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Rodrigues RM, Farhat SCL, Lucato LT, Sakano TMS, Plaggert PSG, Casella EB, da Paz JA, Schvartsman C. Post-varicella arterial ischemic stroke in children and neurocognitive performance: a 4-year follow-up study. EINSTEIN-SAO PAULO 2022; 20:eAO6360. [PMID: 35544890 PMCID: PMC9070992 DOI: 10.31744/einstein_journal/2022ao6360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 04/24/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To analyze data from children who were previously healthy and presented with post-varicella arterial ischemic stroke upon arrival when admitted to the emergency room, with focus on the clinical/laboratory aspects, and neurocognitive performance after four-year follow-up. METHODS Seven children presenting with arterial ischemic stroke after varicella were evaluated at pediatric emergency services in the city of São Paulo (SP), Brazil. Ischemic stroke was determined by magnetic resonance imaging/magnetic resonance angiography in a topography compatible with the areas supplied by the middle cerebral or internal carotid arteries. IgG-class antibodies against varicella zoster virus and varicella-zoster virus DNA by polymerase chain reaction in cerebrospinal fluid were tested. Patients with prothrombotic conditions were excluded. The Pediatric Stroke Outcome Measure was applied upon admission and 4-years after the stroke. RESULTS All patients (age range: 1.3 to 4 years) included presented chickenpox 5.1 (±3.5) months before. All patients had analysis of anti-varicella-zoster-virus-IgG in cerebrospinal fluid, but only three (43%) had a positive result. Of the patients 43% had no vascular lesions identified in magnetic resonance angiography. All patients showed improvement in their sequela scores. After 4 years, five patients displayed good evolution in the Pediatric Stroke Outcome Measure, and only one patient presented with a score of 2 in the sensorimotor and cognition areas. No recurrence of arterial ischemic stroke was observed. CONCLUSION We reinforced the non-progressive course of post-varicella arterial ischemic stroke after 4-year follow-up. The presence of varicella-zoster-virus-DNA detected by polymerase chain reaction, and/or intrathecal IgG antibody against varicella zoster virus, and angiopathy location in magnetic resonance angiography were not determining for the diagnosis. Invasive tests, with low sensitivity, should be well considered in the diagnosis of post-varicella arterial ischemic stroke.
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Affiliation(s)
- Regina Maria Rodrigues
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrazil Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Sylvia Costa Lima Farhat
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrazil Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Leandro Tavares Lucato
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrazilHospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Tania Miyuki Shimoda Sakano
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrazil Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Paulo Scatulin Gerritsen Plaggert
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrazil Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Erasmo Barbante Casella
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - José Albino da Paz
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrazil Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Cláudio Schvartsman
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
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Bertamino M, Signa S, Vagelli G, Caorsi R, Zanetti A, Volpi S, Losurdo G, Amico G, Dodi I, Prato G, Ronchetti AB, Di Rocco M, Nagel M, Severino M. An atypical case of post-varicella stroke in a child presenting with hemichorea followed by late-onset inflammatory focal cerebral arteriopathy. Quant Imaging Med Surg 2021; 11:463-471. [PMID: 33392044 DOI: 10.21037/qims-20-628] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Marta Bertamino
- Rehabilitation Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Sara Signa
- Department of Neuroscience, Ophthalmology, Genetics and Maternal Infantile Sciences (DINOGMI), University of Genoa, Genoa, Italy.,Autoinflammatory Diseases and Immunodeficiencies Center, IRCCS Istituto Gianina Gaslini, Genoa, Italy
| | - Giulia Vagelli
- Department of Neuroscience, Ophthalmology, Genetics and Maternal Infantile Sciences (DINOGMI), University of Genoa, Genoa, Italy
| | - Roberta Caorsi
- Autoinflammatory Diseases and Immunodeficiencies Center, IRCCS Istituto Gianina Gaslini, Genoa, Italy
| | - Alice Zanetti
- Rehabilitation Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Stefano Volpi
- Department of Neuroscience, Ophthalmology, Genetics and Maternal Infantile Sciences (DINOGMI), University of Genoa, Genoa, Italy.,Autoinflammatory Diseases and Immunodeficiencies Center, IRCCS Istituto Gianina Gaslini, Genoa, Italy
| | - Giuseppe Losurdo
- Infectious Diseases Unit, IRCCS Istituto Gianina Gaslini, Genoa, Italy
