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Grygorczuk S, Osada J, Sulik A, Toczyłowski K, Dunaj-Małyszko J, Czupryna P, Adamczuk J, Moniuszko-Malinowska A. Associations of the cerebrospinal fluid lymphocyte population with a clinical presentation of tick-borne encephalitis. Ticks Tick Borne Dis 2023; 14:102204. [PMID: 37245253 DOI: 10.1016/j.ttbdis.2023.102204] [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] [Received: 02/23/2023] [Revised: 05/11/2023] [Accepted: 05/20/2023] [Indexed: 05/30/2023]
Abstract
In tick-borne encephalitis (TBE), lymphocytes infiltrating central nervous system are indispensable for the infection control, but also potentially immunopathogenic. To clarify their roles, we have evaluated cerebrospinal fluid (CSF) count of the main lymphocyte populations (considered as a proxy of the brain parenchyma lymphocytic infiltrate) in TBE patients and analyzed if they associate with clinical presentation, blood-brain barrier disruption and intrathecal antibody synthesis. We have studied CSF from 96 adults with TBE (50 with meningitis, 40 with meningoencephalitis, 6 with meningoencephalomyelitis), 17 children and adolescents with TBE and 27 adults with non-TBE lymphocytic meningitis. Th CD3+CD4+, Tc CD3+CD8+, double positive T CD3+CD4+CD8+, B CD19+ and NK CD16+/56+ cells were counted cytometrically with a commercial fluorochrome-stained monoclonal antibody set. The associations between the counts and fractions of these cells and clinical parameters were analyzed with non-parametric tests, p<0.05 considered significant. The TBE patients had lower pleocytosis with similar proportions of the lymphocyte populations compared to non-TBE meningitis. The different lymphocyte populations correlated positively with one another, as well as with CSF albumin, IgG and IgM quotients. The higher pleocytosis and expansion of Th, Tc and B cells associated with a more severe disease and neurologic involvement: Th with encephalopathy, myelitis and weakly with cerebellar syndrome, Tc with myelitis and weakly with encephalopathy, B with myelitis and with at least moderately severe encephalopathy. The double-positive T lymphocytes associated with myelitis, but not with other forms of CNS involvement. The fraction of double positive T cells decreased in encephalopathy and the fraction of NK in patients with neurologic deficits. In children with TBE, Tc and B counts were increased at the expense of Th lymphocytes in comparison with adults. The concerted intrathecal immune response, involving the main lymphocyte populations, increases with the clinical severity of TBE, with no evidently protective or pathogenic elements distinguishable. However, the particular populations including B, Th and Tc cells associate with different, though overlapping, spectra of CNS manifestations, suggesting they may be specifically related to TBE manifesting as myelitis, encephalopathy and cerebellitis. The double-positive T and NK cells do not expand evidently with severity and may be most closely associated with the protective anti-TBEV response.
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Affiliation(s)
- Sambor Grygorczuk
- Department of the Infectious Diseases and Neuroinfections, Medical University in Białystok, ul. Żurawia 14, Białystok 15-540, Poland.
| | - Joanna Osada
- Department of Hematologic Diagnostics, Medical University in Białystok, ul. Jerzego Waszyngtona 15A, Białystok 15-269, Poland
| | - Artur Sulik
- Department of Pediatric Infectious Diseases, Medical University in Białystok, ul. Jerzego Waszyngtona 17, Białystok 15-274, Poland
| | - Kacper Toczyłowski
- Department of Pediatric Infectious Diseases, Medical University in Białystok, ul. Jerzego Waszyngtona 17, Białystok 15-274, Poland
| | - Justyna Dunaj-Małyszko
- Department of the Infectious Diseases and Neuroinfections, Medical University in Białystok, ul. Żurawia 14, Białystok 15-540, Poland
| | - Piotr Czupryna
- Department of the Infectious Diseases and Neuroinfections, Medical University in Białystok, ul. Żurawia 14, Białystok 15-540, Poland
| | - Justyna Adamczuk
- University Hospital in Białystok, ul. Żurawia 14, Białystok 15-540, Poland
| | - Anna Moniuszko-Malinowska
- Department of the Infectious Diseases and Neuroinfections, Medical University in Białystok, ul. Żurawia 14, Białystok 15-540, Poland
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Hayes LH, Hopkins SE, Liu S, Pardo CA, Garcia-Dominguez MA, Oleszek J, Yea C, Ciftci-Kavaklioglu B, Yeh EA, Dean J, Sadowsky CL, Desai J, Wiegand S, Farias-Moeller R, Nash K, Thakur KT, Vargas WS, Hong-Routson SJ, Yeshokumar A, Zhou MS, Makhani N, Wilson-Murphy M, Bove R, Zhang B, Benson LA. Challenges in the Clinical Recognition of Acute Flaccid Myelitis and its Implications. J Pediatr 2023; 253:55-62.e4. [PMID: 36115622 DOI: 10.1016/j.jpeds.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 09/07/2022] [Accepted: 09/09/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To explore the challenges in diagnosing acute flaccid myelitis (AFM) and evaluate clinical features and treatment paradigms associated with under recognition. STUDY DESIGN This was a retrospective multicenter study of pediatric patients (≤18 years) who were diagnosed with AFM from 2014 to 2018 using the Centers for Disease Control and Prevention's case definition. RESULTS In 72% of the cases (126 of 175), AFM was not considered in the initial differential diagnosis (n = 108; 61.7%) and/or the patient was not referred for acute care (n = 90; 51.4%) at the initial clinical encounter, and this did not improve over time. Although many features of the presentation were similar in those initially diagnosed with AFM and those who were not; preceding illness, constipation, and reflexes differed significantly between the 2 groups. Patients with a non-AFM initial diagnosis more often required ventilatory support (26.2% vs 12.2%; OR, 0.4; 95% CI, 0.2-1.0; P = .05). These patients received immunomodulatory treatment later (3 days vs 2 days after neurologic symptom onset; 95% CI, -2 to 0; P = .05), particularly intravenous immunoglobulin (5 days vs 2 days; 95% CI, -4 to -2; P < .001). CONCLUSIONS Delayed recognition of AFM is concerning because of the risk for respiratory decompensation and need for intensive care monitoring. A non-AFM initial diagnosis was associated with delayed treatment that could have a clinical impact, particularly as new treatment options emerge.
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Affiliation(s)
- Leslie H Hayes
- Department of Neurology, Boston Children's Hospital, Boston, MA
| | - Sarah E Hopkins
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, MA
| | - Shanshan Liu
- Department of Neurology and Institutional Centers for Clinical and Translational Research Biostatistics and Research Design Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Carlos A Pardo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MA
| | | | - Joyce Oleszek
- Department of Physical Medicine & Rehabilitation, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Carmen Yea
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - E Ann Yeh
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Janet Dean
- Department of Physical Medicine and Rehabilitation, International Center for Spinal Cord Injury, Johns Hopkins School of Medicine, Kennedy Krieger Institute, Baltimore, MD
| | - Cristina L Sadowsky
- Department of Physical Medicine and Rehabilitation, International Center for Spinal Cord Injury, Johns Hopkins School of Medicine, Kennedy Krieger Institute, Baltimore, MD
| | - Jay Desai
- Department of Neurology, Children's Hospital Los Angeles, Los Angeles, CA
| | - Sarah Wiegand
- Department of Neurology, Children's Hospital Los Angeles, Los Angeles, CA
| | - Raquel Farias-Moeller
- Division of Child Neurology, Department of Neurology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI
| | - Kendall Nash
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA
| | - Kiran T Thakur
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY
| | - Wendy S Vargas
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY
| | - Sue J Hong-Routson
- Division of Critical Care, Departments of Pediatrics & Neurology, Lurie Children's Hospital of Chicago, Chicago, IL
| | - Anusha Yeshokumar
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Melissa S Zhou
- Department of Pediatrics, Yale School of Medicine, New Haven, CT; Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Naila Makhani
- Department of Pediatrics, Yale School of Medicine, New Haven, CT; Department of Neurology, Yale School of Medicine, New Haven, CT
| | | | - Riley Bove
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA
| | - Bo Zhang
- Department of Neurology and Institutional Centers for Clinical and Translational Research Biostatistics and Research Design Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Leslie A Benson
- Department of Neurology, Boston Children's Hospital, Boston, MA.
