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Peternell A, Lechner C, Breu M, Preisel M, Schimmel M, Eisenkölbl A, Zobel J, Wendel EM, Reindl M, Rostásy K, Baumann M. Blood parameters in pediatric myelin oligodendrocyte glycoprotein antibody-associated disorders. Eur J Paediatr Neurol 2024; 50:86-95. [PMID: 38705015 DOI: 10.1016/j.ejpn.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 04/16/2024] [Accepted: 04/23/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND AND OBJECTIVES Patients with myelin oligodendrocyte glycoprotein antibody-associated disorders (MOGAD) clinically present e.g. with acute disseminated encephalomyelitis (ADEM), optic neuritis (ON), transverse myelitis (TM) or aquaporin-4-IgG (AQP4-IgG) negative neuromyelitis optica spectrum disorders (NMOSD)-like phenotypes. We aimed to analyze and compare blood parameters in children with MOGAD, AQP4-IgG-positive NMOSD (hence NMOSD), multiple sclerosis (MS) and healthy controls (HC). METHODS We evaluated differences in complete blood counts (CBC), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR) and C-reactive protein (CRP) between these four groups and within the groups between clinical attack, acute treatment and remission. RESULTS Our cohort consisted of 174 children and adolescents with a total of 550 timepoints: 66 patients had MOGAD (202 timepoints), 11 NMOSD (76 timepoints), 58 MS (219 timepoints) and 39 were HC (53 timepoints). At clinical attack, leukocyte counts were elevated in MOGAD compared to remission (p < 0.001) and compared to all other groups (p < 0.001). NLR was high in MOGAD and NMOSD, and PLR was high in NMOSD, however, after correction for multiple testing these findings did not remain significant. While glucocorticoids caused an increase of leukocyte counts and NLR in NMOSD and MS, these values remained stable during acute treatment in MOGAD. In remission, NLR normalized in MOGAD, while it stayed high in NMOSD. PLR increased in NMOSD and was significantly higher compared to all other groups. DISCUSSION Some blood parameters, mainly leukocyte and differential counts, might help clinicians to evaluate disease activity, differentiate relapses from pseudo-relapses and even distinguish between different disease entities.
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Affiliation(s)
- Alina Peternell
- Division of Pediatric Neurology, Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Lechner
- Division of Pediatric Neurology, Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Markus Breu
- Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Martin Preisel
- Department of Pediatric Neurology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Mareike Schimmel
- Division of Pediatric Neurology, Children's Hospital, Medical University of Augsburg, Augsburg, Germany
| | - Astrid Eisenkölbl
- Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Kepler University Hospital, Linz, Austria
| | - Joachim Zobel
- Division of Pediatric Neurology, Department of Pediatrics, Medical University of Graz, Graz, Austria
| | - Eva-Maria Wendel
- Department of Pediatric Neurology, Olgahospital Stuttgart, Stuttgart, Germany
| | - Markus Reindl
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Kevin Rostásy
- Department of Pediatric Neurology, Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany
| | - Matthias Baumann
- Division of Pediatric Neurology, Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria.
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Tamanini JVG, Sabino JV, Cordeiro RA, Mizubuti V, Villarinho LDL, Duarte JÁ, Pereira FV, Appenzeller S, Damasceno A, Reis F. The Role of MRI in Differentiating Demyelinating and Inflammatory (not Infectious) Myelopathies. Semin Ultrasound CT MR 2023; 44:469-488. [PMID: 37555683 DOI: 10.1053/j.sult.2023.03.017] [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: 04/09/2023]
Abstract
Demyelinating and inflammatory myelopathies represent a group of diseases with characteristic patterns in neuroimaging and several differential diagnoses. The main imaging patterns of demyelinating myelopathies (multiple sclerosis, neuromyelitis optica spectrum disorder, acute disseminated encephalomyelitis, and myelin oligodendrocyte glycoprotein antibody-related disorder) and inflammatory myelopathies (systemic lupus erythematosus-myelitis, sarcoidosis-myelitis, Sjögren-myelitis, and Behçet's-myelitis) will be discussed in this article, highlighting key points to the differential diagnosis.
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Affiliation(s)
| | - João Vitor Sabino
- Department of Anesthesiology, Oncology and Radiology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Rafael Alves Cordeiro
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Sao Paulo University, SP, Brazil
| | - Vanessa Mizubuti
- Department of Anesthesiology, Oncology and Radiology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | | | - Juliana Ávila Duarte
- Department of Radiology and Diagnostic Imaging, HCPA, Porto Alegre, Rio Grande do Sul, Brazil
| | - Fernanda Veloso Pereira
- Department of Anesthesiology, Oncology and Radiology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Simone Appenzeller
- Department of Orthopedics, Rheumatology and Traumatology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Alfredo Damasceno
- Department of Neurology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Fabiano Reis
- Department of Anesthesiology, Oncology and Radiology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil.
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Prajjwal P, M.D.M. M, Natarajan B, Inban P, Gadam S, Sowndarya D, John J, Abbas R, Vaja H, A.D.M. M, Amir Hussin O. Juvenile multiple sclerosis: addressing epidemiology, diagnosis, therapeutic, and prognostic updates along with cognitive dysfunction and quality of life. Ann Med Surg (Lond) 2023; 85:4433-4441. [PMID: 37663711 PMCID: PMC10473341 DOI: 10.1097/ms9.0000000000000930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 05/19/2023] [Indexed: 09/05/2023] Open
Abstract
Juvenile multiple sclerosis (JMS) is a rare but significant subtype of multiple sclerosis (MS) that affects a small percentage of patients under the age of 10 and 3-5% of all MS patients. Despite its rarity, JMS poses unique challenges in terms of diagnosis, treatment, and management, as it can significantly impact a child or adolescent's physical, cognitive, and emotional development. JMS presents with a varying spectrum of signs and symptoms such as coordination difficulties and permanent cognitive dysfunctions and may include atypical clinical features such as seizures, acute disseminated encephalomyelitis, and optic neuritis, making diagnostic evaluations challenging. Whilst the biology of JMS shares similarities with adult-onset MS, there exist notable distinctions in disease progression, clinical manifestations, and ultimate prognoses. The International Pediatric MS Study Group (IPMSSG) was founded in 2005 to improve understanding of JMS, but there remains a lack of knowledge and guidelines on the management of this condition. This review summarizes the current knowledge on JMS, including its epidemiology, clinical presentations, diagnostic challenges, current treatment options, and outcomes. Current treatment options for JMS include disease-modifying therapies, but JMS can also result in impaired quality of life and psychiatric comorbidity, highlighting the need for comprehensive care for affected children. Through gathering and analyzing scattered studies and recent updates on JMS, the authors aim to address the gaps in current knowledge on JMS and provide an improved understanding of appropriate care for affected children. By doing so, this review hopes to contribute to improving the quality of life and outcomes for JMS patients.
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Affiliation(s)
| | - Marsool M.D.M.
- University of Baghdad, Al-Kindy College of Medicine, Baghdad, Iraq
| | - Balaganesh Natarajan
- St. George’s University School of Medicine, University Centre Grenada, West Indies
| | - Pugazhendi Inban
- Internal Medicine, Government Medical College, Omandurar, Chennai
| | - Srikanth Gadam
- Internal Medicine, Postdoctoral Research Fellow, Mayo Clinic, USA
| | | | - Jobby John
- Somervell Memorial CSI Medical College and Hospital, Karakonam, Trivandrum
| | - Rahim Abbas
- Asfendiyarov Kazakh National Medical University, Almaty, Kazakhstan
| | - HariOm Vaja
- Internal Medicine, BJ Medical College, Ahmedabad, India
| | - Marsool A.D.M.
