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Nguyen THO, Rowntree LC, Chua BY, Thwaites RS, Kedzierska K. Defining the balance between optimal immunity and immunopathology in influenza virus infection. Nat Rev Immunol 2024:10.1038/s41577-024-01029-1. [PMID: 38698083 DOI: 10.1038/s41577-024-01029-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 05/05/2024]
Abstract
Influenza A viruses remain a global threat to human health, with continued pandemic potential. In this Review, we discuss our current understanding of the optimal immune responses that drive recovery from influenza virus infection, highlighting the fine balance between protective immune mechanisms and detrimental immunopathology. We describe the contribution of innate and adaptive immune cells, inflammatory modulators and antibodies to influenza virus-specific immunity, inflammation and immunopathology. We highlight recent human influenza virus challenge studies that advance our understanding of susceptibility to influenza and determinants of symptomatic disease. We also describe studies of influenza virus-specific immunity in high-risk groups following infection and vaccination that inform the design of future vaccines to promote optimal antiviral immunity, particularly in vulnerable populations. Finally, we draw on lessons from the COVID-19 pandemic to refocus our attention to the ever-changing, highly mutable influenza A virus, predicted to cause future global pandemics.
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Affiliation(s)
- Thi H O Nguyen
- Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Louise C Rowntree
- Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Brendon Y Chua
- Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Ryan S Thwaites
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Katherine Kedzierska
- Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia.
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Keilich SR, Bartley JM, Haynes L. Diminished immune responses with aging predispose older adults to common and uncommon influenza complications. Cell Immunol 2019; 345:103992. [PMID: 31627841 PMCID: PMC6939636 DOI: 10.1016/j.cellimm.2019.103992] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/08/2019] [Accepted: 10/08/2019] [Indexed: 02/06/2023]
Abstract
Influenza (flu) is a serious disease for older adults, with increased severity of infection and greater risk for hospitalization and death. Flu infection is limited to pulmonary epithelial cells, yet there are many systemic symptoms and older adults are more susceptible to flu-related complications. In older adults, flu rarely comes without additional complications and there is a perfect storm for enhanced disease due to multiple factors including existing co-morbidities, plus impaired lung function and dysregulated immune responses that occur with even healthy aging. Commonly, opportunistic secondary bacterial infections prosper in damaged lungs. Intensified systemic inflammation with aging can cause dysfunction in extra-pulmonary organs and tissues such as cardiovascular, musculoskeletal, neuropathologic, hepatic, and renal complications. Often overlooked is the underappreciated connections between many of these conditions, which exacerbate one another when in parallel. This review focuses on flu infection and the numerous complications in older adults associated with diminished immune responses.
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Affiliation(s)
- Spencer R Keilich
- UConn Center on Aging, University of Connecticut School of Medicine, Farmington, CT 06030, USA.
| | - Jenna M Bartley
- UConn Center on Aging, University of Connecticut School of Medicine, Farmington, CT 06030, USA; Department of Immunology, University of Connecticut School of Medicine, Farmington, CT 06030, USA.
| | - Laura Haynes
- UConn Center on Aging, University of Connecticut School of Medicine, Farmington, CT 06030, USA; Department of Immunology, University of Connecticut School of Medicine, Farmington, CT 06030, USA.
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Sellers SA, Hagan RS, Hayden FG, Fischer WA. The hidden burden of influenza: A review of the extra-pulmonary complications of influenza infection. Influenza Other Respir Viruses 2018; 11:372-393. [PMID: 28745014 PMCID: PMC5596521 DOI: 10.1111/irv.12470] [Citation(s) in RCA: 239] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2017] [Indexed: 12/13/2022] Open
Abstract
Severe influenza infection represents a leading cause of global morbidity and mortality. Although influenza is primarily considered a viral infection that results in pathology limited to the respiratory system, clinical reports suggest that influenza infection is frequently associated with a number of clinical syndromes that involve organ systems outside the respiratory tract. A comprehensive MEDLINE literature review of articles pertaining to extra‐pulmonary complications of influenza infection, using organ‐specific search terms, yielded 218 articles including case reports, epidemiologic investigations, and autopsy studies that were reviewed to determine the clinical involvement of other organs. The most frequently described clinical entities were viral myocarditis and viral encephalitis. Recognition of these extra‐pulmonary complications is critical to determining the true burden of influenza infection and initiating organ‐specific supportive care.
