1
|
Zhang W, Nie P, Zhou J, Zhang Z, Tang J. A rare case of near complete recovery in an apneic coma patient with brainstem encephalitis for 14 days and a 9-year follow-up. Acta Neurol Belg 2023:10.1007/s13760-023-02440-6. [PMID: 37989971 DOI: 10.1007/s13760-023-02440-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/09/2023] [Indexed: 11/23/2023]
Affiliation(s)
- Weiyun Zhang
- Department of Neurology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Ping Nie
- Department of Neurology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Jing Zhou
- Department of Intensive Care Unit, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhaohui Zhang
- Department of Acupuncture, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jinrong Tang
- Department of Neurology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China.
| |
Collapse
|
2
|
Takai Y, Tobisawa S, Funai A, Komori T, Takahashi K. An Autopsy Case of Elderly Onset Brainstem Acute Disseminated Encephalomyelitis. Case Rep Neurol 2023; 15:31-40. [PMID: 36817729 PMCID: PMC9929651 DOI: 10.1159/000529180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 01/09/2023] [Indexed: 02/16/2023] Open
Abstract
Acute disseminated encephalomyelitis (ADEM), which is a disease that causes multifocal inflammatory demyelination of the central nervous system, occurs predominantly in children and young adults. We report an autopsy case of an elderly man with brainstem ADEM that progressed over a period of about 3 months. An 82-year-old man developed disturbance of consciousness, dysphagia, and ataxic gait over a period of about 3 months. He was admitted to another hospital for aspiration pneumonia and recovered but was transferred to our hospital due to prolonged disturbance of consciousness. The patient was able to follow simple commands but had a tendency to somnolence. In addition to meningeal stimulation signs, the patient had left-dominant upper and lower limb ataxia and right-dominant limb spasticity. Brain FLAIR/T2-weighted imaging showed high-intensity lesions from the brainstem to the middle cerebellar peduncle bilaterally, medulla oblongata and upper cervical spinal cord, and T1-weighted imaging revealed contrast-enhanced lesions in the left middle cerebellar peduncle and cervical spinal cord. Although spinal fluid examination revealed elevated proteins, other laboratory tests indicated no evidence of infection, vasculitis, collagen diseases or tumors, and anti-ganglioside, anti-AQP4 and anti-MOG antibodies were negative. After admission, the patient again developed aspiration pneumonia, which progressed to acute respiratory distress syndrome, and he died on the 15th day of hospitalization. Autopsy findings indicated acute and subacute demyelination mainly in the brainstem and cerebellum, and perivascular lymphocyte and macrophage infiltration in the areas of demyelination. A postmortem diagnosis of ADEM was made based on the generally monophasic course of the disease and the absence of regenerating myelinated sheaths. There are very few reports of elderly patients with brainstem ADEM. ADEM should be considered as a differential diagnosis in patients with brainstem encephalitis.
Collapse
Affiliation(s)
- Yasuyuki Takai
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan,Inouye eye Hospital, Tokyo, Japan
| | - Shinsuke Tobisawa
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Asuka Funai
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Takashi Komori
- Department of Laboratory Medicine and Pathology (Neuropathology), Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Kazushi Takahashi
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| |
Collapse
|
3
|
Jarius S, Bieber N, Haas J, Wildemann B. MOG encephalomyelitis after vaccination against severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2): case report and comprehensive review of the literature. J Neurol 2022; 269:5198-5212. [PMID: 35737110 PMCID: PMC9219396 DOI: 10.1007/s00415-022-11194-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/09/2022] [Accepted: 05/10/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND In around 20% of cases, myelin oligodendrocyte glycoprotein (MOG) immunoglobulin (IgG)-associated encephalomyelitis (MOG-EM; also termed MOG antibody-associated disease, MOGAD) first occurs in a postinfectious or postvaccinal setting. OBJECTIVE To report a case of MOG-EM with onset after vaccination with the Pfizer BioNTech COVID-19 mRNA vaccine BNT162b2 (Comirnaty®) and to provide a comprehensive review of the epidemiological, clinical, radiological, electrophysiological and laboratory features as well as treatment outcomes of all published patients with SARS-CoV-2 vaccination-associated new-onset MOG-EM. METHODS Case report and review of the literature. RESULTS In our patient, MOG-IgG-positive (serum 1:1000, mainly IgG1 and IgG2; CSF 1:2; MOG-specific antibody index < 4) unilateral optic neuritis (ON) occurred 10 days after booster vaccination with BNT162b2, which had been preceded by two immunizations with the vector-based Oxford AstraZeneca vaccine ChAdOx1-S/ChAdOx1-nCoV-19 (AZD1222). High-dose steroid treatment with oral tapering resulted in complete recovery. Overall, 20 cases of SARS-CoV2 vaccination-associated MOG-EM were analysed (median age at onset 43.5 years, range 28-68; female to male ratio = 1:1.2). All cases occurred in adults and almost all after immunization with ChAdOx1-S/ChAdOx1 nCoV-19 (median interval 13 days, range 7-32), mostly after the first dose. In 70% of patients, more than one CNS region (spinal cord, brainstem, supratentorial brain, optic nerve) was affected at onset, in contrast to a much lower rate in conventional MOG-EM in adults, in which isolated ON is predominant at onset and ADEM-like phenotypes are rare. The cerebrospinal fluid white cell count (WCC) exceeded 100 cells/μl in 5/14 (36%) patients with available data (median peak WCC 58 cells/μl in those with pleocytosis; range 6-720). Severe disease with tetraparesis, paraplegia, functional blindness, brainstem involvement and/or bladder/bowel dysfunction and a high lesion load was common, and treatment escalation with plasma exchange (N = 9) and/or prolonged IVMP therapy was required in 50% of cases. Complete or partial recovery was achieved in the majority of patients, but residual symptoms were significant in some. MOG-IgG remained detectable in 7/7 cases after 3 or 6 months. CONCLUSIONS MOG-EM with postvaccinal onset was mostly observed after vaccination with ChAdOx1-S/ChAdOx1 nCoV-19. Attack severity was often high at onset. Escalation of immunotherapy was frequently required. MOG-IgG persisted in the long term.
Collapse
Affiliation(s)
- S Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany.
