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Skudal H, Lorentzen ÅR, Stenstad T, Quist-Paulsen E, Egeland J, Fevang B, Jaioun K, Hansen BÅ, Solheim AM, Tveten Y, Veje M, Eikeland R, Kersten H. Clinical characteristics and factors affecting disease severity in hospitalized tick-borne encephalitis patients in Norway from 2018 to 2022. Eur J Clin Microbiol Infect Dis 2024; 43:1355-1366. [PMID: 38801484 PMCID: PMC11271349 DOI: 10.1007/s10096-024-04855-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 05/17/2024] [Indexed: 05/29/2024]
Abstract
PURPOSE To describe the clinical characteristics and factors associated with disease severity in a Norwegian cohort of hospitalized patients with tick-borne encephalitis (TBE). METHODS This observational multicenter study included hospitalized patients with TBE in the endemic area in the southeastern region of Norway from 2018 to 2022. Clinical signs and findings from laboratory tests, EEG, CT and MRI scans were recorded. Patient characteristics were compared among those with mild, moderate, and severe TBE, and factors associated with disease severity were identified. RESULTS Nearly all eligible patients were included in the final cohort (153/189 participants, 81%). The median age was 56 years, 63% were men, and 7% were vaccinated against TBE; no participants were fully vaccinated. TBE presented as mild (meningeal) disease in 31% of patients and as moderate or severe (encephalitic) disease in 54% and 14% of patients, respectively. We found that 46% of the patients had a monophasic course, 64% had hyponatremia, and 7% presented with central nervous system (CNS) symptoms without pleocytosis in cerebrospinal fluid (CSF). Dysesthesia, a symptom previously not described, was reported in 10% of the patients. Most objective findings were related to the CNS. Preexisting comorbidities, CRP and CSF protein levels were predictors of more severe disease. CONCLUSION This novel presentation of a large Norwegian cohort supports TBE as a serious disease in the southeastern region of Norway. The majority of hospitalized patients presented with encephalitis, and fewer presented with meningitis. Comorbidities, CRP and CSF protein levels were associated with more severe disease. TRIAL REGISTRATION Prosjekt #2,296,959 - The Norwegian Tick-borne Encephalitis Study - NOTES. Acute phase characteristics and long-term outcomes. - Cristin.
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Affiliation(s)
- Hilde Skudal
- Department of Infectious Diseases, Telemark Hospital Trust, Skien, Norway.
- Institute of Clinical Medicine, Faculty of Medicine, Oslo University Hospital, Oslo, Norway.
| | - Åslaug Rudjord Lorentzen
- Department of Neurology, Sørlandet Hospital Trust, Kristiansand, Norway
- Norwegian National Advisory Unit on Tick-borne Diseases, Sørlandet Hospital Trust, Kristiansand, Norway
| | - Tore Stenstad
- Department of Infectious Diseases, Vestfold Hospital Trust, Tønsberg, Norway
| | | | - Jens Egeland
- Division of Mental Health and Addiction, Vestfold Hospital Trust, Tønsberg, Norway
- Department of Psychology, University of Oslo, Oslo, Norway
| | - Børre Fevang
- Section of Clinical Immunology and Infectious Diseases, Department of Rheumatology Dermatology and Infectious Diseases, Oslo University Hospital, Oslo, Norway
| | - Keson Jaioun
- Department of Research, Telemark Hospital Trust, Skien, Norway
| | - Bjørn Åsheim Hansen
- Department of Infectious Diseases, Vestfold Hospital Trust, Tønsberg, Norway
| | - Anne Marit Solheim
- Department of Neurology, Sørlandet Hospital Trust, Kristiansand, Norway
- Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Yngvar Tveten
- Department of Clinical Microbiology, Telemark Hospital Trust, Skien, Norway
| | - Malin Veje
- Department of Infectious Diseases, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Biomedicine, Department of Infectious Diseases, University of Gothenburg, Gothenburg, Sweden
| | - Randi Eikeland
- Norwegian National Advisory Unit on Tick-borne Diseases, Sørlandet Hospital Trust, Kristiansand, Norway
- Faculty of Health and Sport Sciences, University of Agder, Grimstad, Norway
| | - Hege Kersten
