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Kalafatakis K, Margoni A, Liakou ME, Stenos C, Toulas P, Korkolopoulou P, Lakiotaki E, Lafazanos SA, Zekiou K, Kardara P, Terentiou A, Nikolaou G, Stouraitis G. Acute hemorrhagic leukoencephalitis following the first dose of BNT162b2 vaccine against SARS-CoV-2: A case report. Heliyon 2024; 10:e25545. [PMID: 38356507 PMCID: PMC10865252 DOI: 10.1016/j.heliyon.2024.e25545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 12/20/2023] [Accepted: 01/29/2024] [Indexed: 02/16/2024] Open
Abstract
Acute hemorrhagic leukoencephalitis (AHLE), is a rare inflammatory demyelinating disorder, variant of acute disseminated encephalomyelitis. The diagnosis of AHLE remains challenging due to the rarity of the disease and the lack of a reliable biomarker. We report here a case of a 73-year-old male patient with a progressive, low-grade febrile confusional syndrome 20 days after receiving the first dose of BNT162b2 vaccine against SARS-CoV-2. Evidence indicative of the underlying condition by an extensive panel of imaging (brain magnetic resonance imaging, computed tomography and digital subtraction angiography), laboratory (complete blood count, biochemistry, coagulation, tests for autoimmune or infectious disorders, tumor markers, hormonal levels, cerebrospinal fluid analysis) and electrodiagnostic tests were scarce, and mainly non-specific. Sequential neuroimaging revealed the appearance of extensive T2 lesions (signs of gliosis) along with multiple hemorrhagic lesions at various cortical sites. The patient was treated with corticosteroids, discontinued due to severe adverse effects, and subsequently with sessions of plasmapheresis and monthly intravenous administration of cyclophosphamide. Considering the rapid aggravation of the patient's neurological status, the MRI findings of cortical lesions and the lack of response to any treatment, a biopsy of a frontal lobe lesion was conducted, confirming the presence of confluent, inflammatory-edematous lesions with scattered areas of necrosis and hemorrhage, and ultimately areas of demyelination, thus confirming the diagnosis of AHLE. After more than 5 months of hospitalization the patient was transferred in a primary care facility and remained in a permanent vegetative state until his death, more than 2 years later.
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Affiliation(s)
- Konstantinos Kalafatakis
- Department of Neurology, 417 Army Share Fund Hospital, Athens, Greece
- Faculty of Medicine & Dentistry (Malta Campus), Queen Mary University of London, Victoria, Malta
| | - Anna Margoni
- Department of Neurology, 417 Army Share Fund Hospital, Athens, Greece
| | | | - Christos Stenos
- Department of Neurology, 417 Army Share Fund Hospital, Athens, Greece
| | - Panagiotis Toulas
- Research Unit of Radiology, Second Department of Radiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Penelope Korkolopoulou
- First Department of Pathology, LAIKON University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleftheria Lakiotaki
- First Department of Pathology, LAIKON University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Katerina Zekiou
- Department of Neurology, 417 Army Share Fund Hospital, Athens, Greece
| | - Panagiota Kardara
- Department of Neurology, 417 Army Share Fund Hospital, Athens, Greece
| | - Aspasia Terentiou
- Department of Neurology, 417 Army Share Fund Hospital, Athens, Greece
| | - Georgios Nikolaou
- Department of Neurology, 417 Army Share Fund Hospital, Athens, Greece
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Zakroyshchikova IV, Askarova LS, Bryukhov VV, Anufriev PL, Kozlova AO, Zakharova MN. [Acute hemorrhagic leukoencephalitis with a subacute onset]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:116-121. [PMID: 37560843 DOI: 10.17116/jnevro2023123072116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
Acute hemorrhagic leukoencephalitis (AHLE), also called Hurst's encephalitis, is a rare demyelinating disease of the central nervous system characterized by rapid progression and acute inflammation of the white matter of the brain and spinal cord. AHLE is currently considered as a rare, most severe variant of acute disseminated encephalomyelitis. Clinically AHLE is characterized by a fulminant course with a rapid development of encephalopathy and multifocal neurological symptoms. AHLE is associated with high mortality rate that requires immediate and aggressive treatment initiation. This article describes a case of AHLE with an atypical course, a subacute form, which is extremely rarely described in the literature, with the progressive symptoms' development over several months. Due to delayed treatment initiation, unfortunately, a fatal outcome has been observed. Subsequent histological examination of the autopsy material confirmed the presence of a subacute form of AHLE in the patient.
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Affiliation(s)
| | | | | | | | - A O Kozlova
- Research center of Neurology, Moscow, Russia
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3
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Wu C, Zhang W, Jiao Y, Dong M, Zhou H, Lv Y, Yang J. Two-year follow-up of a young male with possible acute hemorrhagic leukoencephalitis: A case report. Medicine (Baltimore) 2022; 101:e32073. [PMID: 36482561 PMCID: PMC9726406 DOI: 10.1097/md.0000000000032073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
RATIONALE Acute hemorrhagic leukoencephalitis (AHLE) is a rare but fetal fulminant demyelinating disease of unknown etiology. It is commonly regarded as a severe variant of acute demyelinating encephalomyelitis (ADEM). Its rapid clinical deterioration and high mortality appeal to clinicians to attach importance to early diagnosis. Immunosuppressive therapy is the main management to attenuate the autoimmune process, but with varied response and prognosis. PATIENT CONCERNS A young male presented with moderate fever, headache and seizures after extraction of impacted teeth, and then deteriorated rapidly to deep coma. Initial magnetic resonance imaging (MRI) revealed multiple plaque-like lesions in bilateral cerebra, right thalamus and pontobulbar region with massive edematous swelling and multifocal small hemorrhagic foci. Inflammatory parameters in the peripheral blood were only mild higher with a pleocytosis in CSF. DIAGNOSIS His clinical presentation, laboratory evaluation and radiological features were consistent with a suspected diagnosis of AHLE. INTERVENTIONS He underwent pulse corticosteroids initially but failed to respond to it. However, his consciousness improved obviously when he was treated with multiple courses of intravenous injection of immunoglobulin (IVIG) combined with mycophenolate mofetil (MMF). OUTCOMES The patient regained consciousness gradually on day 180 and was in minimally conscious state (MCS) during the two-year follow-up. LESSONS AHLE presents distinctly from classical ADEM, and the situation may pose a diagnostic challenge. Clinicians should be vigilant in recognizing AHLE because of its rapid clinical deterioration and high mortality. We highlight the critical role of multimodal MRI, particularly susceptibility-weighted imaging (SWI) in the diagnosis of AHLE if cerebral biopsies are unavailable. Multiple courses of IVIG with MMF may be effective when early single pulse of corticosteroids fails. Individual who survives the initial insult may carry relatively good prognosis.
