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Mahmood H, Kiani M, Madani Y. 'A kiss that took my legs away': a rare presentation of Epstein-Barr virus in the older population. Clin Med (Lond) 2023; 23:621-624. [PMID: 38065604 PMCID: PMC11046652 DOI: 10.7861/clinmed.2023-0415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
We present the case of a 70-year-old woman presenting with nausea, diarrhoea and a generalised rash. Initial blood tests revealed obstructive deranged liver function tests and low haemoglobin. A haemolysis screen revealed raised reticulocytes, low haptoglobin and a positive direct antiglobulin test. 6 days into her admission, she developed lower limb weakness and loss of sensation. MRI spine showed no significant findings. Cerebrospinal fluid showed raised white blood cell count and raised protein. Nerve conduction studies were normal. The clinical picture was in keeping with transverse myelitis. Autoimmune and viral screens were negative except for a single result which provided the unifying diagnosis: Epstein-Barr virus (EBV). She responded to high dose intravenous corticosteroids and her rehabilitation is ongoing. EBV should be considered even in the older population.
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Affiliation(s)
| | | | - Yasser Madani
- Wexham Park Hospital, Slough, UK; Wexham Park Hospital, Wexham Street, Slough, Berkshire, SL2 4HL
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2
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Hardy D. Monophasic Acquired Demyelinating Syndromes of the Central Nervous System in Children. Semin Pediatr Neurol 2023; 46:101050. [PMID: 37451746 DOI: 10.1016/j.spen.2023.101050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/10/2023] [Accepted: 04/23/2023] [Indexed: 07/18/2023]
Abstract
Acquired demyelinating syndromes of the central nervous system are immune-mediated demyelinating disorders that can affect the brain, optic nerves, and spinal cord. These disorders have become increasingly recognized in children due to advances in imaging techniques, improvements in diagnostic testing, extensive research into understanding the pathophysiology underlying these disorders, and collaborative multi-institutional efforts to raise awareness of these disorders in children. Moreover, developments in the field of neuroimmunology have allowed us to identify autoantibodies that have presumed causal roles in acquired demyelinating syndromes. Identification of these autoantibodies helps determine clinical course (ie, monophasic vs relapsing course), prognosis, and treatment approach. Acquired demyelinating disorders can affect both children and adults. However, the clinical features, disease course, and treatments are often unique in the pediatric population. Thus, it is important to understand the spectrum of these disorders in children to help provide a timely diagnosis and prompt treatment to achieve optimal outcomes. In this article, the epidemiology, clinical features, diagnosis, treatment, and outcomes of the most common monophasic acquired demyelinating syndromes in children will be reviewed.
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Affiliation(s)
- Duriel Hardy
- Department of Neurology, Dell Medical School, University of Texas at Austin, Austin, TX.
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3
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Abstract
PURPOSE OF REVIEW This article reviews the clinical presentation, diagnostic evaluation, treatment, and prognosis of the most common monophasic and relapsing acquired demyelinating disorders presenting in childhood. RECENT FINDINGS Our understanding of neuroimmune disorders of the central nervous system is rapidly expanding. Several clinical and paraclinical factors help to inform the diagnosis and ultimately the suspicion for a monophasic versus relapsing course, including the age of the patient (prepubertal versus postpubertal), presence or absence of clinical encephalopathy, identification of serum autoantibodies (eg, myelin oligodendrocyte glycoprotein [MOG] and aquaporin-4), presence of intrathecally unique oligoclonal bands, and location/extent of radiologic abnormalities. Collaborative international research efforts have facilitated understanding of the safety and efficacy of currently available immunotherapies in children with acquired demyelinating disorders, particularly multiple sclerosis. SUMMARY Although many of the demyelinating disorders presented in this article can affect children and adults across the age spectrum, the clinical and radiologic phenotypes, treatment considerations, and long-term prognoses are often distinct in children.
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Barman A, Sahoo J, Viswanath A, Roy SS, Swarnakar R, Bhattacharjee S. Clinical Features, Laboratory, and Radiological Findings of Patients With Acute Inflammatory Myelopathy After COVID-19 Infection: A Narrative Review. Am J Phys Med Rehabil 2021; 100:919-939. [PMID: 34347629 PMCID: PMC8436817 DOI: 10.1097/phm.0000000000001857] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT The objective of this review was to analyze the existing data on acute inflammatory myelopathies associated with coronavirus disease 2019 infection, which were reported globally in 2020. PubMed, CENTRAL, MEDLINE, and online publication databases were searched. Thirty-three acute inflammatory myelopathy cases (among them, seven cases had associated brain lesions) associated with coronavirus disease 2019 infection were reported. Demyelinating change was seen in cervical and thoracic regions (27.3% each, separately). Simultaneous involvement of both regions, cervical and thoracic, was seen in 45.4% of the patients. Most acute inflammatory myelopathy disorders reported sensory motor and bowel bladder dysfunctions. On cerebrospinal fluid analysis, pleocytosis and increased protein were reported in 56.7% and 76.7% of the patients, respectively. Cerebrospinal fluid severe acute respiratory syndrome coronavirus 2 reverse transcriptase-polymerase chain reaction was positive in five patients. On T2-weighted imaging, longitudinally extensive transverse myelitis and short-segment demyelinating lesions were reported in 76% and 21%, respectively. Among the patients with longitudinally extensive transverse myelitis, 61% reported "moderate to significant" improvement and 26% demonstrated "no improvement" in the motor function of lower limbs. Demyelinating changes in the entire spinal cord were observed in three patients. Most of the patients with acute inflammatory myelopathy (including brain lesions) were treated with methylprednisolone (81.8%) and plasma-exchange therapy (42.4%). An early treatment, especially with intravenous methylprednisolone with or without immunoglobulin and plasma-exchange therapy, helped improve motor recovery in the patients with acute inflammatory myelopathy associated with coronavirus disease 2019.
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He CB, Lee JR, Kahana M. Mycoplasma pneumoniae Associated Acute Transverse Myelitis: An Atypical Clinical Presentation in an Adolescent Child. Cureus 2021; 13:e17259. [PMID: 34540483 PMCID: PMC8445634 DOI: 10.7759/cureus.17259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2021] [Indexed: 11/30/2022] Open
Abstract
We report an atypical case of a 15-year-old pediatric patient diagnosed with Mycoplasma pneumoniae associated acute transverse myelitis (ATM). The patient had no prodromal or pulmonary symptoms that are commonly associated with mycoplasma infection. Yet, the patient exhibited acute bilateral lower extremity paralysis, paresthesia, decreased sensation at the level of T11 and below, bowel and bladder dysfunction, and thrombocytopenia. Magnetic resonance imaging of the spinal cord revealed transverse myelitis from T10 to the end of the conus medullaris. The patient showed only slow clinical improvement despite therapy consisting of azithromycin, high-dose intravenous methylprednisolone, intravenous immunoglobulin, and plasmapheresis. This report calls attention to the importance of early identification of mycoplasma as an underlying cause of ATM and the potential consequences of delayed detection and treatment: more severe neurologic complications, prolonged hospitalization, and unfavorable clinical outcomes.
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Affiliation(s)
- Chong Bin He
- Pediatrics, University of Central Florida College of Medicine, Orlando, USA
| | - James R Lee
- Emergency Medicine, North Florida Regional Medical Center, Gainesville, USA
| | - Madelyn Kahana
- Pediatric Critical Care Medicine, Nemours Children's Hospital, Orlando, USA
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Wörner N, Rodrigo-García R, Antón A, Castellarnau E, Delgado I, Vazquez È, González S, Mayol L, Méndez M, Solé E, Rosal J, Andrés C, Casquero A, Lera E, Sancosmed M, Campins M, Pumarola T, Rodrigo C. Enterovirus-A71 Rhombencephalitis Outbreak in Catalonia: Characteristics, Management and Outcome. Pediatr Infect Dis J 2021; 40:628-633. [PMID: 34097655 PMCID: PMC8189429 DOI: 10.1097/inf.0000000000003114] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/27/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Between April and June 2016, an outbreak of rhombencephalitis (RE) caused by enterovirus (EV) A71 was detected in Catalonia, Spain-the first documented in Western Europe. The clinical characteristics and outcome of patients with this condition differed from those reported in outbreaks occurring in Southeast Asia. METHODS Observational, multicenter study analyzing characteristics, treatment and outcome of patients with EV-A71 rhombencephalitis diagnosed in 6 publicly funded hospitals within the Catalonian Health Institute. A review of clinical characteristics, diagnosis, treatment and outcome of these patients was conducted. RESULTS Sixty-four patients met the clinical and virologic criteria for rhombencephalitis caused by EV-A71. All patients had symptoms suggesting viral disease, mainly fever, lethargy, ataxia and tremor, with 30% of hand-foot-mouth disease. Intravenous immunoglobulin therapy was given to 44/64 (69%) patients and methylprednisolone to 27/64 (42%). Six patients (9%) required pediatric intensive care unit admission. Three patients had acute flaccid paralysis of 1 limb, and another had autonomic nervous system (ANS) dysfunction with cardiorespiratory arrest. Outcome in all patients (except the patient with hypoxic-ischemic encephalopathy) was good, with complete resolution of the symptoms. CONCLUSIONS During the 2016 outbreak, rhombencephalitis without ANS symptoms was the predominant form of presentation and most patients showed no hand-foot-mouth disease. These findings contrast with those of other patient series reporting associated ANS dysfunction (10%-15%) and hand-foot-mouth disease (60%-80%). Complete recovery occurred in almost all cases. In light of the favorable outcome in untreated mild cases, therapies for this condition should be reserved for patients with moderate-severe infection. The main relevance of this study is to provide useful information for setting priorities, management approaches and adequate use of resources in future EV-A71 associated rhombencephalitis outbreaks.