- Otto Meyerhof Center, Im Neuenheimer Feld 350, 69120, Heidelberg, Germany.
| | - N Bieber
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - J Haas
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - B Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| |
Collapse
|
4
|
Wanigasinghe J, Jayawickrama A, Sumanasekera N. Herpes Simplex Virus-2 Encephalitis Complicated with Multiple Cranial Neuritis and Dysautonomia. J Pediatr Neurosci 2021; 16:344-346. [PMID: 36531770 PMCID: PMC9757526 DOI: 10.4103/jpn.jpn_239_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/22/2020] [Accepted: 12/29/2020] [Indexed: 06/17/2023] Open
Abstract
INTRODUCTION Herpes simplex encephalitis (HSE) is mainly caused by herpes simplex virus-1 infection (HSV-1). Herpes simplex virus-2 (HSV-2) infection is rare except in neonates or the immune-compromised. Cranial neuritis is rarely reported in association with HSE. This case study in an eleven-month-old followed by a literature review on cranial neuritis in HSE in children is presented due to the rarity of both situations. CASE REPORT An eleven-month old otherwise healthy infant presented with encephalitis due to HSV-2 infection which was complicated with dysautonomia manifesting as blood pressure fluctuations and tachycardia, and cranial neuritis manifesting as unilateral ptosis and palatal palsy. The clinical presentation of brain stem encephalitis was confirmed by the Magnetic Resonance Imaging findings of hyperintense foci and contrast enhancement in the medulla oblongata. Following treatment with acyclovir, he made a complete recovery. He did not have any clinical or laboratorial evidence suggestive of immune deficiency. CONCLUSION HSV-2 infection can occur beyond the neonatal age group even in the absence of immune compromise. The brainstem encephalitis manifesting as cranial neuritis and autonomic dysfunction made a complete recovery.
Collapse
Affiliation(s)
| | - Ashan Jayawickrama
- Department of Paediatrics, University of Colombo Colombo 7, Colombo, Sri Lanka
| | | |
Collapse
|
5
|
Jeanneret V, Winkel D, Risman A, Shi H, Gombolay G. Post-infectious rhombencephalitis after coronavirus-19 infection: A case report and literature review. J Neuroimmunol 2021; 357:577623. [PMID: 34082192 DOI: 10.1016/j.jneuroim.2021.577623] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/25/2021] [Accepted: 05/27/2021] [Indexed: 12/18/2022]
Abstract
A wide number of neurological manifestations have been described in association with coronavirus disease 19 (COVID-19). We describe an unusual case of a young man who developed severe rhombencephalitis after COVID-19. He demonstrated clinical and radiological improvement with high dose corticosteroids, plasma exchange and intravenous immune globulin. Our findings, along with previously reported cases that we review here, support an autoimmune para- or post-infectious mechanism and highlight a possible role for immunotherapy in patients with rhombencephalitis after COVID-19.
Collapse
|
6
|
Reniers W, Ernon L, Bekelaar K. A fatal case of glycine receptor antibody-mediated autoimmune encephalitis. Acta Neurol Belg 2021; 121:269-270. [PMID: 33449270 DOI: 10.1007/s13760-020-01590-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 12/28/2020] [Indexed: 10/22/2022]
|
7
|
Hanyu R, Hatakeyama M, Namekawa M, Otsu Y, Sukegawa M, Hashida H, Kawachi I, Kanazawa M, Onodera O. Progressive micrographia without parkinsonism caused by autoimmune brainstem encephalitis: A case report. Clin Neurol Neurosurg 2021; 202:106496. [PMID: 33476883 DOI: 10.1016/j.clineuro.2021.106496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 12/30/2020] [Accepted: 01/11/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Ryutaro Hanyu
- Department of Neurology, Brain Research Institute, Niigata University, Japan
| | - Masahiro Hatakeyama
- Department of Neurology, Brain Research Institute, Niigata University, Japan.
| | - Masaki Namekawa
- Department of Neurology, Brain Research Institute, Niigata University, Japan
| | - Yutaka Otsu
- Department of Neurology, Brain Research Institute, Niigata University, Japan
| | - Mayura Sukegawa
- Department of Neurology, Brain Research Institute, Niigata University, Japan
| | - Hiromi Hashida
- Rehabilitation Center, Niigata University Medical & Dental Hospital, Japan
| | - Izumi Kawachi
- Department of Neurology, Brain Research Institute, Niigata University, Japan
| | - Masato Kanazawa
- Department of Neurology, Brain Research Institute, Niigata University, Japan
| | - Osamu Onodera
- Department of Neurology, Brain Research Institute, Niigata University, Japan
| |
Collapse
|
8
|
Jarius S, Lechner C, Wendel EM, Baumann M, Breu M, Schimmel M, Karenfort M, Marina AD, Merkenschlager A, Thiels C, Blaschek A, Salandin M, Leiz S, Leypoldt F, Pschibul A, Hackenberg A, Hahn A, Syrbe S, Strautmanis J, Häusler M, Krieg P, Eisenkölbl A, Stoffels J, Eckenweiler M, Ayzenberg I, Haas J, Höftberger R, Kleiter I, Korporal-Kuhnke M, Ringelstein M, Ruprecht K, Siebert N, Schanda K, Aktas O, Paul F, Reindl M, Wildemann B, Rostásy K. Cerebrospinal fluid findings in patients with myelin oligodendrocyte glycoprotein (MOG) antibodies. Part 2: Results from 108 lumbar punctures in 80 pediatric patients. J Neuroinflammation 2020; 17:262. [PMID: 32883358 PMCID: PMC7470445 DOI: 10.1186/s12974-020-01825-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 04/23/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND New-generation, cell-based assays have demonstrated a robust association of serum autoantibodies to full-length human myelin oligodendrocyte glycoprotein (MOG-IgG) with (mostly recurrent) optic neuritis, myelitis, and brainstem encephalitis, as well as with neuromyelitis optica (NMO)-like or acute-disseminated encephalomyelitis (ADEM)-like presentations. However, only limited data are yet available on cerebrospinal fluid (CSF) findings in MOG-IgG-associated encephalomyelitis (MOG-EM; also termed MOG antibody-associated disease, MOGAD). OBJECTIVE To describe systematically the CSF profile in children with MOG-EM. MATERIAL AND METHODS Cytological and biochemical findings (including white cell counts [WCC] and differentiation; frequency and patterns of oligoclonal bands; IgG/IgM/IgA and albumin concentrations and CSF/serum ratios; intrathecal IgG/IgM/IgA fractions; locally produced IgG/IgM/IgA concentrations; immunoglobulin class patterns; IgG/IgA/IgM reibergrams; Link index; measles/rubella/zoster [MRZ] reaction; other anti-viral and anti-bacterial antibody indices; CSF total protein; CSF L-lactate) from 108 lumbar punctures in 80 pediatric patients of mainly Caucasian descent with MOG-EM were analyzed retrospectively. RESULTS Most strikingly, CSF-restricted oligoclonal IgG bands, a hallmark of multiple sclerosis (MS), were absent in 89% of samples (N = 96), and the MRZ reaction, the most specific laboratory marker of MS known so far, in 100% (N = 29). If present at all, intrathecal IgG synthesis was low, often transient and mostly restricted to acute attacks. Intrathecal IgM synthesis was present in 21% and exclusively detectable during acute attacks. CSF WCC were elevated in 54% of samples (median 40 cells/μl; range 6-256; mostly lymphocytes and monocytes; > 100/μl in 11%). Neutrophils were present in 71% of samples; eosinophils, activated lymphocytes, and plasma cells were seen only rarely (all < 7%). Blood-CSF barrier dysfunction (as indicated by an elevated albumin CSF/serum ratio) was present in 46% of all samples (N = 79) and at least once in 48% of all patients (N = 67) tested. CSF alterations were significantly more frequent and/or more pronounced in patients with acute spinal cord or brain disease than in patients with acute ON and varied strongly depending on attack severity. CSF L-lactate levels correlated significantly with the spinal cord lesions load (measured in vertebral segments) in patients with acute myelitis (p = 0.0099). An analysis of pooled data from the pediatric and the adult cohort showed a significant relationship of QAlb (p < 0.0005), CST TP (p < 0.0001), and CSF L-lactate (p < 0.0003) during acute attacks with age. CONCLUSION MOG-IgG-associated EM in children is characterized by CSF features that are distinct from those in MS. With regard to most parameters, no marked differences between the pediatric cohort and the adult cohort analyzed in Part 1 were noted. Our findings are important for the differential diagnosis of pediatric MS and MOG-EM and add to the understanding of the immunopathogenesis of this newly described autoimmune disease.