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Affiliation(s)
- Subhashini A Sellers
- Division of Pulmonary and Critical Care Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Robert S Hagan
- Division of Pulmonary and Critical Care Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Frederick G Hayden
- Division of Infectious Diseases, The University of Virginia, Charlottesville, VA, USA
| | - William A Fischer
- Division of Pulmonary and Critical Care Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Does influenza subtype H1N1 have a place in the etiology of pityriasis rosea? Postepy Dermatol Alergol 2018; 36:164-166. [PMID: 31320848 PMCID: PMC6627266 DOI: 10.5114/ada.2018.73139] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 12/28/2017] [Indexed: 11/17/2022] Open
Abstract
Introduction Pityriasis rosea (PR) is an acute, inflammatory skin disease of unknown cause. Various infectious agents including viruses have been proposed as causative agents and presence of influenza subtype H1N1 was shown in case reports with PR, but the relation was not conclusive. We hypothesited that there may be a relation between PR and H1N1, since both of them are prevalent in the same period as winter or season transitions. Aim To investigate the effect of the H1N1 virus in PR in this study. Material and methods Twenty-one female and 12 male PR patients who applied to Kırıkkale University Faculty of Medicine Hospital Dermatology Outpatient Clinic were included in the study. Influenza subtype H1N1 IgM and IgG antibodies were detected by enzyme immunoassay (EIA) in sera of patients; tissue biopsy specimens were examined for influenza subtype H1N1 RNA by PCR. Results Seven (23%) of the 33 patients had positive IgM and IgG antibodies. Influenza subtype H1N1 RNA was not detected in the tissue samples of 33 PR patients. Conclusions According to the results of this study, we can say that influenza subtype H1N1 does not play a role in PR etiology.
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Meijer WJ, Linn FHH, Wensing AMJ, Leavis HL, van Riel D, GeurtsvanKessel CH, Wattjes MP, Murk JL. Acute influenza virus-associated encephalitis and encephalopathy in adults: a challenging diagnosis. JMM Case Rep 2016; 3:e005076. [PMID: 28348797 PMCID: PMC5343125 DOI: 10.1099/jmmcr.0.005076] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Accepted: 11/29/2016] [Indexed: 11/18/2022] Open
Abstract
Background: Acute influenza-associated encephalopathy/encephalitis (IAE) in adults is a rare but well-known complication of influenza virus infection. The diagnosis is difficult to make due to the absence of distinctive clinical symptoms and validated diagnostic criteria. We present an illustrative case and a case review on acute IAE in adults. Methods: We performed a Medline search of the English literature using the terms influenz*, encephal* and adult, and constructed a database of detailed descriptions of patients with influenza virus infection with influenza-like symptoms at the onset of neurological symptoms. Results: A total of 44 patients were included. Confusion and seizures were the most prevalent neurological symptoms, present in 12 (27 %) and 10 (23 %) patients, respectively. Magnetic resonance imaging (MRI) was performed in 21 patients and anomalies were found in 13 (62 %), with lesions located throughout the brain. Influenza virus RNA was detected in cerebrospinal fluid (CSF) in 5 (16 %) of 32 patients. Eight (18 %) of the forty-four patients died. The benefits of antiviral and immunomodulatory therapy have not been well studied. Discussion: Our results show that many different neurological symptoms can be present in patients with acute onset IAE. Therefore, the diagnosis should be considered in patients with fever and neurological symptoms, especially during the influenza season. Laboratory diagnosis consists of demonstration of influenza virus RNA in brain tissue, CSF or respiratory samples, and demonstration of intrathecal antibody production against influenza virus. The presence of brain lesions in MRI and influenza virus in CSF appear to be of prognostic value.