- Institute of Clinical Medicine, Faculty of Medicine, Oslo University Hospital, Oslo, Norway
- Department of Research, Telemark Hospital Trust, Skien, Norway
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Branigan GL, Ozgur HT, Lim J, Riaz T. Syndrome of inappropriate antidiuretic hormone release secondary to central nervous system coccidioidomycosis with vasculitis. BMJ Case Rep 2024; 17:e258915. [PMID: 38553023 PMCID: PMC10982722 DOI: 10.1136/bcr-2023-258915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2024] [Indexed: 04/02/2024] Open
Abstract
A man in his 60s presented to the clinic due to night sweats and weight loss following pneumonia. He was found to have hyponatraemia due to a syndrome of inappropriate antidiuretic hormone (SIADH). CT of the thorax was concerning for pulmonary nodules. He was ultimately diagnosed with pulmonary coccidioidomycosis (CM) and started on fluconazole 400 mg daily with improvement in symptoms. Due to the report of headaches, head MRI was conducted which suggested central nervous system (CNS) involvement. Cerebrospinal fluid analysis was consistent with CNS CM and head magnetic resonance angiography confirmed the presence of CNS vasculitis. Fluconazole dose was increased to 800 mg daily which the patient continued to tolerate and showed improvement. This report depicts a case of SIADH associated with CNS CM with vasculitis and demonstrates the importance of high clinical suspicion for SIADH secondary to CNS CM in the setting of hyponatraemia and headache.
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Affiliation(s)
- Gregory Lawrence Branigan
- Medical Scientist Training Program, Department of Neurology, The University of Arizona College of Medicine Tucson, Tucson, Arizona, USA
| | - Hasan T Ozgur
- Department of Medical Imaging, University of Arizona College of Medicine Tucson, Tucson, Arizona, USA
| | - James Lim
- Department of Medicine, Divison of Infectious Disease, University of Arizona College of Medicine Tucson, Tucson, Arizona, USA
| | - Talha Riaz
- Department of Medicine, Divison of Infectious Disease, University of Arizona College of Medicine Tucson, Tucson, Arizona, USA
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Lourbopoulos A, Schnurbus L, Guenther R, Steinlein S, Ruf V, Herms J, Jahn K, Huge V. Case report: Fatal Borna virus encephalitis manifesting with basal brain and brainstem symptoms. Front Neurol 2024; 14:1305748. [PMID: 38333183 PMCID: PMC10850352 DOI: 10.3389/fneur.2023.1305748] [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: 10/02/2023] [Accepted: 12/26/2023] [Indexed: 02/10/2024] Open
Abstract
Background Since the first report of fatal Borna virus-1 (BoDV-1) encephalitis in 2018, cases gradually increased. There is a lack of diagnostic algorithm, and there is no effective treatment so far. Case presentation We report an acute BoDV-1 encephalitis in a 77-year-old female with flu-like onset, rapid progression to word-finding difficulties, personality changes, global disorientation, diffuse cognitive slowness, and gait ataxia and further deterioration with fever, meningism, severe hyponatremia, epileptic seizures, cognitive decline, and focal cortical and cerebellar symptoms/signs. The extensive diagnostic workup (cerebrovascular fluid, serum, and MRI) for (meningo-)encephalitis was negative for known causes. Our empirical common antiviral, antimicrobial, and immunosuppressive treatment efforts failed. The patient fell into coma 5 days after admission, lost all brainstem reflexes on day 18, remained fully dependent on invasive mechanical ventilation thereafter and died on day 42. Brain and spinal cord autopsy confirmed an extensive, diffuse, and severe non-purulent, lymphocytic sclerosing panencephalomyelitis due to BoDV-1, affecting neocortical, subcortical, cerebellar, neurohypophysis, and spinal cord areas. Along with our case, we critically reviewed all reported BoDV-1 encephalitis cases. Conclusion The diagnosis of acute BoDV-1 encephalitis is challenging and delayed, while it progresses to fatal. In this study, we list all tried and failed treatments so far for future reference and propose a diagnostic algorithm for prompt suspicion and diagnosis.
