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Jomaa N, El Halabi T, Melhem J, Dib G, Ghosn Y, Hourani M, Nasreddine W, Beydoun A. COVID-19–Associated Acute Asymmetric Hemorrhagic Necrotizing Encephalopathy: A Case Report. Neurohospitalist 2022; 12:371-376. [PMID: 35401914 PMCID: PMC8977755 DOI: 10.1177/19418744211055360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Coronavirus disease 2019 (COVID-19) has been associated with
many neurological complications affecting the central nervous system.
Purpose: Our aim was to describe a case of COVID-19 associated with a
probable variant of acute necrotizing encephalopathy (ANE). Results: A
60-year-old man who presented with a 3-day history of dyspnea, fever, and cough tested
positive for severe acute respiratory syndrome–coronavirus 2 (SARS-CoV-2). Five days
following his admission, the patient was intubated secondary to respiratory failure.
Following his extubation 16 days later, he was found to have a left-sided weakness.
Magnetic resonance imaging (MRI) of the brain showed hemorrhagic rim-enhancing lesions
involving the right thalamus, left hippocampus, and left parahippocampal gyrus. These
lesions showed decreased relative cerebral blood flow on MR perfusion and restricted on
diffusion-weighted imaging. These neuroimaging findings were consistent with ANE. The
left-sided weakness gradually improved over the subsequent weeks.
Conclusions: We concluded that COVID-19 can be associated with ANE, a
condition believed to be the result of an immune-mediated process with activation of the
innate immune system. Future studies must address whether biological drugs targeting the
pro-inflammatory cytokines could prevent the development of this condition.
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Affiliation(s)
- Najo Jomaa
- Department of Neurology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Tarek El Halabi
- Department of Neurology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jawad Melhem
- Department of Neurology, Montreal Neurological Institute-Hospital, Montreal, Canada
| | - Georgette Dib
- Department of Neurology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Youssef Ghosn
- Department of Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mukbil Hourani
- Department of Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Wassim Nasreddine
- Department of Neurology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ahmad Beydoun
- Department of Neurology, American University of Beirut Medical Center, Beirut, Lebanon
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2
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Appavu B, Foldes S, Fox J, Shetty S, Oh A, Bassal F, Marku I, Mangum T, Boerwinkle V, Neilson D, Kruer M. Treatment Timing, EEG, Neuroimaging, and Outcomes After Acute Necrotizing Encephalopathy in Children. J Child Neurol 2021; 36:517-524. [PMID: 33393838 DOI: 10.1177/0883073820984063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Acute necrotizing encephalopathy (ANE) is a rare condition associated with rapid progression to coma and high incidence of morbidity and mortality. METHODS Clinical, electroencephalographic (EEG), and brain magnetic resonance imaging (MRI) characteristics and immunomodulatory therapy timing were retrospectively analyzed in children with ANE. ANE severity scores (ANE-SS) and MRI scores were also assessed. The associations of patient characteristics with 6-month modified Rankin scale (mRS) and length of hospitalization were determined using either univariate linear regression or one-way analysis of variance. RESULTS 7 children were retrospectively evaluated. Normal EEG sleep spindles (P = .024) and early treatment (R2 = .57, P = .030) were associated with improved outcomes (ie, decreased mRS). Higher ANE-SS (R2 = .79, P = .011), higher age (R2 = .62, P = .038), and presence of brainstem lesions (P = .015) were associated with longer length of hospitalization. Other patient characteristics were not significantly associated with mRS or length of hospitalization. CONCLUSION Early immunomodulatory therapy and normal sleep spindles are associated with better functional outcome in children with ANE.
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Affiliation(s)
- Brian Appavu
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Stephen Foldes
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Jordana Fox
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Sheetal Shetty
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Ann Oh
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Freddy Bassal
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Iris Marku
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Tara Mangum
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Varina Boerwinkle
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Derek Neilson
- Department of Genetics, Phoenix Children's Hospital, 42283University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Michael Kruer
- Department of Neurosciences, Barrow Neurological Institute at 14524Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
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Levine JM, Ahsan N, Ho E, Santoro JD. Genetic Acute Necrotizing Encephalopathy Associated with RANBP2: Clinical and Therapeutic Implications in Pediatrics. Mult Scler Relat Disord 2020; 43:102194. [PMID: 32426208 PMCID: PMC7228726 DOI: 10.1016/j.msard.2020.102194] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/05/2020] [Accepted: 05/08/2020] [Indexed: 11/26/2022]
Abstract
Genetic (also known as familial) acute necrotizing encephalopathy (ANE1) is a rare disease presenting with encephalopathy often following preceding viral febrile illness in patients with a genetic predisposition resulting from a missense mutation in the gene encoding RAN Binding Protein 2 (RANBP2). The acute episode is characterized by deterioration in consciousness, often with focal neurologic deficits and seizures. Additionally, symmetric multifocal brain lesions are seen in the bilateral thalami as well as other characteristic regions, involving both gray and white matter. Prognosis is variable, with a high mortality rate and most surviving patients having persistent neurologic deficits. Early treatment with high dose steroids is associated with a more favorable outcome, however the diagnosis is often overlooked resulting in delayed treatment. The RANBP2 mutation associated with ANE1 causes an incompletely penetrant predisposition to encephalopathy in the setting of febrile illness through a mechanism that remains elusive. There are several non-mutually exclusive hypotheses suggesting possible etiologies for this phenotype based on the many functions of RANBP2 within the cell. These include dysfunctions in nucleocytoplasmic trafficking and intracellular metabolic regulation, as well as cytokine storm, and abnormal distribution of mitochondria. This narrative review explores these key concepts of the RANBP2 mutation and its clinical and therapeutic implications in pediatric populations.