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Affiliation(s)
- Wouter J. Meijer
- Perinatal Center, Wilhelmina Childs Hospital, University Medical Center Utrecht, KE 04.123.1, Lundlaan 6, PO Box 85090, Utrecht, The Netherlands
| | - Francisca H. H. Linn
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Room G03-228, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Anne M. J. Wensing
- Department of Medical Microbiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Helen L. Leavis
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Debby van Riel
- Department of Viroscience, Erasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | | | - Mike P. Wattjes
- Department of Radiology and Nuclear Medicine, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Jean-Luc Murk
- Department of Medical Microbiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Vision Loss Caused by Retinal and Lateral Geniculate Nucleus Infarction in H1N1 Influenza. J Neuroophthalmol 2016; 35:265-9. [PMID: 25887303 DOI: 10.1097/wno.0000000000000247] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A 13-year-old girl developed encephalopathy and severe bilateral vision loss to the level of light perception within 24 hours of having fever and myalgias heralding H1N1 influenza A. Ophthalmoscopy demonstrated findings of confluent ischemic retinopathy. Brain MRI disclosed lateral geniculate body signal abnormalities indicative of hemorrhagic infarction. Despite aggressive treatment with intravenous corticosteroids, intravenous immunoglobulin, and plasmapheresis, vision did not substantially improve. This case demonstrates that H1N1 can cause simultaneous retinal and lateral geniculate body infarctions, a combination of findings not previously described in any condition. We postulate an immunologic response to the virus marked by occlusive damage to arteriolar endothelium.
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National surveillance of influenza-associated encephalopathy in Japan over six years, before and during the 2009-2010 influenza pandemic. PLoS One 2013; 8:e54786. [PMID: 23355899 PMCID: PMC3552950 DOI: 10.1371/journal.pone.0054786] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 12/14/2012] [Indexed: 11/19/2022] Open
Abstract
Influenza-associated encephalopathy (IAE) is a serious complication of influenza and is reported most frequently in Japan. This paper presents an assessment of the epidemiological characteristics of influenza A (H1N1) 2009-associated encephalopathy in comparison to seasonal IAE, based on Japanese national surveillance data of influenza-like illness (ILI) and IAE during flu seasons from 2004–2005 through 2009–2010. In each season before the pandemic, 34–55 IAE cases (mean 47.8; 95% confidence interval: 36.1–59.4) were reported, and these cases increased drastically to 331 during the 2009 pandemic (6.9-fold the previous seasons). Of the 331 IAE cases, 322 cases were reported as influenza A (H1N1) 2009-associated encephalopathy. The peaks of IAE were consistent with the peaks of the influenza epidemics and pandemics. A total of 570 cases of IAE (seasonal A, 170; seasonal B, 50; influenza A (H1N1) 2009, 322; unknown, 28) were reported over six seasons. The case fatality rate (CFR) ranged from 4.8 to 18.2% before the pandemic seasons and 3.6% in the 2009 pandemic season. The CFR of pandemic-IAE was 3.7%, which is lower than that of influenza A−/B-associated encephalopathy (12.9%, p<0.001; 14.0%, p = 0.002; respectively). The median age of IAE was 7 years during the pandemic, which is higher than that of influenza A−/B-associated encephalopathy (4, p<0.001; 4.5, p = 0.006; respectively). However, the number of pandemic-IAE cases per estimated ILI outpatients peaked in the 0–4-year age group and data both before and during the pandemic season showed a U-shape pattern. This suggests that the high incidence of influenza infection in the 0–4 year age group may lead to a high incidence of IAE in the same age group in a future influenza season. Further studies should include epidemiologic case definitions and clinical details of IAE to gain a more accurate understanding of the epidemiologic status of IAE.
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Rapid Test for Influenza in Diagnostics. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2013; 756:263-9. [DOI: 10.1007/978-94-007-4549-0_33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Severe form of encephalopathy associated with 2009 pandemic influenza A (H1N1) in Japan. J Clin Virol 2012; 56:25-30. [PMID: 23107158 DOI: 10.1016/j.jcv.2012.10.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Revised: 10/08/2012] [Accepted: 10/10/2012] [Indexed: 11/20/2022]
Abstract
BACKGROUND Every year, an estimated 200-500 children in Japan develop influenza-associated encephalopathy (IAE), and 10-30% of these children die. OBJECTIVE To clarify the clinical features of a severe form of acute encephalopathy seen with 2009 pandemic influenza A (H1N1). STUDY DESIGN This retrospective survey examined 20 children with acute encephalopathy associated with the 2009 pandemic influenza A (H1N1) who died or were in a prolonged deep coma with a flat electroencephalogram tracing and loss of spontaneous respiration. We obtained demographic, clinical, laboratory, and neuroimaging data through interviews with the attending physicians and chart reviews. RESULTS Subjects were 13 boys and seven girls. Their median age was 45 (range 11-200) months. Five patients had one or more pre-existing conditions. Acute encephalopathy developed within 2 days after influenza onset in 16 patients. As the initial neurological symptom, delirious behavior was seen in six children, and brief seizures in six. Eighteen patients were comatose within 6h of the onset of encephalopathy. Marked brain edema on computed tomography (CT) was seen in all but one patient. Brainstem lesions on CT were recognized in 12 patients. Sixteen patients died 0-45 (median 2.5) days after the onset of acute encephalopathy, and the others remained in deep comas without spontaneous respiration. CONCLUSIONS The clinical course of the patients was characterized by an onset with mild neurological symptoms and rapid deterioration of consciousness into coma. Head CT revealed marked cerebral edema, often associated with brainstem lesions.