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Affiliation(s)
- Núria Wörner
- From the Pediatric Emergency Department, Department of Pediatrics, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Rocío Rodrigo-García
- From the Pediatric Emergency Department, Department of Pediatrics, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Andrés Antón
- Department of Microbiology, Vall d’Hebron University Hospital, Barcelona, Spain
- Vall d’Hebron Research Institute, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ester Castellarnau
- Department of Pediatrics, Joan XXIII University Hospital, Tarragona, Spain
| | - Ignacio Delgado
- Department of Pediatric Radiology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Èlida Vazquez
- Department of Pediatric Radiology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Sebastià González
- From the Pediatric Emergency Department, Department of Pediatrics, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Lluís Mayol
- Department of Pediatrics, Josep Trueta University Hospital, Girona, Spain
| | - Maria Méndez
- Department of Pediatrics, Germans Trias i Pujol University Hospital, Badalona, Spain
| | - Eduard Solé
- Department of Pediatrics, Arnau de Vilanova University Hospital, Lleida, Spain
| | - Jaume Rosal
- Department of Pediatrics, Verge de la Cinta Hospital, Tortosa, Spain
| | - Cristina Andrés
- Department of Microbiology, Vall d’Hebron University Hospital, Barcelona, Spain
- Vall d’Hebron Research Institute, Barcelona, Spain
| | - Alejandro Casquero
- From the Pediatric Emergency Department, Department of Pediatrics, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Esther Lera
- From the Pediatric Emergency Department, Department of Pediatrics, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Mónica Sancosmed
- From the Pediatric Emergency Department, Department of Pediatrics, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Magda Campins
- Vall d’Hebron Research Institute, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Preventive Medicine and Epidemiology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Tomàs Pumarola
- Department of Microbiology, Vall d’Hebron University Hospital, Barcelona, Spain
- Vall d’Hebron Research Institute, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carlos Rodrigo
- From the Pediatric Emergency Department, Department of Pediatrics, Vall d’Hebron University Hospital, Barcelona, Spain
- Vall d’Hebron Research Institute, Barcelona, Spain
- Faculty of Medicine at Germans Trias i Pujol University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain. Carlos Rodrigo, MD, PhD, is currently at the Department of Pediatrics, Germans Trias i Pujol University Hospital, Badalona, Barcelona, Spain
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Helfferich J, Bruijstens AL, Wong YYM, Danielle van Pelt E, Boon M, Neuteboom RF. Prognostic factors for relapse and outcome in pediatric acute transverse myelitis. Brain Dev 2021; 43:626-636. [PMID: 33509615 DOI: 10.1016/j.braindev.2020.12.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 12/04/2020] [Accepted: 12/24/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE It may be difficult for clinicians to estimate the prognosis of pediatric acute transverse myelitis (ATM). The aim of this study was to define prognostic factors for relapsing disease and poor outcome in pediatric ATM. METHODS This prospective cohort study included 49 children, 18 boys and 31 girls (median age 13.1 years, IQR 6.5-16.2) with a first episode of ATM. Factors associated with relapsing disease and poor outcome (Expanded Disability Status Scale (EDSS) ≥ 4) were assessed during a median follow-up of 37 months (IQR 18-75). RESULTS In total, 14 patients (29%) experienced ≥ 1 relapse(s) and nine patients (18%) had a poor outcome. Factors at onset associated with relapsing disease included higher age (16.1 vs. 11.6 years, p = 0.002), longer time to maximum severity of symptoms (5.5 vs. 3 days, p = 0.01), lower maximum EDSS score (4.0 vs. 6.5, p = 0.003), short lesion on spinal MRI (64 vs. 21%, p = 0.006), abnormalities on brain MRI (93 vs. 44%, p = 0.002) and presence of oligoclonal bands in cerebrospinal fluid (67 vs. 14%, p = 0.004). The only factor associated with poor outcome was presence of a spinal cord lesion on MRI without cervical involvement (56 vs. 14%, p = 0.02). CONCLUSION Pediatric ATM patients presenting with clinical, radiological and laboratory features associated with multiple sclerosis (MS) are at risk for relapsing disease. In absence of these known MS risk factors at onset of disease these patients are at low risk for relapses. Only a minority of pediatric ATM patients in this cohort have a poor outcome.
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Affiliation(s)
- Jelte Helfferich
- Department of Neurology, University Medical Center Groningen, PO Box 30001, 9700 RB Groningen, the Netherlands; Department of Neurology, Erasmus Medical Center, Room Ee-2230, PO Box 2040, 3000 CA Rotterdam, the Netherlands.
| | - Arlette L Bruijstens
- Department of Neurology, Erasmus Medical Center, Room Ee-2230, PO Box 2040, 3000 CA Rotterdam, the Netherlands.
| | - Yu Yi M Wong
- Department of Neurology, Erasmus Medical Center, Room Ee-2230, PO Box 2040, 3000 CA Rotterdam, the Netherlands.
| | - E Danielle van Pelt
- Department of Neurology, Erasmus Medical Center, Room Ee-2230, PO Box 2040, 3000 CA Rotterdam, the Netherlands.
| | - Maartje Boon
- Department of Neurology, University Medical Center Groningen, PO Box 30001, 9700 RB Groningen, the Netherlands.
| | - Rinze F Neuteboom
- Department of Neurology, Erasmus Medical Center, Room Ee-2230, PO Box 2040, 3000 CA Rotterdam, the Netherlands.
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Wang P, Zhang S, Lv H, Qiao G, Zhong X, Li H, Zhang L. Clinical efficacy of γ-globulin combined with dexamethasone and methylprednisolone, respectively, in the treatment of acute transverse myelitis and its effects on immune function and quality of life. Exp Ther Med 2020; 20:104. [PMID: 32989383 PMCID: PMC7517252 DOI: 10.3892/etm.2020.9234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 04/29/2020] [Indexed: 11/25/2022] Open
Abstract
Effects of γ-globulin combined with dexamethasone or methylprednisolone in the treatment of acute transverse myelitis (ATM) were investigated. A retrospective analysis of medical records from 136 ATM patients admitted to Linzi District People's Hospital from July 2014 to September 2017 was performed. Patients treated with dexamethasone combined with γ-globulin were in group A (66 cases), and patients treated with methylprednisolone combined with γ-globulin were in group B (70 cases). Clinical efficacy, recovery time of bone marrow function and incidence rate of adverse reactions were analyzed and compared between the two groups. T-lymphocyte subsets in peripheral blood of both groups were detected by Flow cytometry. Quality of life of patients was assessed by the Quality of Life Scale (SF-36) developed by the American Institute of Medicine. Time of sensory recovery, self-walking, improving muscle strength at two levels and urination recovery after treatment in group B were significantly shorter than those in group A (P<0.001); effective rate of treatment in group B was significantly higher than that in group A (P<0.05); incidence rate of adverse reactions in group B was significantly lower than that in group A (P<0.05); ratios of CD3+, CD4+, CD8+ cells and CD4+/CD8+ in peripheral blood of group A and group B after treatment were significantly higher than those before treatment (P<0.05); scores of general health (GH), physical function (PF), role physical (RP), body pain (BP), social function (SF), role emotional (RE), mental health (MH) and vitality (VT) in group B after treatment were significantly higher than those in group A (P<0.05). In conclusion, clinical efficacy of γ-globulin combined with methylprednisolone in the treatment of ATM patients shows definitely fewer adverse reactions, which can improve their immune function and quality of life.
