Herpes zoster myelitis occurring during treatment for systemic lupus erythematosus

Navigating for reward

An organism's survival can depend on its ability to recall and navigate to spatial locations associated with rewards, such as food or a home. Accumulating research has revealed that computations of reward and its prediction occur on multiple levels across a complex set of interacting brain regions, including those that support memory and navigation. However, how the brain coordinates the encoding, recall and use of reward information to guide navigation remains incompletely understood. In this Review, we propose that the brain's classical navigation centres - the hippocampus and the entorhinal cortex - are ideally suited to coordinate this larger network by representing both physical and mental space as a series of states. These states may be linked to reward via neuromodulatory inputs to the hippocampus-entorhinal cortex system. Hippocampal outputs can then broadcast sequences of states to the rest of the brain to store reward associations or to facilitate decision-making, potentially engaging additional value signals downstream. This proposal is supported by recent advances in both experimental and theoretical neuroscience. By discussing the neural systems traditionally tied to navigation and reward at their intersection, we aim to offer an integrated framework for understanding navigation to reward as a fundamental feature of many cognitive processes.

Meningismus in children with chronic headache is most likely due to streptococcal infection

We previously found that 97% of children diagnosed with chronic tension-type headaches had meningismus. In the present study, we investigate the relationship between streptococcal infection and meningismus in children suffering from chronic headaches. Six hundred and forty children suffering from idiopathic chronic headaches were examined by a neurologist in an outpatient setting. Antistreptolysin titer (ASOT) was determined from blood samples taken from all the children. Meningismus was diagnosed in 337 patients. Patients were divided into two groups: 337 children (Group 1) with meningismus with an increased ASOT (200-1790 IU/ml) in 264 children (78%), and 303 children (Group 2) without meningismus with an increased ASOT (200-1030 IU/ml) in 117 children (39%). We report herein that a majority of children with headaches associated with meningismus, had evidence of a streptococcal infection when compared to a non-meningismus group. We postulate that streptococcal infection may play an important role in the etiology of meningismus-positive chronic headaches in children.

Newly developed urinary retention and motor weakness of lower extremities in a postherpetic neuralgia patient

During the early stage of postherpetic neuralgia, an epidural block on the affected segment is helpful in controlling pain and preventing progression to a chronic state. The main neurologic complication following an epidural block is cord compression symptom due to an epidural hematoma. When neurologic complications arise from an epidural block for the treatment of postherpetic neuralgia, it is important to determine whether the complications are due to the procedure or due to the herpes zoster itself. We report a case of a patient who was diagnosed with herpes zoster myelitis during treatment for postherpetic neuralgia. The patient complained of motor weakness in the lower extremities after receiving a thoracic epidural block six times. Although initially, we believed that the complications were due to the epidural block, it was ultimately determined to be from the herpes zoster myelitis.

Meningismus is a commonly overlooked finding in tension-type headache in children and adolescents

At present, both migraine and tension-type headaches in children are believed to be chronic primary headaches. Meningeal signs in both cases are ignored or not examined, and the neurologic status is considered normal. This is the first study that focuses on meningeal signs in children with chronic headaches. The study population comprised 1738 patients aged 5 to 17 years who were examined in an outpatient neurologic clinic over a 6-year period. Particular attention was paid to examination of meningeal signs, including nuchal rigidity, Kernig's sign, Brudzinski's three signs (upper, middle, and lower), the "tripod" sign, and Guillain's and facial signs; the presence of these signs was regarded as meningismus syndrome. Some meningeal signs were found in 12% of 1007 children suffering from migraine, whereas 97% of 731 children with tension-type headaches had the whole set of meningeal signs. This suggested that meningismus is the major clinical syndrome in chronic tension-type headaches in children and adolescents. Chronic mild sterile (possibly autoimmune) inflammation of meninges (dura mater) can be caused by a preceding infection, as well as minor trauma of the head and/or back. Prolonged rest in a recumbent position usually resulted in relief or complete disappearance of both headache and meningeal signs. Monitoring of the meningeal signs is helpful for evaluation of the patient's condition in the course of treatment.

Case report: varicella-zoster virus myelitis--serial MR findings

The authors describe a 32-year-old male in whom herpes zoster of the left upper extremity was complicated by the development of cervical myelitis. Contrast enhancement and abnormal signal intensity on T1 and T2 weighted images was seen at C1-C6 levels in the spinal cord and medulla. There was also slight enlargement of the cord at these levels. On serial MR imaging the degree of enhancement changed from marked to none with corresponding clinical improvement.

Treatment Parameters for the Successful Management of Varicella Zoster Virus

Antiviral therapy has an important role to play in the management of shingles. However, one needs to define clearly when the therapy is effective, who is likely to benefit from it, and whether or not its use can be justified from an economic point of view. Early medical consultation is of paramount importance if the clinical effectiveness and economic benefits from antiviral therapy are to be optimized.

Recognition and treatment of shingles

Varicella zoster virus (VZV) is responsible for a primary infection (varicella) followed by a latency, eventually resulting in herpes zoster (shingles). The replication cycle of VZV is normally interrupted after varicella. Consequently, VZV remains dormant in the organism. Reactivation occurs after viraemia, and the development of tissue alterations (skin and viscera) depends on the immunological status of the patient. Diagnosis of herpes zoster relies on clinical recognition and cytological and histological evaluations combined with immunohistochemistry and molecular biology techniques. Treatment of herpes zoster primarily relies upon antiviral drugs and incidentally on immunomodulating agents, specific immunoglobulins, antimicrobial agents, antiviral enzymes and corticosteroids. Drugs with a clinically relevant activity against varicella zoster virus infections include aciclovir, adenosine monophosphate, bromodeoxyuridine, desciclovir, fiacitabine, idoxuridine, interferon-alpha and vidarabine. Among them, aciclovir appears to be a first-line agent. Its efficacy has been well established by many clinical studies. Promising drugs for the future include famciclovir, penciclovir, valaciclovir and other molecules currently under investigation. Recent and promising improvements in antiviral drug development may increase patient compliance, cost-benefit ratios and therapeutic efficacy.

Recurrent herpes zoster myelitis treated with human interferon alpha: a case report

Recurrent herpes zoster myelitis is very rare. However, a case was recently observed in our hospital. A 43-year-old woman developed myelitis 2 weeks after development of shingles. Her condition was improved by methylprednisolone. Seven months later, she developed myelitis after development of shingles again. Antibody against varicella-zoster (VZV), increased in the serum, but was negative in the cerebrospinal fluid. Methylprednisolone was not sufficiently effective against this attack. The refractory sensory disturbance was improved by human interferon alpha (IFN-alpha). Natural killer cell activity, the helper T-cell/suppressor T-cell ratio and the kappa/lambda ratio of B-cells increased with clinical improvement. In this case, delayed-type hypersensitivity after VZV infection played a role in the occurrence of myelopathy and clinical improvement resulted from the immunosuppressive effects of IFN-alpha.