Lumbosacral radiculomyelitis associated with pandemic acute haemorrhagic conjunctivitis

The leptomeninges as a critical organ for normal CNS development and function: First patient and public involved systematic review of arachnoiditis (chronic meningitis)

BACKGROUND & IMPORTANCE

This patient and public-involved systematic review originally focused on arachnoiditis, a supposedly rare "iatrogenic chronic meningitis" causing permanent neurologic damage and intractable pain. We sought to prove disease existence, causation, symptoms, and inform future directions. After 63 terms for the same pathology were found, the study was renamed Diseases of the Leptomeninges (DLMs). We present results that nullify traditional clinical thinking about DLMs, answer study questions, and create a unified path forward.

METHODS

The prospective PRISMA protocol is published at Arcsology.org. We used four platforms, 10 sources, extraction software, and critical review with ≥2 researchers at each phase. All human sources to 12/6/2020 were eligible for qualitative synthesis utilizing R. Weekly updates since cutoff strengthen conclusions.

RESULTS

Included were 887/14286 sources containing 12721 DLMs patients. Pathology involves the subarachnoid space (SAS) and pia. DLMs occurred in all countries as a contributor to the top 10 causes of disability-adjusted life years lost, with communicable diseases (CDs) predominating. In the USA, the ratio of CDs to iatrogenic causes is 2.4:1, contradicting arachnoiditis literature. Spinal fusion surgery comprised 54.7% of the iatrogenic category, with rhBMP-2 resulting in 2.4x more DLMs than no use (p<0.0001). Spinal injections and neuraxial anesthesia procedures cause 1.1%, and 0.2% permanent DLMs, respectively. Syringomyelia, hydrocephalus, and arachnoid cysts are complications caused by blocked CSF flow. CNS neuron death occurs due to insufficient arterial supply from compromised vasculature and nerves traversing the SAS. Contrast MRI is currently the diagnostic test of choice. Lack of radiologist recognition is problematic.

DISCUSSION & CONCLUSION

DLMs are common. The LM clinically functions as an organ with critical CNS-sustaining roles involving the SAS-pia structure, enclosed cells, lymphatics, and biologic pathways. Cases involve all specialties. Causes are numerous, symptoms predictable, and outcomes dependent on time to treatment and extent of residual SAS damage. An international disease classification and possible treatment trials are proposed.

Acute Flaccid Paralysis and Enteroviral Infections

PURPOSE OF REVIEW

The focus of this review is on enterovirus (EV)-associated acute flaccid paralysis (AFP) due to spinal cord anterior horn cell disease. Emphasis is placed on the epidemiology, pathogenesis, diagnosis, treatment, and outcome of AFP caused by polioviruses, vaccine-derived polioviruses, EV-D68, and EV-A71.

RECENT FINDINGS

Since the launch of The Global Polio Eradication Initiative in 1988, the worldwide incidence of polio has been reduced by 99.9%, with small numbers of poliomyelitis cases being reported only in Afghanistan, Pakistan, and Nigeria. With the planned phaseout of oral polio vaccine, vaccine-associated poliomyelitis is also expected to be eliminated. In their place, other EVs, chiefly EV-D68 and EV-A71, have emerged as the principal causes of AFP. There is evidence that the emergence of EV-D68 as a cause of severe respiratory disease and AFP was due to recent genetic virus evolution. Antiviral medications targeting EV-D68, EV-A71, and other EVs will likely be available in the near future. An effective EV-A71 vaccine has been developed, and preliminary investigations suggest an EV-D68 vaccine could be on the horizon. The eradication of poliomyelitis and vaccine-associated poliomyelitis is near, after which other EVs, presently EV-D68 and EV-A71, will be the principle viral causes of AFP. Moving forward, it is essential that EV outbreaks, in particular those associated with neurologic complications, be investigated carefully and the causal strains identified, so that treatment and prevention efforts can be rapidly developed and implemented.

Enterovírus-70 na região metropolitana de São Paulo, Brasil, de 1984 a 1987: aspectos da infecção em períodos epidêmico e endêmico

São apresentados os resultados de estudos sobre o comportamento do Enterovírus-70 (EV-70) na região metropolitana de São Paulo desde sua provável introdução no verão de 1984, determinando extensa epidemia de conjuntivite hemorrágica aguda (C.H.A.), até o final de 1987 abrangendo período em que este agravo foi pouco notado. Na fase epidêmica ocorrida no primeiro trimestre de 1984 foram estudados 291 indivíduos divididos em três grupos denominados A, B e C, o primeiro formado por pessoas atingidas pela C.H.A. e os outros dois por indivíduos não atingidos por este agravo mas que, respectivamente, referiam contato domiciliar com casos de C.H.A. e os que não referiam o citado contato. A demonstração de anticorpos se fez pela técnica de imunofluorescência indireta (IFI) para detectar IgM específico para EV-70 e pela prova de neutralização em cultura de células BHK-21. Verificou-se que 56,7%, 33,3% e 20,6% dos indivíduos pertencentes, respectivamente, aos grupos A, B e C apresentavam anticorpos específicos da classe IgM. No grupo A a faixa etária mais atingida foi a de 10 a 29 anos. No período que vai do fim da primeira e única epidemia até o final de 1987, identificaram-se três casos esporádicos de C.H.A. e 10 pacientes com afecção neurológica aguda associada à infecção recente pelo EV-70. Nove, destes 10 casos, apresentaram paralisia de nervos cranianos, todos evoluindo sem seqüelas clinicamente discerníveis. As formas assintomáticas e os casos esporádicos de C.H.A. e de afecções neurológicas mantiveram a circulação do EV-70 no período não epidêmico.