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Affiliation(s)
- Chen Wu
- Department of Neurology, Xi’an Jiaotong University Second Affiliated Hospital, Shaanxi, China
- Department of Neurology, General Hospital of Xinjiang Military Region of the Chinese People’s Liberation Army, Xinjiang, China
| | - Weiliang Zhang
- Department of Neurology, General Hospital of Xinjiang Military Region of the Chinese People’s Liberation Army, Xinjiang, China
| | - Yan Jiao
- Department of Neurology, General Hospital of Xinjiang Military Region of the Chinese People’s Liberation Army, Xinjiang, China
| | - Minhui Dong
- Department of Neurology, General Hospital of Xinjiang Military Region of the Chinese People’s Liberation Army, Xinjiang, China
| | - Heng Zhou
- Department of Anesthesia, General Hospital of Xinjiang Military Region of the Chinese People’s Liberation Army, Xinjiang, China
| | - Yun Lv
- Department of Neurology, General Hospital of Xinjiang Military Region of the Chinese People’s Liberation Army, Xinjiang, China
| | - Jun Yang
- Department of Neurology, General Hospital of Xinjiang Military Region of the Chinese People’s Liberation Army, Xinjiang, China
- * Correspondence: Jun Yang, Department of Neurology, No. 359 Youhao North Road, Urumqi, Xinjiang 830013, China (e-mail: )
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Alromaihi M. Acute Hemorrhagic Leukoencephalitis (AHLE): A Comprehensive Review on Causes, Symptoms, Link with COVID-19, Diagnosis, and Treatment. BioMed Research International 2022; 2022:1-9. [PMID: 36425337 PMCID: PMC9681543 DOI: 10.1155/2022/6008375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 10/12/2022] [Accepted: 11/01/2022] [Indexed: 11/17/2022]
Abstract
Acute hemorrhagic leukoencephalitis (AHLE), also called Hurst disease, is a rare demyelinating disease of the central nervous system (CNS) marked by rapid progression and acute inflammation of the white matter. Due to the correlation in their suspected postinfectious autoimmune pathogenesis, it is regarded as the most severe form of acute disseminated encephalomyelitis (ADEM). Because this clinical scenario has a high mortality rate, aggressive and immediate treatment is required. Although the exact cause of AHLE is unknown, it usually occurs after a bacterial or viral infection, or, less frequently, after a measles or rabies vaccination. AHLE has been reported in patients with coronavirus disease 2019 (COVID-19) as a rare but serious neurological complication. However, due to the lack of evidence-based diagnostic criteria, diagnosis is difficult. The small number of cases described in the literature, which most likely reflects underreporting and/or low incidence, necessitates greater public awareness. Increased clinical suspicion and early imaging identification of this entity may allow clinicians to pursue more aggressive treatment options, potentially reducing fatal outcomes. This study focuses on symptoms and causes of AHLE, difference between AHLE and ADME, diagnosis and treatment of AHLE, and its link with COVID-19.
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Bamnawat H, Khera D, Didel S, Tiwari S. Paediatric acute haemorrhagic leukoencephalitis. BMJ Case Rep 2022; 15:e246654. [PMID: 35680284 PMCID: PMC9185211 DOI: 10.1136/bcr-2021-246654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report a case of a preschool age girl, previously healthy, referred to our hospital on ventilatory support with a history of vomiting, headache, and rapid neurological worsening within 24 hours in the form of seizures, encephalopathy and loss of consciousness. On presentation, she was deeply comatose with dilated non-reactive pupils, absent brainstem reflexes and flaccid quadriplegia. Diagnosis of acute haemorrhagic leukoencephalitis was considered based on laboratory and neuroimaging findings. MRI of the brain showed fluffy white matter hyperintensities and microhaemorrhages in bilateral cerebral hemispheres and thalami. Aggressive treatment with methylprednisolone, plasmapheresis and intravenous immunoglobulin showed dramatic improvement with no neurological sequelae. Our case is unique in a way that despite the hyperacute onset and rapid deterioration, with a fulminant course in the intensive care unit, the child recovered dramatically with aggressive management.
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Affiliation(s)
- Harshita Bamnawat
- Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Daisy Khera
- Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Siyaram Didel
- Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Sarbesh Tiwari
- Radiodiagnosis, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Pujari SS, Kulkarni RV, Ojha P, Gursahani R, Nadgir D, Patil S, Soni G, Bangar S, Harshe A, Mandolkar M, Joshi A, Kadam S, Goyal A. Acute haemorrhagic leukoencephalitis (AHLE) - our experience and a short review. J Neuroimmunol 2021; 361:577751. [PMID: 34739912 DOI: 10.1016/j.jneuroim.2021.577751] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 09/21/2021] [Accepted: 10/10/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Acute haemorrhagic leukoencephalitis (AHLE), a rare variant of acute disseminated encephalomyelitis (ADEM), often presents differently from classical ADEM, thereby posing a diagnostic challenge to the clinician. AIM To report AHLE, its clinic-radiological manifestations, process of diagnosis and prognosis. METHOD AND RESULTS Eight patients presented with altered sensorium, acute focal deficits with or without seizures. Initial workup showed evidence of haemorrhagic lobar or thalamic lesions in seven patients. All patients underwent extensive evaluation for collagen vascular disease and vasculitis profile, autoimmune encephalitis panel and aquaporin-4 antibody, which were found to be normal. Cerebrospinal fluid (CSF) biochemistry and microscopy was non-contributory and CSF viral PCRs, toxoplasma antibodies, cryptococcal antigen were also negative. All patients had progressively worsening sensorium and neurological deficits. Repeat MRIs showed increase in oedema in the lesions and appearance/expansion of haemorrhage in the thalamic/hemispherical lesions. All patients received intravenous methylprednisolone (IVMP) without any benefit. Four patients underwent plasmapheresis (PLEX), one received intravenous immunoglobulin (IVIG) and one received both second line immunotherapies, without significant improvement. Brain biopsy (performed in three patients) showed inflammatory demyelination and areas of haemorrhage, thus confirming the diagnosis. Six patients succumbed in 7-30 days of the illness, despite aggressive treatment and only two survived, albeit with a significant disability. CONCLUSION AHLE is a rare, yet very severe variant of ADEM. MRI shows lesions with haemorrhages, oedema and mass effect and histology findings reveal inflammatory infiltrates, haemorrhagic foci and fibrinoid necrosis of vessel walls. Prognosis is worse as compared to the classic ADEM, with a high mortality rate. To the best of our knowledge, this is one of the largest series of AHLE to have been reported anywhere in the world. KEYMESSAGE Acute encephalopathy, multifocal deficits accompanied by haemorrhagic CNS demyelinating lesions with oedema and mass effect are the key features of AHLE. It is a rare, yet very severe form of ADEM with very high morbidity and mortality.
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Gupta N, Jindal G, Singla H. A Rare Case of Acute Hemorrhagic Leukoencephalitis in a Neonate. Journal of Pediatric Neurology 2021. [DOI: 10.1055/s-0041-1736600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AbstractAcute hemorrhagic leukoencephalitis (AHLE) is a fulminant demyelinating disease associated with severe inflammation of the white matter. In this article, we reported a case of previously healthy 27 days old baby admitted to the hospital with fever, excessive crying, seizures, and respiratory distress. A diagnosis of AHLE was made based on the clinical and radiological findings. The infant patient was managed in the neonatal intensive care unit; however, he died unfortunately on the 35th day of his life. Although this highly fatal disease is very rare in this age group, early diagnosis can help in reducing morbidity and mortality.