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Affiliation(s)
- Athanasios Lourbopoulos
- Department of Neurology and Neurointensive Care, Schoen Clinic Bad Aibling, Bad Aibling, Germany
- Institute for Stroke and Dementia Research (ISD), LMU Munich University Hospital, Munich, Germany
| | - Lea Schnurbus
- Department of Neurology and Neurointensive Care, Schoen Clinic Bad Aibling, Bad Aibling, Germany
| | - Ricarda Guenther
- Department of Neurology and Neurointensive Care, Schoen Clinic Bad Aibling, Bad Aibling, Germany
| | - Susanne Steinlein
- Department of Neurology and Neurointensive Care, Schoen Clinic Bad Aibling, Bad Aibling, Germany
| | - Viktoria Ruf
- Center for Neuropathology and Prion Research, LMU, Munich, Germany
| | - Jochen Herms
- Center for Neuropathology and Prion Research, LMU, Munich, Germany
| | - Klaus Jahn
- Department of Neurology and Neurointensive Care, Schoen Clinic Bad Aibling, Bad Aibling, Germany
- German Center of Vertigo and Balance Disorders (DSGZ), University of Munich (LMU), Munich, Germany
| | - Volker Huge
- Department of Neurology and Neurointensive Care, Schoen Clinic Bad Aibling, Bad Aibling, Germany
- Department of Anaesthesiology, LMU Munich University Hospital, Munich, Germany
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4
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Windpessl M, Oel D, Müller P. A Tick-Borne Cause of Hyponatremia: SIADH Due to Lyme Meningitis. Am J Med 2022; 135:e389-e390. [PMID: 35636484 DOI: 10.1016/j.amjmed.2022.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 05/04/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Martin Windpessl
- Department of Internal Medicine IV, Nephrology, Klinikum Wels-Grieskirchen, Wels, Austria.
| | - Dierk Oel
- Department of Neurology, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Petra Müller
- Department of Neurology, Klinikum Wels-Grieskirchen, Wels, Austria
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5
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Ladzinski AT, Baker M, Dunning K, Patel PP. Human Granulocytic Anaplasmosis presenting as Subacute Abdominal Pain and Hyponatremia. IDCases 2021; 25:e01183. [PMID: 34189035 PMCID: PMC8220232 DOI: 10.1016/j.idcr.2021.e01183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/18/2021] [Accepted: 06/09/2021] [Indexed: 12/03/2022] Open
Abstract
Human Granulocytic Anaplasmosis (HGA) is an acute febrile tick-borne illness caused by the organism Anaplasma phagocytophilum. Patients often present with fever and a flu-like symptoms following a tick bite. In this case, the patient presented with subacute abdominal pain and severe hyponatremia consistent with SIADH. The patient was started on appropriate empiric antibiotics given the patient’s tick exposure. Blood smear confirmed findings consistent with HGA and the patient continued antibiotic treatment with resolution of his symptoms. This case is unique in that the patient presented with severe hyponatremia that improved with treatment of the HGA. He also had subacute abdominal pain which is also a rare presentation of HGA. Our hope is that our case highlights the value of empiric treatment with appropriate monitoring to prevent downstream, severe sequelae from undiagnosed HGA. In the setting of climate change, increased duration of Ixodes spp. tick life cycles with emerging regional distribution of the ticks, coinfections with Borrelia burgdorferi and increased incidence of HGA in the last two decades, it is important to recognize this entity.
