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Sloof N, Hue CD, Campbell C, Barton MA, Nouri MN. Acute Flaccid Paralysis, Seizures, and Encephalopathy in a Pediatric Patient With Influenza A and Coronavirus Disease 2019 Infection. Pediatr Neurol 2024; 152:127-129. [PMID: 38262228 DOI: 10.1016/j.pediatrneurol.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 12/04/2023] [Accepted: 12/28/2023] [Indexed: 01/25/2024]
Affiliation(s)
- Natalie Sloof
- Department of Paediatrics, Western University, London, Ontario, Canada
| | - Christopher Donald Hue
- Department of Clinical Neurological Sciences, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Craig Campbell
- Department of Paediatrics, Western University, London, Ontario, Canada
| | - Michelle A Barton
- Department of Paediatrics, Western University, London, Ontario, Canada
| | - Maryam Nabavi Nouri
- Department of Paediatrics, Western University, London, Ontario, Canada; Department of Clinical Neurological Sciences, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.
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2
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Peranzoni F, Martins C, Lebon S, Crisinel PA, Perez MH. Seizures in Children with Influenza during the 2022-2023 Winter Season, a Case Series. Clin Pract 2024; 14:173-178. [PMID: 38391400 PMCID: PMC10888020 DOI: 10.3390/clinpract14010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/02/2024] [Accepted: 01/08/2024] [Indexed: 02/24/2024] Open
Abstract
Influenza is a viral infection presenting with general symptoms such as fever, headache, fatigue, and involvement of airways or the gastrointestinal tract. The nervous system may be involved, but less frequently. These neurological complications remain challenging to diagnose; moreover, no guidelines for management and treatment exist. Therefore, when presenting with neurological symptoms, patients undergo invasive diagnostic procedures and empirical treatments before making the correct diagnosis. During the winter of 2022-2023, four children between nine months and nine years of age were admitted to the Lausanne University Hospital, Switzerland, complaining of influenza and neurological complications. This report presents the symptoms of neurological manifestation and the treatment management of the four patients. All the legally authorized representatives gave their written informed consent before study inclusion.
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Affiliation(s)
- Francesca Peranzoni
- Pediatric Intensive and Intermediate Care Units, Service of Pediatrics, Women-Mother-Child Department, Lausanne University Hospital, 1005 Lausanne, Switzerland
| | - Carine Martins
- Pediatric Intensive and Intermediate Care Units, Service of Pediatrics, Women-Mother-Child Department, Lausanne University Hospital, 1005 Lausanne, Switzerland
| | - Sébastien Lebon
- Unit of Pediatric Neurology and Neurorehabilitation, Service of Pediatrics, Women-Mother-Child Department, Lausanne University Hospital, 1005 Lausanne, Switzerland
| | - Pierre Alex Crisinel
- Unit of Pediatric Infectious Diseases and Vaccinology, Service of Pediatrics, Women-Mother-Child Department, Lausanne University Hospital, 1005 Lausanne, Switzerland
| | - Marie-Helena Perez
- Pediatric Intensive and Intermediate Care Units, Service of Pediatrics, Women-Mother-Child Department, Lausanne University Hospital, 1005 Lausanne, Switzerland
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3
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Weisheng H, Hui Z, Shuang W, Qing G, Tianying S, Chenguang Y, Hongmei D. A sudden death due to acute necrotizing encephalopathy associated with influenza A virus infection: An autopsy case report. Leg Med (Tokyo) 2022; 58:102098. [PMID: 35662069 DOI: 10.1016/j.legalmed.2022.102098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 05/18/2022] [Accepted: 05/27/2022] [Indexed: 11/25/2022]
Abstract
Influenza occasionally causes central nervous system disorders. Acute necrotizing encephalopathy (ANE) is one of the most severe influenza-associated complications, predominantly affecting infants and young children under 5 years of age. We present this case as it involves a very rare complication of influenza infection that is known to have a high rate of mortality. A 5-year-old girl presented with a high fever and convulsions. Her condition deteriorated rapidly, and she died within 24 h. Autopsy revealed extensive brain edema, multifocal perivascular hemorrhage, and necrosis of neurons without inflammatory cell infiltration in the pons and bilateral thalamus. Tests for influenza virus A and antibodies to it were positive. The girl's death was attributed to ANE associated with influenza A infection based on the clinical presentation, the postmortem neuropathology, and identification of the virus. The goal of this report is to draw attention to the potentially serious complications of influenza A infection. We hope that the lethal outcome of this disease will be fully recognized by medical personnel.
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Affiliation(s)
- Huang Weisheng
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, No. 13 Hangkong Road, Hankou, Wuhan, PR China
| | - Zhang Hui
- Central Laboratory, University of Chinese Academy of Sciences Shenzhen Hospital, Shenzhen, China
| | - Wu Shuang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
| | - Gao Qing
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, No. 13 Hangkong Road, Hankou, Wuhan, PR China
| | - Sun Tianying
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, No. 13 Hangkong Road, Hankou, Wuhan, PR China
| | - Yang Chenguang
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, No. 13 Hangkong Road, Hankou, Wuhan, PR China
| | - Dong Hongmei
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, No. 13 Hangkong Road, Hankou, Wuhan, PR China.
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4
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Xu H, Cai L, Hufnagel S, Cui Z. Intranasal vaccine: Factors to consider in research and development. Int J Pharm 2021; 609:121180. [PMID: 34637935 DOI: 10.1016/j.ijpharm.2021.121180] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 10/04/2021] [Accepted: 10/07/2021] [Indexed: 01/01/2023]
Abstract
Most existing vaccines for human use are administered by needle-based injection. Administering vaccines needle-free intranasally has numerous advantages over by needle-based injection, but there are only a few intranasal vaccines that are currently approved for human use, and all of them are live attenuated influenza virus vaccines. Clearly, there are immunological as well as non-immunological challenges that prevent vaccine developers from choosing the intranasal route of administration. We reviewed current approved intranasal vaccines and pipelines and described the target of intranasal vaccines, i.e. nose and lymphoid tissues in the nasal cavity. We then analyzed factors unique to intranasal vaccines that need to be considered when researching and developing new intranasal vaccines. We concluded that while the choice of vaccine formulations, mucoadhesives, mucosal and epithelial permeation enhancers, and ligands that target M-cells are important, safe and effective intranasal mucosal vaccine adjuvants are needed to successfully develop an intranasal vaccine that is not based on live-attenuated viruses or bacteria. Moreover, more effective intranasal vaccine application devices that can efficiently target a vaccine to lymphoid tissues in the nasal cavity as well as preclinical animal models that can better predict intranasal vaccine performance in clinical trials are needed to increase the success rate of intranasal vaccines in clinical trials.