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Affiliation(s)
- Peiquan Wang
- Department of Critical Care Medicine, Linzi District People's Hospital, Zibo, Shandong 255400, P.R. China
| | - Suhua Zhang
- Department of Critical Care Medicine, Linzi District People's Hospital, Zibo, Shandong 255400, P.R. China
| | - Hongchun Lv
- Department of Critical Care Medicine, Linzi District People's Hospital, Zibo, Shandong 255400, P.R. China
| | - Gang Qiao
- Department of Critical Care Medicine, Linzi District People's Hospital, Zibo, Shandong 255400, P.R. China
| | - Xiaodong Zhong
- Department of Critical Care Medicine, Linzi District People's Hospital, Zibo, Shandong 255400, P.R. China
| | - Hua Li
- Department of Critical Care Medicine, Linzi District People's Hospital, Zibo, Shandong 255400, P.R. China
| | - Lili Zhang
- Department of Critical Care Medicine, Linzi District People's Hospital, Zibo, Shandong 255400, P.R. China
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D’Amico S, Pavone P, Testa G, Greco F, Marino L, Smilari P, Pavone V. Secondary Scoliosis as a Complication of Acute Transverse Myelitis in a Child. J Funct Morphol Kinesiol 2020; 5:jfmk5020039. [PMID: 33467256 PMCID: PMC7739325 DOI: 10.3390/jfmk5020039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 05/26/2020] [Accepted: 06/06/2020] [Indexed: 11/26/2022] Open
Abstract
Acute transverse myelitis (ATM) is a rare neurological condition that affects the spinal cord. Several events, including infections, autoimmune conditions, inflammatory, and drug-induced factors, may cause this disorder. Correct and rapid etiological diagnosis is necessary in order to start appropriate treatment that mainly consists of immunomodulating therapy, high dose intravenous corticosteroids, and in plasma exchange in noninfectious cases. The outcome is varied and depends on several factors. In children, the prognosis is usually good. We report a case of an 11-year-old boy who presented with interscapular pain, right leg steppage, homolateral hyposthenia of the upper limb, and signs of autonomic dysfunction. After performing specific and instrumental exams, a diagnosis of transverse myelitis was reached, and appropriate therapy was performed. A few days post-treatment, the child developed a secondary scoliosis, involving a thoracolumbar curve with loss of cervical and lumbar lordosis. After rehabilitative treatment was undertaken for 12 months, a complete recovery and normal restoration of spinal physiological curves was obtained. The pediatric cases of ATM have a good response to steroid therapy combined with physiotherapy. Collaboration among the various specialists is worthwhile, in order to lead to a correct and rapid diagnosis.
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Affiliation(s)
- Silvia D’Amico
- Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy; (S.D.); (P.P.); (F.G.); (L.M.); (P.S.)
| | - Piero Pavone
- Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy; (S.D.); (P.P.); (F.G.); (L.M.); (P.S.)
| | - Gianluca Testa
- Department of Orthopaedics and Traumatologic Surgery, AOU Policlinico-Vittorio Emanuele, University of Catania, Via Santa Sofia, 78, 95123 Catania, Italy;
| | - Filippo Greco
- Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy; (S.D.); (P.P.); (F.G.); (L.M.); (P.S.)
| | - Lidia Marino
- Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy; (S.D.); (P.P.); (F.G.); (L.M.); (P.S.)
| | - Pierluigi Smilari
- Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy; (S.D.); (P.P.); (F.G.); (L.M.); (P.S.)
| | - Vito Pavone
- Department of Orthopaedics and Traumatologic Surgery, AOU Policlinico-Vittorio Emanuele, University of Catania, Via Santa Sofia, 78, 95123 Catania, Italy;
- Correspondence: ; Tel.: +39-095-378-2273; Fax: +39-095-378-2320
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Transverse myelitis masquerading as cauda equina syndrome, stroke and cervical myelopathy. Biomedicine (Taipei) 2020; 10:45-50. [PMID: 33854913 PMCID: PMC7608839 DOI: 10.37796/2211-8039.1005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 06/18/2019] [Indexed: 11/19/2022] Open
Abstract
Transverse myelitis is an uncommon but well-defined neurological syndrome. However, a high index of suspicion is needed to diagnose this condition, especially when it occurs in concomitance with preexisting spinal canal stenosis. We report our patient, a 48 year old male, who initially presented to our spine clinic with acute onset unilateral lower limb weakness associated with urinary retention, which was suspected to be cauda equina syndrome due to a prolapsed intervertebral disc. However, initial magnetic resonance (MR) imaging showed only mild spinal canal stenosis from L2-L5 and C3– C6 levels; thus, the possibility of cauda equina syndrome was ruled out. A few days later, patient developed ipsilateral upper limb weakness giving an impression of hemiparesis due to stroke. However, imaging of brain returned normal. There was still a dilemma whether symptoms could be due to cervical myelopathy as there was mild cervical cord compression with early myelomalacia changes, but the findings were subtle to come to a definite conclusion. Subsequently, patient desaturated and required ventilatory support. Repeat MR imaging of the cervical spine revealed T2 hyperintensities spanning multiple levels in the cervical cord which highlighted the possibility of transverse myelitis and the diagnosis was clinched after a CSF analysis. Despite the debilitating effects, patient responded well to corticosteroid therapy and gradually recovered. This case is reported to highlight the diagnostic dilemma and the rapid progression of transverse myelitis that demands timely medical intervention to avoid permanent disabilities.
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Abstract
In this chapter, we will review monophasic and recurrent demyelinating disorders in children. We will first review consensus definitions and provide an approach to the evaluation of children with first episode of acquired demyelinating disorder. We will discuss typical clinical and radiological features of these syndromes. In the second section, we will review features of recurrent demyelinating syndromes in children, focusing on clinical presentation and treatment options.
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Affiliation(s)
- Mustafa A.M. Salih
- College of Medicine Division of Pediatric Neurology, King Saud University, Riyadh, Saudi Arabia
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13
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Konuskan B, Anlar B. Treatment in childhood central nervous system demyelinating disorders. Dev Med Child Neurol 2019; 61:1281-1288. [PMID: 30993677 DOI: 10.1111/dmcn.14228] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/05/2019] [Indexed: 11/30/2022]
Abstract
The last two decades witnessed significant advances in the treatment of acquired demyelinating disorders: thirteen new agents have been approved for the treatment of multiple sclerosis in adults by the European Medicines Agency and US Food and Drug Administration in the last twenty years. Although the long-term efficacy and safety profiles of some new drugs are still being assessed in paediatric MS, clinicians may have to use them in the management of paediatric onset MS resistant to first-line medications, based on results obtained in adult-onset disease. This review summarizes the current approach to treatment in children with demyelinating syndromes. WHAT THIS PAPER ADDS: Serological markers affect management in paediatric demyelinating diseases. Antibodies against aquaporin-4 and myelin oligodendrocyte glycoprotein should be tested in children with acute demyelinating disease. New therapeutic agents currently in trial for pediatric disease should be used with close follow-up.
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Affiliation(s)
- Bahadir Konuskan
- Department of Pediatric Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Banu Anlar
- Department of Pediatric Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Taravilla CN, Pérez-Sebastián I, Salido AG, Serrano CV, Extremera VC, Rodríguez AD, Marín LL, Sanz MA, Traba OMS, González AS. Enterovirus A71 Infection and Neurologic Disease, Madrid, Spain, 2016. Emerg Infect Dis 2019; 25. [PMID: 30560775 PMCID: PMC6302576 DOI: 10.3201/eid2501.181089] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
For children with brainstem encephalitis or encephalomyelitis, clinicians should look for enterovirus and not limit testing to cerebrospinal fluid. We conducted an observational study from January 2016 through January 2017 of patients admitted to a reference pediatric hospital in Madrid, Spain, for neurologic symptoms and enterovirus infection. Among the 30 patients, the most common signs and symptoms were fever, lethargy, myoclonic jerks, and ataxia. Real-time PCR detected enterovirus in the cerebrospinal fluid of 8 patients, nasopharyngeal aspirate in 17, and anal swab samples of 5. The enterovirus was genotyped for 25 of 30 patients; enterovirus A71 was the most common serotype (21/25) and the only serotype detected in patients with brainstem encephalitis or encephalomyelitis. Treatment was intravenous immunoglobulins for 21 patients and corticosteroids for 17. Admission to the pediatric intensive care unit was required for 14 patients. All patients survived. At admission, among patients with the most severe disease, leukocytes were elevated. For children with brainstem encephalitis or encephalomyelitis, clinicians should look for enterovirus and not limit testing to cerebrospinal fluid.