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Neill L, Checkley AM, Benjamin LA, Herdman MT, Carter DP, Pullan ST, Aarons E, Griffiths K, Monaghan B, Karunaratne K, Ciccarelli O, Spillane J, Moore DAJ, Kullmann DM. Rhombencephalitis and Myeloradiculitis Caused by a European Subtype of Tick-Borne Encephalitis Virus. Emerg Infect Dis 2020; 25:2317-2319. [PMID: 31742526 PMCID: PMC6874248 DOI: 10.3201/eid2512.191017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
We report a case of a previously healthy man returning to the United Kingdom from Lithuania who developed rhombencephalitis and myeloradiculitis due to tick-borne encephalitis. These findings add to sparse data on tick-borne encephalitis virus phylogeny and associated neurologic syndromes and underscore the importance of vaccinating people traveling to endemic regions.
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Riccardi N, Antonello RM, Luzzati R, Zajkowska J, Di Bella S, Giacobbe DR. Tick-borne encephalitis in Europe: a brief update on epidemiology, diagnosis, prevention, and treatment. Eur J Intern Med 2019; 62:1-6. [PMID: 30678880 DOI: 10.1016/j.ejim.2019.01.004] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 12/30/2018] [Accepted: 01/14/2019] [Indexed: 12/30/2022]
Abstract
Tick-borne encephalitis (TBE) is an emerging health threat that is spreading in many parts of Europe. The mix of socio-economical, ecological and climatic factors as well as the presence of more susceptible hosts is actively contributing to the increasing number of TBE reported cases. TBE is an important cause of central nervous system (CNS) infection that can result in long-term neurological sequelae and even death. Diagnosis of TBE relays mainly on high clinical suspicion confirmed by serological and molecular assays both on serum and cerebrospinal fluid (CSF) with an ancillary role for neuroimaging in supporting the diagnosis. No specific antiviral treatment is currently available for TBE; indeed, supportive treatment as well as intensive care and assisted ventilation in severe forms may be needed. Because of limited option for TBE treatment, of crucial importance is effective vaccination to prevent disease-related morbidity and mortality. Due to expanding proportion of subject possibly exposed to TBE (and new populations such as: unaware travellers to TBE-endemic areas and immunocompromised patients), we performed a comprehensive review of TBE epidemiology, clinical presentation, current available diagnostic tools and treatment.
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Affiliation(s)
- Niccolò Riccardi
- Infectious Diseases Unit, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, Genoa, Italy; Department Health Science (DISSAL), University of Genoa, Genoa, Italy.
| | | | - Roberto Luzzati
- Infectious Diseases Department, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Joanna Zajkowska
- Department of Infectious Diseases and Neuroinfections, Medical University in Białystok, Poland
| | - Stefano Di Bella
- Infectious Diseases Department, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
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Abstract
PURPOSE OF REVIEW The focus of this review is on enterovirus (EV)-associated acute flaccid paralysis (AFP) due to spinal cord anterior horn cell disease. Emphasis is placed on the epidemiology, pathogenesis, diagnosis, treatment, and outcome of AFP caused by polioviruses, vaccine-derived polioviruses, EV-D68, and EV-A71. RECENT FINDINGS Since the launch of The Global Polio Eradication Initiative in 1988, the worldwide incidence of polio has been reduced by 99.9%, with small numbers of poliomyelitis cases being reported only in Afghanistan, Pakistan, and Nigeria. With the planned phaseout of oral polio vaccine, vaccine-associated poliomyelitis is also expected to be eliminated. In their place, other EVs, chiefly EV-D68 and EV-A71, have emerged as the principal causes of AFP. There is evidence that the emergence of EV-D68 as a cause of severe respiratory disease and AFP was due to recent genetic virus evolution. Antiviral medications targeting EV-D68, EV-A71, and other EVs will likely be available in the near future. An effective EV-A71 vaccine has been developed, and preliminary investigations suggest an EV-D68 vaccine could be on the horizon. The eradication of poliomyelitis and vaccine-associated poliomyelitis is near, after which other EVs, presently EV-D68 and EV-A71, will be the principle viral causes of AFP. Moving forward, it is essential that EV outbreaks, in particular those associated with neurologic complications, be investigated carefully and the causal strains identified, so that treatment and prevention efforts can be rapidly developed and implemented.
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Affiliation(s)
- Ari Bitnun
- Division of Infectious Diseases, The Hospital for Sick Children and Department of Pediatrics, University of Toronto, Toronto, ON, M5G 1X8, Canada.
| | - E Ann Yeh
- Division of Neurology, The Hospital for Sick Children and Department of Pediatrics, Division of Neurosciences and Mental Health, SickKids Research Institute, University of Toronto, Toronto, Canada
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Intrathecal expression of IL-5 and humoral response in patients with tick-borne encephalitis. Ticks Tick Borne Dis 2018; 9:896-911. [PMID: 29602685 DOI: 10.1016/j.ttbdis.2018.03.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 03/10/2018] [Accepted: 03/11/2018] [Indexed: 01/31/2023]
Abstract
AIM The aim of the study was to assess the role of an early specific humoral response in human infection with a tick-borne encephalitis virus (TBEV) and the role of IL-5 as its potential mediator and marker. MATERIALS AND METHODS The retrospective study involved a cohort of 199 patients diagnosed with TBE, in whom anti-TBEV IgM and IgG antibody titers were analyzed on admission and compared with clinical presentation and basic laboratory parameters. The prospective study included 50 TBE patients in whom IL-5 serum and CSF concentration was measured with ELISA on admission in the TBE neurologic phase and in selected patients before discharge, at follow-up or in samples obtained before the neurologic phase onset. RESULTS The serum anti-TBEV IgM correlated with good clinical outcome and the CSF anti-TBEV IgM with more pronounced CSF inflammation on admission, but also with its more complete resolution on follow-up. The serum anti-TBEV IgG correlated with milder presentation and better outcome. Concentration of IL-5 was increased in CSF but not in the serum of TBE patients. IL-5 concentration index on admission favored its intrathecal synthesis. IL-5 did not correlate significantly with clinical presentation and specific IgM and IgG titers. CONCLUSIONS Specific anti-TBEV IgM systemic and intrathecal response and IgG systemic response are protective, together favoring milder presentation, better outcome and resolution of central nervous system (CNS) inflammation. IL-5 is expressed intrathecally in TBE, but its pathogenetic role remains unclear.
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Zawadzki R, Garkowski A, Kubas B, Zajkowska J, Hładuński M, Jurgilewicz D, Łebkowska U. Evaluation of Imaging Methods in Tick-Borne Encephalitis. Pol J Radiol 2017; 82:742-747. [PMID: 29657640 PMCID: PMC5894064 DOI: 10.12659/pjr.903940] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 03/21/2017] [Indexed: 12/30/2022] Open
Abstract
Tick-borne encephalitis (TBE) is caused by a virus that belongs to the Flaviviridae family and is transmitted by tick bites. The disease has a biphasic course. Diagnosis is based on laboratory examinations because of non-specific clinical features, which usually entails the detection of specific IgM antibodies in either blood or cerebrospinal fluid that appear in the second phase of the disease. Neurological symptoms, time course of the disease, and imaging findings are multifaceted. During the second phase of the disease, after the onset of neurological symptoms, magnetic resonance imaging (MRI) abnormalities are observed in a limited number of cases. However, imaging features may aid in predicting the prognosis of the disease.
