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Abbuehl LS, Branca M, Ungureanu A, Federspiel A, Leib SL, Bassetti CLA, Hakim A, Dietmann A. Magnetic resonance imaging in acute meningoencephalitis of viral and unknown origin: frequent findings and prognostic potential. Front Neurol 2024; 15:1359437. [PMID: 38299018 PMCID: PMC10829495 DOI: 10.3389/fneur.2024.1359437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 01/05/2024] [Indexed: 02/02/2024] Open
Abstract
Background Magnetic resonance imaging (MRI) findings in meningoencephalitis have mainly been described in terms of their diagnostic value rather than their prognostic potential, except for herpes simplex virus (HSV) encephalitis. The aims of our study were to describe frequency and anatomic locations of MRI abnormalities specific to limbic, circadian and motor systems in a cohort of meningoencephalitis patients, as well as to investigate the prognostic value of these MRI findings. Methods A secondary, selective analysis of a retrospective database including all meningitis, meningoencephalitis and encephalitis cases treated between 2016 and 2018 in the University hospital of Bern, Switzerland was performed. Patients with meningitis of any cause, bacterial or autoimmune causes of encephalitis were excluded. Results MRI scans and clinical data from 129 meningoencephalitis cases found that the most frequent causes were tick-borne encephalitis (TBE, 42%), unknown pathogens (40%), VZV (7%), and HSV1 (5%). At discharge, median modified Rankin Score (mRS) was 3 (interquartile range, IQR, 1), 88% of patients had persisting signs and symptoms. After a median of 17 months, median Glasgow Outcome Score (GOS) was 5 (IQR 1), 39% of patients still had residual signs or symptoms. All patients with HSV, 27% with TBE and 31% of those with meningoencephalitis of unknown etiology had fluid-attenuated inversion recovery (FLAIR) and to a lesser extent diffusion-weighted imaging (DWI) lesions in their initial MRI, with highly overlapping anatomical distribution. In one fifth of TBE patients the limbic system was affected. Worse outcome was associated with presence of DWI and/or FLAIR lesions and lower normalized apparent diffusion coefficient (ADC) signal intensities. Conclusion Presence of FLAIR lesions, restricted diffusion as well as the extent of ADC hypointensity in initial MRI are parameters which might be of prognostic value regarding the longterm clinical outcome for patients with meningoencephalitis of viral and of unknown origin. Although not described before, affection of limbic structures by TBE is possible as shown by our results: A substantial proportion of our TBE patients had FLAIR signal abnormalities in these regions.
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Affiliation(s)
- Lena S. Abbuehl
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Anamaria Ungureanu
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andrea Federspiel
- Support Center for Advanced Neuroimaging Translational Imaging Center (sitem-insel), Institute for Diagnostic and Interventional Neuroradiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephen L. Leib
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Claudio L. A. Bassetti
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Arsany Hakim
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anelia Dietmann
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Hills SL, Poehling KA, Chen WH, Staples JE. Tick-Borne Encephalitis Vaccine: Recommendations of the Advisory Committee on Immunization Practices, United States, 2023. MMWR Recomm Rep 2023; 72:1-29. [PMID: 37943707 PMCID: PMC10651317 DOI: 10.15585/mmwr.rr7205a1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023] Open
Abstract