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Affiliation(s)
- Haiyue Xu
- The University of Texas at Austin, College of Pharmacy, Division of Molecular Pharmaceutics and Drug Delivery, Austin, TX, United States
| | - Lucy Cai
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Stephanie Hufnagel
- The University of Texas at Austin, College of Pharmacy, Division of Molecular Pharmaceutics and Drug Delivery, Austin, TX, United States
| | - Zhengrong Cui
- The University of Texas at Austin, College of Pharmacy, Division of Molecular Pharmaceutics and Drug Delivery, Austin, TX, United States.
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5
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Neurovirulence of avian influenza virus is dependent on the interaction of viral NP protein with host factor FMRP in the murine brain. J Virol 2021; 95:JVI.01272-20. [PMID: 33408179 PMCID: PMC8092684 DOI: 10.1128/jvi.01272-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Avian influenza viruses (AIVs) are zoonotic viruses that exhibit a range infectivity and severity in the human host. Severe human cases of AIVs infection are often accompanied by neurological symptoms, however, the factors involved in the infection of the central nervous system (CNS) are not well known. In this study, we discovered that avian-like sialic acid (SA)-α2, 3 Gal receptor is highly presented in mammalian (human and mouse) brains. In the generation of a mouse-adapted neurotropic H9N2 AIV (SD16-MA virus) in BALB/c mice, we identified key adaptive mutations in its hemagglutinin (HA) and polymerase basic protein 2 (PB2) genes that conferred viral replication ability in mice brain. The SD16-MA virus showed binding affinity for avian-like SA-α2, 3 Gal receptor, enhanced viral RNP polymerase activity, increased viral protein production and transport that culminated in elevated progeny virus production and severe pathogenicity. We further established that host Fragile X Mental Retardation Protein (FMRP), a highly expressed protein in the brain that physically associated with viral nucleocapsid protein (NP) to facilitate RNP assembly and export, was an essential host factor for the neuronal replication of neurotropic AIVs (H9N2, H5N1 and H10N7 viruses). Our study identified a mechanistic process for AIVs to acquire neurovirulence in mice.IMPORTANCE Infection of the CNS is a serious complication of human cases of AIVs infection. The viral and host factors associated with neurovirulence of AIVs infection are not well understood. We identified and functionally characterized specific changes in the viral HA and PB2 genes of a mouse-adapted neurotropic avian H9N2 virus responsible for enhanced virus replication in neuronal cells and pathogenicity in mice. Importantly, we showed that host FMRP was a crucial host factor that was necessary for neurotropic AIVs (H9N2, H5N1 and H10N7 viruses) to replicate in neuronal cells. Our findings have provided insights into the pathogenesis of neurovirulence of AIV infection.
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Radzišauskienė D, Vitkauskaitė M, Žvinytė K, Mameniškienė R. Neurological complications of pandemic A(H1N1)2009pdm, postpandemic A(H1N1)v, and seasonal influenza A. Brain Behav 2021; 11:e01916. [PMID: 33155427 PMCID: PMC7821618 DOI: 10.1002/brb3.1916] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 09/21/2020] [Accepted: 10/09/2020] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES Not much is known about influenza-associated neurological complications. We aimed to describe the case series of hospitalized patients who were confirmed with influenza A and presented with neurological symptoms in order to capture the broad spectrum of influenza clinical manifestation and suggest including influenza diagnostic in some neurological conditions. MATERIALS AND METHODS The inclusion criteria were age ≥ 18 and laboratory-confirmed influenza presenting with neurological symptoms. Influenza-associated neurological complication was described as a development of neurological symptom with no other origin. The outcomes were classified into 5 categories: 1. recovery with no significant disability; 2. minor disability (able to manage on their own); 3. moderate disability (requiring some help but able to walk without assistance); 4. severe disability (unable to walk without assistance and perform daily activities); 5. death. RESULTS In total, 12 patients (five women and seven men) were enrolled, with age range 18-71 years old. Neurological complications of pandemic A(H1 N1 )2009pdm influenza developed in seven out of 69 (10.1%) hospitalized patients. The most common neurological complication was encephalopathy. Neurological complications developed in two out of 24 (8.3%) hospitalized patients during postpandemic (H1 N1 )V period. One patient presented with encephalopathy, another with meningoencephalitis. During the 2018 influenza season, there was one patient who has developed influenza A neurological complications. Overall, two out of 104 (1.9%) influenza A patients developed influenza-associated neurological complications in 2019. CONCLUSIONS Every patient with unexplained neurological symptoms and signs similar to aseptic and septic meningitis/encephalitis has to be tested for influenza virus during epidemics and pandemics.
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Affiliation(s)
- Daiva Radzišauskienė
- Department of Infectious Diseases and Dermatovenerology, Vilnius University, Vilnius, Lithuania
| | | | | | - Rūta Mameniškienė
- Department of Neurology and Neurosurgery, Vilnius University, Vilnius, Lithuania
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7
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Iadecola C, Anrather J, Kamel H. Effects of COVID-19 on the Nervous System. Cell 2020; 183:16-27.e1. [PMID: 32882182 PMCID: PMC7437501 DOI: 10.1016/j.cell.2020.08.028] [Citation(s) in RCA: 401] [Impact Index Per Article: 100.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/13/2020] [Accepted: 08/14/2020] [Indexed: 02/06/2023]
Abstract
Neurological complications have emerged as a significant cause of morbidity and mortality in the ongoing COVID-19 pandemic. Beside respiratory insufficiency, many hospitalized patients exhibit neurological manifestations ranging from headache and loss of smell, to confusion and disabling strokes. COVID-19 is also anticipated to take a toll on the nervous system in the long term. Here, we will provide a critical appraisal of the potential for neurotropism and mechanisms of neuropathogenesis of SARS-CoV-2 as they relate to the acute and chronic neurological consequences of the infection. Finally, we will examine potential avenues for future research and therapeutic development.
