic scientists presented their work on this disease and on the interactions between RanBP2/Nup358, viral infections, the innate immune response and other cellular processes.
Collapse
Affiliation(s)
| | - Jomon Joseph
- National Centre for Cell Science, S.P. Pune University Campus, Pune, India
| | - Ming Lim
- Children's Neurosciences, Evelina London Children's Hospital, and the Department of Women and Children's Health, King's College London, London, UK
| | - Kiran T Thakur
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, and the New York Presbyterian Hospital, New York
| |
Collapse
|
29
|
Runzhong H, Yingjin Z, Jianlan W, Yongmian S, Zhuxiao R. Favorable Outcome with Early and Repeated Continuous Renal Replacement Therapy in Acute Necrotizing Encephalopathy. Indian J Pediatr 2022; 89:412. [PMID: 35025037 DOI: 10.1007/s12098-021-04012-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 10/04/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Huang Runzhong
- Department of Neonatology, Shunde Women and Children's Hospital, Guangdong Medical University, Foshan, Guangdong Province, China
| | - Zhang Yingjin
- Department of Neonatology, Shunde Women and Children's Hospital, Guangdong Medical University, Foshan, Guangdong Province, China
| | - Wang Jianlan
- Department of Neonatology, Shunde Women and Children's Hospital, Guangdong Medical University, Foshan, Guangdong Province, China
| | - Su Yongmian
- Department of Neonatology, Shunde Women and Children's Hospital, Guangdong Medical University, Foshan, Guangdong Province, China
| | - Ren Zhuxiao
- Department of Neonatology, Guangdong Women and Children Hospital, Guangzhou Medical University, Guangzhou, 511442, China.
| |
Collapse
|
30
|
Hemachudha P, Pongpitakmetha T, Rattanawong W, Thanapornsungsuth P, Joyjinda Y, Bunprakob S, Ruchisrisarod C, Hemachudha T. A case of successive development of possible acute necrotizing encephalopathy after COVID-19 pneumonia. SAGE Open Med Case Rep 2022; 10:2050313X221083653. [PMID: 35308052 PMCID: PMC8928348 DOI: 10.1177/2050313x221083653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 02/09/2022] [Indexed: 02/03/2023] Open
Abstract
COVID-19 infection often results in an excessive inflammatory response with a spectrum of neurological manifestations. Here, we describe an 81-year-old female with severe COVID-19 pneumonia and subsequent alteration of consciousness after high-dose intravenous dexamethasone and remdesivir. A non-contrast head computed tomography (CT) demonstrated bilateral hypodensities involving bilateral cerebellar hemispheres, thalami, cerebral peduncles and medial parieto-occipital areas. There was no improvement and repeat CT showed progression with findings suggestive of acute necrotizing encephalopathy. Interleukin-6 levels were initially normal; however, subsequent levels were found to be markedly elevated. Acute necrotizing encephalopathy associated with COVID-19 may occur in the setting of severe pneumonia and may represent an immune-mediated process involving inflammatory cytokines such as interleukin-6.
