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Tang A, Yoshida K, Lahey H, Wilcox DR, Guan H, Costenbader K, Solomon D, Miyawaki EK, Bhattacharyya S. Herpes Simplex Virus Encephalitis in Patients With Autoimmune Conditions or Exposure to Immunomodulatory Medications. Neurology 2024; 102:e209297. [PMID: 38696733 PMCID: PMC11177586 DOI: 10.1212/wnl.0000000000209297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 02/06/2024] [Indexed: 05/04/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Among infectious etiologies of encephalitis, herpes simplex virus type 1 (HSV-1) is most common, accounting for ∼15%-40% of adult encephalitis diagnoses. We aim to investigate the association between immune status and HSV encephalitis (HSVE). Using a US Medicaid database of 75.6 million persons, we evaluated the association between HSVE and autoimmune conditions, exposure to immunosuppressive and immunomodulatory medications, and other medical comorbidities. METHODS We used the US Medicaid Analytic eXtract data between 2007 and 2010 from the 29 most populated American states. We first examined the crude incidence of HSVE in the population. We then age and sex-matched adult cases of HSVE with a sufficient enrollment period (12 months before HSVE diagnosis) to a larger control population without HSVE. In a case-control analysis, we examined the association between HSVE and exposure to both autoimmune disease and immunosuppressive/immunomodulatory medications. Analyses were conducted with conditional logistic regression progressively adjusting for sociodemographic factors, Charlson Comorbidity Index, and non-autoimmune comorbidities. RESULTS Incidence of HSVE was ∼3.01 per 105 person-years among adults. A total of 951 HSVE cases and 95,100 age and sex-matched controls were compared. The HSVE population had higher rates of medical comorbidities than the control population. The association of HSVE and autoimmune conditions was strong (adjusted odds ratio (OR) 2.6; 95% CI 2.2-3.2). The association of HSVE and immunomodulating medications had an OR of 2.2 (CI 1.9-2.6), also after covariate adjustment. When both exposures were included in regression models, the associations remained robust: OR 2.3 (CI 1.9-2.7) for autoimmune disease and 2.0 (CI 1.7-2.3) for immunosuppressive and immunomodulatory medications. DISCUSSION In a large, national population, HSVE is strongly associated with preexisting autoimmune disease and exposure to immunosuppressive and immunomodulatory medications. The role of antecedent immune-related dysregulation may have been underestimated to date.
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Affiliation(s)
- Alice Tang
- From the Division of Rheumatology, Inflammation and Immunity (K.Y., H.G., K.C., D.S.), and Department of Neurology (A.T., D.R.W., E.K.M., S.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Frank H. Netter MD School of Medicine at Quinnipiac University (H.L.), North Haven, CT; and Department of Neurology, Neuroimmunology and Neuro-Infectious Diseases Division (D.R.W.), Massachusetts General Hospital
| | - Kazuki Yoshida
- From the Division of Rheumatology, Inflammation and Immunity (K.Y., H.G., K.C., D.S.), and Department of Neurology (A.T., D.R.W., E.K.M., S.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Frank H. Netter MD School of Medicine at Quinnipiac University (H.L.), North Haven, CT; and Department of Neurology, Neuroimmunology and Neuro-Infectious Diseases Division (D.R.W.), Massachusetts General Hospital
| | - Hannah Lahey
- From the Division of Rheumatology, Inflammation and Immunity (K.Y., H.G., K.C., D.S.), and Department of Neurology (A.T., D.R.W., E.K.M., S.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Frank H. Netter MD School of Medicine at Quinnipiac University (H.L.), North Haven, CT; and Department of Neurology, Neuroimmunology and Neuro-Infectious Diseases Division (D.R.W.), Massachusetts General Hospital
| | - Douglas R Wilcox
- From the Division of Rheumatology, Inflammation and Immunity (K.Y., H.G., K.C., D.S.), and Department of Neurology (A.T., D.R.W., E.K.M., S.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Frank H. Netter MD School of Medicine at Quinnipiac University (H.L.), North Haven, CT; and Department of Neurology, Neuroimmunology and Neuro-Infectious Diseases Division (D.R.W.), Massachusetts General Hospital
| | - Hongshu Guan
- From the Division of Rheumatology, Inflammation and Immunity (K.Y., H.G., K.C., D.S.), and Department of Neurology (A.T., D.R.W., E.K.M., S.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Frank H. Netter MD School of Medicine at Quinnipiac University (H.L.), North Haven, CT; and Department of Neurology, Neuroimmunology and Neuro-Infectious Diseases Division (D.R.W.), Massachusetts General Hospital