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Affiliation(s)
- Costantino Iadecola
- Feil Family Brain and Mind Research Institute, Clinical Translational Neuroscience Unit, Weill Cornell Medicine, New York, NY 10021, USA.
| | - Josef Anrather
- Feil Family Brain and Mind Research Institute, Clinical Translational Neuroscience Unit, Weill Cornell Medicine, New York, NY 10021, USA
| | - Hooman Kamel
- Feil Family Brain and Mind Research Institute, Clinical Translational Neuroscience Unit, Weill Cornell Medicine, New York, NY 10021, USA
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Al Mazrouei SS, Saeed GA, Al Helali AA, Ahmed M. COVID-19-associated encephalopathy: Neurological manifestation of COVID-19. Radiol Case Rep 2020; 15:1646-1649. [PMID: 32690988 PMCID: PMC7342008 DOI: 10.1016/j.radcr.2020.07.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 12/26/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a viral disease, also known as severe acute respiratory syndrome coronavirus 2, was first reported in Wuhan, China, December 2019. Respiratory manifestations from the induced acute lung injury were the most common reported findings. Few cases showed extrapulmonary manifestations. COVID-19-associated neurological manifestations have not been widely reported. In this report, we describe a case of encephalopathy in a patient with COVID-19 infection.
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Key Words
- ADC, apparent diffusion coefficient
- CNS, central nervous system
- COVID-19, coronavirus disease 2019
- CT, computed tomography
- Covid-19, coronavirus
- DWI, diffusion weighted imaging
- ED, emergency department
- Encephalopathy
- FLAIR, fluid attenuated inversion recovery
- GCS, Glasgow Coma Scale
- HRCT, high-resolution computed tomography
- ICU, intensive care unit
- MRI, magnetic resonance imaging
- RT-PCR, reverse transcription polymerase chain reaction
- SARS-Cov-2, severe acute respiratory syndrome coronavirus 2
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Affiliation(s)
| | - Ghufran Aref Saeed
- Department of Radiology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Abeer Ahmed Al Helali
- Department of Radiology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Manzoor Ahmed
- Department of Radiology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
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Gautam A, Akauliya M, Thapa B, Park BK, Kim D, Kim J, Lee K, Choi KC, Bae JY, Park MS, Lee Y, Kwon HJ. Abdominal and Pelvic Organ Failure Induced by Intraperitoneal Influenza A Virus Infection in Mice. Front Microbiol 2020; 11:1713. [PMID: 32765481 PMCID: PMC7379156 DOI: 10.3389/fmicb.2020.01713] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/30/2020] [Indexed: 11/13/2022] Open
Abstract
In humans, respiratory infections with influenza A viruses can be lethal, but it is unclear whether non-respiratory influenza A infections can be equally lethal. Intraperitoneal infection makes the abdominal and pelvic organs accessible to pathogens because of the circulation of peritoneal fluid throughout the pelvis and abdomen. We found that high-dose intraperitoneal infection in mice with influenza A viruses resulted in severe sclerosis and structural damage in the pancreas, disruption of ovarian follicles, and massive infiltration of immune cells in the uterus. The intraperitoneal infections also caused robust upregulation of proinflammatory mediators including IL-6, BLC, and MIG. In addition, low-dose intraperitoneal infection with one influenza strain provided cross-protection against subsequent intraperitoneal or intranasal challenge with another influenza strain. Our results suggest that low-dose, non-respiratory administration might provide a route for influenza vaccination. Furthermore, these results provide insight on the pathological role of influenza A viruses in high-risk patients, including women and diabetic individuals.
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Affiliation(s)
- Avishekh Gautam
- Department of Microbiology, College of Medicine, Hallym University, Chuncheon, South Korea
| | - Madhav Akauliya
- Department of Microbiology, College of Medicine, Hallym University, Chuncheon, South Korea
| | - Bikash Thapa
- Institute of Bioscience and Biotechnology, Hallym University, Chuncheon, South Korea
| | - Byoung Kwon Park
- Center for Medical Science Research, College of Medicine, Hallym University, Chuncheon, South Korea
| | - Dongbum Kim
- Center for Medical Science Research, College of Medicine, Hallym University, Chuncheon, South Korea
| | - Jinsoo Kim
- Department of Microbiology, College of Medicine, Hallym University, Chuncheon, South Korea
| | - Keunwook Lee
- Institute of Bioscience and Biotechnology, Hallym University, Chuncheon, South Korea.,Department of Biomedical Science, College of Natural Sciences, Hallym University, Chuncheon, South Korea
| | - Kyung Chan Choi
- Department of Pathology, Hallym University Sacred Heart Hospital, Chuncheon, South Korea
| | - Joon-Yong Bae
- Department of Microbiology, College of Medicine and the Institute for Viral Diseases, Korea University, Seoul, South Korea
| | - Man-Seong Park
- Department of Microbiology, College of Medicine and the Institute for Viral Diseases, Korea University, Seoul, South Korea
| | - Younghee Lee
- Department of Biochemistry, College of Natural Sciences, Chungbuk National University, Cheongju, South Korea
| | - Hyung-Joo Kwon
- Department of Microbiology, College of Medicine, Hallym University, Chuncheon, South Korea.,Institute of Bioscience and Biotechnology, Hallym University, Chuncheon, South Korea
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10
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Chen Q, Li P, Li S, Xiao W, Yang S, Lu H. Brain Complications with Influenza Infection in Children. ACTA ACUST UNITED AC 2020. [DOI: 10.4236/jbbs.2020.103008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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11
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Mastrolia MV, Rubino C, Resti M, Trapani S, Galli L. Characteristics and outcome of influenza-associated encephalopathy/encephalitis among children in a tertiary pediatric hospital in Italy, 2017-2019. BMC Infect Dis 2019; 19:1012. [PMID: 31783806 PMCID: PMC6884834 DOI: 10.1186/s12879-019-4636-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 11/18/2019] [Indexed: 12/20/2022] Open
Abstract