Spectrum of patients with EMG features of polyradiculopathy without neuropathy

We reviewed the medical records of 233 patients having electrodiagnostic evidence of polyradiculopathy. Patients with polyneuropathy or incomplete diagnostic evaluation were excluded. A clinical diagnosis was secured in 92 of the 118 remaining patients. Patients were separated into three groups based upon the anatomic location of root involvement: extradural (55), intradural-extraaxial (23), and intraaxial (14). Collectively, patients with intradural-extraaxial disorders had earlier disease onset, shorter symptom duration, and a higher disability score compared with the intraaxial or extradural groups. Pain was an initial complaint in 50 of 55 patients with extradural lesions, 20 of 23 with intradural-extraaxial disease, but only in 4 of 14 with intraaxial involvement. CSF abnormalities and reduced compound muscle action potential amplitudes were more common in the intradural-extraaxial group. We conclude that the anatomic localization of root involvement in patients with polyradiculopathy can be suggested by a combination of clinical, laboratory, and electrodiagnostic features.

A recent epidemic of Coxsackie virus type A24 acute haemorrhagic conjunctivitis in Singapore

A recent epidemic of acute conjunctivitis in Singapore showed again the importance of Coxsackie virus type A24 variant as a causative agent of acute haemorrhagic conjunctivitis (AHC). Although the ocular manifestations appeared similar to those described for the 1970 and 1975 outbreaks, a markedly higher rate of respiratory involvements was noted. Not observed in previous epidemics were herpes-like vesicles in the conjunctiva and eyelids of one patient and vesicles in the buccal mucosa and lips of another from whom Coxsackie virus A24 was isolated. The most interesting finding in this study was the isolation of five wild (non-Sabin) poliovirus type 1 strains. Three strains were obtained from conjunctival and two from throat swabs of patients with mild to severe conjunctivitis. It is conceivable that the rare reports of polio-like paralysis or radiculomyelitis accompanying or following AHC in a few Asian countries could be attributed to concurrent infections with a poliovirus and either enterovirus type 70 or Coxsackie virus type A24.

Polyradiculoneuritis in children groups during simultaneous circulation of enteroviruses and adenoviruses

Two cases of polyradiculoneuritis in children were noted during January, 1984. Each girl was a member of a different group of children: the first group was newly constituted of children from various remote regions of Czechoslovakia in a Medical Institution, the second one included children attending the same nursery school for a long time. In both groups, all or most of the children went through one or two respiratory infections which preceded the development of a paralytic disease. From the first girl, coxsackievirus A9 was recovered in nasopharyngeal swabs and in a stool sample. Among contacts in the Children's Medical Institution, a concurrent circulation of this enterovirus and of an adenovirus type 3 was demonstrated by isolation attempts and confirmed by serological examinations. From the second girl, coxsackie A9 and an adenovirus type 29 were demonstrated in the same stool sample and a simultaneous circulation of both virus species among the nursery school and family contacts was proved by isolation attempts and by serological investigations. The concurrent, overlapping or sequential circulation of adenoviruses and enteroviruses may perhaps contribute to a compromised immunity resulting in a manifestation of paralysis.

Virus-specific, early appearing neutralizing activity and interferon in tears of patients with acute hemorrhagic conjunctivitis

Virus-specific, early appearing neutralizing activities (ENA) and interferon (IFN) were detected in tears collected from patients during epidemics of acute hemorrhagic conjunctivitis (AHC). In one study, ENA that neutralized enterovirus type 70 (EV70) was detected in tears collected from 114 of 130 AHC patients in Florida. In another study, ENA against coxsackievirus type A24 (CA24) was detected in tears collected from 39 of 57 patients in Singapore with AHC caused by CA24. No tear samples contained ENAs to both EV70 and CA24. Tear samples from uninfected eyes did not contain ENA to EV70 or CA24. ENA to EV70 was detected in 6 of 11 patients 1-6h before the onset of AHC. In addition, tears of 68% of patients seen on the day of onset produced tears that contained ENA to EV70. Thus, ENA to EV70 may be detected less than 24h after infection (based on 24h incubation period). IFN beta was detected in 30% of tear samples collected from patients on the day of onset of AHC caused by EV70. This finding suggested that ENA and IFN could act together to inhibit primary infections of AHC. It was found that the combination of ENA and IFN inhibited virus replication synergistically (greater than or equal to 300 fold reduction) in preinfected cells. Our findings suggest that ENA represents a previously unreported early defense mechanism of the eye, that endogenous ENA and endogenous IFN could inhibit viruses synergistically in vivo, and that ENA in tears could be useful in identifying the agent causing AHC.