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Affiliation(s)
- Radosław Zawadzki
- Department of Radiology, Medical University of Białystok, Białystok, Poland
| | - Adam Garkowski
- Department of Radiology, Medical University of Białystok, Białystok, Poland
| | - Bożena Kubas
- Laboratory of Molecular Imaging, Medical University of Białystok, Białystok, Poland
| | - Joanna Zajkowska
- Department of Infectious Diseases and Neuroinfections, Medical University of Białystok, Białystok, Poland
| | - Marcin Hładuński
- Laboratory of Molecular Imaging, Medical University of Białystok, Białystok, Poland
| | - Dorota Jurgilewicz
- Laboratory of Molecular Imaging, Medical University of Białystok, Białystok, Poland
| | - Urszula Łebkowska
- Department of Radiology, Medical University of Białystok, Białystok, Poland
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Taba P, Schmutzhard E, Forsberg P, Lutsar I, Ljøstad U, Mygland Å, Levchenko I, Strle F, Steiner I. EAN consensus review on prevention, diagnosis and management of tick‐borne encephalitis. Eur J Neurol 2017; 24:1214-e61. [DOI: 10.1111/ene.13356] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 06/01/2017] [Indexed: 12/30/2022]
Affiliation(s)
- P. Taba
- Department of Neurology and Neurosurgery University of Tartu Tartu Estonia
| | - E. Schmutzhard
- Department of Neurology Medical University Innsbruck Innsbruck Austria
| | - P. Forsberg
- Department of Clinical and Experimental Medicine and Department of Infectious Diseases Linköping University Linköping Sweden
| | - I. Lutsar
- Department of Microbiology University of Tartu Tartu Estonia
| | - U. Ljøstad
- Department of Neurology Sørlandet Hospital Kristiansand Norway
- Department of Clinical Medicine University of Bergen Bergen Norway
| | - Å. Mygland
- Department of Neurology Sørlandet Hospital Kristiansand Norway
- Department of Clinical Medicine University of Bergen Bergen Norway
| | - I. Levchenko
- Institute of Neurology Psychiatry and Narcology of the National Academy of Medical Sciences of Ukraine Kharkiv Ukraine
| | - F. Strle
- Department of Infectious Diseases University Medical Centre Ljubljana Ljubljana Slovenia
| | - I. Steiner
- Department of Neurology Rabin Medical Center Petach Tikva Israel
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Grygorczuk S, Parczewski M, Świerzbińska R, Czupryna P, Moniuszko A, Dunaj J, Kondrusik M, Pancewicz S. The increased concentration of macrophage migration inhibitory factor in serum and cerebrospinal fluid of patients with tick-borne encephalitis. J Neuroinflammation 2017. [PMID: 28646884 PMCID: PMC5483307 DOI: 10.1186/s12974-017-0898-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background Host factors determining the clinical presentation of tick-borne encephalitis (TBE) are not fully elucidated. The peripheral inflammatory response to TBE virus is hypothesized to facilitate its entry into central nervous system by disrupting the blood-brain barrier with the involvement of a signaling route including Toll-like receptor 3 (TLR3) and pro-inflammatory cytokines macrophage migration inhibitory factor (MIF), tumor necrosis factor-α (TNFα), and interleukin-1 beta (IL-1β). Methods Concentrations of MIF, TNFα, and IL-1β were measured with commercial ELISA in serum and cerebrospinal fluid (CSF) from 36 hospitalized TBE patients, 7 patients with non-TBE meningitis, and 6 controls. The CSF albumin quotient (AQ) was used as a marker of blood-brain barrier permeability. Single nucleotide polymorphisms rs3775291, rs5743305 (associated with TLR3 expression), and rs755622 (associated with MIF expression) were assessed in blood samples from 108 TBE patients and 72 non-TBE controls. The data were analyzed with non-parametric tests, and p < 0.05 was considered significant. Results The median serum and CSF concentrations of MIF and IL-1β were significantly increased in TBE group compared to controls. MIF concentration in serum tended to correlate with AQ in TBE, but not in non-TBE meningitis. The serum concentration of TNFα was increased in TBE patients bearing a high-expression TLR3 rs5743305 TT genotype, which also associated with the increased risk of TBE. The low-expression rs3775291 TLR3 genotype TT associated with a prolonged increase of CSF protein concentration. The high-expression MIF rs755622 genotype CC tended to correlate with an increased risk of TBE, and within TBE group, it was associated with a mild presentation. Conclusions The results point to the signaling route involving TLR3, MIF, and TNFα being active in TBE virus infection and contributing to the risk of an overt neuroinvasive disease. The same factors may play a protective role intrathecally contributing to the milder course of neuroinfection. This suggests that the individual variability of the risk and clinical presentation of TBE might be traced to the variable peripheral and intrathecal expression of the mediators of the inflammatory response, which in turn associates with the host genetic background.
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Affiliation(s)
- Sambor Grygorczuk
- Department of the Infectious Diseases and Neuroinfections, Medical University in Białystok, ul. Żurawia 14, 15-540, Białystok, Poland.
| | - Miłosz Parczewski
- Department of Infectious Diseases and Hepatology, Pomeranian Medical University in Szczecin, ul. Arkońska 4, 71-455, Szczecin, Poland
| | - Renata Świerzbińska
- Department of the Infectious Diseases and Neuroinfections, Medical University in Białystok, ul. Żurawia 14, 15-540, Białystok, Poland
| | - Piotr Czupryna
- Department of the Infectious Diseases and Neuroinfections, Medical University in Białystok, ul. Żurawia 14, 15-540, Białystok, Poland
| | - Anna Moniuszko
- Department of the Infectious Diseases and Neuroinfections, Medical University in Białystok, ul. Żurawia 14, 15-540, Białystok, Poland
| | - Justyna Dunaj
- Department of the Infectious Diseases and Neuroinfections, Medical University in Białystok, ul. Żurawia 14, 15-540, Białystok, Poland
| | - Maciej Kondrusik
- Department of the Infectious Diseases and Neuroinfections, Medical University in Białystok, ul. Żurawia 14, 15-540, Białystok, Poland
| | - Sławomir Pancewicz
- Department of the Infectious Diseases and Neuroinfections, Medical University in Białystok, ul. Żurawia 14, 15-540, Białystok, Poland
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Leis AA, Stokic DS. Zika Virus and Guillain-Barre Syndrome: Is There Sufficient Evidence for Causality? Front Neurol 2016; 7:170. [PMID: 27746763 PMCID: PMC5044512 DOI: 10.3389/fneur.2016.00170] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Accepted: 09/20/2016] [Indexed: 11/13/2022] Open
Abstract
Worldwide concern over Zika virus causing Guillain–Barre syndrome (GBS) soared after recent reports that Zika-related weakness was due to GBS. A global strategic response plan was initiated with recommendations for at-risk countries to prepare for GBS. This plan has major economic implications, as nations with limited resources struggle to implement costly immunotherapy. Since confirmation of causality is prerequisite to providing specific management recommendations, it is prudent to review data endorsing a GBS diagnosis. We searched PubMed for manuscripts reporting original clinical, laboratory, and electrodiagnostic data on Zika virus and GBS. Five papers met criteria; four case reports and one large case–control study (French Polynesia) that attributed 42 paralysis cases to a motor variant of GBS. Brighton criteria were reportedly used to diagnose GBS, but no differential diagnosis was presented, which violates criteria. GBS was characterized by early onset (median 6 days post-viral syndrome), rapid progression (median 6 days from onset to nadir), and atypical clinical features (52% lacked areflexia, 48% of facial palsies were unilateral). Electrodiagnostic evaluations fell short of guidelines endorsed by American Academy of Neurology. Typical anti-ganglioside antibodies in GBS motor variants were rarely present. We conclude that there is no causal relationship between Zika virus and GBS because data failed to confirm GBS and exclude other causes of paralysis. Focus should be redirected at differential diagnosis, proper use of diagnostic criteria, and electrodiagnosis that follows recommended guidelines. We also call for a moratorium on recommendations for at-risk countries to prepare costly immunotherapies directed at GBS.