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Affiliation(s)
- Jesse M Levine
- Medical Scientist Training Program, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States
| | - Nusrat Ahsan
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States; Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Eugenia Ho
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States; Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Jonathan D Santoro
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States; Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA.
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4
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Bashiri FA, Al Johani S, Hamad MH, Kentab AY, Alwadei AH, Hundallah K, Hasan HH, Alshuaibi W, Jad L, Alrifai MT, Hudairi A, Al Sheikh R, Alenizi A, Alharthi NA, Abdelmagid TA, Ba-Armah D, Salih MA, Tabarki B. Acute Necrotizing Encephalopathy of Childhood: A Multicenter Experience in Saudi Arabia. Front Pediatr 2020; 8:526. [PMID: 33163461 PMCID: PMC7581867 DOI: 10.3389/fped.2020.00526] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/24/2020] [Indexed: 11/17/2022] Open
Abstract
Background: Acute necrotizing encephalopathy of childhood (ANEC) is a rapidly progressing encephalopathy characterized by fever, depressed level of consciousness, and seizures. Diagnosis depends on clinical presentation and characteristic neuroimaging findings of abnormal signal intensity involving the thalami as well as the supra and infra-tentorial areas. Treatment modalities are not well-established; empirical treatment with antibiotics and antiviral agents is the initial step, followed by steroids and immunoglobulin, as well as supportive care. Patients with ANEC have a variable prognosis, but mortality is very high. Methods: A retrospective chart review of patients diagnosed with ANEC in five tertiary centers from January 2015 to October 2018 was performed. Clinical and radiological findings, as well as the therapeutic approach and outcomes, were described. Results: Twelve children were included ranging in age from 10 months to 6 years. All patients presented with preceding febrile illness, altered level of consciousness, and seizure. Radiological features showed abnormal signals in the thalami, and five patients (41.7%) had brainstem involvement. All patients received empirical treatment with antibiotics and antiviral agents. Ten patients (83.3%) received intravenous immunoglobulin (IVIG) and IV Methylprednisolone therapy. Outcomes were variable ranging from good outcomes with minimal neurological deficits to poor outcomes and death in 25% of cases. Conclusion: ANEC is a rare fulminant disease in children. The treatment is challenging. Early interventions with the use of IVIG and IV Methylprednisolone may change the outcome; however, further studies are needed to establish a consensus guideline for the management.
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Affiliation(s)
- Fahad A Bashiri
- Division of Pediatric Neurology, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Sultan Al Johani
- Division of Pediatric Neurology, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Muddathir H Hamad
- Division of Pediatric Neurology, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Amal Y Kentab
- Division of Pediatric Neurology, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ali H Alwadei
- Pediatric Neurology Department, National Neuroscience Institute, King Fahd Medical City, Riyadh, Saudi Arabia
| | - Khalid Hundallah
- Division of Pediatric Neurology, Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Hamdi H Hasan
- Neuroradiology Division, Department of Radiology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Walaa Alshuaibi
- Medical Genetics Division, Department of Pediatrics, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Lamyaa Jad
- Pediatric Neurology Department, National Neuroscience Institute, King Fahd Medical City, Riyadh, Saudi Arabia
| | - Muhammad Talal Alrifai
- Division of Neurology, Pediatric Department, King Abdullah Children Hospital, King Abdulaziz Medical City, Ministry of National Guard, Riyadh, Saudi Arabia
| | - Abrar Hudairi
- Division of Pediatric Neurology, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Rana Al Sheikh
- Division of Pediatric Neurology, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Asma'a Alenizi
- Division of Pediatric Neurology, Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Nawaf A Alharthi
- Pediatric Department, King Abdullah bin Abdulaziz University Hospital, College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Tayseer A Abdelmagid
- Department of Pediatrics, Armed Forces Hospital Southern Region, Khamis Mushayt, Saudi Arabia
| | - Duaa Ba-Armah
- Division of Neurology, Pediatric Department, King Abdullah Children Hospital, King Abdulaziz Medical City, Ministry of National Guard, Riyadh, Saudi Arabia
| | - Mustafa A Salih
- Division of Pediatric Neurology, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Brahim Tabarki
- Division of Pediatric Neurology, Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
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Kamaşak T, Şahin S, Eyuboglu İ, Reis GP, Cansu A. Reply to Huo et al. Pediatr Neurol 2015; 53:e19-20. [PMID: 26260995 DOI: 10.1016/j.pediatrneurol.2015.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 04/23/2015] [Accepted: 04/24/2015] [Indexed: 11/15/2022]
Affiliation(s)
- Tülay Kamaşak
- Pediatric Neurology, Karadeniz Teknik University, Trabzon, Turkey
