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Alicino C, Infante MT, Gandoglia I, Miolo N, Mancardi GL, Zappettini S, Capello E, Orsi A, Tamburini T, Grandis M. Acute disseminated encephalomyelitis with severe neurological outcomes following virosomal seasonal influenza vaccine. Hum Vaccin Immunother 2014; 10:1969-73. [PMID: 25424806 PMCID: PMC4186031 DOI: 10.4161/hv.28961] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Acute disseminated encephalomyelitis (ADEM) is an inflammatory, usually monophasic, immune mediate, demyelinating disease of the central nervous system which involves the white matter. ADEM is more frequent in children and usually occurs after viral infections, but may follow vaccinations, bacterial infections, or may occur without previous events. Only 5% of cases of ADEM are preceded by vaccination within one month prior to symptoms onset. The diagnosis of ADEM requires both multifocal involvement and encephalopathy and specific demyelinating lesions of white matter. Overall prognosis of ADEM patients is often favorable, with full recovery reported in 23% to 100% of patients from pediatric cohorts, and more severe outcome in adult patients. We describe the first case of ADEM occurred few days after administration of virosomal seasonal influenza vaccine. The patient, a 59-year-old caucasic man with unremarkable past medical history presented at admission decreased alertness, 10 days after flu vaccination. During the 2 days following hospitalization, his clinical conditions deteriorated with drowsiness and fever until coma. The magnetic resonance imaging of the brain showed multiple and symmetrical white matter lesions in both cerebellar and cerebral hemispheres, suggesting demyelinating disease with inflammatory activity, compatible with ADEM. The patient was treated with high dose of steroids and intravenous immunoglobulin with relevant sequelae and severe neurological outcomes.
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Affiliation(s)
- Cristiano Alicino
- a Department of Health Sciences; Vaccines and Clinical Trials Unit; University of Genoa; Genoa Italy
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Zeb Q, Alegria A. Acute disseminated encephalomyelitis (ADEM) following a H3N3 parainfluenza virus infection in a pregnant asthmatic woman with respiratory failure. BMJ Case Rep 2014; 2014:bcr-2013-201072. [PMID: 25281245 DOI: 10.1136/bcr-2013-201072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This case report relates to a 31-year-old pregnant woman, asthmatic, admitted to the intensive care unit with respiratory failure, secondary to a viral community-acquired pneumonia. A type 3 (H3N3) parainfluenza virus RNA was isolated in her throat swab. The patient developed neurological symptoms (behavioural changes, irritability, agitation and impaired consciousness) while being weaned off sedation and ventilatory support. Cerebrospinal fluid was clear with an opening pressure of 26 cm H2O. Brain MRI showed features compatible with acute disseminated encephalomyelitis. Immune screen and EEG were normal. She was treated with intravenous methylprednisolone followed by oral prednisolone. The patient made an almost full neurological recovery within 4 weeks after starting on steroids. The patient delivered a healthy baby at 38 weeks gestation. This case highlights the importance to keep in mind rare conditions that need early recognition and prompt treatment. Brain MRI is the key to early diagnosis and treatment.
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Affiliation(s)
- Qaiser Zeb
- Department of Anaesthesia and Critical Care, Queen Elizabeth the Queen Mother Hospital, Margate, Kent, UK
| | - Ana Alegria
- Department of Anaesthesia and Critical Care, Queen Elizabeth the Queen Mother Hospital, Margate, Kent, UK
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Miyamoto K, Kozu S, Arakawa A, Tsuboi T, Hirao JI, Ono K, Arisaka O. Therapeutic hypothermia with the use of intracranial pressure monitoring for acute disseminated encephalomyelitis with brainstem lesion: a case report. J Child Neurol 2014; 29:NP69-73. [PMID: 24072019 DOI: 10.1177/0883073813501874] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute disseminated encephalomyelitis confined to the brainstem is associated with poor prognosis. We describe a case of a 10-year-old boy with acute disseminated encephalomyelitis in the brainstem that developed after influenza A infection. A 10-year-old boy presented with fever and prolonged disturbance of consciousness and was admitted to our hospital. Magnetic resonance imaging (MRI) of the midbrain, with T2-weighted and fluid-attenuated inversion recovery images, suggested acute disseminated encephalomyelitis accompanied by a brainstem lesion. Lumbar puncture showed pleocytosis and increased protein content, including myelin basic protein, interleukin-6, and immunoglobulin G, all suggestive of acute disseminated encephalomyelitis. Treatments such as methylprednisolone pulse therapy, intravenous immunoglobulin, and therapeutic hypothermia were performed. Although the patient presented with anisocoria with increased intracranial pressure monitoring during hypothermia, prompt therapy with d-mannitol and dopamine was effective. Our case results suggest that hypothermia could be included in the choice of therapy for acute disseminated encephalomyelitis with brainstem lesions.