Collapse
Affiliation(s)
- Pasin Hemachudha
- Thai Red Cross Emerging Infectious Diseases Health Science Centre, World Health Organization Collaborating Centre for Research and Training on Viral Zoonoses, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Division of Neurology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Chulalongkorn University, Bangkok, Thailand
| | - Thanakit Pongpitakmetha
- Division of Neurology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Chulalongkorn University, Bangkok, Thailand
- Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Chula Neuroscience Center, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Wanakorn Rattanawong
- Division of Neurology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Chulalongkorn University, Bangkok, Thailand
- Department of Medicine, King Mongkut’s Institute of Technology Ladkrabang, Bangkok, Thailand
| | - Poosanu Thanapornsungsuth
- Thai Red Cross Emerging Infectious Diseases Health Science Centre, World Health Organization Collaborating Centre for Research and Training on Viral Zoonoses, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Division of Neurology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Chulalongkorn University, Bangkok, Thailand
- Chula Neuroscience Center, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yutthana Joyjinda
- Thai Red Cross Emerging Infectious Diseases Health Science Centre, World Health Organization Collaborating Centre for Research and Training on Viral Zoonoses, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Saowalak Bunprakob
- Thai Red Cross Emerging Infectious Diseases Health Science Centre, World Health Organization Collaborating Centre for Research and Training on Viral Zoonoses, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Chanida Ruchisrisarod
- Thai Red Cross Emerging Infectious Diseases Health Science Centre, World Health Organization Collaborating Centre for Research and Training on Viral Zoonoses, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Thiravat Hemachudha
- Thai Red Cross Emerging Infectious Diseases Health Science Centre, World Health Organization Collaborating Centre for Research and Training on Viral Zoonoses, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Division of Neurology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Chulalongkorn University, Bangkok, Thailand
| |
Collapse
|
31
|
Mierzewska-Schmidt M, Baranowski A, Szymanska K, Ciaston M, Kuchar E, Ploski R, Kosinska J, Pagowska-Klimek I. The case of fatal acute hemorrhagic necrotizing encephalitis in a two-month-old boy with Covid-19. Int J Infect Dis 2022; 116:151-153. [PMID: 34929359 PMCID: PMC8683211 DOI: 10.1016/j.ijid.2021.12.334] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 12/10/2021] [Accepted: 12/14/2021] [Indexed: 11/16/2022] Open
Abstract
SARS-CoV-2 infection in healthy children is usually benign. However, severe, life-threatening cases have previously been reported, notably in infants. We must be aware that data on the natural history of COVID-19 are still full of gaps, especially as far as the pediatric population is concerned. Therefore, it is important to describe rare manifestations of SARS-CoV-2 acute infection in children. Here we present the case of acute hemorrhagic necrotizing encephalitis (AHNE) in a previously healthy, 2-month-old male infant with SARS-CoV-2 infection. After 2 days of fever with signs of respiratory tract infection, neurological manifestations appeared: irritability, nystagmus, agitation then apathy. As a consequence of apnea, he required emergent intubation and was transferred to our PICU. Brain MRI revealed diffuse areas of oedema associated with numerous symmetrical changes with punctate hemorrhages in basal ganglia, thalami, brainstem, and cerebral gray matter. CSF was clear with pleocytosis 484 cells/µl, elevated lactic acid and protein. Despite broad microbiological testing, only SARS-CoV2 was detected in PCR nasal swab. Therefore, acute hemorrhagic necrotizing encephalitis (AHNE) as a result of COVID-19 was the most probable diagnosis. The outcome was unfavorable - brain death was confirmed, life support was withdrawn.
Collapse
Affiliation(s)
- Magdalena Mierzewska-Schmidt
- Department of Paediatric Anaesthesiology and Intensive Therapy, Medical University of Warsaw, Poland. 63a Zwirki i Wigury Str., 02-091.
| | - Artur Baranowski
- Department of Paediatric Anaesthesiology and Intensive Therapy, Medical University of Warsaw, Poland. 63a Zwirki i Wigury Str., 02-091.
| | - Krystyna Szymanska
- Department of Experimental and Clinical Neuropathology, Mossakowski Medical Research Center, Polish Academy of Sciences, Warsaw, Poland. 5 Pawinskiego Str., 02-106 Warsaw.
| | - Michal Ciaston
- Department of Pediatric Radiology, Medical University of Warsaw, Poland. 63a Zwirki i Wigury Str., 02-091 Warsaw.
| | - Ernest Kuchar
- Department of Pediatrics with Clinical Assessment Unit, Medical University of Warsaw, Poland. 63a Zwirki i Wigury Str., 02-091 Warsaw.
| | - Rafal Ploski
- Department of Medical Genetics, Medical University of Warsaw, Poland. 3c Pawinskiego Str., 02-106 Warsaw.
| | - Joanna Kosinska
- Department of Medical Genetics, Medical University of Warsaw, Poland. 3c Pawinskiego Str., 02-106 Warsaw.
| | - Izabela Pagowska-Klimek
- Department of Paediatric Anaesthesiology and Intensive Therapy, Medical University of Warsaw, Poland. 63a Zwirki i Wigury Str., 02-091.
| |
Collapse
|
32
|
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.
