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Mashkoor Y, Nadeem A, Fatima T, Aamir M, Vohra LI, Habib A, Khan A, Raufi N, Habte A. Neurological complications of influenza vaccination: navigating the spectrum with a focus on acute disseminated encephalomyelitis (ADEM). Ann Med Surg (Lond) 2024; 86:1029-1041. [PMID: 38333316 PMCID: PMC10849354 DOI: 10.1097/ms9.0000000000001656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 12/13/2023] [Indexed: 02/10/2024] Open
Abstract
Introduction Acute disseminated encephalomyelitis (ADEM) is a rare neurological disorder characterized by inflammation in the brain and spinal cord. This systematic review aims to investigate the potential association between ADEM and influenza vaccination by analyzing relevant case reports. ADEM is traditionally thought to be a monophasic condition, predominantly affecting children, often following viral illnesses or immunizations. Recent attention has focused on a possible link between ADEM and influenza vaccination, prompting the need for a thorough investigation. Methods The systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the AMSTAR2 (A MeaSurement Tool to Assess systematic Reviews 2) guidelines. Electronic searches were conducted on PubMed, Cochrane Library, and clinicaltrials.gov databases, spanning up to August 2023. Inclusion criteria encompassed full-text articles in English, observational studies, case reports, and case series providing comprehensive details for confirming clinical diagnoses of ADEM following influenza vaccination. Data were extracted, including demographic information, vaccination details, clinical symptoms, diagnostic evaluations, treatment modalities, and outcomes. Quality assessment was performed using the Joanna Briggs Institute (JBI) Critical Appraisal tool. Results A total of 23 cases of ADEM following influenza vaccination were identified from 19 included articles. The mean age of affected individuals was 40.2 years (±25.7) with 60.8% being male. Common presenting symptoms included muscle weakness (52.1%), urinary abnormalities (30.4%), altered consciousness (26%), and sensory disturbances (26%). Neurological examination revealed findings such as extensor plantar reflex (positive Babinski sign) in 26%, hyperreflexia in 30.4%, and generalized hyporeflexia in 13% of the cases. Diagnostic evaluations involved MRI, showing multiple hyperintense lesions in cerebral hemispheres (43.4%), subcortex (60.8%), and spinal cord (39.1%). Cerebrospinal fluid analysis indicated elevated white blood cell count in 69.5% of cases, with lymphocytic pleocytosis in 52.1%. Oligoclonal bands were reported positively in 8.6% of cases. Treatment approaches varied, with intravenous methylprednisolone being the most common (39.1%). Out of the 23 cases, two (8.6%) patients had a fatal outcome, while the rest showed clinical improvement with complete or partial resolution of symptoms. Persisting symptoms included numbness in the lower extremities (8.6%) and impaired ability to walk after 10 months (4.3%). Conclusion While the association between ADEM and influenza vaccination is rare, healthcare professionals should remain vigilant and consider patients' vaccination history, particularly following an influenza immunization. This systematic review highlights the clinical manifestations, diagnostic tools, treatment approaches, and outcomes of ADEM cases post-influenza vaccination. Further research is essential to understand this association and improve clinical decision-making, ensuring the safety and efficacy of immunization programs.
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Affiliation(s)
| | | | - Tehreem Fatima
- Department of Medicine, Dow University of Health Sciences
| | - Minahil Aamir
- Department of Medicine, Dow University of Health Sciences
| | - Laiba I. Vohra
- Department of Medicine, Ziauddin University, Karachi, Sindh, Pakistan
| | | | - Afsheen Khan
- Department of Medicine, Dow University of Health Sciences
| | - Nahid Raufi
- Department of Medicine, Kabul Medical University, Kabul, Afghanistan
| | - Alexander Habte
- Department of Surgery, Assab Military Hospital, Assab, Eritrea
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Walter A, Kraemer M. A neurologist's rhombencephalitis after comirnaty vaccination. A change of perspective. Neurol Res Pract 2021; 3:56. [PMID: 34743758 PMCID: PMC8572650 DOI: 10.1186/s42466-021-00156-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 09/13/2021] [Indexed: 11/30/2022] Open
Abstract
Rhombencephalitis is an orphan disease of multiple causes that may manifest with facial palsy, limb ataxia and reduced consciousness. Up to now it is described after COVID-19 infection and in this (personal) case was found up to 8 weeks after Comirnaty vaccination. So far, we do not fully understand the pathophysiological characteristics of encephalitis associated with SARS-CoV-2. In rare cases, vaccination may cause an immunological reaction and delayed inflammation, the consequences of which we have not yet deciphered. Rhombencephalitis should be considered as a rare potential mRNA-associated vaccination side effect.