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Affiliation(s)
- Philip Overby
- Department of Neurology and.,Department of Pediatrics, New York Medical College, Valhalla, NY
| | - Matthew Kapklein
- Department of Pediatrics, New York Medical College, Valhalla, NY
| | - Ronald I Jacobson
- Department of Neurology and.,Department of Pediatrics, New York Medical College, Valhalla, NY
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Pascual-Goñi E, Josa M, Launes C, Querol L, Del Cuerpo M, Bosch MA, Jordan I, Turón-Viñas E. Excellent Response to Plasma Exchange in Three Patients With Enterovirus-71 Neurological Disease. Front Neurol 2019; 10:548. [PMID: 31178823 PMCID: PMC6542981 DOI: 10.3389/fneur.2019.00548] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 05/07/2019] [Indexed: 12/05/2022] Open
Abstract
The clinical spectrum of Enterovirus-71-associated neurological disease includes acute flaccid paralysis, encephalomyelitis, or brainstem encephalitis with autonomic dysfunction. As no specific antiviral treatments are available, intravenous human immunoglobulin is used in early stages of the illness, decreasing serum proinflammatory cytokines, and improving clinical outcomes. Plasma exchange aims to eliminate pathogenic autoantibodies and proinflammatory cytokines, and is used in diverse immune-mediated neurologic conditions. However, its effect in Enterovirus-71 infections is unknown. We report three cases of severe Enterovirus-71 neurological disease treated with plasma exchange during an outbreak in Catalonia (Spain) in 2016. We observed a striking improvement in all three patients within 48 h of starting plasma exchange. Patients received four to six sessions every other day. Good outcomes were confirmed at the 1-year follow-up visit. Our observations suggest that plasma exchange is an effective complementary therapy for severe Enterovirus-71 neurological disease.
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Affiliation(s)
- Elba Pascual-Goñi
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Maria Josa
- Department of Pediatrics, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Cristian Launes
- Pediatric Infectious Diseases Research Group, CIBER of Epidemiology and Public Health (CB15/00067 Group), Institut de Recerca Pediàtrica Sant Joan de Déu, Esplugues, Spain
| | - Luis Querol
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Marga Del Cuerpo
- Department of Microbiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - M Alba Bosch
- Banc de Sang i Teixits, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Iolanda Jordan
- Pediatric Infectious Diseases Research Group, CIBER of Epidemiology and Public Health (CB15/00067 Group), Institut de Recerca Pediàtrica Sant Joan de Déu, Esplugues, Spain.,Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, Esplugues de Llobregat, Spain
| | - Eulàlia Turón-Viñas
- Department of Pediatrics, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Golub D, Williams F, Wong T, Iyengar N, Jolley H, Sabadiah S, Rhee D, Gold-von Simson G. A Longitudinally Extensive Spinal Cord Lesion Restricted to Gray Matter in an Adolescent Male. Front Neurol 2019; 10:270. [PMID: 30949125 PMCID: PMC6435483 DOI: 10.3389/fneur.2019.00270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 02/28/2019] [Indexed: 01/19/2023] Open
Abstract
Longitudinally extensive spinal cord lesions (LECL) restricted to gray matter are poorly understood as are their neurodevelopmental repercussions in children. We herein report the critical case of a 13-year-old male presenting with progressive quadriparesis found to have cervical LECL restricted to the anterior horns. Challenged with a rare diagnostic dilemma, the clinical team systematically worked through potential vascular, genetic, infectious, rheumatologic, and paraneoplastic diagnoses before assigning a working diagnosis of acute inflammatory myelopathy. Nuanced consideration of and workup for both potential ischemic causes (arterial dissection, fibrocartilaginous embolism, vascular malformation) and specific inflammatory conditions including Transverse Myelitis, Neuromyelitis Optica Spectrum Disorders (NMOSD), Multiple Sclerosis (MS), Acute Disseminated Encephalomyelitis (ADEM), and Acute Flaccid Myelitis (AFM) is explained in the context of a comprehensive systematic review of the literature on previous reports of gray matter-restricted longitudinally extensive cord lesions in children. Treatment strategy was ultimately based on additional literature review of treatment-refractory acute inflammatory neurological syndromes in children. A combination of high-dose steroids and plasmapheresis was employed with significant improvement in functional outcome, suggesting a potential benefit of combination immune-modulatory treatment in these patients. This case furthermore highlights quality clinical reasoning with respect to the elusive nature of diagnosis, nuances in neuroimaging, and multifocal treatment strategies in pediatric LECL.
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Affiliation(s)
- Danielle Golub
- New York University School of Medicine, New York, NY, United States
| | - Faith Williams
- School of Medicine, Washington University School of Medicine, Saint Louis, MO, United States
| | - Taylor Wong
- New York University School of Medicine, New York, NY, United States
| | - Nishanth Iyengar
- New York University School of Medicine, New York, NY, United States
| | - Hannah Jolley
- Department of Pediatrics, New York University School of Medicine, New York, NY, United States
| | - Sakinah Sabadiah
- Department of Neurology, New York University School of Medicine, New York, NY, United States
| | - David Rhee
- Department of Pediatrics, New York University School of Medicine, New York, NY, United States
| | - Gabrielle Gold-von Simson
- Department of Pediatrics, New York University School of Medicine, New York, NY, United States.,Health and Hospitals, Clinical Translational Science Institute, New York University, New York, NY, United States
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TAVASOLI A, TABRIZI A. Acute Transverse Myelitis in Children, Literature Review. IRANIAN JOURNAL OF CHILD NEUROLOGY 2018; 12:7-16. [PMID: 29696041 PMCID: PMC5904733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 11/11/2017] [Accepted: 12/03/2017] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Acute transverse myelitis (ATM) is a rare inflammatory demyelinating disorder characterized by relatively acute onset of motor, sensory, and autonomic dysfunction. Children comprise 20% of total cases of ATM. In this review, we described the current literature on childhood ATM, focusing on the epidemiology, pathogenesis, clinical presentation, approach to diagnosis, differential diagnosis, treatment and outcome in the pediatric population. MATERIALS &METHODS We searched the related articles in electronic databases such as Scopus, EMBASE, Google Scholar, and PubMed. All study designs were included and the essential key words for searching were myelitis, acute transverse myelitis, childhood transverse myelitis, and acquired demyelinating syndromes. RESULTS The related data focusing on the epidemiology, pathogenesis, clinical presentation, diagnostic approach and differential diagnosis, treatment and outcome of pediatric ATM were gathered and described. CONCLUSION ATM is a heterogeneous disorder in children with a broad spectrum of clinical presentation, etiology, and outcome. It may be the first presentation of relapsing acquired demyelinating syndromes and also must be distinguished from compressive and noninflamatory myelopathies. Correct diagnosis is crucial for treatment and prognosis.
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Affiliation(s)
- Azita TAVASOLI
- Department of Pediatric Neurology, Iran University of Medical Sciences, Tehran, Iran
| | - Aidin TABRIZI
- Pediatric Neurology Research Center, Shahid Beheshti University of Medical Siences, Tehran, Iran
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Andersen EW, Kornberg AJ, Freeman JL, Leventer RJ, Ryan MM. Acute flaccid myelitis in childhood: a retrospective cohort study. Eur J Neurol 2017. [DOI: 10.1111/ene.13345] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- E. W. Andersen
- Department of Neurology; The Royal Children's Hospital; Melbourne Victoria Australia
- Department of Paediatrics and Child Health; University of Otago Wellington; Wellington New Zealand
| | - A. J. Kornberg
- Department of Neurology; The Royal Children's Hospital; Melbourne Victoria Australia
| | - J. L. Freeman
- Department of Neurology; The Royal Children's Hospital; Melbourne Victoria Australia
- Murdoch Children's Research Institute; Melbourne Victoria Australia
| | - R. J. Leventer
- Department of Neurology; The Royal Children's Hospital; Melbourne Victoria Australia
- Murdoch Children's Research Institute; Melbourne Victoria Australia
- Department of Paediatrics; University of Melbourne; Melbourne Victoria Australia
| | - M. M. Ryan
- Department of Neurology; The Royal Children's Hospital; Melbourne Victoria Australia
- Murdoch Children's Research Institute; Melbourne Victoria Australia
- Department of Paediatrics; University of Melbourne; Melbourne Victoria Australia
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21
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Collongues N, Kremer S, de Sèze J. Mielopatie acute. Neurologia 2017. [DOI: 10.1016/s1634-7072(17)83854-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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22
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Casas-Alba D, de Sevilla MF, Valero-Rello A, Fortuny C, García-García JJ, Ortez C, Muchart J, Armangué T, Jordan I, Luaces C, Barrabeig I, González-Sanz R, Cabrerizo M, Muñoz-Almagro C, Launes C. Outbreak of brainstem encephalitis associated with enterovirus-A71 in Catalonia, Spain (2016): a clinical observational study in a children's reference centre in Catalonia. Clin Microbiol Infect 2017; 23:874-881. [PMID: 28344164 DOI: 10.1016/j.cmi.2017.03.016] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 03/15/2017] [Accepted: 03/18/2017] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To describe the characteristics of an outbreak of brainstem encephalitis and encephalomyelitis related to enterovirus (EV) infection in Catalonia (Spain), a setting in which these manifestations were uncommon. METHODS Clinical and microbiological data were analysed from patients with neurological symptoms associated with EV detection admitted to a reference paediatric hospital between April and June 2016. RESULTS Fifty-seven patients were included. Median age was 27.7 months (p25-p75 17.1-37.6). Forty-one (72%) were diagnosed with brainstem encephalitis, seven (12%) with aseptic meningitis, six (11%) with encephalitis, and three (5%) with encephalomyelitis (two out of three with cardiopulmonary failure). Fever, lethargy, and myoclonic jerks were the most common symptoms. Age younger than 12 months, higher white-blood-cell count, and higher procalcitonin levels were associated with cardiopulmonary failure. Using a PAN-EV real-time PCR, EV was detected in faeces and/or nasopharyngeal aspirate in all the patients, but it was found in cerebrospinal fluid only in patients with aseptic meningitis. EV was genotyped in 47 out of 57 and EV-A71 was identified in 40 out of 47, being the only EV type found in patients with brainstem symptoms. Most of the detected EV-A71 strains were subgenogroup C1. Intravenous immunoglobulins were used in 34 patients. Eight cases (14%) were admitted to the intensive care unit. All the patients but three, those with encephalomyelitis, showed a good clinical course and had no significant sequelae. No deaths occurred. CONCLUSIONS The 2016 outbreak of brainstem encephalitis in Catalonia was associated with EV-A71 subgenogroup C1. Despite the clinical manifestations of serious disease, a favourable outcome was observed in the majority of patients.
