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Das S, Ray BK, Mishra L, Chatterjee K, Mondal G, Paul DK. The Spectrum of Pediatric Infection-Associated Intracranial Arteriopathies and Acute Ischemic Stroke at 2 Eastern Indian Tertiary Care Centres. J Child Neurol 2023; 38:422-434. [PMID: 37138497 DOI: 10.1177/08830738231171800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
INTRODUCTION Major and minor pediatric infections may cause intracranial arteriopathies, the long-term outcome of which we investigated and identified the factors influencing the progression/resolution of arteriopathies. METHODS We collected the clinical and radiological data of children aged 1 month-15 years who had ischemic stroke with definite arteriopathy following a recent febrile infection. Repeated neuroimaging was done over the next year to ascertain recurrent strokes and the progression and resolution of arteriopathies. RESULTS The anterior circulation was more frequently affected (83.33%), predominantly involving the middle cerebral artery (41.67%), resolving in 20.84% of cases and progressing in 33.33% of cases. Lesions were commonly unilateral (54.17%) and stenotic (75%), resulting predominantly in cortical infarcts (45.83%), with hemiparesis being the most common neurodeficiency. Apart from tubercular meningitis patients, others had a good functional outcome. CONCLUSION Lower age, minor infections, and unilateral arteriopathies had a significantly higher chance of resolution. Postviral arteriopathies had a significantly lower chance of progression compared with those following bacterial infections. Progressive and bilateral arteriopathies were significantly associated with worse outcomes and recurrent strokes.
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Affiliation(s)
- Suman Das
- Department of Neurology, North Bengal Medical College, Shusrutnagar, Darjeeling, West Bengal, India
| | - Biman Kanti Ray
- Department of Neurology, Bangur Institute of Neurology, Kolkata, West Bengal, India
| | | | - Kaushani Chatterjee
- Dr. B C Roy Post Graduate Institute of Pediatric Sciences, Kolkata, West Bengal, India
| | - Gobinda Mondal
- Dr. B C Roy Post Graduate Institute of Pediatric Sciences, Kolkata, West Bengal, India
| | - Dilip Kumar Paul
- Dr. B C Roy Post Graduate Institute of Pediatric Sciences, Kolkata, West Bengal, India
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Rona G, Arifoğlu M, Günbey HP, Yükselmiş U. Influenza A (H1N1)-Associated Acute Necrotizing Encephalopathy with Unusual Posterior Reversible Encephalopathy Syndrome in a Child. ACTA ACUST UNITED AC 2021; 3:1528-1533. [PMID: 33937633 PMCID: PMC8068560 DOI: 10.1007/s42399-021-00928-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 11/26/2022]
Abstract
Other than respiratory symptoms, influenza A (H1N1) can rarely cause neurological complications in children and adults. In this article, we aimed to present H1N1-associated acute necrotizing encephalopathy (ANE) and asymmetrical involvement of posterior reversible encephalopathy syndrome (PRES) in a 30-month-old male patient with clinical and radiological imaging findings. The patient who presented to the hospital with febrile convulsion and lethargy had elevated liver enzymes and coagulopathy. The magnetic resonance (MR) examination revealed diffusion restriction in bilateral cerebellar white matter, thalami, and periventricular white matter which was consistent with ANE. Susceptibility-weighted imaging (SWI) sequence showed hemorrhage in bilateral thalami and cerebellar white matter. There was high signal on fluid-attenuated inversion recovery (FLAIR) sequences in right temporooccipital cortical, subcortical, and periventricular white matter suggestive of PRES. MR angiography showed vasculopathy which is supportive for PRES. This is the second case of H1N1-associated pediatric PRES reported in the literature.