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Affiliation(s)
- Alexander Walter
- Department of Psychiatry, Kliniken Essen-Mitte/ Huyssenstift, Essen, Germany
| | - Markus Kraemer
- Department of Neurology, Alfried-Krupp-Krankenhaus Essen, Essen, Germany
- Department of Neurology, Medical Faculty, J`Heinrich Heine University Duesseldorf, Duesseldorf, Germany
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Román GC, Gracia F, Torres A, Palacios A, Gracia K, Harris D. Acute Transverse Myelitis (ATM):Clinical Review of 43 Patients With COVID-19-Associated ATM and 3 Post-Vaccination ATM Serious Adverse Events With the ChAdOx1 nCoV-19 Vaccine (AZD1222). Front Immunol 2021; 12:653786. [PMID: 33981305 PMCID: PMC8107358 DOI: 10.3389/fimmu.2021.653786] [Citation(s) in RCA: 142] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/08/2021] [Indexed: 01/13/2023] Open
Abstract
Introduction Although acute transverse myelitis (ATM) is a rare neurological condition (1.34-4.6 cases per million/year) COVID-19-associated ATM cases have occurred during the pandemic. Case-finding methods We report a patient from Panama with SARS-CoV-2 infection complicated by ATM and present a comprehensive clinical review of 43 patients with COVID-19-associated ATM from 21 countries published from March 2020 to January 2021. In addition, 3 cases of ATM were reported as serious adverse events during the clinical trials of the COVID-19 vaccine ChAdOx1 nCoV-19 (AZD1222). Results All patients had typical features of ATM with acute onset of paralysis, sensory level and sphincter deficits due to spinal cord lesions demonstrated by imaging. There were 23 males (53%) and 20 females (47%) ranging from ages 21- to 73- years-old (mean age, 49 years), with two peaks at 29 and 58 years, excluding 3 pediatric cases. The main clinical manifestations were quadriplegia (58%) and paraplegia (42%). MRI reports were available in 40 patients; localized ATM lesions affected ≤3 cord segments (12 cases, 30%) at cervical (5 cases) and thoracic cord levels (7 cases); 28 cases (70%) had longitudinally-extensive ATM (LEATM) involving ≥4 spinal cord segments (cervicothoracic in 18 cases and thoracolumbar-sacral in 10 patients). Acute disseminated encephalomyelitis (ADEM) occurred in 8 patients, mainly women (67%) ranging from 27- to 64-years-old. Three ATM patients also had blindness from myeloneuritis optica (MNO) and two more also had acute motor axonal neuropathy (AMAN). Conclusions We found ATM to be an unexpectedly frequent neurological complication of COVID-19. Most cases (68%) had a latency of 10 days to 6 weeks that may indicate post-infectious neurological complications mediated by the host’s response to the virus. In 32% a brief latency (15 hours to 5 days) suggested a direct neurotropic effect of SARS-CoV-2. The occurrence of 3 reported ATM adverse effects among 11,636 participants in the AZD1222 vaccine trials is extremely high considering a worldwide incidence of 0.5/million COVID-19-associated ATM cases found in this report. The pathogenesis of ATM remains unknown, but it is conceivable that SARS-CoV-2 antigens –perhaps also present in the AZD1222 COVID-19 vaccine or its chimpanzee adenovirus adjuvant– may induce immune mechanisms leading to the myelitis.