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Affiliation(s)
- Nishu Gupta
- Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana, Haryana, India
| | - Gunjan Jindal
- Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana, Haryana, India
| | - Hanish Singla
- Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana, Haryana, India
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8
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Abstract
The neurological complications of coronavirus disease 2019 (SARS-CoV-2, COVID-19)
have so far included a range of para- and post-infectious neuroinflammatory
syndromes inclusive of all components of the neuraxis and peripheral
neuromuscular system. In comparison to the para-infectious manifestations of
anosmia, ageusia, encephalopathy, and encephalitis, cases of post-infectious
ADEM have rarely been reported and have most commonly affected the
supratentorial component with or without spinal cord involvement. In this
report, we describe a case of isolated involvement of the cervicothoracic spinal
cord and medulla, occurring in association with microhemorrhages and hemosiderin
deposition in the medulla, that presented fulminantly and required aggressive
immunotherapy to control the inflammatory attack. We compare and contrast this
case against prior reports of acute hemorrhagic leukoencephalitis (Weston Hurst
syndrome) and review the atypical features of neuroinflammation reported to
occur following COVID-19 infection.
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Affiliation(s)
- Spencer Kristian Hutto
- Division of Hospital Neurology, Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Otto Rapalino
- Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Nagagopal Venna
- Division of Neuroimmunology and Neuroinfectious Diseases, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
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9
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Loesch-Biffar AM, Junker A, Linn J, Thon N, Heck S, Ottomeyer C, Straube A, Pfister HW. Case Report: Minimal Neurological Deficit of Two Adult Patients With Weston-Hurst Syndrome Due to Early Craniectomy: Case Series and Review of Literature on Craniectomy. Front Neurol 2021; 12:673611. [PMID: 34531810 PMCID: PMC8438150 DOI: 10.3389/fneur.2021.673611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 07/30/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: We describe two new cases of acute hemorrhagic leucoencephalitis (AHLE), who survived with minimal sequelae due to early measures against increased intracranial pressure, particularly craniotomy. The recently published literature review on treatment and outcome of AHLE was further examined for the effect of craniotomy. Methods: We present two cases from our institution. The outcome of 44 cases from the literature was defined either as good (no deficit, minimal deficit/no daily help) or poor outcome (severe deficit/disabled, death). Patients with purely infratentorial lesions (n = 9) were excluded. Fisher's exact test was applied. Results: Two cases are presented: A 43-year-old woman with rapidly progressive aphasia and right hemiparesis due to a huge left frontal white matter lesion with rim contrast enhancement. Pathology was consistent with AHLE. The second case was a 56-year-old woman with rapidly progressive aphasia and right hemiparesis. Cranial MRI showed a huge left temporo-occipital white matter lesion with typical morphology for AHLE. Both patients received craniotomy within the first 24 h and consequent immunosuppressive-immunomodulatory treatment and survived with minimal deficits. Out of 35 supratentorial reported AHLE cases, seven patients received decompressive craniotomy. Comparing all supratentorial cases, patients who received craniotomy were more likely to have a good outcome (71 vs. 29%). Conclusion: Due to early control of the intracranial pressure, particularly due to early craniotomy; diagnosis per biopsy; and immediate start of immunosuppressive-immunomodulatory therapies (cortisone pulse, plasma exchanges), both patients survived with minimal sequelae. Craniotomy plays an important role and should be considered early on in patients with probable AHLE.
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Affiliation(s)
- Anna Mira Loesch-Biffar
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Andreas Junker
- Institute of Neuropathology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Jennifer Linn
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Niklas Thon
- Department of Neurosurgery, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Suzette Heck
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Caroline Ottomeyer
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Andreas Straube
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Hans Walter Pfister
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
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10
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Podduturi V, Blessing MM, Joseph DM, Ross JL, Sandberg GD. A Case Series of Acute Hemorrhagic Leukoencephalitis. Am J Forensic Med Pathol 2021; 42:263-266. [PMID: 33394682 DOI: 10.1097/paf.0000000000000642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Acute hemorrhagic leukoencephalitis (AHL) is an acute, hemorrhagic demyelinating disease thought to be caused by an immune-mediated process. Acute hemorrhagic leukoencephalitis is both diagnostically challenging and fatal in the majority of cases. We present two cases of AHL unexpectedly diagnosed at autopsy. These cases demonstrate the often nonspecific and challenging nature of AHL clinical presentation, review neuropathological mimics, and emphasize the importance of considering this diagnosis in the forensic setting.
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Affiliation(s)
- Varsha Podduturi
- From the Department of Pathology, Harris County Institute of Forensic Sciences
| | - Melissa M Blessing
- From the Department of Pathology, Harris County Institute of Forensic Sciences
| | - David M Joseph
- Pathology and Genomic Medicine Department, Houston Methodist Hospital, Houston, TX
| | - Jennifer L Ross
- From the Department of Pathology, Harris County Institute of Forensic Sciences
| | - Glenn D Sandberg
- From the Department of Pathology, Harris County Institute of Forensic Sciences
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11
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Grzonka P, Scholz MC, De Marchis GM, Tisljar K, Rüegg S, Marsch S, Fladt J, Sutter R. Acute Hemorrhagic Leukoencephalitis: A Case and Systematic Review of the Literature. Front Neurol 2020; 11:899. [PMID: 32973663 PMCID: PMC7468463 DOI: 10.3389/fneur.2020.00899] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 07/13/2020] [Indexed: 11/13/2022] Open
Abstract
Objectives: To present a patient with acute hemorrhagic leukoencephalitis (AHLE) and a systematic review of the literature analyzing diagnostic procedures, treatment, and outcomes of AHLE. Methods: PubMed and Cochrane databases were screened. Papers published since 01/01/2000 describing adult patients are reported according to the PRISMA-guidelines. Results: A 59-year old male with rapidly developing coma and cerebral biopsy changes compatible with AHLE is presented followed by 43 case reports from the literature including males in 67% and a mean age of 38 years. Mortality was 47%. Infectious pathogens were reported in 35%, preexisting autoimmune diseases were identified in 12%. Neuroimaging revealed uni- or bihemispheric lesions in 65% and isolated lesions of the cerebellum, pons, medulla oblongata or the spinal cord without concomitant hemispheric involvement in 16%. Analysis of the cerebrospinal fluid showed an increased protein level in 87%, elevated white blood cells in 65%, and erythrocytes in 39%. Histology (reported in 58%) supported the diagnosis of AHLE in all cases. Glucocorticoids were used most commonly (97%), followed by plasmapheresis (26%), and intravenous immunoglobulins (12%), without a clear temporal relationship between treatment and the patients' clinical course. Conclusions: Although mortality was lower than previously reported, AHLE remains a life-threatening neurologic emergency with high mortality. Diagnosis is challenging as the level of evidence regarding the diagnostic yield of clinical, neuroimaging and laboratory characteristics remains low. Hence, clinicians are urged to heighten their awareness and to prompt cerebral biopsies in the context of rapidly progressive neurologic decline of unknown origin with the concurrence of the compiled characteristics. Future studies need to focus on treatment characteristics and their effects on course and outcome.