- University of Baghdad, Al-Kindy College of Medicine, Baghdad, Iraq
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Hwang J, Chae SA, Lim BC, Choi SA. Incidence of Pediatric Acute Disseminated Encephalomyelitis During the Coronavirus Disease 2019 Pandemic in South Korea. Pediatr Neurol 2023; 146:44-49. [PMID: 37429226 DOI: 10.1016/j.pediatrneurol.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 05/03/2023] [Accepted: 06/12/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Acute disseminated encephalomyelitis (ADEM) is an immune-mediated demyelinating disorder of the central nervous system that is usually triggered by infections. We aimed to determine the temporal trends in the incidence of ADEM before and during the pandemic and their correlation with viral epidemiology. METHODS We conducted a nationwide, population-based, retrospective, ADEM cohort study by using the Health Insurance Review and Assessment Service database. New-onset ADEM was defined as a patient (age <19 years) who was hospitalized with a diagnostic code of G04.0, G36.8, and G36.9 and a prescription of intravenous methylprednisolone. The National Infectious Disease Surveillance System was used to collect the nationwide viral epidemics. RESULTS A total of 185 new-onset pediatric ADEM cases were included. The mean patient age was 7.0 ± 4.9 years. The incidence of ADEM was 0.34 to 0.48 of 100,000 persons per year before the pandemic, which dropped to 0.22 of 100,000 persons per year during the first pandemic year. The risk of ADEM occurrence was approximately 1.74% higher during the prepandemic years compared with the first pandemic year (odds ratio = 1.017, P = 0.009). There was a weak positive correlation between acute respiratory viral infection and ADEM incidence (r = 0.28, P = 0.03). CONCLUSION This study demonstrates how infection control during the early coronavirus disease 2019 (COVID-19) pandemic influenced the incidence of ADEM. The low incidence of ADEM in the early COVID-19 pandemic may be related to the decline in acute respiratory viral infections, which are potential triggers of ADEM.
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Affiliation(s)
- Junho Hwang
- Department of Pediatrics, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Soo Ahn Chae
- Department of Pediatrics, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Byung Chan Lim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sun Ah Choi
- Department of Pediatrics, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Republic of Korea.
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Shen J, Lin D, Jiang T, Gao F, Jiang K. Clinical characteristics and associated factors of pediatric acute disseminated encephalomyelitis patients with MOG antibodies: a retrospective study in Hangzhou, China. BMC Neurol 2022; 22:418. [DOI: 10.1186/s12883-022-02963-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 11/03/2022] [Indexed: 11/11/2022] Open
Abstract
Abstract
Background
To explore the clinical characteristics and related factors of children with acute disseminated encephalomyelitis (ADEM) with positive anti-myelin oligodendrocyte glycoprotein (MOG) antibody.
Methods
A retrospective study was conducted and enrolled pediatric ADEM patients who underwent serum MOG antibody detection from May 2017 to August 2020. The patients were divided into two groups: MOG- immunoglobulin G (IgG) positive (n = 35) and MOG-IgG negative (n = 50). We analyzed the clinical characteristics of MOG-IgG-positive ADEM pediatric patients and conducted a comparative analysis between the two groups.
Results
Thirty-five patients (21 males and 14 females) in the MOG-IgG-positive group with encephalopathy, multifocal neurological symptoms, and typical magnetic resonance imaging (MRI) abnormalities were enrolled. They usually had a favorable outcome, while some suffered from relapse. Compared to the MOG-IgG-negative group, MOG-IgG-positive ADEM patients had a longer disease duration (median: 10 vs. 6 days), more meningeal involvement (31.4% vs. 8%) and frontal lobe involvement (82.8% vs. 68%), higher relapse rates (14.3% vs. 2%), lower serum tumor necrosis factor (1–12.4 pg/ml, median 1.7 vs. 1–34 pg/ml, median 2.2) and interferon-gamma (1–9.4 pg/ml, median 1.3 vs. 1–64 pg/ml, median 3) (P < 0.05, respectively). Multivariate logistic regression analysis showed that the longer disease duration, meningeal involvement and frontal lobe involvement were the correlated factors of patients with ADEM with MOG antibody (P < 0.05).
Conclusions
Our findings provide clinical evidence that MOG-IgG positivity is associated with longer disease duration, meningeal involvement, and frontal lobe involvement.
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Lim H, Hwang SK, Lee YJ, Kwon S. The Wide Variety of Acute Disseminated Encephalomyelitis in Children: A Clinical Perspective. ANNALS OF CHILD NEUROLOGY 2022. [DOI: 10.26815/acn.2022.00220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Acute disseminated encephalomyelitis (ADEM) is an acute demyelinating inflammatory disorder of the central nervous system. It is characterized by encephalopathy, multifocal neurological deficits, and typical magnetic resonance imaging findings of widespread demyelinating lesions, predominantly involving the white matter of the brain and spinal cord. ADEM mainly affects children and is commonly associated with preceding viral and bacterial infections, and, rarely, vaccinations. Despite substantial advances in the understanding of the association of myelin oligodendrocyte glycoprotein antibody with recurrent forms of ADEM or other demyelinating conditions, specific etiologic agents or biological markers have not been identified. Therefore, the diagnosis of ADEM is still based on clinical and radiological findings and the exclusion of other conditions mimicking ADEM. However, a prompt diagnosis and adequate treatment are crucial because diagnostic delays or inappropriate treatment may lead to unwanted neurological sequelae in some children. There is no standardized treatment protocol for ADEM, but the use of corticosteroids, intravenous immunoglobulin, and plasmapheresis has been associated with good clinical outcomes. Adequate treatment has reportedly resulted in favorable outcomes, with full or almost full recovery in most children with ADEM, although some children may develop neurological sequelae, such as cognitive impairment and motor deficits. Further studies are needed to identify biological clues and optimal treatment protocols to minimize the incidence of neurological sequelae.
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Kim SH, Chae SA. Promising candidate cerebrospinal fluid biomarkers of seizure disorder, infection, inflammation, tumor, and traumatic brain injury in pediatric patients. Clin Exp Pediatr 2022; 65:56-64. [PMID: 34425669 PMCID: PMC8841973 DOI: 10.3345/cep.2021.00241] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 07/11/2021] [Indexed: 11/27/2022] Open
Abstract
Cerebrospinal fluid (CSF) is a dynamic metabolically active body fluid that has many important roles and is commonly analyzed in pediatric patients, mainly to diagnose central nervous system infection and inflammation disorders. CSF components have been extensively evaluated as biomarkers of neurological disorders in adult patients. Circulating microRNAs in CSF are a promising class of biomarkers for various neurological diseases. Due to the complexity of pediatric neurological disorders and difficulty in acquiring CSF samples from pediatric patients, there are challenges in developing CSF biomarkers of pediatric neurological disorders. This review aimed to provide an overview of novel CSF biomarkers of seizure disorders, infection, inflammation, tumor, traumatic brain injuries, intraventricular hemorrhage, and congenital hydrocephalus exclusively observed in pediatric patients.