Collapse
Affiliation(s)
- Sven Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany.
| | - Christian Lechner
- Division of Pediatric Neurology, Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Eva M Wendel
- Department of Pediatrics, Olgahospital, Klinikum Stuttgart, Stuttgart, Germany
| | - Matthias Baumann
- Division of Pediatric Neurology, Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Markus Breu
- Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Mareike Schimmel
- Division of Pediatric Neurology, Children's Hospital, Medical University of Augsburg, Augsburg, Germany
| | - Michael Karenfort
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Heinrich-Heine-University, Düsseldorf, Germany
| | - Adela Della Marina
- Department of Neuropediatrics, Developmental Neurology and Social Pediatrics, Children's Hospital, University of Duisburg-Essen, Duisburg, Germany
| | - Andreas Merkenschlager
- Division of Pediatric Neurology, University Hospital for Children and Adolescents, Leipzig, Germany
| | - Charlotte Thiels
- Department of Neuropediatrics, University Children's Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Astrid Blaschek
- Department of Pediatric Neurology and Developmental Medicine, Dr. von Hauner Children's Hospital, University of Munich, Munich, Germany
| | | | - Steffen Leiz
- Department of Pediatrics, Division of Pediatric Neurology, Klinikum Dritter Orden, Munich, Germany
| | - Frank Leypoldt
- Neuroimmunology, Institute of Clinical Chemistry and Department of Neurology, Christian-Albrechts-University Kiel and Medical University Hospital Schleswig-Holstein, Kiel, Germany
| | - Alexander Pschibul
- Department of Neuropediatrics and Muscle Disorders, University Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Annette Hackenberg
- Division of Pediatric Neurology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Andreas Hahn
- Department of Pediatric Neurology, University Children's Hospital Giessen, Giessen, Germany
| | - Steffen Syrbe
- Division of Child Neurology and Inherited Metabolic Diseases, Department of General Pediatrics, Center for Child and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Jurgis Strautmanis
- Department of Neurology, Children's Clinical University Hospital, Riga, Latvia
| | - Martin Häusler
- Department of Pediatrics, Division of Neuropediatrics and Social Pediatrics, Medical University RWTH Aachen, Aachen, Germany
| | - Peter Krieg
- Department of Pediatrics, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Astrid Eisenkölbl
- Department of Pediatrics, Women's and Children's Hospital, Linz, Austria
| | - Johannes Stoffels
- Department of Pediatric Neurology, Children's Hospital Neuburg, Neuburg, Germany
| | - Matthias Eckenweiler
- Department of Neuropediatrics and Muscle Disorders, University Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ilya Ayzenberg
- Department of Neurology, St Josef Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Jürgen Haas
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Romana Höftberger
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Ingo Kleiter
- Department of Neurology, St Josef Hospital, Ruhr-University Bochum, Bochum, Germany
- Marianne-Strauß-Klinik, Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke gGmbH, Berg, Germany
| | - Mirjam Korporal-Kuhnke
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Marius Ringelstein
- Department of Neurology, Medical Faculty, Heinrich Heine University Dusseldorf, Düsseldorf, Germany
- Department of Neurology, Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Dusseldorf, Düsseldorf, Germany
| | - Klemens Ruprecht
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nadja Siebert
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine, and Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Kathrin Schanda
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Orhan Aktas
- Department of Pediatric Neurology, Children's Hospital Neuburg, Neuburg, Germany
| | - Friedemann Paul
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine, and Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Markus Reindl
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Brigitte Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Kevin Rostásy
- Department of Pediatric Neurology, Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany.
| |
Collapse
|
9
|
Abstract
Enterovirus A71 (EV-A71) is one of the causative pathogens of hand, foot, and mouth disease (HFMD), which may cause severe neurological and cardiopulmonary complications in children. In this review, we discuss the pathogenesis, clinical manifestations, management strategy, and clinical outcomes of cardiopulmonary failure (CPF) in patients with EV-A71 infection. The pathogenesis of CPF involves both catecholamine-related cardiotoxicity following brainstem encephalitis and vasodilatory shock due to cytokine storm. Sympathetic hyperactivity, including tachycardia and hypertension, are the early clinical manifestations of cardiopulmonary involvement, which may progress to pulmonary edema/hemorrhage and/or CPF. The management strategy comprises multidisciplinary supportive treatment, including fluid management, positive pressure ventilation support, and use of milrinone, vasopressors, and inotropes. Some patients may require extracorporeal membrane oxygenation. Major neurological sequelae are almost inevitable once a child develops life-threatening illness. Long-term care of these children is an important medico-social issue.
Collapse
Affiliation(s)
- Shao-Hsuan Hsia
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Pediatric Respiratory Therapy, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Pediatric Respiratory Therapy, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Oi-Wa Chan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tzou-Yien Lin
- Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, No. 5, Fuxing Street, Guishan District, Taoyuan, 333, Taiwan.