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Affiliation(s)
- Kenji Miyamoto
- Department of Pediatrics, Dokkyo Medical University, Tochigi, Japan
| | - Seiki Kozu
- Department of Intensive and Critical Care Medicine, Dokkyo Medical University, Tochigi, Japan
| | - Akiko Arakawa
- Department of Neurosurgery, Dokkyo Medical University, Tochigi, Japan
| | - Tatsuo Tsuboi
- Department of Pediatrics, Dokkyo Medical University, Tochigi, Japan
| | - Jun-Ichi Hirao
- Department of Pediatrics, Dokkyo Medical University, Tochigi, Japan
| | - Kazuyuki Ono
- Department of Intensive and Critical Care Medicine, Dokkyo Medical University, Tochigi, Japan
| | - Osamu Arisaka
- Department of Pediatrics, Dokkyo Medical University, Tochigi, Japan
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Collongues N, Papeix C, Zéphir H, Audoin B, Cotton F, Durand-dubief F, Vukusic S, Brassat D, Laplaud D, Marignier R. Cadre nosologique et stratégie diagnostique de la myélite aiguë transverse longitudinalement étendue. Rev Neurol (Paris) 2014; 170:6-12. [DOI: 10.1016/j.neurol.2013.04.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 04/05/2013] [Indexed: 12/14/2022]
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Ichikawa K, Motoi H, Oyama Y, Watanabe Y, Takeshita S. Fulminant form of acute disseminated encephalomyelitis in a child treated with mild hypothermia. Pediatr Int 2013; 55:e149-51. [PMID: 24330300 DOI: 10.1111/ped.12180] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 06/24/2013] [Accepted: 06/28/2013] [Indexed: 11/29/2022]
Abstract
We describe the case of a 3-year-old boy diagnosed with the fulminant form of acute disseminated encephalomyelitis (ADEM). He developed general fatigue, fever, drowsiness and difficulty in walking. He had extensive multiple high-intensity lesions in the white matter of the cerebrum and cerebellum, which are typical findings of ADEM. He became comatose and developed decerebrate rigidity with severe brain edema despite high-dose methylprednisolone therapy, and then was subjected to mild hypothermia therapy, and given i.v. immunoglobulin. The patient recovered remarkably with the sequela of only mild action tremor. The patient was considered to have acute hemorrhagic leukoencephalitis (AHLE), an extremely severe form of ADEM, in terms of the rapidly deteriorating clinical course and neuroimaging features. It was speculated that AHLE and ADEM might be a continuous disease spectrum. It is considered that the severe brain edema associated with ADEM or AHLE is a suitable indication for mild hypothermia therapy.
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Affiliation(s)
- Kazushi Ichikawa
- Department of Pediatrics, Yokohama City University Medical Center, Yokohama, Japan
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56
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Tenembaum SN. Treatment of multiple sclerosis and neuromyelitis optica in children and adolescents. Clin Neurol Neurosurg 2013; 115 Suppl 1:S21-9. [DOI: 10.1016/j.clineuro.2013.09.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Pediatric multiple sclerosis: current concepts and consensus definitions. Autoimmune Dis 2013; 2013:673947. [PMID: 24294520 PMCID: PMC3835839 DOI: 10.1155/2013/673947] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 08/23/2013] [Accepted: 09/03/2013] [Indexed: 12/29/2022] Open
Abstract
Multiple sclerosis (MS), a chronic inflammatory autoimmune disease of the central nervous system (CNS) commonly diagnosed in adults, is being recognized increasingly in children. An estimated 1.7%-5.6% of all patients with MS have clinical symptoms before reaching the age of 18 years. In comparison with adults, the diagnosis of MS in children can be more difficult, being dismissed or misdiagnosed as other clinical disorders. Although adults and children share basic aspects of the disorder, children have distinctive clinical features, neuroimaging, laboratory, and courses of the disease. The 2010 McDonald criteria have simplified the requirements for establishing the diagnosis of MS and have been proposed to be applicable for the diagnosis of pediatric MS, mainly in children 12 years and older. This paper describes the distinctive features of common pediatric demyelinating disorders, including MS, and summarizes the most recent advances based on the available literature.
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Ryu WY, Sohn EJ, Kwon YH, Jeung WJ, Ahn HB, Park WC, Rho SH. Acute Disseminated Encephalomyelitis Without Optic Neuritis Followed by Optic Neuritis in a Child Due to the Sudden Cessation of Steroid Therapy. Semin Ophthalmol 2013; 29:18-21. [DOI: 10.3109/08820538.2013.835837] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kaur G, Neekhra A, Houghton D, Scarff JR, Lippmann S. Resolution of acute disseminated encephalomyelitis following termination of pregnancy. PSYCHOSOMATICS 2013; 55:101-4. [PMID: 24012291 PMCID: PMC7111698 DOI: 10.1016/j.psym.2013.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 05/20/2013] [Accepted: 05/21/2013] [Indexed: 01/13/2023]
Affiliation(s)
- Gagandeep Kaur
- Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY
| | - Aneesh Neekhra
- Burlington Neurology & Sleep Clinic, West Burlington, IA
| | | | - Jonathan R Scarff
- Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY
| | - Steven Lippmann
- Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY.