| | - Karen Costenbader
- From the Division of Rheumatology, Inflammation and Immunity (K.Y., H.G., K.C., D.S.), and Department of Neurology (A.T., D.R.W., E.K.M., S.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Frank H. Netter MD School of Medicine at Quinnipiac University (H.L.), North Haven, CT; and Department of Neurology, Neuroimmunology and Neuro-Infectious Diseases Division (D.R.W.), Massachusetts General Hospital
| | - Daniel Solomon
- From the Division of Rheumatology, Inflammation and Immunity (K.Y., H.G., K.C., D.S.), and Department of Neurology (A.T., D.R.W., E.K.M., S.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Frank H. Netter MD School of Medicine at Quinnipiac University (H.L.), North Haven, CT; and Department of Neurology, Neuroimmunology and Neuro-Infectious Diseases Division (D.R.W.), Massachusetts General Hospital
| | - Edison K Miyawaki
- From the Division of Rheumatology, Inflammation and Immunity (K.Y., H.G., K.C., D.S.), and Department of Neurology (A.T., D.R.W., E.K.M., S.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Frank H. Netter MD School of Medicine at Quinnipiac University (H.L.), North Haven, CT; and Department of Neurology, Neuroimmunology and Neuro-Infectious Diseases Division (D.R.W.), Massachusetts General Hospital
| | - Shamik Bhattacharyya
- From the Division of Rheumatology, Inflammation and Immunity (K.Y., H.G., K.C., D.S.), and Department of Neurology (A.T., D.R.W., E.K.M., S.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Frank H. Netter MD School of Medicine at Quinnipiac University (H.L.), North Haven, CT; and Department of Neurology, Neuroimmunology and Neuro-Infectious Diseases Division (D.R.W.), Massachusetts General Hospital
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Shrestha GS, Nepal G, Prust ML. Developing Systems of Emergency and Inpatient Neurologic Care in Resource-Limited Settings. Semin Neurol 2024; 44:105-118. [PMID: 38485125 DOI: 10.1055/s-0043-1778638] [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: 04/19/2024]
Abstract
Neurologic diseases represent a significant global health challenge, leading to disability and mortality worldwide. Healthcare systems in low- and middle-income countries are disproportionally affected. In these resource-limited settings, numerous barriers hinder the effective delivery of emergency and inpatient neurologic care, including shortages of trained personnel, limited access to diagnostics and essential medications, inadequate facilities, and absence of rehabilitation services. Disparities in the neurology workforce, limited access to neuroimaging, and availability of acute interventions further exacerbate the problem. This article explores strategies to enhance global capacity for inpatient neurologic care, emphasizing the importance of workforce development, context-specific protocols, telehealth solutions, advocacy efforts, and collaborations.
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Affiliation(s)
- Gentle Sunder Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Gaurav Nepal
- Department of General Medicine, Rani Primary Healthcare Centre, Rani, Biratnagar, Nepal
| | - Morgan Lippitt Prust
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
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Granerod J, Huang Y, Davies NWS, Sequeira PC, Mwapasa V, Rupali P, Michael BD, Solomon T, Easton A. Global Landscape of Encephalitis: Key Priorities to Reduce Future Disease Burden. Clin Infect Dis 2023; 77:1552-1560. [PMID: 37436770 PMCID: PMC10686956 DOI: 10.1093/cid/ciad417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/28/2023] [Accepted: 07/10/2023] [Indexed: 07/13/2023] Open
Abstract
Encephalitis affects people across the lifespan, has high rates of mortality and morbidity, and results in significant neurological sequelae with long-term consequences to quality of life and wider society. The true incidence is currently unknown due to inaccurate reporting systems. The disease burden of encephalitis is unequally distributed across the globe being highest in low- and middle-income countries where resources are limited. Here countries often lack diagnostic testing, with poor access to essential treatments and neurological services, and limited surveillance and vaccination programs. Many types of encephalitis are vaccine preventable, whereas others are treatable with early diagnosis and appropriate management. In this viewpoint, we provide a narrative review of key aspects of diagnosis, surveillance, treatment, and prevention of encephalitis and highlight priorities for public health, clinical management, and research, to reduce the disease burden.
