Infectious and non-infectious neurologic complications in heart transplant recipients

Symptomatic central nervous system infections in kidney transplant recipients: a 20-years multicenter observational study

BACKGROUND

Central nervous system (CNS) infections in kidney transplant recipients (KTRs) remain poorly characterized, with current evidence largely derived from isolated case reports over the past two decades. This multicenter study aims to systematically delineate the epidemiology, clinical profiles, and outcomes of CNS infections in a large KTR cohort.

METHODS

We conducted a retrospective analysis of 3,602 KTRs across three transplant centers in China (May 2004-July 2024). CNS infections were defined by: 1) neurological symptoms/signs, and 2) microbiological confirmation via cerebrospinal fluid (CSF) analysis, including metagenomic next-generation sequencing (mNGS) and routine microbiologic testing (bacterial and fungal cultures).

RESULTS

CNS infections were diagnosed in 0.53% of KTRs (19/3602), with symptom onset occurring 2-121 months post-transplantation. Etiologies included bacterial (47%, 9/19), viral (32%, 6/19), and fungal (21%, 4/19) pathogens. Notably, 79% of cases (15/19) were exclusively identified by mNGS, whereas conventional cultures failed detection. Presenting symptoms included headache (79%) and altered mental status (42%). Mortality reached 42% (8/19) within 9-22 days of diagnosis; among survivors, 73% (8/11) exhibited neurological sequelae.

CONCLUSIONS

CNS infections in KTRs are rare but characterized by rapid progression and high fatality rate. While the risk of CNS infections persists throughout the post-transplant period, 1-6 months after transplantation is a higher-incidence period of CNS infections. KTRs with neurological symptoms (particularly headache and elevated CSF pressure) should undergo CSF mNGS which is critical in diagnosing such infections.

Identifying CNS infections in transplantation and immunomodulatory therapy

Opportunistic central nervous system (CNS) infections are a significant cause of morbidity and mortality in immunocompromized patients, including those undergoing transplantation and receiving immunomodulatory therapy. Particularly in these individuals, the clinical presentation of these infections may have atypical patterns, emphasizing the need to consider various diagnostic possibilities, including noninfectious conditions. Quick and accurate identification, along with prompt treatment, is crucial for improving patient outcomes. Therefore, understanding which pathogens are likely to cause infection based on factors such as timing post-transplantation, specific organ transplant, and the mechanism of action of immunomodulatory medications is essential. This review will provide a detailed description of the types of infections that may arise in the context of transplantation and immunomodulatory therapy.

Central Nervous System Infections in Solid Organ Transplant Recipients: Results from the Swiss Transplant Cohort Study

OBJECTIVES

To describe the epidemiology and clinical presentation of central nervous system (CNS) infections in solid organ transplant (SOT) recipients in the current era of transplantation.

METHODS

Patients from the Swiss Transplant Cohort Study (STCS) transplanted between 2008 and 2018 were included with a median follow-up of 3.8 years. Epidemiological, microbiological, and clinical data were extracted from the STCS database and patients' medical records. We calculated incidence rates and 90-day survival of transplant recipients with CNS infection.

RESULTS

Among 4762 patients, 42 episodes of CNS infection in 41 (0.8%) SOT recipients were identified, with an overall incidence rate of 2.06 per 1000 patient-years. Incidence of CNS infections was similar across all types of transplantations. Time to CNS infection onset ranged from 0.6 to 97 months after transplant. There were 22/42 (52.4%) cases of viral infections, 11/42 (26.2%) of fungal infections, 5/42 (11.9%) of bacterial infections and 4/42 (9.5%) of probable viral/bacterial etiology. Clinical presentation was meningitis/encephalitis in 25 cases (59.5%) and brain-space occupying lesions in 17 cases (40.5%). Twenty-three cases (60.5%) were considered opportunistic infections. Diagnosis were achieved mainly by brain biopsy/necropsy (15/42, 36%) or by cerebrospinal fluid analysis (20/42, 48%). Up to 40% of cases (17/42) had concurrent extra-neurological disease localizations. Overall, 90-day mortality rate was 29.0% (73.0% for fungal, 14.0% for viral and 11.0% for bacterial and probable infections, p<0.0001).

CONCLUSIONS

CNS infections were rare in the STCS, with viral meningoencephalitis being the most common disease. Fungal infections were associated with a high mortality.