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Affiliation(s)
- Seh Hyun Kim
- Department of Pediatrics, Chung-Ang University Hospital, Seoul, Korea
| | - Soo Ahn Chae
- Department of Pediatrics, Chung-Ang University Hospital, Seoul, Korea.,College of Medicine, Chung-Ang University, Seoul, Korea
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Acute disseminated encephalomyelitis: A retrospective study of 20 children in a pediatrics department in Tunisia. Arch Pediatr 2021; 28:638-646. [PMID: 34690025 DOI: 10.1016/j.arcped.2021.09.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 08/03/2021] [Accepted: 09/26/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Acute disseminated encephalomyelitis (ADEM) is an inflammatory demyelinating disorder of the central nervous system. Little information is available about the clinical and neuroradiological profile or the follow-up of this disease in Tunisian children. AIM To determine the clinical, laboratory, and radiological features and the outcome of ADEM in children admitted to the pediatrics department of a university hospital in Tunisia. METHODS All children ≤ 18 years old presenting with ADEM and admitted to the tertiary referral center for pediatrics at Sahloul University Hospital from January 2000 to December 2020 were included in the study. The diagnosis of ADEM was confirmed according to the international pediatric multiple sclerosis study group criteria. RESULTS A total of 20 patients (13 girls and 7 boys) fulfilled the diagnostic criteria for ADEM. The mean age at diagnosis was 5.6 years. The clinical presentation included polyfocal neurological signs such as cranial hypertension (45%), seizures (35%), and motor weaknesses (55%). Pyramidal tract signs and cranial nerve palsies were noted in 55% of cases. Brain magnetic resonance imaging showed particular features, namely, a relapsing tumor-like form in one case, and optic neuritis and demyelinating lesions of the white matter in the brain and the spinal cord with gadolinium cerebral ring-like enhancement in another case. The treatment consisted of intravenous immunoglobulin in 16 cases (80%) and corticosteroid in 19 cases (95%). Plasmapheresis was used for one patient. Complete recovery was observed in 12 patients (60%); 19 patients (95%) had a monophasic course of the disease while only one patient developed multiphasic ADEM. CONCLUSIONS ADEM remains a difficult diagnosis in children. Nevertheless, after prompt diagnosis and adequate treatment, most children with ADEM have a favorable outcome with restitutio ad integrum.
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Mahapure KS, Prabhune AS, Chouvhan AV. COVID-19-Associated Acute Disseminated Encephalomyelitis: A Systematic Review. Asian J Neurosurg 2021; 16:457-469. [PMID: 34660355 PMCID: PMC8477843 DOI: 10.4103/ajns.ajns_406_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 01/29/2021] [Accepted: 05/19/2021] [Indexed: 11/06/2022] Open
Abstract
Objective: The objective of this study was to provide an overview of acute disseminating encephalomyelitis, a potential and serious complication of COVID-19. Methods: Three primary databases were used, PubMed, LitCovid, and WHO. The final review articles reported acute disseminated encephalomyelitis (ADEM) in COVID-19-positive patients and were full-text, peer-reviewed articles. Articles which did not have patient data such as in vitro studies and articles with unclear inference were excluded. Results: Out of 21 cases of ADEM, the diagnosis of severe acute respiratory syndrome-coronavirus 2 was confirmed in 18 and suspected in 3. Among the neurological symptoms, altered consciousness was most common (7/21), followed by anosmia (3), paraplegia (3/21), brain stem involvement (3/21), sphincter involvement (2/21), and quadriplegia (1/21). Raised inflammatory markers were most commonly seen in 9/17. Central nervous system imaging was abnormal in 19 cases and unavailable in 2 cases. Fifteen patients were treated with corticosteroids, 11 patients received intravenous immunoglobulin, while 3 patients received convalescent plasma. Two patients needed surgical intervention. Complications included seizures (1), acute kidney injury and septicemic shock (1), raised intracranial pressure (1), and supraventricular tachycardia secondary to hydroxychloroquine (1). One patient recovered completely and one had good recovery with mild deficits. Thirteen patients had incomplete recovery with residual neurological deficit while three patients died as the consequence of the disease. Conclusion: The physicians and neurosurgeons should be diligent while treating the COVID-19 patients with neurological manifestations and include ADEM as a differential diagnosis and stress on early diagnosis and treatment to reduce mortality and achieve satisfactory clinical outcome.
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Affiliation(s)
- Kiran Sunil Mahapure
- Department of Plastic Surgery, KAHER J N Medical College, Belgaum, Karnataka, India
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McLendon LA, Rao CK, Da Hora CC, Islamovic F, Galan FN. Post-COVID-19 Acute Disseminated Encephalomyelitis in a 17-Month-Old. Pediatrics 2021; 147:peds.2020-049678. [PMID: 33762311 DOI: 10.1542/peds.2020-049678] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2021] [Indexed: 11/24/2022] Open
Abstract
Neurologic manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pediatric patients have been reported in the acute and postinfectious stages of coronavirus disease 2019. Acute disseminated encephalomyelitis (ADEM) typically presents in children after a viral illness at a mean age of 3 to 7 years. A total of 60% to 90% of literature-reported pediatric patients with ADEM have minimal to no neurologic deficits at long-term follow-up. We present a 17-month-old developmentally typical girl with parental complaints of irritability, upper extremity weakness, and gait disturbance. She presented to the hospital afebrile and irritable with right-sided nasolabial fold flattening, neck stiffness, left upper extremity rigidity, right upper extremity paresis, bilateral lower extremity hyperreflexia, and truncal ataxia. During her hospital course, she became somnolent with autonomic instability and was transferred to intensive care. Contrasted brain MRI revealed diffuse patchy T2 hyperintensities without contrast enhancement. Nasopharyngeal SARS-CoV-2 polymerase chain reaction and serum antibody testing results were positive. Cerebral spinal fluid analysis was unremarkable. Respiratory viral panel and autoimmune encephalitis and demyelinating disorders panel results were negative. She was started on high-dose methylprednisolone and intravenous immunoglobulin, with improvement in mental status, focal deficits, and ambulation. After hospital discharge, she received inpatient rehabilitation for 2 weeks and at 2 month follow-up had a full neurologic recovery. We report the youngest case of postinfectious ADEM due to SARS-CoV-2 in a toddler. Early recognition of autoimmune and inflammatory complications of SARS-CoV-2 is vital for early aggressive immunomodulatory treatment and, consequently, improved morbidity in these patients.
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Affiliation(s)
- Loren A McLendon
- Division of Child and Adolescent Neurology, Mayo Clinic College of Medicine and Science, Jacksonville, Florida.,Division of Pediatric Neurology, Nemours Children Specialty Clinic, Jacksonville, Florida; and
| | - Chethan K Rao
- Division of Child and Adolescent Neurology, Mayo Clinic College of Medicine and Science, Jacksonville, Florida.,Division of Pediatric Neurology, Nemours Children Specialty Clinic, Jacksonville, Florida; and
| | - Cintia Carla Da Hora
- Department of Pediatrics, College of Medicine - Jacksonville, University of Florida, Jacksonville, Florida
| | - Florinda Islamovic
- Department of Pediatrics, College of Medicine - Jacksonville, University of Florida, Jacksonville, Florida
| | - Fernando N Galan
- Division of Pediatric Neurology, Nemours Children Specialty Clinic, Jacksonville, Florida; and
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Kilic H, Mavi D, Yalcinkaya BC, Yildiz EP, Kizilkilic O, Saltik S. Evaluation of inflammatory acquired demyelinating syndromes in children: a single-center experience. Acta Neurol Belg 2021; 122:1485-1491. [PMID: 33973168 DOI: 10.1007/s13760-021-01703-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/03/2021] [Indexed: 11/30/2022]
Abstract
To evaluate the clinical and neuroimaging features of pediatric acquired demyelinating syndromes (ADS) in a tertiary pediatric neurology clinic in Turkey. All children diagnosed with any subset of ADS between 2013 and 2018 were included in this retrospective cohort study. Forty-two patients (21 female) with a median follow-up period of 30 months were included. The median age of the patients at disease onset was 11 years (range 1.5-17 years). The most common pediatric ADS categories according to the International pediatric Multiple Sclerosis Study Group consensus classification criteria were acute disseminated encephalomyelitis (ADEM) and multiple sclerosis (MS), each of which seen in 15 patients, followed by clinically isolated syndrome (CIS) (n = 11) and Neuromyelitis Optica Spectrum Disorder (NMOSD) (n = 1). At the first clinical event, children with ADEM significantly differed from the children affected by MS and CIS in terms of the following parameters: median age at onset (7 vs. 13.5 and 14.5 years; p < 0.001), encephalopathy (93.3 vs 0% and 0%; p < 0.001), and basal ganglia/thalamus lesions (73.3 vs 9.1% and 9.1%; p < 0.001). The frequency of seizure and pleocytosis were higher in ADEM group than MS group (p < 0.05), whereas oligoclonal bands (p < 0.001) and periventricular white matter lesions (p < 0.01) were more frequently observed in MS patients. Rituximab was used with great success in the prevention of relapses in 3 patients: NMOSD (n = 1), MS (n = 1) and ADEM followed by recurrent optic neuritis (n = 1). Our results define the longitudinal disease course of various ADS categories in a single referral center. In addition, this study compares various clinical, laboratory and neuroimaging features between these ADS categories.