| | - Sevim Şahin
- Pediatric Neurology, Karadeniz Teknik University, Trabzon, Turkey
| | - İlker Eyuboglu
- Department of Radiology, Karadeniz Teknik University, Trabzon, Turkey
| | - Gökce Pınar Reis
- Pediatric Hematology and Oncology, Karadeniz Teknik University, Trabzon, Turkey
| | - Ali Cansu
- Pediatric Neurology, Karadeniz Teknik University, Trabzon, Turkey
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Acute necrotizing encephalopathy: an underrecognized clinicoradiologic disorder. Mediators Inflamm 2015; 2015:792578. [PMID: 25873770 PMCID: PMC4385702 DOI: 10.1155/2015/792578] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 10/13/2014] [Indexed: 01/02/2023] Open
Abstract
Acute necrotizing encephalopathy (ANE) is a rare but distinctive type of acute encephalopathy with global distribution. Occurrence of ANE is usually preceded by a virus-associated febrile illness and ensued by rapid deterioration. However, the causal relationship between viral infections and ANE and the exact pathogenesis of ANE remain unclear; both environmental and host factors might be involved. Most cases of ANE are sporadic and nonrecurrent, namely, isolated or sporadic ANE; however, few cases are recurrent and with familial episodes. The recurrent and familial forms of ANE were found to be incompletely autosomal-dominant. Further the missense mutations in the gene encoding the nuclear pore protein Ran Binding Protein 2 (RANBP2) were identified. Although the clinical course and the prognosis of ANE are diverse, the hallmark of neuroradiologic manifestation of ANE is multifocal symmetric brain lesions which are demonstrated by computed tomography (CT) or magnetic resonance imaging (MRI). The treatment of ANE is still under investigation. We summarize the up-to-date knowledge on ANE, with emphasis on prompt diagnosis and better treatment of this rare but fatal disease.
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7
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Fernández-Alvarez E, Nardocci N. Update on pediatric dystonias: etiology, epidemiology, and management. Degener Neurol Neuromuscul Dis 2012; 2:29-41. [PMID: 30890876 DOI: 10.2147/dnnd.s16082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Dystonia is a movement disorder characterized by sustained muscle contractions producing twisting, repetitive, and patterned movements or abnormal postures. Dystonia is among the most commonly observed movement disorders in clinical practice both in adults and children. It is classified on the basis of etiology, age at onset of symptoms, and distribution of affected body regions. Etiology The etiology of pediatric dystonia is quite heterogeneous. There are many different genetic syndromes and several causes of symptomatic syndromes. Dystonia can be secondary to virtually any pathological process that affects the motor system, and particularly the basal ganglia. Classification The etiological classification distinguishes primary dystonia with no identifiable exogenous cause or evidence of neurodegeneration and secondary syndromes. Treatment Treatment for most forms of dystonia is symptomatic and includes drugs (systemic or focal treatments, such as botulinum toxin) and surgical procedures. There are several medications including anticholinergic, dopamine-blocking and depleting agents, baclofen, and benzodiazepines. In patients with dopamine synthesis defects L-dopa treatment may be very useful. Botulinum toxin treatment may be helpful in controlling the most disabling symptoms of segmental or focal dystonia. Long-term electrical stimulation of the globus pallidum internum appears to be especially successful in children suffering from generalized dystonia.
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Affiliation(s)
| | - Nardo Nardocci
- Child Neurology Department, Fondazione IRCCS Istituto Neurologico "C. Besta", Milano, Italy
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8
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Kumakura A, Iida C, Saito M, Mizuguchi M, Hata D. Pandemic influenza A-associated acute necrotizing encephalopathy without neurologic sequelae. Pediatr Neurol 2011; 45:344-6. [PMID: 22000319 DOI: 10.1016/j.pediatrneurol.2011.08.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 08/08/2011] [Indexed: 10/16/2022]
Abstract
We describe an 8-year-old girl with the mildest form of acute necrotizing encephalopathy, associated with pandemic influenza A. She manifested a convulsion engendering deterioration of consciousness, although cranial computed tomography and magnetic resonance imaging within 4 hours after the convulsion revealed no abnormalities. Cranial magnetic resonance imaging 20 hours after the convulsion revealed lesions of the thalamus bilaterally, brainstem tegmentum, internal capsule, and white matter. She was diagnosed with acute necrotizing encephalopathy. Typically, the prognosis of acute necrotizing encephalopathy with a brainstem lesion is poor. Nevertheless, she recovered almost completely, after early intervention with pulsed methylprednisolone and high-dose γ-globulin therapy. She manifested a thermolabile phenotype of carnitine palmitoyltransferase II variants such as cystine-isoleucine-methionine phenotype type 9 (FVM-CIM; Phe352Cys-Val388Ile-Met647Met alleles), resulting in a predisposition to encephalopathy during influenza infection. This case is the first, to the best of our knowledge, of pandemic influenza A-associated acute necrotizing encephalopathy with a good outcome despite severe magnetic resonance imaging findings.