Burden of pneumococcal disease among adults in Southern Europe (Spain, Portugal, Italy, and Greece): a systematic review and meta-analysis

The aim was to summarize pneumococcal disease burden data among adults in Southern Europe and the potential impact of vaccines on epidemiology. Of 4779 identified studies, 272 were selected. Invasive pneumococcal disease (IPD) incidence was 15.08 (95% CI 11.01-20.65) in Spain versus 2.56 (95% CI 1.54-4.24) per 100,000 population in Italy. Pneumococcal pneumonia incidence was 19.59 (95% CI 10.74-35.74) in Spain versus 2.19 (95% CI 1.36-3.54) per 100,000 population in Italy. Analysis of IPD incidence in Spain comparing pre-and post- PCV7 and PCV13 periods unveiled a declining trend in vaccine-type IPD incidence (larger and statistically significant for the elderly), suggesting indirect effects of childhood vaccination programme. Data from Portugal, Greece and, to a lesser extent, Italy were sparse, thus improved surveillance is needed. Pneumococcal vaccination uptake, particularly among the elderly and adults with chronic and immunosuppressing conditions, should be improved, including shift to a higher-valency pneumococcal conjugate vaccine when available.

Risk Factors for Brain Abscess: A Nationwide, Population-Based, Nested Case-Control Study

BACKGROUND

Knowledge on risk factors for brain abscess is limited and relies on single-center cohort studies.

METHODS

We accessed nationwide medical registries to conduct a population-based, nested case-control study of risk factors for brain abscess. We applied risk-set sampling for the selection of population controls (1:10), who were individually matched by age, sex, and area of residence. Conditional logistic regression was used to compute adjusted odds ratios (aOR) with 95% confidence intervals (CIs). Population-attributable fractions were calculated.

RESULTS

We identified 1384 brain abscess patients in Denmark from 1982 through 2016, and 13 839 matched population controls. The median age of patients was 50 years (interquartile range 33-63) and 37% were female. Cases often had Charlson comorbidity scores >2 (16%), compared with controls (3%). Our calculated aORs were 2.15 (95% CI 1.72-2.70) for head trauma; 19.3 (95% CI 14.3-26.0) for neurosurgery; 4.61 (95% CI 3.39-6.26) for dental infections; 2.57 (95% CI 1.71-3.84) for dental surgery; 3.81 (95% CI 3.11-4.67) for ear, nose, and throat infection; 2.85 (95% CI 2.21-3.70) for ear, nose, and throat surgery; 15.6 (95% CI 9.57-25.4) for congenital heart disease; 1.74 (95% CI 1.33-2.29) for diabetes mellitus; 2.22 (95% CI 1.58-3.11) for alcohol abuse; 2.37 (95% CI 1.53-3.68) for liver disease; 2.04 (95% CI 1.30-3.20) for kidney disease and 8.15 (95% CI 3.59-18.5) for lung abscess or bronchiectasis. The aORs were 4.12 (95% CI 3.37-5.04) for solid cancer; 8.77 (95% CI 5.66-13.6) for hematological cancer; 12.0 (95% CI 6.13-23.7) for human immunodeficiency virus; and 5.71 (95% CI 4.22-7.75) for immunomodulating treatments. Population-attributable fractions showed were substantial contributors to the occurrence of brain abscess neurosurgery (12%); solid cancer (11%); ear, nose, and throat infections (7%); and immunomodulating treatments (5%).

CONCLUSIONS

Important risk factors included neurosurgery; cancer; ear, nose, and throat infections; and immunomodulating treatments.

Neurological Complications in Patients with Heart Transplantation

Neurological complications after heart transplantation are common and include cerebrovascular events (ischemic strokes, hemorrhagic strokes, and transient ischemic attacks), seizures, encephalopathy, central nervous system (CNS) infections, malignancies, and peripheral nervous system complications. Although most neurological complications are transient, strokes and CNS infections can result in high mortality and morbidity. Early recognition and timely management of these serious complications are crucial to improve survival and recovery. Diagnosing CNS infections can be challenging because their clinical presentation can be subtle in the setting of immunosuppression. Immunosuppressive medications themselves can cause a broad spectrum of neurological complications including seizures and posterior reversible encephalopathy syndrome. This article provides a review of the diagnosis and management of neurological complications after cardiac transplantation.

Factor Structure of Cotard's Syndrome: Systematic Review of Case Reports

INTRODUCTION

Cotard's syndrome is a rare psychiatric condition. As a result, current information is mainly based on reports and case series.

OBJECTIVE

To analyse the psychopathological characteristics and the grouping of the symptoms of the Cotard's syndrome cases reported in the medical literature.