| | - Giulia Amico
- Department of Neuroscience, Ophthalmology, Genetics and Maternal Infantile Sciences (DINOGMI), University of Genoa, Genoa, Italy.,Laboratory of Genetic and Genomics of Rare Disease, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Icilio Dodi
- Emergency Unit, Pietro Barilla Children Hospital, Parma, Italy
| | - Giulia Prato
- Child Neuropsychiatry Unit, IRCCS Istituto Gianina Gaslini, Genoa, Italy
| | | | - Maja Di Rocco
- Rare Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Maria Nagel
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
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Infections causing stroke or stroke-like syndromes. Infection 2020; 48:323-332. [PMID: 32239441 DOI: 10.1007/s15010-020-01415-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/20/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Stroke has relevant morbidity and mortality despite appropriate treatments and early diagnosis. Beside common risk factors such as diabetes and atrial fibrillation, infections can be involved in stroke pathogenesis, probably causing a systemic release of cytokines and other inflammatory mediators, triggering a latent pro-thrombotic state or damaging the vascular endothelium. In other cases, infections can occur as stroke-like syndromes, requiring a high grade of suspicion to avoid a delay in establishing a correct diagnosis. RESULTS Treatment of stroke or stroke-like syndromes of infectious origin can be difficult. When a previous infective event triggers stroke, Alteplase administration can be associated with a higher incidence of bleeding and the extension of the ischaemic area can be major than expected. On the other hand, when stroke is part of some infectious diseases' presentation as in endocarditis, bacterial or tuberculous meningitis and meningo-vascular syphilis, a correct diagnosis can be difficult. The management of these stroke-like syndromes is not standardised because common treatments proven to be effective for patients with stroke of vascular origin can worsen the prognosis, as it can be demonstrated after to be incorrect Alteplase administration to patients with endocarditis with septic embolism to the brain is associated with an increase of the risk of haemorrhage. CONCLUSIONS Stroke or stroke-like syndrome of infectious origin can be observed in an important proportion of case presenting with sensory-motor deficit of unknown origin; their accurate diagnosis has a considerable impact in terms of treatment choices and outcome.
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Liu CH, Yeh YC, Huang WT, Chie WC, Chan KA. Assessment of pre-specified adverse events following varicella vaccine: A population-based self-controlled risk interval study. Vaccine 2020; 38:2495-2502. [PMID: 32046891 DOI: 10.1016/j.vaccine.2020.01.090] [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: 10/13/2019] [Revised: 12/20/2019] [Accepted: 01/30/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Clinical trials and spontaneous reporting systems have revealed rare but biologically plausible adverse events following varicella immunization. Few post-marketing controlled studies have been conducted to assess the relationship between the varicella vaccine and these outcomes. OBJECTIVES To evaluate the risk of pneumonia, idiopathic thrombocytopenic purpura (ITP), meningitis, encephalitis and ischemic stroke following varicella immunization. MATERIALS AND METHODS This nationwide observational study was based on Taiwan National Health Insurance data and National Immunization Information System from 2004 through 2014. Primary analysis included children aged 12-35 months who received the single varicella vaccine on the date of administration. The self-controlled risk interval design compared the incidence of pre-specified outcomes during a risk interval of 1-42 days post-vaccination and a control interval of 43-84 days. The outcomes of interest were defined as admitted pneumonia, ITP, meningitis, encephalitis, and ischemic stroke, as well as fracture as a negative control. Conditional Poisson regression was used to assess the incidence rate ratio (aIRR) with adjustments for age and seasonal effects. RESULTS Among 1,194,189 children, who receiving the varicella vaccine, there was no observed increase in the risk for ITP (aIRR 1.00; 95% CI, 0.76-1.33), meningitis (aIRR 1.21; 95% CI, 0.49-2.95), encephalitis (aIRR 1.00; 95% CI, 0.62-1.60), or ischemic stroke (aIRR 1.24; 95% CI, 0.31-4.95). A clustering feature with pneumonia occurred during days 36-42 post-vaccination (aIRR 1.10; 95% CI, 1.02-1.18). An increase in the risk for ITP was observed in children receiving the varicella and MMR vaccines concomitantly (aIRR 1.70; 95% CI, 1.19-2.43), but not among those receiving the varicella vaccine only. CONCLUSIONS We detected a small risk of incidental pneumonia associated with varicella vaccine in the 6th week after immunization. There was no increase in the risk of other pre-specified adverse events.