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Affiliation(s)
- Pascale Grzonka
- Intensive Care Units, University Hospital Basel, Basel, Switzerland
| | - Marleen C Scholz
- Intensive Care Units, University Hospital Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology, University Hospital Basel, Basel, Switzerland.,Medical Faculty, University of Basel, Basel, Switzerland
| | - Kai Tisljar
- Intensive Care Units, University Hospital Basel, Basel, Switzerland
| | - Stephan Rüegg
- Department of Neurology, University Hospital Basel, Basel, Switzerland.,Medical Faculty, University of Basel, Basel, Switzerland
| | - Stephan Marsch
- Intensive Care Units, University Hospital Basel, Basel, Switzerland.,Medical Faculty, University of Basel, Basel, Switzerland
| | - Joachim Fladt
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Raoul Sutter
- Intensive Care Units, University Hospital Basel, Basel, Switzerland.,Department of Neurology, University Hospital Basel, Basel, Switzerland.,Medical Faculty, University of Basel, Basel, Switzerland
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12
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Svedung Wettervik T, Kumlien E, Rostami E, Howells T, von Seth M, Velickaite V, Lewén A, Enblad P. Intracranial Pressure Dynamics and Cerebral Vasomotor Reactivity in Coronavirus Disease 2019 Patient With Acute Encephalitis. Crit Care Explor 2020; 2:e0197. [PMID: 32885174 DOI: 10.1097/CCE.0000000000000197] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
We describe the intracranial pressure dynamics and cerebral vasomotor reactivity in a coronavirus disease 2019 patient with acute encephalitis treated with cerebrospinal fluid drainage and therapeutic plasma exchange.
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13
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Sharma A, Foutz TJ, Gonzalez-Cuyar LF, Latimer CS, Longstreth WT, Tirschwell DL, Davis AP. From Herniation to Rehabilitation: A Young Woman With Rapidly Progressive Neurological Deficits. Neurohospitalist 2019; 9:215-221. [PMID: 31534611 DOI: 10.1177/1941874419832437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Akanksha Sharma
- Department of Neurology, Mayo Clinic Arizona, Phoenix, AZ, USA.,Authors share the first authorship for the article
| | - Thomas J Foutz
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA.,Authors share the first authorship for the article
| | | | - Caitlin S Latimer
- Department of Neurology, Mayo Clinic Arizona, Phoenix, AZ, USA.,Department of Neurology, University of North Carolina, Chapel Hill, NC, USA.,Department of Neuropathology, Harborview Medical Center, Seattle, WA, USA.,Department of Neurology, Harborview Medical Center, Seattle, WA, USA.,Authors share the first authorship for the article
| | - W T Longstreth
- Department of Neurology, Harborview Medical Center, Seattle, WA, USA
| | | | - Arielle P Davis
- Department of Neurology, Harborview Medical Center, Seattle, WA, USA
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14
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Panchal A, Perez‐Marques F. Intravenous immunoglobulin for acute hemorrhagic leukoencephalitis refractory to plasmapheresis. Clin Case Rep 2019; 7:160-163. [PMID: 30656033 PMCID: PMC6332821 DOI: 10.1002/ccr3.1843] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 08/28/2018] [Accepted: 09/13/2018] [Indexed: 12/18/2022] Open
Abstract
Intravenous immunoglobulin therapy should be considered in pediatric acute hemorrhagic leukoencephalitis that is refractory to steroid and plasmapheresis.
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Affiliation(s)
- Apurva Panchal
- Department of PediatricsUniversity of Kansas Medical CenterKansas CityKansas
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15
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Bonduelle T, Stricker J, Minéo JF, Massri A, Guesdon C, Barroso B, Bonnan M. Weston-Hurst syndrome with acute hemorrhagic cerebellitis. Clin Neurol Neurosurg 2018; 173:118-119. [PMID: 30121019 DOI: 10.1016/j.clineuro.2018.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 07/25/2018] [Accepted: 08/01/2018] [Indexed: 11/19/2022]
Abstract
Weston-Hurst syndrome is an exceptional variant of ADEM characterized by brain hemorrhages. Lesions are usually supratentorial and death is a usual outcome. We report a cerebellar Weston-Hurst syndrome early treated by craniectomy, steroids and plasma exchange. This is the first case of infratentorial Weston-Hurst syndrome associated with a favorable outcome.
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Affiliation(s)
- Thomas Bonduelle
- Department of Neurology, Bordeaux University Hospital, Bordeaux, France.
| | | | | | - Alexandre Massri
- Department of Reanimation, Centre Hospitalier Francois Mitterand Pau, France
| | - Charlotte Guesdon
- Department of Reanimation, Centre Hospitalier Francois Mitterand Pau, France
| | - Bruno Barroso
- Department of Neurology, Centre Hospitalier Francois Mitterrand, Pau, France
| | - Mickael Bonnan
- Department of Neurology, Centre Hospitalier Francois Mitterrand, Pau, France.
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George IC, Youn TS, Marcolini EG, Greer DM. Clinical Reasoning: Acute onset facial droop in a 36-year-old pregnant woman. Neurology 2017; 88:e240-e244. [DOI: 10.1212/wnl.0000000000004030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Solis WG, Waller SE, Harris AK, Sugo E, Hansen MA, Lechner-Scott J. Favourable Outcome in a 33-Year-Old Female with Acute Haemorrhagic Leukoencephalitis. Case Rep Neurol 2017; 9:106-113. [PMID: 28559834 PMCID: PMC5437433 DOI: 10.1159/000472706] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 03/27/2017] [Indexed: 11/19/2022] Open
Abstract
Background Acute haemorrhagic leukoencephalitis (AHLE) is a rare and rapidly fatal disease of unknown aetiology. There is a paucity of literature on the presentation and management of this rare disease. Case Description We report the case of a 33-year-old female presenting with headache and left-sided apraxia. Imaging revealed a right-sided white matter lesion with extensive cytotoxic oedema. Pathology was suggestive of AHLE. She underwent an open excisional biopsy and was treated with high-dose corticosteroids. Three months since symptom onset she remains clinically well with resolving apraxia and radiological appearance. Conclusion This case may represent a milder spectrum of AHLE, which responded favourably to corticosteroids.