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Affiliation(s)
- Adam Timothy Ladzinski
- Department of Internal Medicine, Western Michigan University Homer Stryker M D School of Medicine, 1000 Oakland Drive, Kalamazoo, MI, USA
| | - Melissa Baker
- Department of Internal Medicine, Western Michigan University Homer Stryker M D School of Medicine, 1000 Oakland Drive, Kalamazoo, MI, USA
| | - Karla Dunning
- Pathology Services of Kalamazoo, 601 John St., Kalamazoo, MI, USA
| | - Prashant P Patel
- Department of Internal Medicine, Western Michigan University Homer Stryker M D School of Medicine, 1000 Oakland Drive, Kalamazoo, MI, USA
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Kleybolte J, Storek B, Hegner B. SARS-CoV-2-induced SIADH: a novel cause of hyponatremia. Z Gerontol Geriatr 2021; 54:301-304. [PMID: 33649867 PMCID: PMC7919984 DOI: 10.1007/s00391-021-01863-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 02/02/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Johannes Kleybolte
- Vivantes Ida Wolff Hospital for Geriatric Medicine, Juchaczweg 21, 12351, Berlin, Germany
| | - Benjamin Storek
- Vivantes Ida Wolff Hospital for Geriatric Medicine, Juchaczweg 21, 12351, Berlin, Germany
| | - Björn Hegner
- Vivantes Ida Wolff Hospital for Geriatric Medicine, Juchaczweg 21, 12351, Berlin, Germany. .,Clinic for Nephrology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
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7
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A Systematic Review of Sodium Disorders in HHV-6 Encephalitis. Biol Blood Marrow Transplant 2020; 26:1034-1039. [PMID: 32028025 DOI: 10.1016/j.bbmt.2020.01.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 01/24/2020] [Accepted: 01/28/2020] [Indexed: 12/17/2022]
Abstract
Human herpesvirus 6 (HHV-6) encephalitis has a high mortality rate. Among those who survive, ~80% develop some type of permanent neurologic disorder. Early diagnosis and treatment may help prevent long-term sequelae. There have been several case reports as well as retrospective and prospective studies associating HHV-6 encephalitis with some form of sodium imbalance, either hyponatremia or hypernatremia; however, the exact frequency post-HCT is unknown, with reports ranging from 30% to 100%. We performed a systematic review of the literature and found 34 cases of HHV-6 encephalitis reported in conjunction with sodium imbalance that documented the timing of that imbalance relative to the onset of encephalitis. Sodium imbalance occurred before or at the onset of HHV-6 encephalitis in all but 2 cases (94%). This finding supports previous suggestions that sodium imbalance can be considered an early indicator of the potential development or presence of HHV-6 encephalitis in at-risk patient populations.
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8
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Cui H, He G, Yang S, Lv Y, Jiang Z, Gang X, Wang G. Inappropriate Antidiuretic Hormone Secretion and Cerebral Salt-Wasting Syndromes in Neurological Patients. Front Neurosci 2019; 13:1170. [PMID: 31780881 PMCID: PMC6857451 DOI: 10.3389/fnins.2019.01170] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 10/16/2019] [Indexed: 12/13/2022] Open
Abstract
The differential diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) and cerebral salt-wasting syndrome (CSWS) in patients with neurological disorders has been a perplexing clinical controversy. The purpose of this review is to summarize the characteristics and risk factors of patients with different types of neurological disorders complicated by hyponatremia (HN) and review various methods to distinguish SIADH from CSWS. Common neurological disorders with high rates of HN include subarachnoid hemorrhage (SAH), traumatic brain injuries, stroke, cerebral tumors, central nervous system (CNS) infections, and Guillain-Barré syndrome (GBS), which have their own characteristics. Extracellular volume (ECV) status of patients is a key point to differentiate SIADH and CSWS, and a comprehensive assessment of relevant ECV indicators may be useful in differentiating these two syndromes. Besides, instead of monitoring the urinary sodium excretion, more attention should be paid to the total mass balance, including Na+, K+, Cl-, and extracellular fluid. Furthermore, the dynamic detection of fractional excretions (FE) of urate before and after correction of HN and a short-term infusion of isotonic saline solution may be useful in identifying the etiology of HN. As for brain natriuretic peptide (BNP) or N-terminal prohormone of BNP (NT-proBNP), more prospective studies and strong evidence are needed to determine whether there is a pertinent and clear difference between SIADH and CSWS.