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Affiliation(s)
- Günay Rona
- Department of Radiology, University of Health Sciences Kartal Lutfi Kırdar Training and Research Hospital, Kartal, 34890 Istanbul, Turkey
| | - Meral Arifoğlu
- Department of Radiology, University of Health Sciences Kartal Lutfi Kırdar Training and Research Hospital, Kartal, 34890 Istanbul, Turkey
| | - Hediye P. Günbey
- Department of Radiology, University of Health Sciences Kartal Lutfi Kırdar Training and Research Hospital, Kartal, 34890 Istanbul, Turkey
| | - Ufuk Yükselmiş
- Department of Pediatrics, University of Health Sciences Kartal Lutfi Kırdar Training and Research Hospital, Istanbul, Turkey
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Dawood H, Nasir S, Ahmed M, O'Brien C, Dawood M. Posterior Reversible Encephalopathy Syndrome Secondary to Varicella Encephalitis. Cureus 2021; 13:e12484. [PMID: 33564499 PMCID: PMC7861057 DOI: 10.7759/cureus.12484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a rapidly progressive neurologic condition presenting with typical symptoms including headache, nausea, vomiting, altered mental status, and visual defects. Neuroimaging profile, particularly magnetic resonance imaging (MRI), is the most important tool for diagnosis. The most commonly reported etiological factors include hypertensive emergency and renal disease. We describe a 67-year-old lady who developed clinical and radiological characteristics of PRES secondary to Varicella encephalitis.
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Affiliation(s)
| | - Saad Nasir
- Internal Medicine, United Medical and Dental College, Creek General Hospital, Karachi, PAK
| | - Mushtaq Ahmed
- Pediatrics, Our Lady of Lourdes Hospital, Drogheda, IRL
| | | | - Mustafa Dawood
- Nephrology, Emory University School of Medicine, Atlanta, USA
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Ghali MGZ, Styler MJ. Etiologies, Cerebral Vasomotion, and Endothelial Dysfunction in the Pathophysiology of Posterior Reversible Encephalopathy Syndrome in Pediatric Patients. JOURNAL OF PEDIATRIC NEUROLOGY 2020. [DOI: 10.1055/s-0040-1702934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AbstractThe posterior reversible encephalopathy syndrome was characterized by Hinchey and colleagues in the 1990s. The condition frequently afflicts patients suffering from hematologic and solid organ malignancy and individuals undergoing transplantation. Cases are more frequently described in the adult population compared with children. In the pediatric population, malignancy, transplantation, renal disease, and hypertension represent the most common etiologies. Theories on pathogenesis have centered upon cerebrovascular dysautoregulation with increases in blood–brain barrier permeability. This generates vasogenic edema of the cerebral parenchyma and consequent neurologic deficits. The parietal and occipital lobes are affected with greatest prevalence, though frontal and temporal lobe involvement is frequent, and that of the contents of the infratentorial posterior cranial fossa are occasionally described. The clinical presentation involves a characteristic constellation of neurologic signs and symptoms, most typically inclusive of headache, visual-field disturbances, abnormalities of visual acuity, and seizures. Supportive care, withdrawal of the offending agent, antihypertensive therapy, and prophylactic anticonvulsants affect convalescence in majority of cases. The principal challenge lies in identifying the responsible agent precipitating the condition in patients with malignancy and those having undergone transplantation and thus deciding which medication among a multidrug treatment regimen to withhold, the duration of drug cessation required to effect clinical resolution, and the safety of resuming treatment with the compound. We accordingly reviewed and evaluated the literature discussing the posterior reversible encephalopathy syndrome in children.
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Affiliation(s)
- Michael G. Z. Ghali
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, United States
| | - Michael J. Styler
- Department of Hematology and Oncology, Hahnemann University Hospital, Philadelphia, Pennsylvania, United States
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Ito Y, Toyama K, Honda A, Nakazaki K, Arai S, Kurokawa M. Posterior reversible encephalopathy syndrome concurrent with human herpesvirus-6B encephalitis after allogeneic hematopoietic stem cell transplantation. J Infect Chemother 2019; 26:265-268. [PMID: 31421950 DOI: 10.1016/j.jiac.2019.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 07/20/2019] [Accepted: 07/24/2019] [Indexed: 11/18/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) and human herpesvirus (HHV)-6 encephalitis are both serious neurological complications post hematopoietic stem cell transplantation. Although infection is one of the important causes of PRES, only few cases have reported the relation between PRES and viral infection. Herein, we report the first adult case of PRES concurrent with HHV-6 encephalitis after allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia. This case suggests that HHV-6 reactivation is associated with the pathogenesis of PRES. Also, PRES and HHV-6 encephalitis cause similar symptoms, and switching the immunosuppressant from calcineurin inhibitor to prednisolone for treating PRES may worsen HHV-6 encephalitis. Therefore, we should pay attention to the complication of HHV-6 encephalitis even after PRES is diagnosed.
