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Chiara R, Vanessa P, Nazerian P, Gabriele V, Antonio F, Luca M, Francesco A. Adult-onset of mild encephalitis/encephalopathy with reversible splenial lesion (MERS): case report and systematic review. Neurol Sci 2024:10.1007/s10072-024-07627-0. [PMID: 38904900 DOI: 10.1007/s10072-024-07627-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 05/27/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Mild encephalitis/encephalopathy with reversible splenial lesion (MERS) is a clinical-radiological syndrome characterized by transient central nervous system symptoms and a reversible lesion in the splenium of the corpus callosum (SCC) on magnetic resonance (MR). We reported a case of adult-onset MERS with uncommon presentation and reviewed the existing literature. METHODS We described a case of adult-onset MERS with uncommon symptoms and signs and performed a systematic review of case series including more than four patients of adult-onset (> 14 years old) MERS, from January 2000 to December 2022. We summarized the clinical, laboratory, imaging and therapy data. RESULTS We included seven eligible studies for a total of 51 adult-onset MERS patients. Neurological manifestations were preceded by prodromal symptoms in most of the patients (88%), mainly with fever (78%). Headache was the most common symptom (50%), followed by seizures (22%) and disturbance of consciousness (22%). Inflammatory changes on cerebrospinal fluid were present in a half of patient, so defining encephalitis cases. Clinal recovery, was achieved in all patients but two with severe disturbance of consciousness who required ventilator support in the acute phase. MR showed isolated lesion in the SCC in 92% of patients, while 8% of patients showed also extracallosal lesions, all the lesions resolved or improved on follow-up imaging. CONCLUSIONS MERS is a form of encephalitis/encephalopathy with a broad range of central nervous system manifestation, often with mild symptoms, such as headache alone, that can lead to overlooked some cases, with an excellent prognosis in most patient.
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Affiliation(s)
- Rinaldi Chiara
- Neurology Unit, Nuovo Ospedale Santo Stefano, Prato, Italy.
| | | | - Peyman Nazerian
- Department of Critical Care Medicine and Surgery, Careggi University Hospital, Florence, Italy
| | - Viviani Gabriele
- Department of Critical Care Medicine and Surgery, Careggi University Hospital, Florence, Italy
| | - Farina Antonio
- NEUROFARBA Department, University of Florence, Florence, Italy
- Department of Neurology 2, AOU Careggi, Florence, Italy
| | - Massacesi Luca
- NEUROFARBA Department, University of Florence, Florence, Italy
- Department of Neurology 2, AOU Careggi, Florence, Italy
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Tsuchida A, Sawada K. Mild encephalitis/encephalopathy with a reversible splenial lesion (MERS). PCN REPORTS : PSYCHIATRY AND CLINICAL NEUROSCIENCES 2024; 3:e191. [PMID: 38868082 PMCID: PMC11114290 DOI: 10.1002/pcn5.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 03/15/2024] [Accepted: 03/20/2024] [Indexed: 06/14/2024]
Abstract
Background Mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) is increasingly recognized as a clinicoradiological syndrome. Its etiology is diverse, encompassing a variety of triggers, including infections and metabolic abnormalities. Uniquely, MERS may present with psychiatric symptoms, such as delirium, visual hallucinations, and catatonia, posing diagnostic challenges. The variability of these neuropsychiatric symptoms necessitates early diagnosis through magnetic resonance imaging (MRI) to avoid prolonged antipsychotic treatment. Case Presentation This report details a case of MERS in a 39-year-old male. The patient initially presented with headache, sore throat, and abnormal laboratory results: leukocytosis, neutrophilia with a left shift, elevated C-reactive protein (CRP) levels, and hyponatremia. On the fourth day of admission, he developed severe anxiety and restlessness, exhibited thoughts of death, and reported experiencing vivid hallucinations upon closing his eyes. MRI revealed a hyperintense lesion in the corpus callosum. A lumbar puncture showed no increase in cell count or protein. The patient showed a positive response to treatment with antibiotics and olanzapine, demonstrating rapid symptomatic improvement. A follow-up MRI on the 11th day showed complete resolution of the brain lesions. Six months later, no neurological or psychiatric sequelae were noted. The patient's clinical progression and imaging findings led to a definitive diagnosis of MERS. Conclusion The early presentation of symptoms such as restlessness, hallucinations, and death ideation played a critical role in diagnosing MERS, with early MRI examination being instrumental in both diagnosis and preventing prolonged antipsychotic medication use.
