Parainfectious encephalomyeloradiculitis associated with herpes simplex virus 1 DNA in cerebrospinal fluid

Encephalomyeloradiculitis after COVID-19 infection

A woman in her 20s presented with ascending weakness and paraesthesia along with flu-like symptoms. Neurological examination revealed right facial numbness along V2 distribution and flaccidity in her lower extremities, with a motor power of 0/5 throughout. The T4 sensory level and bilaterally positive Babinski sign were noted. Brain MRI revealed multiple bilateral T2/fluid attenuated inversion recovery hyperintense lesions with central enhancement involving the right trigeminal nerve. Full spine MRI demonstrated long-segment thoracic cord demyelination extending from T1 to T11 and nerve root enhancement. An extensive workup for infectious and autoimmune aetiologies was conducted, which revealed a positive COVID-19 result. The patient was diagnosed with encephalomyeloradiculitis secondary to COVID-19 infection. Encephalomyeloradiculitis is a rare neurological condition associated with various underlying conditions. Understanding the causes and differentiating these conditions is essential for appropriate treatment.

Infectious Myelopathies

PURPOSE OF REVIEW

This article reviews bacterial, viral, fungal, and parasitic pathogens associated with myelopathy. Infectious myelopathies may be due to direct infection or parainfectious autoimmune-mediated mechanisms; this article focuses primarily on the former.

RECENT FINDINGS

Some microorganisms exhibit neurotropism for the spinal cord (eg, enteroviruses such as poliovirus and flaviviruses such as West Nile virus), while others are more protean in neurologic manifestations (eg, herpesviruses such as varicella-zoster virus), and others are only rarely reported to cause myelopathy (eg, certain fungal and parasitic infections). Individuals who are immunocompromised are at increased risk of disseminated infection to the central nervous system. Within the last few years, an enterovirus D68 outbreak has been associated with cases of acute flaccid paralysis in children, and emerging Zika virus infection has been concurrent with cases of acute flaccid paralysis due to Guillain-Barré syndrome, although cases of myelitis have also been reported. Associated pathogens differ by geographic distribution, with myelopathies related to Borrelia burgdorferi (Lyme disease) and West Nile virus more commonly seen in the United States and parasitic infections encountered more often in Latin America, Southeast Asia, and Africa. Characteristic CSF and MRI patterns have been identified with many of these infections.

SUMMARY

A myriad of pathogens are associated with infectious myelopathies. Host factors, geographic distribution, clinical features, CSF profiles, and MRI findings can assist in formulating the differential diagnosis and ultimately guide management.

Severe presentation of antibody-negative, postinfectious steroid-responsive encephalitis and atonic bladder after herpes simplex encephalitis

A 75-year-old woman presented with new onset of confusion, intense episodic dizziness and formed visual hallucinations. Herpes simplex encephalitis and non-convulsive temporal lobe seizures were confirmed with cerebrospinal fluid (CSF) and electroencephalography testing. In addition, her hospital course was complicated by syndrome of inappropriate antidiuretic hormone secretion and atonic bladder contributing to an episode of urinary tract infection. After completing 3 weeks of acyclovir treatment, the patient became obtunded with right arm choreiform movements and persistent inflammatory CSF findings not attributable to persistent herpes simplex virus infection or other confounding factors. The patient responded to steroid treatment. Repeated autoimmune and paraneoplastic evaluations were negative. Both clinical (cognitive testing and atonic bladder) and CSF inflammatory finding improved in the follow-up period.

A case of urinary retention in the early stages of herpes simplex virus type-1 encephalitis

A 70-year-old man developed urinary retention in the early stages of herpes simplex virus (HSV) type-1 encephalitis. A nerve conduction study suggested latent myeloradiculitis. This is the first report of human herpes simplex virus-1 encephalitis followed by urinary retention at early stage from the onset like the Elsberg syndrome. Although relatively few similar cases have been reported, we consider that urinary retention is common in HSV-1 encephalitis, in which disturbances of consciousness usually require bladder catheterization from the onset. We further emphasize that urinary retention may occasionally occur in early stages of HSV-1 encephalitis, with a significant possibility of recovery.