Tick-borne encephalitis (TBE) virus is focally endemic in parts of Europe and Asia. The virus is primarily transmitted to humans by the bites of infected Ixodes species ticks but can also be acquired less frequently by alimentary transmission. Other rare modes of transmission include through breastfeeding, blood transfusion, solid organ transplantation, and slaughtering of viremic animals. TBE virus can cause acute neurologic disease, which usually results in hospitalization, often permanent neurologic or cognitive sequelae, and sometimes death. TBE virus infection is a risk for certain travelers and for laboratory workers who work with the virus. In August 2021, the Food and Drug Administration approved Ticovac TBE vaccine for use among persons aged ≥1 year. This report summarizes the epidemiology of and risks for infection with TBE virus, provides information on the immunogenicity and safety of TBE vaccine, and summarizes the recommendations of the Advisory Committee on Immunization Practices (ACIP) for use of TBE vaccine among U.S. travelers and laboratory workers. The risk for TBE for most U.S. travelers to areas where the disease is endemic is very low. The risk for exposure to infected ticks is highest for persons who are in areas where TBE is endemic during the main TBE virus transmission season of April–November and who are planning to engage in recreational activities in woodland habitats or who might be occupationally exposed. All persons who travel to areas where TBE is endemic should be advised to take precautions to avoid tick bites and to avoid the consumption of unpasteurized dairy products because alimentary transmission of TBE virus can occur. TBE vaccine can further reduce infection risk and might be indicated for certain persons who are at higher risk for TBE. The key factors in the risk-benefit assessment for vaccination are likelihood of exposure to ticks based on activities and itinerary (e.g., location, rurality, season, and duration of travel or residence). Other risk-benefit considerations should include 1) the rare occurrence of TBE but its potentially high morbidity and mortality, 2) the higher risk for severe disease among certain persons (e.g., older persons aged ≥60 years), 3) the availability of an effective vaccine, 4) the possibility but low probability of serious adverse events after vaccination, 5) the likelihood of future travel to areas where TBE is endemic, and 6) personal perception and tolerance of risk ACIP recommends TBE vaccine for U.S. persons who are moving or traveling to an area where the disease is endemic and will have extensive exposure to ticks based on their planned outdoor activities and itinerary. Extensive exposure can be considered based on the duration of travel and frequency of exposure and might include shorter-term (e.g., <1 month) travelers with daily or frequent exposure or longer-term travelers with regular (e.g., a few times a month) exposure to environments that might harbor infected ticks. In addition, TBE vaccine may be considered for persons who might engage in outdoor activities in areas where ticks are likely to be found, with a decision to vaccinate made on the basis of an assessment of their planned activities and itinerary, risk factors for a poor medical outcome, and personal perception and tolerance of risk. In the laboratory setting, ACIP recommends TBE vaccine for laboratory workers with a potential for exposure to TBE virus
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Worku DA. Tick-Borne Encephalitis (TBE): From Tick to Pathology. J Clin Med 2023; 12:6859. [PMID: 37959323 PMCID: PMC10650904 DOI: 10.3390/jcm12216859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/19/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
Tick-borne encephalitis (TBE) is a viral arthropod infection, endemic to large parts of Europe and Asia, and is characterised by neurological involvement, which can range from mild to severe, and in 33-60% of cases, it leads to a post-encephalitis syndrome and long-term morbidity. While TBE virus, now identified as Orthoflavivirus encephalitidis, was originally isolated in 1937, the pathogenesis of TBE is not fully appreciated with the mode of transmission (blood, tick, alimentary), viral strain, host immune response, and age, likely helping to shape the disease phenotype that we explore in this review. Importantly, the incidence of TBE is increasing, and due to global warming, its epidemiology is evolving, with new foci of transmission reported across Europe and in the UK. As such, a better understanding of the symptomatology, diagnostics, treatment, and prevention of TBE is required to inform healthcare professionals going forward, which this review addresses in detail. To this end, the need for robust national surveillance data and randomised control trial data regarding the use of various antivirals (e.g., Galidesivir and 7-deaza-2'-CMA), monoclonal antibodies, and glucocorticoids is required to improve the management and outcomes of TBE.