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Affiliation(s)
- Aki Tsuchida
- Department of PsychiatryKochi Health Sciences CenterKochiJapan
| | - Ken Sawada
- Department of PsychiatryKochi Health Sciences CenterKochiJapan
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Chen H, Yu X, Chen Y, Wu H, Wu Z, Zhong J, Tang Z. Reversible splenial lesion syndrome in children: a retrospective study of 130 cases. Front Neurol 2023; 14:1241549. [PMID: 37731857 PMCID: PMC10507860 DOI: 10.3389/fneur.2023.1241549] [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] [Received: 06/16/2023] [Accepted: 08/15/2023] [Indexed: 09/22/2023] Open
Abstract
Background Reversible splenial lesion syndrome (RESLES) is a new clinico-radiological syndrome. We retrospectively analyzed the clinical features of 130 children with RESLES in China, which is the largest case series available in the literature. Methods The clinical data of children diagnosed as RESLES in Jiangxi Provincial Children's Hospital between 2017 and 2023 were retrospectively analyzed. The 130 cases were divided into two groups: ≤ 3 years old group (group A) (n = 83) and > 3 years old group (group B) (n = 47). The chi-squared test or Fisher's test was used to evaluate the data. Results The vast majority of patients (127/130 cases, 97.7%) had prodromal symptoms of infection. Preceding infections of the gastrointestinal tract were statistically more significant in group A (60/83, 72.3%) than in group B (11/47, 23.4%) (P < 0.05). Preceding infections of the respiratory tract were statistically more significant in group B (33/47, 70.2%) than in group A (17/83, 20.5%) (P < 0.05). Seizures were statistically more significant in group A (82/83, 98.8%) than in group B (24/47,51.1%) (P < 0.05). The disturbance of consciousness and headache/dizziness were statistically more significant in group B (27/47, 57.4%; 37/47, 78.7%) than in group A (3/83, 3.6%; 1/83, 1.2%), respectively (P < 0.05). Convulsions with mild gastroenteritis (CwG) were statistically more significant in group A (50/83, 60.2%) than in group B (8/47, 17.0%) (P < 0.05). However, encephalitis/encephalopathy was statistically more significant in group B (20/47, 42.6%) than in group A (10/83, 12.0%) (P < 0.05). MRI showed cytotoxic edema in typical locations (RESLES type-1 limited to the splenium of the corpus callosum and RESLES type-2 spread to the entire corpus callosum, adjacent white matter, or both). There was full recovery of the lesions of MRI in all cases from 3 days to 50 days after the initial examinations. All the children showed normal neurodevelopment. Conclusion Infection was the most common cause of RESLES. Infections of the gastrointestinal tract are common in ≤ 3 years old children, while infections of the respiratory tract are common in >3 years old children. Younger patients are more likely to develop convulsions, and older children were more likely to have symptoms with disturbance of consciousness and headache/dizziness. RESLES has characteristic MRI manifestations and a good prognosis.
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Affiliation(s)
- Hui Chen
- Nanchang University, Nanchang, China
- Department of Neurology, Children's Hospital of Jiangxi Province, Nanchang, China
| | - Xiongying Yu
- Department of Neurology, Children's Hospital of Jiangxi Province, Nanchang, China
| | - Yong Chen
- Department of Neurology, Children's Hospital of Jiangxi Province, Nanchang, China
| | - Huaping Wu
- Department of Neurology, Children's Hospital of Jiangxi Province, Nanchang, China
| | - Zhuqiang Wu
- Department of Magnetic Resonance, Children's Hospital of Jiangxi Province, Nanchang, China
| | - Jianmin Zhong
- Department of Neurology, Children's Hospital of Jiangxi Province, Nanchang, China
| | - Zhenyu Tang
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang University, Nanchang, China
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Yum KS, Shin DI. Transient splenial lesions of the corpus callosum and infectious diseases. Acute Crit Care 2022; 37:269-275. [PMID: 35977887 PMCID: PMC9475166 DOI: 10.4266/acc.2022.00864] [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] [Received: 07/08/2022] [Accepted: 08/04/2022] [Indexed: 11/30/2022] Open
Abstract
Transient splenial lesion of the corpus callosum can be observed in various diseases such as cancer, drug use, metabolic disorders, and cerebrovascular disorders, as well as in patients with infectious diseases. During the coronavirus disease 2019 (COVID-19) pandemic, there were increasing reports of these lesions being detected on brain imaging tests performed in patients with neurological symptoms. On brain magnetic resonance imaging, findings suggestive of cytotoxic edema are observed in the splenium; these are known to disappear with improvement of clinical symptoms. Cytokinopathy caused by infection increases the permeability of the blood–brain barrier and activates the glial cells of the brain to induce cytotoxic edema. Most patients have a good prognosis. The causes, mechanism, diagnosis, treatment and prognosis of transient splenial lesions of the corpus callosum will be summarized in this review.