Parainfectious encephalomyeloradiculitis associated with bacterial meningitis: a case report

Introduction

Acute disseminated encephalomyelitis in adulthood occurs in most cases after a viral infection. Acute disseminated encephalomyelitis associated with bacterial meningitis, however, is quite rare.

Case presentation

An 82-year-old Japanese woman presented with a fever and somnolence. Increased neutrophil count and protein content, and decreased glucose levels in her cerebrospinal fluid initially suggested bacterial meningitis. Brain magnetic resonance imaging on admission showed bilateral symmetrical lesions in her brainstem and her cerebellum. She was diagnosed with acute disseminated encephalomyelitis following bacterial meningitis. Even though appropriate antibiotic and steroid treatment improved her symptoms, she developed transverse myelitis and lumbosacral polyradiculitis on day 9.

Conclusions

Parainfectious encephalomyeloradiculitis, a variant of acute disseminated encephalomyelitis, is a unique neurological syndrome that may be caused by bacterial infection in the central nervous system.

Transverse myelitis

Transverse myelitis (TM) includes a pathobiologically heterogeneous syndrome characterized by acute or subacute spinal cord dysfunction resulting in paresis, a sensory level, and autonomic (bladder, bowel, and sexual) impairment below the level of the lesion. Etiologies for TM can be broadly classified as parainfectious, paraneoplastic, drug/toxin-induced, systemic autoimmune disorders, and acquired demyelinating diseases. We discuss the clinical evaluation, workup, and acute and long-term management of patients with TM. Additionally, we briefly discuss various disease entities that may cause TM and their salient distinguishing features, as well as disorders that may mimic TM.

"Meningitis-retention syndrome": a review

AIMS

A peculiar combination of acute urinary retention and aseptic meningitis has been described. This combination is referred to as meningitis-retention syndrome (MRS), since patients with this syndrome exhibited no other abnormalities, except for mild pyramidal involvement. We aimed to delineate this syndrome by reviewing literatures.

METHODS

We performed a systematic review of the literature to identify the frequency, clinical symptoms, urodynamic findings, putrative underlying pathology, and management of this syndrome.

RESULTS

Patients with MRS have typical symptoms of fever, headache, stiff neck, and minor pyramidal signs, together with acute urinary retention. The bladder is initially areflexic, but soon becomes either normal or overactive in the repeated urodynamics during the course of the disorder. MRS is thought to be a very mild form of acute disseminated encephalomyelopathy (ADEM), with increased cell count, total protein, and occasional myelin basic protein in the cerebrospinal fluid. Proper management of the acute urinary retention is necessary to avoid bladder injury due to overdistension. The effectiveness of immune treatments (e.g., steroid pulse therapy) in shortening the urinary retention period awaits further study.

CONCLUSIONS

Although rare, MRS is a disorder that both urologists and neurologists may encounter. MRS should be listed in the differential diagnosis of acute urinary retention.

Central nervous system infections of herpesvirus family

Herpesviruses are one of the most common groups of pathogens causing central nervous system infections in humans. They mostly cause encephalitis, meningitis, or myelitis in immunocompetent and immunocompromised patients. Children, adults, and the elderly can all be affected. Although contrast-enhanced CT is more widely used for diagnosis, contrast-enhanced MR imaging combined with diffusion-weighted imaging is superior to CT in the detection of early changes and the real extent of the disease, and in assessing prognosis and monitoring response to antiviral treatment. More sophisticated techniques, such as MR spectroscopy and perfusion imaging, can aid in the differential diagnosis of herpesvirus infections from other tumoral, demyelinating, and ischemic processes.

Herpes simplex virus type-1 meningoencephalitis showing disseminated cortical lesions

We report a 41-year-old man with meningoencephalitis associated with herpes simplex virus type 1 (HSV-1). The patient developed fever, headache and dysuria followed by generalized convulsion and neck stiffness, and the CSF showed pleocytosis. The titers of enzyme-linked immunosorbent assay against HSV measured 6 days after onset showed a significant rise; IgG antibody 4.89 (<0.2) and IgM antibody 1.45 (<0.8) in CSF, IgG antibody 46.1 (<2.0) and IgM antibody 1.76 (<0.8) in the serum. The antibody index for IgG was 0.50, and that for IgM was 4.2. CFS neutralization test showed HSV-1 antibody of x16 and HSV-2 antibody of <x4. MRI showed atypical features: disseminated cortical lesions without massive hemispheric involvement. All of the cortical lesions were small and appeared to be located in the gray matter. The patient recovered with acyclovir. This report demonstrates that disseminated encephalitis can be a feature of acute HSV-1 infection.