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Affiliation(s)
- Dominic Adam Worku
- Infectious Diseases, Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea SA6 6NL, UK;
- Public Health Wales, 2 Capital Quarter, Cardiff CF10 4BZ, UK
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Chiffi G, Grandgirard D, Leib SL, Chrdle A, Růžek D. Tick-borne encephalitis: A comprehensive review of the epidemiology, virology, and clinical picture. Rev Med Virol 2023; 33:e2470. [PMID: 37392370 DOI: 10.1002/rmv.2470] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/31/2023] [Accepted: 06/12/2023] [Indexed: 07/03/2023]
Abstract
Tick-borne encephalitis virus (TBEV) is a flavivirus commonly found in at least 27 European and Asian countries. It is an emerging public health problem, with steadily increasing case numbers over recent decades. Tick-borne encephalitis virus affects between 10,000 and 15,000 patients annually. Infection occurs through the bite of an infected tick and, much less commonly, through infected milk consumption or aerosols. The TBEV genome comprises a positive-sense single-stranded RNA molecule of ∼11 kilobases. The open reading frame is > 10,000 bases long, flanked by untranslated regions (UTR), and encodes a polyprotein that is co- and post-transcriptionally processed into three structural and seven non-structural proteins. Tick-borne encephalitis virus infection results in encephalitis, often with a characteristic biphasic disease course. After a short incubation time, the viraemic phase is characterised by non-specific influenza-like symptoms. After an asymptomatic period of 2-7 days, more than half of patients show progression to a neurological phase, usually characterised by central and, rarely, peripheral nervous system symptoms. Mortality is low-around 1% of confirmed cases, depending on the viral subtype. After acute tick-borne encephalitis (TBE), a minority of patients experience long-term neurological deficits. Additionally, 40%-50% of patients develop a post-encephalitic syndrome, which significantly impairs daily activities and quality of life. Although TBEV has been described for several decades, no specific treatment exists. Much remains unknown regarding the objective assessment of long-lasting sequelae. Additional research is needed to better understand, prevent, and treat TBE. In this review, we aim to provide a comprehensive overview of the epidemiology, virology, and clinical picture of TBE.
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Affiliation(s)
- Gabriele Chiffi
- Department for BioMedical Research, University of Bern, Bern, Switzerland
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Denis Grandgirard
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Stephen L Leib
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Aleš Chrdle
- Department of Infectious Diseases, Hospital Ceske Budejovice, Ceske Budejovice, Czech Republic
- Faculty of Health and Social Sciences, University of South Bohemia, Ceske Budejovice, Czech Republic
- Royal Liverpool University Hospital, Liverpool, UK
| | - Daniel Růžek
- Veterinary Research Institute, Emerging Viral Diseases, Brno, Czech Republic
- Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic
- Institute of Parasitology, Biology Centre of the Czech Academy of Sciences, Ceske Budejovice, Czech Republic
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Chotiwan N, Rosendal E, Willekens SMA, Schexnaydre E, Nilsson E, Lindqvist R, Hahn M, Mihai IS, Morini F, Zhang J, Ebel GD, Carlson LA, Henriksson J, Ahlgren U, Marcellino D, Överby AK. Type I interferon shapes brain distribution and tropism of tick-borne flavivirus. Nat Commun 2023; 14:2007. [PMID: 37037810 PMCID: PMC10086010 DOI: 10.1038/s41467-023-37698-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 03/28/2023] [Indexed: 04/12/2023] Open
Abstract
Viral tropism within the brain and the role(s) of vertebrate immune response to neurotropic flaviviruses infection is largely understudied. We combine multimodal imaging (cm-nm scale) with single nuclei RNA-sequencing to study Langat virus in wildtype and interferon alpha/beta receptor knockout (Ifnar-/-) mice to visualize viral pathogenesis and define molecular mechanisms. Whole brain viral infection is imaged by Optical Projection Tomography coregistered to ex vivo MRI. Infection is limited to grey matter of sensory systems in wildtype mice, but extends into white matter, meninges and choroid plexus in Ifnar-/- mice. Cells in wildtype display strong type I and II IFN responses, likely due to Ifnb expressing astrocytes, infiltration of macrophages and Ifng-expressing CD8+ NK cells, whereas in Ifnar-/-, the absence of this response contributes to a shift in cellular tropism towards non-activated resident microglia. Multimodal imaging-transcriptomics exemplifies a powerful way to characterize mechanisms of viral pathogenesis and tropism.
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Affiliation(s)
- Nunya Chotiwan
- Department of Clinical Microbiology, Umeå University, 90185, Umeå, Sweden.