Collapse
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
| |
Collapse
|
33
|
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.
Collapse
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:
| |
Collapse
|
34
|
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.
Collapse
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
| |
Collapse
|
35
|
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.
Collapse
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
| |
Collapse
|
36
|
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.
Collapse
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
| |
Collapse
|
37
|
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.
Collapse
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
| |
Collapse
|
38
|
The Novel Coronavirus Infection (COVID-19) and Nervous System Involvement: Mechanisms of Neurological Disorders, Clinical Manifestations, and the Organization of Neurological Care. ACTA ACUST UNITED AC 2021; 51:147-154. [PMID: 33619413 PMCID: PMC7889305 DOI: 10.1007/s11055-021-01050-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 04/30/2020] [Indexed: 11/08/2022]
Abstract
The new coronavirus SARS-CoV-2 and the disease it causes COVID-19 involves not only respiratory system damage, but can also lead to disorders of the central and peripheral nervous system, as well as the muscular system. This article presents published data and our own observations on the course of neurological disorders in COVID-19 patients. There is a relationship between the severity of COVID-19 and the severity and frequency of neurological manifestations. Severe neurological disorders are mostly seen in severe cases of COVID-19 and include acute cerebrovascular accidents (aCVA), acute necrotizing encephalopathy, and Guillain–Barré syndrome. Factors potentially complicating the course of COVID-19 and increasing the development of neurological complications include arterial hypertension, diabetes mellitus, and chronic cardiac and respiratory system diseases. Questions of the possible effects of human coronaviruses on the course of chronic progressive neurological diseases are addressed using multiple sclerosis (MS) as an example. We discuss the management of patients with aCVA and MS depending on the risk of developing coronavirus infection.
Collapse
|
39
|
Pignataro G, Cataldi M, Taglialatela M. Neurological risks and benefits of cytokine-based treatments in coronavirus disease 2019: from preclinical to clinical evidence. Br J Pharmacol 2021; 179:2149-2174. [PMID: 33512003 DOI: 10.1111/bph.15397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/22/2021] [Accepted: 01/24/2021] [Indexed: 12/15/2022] Open
Abstract
Immunodeficiency and hyperinflammation are responsible for the most frequent and life-threatening forms of coronavirus disease 2019 (COVID-19). Therefore, cytokine-based treatments targeting immuno-inflammatory mechanisms are currently undergoing clinical scrutiny in COVID-19-affected patients. In addition, COVID-19 patients also exhibit a wide range of neurological manifestations (neuro-COVID), which may also benefit from cytokine-based treatments. In fact, such drugs have shown some clinical efficacy also in neuroinflammatory diseases. On the other hand, anti-cytokine drugs are endowed with significant neurological risks, mainly attributable to their immunodepressant effects. Therefore, the aim of the present manuscript is to briefly describe the role of specific cytokines in neuroinflammation, to summarize the efficacy in preclinical models of neuroinflammatory diseases of drugs targeting these cytokines and to review the clinical data regarding the neurological effects of these drugs currently being investigated against COVID-19, in order to raise awareness about their potentially beneficial and/or detrimental neurological consequences.
Collapse
Affiliation(s)
- Giuseppe Pignataro
- Division of Pharmacology, Department of Neuroscience, University of Naples "Federico II", Naples, Italy
| | - Mauro Cataldi
- Division of Pharmacology, Department of Neuroscience, University of Naples "Federico II", Naples, Italy
| | - Maurizio Taglialatela
- Division of Pharmacology, Department of Neuroscience, University of Naples "Federico II", Naples, Italy
| |
Collapse
|
40
|
Jain A, Lodha R. Influenza Associated Neurological Diseases in Children. Indian J Pediatr 2020; 87:889-890. [PMID: 33006119 DOI: 10.1007/s12098-020-03511-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 09/23/2020] [Indexed: 12/28/2022]
Affiliation(s)
- Agam Jain
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.