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Affiliation(s)
- Akira Kumakura
- Department of Pediatrics, Kitano Hospital, Tazuke Kofukai Medical Institute, Osaka, Japan.
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9
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Weng WC, Peng SSF, Lee WT. Acute necrotizing encephalopathy of childhood with spinal cord involvement: a case report. J Child Neurol 2010; 25:1539-41. [PMID: 20823028 DOI: 10.1177/0883073810374877] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute necrotizing encephalopathy of childhood is a rare acute encephalopathy occurring after febrile illness with subsequent rapid deterioration of consciousness and convulsions. Typical brain magnetic resonance imaging (MRI) findings are symmetric involvement of the bilateral thalami, brainstem, and cerebral periventricular white matter or the cerebellum. Spinal cord involvement has never been reported. This report describes a healthy 2-year-old girl, who displayed typical clinical manifestations of acute necrotizing encephalopathy. Brain MRI demonstrated symmetrical lesions over the bilateral thalami and periventricular white matter. The clinical features and radiologic images suggested spinal cord involvement. This is the first reported case of acute necrotizing encephalopathy with spinal cord involvement. Spinal cord lesions are, therefore, possible in cases of acute necrotizing encephalopathy of childhood, and these require special attention.
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Affiliation(s)
- Wen-Chin Weng
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan.
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10
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Seo HE, Hwang SK, Choe BH, Cho MH, Park SP, Kwon S. Clinical spectrum and prognostic factors of acute necrotizing encephalopathy in children. J Korean Med Sci 2010; 25:449-53. [PMID: 20191046 PMCID: PMC2826728 DOI: 10.3346/jkms.2010.25.3.449] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Accepted: 05/18/2009] [Indexed: 11/20/2022] Open
Abstract
This study was conducted to investigate the etiology, the clinical characteristics and prognosis of acute necrotizing encephalopathy (ANE) in Korean children. Six children (1 yr to 7 yr) patients with ANE were enrolled. They were diagnosed by clinical and radiological characteristics and their clinical data were retrospectively analyzed. In a search of clinically plausible causes, brain MRI in all patients, mitochondrial DNA studies for mitochondrial encephalomyopathy, lactic acidosis, and strokelike episodes (MELAS) and myoclonus epilepsy and ragged red fibers (MERRF) in four patients, and genomic typing on HLA DRB/HLA DQB genes in three patients were performed. All had precedent illnesses and the main initial symptoms included mental change (83%), seizures (50%), and focal deficits (50%). MRI revealed increased T2 signal density in the bilateral thalami and/or the brainstem in all patients. Mitochodrial DNA studies for MELAS and MERRF were negative in those children and HLA-DRB1*1401, HLA-DRB3*0202, and HLA-DQB1*0502 seemed to be significant. A high dose steroid was given to all patients, which seemed to be partly effective except for 2 patients. In conclusion, ANE is relatively rare, but can result in serious neurological complication in children. Early detection and appropriate treatment may lead to a better neurological outcome.
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Affiliation(s)
- Hye-Eun Seo
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Su-Kyeong Hwang
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Byung Ho Choe
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Min-Hyun Cho
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sung-Pa Park
- Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Soonhak Kwon
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
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11
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Neurological sequelae of 2009 influenza A (H1N1) in children: a case series observed during a pandemic. Pediatr Crit Care Med 2010; 11:179-84. [PMID: 20081552 DOI: 10.1097/pcc.0b013e3181cf4652] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To outline a series of cases demonstrating neurologic complications in children with Influenza infection. The ongoing 2009 influenza A (H1N1) presents significant challenges to the field of pediatric critical care and requires increased awareness of new presentations and sequelae of infection. Since World Health Organization declared a H1N1 pandemic, much attention has been focused on its respiratory manifestations of the illness, but limited information regarding neurologic complications has been reported. DESIGN Case series. SETTING Pediatric intensive care unit of a tertiary care medical facility. PATIENTS Four children admitted to the pediatric intensive care unit between March and November 2009 at the Children's Hospital of Pittsburgh with altered mental status and influenza infection. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The clinical course was extracted by chart review and is summarized. All children demonstrated a coryzal prodrome, fever, and altered level of consciousness at admission, and one child presented with clinical seizures. Diagnostic studies performed to establish a diagnosis are summarized. All children had abnormal electroencephalograms early in their intensive care unit course and 50% had abnormal imaging studies. All children survived but 50% had neurologic deficits at hospital discharge. CONCLUSION We conclude that 2009 influenza A (H1N1) can cause significant acute and residual neurologic sequelae. Clinicians should consider Influenza within a comprehensive differential diagnosis in children with unexplained mental status changes during periods of pandemic influenza.
