Unilateral cortical FLAIR-hyperintense Lesions in Anti-MOG-associated Encephalitis with Seizures (FLAMES): characterization of a distinct clinico-radiographic syndrome

OBJECTIVE

To characterize the clinical symptoms and magnetic resonance imaging (MRI) findings of unilateral cortical FLAIR-hyperintense Lesions in Anti-MOG-associated Encephalitis with Seizures (FLAMES).

METHODS

This is a case report and systematic review of the literature to identify cases of unilateral cortical FLAMES. Cases were reviewed to determine the frequency of clinical symptoms (seizures, headache, fever and cortical symptoms referable to FLAMES location), and to determine whether MRI abnormalities are restricted to the unilateral cortex in this syndrome.

RESULTS

We identified 20 cases of unilateral cortical FLAMES for review. Among them, 17/20 (85%) had seizures, 14/20 (70%) had headache, 13/20 (65%) had fever, 11/20 (55%) reported cortical symptoms referable to the FLAMES location, and 19/20 (95%) reported at least two of these four findings. On MRI 4/20 (20%) had some contralateral hemispheric cortical signal abnormality, and 6/20 (30%) had MRI findings concerning for meningeal inflammation.

CONCLUSIONS

In patients with unilateral cortical FLAMES, the clinical symptoms of seizures, headache, fever and cortical symptoms referable to the FLAMES location are frequent. Although initially described as a unilateral cortical encephalitis, bilateral cortical involvement and possible meningeal inflammation could indicate a broader disease spectrum. Recognition of this distinct clinico-radiographic syndrome may facilitate prompt diagnosis and treatment.

High-dose corticosteroids for acute cytomegalovirus-associated transverse myelitis in the immunocompetent patient: a case report and systematic review

We present an immunocompetent patient with transverse myelitis (TM) during acute cytomegalovirus (CMV) infection, as evidenced by a reactive serum CMV IgM and CMV viremia. The patient had an excellent outcome after receiving only high-dose methylprednisolone. Given concerns that practitioners may have around the use of immunosuppressive therapy for this potentially infectious myelopathy, we systematically reviewed the literature to assess outcomes after administration of high-dose corticosteroids to this population. Despite severe disease at clinical nadir with inability to ambulate, immunocompetent patients with acute CMV-associated TM who received high-dose corticosteroids had good clinical outcomes 1 month to 1 year after presentation.

Primary Epstein-Barr virus infection, seroconversion, and post-transplant lymphoproliferative disorder in seronegative renal allograft recipients: a prospective cohort study

BACKGROUND

Epstein-Barr virus (EBV)-seronegative renal transplant recipients are at risk of post-transplant lymphoproliferative disorder (PTLD). We compared primary EBV infection, seroconversion, and PTLD in EBV-seronegative patients who received renal allograft from seropositive or seronegative donors (D+/R- and D-/R-, respectively).

METHODS

We prospectively followed 25 D+/R- and 8 D-/R- recipients. We followed patients from January 1999 to June 2009 with clinical visits, monthly EBV polymerase chain reaction tests, and serologic tests for a period of 1 year after kidney transplantation and on an individual basis thereafter.

RESULTS

Three patients (9%) developed PTLD including 2 early-onset (<12 months) and 1 late-onset (>12 months) disease. In D+/R- and D-/R- patients, the frequencies of PTLD (8% vs. 12.5%, P = 0.7), EBV seroconversion (64% vs. 50%, P = 0.4), and EBV viremia (40% vs. 25%, P = 0.6) were not significantly different. Clinical, serologic, and virologic surveillance as well as reduction in immunosuppression after evidence of primary EBV infection resulted in a PTLD rate of 9%, despite a seroconversion rate of 60.6%. Rate of graft loss after reduction in immunosuppression was 10% (2 of 20), which was not significantly different from 13 patients without EBV seroconversion (no graft loss, P = 0.5). Rates of viremia, seroconversion, and PTLD in D+/R- and D-/R- patients appear to be similar.

CONCLUSIONS

The incidence of PTLD in renal transplants ranges from 0.5% to 2.9%. Our data show a significantly higher rate in EBV-seronegative renal allograft recipients, suggesting the need for close surveillance. Our data also suggest that donors for EBV-seronegative recipients may be accepted irrespective of positive or negative serostatus, with ongoing surveillance important in either circumstance.