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Patel KK, Patel AK, Shah S, Ranjan R, Shah SV. Adult Patient with Novel H1N1 Infection Presented with Encephalitis, Rhabdomyolysis, Pneumonia and Polyneuropathy. J Glob Infect Dis 2012; 4:178-81. [PMID: 23055650 PMCID: PMC3459436 DOI: 10.4103/0974-777x.100581] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Neurological complications of influenza are well known. Influenza A is commonly associated with neurological complications. Neurological complications especially encephalitis is described in the pediatric age group of patients with current pandemic novel H1N1 infection. We are describing a case of novel H1N1 infection presenting with multi-system involvement (encephalitis, bilateral pneumonia, severe rhabdomyolysis leading to renal failure and polyneuropathy) in adult patient.
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Affiliation(s)
- Ketan K Patel
- Infectious Diseases Consultant, Infectious Diseases Clinic, "VEDANTA" Institute of Medical Sciences, Navarangpura, Ahmedabad, India
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Joosten A, Moya B, Nunes J, Germano N, Alcântara J, Bento L. H1N1 influenza virus-associated encephalitis: A case report. Med Intensiva 2012; 36:520-2. [DOI: 10.1016/j.medin.2012.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2011] [Accepted: 01/09/2012] [Indexed: 11/25/2022]
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Post-marketing assessment of neuropsychiatric adverse events in influenza patients treated with oseltamivir: an updated review. Adv Ther 2012; 29:826-48. [PMID: 23054689 DOI: 10.1007/s12325-012-0050-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Indexed: 10/27/2022]
Abstract
A 2008 review by our group concluded that the risk of neuropsychiatric adverse events (NPAEs) in influenza patients was not increased by oseltamivir exposure, and did not identify any mechanism by which oseltamivir or its metabolites could cause or worsen such events. The current article reviews new information on this topic. Between September 16, 2007 and May 15, 2010, 1,805 spontaneously-reported NPAEs were identified in 1,330 patients receiving oseltamivir: 767 (42.5%) from Japan, 296 (16.4%) from the USA, and 742 (41.1%) from other countries. NPAEs were more common in children: 1,072 (59.4%) events were in those aged ≤16 years. NPAEs often occurred within 48 h of treatment initiation (953 events; 52.8%). Nearly half of the events were serious in nature (838; 46.4%). The three largest categories of events were abnormal behavior (457 events, 25.3%), miscellaneous psychiatric events (370; 20.5%), and delusions/perceptual disturbances (316 events, 17.5%). A total of 1,545 events (85.6%) in eight different categories were considered to be delirium or delirium-like. Twenty-eight suicide-related events were reported. A US healthcare claims database analysis showed that the risk of NPAEs in 7,798 oseltamivir-treated patients was no higher than that in 10,411 patients not on antivirals, but a study on oseltamivir and abnormal behavior in Japan was less conclusive. NPAE frequency in oseltamivir-exposed Japanese and Taiwanese children with influenza was the same as in unexposed children. New analysis of the UK General Practice Research Database showed that the relative adjusted risk of NPAEs in influenza patients was 2.18-times higher than in the general population. Other epidemiology studies report frequent occurrence of encephalitis and similar disorders in influenza patients independently of oseltamivir exposure. The new data support the findings of the original assessment. Evidence suggests that influenza-related encephalopathies are caused by influenza-induced inflammatory responses, but more work is needed to confirm the underlying mechanisms.