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Affiliation(s)
- Huseyin Kilic
- Department of Pediatric Neurology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey.
| | - Deniz Mavi
- Department of Pediatric Neurology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | | | - Edibe Pembegul Yildiz
- Division of Pediatric Neurology, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Osman Kizilkilic
- Department of Radiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sema Saltik
- Department of Pediatric Neurology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Bozzola E, Spina G, Valeriani M, Papetti L, Ursitti F, Agostiniani R, Mascolo C, Ruggiero M, Di Camillo C, Quondamcarlo A, Matera L, Vecchio D, Memo L, Villani A. Management of pediatric post-infectious neurological syndromes. Ital J Pediatr 2021; 47:17. [PMID: 33494818 PMCID: PMC7836589 DOI: 10.1186/s13052-021-00968-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 01/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Post-Infectious Neurological Syndromes (PINS) are heterogeneous neurological disorders with post or para-infectious onset. PINS diagnosis is complex, mainly related to the absence of any recognized guidelines and a univocal definition. AIM OF THE STUDY To elaborate a diagnostic guide for PINS. MATERIALS AND METHODS We retrospectively analysed patients younger than 14 years old admitted to Bambino Gesù Children's Hospital in Rome for PINS from December 2005 to March 2018. Scientific literature using PubMed as research platform was analysed: the key words "Post-Infectious Neurological Syndromes" were used. RESULTS A polysymptomatic presentation occurred in a percentage of 88% of the children. Motor signs and visual disturbances the most observed symptoms/signs were the most detached, followed by fever, speech disturbances, sleepiness, headache and bradipsychism. Blood investigations are compatible with inflammation, as a prodromal illnesses was documented in most cases. Normal cerebral spinal fluid (CSF) characteristics has been found in the majority of the study population. Magnetic resonance imaging (MRI) was positive for demyelinating lesions. Antibiotics, acyclovir and steroids have been given as treatment. DISCUSSION We suggest diagnostic criteria for diagnosis of PINS, considering the following parameters: neurological symptoms, timing of disease onset, blood and CSF laboratory tests, MRI imaging. CONCLUSIONS We propose criteria to guide clinician to diagnose PINS as definitive, probable or possible. Further studies are required to validate diagnostic criteria.
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Affiliation(s)
| | | | - Massimiliano Valeriani
- Department of Neuroscience, Headache Center, Bambino Gesù Children Hospital, Rome, Italy
| | - Laura Papetti
- Department of Neuroscience, Headache Center, Bambino Gesù Children Hospital, Rome, Italy
| | - Fabiana Ursitti
- Department of Neuroscience, Headache Center, Bambino Gesù Children Hospital, Rome, Italy
| | | | | | | | | | | | | | | | - Luigi Memo
- Italian Pediatric Society, Florence, Italy
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13
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Meirson H, Shiran SI, Raz M, Roth J, Fattal-Valevski A. Fulminant Acute Disseminated Encephalomyelitis: A Remarkable Outcome with Cyclophosphamide. JOURNAL OF PEDIATRIC NEUROLOGY 2020. [DOI: 10.1055/s-0040-1716824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractAcute disseminated encephalomyelitis (ADEM) is an inflammatory demyelinating disease of the central nervous system which occurs predominantly in the pediatric population. Acute treatment is high-dose intravenous glucocorticoids. Alternative treatment is usually intravenous immune globulin and/or plasma exchange. Fulminant ADEM is rare in children. Only a few cases of cyclophosphamide use in refractory ADEM have been reported. Here, we report a case of a 12-year-old girl with fulminant ADEM who was comatose and improved dramatically after cyclophosphamide administration. Cyclophosphamide treatment should be considered as a therapy in children with fulminant ADEM nonresponsive to standard therapies.
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Affiliation(s)
- Hadas Meirson
- Pediatric Neurology Institute, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shelly I. Shiran
- Pediatric Radiology Unit, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Raz
- Department of Pathology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan Roth
- Department of Pediatric Neurosurgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aviva Fattal-Valevski
- Pediatric Neurology Institute, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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14
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Marrodan M, Gaitán MI, Correale J. Spinal Cord Involvement in MS and Other Demyelinating Diseases. Biomedicines 2020; 8:E130. [PMID: 32455910 PMCID: PMC7277673 DOI: 10.3390/biomedicines8050130] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 12/13/2022] Open
Abstract
Diagnostic accuracy is poor in demyelinating myelopathies, and therefore a challenge for neurologists in daily practice, mainly because of the multiple underlying pathophysiologic mechanisms involved in each subtype. A systematic diagnostic approach combining data from the clinical setting and presentation with magnetic resonance imaging (MRI) lesion patterns, cerebrospinal fluid (CSF) findings, and autoantibody markers can help to better distinguish between subtypes. In this review, we describe spinal cord involvement, and summarize clinical findings, MRI and diagnostic characteristics, as well as treatment options and prognostic implications in different demyelinating disorders including: multiple sclerosis (MS), neuromyelitis optica spectrum disorder, acute disseminated encephalomyelitis, anti-myelin oligodendrocyte glycoprotein antibody-associated disease, and glial fibrillary acidic protein IgG-associated disease. Thorough understanding of individual case etiology is crucial, not only to provide valuable prognostic information on whether the disorder is likely to relapse, but also to make therapeutic decision-making easier and reduce treatment failures which may lead to new relapses and long-term disability. Identifying patients with monophasic disease who may only require acute management, symptomatic treatment, and subsequent rehabilitation, rather than immunosuppression, is also important.
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Affiliation(s)
| | | | - Jorge Correale
- Neurology Department, Fleni, C1428AQK Buenos Aires, Argentina; (M.M.); (M.I.G.)
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15
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Abstract
In this chapter, we will review monophasic and recurrent demyelinating disorders in children. We will first review consensus definitions and provide an approach to the evaluation of children with first episode of acquired demyelinating disorder. We will discuss typical clinical and radiological features of these syndromes. In the second section, we will review features of recurrent demyelinating syndromes in children, focusing on clinical presentation and treatment options.
