Longitudinal extensive transverse myelitis with cervical epidural haematoma following dengue virus infection

Dengue-associated longitudinally extensive transverse myelitis

We diagnosed a patient with dengue fever who developed acute onset of sensorimotor quadriparesis with bladder involvement, and facial nerve involvement. Despite initial negative results in routine investigations and cerebrospinal fluid analysis, spinal MRI confirmed longitudinally extensive transverse myelitis. The aetiological workup was negative, prompting an investigation into the presence of dengue in the cerebrospinal fluid, which returned positive. This case underscores the importance of considering rare neurological complications in dengue, the value of advanced diagnostic techniques and the potential effectiveness of tailored interventions in challenging cases.

Re-examination of the risk of autoimmune diseases after dengue virus infection: A population-based cohort study

Previous studies suggested that dengue was associated with an increased risk of several autoimmune diseases. However, this association still needs to be explored due to the limitations of these studies. A population-based cohort study was conducted using national health databases in Taiwan and included 63,814 newly diagnosed, laboratory-confirmed dengue patients between 2002 and 2015 and 1:4 controls (n = 255,256) matched by age, sex, area of residence and symptom onset time. Multivariate Cox proportional hazard regression models were used to investigate the risk of autoimmune diseases after dengue infection. Dengue patients had a slightly higher risk of overall autoimmune diseases than non-dengue controls (aHR 1.16; P = 0.0002). Stratified analyses by specific autoimmune diseases showed that only autoimmune encephalomyelitis remained statistically significant after Bonferroni correction for multiple testing (aHR 2.72; P < 0.0001). Sixteen (0.025%) dengue patients and no (0%) controls developed autoimmune encephalomyelitis in the first month of follow-up (HR >9999, P < 0.0001), but the risk between groups was not significantly different thereafter. Contrary to previous studies, our findings showed that dengue was associated with an increased short-term risk of a rare complication, autoimmune encephalomyelitis, but not associated with other autoimmune diseases.

Long-Segment Epidural Hemorrhage of the Cervical and Dorsal Spine: A Case Report of a Rare Complication of Dengue Virus Disease

Dengue hemorrhagic fever is a severe form of dengue virus disease, characterized by minor to major bleeding, thrombocytopenia, and plasma leakage. Common hemorrhagic manifestations include epistaxis, gum bleeding, gastrointestinal bleeding, hypermenorrhea, and hematuria. Intracranial hemorrhage is one of the most fatal manifestations of central nervous system involvement by dengue disease which is a part of the expanded dengue syndrome. Here we present a case of A 37-year-old male patient who presented with complaints of intermittent high-grade fever and generalized weakness four days prior to consultation. Laboratory investigations revealed mild thrombocytopenia and positive dengue serology. Magnetic resonance imaging of the brain and spine revealed mild diffuse subarachnoid hemorrhage in bilateral parieto-occipital lobes with long segment cervical and dorsal spinal epidural hemorrhage.

Association Between a History of Dengue Fever and the Risk of Systemic Autoimmune Rheumatic Diseases: A Nationwide, Population-Based Case-Control Study

