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Sheikh IS, Afreen E, Sheikh A. Unusual Movement Disorders and Atypical Magnetic Resonance Imaging (MRI) Findings in Patients with West Nile Encephalitis: Case Reports of 2 Patients with Evidence of Clinical and Imaging Resolution with IVIG. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e932215. [PMID: 34290220 PMCID: PMC8311389 DOI: 10.12659/ajcr.932215] [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: 11/09/2022]
Abstract
BACKGROUND West Nile virus (WNv) is the leading cause of epidemic arbovirus encephalitis in the continental United States. Movement disorders (MDs) have been reported in 20% to 40% of patients with WNv and about 37% of patients with WNv encephalitis have changes on magnetic resonance imaging (MRI). We report 2 unusual cases of neuroinvasive WNv in patients with unusual MDs and unreported MRI findings. CASE REPORT In the first case, a 34-year-old man presented with a 1-week history of disinhibition, agitation, opsoclonus-myoclonus and ataxia syndrome (OMAS), tremor, and facial agnosia. Evaluation of his cerebrospinal fluid (CSF) revealed elevated immunoglobulin (Ig)M against WNv, a high level of protein (98 mg/dL), and an elevated white blood cell (WBC) count (134, 37% lymphocytes). An MRI of the brain showed an area of diffusion restriction in the splenium of the corpus callosum. The patient's MRI findings and OMA improved significantly after 2 treatments with i.v. IG (IVIG). In the second case, a 57-year-old woman presented with fever, headaches, psychosis, and ataxia; she was subsequently intubated for airway protection. Analysis of her CSF showed elevated IgM against WNv, a high level of protein (79 mg/dL), and elevated WBC count (106, 90% lymphocytes). One week after the onset of symptoms, the patient experienced facial dyskinesia. Later, she developed proximal bilateral lower extremity weakness. An MRI of her lumbar spine showed evidence of myeloradiculitis with contrast enhancement of the conus medullaris and ventral nerve roots. After a single treatment with IVIG, she had partial improvement in weakness. CONCLUSIONS MDs and changes on MRI have been reported in patients with neuroinvasive WNv disease. Our patient with OMAS also had transient splenial diffusion restriction on imaging, which, to the best of our knowledge, has not been previously reported with WNv infection. In both patients, treatment with IVIG resulted in improvement in symptoms.
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Affiliation(s)
- Irfan S Sheikh
- Department of Neurology, The University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Ehad Afreen
- Department of Neurology, The University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Ajaz Sheikh
- Department of Neurology, The University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
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Imported Human West Nile Virus Lineage 2 Infection in Spain: Neurological and Gastrointestinal Complications. Viruses 2020; 12:v12020156. [PMID: 32013149 PMCID: PMC7077332 DOI: 10.3390/v12020156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 01/21/2020] [Accepted: 01/26/2020] [Indexed: 01/04/2023] Open
Abstract
We report the first human case of West Nile virus (WNV) lineage 2 infection imported to Spain by a traveler returning from Romania. Serum, cerebrospinal fluid and urine samples were analyzed and West Nile virus infection was identified by PCR and serological tests. The patient developed fever, diarrhea and neurological symptoms, accompanied by mild pancreatitis, described previously in very few cases as a complication of WNV infection and by alithiasic cholecystitis. Viral RNA was detected in urine until 30 days after the onset of symptoms and neutralizing antibodies were detected at very low titers. The phylogenetic analysis in a fragment of the NS5 gene of the virus showed a homology with sequences from WNV lineage 2 belonging to the monophyletic Central/Southern European group.
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Lenka A, Kamat A, Mittal SO. Spectrum of Movement Disorders in Patients With Neuroinvasive West Nile Virus Infection. Mov Disord Clin Pract 2019; 6:426-433. [PMID: 31392241 DOI: 10.1002/mdc3.12806] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 05/28/2019] [Accepted: 06/05/2019] [Indexed: 11/05/2022] Open
Abstract
Background West Nile virus (WNV) is a flavivirus that is recognized as one of the common causes of arboviral neurological disease in the world. WNV infections usually manifest with constitutional symptoms such as fever, fatigue, myalgia, rash, arthralgia, and headache. Neuroinvasive WNV infections are characterized by signs and symptoms suggestive of meningitis, encephalitis, meningoencephalitis, and acute flaccid paralysis. In addition, many patients with neuroinvasive WNV infection develop a wide range of movement disorders. This article aims to comprehensively review the spectrum and natural course of the movement disorders observed in patients with neuroinvasive WNV infections. Methods A literature search was performed in March 2019 (in PubMed and EMBASE) to identify articles for this review. Results Movement disorders observed in the context of WNV infections include tremor, opsoclonus-myoclonus, parkinsonism, myoclonus, ataxia, and chorea. Most often, these movement disorders resolve within a few weeks to months with an indolent course. The commonly observed tremor phenotypes include action tremor of the upper extremities (bilateral > unilateral). Tremor in patients with West Nile meningitis subsides earlier than that in patients with West Nile encephalitis/acute flaccid paralysis. Opsoclonus-myoclonus in WNV infections responds well to intravenous immunoglobulins/plasmapheresis/corticosteroids. Parkinsonism has been reported to be mild in nature and usually lasts for a few weeks to months in the majority of the patients. Conclusion A wide spectrum of movement disorders is observed in neuroinvasive WNV infections. Longitudinal studies are warranted to obtain better insights into the natural course of these movement disorders.