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Affiliation(s)
- A Arturo Leis
- Center for Neurosciences and Neurological Recovery, Methodist Rehabilitation Center, Jackson, MS, USA; Department of Neurology, Mayo Clinic, Scottsdale, AZ, USA
| | - Dobrivoje S Stokic
- Center for Neurosciences and Neurological Recovery, Methodist Rehabilitation Center , Jackson, MS , USA
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Santos RI, Hermance ME, Gelman BB, Thangamani S. Spinal Cord Ventral Horns and Lymphoid Organ Involvement in Powassan Virus Infection in a Mouse Model. Viruses 2016; 8:E220. [PMID: 27529273 PMCID: PMC4997582 DOI: 10.3390/v8080220] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 07/26/2016] [Accepted: 08/02/2016] [Indexed: 12/30/2022] Open
Abstract
Powassan virus (POWV) belongs to the family Flaviviridae and is a member of the tick-borne encephalitis serogroup. Transmission of POWV from infected ticks to humans has been documented in the USA, Canada, and Russia, causing fatal encephalitis in 10% of human cases and significant neurological sequelae in survivors. We used C57BL/6 mice to investigate POWV infection and pathogenesis. After footpad inoculation, infected animals exhibited rapid disease progression and 100% mortality. Immunohistochemistry and immunofluorescence revealed a very strong neuronal tropism of POWV infection. The central nervous system infection appeared as a meningoencephalitis with perivascular mononuclear infiltration and microglial activation in the brain, and a poliomyelitis-like syndrome with high level of POWV antigen at the ventral horn of the spinal cord. Pathological studies also revealed substantial infection of splenic macrophages by POWV, which suggests that the spleen plays a more important role in pathogenesis than previously realized. This report provides a detailed description of the neuroanatomical distribution of the lesions produced by POWV infection in C57BL/6 mice.
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Affiliation(s)
- Rodrigo I Santos
- Department of Pathology, University of Texas Medical Branch, Galveston, TX 77555, USA.
- Galveston National Laboratory, University of Texas Medical Branch, Galveston, TX 77555, USA.
| | - Meghan E Hermance
- Department of Pathology, University of Texas Medical Branch, Galveston, TX 77555, USA.
| | - Benjamin B Gelman
- Department of Pathology, University of Texas Medical Branch, Galveston, TX 77555, USA.
| | - Saravanan Thangamani
- Department of Pathology, University of Texas Medical Branch, Galveston, TX 77555, USA.
- Institute for Human Infections and Immunity, University of Texas Medical Branch, Galveston, TX 77555, USA.
- Galveston National Laboratory, University of Texas Medical Branch, Galveston, TX 77555, USA.
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Neumann B, Schulte-Mattler W, Brix S, Pöschl P, Jilg W, Bogdahn U, Steinbrecher A, Kleiter I. Autonomic and peripheral nervous system function in acute tick-borne encephalitis. Brain Behav 2016; 6:e00485. [PMID: 27247855 PMCID: PMC4864130 DOI: 10.1002/brb3.485] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 03/29/2016] [Accepted: 04/01/2016] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Tick-borne encephalitis (TBE) is an emerging flaviviral zoonosis in Central and Eastern Europe. TBE can present as meningitis, meningoencephalitis, or meningoencephalomyelitis. Dysfunction of the autonomic (ANS) and peripheral motoric and sensory nervous system (PNS) might contribute to acute and long-term complications. We aimed to examine, whether the ANS and PNS are affected in acute TBE. METHODS Fourteen patients with acute TBE, 17 with diabetic polyneuropathy (d-PNP), and 30 healthy controls (HC) were examined in our single-center, prospective study. ANS and PNS function was assessed by time- and frequency-domain parameters of the heart rate (HR) variability at rest and deep respiration, and by sural and tibial nerve neurography. Primary endpoint was the HR variability at rest measured by root mean square of the successive differences (RMSSD). Autonomic symptoms and quality of life (QoL) were assessed by questionnaires. RESULTS Tick-borne encephalitis patients had a lower RMSSD at rest (TBE 13.1 ± 7.0, HC 72.7 ± 48.3; P < 0.001) and deep respiration (TBE 42.8 ± 27.0, HC 109.7 ± 68.8; P < 0.01), an increased low-frequency to high-frequency power component ratio at rest (TBE 4.0 ± 4.0, HC 0.8 ± 0.5; P < 0.001), and a higher minimal heart rate at rest (TBE 85.4 ± 7.0, HC 69.5 ± 8.5; P < 0.001), all similar to patients with d-PNP, indicating sympathovagal imbalance with increased sympathetic activation. Compared to HC, sural and tibial nerve conduction velocities and action potential amplitudes were reduced, ANS symptoms were more frequent, and QoL was lower in patients with TBE. CONCLUSIONS The ANS and to a lesser degree the PNS are affected by acute TBE, which could potentially contribute to short- and long-term morbidity.
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Affiliation(s)
- Bernhard Neumann
- Department of Neurology University Medical Centre Regensburg Regensburg Germany
| | | | - Sophie Brix
- Department of Neurology University Medical Centre Regensburg Regensburg Germany
| | - Peter Pöschl
- Department of Neurology Krankenhaus der Barmherzigen Brüder Regensburg Regensburg Germany
| | - Wolfgang Jilg
- Department of Medical Microbiology and Hygiene University Medical Centre Regensburg Regensburg Germany
| | - Ulrich Bogdahn
- Department of Neurology University Medical Centre Regensburg Regensburg Germany
| | - Andreas Steinbrecher
- Department of Neurology University Medical Centre Regensburg Regensburg Germany; Department of Neurology HELIOS Klinikum Erfurt Erfurt Germany
| | - Ingo Kleiter
- Department of Neurology St. Josef-Hospital Ruhr-University Bochum Bochum Germany
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Grygorczuk S, Osada J, Parczewski M, Moniuszko A, Świerzbińska R, Kondrusik M, Czupryna P, Dunaj J, Dąbrowska M, Pancewicz S. The expression of the chemokine receptor CCR5 in tick-borne encephalitis. J Neuroinflammation 2016; 13:45. [PMID: 26906062 PMCID: PMC4763437 DOI: 10.1186/s12974-016-0511-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 02/16/2016] [Indexed: 12/12/2022] Open
Abstract
Background Chemokine receptor 5 (CCR5) is hypothesized to drive the lymphocyte migration to central nervous system in flavivirus encephalitis, and the non-functional CCR5Δ32 genetic variant was identified as a risk factor of a West Nile virus infection and of tick-borne encephalitis (TBE). We have attempted to investigate how CCR5 expression corresponds to the clinical course and severity of TBE. Methods We have repeatedly studied CCR5 expression in 76 patients during encephalitic and convalescent TBE phase, analyzing its association with clinical features, cerebrospinal fluid (csf) pleocytosis, and concentrations of CCR5 ligands (chemokines CCL3, CCL4, and CCL5) and CCR5 genotype. Fifteen patients with neuroborreliosis, 7 with aseptic meningitis, 17 in whom meningitis/encephalitis had been excluded, and 18 healthy blood donors were studied as controls. Expression of CCR5 was measured cytometrically in blood and csf-activated Th lymphocytes (CD3+CD4+CD45RO+). Concentrations of chemokines in serum and csf were measured immunoenzymatically, and CCR5Δ32 was detected with sequence-specific primers. Data were analyzed with non-parametric tests, and p < 0.05 was considered significant. Results The blood expression of CCR5 did neither differ between the groups nor change in the course of TBE. The CCR5 expression in the inflammatory csf was several-fold increased in comparison with blood but lower in TBE than in neuroborreliosis. The csf concentration of CCL5 was increased in TBE, the highest in the most severe presentation (meningoencephalomyelitis) and correlated with pleocytosis. The CCR5Δ32/wt genotype present in 7 TBE patients was associated with a decreased CCR5 expression, but enrichment of csf Th population in CCR5-positive cells and the intrathecal inflammatory response were preserved, without a compensatory increase of CCL5 expression. Conclusions We infer CCR5 and CCL5 participate in the response to TBE virus, as well as to other neurotropic pathogens. The intrathecal response to TBE is not hampered in the bearers of a single copy of CCR5Δ32 allele, suggesting that the association of CCR5Δ32 with TBE may be mediated in the periphery at the earlier stage of the infection. Otherwise, a variability of the CCR5 expression in the peripheral blood lymphocytes seems not to be associated with a variable susceptibility to TBE.