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Horby P, Nguyen NY, Dunstan SJ, Baillie JK. The role of host genetics in susceptibility to influenza: a systematic review. PLoS One 2012; 7:e33180. [PMID: 22438897 PMCID: PMC3305291 DOI: 10.1371/journal.pone.0033180] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Accepted: 02/06/2012] [Indexed: 12/24/2022] Open
Abstract
Background The World Health Organization has identified studies of the role of host genetics on susceptibility to severe influenza as a priority. A systematic review was conducted to summarize the current state of evidence on the role of host genetics in susceptibility to influenza (PROSPERO registration number: CRD42011001380). Methods and Findings PubMed, Web of Science, the Cochrane Library, and OpenSIGLE were searched using a pre-defined strategy for all entries up to the date of the search. Two reviewers independently screened the title and abstract of 1,371 unique articles, and 72 full text publications were selected for inclusion. Mouse models clearly demonstrate that host genetics plays a critical role in susceptibility to a range of human and avian influenza viruses. The Mx genes encoding interferon inducible proteins are the best studied but their relevance to susceptibility in humans is unknown. Although the MxA gene should be considered a candidate gene for further study in humans, over 100 other candidate genes have been proposed. There are however no data associating any of these candidate genes to susceptibility in humans, with the only published study in humans being under-powered. One genealogy study presents moderate evidence of a heritable component to the risk of influenza-associated death, and while the marked familial aggregation of H5N1 cases is suggestive of host genetic factors, this remains unproven. Conclusion The fundamental question “Is susceptibility to severe influenza in humans heritable?” remains unanswered. Not because of a lack of genotyping or analytic tools, nor because of insufficient severe influenza cases, but because of the absence of a coordinated effort to define and assemble cohorts of cases. The recent pandemic and the ongoing epizootic of H5N1 both represent rapidly closing windows of opportunity to increase understanding of the pathogenesis of severe influenza through multi-national host genetic studies.
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Affiliation(s)
- Peter Horby
- Oxford University Clinical Research Unit-Wellcome Trust Major Overseas Programme, Hanoi, Vietnam.
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Olcay L, Oztürkmen S, Bıçakçı Z, Akyay A, Iskender G, Sayılır KT, Cetin N, Menteş SD, Kapusuz O, Ertem M. H1N1-Associated Encephalitis in a Child with Acute Myeloblastic Leukemia and Bacteremia due to Klebsiella Pneumoniae. Turk J Haematol 2012; 29:67-71. [PMID: 24744626 PMCID: PMC3986771 DOI: 10.5505/tjh.2012.80947] [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: 09/10/2010] [Accepted: 03/05/2011] [Indexed: 11/11/2022] Open
Abstract
Herein we present a neutropenic 16-year-old female with acute myeloblastic leukemia that developed recurrentgeneralized seizures while receiving antimicrobial therapy (including oseltamivir) due to pneumonia, bacteremiaof Klebsiella pneumoniae, and H1N1 infection. The patient’s seizures were controlled using assisted ventilation.Electroencephalography showed that the patient had encephalopathy. Cranial computed tomography (CT), magneticresonance imaging (MRI), and MRI angiography findings were normal. The patient fully recovered without sequelae.This case indicates that during pandemics of influenza-like diseases H1N1 infection should always be a consideration.