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Affiliation(s)
- Haiying Cui
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Guangyu He
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Shuo Yang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - You Lv
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Zongmiao Jiang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Xiaokun Gang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Guixia Wang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
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9
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A Cross-Sectional Study of Hyponatremia Associated with Acute Central Nervous System Infections. J Clin Med 2019; 8:jcm8111801. [PMID: 31717875 PMCID: PMC6912743 DOI: 10.3390/jcm8111801] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 10/19/2019] [Accepted: 10/25/2019] [Indexed: 01/20/2023] Open
Abstract
Hyponatremia can occur with central nervous system (CNS) infections, but the frequency and severity may depend on the organism and nature of CNS involvement. In this cross-sectional study at a large Australian hospital network from 2015 to 2018, we aimed to determine the prevalence and severity of hyponatremia associated with CNS infection clinical syndromes, and the association with specific organisms. We examined the results of cerebrospinal fluid analysis from lumbar punctures performed in 184 adult patients with a serum sodium below 135 mmol/L who had abnormal cerebrospinal fluid analysis and a clinical syndrome consistent with an acute CNS infection (meningitis or encephalitis). Hyponatremia affected 39% of patients and was more severe and frequent in patients with encephalitis compared to meningitis (odds ratio = 3.03, 95% CI: 1.43–6.39, after adjusting for age). Hyponatremia was present on admission in 85% of cases. Herpes simplex virus infection was associated with the highest odds of hyponatremia (odds ratio = 3.25, 95% CI: 1.13–7.87) while enterovirus infection was associated with the lowest (odds ratio = 0.36, 95% CI: 0.14–0.92), compared to cases without an isolated organism. We concluded that the risk of hyponatremia may vary by the organism isolated but the clinical syndrome was a useful surrogate for predicting the probability of developing hyponatremia.
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10
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Basaran S, Yavuz SS, Bali EA, Cagatay A, Oncul O, Ozsut H, Eraksoy H. Hyponatremia Is Predictive of HSV-1 Encephalitis among Patients with Viral Encephalitis. TOHOKU J EXP MED 2019; 247:189-195. [PMID: 30890665 DOI: 10.1620/tjem.247.189] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Encephalitis is an inflammatory process involving the brain parenchyma associated with neurologic dysfunction. The main causes of infectious encephalitis are viruses, including Herpes simplex virus type 1 (HSV-1). As the mortality rate of HSV-1 encephalitis could be reduced with early acyclovir treatment, it is imperative to distinguish HSV-1 encephalitis from other type of viral encephalitis as early as possible. However, sophisticated methods for definitive diagnosis of HSV-1 encephalitis are not readily available. We aimed to explore distinctive clinical and laboratory features of HSV-1 encephalitis. All of the adult patients with viral encephalitis hospitalized between 2011-2017 were enrolled, including 16 patients with HSV-1 encephalitis and 51 patients non-HSV-1 viral encephalitis. Determination of viruses in cerebrospinal fluid was performed by PCR tests. Female sex, hyponatremia, and abnormalities in MRI were independently associated with HSV-1 encephalitis (p < 0.05 for each). In particular, hyponatremia (< 135 mEq/L) was found in nine patients with HSV-1 encephalitis (56.3%) and 10 patients with non-HSV-1 viral encephalitis (19.6%) (p = 0.005). As serum sodium is determined easily and quickly in clinical practice, the presence of hyponatremia among patients with viral encephalitis could be helpful for the early diagnosis of HSV-1 encephalitis before cerebrospinal fluid PCR results were available. Moreover, the presence of positive finding in MRI could further support the diagnosis. This is the first study that compared the serum sodium levels among patients between HSV-1 and non-HSV-1 viral encephalitis. We thus propose the diagnostic value of hyponatremia for HSV-1 encephalitis.