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Affiliation(s)
- Waldo G Solis
- Department of Neurosurgery, John Hunter Hospital, New Lambton, New South Wales, Australia
| | - Sophie E Waller
- Department of Neurology, John Hunter Hospital, New Lambton, New South Wales, Australia
| | - Angela K Harris
- Department of Anatomical Pathology, Pathology North Hunter, New Lambton, New South Wales, Australia
| | - Ella Sugo
- Department of Anatomical Pathology, Pathology North Hunter, New Lambton, New South Wales, Australia
| | - Mitchell A Hansen
- Department of Neurosurgery, John Hunter Hospital, New Lambton, New South Wales, Australia
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Fukuoka M, Kuki I, Kawawaki H, Kim K, Hattori Y, Tsuji H, Horino A, Nukui M, Okazaki S. A pediatric patient of hemorrhagic acute transverse myelitis. Brain Dev 2017; 39:252-255. [PMID: 27686688 DOI: 10.1016/j.braindev.2016.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 09/12/2016] [Accepted: 09/12/2016] [Indexed: 01/27/2023]
Abstract
An 11-year-old boy presented with progressive leg hypesthesia but no history of trauma. Dysuria and constipation appeared subsequent to gait difficulty. He was admitted 8days after onset. Spinal magnetic resonance imaging (MRI) revealed longitudinal hyperintensity with cord swelling and hypointensity on T2-weighted images, suggesting severe inflammation and microbleeding change, respectively. Gadolinium contrast-enhanced MRI demonstrated mild enhancement in the lesions. Platelet count and coagulation findings were normal, and cerebrospinal fluid analysis showed no pleocytosis. He was diagnosed with idiopathic acute transverse myelitis (ATM), and intravenous methylprednisolone pulse therapy and plasmapheresis were initiated. On day 14, motor dysfunction aggravated suddenly, accompanied by expanding hemorrhagic lesions. Thereafter, administration of intravenous immunoglobulin, repeated intravenous methylprednisolone pulse therapy and prednisolone for one month resulted in complete recovery four months later. Both anti-aquaporin-4 and anti-myelin oligodendrocyte glycoprotein antibodies were negative. We presented the first pediatric case showing hemorrhagic spinal lesions in the clinical course of ATM. This severe complication should be recognized in the management of ATM.
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Affiliation(s)
- Masataka Fukuoka
- Department of Pediatric Neurology, Osaka City General Hospital, Osaka, Japan
| | - Ichiro Kuki
- Department of Pediatric Neurology, Osaka City General Hospital, Osaka, Japan.
| | - Hisashi Kawawaki
- Department of Pediatric Neurology, Osaka City General Hospital, Osaka, Japan
| | - Kiyohiro Kim
- Department of Pediatric Neurology, Osaka City General Hospital, Osaka, Japan
| | - Yuka Hattori
- Department of Pediatric Neurology, Osaka City General Hospital, Osaka, Japan
| | - Hitomi Tsuji
- Department of Pediatric Neurology, Osaka City General Hospital, Osaka, Japan
| | - Asako Horino
- Department of Pediatric Neurology, Osaka City General Hospital, Osaka, Japan
| | - Megumi Nukui
- Department of Pediatric Neurology, Osaka City General Hospital, Osaka, Japan
| | - Shin Okazaki
- Department of Pediatric Neurology, Osaka City General Hospital, Osaka, Japan
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Moss HE, Stroup TS, Lin AY, Graf OW, Halfpenny AM, Lipton HL, Blitz AM, Valyi-Nagy T. Innocent Until Proven Guilty. J Neuroophthalmol 2016; 36:92-7. [PMID: 26882235 DOI: 10.1097/wno.0000000000000338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Heather E Moss
- Departments of Ophthalmology and Visual Sciences (HEM, AYL) and Neurology and Rehabilitation (HEM, HLL), University of Illinois at Chicago, Chicago, Illinois; Department of Neurology (TS), University of Chicago, Chicago, Illinois; Departments of Pathology (AYL, OG, AH, TV-N) and Microbiology and Immunology (HLL), University of Illinois at Chicago, Chicago, Illinois; and Department of Radiology and Radiological Sciences (AMB), Johns Hopkins Medical Center, Baltimore, Maryland
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Nabi S, Badshah M, Ahmed S, Nomani AZ. Weston-Hurst syndrome: a rare fulminant form of acute disseminated encephalomyelitis (ADEM). BMJ Case Rep 2016; 2016:bcr-2016-217215. [PMID: 27797801 DOI: 10.1136/bcr-2016-217215] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 25-year-old Pakistani woman presented to the emergency department with a 2-day history of rapidly progressive tetraplegia followed by sudden loss of consciousness. This was preceded by an upper respiratory tract infection. On examination, she was deeply comatose with a GCS of 3/15 and intact brainstem reflexes. She was in respiratory distress, and an endotracheal tube had been passed. She had flaccid quadriplegia with depressed deep tendon reflexes and upgoing plantar response. Her MRI brain with contrast showed extensive brainstem involvement with haemorrhagic foci along with signal changes in the corpus callosum. The patient was put on a respirator. She was given IV methyl prednisolone, and later on 5 sessions of plasmapheresis were performed. After 3 months, the patient gradually recovered and started communicating. Her motor power had improved to 2/5 in her arms and 1/5 in the lower extremities. She was then discharged for further rehabilitation at home.
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Affiliation(s)
- Sumaira Nabi
- Department of Neurology, PIMS, Islamabad, Pakistan
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dos Santos MP, Martin J, Woulfe J, Lim SP, Chakraborty S. Autopsy-proven Acute Hemorrhagic Leukoencephalitis in an Elderly Patient. Can J Neurol Sci 2014; 41:99-102. [PMID: 24384347 DOI: 10.1017/s031716710001636x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Khademi GR, Aelami MH. Acute Hemorrhagic Leukoencephalitis in Children: A Case Report. Iran J Med Sci 2016; 41:245-8. [PMID: 27217610 PMCID: PMC4876304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Acute hemorrhagic leukoencephalitis (AHLE) is a rare demyelinating disease characterized by an acute rapidly progressive fulminant inflammation of the white matter. In this case report, we introduce a case of AHLE in children with an interesting and lengthy process and successful treatment. A previously healthy 13-year-old girl was admitted to the hospital because of fever and loss of consciousness. After 4 days, she was referred to our pediatric intensive care unit in Mashhad, Iran. On admission, she had right-sided parotiditis. With a diagnosis of AHLE, our patient was treated with methylprednisolone, intravenous immunoglobulin, acyclovir, and plasmapheresis. AHLE is a rare and severe demyelinating disease, the mortality and morbidity of which can be decreased by early detection and treatment with steroid therapy, intravenous immunoglobulin, acyclovir, and plasmapheresis.