Purpose: To determine the association between a history of clinically diagnosed dengue infection and the risk of systemic autoimmune rheumatic diseases (SARDs). Methods: Using claims data from the 1997-2013 Taiwanese National Health Insurance Research Database, we included 74,422 patients who were diagnosed with SARDs and 297,688 patients without SARDs who were matched (in a 1:4 ratio) for age, sex, year of SARDs index date, and city of residence. The associations between the development of SARDs and a history of dengue infection (International Classification of Diseases, Ninth Revision, Clinical Modification code 061) were investigated using conditional logistic regression analysis shown as odds ratios (ORs) with 95% confidence intervals (CIs) after adjusting for potential confounders. Results: We included 17,126 patients with systemic lupus erythematosus (SLE), 15,531 patients with Sjogren's syndrome (SS), 37,685 patients with rheumatoid arthritis (RA), 1,911 patients with systemic sclerosis (SSc), 1,277 patients with dermatomyositis (DM), and 892 patients with polymyositis (PM). SLE (OR, 4.55; 95% CI, 2.77-7.46; p <0.001) risk was significantly associated with a history of dengue infection. However, no statistically significant association was found between dengue infection and SS (OR, 1.41; 95% CI, 0.88-2.26; p = 0.155), RA (OR, 1.03; 95% CI, 0.70-1.50; p = 0.888), SSc (OR, 1.97; 95% CI, 0.38-10.29; p = 0.420), DM (OR, 0.54; 95% CI, 0.04-7.27; p = 0.641), or PM (OR, 2.08; 95% CI, 0.23-18.79; p = 0.513). Conclusion: This study revealed that a history of dengue infection was significantly associated with the risk of SLE, but not SS, RA, SSc, DM, or PM.

Longitudinally extensive transverse myelitis with positive aquaporin-4 IgG associated with dengue infection: a case report and systematic review of cases

BACKGROUND

Neuromyelitis Optica Spectrum Disorder can be associated with parainfectious and post-infectious triggers. Dengue virus infection is one of the most common arbovirus infections in the world, and may present with neurological manifestations.

OBJECTIVES

We present a case of DENV-associated with LETM and positive aquaporin-4 IgG, and a systematic review of published cases.

METHODS

Medline (Ovid) and PubMed were search through June 2021, for case reports, series and observational studies that described patients with DENV-associated LETM and/or NMOSD.

RESULTS

An adolescent girl who had recently immigrated from a Dengue-endemic region presented with a LETM with high positive AQP4-IgG titer and seropositive DENV IgM/IgG antibodies. She responded well to steroids and subsequently started maintenance rituximab for her NMOSD diagnosis.

LITERATURE REVIEW

22 publications describing 27 patients met inclusion criteria. In addition to this case, three published cases met current criteria for NMOSD with serological evidence of acute DENV infection.

CONCLUSIONS

It is unknown whether there is a pathophysiological association between DENV infection and NMOSD. Regardless, if an immune-mediated event is suspected, particularly NMOSD, appropriate immunotherapy should be considered early. Decision regarding long term immunotherapy may depend on index of suspicion of true NMOSD, and this is where AQP4-IgG status and follow-up is helpful.

Viral and Prion Infections Associated with Central Nervous System Syndromes in Brazil

Virus-induced infections of the central nervous system (CNS) are among the most serious problems in public health and can be associated with high rates of morbidity and mortality, mainly in low- and middle-income countries, where these manifestations have been neglected. Typically, herpes simplex virus 1 and 2, varicella-zoster, and enterovirus are responsible for a high number of cases in immunocompetent hosts, whereas other herpesviruses (for example, cytomegalovirus) are the most common in immunocompromised individuals. Arboviruses have also been associated with outbreaks with a high burden of neurological disorders, such as the Zika virus epidemic in Brazil. There is a current lack of understanding in Brazil about the most common viruses involved in CNS infections. In this review, we briefly summarize the most recent studies and findings associated with the CNS, in addition to epidemiological data that provide extensive information on the circulation and diversity of the most common neuro-invasive viruses in Brazil. We also highlight important aspects of the prion-associated diseases. This review provides readers with better knowledge of virus-associated CNS infections. A deeper understanding of these infections will support the improvement of the current surveillance strategies to allow the timely monitoring of the emergence/re-emergence of neurotropic viruses.

Compressive Myelopathy in Dengue Infection: A Report of 2 Cases and Literature Review

CASES

We report 2 cases of compressive myelopathy secondary to spontaneous neuroaxial bleed in dengue infection. One was treated by surgical decompression during the recovery phase of illness, whereas the other was treated nonoperatively.

CONCLUSION

A conscious decision for surgical decompression should be taken in cases not responding to initial medical management and planned during the recovery phase of dengue infection.