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Affiliation(s)
- Julia Granerod
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, United Kingdom
- Dr JGW Consulting Ltd., London, United Kingdom
| | - Yun Huang
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, United Kingdom
- National Institute for Health and Care Research (NIHR) Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, United Kingdom
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | | | | | - Victor Mwapasa
- University of Malawi, College of Medicine, Blantyre, Malawi
| | - Priscilla Rupali
- Department of Infectious Diseases, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - Benedict D Michael
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, United Kingdom
- National Institute for Health and Care Research (NIHR) Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, United Kingdom
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Tom Solomon
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, United Kingdom
- National Institute for Health and Care Research (NIHR) Health Protection Research Unit for Emerging and Zoonotic Infection, Liverpool, United Kingdom
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
- The Pandemic Institute, Liverpool, United Kingdom
| | - Ava Easton
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, United Kingdom
- The Encephalitis Society, Malton, United Kingdom
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Seasonal variation in autoimmune encephalitis: A multi-center retrospective study. J Neuroimmunol 2021; 359:577673. [PMID: 34333343 DOI: 10.1016/j.jneuroim.2021.577673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 07/14/2021] [Accepted: 07/21/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The aim of this study was to examine the seasonal distribution in clinical onset of autoimmune encephalitis (AE) in a multi-center cohort in China. METHODS This retrospective study consecutively recruited patients with new-onset definite neuronal surface antibody-associated AE between January 2015 and December 2020 from 3 tertiary hospitals. Demographic and clinical characteristics of the participants were comprehensively collected. Statistical analyses were performed using R. RESULTS Of the 184 patients of AE in our database, 149 (81.0%) were included in the final analysis. The median age of onset was 40.0 years, and 66 (44.3%) patients were female. AE predominantly started in autumn (47, 31.5%) and summer (43, 28.9%) months. Summer-autumn predominance of the clinical onsets was also present in the anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis group (54, 60.0%) and anti-leucine-rich glioma inactivated 1 (LGI1) encephalitis group (20, 76.9%). No obvious seasonal variations were observed among gender, onset age, disease duration, prodromal symptoms, clinical type of initial symptoms, and disease severity by the time of admission. CONCLUSION This study suggested summer-autumn predominance of the clinical onsets in patients with AE, especially anti-NMDAR and anti-LGI1 encephalitis. Therefore, clinicians should have a high index of suspicion for AE in encephalopathy patients in summer and autumn period.
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Lu B, Cai Y, Yin J, Wang J, Jia Z, Hu W, Fang J. HSV encephalitis after successful minimally invasive debridement for infected pancreatic necrosis: A case of rare central nervous system complication. EUR J INFLAMM 2021. [DOI: 10.1177/20587392211000571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Patients with acute pancreatitis (AP) often suffer tough complications, some of which are fatal. The early diagnosis and definite treatment of central nervous system (CNS) complications have not been fully achieved yet, which seriously affects the mortality of severe acute pancreatitis (SAP). We present a case of infected pancreatic necrosis (IPN) in a 62-year Chinese man who developed acute herpes simplex encephalitis (HSE) caused by herpes simplex virus type 1 (HSV-1) after favorable minimally invasive retroperitoneal approaches (MIRAs). The patient was successfully treated with 115 days stayed in our hospital. The MIRAs included image-guided retroperitoneal percutaneous catheter drainage (PCD), nephroscopic pancreatic necrosectomy (NPN), and ultrasonic pneumatic lithotripsy system (UPLS) assisted non-narcotic sinus track necrosectomy (NSN). HSE is relatively rare and potentially life threatening. We attempt to discuss the probable risk factors and how the relatively rare HSE are related to the patients of SAP with latent HSV.