METHODS

A systematic review of the literature of all reported cases of Cotard's syndrome from 2005 to January 2018 was performed in the MEDLINE/PubMed database. Demographic variables and clinical characteristics of each case were collected. An exploratory factor analysis of the symptoms was performed.

RESULTS

The search identified 86 articles, of which 69 were potentially relevant. After reviewing the full texts, 55 articles were selected for the systematic review, in which we found 69 cases. We found that the diagnosis of major depression (P<0.001) and organic mental disorder (P=0.004) were more frequent in the older group with Cotard's syndrome. An exploratory factor analysis extracted 3 factors: psychotic depression, in which it includes patients with delusions of guilt (0.721), suicidal ideas (0.685), delusions of damnation (0.662), nihilistic delusions of the body (0.642), depression (0.522), and hypochondriacal delusions (0.535); delusive-hallucinatory, with patients who presented delusions of immortality (0.566), visual hallucinations (0.545) and nihilistic delusions of existence (0.451), and mixed, with patients who presented nihilistic delusions of concepts (0.702), anxiety (0.573), and auditory hallucinations (0.560).

CONCLUSIONS

The psychopathology of Cotard's syndrome is more complex than the simple association with the delusion of being dead, since it encompasses a factorial structure organised into 3 factors.

Risk Factors Associated With Peripheral Neuropathy in Heart Failure Patients Candidates for Transplantation

INTRODUCTION

Peripheral neuropathy can affect patients with heart failure, though its prevalence is unknown. After heart transplantation, it can influence the postoperative course and quality of life, but screening for neuromuscular disease is not routinely performed.

OBJECTIVE

The aim of this study was to identify the factors associated with neuropathy in a population of patients with heart failure who are candidates for heart transplantation.

STUDY DESIGN

Data regarding patients' clinical history, including recent hospitalizations, were collected. All patients underwent a complete neurological examination and a neurophysiological protocol including nerve conduction studies and concentric needle electromyography.

RESULTS

Thirty-two patients were included in the study, and neuropathy was diagnosed in 10 (31.3%). Neuropathy was associated with the number of admissions ( P = .023; odds ratio [OR]: 1.96) and the total number of days of hospitalization in the year prior to inclusion in the study ( P = .010; OR: 1.03). The majority of hospitalizations occurred in the step-down unit (85%), with acute heart failure the leading cause of admission (42%).

CONCLUSIONS

This study shows that neuropathy is frequent in patients with advanced heart failure and that hospitalization for cardiac care, also in the absence of intensive care, is a marker of high risk of neurologic damage. These data can help physicians in selecting and managing candidates for transplantation and can guide decisions on the best immunosuppressive regimen or rehabilitation strategy.

Neurologic Complications of Transplantation

Neurologic disturbances including encephalopathy, seizures, and focal deficits complicate the course 10-30% of patients undergoing organ or stem cell transplantation. While much or this morbidity is multifactorial and often associated with extra-cerebral dysfunction (e.g., graft dysfunction, metabolic derangements), immunosuppressive drugs also contribute significantly. This can either be through direct toxicity (e.g., posterior reversible encephalopathy syndrome from calcineurin inhibitors such as tacrolimus in the acute postoperative period) or by facilitating opportunistic infections in the months after transplantation. Other neurologic syndromes such as akinetic mutism and osmotic demyelination may also occur. While much of this neurologic dysfunction may be reversible if related to metabolic factors or drug toxicity (and the etiology is recognized and reversed), cases of multifocal cerebral infarction, hemorrhage, or infection may have poor outcomes. As transplant patients survive longer, delayed infections (such as progressive multifocal leukoencephalopathy) and post-transplant malignancies are increasingly reported.

'I am dead': Cotard syndrome and dementia

Background: Cotard syndrome is a rare condition whose main feature is a nihilistic delusion ranging from the denial of body parts to that of the existence of one's own life or even the entire universe. Objectives: The aim of this article is to review the nosological significance of Cotard syndrome and to explore the disorder among patients with dementia. Methods: Medline and Google Scholar searches were conducted for relevant articles, chapters and books published before 2018. Search terms used included Cotard delusion, Cotard syndrome and dementia, nihilistic delusion. Publications found through this indexed search were reviewed for further relevant references. Results and conclusion: In this narrative review we emphasise the fact that cases of Cotard syndrome involving patients with dementia are reported quite infrequently. Published studies are limited to very short series or isolated cases. Clinicians are obliged to treat the disorder. They should be alert to the potential high risk inherent in this condition. Keypoints Cotard syndrome is a rare condition characterised by nihilistic delusions that may range from negation of existence of parts of the body to delusion of being dead. The prevalence and incidence of this rare syndrome are not known. Since Cotard's syndrome is conceptualised as part of an underlying disorder, several psychiatric and somatic diseases have been associated with the syndrome. The syndrome may occur in patients suffering from dementia.