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Affiliation(s)
- Abhishek Lenka
- Department of Neurology MedStar Georgetown University Hospital Washington DC USA
| | - Anuja Kamat
- Department of Internal Medicine Texas Tech University Health Sciences Center Amarillo TX USA
| | - Shivam Om Mittal
- Department of Neurology Cleveland Clinic Abu Dhabi United Arab Emirates
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Radu RA, Terecoasă EO, Ene A, Băjenaru OA, Tiu C. Opsoclonus-Myoclonus Syndrome Associated With West-Nile Virus Infection: Case Report and Review of the Literature. Front Neurol 2018; 9:864. [PMID: 30386288 PMCID: PMC6198716 DOI: 10.3389/fneur.2018.00864] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 09/25/2018] [Indexed: 12/29/2022] Open
Abstract
Opsoclonus-myoclonus syndrome (OMS) is a very rare condition with different autoimmune, infectious and paraneoplastic aetiologies or in most cases idiopathic. We report the case of a 75-year-old woman who was admitted in our department in early fall for altered mental status, opsoclonus, multifocal myoclonus, truncal titubation and generalized tremor, preceded by a 5 day prodrome consisting of malaise, nausea, fever and vomiting. Brain computed tomography and MRI scans showed no significant abnormalities and cerebrospinal fluid changes consisted of mildly increased protein content and number of white cells. Work-up for paraneoplastic and autoimmune causes of OMS was negative but serologic tests identified positive IgM and IgG antibodies against West Nile virus (WNV). The patient was treated with Dexamethasone and Clonazepam with progressive improvement of mental status, myoclonus, opsoclonus and associated neurologic signs. Six months after the acute illness she had complete recovery. To our knowledge this is the 14th case of WNV associated OMS reported in the literature so far. We briefly describe the clinical course of the other reported cases together with the different treatment strategies that have been employed.
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Affiliation(s)
- Răzvan Alexandru Radu
- Department of Neurology, University Emergency Hospital Bucharest, Bucharest, Romania.,Department of Clinical Neurosciences, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Elena Oana Terecoasă
- Department of Neurology, University Emergency Hospital Bucharest, Bucharest, Romania.,Department of Clinical Neurosciences, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Amalia Ene
- Department of Neurology, University Emergency Hospital Bucharest, Bucharest, Romania
| | - Ovidiu Alexandru Băjenaru
- Department of Neurology, University Emergency Hospital Bucharest, Bucharest, Romania.,Department of Clinical Neurosciences, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Cristina Tiu
- Department of Neurology, University Emergency Hospital Bucharest, Bucharest, Romania.,Department of Clinical Neurosciences, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
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Singh S, Kumar A. Ocular Manifestations of Emerging Flaviviruses and the Blood-Retinal Barrier. Viruses 2018; 10:v10100530. [PMID: 30274199 PMCID: PMC6213219 DOI: 10.3390/v10100530] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 09/25/2018] [Accepted: 09/26/2018] [Indexed: 12/19/2022] Open
Abstract
Despite flaviviruses remaining the leading cause of systemic human infections worldwide, ocular manifestations of these mosquito-transmitted viruses are considered relatively uncommon in part due to under-reporting. However, recent outbreaks of Zika virus (ZIKV) implicated in causing multiple ocular abnormalities, such as conjunctivitis, retinal hemorrhages, chorioretinal atrophy, posterior uveitis, optic neuritis, and maculopathies, has rejuvenated a significant interest in understanding the pathogenesis of flaviviruses, including ZIKV, in the eye. In this review, first, we summarize the current knowledge of the major flaviviruses (Dengue, West Nile, Yellow Fever, and Japanese Encephalitis) reported to cause ocular manifestations in humans with emphasis on recent ZIKV outbreaks. Second, being an immune privilege organ, the eye is protected from systemic infections by the presence of blood-retinal barriers (BRB). Hence, we discuss how flaviviruses modulate retinal innate response and breach the protective BRB to cause ocular or retinal pathology. Finally, we describe recently identified infection signatures of ZIKV and discuss whether these system biology-predicted genes or signaling pathways (e.g., cellular metabolism) could contribute to the pathogenesis of ocular manifestations and assist in the development of ocular antiviral therapies against ZIKV and other flaviviruses.