- The Laboratory for Molecular Infection Medicine Sweden (MIMS), Umeå University, 90187, Umeå, Sweden.
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, 10540, Thailand.
| | - Ebba Rosendal
- Department of Clinical Microbiology, Umeå University, 90185, Umeå, Sweden
- The Laboratory for Molecular Infection Medicine Sweden (MIMS), Umeå University, 90187, Umeå, Sweden
| | - Stefanie M A Willekens
- Department of Clinical Microbiology, Umeå University, 90185, Umeå, Sweden
- The Laboratory for Molecular Infection Medicine Sweden (MIMS), Umeå University, 90187, Umeå, Sweden
- Umeå Centre for Molecular Medicine (UCMM), Umeå University, 90187, Umeå, Sweden
| | - Erin Schexnaydre
- Department of Clinical Microbiology, Umeå University, 90185, Umeå, Sweden
- The Laboratory for Molecular Infection Medicine Sweden (MIMS), Umeå University, 90187, Umeå, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, 90187, Umeå, Sweden
- Department of Medical Biochemistry and Biophysics, Umeå University, 90187, Umeå, Sweden
- Umeå Centre for Microbial Research, Umeå University, 90187, Umeå, Sweden
| | - Emma Nilsson
- Department of Clinical Microbiology, Umeå University, 90185, Umeå, Sweden
- The Laboratory for Molecular Infection Medicine Sweden (MIMS), Umeå University, 90187, Umeå, Sweden
| | - Richard Lindqvist
- Department of Clinical Microbiology, Umeå University, 90185, Umeå, Sweden
- The Laboratory for Molecular Infection Medicine Sweden (MIMS), Umeå University, 90187, Umeå, Sweden
| | - Max Hahn
- Umeå Centre for Molecular Medicine (UCMM), Umeå University, 90187, Umeå, Sweden
| | - Ionut Sebastian Mihai
- The Laboratory for Molecular Infection Medicine Sweden (MIMS), Umeå University, 90187, Umeå, Sweden
- Department of Department of Molecular biology, Umeå University, 90187, Umeå, Sweden
- Företagsforskarskolan, Umeå University, 90187, Umeå, Sweden
| | - Federico Morini
- Umeå Centre for Molecular Medicine (UCMM), Umeå University, 90187, Umeå, Sweden
| | - Jianguo Zhang
- Department of Clinical Microbiology, Umeå University, 90185, Umeå, Sweden
- The Laboratory for Molecular Infection Medicine Sweden (MIMS), Umeå University, 90187, Umeå, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, 90187, Umeå, Sweden
- Department of Medical Biochemistry and Biophysics, Umeå University, 90187, Umeå, Sweden
- Umeå Centre for Microbial Research, Umeå University, 90187, Umeå, Sweden
| | - Gregory D Ebel
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO, USA
| | - Lars-Anders Carlson
- The Laboratory for Molecular Infection Medicine Sweden (MIMS), Umeå University, 90187, Umeå, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, 90187, Umeå, Sweden
- Department of Medical Biochemistry and Biophysics, Umeå University, 90187, Umeå, Sweden
- Umeå Centre for Microbial Research, Umeå University, 90187, Umeå, Sweden
| | - Johan Henriksson
- The Laboratory for Molecular Infection Medicine Sweden (MIMS), Umeå University, 90187, Umeå, Sweden
- Umeå Centre for Microbial Research, Umeå University, 90187, Umeå, Sweden
- Department of Department of Molecular biology, Umeå University, 90187, Umeå, Sweden
| | - Ulf Ahlgren
- Umeå Centre for Molecular Medicine (UCMM), Umeå University, 90187, Umeå, Sweden
| | - Daniel Marcellino
- Department of Integrative Medical Biology, Umeå University, 90187, Umeå, Sweden
| | - Anna K Överby
- Department of Clinical Microbiology, Umeå University, 90185, Umeå, Sweden.
- The Laboratory for Molecular Infection Medicine Sweden (MIMS), Umeå University, 90187, Umeå, Sweden.