Systematic review of the evidence on the epidemiology of herpes zoster: incidence in the general population and specific subpopulations in Spain

OBJECTIVES

Herpes zoster (HZ) is an important cause of morbidity around the world, especially among the adult population aged >50 years.

STUDY DESIGN

A systematic review of the literature (up to October 31, 2016) was performed to identify available evidence on incidence of HZ in the general population and in a specific subpopulation in Spain.

METHODS

PubMed and Embase databases were searched, combining the following search terms: 'herpes zoster', 'diabetes mellitus (DM)', 'chronic obstructive pulmonary disease (COPD)', 'chronic heart failure', 'mental disorders' and 'immunocompromised'. Supplements for local scientific congresses, non-indexed Spanish journals and official epidemiological reports, potentially HZ related, were also manually searched. The inclusion criteria were the following: English or Spanish publications reporting incidence of HZ in the Spanish general population and/or specific subpopulations. No restrictions were applied on the study design or population age.

RESULTS

Among 269 references retrieved (48 PubMed, 148 Embase and 73 manual searching), 34 were finally included. Incidence of HZ in the general population ranged from 2.1 to 5.5/1000 person-years. HZ incidence ranged from 9.4 to 15.3/1000 patients with DM and from 11.0 to 11.4/1000 population with COPD or cardiovascular disease. In asthmatic patients, 6.9 HZ cases/1000 subjects were reported. The highest HZ incidence (1.3-400.0/1000 person-years) was in immunocompromised persons (10.0/1000 patients with cancer, 12.5/1000 patients with AIDS, from 5.0 to 240.0/1000 transplanted patients and from 6.6 to 27.0/1000 population with rheumatic diseases). Three studies estimated an increased risk of HZ in comparison with general population, for patients with DM (24%), COPD (39%) and COPD receiving inhaled corticosteroids (61%).

CONCLUSIONS

The results suggest a high risk of HZ in certain age groups and specific subpopulations. This study could contribute to identify target age populations and at-risk groups if implementation of HZ vaccination programmes in Spain would be considered.

Infections in Heart, Lung, and Heart-Lung Transplantation

Half a century has passed since the first orthotopic heart transplant took place. Surgical innovations allowed for heart, lung, and heart-lung transplantation to save lives of patients with incurable chronic cardiopulmonary conditions. The complexity of the surgical interventions, chronic host health conditions, and antirejection immunosuppressive medications makes infectious complications common. Infections have remained one of the main barriers for successful transplantation and a source of significant morbidity and mortality. Recognition of infections and its management in this setting require outstanding clinical skills since transplant recipients may not exhibit classic signs or symptoms of disease, and laboratory work has some pitfalls. The prevention, identification, and management of infectious diseases complications in this population are a priority to undertake to improve the medical outcomes of transplantation. Herein, we reviewed the historical aspects, epidemiology, and prophylaxis of infections in heart, lung, and heart-lung transplantation. We also discuss the most prevalent organisms affecting the host and the organ systems involved.

Neurologic Complications of Transplantation

PURPOSE OF REVIEW

This article describes the diagnosis and management of neurologic problems during hematopoietic cell and solid organ transplantation using time elapsed since transplantation as a guide to expected complications, including drug toxicities, infections, strokes, autoimmune phenomena, disease recurrence, and secondary neoplasms.

RECENT FINDINGS

Growing clinical experience in the neurology of transplantation has led to appreciation of the diverse clinical and radiographic spectrum of calcineurin inhibitor-related posterior reversible encephalopathy syndrome (PRES) and progressive multifocal leukoencephalopathy. Novel autoimmune phenomena illustrate the delicate balance between adequate immunosuppression and necessary host inflammatory defenses that can lead to organ rejection. The spectrum of infectious complications has changed with the evolution of new conditioning regimens.

SUMMARY

Neurologic problems remain an important source of morbidity and mortality, both in the immediate transplantation period and for years after the procedure. As perioperative management has reduced the incidence of acute infections, graft versus host disease, and organ rejection, problems of long-term survivors require neurologic input into multidisciplinary management of chronic neurologic conditions impacting quality of life.