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Affiliation(s)
- Gustavo C Román
- Department of Neurology, Neurological Institute, Houston Methodist Hospital, Houston, TX, United States.,Weill Cornell College of Medicine, Cornell University, New York, NY, United States.,Department of Neurology, Texas A&M University College of Medicine, Bryan, TX, United States
| | - Fernando Gracia
- Neurology Service, Hospital Paitilla, Panama City, Panama.,Faculty of Health Sciences, Interamerican University of Panama, Panama City, Panama.,Neurology Service, Hospital Santo Tomás, Panama City, Panama
| | - Antonio Torres
- Infectious Disease Service, Hospital Santo Tomás, Panama City, Panama
| | - Alexis Palacios
- Neuroradiology Service, Complejo Hospitalario Metropolitano, CSS (Caja de Seguro Social), Panama City, Panama
| | - Karla Gracia
- Interamerican University of Panama, Panama City, Panama
| | - Diógenes Harris
- Neurosurgery Service, Complejo Hospitalario Metropolitano, CSS, Panama City, Panama
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Gao B. Emerging Infectious Diseases. IMAGING OF CNS INFECTIONS AND NEUROIMMUNOLOGY 2019. [PMCID: PMC7120467 DOI: 10.1007/978-981-13-6904-9_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Emerging infectious diseases (EIDs) including novel avian influenza viruses or even recently reported Zika virus (ZIKV) have drawn great attentions globally. The application of modern diagnostic technologies is expected to increase. Imaging plays a key role on diagnosis and prognosis assessment in patients with EID.
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Ghaderi S, Størdal K, Gunnes N, Bakken IJ, Magnus P, Håberg SE. Encephalitis after influenza and vaccination: a nationwide population-based registry study from Norway. Int J Epidemiol 2018; 46:1618-1626. [PMID: 29024996 PMCID: PMC7313985 DOI: 10.1093/ije/dyx149] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2017] [Indexed: 11/14/2022] Open
Abstract
Background Influenza is known to be associated with various neurological complications, including encephalitis. We conducted a registry-based study to assess the risk of encephalitis after influenza and A(H1N1)pdm09 vaccine. Methods Data from Norwegian national health registries during 2008-14 were linked using the unique personal identifiers given to all Norwegian residents (N = 5 210 519). Cox proportional-hazard models with time-varying variables were fitted to estimate hazard ratios (HRs) of encephalitis after influenza and A(H1N1)pdm09 vaccine, using the risk windows 0-7, 0-14, 0-30, 0-60, 0-90 and 0-180 days. Results In Norway, 684 172 individuals received an influenza diagnosis and 2793 patients were hospitalized with encephalitis during 2008-14. The risk of encephalitis increased after influenza: HR, 7-day risk window: 47.8 (95% confidence interval (CI): 35.8-63.8), and the HR decreased for longer risk windows; HR, 180-day risk window: 3.8 (95% CI: 3.1-4.7). HR of encephalitis after influenza during the 2009 main pandemic wave using a 7-day risk window was 30.0 (95% CI: 10.8-83.2). We found no differences in the risk of encephalitis after the seasonal influenza compared with influenza during the 2009 main pandemic wave; HR, 7-day risk window: 1.3 (95% CI: 0.4-4.3). A(H1N1)pdm09 vaccine was not associated with the risk of encephalitis: HR, 14-day risk window: 0.6 (95% CI: 0.2-2.1). Conclusions There was an increased risk of encephalitis following influenza but not after A(H1N1)pdm09 vaccine. The risk of encephalitis was highest in the first few weeks after influenza.
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Affiliation(s)
- Sara Ghaderi
- Norwegian Institute of Public Health, Oslo, Norway
| | - Ketil Størdal
- Norwegian Institute of Public Health, Oslo, Norway.,Østfold Hospital Trust, Paeds Department, Grålum, Norway
| | - Nina Gunnes
- Norwegian Institute of Public Health, Oslo, Norway
| | | | - Per Magnus
- Norwegian Institute of Public Health, Oslo, Norway
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Pandemic H1N1 Vaccination and Incidence of Acute Disseminated Encephalomyelitis in Manitoba. Can J Neurol Sci 2016; 43:819-823. [DOI: 10.1017/cjn.2016.291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
AbstractBackground: An increased incidence of hospital admissions coded as acute disseminated encephalomyelitis (ADEM) was noted in Winnipeg, Manitoba, Canada, during the second wave of the influenza pandemic from October 2009 to March 2010. However, it was not clear whether this was due to heightened awareness of potential neurological complications of influenza or influenza vaccination or an actual increase in the number of cases. Methods: We extracted data from the charts of 139 patients hospitalized with an International Classification of Diseases-10 discharge code indicating ADEM (G04.0) or unspecified noninfectious encephalitis or myelitis (G04.8, G04.9) between January 2006 and December 2012. Clinical and laboratory data were reviewed by a neurologist, and diagnoses were determined using the Brighton criteria. Results: Over the entire study period, there were 22 cases of ADEM. During the peak pandemic period (April-December 2009), seven patients were hospitalized with ADEM, corresponding to a rate of 7.8/million/year; 4.7 (95% confidence interval: 1.9-11.4) times higher than the rate before or after the pandemic period. Only one patient with ADEM had received the monovalent A(H1N1)pdm09 vaccine within 12 weeks of hospitalization. Conclusions: We have found an increased incidence of ADEM during the pandemic period that may be related, at least in part, to the increased incidence of influenza during that period. However, there was no temporal relationship with the administration of A(H1N1)pdm09 or seasonal influenza vaccines. Our study provides reassurance that use of these vaccines was not associated with increased risk of ADEM.