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Affiliation(s)
- D Casas-Alba
- Department of Paediatrics, Hospital Sant Joan de Deu (University of Barcelona), Spain
| | - M F de Sevilla
- Department of Paediatrics, Hospital Sant Joan de Deu (University of Barcelona), Spain; Paediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; CIBER en Epidemiología y Salud Pública, CIBERESP, Spain
| | - A Valero-Rello
- Paediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; Department of Molecular Microbiology, Hospital Sant Joan de Deu, Spain
| | - C Fortuny
- Department of Paediatrics, Hospital Sant Joan de Deu (University of Barcelona), Spain; Paediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; CIBER en Epidemiología y Salud Pública, CIBERESP, Spain
| | - J-J García-García
- Department of Paediatrics, Hospital Sant Joan de Deu (University of Barcelona), Spain; Paediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; CIBER en Epidemiología y Salud Pública, CIBERESP, Spain
| | - C Ortez
- Department of Paediatric Neurology, Hospital Sant Joan de Deu (University of Barcelona), Spain
| | - J Muchart
- Department of Diagnostic Imaging, Hospital Sant Joan de Deu (University of Barcelona), Spain
| | - T Armangué
- Department of Paediatric Neurology, Hospital Sant Joan de Deu (University of Barcelona), Spain
| | - I Jordan
- Paediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; CIBER en Epidemiología y Salud Pública, CIBERESP, Spain; Paediatric Intensive Care Unit, Hospital Sant Joan de Deu (University of Barcelona), Spain
| | - C Luaces
- Emergency Department, Hospital Sant Joan de Deu (University of Barcelona), Spain
| | - I Barrabeig
- Epidemiological Surveillance Unit of Health Region, Barcelona-South, Public Health Agency of Catalonia, Hospitalet de Llobregat, Spain
| | - R González-Sanz
- Enterovirus Unit, National Centre for Microbiology, Institute of Public Health "Carlos III", Madrid, Spain
| | - M Cabrerizo
- Enterovirus Unit, National Centre for Microbiology, Institute of Public Health "Carlos III", Madrid, Spain
| | - C Muñoz-Almagro
- Paediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; CIBER en Epidemiología y Salud Pública, CIBERESP, Spain; Emergency Department, Hospital Sant Joan de Deu (University of Barcelona), Spain; School of Medicine, Universitat Internacional de Catalunya, Barcelona, Spain
| | - C Launes
- Department of Paediatrics, Hospital Sant Joan de Deu (University of Barcelona), Spain; Paediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; CIBER en Epidemiología y Salud Pública, CIBERESP, Spain.
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Perinpanathan K, Paramaguru S, Kazibwe NJ. A 20-Year-Old Woman with Sudden Onset of Neurologic Deficits of Unknown Cause. Pediatr Ann 2016; 45:e112-5. [PMID: 27064465 DOI: 10.3928/00904481-20160301-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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24
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Kameda K, Shirano M, Hadano Y, Kasamatsu Y, Nakamura T, Ota M, Goto T. Cytomegalovirus polyradiculopathy in three Japanese patients with AIDS. Intern Med 2015; 54:513-8. [PMID: 25758080 DOI: 10.2169/internalmedicine.54.2438] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Polyradiculopathy (PRP) is a rare but serious neurologic complication of cytomegalovirus (CMV) in patients with acquired immunodeficiency syndrome (AIDS). We herein report three cases of CMV PRP in patients with AIDS. Although providing a prompt diagnosis and initiating anti-CMV therapy may achieve clinical improvements, administering single-drug treatment may result in virologic failure. Therefore, introducing antiretroviral therapy is a key step for improving the treatment outcomes of CMV PRP.
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Affiliation(s)
- Kazuaki Kameda
- Department of Infectious Diseases, Osaka City General Hospital, Japan
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25
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Abstract
PURPOSE OF REVIEW In the past decade, the number of studies related to demyelinating diseases in children has exponentially increased. Demyelinating disease in children may be monophasic or chronic. Typical monophasic disorders in children are acute disseminated encephalomyelitis and clinically isolated syndromes, including optic neuritis and transverse myelitis. However, some cases of acute disseminated encephalomyelitis or clinically isolated syndrome progress to become chronic disorders, including multiple sclerosis and neuromyelitis optica. This review summarizes the current knowledge on monophasic and chronic demyelinating disorders in children, focusing on an approach to diagnosis and management. RECENT FINDINGS Improved diagnostic definitions for pediatric demyelinating diseases have led to enhanced recognition of these disorders. Additionally, increased awareness and focused national and international efforts continue to inform about the clinical course, response to treatment, and disease pathogenesis. SUMMARY Significant advances have been made in the recognition, diagnosis, and management of pediatric demyelinating disorders over the past 10 years. This review summarizes these advances and provides an updated approach to the diagnosis and management of pediatric demyelinating disorders.
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Affiliation(s)
- Tanuja Chitnis
- Massachusetts General Hospital, Department of Child Neurology, Boston, MA 02114, USA.
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26
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Razzouki K, Draiss G, Rada N, Bourrous M, Bouskraoui M. Myélite aiguë compliquant une infection à Salmonella typhi. Arch Pediatr 2014; 21:327-8. [DOI: 10.1016/j.arcped.2013.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 11/07/2013] [Accepted: 12/11/2013] [Indexed: 10/25/2022]
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Chen L, Li J, Guo Z, Liao S, Jiang L. Prognostic indicators of acute transverse myelitis in 39 children. Pediatr Neurol 2013; 49:397-400. [PMID: 24112847 DOI: 10.1016/j.pediatrneurol.2013.08.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Revised: 08/20/2013] [Accepted: 08/20/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND The Transverse Myelitis Consortium Working Group has proposed new diagnostic criteria for acute transverse myelitis. The purpose of the present study is to evaluate the relations between clinical variables and functional prognosis using new criteria. METHODS We reviewed 39 Chinese cases meeting the new criteria, recorded clinical epidemiological data, and followed activities of daily living measuring scale (Modified Barthel Index). RESULTS Thirty-nine children met new criteria for definite acute transverse myelitis in the past 14 years between 1995 and 2008. Mean follow-up time was 102.7 months. Conversion to multiple sclerosis occurred in two patients (5.1%). Those children with a short time to maximal deficits, long time of peak neurological impairment and initial time of treatment, increased protein levels of the cerebrospinal fluid, and secondary infection were more likely to have residual neurological deficits, resulting in lower qualities of life (P = 0.005, P = 0.003, P = 0.011, P = 0.0012, P = 0.000, respectively). CONCLUSIONS A short time to maximal deficits, long time of peak neurological impairment and initial time of treatment, increased protein levels of cerebrospinal fluid, and secondary infection played important roles in predicting poor prognosis.