Rare Event Captured with Intracranial Pressure Monitor: Malignant Spike in Intracranial Pressure During Delayed Chest Closure in Heart-Transplant Patient with Ischemic Stroke

BACKGROUND

Patients with open chest wounds, either related to trauma or cardiothoracic procedures, are subjected to significant physiologic alterations when undergoing chest wound closure. Sudden increased intrathoracic pressure at closure decreases venous return from the brain to the heart; consequently the total blood volume in the ridged skull increases, resulting in increased intracranial pressure (ICP). Patients with intact cerebrovascular autoregulation can compensate for these sudden changes by adjusting cerebral blood flow to maintain physiologic ICP. In cases where the autoregulatory mechanisms are compromised, such as stroke or trauma, the ICP can become pathologically elevated. If the patient does not have an ICP monitor, the spike in ICP can go unrecognized, compromising cerebral perfusion pressure and resulting in increased morbidity and mortality.

CASE DESCRIPTION

Herein we describe a case of pathologic elevations in ICP captured with an ICP monitor at the time of chest wound closure in a patient with delayed chest wound closure after orthotopic heart transplant and comorbid embolic stroke.

CONCLUSIONS

This case report demonstrates the potential utility of ICP monitoring in patients with impaired cerebrovascular autoregulation with open and manipulated chest wounds from transplant or trauma.

Imaging spectrum of central nervous system complications of hematopoietic stem cell and solid organ transplantation

Neurologic complications are common after hematopoietic stem cell transplantation (HSCT) and solid organ transplantation (SOT) and affect 30-60% of transplant recipients. The aim of this article is to provide a practical imaging approach based on the timeline and etiology of CNS abnormalities, and neurologic complications related to transplantation of specific organs. The lesions will be classified based upon the interval from HSCT procedure: pre-engraftment period <30 days, early post-engraftment period 30-100 days, late post-engraftment period >100 days, and the interval from SOT procedure: postoperative phase 1-4 weeks, early posttransplant syndromes 1-6 months, late posttransplant syndromes >6 months. Further differentiation will be based on etiology: infections, drug toxicity, metabolic derangements, cerebrovascular complications, and posttransplantation malignancies. In addition, differentiation will be based on complications specific to the type of transplantation: allogeneic and autologous hematopoietic stem cells (HSC), heart, lung, kidney, pancreas, and liver. Thus, in this article we emphasize the strategic role of neuroradiology in the diagnosis and response to treatment by utilizing a methodical approach in the work up of patients with neurologic complications after transplantation.

Neurologic complications of transplantation

Major neurologic morbidity, such as seizures and encephalopathy, complicates 20-30% of organ and stem cell transplantation procedures. The majority of these disorders occur in the early posttransplant period, but recipients remain at risk for opportunistic infections and other nervous system disorders for many years. These long-term risks may be increasing as acute survival increases, and a greater number of "sicker" patients are exposed to long-term immunosuppression. Drug neurotoxicity accounts for a significant proportion of complications, with posterior reversible leukoencephalopathy syndrome, primarily associated with calcineurin inhibitors (i.e., cyclosporine and tacrolimus), being prominent as a cause of seizures and neurologic deficits. A thorough evaluation of any patient who develops neurologic symptoms after transplantation is mandatory, since reversible and treatable conditions could be found, and important prognostic information can be obtained.

Neurologic emergencies in HIV-negative immunosuppressed patients

HIV-negative immunosuppressed patients comprise a heterogeneous group including transplant patients, patients undergoing treatment with immunosuppressors, uremic patients, alcoholics, undernourished patients, diabetics, patients on dialysis, elderly patients, and those diagnosed with severe or neoplastic processes. Epileptic seizures, focal neurologic signs, and meningoencephalitis are neurologic syndromes that require urgent action. In most of these situations, neuroimaging tests are necessary, but the findings can be different from those observed in immunocompetent patients in function of the inflammatory response. Infectious disease is the first diagnostic suspicion, and the identification of an opportunistic pathogen should be oriented in function of the type and degree of immunosuppression. Other neurologic emergencies include ischemic stroke, cerebral hemorrhage, neoplastic processes, and pharmacological neurotoxicity. This article reviews the role of neuroimaging in HIV-negative immunodepressed patients with a neurologic complication that requires urgent management.