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Affiliation(s)
- Gholam Reza Khademi
- Department of Pediatrics, Dr. Sheikh Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Hasan Aelami
- Department of Pediatrics & Infection Control and Hand Hygiene Research Center, Imam Reza Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran,Correspondence: Mohammad Hasan Aelami, MD; Department of Pediatrics, Imam Reza Hospital, Imam Reza Square, Khorasan Razavi, Mashhad, Iran Tel: +98 51 37273943 Fax: +98 51 37277470
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Magun R, Verschoor CP, Bowdish DME, Provias J. Mycoplasma pneumoniae, a trigger for Weston Hurst syndrome. Neurol Neuroimmunol Neuroinflamm 2016; 3:e187. [PMID: 26819961 PMCID: PMC4723134 DOI: 10.1212/nxi.0000000000000187] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 11/03/2015] [Indexed: 11/28/2022]
Abstract
Objective: We report a case of Mycoplasma pneumoniae infection as one possible trigger for Weston Hurst syndrome (acute hemorrhagic leukoencephalitis), a rare disorder of microvascular injury often described as a postinfectious complication of an upper respiratory illness. Methods: This is a case of a 27-year-old man presenting with a Glasgow Coma Scale score of 3 and an acute head CT revealing extensive vasogenic edema in the right hemisphere associated with mass effect in the context of a recent upper respiratory illness. Right frontal biopsy was performed on day 2, which showed acute cerebritis, and the patient was aggressively treated with antibiotics. However, over the next 5 days from presentation, the vasogenic edema increased, leading ultimately to brain herniation and death. Results: A full autopsy was performed at 5 days from presentation, which showed areas of vessel wall fibrinoid necrosis throughout the right hemisphere as well as, but less so, in the left frontal lobe and pons. Chest x-ray on presentation revealed atypical pneumonia, blood tests were positive for cold agglutinins, and at full autopsy, there was myocarditis, all in keeping with recent M pneumoniae infection. DNA obtained from lung and diseased brain (postmortem) was positive for Mycoplasma providing more direct evidence for brain invasion by this organism as the ultimate trigger for Weston Hurst syndrome. Conclusions: This is a rare case report of Weston Hurst syndrome having both initial brain biopsy on day 2 and full autopsy results on day 5 of presentation revealing important clinical clues about the pathogenesis of this often fatal disorder.
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Affiliation(s)
- Rick Magun
- Department of Neurology (R.M.), McMaster Immunology Research Centre (C.P.V., D.M.E.B.), and Department of Pathology and Molecular Medicine (Neuropathology) (J.P.), McMaster University, Hamilton, Ontario, Canada
| | - Chris P Verschoor
- Department of Neurology (R.M.), McMaster Immunology Research Centre (C.P.V., D.M.E.B.), and Department of Pathology and Molecular Medicine (Neuropathology) (J.P.), McMaster University, Hamilton, Ontario, Canada
| | - Dawn M E Bowdish
- Department of Neurology (R.M.), McMaster Immunology Research Centre (C.P.V., D.M.E.B.), and Department of Pathology and Molecular Medicine (Neuropathology) (J.P.), McMaster University, Hamilton, Ontario, Canada
| | - John Provias
- Department of Neurology (R.M.), McMaster Immunology Research Centre (C.P.V., D.M.E.B.), and Department of Pathology and Molecular Medicine (Neuropathology) (J.P.), McMaster University, Hamilton, Ontario, Canada
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Fay AJ, Noetzel MJ, Mar SS. Pediatric Hemorrhagic Brainstem Encephalitis Associated With HHV-7 Infection. Pediatr Neurol 2015; 53:523-6. [PMID: 26255752 DOI: 10.1016/j.pediatrneurol.2015.06.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 06/19/2015] [Accepted: 06/21/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Human herpesviruses-6 and -7 have been associated with febrile seizures and with encephalitis, the latter predominantly in immunocompromised individuals. Acute hemorrhagic encephalitis is frequently a fatal disease that can occur in the setting of viral infection or can be a postinfectious phenomenon, often with no cause identified. Although hemorrhagic encephalitis has been reported with human herpesvirus-6 infection, only one individual, an immunocompromised child, has been documented with human herpesvirus-7 infection. The role of immunosuppression is not well-established in the management of this rare condition. PATIENT DESCRIPTION We present an 11-year-old boy with hemorrhagic brainstem encephalitis who underwent extensive infectious and autoimmune testing, positive only for human herpesvirus-7 in the cerebrospinal fluid. The patient recovered after treatment with intravenous immunoglobulin, high-dose steroids, and plasma exchange. CONCLUSION This is the first report of hemorrhagic brainstem encephalitis with human herpesvirus-7 in a previously healthy individual, adding to existing reports of late-onset human herpesvirus-7 infection associated with encephalitis in children. It also underscores that aggressive immunosuppression may be used early in the course of this disorder and may be beneficial for recovery.
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Kitulwatte ID, Kim PJH, Pollanen MS. Acute hemorrhagic leukoencephalomyelitis in a man with viral myocarditis. Forensic Sci Med Pathol 2015; 11:416-20. [PMID: 26148811 DOI: 10.1007/s12024-015-9692-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2015] [Indexed: 10/23/2022]
Abstract
We report a case of acute hemorrhagic leukoencephalomyelitis in a man with viral myocarditis. A 48-year-old previously healthy male was found dead in his locked apartment. At autopsy he was found to be malnourished, and his lungs showed gross evidence of bilateral pneumonia with abscess formation and bullous emphysema. Multiple petechial hemorrhages were observed in the brain and mainly involved white matter in the cerebral hemispheres including the corpus callosum and internal capsule, as well as the cerebellum, brainstem, and spinal cord. Microscopy of the brain and spinal cord revealed perivenular hemorrhages, central microthrombi in venules with fibrin exudation into the subcortical white matter, and early perivenular demyelination associated with scanty mixed cellular infiltrates. Other microscopic features included widespread diffuse viral myocarditis, extensive suppurative bronchopneumonia, and chronic bronchitis. This case illustrates the death of a man with a rare fatal disease associated with two other potentially lethal diseases. The case also illustrates the importance of a holistic approach when determining the cause of death, especially when there are competing causes of death.
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Affiliation(s)
- Indira D Kitulwatte
- Department of Forensic Medicine, Faculty of Medicine, University of Kelaniya, Thalagolla Road, Ragama, Sri Lanka,
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Serrano-Martínez JL, Redondo-Orts M, Madrid-Navarro C, Pérez-Villares JM, Fernández-Carmona A. [Weston-Hurst disease in a patient with seizures]. Med Intensiva 2015; 39:579-81. [PMID: 25865583 DOI: 10.1016/j.medin.2015.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 02/06/2015] [Accepted: 02/12/2015] [Indexed: 11/23/2022]
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Abstract
Neurocritical care aims to improve outcomes in patients with life-threatening neurologic illness. The scope of neurocritical care extends beyond the more commonly encountered and important field of cerebrovascular disease, as described previously. This article focuses on neuromuscular, neuroinfectious, and neuroimmunologic conditions that are significant causes of morbidity and mortality in the acutely neurologically ill patient. As understanding continues to increase regarding the physiology of these conditions and the best treatment, rapid identification, triage, and treatment of these patients in the emergency department is paramount.
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Affiliation(s)
- Anthony Noto
- Divisions of Neurocritical Care and Emergency Neurology and Surgical Critical Care, Departments of Emergency Medicine and Neurology, Yale University School of Medicine, 464 Congress St. Suite 260, New Haven, CT 06519, USA
| | - Evie Marcolini
- Divisions of Neurocritical Care and Emergency Neurology and Surgical Critical Care, Departments of Emergency Medicine and Neurology, Yale University School of Medicine, 464 Congress St. Suite 260, New Haven, CT 06519, USA.