Background Influenza is the most frequent cause of acute upper respiratory tract infections during winter season. Although rare, neurological manifestations are known to occur during influenza infection and approximatively three-quarters of cases are in children. In this study, we aimed to characterize the burden and clinical spectrum of influenza-associated encephalopathy and encephalitis in children admitted at a tertiary pediatric hospital in Italy over two influenza seasons (2017–2019). Methods We retrospectively analyzed clinical, laboratory, instrumental data and outcome of patients discharged with ICD9-CM 487.0 code. Results Fifteen children (13.1% of those discharged with a diagnosis of influenza infection in the study period), had influenza-associated central nervous system (CNS) manifestations. Eight patients (53.3%) were diagnosed as influenza encephalitis, 7 (46.7%) as influenza encephalopathy. Median age was 27 months. In children under 2 years of age (40% of all cases) altered consciousness was the most frequent neurological manifestation while respiratory symptoms were present at admission in all cases. Younger children also required intensive care support more frequently. Five subjects (33.3%) presented comorbidity. None of the patients had received seasonal influenza vaccination. The median time from onset of respiratory signs to onset of neurological manifestations was 24 h. Cerebrospinal fluid (CSF) analysis was normal in most patients and polymerase chain reaction for influenza virus RNA on CSF, when performed, was negative in all samples. Neuroradiological investigations, performed in 5 children, reported cortical and subcortical white matter signal alterations. Oseltamivir was administered only in 2 cases. Fourteen patients recovered without sequelae, and only a 2-year-old girl had minimal impairment in fine motor skills at discharge. Conclusions All children presenting acute neurological features during influenza season should be evaluated for influenza-associated CNS complications even if the respiratory involvement is mild. Absence of underlying diseases or other risk factors are not protective factors against CNS influenza-associated complications. The lack of CSF pleocytosis does not exclude CNS involvement. Children under 2 years of age are at higher risk of requiring intensive care support.
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Affiliation(s)
- Maria Vincenza Mastrolia
- Post-graduate School of Pediatrics, University of Florence, Viale Gaetano Pieraccini, 24, 50139, Florence, Italy.
| | - Chiara Rubino
- Post-graduate School of Pediatrics, University of Florence, Viale Gaetano Pieraccini, 24, 50139, Florence, Italy
| | - Massimo Resti
- Pediatric Department, Anna Meyer Children's University Hospital, Florence, Italy
| | - Sandra Trapani
- Pediatric Department, Anna Meyer Children's University Hospital, Florence, Italy
| | - Luisa Galli
- Department of Health Sciences University of Florence, Paediatric Infectious Diseases Division, Anna Meyer Children's University Hospital, Florence, Italy
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12
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Ashfaq I, Vrahimi M, Waugh S, Soomro T, Grinton ME, Browning AC. Acute Macular Neuroretinopathy Associated with Acute Influenza Virus Infection. Ocul Immunol Inflamm 2019; 29:333-339. [PMID: 31697568 DOI: 10.1080/09273948.2019.1681470] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Purpose: To describe a prospective case series of patients with acute macular neuroretinopathy (AMN) associated with acute influenza virus infectionMethods: Patients who presented with acute macular neuroretinopathy associated with confirmed influenza virus infection were subject to a detailed clinical history, HLA typing and longitudinal ophthalmological and imaging examinations.Results: Four female patients aged 18 to 32 years were studied. They reported the onset of ocular symptoms between 2 and 5 days after the development of flu like symptoms. Three patients had confirmed acute influenza B infection, while the fourth had influenza A. OCT angiography only demonstrated abnormal choriocapillaris perfusion in 1 patient and early oral Oseltamivir treatment appeared not to affect the ophthalmic outcome in one patient.Conclusion: This is the first report of AMN associated with virologically confirmed acute influenza virus infection. Variation in HLA alleles do not appear to predispose patients to influenza associated AMN.
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Affiliation(s)
- Imran Ashfaq
- Ophthalmology Department, Newcastle Eye Centre, Newcastle upon Tyne, UK
| | - Maria Vrahimi
- Ophthalmology Department, Newcastle Eye Centre, Newcastle upon Tyne, UK
| | - Sheila Waugh
- Virology Department, Freeman Hospital, Newcastle upon Tyne, UK
| | - Taha Soomro
- Ophthalmology Department, Newcastle Eye Centre, Newcastle upon Tyne, UK
| | - Michael E Grinton
- Ophthalmology Department, Newcastle Eye Centre, Newcastle upon Tyne, UK
| | - Andrew C Browning
- Ophthalmology Department, Newcastle Eye Centre, Newcastle upon Tyne, UK
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13
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Lim HK, Huang SXL, Chen J, Kerner G, Gilliaux O, Bastard P, Dobbs K, Hernandez N, Goudin N, Hasek ML, García Reino EJ, Lafaille FG, Lorenzo L, Luthra P, Kochetkov T, Bigio B, Boucherit S, Rozenberg F, Vedrinne C, Keller MD, Itan Y, García-Sastre A, Celard M, Orange JS, Ciancanelli MJ, Meyts I, Zhang Q, Abel L, Notarangelo LD, Snoeck HW, Casanova JL, Zhang SY. Severe influenza pneumonitis in children with inherited TLR3 deficiency. J Exp Med 2019; 216:2038-2056. [PMID: 31217193 PMCID: PMC6719423 DOI: 10.1084/jem.20181621] [Citation(s) in RCA: 120] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 04/10/2019] [Accepted: 05/09/2019] [Indexed: 12/20/2022] Open
Abstract
Autosomal recessive IRF7 and IRF9 deficiencies impair type I and III IFN immunity and underlie severe influenza pneumonitis. We report three unrelated children with influenza A virus (IAV) infection manifesting as acute respiratory distress syndrome (IAV-ARDS), heterozygous for rare TLR3 variants (P554S in two patients and P680L in the third) causing autosomal dominant (AD) TLR3 deficiency. AD TLR3 deficiency can underlie herpes simplex virus-1 (HSV-1) encephalitis (HSE) by impairing cortical neuron-intrinsic type I IFN immunity to HSV-1. TLR3-mutated leukocytes produce normal levels of IFNs in response to IAV. In contrast, TLR3-mutated fibroblasts produce lower levels of IFN-β and -λ, and display enhanced viral susceptibility, upon IAV infection. Moreover, the patients' iPSC-derived pulmonary epithelial cells (PECs) are susceptible to IAV. Treatment with IFN-α2b or IFN-λ1 rescues this phenotype. AD TLR3 deficiency may thus underlie IAV-ARDS by impairing TLR3-dependent, type I and/or III IFN-mediated, PEC-intrinsic immunity. Its clinical penetrance is incomplete for both IAV-ARDS and HSE, consistent with their typically sporadic nature.