Epilepsy After Heart Transplant: A Single Center Experience

OBJECTIVES

Cardiac transplant is the best treatment for patients with end-stage heart failure. Neurologic complications occur at a rate of 30% to 80% in patients undergoing cardiac transplant. Seizures occur at a rate of 2% to 20%. The main causative factors include immunosuppressant drug toxicity, infections, brain lesions, and metabolic disorders. Here, our aim was to determine seizure types and associated conditions in patients undergoing cardiac transplant and to report our treatment experience at our institution.

MATERIALS AND METHODS

We retrospectively evaluated the medical records of 109 patients who underwent cardiac transplant between 2004 and 2016. We recorded demographic data, immunosuppressive treatment, seizure type, cause, recurrence rate, and treatment.

RESULTS

Of 109 patients, 13 had seizures after cardiac transplant. Our study involved 69 adult and 40 pediatric patients. The pediatric patients had an age range of 1 to 17 years, with a mean age of 9.6 years (22 female and 18 male patients). Five pediatric patients had seizures (4 female and 1 male patient). The seizure causes included 2 postarrest hypoxic encephalopathies and 3 posterior reversible encephalopathies. Adult patients ranged from 18 to 63 years old, with a mean age of 42.3 years (54 male and 15 female patients). Eight patients in the adult patient group had seizures (5 female and 3 male patients). Seizure causes were ischemic cerebrovascular events in 2 patients, metabolic disorders in 2, posterior reversible encephalopathies in 3, and postarrest hypoxic brain in 1.

CONCLUSIONS

Seizure is an important complication after cardiac transplant. At our institution, the most common cause of seizure was posterior reversible encephalopathy, with immunosuppressant drugs being responsible.

Neurologic Complications After Cardiac Transplant

OBJECTIVES

Cardiac transplant is the best available therapy for patients with end-stage heart failure. Neurologic complications occur at a rate of 30% to 70% in patients undergoing cardiac transplant, and they affect mortality and morbidity of these patients. Risk factors for neurologic complications include immunosuppressive medication toxicity, infections, brain lesions, and metabolic disorders. The aim of our study was to determine the incidence of neurologic complications in adult patients undergoing cardiac transplant.

MATERIALS AND METHODS

We retrospectively evaluated the medical records of 70 patients who underwent cardiac transplant between 2004 and April 2016. We recorded the demographic data, neurologic symptoms, neurologic examination findings, laboratory test results, brain imaging study results, and treatments received of the patients.

RESULTS

Of the 70 patients enrolled, 55 were male and 15 were female patients. The age range was 18 to 63 years, and the mean age was 42.4 years. Twelve patients had encephalopathy, 4 had neuropathic pain, 3 had tremor, 2 had ischemic cerebrovascular accident, 7 had posterior reversible encephalopathy syndrome, and 1 had drop foot. Encephalopathy usually developed secondary to other neurologic disorders. The incidence of neurologic complications in adult patients undergoing cardiac transplant was 30%.

CONCLUSIONS

Neurologic complications are common after cardiac transplant. We observed an incidence of 30% for neurologic complications in our clinic, with encephalopathy being the most common complication. Encephalopathy most commonly developed secondary to posterior reversible encephalopathy syndrome.

Metabolische Störungen

Im folgenden Kapitel werden die verschiedenen metabolischen Störungen betrachtet. Zunächst wird auf die allgemeinen und spezifischen neurologischen Komplikationen bei Organtransplantation eingegangen. Dann geht es um die metabolischen Enzephalopathien: Störungen der Gehirntätigkeit bei angeborenen und erworbenen Stoffwechselerkrankungen im engeren Sinn, Elektrolytstörungen, Hypovitaminosen, zerebrale Folgen einzelner Organdysfunktionen, zerebrale Hypoxien, Endotheliopathien und Mitochondropathien. Anschließend werden das Alkoholdelir und die Wernicke-Enzephalopathie erörtert. Bei zahlreichen akuten Erkrankungen von Gehirn, Rückenmark und peripherem Nervensystem treten typische Störungen vegetativer Systeme auf, deren Erkennung und Therapie insbesondere bei Intensivpatienten eine vitale Bedeutung haben kann: die autonomen Störungen. Bei der zentralen pontinen Myelinolyse kommt es zu einer akuten, vorwiegend fokal-symmetrischen Demyelinisierung im Hirnparenchym. Auch Basalganglienerkrankungen können intensivmedizinisch relevant werden. Und schließlich wird die akute Stressreaktion betrachtet, die aufgrund der vielfältigen metabolischen und endokrinen Veränderungen bei kritischen Erkrankungen entsteht. Gerade das RCVS als neuere Krankheitsentität und wichtige Differenzialdiagnose zur Vaskulitis des ZNS verdient einen eigenen Platz, in diesem Unterkapitel werden ebenfalls verwandte Syndrome wie die hypertensive Enzephalopathie und das PRES abgehandelt.

