A sudden death due to acute necrotizing encephalopathy associated with influenza A virus infection: An autopsy case report

Predictive value of the serum procalcitonin level for fulminant virus-associated encephalopathy

BACKGROUND

Fulminant virus-associated encephalopathy (VAE) is a rare complication of viral infection that presents as acute brain dysfunction and requires respiratory support and/or vasoactive agents. However, the mechanism of VAE is undetermined. The mortality rate is high since there is no specific treatment for fulminant VAE. The aim of this study was to identify risk factors for children with fulminant VAE on the basis of clinical data since timely recognition and treatment might be needed to improve the poor prognosis.

METHODS

This retrospective study included children with fulminant VAE who were diagnosed between June 2018 and October 2023 in the PICU of Guangdong Women and Children Hospital. Clinical data were analyzed, and receiver operating characteristic (ROC) curve analysis was performed to determine the prognostic value of the selected variables.

RESULTS

Twenty-three children with fulminant VAE were included and divided into a survival group (n = 16) and a nonsurvival group (n = 7). The mortality rate of patients with fulminant VAE was 30.8%. Compared with the survival group, the nonsurvival group had higher incidences of shock 48 h after onset, a higher acute necrotizing encephalopathy severity score (ANE-SS), higher procalcitonin (PCT) levels, and lower platelet counts (p < 0.05). The serum PCT level was significantly higher in the children with shock than in those without shock (p = 0.015). The serum PCT concentration was positively correlated with the ANE-SS (correlation coefficient 0.544, p < 0.039). Combined immunotherapies might help to decrease PCT levels in some children. Low PCT levels might be related to a good outcome. The area under the curve (AUC) for PCT used to predict death in patients with fulminant VAEs was 0.821 (95% CI 0.626-1.00). The sensitivity and specificity of PCT > 101.58 ng/ml for predicting death in patients with fulminant VAE were 57.1% and 100.0%, respectively.

CONCLUSIONS

Patients with fulminant VAE deteriorate rapidly and are at high risk of death if they develop shock within 48 h after onset, exhibit extremely elevated serum PCT levels, or have decreased platelet counts. The serum PCT level might predict the death outcome of patients with fulminant VAE.

Viral entry and translation in brain endothelia provoke influenza-associated encephalopathy

Influenza-associated encephalopathy (IAE) is extremely acute in onset, with high lethality and morbidity within a few days, while the direct pathogenesis by influenza virus in this acute phase in the brain is largely unknown. Here we show that influenza virus enters into the cerebral endothelium and thereby induces IAE. Three-weeks-old young mice were inoculated with influenza A virus (IAV). Physical and neurological scores were recorded and temporal-spatial analyses of histopathology and viral studies were performed up to 72 h post inoculation. Histopathological examinations were also performed using IAE human autopsy brains. Viral infection, proliferation and pathogenesis were analyzed in cell lines of endothelium and astrocyte. The effects of anti-influenza viral drugs were tested in the cell lines and animal models. Upon intravenous inoculation of IAV in mice, the mice developed encephalopathy with brain edema and pathological lesions represented by micro bleeding and injured astrocytic process (clasmatodendrosis) within 72 h. Histologically, massive deposits of viral nucleoprotein were observed as early as 24 h post infection in the brain endothelial cells of mouse models and the IAE patients. IAV inoculated endothelial cell lines showed deposition of viral proteins and provoked cell death, while IAV scarcely amplified. Inhibition of viral transcription and translation suppressed the endothelial cell death and the lethality of mouse models. These data suggest that the onset of encephalopathy should be induced by cerebral endothelial infection with IAV. Thus, IAV entry into the endothelium, and transcription and/or translation of viral RNA, but not viral proliferation, should be the key pathogenesis of IAE.