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Affiliation(s)
- Hye Kyung Lim
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY.,Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale UMR 1163, Paris, France.,Paris Descartes University, Imagine Institute, Paris, France
| | - Sarah X L Huang
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY.,Department of Medicine, Columbia University Medical Center, New York, NY.,Center for Stem Cell and Regenerative Medicine, University of Texas Health Science Center at Texas, Houston, TX
| | - Jie Chen
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY.,Department of Infectious Diseases, Shanghai Sixth Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Gaspard Kerner
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale UMR 1163, Paris, France.,Paris Descartes University, Imagine Institute, Paris, France
| | - Olivier Gilliaux
- Laboratory of Experimental Medicine (ULB222), Medicine Faculty, Libre de Bruxelles University, Brussels, Belgium.,Department of Pediatrics, University Hospital Center of Charleroi, Charleroi, Belgium
| | - Paul Bastard
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale UMR 1163, Paris, France.,Paris Descartes University, Imagine Institute, Paris, France
| | - Kerry Dobbs
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Nicholas Hernandez
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY
| | - Nicolas Goudin
- Cell Imaging Platform Structure Fédérative de Recherche Necker, Institut National de la Santé et de la Recherche Médicale US 24, Paris, France
| | - Mary L Hasek
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY
| | - Eduardo Javier García Reino
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY
| | - Fabien G Lafaille
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY
| | - Lazaro Lorenzo
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale UMR 1163, Paris, France.,Paris Descartes University, Imagine Institute, Paris, France
| | - Priya Luthra
- Department of Microbiology, Global Health and Emerging Pathogens Institute, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY.,Department of Medicine, Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Tatiana Kochetkov
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY
| | - Benedetta Bigio
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY
| | - Soraya Boucherit
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale UMR 1163, Paris, France.,Paris Descartes University, Imagine Institute, Paris, France
| | - Flore Rozenberg
- Virology, Cochin-Saint-Vincent de Paul Hospital, Paris Descartes University, Paris, France
| | - Catherine Vedrinne
- Department of Anesthesia and Intensive Care Medicine in Cardiovascular Surgery, Louis Pradel Cardiological Hospital, Lyon, France
| | - Michael D Keller
- Division of Allergy and Immunology, Center for Cancer and Immunology Research, Children's National Health System, Washington, DC
| | - Yuval Itan
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY.,The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Adolfo García-Sastre
- Department of Microbiology, Global Health and Emerging Pathogens Institute, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY.,Department of Medicine, Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Marie Celard
- National Center for Staphylococcus, Lyon Civil Hospital, Lyon, France
| | - Jordan S Orange
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Michael J Ciancanelli
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY
| | - Isabelle Meyts
- Laboratory for Inborn Errors of Immunity, Department of Immunology, Microbiology, and Transplantation, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium.,Precision Immunology Institute and Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Qian Zhang
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY
| | - Laurent Abel
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY.,Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale UMR 1163, Paris, France.,Paris Descartes University, Imagine Institute, Paris, France
| | - Luigi D Notarangelo
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Hans-Willem Snoeck
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY.,Department of Medicine, Columbia University Medical Center, New York, NY
| | - Jean-Laurent Casanova
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY.,Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale UMR 1163, Paris, France.,Paris Descartes University, Imagine Institute, Paris, France.,Pediatric Immuno-Hematology Unit, Necker Hospital for Sick Children, Assistance Publique-Hôpitaux de Paris, Paris, France.,Howard Hughes Medical Institute, New York, NY
| | - Shen-Ying Zhang
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY .,Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale UMR 1163, Paris, France.,Paris Descartes University, Imagine Institute, Paris, France
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14
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Syncope and Influenza B: A Case of an Arresting Association. Case Rep Emerg Med 2018; 2018:1853473. [PMID: 30174963 PMCID: PMC6098913 DOI: 10.1155/2018/1853473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 07/18/2018] [Accepted: 07/18/2018] [Indexed: 11/18/2022] Open
Abstract
Influenza is a contagious viral illness that usually presents with upper respiratory and pulmonary symptoms. While generally self-limited, pulmonary, renal, metabolic, neurologic, and cardiac complications have all been described in the literature. Here we describe a case of a 46-year-old male with multiple episodes of syncope, found to have severe bradycardia, sinus arrest, and positive influenza B, requiring permanent pacemaker placement. The viruses responsible for the flu can be differentiated into four types: A, B, C, and D. The two primary viruses responsible for the seasonal winter epidemic influenza in the United States are Human Influenza A and B viruses. It has been postulated that the influenza virus may be responsible for activating acute inflammatory cytokines, which then alter electrical conduction properties of endothelial cells. Although there have been cases of sinus arrest in association with influenza, some requiring pacemaker placement, our patient's presentation with multiple episodes of syncope with severe bradycardia and sinus arrest requiring permanent pacemaker placement, in association with influenza B, is very unusual and possibly unique. Since emergency physicians are at the forefront in the diagnosis, treatment, and disposition of these patients, awareness of influenza triggered cardiac events is essential and lifesaving, especially in unvaccinated patients.