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Affiliation(s)
- Sneha Singh
- Department of Ophthalmology, Visual and Anatomical Sciences, Wayne State University, Detroit, MI 48201, USA.
| | - Ashok Kumar
- Department of Ophthalmology, Visual and Anatomical Sciences, Wayne State University, Detroit, MI 48201, USA.
- Department of Biochemistry, Microbiology, and Immunology, Wayne State University, Detroit, MI 48201, USA.
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Desai SD, Gandhi FR, Vaishnav A. Opsoclonus Myoclonus Syndrome: A Rare Manifestation of Dengue Infection in a Child. J Pediatr Neurosci 2018; 13:455-458. [PMID: 30937088 PMCID: PMC6413617 DOI: 10.4103/jpn.jpn_55_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Opsoclonus myoclonus syndrome (OMS) is an inflammatory neurological disorder, which is characterized by chaotic uncontrolled movements of the eyes and involuntary jerk-like movements of the body. Different modalities of treatment have been described in medical literature to treat OMS. Immunomodulatory treatment with either steroids or intravenous immunoglobulin has been considered. Our case was a 14-year-old boy who presented with fever, mild confusion, without any seizures or focal deficits. On examination, he had opsoclonus in his eyes and had cortical myoclonus in his hands and body. On evaluation, he had low platelets, normal metabolic workup, normal brain imaging, and cerebrospinal fluid showed lymphocytic pleocytosis. He was managed conservatively and had spontaneous improvement in opsoclonus myoclonus by 5th day of his illness and complete recovery in 2 weeks. Although dengue is primarily considered hematotropic virus, it can involve nervous system as well and manifest with OMS.
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Affiliation(s)
- Soaham D Desai
- Department of Neurology, Pramukhswami Medical College, Shree Krishna Hospital, Karamsad, Anand, Gujarat, India
| | - Fenil R Gandhi
- Intern Student, Pramukhswami Medical College, Karamsad, Anand, Gujarat, India
| | - Anand Vaishnav
- Department of Neurology, Pramukhswami Medical College, Shree Krishna Hospital, Karamsad, Anand, Gujarat, India
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Sountharalingam S, Herath HMMTB, Wijegunasinghe D, Senanayke S. Opsoclonus myoclonus syndrome in a patient with Japanese encephalitis: a case report. J Med Case Rep 2017; 11:294. [PMID: 29058581 PMCID: PMC5651589 DOI: 10.1186/s13256-017-1454-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 09/13/2017] [Indexed: 11/12/2022] Open
Abstract
Background Opsoclonus myoclonus syndrome is a rare neurological disorder that usually manifests as a paraneoplastic phenomenon. Although some viruses are reported to cause this condition, opsoclonus myoclonus syndrome by Japanese encephalitis has not been reported previously. Case presentation Here we present the case of a 31-year-old Sri Lankan woman who presented with fever, altered level of consciousness, opsoclonus, and facial myoclonus. She was diagnosed as having Japanese encephalitis based on cerebrospinal fluid and serum Japanese encephalitis-specific immunoglobulin M antibody and characteristic magnetic resonance imaging abnormalities. She was given intravenously administered methylprednisolone pulses (1000 mg per day) for 5 days. With this she improved gradually with reduction in opsoclonus and myoclonic movements. Her limb muscle power and speech also improved slowly. Conclusions We intended to highlight the fact that opsoclonus myoclonus syndrome can be a feature of infection with Japanese encephalitis and that it can be added to the list of viruses which cause opsoclonus. Currently there is no well-accepted treatment for opsoclonus myoclonus syndrome and intravenously administered methylprednisolone pulses and immunosuppressants can be used successfully in these patients for early recovery.