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Jeganathan N, Fox M, Schneider J, Gurka D, Bleck T. Acute hemorrhagic leukoencephalopathy associated with influenza A (H1N1) virus. Neurocrit Care 2013; 19:218-21. [PMID: 23943349 DOI: 10.1007/s12028-013-9880-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Acute hemorrhagic leukoencephalopathy (AHLE) is a rare condition associated with H1N1. In this condition the infection triggers an autoimmune response which results in perivascular demyelination and hemorrhage in the brain parenchyma. METHODS We report a case of a patient who developed brain edema and herniation as a result of AHLE. RESULTS A 27-year-old presented to a community hospital with fever, dyspnea, and malaise and was found to have H1N1-associated pneumonia. Despite treatment he progressed to acute respiratory distress syndrome and required mechanical ventilation. Due to failure on conventional ventilation, he was transferred to our hospital and was placed on high-frequency oscillatory ventilation. He was showing improvement until day 6 of transfer to our hospital when he was suddenly noted to have a rise in his blood pressure followed by hypotension. The following morning he was noted to have non-reactive pupils and was declared brain dead. Autopsy of the brain was consistent with AHLE. CONCLUSIONS This case emphasizes the importance of awareness of this disease. The non-specific signs and symptoms, and the use of sedatives, make diagnosis challenging in the early stages of this disease. If suspected early, appropriate imaging can aid in the diagnosis. Treatment with immunosuppressive agents and plasmapheresis may prevent rapid progression and death. This is the first published case of AHLE in association with H1N1 that has been confirmed pathologically.
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Karaca S, Kozanoğlu İ, Karakurum Göksel B, Karataş M, Tan M, Yerdelen VD, Giray S, Arlier Z. Therapeutic Plasma Exchange in Neurologic Diseases: An Experience with 91 Patients in Seven Years. Noro Psikiyatr Ars 2014; 51:63-68. [PMID: 28360597 DOI: 10.4274/npa.y6879] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Accepted: 12/04/2012] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION In this study, we report the results of our experience of therapeutic plasma exchange (TPE) for neuroimmunologic disorders performed at our hospital over a seven-year period. METHODS We retrospectively reviewed the medical records of 91 patients (53 male, 38 female) who had been treated at our center with TPE. RESULTS 60 patients with Guillain-Barrè syndrome (GBS), 23 with myasthenia gravis (MG), 4 with chronic inflammatory demyelinating polyneuropathy (CIDP) and 1 patient each with polymyositis, septic encephalopathy, acute disseminated encephalomyelitis (ADEM) and Opsoclonus-Myoclonus syndrome (OMS) received TPE. 26.7% of GBS patient's made complete recovery, 61.7% had partial recovery and 11.7% patients died due to respiratory failure. Despite our best efforts and effective TPE treatments, 13.4% of MG patients deceased, however, 78% had full recovery. Three patients with CIDP were discharged with full and 1 patient with partial recovery. The patient with ADEM had partial recovery with TPE at first, but deceased 2 months later due to pneumonia-related respiratory insufficiency. While, patient with polymyositis had slight-partial recovery, we obtained full recovery with TPE in septic encephalopathy and OMS patients. The side effects and complications of treatments with TPE, which included hypotension, hypocalcaemia and anemia, were mild and manageable. CONCLUSION The improvement rates were encouraging and we concluded that significant benefit can be achieved with TPE for the treatment of neuroimmunological disorders.
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Affiliation(s)
- Sibel Karaca
- Başkent University Faculty of Medicine, Adana Research and Implementation Center, Department of Neurology, Adana, Turkey
| | - İlknur Kozanoğlu
- Başkent University Faculty of Medicine, Adana Research and Implementation Center, Department of Hematology, Adana, Turkey
| | - Başak Karakurum Göksel
- Başkent University Faculty of Medicine, Adana Research and Implementation Center, Department of Neurology, Adana, Turkey
| | - Mehmet Karataş
- Başkent University Faculty of Medicine, Adana Research and Implementation Center, Department of Neurology, Adana, Turkey
| | - Meliha Tan
- Başkent University Faculty of Medicine, Adana Research and Implementation Center, Department of Neurology, Adana, Turkey
| | - V Deniz Yerdelen
- Başkent University Faculty of Medicine, Adana Research and Implementation Center, Department of Neurology, Adana, Turkey
| | - Semih Giray
- Başkent University Faculty of Medicine, Adana Research and Implementation Center, Department of Neurology, Adana, Turkey
| | - Zülfikar Arlier
- Başkent University Faculty of Medicine, Adana Research and Implementation Center, Department of Neurology, Adana, Turkey
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Abstract
Fulminant demyelinating disease is a heading that covers acute disseminated encephalomyelitis and its variant acute hemorrhagic leukoencephalitis (Hurst disease), severe relapses of multiple sclerosis (MS), variants of MS (tumefactive MS, Marburg variant, Balo concentric sclerosis, myelinoclastic diffuse sclerosis), and neuromyelitis optica-spectrum disorders associated with aquaporin autoimmunity. These categories of inflammatory demyelinating disease often prompt hospital admission and many necessitate intensive care monitoring due to the aggressive nature of the illness and associated neurologic morbidity. In this review, we highlight the discriminating clinical, radiographic, and pathologic features of these disorders. Acute management is often accomplished with use of high-dose intravenous steroids and plasma exchange. Aggressive disease may respond to immunosuppression. Prognosis for recovery varies among the disorders but most patients improve. Factors influencing outcome are also discussed.
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Abstract
OPINION STATEMENT Acute disseminated encephalomyelitis (ADEM) is an inflammatory demyelinating disease, characterized by an acute onset of polyfocal central nervous system (CNS) deficits, including encephalopathy, demonstrating multifocal lesions on MRI. ADEM is typically a monophasic disorder, but recurrent and multiphasic courses have been described. Furthermore, an ADEM presentation has been reported in neuromyelitis optica (NMO) and multiple sclerosis (MS), particularly in younger children. CNS infections, other autoimmune diseases, and neurometabolic disorders may mimic ADEM at manifestation. There is no single test confirming the diagnosis of ADEM, and diagnosis is based upon a combination of clinical and radiologic features and exclusion of diseases that resemble ADEM. Therefore, a broad workup including infectious, immunologic, and metabolic tests, as well as a systematic follow-up including MRI, is indicated to establish an accurate diagnosis as a prerequisite for an optimized treatment approach. There is a lack of evidence-based, prospective clinical trial data for the management of ADEM. Empiric antibacterial and antiviral treatment is standard of care until an infectious disease process is ruled out. Based on the presumed autoimmune etiology of ADEM, the common treatment approach consists of intravenous methylprednisolone at a dosage of 20 to 30 mg/kg per day (maximum 1 g/day) for 3 to 5 days, followed by an oral corticosteroid taper of 4 to 6 weeks. In case of insufficient response or contraindications to corticosteroids, intravenous immunoglobulin G (IVIG) at a dosage of 2 g/kg divided over 2 to 5 days is a therapeutic option. For severe or life-threatening cases of ADEM, plasmapheresis should be considered early in the disease course. Decompressive craniectomy has been reported as a life-saving measure for ADEM patients with intracranial hypertension. There is a lack of specific recommendations for the long-term management of recurrent and multiphasic ADEM. In children with relapsing demyelinating events, the diagnosis of a chronic autoimmune CNS disease like MS or NMO should be considered.