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15
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Paksu MS, Aslan K, Kendirli T, Akyildiz BN, Yener N, Yildizdas RD, Davutoglu M, Yaman A, Isikay S, Sensoy G, Tasdemir HA. Neuroinfluenza: evaluation of seasonal influenza associated severe neurological complications in children (a multicenter study). Childs Nerv Syst 2018; 34:335-347. [PMID: 28762041 DOI: 10.1007/s00381-017-3554-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 07/19/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Although influenza primarily affects the respiratory system, in some cases, it can cause severe neurological complications. Younger children are especially at risk. Pediatric literature is limited on the diagnosis, treatment, and prognosis of influenza-related neurological complications. The aim of the study was to evaluate children who suffered severe neurological manifestation as a result of seasonal influenza infection. METHODS The medical records of 14 patients from six hospitals in different regions of the country were evaluated. All of the children had a severe neurological manifestations related to laboratory-confirmed influenza infection. RESULTS Median age of the patients was 59 months (6 months-15.5 years) and nine (64.3%) were male. Only 4 (28.6%) of the 14 patients had a comorbid disease. Two patients were admitted to hospital with influenza-related late complications, and the remainder had acute complication. The most frequent complaints at admission were fever, altered mental status, vomiting, and seizure, respectively. Cerebrospinal fluid (CSF) analysis was performed in 11 cases, and pleocytosis was found in only two cases. Neuroradiological imaging was performed in 13 patients. The most frequent affected regions of nervous system were as follows: cerebellum, brainstem, thalamus, basal ganglions, periventricular white matter, and spinal cords. Nine (64.3%) patients suffered epileptic seizures. Two patients had focal seizure, and the rest had generalized seizures. Two patients developed status epilepticus. Most frequent diagnoses of patients were encephalopathy (n = 4), encephalitis (n = 3), and meningitis (n = 3), respectively. The rate of recovery without sequelae from was found to be 50%. At discharge, three (21.4%) patients had mild symptoms, another three (21.4%) had severe neurological sequelae. One (7.1%) patient died. The clinical findings were more severe and outcome was worse in patients <5 years old than patients >5 years old and in patients with comorbid disease than previously healthy group. CONCLUSION Seasonal influenza infection may cause severe neurological complications, especially in children. Healthy children are also at risk such as patients with comorbid conditions. All children who are admitted with neurological findings, especially during the influenza season, should be evaluated for influenza-related neurological complications even if their respiratory complaints are mild or nonexistent.
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Affiliation(s)
- Muhammet Sukru Paksu
- Pediatric Intensive Care Unit, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey. .,Ondokuz Mayis Universitesi Tip Fakultesi Cocuk Yogun Bakim Unitesi, 55139, Samsun, Turkey.
| | - Kerim Aslan
- Department of Radiology, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
| | - Tanil Kendirli
- Pediatric Intensive Care Unit, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Basak Nur Akyildiz
- Pediatric Intensive Care Unit, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Nazik Yener
- Pediatric Intensive Care Unit, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
| | - Riza Dincer Yildizdas
- Pediatric Intensive Care Unit, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Mehmet Davutoglu
- Pediatric Intensive Care Unit, Sutcu Imam University Faculty of Medicine, Kahramanmaras, Turkey
| | - Ayhan Yaman
- Pediatric Intensive Care Unit, Obstetrics and Gynecology and Children's Hospital, Gaziantep, Turkey
| | - Sedat Isikay
- Pediatric Neurology, Sutcu Imam University Faculty of Medicine, Kahramanmaras, Turkey
| | - Gulnar Sensoy
- Department of Pediatric Infection Diseases, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
| | - Haydar Ali Tasdemir
- Department of Pediatric Neurology, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
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16
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Simon E, Long B, Koyfman A. Clinical Mimics: An Emergency Medicine-Focused Review of Influenza Mimics. J Emerg Med 2017; 53:49-65. [PMID: 28215397 PMCID: PMC7135326 DOI: 10.1016/j.jemermed.2016.12.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 12/22/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Influenza viruses are a significant cause of morbidity and mortality in the United States. Given the wide range of symptoms, emergency physicians must maintain a broad differential diagnosis in the evaluation and treatment of patients presenting with influenza-like illnesses. OBJECTIVE This review addresses objective and subjective symptoms commonly associated with influenza and discusses important mimics of influenza viruses, while offering a practical approach to their clinical evaluation and treatment. DISCUSSION Influenza-like symptoms are common in the emergency department (ED), and influenza accounts for > 200,000 hospitalizations annually. The three predominant types are A, B, and C, and these viruses are commonly transmitted through aerosolized viral particles with a wide range of symptoms. The most reliable means of identifying influenza in the ED is rapid antigen detection, although consideration of local prevalence is required. High-risk populations include children younger than 4 years, adults older than 50 years, adults with immunosuppression or chronic comorbidities, pregnancy, obesity, residents of long-term care facilities, and several others. The Centers for Disease Control and Prevention recommends treatment with neuraminidase inhibitors in these populations. However, up to 70% of patients with these symptoms may have a mimic. These mimics include infectious and noninfectious sources. The emergency physician must be aware of life-threatening mimics and assess for these conditions while beginning resuscitation and treatment. CONCLUSIONS The wide range of symptoms associated with influenza overlap with several life-threatening conditions. Emergency physicians must be able to rapidly identify patients at risk for complications and those who require immediate resuscitation.
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Affiliation(s)
- Erica Simon
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
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17
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Abstract
Influenza infects 5% to 20% of school-age children annually. Although universal influenza vaccine is recommended for children and adults 6 months of age and older, uptake is below national targets. Influenza immunization of the child and the family is the key to decreasing annual disease burden. Antiviral therapy is an important treatment strategy for children and adults, especially those who are at high risk of complications from influenza, irrespective of immunization status or whether illness onset is greater than 48 hours. Although antiviral therapy may also be used for pre-exposure and postexposure prophylaxis, it should not replace immunization as a preventive strategy when immunization is feasible.