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Affiliation(s)
- Chia-Hung Liu
- Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan; Department of Family Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Department of Family Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yi-Chun Yeh
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
| | - Wan-Ting Huang
- Taiwan Centers for Disease Control, Ministry of Health and Welfare, Taipei, Taiwan.
| | - Wei-Chu Chie
- Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - K Arnold Chan
- Health Data Research Center, National Taiwan University, Taipei, Taiwan
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Herpes zoster in the context of varicella vaccination – An equation with several variables. Vaccine 2018; 36:7072-7082. [DOI: 10.1016/j.vaccine.2018.09.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 09/07/2018] [Accepted: 09/10/2018] [Indexed: 12/12/2022]
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Davico C, Canavese C, Tocchet A, Brusa C, Vitiello B. Acute Hemichorea Can Be the Only Clinical Manifestation of Post-Varicella Vasculopathy: Two Pediatric Clinical Cases. Front Neurol 2018; 9:164. [PMID: 29615962 PMCID: PMC5869195 DOI: 10.3389/fneur.2018.00164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/05/2018] [Indexed: 11/13/2022] Open
Abstract
Acute hemichorea can occur in the context of infectious, autoimmune, metabolic, toxic, and vascular neuropathologies. Primary infection by varicella zoster virus (VZV) can result in vasculopathy with neurological manifestations, such as hemiparesis, at times accompanied by hemichorea. Isolated hemichorea, however, had not been reported. We here describe two cases of VZV-induced vasculopathy whose sole clinical manifestation was acute hemichorea. Both cases involved young boys of 3 years of age, who presented with acute hemichorea 4–6 months after initial VZV infection. All hematological, immunological, and toxicological tests were normal, except for the presence of VZV IgG. Brain structural magnetic resonance imaging (MRI) and magnetic resonance angiography revealed specific signs of vasculitis and ischemic lesions in the basal ganglia region (lentiform nucleus, thalamus, and internal capsule). Following corticosteroid and acetylsalicylic acid treatment, full symptomatic recovery was achieved within 3 weeks. Repeated MRI documented full neurostructural recovery, which was confirmed at extended follow-up for more than 1 year. These cases indicate that VZV-induced vasculopathy should be considered in the case of pediatric isolated acute hemichorea.
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Affiliation(s)
- Chiara Davico
- Division of Child and Adolescent Neuropsychiatry, University of Turin, Turin, Italy
| | - Carlotta Canavese
- Division of Child and Adolescent Neuropsychiatry, University of Turin, Turin, Italy
| | - Aba Tocchet
- Division of Child and Adolescent Neuropsychiatry, University of Turin, Turin, Italy
| | - Chiara Brusa
- Division of Child and Adolescent Neuropsychiatry, University of Turin, Turin, Italy
| | - Benedetto Vitiello
- Division of Child and Adolescent Neuropsychiatry, University of Turin, Turin, Italy
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Helmuth IG, Mølbak K, Uldall PV, Poulsen A. Post-varicella Arterial Ischemic Stroke in Denmark 2010 to 2016. Pediatr Neurol 2018; 80:42-50. [PMID: 29307566 DOI: 10.1016/j.pediatrneurol.2017.11.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 10/17/2017] [Accepted: 11/27/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Varicella, most often a benign disease of childhood, is associated with an increased risk of arterial ischemic stroke in children. The aim of the present study was to estimate the incidence of post-varicella arterial ischemic stroke in the Danish child population and describe clinical characteristics of children admitted with post-varicella arterial ischemic stroke. METHODS In the Danish National Patient Register, we identified inpatients 28 days to 16 years of age with a discharge diagnosis of stroke or cerebrovascular disease from 2010 to 2016. Medical files were reviewed, and children with arterial ischemic stroke and varicella infection less than 12 months before onset of symptoms were included. RESULTS We identified 15 children with arterial ischemic stroke and varicella less than 12 months before. In nine children, the diagnosis was confirmed by detection of varicella zoster virus DNA or varicella zoster virus immunoglobulin G in the cerebrospinal fluid. All children were previously healthy, the mean age was four years, and 67% were male. The median time from varicella rash to arterial ischemic stroke was 4.6 months. The most common location of arterial ischemic stroke was the basal ganglia, and affected vessels were most often in the anterior circulation. Fifty-three percent experienced neurological sequelae of varying degree. CONCLUSIONS In Denmark, where varicella vaccination is not part of the childhood vaccination program, the estimated risk of post-varicella arterial ischemic stroke was one case (including possible cases) per 26,000 children with varicella.