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Ibatullin R, Magzhanov R, Usmanov I. Thalamic lesion in tick-borne encephalitis. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:154-158. [DOI: 10.17116/jnevro2022122081154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Radzišauskienė D, Urbonienė J, Kaubrys G, Andruškevičius S, Jatužis D, Matulytė E, Žvirblytė-Skrebutienė K. The epidemiology, clinical presentation, and predictors of severe Tick-borne encephalitis in Lithuania, a highly endemic country: A retrospective study of 1040 patients. PLoS One 2020; 15:e0241587. [PMID: 33211708 PMCID: PMC7676731 DOI: 10.1371/journal.pone.0241587] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 10/17/2020] [Indexed: 12/11/2022] Open
Abstract
Introduction In recent decades, the incidence of Tick-borne encephalitis (TBE) has been increasing and posing a growing health problem because of the high costs to the healthcare system and society. The clinical manifestations are well studied but there is a lack of research analyzing the severity of the disease. Objective The aim of this study was to analyze the epidemiology and clinical presentation of severe TBE, to identify the predictors for a severe disease course, and also predictors for meningoencephalomyelitic and severe meningoencephalitic/encephalitic forms. Methods A retrospective study was conducted in the Center of Infectious Diseases and the Center of Neurology at Vilnius University Hospital Santaros Klinikos in the years 2005–2017 to describe the clinical and epidemiological features of TBE in adults. Results 1040 patients were included in the study. A total of 152/1040 (14.6%) patients had a severe course. The highest proportion of severe cases, reaching 41.2%, was reported in the 70–79 year-old age group. A total of 36/152 (23.7%) severe patients presented meningoencephalomyelitis. Myelitic patients were older, were frequently infected in their living areas, and usually reported a monophasic disease course compared with severe meningoencephalitic/encephalitic patients. Severe meningoencephalitic/encephalitic patients, compared with non-severe meningoencephalitic/encephalitic, were older, less often noticed the tick bite, and often had a monophasic course. The sequelae on discharge were observed in 810/1000 (81%) of patients. Conclusions The prognostic factors associated with a severe disease course and severe meningoencephalitic form are: older age, comorbidities, a monophasic course, a fever of 40˚C and above, CRP more than 30 mg/l, CSF protein more than 1 g/l, delayed immune response of TBEV IgG, pathological findings in CT. Age above 60 years, presence of CNS disease, bulbar syndrome, pleocytosis 500x106/l and above, and delayed immune response of TBEV IgG are predictors of the most severe myelitic form.
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Affiliation(s)
- Daiva Radzišauskienė
- Clinic of Infectious Diseases and Dermatovenerology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- * E-mail:
| | - Jurgita Urbonienė
- Center of Infectious Diseases, Vilnius University, Vilnius, Lithuania
| | - Gintaras Kaubrys
- Clinic of Neurology and Neurosurgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Saulius Andruškevičius
- Clinic of Neurology and Neurosurgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Dalius Jatužis
- Clinic of Neurology and Neurosurgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Elžbieta Matulytė
- Clinic of Infectious Diseases and Dermatovenerology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Karolina Žvirblytė-Skrebutienė
- Clinic of Infectious Diseases and Dermatovenerology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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Finck T, Liesche-Starnecker F, Probst M, Bette S, Ruf V, Wendl C, Dorn F, Angstwurm K, Schlegel J, Zimmer C, Wiestler B, Wiesinger I. Bornavirus Encephalitis Shows a Characteristic Magnetic Resonance Phenotype in Humans. Ann Neurol 2020; 88:723-735. [PMID: 32794235 DOI: 10.1002/ana.25873] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/05/2020] [Accepted: 08/07/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The number of diagnosed fatal encephalitis cases in humans caused by the classical Borna disease virus (BoDV-1) has been increasing, ever since it was proved that BoDV-1 can cause human infections. However, awareness of this entity is low, and a specific imaging pattern has not yet been identified. We therefore provide the first comprehensive description of the morphology of human BoDV-1 encephalitis, with histopathological verification of imaging abnormalities. METHODS In an institutional