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Affiliation(s)
- Mustafa A.M. Salih
- College of Medicine Division of Pediatric Neurology, King Saud University, Riyadh, Saudi Arabia
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16
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Cole J, Evans E, Mwangi M, Mar S. Acute Disseminated Encephalomyelitis in Children: An Updated Review Based on Current Diagnostic Criteria. Pediatr Neurol 2019; 100:26-34. [PMID: 31371120 DOI: 10.1016/j.pediatrneurol.2019.06.017] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 06/25/2019] [Accepted: 06/26/2019] [Indexed: 11/16/2022]
Abstract
Acute disseminated encephalomyelitis is an inflammatory disorder of the central nervous system. Uniform diagnostic criteria for acute disseminated encephalomyelitis did not exist until publication of expert-defined consensus definitions by the International Pediatric Multiple Sclerosis Society Group in 2007, with updates in 2013. In the expanding field of pediatric neuroimmunology, consistent diagnostic criteria are essential to correctly categorize patients as increasing information regarding prognosis and management becomes available. Scientific literature is relatively lacking in review articles on International Pediatric Multiple Sclerosis Society Group-defined acute disseminated encephalomyelitis. This review focuses primarily on references applying the International Pediatric Multiple Sclerosis Society Group criteria for acute disseminated encephalomyelitis presenting specific, up-to-date, and translatable information regarding the epidemiology, pathophysiology, clinical features, diagnosis, management, and prognosis of acute disseminated encephalomyelitis in the pediatric population.
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Affiliation(s)
- Jordan Cole
- Pediatric Multiple Sclerosis and Demyelinating Diseases Center, Washington University in St. Louis, St. Louis, Missouri.
| | - Emily Evans
- Pediatric Multiple Sclerosis and Demyelinating Diseases Center, Washington University in St. Louis, St. Louis, Missouri
| | - Martin Mwangi
- Pediatric Multiple Sclerosis and Demyelinating Diseases Center, Washington University in St. Louis, St. Louis, Missouri
| | - Soe Mar
- Pediatric Multiple Sclerosis and Demyelinating Diseases Center, Washington University in St. Louis, St. Louis, Missouri
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Qiu K, He Q, Chen X, Liu H, Deng S, Lu W. Pregnancy-Related Immune Changes and Demyelinating Diseases of the Central Nervous System. Front Neurol 2019; 10:1070. [PMID: 31649614 PMCID: PMC6794637 DOI: 10.3389/fneur.2019.01070] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 09/23/2019] [Indexed: 12/31/2022] Open
Abstract
Demyelinating diseases of the central nervous system comprise a heterogeneous group of autoimmune disorders characterized by myelin loss with relative sparing of axons occurring on a background of inflammation. Some of the most common demyelinating diseases are multiple sclerosis, acute disseminated encephalomyelitis, and neuromyelitis optica spectrum disorders. Besides showing clinical, radiological, and histopathological features that complicate their diagnosis, demyelinating diseases often involve different immunological processes that produce distinct inflammatory patterns. Evidence of demyelination diseases derives mostly from animal studies of experimental autoimmune encephalomyelitis (EAE), a model that relies on direct antibody–antigen interactions induced by encephalitogenic T cells. Pregnancy is characterized by non-self-recognition, immunomodulatory changes and an altered Th1/Th2 balance, generally considered a Th2-type immunological state that protects the mother from infections. During pregnancy, the immune response of patients with autoimmune disease complicated with pregnancy is different. Immune tolerance in pregnancy may affect the course of some diseases, which may reach remission or be exacerbated. In this review, we summarize current knowledge on the immune status during pregnancy and discuss the relationship between pregnancy-related immune changes and demyelinating diseases of the central nervous system.
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Affiliation(s)
- Ke Qiu
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Qiang He
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Xiqian Chen
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Hui Liu
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Shuwen Deng
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Wei Lu
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
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18
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Galardi MM, Gaudioso C, Ahmadi S, Evans E, Gilbert L, Mar S. Differential Diagnosis of Pediatric Multiple Sclerosis. CHILDREN-BASEL 2019; 6:children6060075. [PMID: 31163654 PMCID: PMC6617098 DOI: 10.3390/children6060075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 05/16/2019] [Accepted: 05/20/2019] [Indexed: 01/28/2023]
Abstract
The differential diagnosis of pediatric multiple sclerosis (MS) can be broad and pose diagnostic challenges, particularly at initial presentation. Among demyelinating entities, neuromyelitis optica spectrum disorders (NMOSD), myelin oligodendrocyte glycoprotein antibodies (MOG-ab) associated disorders, and acute disseminated encephalomyelitis (ADEM) are now well-known as unique disease processes and yet continue to overlap with MS in regards to clinical presentation and imaging. In non-inflammatory entities, such as metabolic disorders and leukodystrophies, an erroneous diagnosis of MS can be made even while applying appropriate diagnostic criteria. Knowing the epidemiology, typical clinical presentation, diagnostic criteria, and ancillary test results in each disease, can aid in making the correct diagnosis by contrasting these features with those of pediatric MS. Determining the correct diagnosis early, allows for efficient and effective treatment as well as appropriate prognostication.
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Affiliation(s)
| | - Cristina Gaudioso
- Department of Neurology, Washington University in St. Louis, St. Louis, MO 63110, USA.
| | - Saumel Ahmadi
- Department of Neurology, Washington University in St. Louis, St. Louis, MO 63110, USA.
| | - Emily Evans
- Department of Neurology, Washington University in St. Louis, St. Louis, MO 63110, USA.
| | - Laura Gilbert
- Department of Neurology, Washington University in St. Louis, St. Louis, MO 63110, USA.
| | - Soe Mar
- Department of Neurology, Washington University in St. Louis, St. Louis, MO 63110, USA.
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19
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Aldamkh BA, Alamer AF, Altuwaijri MM, Alrumayyan MA, Alhaqbani AH, Alharthi NA, Aldamkh SA, Aldrees AS, Alrifai MT, Altuwaijri W, Alrumayyan A. Clinical Presentation and outcome of acute disseminated encephalomyelitis in Saudi Arabia. Tertiary Center Experience. ACTA ACUST UNITED AC 2019; 24:89-94. [PMID: 31056539 PMCID: PMC8015459 DOI: 10.17712/nsj.2019.2.20180017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Objectives: To evaluate the clinical presenation of acute disseminated Encephalomyelitis (ADEM) in pediatric age group, treatments, and to asses the outcome at King Abdulaziz Medical City, Riyadh, Kingdom of Saudia Arabia. Methods: The medical records of all patients younger than 18 years of age with a diagnosis of ADEM and treated at King Abdulaziz Medical City from January 1996 to Decemeber 2016 were collected. A total of 20 patients were included. Results: Of 20 patients enrolled in our study, 13 (65%) were female. Autumn and summer were the most common seasons in which ADEM presented (60%); 19 (95%) patients had a history of preceding viral illnesses. The most common neurological deficits on presentation were weakness (85%), ataxia (45%), and nystagmus (45%). Cortical and subcortical lesions (60%) were the most common finding on cranial magnetic resonance imaging. Seventeen patients (85%) received steroid only. Only 16 patients continued with follow-up, with a mean duration of 7 months. All 16 patients improved: 11 patients were recovered and 5 patients still had a neurological deficit at the clinic visits. No patient had relapsed. Conclusion: Most of the patients in this case series have an excellent outcome and attended follow-up visits and no disease relapses were identified. Further exploration of the disease is recommended.
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Affiliation(s)
- Bander A Aldamkh
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia. E-mail:
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20
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Scripchenko NV, Ivanova GP, Skripchenko EY, Egorova ES, Surovtseva AV. [Cytoflavin efficacy in the treatment of disseminated encephalomyelitis in children]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 117:67-74. [PMID: 29359722 DOI: 10.17116/jnevro201711711267-74] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To evaluate the efficacy of cytoflavin in the complex therapy of disseminated encephalomyelitis in children. MATERIAL AND METHODS A blind, placebo - controlled, randomized study was carried out. Thirty-two patients, aged form 1 to 17 years, received cytoflavin from the first day after admission in intravenous drips in 5% glucose solution during 10 days. The control group consisted of 30 children who received a standard infusion therapy. Clinical and laboratory evaluation was carried out on the 11th and 30th days, MRT was performed before hospitalization and on the 30th day. RESULTS AND CONCLUSION Cytoflavin had a positive effect on the rate of recovery of the majority of neurological symptoms. The average EDSS score decreased by 1.5 times to the 30th day compared with the control group. The complete regression of clinical symptoms and focal changes on MRI on the 30th day was observed in 25% of children of the main group and in 3.3% in the control group (р=0.001). The drug exerted the endothelium protective and antioxidant effects, improved blood rheology and restored the content of circulating endothelial cells, the level of D-dimer and indicators of free radical oxidation to the 30th day of treatment.
