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Bamnawat H, Khera D, Didel S, Tiwari S. Paediatric acute haemorrhagic leukoencephalitis. BMJ Case Rep 2022; 15:e246654. [PMID: 35680284 PMCID: PMC9185211 DOI: 10.1136/bcr-2021-246654] [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] [Accepted: 05/17/2022] [Indexed: 11/03/2022] Open
Abstract
We report a case of a preschool age girl, previously healthy, referred to our hospital on ventilatory support with a history of vomiting, headache, and rapid neurological worsening within 24 hours in the form of seizures, encephalopathy and loss of consciousness. On presentation, she was deeply comatose with dilated non-reactive pupils, absent brainstem reflexes and flaccid quadriplegia. Diagnosis of acute haemorrhagic leukoencephalitis was considered based on laboratory and neuroimaging findings. MRI of the brain showed fluffy white matter hyperintensities and microhaemorrhages in bilateral cerebral hemispheres and thalami. Aggressive treatment with methylprednisolone, plasmapheresis and intravenous immunoglobulin showed dramatic improvement with no neurological sequelae. Our case is unique in a way that despite the hyperacute onset and rapid deterioration, with a fulminant course in the intensive care unit, the child recovered dramatically with aggressive management.
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Affiliation(s)
- Harshita Bamnawat
- Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Daisy Khera
- Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Siyaram Didel
- Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Sarbesh Tiwari
- Radiodiagnosis, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Fulminant acute hemorrhagic leukoencephalopathy: ineffective treatment with immunotherapy. Acta Neurol Belg 2022; 122:529-533. [PMID: 33403607 DOI: 10.1007/s13760-020-01568-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 12/02/2020] [Indexed: 10/22/2022]
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Lin JJ, Hsia SH, Chiang MC, Lin KL. Clinical application of target temperature management in children with acute encephalopathy-A practical review. Biomed J 2020; 43:211-217. [PMID: 32611538 PMCID: PMC7424089 DOI: 10.1016/j.bj.2019.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 12/07/2019] [Accepted: 12/08/2019] [Indexed: 12/29/2022] Open
Abstract
Acute encephalopathy is a life-threatening disease involving acute brain dysfunction, and it is one of the most important causes of mortality and severe neurological sequelae in infants and children. Approximately 30% of cases of acute encephalopathy result in some degree of neurological sequelae. Although many strategies have been proposed, effective therapies to ameliorate the outcomes of acute encephalopathy have not yet been established. Target temperature management (TTM), previously termed therapeutic hypothermia, has been shown to be effective for various brain injuries due to multiple neuroprotective mechanisms, and it may be considered to be the cornerstone of neuroprotective strategies. Consequently, TTM is currently used in the neurocritical care of adult patients with cardiac arrest with shockable rhythm and perinatal asphyxia. In addition, increasing evidence also indicates that TTM could be useful in other acute encephalopathies, including status epilepticus, acute encephalitis/encephalopathy and traumatic brain injury. In this review, we discuss the recent practical aspects of TTM as a potential intervention for various acute encephalopathies in children.
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Affiliation(s)
- Jainn-Jim Lin
- Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Pediatric Neurology, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shao-Hsuan Hsia
- Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Chou Chiang
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Neonatology, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kuang-Lin Lin
- Division of Pediatric Neurology, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Yae Y, Kawano G, Yokochi T, Imagi T, Akita Y, Ohbu K, Matsuishi T. Fulminant acute disseminated encephalomyelitis in children. Brain Dev 2019; 41:373-377. [PMID: 30522797 DOI: 10.1016/j.braindev.2018.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/23/2018] [Accepted: 11/16/2018] [Indexed: 10/27/2022]
Abstract
Acute disseminated encephalomyelitis (ADEM) is a typically monophasic inflammatory demyelinating disease of the central nervous system with a favorable outcome. However, 2% of ADEM involves acute hemorrhagic leukoencephalitis (AHLE), which is a fulminant and hyperacute variant of ADEM with a poor outcome and high mortality. There are limited case reports of fulminant ADEM including AHLE in children. Herein, we report two pediatric cases of fulminant ADEM. Both cases had a rapid deterioration of consciousness, repetitive seizures, and brain edema on neuroimaging, in addition to atypical neuroradiological findings on magnetic resonance imaging (MRI), a reversible splenial lesion in case 1, and bilateral frontal and occipital cortical lesions in case 2. Both cases were treated with early high-dose methyl-prednisolone and immunoglobulin, while therapeutic hypothermia was also initiated in case 2 after the patient exhibited a decerebrate posture and irregular breathing pattern. Both cases had a favorable outcome. Further case reports on pediatric fulminant ADEM are required to clarify the various clinical types, and to examine the efficacy of various treatment modalities for fulminant ADEM and AHLE in children.