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Affiliation(s)
- Long Chen
- Department of Pediatrics, Daping Hospital and Research Institute of Surgery, Third Military Medical University, Chongqing, People's Republic of China
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29
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Wolf VL, Lupo PJ, Lotze TE. Pediatric acute transverse myelitis overview and differential diagnosis. J Child Neurol 2012; 27:1426-36. [PMID: 22914370 DOI: 10.1177/0883073812452916] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Acute transverse myelitis is a clinical syndrome affecting the spinal cord, which is characterized by acute onset of motor, sensory, and autonomic dysfunction. Approximately 20% of cases of acute transverse myelitis occur in children. This review summarizes the current published literature on acute transverse myelitis, including epidemiology, diagnostic criteria, pathogenesis, clinical presentation, clinical evaluation, and differential diagnosis. The article also summarizes the neuroimaging features, acute and chronic complications, treatments, and prognosis of acute transverse myelitis in the pediatric population. The initial evaluation centers on differentiation from other causes of myelopathy, and cases are further divided into idiopathic or disease-associated acute transverse myelitis. Correct diagnosis is important for treatment and prognosis. Treatment begins with intensive surveillance for acute life-threatening respiratory or autonomic complications. Immunomodulating therapy is recommended for noninfectious causes, using high-dose intravenous corticosteroids or plasma exchange. Other therapeutic options are also discussed. Prognosis depends on a number of factors, and evidence suggests that the majority of children have a good outcome. A small percentage of children diagnosed with acute transverse myelitis later are diagnosed with other demyelinating diseases, especially neuromyelitis optica, or multiple sclerosis. The most common long-term complications of acute transverse myelitis are urinary, motor, or sensory dysfunction.
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30
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Awad A, Stüve O. Idiopathic transverse myelitis and neuromyelitis optica: clinical profiles, pathophysiology and therapeutic choices. Curr Neuropharmacol 2012; 9:417-28. [PMID: 22379456 PMCID: PMC3151596 DOI: 10.2174/157015911796557948] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2010] [Revised: 04/18/2010] [Accepted: 04/19/2010] [Indexed: 12/05/2022] Open
Abstract
Transverse myelitis is a focal inflammatory disorder of the spinal cord which may arise due to different etiologies. Transverse myelitis may be idiopathic or related/secondary to other diseases including infections, connective tissue disorders and other autoimmune diseases. It may be also associated with optic neuritis (neuromyelitis optica), which may precede transverse myelitis. In this manuscript we review the pathophysiology of different types of transverse myelitis and neuromyelitis optica and discuss diagnostic criteria for idiopathic transverse myelitis and risk of development of multiple sclerosis after an episode of transverse myelitis. We also discuss treatment options including corticosteroids, immunosuppressives and monoclonal antibodies, plasma exchange and intravenous immunoglobulins.
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Affiliation(s)
- Amer Awad
- Department of Neurology, Case Western Reserve University, Cleveland, OH, USA
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31
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Abstract
Acute transverse myelitis (ATM) has many potential etiologies, but a significant proportion of cases are categorized as idiopathic despite thorough evaluation. Clinical presentation of ATM typically includes some combination of motor weakness, sensory symptoms, and bowel and bladder dysfunction. Prompt recognition, even before a final etiologic diagnosis is reached, is critical to initiating early therapeutic intervention to reduce the harmful effects of inflammation. Acute therapeutic options for ATM include corticosteroids, plasma exchange, IV immunoglobulin, and chemotherapeutic agents such as cyclophosphamide. In some instances, combinations of these therapies are used. This article examines the therapeutic approach to ATM and its various acute clinical manifestations.
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Thomas T, Branson HM, Verhey LH, Shroff M, Stephens D, Magalhaes S, Banwell B. The demographic, clinical, and magnetic resonance imaging (MRI) features of transverse myelitis in children. J Child Neurol 2012; 27:11-21. [PMID: 21968984 DOI: 10.1177/0883073811420495] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The authors collected demographic, clinical, and neuroimaging data prospectively on 38 children with transverse myelitis. One child died during the illness. The female:male ratio was 1.2:1 for children under age 10 years and 2.6:1 over age 10 years. Twenty-eight (74%) reported a prodromal event. Twenty-two patients (58%) had longitudinally extensive transverse myelitis, 9 (24%) had focal lesions, and 5 (13%) had both. Twenty of 33 with brain imaging (61%) had brain lesions; 7 fulfilled McDonald criteria for dissemination in space. Seven of 22 (36%) tested had cerebrospinal fluid oligoclonal banding, 6 of whom had brain lesions. Serum neuromyelitis optica IgG antibodies were absent in all 20 of the children for whom this test was available. At follow-up (mean 3.2 ± 2.0 years), 16% are wheelchair-dependent, 22% have persisting bladder dysfunction, and 13% have been diagnosed with multiple sclerosis.
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Affiliation(s)
- Terrence Thomas
- Neurology Service, Department of Pediatrics, KK Women's & Children's Hospital, Singapore
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Kim BS, Joo SH, Rhee HY, Park HC. Acute Hepatic Failure Associated with Stevens-Johnson Syndrome Induced by Carbamazepine Treatment in a Patient with Transverse Myelitis. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2011. [DOI: 10.4174/jkss.2011.80.2.157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Bum-Soo Kim
- Department of Surgery, Kyung Hee University School of Medicine and the Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Sun-Hyung Joo
- Department of Surgery, Kyung Hee University School of Medicine and the Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Hak-Young Rhee
- Department of Neurology, Kyung Hee University School of Medicine and the Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Ho-Cheol Park
- Department of Surgery, Kyung Hee University School of Medicine and the Kyung Hee University Hospital at Gangdong, Seoul, Korea
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De Goede CGEL, Holmes EM, Pike MG. Acquired transverse myelopathy in children in the United Kingdom--a 2 year prospective study. Eur J Paediatr Neurol 2010; 14:479-87. [PMID: 20089428 DOI: 10.1016/j.ejpn.2009.12.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2009] [Revised: 12/06/2009] [Accepted: 12/13/2009] [Indexed: 10/19/2022]
Abstract
AIMS To define the incidence, describe presentation, management and outcome and identify prognostic factors in Acquired Transverse Myelopathy (ATM) in children under 16 years. METHODS A prospective population-based surveillance study, involving all consultant paediatric neurologists in the United Kingdom from 1 July 2002 to 30 June 2004. RESULTS AND DISCUSSION Response rate was 91%, and 60 children were reported, of whom 41 were included. Median age was 9 years. The incidence of ATM in children under 16 years in confirmed cases is at least 1.72 per million children per year. There was a previously unrecognised male predominance (M:F 25:16). Early evaluation of bladder function is sometimes omitted. MR imaging should include whole spine and brain to maximise diagnostic information. Despite the use of high dose steroids, 25% of cases were left with significant sequelae. Outcome data was available for 36 children in whom recovery was defined as 'complete' in 19, 'good' in 8, 'fair' in 3 and 'poor' in 6. Significant positive prognostic factors were preceding infection, start of recovery within a week of onset, age less than 10 years, and lumbosacral spinal level on clinical assessment. Significant negative predictors were flaccid legs at presentation, sphincter involvement and rapid progression from onset to nadir within 24h.
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Affiliation(s)
- Christian G E L De Goede
- Department of Paediatric Neurology, Royal Preston Hospital, Sharoe Green Lane, Preston PR2 9HT, UK.
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Yiu EM, Kornberg AJ, Ryan MM, Coleman LT, Mackay MT. Acute transverse myelitis and acute disseminated encephalomyelitis in childhood: spectrum or separate entities? J Child Neurol 2009; 24:287-96. [PMID: 19258287 DOI: 10.1177/0883073808323522] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The clinical and radiological features of childhood acute transverse myelitis are compared to those of acute disseminated encephalomyelitis with spinal cord involvement in 22 children with acute transverse myelitis and 12 children with acute disseminated encephalomyelitis with spinal cord involvement. Children with acute transverse myelitis were more likely to have a sensory level (55%) and areflexia. Sixty-eight percent of the children with acute transverse myelitis, and 92% of children with acute disseminated encephalomyelitis had longitudinally extensive transverse myelitis. Demyelination was more extensive in acute disseminated encephalomyelitis (mean 15.6 vertebral segments) than in acute transverse myelitis (mean 8.0 vertebral segments). The outcome was normal to good in 82% with acute transverse myelitis and in 100% with acute disseminated encephalomyelitis. Persistent bladder dysfunction was uncommon in both. Poor prognostic factors in acute transverse myelitis are flaccid paraparesis, respiratory failure, and age less than 6 months. These clinical and radiological differences suggest acute transverse myelitis and acute disseminated encephalomyelitis are separate entities.
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Affiliation(s)
- Eppie M Yiu
- Children's Neuroscience Centre, Royal Children's Hospital, Melbourne, Australia
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LaRovere KL, Raju GP, Gorman MP. Postvaricella acute transverse myelitis in a previously vaccinated child. Pediatr Neurol 2008; 38:370-2. [PMID: 18410857 DOI: 10.1016/j.pediatrneurol.2008.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2007] [Accepted: 01/14/2008] [Indexed: 11/18/2022]
Abstract
We describe a 14-year-old boy with acute transverse myelitis after breakthrough varicella infection, despite immunization with the Varicella zoster virus vaccine 8 years earlier. He recovered fully after treatment with intravenous corticosteroids and acyclovir. To our knowledge, there are no previously reported cases of postvaricella acute transverse myelitis in vaccinated individuals. Our report emphasizes that the Varicella zoster virus booster vaccine may be necessary to prevent not only acute varicella, but also its postinfectious neurologic complications.