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Affiliation(s)
- Sambor Grygorczuk
- Department of the Infectious Diseases and Neuroinfections, Medical University of Białystok, ul. Żurawia 14, 15-540, Białystok, Poland.
| | - Joanna Osada
- Department of Hematologic Diagnostics, Medical University of Białystok, ul. Waszyngtona 15A, 15-269, Białystok, Poland.
| | - Miłosz Parczewski
- Department of Infectious Diseases and Hepatology, Pomeranian Medical University in Szczecin, ul Arkońska 4, 71-455, Szczecin, Poland.
| | - Anna Moniuszko
- Department of the Infectious Diseases and Neuroinfections, Medical University of Białystok, ul. Żurawia 14, 15-540, Białystok, Poland.
| | - Renata Świerzbińska
- Department of the Infectious Diseases and Neuroinfections, Medical University of Białystok, ul. Żurawia 14, 15-540, Białystok, Poland.
| | - Maciej Kondrusik
- Department of the Infectious Diseases and Neuroinfections, Medical University of Białystok, ul. Żurawia 14, 15-540, Białystok, Poland.
| | - Piotr Czupryna
- Department of the Infectious Diseases and Neuroinfections, Medical University of Białystok, ul. Żurawia 14, 15-540, Białystok, Poland.
| | - Justyna Dunaj
- Department of the Infectious Diseases and Neuroinfections, Medical University of Białystok, ul. Żurawia 14, 15-540, Białystok, Poland.
| | - Milena Dąbrowska
- Department of Hematologic Diagnostics, Medical University of Białystok, ul. Waszyngtona 15A, 15-269, Białystok, Poland.
| | - Sławomir Pancewicz
- Department of the Infectious Diseases and Neuroinfections, Medical University of Białystok, ul. Żurawia 14, 15-540, Białystok, Poland.
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Infektionen. NEUROINTENSIV 2015. [PMCID: PMC7175474 DOI: 10.1007/978-3-662-46500-4_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In diesem Kapitel werden zunächst die für die Neurointensivmedizin wesentlichen bakteriellen Infektionen (Meningitis, spinale und Hirnabszesse, Spondylodiszitis, septisch-embolische Herdenzephalitis) abgehandelt, die trotz gezielt eingesetzter Antibiotika und neurochirurgischer Therapieoptionen noch mit einer erheblichen Morbidität und Mortalität behaftet sind. Besonderheiten wie neurovaskuläre Komplikationen, die Tuberkulose des Nervensystems, Neuroborreliose, Neurosyphilis und opportunistische Infektionen bei Immunsuppressionszuständen finden hierbei besondere Berücksichtigung. Der zweite Teil dieses Kapitels behandelt akute und chronische Virusinfektionen des ZNS sowie in einem gesonderten Abschnitt die HIVInfektion und HIV-assoziierte Krankheitsbilder sowie Parasitosen und Pilzinfektionen, die in Industrieländern seit Einführung der HAART bei HIV zwar eher seltener, aber mit zunehmender Globalisierung auch in unseren Breiten immer noch anzutreffen sind.
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Neurological complications of tick borne encephalitis: the experience of 89 patients studied and literature review. Neurol Sci 2013; 35:15-21. [DOI: 10.1007/s10072-013-1565-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 10/15/2013] [Indexed: 10/26/2022]
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Abstract
Worldwide, arboviral illnesses constitute the most important international infectious threat to human neurological health and welfare. Before the availability of effective immunizations, approximately 50,000 cases of Japanese encephalitis occurred in the world each year, one-fifth of which cases proved lethal and a much larger number were left with severe neurological handicaps. With global climate change and perhaps other factors, the prevalences of some arboviral illnesses appear to be increasing. Arboviral illnesses, including Japanese encephalitis, tick-borne encephalitis, Yellow fever, and others, are emerging as possible global health care threats because of biological warfare. This chapter will review ecology, pathophysiology, diagnosis, management, and outcome of the forms of arboviral encephalitis that are of greatest importance in North America, together with some of the most important arboviral encephalitides prevalent in other parts of the world.
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Horger M, Beck R, Fenchel M, Ernemann U, Nägele T, Brodoefel H, Heckl S. Imaging Findings in Tick-Borne Encephalitis With Differential Diagnostic Considerations. AJR Am J Roentgenol 2012; 199:420-427. [DOI: 10.2214/ajr.11.7911] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Marius Horger
- Department of Diagnostic Radiology, Eberhard-Karls-University, Hoppe-Seyler-Strasse 3, Tübingen 72076, Germany
| | - Robert Beck
- Institute of Medical Virology, Eberhard-Karls-University, Tübingen, Germany
| | - Michael Fenchel
- Department of Diagnostic Radiology-Neuroradiology, Eberhard-Karls-University, Tübingen, Germany
| | - Ulrike Ernemann
- Department of Diagnostic Radiology-Neuroradiology, Eberhard-Karls-University, Tübingen, Germany
| | - Thomas Nägele
- Department of Diagnostic Radiology-Neuroradiology, Eberhard-Karls-University, Tübingen, Germany
| | - Harald Brodoefel
- Department of Diagnostic Radiology, Eberhard-Karls-University, Hoppe-Seyler-Strasse 3, Tübingen 72076, Germany
- Department of Neuroradiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Stefan Heckl
- Department of Diagnostic Radiology-Neuroradiology, Eberhard-Karls-University, Tübingen, Germany
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Ponfick M, Hacker S, Gdynia HJ, Linden R, Gränz M, Nowak DA. Meningoencephaloradiculomyelitis after tick-borne encephalitis virus infection: a case series. Eur J Neurol 2012; 19:776-82. [DOI: 10.1111/j.1468-1331.2011.03651.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Infektionen. NEUROINTENSIV 2012. [PMCID: PMC7123678 DOI: 10.1007/978-3-642-16911-3_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Trotz Weiterentwicklung moderner Antibiotika in den letzten Jahren sind die Letalitätszahlen der bakteriellen (eitrigen) Meningitis weiterhin hoch; Überlebende haben häufig neurologische Residuen. Die ungünstigen klinischen Verläufe der bakteriellen Meningitis sind meist Folge intrakranieller Komplikationen, wie z. B. eines generalisierten Hirnödems, einer zerebrovaskulären arteriellen oder venösen Beteiligung oder eines Hydrozephalus.