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Affiliation(s)
- N V Scripchenko
- Pediatric Research and Clinical Center for Infectious Diseases St. Petersburg, Russia; St. Petersburg State Pediatric Medical University, St. Petersburg, Russia
| | - G P Ivanova
- Pediatric Research and Clinical Center for Infectious Diseases St. Petersburg, Russia; St. Petersburg State Pediatric Medical University, St. Petersburg, Russia
| | - E Yu Skripchenko
- Pediatric Research and Clinical Center for Infectious Diseases St. Petersburg, Russia; St. Petersburg State Pediatric Medical University, St. Petersburg, Russia
| | - E S Egorova
- Pediatric Research and Clinical Center for Infectious Diseases St. Petersburg, Russia
| | - A V Surovtseva
- Pediatric Research and Clinical Center for Infectious Diseases St. Petersburg, Russia
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Poulet A, Bou Ali H, Savini H, Kaphan E, Parola P. Post-malaria neurological syndrome: Imported case series and literature review to unscramble the auto-immune hypothesis. Travel Med Infect Dis 2018; 29:16-20. [PMID: 30217773 DOI: 10.1016/j.tmaid.2018.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/31/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
Abstract
Post-malaria neurological syndrome (PMNS) is a complication that occurs after recovery from a severe Plasmodium falciparum attack. Over the past two decades, the description of several imported cases has confirmed that this syndrome is a clearly distinct entity, different from other post malarial neurological disorders. However, the underlying mechanisms are not yet elucidated. Herein, we present five imported PMNS cases managed in Marseille, France. The detection of neuronal surface antibodies to an encephalitic syndrome of unknown origin allowed us to reveal positivity of anti Voltage-Gated-Potassium Channel antibodies (anti VGKC) in one of them. Using treatment options from other autoimmune encephalitis has to be explored in patients with PMNS.
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Affiliation(s)
- Antoine Poulet
- Aix Marseille Univ, IRD, AP-HM, SSA, VITROME, IHU-Méditerranée Infection, Marseille, France
| | - Hanna Bou Ali
- Pôle de Neurosciences Cliniques, CHU de la Timone, Assistance Publique, Hôpitaux de Marseille, Marseille, France
| | - Helene Savini
- Service de pathologie infectieuse et tropicale, Hôpital d'instruction des armées Laveran, Marseille, France
| | - Elsa Kaphan
- Pôle de Neurosciences Cliniques, CHU de la Timone, Assistance Publique, Hôpitaux de Marseille, Marseille, France
| | - Philippe Parola
- Aix Marseille Univ, IRD, AP-HM, SSA, VITROME, IHU-Méditerranée Infection, Marseille, France.
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Abstract
Acute disseminated encephalomyelitis (ADEM) is an inflammatory demyelinating syndrome with encephalopathy. ADEM typically affects young children, is often postinfectious, and is typically monophasic. MRI neuroimaging, which shows new lesions with poorly demarcated borders, but not old and established lesions, is essential to diagnosis. Autoantibodies against myelin oligodendrocyte glycoprotein (MOG) are found in ∼40% of ADEM patients, and these patients have different clinical and neuroimaging features to seronegative patients. Treatment in the acute phase is typically with high-dose corticosteroids and intravenous immunoglobulin or plasma exchange for refractory patients. Outcome is usually good, but residual cognitive, inattentive, and executive issues are likely underestimated. In patients who have a relapse, biomarkers and imaging should help differentiate multiphasic ADEM, neuromyelitis optica spectrum disorder, anti-MOG antibody–associated relapsing demyelination, and multiple sclerosis.
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23
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Iro MA, Martin NG, Absoud M, Pollard AJ. Intravenous immunoglobulin for the treatment of childhood encephalitis. Cochrane Database Syst Rev 2017; 10:CD011367. [PMID: 28967695 PMCID: PMC6485509 DOI: 10.1002/14651858.cd011367.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Encephalitis is a syndrome of neurological dysfunction due to inflammation of the brain parenchyma, caused by an infection or an exaggerated host immune response, or both. Attenuation of brain inflammation through modulation of the immune response could improve patient outcomes. Biological agents such as immunoglobulin that have both anti-inflammatory and immunomodulatory properties may therefore be useful as adjunctive therapies for people with encephalitis. OBJECTIVES To assess the efficacy and safety of intravenous immunoglobulin (IVIG) as add-on treatment for children with encephalitis. SEARCH METHODS The Cochrane Multiple Sclerosis and Rare Diseases of the CNS group's Information Specialist searched the following databases up to 30 September 2016: CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, and the WHO ICTRP Search Portal. In addition, two review authors searched Science Citation Index Expanded (SCI-EXPANDED) & Conference Proceedings Citation Index - Science (CPCI-S) (Web of Science Core Collection, Thomson Reuters) (1945 to January 2016), Global Health Library (Virtual Health Library), and Database of Abstracts of Reviews of Effects (DARE). SELECTION CRITERIA Randomised controlled trials (RCTs) comparing IVIG in addition to standard care versus standard care alone or placebo. DATA COLLECTION AND ANALYSIS Two review authors independently selected articles for inclusion, extracted relevant data, and assessed quality of trials. We resolved disagreements by discussion among the review authors. Where possible, we contacted authors of included studies for additional information. We presented results as risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CI). MAIN RESULTS The search identified three RCTs with 138 participants. All three trials included only children with viral encephalitis, one of these included only children with Japanese encephalitis, a specific form of viral encephalitis. Only the trial of Japanese encephalitis (22 children) contributed to the primary outcome of this review and follow-up in that study was for three to six months after hospital discharge. There was no follow-up of participants in the other two studies. We identified one ongoing trial.For the primary outcomes, the results showed no significant difference between IVIG and placebo when used in the treatment of children with Japanese encephalitis: significant disability (RR 0.75, 95% CI 0.22 to 2.60; P = 0.65) and serious adverse events (RR 1.00, 95% CI 0.07 to 14.05; P = 1.00).For the secondary outcomes, the study of Japanese encephalitis showed no significant difference between IVIG and placebo when assessing significant disability at hospital discharge (RR 1.00, 95% CI 0.60 to 1.67). There was no significant difference (P = 0.53) in Glasgow Coma Score at discharge between IVIG (median score 14; range 3 to 15) and placebo (median 14 score; range 7 to 15) in the Japanese encephalitis study. The median length of hospital stay in the Japanese encephalitis study was similar for IVIG-treated (median 13 days; range 9 to 21) and placebo-treated (median 12 days; range 6 to 18) children (P = 0.59).Pooled analysis of the results of the other two studies resulted in a significantly lower mean length of hospital stay (MD -4.54 days, 95% CI -7.47 to -1.61; P = 0.002), time to resolution of fever (MD -0.97 days, 95% CI -1.25 to -0.69; P < 0.00001), time to stop spasms (MD -1.49 days, 95% CI -1.97 to -1.01; P < 0.00001), time to regain consciousness (MD -1.10 days, 95% CI -1.48 to -0.72; P < 0.00001), and time to resolution of neuropathic symptoms (MD -3.20 days, 95% CI -3.34 to -3.06; P < 0.00001) in favour of IVIG when compared with standard care.None of the included studies reported other outcomes of interest in this review including need for invasive ventilation, duration of invasive ventilation, cognitive impairment, poor adaptive functioning, quality of life, number of seizures, and new diagnosis of epilepsy.The quality of evidence was very low for all outcomes of this review. AUTHORS' CONCLUSIONS The findings suggest a clinical benefit of adjunctive IVIG treatment for children with viral encephalitis for some clinical measures (i.e. mean length of hospital stay, time (days) to stop spasms, time to regain consciousness, and time to resolution of neuropathic symptoms and fever. For children with Japanese encephalitis, IVIG had a similar effect to placebo when assessing significant disability and serious adverse events.Despite these findings, the risk of bias in the included studies and quality of the evidence make it impossible to reach any firm conclusions on the efficacy and safety of IVIG as add-on treatment for children with encephalitis. Furthermore, the included studies involved only children with viral encephalitis, therefore findings of this review cannot be generalised to all forms of encephalitis. Future well-designed RCTs are needed to assess the efficacy and safety of IVIG in the management of children with all forms of encephalitis. There is a need for internationally agreed core outcome measures for clinical trials in childhood encephalitis.