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Affiliation(s)
- Kerri L LaRovere
- Department of Neurology, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts, USA
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Banwell B, Ghezzi A, Bar-Or A, Mikaeloff Y, Tardieu M. Multiple sclerosis in children: clinical diagnosis, therapeutic strategies, and future directions. Lancet Neurol 2007; 6:887-902. [PMID: 17884679 DOI: 10.1016/s1474-4422(07)70242-9] [Citation(s) in RCA: 235] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The onset of multiple sclerosis (MS) in childhood poses diagnostic and therapeutic challenges, particularly if the symptoms of the first demyelinating event resemble acute disseminated encephalomyelitis (ADEM). MRI is an invaluable diagnostic tool but it lacks the specificity to distinguish ADEM from the first attack of MS. Advanced MRI techniques might have the required specificity to reveal whether the loss of integrity in non-lesional tissue occurs as a fundamental feature of MS. Although the onset of MS in childhood typically predicts a favourable short-term prognosis, some children are severely disabled, either physically or cognitively, and more than 50% are predicted to enter the secondary-progressive phase of the disease by the age of 30 years. Immunomodulatory therapies for MS and their safe application in children can improve long-term prognosis. Genetic and environmental factors, such as viral infection, might be uniquely amenable to study in paediatric patients with MS. Understanding the immunological consequences of these putative exposures will shed light on the early pathological changes in MS.
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Affiliation(s)
- Brenda Banwell
- Department of Paediatrics, Division of Neurology, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
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Krishnan C, Kaplin AI, Pardo CA, Kerr DA, Keswani SC. Demyelinating disorders: Update on transverse myelitis. Curr Neurol Neurosci Rep 2006; 6:236-43. [PMID: 16635433 DOI: 10.1007/s11910-006-0011-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Transverse myelitis (TM) is a focal inflammatory disorder of the spinal cord. Perivascular monocytic and lymphocytic infiltration, demyelination, and axonal injury are prominent histopathogic features of TM. The clinical manifestations of TM are consequent to dysfunction of motor, sensory, and autonomic pathways. At peak deficit, 50% of patients with TM are completely paraplegic (with no volitional movements of legs), virtually all have some degree of bladder dysfunction, and 80% to 94% have numbness, paresthesias, or band-like dysesthesias. Longitudinal case series of TM reveal that approximately one third of patients recover with little to no sequelae, one third are left with a moderate degree of permanent disability, and one third have severe disability. Recent studies have shown that the cytokine interleukin-6 may be a useful biomarker, as the levels of interleukin-6 in the cerebrospinal fluid of acute TM patients strongly correlate with and are highly predictive of disability. Clinical trials testing the efficacy of promising axonoprotective agents in combination with intravenous steroids in the treatment of TM are currently underway.
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Affiliation(s)
- Chitra Krishnan
- Department of Neurology, Johns Hopkins University School of Medicine, Pathology 627, 600 North Wolfe Street, Baltimore, MD 21287-6965, USA
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Abstract
BACKGROUND Acute myelopathies represent a heterogeneous group of disorders with distinct etiologies, clinical and radiologic features, and prognoses. Transverse myelitis (TM) is a prototype member of this group in which an immune-mediated process causes neural injury to the spinal cord, resulting in varying degrees of weakness, sensory alterations, and autonomic dysfunction. TM may exist as part of a multifocal CNS disease (eg, MS), multisystemic disease (eg, systemic lupus erythematosus), or as an isolated, idiopathic entity. REVIEW SUMMARY In this article, we summarize recent classification and diagnostic schemes, which provide a framework for the diagnosis and management of patients with acute myelopathy. Additionally, we review the state of current knowledge about the epidemiology, natural history, immunopathogenesis, and treatment strategies for patients with TM. CONCLUSIONS Our understanding of the classification, diagnosis, pathogenesis, and treatment of TM has recently begun to expand dramatically. With more rigorous criteria applied to distinguish acute myelopathies and with an emerging understanding of immunopathogenic events that underlie TM, it may now be possible to effectively initiate treatments in many of these disorders. Through the investigation of TM, we are also gaining a broader appreciation of the mechanisms that lead to autoimmune neurologic diseases in general.
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Affiliation(s)
- Adam I Kaplin
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Osler 320, 600 N. Wolfe Street, Baltimore, MD 21287, USA.
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Ramirez C, de Seze J, Delalande S, Michelin E, Ferriby D, Al Khedr A, Stojkovic T, Destée A, Vermersch P. [Infectious myelopathies: clinical, serological, and prognostic patterns]. Rev Neurol (Paris) 2005; 160:1048-58. [PMID: 15602347 DOI: 10.1016/s0035-3787(04)71142-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Serological confirmation of an infectious acute myelitis injury is difficult to confirm as it is sometimes due to a post-infectious etiology. OBJECTIVES The aim of this study was to define the clinical, biological and prognostic patterns of infectious myelitis. PATIENTS AND METHODS This retrospective study included 153 subjects hospitalized in the department of neurology between 1993 and 2002 for treatment of a noncompressive acute myelopathy. Biological confirmation of recent infection was obtained in 12 patients (8 p. 100). RESULTS An infectious syndrome, beginning prior to the neurological symptoms, was found in 67 percent of patients. The clinical symptoms were severe with loss of sensoromotor and sphincter functions and ascending spinal cord dysfunction (acute transverse myelopathy). Spinal cord MRI showed extended centromedullar high intensity signals with rapid and complete regression. CSF analysis cell count was above 30/mm3 with hyperproteinorachia, in 75 percent and 58 percent of patients respectively. CSF electrophoresis did not detect oligoclonal bands. Clinical outcome was good in all patients except one, however sphincter disorders recovered slowly. DISCUSSION Our study illustrates a stereotypical clinical, biological and prognostic pattern for infectious acute myelitis. These findings contribute significantly to therapeutic decision making and establishing prognosis at the initial phase of acute myelopathy.
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Affiliation(s)
- C Ramirez
- Clinique Neurologique, Hôpital R. Salengro, CHRU, Lille
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Dallot N, de Pontual L, Guilbert J, Maury-Tisseron B, Nathanson M, Gaudelus J. Myélite aiguë transverse a Mycoplasma pneumoniae chez un enfant de huit ans. Med Mal Infect 2005; 35:170-2. [PMID: 15878818 DOI: 10.1016/j.medmal.2005.03.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2004] [Accepted: 03/15/2005] [Indexed: 11/30/2022]
Abstract
Many Mycoplasma pneumoniae extra respiratory infections have already been reported. The authors report the case of an eight year old child, presenting with acute transverse myelitis, with a PCR proven involvement of M. pneumoniae in CSF as well as the presence of specific IgM in blood. Acute transverse myelitis may have many causes, most of the time viral. The mechanisms of neurological involvement in M. pneumoniae infections are still unclear, but several points indicate an immune reaction. Corticotherapy first i.v. then per os has proved to be an efficient treatment for acute myelitis. Antibiotherapy is discussed because of the undocumented mechanisms of neurological involvement related to the mycoplasma.
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Affiliation(s)
- N Dallot
- Service de pédiatrie, hôpital Jean-Verdier, avenue du 14-Juillet, 93143, Bondy cedex, France.
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Mikaeloff Y, Suissa S, Vallée L, Lubetzki C, Ponsot G, Confavreux C, Tardieu M. First episode of acute CNS inflammatory demyelination in childhood: prognostic factors for multiple sclerosis and disability. J Pediatr 2004; 144:246-52. [PMID: 14760270 DOI: 10.1016/j.jpeds.2003.10.056] [Citation(s) in RCA: 189] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate prognostic factors for second attack and for disability in children presenting with an initial episode of central nervous system (CNS) demyelination. STUDY DESIGN A cohort of 296 children having a first episode of acute CNS inflammatory demyelination was studied by survival analysis. RESULTS The average follow-up was 2.9+/-3 years. At the end of the follow-up, 57% of patients had a diagnosis of multiple sclerosis (MS), 29% had a monophasic acute disseminated encephalomyelitis, and 14% had a single focal episode. The rate of a second attack was (1). higher in patients with age at onset >or=10 years (hazard ratio, 1.67; 95% CI, 1.04-2.67), MS-suggestive initial MRI (1.54; 1.02-2.33), or optic nerve lesion (2.59; 1.27-5.29); and (2). lower in patients with myelitis (0.23; 0.10-0.56) or mental status change (0.59; 0.33-1.07). Of patients with a second attack, 29% had an initial diagnosis of acute disseminated encephalomyelitis. At the end of the follow-up period, 90% of patients had no or minor disability. Occurrence of severe disability was associated with a polysymptomatic onset (3.25; 1.16-11.01), sequelae after the first attack (26.65; 9.42-75.35), further relapses (1.49; 1.16-1.92), and progressive MS (3.57; 1.21-8.72). CONCLUSIONS Risk of second attack of CNS demyelination is higher in older patients and lower in patients with mental status change. Risk of disability is higher in polysymptomatic and relapsing patients.