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Li X, Xu D, Zhou Y, Cheng B, Wang Y, Chen Z. Mild Encephalitis/Encephalopathy with Reversible Splenial Lesion Associated with Scrub Typhus in a Child: A Case Report. Vector Borne Zoonotic Dis 2022; 22:191-194. [PMID: 35319920 DOI: 10.1089/vbz.2021.0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) is a rare clinicoradiological syndrome characterized by transient mild encephalopathy and magnetic resonance imaging (MRI) findings of a reversible lesion in the splenium of the corpus callosum (SCC). Multiple causes have been proposed for the pathogenesis of MERS, with infection as the most pre-eminent. Case Presentation: We report the case of a 10-year-old girl with MERS due to scrub typhus. Her clinical manifestations of headache and drowsiness, together with lesions involving the SCC, as shown by MRI, and their complete resolution upon follow-up fulfilled the diagnosis of MERS. At the same time, the characteristic eschar of the skin and the positive Weil-Felix test result confirmed the existence of scrub typhus infection. Conclusions: To the best of our knowledge, we described the first pediatric case of MERS associated with scrub typhus. The case indicated that an MERS patient with fever should be considered as possibly having a scrub typhus infection. The characteristic black eschar of scrub typhus generally occurs after bite of mite that is important and useful to the doctor for making proper diagnosis.
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Affiliation(s)
- Xuejing Li
- Department of Pulmonology, Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Children's Regional Medical Center, Hangzhou, China
| | - Dan Xu
- Department of Pulmonology, Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Children's Regional Medical Center, Hangzhou, China
| | - Yunlian Zhou
- Department of Pulmonology, Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Children's Regional Medical Center, Hangzhou, China
| | - Beilei Cheng
- Department of Pulmonology, Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Children's Regional Medical Center, Hangzhou, China
| | - Yingshuo Wang
- Department of Pulmonology, Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Children's Regional Medical Center, Hangzhou, China
| | - Zhimin Chen
- Department of Pulmonology, Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Children's Regional Medical Center, Hangzhou, China
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Li XL, Han J, Yan ZR, Zhang BW, Wang HY. Mild encephalitis/encephalopathy with a reversible splenial lesion associated with respiratory syncytial virus infection in infants. J Neurovirol 2021; 27:638-643. [PMID: 34227046 DOI: 10.1007/s13365-021-00992-y] [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] [Received: 12/03/2020] [Revised: 04/30/2021] [Accepted: 06/18/2021] [Indexed: 10/20/2022]
Abstract
Mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) is a clinicoradiologic syndrome typically characterized by transient mild encephalitis or encephalopathy with reversible lesions being found in the splenium of corpus callosum (SCC) by magnetic resonance imaging (MRI). A variety of pathogens including influenza virus, rotavirus, and adenovirus associated with MERS have been reported. However, respiratory syncytial virus (RSV)-related MERS is relatively rare in infants. In this study, we report two Chinese infants who suffered from RSV-related MERS. Both infants manifested as fever, seizure, and altered states of consciousness with confirmed detections of RSV-RNA in the specimens from throat swab. Clinical symptoms/signs such as apnea and shallow breathing were also noted in these two infants. Furthermore, brain MRI images indicated reversible isolated lesions with transiently reduced diffusion in the SCC. Fortunately, both of these two infants recovered completely following treatment within a month. Our study suggests that RSV may serve as a novel causative agent for MERS in infants. Clinicians should focus more attention on RSV-related MERS in infants in order to improve early accurate diagnosis and therapeutic decision making.
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Affiliation(s)
- Xue-Lin Li
- Department of Intensive Care Unit, Jining No. 1 People's Hospital, Jining, 272000, China
| | - Jinming Han
- Department of Neurology , Xuanwu Hospital Capital Medical University , 100053, Beijing, China
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Zhong-Rui Yan
- Department of Neurology, Jining No. 1 People's Hospital, Jining, 272000, China
| | - Bing-Wei Zhang
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, 116011, Dalian, China
| | - Hai-Yang Wang
- Department of Neurology, Jining No. 1 People's Hospital, Jining, 272000, China.