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12
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Okumura A, Mizuguchi M, Aiba H, Tanabe T, Tsuji T, Ohno A. Delirious behavior in children with acute necrotizing encephalopathy. Brain Dev 2009; 31:594-9. [PMID: 18842369 DOI: 10.1016/j.braindev.2008.09.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2008] [Revised: 07/24/2008] [Accepted: 09/03/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To clarify the features of delirious behavior in patients with acute necrotizing encephalopathy. METHODS We retrospectively evaluated the clinical course of 38 children with acute necrotizing encephalopathy diagnosed on the basis of neuroradiological findings. The patients were divided into two groups according to the presence or absence of delirious behavior. We compared clinical features, laboratory data, neuroimaging findings, and outcome between those with and without delirious behavior. In patients with delirious behavior, chronological sequence of neurological symptoms and the characteristics of delirious behavior were investigated. RESULTS Delirious behavior was observed in 8 patients. Patient characteristics or most laboratory data on admission were not significantly different between those with and without delirious behavior. Brainstem lesions were more frequent in patients with delirious behavior than in those without. In contrast, lesions in lentiform nuclei, cerebral hemisphere, or cerebellum were relatively more frequent in patients without delirious behavior. It was the initial neurological symptom in 7 of 8 patients. Stupor and seizures were observed after delirious behavior in most patients. CONCLUSIONS Delirious behavior was not uncommon in children with acute necrotizing encephalopathy. Brainstem lesions may be related to the development of delirious behavior of children with acute necrotizing encephalopathy.
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Affiliation(s)
- Akihisa Okumura
- Department of Pediatrics, Juntendo University School of Medicine, Tokyo, Japan.
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13
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Mastroyianni SD, Gionnis D, Voudris K, Skardoutsou A, Mizuguchi M. Acute necrotizing encephalopathy of childhood in non-Asian patients: report of three cases and literature review. J Child Neurol 2006; 21:872-9. [PMID: 17005104 DOI: 10.1177/08830738060210101401] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute necrotizing encephalopathy of childhood is a novel type of parainfectious encephalopathy with a racial and geographic predilection, rarely reported from other than East Asian areas. The objective was to describe the clinical, imaging, and other laboratory findings of non-Asian patients with acute necrotizing encephalopathy. Data were collected from three patients diagnosed in Athens over a 4-year period plus 16 cases reported from other European and North American countries. One of the Greek children died, and the other two had a normal outcome. A neuropathologic examination in the fatal case showed edematous necrosis without inflammatory, reactive, or proliferative changes. Data from Greek and other non-Asian patients support the homogeneity of the disease worldwide.
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14
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Manara R, Franzoi M, Cogo P, Battistella PA. Acute necrotizing encephalopathy: combined therapy and favorable outcome in a new case. Childs Nerv Syst 2006; 22:1231-6. [PMID: 16816978 DOI: 10.1007/s00381-006-0076-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2005] [Indexed: 10/24/2022]
Abstract
BACKGROUND Acute necrotizing encephalopathy (ANE) is a rare disease characterized by multiple, symmetrical brain lesions, affecting thalami, brainstem tegmentum, and cerebellar medulla; more inconstantly, other structures are involved, i.e., internal capsules, posterolateral putamen, and deep periventricular white matter. FEATURES The clinical picture consists of rapidly deteriorating acute monophasic encephalopathy preceded by prodromal febrile illness; the symptoms include hyperpyrexia, convulsions, recurrent vomiting, and coma within 24 h. PROGNOSIS The outcome is usually poor and approximately 70% of the patients die within a few days from the onset of fever. There is no specific therapy for ANE but, in some patients, the clinical status improved with steroid treatment.
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Affiliation(s)
- Renzo Manara
- Service of Neuroradiology, Hospital of Padova, Padova, Italy
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15
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Ohsaka M, Houkin K, Takigami M, Koyanagi I. Acute necrotizing encephalopathy associated with human herpesvirus-6 infection. Pediatr Neurol 2006; 34:160-3. [PMID: 16458833 DOI: 10.1016/j.pediatrneurol.2005.07.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2005] [Revised: 05/31/2005] [Accepted: 07/21/2005] [Indexed: 11/22/2022]
Abstract
An extremely rare case of acute necrotizing encephalopathy caused by human herpesvirus-6 variant type B infection is reported. The patient, a 14-month-old previously healthy female, presented with high fever and generalized tonic convulsion followed by rapid deterioration of consciousness. On the second day of the illness, the protein level of the cerebrospinal fluid increased without pleocytosis. On the third day, magnetic resonance images demonstrated symmetric, abnormal signal intensity lesions in the bilateral thalamus, cerebellum, and brainstem. On the fourth day, characteristic maculopapular rash of exanthema subitum appeared on the trunk. Human herpesvirus-6 deoxyribonucleic acid was detected by the polymerase chain reaction in the serum, and immunoglobulin G and immunoglobulin M of serum human herpesvirus-6 were positive. On the twelfth day of illness, the patient died as a result of severe brain damage. Acute necrotizing encephalopathy should be included in the differential diagnosis when examining infants and young children with fulminating consciousness disturbance and intractable convulsion. In addition, as a causative virus, human herpesvirus-6 has to be considered at the pre-eruptive stage of exanthema subitum. Magnetic resonance images are useful because they reveal the characteristic distribution of lesions specific to acute necrotizing encephalopathy.