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Affiliation(s)
- Yann Mikaeloff
- Service de Neurologie Pédiatrique, Hôpital Roger Salengro, Lille, France.
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Minami K, Tsuda Y, Maeda H, Yanagawa T, Izumi G, Yoshikawa N. Acute transverse myelitis caused by Coxsackie virus B5 infection. J Paediatr Child Health 2004; 40:66-8. [PMID: 14718010 DOI: 10.1111/j.1440-1754.2004.00295.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A 6-year-old boy developed symptoms of rapidly progressive paraplegia, associated with bowel and urinary dysfunction, but without sensory loss. Magnetic resonance imaging (MRI) examination showed diffuse swelling of the lower spinal cord on T1-weighted images. Based on the clinical presentation and MRI findings, a diagnosis of acute transverse myelitis was made. The serum titer of neutralizing antibody against Coxsackie virus B5 rose from 1/4 on admission to 1/256 1 month later and Coxsackie virus B5 was isolated from stool samples. This case serves as a reminder that acute transverse myelitis can be a rare clinical manifestation of Coxsackie virus B5 infection.
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Affiliation(s)
- K Minami
- Department of Pediatrics, Wakayama Medical University School of Medicine, Wakayama, Japan.
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Fux CA, Pfister S, Nohl F, Zimmerli S. Cytomegalovirus-associated acute transverse myelitis in immunocompetent adults. Clin Microbiol Infect 2003; 9:1187-90. [PMID: 14686983 DOI: 10.1111/j.1469-0691.2003.00796.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We report a case of transverse myelitis as a complication of acute cytomegalovirus (CMV) infection in immunocompetent patients; and review the literature on the entity. Primary CMV infection was documented by CMV antigenemia and high serum titers of CMV IgM and IgG antibodies. Cerebrospinal fluid (CSF) pleocytosis indicated central nervous system inflammation; CSF polymerase chain reaction (PCR) for CMV, however, was negative. The results of magnetic resonance imaging of the myelon were normal. Although CMV-associated transverse myelitis has been well described in HIV-positive individuals, but is very rare in immunocompetent individuals. It remains unclear whether the neuronal damage is immune mediated or due to a cytotoxic effect of viral infection. The outcome is mainly favorable.
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Affiliation(s)
- C A Fux
- Institute for Infectious Diseases, University of Bern, Switzerland
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Fonseca LF, Noce TR, Teixeira MLG, Teixeira AL, Lana-Peixoto MA. Early-onset acute transverse myelitis following hepatitis B vaccination and respiratory infection: case report. ARQUIVOS DE NEURO-PSIQUIATRIA 2003; 61:265-8. [PMID: 12806509 DOI: 10.1590/s0004-282x2003000200020] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Acute transverse myelitis is an acute inflammatory process of the spinal cord and it is a rare clinical syndrome in childhood. In this paper, we report a case of 3 years-old boy who developed acute onset tetraparesia following a viral respiratory infecction and hepatitis B vaccination. Magnetic resonance imaging of the spinal cord disclosed signal-intensity abnormalities from C4 to C3. A diagnosis of acute transverse myelitis was made and the patient was treated with IV methylprednisolone and IV immunoglobulin. The child had a fair outcome despite of the very acute course of the disease and the presence of a cervical sensory level which usually harbor a poor prognosis.
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Defresne P, Hollenberg H, Husson B, Tabarki B, Landrieu P, Huault G, Tardieu M, Sébire G. Acute transverse myelitis in children: clinical course and prognostic factors. J Child Neurol 2003; 18:401-6. [PMID: 12886975 DOI: 10.1177/08830738030180060601] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of this study was to describe the clinical course of acute transverse myelitis in children, to identify prognostic factors, and to compare our findings with published data Twenty-four children, aged 2 to 14 years and admitted with a diagnosis of acute transverse myelitis, were studied. Clinical features and results of investigations were collected at admission and during the course of the disease. Motor, sphincter, and global outcomes were compared with those in the main adult and pediatric series. During the initial phase, the most common presenting symptoms were pain (88%) and fever (58%). Motor loss preceded sphincter dysfunction in two thirds of patients and became bilateral in half of the patients. When maximal deficit was achieved (plateau), the patients presented a combination of sensory, motor, and sphincter dysfunctions without radicular involvement The motor loss consistently involved the lower limbs but was inconsistent and moderate in the upper limbs. The mean duration of the plateau was 1 week. The recovery phase was characterized by a progressive improvement of all deficits. Sphincter dysfunction improved more slowly than did the other deficits. A full recovery was achieved by 31% of the patients; minimal sequelae were present in 25% and mild to severe sequelae in 44%. An unfavorable outcome was associated with complete paraplegia (P = .03) and/or a time to maximal deficit shorter than 24 hours (P = .005). A favorable outcome was associated with a plateau shorter than 8 days (P = .03), the presence of supraspinal symptoms (P = .01), and a time to independent walking shorter than 1 month (P = .01). The course of acute transverse myelitis in children proceeds through three stages, an initial phase, a plateau, and a recovery phase, each characterized by specific clinical features. The global outcome was favorable in 56% of patients. Several prognostic factors were identified.
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Affiliation(s)
- Pierre Defresne
- Service de Neurologie, Département de Pédiatrie, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Bruxelles, Belgium.
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Kadhim H, De Prez C, Gazagnes MD, Sébire G. In situ cytokine immune responses in acute disseminated encephalomyelitis: insights into pathophysiologic mechanisms. Hum Pathol 2003; 34:293-7. [PMID: 12673567 DOI: 10.1053/hupa.2003.34] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Acute disseminated encephalomyelitis (ADEM) is thought to be an autoimmune disorder of the central nervous system in which myelin is targeted. Pathological studies on closely related human diseases (eg, multiple sclerosis) and on animal models for these demyelinating disorders have suggested the involvement of cytokines. Studies on peripheral immunocytes and on cerebrospinal fluid revealed the presence of cytokine-mediated responses in ADEM. We carried out this neuroimmunopathologic exploration and report for the first time the in situ expression of "inflammatory" cytokines in ADEM. Moreover, we note a particular spatial and molecular pattern whereby tumor necrosis factor-alpha and interleukin (IL)-1beta are intensely expressed, whereas IL-6 is absent. Differential expression at different levels of the neuraxis was also noticed. Our findings suggest that these cytokines, reported to be toxic to myelin, are implicated in the molecular cascade, resulting in the neural damage. These observations might provide insights into molecular pathways involved in the immunopathogenesis of ADEM and might open new horizons in neuroimmunomodulation and anticytokine treatment.
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Affiliation(s)
- Hazim Kadhim
- Unité de Neuropathologie, Service d'Anatomopathologie, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
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Abstract
Acute transverse myelitis is a group of disorders characterized by focal inflammation of the spinal cord and resultant neural injury. Acute transverse myelitis may be an isolated entity or may occur in the context of multifocal or even multisystemic disease. It is clear that the pathological substrate--injury and dysfunction of neural cells within the spinal cord--may be caused by a variety of immunological mechanisms. For example, in acute transverse myelitis associated with systemic disease (i.e. systemic lupus erythematosus or sarcoidosis), a vasculitic or granulomatous process can often be identified. In idiopathic acute transverse myelitis, there is an intraparenchymal or perivascular cellular influx into the spinal cord, resulting in the breakdown of the blood-brain barrier and variable demyelination and neuronal injury. There are several critical questions that must be answered before we truly understand acute transverse myelitis: (1) What are the various triggers for the inflammatory process that induces neural injury in the spinal cord? (2) What are the cellular and humoral factors that induce this neural injury? and (3) Is there a way to modulate the inflammatory response in order to improve patient outcome? Although much remains to be elucidated about the causes of acute transverse myelitis, tantalizing clues as to the potential immunopathogenic mechanisms in acute transverse myelitis and related inflammatory disorders of the spinal cord have recently emerged. It is the purpose of this review to illustrate recent discoveries that shed light on this topic, relying when necessary on data from related diseases such as acute disseminated encephalomyelitis, Guillain-Barré syndrome and neuromyelitis optica. Developing a further understanding of how the immune system induces neural injury will depend upon confirmation and extension of these findings and will require multicenter collaborative efforts.
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Affiliation(s)
- Douglas A Kerr
- Department of Neurology, School of Medicine, Johns Hopkins University, Pathology 627 C, 6000 N Wolfe Street, Baltimore, MD 21287-6965, USA.
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