Infektionen

In diesem Kapitel werden zunächst die für die Neurointensivmedizin wesentlichen bakteriellen Infektionen (Meningitis, spinale und Hirnabszesse, Spondylodiszitis, septisch-embolische Herdenzephalitis) abgehandelt, die trotz gezielt eingesetzter Antibiotika und neurochirurgischer Therapieoptionen noch mit einer erheblichen Morbidität und Mortalität behaftet sind. Besonderheiten wie neurovaskuläre Komplikationen, die Tuberkulose des Nervensystems, Neuroborreliose, Neurosyphilis und opportunistische Infektionen bei Immunsuppressionszuständen finden hierbei besondere Berücksichtigung. Der zweite Teil dieses Kapitels behandelt akute und chronische Virusinfektionen des ZNS sowie in einem gesonderten Abschnitt die HIVInfektion und HIV-assoziierte Krankheitsbilder sowie Parasitosen und Pilzinfektionen, die in Industrieländern seit Einführung der HAART bei HIV zwar eher seltener, aber mit zunehmender Globalisierung auch in unseren Breiten immer noch anzutreffen sind.

Cotard's syndrome: Two case reports and a brief review of literature

Cotard's syndrome is a rare neuropsychiatric condition in which the patient denies existence of one's own body to the extent of delusions of immortality. One of the consequences of Cotard's syndrome is self-starvation because of negation of existence of self. Although Cotard's syndrome has been reported to be associated with various organic conditions and other forms of psychopathology, it is less often reported to be seen in patients with catatonia. In this report we present two cases of Cotard's syndrome, both of whom had associated self-starvation and nutritional deficiencies and one of whom had associated catatonia.

Neurological complications of solid organ transplantation

Solid organ transplantation (SOT) is the preferred treatment for an expanding range of conditions whose successful therapy has produced a growing population of chronically immunosuppressed patients with potential neurological problems. While the spectrum of neurological complications varies with the type of organ transplanted, the indication for the procedure, and the intensity of long-term required immunosuppression, major neurological complications occur with all SOT types. The second part of this 2-part article on transplantation neurology reviews central and peripheral nervous system problems associated with SOT with clinical and neuroimaging examples from the authors' institutional experience. Particular emphasis is given to conditions acquired from the donated organ or tissue, problems specific to types of organs transplanted and drug therapy-related complications likely to be encountered by hospitalists. Neurologically important syndromes such as immune reconstitution inflammatory syndrome (IRIS), posterior reversible encephalopathy syndrome (PRES), and posttransplantation lymphoproliferative disorder (PTLD) are readdressed in the context of SOT.

Incidence and risk factors for herpes zoster following heart transplantation

BACKGROUND

Data on the incidence, timing, and risk factors for herpes zoster (HZ) in heart transplant (HT) recipients are limited.

METHODS

We determined HZ incidence rates and actuarial estimates of time to first HZ episode in 314 HT recipients at our institution from 1995 to 2010. We developed Cox models to assess potential risk factors for HZ in HT.

RESULTS

Median age at HT was 54 (range, 17-71) years; 237 (76%) were male. There were 60 episodes of HZ in 51 patients, with an overall incidence rate of 31.6 cases (95% confidence interval [CI], 23.5-41.6)/1000 person-years. Although most cases occurred during the first post-HT year, cumulative HZ incidence was 0.078 at 1, 0.15 at 5, and 0.20 at 10 years. Many patients had substantial HZ morbidity, including 14% with HZ ophthalmicus and 45% with post-herpetic neuralgia. Adjusting for age, gender, and acute cellular rejection episodes, exposure to mycophenolate mofetil (MMF) was an independent risk factor for HZ (adjusted hazard ratio [HR] 2.18; 95% CI, 1.20-3.96; P = 0.01), while ganciclovir-based cytomegalovirus prophylaxis reduced HZ risk (adjusted HR 0.09; 95% CI, 0.01-0.71; P = 0.02). Although age and female gender increased HZ risk, the magnitude of their effect was not statistically significant in Cox models.

CONCLUSIONS

HZ is common and morbid after HT, particularly with MMF exposure. Ganciclovir prophylaxis is effective in reducing the short-term risk of HZ, but the steady incidence of cases for years post HT makes long-term HZ prevention challenging. Augmenting varicella zoster virus immunity post HT with vaccines warrants further exploration.