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Affiliation(s)
- Misuzu Ohsaka
- Department of Neurosurgery, Sapporo City General Hospital, Sapporo, Japan
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16
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Kirton A, Busche K, Ross C, Wirrell E. Acute necrotizing encephalopathy in caucasian children: two cases and review of the literature. J Child Neurol 2005; 20:527-32. [PMID: 15996405 DOI: 10.1177/088307380502000612] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Acute necrotizing encephalopathy is a fulminant neurologic disease seen predominantly in Japan and Taiwan. We present two cases diagnosed at a Canadian center within the same year in Caucasian children. Both were previously well, developed an acute viral illness with fever and vomiting, and progressed to brain death within 2 to 4 days. Neuroimaging and postmortem examination demonstrated the unique features of bilateral and severe necrosis of deep gray- and subcortical white-matter structures. The first case was associated with extensive, but transient, hepatic involvement, recent varicella and rotavirus infections, and detailed metabolic studies, including mitochondrial functional analysis, were normal. The second case tested positive for influenza A infection, whereas evidence of liver damage was lacking. Both children demonstrated early lymphopenia and myocardial necrosis, two features not previously associated with acute necrotizing encephalopathy. These cases are unique in their occurrence in non-Japanese children and are among the first published reports in Canada.
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Affiliation(s)
- Adam Kirton
- Division of Pediatric Neurology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
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Kim JH, Kim IO, Lim MK, Park MS, Choi CG, Kim HW, Kim JE, Choi SJ, Koh YH, Yang DM, Choo SW, Chung MJ, Yoon HK, Goo HW, Lee M. Acute necrotizing encephalopathy in Korean infants and children: imaging findings and diverse clinical outcome. Korean J Radiol 2005; 5:171-7. [PMID: 15467414 PMCID: PMC2698159 DOI: 10.3348/kjr.2004.5.3.171] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Objective The purpose of our study was to describe acute necrotizing encephalopathy in Korean infants and children, and we sought to evaluate the prognostic factors. Materials and Methods Acute necrotizing encephalopathy was diagnosed in 14 Korean infants and children. We retrospectively analyzed the neuroimaging findings including the follow-up changes. The clinical course of the disease was graded, and we evaluated prognostic factors including age, serum level of the aminotransferase, hemorrhage, and localized atrophy of the brain. Results This encephalopathy predominantly affected the bilateral thalami (n=14), pons (n=12), and midbrain (n=10) in a symmetrical pattern. Hemorrhage was observed in eight patients (57%). On the follow-up images (n=12), the brain lesions were reduced in extent for all patients, and generalized atrophy was seen in six patients. Localized tissue loss was observed in five patients and a complete resolution occurred for one patient. All the patients survived and two recovered completely; mild (n=6) to severe (n=6) neurological deficits persisted in the remaining 12 patients. The significant prognostic factors identified in this study were the presence of hemorrhage (p = 0.009) and localized atrophy (p = 0.015). Conclusion Acute necrotizing encephalopathy in Korean patients showed the characteristic patterns of the post-infectious encephalopathy as described in the literature. The high survival rate and the relatively favorable clinical course observed for the present study suggest a more diverse spectrum of disease severity than was previously described. The presence of hemorrhage and localized tissue loss on MR images may suggest a poor prognosis.
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Affiliation(s)
- Ji Hye Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Kangnam-gu, Seoul, Korea.
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18
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Oh HH, Kwon SH, Kim CW, Choe BH, Ko CW, Jung HD, Suh JS, Lee JH. Molecular analysis of HLA class II-associated susceptibility to neuroinflammatory diseases in Korean children. J Korean Med Sci 2004; 19:426-30. [PMID: 15201511 PMCID: PMC2816846 DOI: 10.3346/jkms.2004.19.3.426] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The work was done to study immunogenetic peculiarities of neuroinflammatory diseases among Korean children. A total of 13 children with neuroinflammatory diseases (8 males and 5 females; mean age 4.6 +/-2.6 yr) were consecutively recruited. Geno-mic typing was performed on their HLA DRB/HLA DQB genes using PCR-SSOP/SSP techniques with gel immunoelectrophoresis. The frequencies of HLA-DR1 *15 in children with acute disseminated encephalomyelitis (ADEM) (31%) and DQB1 *06 in other neuroinflammatory diseases (38%) were significantly increased compared with control subjects. The frequencies of HLA-DRB3 * 0202 (100%), HLA-DRB1 * 1302 (67%), HLA-DRB3 * 0301 (67%), and HLA-DQB1 * 0301 (67%) were significantly increased in children with multiple sclerosis and the frequencies of HLA-DRB1 * 1501 (40%) and HLA-DRB5 * 0101 (40%) were significantly increased in children with ADEM. HLA-DRB1 * 1401, HLA- DRB3 * 0202, and HLA-DQB1 * 0502 were found in children with acute necrotizing encephalopathy. In conclusion, HLA-DR1 * 15 and DQB1 * 06 may be involved in susceptibility to inflammation in Korean children. The frequencies of HLA-DRB1 * 1501, HLA-DRB5 * 0101, HLA-DRB3 * 0301, and HLA-DQB1* 0602 were not as high in Korean children with multiple sclerosis as in western children. However, HLA-DRB3 * 0202 was seen in all children with multiple sclerosis. Our data may provide further evidence that the immunogenetic background of neuroinflammatory diseases in Korean is distinctly different from the ones in western countries. Further studies are necessary to confirm this finding.