Risk factors for voriconazole hepatotoxicity at 12 weeks in lung transplant recipients

Voriconazole is commonly used for prophylaxis and treatment of invasive aspergillosis in lung transplant recipients. However, the use of voriconazole may at times be limited by the development of hepatotoxicity. Our goal is to determine predictors of voriconazole-associated hepatotoxicity in lung transplant recipients. We conducted a single center retrospective cohort study of lung transplant recipients from 2006 to 2010 who received voriconazole therapy. We compared characteristics of patients who developed hepatotoxicity and those who did not. One hundred five lung transplant recipients received voriconazole. Hepatotoxicity occurred in 51% (54/105) of patients and lead to discontinuation in 34% (36/105). In univariate analysis, age less than 40 years, cystic fibrosis, use of azathioprine, history of liver disease and early initiation of voriconazole were associated with hepatotoxicity. In multivariable logistic regression analysis, perioperative initiation of voriconazole (within 30 days of transplantation) was independently associated with hepatotoxicity (OR 4.37, 95% CI: 1.53-12.43, p = 0.006). The five risk factors identified in the univariate analysis were used to build a K-nearest neighbor algorithm predictive model for hepatotoxicity. This model predicted hepatotoxicity with an accuracy of 70%. Voriconazole therapy initiated within the first 30 days of transplantation is associated with a greater risk of developing hepatotoxicity.

The risk factors and laboratory diagnostics for post renal transplant tuberculosis: a case-control, country-wide study on definitive cases

BACKGROUND

Tuberculosis (TB) is an important cause of morbidity and mortality in renal transplant recipients and, because of its infrequency and the lack of medical awareness, it is usually misdiagnosed. This study was carried out to determine frequency and weight of multiple risk factors for post kidney transplantation TB.

METHODS

A total of 44 cases (0.3%), out of 12,820 patients from 12 major kidney transplantation centers in Iran from 1984 to 2003, were compared with 184 healthy transplant subjects who were transplanted by the same surgical team.

RESULTS

The mean age of cases and controls was 37.7 (13-63) and 35.6 (8-67) years (P=0.3), respectively. The mean duration of pre-transplantation hemodialysis was 30.3 (3-168) months in cases and 18.2 (1-180) months in controls (P=0.03). A positive past history of TB was detected in 2 cases and 1 control (P=0.3). The mean doses of initial and maintenance immunosuppressive drugs in cases and controls were not significantly different. A total of 25 cases (56.8%) and 60 controls (32.6%) had rejection before diagnosis of TB (P=0.004; OR=2.7, CI(95%): 1.3-5.6).

CONCLUSIONS

To our knowledge, this is the first study that demonstrated an increase in the risk of post-transplant TB by increasing the duration of pre-transplant hemodialysis and the number of post-transplant rejection episodes as 2 immunocompromised states. Further study is needed to clarify our new findings, specifically in relation to different immunosuppressive regimens.

Slow graft function after pediatric renal transplantation from volunteer live donors

Slow graft function (SGF) may occur during the early post-transplant period. In this paper, we present our findings regarding SGF after pediatric renal transplantation and its predictive variables. From 1985 to 2004, a total of 300 pediatric renal transplants were performed at our institution. A total of 10 cases with SGF and 50 controls that were operated by the same surgeons were enrolled in this study. The mean age of the recipients and donors was 11.4 (3-15 yr) and 28.05 yr (20-50 yr), respectively. All kidneys were retrieved from living donors. We compared patients with SGF with controls regarding four independent variables: age difference between donors and recipients, serum hemoglobin difference between donors and recipients, mean blood pressure (systolic blood pressure + 2 [diastolic blood pressure]/3) difference between donors and recipients, and weight difference between donors and recipients. The mean age of recipients was 10.5 +/- 4.1 in SGF group and 11.6 +/- 2.5 in control group (p = 0.4). The differences between donors and recipients regarding weight and mean blood pressure in subjects with SGF were not higher than other patients (42 kg vs. 37.4 kg, p = 0.4; -3 mmHg vs. -4.1 mmHg, p = 0.8). The mean hemoglobin difference between donors and recipients was 6.3 +/- 2.1 g/dL in SGF group and 6.7 +/- 2.3 g/dL in control group (p = 0.6). The differences between donors and recipients regarding age, weight, mean blood pressure and serum hemoglobin level are not predictive variables for SGF.