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Affiliation(s)
- Lale Olcay
- Dr A.Y. Ankara Oncology Training and Research Hospital, Department of Pediatric Hematology, Ankara, Turkey
| | - Seda Oztürkmen
- Dr A.Y. Ankara Oncology Training and Research Hospital, Department of Pediatric Hematology, Ankara, Turkey
| | - Zafer Bıçakçı
- Dr A.Y. Ankara Oncology Training and Research Hospital, Department of Pediatric Hematology, Ankara, Turkey
| | - Arzu Akyay
- Dr A.Y. Ankara Oncology Training and Research Hospital, Department of Pediatric Hematology, Ankara, Turkey
| | - Gülşen Iskender
- Dr A.Y. Ankara Oncology Training and Research Hospital, Department of Infectious Diseases, Ankara, Turkey
| | - Kamuran Türker Sayılır
- Dr A.Y. Ankara Oncology Training and Research Hospital, Department of Infectious Diseases, Ankara, Turkey
| | - Nil Cetin
- Dr A.Y. Ankara Oncology Training and Research Hospital, Department of Neurology, Ankara, Turkey
| | - Saadet Dikmen Menteş
- Dr A.Y. Ankara Oncology Training and Research Hospital, Department of Anesthesia, Ankara, Turkey
| | - Ozlem Kapusuz
- Dr A.Y. Ankara Oncology Training and Research Hospital, Department of Anesthesia, Ankara, Turkey
| | - Mehmet Ertem
- Ankara University, School of Medicine, Department of Pediatrics, Division of Pediatric Hematology, Ankara, Turkey
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Frobert E, Sarret C, Billaud G, Gillet Y, Escuret V, Floret D, Casalegno JS, Bouscambert M, Morfin F, Javouhey E, Lina B. Pediatric neurological complications associated with the A(H1N1)pdm09 influenza infection. J Clin Virol 2011; 52:307-13. [PMID: 21920811 DOI: 10.1016/j.jcv.2011.08.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Revised: 08/11/2011] [Accepted: 08/16/2011] [Indexed: 01/13/2023]
Abstract
BACKGROUND Influenza-related neurological complications (INC) have been reported during seasonal flu in children. OBJECTIVES To investigate the types, outcomes and incidence of INC occurring during the 2009 A(H1N1) pandemic, a retrospective analyze was conducted in the single French pediatric hospital of Lyon from October 2009 to February 2010. STUDY DESIGN All children presenting with fever, influenza-like illness, respiratory distress or neurological symptoms were tested for influenza A(H1N1)pdm09 infection from respiratory specimens using real time RT-PCR. RESULTS INC occurred in 14 A(H1N1)pdm09 positive children (7.7% of A(H1N1)pdm09 positive children admitted to hospital) with a median age of 5.1 years. Admission to the intensive care unit (ICU) was required for nine children (64.3%). Half of the children with INC had comorbidity and three had coinfection, both characteristics mainly found in children requiring the ICU. All children received oral oseltamivir treatment. Febrile seizures were observed in eight children, half of them having a chronic comorbidity (2 epilepsy, 1 nonketotic hyperglycinemia, 1 anoxic encephalopathy). Other INC, less commonly reported, included 2 cases of encephalitis, 1 encephalopathy, 1 basilar artery thrombosis, 1 myasthenic crisis and 1 coma. Eleven of the 14 children (78.6%) recovered, one had a minor disability, one child developed a locked-in syndrome and one died from complications of an acute necrotizing encephalopathy. DISCUSSION INC can be observed even in children with no underlying disorder. It may lead to dramatic issue in a significant number of cases.
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Affiliation(s)
- E Frobert
- Laboratoire de Virologie Est, Centre de Biologie et Pathologie Est, Hospices Civils de Lyon, Lyon, France.
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Donner B, Bader-Weder S, Schwarz R, Peng MM, Smith JR, Niranjan V. Safety profile of oseltamivir during the 2009 influenza pandemic. Pharmacoepidemiol Drug Saf 2011; 20:532-43. [PMID: 21448900 DOI: 10.1002/pds.2136] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
PURPOSE This study evaluated the safety of oseltamivir during the 2009 influenza pandemic. METHODS Case reports were obtained from the Roche safety database. The incidence of adverse events (AEs) during the pandemic (1 May 2009 to 31 December 2009) was compared with that beforehand (during previous influenza seasons) for USA and Japan only, as exposure data in other countries were collected inconsistently. Events with significantly higher reporting during the pandemic (lower bound of 95%CI for crude rate ratio >1) were analyzed further. RESULTS Global exposure in the pandemic and prepandemic periods was 18.3 and 64.7 million patients, respectively. In USA and Japan, exposure was 15.5 (1382 cases, 2225 events) and 62.0 million (8387 cases, 12,749 events), respectively. AEs with significantly higher reporting during the pandemic were generally consistent with influenza and its complications and/or with the circulation of a novel virus strain. As might be expected in a pandemic, mortality increased (crude rate ratio, 2.83; 95%CI, 2.23-3.59) versus the prepandemic period. Medical review of serious AEs (fatal or non-fatal outcome) found that most were consistent with pre-existing risk factors, underlying disease, and/or progression of influenza or its complications. Analysis of the remainder did not suggest a causal link with oseltamivir. A review of AEs in previously underexposed subpopulations did not support an association with oseltamivir. CONCLUSIONS During the first 8 months of the 2009 influenza pandemic, AEs reported in patients exposed to oseltamivir were consistent with the drug's labeled safety profile, underlying medical conditions, or infection with the pandemic virus.