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Affiliation(s)
- Seniha Basaran
- Department of Infectious Diseases and Clinical Microbiology, Istanbul Faculty of Medicine, Istanbul University
| | - Serap Simsek Yavuz
- Department of Infectious Diseases and Clinical Microbiology, Istanbul Faculty of Medicine, Istanbul University
| | - Elif Aguloglu Bali
- Department of Infectious Diseases and Clinical Microbiology, Istanbul Faculty of Medicine, Istanbul University
| | - Atahan Cagatay
- Department of Infectious Diseases and Clinical Microbiology, Istanbul Faculty of Medicine, Istanbul University
| | - Oral Oncul
- Department of Infectious Diseases and Clinical Microbiology, Istanbul Faculty of Medicine, Istanbul University
| | - Halit Ozsut
- Department of Infectious Diseases and Clinical Microbiology, Istanbul Faculty of Medicine, Istanbul University
| | - Haluk Eraksoy
- Department of Infectious Diseases and Clinical Microbiology, Istanbul Faculty of Medicine, Istanbul University
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11
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Zheng F, Ye X, Shi X, Lin Z, Yang Z, Jiang L. Hyponatremia in Children With Bacterial Meningitis. Front Neurol 2019; 10:421. [PMID: 31114536 PMCID: PMC6503034 DOI: 10.3389/fneur.2019.00421] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 04/05/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Hyponatremia has frequently been described as a common complication associated with bacterial meningitis, though its frequency and clinical course in children with bacterial meningitis are unclear. The present study aimed to investigate the frequency, clinical characteristics, and prognosis associated with pediatric hyponatremia due to bacterial meningitis. Methods: We performed a retrospective review of children with bacterial meningitis provided with standard care. One hundred seventy-five children were included. We documented all participants' symptoms and signs, laboratory and microbiological data, radiological findings, and complications that occurred during their hospital admission. Disease severity was determined using the maximum Pediatric Cerebral Performance Category (PCPC) and minimum Glasgow Coma Scale (GCS). Residual deficits were assessed using PCPC at discharge. Results: Hyponatremia (<135 mmol/L) was seen in 116 (66.4%) of the patients assessed and was classified as mild (130-135 mmol/L) in 77, moderate (125-129 mmol/L) in 26, and severe (<125 mmol/L) in 13. Hyponatremia was associated with a shorter duration of symptoms before admission, higher CSF white cell counts, and a longer duration of hospitalization. Moderate and severe hyponatremia were associated with an increase in convulsions, impaired consciousness, altered CSF protein levels, higher maximum PCPC scores, and lower minimum GCS scores. Severe hyponatremia was further associated with the development of systemic complications including shock, multiple organ dysfunction syndrome, respiratory failure requiring mechanical ventilation, and an increase in poor outcome (PCPC ≥ 2). Hyponatremia was not associated with the development of neurologic complications. Logistic regression analyses revealed that convulsions (OR 12.09, 95% CI 2.63-56.84) and blood glucose levels > 6.1 mmol/L (OR 8.28, 95% CI 1.65-41.60) predicted severe hyponatremia. Conclusion: Hyponatremia occurred in 66.4% of the assessed pediatric bacterial meningitis patients. Moderate and severe hyponatremia affected the severity of pediatric bacterial meningitis. Only severe hyponatremia affected the short-term prognosis of patients with pediatric bacterial meningitis. We recommend that patients with pediatric bacterial meningitis who exhibit convulsions and increased blood glucose levels should be checked for severe hyponatremia. Further studies are needed to evaluate the effectiveness of treatment of hyponatremia.
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Affiliation(s)
- Feixia Zheng
- Department of Pediatrics, The Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiuyun Ye
- Department of Pediatrics, The Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xulai Shi
- Department of Pediatrics, The Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhongdong Lin
- Department of Pediatrics, The Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zuqin Yang
- Department of Pediatrics, The Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Longxiang Jiang
- Department of Respiratory Medicine, Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine, Wenzhou, China
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12
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Venkatesan A, Michael BD, Probasco JC, Geocadin RG, Solomon T. Acute encephalitis in immunocompetent adults. Lancet 2019; 393:702-716. [PMID: 30782344 DOI: 10.1016/s0140-6736(18)32526-1] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 10/01/2018] [Accepted: 10/04/2018] [Indexed: 01/26/2023]
Abstract
Encephalitis is a condition of inflammation of the brain parenchyma, occurs as a result of infectious or autoimmune causes, and can lead to encephalopathy, seizures, focal neurological deficits, neurological disability, and death. Viral causes account for the largest proportion, but in the last decade there has been growing recognition of anti-neuronal antibody syndromes. This Seminar focuses on the diagnosis and management of acute encephalitis in adults. Although viral and autoimmune causes are highlighted because of their prominent roles in encephalitis, other infectious pathogens are also considered. The role of cerebrospinal fluid studies, MRI, and novel diagnostic modalities (eg, next-generation sequencing) are discussed. Management approaches, including treatment of acute neurological complications and the use of immune suppressive and modulatory drugs for cases of suspected or confirmed autoimmune cause, are covered. Additionally, we discuss the remaining challenges in the diagnosis, management, and prognosis of encephalitis.