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Affiliation(s)
- Yukako Yae
- Department of Pediatrics, St Mary's Hospital, 422 Tsubukuhonmachi, Kurume, Fukuoka 830-8543, Japan
| | - Go Kawano
- Department of Pediatrics, St Mary's Hospital, 422 Tsubukuhonmachi, Kurume, Fukuoka 830-8543, Japan
| | - Takaoki Yokochi
- Department of Pediatrics, St Mary's Hospital, 422 Tsubukuhonmachi, Kurume, Fukuoka 830-8543, Japan
| | - Toru Imagi
- Department of Pediatrics, St Mary's Hospital, 422 Tsubukuhonmachi, Kurume, Fukuoka 830-8543, Japan
| | - Yukihiro Akita
- Department of Pediatrics, St Mary's Hospital, 422 Tsubukuhonmachi, Kurume, Fukuoka 830-8543, Japan
| | - Keizo Ohbu
- Department of Pediatrics, St Mary's Hospital, 422 Tsubukuhonmachi, Kurume, Fukuoka 830-8543, Japan
| | - Toyojiro Matsuishi
- Department of Pediatrics, St Mary's Hospital, 422 Tsubukuhonmachi, Kurume, Fukuoka 830-8543, Japan; Research Centre for Children and Research Centre for Rett Syndrome, St Mary's Hospital, 422 Tsubukuhonmachi, Kurume, Fukuoka 830-8543, Japan.
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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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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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Newmyer R, Mendelson J, Pang D, Fink EL. Targeted Temperature Management in Pediatric Central Nervous System Disease. CURRENT TREATMENT OPTIONS IN PEDIATRICS 2015; 1:38-47. [PMID: 26042193 PMCID: PMC4450147 DOI: 10.1007/s40746-014-0008-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Acute central nervous system conditions due to hypoxic-ischemic encephalopathy, traumatic brain injury (TBI), status epilepticus, and central nervous system infection/inflammation, are a leading cause of death and disability in childhood. There is a critical need for effective neuroprotective therapies to improve outcome targeting distinct disease pathology. Fever, defined as patient temperature > 38°C, has been clearly shown to exacerbate brain injury. Therapeutic hypothermia (HT) is an intervention using targeted temperature management that has multiple mechanisms of action and robust evidence of efficacy in multiple experimental models of brain injury. Prospective clinical evidence for its neuroprotective efficacy exists in narrowly-defined populations with hypoxic-ischemic injury outside of the pediatric age range while trials comparing hypothermia to normothermia after TBI have failed to demonstrate a benefit on outcome but consistently demonstrate potential use in decreasing refractory intracranial pressure. Data in children from prospective, randomized controlled trials using different strategies of targeted temperature management for various outcomes are few but a large study examining HT versus controlled normothermia to improve neurological outcome in cardiac arrest is underway.
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Affiliation(s)
- Robert Newmyer
- Children's Hospital of Pittsburgh of UPMC (Pittsburgh, PA USA)
| | - Jenny Mendelson
- Children's Hospital of Pittsburgh of UPMC (Pittsburgh, PA USA)
| | - Diana Pang
- Children's Hospital of Pittsburgh of UPMC (Pittsburgh, PA USA)
| | - Ericka L Fink
- Children's Hospital of Pittsburgh of UPMC (Pittsburgh, PA USA)
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