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Affiliation(s)
- Robyn A Livingston
- Division of Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, USA; University of Missouri-Kansas City School of Medicine, 2411 Holmes Road, Kansas City, MO 64108, USA.
| | - Henry H Bernstein
- Department of Pediatrics, Cohen Children's Medical Center of NY, Hofstra Northshore-LIJ School of Medicine, 410 Lakeville Road, Suite 108, New Hyde Park, NY 11042, USA
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18
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The inhibitory effect of kakkonto, Japanese traditional (kampo) medicine, on brain penetration of oseltamivir carboxylate in mice with reduced blood-brain barrier function. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2015; 2015:917670. [PMID: 25788966 PMCID: PMC4350872 DOI: 10.1155/2015/917670] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 01/30/2015] [Accepted: 01/31/2015] [Indexed: 11/17/2022]
Abstract
Oseltamivir phosphate (OP) is used to treat influenza virus infections. However, its use may result in central nervous system (CNS) adverse effects. In Japan, OP is used with Kampo formulations to improve clinical effectiveness. We evaluated the potential for using Kampo formulations to reduce CNS adverse effects by quantifying the CNS distribution of oseltamivir and its active metabolite oseltamivir carboxylate (OC) when administered with maoto and kakkonto. We administered lipopolysaccharide (LPS) by intraperitoneal injection to C57BL/6 mice to reduce blood-brain barrier function. Saline, maoto, and kakkonto were administered orally at the same time as LPS. OP was orally administered 4 hours after the last LPS injection and the migration of oseltamivir and OC was examined. Additionally, we examined the brain distribution of OC following intravenous administration. Changes in OC concentrations in the brain suggest that, in comparison to LPS-treated control mice, both Kampo formulations increased plasma levels of OC, thereby enhancing its therapeutic effect. Additionally, our findings suggest kakkonto may not only improve the therapeutic effect of oseltamivir but also reduce the risk of CNS-based adverse effects. Considering these findings, it should be noted that administration of kakkonto during periods of inflammation has led to increased OAT3 expression.
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19
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Elevated serum levels of neutrophil elastase in patients with influenza virus-associated encephalopathy. J Neurol Sci 2015; 349:190-5. [DOI: 10.1016/j.jns.2015.01.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 01/06/2015] [Accepted: 01/09/2015] [Indexed: 12/12/2022]
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20
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Neurologic manifestations and complications of pandemic influenza A H1N1 in Malaysian children: what have we learnt from the ordeal? Brain Dev 2015; 37:120-9. [PMID: 24746706 DOI: 10.1016/j.braindev.2014.03.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 03/04/2014] [Accepted: 03/07/2014] [Indexed: 11/23/2022]
Abstract
INTRODUCTION In 2009, pandemic influenza A H1N1 emerged in Mexico and subsequently spread worldwide. In Malaysia, there were more than a thousand of confirmed cases among children. The general clinical characteristics of these children have been well-published. However, the description of neurologic complications is scarce. OBJECTIVE This study aims to describe the characteristics of neurologic manifestations and complications in a national paediatric cohort with pandemic influenza A H1N1. METHODS During the pandemic, children (12 years or less) admitted for novel influenza A H1N1 in 68 Malaysian public hospitals, were prospectively enrolled into national database. The clinical, laboratory and neuro-imaging data for children with neurologic manifestations, hospitalized from 15th June 2009 till 30th November 2009, was reviewed. RESULTS Of 1244 children with influenza A H1N1 during the study period, 103 (8.3%) presented with influenza-related neurological manifestations. The mean age of our study cohort was 4.2 years (SD: 3.3 years). Sixty percent of them were males. Sixty-nine (66.9%) were diagnosed as febrile seizures, 16 (15.5%) as breakthrough seizures with underlying epilepsy, 14 (13.6%) as influenza-associated encephalopathy or encephalitis (IAE) and 4 (3.9%) as acute necrotizing encephalopathy of childhood (ANEC). All 4 available CSF specimens were negative for influenza viral PCR. Among 14 children with brain-imaging done, 9 were abnormal (2: cerebral oedema, 4: ANEC and 3: other findings). There were four deaths and three cases with permanent neurological sequelae. CONCLUSION About one-tenth of children with pandemic influenza A H1N1 presented with neurologic complications. The most common diagnosis was febrile seizures. One-fifth of those children with neurologic presentation had IAE or ANEC, which carried higher mortality and morbidity. This large national study provides us useful data to better manage children with neurologic complications in the future pandemic influenza outbreaks.
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21
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McSwiney P, Purnama J, Kornberg A, Danchin M. A severe neurological complication of influenza in a previously well child. BMJ Case Rep 2014; 2014:bcr-2014-206930. [PMID: 25342191 DOI: 10.1136/bcr-2014-206930] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We describe a case of a 3-year-old girl who was admitted with encephalopathy and a right-sided hemiparesis secondary to acute influenza A. She was up-to-date with the Australian National Immunisation Program (which does not routinely include the seasonal influenza vaccine). After initial treatment with intravenous antimicrobials and acyclovir, a brain and spinal cord MRI demonstrated extensive focal necrotic and haemorrhagic changes in keeping with acute necrotising encephalopathy (ANE). She was started on a course of oseltamivir and intravenous pulse methylprednisolone, followed by an oral weaning regimen of prednisolone. After an intense period of rehabilitation, she has made a remarkable recovery. Genetic testing has since confirmed that this girl has the RANBP2 gene mutation, which leads to increased susceptibility of developing ANE. This case report highlights ANE as a rare but severe complication of influenza, the unfortunate complication of having the RANBP2 mutation and the importance of paediatric influenza vaccination.