| |
Collapse
|
10
|
Phan QT, Phung LK, Truong KH, Huynh TT, Phạm GT, Nguyen BN, Tran QT, Huynh VNT, Nguyen TTM, Le TPK, Le NNT, Sabanathan S, van Doorn HR, Van Le T, Nguyen TD, Merson L, Nguyen DTP, Geskus R, Nguyen HT, Nguyen CVV, Wills B. Assessing the efficacy and safety of magnesium sulfate for management of autonomic nervous system dysregulation in Vietnamese children with severe hand foot and mouth disease. BMC Infect Dis 2019; 19:737. [PMID: 31438878 DOI: 10.1186/s12879-019-4356-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 08/05/2019] [Indexed: 01/21/2023] Open
Abstract
Background Brainstem encephalitis is a serious complication of hand foot and mouth disease (HFMD) in children. Autonomic nervous system (ANS) dysregulation and hypertension may occur, sometimes progressing to cardiopulmonary failure and death. Vietnamese national guidelines recommend use of milrinone if ANS dysregulation with Stage 2 hypertension develops. We wished to investigate whether magnesium sulfate (MgSO4) improved outcomes in children with HFMD if used earlier in the evolution of the ANS dysregulation (Stage 1 hypertension). Methods During a regional epidemic we conducted a randomized, double-blind, placebo-controlled trial of MgSO4 in children with HFMD, ANS dysregulation and Stage 1 hypertension, at the Hospital for Tropical Diseases in Ho Chi Minh city. Study participants received an infusion of MgSO4 or matched placebo for 72 h. We also reviewed data from non-trial HFMD patients in whom milrinone failed to control hypertension, some of whom received MgSO4 as second line therapy. The primary outcome for both analyses was a composite of disease progression within 72 h - addition of milrinone (trial participants only), need for ventilation, shock, or death. Results Between June 2014 and September 2016, 14 and 12 participants received MgSO4 or placebo respectively, before the trial was stopped due to futility. Among 45 non-trial cases with poorly controlled hypertension despite high-dose milrinone, 33 received MgSO4 while 12 did not. There were no statistically significant differences in the composite outcome between the MgSO4 and the placebo/control groups in either study (adjusted relative risk (95%CI) of [6/14 (43%) vs. 6/12 (50%)], 0.84 (0.37, 1.92), p = 0.682 in the trial and [1/33 (3%) vs. 2/12 (17%)], 0.16 (0.01, 1.79), p = 0.132 in the observational cohort). The incidence of adverse events was similar between the groups. Potentially toxic magnesium levels occurred very rarely with the infusion regime used. Conclusion Although we could not demonstrate efficacy in these studies, there were no safety signals associated with use of 30-50 mg/kg/hr. MgSO4 in severe HFMD. Intermittent outbreaks of HFMD are likely to continue across the region, and an adequately powered trial is still needed to evaluate use of MgSO4 in controlling hypertension in severe HFMD, potentially involving a higher dose regimen. Trial registration ClinicalTrials.gov Identifier: NCT01940250 (Registered 22 AUG 2013). Trial sponsor: University of Oxford Electronic supplementary material The online version of this article (10.1186/s12879-019-4356-x) contains supplementary material, which is available to authorized users.
Collapse
|
11
|
Casas-Alba D, Valero-Rello A, Muchart J, Armangué T, Jordan I, Cabrerizo M, Molero-Luís M, Artuch R, Fortuny C, Muñoz-Almagro C, Launes C. Cerebrospinal Fluid Neopterin in Children With Enterovirus-Related Brainstem Encephalitis. Pediatr Neurol 2019; 96:70-73. [PMID: 30935719 DOI: 10.1016/j.pediatrneurol.2019.01.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 01/29/2019] [Accepted: 01/31/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Enterovirus-A71 causes outbreaks of brainstem encephalitis, ranging from self-limited disease to acute flaccid paralysis. The aim of this study was to assess the role of cerebrospinal fluid (CSF) neopterin as a biomarker of disease severity in children with enterovirus-related brainstem encephalitis. METHODS A descriptive, prospective cohort study was conducted from April 2016 to March 2017 in a tertiary hospital. Pediatric patients with a diagnosis of brainstem encephalitis with or without myelitis due to enterovirus infection were enrolled. The final study group comprised a convenience sample including all patients with sufficient CSF volume for neopterin determination. The major variables considered in estimating the severity were the diagnosis of encephalomyelitis, the presence of lesions and extensive lesions on brain and spinal magnetic resonance imaging (MRI), hospital stay length greater than seven days, and sequelae at day 30. RESULTS Of 60 patients, CSF neopterin could be measured in 36. Median age was 26 months (interquartile range: 19 to 32). Thirty-three were diagnosed with brainstem encephalitis and three with encephalomyelitis. Enterovirus-A71 was the only identified genotype (25 of 25). CSF neopterin levels were elevated (>61 nmol/L) in 33 of 36 (92%), with a median of 347 nmol/L (interquartile range: 204 to 525). CSF neopterin was useful to distinguish patients with lesions on MRI (area under the receiver operating characteristic curve = 0.76; P = 0.02) and extensive lesions (area under the receiver operating characteristic curve = 0.76; P = 0.04). CONCLUSIONS This study suggests an association between CSF neopterin levels and the presence of inflammatory lesions on MRI.
Collapse
Affiliation(s)
- Dídac Casas-Alba
- Department of Pediatrics, Hospital Sant Joan de Deu (University of Barcelona), Barcelona, Spain; Pediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Deu, Barcelona, Spain
| | - Ana Valero-Rello
- Pediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Deu, Barcelona, Spain; Department of Molecular Microbiology, Hospital Sant Joan de Deu (University of Barcelona), Barcelona, Spain
| | - Jordi Muchart
- Department of Diagnostic Imaging, Hospital Sant Joan de Deu (University of Barcelona), Barcelona, Spain
| | - Thaís Armangué
- Pediatric Neuroimmunology Unit, Department of Pediatric Neurology, Hospital Sant Joan de Deu (University of Barcelona), Barcelona, Spain; Neuroimmunology Program, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS)-Hospital Clinic (University of Barcelona), Barcelona, Spain; CIBER en Enfermedades Raras (CIBERER), Madrid, Spain
| | - Iolanda Jordan
- Pediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Deu, Barcelona, Spain; CIBER en Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Pediatric Intensive Care Unit, Hospital Sant Joan de Deu (University of Barcelona), Barcelona, Spain
| | - María Cabrerizo
- Enterovirus Unit, National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain
| | - Marta Molero-Luís
- CIBER en Enfermedades Raras (CIBERER), Madrid, Spain; Department of Clinical Biochemistry, Institut de Recerca Sant Joan de Deu, Barcelona, Spain
| | - Rafael Artuch
- Department of Clinical Biochemistry, Institut de Recerca Sant Joan de Deu, Barcelona, Spain
| | - Claudia Fortuny
- Department of Pediatrics, Hospital Sant Joan de Deu (University of Barcelona), Barcelona, Spain; Pediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Deu, Barcelona, Spain; CIBER en Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Carmen Muñoz-Almagro
- Pediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Deu, Barcelona, Spain; Department of Molecular Microbiology, Hospital Sant Joan de Deu (University of Barcelona), Barcelona, Spain; CIBER en Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; School of Medicine, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Cristian Launes
- Department of Pediatrics, Hospital Sant Joan de Deu (University of Barcelona), Barcelona, Spain; Pediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Deu, Barcelona, Spain; CIBER en Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.