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Zambito Marsala S, Francavilla E, Gioulis M, Candeago RM, Mondardini V, Gentile M, Ferracci F, Guzzo F, Granata C, Marchini C. Isolated polio-like syndrome after tick-borne encephalitis presenting with acute hyperckemia. Neurol Sci 2011; 33:669-72. [DOI: 10.1007/s10072-011-0834-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Accepted: 10/21/2011] [Indexed: 11/29/2022]
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Růžek D, Dobler G, Donoso Mantke O. Tick-borne encephalitis: pathogenesis and clinical implications. Travel Med Infect Dis 2010; 8:223-32. [PMID: 20970725 DOI: 10.1016/j.tmaid.2010.06.004] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Revised: 06/07/2010] [Accepted: 06/28/2010] [Indexed: 12/13/2022]
Abstract
Tick-borne encephalitis (TBE) is an important and severe neurological illness occurring in large areas of Europe and northern Asia. Only a small proportion of those infected develop clinical symptoms. The symptomatic cases are, however, characterized with fevers and debilitating encephalitis that might progress into chronic disease or fatal infections. This review summarizes data on clinical presentation, pathogenesis and pathology of TBE in humans, and of experimental TBE in animal models with the purpose to explain why is TBE such a severe disease clinically.
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Affiliation(s)
- Daniel Růžek
- Institute of Parasitology, Biology Centre of the Academy of Sciences of the Czech Republic, Branišovská 31, CZ-37005 České Budějovice, Czech Republic.
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Růžek D, Vancová M, Tesařová M, Ahantarig A, Kopecký J, Grubhoffer L. Morphological changes in human neural cells following tick-borne encephalitis virus infection. J Gen Virol 2009; 90:1649-1658. [DOI: 10.1099/vir.0.010058-0] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
Tick-borne encephalitis (TBE) is one of the leading and most dangerous human viral neuroinfections in Europe and north-eastern Asia. The clinical manifestations include asymptomatic infections, fevers and debilitating encephalitis that might progress into chronic disease or fatal infection. To understand TBE pathology further in host nervous systems, three human neural cell lines, neuroblastoma, medulloblastoma and glioblastoma, were infected with TBE virus (TBEV). The susceptibility and virus-mediated cytopathic effect, including ultrastructural and apoptotic changes of the cells, were examined. All the neural cell lines tested were susceptible to TBEV infection. Interestingly, the neural cells produced about 100- to 10 000-fold higher virus titres than the conventional cell lines of extraneural origin, indicating the highly susceptible nature of neural cells to TBEV infection. The infection of medulloblastoma and glioblastoma cells was associated with a number of major morphological changes, including proliferation of membranes of the rough endoplasmic reticulum and extensive rearrangement of cytoskeletal structures. The TBEV-infected cells exhibited either necrotic or apoptotic morphological features. We observed ultrastructural apoptotic signs (condensation, margination and fragmentation of chromatin) and other alterations, such as vacuolation of the cytoplasm, dilatation of the endoplasmic reticulum cisternae and shrinkage of cells, accompanied by a high density of the cytoplasm. On the other hand, infected neuroblastoma cells did not exhibit proliferation of membranous structures. The virions were present in both the endoplasmic reticulum and the cytoplasm. Cells were dying preferentially by necrotic mechanisms rather than apoptosis. The neuropathological significance of these observations is discussed.
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Affiliation(s)
- Daniel Růžek
- Institute of Parasitology, Biology Centre of the Academy of Sciences of the Czech Republic and Faculty of Science, University of South Bohemia, Branišovská 31, CZ-37005 České Budějovice, Czech Republic
| | - Marie Vancová
- Institute of Parasitology, Biology Centre of the Academy of Sciences of the Czech Republic and Faculty of Science, University of South Bohemia, Branišovská 31, CZ-37005 České Budějovice, Czech Republic
| | - Martina Tesařová
- Institute of Parasitology, Biology Centre of the Academy of Sciences of the Czech Republic and Faculty of Science, University of South Bohemia, Branišovská 31, CZ-37005 České Budějovice, Czech Republic
| | - Arunee Ahantarig
- Faculty of Science, Mahidol University, 6 Rama Road, Bangkok 10400, Thailand
| | - Jan Kopecký
- Institute of Parasitology, Biology Centre of the Academy of Sciences of the Czech Republic and Faculty of Science, University of South Bohemia, Branišovská 31, CZ-37005 České Budějovice, Czech Republic
| | - Libor Grubhoffer
- Institute of Parasitology, Biology Centre of the Academy of Sciences of the Czech Republic and Faculty of Science, University of South Bohemia, Branišovská 31, CZ-37005 České Budějovice, Czech Republic
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Fauser S, Stich O, Rauer S. Unusual case of tick borne encephalitis with isolated myeloradiculitis. J Neurol Neurosurg Psychiatry 2007; 78:909-10. [PMID: 17237139 PMCID: PMC2117725 DOI: 10.1136/jnnp.2006.110882] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Stich O, Reinhard M, Rauer S. MRI scans of cervical cord provide evidence of anterior horn lesion in a patient with tick-borne encephalomyeloradiculitis. Eur J Neurol 2007; 14:e5-6. [PMID: 17539929 DOI: 10.1111/j.1468-1331.2007.01774.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Logina I, Krumina A, Karelis G, Elsone L, Viksna L, Rozentale B, Donaghy M. Clinical features of double infection with tick-borne encephalitis and Lyme borreliosis transmitted by tick bite. J Neurol Neurosurg Psychiatry 2006; 77:1350-3. [PMID: 16754695 PMCID: PMC2077418 DOI: 10.1136/jnnp.2004.060731] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND In Latvia and other endemic regions, a single tick bite has the potential to transmit both tick-borne encephalitis (TBE) and Lyme borreliosis. OBJECTIVE To analyse both the clinical features and differential diagnosis of combined tick-borne infection with TBE and Lyme borreliosis, in 51 patients with serological evidence, of whom 69% had tick bites. RESULTS Biphasic fever suggestive of TBE occurred in 55% of the patients. Meningitis occurred in 92%, with painful radicular symptoms in 39%. Muscle weakness occurred in 41%; in 29% the flaccid paralysis was compatible with TBE. Only two patients presented with the bulbar palsy typical of TBE. Typical Lyme borreliosis facial palsy occurred in three patients. Typical TBE oculomotor disturbances occurred in two. Other features typical of Lyme borreliosis detected in our patients were distal peripheral neuropathy (n = 4), arthralgia (n = 9), local erythema 1-12 days after tick bite (n = 7) and erythema chronicum migrans (n = 1). Echocardiogram abnormalities occurred in 15. CONCLUSIONS Patients with double infection with TBE and Lyme borreliosis fell into three main clinical groups: febrile illness, 3 (6%); meningitis, 15 (30%); central or peripheral neurological deficit (meningoencephalitis, meningomyelitis, meningoradiculitis and polyradiculoneuritis), 33 (65%). Systemic features pointing to Lyme borreliosis were found in 25 patients (49%); immunoglobulin (Ig)M antibodies to borreliosis were present in 18 of them. The clinical occurrence of both Lyme borreliosis and TBE vary after exposure to tick bite, and the neurological manifestations of each disorder vary widely, with considerable overlap. This observational study provides no evidence that co-infection produces unusual manifestations due to unpredicted interaction between the two diseases. Patients with tick exposure presenting with acute neurological symptoms in areas endemic for both Lyme borreliosis and TBE should be investigated for both conditions. The threshold for simultaneous treatment of both conditions should be low, given the possibility of co-occurrence and the difficulty in ascribing individual neurological manifestations to one condition or the other.
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Affiliation(s)
- I Logina
- Stradin's University Hospital, Riga, Latvia
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Thuong NTT, Dunstan SJ, Dung NM, Charlieu JP, Loan HT, Wills B, Solomon T, Farrar JJ. Polymorphisms of the gene coding for copper/zinc superoxide dismutase (SOD1) in patients with Japanese encephalitis. ANNALS OF TROPICAL MEDICINE AND PARASITOLOGY 2006; 100:631-6. [PMID: 16989689 DOI: 10.1179/136485906x105606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Japanese encephalitis is the commonest form of encephalitis globally. Most cases develop characteristic encephalitis but some also present with flaccid paralysis. The paralysis is secondary to damage at the alpha motor neurone, the site that is also damaged in amyotrophic lateral sclerosis (ALS). The gene coding for superoxide dismutase 1 (SOD1) is thought to be involved in ALS and may also be linked to susceptibility to Japanese encephalitis. To investigate this possibility, polymorphisms in the SOD1 gene were investigated, in 61 cases of Japanese encephalitis, 61 matched controls and 171 population controls, in Vietnam. Novel polymorphisms, found only in three of the cases and one of the population controls, may be involved with susceptibility to Japanese encephalitis and potentially to other flavivirus infections that lead to damage to the cells of the anterior horn. Further research on this possible association is required.