review board-approved multicenter study, we carried out a retrospective analysis of 55 magnetic resonance imaging (MRI) examinations of 19 patients with confirmed BoDV-1 encephalitis. Fifty brain regions were analyzed systematically (T1w, T2w, T2*w, T1w + Gd, and DWI), in order to discern a specific pattern of inflammation. Histopathological analysis of 25 locations in one patient served as correlation for MRI abnormalities. RESULTS Baseline imaging, acquired at a mean of 11 ± 10 days after symptom onset, in addition to follow-up scans of 16 patients, revealed characteristic T2 hyperintensities with a predilection for the head of the caudate nucleus, insula, and cortical spread to the limbic system, whereas the occipital lobes and cerebellar hemispheres were unaffected. This gradient was confirmed by histology. Nine patients (47.4%) developed T1 hyperintensities of the basal ganglia, corresponding to accumulated lipid phagocytes on histology and typical for late-stage necrosis. INTERPRETATION BoDV-1 encephalitis shows a distinct pattern of inflammation in both the early and late stages of the disease. Its appearance can mimic sporadic Creutzfeldt-Jakob disease on MRI and should be considered a differential diagnosis in the case of atypical clinical presentation. ANN NEUROL 2020;88:723-735.
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Affiliation(s)
- Tom Finck
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | | | - Monika Probst
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Stefanie Bette
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Augsburg University Hospital, Augsburg, Germany
| | - Viktoria Ruf
- Center for Neuropathology and Prion Research, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Christina Wendl
- Department of Radiology, Center of Neuroradiology, University Hospital Regensburg, Regensburg, Germany
| | - Franziska Dorn
- Department of Diagnostic and Interventional Neuroradiology, Ludwig- Maximilians-Universität München, Munich, Germany
| | - Klemens Angstwurm
- Department of Neurology, Regensburg University Hospital, Regensburg, Germany
| | - Jürgen Schlegel
- Department of Neuropathology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Benedikt Wiestler
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Isabel Wiesinger
- Department of Radiology, Center of Neuroradiology, University Hospital Regensburg, Regensburg, Germany
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Wagner JN, Sonnberger M, Troescher A, Krehan I, Hauser A, Panholzer J, von Oertzen TJ. Patients with breakthrough tick-borne encephalitis suffer a more severe clinical course and display extensive magnetic resonance imaging changes. Eur J Neurol 2020; 27:1201-1209. [PMID: 32324925 PMCID: PMC7383477 DOI: 10.1111/ene.14276] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 04/17/2020] [Accepted: 04/18/2020] [Indexed: 12/25/2022]
Abstract
Background and purpose Tick‐borne encephalitis (TBE) is a common viral disease in central Europe and Asia. Severe or even lethal neurological symptoms may ensue. With limited therapeutic options, active vaccination against the TBE virus (TBEV) is strongly recommended in endemic areas. A systematic analysis of the clinical picture and cerebral imaging findings associated with TBE was conducted with particular focus on patients who acquired TBE despite previous vaccination. Methods A cohort of 52 patients with serologically proven TBE treated at our centre in a 10‐year period who received at least one cerebral magnetic resonance imaging (MRI) was retrospectively described. Extension of MRI changes was systematically assessed by an experienced neuroradiologist. Standard statistical procedures were performed. Results Fifty‐two patients with a definite serological diagnosis of TBE were included. The most common presentation was encephalitis (67%). MRI showed TBE‐associated parenchymal lesions in 33% of all patients. Sites of predilection included the periaqueductal grey, the thalamus and the brainstem. Ten patients had received at least one prior active or passive TBEV immunization. All of these had a maximal Rankin Scale score of at least 4. The median number of affected anatomical regions on MRI was significantly higher than in the non‐vaccinated cohort. Conclusions To our knowledge, this is the first study systematically describing the peculiarities of MRI in patients vaccinated against TBE. In addition to a severe clinical course, they exhibit more extensive MRI lesions than a non‐vaccinated cohort. Possible reasons for these findings include incomplete seroconversion, more virulent TBEV strains or antibody‐dependent enhancement.