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Affiliation(s)
- Ida Glode Helmuth
- Department of Paediatric and Adolescent Medicine, Rigshospitalet, Copenhagen Ø, Denmark; Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen S, Denmark.
| | - Kåre Mølbak
- Division of Infectious Disease Preparedness, Statens Serum Institut, Copenhagen S, Denmark
| | - Peter Vilhelm Uldall
- Department of Paediatric and Adolescent Medicine, Rigshospitalet, Copenhagen Ø, Denmark
| | - Anja Poulsen
- Department of Paediatric and Adolescent Medicine, Rigshospitalet, Copenhagen Ø, Denmark
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8
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Leung J, Harpaz R. Impact of the Maturing Varicella Vaccination Program on Varicella and Related Outcomes in the United States: 1994-2012. J Pediatric Infect Dis Soc 2016; 5:395-402. [PMID: 26407276 PMCID: PMC4752432 DOI: 10.1093/jpids/piv044] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 06/30/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although the 1-dose varicella vaccination program, introduced in 1996, has led to significant declines in varicella disease, outbreaks continued to occur, which led to the adoption of a 2-dose vaccination program in 2007. We previously reported an 88% decline in varicella-related hospitalizations and a 59% decline in outpatient visits during 1994-2002. We now update data on varicella healthcare utilization with 10 years of additional data, during a period of stabilizing first-dose coverage and rapidly increasing second-dose coverage. METHODS We performed a retrospective cohort study using claims data from 1994-2012 Truven Health MarketScan databases. We examined trends in rates of varicella-related outpatient visits and hospitalizations for MarketScan enrollees aged 0-49 years, including outpatient laboratory testing, outpatient antiviral use, and pediatric strokes, with 1994-1995 as the prevaccination period and 2006-2012 as the 2-dose varicella vaccination period. RESULTS Varicella outpatient visits declined 84% in 2012 versus the prevaccination period, with a 60% decline during the 2-dose period. Varicella hospitalizations declined 93% in 2012 versus the prevaccination period, with a 38% decline during the 2-dose period. The proportion of those with a varicella outpatient visit having varicella laboratory testing increased from 6% in 2003 to 17% in 2012. There were 21 445 (17%) with a claim for antivirals, which was relatively stable over time. There was no reduction in pediatric strokes during 1994-2012. CONCLUSIONS We document from our large study population that the varicella vaccination program has led to significant declines in outpatient visits and hospitalizations from the prevaccination period through 2012, with additional declines during the 2-dose varicella vaccination period.
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Affiliation(s)
- Jessica Leung
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA,Corresponding author: Jessica Leung, MPH, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, MS A-34, Atlanta, GA 30333, Tel: 404-639-6067, Fax: 404-315-2486,
| | - Rafael Harpaz
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Abstract
Stroke and deep venous thrombosis are rare complications of varicella zoster infection. We report 3 cases of children with a stroke and 1 case of a boy with a deep venous thrombosis after recent chicken pox.
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Magagnini MC, Spina LL, Gioé D, Campo GD, Belfiore G, Smilari P, Greco F. A case of postvaricella cerebral angiopathy with a good outcome in a child. J Pediatr Neurosci 2015; 10:156-8. [PMID: 26167223 PMCID: PMC4489063 DOI: 10.4103/1817-1745.159193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Cerebral vasculopathy is a serious but uncommon complication of varicella-zoster-virus (VZV) infection. Diagnosis is based on a recent history of VZV infection, signs and symptoms of transient ischemic attack or stroke, and vascular anomalies on neuroimaging. We report a case of postvaricella cerebral angiopathy in a 5-year-old child, who was admitted after three episodes of transient right hemiplegia, each one lasting a few minutes. He had contracted chicken pox, the month prior to admission. Brain magnetic resonance imaging showed hyperintense signals in the left lenticular and caudate nuclei, which can be considered to be a result of vasculopathy.
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Affiliation(s)
- Maria Cristina Magagnini
- Department of Medical and Pediatric Sciences, Unit of Clinical Pediatrics, University of Catania, Italy
| | - Luisa La Spina
- Department of Medical and Pediatric Sciences, Unit of Clinical Pediatrics, University of Catania, Italy
| | - Daniela Gioé
- Department of Medical and Pediatric Sciences, Unit of Clinical Pediatrics, University of Catania, Italy
| | - G Del Campo
- Department of Medical and Pediatric Sciences, Unit of Clinical Pediatrics, University of Catania, Italy
| | - G Belfiore
- Department of Radiology, Unit of Pediatrics Radiology, University of Catania, 95123 Catania, Italy
| | - P Smilari
- Department of Medical and Pediatric Sciences, Unit of Clinical Pediatrics, University of Catania, Italy
| | - Filippo Greco
- Department of Medical and Pediatric Sciences, Unit of Clinical Pediatrics, University of Catania, Italy
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