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Affiliation(s)
- N T T Thuong
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, 190 Ben Ham Tu, Quan 5, Ho Chi Minh City, Vietnam
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Leyssen P, Croes R, Rau P, Heiland S, Verbeken E, Sciot R, Paeshuyse J, Charlier N, De Clercq E, Meyding‐Lamadé U, Neyts J. Acute encephalitis, a poliomyelitis-like syndrome and neurological sequelae in a hamster model for flavivirus infections. Brain Pathol 2006; 13:279-90. [PMID: 12946018 PMCID: PMC8095928 DOI: 10.1111/j.1750-3639.2003.tb00028.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Infection of hamsters with the murine flavivirus Modoc results in (meningo)encephalitis, which is, during the acute phase, frequently associated with flaccid paralysis, as also observed in patients with West Nile virus encephalitis. Twenty percent of the hamsters that recover from the acute encephalitis develop life-long neurological sequelae, reminiscent of those observed, for example, in survivors of Japanese encephalitis. Magnetic resonance imaging and histology revealed severe lesions predominantly located in the olfactory-limbic system, both in hamsters with acute encephalitis as in survivors. Prominent pathology was also detected in the spinal cord of hamsters with paralysis. Modoc virus infections in hamsters provide a unique model for the study of encephalitis, a poliomyelitis-like syndrome and neurological sequelae following flavivirus infection.
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Affiliation(s)
- Pieter Leyssen
- Rega Institute for Medical Research, Katholieke Universiteit Leuven, Belgium
| | - Romaric Croes
- Department of Morphology and Molecular Pathology, Katholieke Universiteit Leuven, Belgium
| | - Philipp Rau
- Department of Neurology, University of Heidelberg, Germany
| | - Sabine Heiland
- Department of Neurology, University of Heidelberg, Germany
| | - Erik Verbeken
- Department of Morphology and Molecular Pathology, Katholieke Universiteit Leuven, Belgium
| | - Raphael Sciot
- Rega Institute for Medical Research, Katholieke Universiteit Leuven, Belgium
| | - Jan Paeshuyse
- Rega Institute for Medical Research, Katholieke Universiteit Leuven, Belgium
| | - Nathalie Charlier
- Rega Institute for Medical Research, Katholieke Universiteit Leuven, Belgium
| | - Erik De Clercq
- Rega Institute for Medical Research, Katholieke Universiteit Leuven, Belgium
| | | | - Johan Neyts
- Rega Institute for Medical Research, Katholieke Universiteit Leuven, Belgium
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Abstract
Tick-borne encephalopathies constitute a broad range of infectious diseases affecting the brain and other parts of the CNS. The causative agents are both viral and bacterial. This review focuses on the current most important tick-borne human diseases: tick-borne encephalitis (TBE; including Powassan encephalitis) and Lyme borreliosis. Rocky Mountain spotted fever (RMSF) and Colorado tick fever (CTF), less common tick-borne diseases associated with encephalopathy, are also discussed. TBE is the most important flaviviral infection of the CNS in Europe and Russia, with 10 000-12 000 people diagnosed annually. The lethality of TBE in Europe is 0.5% and a post-encephalitic syndrome is seen in over 40% of affected patients, often producing a pronounced impairment in quality of life. There is no specific treatment for TBE. Two vaccines are available to prevent infection. Although these have a good protection rate and good efficacy, there are few data on long-term immunity. Lyme borreliosis is the most prevalent tick-borne disease in Europe and North America, with >50 000 cases annually. Localised early disease can be treated with oral phenoxymethylpenicillin (penicillin V), doxycycline or amoxicillin. The later manifestations of meningitis, arthritis or acrodermatitis can be treated with oral doxycycline, oral amoxicillin or intravenous ceftriaxone; intravenous benzylpenicillin (penicillin G) or cefotaxime can be used as alternatives. The current use of vaccines against Lyme borreliosis in North America is under discussion, as the LYMErix vaccine has been withdrawn from the market because of possible adverse effects, for example, arthritis. RMSF and CTF appear only in North America. RMSF is an important rickettsial disease and is effectively treated with doxycycline. There is no treatment or preventative measure available for CTF.
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Affiliation(s)
- Göran Günther
- Infectious Diseases, Department of Medical Sciences, Akademiska Sjukhuset, Uppsala University Hospital, Uppsala, Sweden.
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Gelpi E, Preusser M, Garzuly F, Holzmann H, Heinz FX, Budka H. Visualization of Central European tick-borne encephalitis infection in fatal human cases. J Neuropathol Exp Neurol 2005; 64:506-12. [PMID: 15977642 DOI: 10.1093/jnen/64.6.506] [Citation(s) in RCA: 130] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Central European tick-borne encephalitis (TBE) is caused by a flavivirus vectored by the Ixodes ricinus tick. In severe infections, TBE presents as (myelo)meningoencephalitis with considerable mortality. Characteristic neuropathologic changes feature a multinodular to patchy polioencephalomyelitis accentuated in spinal cord, brainstem, and cerebellum. Visualization of viral infection by immunohistochemistry has not yet been achieved. We analyzed immunohistochemically the distribution of viral antigens and its correlation with neuropathologic changes, serological data, and disease duration in 28 brains of cases with a clinical diagnosis of TBE and neuropathologically confirmed (meningo)encephalomyelitis. In 20 brains (including 10 seropositives), viral antigens were detectable. These cases were characterized by relatively short clinical duration ranging from 4 to 35 days. Immunoreactivity was most prominent in perikarya and processes of Purkinje cells and large neurons of dentate nucleus, inferior olives, and anterior horns. In addition, immunoreactivity was detected in neurons of other brainstem nuclei, isocortex, and basal ganglia. There was an inverse topographical association of severe inflammatory changes with presence of viral antigens. Some cytotoxic T cells were in direct contact with tick-borne encephalitis virus (TBEV)-infected neurons. We conclude that 1) TBE viral antigens are immunohistochemically detectable in brains of fatal cases with relatively short natural clinical course; 2) TBE virus neurotropism preferentially targets large neurons of anterior horns, medulla oblongata, pons, dentate nucleus, Purkinje cells, and striatum; 3) topographical correlation between inflammatory changes and distribution of viral antigens is poor; and 4) immunologic mechanisms may contribute to nerve cell destruction in human TBE.
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Affiliation(s)
- Ellen Gelpi
- Institutes of Neurology, Medical University of Vienna, Vienna, Austria
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Abstract
PURPOSE OF REVIEW Although acute flaccid paralysis (AFP) is more frequently seen in the tropics than in temperate regions, recent outbreaks of West Nile virus (WNV) in North America have drawn attention to this important presentation. Starting with anatomical and neurophysiological considerations, this article examines data on AFP caused by WNV, and considers recent data on paralysis caused by enteroviruses, and Guillain-Barré syndrome (GBS). RECENT FINDINGS Neurophysiological, radiological and pathological studies suggest WNV causes AFP by damaging anterior horn cells in the spinal cord. The clinical presentation is probably best described as a 'poliomyelitis-like illness', and the disease as 'WNV myelitis'. Other findings during the recent outbreaks include increasing recognition of a Parkinson's-disease like presentation, and descriptions of virus transmission in blood transfusions and transplanted organs. GBS is now recognized as several disorders characterized by immune-mediated attack on peripheral nerves: in acute inflammatory demyelinating polyneuropathy the myelin sheath and Schwann cell of sensory and motor nerves are targeted; acute motor axonal and acute motor and sensory axonal neuropathy often follow Campylobacter jejuni enteritis and are associated with antibodies against the ganglioside component of the nerve axolemmal membrane. In Asia-Pacific, enterovirus 71 has caused outbreaks of neurological diseases with AFP and encephalitis, but no single genogroup of virus appears responsible for severe disease. SUMMARY Despite the near eradication of poliomyelitis, AFP caused by viruses remains an important clinical presentation. Distinguishing direct viral causes from GBS is important for public health reasons, and to avoid inappropriate therapies.