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Affiliation(s)
- J N Wagner
- Department of Neurology 1, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
| | - M Sonnberger
- Department of Neuroradiology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
| | - A Troescher
- Department of Neurology 1, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
| | - I Krehan
- Department of Neurology 2, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
| | - A Hauser
- Department of Neurology 1, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
| | - J Panholzer
- Department of Neurology 1, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
| | - T J von Oertzen
- Department of Neurology 1, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
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Feige J, Moser T, Hauer L, Pikija S, Sellner J. Clinical Challenges in a 49-Year-Old Patient with Severe Tick-Borne Myeloradiculitis Despite Complete Active Vaccination. Vaccines (Basel) 2020; 8:vaccines8010093. [PMID: 32093148 PMCID: PMC7157544 DOI: 10.3390/vaccines8010093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 02/13/2020] [Accepted: 02/17/2020] [Indexed: 12/15/2022] Open
Abstract
Vaccination is an effective means to prevent infectious diseases including tick-borne encephalitis (TBE), an emerging Flavivirus infection. There is, however, only limited knowledge about risk of vaccination failure, the disease course and the challenges for work-up and care. Of note, there is evidence that patients with breakthrough disease experience a more severe disease course. We report the case of a previously healthy 49-year-old woman who developed severe myeloradiculitis caused by the TBE virus despite receiving a complete cycle of primary immunization and booster vaccinations within the recommended timeframe. The disease course was characterized by progressive tetraparesis, pain and bladder dysfunction and necessitated intensive care unit admission (ICU) and the escalation of pain management. This case raises awareness for the recognition of breakthrough disease in younger patients and reinforces the need to develop measures to identify patients with insufficient protection.
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Affiliation(s)
- Julia Feige
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria; (J.F.); (T.M.); (S.P.)
| | - Tobias Moser
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria; (J.F.); (T.M.); (S.P.)
| | - Larissa Hauer
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria;
| | - Slaven Pikija
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria; (J.F.); (T.M.); (S.P.)
| | - Johann Sellner
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria; (J.F.); (T.M.); (S.P.)
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, 81675 München, Germany
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, 2130 Mistelbach, Austria
- Correspondence: ; Tel.: +43-2572-9004-12850
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11
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Lee MY, Jung JY. A Case of Contrast Enhanced Cystic Mass of External Ear Canal Diagnosed as Engorged Hard Tick. J Audiol Otol 2018; 22:167-169. [PMID: 29719948 PMCID: PMC6103489 DOI: 10.7874/jao.2017.00388] [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: 12/28/2017] [Accepted: 02/27/2018] [Indexed: 11/22/2022] Open
Abstract
A 58-year-old female complained earfullness and otalgia and came to the clinic. Dark gray colored cystic mass obstructing the left ear canal was observed during the endoscopic exam. Contrast enhanced CT image showed an oval shape soft tissue lesion in the mid part of the external auditory canal with a homogenous increased contrast uptake. The mass was removed under microscopic view at outpatient clinic. While dissecting the mass in the ear canal, a pod like structure was visualized. The external organism was densely adherent to the skin and turned out to be an engorged hard tick. Considering the final diagnosis, contrast uptake observed in the CT scan implicates the patient communication of blood between host and parasite. This unique image finding differs from a benign mass lesion in the ear canal was one of the differential diagnosis points for the lesion. This article is reporting the case of tick bite in the ear canal with a rare CT scan finding.