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Affiliation(s)
- Hyun Hee Oh
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
| | - Soon Hak Kwon
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
| | - Chang Woo Kim
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
| | - Byung Ho Choe
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
| | - Cheol Woo Ko
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
| | - Hee Du Jung
- Department of Laboratory Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jang Soo Suh
- Department of Laboratory Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jun Hwa Lee
- Department of Pediatrics, Catholic University of Daegu School of Medicine, Daegu, Korea
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Huang SM, Chen CC, Chiu PC, Cheng MF, Lai PH, Hsieh KS. Acute necrotizing encephalopathy of childhood associated with influenza type B virus infection in a 3-year-old girl. J Child Neurol 2004; 19:64-7. [PMID: 15032389 DOI: 10.1177/08830738040190010709] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute necrotizing encephalopathy of childhood represents a novel entity of acute encephalophathy, predominantly affecting infants and young children living in Taiwan and Japan. It manifests with symptoms of coma, convulsions, and hyperpyrexia after 2 to 4 days of respiratory tract infections in previously healthy children. The hallmark of acute necrotizing encephalopathy of childhood consists of multifocal and symmetric brain lesions affecting the bilateral thalami, brainstem tegmentum, cerebral periventricular white matter, or cerebellar medulla. The etiology and pathogenesis of this kind of acute encephalopathy remain unknown, and there is no specific therapy or prevention. The prognosis is usually poor, and less than 10% of patients recover completely. We report a 3-year-old previously healthy girl presenting with acute necrotizing encephalopathy of childhood associated with influenza type B virus infection, which resulted in severe neurologic sequelae. We also review the current knowledge of the clinical, neuroimaging, and pathologic aspects of acute necrotizing encephalopathy of childhood.
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MESH Headings
- Brain/pathology
- Brain Damage, Chronic/diagnosis
- Brain Damage, Chronic/rehabilitation
- Brain Edema/diagnosis
- Child, Preschool
- Developmental Disabilities/diagnosis
- Developmental Disabilities/rehabilitation
- Dominance, Cerebral/physiology
- Female
- Follow-Up Studies
- Humans
- Immunization, Passive
- Influenza B virus
- Influenza, Human/diagnosis
- Influenza, Human/rehabilitation
- Leukoencephalitis, Acute Hemorrhagic/diagnosis
- Leukoencephalitis, Acute Hemorrhagic/rehabilitation
- Magnetic Resonance Imaging
- Thalamic Diseases/diagnosis
- Tomography, X-Ray Computed
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Affiliation(s)
- Shih-Ming Huang
- Department of Pediatrics, Veterans General Hospital-Kaohsiung National Yang-Ming University, Taiwan, Republic of China
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20
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Mastroyianni SD, Voudris KA, Katsarou E, Gionnis D, Mavromatis P, Vagiakou EA, Skardoutsou A. Acute necrotizing encephalopathy associated with parainfluenza virus in a Caucasian child. J Child Neurol 2003; 18:570-2. [PMID: 13677585 DOI: 10.1177/08830738030180081301] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Acute necrotizing encephalopathy is a severe parainfectious disorder with a clear racial predilection for Oriental children living in the Far East. The prognosis was originally reported as grave; however, a mild form of the disease has recently been described. A case of parainfluenza virus-associated acute necrotizing encephalopathy in a Caucasian child with a mild clinical course and excellent prognosis is presented. In this patient, the initial clinical picture was not very impressive, and the diagnosis was delayed until the third week of the illness, when neuroimaging was performed. Two months later, clinical and neuroimaging findings had almost completely resolved. Suggested criteria for a benign prognosis, such as normal liver function and cerebrospinal fluid protein levels, asymmetric thalamic lesions, and no brainstem involvement, were relevant in the present case. An extended diagnostic work-up for metabolic, vascular, coagulation, and infectious diseases was negative apart from a seroconversion for parainfluenza virus. To our knowledge, this is the first reported case of acute necrotizing encephalopathy associated with parainfluenza virus infection. Acute necrotizing encephalopathy, especially in the mild form, might not be fully recognized and could be underdiagnosed in Europe, where the reported incidence of the syndrome is very low.