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Affiliation(s)
| | - H M M T B Herath
- Medical Department, National Hospital of Sri Lanka, Colombo, Sri Lanka.
| | | | - Sunethra Senanayke
- Neurology Department, National Hospital of Sri Lanka, Colombo, Sri Lanka
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Opsoclonus myoclonus ataxia associated with West Nile virus infection: A dramatic presentation with benign prognosis? J Neurol Sci 2017; 376:38-41. [DOI: 10.1016/j.jns.2017.02.057] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 02/07/2017] [Accepted: 02/24/2017] [Indexed: 11/19/2022]
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Hébert J, Armstrong D, Daneman N, Jain JD, Perry J. Adult-onset opsoclonus-myoclonus syndrome due to West Nile Virus treated with intravenous immunoglobulin. J Neurovirol 2016; 23:158-159. [PMID: 27473195 DOI: 10.1007/s13365-016-0470-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 06/12/2016] [Accepted: 07/01/2016] [Indexed: 11/26/2022]
Abstract
A 63-year-old female with no significant past medical history was presented with a 5-day history of progressive opsoclonus-myoclonus, headaches, and fevers. Her workup was significant only for positive West-Nile Virus serum serologies. She received a 2-day course of intravenous immunoglobulin (IvIG). At an 8-week follow up, she had a complete neurological remission. Adult-onset opsoclonus-myoclonus syndrome is a rare condition for which paraneoplastic and infectious causes have been attributed. To our knowledge, this is the first case reported of opsoclonus-myoclonus secondary to West-Nile Virus treated with intravenous immunoglobulin monotherapy.
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Affiliation(s)
- Julien Hébert
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - David Armstrong
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Nick Daneman
- Division of Infectious Diseases, Sunnybrook Health Sciences Center, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Jennifer Deborah Jain
- Division of Neurology, Sunnybrook Health Sciences Center, A402, 2075 Bayview avenue, Toronto, ON, Canada, M4N 3M5
| | - James Perry
- Division of Neurology, Sunnybrook Health Sciences Center, A402, 2075 Bayview avenue, Toronto, ON, Canada, M4N 3M5.
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Sutter R, Ristic A, Rüegg S, Fuhr P. Myoclonus in the critically ill: Diagnosis, management, and clinical impact. Clin Neurophysiol 2015; 127:67-80. [PMID: 26428447 DOI: 10.1016/j.clinph.2015.08.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 08/09/2015] [Accepted: 08/20/2015] [Indexed: 12/22/2022]
Abstract
Myoclonus is the second most common involuntary non-epileptic movement in intensive care units following tremor-like gestures. Although there are several types of myoclonus, they remain underappreciated, and their diagnostic and prognostic associations are largely ignored. This review discusses clinical, electrophysiological, neuroanatomical, and neuroimaging characteristics of different types of myoclonus in critically ill adults along with their prognostic impact and treatment options. Myoclonus is characterized by a sudden, brief, and sometimes repetitive muscle contraction of body parts, or a brief and sudden cessation of tonic muscle innervation followed by a rapid recovery of tonus. Myoclonus can resemble physiologic and other pathologic involuntary movements. Neurologic injuries, anesthetics, and muscle relaxants interfere with the typical appearance of myoclonus. Identifying "real myoclonus" and determining the neuroanatomical origin are important, as treatment responses depend on the involved neuroanatomical structures. The identification of the type of myoclonus, the involved neuroanatomical structures, and the associated illnesses is essential to direct treatment. In conclusion, the combined clinical, electrophysiological, and neuroradiological examination reliably uncovers the neuroanatomical sources and the pathophysiology of myoclonus. Recognizing cortical myoclonus is critical, as it is treatable and may progress to generalized convulsive seizures or status epilepticus.
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Affiliation(s)
- Raoul Sutter
- Clinic for Intensive Care Medicine, University Hospital Basel, Basel, Switzerland; Division of Clinical Neurophysiology, Department of Neurology, University Hospital Basel, Basel, Switzerland.
| | - Anette Ristic
- Clinic for Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| | - Stephan Rüegg
- Division of Clinical Neurophysiology, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Peter Fuhr
- Division of Clinical Neurophysiology, Department of Neurology, University Hospital Basel, Basel, Switzerland
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Wiwanitkit V. Opsoclonus-myoclonus-ataxia syndrome associated with dengue. Parkinsonism Relat Disord 2014; 21:159. [PMID: 25443557 DOI: 10.1016/j.parkreldis.2014.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 11/12/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Viroj Wiwanitkit
- Hainan Medical University, China; Faculty of Medicine, University of Nis, Serbia; Joseph Ayobabalola University, Nigeria; Dr DY Patil Medical University, India.
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