A study of the neurological disorder associated with acute haemorrhagic conjunctivitis due to enterovirus 70

Ninety cases of the neurological manifestations associated with acute haemorrhagic conjunctivitis caused by Enterovirus 70 (EV 70) are reported. The patients were seen during the widespread epidemics in 1971 and 1981. Male adults were predominantly affected by a "polio-like" paralysis of the limbs and/or cranial nerves. Root pains were often complained of early in the disease. In the absence of a necropsy, clinical and neurophysiological examinations helped to localise the lesions. Significant antibody titres against EV 70 were demonstrated in the serum and more relevantly in the CSF. Though other viruses can cause sporadic and epidemic conjunctivitis and similar paralysis independently, the combination of a haemorrhagic conjunctivitis and a neurological disease mostly simulating poliomyelitis is caused by EV 70 alone. It is therefore suggested that this combination be called "Enterovirus 70 disease". Because of its neurovirulence, it is important to identify this virus at the very beginning of an epidemic of conjunctivitis, so as to limit its spread by strict public health measures.

Adult polio-like syndrome following Enterovirus 70 conjunctivitis (natural history of the disease)

During the Indian EV 70 conjunctivitis epidemic in 1981, 79 patients with neurological complications were evaluated by clinical, electrophysiological, histopathological and virological studies. The disease was heralded by an attack of conjunctivitis and was followed, after a variable latent period, by a pre-paralytic, paralytic, and post-paralytic stage of slow recovery. The above events occurred in an orderly sequence. The paralysis affected the cranial nerves, limbs or both. The clinical course closely simulated poliomyelitis, without any evidence of radiculopathy or myelopathy. Cranial nerve palsies were seen in approximately half of the patients. The electrophysiological and histologicl studies pointed towards the affection of anterior horn cells. The raised neutralizing antibody titres to Enterovirus 70, confirmed the aetiology of the disease. On the available data, we believe that this nosological entity should be considered under the general title of "polio-like syndrome" following EV 70 conjunctivitis. On account of two epidemics in 1971 and 1981 with unfavourable prognosis and high resultant disability, and because of lack of specific therapy, it has become imperative to develop, as a top priority, a vaccine for immunization.

A benign motor neuron disorder: delayed cramps and fasciculation after poliomyelitis or myelitis

Two patients had a delayed syndrome of benign fasciculation after complete recovery from paralytic poliomyelitis and a third had the syndrome after an attack of purely motor myelitis. Myalgia was prominent in all three, and two had frequent cramps. Denervation hypertrophy occurred in two. The patients were observed for at least three years, and no new weakness was seen. These cases suggest that some chronic diseases of motor neurons may be benign.

The investigation of a recurrence of an AHC virus epidemic at Lucknow: a serosurvey for AHC virus antibodies before and after the epidemic

An epidemic of acute haemorrhagic conjunctivitis (AHC) recurred at Lucknow during July to September 1975, after a gap of 4 years. Out of the 35 cases investigated thoroughly, 20 Entero-70-like cytopathogenic agents were isolated from the conjunctiva which were neutralized by antisera against AHC virus J670/71 of Japan. Seroconversion was seen in 7 out of 11 paired sera from patients. Serological study was also done on 100 sera collected before the AHC epidemic of 1971, 100 sera after 1971 and 100 sera after 1975 epidemic. There were no neutralizing antibodies in the pre-epidemic period, while 18% of sera after the first epidemic and 32% after the second epidemic showed antibodies. The incidence of antibodies was highest (43%) in children aged below 10 years. Of the children born after the first epidemic, 44% had antibodies. Thus our findings show that the AHC virus appeared for the firt time at Lucknow in 1971 and the almost complete absence of disease in children, and its mildness during second epidemic, may be due to immunity.

Radiculomyelitis complicating acute haemorrhagic conjunctivitis. A clinical study

Fourteen patients with radiculomyelitis following acute haemorrhagic conjunctivitis (AHC) were seen in Bangkok during October to December 1974. Most patients developed weakness of extremities 2 weeks after AHC. Prodromal symptoms consisted of fever and malaise for a few days, followed by the acute onset of root pain in the legs and flaccid paralysis. Knee and ankle reflexes were absent or diminished. Cerebrospinal fluid examination revealed lymphocytosis and an increase in protein. Electromyographic findings were consistent with anterior horn cell or motor root lesions. Ten of the 12 cases in which virological studies were performed showed definite serological evidence of AHC virus infection. Six patients received corticosteroid treatment but apart from relief of pain no significant improvement was seen. Motor weakness in 10 patients was less at the end of 2 months, but in 4 it remained unchanged. The occurrence of disabling neurological sequelae calls for effective public health control of AHC outbreak.