Acute urinary retention due to benign inflammatory nervous diseases

Both neurologists and urologists might encounter patients with acute urinary retention due to benign inflammatory nervous diseases. Based on the mechanism of urinary retention, these disorders can be divided into two subgroups: disorders of the peripheral nervous system (e.g., sacral herpes) or the central nervous system (e.g., meningitis-retention syndrome [MRS]). Laboratory abnormalities include increased herpes virus titers in sacral herpes, and increased myelin basic protein in the cerebrospinal fluid (CSF) in some cases with MRS. Urodynamic abnormality in both conditions is detrusor areflexia; the putative mechanism of it is direct involvement of the pelvic nerves in sacral herpes; and acute spinal shock in MRS. There are few cases with CSF abnormality alone. Although these cases have a benign course, management of the acute urinary retention is necessary to avoid bladder injury due to overdistension. Clinical features of sacral herpes or MRS differ markedly from those of the original "Elsberg syndrome" cases.

Aseptic meningo-radiculo-encephalitis presenting initially with urinary retention: a variant of acute disseminated encephalomyelitis

We report three male patients with aseptic meningoencephalo- radiculitis presenting with acute urinary retention. Viral antibody titers for herpes types I and II and the PCR studies were negative. The cerebrospinal fluid revealed elevated myelin basic protein. The serum antibodies against a panel of gangliosides, some of which are known to be associated with acquired demyelinating neuropathies, were all negative. The magnetic resonance imaging (MRI) studies revealed spotty T2 high intensities in the basal ganglia, thalamus and brainstem in two patients. In one patient,meningeal gadolinium enhancement of the conus and cauda equina of the spinal cord was recognized. On urodynamic studies, all patients showed features of atonic bladder with or without detrusor hyperactivity. They were treated conservatively without using steroids or immunoglobulins, and made a remarkable functional recovery with the disappearance of abnormal MRI findings.However, all three were left with erectile dysfunction, and two continued to use self-intermittent catheterization at more than 3-year follow-up. There was no recurrence of symptoms. The underlying causes remain unclear, though they may represent a variant of acute disseminated encephalomyelitis.

Extra temporal involvement in herpes simplex encephalitis

Temporal lobe abnormalities on brain imaging have been described as strong evidence for herpes simplex encephalitis (HSE) in appropriate clinical settings. Extra temporal abnormalities are less well described in these patients. We retrospectively reviewed 20 patients of HSE and found extra temporal involvement in 11 (55%) patients. Three patients (15 %) had pure extra temporal abnormalities. Twelve patients (60%) had temporal lobe involvement, four patients (20%) had pure temporal lobe involvement and five patients (25%) had normal CT/MRI scans. Our study suggests that extra temporal involvement on brain imaging is common in HSE and in a significant minority of the patients this can even be the sole abnormality.

Life-threatening cutaneous viral diseases

Most viral infections present with a cutaneous eruption that in the greater majority of cases is self-healing. Only in rare instances is the eruption accompanied by constitutional symptoms, and even more rarely, irreversible damage may occur or death may ensue. As with other infectious diseases, prognosis depends on the status of immunologic surveillance. Immunodepressed patients are, therefore, at the greatest risk. It has become more evident, however, that even in immunocompetent patients, eruption that were considered not long ago as benign diseases may in fact result in complications and even death. The introduction of polymerase chain reaction assays has allowed us to attribute conditions to a specific viral infection, which in the past was not possible. Therefore, dermatologists may come across, directly or during consultation, patients presenting with skin lesions that may be related to a viral disease and may lead to possible severe systemic complications. Dermatologists, however, may not be prepared for such developments, and thus the goal of this article is to suggest some of the possibilities. Discussing all the viral diseases that may present with cutaneous manifestations would be cumbersome; thus this article will be limited to the diseases that may endanger the life of a patient who is seeking dermatologic advice and who does not seem to have, at first sight, severe systemic involvement.