Spinal Epidural Hematoma Post Evacuation of Spontaneous Spinal Intradural Hematoma

BACKGROUND

Spinal hematomas are rarely associated with dengue syndrome and usually occur at the time of active dengue fever. Late presentation after recovery from dengue fever, intradural hematoma, presentation as a multiloculated cystic lesion with longitudinal extensive myelitis, and recurrence after surgery are rarely or not described. Due to the peculiar association of all these findings, we report this case to provide insight into the existence of such a rare presentation.

CASE DESCRIPTION

A 79-year-old-male developed sudden-onset paraparesis after 1 week of recovery from dengue fever. The blood counts were normal. Magnetic resonance imaging of the thoracic spine was suggestive of intradural hematoma. The patient underwent emergency decompression and drainage of hematoma with recovery in the neurologic status over the next few weeks. He presented to our emergency department after 5 weeks of the first surgery with deterioration in the neurologic status to complete paraplegia. Repeat magnetic resonance imaging showed a posterior epidural collection bulging anteriorly, causing cord compression. The patient was reoperated on by decompression. There was no neurologic recovery. The patient was managed with multidisciplinary rehabilitation, and he was independent in most of the activities at the time of discharge.

CONCLUSIONS

Spinal hematoma should be kept in mind in patients who present with neurologic complications after dengue fever. It can have an atypical radiologic presentation and may present with recurrent hemorrhage after surgery. Attention should also be given to delayed presentation of neurologic complications, which may develop even after weeks of recovery from dengue fever.

Dengue Virus Infection of Blood-Brain Barrier Cells: Consequences of Severe Disease

More than 500 million people worldwide are infected each year by any of the four-dengue virus (DENV) serotypes. The clinical spectrum caused during these infections is wide and some patients may develop neurological alterations during or after the infection, which could be explained by the cryptic neurotropic and neurovirulent features of flaviviruses like DENV. Using in vivo and in vitro models, researchers have demonstrated that DENV can affect the cells from the blood-brain barrier (BBB) in several ways, which could result in brain tissue damage, neuronal loss, glial activation, tissue inflammation and hemorrhages. The latter suggests that BBB may be compromised during infection; however, it is not clear whether the damage is due to the infection per se or to the local and/or systemic inflammatory response established or activated by the BBB cells. Similarly, the kinetics and cascade of events that trigger tissue damage, and the cells that initiate it, are unknown. This review presents evidence of the BBB cell infection with DENV and the response established toward it by these cells; it also describes the consequences of this response on the nervous tissue, compares these evidence with the one reported with neurotropic viruses of the Flaviviridae family, and shows the complexity and unpredictability of dengue and the neurological alterations induced by it. Clinical evidence and in vitro and in vivo models suggest that this virus uses the bloodstream to enter nerve tissue where it infects the different cells of the neurovascular unit. Each of the cell populations respond individually and collectively and control infection and inflammation, in other cases this response exacerbates the damage leaving irreversible sequelae or causing death. This information will allow us to understand more about the complex disease known as dengue, and its impact on a specialized and delicate tissue like is the nervous tissue.

Burden of Dengue-related Neurosurgical Emergencies during an Epidemic: A Tertiary Care Experience

Dengue is one of the most common flavivirus infections which can manifest from common flu-like fever to fatal hemorrhagic complication. Epidemics of dengue return every year with peaks during the rainfall claiming substantial number of lives in the tropical and subtropical regions of the world. We present manifestations of dengue in patients who underwent neurosurgery in a tertiary referral center during such an epidemic. There were total four patients referred for neurosurgical intervention as sequelae to dengue coagulopathy. Among them, three had intracranial bleeds and one had spinal cord hematoma along with intracranial hemorrhages. This small series includes the youngest reported case of dengue coagulopathy with intracranial bleed and only the second case of spontaneous intraspinal hematoma sequelae to dengue hemorrhagic fever. The situations where patients contract dengue in a setting of neurosurgical intervention are grave. The margin of safety in the presence of dengue coagulopathy is narrow. The surgeon has to outweigh benefit against risk of surgery in each individual.