Opportunistic infections of the central nervous system in the transplant patient

Therapeutic advances in transplantation medicine have resulted in ever expanding patient populations that receive organ or stem cell transplantation. Modern potent immunomodulatory therapies have resulted in improvements in allograft and patient survival, but, consequently, as a result of the immunosuppressive state, transplant recipients are highly vulnerable to infection, including those that affect the central nervous system (CNS). CNS infections present a diagnostic and therapeutic challenge for clinicians involved in the care of the transplant patient, with a propensity to result in profound morbidity and often high mortality in this patient population. Here, we review major opportunistic pathogens of the CNS seen in transplant patients, highlighting distinguishing epidemiologic and clinical features.

Parasitic infections in solid organ transplant recipients

Parasitic diseases are rare infections after a solid organ transplant (SOT). Toxoplasmosis, Trypanosoma cruzi, and visceral leishmanias are the 3 main opportunistic protozoal infections that have the potential to be lethal if not diagnosed early and treated appropriately after SOT. Strongyloides stercoralis is the one helminthic disease that is life-threatening after transplant. This review addresses modes of transmission, methods of diagnosis, and treatment of the most serious parasitic infections in SOT. The role of targeted pretransplant screening of the donor and recipient for parasitic diseases is also discussed.

[Neurological complications in patients receiving solid organ transplants]

INTRODUCTION

Neurological complications (NC) are a significant cause of morbidity and mortality in paediatric patients receiving solid organ transplants. Our aim was to describe the experience of our hospital with NC in paediatric patients receiving heart, lung and liver transplants.

PATIENTS AND METHODS

A retrospective study was conducted on 140 paediatric patients who received a solid organ transplant during the period 2000-2011.

RESULTS

A total of 23 paediatric solid organ transplant recipients (16.4% of cases), with a median age of 6 years, had NC. The symptoms were, in order of frequency: acute symptomatic seizures (12 patients); acute encephalopathy (11 patients); neuromuscular weakness (4 children), tremor (4 children), headache (2 children), neuropathic pain (2 children), and visual disturbances (2 children). The aetiologies of NC were: the neurotoxicity of the immunosuppressive drugs (12 patients), post-hypoxic-ischaemic encephalopathy (6 patients), infections (2 cases), mechanical compression of peripheral nerve during surgery (2 cases), and a metabolic complication (1 case). The five patients who met the criteria of posterior reversible encephalopathy syndrome had a favourable outcome. Seven patients died, four of them due to hypoxic-ischaemic encephalopathy.

CONCLUSIONS

NC are common in paediatric patients receiving heart, liver, lung, and renal transplants, with acute symptomatic seizures and acute encephalopathy being the most common clinical signs. No differences were found in the NC with the different types of transplants. Neurotoxicity of the immunosuppressive drugs and hypoxic-ischaemic encephalopathy were the main causes of NC, having different management and outcomes. The prognosis was favourable in most of the patients, except for those who had moderate or severe post-hypoxic-ischaemic damage.

Infektionen

Trotz Weiterentwicklung moderner Antibiotika in den letzten Jahren sind die Letalitätszahlen der bakteriellen (eitrigen) Meningitis weiterhin hoch; Überlebende haben häufig neurologische Residuen. Die ungünstigen klinischen Verläufe der bakteriellen Meningitis sind meist Folge intrakranieller Komplikationen, wie z. B. eines generalisierten Hirnödems, einer zerebrovaskulären arteriellen oder venösen Beteiligung oder eines Hydrozephalus.

[A case of neuromyelitis optica with varicella zoster virus meningitis during mitoxantrone treatment]

A 36-year-old woman with neuromyelitis optica had been treated with steroids for the prevention of relapse. However, her treatment was not effective and she showed adverse effects such as diabetes mellitus, osteoporosis, compression fractures, and Pneumocystis carinii pneumonia. Therefore, we started her on mitoxantrone treatment. After five courses of mitoxantrone injection, she developed a herpes zoster infection in her thigh followed by aseptic meningitis. PCR for varicella zoster virus (VZV)-DNA was positive in the cerebrospinal fluid. The mechanisms that caused VZV reactivation by mitoxantrone are not known. Opportunistic herpes virus reactivation may occur easily with increasing use of immunosuppressive drugs for both neuromyelitis optica and multiple sclerosis. These drugs must be used under careful supervision.