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Affiliation(s)
- Yusuke Ito
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Kazuhiro Toyama
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Akira Honda
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Kumi Nakazaki
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Shunya Arai
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Mineo Kurokawa
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Japan; Department of Cell Therapy and Transplantation Medicine, The University of Tokyo Hospital, Japan.
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Racchiusa S, Mormina E, Ax A, Musumeci O, Longo M, Granata F. Posterior reversible encephalopathy syndrome (PRES) and infection: a systematic review of the literature. Neurol Sci 2019; 40:915-922. [PMID: 30604335 DOI: 10.1007/s10072-018-3651-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 11/16/2018] [Indexed: 11/24/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is an encephalopathy characterized by a rapid onset of symptoms including headache, seizures, confusion, blurred vision, and nausea associated with a typical magnetic resonance imaging appearance of reversible subcortical vasogenic edema prominent and not exclusive of parieto-occipital lobes. Vasogenic edema is caused by a blood-brain barrier leak induced by endothelial damage or a severe arterial hypertension exceeding the limits of cerebral blood flow autoregulation. Although the exact pathophysiological mechanism is still unclear, frequent conditions that may induce PRES include severe hypertension, eclampsia/pre-eclampsia, acute kidney diseases and failure, immunosuppressive therapy, solid organ, or bone marrow transplantation. Conversely to other conditions, which may induce PRES, the link between severe infection or sepsis and PRES, often associated with gram-positive bacteria, is still poorly understood and less well known. Clinicians from multiple disciplines, such as neurologists and internists, may encounter during their profession patients with severe infection or sepsis and should consider the possible association between PRES and these conditions. We systematically reviewed the literature about this association in order to provide a helpful clinical insight of such complex pathophysiological mechanism, highlighting the importance of recognizing PRES in such a complex clinical scenario.
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Affiliation(s)
- Sergio Racchiusa
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico "G. Martino" Via Consolare Valeria 1, 98100, Messina, Italy.
| | - Enricomaria Mormina
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico "G. Martino" Via Consolare Valeria 1, 98100, Messina, Italy.,Department of Clinical and experimental Medicine, University of Messina, Policlinico "G. Martino" Via Consolare Valeria 1, 98100, Messina, Italy
| | - Antonietta Ax
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico "G. Martino" Via Consolare Valeria 1, 98100, Messina, Italy
| | - Olimpia Musumeci
- Department of Clinical and experimental Medicine, University of Messina, Policlinico "G. Martino" Via Consolare Valeria 1, 98100, Messina, Italy
| | - Marcello Longo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico "G. Martino" Via Consolare Valeria 1, 98100, Messina, Italy
| | - Francesca Granata
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico "G. Martino" Via Consolare Valeria 1, 98100, Messina, Italy
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Mungaomklang A, Chomcheoy J, Wacharapluesadee S, Joyjinda Y, Jittmittraphap A, Rodpan A, Ghai S, Saraya A, Hemachudha T. Influenza Virus-Associated Fatal Acute Necrotizing Encephalopathy: Role of Nonpermissive Viral Infection? CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2016; 9:99-102. [PMID: 27812294 PMCID: PMC5091092 DOI: 10.4137/ccrep.s40610] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 09/19/2016] [Accepted: 09/26/2016] [Indexed: 12/02/2022]
Abstract
In 2014, two unusual peaks of H1N1 influenza outbreak occurred in Nakhon Ratchasima Province, in Thailand. Among 2,406 cases, one of the 22 deaths in the province included a 6-year-old boy, who initially presented with acute necrotizing encephalopathy. On the other hand, his sibling was mildly affected by the same influenza virus strain, confirmed by whole-genome sequencing, with one silent mutation. Absence of acute necrotizing encephalopathy and other neurological illnesses in the family and the whole province, with near identical whole viral genomic sequences from the two siblings, and an absence of concomitant severe lung infection (cytokine storm) at onset suggest nonpermissive infection as an alternative pathogenetic mechanism of influenza virus.
