Posterior reversible encephalopathy syndrome during systemic lupus erythematosus: four new cases and review of the literature

Posterior reversible encephalopathy syndrome (PRES) associates various neurological manifestations (headaches, seizures, altered mental status, cortical blindness, focal neurological deficits, vomiting) and transient changes on neuroimaging consistent with cerebral edema. Posterior reversible encephalopathy syndrome mainly occurs in the setting of hypertension, eclampsia, renal failure and/or use of immunosuppressive drugs. We report four cases of PRES complicating systemic lupus erythematosus (SLE). In all our cases, renal involvement and hypertension were present. Neurological symptoms were typical. Magnetic resonance imaging showed posterior cerebral edema and in one case hemorrhagic complication. With symptomatic treatment and immunosuppressor withdrawal when they were previously used, symptoms fully resolved within 15 days in all cases, but one who had only partial regression related to cerebral hemorrhage. Including our cases, we reviewed a total of 46 patients with SLE and PRES. Their clinical and radiological presentation was not specific. The peculiar role of SLE itself in the occurrence of PRES was not clear, since hypertension (95%), renal involvement (91%), recent onset of immunosuppressive drugs (54%) and/or recent treatment with high intravenous dose of steroids (43%) were often present. The hypertension and other worsening factors should be treated. Finally, the evolution of this clinical and radiological spectacular syndrome is generally rapidly favorable.

Hépatite aiguë lors d’une primo-infection à Herpès simplex virus 2 chez un malade atteint d’un lupus érythémateux disséminé

BACKGROUND

Herpes simplex virus hepatitis is a rare complication associated with a poor prognosis and a high mortality rate. It mainly affects adults with impaired cell-mediated immunity. Mucocutaneous involvement is seen in only 57% to 70% of patients and the clinical aspects of the lesions may sometimes be misleading. Here we report a new case that developed during primary HSV-2 infection in a patient with systemic lupus erythematosus.

CASE REPORT

A 57 year-old man with systemic lupus erythematosus treated with oral prednisone presented a disseminated varicella-like eruption with acute liver failure related to primary genital HSV-2 infection. Type-specific HSV deoxyribonucleic acid amplification by polymerase chain reaction on serum and oral lesion samples revealed type 2 HSV. Dramatic improvement was observed with parenteral acyclovir.

DISCUSSION

Hepatitis due to HSV is a rare but potentially fatal disorder chiefly affecting adults with impaired immune systems. In this case, HSV affects the liver during primary or recurrent infection. If initiated quickly, parenteral acyclovir can cure hepatitis, which means that this diagnosis must be considered in both immunocompromised and immunocompetent patients with high fever, leucopoenia and marked elevation of aminotransferase levels. Mucocutaneous signs are present in only 57 to 70% of cases. Careful physical examination to detect herpes lesions should be done in all cases of acute liver failure. HSV viremia testing may confirm the diagnosis by non-invasive means. Patients with systemic lupus erythematosus are at increased risk for infection due to immunosuppressive drugs, but also to numerous intrinsic immunologic abnormalities such as a recently reported deficit in NK cells and plasmacytoid dendritic cells.

Characterization of a variant of vga(A) conferring resistance to streptogramin A and related compounds

A variant of the vga(A) gene (1,575 bp), encoding an ATP-binding cassette protein conferring resistance to streptogramin A and related antibiotics, was cloned from the chromosome of a Staphylococcus aureus clinical isolate and sequenced. The sequence of the variant was similar to that of the vga(A) gene (83.2% identity). However, the G+C content of the variant (35.6%) was higher than that of vga(A) (29%) and there was no cross hybridization between vga(A) and the variant at high stringency (> or =60 degrees C), the highest temperature at which a signal was detected being 55 degrees C. Unlike previous reports for vga(A) and vga(B), the variant of vga(A) may be present in multiple copies in the genome. These copies are chromosomal in some isolates and both chromosomal and plasmid-borne in others. Nucleotide sequences hybridizing at 65 degrees C with the vga(A) variant were found in all the staphylococcal strains harboring plasmids carrying both vga(B) and vat(B), which also encode resistance to streptogramin A.

satG, conferring resistance to streptogramin A, is widely distributed in Enterococcus faecium strains but not in staphylococci

A gene almost identical to satG was isolated from an Enterococcus faecium strain. This gene was transferred to a Staphylococcus aureus recipient strain where it conferred resistance to streptogramin A. satG was found to be widely distributed among E. faecium strains but not detected among staphylococci.