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Affiliation(s)
- Arun Venkatesan
- Johns Hopkins Encephalitis Center, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Benedict D Michael
- Center for Immune and Inflammatory Disease, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK; Department of Neurology, the Walton Center NHS Foundation Trust, Liverpool, UK
| | - John C Probasco
- Johns Hopkins Encephalitis Center, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Romergryko G Geocadin
- Johns Hopkins Encephalitis Center, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Anaesthesia/Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tom Solomon
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK; Department of Neurology, the Walton Center NHS Foundation Trust, Liverpool, UK
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Czupryna P, Moniuszko-Malinowska A, Grygorczuk S, Pancewicz S, Dunaj J, Król M, Borawski K, Zajkowska J. Effect of a single dose of mannitol on hydration status and electrolyte concentrations in patients with tick-borne encephalitis. J Int Med Res 2018; 46:5083-5089. [PMID: 30124371 PMCID: PMC6300936 DOI: 10.1177/0300060518790175] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 06/28/2018] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE This study was performed to assess the effect of a single dose of 15% mannitol on the hydration status and electrolyte balance in patients with tick-borne encephalitis (TBE). METHODS Forty-one patients with TBE were treated with 0.25 g/kg of 15% mannitol. The electrolyte concentrations (Na, K, and Cl), creatinine concentration, and hydration status were measured before and after mannitol infusion. RESULTS After mannitol administration, 7 patients had hyponatremia, 3 had hypokalemia, 1 had hyperkalemia, and 17 had hypochloremia. The total body water volume (TBW) changed by 0.44% ± 0.55%, the external body water volume (EBW) changed by 0.12% ± 0.15%, and the internal body water volume (IBW) changed by 0.19% ± 0.40%. The mean ECW/ICW ratio was 0.7694 ± 0.07 before treatment and 0.7699 ± 0.07 after treatment. Age was correlated with the TBW change in men (R = 0.42, p < 0.05) and with the potassium change in women (R = 0.66, p < 0.05). CONCLUSIONS Patients with TBE should receive mannitol two to four times daily depending on the clinical manifestation. Administration of a single dose of mannitol (0.25 g/kg) requires at least 300 mL of fluid supplementation. Bioimpedance might be useful for individual evaluation of dehydration. Additionally, patients require monitoring for potential hyponatremia. Older men may be more prone to dehydration after receiving mannitol.
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Affiliation(s)
- Piotr Czupryna
- Department of Infectious Diseases and Neuroinfections, Medical University of Białystok, Białystok, Poland
| | - Anna Moniuszko-Malinowska
- Department of Infectious Diseases and Neuroinfections, Medical University of Białystok, Białystok, Poland
| | - Sambor Grygorczuk
- Department of Infectious Diseases and Neuroinfections, Medical University of Białystok, Białystok, Poland
| | - Sławomir Pancewicz
- Department of Infectious Diseases and Neuroinfections, Medical University of Białystok, Białystok, Poland
| | - Justyna Dunaj
- Department of Infectious Diseases and Neuroinfections, Medical University of Białystok, Białystok, Poland
| | - Monika Król
- Department of Infectious Diseases and Neuroinfections, Medical University of Białystok, Białystok, Poland
| | - Karol Borawski
- Department of Infectious Diseases and Neuroinfections, Medical University of Białystok, Białystok, Poland
| | - Joanna Zajkowska
- Department of Infectious Diseases and Neuroinfections, Medical University of Białystok, Białystok, Poland