Risk of Transverse Myelitis Following Dengue Infection: A Systematic Review of the Literature

INTRODUCTION

Dengue virus (DENV) is one of the most common arbovirus diseases, with a wide spectrum of presentation. Spinal cord involvement in dengue infection (DF) is rare. However, the risk of transverse myelitis (TM) following Dengue has not been systematically assessed.

METHODS

We undertook a systematic review of published English literature from January 1974 to December 2017 to assess risk of TM and outcomes following DF. Data sources included EMBASE, MEDLINE, Cochrane library, ISI web of knowledge, conference proceedings and references within identified articles.

RESULTS

We identified 242 potential studies, 62 were duplicates. A further 136 were excluded on the basis of title and abstract and 19 studies did not meet the eligibility criteria on full text screening. We included 25 publications involving 2672 cases of DF. A small proportion (10.8%, (289/2672)) had neurological complications, of which 2.3% (61/2672) was TM. For articles reporting epidemiological data, the neurological complication was twice in males compared to female 67.7% (130/192) vs. 32.7% (62/192) and 1.5-fold increase TM for males 59.3% (32/54) vs 40.7% (22/54). The mean age at presentation was 33.1years (range 0.75⁻61), with onset at 11.7days. The method of diagnosing TM due to DF was mainly IgM seropositivity 92% (n = 23/25) and the commonest treatment modality was steroid 78.3% (n = 18/23). Only half had full recovery 50.8% (n = 31/61). There was no mortality following dengue, however, the crude case fatality rate following TM was 3.3% (n = 2/61).

CONCLUSION

This review highlights the risk of TM following dengue. Although neurological complications are rare, especially TM, once set in, it is associated with a significant morbidity.

Beyond thrombocytopaenia, haemorrhage and shock: the expanded dengue syndrome

Dengue infection classically presents with fever, thrombocytopaenia, and varying degrees of plasma leakage, giving rise to shock. However, a myriad of other manifestations, involving the cardiovascular system, the nervous system, the liver, the kidneys, the gut and the haematological system have been reported in dengue. This review summarizes these varied presentations.

Increased risk of autoimmune diseases in dengue patients: A population-based cohort study

OBJECTIVE

To investigate the risk of autoimmune diseases in dengue patients.

METHODS

We conducted a population-based cohort study by the Taiwan National Health Insurance Research Database, including a total of 12,506 newly diagnosed dengue patients and 112,554 control subjects between 2000 and 2010, matched by gender, age, income, urbanization, and comorbidities. Both cohorts were followed for a 3-year period to examine the incidence of autoimmune diseases. A Cox proportional hazards regression analysis was applied to calculate the risk of autoimmune diseases between both groups.

RESULTS

The dengue group showed an overall increased risk for 21 autoimmune diseases, with an adjusted hazard ratio (aHR) of 1.88 (95% confidence interval [CI], 1.49-2.37, p < 0.001). Compared with the control group, the dengue group had higher risks of Reiter's syndrome (aHR 14.03, 95 % CI 1.63-120.58), multiple sclerosis (aHR 11.57, 95 % CI 1.8-74.4), myasthenia gravis (aHR 5.35, 95 % CI 1.43-20.02), autoimmune encephalomyelitis (aHR 3.8, 95% CI 1.85-7.8), systemic vasculitis (aHR 3.7, 95 % CI 1.11-12.28), systemic lupus erythematosus (aHR 3.5, 95% CI 1.85-6.63), and primary adrenocortical insufficiency (aHR 2.05, 95% CI 1.25-3.35).

CONCLUSION

Dengue patients were associated with an increased risk of autoimmune diseases.