| |
Collapse
|
12
|
Chen YF, Hu L, Xu F, Liu CJ, Li J. A case report of a teenager with severe hand, foot, and mouth disease with brainstem encephalitis caused by enterovirus 71. BMC Pediatr 2019; 19:59. [PMID: 30760232 PMCID: PMC6373151 DOI: 10.1186/s12887-019-1428-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 02/06/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hand, foot, and mouth disease (HFMD) is an acute viral infection occurring mostly in infants and children. Enterovirus 71 (EV71) infection mostly occurs in children < 5 years of age. Severe cases, however, are usually encountered in children under the age of 3 years, and exceedingly rare in teenagers > 14 years and adults. CASE PRESENTATION We report a rare case of HFMD in a 16-year-old male teenager residing in Chonqing, China. The clinical presentation was typical of HFMD and included vesicular lesions and oral mucosal ulcers, macular and vesicular lesions on palms and soles. He developed severe neurological complications that were suggestive of brainstem encephalitis. EV71 RNA was detected in the patient's faecal samples by reverse transcription-polymerase chain reaction. Specific IgM antibody to EV71 was detected in both serum and cerebrospinal fluid by ELISA. Gamma immunoglobulin therapy at 25 g/day was administered for 2 days, along with methylprednisolone, mannitol, ganglioside, and creatine phosphate sodium. The patient showed neurological improvement and recovered completely in 1 month. CONCLUSIONS This case indicates that EV71 infection may cause HFMD in teenagers with potentially severe neurological involvement. Clinicians should be aware of the possibility of HFMD occurring in adults and teenagers as prompt treatment could be life-saving in these patients.
Collapse
Affiliation(s)
- Ying-Fu Chen
- Intensive Care Unit, Key Medical Laboratory of Pediatrics, Chongqing Health Bureau, Ministry of Education; Key Laboratory of Child Development and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Lan Hu
- Intensive Care Unit, Key Medical Laboratory of Pediatrics, Chongqing Health Bureau, Ministry of Education; Key Laboratory of Child Development and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Feng Xu
- Intensive Care Unit, Key Medical Laboratory of Pediatrics, Chongqing Health Bureau, Ministry of Education; Key Laboratory of Child Development and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Cheng-jun Liu
- Intensive Care Unit, Key Medical Laboratory of Pediatrics, Chongqing Health Bureau, Ministry of Education; Key Laboratory of Child Development and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Jing Li
- Intensive Care Unit, Key Medical Laboratory of Pediatrics, Chongqing Health Bureau, Ministry of Education; Key Laboratory of Child Development and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| |
Collapse
|
13
|
Inagaki A, Toyoda T, Mutou M, Murakami S. Ramsay Hunt syndrome associated with solitary nucleus, spinal trigeminal nucleus and tract, and vestibular nucleus involvement on sequential magnetic resonance imaging. J Neurovirol 2018; 24:776-779. [PMID: 30168017 DOI: 10.1007/s13365-018-0673-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 08/14/2018] [Accepted: 08/22/2018] [Indexed: 11/29/2022]
Abstract
Ramsay Hunt syndrome (RHS) is an acute peripheral facial nerve paralysis typically accompanied by erythematous vesicular lesions of the auricular skin. The etiology is considered to be geniculate ganglionitis due to reactivation of varicella-zoster virus (VZV). Encephalitis is a rare but serious complication of VZV reactivation. Clarifying the regional and temporal evolution of the lesions on magnetic resonance imaging (MRI) would help with understanding the pathology of the lesion, but this information is lacking in encephalitis with RHS. Therefore, here, we reviewed sequential MR images in three RHS cases complicated by brainstem lesions. All the regions of the lesions represent specific neuronal structures-the ipsilateral solitary nucleus (SN) and spinal trigeminal nucleus and tract (STNT) in case 1; bilateral SN, ipsilateral STNT, and vestibular nucleus in case 2; ipsilateral SN and vestibular nucleus in case 3-and this seems to account for the persistent robust symptoms. Case 1 initially showed no abnormalities on MRI and cases 2 and 3 showed weak signals on the first MRI which subsequently plateaued. These observations suggest the timeframe within which it becomes possible to detect regional and temporal evolution, namely, that the distribution of the affected regions expands between weeks 2 and 5 after onset of facial paralysis. These observations and the findings of a literature review indicate that the SN, STNT, and vestibular nucleus are relatively prone to developing encephalitis after RHS.
Collapse
Affiliation(s)
- Akira Inagaki
- Department of Otolaryngology, Head and Neck Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan.
| | - Takanari Toyoda
- Department of Neurology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Masahiro Mutou
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Shingo Murakami
- Department of Otolaryngology, Head and Neck Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| |
Collapse
|
14
|
Abstract
PURPOSE OF REVIEW Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a recently described treatable, inflammatory, brainstem predominant encephalomyelitis. The diagnosis of CLIPPERS is challenging without a specific biomarker, and thus it is important to consider if both the clinical and radiographic features are consistent with the diagnosis, or rather a disease mimicker. RECENT FINDINGS Many patients with CLIPPERS-like lesions have been described in the literature with follow-up revealing a range of alternative diagnoses, such as malignancies, vasculitis, and other specific inflammatory diseases. As a result, some have proposed that CLIPPERS might represent a pre-malignancy state or simply an initial clinical syndrome of a variety of possible etiologies. We describe the typical clinical, radiographic, and pathological features of CLIPPERS and emphasize consideration for alternative diagnoses when findings are not classic. A recommended diagnostic evaluation and initial treatment plan is provided.
Collapse
|
15
|
Togashi T, Baba H, Kitazawa M, Takahashi N, Samejima Y, Yumoto E, Horii A. Surgical treatment of enterovirus D68 brainstem encephalitis-induced dysphagia. Auris Nasus Larynx 2018; 45:1093-1097. [PMID: 29366609 DOI: 10.1016/j.anl.2017.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 12/23/2017] [Accepted: 12/26/2017] [Indexed: 11/26/2022]
Abstract
Cluster of acute flaccid paralysis and cranial nerve dysfunction was associated with a 2014 outbreak of enterovirus D68 (EV-D68) respiratory illness in US. We describe a 33 year-old male patient of refractory dysphagia due to EV-D68-induced brainstem encephalitis successfully treated by surgery. Following acute upper respiratory tract infection, he developed dysphagia and bilateral facial paralysis. A coughing reflex was readily produced when the laryngopharyngeal fiberscope touched the epiglottis, however, water infusion induced only very weak and slow swallowing reflex, suggesting that only motor component was impaired but sensory function was preserved during swallowing. Despite eight months-conservative rehabilitations, Food Intake Level Scale (FILS) remained level 4. Therefore, corrective surgeries including cricopharyngeal myotomy, laryngeal suspension, and pharyngeal flap were performed. Thirty-six days after surgery, FILS rapidly and dramatically improved to level 8. This is the first report describing a successful surgical intervention for EV-D68-induced refractory dysphagia. Surgical treatment was suitable for EV-D68-induced dysphagia, perhaps because sensory function was preserved and only motor disturbance was present during the pharyngeal stage of swallowing.