| |
Collapse
|
41
|
Levine JM, Ahsan N, Ho E, Santoro JD. Genetic Acute Necrotizing Encephalopathy Associated with RANBP2: Clinical and Therapeutic Implications in Pediatrics. Mult Scler Relat Disord 2020; 43:102194. [PMID: 32426208 PMCID: PMC7228726 DOI: 10.1016/j.msard.2020.102194] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/05/2020] [Accepted: 05/08/2020] [Indexed: 11/26/2022]
Abstract
Genetic (also known as familial) acute necrotizing encephalopathy (ANE1) is a rare disease presenting with encephalopathy often following preceding viral febrile illness in patients with a genetic predisposition resulting from a missense mutation in the gene encoding RAN Binding Protein 2 (RANBP2). The acute episode is characterized by deterioration in consciousness, often with focal neurologic deficits and seizures. Additionally, symmetric multifocal brain lesions are seen in the bilateral thalami as well as other characteristic regions, involving both gray and white matter. Prognosis is variable, with a high mortality rate and most surviving patients having persistent neurologic deficits. Early treatment with high dose steroids is associated with a more favorable outcome, however the diagnosis is often overlooked resulting in delayed treatment. The RANBP2 mutation associated with ANE1 causes an incompletely penetrant predisposition to encephalopathy in the setting of febrile illness through a mechanism that remains elusive. There are several non-mutually exclusive hypotheses suggesting possible etiologies for this phenotype based on the many functions of RANBP2 within the cell. These include dysfunctions in nucleocytoplasmic trafficking and intracellular metabolic regulation, as well as cytokine storm, and abnormal distribution of mitochondria. This narrative review explores these key concepts of the RANBP2 mutation and its clinical and therapeutic implications in pediatric populations.
Collapse
Affiliation(s)
- Jesse M Levine
- Medical Scientist Training Program, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States
| | - Nusrat Ahsan
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States; Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Eugenia Ho
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States; Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Jonathan D Santoro
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States; Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA.
| |
Collapse
|
42
|
Takia L, Patra N, Nallasamy K, Saini L, Suthar R, Angurana SK, Jayashree M. Acute Necrotizing Encephalopathy of Childhood with H1N1 Infection. J Pediatr Intensive Care 2020; 9:222-224. [PMID: 32685254 DOI: 10.1055/s-0040-1705182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 01/31/2020] [Indexed: 10/24/2022] Open
Abstract
Acute necrotizing encephalopathy of childhood (ANEC) is an uncommon and fulminant complication of seasonal influenza infection associated with high mortality and poor neurological outcome. We report a 4.5-year-old female who had pneumonia, ANEC, and raised intracranial pressure (ICP) with polymerase chain reaction proven H1N1 infection. Management included mechanical ventilation, invasive monitoring and control of ICP, oseltamivir, methylprednisolone, and supportive care in pediatric intensive care unit. She survived with poor neurological status at discharge.
Collapse
Affiliation(s)
- Lalit Takia
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nilamani Patra
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Karthi Nallasamy
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Lokesh Saini
- Division of Pediatric Neurology, Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Renu Suthar
- Division of Pediatric Neurology, Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Suresh K Angurana
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Muralidharan Jayashree
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
43
|
Tocilizumab in pediatric refractory status epilepticus and acute epilepsy: Experience in two patients. J Neuroimmunol 2020; 340:577142. [DOI: 10.1016/j.jneuroim.2019.577142] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 12/16/2019] [Accepted: 12/29/2019] [Indexed: 02/08/2023]
|
44
|
Gusev E, Martynov M, Boyko A, Voznyuk I, Latsh N, Sivertseva S, Spirin N, Shamalov N. Novel coronavirus infection (COVID-19) and nervous system involvement: pathogenesis, clinical manifestations, organization of neurological care. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:7-16. [DOI: 10.17116/jnevro20201200617] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|