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Affiliation(s)
- Daniela Pohl
- Department of Neurology, Children's Hospital of Eastern Ontario, University of Ottawa, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada,
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Borlot F, da Paz JA, Casella EB, Marques-Dias MJ. Acute hemorrhagic encephalomyelitis in childhood: Case report and literature review. J Pediatr Neurosci 2011; 6:48-51. [PMID: 21977089 PMCID: PMC3173916 DOI: 10.4103/1817-1745.84408] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Acute disseminated encephalomyelitis (ADEM) is an inflammatory immune-mediated disorder which is more common in pediatric patients. The clinical setting is characterized by a rapid onset of encephalopathy and multifocal neurological features. Acute hemorrhagic encephalomyelitis (AHEM) is considered a rare form of ADEM. This report shows a 2-year-old patient who presented with the classical features of ADEM and after 8 weeks developed severe neurological worsening. The second magnetic resonance image (MRI) showed hemorrhagic lesions. Differences in prognosis between ADEM and AHEM justify the investigation of AHEM whenever a patient has neurological recrudescence in a known patient of ADEM.
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Affiliation(s)
- Felippe Borlot
- Department of Neurology, Children's Institute, Sao Paulo University, Sao Paulo, Brazil
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Pinto PS, Taipa R, Moreira B, Correia C, Melo-Pires M. Acute hemorrhagic leukoencephalitis with severe brainstem and spinal cord involvement: MRI features with neuropathological confirmation. J Magn Reson Imaging 2011; 33:957-61. [PMID: 21448963 DOI: 10.1002/jmri.22505] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Acute hemorrhagic leukoencephalitis (AHLE) is a rare and fulminant demyelinating disease considered to be the most severe form of acute disseminated encephalomyelitis (ADEM). A 70-year-old man was admitted to our emergency department (ED) after 1 week of unspecific abdominal symptoms and moderate fever in the first 3 days. Within the ED he developed a rapid onset coma and flaccid tetraparesis. Cerebrospinal fluid (CSF) analysis showed mild polymorphonuclear pleocytosis and magnetic resonance imaging (MRI) revealed supratentorial focal white matter lesions and diffuse involvement of the medulla and spinal cord. A presumptive diagnosis of ADEM was made and the patient was treated with corticosteroids followed by intravenous immunoglobulin. His neurological state did not improve and the MRI on day 8 after admission showed an increased number of lesions, mainly in the brainstem, with hemorrhagic foci. The patient died the following day and pathological features confirmed the diagnosis of AHLE. This is a unique presentation of a rare disease with detailed MRI characteristics and pathological confirmation. Although this condition is usually fatal, early recognition and aggressive therapeutic management can facilitate survival.
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Affiliation(s)
- Pedro S Pinto
- Neuroradiology Department, Centro Hospitalar do Porto, Porto, Portugal.
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Lann MA, Lovell MA, Kleinschmidt-DeMasters BK. Acute hemorrhagic leukoencephalitis: a critical entity for forensic pathologists to recognize. Am J Forensic Med Pathol 2010; 31:7-11. [PMID: 20010289 DOI: 10.1097/paf.0b013e3181c6be92] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Acute hemorrhagic leukoencephalopathy (AHLE) is a rare, acute disorder characterized by perivenular demyelination and diffuse hemorrhagic necrosis of the central nervous system. AHLE is thought to represent a hyperacute form of acute disseminated encephalomyelitis. AHLE is associated with a greater morbidity and mortality and, fortunately, is much less common than acute disseminated encephalomyelitis. Since most cases of AHLE result in patient demise, forensic pathologists should be cognizant of this entity and consider it in their differential diagnosis.Here we describe an interesting case of a previously healthy 11-year-old boy who initially complained of vague gastroenteritis-like symptoms while visiting a mountain lake. The boy's symptoms evolved to include severe headache and dizziness, necessitating a visit to a rural emergency department. He presented with focal neurologic findings, and head computed tomography (CT) scan confirmed thalamic edema. Cerebrospinal fluid analysis was suggestive of infectious etiology, and multiple empiric therapies were initiated. He was transferred to our institution, and his clinical status continued to worsen. Given the poor prognosis, the family requested withdrawal of supportive care. On day 14 of symptoms the boy succumbed to his illness. An autopsy was requested to further characterize the proximate cause of death.AHLE often presents with abrupt onset of fever, neck stiffness, seizure, and/or focal neurologic signs several days following a viral illness or vaccination. Thus, AHLE can clinically mimic a direct central nervous system infection or a toxic ingestion. AHLE has a very poor prognosis, with rapid deterioration and death usually occurring within days to one week after onset of symptoms. The cause for AHLE is unclear. An autoimmune pathophysiology is likely, with immune cross-reactivity between myelin basic protein moieties and various infectious agent antigens. Treatment for AHLE is not well-established; some authors describe in recent literature that a combination of immunosuppressant medications and/or therapeutic plasma exchange may be of benefit in treating AHLE.
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Affiliation(s)
- Meredith A Lann
- Department of Pathology, University of Colorado Denver, Aurora, Colo., USA.
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Abou Zeid NE, Burns JD, Wijdicks EFM, Giannini C, Keegan BM. Atypical acute hemorrhagic leukoencephalitis (Hurst's disease) presenting with focal hemorrhagic brainstem lesion. Neurocrit Care 2010; 12:95-7. [PMID: 19847676 DOI: 10.1007/s12028-009-9293-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Acute hemorrhagic leukoencephalitis (AHL; Hurst's disease) is a rare, severe, inflammatory CNS disease that is typically diffuse, multifocal and associated with petechial hemorrhage. The objective of this study is to report the clinical, radiologic, and pathologic findings in a fatal AHL case with focal brainstem involvement and gross hemorrhage. METHODS Patient evaluation in a tertiary neurointensive care unit with serial brain magnetic resonance imaging (MRI) and neuropathological examination on autopsy were performed. RESULTS The patient presented with mild, then rapidly worsening, brainstem impairment to a locked-in syndrome. Brain MRI demonstrated an isolated gadolinium enhancing brainstem lesion that enlarged dramatically over weeks and was associated with gross hemorrhage and necrosis. The patient died despite aggressive treatment with intravenous corticosteroids and plasma exchange. Autopsy demonstrated the isolated severe necrotic lesion consistent with AHL. CONCLUSIONS AHL may present as a solitary brainstem lesion with gross hemorrhage and should be considered in patients with isolated enhancing brainstem lesions. AHL may be fatal even despite early, aggressive immunomodulatory therapy.
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Affiliation(s)
- Nuhad E Abou Zeid
- Department of Neurology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
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Mcdaneld LM, Fields JD, Bourdette DN, Bhardwaj A. Immunomodulatory Therapies in Neurologic Critical Care. Neurocrit Care 2010; 12:132-43. [DOI: 10.1007/s12028-009-9274-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2009] [Accepted: 08/28/2009] [Indexed: 10/20/2022]
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Catalan M, Naccarato M, Grandi FC, Capozzoli F, Koscica N, Pizzolato G. Acute hemorrhagic leukoencephalitis with atypical features. Neurol Sci 2009; 30:55-7. [DOI: 10.1007/s10072-008-0003-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2008] [Accepted: 10/13/2008] [Indexed: 12/01/2022]
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