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Lee YJ, Smith DS, Rao VA, Siegel RD, Kosek J, Glaser CA, Flint AC. Fatal H1N1-Related Acute Necrotizing Encephalopathy in an Adult. Case Rep Crit Care 2011; 2011:562516. [PMID: 24826323 PMCID: PMC4010007 DOI: 10.1155/2011/562516] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Accepted: 06/14/2011] [Indexed: 11/17/2022] Open
Abstract
Acute necrotizing encephalopathy (ANE) is a severe neurological complication of influenza infection, including H1N1 influenza. Many cases of ANE have been reported in the pediatric literature, but very few cases have been described in adults. The cause of ANE remains unknown-the influenza virus is not known to be neurotropic, and evidence of direct viral involvement of the central nervous system (CNS) has not been demonstrated in the limited cases of ANE in which pathological specimens have been obtained. Here we report a fatal case of ANE from H1N1 influenza infection in an adult. Neuroimaging and postmortem analysis both showed widespread brain edema, necrosis, and hemorrhage, but molecular studies and postmortem pathology revealed no evidence of direct viral involvement of the CNS. This case of fatal ANE in an adult is consistent with the hypothesis generated from pediatric cases that the host immune response, and not direct viral invasion of the CNS, is responsible for pathogenesis of ANE.
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Affiliation(s)
- Yu-Jin Lee
- Department of Human Biology, Stanford University, Stanford, CA 94305, USA
| | - D. Scott Smith
- Department of Infectious Disease and Geographic Medicine, Kaiser Permanente, Redwood City, CA 94063, USA
| | - Vivek A. Rao
- Department of Neuroscience, Kaiser Permanente, Redwood City, CA 94063, USA
| | - Robert D. Siegel
- Department of Microbiology and Immunology, Stanford University, Stanford, CA 94305, USA
| | - Jon Kosek
- Department of Pathology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA
| | - Carol A. Glaser
- Center for Infectious Diseases, California Department of Public Health, Richmond, CA 94804, USA
| | - Alexander C. Flint
- Department of Neuroscience, Kaiser Permanente, Redwood City, CA 94063, USA
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Abstract
AIM To report on a different clinical course of pandemic influenza A (H1N1) infection among children who were neurologically impaired before the acute onset of the disease, in comparison with children who were neurologically intact. METHODS In a period of 6 months, six children with neurological complications associated with pandemic A (H1N1) infection were identified in a single institution paediatric emergency room. The children suffered from seizures or altered mental status during pandemic A (H1N1) infection. All children underwent extensive clinical and laboratory assessment. Three children were neurologically impaired before the acute onset of the H1N1 infection. The other three were neurologically intact before the acute viral infection. RESULTS In all six patients, pandemic influenza A (H1N1) viral RNA was detected in nasopharyngeal specimens but none in the cerebrospinal fluid. Five children fully recovered or returned to baseline at discharge. The clinical course of the disease and recovery were different between the children who were neurologically impaired before the acute viral infection and those who were neurologically intact. CONCLUSIONS It is possible that children with various neurological conditions are in a higher risk to develop further neurological complications during pandemic influenza A (H1N1) infection.