Collapse
Affiliation(s)
- Takafumi Togashi
- Department of Otolaryngology Head and Neck Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.
| | - Hironori Baba
- Department of Otolaryngology Head and Neck Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Meiko Kitazawa
- Department of Otolaryngology Head and Neck Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Nao Takahashi
- Department of Otolaryngology Head and Neck Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yasuhiro Samejima
- Department of Otolaryngology Head and Neck Surgery, Kumamoto University School of Medicine, Kumamoto, Japan
| | - Eiji Yumoto
- Department of Otolaryngology, Asahino General Hospital, Kumamoto, Japan
| | - Arata Horii
- Department of Otolaryngology Head and Neck Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| |
Collapse
|
16
|
Ricigliano VAG, Saraceno L, Cavalli M, Rodegher M, Meola G. Slowly progressing varicella zoster brainstem encephalitis complicating Ramsay Hunt syndrome in an immunocompetent patient: case report and review of the literature. J Neurovirol 2017; 23:922-8. [PMID: 28905216 DOI: 10.1007/s13365-017-0575-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 07/12/2017] [Accepted: 08/24/2017] [Indexed: 10/18/2022]
Abstract
A 56-year-old immunocompetent male developed brainstem encephalitis complicating Ramsay Hunt syndrome. The disease had a slowly progressing course of months after the triggering infection, much longer than previously reported. Furthermore, magnetic resonance imaging, physical-chemical, and cell count analyses on cerebrospinal fluid were normal, whereas polymerase chain reaction for varicella zoster virus DNA was positive. The simultaneous negativity of both imaging and basic CSF exams is very rare, although possible event which confirms the irreplaceable role of viral screening on CSF. A systematic review of similar reports with highlights on the unusual aspects of our case is also presented.
Collapse
|
17
|
Karlsson WK, Harboe ZB, Roed C, Monrad JB, Lindelof M, Larsen VA, Kondziella D. Early trigeminal nerve involvement in Listeria monocytogenes rhombencephalitis: case series and systematic review. J Neurol 2017; 264:1875-1884. [PMID: 28730571 DOI: 10.1007/s00415-017-8572-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 07/13/2017] [Accepted: 07/13/2017] [Indexed: 01/26/2023]
Abstract
Listeria monocytogenes is associated with rhombencephalitis. However, the exact mechanisms of brainstem invasion remains poorly understood. Here, we demonstrate clinical and radiological data suggesting that Listeria may invade the brainstem via the trigeminal nerve. Three females (41, 64 and 70 years) with culture proven L. monocytogenes bacteremia and rhombencephalitis were investigated in the period of 2014-16. T2-weighted and contrast-enhanced T1-weighted MRI revealed a cerebellopontine abscess in all three patients, including the involvement of the trigeminal nerve root. In two patients, MRI also revealed selective contrast enhancement of the sensory trigeminal tract in the pons and medulla oblongata. Prior to any other neurological symptoms, two patients complained of hypoesthesia and a tingling sensation in the ipsilateral half of the face, consistent with sensory trigeminal nerve dysfunction on that side. In addition, we identified another 120 cases of Listeria rhombencephalitis following a systematic review. Cranial nerves VII, V, IX, and X, respectively, medulla oblongata, cerebellum and pons, were the most frequently involved brain structures. The present clinical and radiological findings corroborate earlier data from animal experiments, indicating that L. monocytogenes may be capable of retrograde intra-axonal migration along the cranial nerves. We suggest that in a subset of patients with rhombencephalitis L. monocytogenes enters the cerebellopontine angle through the trigeminal nerve, invading the brainstem via the sensory trigeminal nuclei.
Collapse
Affiliation(s)
- William K Karlsson
- Department of Neurology, Herlev Sygehus, Copenhagen University Hospital, Copenhagen, Denmark
| | - Zitta Barrella Harboe
- Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Casper Roed
- Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jeppe B Monrad
- Department of Neurology, Herlev Sygehus, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mette Lindelof
- Department of Neurology, Herlev Sygehus, Copenhagen University Hospital, Copenhagen, Denmark
| | - Vibeke Andrée Larsen
- Department of Neuroradiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| |
Collapse
|
18
|
Najjar M, Taylor A, Agrawal S, Fojo T, Merkler AE, Rosenblum MK, Lennihan L, Kluger MD. Anti-Hu paraneoplastic brainstem encephalitis caused by a pancreatic neuroendocrine tumor presenting with central hypoventilation. J Clin Neurosci 2017; 40:72-3. [PMID: 28256369 DOI: 10.1016/j.jocn.2017.02.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 02/08/2017] [Indexed: 01/05/2023]
Abstract
Paraneoplastic neurological syndromes are rare autoimmune manifestations of malignancies associated with specific antibodies. Anti-Hu associated brainstem encephalitis, a well-described syndrome, usually presents subacutely with preferential involvement of the medulla. Anti-Hu antibodies target intraneuronal antigens and are therefore highly correlated with neurological syndromes when present concomitantly with a neoplasm. Reported is a case of anti-Hu brainstem encephalitis associated with a pancreatic neuroendocrine tumor (PNET) presenting with central hypoventilation. This is the first described case of brainstem encephalitis associated with a well-differentiated PNET as well as the first case of Anti-Hu antibodies associated with a PNET. There are no standardized protocols for the treatment of paraneoplastic brainstem encephalitis however, as in the present case, surgical resection and oncological treatment of the tumor is the first line treatment.