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Affiliation(s)
- Tom Solomon
- Department of Neurological Science, and Medical Microbiology, University of Liverpool, Walton Centre for Neurology and Neurosurgery, Liverpool, UK.
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Rauschka H, Jellinger K, Lassmann H, Braier F, Schmidbauer M. Guillain-Barré syndrome with marked pleocytosis or a significant proportion of polymorphonuclear granulocytes in the cerebrospinal fluid: neuropathological investigation of five cases and review of differential diagnoses. Eur J Neurol 2003; 10:479-86. [PMID: 12940826 DOI: 10.1046/j.1468-1331.2003.00644.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In cases with otherwise clinically typical Guillain-Barré syndrome (GBS), pronounced cerebrospinal fluid (CSF) pleocytosis or the mere presence of CSF-polymorphonuclear granulocytes should alert the physician to consider alternative diagnoses. Therefore, we retrospectively studied the neuropathology of central and peripheral nervous system in two cases with a CSF cell count of more than 50/microl and in three cases with a significant proportion of polymorphonuclear granulocytes in the CSF sediment. All cases fulfilled the required criteria for the diagnosis of GBS, the duration from onset to death ranged from 4 to 100 days. Neuropathological investigations included routine staining procedures and immunohistochemistry for antigens of glial and haematopoetic cells as well as for products of relevant neurotropic viruses. Demyelinating polyradiculitis was present in four cases, in one patient with a survival time of 4 days the type of damage to myelinated fibres was unclassifiable. In the central nervous system a consistent finding was diffuse activation of microglia, only one case showed mild meningeal and lower brainstem inflammation. Viral products were generally absent. In summary, the neuropathological findings confirm that marked CSF pleocytosis or the presence of polymorphonuclear granulocytes does not rule out the diagnosis of GBS.
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Affiliation(s)
- H Rauschka
- Department of Neurology, Hospital Lainz, Vienna, Austria
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Doron SI, Dashe JF, Adelman LS, Brown WF, Werner BG, Hadley S. Histopathologically proven poliomyelitis with quadriplegia and loss of brainstem function due to West Nile virus infection. Clin Infect Dis 2003; 37:e74-7. [PMID: 12942423 DOI: 10.1086/377177] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2003] [Accepted: 05/02/2003] [Indexed: 11/03/2022] Open
Abstract
Recent electrophysiological and histopathological reports point to motor neurons in the anterior horn of the spinal cord and the brainstem as targets of severe West Nile virus (WNV) infection. We report histopathological confirmation of this poliomyelitis-like syndrome in a patient with WNV infection in Massachusetts.
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Affiliation(s)
- Shira I Doron
- Department of Geographic Medicine and Infectious Diseases, Tufts-New England Medical Center, Boston, MA, USA.
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Grygorczuk S, Mierzynska D, Zdrodowska A, Zajkowska J, Pancewicz S, Kondrusik M, Swierzbinska R, Pryszmont J, Hermanowska-Szpakowicz T. Tick-borne encephalitis in north-eastern Poland in 1997-2001: a retrospective study. SCANDINAVIAN JOURNAL OF INFECTIOUS DISEASES 2003; 34:904-9. [PMID: 12587623 DOI: 10.1080/0036554021000026979] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The aim of this study was to characterize the epidemiology and clinical features of tick-borne encephalitis in north-eastern Poland. Clinical and epidemiological data were analysed of patients hospitalized with the diagnosis in the Department of the Infectious Diseases and Neuroinfections of the Medical University in Bialystok in 1997-2001. Tick-borne encephalitis was diagnosed in 152 patients: 51 (34%) presented with meningitis, 89 (59%) with meningoencephalitis and 12 (8%) with meningoencephalomyelitis. Headache (84%) and fever (81%) were the most common symptoms. Meningeal signs were present in 137 patients (90%). Most common neurological abnormalities were: Oppenheim and Babinski signs (74 patients, 49%), ataxia (37, 24%), impaired consciousness (37, 24%) and pareses (16, 10%). Of patients examined, 146 (96%) had raised pleiocytosis, frequently accompanied by high cerebrospinal fluid protein concentration (90%), raised erythrocyte sedimentation rate (65%), peripheral blood leucocytosis (26%) and increased aminotransferase activity (16%). There was only 1 forest worker among the patients. Tick-borne encephalitis remains common in north-eastern Poland but, possibly because of effective vaccination, it has virtually disappeared among forest employees. The diagnosis appears difficult in some cases, as meningeal signs may not be present and laboratory findings may not be suggestive of a viral infection.
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Affiliation(s)
- Sambor Grygorczuk
- Department of Infectious Diseases, Medical Academy of Bialystok, Dluski Regional Specialist Hospital, Bialystok, Poland
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Solomon T, Ravi V. Acute flaccid paralysis caused by West Nile virus. THE LANCET. INFECTIOUS DISEASES 2003; 3:189; discussion 189-90. [PMID: 12679260 DOI: 10.1016/s1473-3099(03)00574-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- T Solomon
- Department of Neurological Science, University of Liverpool, Liverpool, UK.
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Ooi MH, Wong SC, Clear D, Perera D, Krishnan S, Preston T, Tio PH, Willison HJ, Tedman B, Kneen R, Cardosa MJ, Solomon T. Adenovirus type 21-associated acute flaccid paralysis during an outbreak of hand-foot-and-mouth disease in Sarawak, Malaysia. Clin Infect Dis 2003; 36:550-9. [PMID: 12594634 DOI: 10.1086/367648] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2002] [Accepted: 10/20/2002] [Indexed: 11/03/2022] Open
Abstract
We report the virological and clinical features of 8 children who presented with adenovirus-associated acute flaccid paralysis (AFP) during an epidemic of enterovirus type 71 (EV71)-associated hand-foot-and-mouth disease (HFMD) in Sarawak, Malaysia, in 1997. Neutralization tests and phylogenetic analysis revealed adenovirus type 21 (Ad21), although DNA restriction digests suggested that this virus was different from the prototype Ad21. Four children had upper-limb monoparesis, 2 had lower-limb monoparesis (one of whom had changes in the anterior spinal cord noted on magnetic resonance imaging), and 2 had flaccid paraparesis. At follow-up, 4 children were noted to have made full recoveries and 3 had residual flaccid weakness and wasting. Neurophysiological investigation revealed a mixture of axonal and demyelinating features in motor and sensory nerves, with denervation. These findings suggest that Ad21 might cause AFP by anterior horn cell damage or neuropathy of the brachial or lumbosacral plexus. The occurrence of these unusual adenovirus infections during an outbreak of EV71-associated HFMD suggests that an interaction between the 2 viruses may have occurred.
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Affiliation(s)
- Mong How Ooi
- Department of Paediatrics, Sibu Hospital, Sibu, Malaysia
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Cécille A, Nahum L, Maisonneuve L, Lanoe Y, Le Pennec MP. [A travelling man...immobilized]. Rev Med Interne 2002; 23 Suppl 2:244s-246s. [PMID: 12108201 DOI: 10.1016/s0248-8663(02)80009-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- A Cécille
- Laboratoire de biologie, hôpital R. Ballanger, 93602 Aulnay-sous-Bois, France
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