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Affiliation(s)
- Ibrahim Omari
- Department of Pediatrics, Hadassah-Hebrew University Medical Center, Mount Scopus Campus, Jerusalem, Israel
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Kwon NH, Kim JE, Cho BK, Park HJ. A novel influenza a (H1N1) virus as a possible cause of pityriasis rosea? J Eur Acad Dermatol Venereol 2011; 25:368-9. [PMID: 20561127 DOI: 10.1111/j.1468-3083.2010.03725.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Akins PT, Belko J, Uyeki TM, Axelrod Y, Lee KK, Silverthorn J. H1N1 encephalitis with malignant edema and review of neurologic complications from influenza. Neurocrit Care 2011; 13:396-406. [PMID: 20811962 PMCID: PMC7100075 DOI: 10.1007/s12028-010-9436-0] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Influenza virus infection of the respiratory tract is associated with a range of neurologic complications. The emergence of 2009 pandemic influenza A (H1N1) virus has been linked to neurological complications, including encephalopathy and encephalitis. Methods Case report and literature review. Results We reviewed case management of a 20-year old Hispanic male who developed febrile upper respiratory tract signs and symptoms followed by a confusional state. He had rapid neurologic decline and his clinical course was complicated by refractory seizures and malignant brain edema. He was managed with oseltamavir and peramavir, corticosteroids, intravenous gamma globulin treatment, anticonvulsants, intracranial pressure management with external ventricular drain placement, hyperosmolar therapy, sedation, and mechanical ventilation. Reverse transcriptase polymerase chain reaction analysis of nasal secretions confirmed 2009 H1N1 virus infection; cerebrospinal fluid (CSF) was negative for 2009 H1N1 viral RNA. Follow-up imaging demonstrated improvement in brain edema but restricted diffusion in the basal ganglia. We provide a review of the clinical spectrum of neurologic complications of seasonal influenza and 2009 H1N1, and current approaches towards managing these complications. Conclusions 2009 H1N1-associated acute encephalitis and encephalopathy appear to be variable in severity, including a subset of patients with a malignant clinical course complicated by high morbidity and mortality. Since the H1N1 influenza virus has not been detected in the CSF or brain tissue in patients with this diagnosis, the emerging view is that the host immune response plays a key role in pathogenesis.
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Affiliation(s)
- Paul Taylor Akins
- Department of Neurosurgery, Permanente Medical Group, Kaiser Sacramento Medical Center, 2025 Morse Avenue, Sacramento, CA 95825, USA.
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23
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Joo EJ, Kang CI, Kim YJ, Chung DR, Peck KR, Song JH. Encephalitis by Co-infection with A/H1N1 Influenza and Herpes Simplex Virus in an Adult Patient. Infect Chemother 2011. [DOI: 10.3947/ic.2011.43.2.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Eun-Jeong Joo
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Cheol-In Kang
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yae Jean Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doo Ryeon Chung
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyong Ran Peck
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae-Hoon Song
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Cisse FA, Antoine JC, Pillet S, Jousserand G, Reynaud-Salard M, Camdessanche JP. Acute hemorrhagic leukoencephalopathy associated with influenza A (H1N1) virus. J Neurol 2010; 258:513-4. [DOI: 10.1007/s00415-010-5772-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2010] [Revised: 09/20/2010] [Accepted: 09/22/2010] [Indexed: 11/29/2022]
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Abstract
PURPOSE OF REVIEW Influenza-associated acute encephalopathy/encephalitis (IAE) is an uncommon but serious complication with high mortality and neurological sequelae. This review discusses recent progress in IAE research for a better understanding of the disease features, populations, outcomes, diagnosis, and pathogenesis. RECENT FINDINGS In recent years, many IAE cases were reported from many countries, including Japan, Canada, Australia, Austria, The Netherlands, United States, Sweden, and other countries and regions. During the novel influenza A/H1N1 pandemic, many IAE cases with A/H1N1 infection in children were reported, particularly in those hospitalized with influenza infection. Pathogenesis of IAE is not fully understood but may involve viral invasion of the CNS, proinflammatory cytokines, metabolic disorders, or genetic susceptibility. An autosomal dominant viral acute necrotizing encephalopathy (ANE) was recently found to have missense mutations in the gene Ran-binding 2 (RANBP2). Another recurrent ANE case following influenza A infection was also reported in a genetically predisposed family with an RANBP2 mutation. SUMMARY Although IAE is uncommon, compared with the high incidence of influenza infection, it is severe. However, this complication is not duly recognized by health practitioners. Recent advances highlight the threat of this complication, which will help us to have a better understanding of IAE.
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Affiliation(s)
- Gefei F Wang
- Department of Microbiology and Immunology, Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, Shantou, Guangdong, PR China
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Influenza-associated encephalopathy and neurolgic features of novel influenza A (H1N1) virus infection. Pediatr Crit Care Med 2010; 11:297-9. [PMID: 20124942 DOI: 10.1097/pcc.0b013e3181cf43a9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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