Cerebral vasculitis and lateral rectus palsy - two rare central nervous system complications of dengue fever: two case reports and review of the literature

BACKGROUND

Dengue fever is a common mosquito-borne viral illness with a clinical spectrum ranging from a simple febrile illness to potentially life-threatening complications such as dengue hemorrhagic fever and dengue shock syndrome. Dengue infection can affect many organs, including the central nervous system. The neurological manifestations reported in dengue infections are meningitis, encephalitis, stroke, acute disseminated encephalomyelitis, and Guillain-Barré syndrome.

CASE PRESENTATION

We report the cases of two interesting patients with confirmed dengue infection who presented with complications of possible central nervous system vasculitis and cranial nerve palsy. The first patient was a 53-year-old previously healthy Singhalese woman who developed acute-onset slurring of speech and ataxia with altered sensorium 1 day after recovery from a critical period of dengue hemorrhagic fever. Subsequent investigations revealed evidence of encephalopathy with brainstem ischemic infarctions. Her clinical picture was compatible with central nervous system vasculitis. She was treated successfully with intravenous steroids and had a full functional recovery. The second patient was a middle-aged Singhalese woman who had otherwise uncomplicated dengue infection. She developed binocular diplopia on day 4 of fever. An ocular examination revealed a convergent squint in the left eye with lateral rectus palsy but no other neurological manifestation.

CONCLUSIONS

Central nervous system vasculitis due to dengue infection is a very rare phenomenon, and to the best of our knowledge, only one case of central nervous system vasculitis has been reported to date, in a patient of pediatric age. Cranial nerve palsy related to dengue infection is also rare, and only a few cases of isolated abducens nerve palsy have been reported to date. The two cases described in this report illustrate the rare but important central nervous system manifestations of dengue fever and support the fact that the central nervous system is one of the important systems that can be affected in patients with dengue infection.

Myelitis and cauda equina involvement following dengue fever. A case report and review of the literature

Dengue fever (DF) is a common arbovirosis in tropical and subtropical countries and may be associated with a wide range of neurological complications. We describe a 41-year-old man who developed weakness in the right arm and lower limbs, paresthesia in the upper and lower limbs, and sphincter disturbance four weeks following DF. Examination disclosed a wheel-chair bound patient with urinary catheter, areflexia in the lower limbs, and a sensation level at T10. Spinal magnetic resonance imaging showed diffuse lesions with contrast-enhanced areas extending from the medullary-cervical junction to the conus medullaris and cauda equina. A review of the literature reveals that this is the first report of clinical and imaging signs of myeloradiculitis with cauda equina involvement following DF infection.

Longitudinally extensive transverse myelitis after Campylobacter jejuni enteritis

Campylobacter jejuni infection is well-known to precipitate Guillain-Barré syndrome through an immune-mediated attack on the peripheral nervous system. Molecular mimicry between C. jejuni lipo-oligosaccharides on the surface of infectious agents and human gangliosides in the peripheral nerves induces cross-reactive immune responses. Although gangliosides also occur in the central nervous system (CNS), autoimmune CNS disorders rarely follow C. jejuni infections. However, longitudinally extensive transverse myelitis commonly has a parainfectious cause, triggered by a wide range of micro-organisms including viruses and bacteria. We report a patient who developed longitudinally extensive transverse myelitis after C. jejuni enteritis associated with antiganglioside antibodies.

Neurological Manifestations of Dengue Infection

Dengue counts among the most commonly encountered arboviral diseases, representing the fastest spreading tropical illness in the world. It is prevalent in 128 countries, and each year >2.5 billion people are at risk of dengue virus infection worldwide. Neurological signs of dengue infection are increasingly reported. In this review, the main neurological complications of dengue virus infection, such as central nervous system (CNS), peripheral nervous system, and ophthalmic complications were discussed according to clinical features, treatment and possible pathogenesis. In addition, neurological complications in children were assessed due to their atypical clinical features. Finally, dengue infection and Japanese encephalitis were compared for pathogenesis and main clinical manifestations.