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Neuroinfection & neuroimmunology: New opportunities, new challenges. RADIOLOGY OF INFECTIOUS DISEASES 2016; 3:51-53. [PMID: 32289069 PMCID: PMC7128164 DOI: 10.1016/j.jrid.2016.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 02/24/2016] [Accepted: 03/25/2016] [Indexed: 11/21/2022]
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Foerster J, Bachman M. Beyond passive immunization: toward a nanoparticle-based IL-17 vaccine as first in class of future immune treatments. Nanomedicine (Lond) 2016; 10:1361-9. [PMID: 25955128 DOI: 10.2217/nnm.14.215] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Nanoparticles occur naturally as part of repetitive molecular structures forming virus-like particles (VLPs). VLPs are powerful immune activators. Specifically, VLP can elicit a direct activation of B lymphocytes to trigger production of antibodies targeted at molecules chemically linked to the VLP. We here review recent data from genetics research, large-scale genomic sequencing, as well as clinical trials which suggest that a VLP-based vaccine against the signaling molecule IL-17 will be safe and effective in the common skin disease psoriasis, as well as other conditions. Active vaccination against IL-17 is capable of replacing the costly manufacture of antibodies currently in clinical use with huge implications for treatment availability and health economics.
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Affiliation(s)
- John Foerster
- College of Medicine, Dentistry, & Nursing, University of Dundee, Dundee, DD1 9SY, UK
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Esposito S, Di Pietro GM, Madini B, Mastrolia MV, Rigante D. A spectrum of inflammation and demyelination in acute disseminated encephalomyelitis (ADEM) of children. Autoimmun Rev 2015; 14:923-9. [PMID: 26079482 PMCID: PMC7105213 DOI: 10.1016/j.autrev.2015.06.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 06/09/2015] [Indexed: 11/15/2022]
Abstract
Acute disseminated encephalomyelitis (ADEM) is an inflammatory demyelinating disease of the central nervous system that involves multifocal areas of the white matter, rarely the gray matter and spinal cord, mainly affecting children and mostly occurring 1-2weeks after infections or more rarely after vaccinations. Though a specific etiologic agent is not constantly identified, to evaluate carefully patient's clinical history and obtain adequate samples for the search of a potential ADEM causal agent is crucial. In the case of a prompt diagnosis and adequate treatment, most children with ADEM have a favorable outcome with full recovery, but in the case of diagnostic delays or inappropriate treatment some patients might display neurological sequelae and persistent deficits or even show an evolution to multiple sclerosis. The suspicion of ADEM rises on a clinical basis and derives from systemic and neurologic signs combined with magnetic resonance imaging of the central nervous system. Other advanced imaging techniques may help an appropriate differential diagnosis and definition of exact disease extension. Although there is no standardized protocol or management for ADEM, corticosteroids, intravenous immunoglobulin, and plasmapheresis have been successfully used. There is no marker that permits to identify the subset of children with worse prognosis and future studies should try to detect any biological clue for prevision of neurologic damage as well as should optimize treatment strategies using an approach based on the effective risk of negative evolution.
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Affiliation(s)
- Susanna Esposito
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Giada Maria Di Pietro
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Barbara Madini
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Vincenza Mastrolia
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Donato Rigante
- Institute of Pediatrics, Università Cattolica Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
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