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Affiliation(s)
- Min Young Lee
- Department of Otorhinolaryngology-Head & Neck Surgery, Dankook University Hospital, Cheonan, Korea
| | - Jae Yun Jung
- Department of Otorhinolaryngology-Head & Neck Surgery, Dankook University Hospital, Cheonan, Korea
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12
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Du Four S, Mertens R, Wiels W, De Keyser J, Bissay V, Flamez A. Meningoencephaloradiculitis following infection with tick borne encephalitis virus: case report and review of the literature. Acta Neurol Belg 2018; 118:93-96. [PMID: 29313244 DOI: 10.1007/s13760-017-0873-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 12/07/2017] [Indexed: 12/30/2022]
Abstract
Tick borne encephalitis (TBE) is an infectious zoonotic disease caused by an RNA virus that is endemic to Central and Eastern Europe, Russia, and large parts of Asia. The tick borne encephalitis virus (TBEV) is transmitted through the saliva of infected ticks and infected goat milk. In the vast majority of cases, an infection with TBEV has a subclinical course. However, in some cases, it leads to neurological symptoms due to meningitis, meningoencephalitis, meningoencephalomyelitis, or meningoencephaloradiculitis. Here, we present the first case of meningoencephaloradiculitis in Belgium.
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Affiliation(s)
- Stephanie Du Four
- Department of Neurosurgery, UZ Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Rembert Mertens
- Department of Infectious Diseases and Internal Medicine, UZ Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Wietse Wiels
- Department of Neurology, UZ Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Jacques De Keyser
- Department of Neurology, UZ Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Veronique Bissay
- Department of Neurology, UZ Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Anja Flamez
- Department of Neurology, UZ Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
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13
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Kunze U. Report of the 19th Annual Meeting of the International Scientific Working Group on Tick-Borne Encephalitis (ISW-TBE) – TBE in a changing world. Ticks Tick Borne Dis 2018; 9:146-150. [DOI: 10.1016/j.ttbdis.2017.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 08/21/2017] [Accepted: 08/21/2017] [Indexed: 01/13/2023]
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14
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Nardone R, Versace V, Brigo F, Tezzon F, Zuccoli G, Pikija S, Hauer L, Sellner J. Herpes Simplex Virus Type 2 Myelitis: Case Report and Review of the Literature. Front Neurol 2017; 8:199. [PMID: 28539913 PMCID: PMC5423910 DOI: 10.3389/fneur.2017.00199] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 04/24/2017] [Indexed: 12/21/2022] Open
Abstract
Non-traumatic myelopathies can result from a wide spectrum of conditions including inflammatory, ischemic, and metabolic disorders. Here, we describe the case of a 60-year old immunocompetent woman who developed acute back pain followed by rapidly ascending flaccid tetraparesis, a C6 sensory level, and sphincter dysfunction within 8 h. Acyclovir and steroids were started on day 2 and herpes simplex virus type 2 (HSV-2) was confirmed by polymerase chain reaction in cerebrospinal fluid. Magnetic resonance imaging revealed a bilateral anterior horn tractopathy expanding from C2 to T2 and cervicothoracic cord swelling. Screening for paraneoplastic antibodies and cancer was negative. Neurophysiology aided in the work-up by corroborating root involvement. Recovery was poor despite early initiation of antiviral treatment, adjuvant anti-inflammatory therapy, and neurorehabilitation efforts. The clinical course, bilateral affection of the anterior horns, and early focal atrophy on follow-up magnetic resonance imaging take a necrotizing myelitis potentially caused by intraneuronal spread of the virus into consideration. Further, we summarize the literature on classical and rare presentations of HSV-2 myeloradiculitis in non-immunocompromised patients and raise awareness for the limited treatment options for a condition with frequent devastating outcome.
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Affiliation(s)
- Raffaele Nardone
- Department of Neurology, Franz Tappeiner Hospital, Merano, Italy.,Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Viviana Versace
- Department of Neurorehabilitation Ospedale di Vipiteno and Research Department for Neurorehabilitation South Tyrol, Bolzano, Italy
| | - Francesco Brigo
- Department of Neuroscience, Biomedicine and Movement, Section of Clinical Neurology, University of Verona, Verona, Italy
| | - Frediano Tezzon
- Department of Neurology, Franz Tappeiner Hospital, Merano, Italy
| | - Giulio Zuccoli
- Section of Neuroradiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Slaven Pikija
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Larissa Hauer
- Department of Psychiatry and Psychotherapy, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Johann Sellner
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria.,Department of Neurology, Klinikum rechts der Isar, Technische Universität München, München, Germany
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