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Lee KH, McKie VC, Sekul EA, Adams RJ, Nichols FT. Unusual encephalopathy after acute chest syndrome in sickle cell disease: acute necrotizing encephalitis. J Pediatr Hematol Oncol 2002; 24:585-8. [PMID: 12368703 DOI: 10.1097/00043426-200210000-00021] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Stroke is the most common neurologic complication of sickle cell disease. Acute chest syndrome (ACS) is a known risk factor for stroke in this population. Two patients (a 12-year-old boy and a 6-year-old girl) developed acute change of mental status and focal neurologic signs during episodes of ACS. The clinical and radiologic findings were compatible with acute necrotizing encephalitis, a variant of acute demyelinating encephalomyelitis. Patients with acute neurologic deterioration in conjunction with ACS should be evaluated thoroughly for other causes of central nervous system disease including infectious/parainfectious processes as well as stroke.
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Affiliation(s)
- Ki Hyeong Lee
- Department of Neurology, Medical College of Georgia, Augusta 30912, USA
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Yoshikawa H, Yamazaki S, Watanabe T, Abe T. Study of influenza-associated encephalitis/encephalopathy in children during the 1997 to 2001 influenza seasons. J Child Neurol 2001; 16:885-90. [PMID: 11785501 DOI: 10.1177/088307380101601204] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The 1997 to 2001 influenza A epidemics in Japan were markedly neurovirulent, and many children died of influenza-associated encephalitis/encephalopathy. We studied 20 patients with influenza-associated encephalitis/encephalopathy during the last four influenza seasons. No patients had been previously inoculated with influenza vaccine. Antipyretics were used in 16 patients before the onset of encephalopathy. Although all patients were treated intensively, 5 patients died and 8 had neurologic sequelae. Patients with coagulopathy, hepatic dysfunction, and computed tomographic abnormalities had a poor prognosis. The plasma concentrations of inflammatory cytokines were variable. The neuroradiologic findings could be divided into four categories. These findings indicated that the pathogenesis of the brain damage induced by influenza infection was variable. Further investigation is necessary to determine whether insufficient influenza vaccination or the use of antipyretics is one of the reasons for these epidemics of encephalopathy in Japanese children.
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Affiliation(s)
- H Yoshikawa
- Department of Pediatrics, Niigata City General Hospital, Niigata, Japan.
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Tran TD, Kubota M, Takeshita K, Yanagisawa M, Sakakihara Y. Varicella-associated acute necrotizing encephalopathy with a good prognosis. Brain Dev 2001; 23:54-7. [PMID: 11226732 DOI: 10.1016/s0387-7604(00)00199-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A patient with acute necrotizing encephalophathy (ANE) following varicella infection with a good prognosis is reported. A somatosensory evoked magnetic field (SEF) study using a 37-channel-magnetoencephalography system demonstrated normal latency and strength of the first component (N20m) elicited by median nerve stimulation, despite bilateral symmetrical thalamic lesions on MRI. The normal SEF findings and the good prognosis suggested a reversible breakdown of the blood-brain barrier, and an edematous process as the brain pathology. Furthermore, our results support the idea of distinct generators for the three earliest cortical SEF components (N20m, P30m, N45m).
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Affiliation(s)
- T D Tran
- Department of Pediatrics, the University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, 113-8655, Tokyo, Japan
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Takahashi M, Yamada T, Nakashita Y, Saikusa H, Deguchi M, Kida H, Tashiro M, Toyoda T. Influenza virus-induced encephalopathy: clinicopathologic study of an autopsied case. Pediatr Int 2000; 42:204-14. [PMID: 10804743 DOI: 10.1046/j.1442-200x.2000.01203.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Rapid progressive encephalopathy with a high fever, consciousness loss and recurrent convulsions has been occasionally reported in children during influenza pandemics in Japan since 1995. We examined a 2-year old girl with hemorrhagic shock and encephalopathy syndrome associated with acute influenza A virus infection (A/Nagasaki/76/98; H3N2), to answer several questions for which no histologic or virologic data exist. METHODS A clinicopathologic study using immunohistochemical staining and viral genome detection by reverse transcriptase polymerase chain reaction (RT-PCR) was performed with this autopsied case. RESULTS The virus antigen was positive in CD8+ T lymphocytes from the lung and spleen. The virus infected a very limited part of the brain, especially Purkinje cells in the cerebellum and many neurons in the pons, without inducing an overt immunologic reaction from the host. The RT-PCR used for detecting the hemagglutinin gene demonstrated positive bands in all frozen tissues and cerebrospinal fluid taken at autopsy and not in samples obtained on admission. CONCLUSIONS The pathologic change induced by the direct viral invasion cannot be responsible for all of the symptoms, especially for the rapid and severe clinical course of the disease within 24-48 h after the initial respiratory symptoms. Together with the rapid production of several inflammatory cytokines, the breakdown of the blood-brain barrier may induce severe brain edema and can be a major pathologic change for the disease. Any therapeutic strategy to control this multistep progression of the disease could be effective.
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Affiliation(s)
- M Takahashi
- Department of Internal Medicine and Health Care, School of Medicine, Fukuoka University, Fukuoka, Japan.
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