Collapse
|
19
|
Jarius S, Kleiter I, Ruprecht K, Asgari N, Pitarokoili K, Borisow N, Hümmert MW, Trebst C, Pache F, Winkelmann A, Beume LA, Ringelstein M, Stich O, Aktas O, Korporal-Kuhnke M, Schwarz A, Lukas C, Haas J, Fechner K, Buttmann M, Bellmann-Strobl J, Zimmermann H, Brandt AU, Franciotta D, Schanda K, Paul F, Reindl M, Wildemann B. MOG-IgG in NMO and related disorders: a multicenter study of 50 patients. Part 3: Brainstem involvement - frequency, presentation and outcome. J Neuroinflammation 2016; 13:281. [PMID: 27802825 PMCID: PMC5088671 DOI: 10.1186/s12974-016-0719-z] [Citation(s) in RCA: 164] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 09/09/2016] [Indexed: 11/17/2022] Open
Abstract
Background Myelin oligodendrocyte glycoprotein antibodies (MOG-IgG) are present in a subset of aquaporin-4 (AQP4)-IgG-negative patients with optic neuritis (ON) and/or myelitis. Little is known so far about brainstem involvement in MOG-IgG-positive patients. Objective To investigate the frequency, clinical and paraclinical features, course, outcome, and prognostic implications of brainstem involvement in MOG-IgG-positive ON and/or myelitis. Methods Retrospective case study. Results Among 50 patients with MOG-IgG-positive ON and/or myelitis, 15 (30 %) with a history of brainstem encephalitis were identified. All were negative for AQP4-IgG. Symptoms included respiratory insufficiency, intractable nausea and vomiting (INV), dysarthria, dysphagia, impaired cough reflex, oculomotor nerve palsy and diplopia, nystagmus, internuclear ophthalmoplegia (INO), facial nerve paresis, trigeminal hypesthesia/dysesthesia, vertigo, hearing loss, balance difficulties, and gait and limb ataxia; brainstem involvement was asymptomatic in three cases. Brainstem inflammation was already present at or very shortly after disease onset in 7/15 (47 %) patients. 16/21 (76.2 %) brainstem attacks were accompanied by acute myelitis and/or ON. Lesions were located in the pons (11/13), medulla oblongata (8/14), mesencephalon (cerebral peduncles; 2/14), and cerebellar peduncles (5/14), were adjacent to the fourth ventricle in 2/12, and periaqueductal in 1/12; some had concomitant diencephalic (2/13) or cerebellar lesions (1/14). MRI or laboratory signs of blood-brain barrier damage were present in 5/12. Cerebrospinal fluid pleocytosis was found in 11/14 cases, with neutrophils in 7/11 (3-34 % of all CSF white blood cells), and oligoclonal bands in 4/14. Attacks were preceded by acute infection or vaccination in 5/15 (33.3 %). A history of teratoma was noted in one case. The disease followed a relapsing course in 13/15 (87 %); the brainstem was involved more than once in 6. Immunosuppression was not always effective in preventing relapses. Interferon-beta was followed by new attacks in two patients. While one patient died from central hypoventilation, partial or complete recovery was achieved in the remainder following treatment with high-dose steroids and/or plasma exchange. Brainstem involvement was associated with a more aggressive general disease course (higher relapse rate, more myelitis attacks, more frequently supratentorial brain lesions, worse EDSS at last follow-up). Conclusions Brainstem involvement is present in around one third of MOG-IgG-positive patients with ON and/or myelitis. Clinical manifestations are diverse and may include symptoms typically seen in AQP4-IgG-positive neuromyelitis optica, such as INV and respiratory insufficiency, or in multiple sclerosis, such as INO. As MOG-IgG-positive brainstem encephalitis may take a serious or even fatal course, particular attention should be paid to signs or symptoms of additional brainstem involvement in patients presenting with MOG-IgG-positive ON and/or myelitis.
Collapse
Affiliation(s)
- Sven Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University Hospital Heidelberg, Otto Meyerhof Center, Im Neuenheimer Feld 350, 69120, Heidelberg, Germany.
| | - Ingo Kleiter
- Department of Neurology, Ruhr University Bochum, Bochum, Germany
| | - Klemens Ruprecht
- Department of Neurology, Charité - University Medicine Berlin, Berlin, Germany
| | - Nasrin Asgari
- Department of Neurology and Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | | | - Nadja Borisow
- Department of Neurology, NeuroCure Clinical Research Center and Clinical and Experimental Multiple Sclerosis Research Center, Charité University Medicine, Berlin, Germany.,Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine, Berlin, Germany
| | - Martin W Hümmert
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Corinna Trebst
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Florence Pache
- Department of Neurology, NeuroCure Clinical Research Center and Clinical and Experimental Multiple Sclerosis Research Center, Charité University Medicine, Berlin, Germany.,Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine, Berlin, Germany
| | | | | | | | - Oliver Stich
- Department of Neurology, Albert Ludwigs University, Freiburg, Germany
| | - Orhan Aktas
- Department of Neurology, Heinrich Heine University, Düsseldorf, Germany
| | - Mirjam Korporal-Kuhnke
- Molecular Neuroimmunology Group, Department of Neurology, University Hospital Heidelberg, Otto Meyerhof Center, Im Neuenheimer Feld 350, 69120, Heidelberg, Germany
| | - Alexander Schwarz
- Molecular Neuroimmunology Group, Department of Neurology, University Hospital Heidelberg, Otto Meyerhof Center, Im Neuenheimer Feld 350, 69120, Heidelberg, Germany
| | - Carsten Lukas
- Department of Neuroradiology, Ruhr University Bochum, Bochum, Germany
| | - Jürgen Haas
- Molecular Neuroimmunology Group, Department of Neurology, University Hospital Heidelberg, Otto Meyerhof Center, Im Neuenheimer Feld 350, 69120, Heidelberg, Germany
| | - Kai Fechner
- Institute of Experimental Immunology, affiliated to Euroimmun AG, Lübeck, Germany
| | - Mathias Buttmann
- Department of Neurology, Julius Maximilians University, Würzburg, Germany
| | - Judith Bellmann-Strobl
- Department of Neurology, NeuroCure Clinical Research Center and Clinical and Experimental Multiple Sclerosis Research Center, Charité University Medicine, Berlin, Germany.,Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine, Berlin, Germany
| | - Hanna Zimmermann
- Department of Neurology, Charité - University Medicine Berlin, Berlin, Germany
| | - Alexander U Brandt
- Department of Neurology, Charité - University Medicine Berlin, Berlin, Germany
| | | | - Kathrin Schanda
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Friedemann Paul
- Department of Neurology, NeuroCure Clinical Research Center and Clinical and Experimental Multiple Sclerosis Research Center, Charité University Medicine, Berlin, Germany.,Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine, Berlin, Germany
| | - Markus Reindl
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Brigitte Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University Hospital Heidelberg, Otto Meyerhof Center, Im Neuenheimer Feld 350, 69120, Heidelberg, Germany
| | | |
Collapse
|
20
|
Moussawi K, Lin DJ, Matiello M, Chew S, Morganstern D, Vaitkevicius H. Brainstem and limbic encephalitis with paraneoplastic neuromyelitis optica. J Clin Neurosci 2015; 23:159-161. [PMID: 26412254 DOI: 10.1016/j.jocn.2015.08.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 08/16/2015] [Indexed: 11/26/2022]
Abstract
The spectrum of disorders associated with anti-neuromyelitis optica (NMO) antibody is being extended to include infrequent instances associated with cancer. We describe a patient with brainstem and limbic encephalitis from NMO-immunoglobulin G in serum and cerebrospinal fluid in the context of newly diagnosed breast cancer. The neurological features markedly improved with excision of her breast cancer and immune suppressive therapy. This case further broadens the NMO spectrum disorders (NMOSD) by an association between NMOSD and cancer and raises the question of coincidental occurrence and the appropriate circumstances to search for a tumor in certain instances of NMO.