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Affiliation(s)
- Philippa McSwiney
- Department of General Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | | | - Andrew Kornberg
- Department of Neurology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Margie Danchin
- Department of General Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia
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22
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Kyan Y, Ueda Y, Yoshida M, Sasahara K, Shinya K. Transcriptome profiling of brain edemas caused by influenza infection and lipopolysaccharide treatment. J Med Virol 2013; 86:905-11. [PMID: 24306925 DOI: 10.1002/jmv.23801] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2013] [Indexed: 12/11/2022]
Abstract
Influenza A virus-associated encephalopathy triggered by influenza virus infection often occurs in children aged five and younger in Japan. However, the mechanisms behind Influenza A virus-associated encephalopathy are not yet well understood. This study developed an Influenza A virus-associated encephalopathy-like model using mice infected with Influenza A virus and given lipopolysaccharide treatment. The results showed that the mice used in the model suffered from brain edemas nearly three times more severe, as well as having higher cytokine levels in sera compared to those of the control groups. Using gene expression profiling, cytokine-related genes were found not to be up-regulated in the brain in situ, while protein coding genes, which are known to be involved in blood-brain barrier disruption, were up-regulated. Categorizing the functional groups using gene ontology revealed the terms "ion channels," "calcium oscillation," and "membrane transporter activities." The blood-brain barrier disruption found in this Influenza A virus-associated encephalopathy model can therefore be assumed to be due to a cellular electrolyte imbalance of the neuronal tissue, in addition to a cytokine storm.
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Affiliation(s)
- Yukihiro Kyan
- Graduate School of Medicine, Kobe University, Hyogo, Japan
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23
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Influenza-associated encephalopathy and neurolgic features of novel influenza A (H1N1) virus infection. Pediatr Crit Care Med 2010; 11:297-9. [PMID: 20124942 DOI: 10.1097/pcc.0b013e3181cf43a9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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24
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Posterior reversible encephalopathy syndrome and cerebral vasculopathy associated with influenza A infection: report of a case and review of the literature. J Comput Assist Tomogr 2010; 33:917-22. [PMID: 19940660 DOI: 10.1097/rct.0b013e3181993a43] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Influenza A infection can precipitate encephalopathy, encephalitis, or Reye syndrome with the development of cerebral edema in children and is associated with an increased incidence of stroke in adults. The mechanism of these events is poorly understood. Posterior reversible encephalopathy syndrome (PRES) is seen in association with infection/sepsis, and cerebral vasculopathy has been demonstrated in PRES. We describe a case of PRES that develops in association with influenza A. SUMMARY OF CASE A normotensive 65-year-old woman presented with altered mentation and nausea in the setting of a viral prodromal illness ultimately confirmed as influenza A. Posterior reversible encephalopathy syndrome developed on the second day after admission. Catheter cerebral angiogram documented vasculopathy in PRES-involved regions with areas of focal vessel dilatation and string-of-bead appearance. CONCLUSIONS The association between influenza A and PRES with documentation of cerebral vasculopathy suggests a common systemic vascular mechanism behind PRES and influenza-related encephalopathic edema and stroke.
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25
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Mild influenza-associated encephalopathy/encephalitis with a reversible splenial lesion in a Caucasian child with additional cerebellar features. Eur J Paediatr Neurol 2010; 14:97-100. [PMID: 19819739 DOI: 10.1016/j.ejpn.2009.09.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Revised: 06/23/2009] [Accepted: 09/17/2009] [Indexed: 11/23/2022]
Abstract
Mild influenza-associated encephalitis/encephalopathy with a reversible splenial lesion is a rare entity recently reported almost exclusively in Asiatic individuals. Hallmarks of this clinical-radiological syndrome include severe encephalopathy at onset, prompt and complete recovery, minimal to absent pleocytosis and rapidly reversible involvement of the splenium of the corpus callosum. We report herein a young Caucasian child who in addition had cerebellar involvement and presented a transient mutism during the recovery phase.
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26
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Bartynski WS, Upadhyaya AR, Petropoulou KA, Boardman JF. Influenza A encephalopathy, cerebral vasculopathy, and posterior reversible encephalopathy syndrome: combined occurrence in a 3-year-old child. AJNR Am J Neuroradiol 2009; 31:1443-6. [PMID: 20037134 DOI: 10.3174/ajnr.a1903] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Encephalopathy is an uncommon complication of childhood influenza infection, typically recognized during influenza epidemics. Imaging hallmarks include characteristic thalamic lesions, thalamic necrosis and hemispheric edema. We describe a child with acute influenza A associated necrotizing encephalopathy with MR angiographic evidence of significant cerebral vasculopathy and a hemispheric edema pattern consistent with PRES. This case reinforces that significant cerebral vasculopathy can accompany influenza infection and that influenza is a likely trigger for PRES.
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Affiliation(s)
- W S Bartynski
- Department of Radiology, Presbyterian University Hospital, University of Pittsburgh, Pittsburgh, PA, USA.
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28
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29
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Sejvar JJ. Acute disseminated encephalomyelitis. Curr Infect Dis Rep 2008; 10:307-14. [PMID: 18765104 PMCID: PMC2568871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Acute disseminated encephalomyelitis (ADEM) is a demyelinating syndrome of the central nervous system. It is considered to be an autoimmune response to an antecedent antigenic stimulus, most frequently a prior infectious illness (postinfectious encephalitis) or immunization (postvaccination encephalitis) occurring in the days or weeks before neurologic illness. Clinically, ADEM is characterized by encephalopathy, or focal/multifocal neurologic signs; brain MRI is characterized by diffuse multifocal or patchy areas of demyelination. The differentiation between ADEM and a first episode of multiple sclerosis, a chronic central nervous system demyelinating disease, may be difficult but has important prognostic and treatment implications. Although no clinical trials have assessed the efficacy of treatment modalities in patients with ADEM, immunomodulators, including corticosteroids and intravenous immunoglobulin, are frequently used empirically. ADEM outcome is generally favorable, with resolution over weeks to months.
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Affiliation(s)
- James J Sejvar
- Division of Viral and Rickettsial Diseases, Division of Vector-Borne Infectious Diseases, National Center for Zoonotic, Vectorborne, and Enteric Diseases, US Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop A-39, Atlanta, GA 30333, USA.
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30
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31
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Millichap JG. Prognostic Value of Cytochrome C and Cytokines in Acute Viral Encephalopathy. Pediatr Neurol Briefs 2006. [DOI: 10.15844/pedneurbriefs-20-6-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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