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Affiliation(s)
- Bei Lu
- Department of Hepato-Pancreato-Biliary Surgery, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yang Cai
- Department of Hepato-Pancreato-Biliary Surgery, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Junjie Yin
- Department of Hepato-Pancreato-Biliary Surgery, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jingrui Wang
- Department of Hepato-Pancreato-Biliary Surgery, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Zhong Jia
- Department of Hepato-Pancreato-Biliary Surgery, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Wei Hu
- Department of Intensive Care Unit, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jianhua Fang
- Department of Ultrasonography, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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Nelson C, Mori N, Ton T, Zunt J, Kochel T, Romero A, Gadea N, Tilley D, Ticona E, Soria J, Celis V, Huanca D, Delgado A, Rivas M, Stiglich M, Sihuincha M, Donayre G, Celis J, Romero R, Tam N, Tipismana M, Espinoza I, Rozas M, Peralta A, Sanchez E, Vasquez L, Muñoz P, Ramirez G, Reyes I. Building a network for multicenter, prospective research of central nervous system infections in South America: Process and lessons learned. eNeurologicalSci 2018; 13:63-69. [PMID: 30547106 PMCID: PMC6284170 DOI: 10.1016/j.ensci.2018.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 03/01/2018] [Accepted: 07/03/2018] [Indexed: 11/21/2022] Open
Abstract
Multicenter collaborative networks are essential for advancing research and improving clinical care for a variety of conditions. Research networks are particularly important for central nervous system infections, which remain difficult to study due to their sporadic occurrence and requirement for collection and testing of cerebrospinal fluid. Establishment of long-term research networks in resource-limited areas also facilitates diagnostic capacity building, surveillance for emerging pathogens, and provision of appropriate treatment where needed. We review our experience developing a research network for encephalitis among twelve hospitals in five Peruvian cities since 2009. We provide practical suggestions to aid other groups interested in advancing research on central nervous system infections in resource-limited areas.
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Affiliation(s)
- Christina Nelson
- Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
- Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
| | - Nicanor Mori
- Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
- US Naval Medical Research Unit-6, Callao, Peru
| | - Thanh Ton
- Department of Neurology, School of Medicine, University of Washington, Seattle, WA, USA
| | - Joseph Zunt
- Department of Neurology, School of Medicine, University of Washington, Seattle, WA, USA
- Departments of Global Health and Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | | | - T. Kochel
- US Naval Medical Research Unit-6, Callao, Peru
| | - A. Romero
- US Naval Medical Research Unit-6, Callao, Peru
| | - N. Gadea
- US Naval Medical Research Unit-6, Callao, Peru
| | - D. Tilley
- US Naval Medical Research Unit-6, Callao, Peru
| | | | - J. Soria
- Dos de Mayo Hospital, Lima, Peru
| | | | - D. Huanca
- Hospital Edgardo Rebagliati Martins, Lima, Peru
| | - A. Delgado
- Hospital Edgardo Rebagliati Martins, Lima, Peru
| | - M. Rivas
- Hospital San Bartolome, Lima, Peru
| | | | | | - G. Donayre
- Hospital Felipe Santiago Arriola Iglesias, Loreto, Peru
| | - J. Celis
- Hospital Felipe Santiago Arriola Iglesias, Loreto, Peru
| | - R. Romero
- Hospital Daniel Alcides Carrion, Callao, Peru
| | - N. Tam
- Hospital Daniel Alcides Carrion, Callao, Peru
| | | | | | - M. Rozas
- Hospital Regional Cusco, Cusco, Peru
| | - A. Peralta
- Hospital Carlos Alberto Seguin, Arequipa, Peru
| | | | | | - P. Muñoz
- Hospital Hipolito Unanue, Lima, Peru
| | - G. Ramirez
- Hospital Emergencias Pediatricas, Lima, Peru
| | - I. Reyes
- Hospital Emergencias Pediatricas, Lima, Peru
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