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Růžek D, Dobler G, Niller HH. May early intervention with high dose intravenous immunoglobulin pose a potentially successful treatment for severe cases of tick-borne encephalitis? BMC Infect Dis 2013; 13:306. [PMID: 23822550 PMCID: PMC3710210 DOI: 10.1186/1471-2334-13-306] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 07/02/2013] [Indexed: 12/18/2022] Open
Abstract
Background Arthropod-borne viral encephalitis of diverse origins shows similar clinical symptoms, histopathology and magnetic resonance imaging, indicating that the patho mechanisms may be similar. There is no specific therapy to date. However, vaccination remains the best prophylaxis against a selected few. Regardless of these shortcomings, there are an increasing number of case reports that successfully treat arboviral encephalitis with high doses of intravenous immunoglobulins. Discussion To our knowledge, high dose intravenous immunoglobulin has not been tested systematically for treating severe cases of tick-borne encephalitis. Antibody-dependent enhancement has been suspected, but not proven, in several juvenile cases of tick-borne encephalitis. Although antibody-dependent enhancement during secondary infection with dengue virus has been documented, no adverse effects were noticed in a controlled study of high dose intravenous immunoglobulin therapy for dengue-associated thrombocytopenia. The inflammation-dampening therapeutic effects of generic high dose intravenous immunoglobulins may override the antibody-dependent enhancement effects that are potentially induced by cross-reactive antibodies or by virus-specific antibodies at sub-neutralizing levels. Summary Analogous to the increasing number of case reports on the successful treatment of other arboviral encephalitides with high dose intravenous immunoglobulins, we postulate whether it may be possible to also treat severe cases of tick-borne encephalitis with high dose intravenous immunoglobulins as early in the course of the disease as possible.
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Affiliation(s)
- Daniel Růžek
- Academy of Sciences of the Czech Republic, Biology Centre, Institute of Parasitology, Branisovska: 31, CZ-37005 Ceske Budejovice, Czech Republic
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Kolias AG, Kirkpatrick PJ, Hutchinson PJ. Decompressive craniectomy: past, present and future. Nat Rev Neurol 2013; 9:405-15. [PMID: 23752906 DOI: 10.1038/nrneurol.2013.106] [Citation(s) in RCA: 146] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Decompressive craniectomy (DC)--a surgical procedure that involves removal of part of the skull to accommodate brain swelling--has been used for many years in the management of patients with brain oedema and/or intracranial hypertension, but its place in contemporary practice remains controversial. Results from a recent trial showed that early (neuroprotective) DC was not superior to medical management in patients with diffuse traumatic brain injury. An ongoing trial is investigating the clinical and cost effectiveness of secondary DC as a last-tier therapy for post-traumatic refractory intracranial hypertension. With regard to ischaemic stroke (malignant middle cerebral artery infarction), a recent Cochrane review concluded that DC improves survival compared with medical management, but that a higher proportion of DC survivors experience moderately severe or severe disability. Although many patients have a good outcome, the issue of DC-related disability raises important ethical issues. As DC and subsequent cranioplasty are associated with a number of complications, indiscriminate use of this surgery is not appropriate. Here, we review the evidence and present considerations regarding surgical technique, ethics and cost-effectiveness of DC. Prospective clinical trials and cohort studies are essential to enable optimization of patient care and outcomes.
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Affiliation(s)
- Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge, CB2 0QQ, UK.
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Affiliation(s)
- Dennis W Simon
- Department of Critical Care Medicine, The Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
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Abstract
The advent of magnetic resonance imaging (MRI) has contributed to increase the interest and awareness in childhood white matter disorders. Pediatric inflammatory demyelinating diseases of the central nervous system (CNS) are clinically heterogeneous with respect to their mode of presentation, clinical severity, rate of progression, and prognosis. Acute disseminated encephalomyelitis (ADEM) is an immune-mediated inflammatory disorder of the CNS, typically transitory and self-limiting. The highest incidence of ADEM is observed during childhood. It is characterized by an acute encephalopathy with polyfocal neurological deficits. In the absence of specific biological markers the diagnosis of ADEM is still based on clinical features and MRI evidence of widespread demyelination, after ruling out other possible explanations for an acute encephalopathy. Over the past decade, many retrospective patient studies have focused on clinical and neuroimaging features, in an attempt to define specific diagnostic criteria. The occurrence of relapses in children with ADEM poses diagnostic difficulties in its differentiation from multiple sclerosis (MS) and neuromyelitis optica (NMO). With the widespread use of high-dose steroids, the long-term prognosis of ADEM with regard to functional and cognitive recovery is favorable. This chapter summarizes the available literature on ADEM in children, including the proposed consensus definitions for its monophasic and relapsing variants.
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Affiliation(s)
- Silvia N. Tenembaum
- Correspondence to: Silvia N. Tenembaum, M.D., Department of Neurology and Neurophysiology, National Paediatric Hospital “Dr. Juan P. Garrahan”, Combate de los Pozos 1881, (C1436AAM) Buenos Aires, Argentina. Tel/Fax: 54 11 4966 2339
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