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Tuscano A, Zoppo M, Canavese C, Cogoni M, Scolfaro C. Transient blindness associated with mild encephalitis/encephalopathy with a reversible splenial lesion (MERS): a case report and review of literature. Ital J Pediatr 2020; 46:152. [PMID: 33046117 PMCID: PMC7552542 DOI: 10.1186/s13052-020-00918-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 10/05/2020] [Indexed: 04/03/2023] Open
Abstract
Background Mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) is a clinical-radiological syndrome that can be related to infectious and non-infectious conditions. The most prominent neurological symptoms are disturbance of consciousness, abnormal speech, delirious behavior, seizures, muscle weakness, ophthalmoplegia, facial nerve paralysis and headache. Here we report the case of a child with MERS presenting with the unusual symptom of bilateral transient blindness. Case presentation A 4-year-old female patient, with a history of fever, abdominal pain, loss of appetite and cough lasted for a few days, experienced 3 episodes of transient bilateral loss of vision with difficulty in walking. Her physical examination showed absence of focal neurological and meningeal irritation signs, although responsiveness was slightly impaired. The ophthalmologic evaluation, including a fundus oculi examination, was negative. The electroencephalogram showed slow activity in the temporo-occipital regions, more evident in the right hemisphere. A lumbar puncture was performed and cerebrospinal fluid analysis revealed normal glycorrhachia, cell counts, protein levels and IgG index. Magnetic resonance imaging of the brain showed a signal alteration in the splenium of the corpus callosum, without contrast enhancement. This finding was suggestive of a reversible cytotoxic lesion. Empiric antiviral treatment with acyclovir and intravenous dexamethasone was initiated. Polymerase chain reaction search for neurotropic viral nucleic acid sequences in the cerebrospinal fluid was negative, while a low number of HHV-6 DNA copies was detected in the blood. Electroencephalograms were repeated in the following days, showing a progressive normalization of the pattern. The child was discharged without symptoms after 10 days of treatment with oral corticosteroids. After 40 days, brain magnetic resonance imaging showed a complete normalization of the signal alteration in the splenium of the corpus callosum. Conclusion Transient blindness was reported as an initial symptom of MERS in a few children. To date, there is no evidence of effective treatment methods. Nonetheless, MERS diagnosis provides pediatricians with valuable prognostic information in order to reassure patients and their families about the good outcome of this disease.
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Affiliation(s)
- Antonella Tuscano
- Department of Pediatric and Public Health Sciences, Postgraduate School of Pediatrics, Regina Margherita Children's Hospital, University of Turin, Turin, Italy.
| | - Marisa Zoppo
- Department of Pediatrics, Infectious Diseases Unit, University of Turin, Regina Margherita Children's Hospital, Turin, Italy
| | - Carlotta Canavese
- Division of Child and Adolescent Neuropsychiatry, Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Maurizio Cogoni
- Department of Neuroradiology, CTO Hospital, Torino, Italy.,No more needed, Turin, Italy.,, No more needed, Italia
| | - Carlo Scolfaro
- Department of Pediatrics, Infectious Diseases Unit, University of Turin, Regina Margherita Children's Hospital, Turin, Italy
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Tetsuka S. Reversible lesion in the splenium of the corpus callosum. Brain Behav 2019; 9:e01440. [PMID: 31588684 PMCID: PMC6851813 DOI: 10.1002/brb3.1440] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/15/2019] [Accepted: 09/18/2019] [Indexed: 12/17/2022] Open
Abstract
AIM OF REVIEW The presence of isolated, reversible lesions in the splenium of the corpus callosum (SCC) is essential to confirm the diagnosis of mild encephalitis/encephalopathy. The lesions usually heal within a month after the onset of neurological symptoms. Magnetic resonance imaging (MRI) has increasingly been used as a diagnostic tool, which has led to the publication of an increasing number of case reports. These have highlighted some inconsistencies about encephalitis/encephalopathy. First, the condition is not always mild and may be severe. Second, reversible lesions in the SCC have been identified in various diseases and conditions other than viral encephalitis/encephalopathy. Third, lesions in SCC are not always completely reversible. On this note, this review describes the specific clinical and radiological features of encephalitis/encephalopathy. FINDINGS The reversible lesion in SCC is an MRI finding observable in a wide variety of diseases and conditions. Thus, it should be considered as a secondary change rather than a peculiar feature associated with mild encephalitis/encephalopathy. If reversible lesions are present in the SCC, the symptoms and prognosis are not necessarily favorable, with manifestations of encephalitis/encephalopathy varying from absent to severe. Neuroradiological features that appear as isolated high-intensity signals on diffusion-weighted images and a decreased apparent diffusion coefficient of the lesion might indicate a diagnosis of cytotoxic edema. Findings of previous studies suggest that cytokine-mediated cytotoxic edema of the SCC may be an important pathophysiological manifestation of this condition. CONCLUSION The reversible lesions in the SCC found on MRI are not exclusive to encephalitis/encephalopathy but may be secondary to other disorders.
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Affiliation(s)
- Syuichi Tetsuka
- Department of Neurology, International University of Health and Welfare Hospital, Nasushiobara, Japan
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