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Affiliation(s)
- Mildred A Iro
- University of Oxford and the NIHR Oxford Biomedical Research CentreDepartment of PaediatricsChurchill Hospital, Old Road, HeadingtonOxfordUK
| | - Natalie G Martin
- Christchurch School of Medicine, University of OtagoDepartment of PaediatricsChristchurchNew Zealand
| | - Michael Absoud
- Evelina London Children's Hospital, Guy's and St Thomas' Hospital, King's Health PartnersChildren's Neurosciences CentreWestminster Bridge RoadLondonUKSE1 7EH
| | - Andrew J Pollard
- Children's HospitalDepartment of Paediatrics, University of OxfordOxfordUKOX3 9DU
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Gadian J, Kirk E, Holliday K, Lim M, Absoud M. Systematic review of immunoglobulin use in paediatric neurological and neurodevelopmental disorders. Dev Med Child Neurol 2017; 59:136-144. [PMID: 27900773 DOI: 10.1111/dmcn.13349] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2016] [Indexed: 01/18/2023]
Abstract
AIM A systematic literature review of intravenous immunoglobulin (IVIG) treatment of paediatric neurological conditions was performed to summarize the evidence, provide recommendations, and suggest future research. METHOD A MEDLINE search for articles reporting on IVIG treatment of paediatric neuroinflammatory, neurodevelopmental, and neurodegenerative conditions published before September 2015, excluding single case reports and those not in English. Owing to heterogeneous outcome measures, meta-analysis was not possible. Findings were combined and evidence graded. RESULTS Sixty-five studies were analysed. IVIG reduces recovery time in Guillain-Barré syndrome (grade B). IVIG is as effective as corticosteroids in chronic inflammatory demyelinating polyradiculoneuropathy (grade C), and as effective as tacrolimus in Rasmussen syndrome (grade C). IVIG improves recovery in acute disseminated encephalomyelitis (grade C), reduces mortality in acute encephalitis syndrome with myocarditis (grade C), and improves function and stabilizes disease in myasthenia gravis (grade C). IVIG improves outcome in N-methyl-d-aspartate receptor encephalitis (grade C) and opsoclonus-myoclonus syndrome (grade C), reduces cataplexy symptoms in narcolepsy (grade C), speeds recovery in Sydenham chorea (grade C), reduces tics in selected cases of Tourette syndrome (grade D), and improves symptoms in paediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (grade B). INTERPRETATION IVIG is a useful therapy in selected neurological conditions. Well-designed, prospective, multi-centre studies with standardized outcome measures are required to compare treatments.
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Affiliation(s)
- Jonathan Gadian
- Evelina London Children's Hospital, St Thomas' Hospital, Children's Neurosciences Centre, London, UK
| | - Emma Kirk
- Evelina London Children's Hospital, St Thomas' Hospital, Paediatric Pharmacy, London, UK
| | | | - Ming Lim
- Evelina London Children's Hospital, St Thomas' Hospital, Children's Neurosciences Centre, London, UK
| | - Michael Absoud
- Evelina London Children's Hospital, St Thomas' Hospital, Children's Neurosciences Centre, London, UK
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25
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Iro MA, Sadarangani M, Absoud M, Chong WK, Clark CA, Easton A, Gray V, Kneen R, Lim M, Pike M, Solomon T, Vincent A, Willis L, Yu LM, Pollard AJ. ImmunoglobuliN in the Treatment of Encephalitis (IgNiTE): protocol for a multicentre randomised controlled trial. BMJ Open 2016; 6:e012356. [PMID: 27810972 PMCID: PMC5129051 DOI: 10.1136/bmjopen-2016-012356] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Infectious and immune-mediated encephalitides are important but under-recognised causes of morbidity and mortality in childhood, with a 7% death rate and up to 50% morbidity after prolonged follow-up. There is a theoretical basis for ameliorating the immune response with intravenous immunoglobulin (IVIG), which is supported by empirical evidence of a beneficial response following its use in the treatment of viral and autoimmune encephalitis. In immune-mediated encephalitis, IVIG is often used after a delay (by weeks in some cases), while diagnosis is confirmed. Wider use of IVIG in infectious encephalitis and earlier use in immune-mediated encephalitis could improve outcomes for these conditions. We describe the protocol for the first ever randomised control trial of IVIG treatment for children with all-cause encephalitis. METHODS AND ANALYSIS 308 children (6 months to 16 years) with a diagnosis of acute/subacute encephalitis will be recruited in ∼30 UK hospitals and randomised to receive 2 doses (1 g/kg/dose) of either IVIG or matching placebo, in addition to standard treatment. Recruitment will be over a 42-month period and follow-up of each participant will be for 12 months post randomisation. The primary outcome is 'good recovery' (score of 2 or lower on the Glasgow Outcome Score Extended-paediatric version), at 12 months after randomisation. Additional secondary neurological measures will be collected at 4-6 weeks after discharge from acute care and at 6 and 12 months after randomisation. Safety, radiological, other autoimmune and tertiary outcomes will also be assessed. ETHICS AND DISSEMINATION This trial has been approved by the UK National Research Ethics committee (South Central-Oxford A; REC 14/SC/1416). Current protocol: V4.0 (10/03/2016). The findings will be presented at national and international meetings and conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBERS NCT02308982, EudraCT201400299735 and ISRCTN15791925; Pre-results.
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Affiliation(s)
- M A Iro
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - M Sadarangani
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Department of Paediatrics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, University of British Columbia, Vancouver BC, Canada
| | - M Absoud
- Department of Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas’ NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK
| | - W K Chong
- Department of Radiology, Great Ormond Street Hospital for Children, London, UK
| | - C A Clark
- Institute of Child Health, University College London, London, UK
| | - A Easton
- The Encephalitis Society, Malton, North Yorkshire, UK
| | - V Gray
- Psychological services (Paediatrics), Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - R Kneen
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
- Littlewoods Neuroscience Foundation, Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - M Lim
- Department of Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas’ NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK
| | - M Pike
- Department of Paediatric Neurology, Oxford University Hospitals NHS Trust, Oxford, UK
| | - T Solomon
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, UK
- Walton Centre NHS Foundation Trust, Liverpool, UK
| | - A Vincent
- Department of Clinical Neurosciences, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - L Willis
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - L-M Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - A J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Department of Paediatrics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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26
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Abstract
Acute disseminated encephalomyelitis is a primarily pediatric, immune-mediated disease characterized by demyelination and polyfocal neurologic symptoms that typically occur after a preceding viral infection or recent immunization. This article presents the pathophysiology, diagnostic criteria, and magnetic resonance imaging characteristics of acute disseminated encephalomyelitis. We also present evaluation and management strategies.