Collapse
Affiliation(s)
- Khaled Moussawi
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA; Department of Neurology, Massachusetts General Hospital, Wang Ambulatory Care Center, Suite 835, 55 Fruit Street, Boston, MA 02114, USA; Harvard Medical School, Boston, MA, USA.
| | - David J Lin
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA; Department of Neurology, Massachusetts General Hospital, Wang Ambulatory Care Center, Suite 835, 55 Fruit Street, Boston, MA 02114, USA; Harvard Medical School, Boston, MA, USA
| | - Marcelo Matiello
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA; Department of Neurology, Massachusetts General Hospital, Wang Ambulatory Care Center, Suite 835, 55 Fruit Street, Boston, MA 02114, USA; Harvard Medical School, Boston, MA, USA
| | - Sheena Chew
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA; Department of Neurology, Massachusetts General Hospital, Wang Ambulatory Care Center, Suite 835, 55 Fruit Street, Boston, MA 02114, USA; Harvard Medical School, Boston, MA, USA
| | - Daniel Morganstern
- Harvard Medical School, Boston, MA, USA; Dana-Farber Cancer Institute, Boston, MA, USA
| | - Henrikas Vaitkevicius
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| |
Collapse
|
21
|
Guo SJ, Wang DX, Dai CL, Wu H. A neonate with hand, foot, and mouth disease complicated with brainstem encephalitis and pulmonary edema:A complete recovery. Pak J Med Sci 2014; 30:917-9. [PMID: 25097545 PMCID: PMC4121726 DOI: 10.12669/pjms.304.4528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 05/14/2014] [Indexed: 11/15/2022] Open
Abstract
Hand, foot, and mouth disease (HFMD) with serious complications and fatal cases have been reported over the last decade worldwide. The authors report a rare case of HFMD in a neonate complicated with brainstem encephalitis and pulmonary edema. She had fever, lethargy, dyspnea. Physical examination revealed shock signs, fine rales on both lungs, absent Moro reflex. The patient had a rapidly progressive course with seizures, coma, no spontaneous breathing, chemosis. There were some vesicles on left sole and red maculopapular rashes on perianal skin. She had a history of exposure to HFMD. Fecal sample was positive for EV71 RNA by real-time PCR. Chest X-rays showed bilateral pulmonary infiltrates. MRI of the brain showed significant hypointensity in the brainstem on T1WI and hyperintensity on T2WI. She recovered well. This case highlights severe HFMD in neonates is rare. Medical history and physical examination are important in making diagnosis.
Collapse
Affiliation(s)
- Shi-Jie Guo
- Shi-Jie Guo, Department of Neonatology, The First Hospital of Jilin University, Changchun 130021, China
| | - Dong-Xuan Wang
- Dong-Xuan Wang, Department of Ultrasonic Diagnosis, The First Hospital of Jilin University, Changchun 130021, China
| | - Chun-Lai Dai
- Chun-Lai Dai, Department of Radiology, The First Hospital of Jilin University, Changchun 130021, China
| | - Hui Wu
- Hui Wu, Department of Neonatology, The First Hospital of Jilin University, Changchun 130021, China
| |
Collapse
|
22
|
|
23
|
Chen F, Li J, Liu T, Wang L, Li Y. MRI characteristics of brainstem encephalitis in hand-foot-mouth disease induced by enterovirus type 71--will different MRI manifestations be helpful for prognosis? Eur J Paediatr Neurol 2013; 17:486-91. [PMID: 23561930 DOI: 10.1016/j.ejpn.2013.03.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 01/01/2013] [Accepted: 03/15/2013] [Indexed: 11/19/2022]
Abstract
The MRI characteristics of 21 HFMD patients with brainstem encephalitis resulting from EV71 infection were examined to identify lesion patterns helpful in disease classification and prognosis. The author reviewed the clinical and MRI data of 21 children with brainstem encephalitis infected during the EV71 outbreak in Hainan, China from May 2008 to September 2010. Thirteen cases of brainstem encephalitis were classified as type I based on unilateral or bilateral symmetrical patch-like hyperintense T₁ and T₂ MRI signals restricted to the posterior brainstem. In a significant minority of these cases (6/13), damage to the spinal ventral horn was also found. Among these 13 type I cases, 2 patients died, 7 recovered fully, and 4 suffered from various neurological sequelae. Eight cases were classified with type II brainstem encephalitis based on a vague, speckled hyperintense T₁ and T₂ signal pattern in the posterior brainstem. Six of these patients recovered fully, and 2 cases suffered from mild sequelae. Reexamination by MRI revealed an enduring lesion in only one type II case, restricted to the medulla oblongata. The prognosis of type II cases was better than that of type I cases. The lesion pattern revealed by MRI can distinguish type I from type II brainstem encephalitis due to EV71 infection and may prove valuable for prognosis. While lesions were usually located in the tegmental part of the brainstem in both patient groups, type I cases also demonstrated spinal, thalamic, and cortical lesions.
Collapse
Affiliation(s)
- Feng Chen
- Department of Radiology, People's Hospital of Hainan Province, 19 Xiuhua Road, Xiuying District, Haikou, Hainan Province, China
| | | | | | | | | |
Collapse
|
24
|
Lim JA, Kim JM, Lee ST, Jung KH, Kim YS, Lee SK, Chu K. Brainstem encephalitis caused by Coxiella burnetii. J Clin Neurosci 2013; 21:699-701. [PMID: 24210800 DOI: 10.1016/j.jocn.2013.05.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 05/26/2013] [Indexed: 11/30/2022]
Abstract
Coxiella burnetii is the causative agent of Q fever, which rarely causes neurologic symptoms. We describe a patient who presented with progressive sensory changes, dizziness, and motor weakness. The cerebrospinal fluid revealed pleocytosis, and MRI indicated the presence of a diffuse brain stem lesion. An indirect immunofluorescence test revealed antibodies against C. burnetii. The symptoms improved with antibiotics against C. burnetii. Q fever should be considered as a possible etiology of brainstem encephalitis.
Collapse
Affiliation(s)
- Jung-Ah Lim
- Department of Neurology, Seoul National University Hospital, 101 Daehangno, Chongro-Gu, 110-744 Seoul, South Korea
| | - Jeong-Min Kim
- Department of Neurology, Chung-Ang University Medical Center, Seoul, South Korea
| | - Soon-Tae Lee
- Department of Neurology, Seoul National University Hospital, 101 Daehangno, Chongro-Gu, 110-744 Seoul, South Korea
| | - Keun-Hwa Jung
- Department of Neurology, Seoul National University Hospital, 101 Daehangno, Chongro-Gu, 110-744 Seoul, South Korea
| | - Young Su Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Sang Kun Lee
- Department of Neurology, Seoul National University Hospital, 101 Daehangno, Chongro-Gu, 110-744 Seoul, South Korea
| | - Kon Chu
- Department of Neurology, Seoul National University Hospital, 101 Daehangno, Chongro-Gu, 110-744 Seoul, South Korea.
| |
Collapse
|