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Kannangara DW, Patel P. Report of Non-Lyme, Erythema Migrans Rashes from New Jersey with a Review of Possible Role of Tick Salivary Toxins. Vector Borne Zoonotic Dis 2018; 18:641-652. [PMID: 30129909 DOI: 10.1089/vbz.2018.2278] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Erythema migrans (EM) rashes once considered pathognomonic of Lyme disease (LD) have been reported following bites of arthropods that do not transmit LD and in areas with no LD. Also, EM rashes have been reported in association with organisms other than members of Borrelia burgdorferi sensu lato complex. Arthropod saliva has chemicals that have effects on the host and pathogen transmission. Tick saliva has protein families similar to spiders and scorpions and even substances homologous to those found in snakes and other venomous animals. Ticks "invertebrate pharmacologists" have a sophisticated arsenal of chemicals that assist in blood feeding, pathogen transmission, and suppressing host defenses. No organisms have been isolated from many EM rashes. We propose that tick salivary toxins may play a role in the causation of rashes and laboratory abnormalities in tick-borne diseases. The role of tick salivary toxins needs further exploration. Cases of Lyme-like EM rashes referred to as STARI (Southern Tick-Associated Rash Illness) following bites of the lone star tick, Amblyomma americanum, in the United States have been reported predominantly in Southeastern Missouri and a few in South Carolina, North Carolina, Georgia, and one case each in Mississippi and Long Island, New York. Although there is one report of Borrelia lonestari in a patient with a rash, biopsies of 31 cases of STARI, with cultures and PCR, failed to show a relationship. Distribution of A. americanum, whose bites are associated with STARI, now extends along the East Coast of the United States, including New Jersey, up to the Canadian border. As far as we are aware, there have been no prior reports of Lyme-like rashes in New Jersey. In this study, we present case examples of 2 Lyme-like rashes, variations of EM rashes, and a brief review of studies that suggest a role of tick salivary toxins in tick-borne diseases.
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Affiliation(s)
| | - Pritiben Patel
- St Luke's Health NetWork , Warren Campus, Phillipsburg, New Jersey
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15
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Misra UK, Kalita J, Singh RK, Bhoi SK. A Study of Hyponatremia in Acute Encephalitis Syndrome: A Prospective Study From a Tertiary Care Center in India. J Intensive Care Med 2017; 34:411-417. [PMID: 28393593 DOI: 10.1177/0885066617701422] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE: To evaluate the frequency and causes of hyponatremia in acute encephalitis syndrome (AES) and its effect on outcome. PATIENTS AND METHODS: Consecutive patients with AES were subjected to neurological evaluation including Glasgow Coma Scale, focal weakness, movement disorder, and reflex changes. The etiology of AES was based on blood and cerebrospinal fluid enzyme-linked immunosorbent assay and polymerase chain reaction. We have categorized patients into neurological or systemic AES. Hyponatremia was diagnosed if 2 consecutive serum sodium levels were below 135 mEq/L, 24 hours apart. Serum and urinary osmolality and electrolytes were measured on alternate days. Fluid intake, output, and body weight were measured daily. The hyponatremia was categorized into syndrome of inappropriate secretion of antidiuretic hormone (SIADH), cerebral salt wasting (CSW), or miscellaneous group. Outcome at 1 month was assessed by modified Rankin scale. RESULTS: Of 79 patients, 34 had neurologic AES and 45 had systemic AES; 22 (27.8%) patients had hyponatremia. The neurologic AES as compared to systemic AES was more commonly associated with hyponatremia (38.2% vs 20%, P = .07), need longer hospitalization (25.0 vs 12.5 days, P = .003), and longer time for sodium correction (13.3 vs 8.2 days, P = .05). The hyponatremia was due to CSW in 12 patients, SIADH in 2 patients, and indeterminate in 8 patients. Thirty-six patients had poor outcome (15 died) and 43 had good outcome which was not related to hyponatremia. CONCLUSION: Hyponatremia occurs in one-third of patients with AES, being commoner in neurologic AES, and CSW is the commonest cause.
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Affiliation(s)
- Usha Kant Misra
- 1 Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Jayantee Kalita
- 1 Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rajesh Kumar Singh
- 1 Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sanjeev Kumar Bhoi
- 1 Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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