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Long-term motor, cognitive and behavioral outcome of acute disseminated encephalomyelitis. Eur J Paediatr Neurol 2016; 20:361-7. [PMID: 26876769 DOI: 10.1016/j.ejpn.2016.01.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 01/06/2016] [Accepted: 01/23/2016] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the long-term motor and neurocognitive outcome of children with acute disseminated encephalomyelitis and to identify prognostic risk factors. METHODS The study included 43 children who were hospitalized due to acute disseminated encephalomyelitis during the years 2002-2012. The children underwent full neurological examinations, along with comprehensive neurocognitive and behavioral assessments. RESULTS Twenty-six (61%) children had different degrees of neurological sequelae after a mean follow-up of 5.5 ± 3.5 years. The most common residual impairment included attention-deficit hyperactivity disorder (44%), behavioral problems (32%), and learning disabilities (21%). Five (12%) children had a full-scale IQ of 70 or less, compared to 2.2% in the general population. CONCLUSIONS Neurocognitive sequelae were found even in children who were considered as fully recovered at the time of discharge. Risk factors for severe neurological sequelae were older age at diagnosis and male gender. We suggest neuropsychological testing and long-term follow-up for all children with acute disseminated encephalomyelitis, even in the absence of neurological deficits at discharge.
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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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29
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Acute disseminated encephalomyelitis progressing to multiple sclerosis: are infectious triggers involved? Immunol Res 2015; 60:16-22. [PMID: 24668297 PMCID: PMC7091333 DOI: 10.1007/s12026-014-8499-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute disseminated encephalomyelitis (ADEM) and multiple sclerosis (MS) are demyelinating disorders affecting the central nervous system. An autoimmune aetiology has been proposed for both. ADEM principally affects adolescents following acute infection by a variety of pathogens and has also been reported to occur following vaccination. ADEM typically resolves following medical treatment, whereas MS follows a more relapsing and remitting course. The pathogenesis of MS remains unclear, but it is thought that a combination of infectious and non-infectious environmental factors and host genetics act synergistically to cause disease. A variety of viruses, including Epstein Barr virus, cytomegalovirus, herpes simplex virus and varicella zoster virus, have been implicated as possible infectious triggers. The similar clinical and pathological presentation of ADEM and MS presents a diagnostic challenge for distinguishing ADEM from a first episode of MS. Some cases of ADEM progress to MS for reasons that are not currently clear. This review examines the evidence for infectious agents as triggers for ADEM progressing to MS and suggests potential methods that may facilitate identification of infectious agents that may be responsible for the pathogenesis of ADEM to MS.
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30
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Luciani K, Abadía I, Martínez-Torres AO, Cisneros J, Guerra I, García M, Estripeaut D, Carrera JP. Madariaga virus infection associated with a case of acute disseminated encephalomyelitis. Am J Trop Med Hyg 2015; 92:1130-2. [PMID: 25870420 DOI: 10.4269/ajtmh.14-0845] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 03/04/2015] [Indexed: 11/07/2022] Open
Abstract
We present the first report of a pediatric case of acute disseminated encephalomyelitis (ADEM) associated with Madariaga virus infection (MADV, Alphavirus, Togaviridae; formerly known as South American variants of eastern equine encephalitis virus [EEEV]) in a patient of the 2010 alphaviral epidemic reported in Panama. The patient was admitted to the Hospital del Niño in Panama City with suspected meningitis, exhibited with decreased alertness and disorientation in space and time, hemiparesis, and left Babinski sign. The patient was transferred to the intensive care unit and treated with aciclovir and methylprednisolone. The magnetic resonance imaging (MRI) of the brain revealed multiple hyperintense lesions at T2-weighted images (T2) and fluid-attenuated inversion recovery (FLAIR) on the cortical-subcortical level. Sera samples obtained on days 6 and 12 were immunoglobulin M (IgM) positive for MADV. The findings on the clinical and cerebrospinal analyses, rapid symptom progression as well as neuroimaging, and serologic studies support our diagnosis. Our results suggest that MADV should be included in the etiologic differential diagnosis of ADEM in endemic countries.
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Affiliation(s)
- Kathia Luciani
- Division of Pediatric Infection Disease and Division of Pediatric Neurology, Hospital del Niño, Panama City, Panama; Department of Research in Virology and Biotechnology, Gorgas Memorial Institute of Health Studies, Panama City, Panama; School of Medicine, Columbus University, Panama City, Panama; Department of Microbiology and Parasitology, University of Panama, Panama City, Panama
| | - Iván Abadía
- Division of Pediatric Infection Disease and Division of Pediatric Neurology, Hospital del Niño, Panama City, Panama; Department of Research in Virology and Biotechnology, Gorgas Memorial Institute of Health Studies, Panama City, Panama; School of Medicine, Columbus University, Panama City, Panama; Department of Microbiology and Parasitology, University of Panama, Panama City, Panama
| | - Alex O Martínez-Torres
- Division of Pediatric Infection Disease and Division of Pediatric Neurology, Hospital del Niño, Panama City, Panama; Department of Research in Virology and Biotechnology, Gorgas Memorial Institute of Health Studies, Panama City, Panama; School of Medicine, Columbus University, Panama City, Panama; Department of Microbiology and Parasitology, University of Panama, Panama City, Panama
| | - Julio Cisneros
- Division of Pediatric Infection Disease and Division of Pediatric Neurology, Hospital del Niño, Panama City, Panama; Department of Research in Virology and Biotechnology, Gorgas Memorial Institute of Health Studies, Panama City, Panama; School of Medicine, Columbus University, Panama City, Panama; Department of Microbiology and Parasitology, University of Panama, Panama City, Panama
| | - Ilka Guerra
- Division of Pediatric Infection Disease and Division of Pediatric Neurology, Hospital del Niño, Panama City, Panama; Department of Research in Virology and Biotechnology, Gorgas Memorial Institute of Health Studies, Panama City, Panama; School of Medicine, Columbus University, Panama City, Panama; Department of Microbiology and Parasitology, University of Panama, Panama City, Panama
| | - Mariana García
- Division of Pediatric Infection Disease and Division of Pediatric Neurology, Hospital del Niño, Panama City, Panama; Department of Research in Virology and Biotechnology, Gorgas Memorial Institute of Health Studies, Panama City, Panama; School of Medicine, Columbus University, Panama City, Panama; Department of Microbiology and Parasitology, University of Panama, Panama City, Panama
| | - Dora Estripeaut
- Division of Pediatric Infection Disease and Division of Pediatric Neurology, Hospital del Niño, Panama City, Panama; Department of Research in Virology and Biotechnology, Gorgas Memorial Institute of Health Studies, Panama City, Panama; School of Medicine, Columbus University, Panama City, Panama; Department of Microbiology and Parasitology, University of Panama, Panama City, Panama
| | - Jean-Paul Carrera
- Division of Pediatric Infection Disease and Division of Pediatric Neurology, Hospital del Niño, Panama City, Panama; Department of Research in Virology and Biotechnology, Gorgas Memorial Institute of Health Studies, Panama City, Panama; School of Medicine, Columbus University, Panama City, Panama; Department of Microbiology and Parasitology, University of Panama, Panama City, Panama
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31
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Acute disseminated encephalomyelitis: current controversies in diagnosis and outcome. J Neurol 2015; 262:2013-24. [DOI: 10.1007/s00415-015-7694-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 02/06/2015] [Accepted: 02/08/2015] [Indexed: 10/23/2022]
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32
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Millichap JG. Single Center Experience of Acute Disseminated Encephalomyelitis. Pediatr Neurol Briefs 2013. [DOI: 10.15844/pedneurbriefs-27-11-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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