The Role of Protein Degradation in Estimation Postmortem Interval and Confirmation of Cause of Death in Forensic Pathology: A Literature Review

It is well known that proteins are important bio-macromolecules in human organisms, and numerous proteins are widely used in the clinical practice, whereas their application in forensic science is currently limited. This limitation is mainly attributed to the postmortem degradation of targeted proteins, which can significantly impact final conclusions. In the last decade, numerous methods have been established to detect the protein from a forensic perspective, and some of the postmortem proteins have been applied in forensic practice. To better understand the emerging issues and challenges in postmortem proteins, we have reviewed the current application of protein technologies at postmortem in forensic practice. Meanwhile, we discuss the application of proteins in identifying the cause of death, and postmortem interval (PMI). Finally, we highlight the interpretability and limitations of postmortem protein challenges. We believe that utilizing the multi-omics method can enhance the comprehensiveness of applying proteins in forensic practice.

Risk factors for death associated with severe influenza in children and the impact of the COVID-19 pandemic on clinical characteristics

Background

To summarize the clinical features of severe influenza in children and the high-risk factors for influenza-related deaths and to raise awareness among pediatricians.

Methods

A retrospective study of clinical manifestations, laboratory tests, and diagnosis and treatment of 243 children with severe influenza admitted to Shenzhen Children's Hospital from January 2009 to December 2022 was conducted. Univariate logistic regression analysis and Boruta analysis were also performed to identify potentially critical clinical characteristics associated with death, and clinically significant were used in further multivariate logistic regression analysis. Subject receiver operating characteristic (ROC) curves were applied to assess the efficacy of death-related independent risk factors to predict death from severe influenza.

Results

There were 169 male and 74 female patients with severe influenza, with a median age of 3 years and 2 months and 77.4% of patients under six. There were 46 cases (18.9%) in the death group. The most common pathogen was Influenza A virus (IAV) (81.5%). The most common complication in the death group was influenza-associated acute necrotizing encephalopathy (ANE [52.2%]). Severe influenza in children decreased significantly during the COVID-19 pandemic, with a median age of 5 years, a high predominance of neurological symptoms such as ANE (P = 0.001), and the most common pathogen being H3N2 (P < 0.001). D-dimer, acute respiratory distress syndrome (ARDS), and acute necrotizing encephalopathy (ANE) were significant independent risk factors for severe influenza-associated death. Furthermore, the ROC curves showed that the combined diagnosis of independent risk factors had significant early diagnostic value for severe influenza-related deaths.

Conclusion

Neurological disorders such as ANE are more significant in children with severe influenza after the COVID-19 pandemic. Influenza virus infection can cause serious multisystem complications such as ARDS and ANE, and D-dimer has predictive value for early diagnosis and determination of the prognosis of children with severe influenza.

Biallelic variants in ribonuclease inhibitor (RNH1), an inflammasome modulator, are associated with a distinctive subtype of acute, necrotizing encephalopathy

PURPOSE

Mendelian etiologies for acute encephalopathies in previously healthy children are poorly understood, with the exception of RAN binding protein 2 (RANBP2)-associated acute necrotizing encephalopathy subtype 1 (ANE1). We provide clinical, genetic, and neuroradiological evidence that biallelic variants in ribonuclease inhibitor (RNH1) confer susceptibility to a distinctive ANE subtype.

METHODS

This study aimed to evaluate clinical data, neuroradiological studies, genomic sequencing, and protein immunoblotting results in 8 children from 4 families who experienced acute febrile encephalopathy.

RESULTS

All 8 healthy children became acutely encephalopathic during a viral/febrile illness and received a variety of immune modulation treatments. Long-term outcomes varied from death to severe neurologic deficits to normal outcomes. The neuroradiological findings overlapped with ANE but had distinguishing features. All affected children had biallelic predicted damaging variants in RNH1: a subset that was studied had undetectable RNH1 protein. Incomplete penetrance of the RNH1 variants was evident in 1 family.

CONCLUSION

Biallelic variants in RNH1 confer susceptibility to a subtype of ANE (ANE2) in previously healthy children. Intensive immunological treatments may alter outcomes. Genomic sequencing in children with unexplained acute febrile encephalopathy can detect underlying genetic etiologies, such as RNH1, and improve outcomes in the probands and at-risk siblings.