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Affiliation(s)
- Anek Mungaomklang
- Maharat Nakhon Ratchasima Hospital, Ministry of Public Health, Nakhon Ratchasima, Thailand
| | - Jiraruj Chomcheoy
- Maharat Nakhon Ratchasima Hospital, Ministry of Public Health, Nakhon Ratchasima, Thailand
| | - Supaporn Wacharapluesadee
- Neuroscience Centre for Research and Development, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Yutthana Joyjinda
- Neuroscience Centre for Research and Development, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Akanitt Jittmittraphap
- Neuroscience Centre for Research and Development, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Apaporn Rodpan
- Neuroscience Centre for Research and Development, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Siriporn Ghai
- Neuroscience Centre for Research and Development, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Abhinbhen Saraya
- Neuroscience Centre for Research and Development, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Thiravat Hemachudha
- Neuroscience Centre for Research and Development, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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Goenka A, Michael BD, Ledger E, Hart IJ, Absoud M, Chow G, Lilleker J, Lunn M, McKee D, Peake D, Pysden K, Roberts M, Carrol ED, Lim M, Avula S, Solomon T, Kneen R. Neurological manifestations of influenza infection in children and adults: results of a National British Surveillance Study. Clin Infect Dis 2013; 58:775-84. [PMID: 24352349 DOI: 10.1093/cid/cit922] [Citation(s) in RCA: 113] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The emergence of influenza A(H1N1) 2009 was met with increased reports of associated neurological manifestations. We aimed to describe neurological manifestations of influenza in adults and children in the United Kingdom that presented at this time. METHODS A 2-year surveillance study was undertaken through the British adult and pediatric neurological surveillance units from February 2011. Patients were included if they met clinical case definitions within 1 month of proven influenza infection. RESULTS Twenty-five cases were identified: 21 (84%) in children and 4 (16%) in adults. Six (29%) children had preexisting neurological disorders. Polymerase chain reaction of respiratory secretions identified influenza A in 21 (81%; 20 of which [95%] were H1N1) and influenza B in 4 (15%). Twelve children had encephalopathy (1 with movement disorder), 8 had encephalitis, and 1 had meningoencephalitis. Two adults had encephalopathy with movement disorder, 1 had encephalitis, and 1 had Guillain-Barré syndrome. Seven individuals (6 children) had specific acute encephalopathy syndromes (4 acute necrotizing encephalopathy, 1 acute infantile encephalopathy predominantly affecting the frontal lobes, 1 hemorrhagic shock and encephalopathy, 1 acute hemorrhagic leukoencephalopathy). Twenty (80%) required intensive care, 17 (68%) had poor outcome, and 4 (16%) died. CONCLUSIONS This surveillance study described a cohort of adults and children with neurological manifestations of influenza. The majority were due to H1N1. More children than adults were identified; many children had specific encephalopathy syndromes with poor outcomes. None had been vaccinated, although 8 (32%) had indications for this. A modified classification system is proposed based on our data and the increasing spectrum of recognized acute encephalopathy syndromes.
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Affiliation(s)
- Anu Goenka
- Institute of Infection and Global Health, University of Liverpool
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Thabet FI, Khalil S, Naz F, Dyme IZ. Cerebellar mutism and reversible cytotoxic edema in influenza B-associated encephalopathy. Pediatr Neurol 2013; 49:489-92. [PMID: 24095574 DOI: 10.1016/j.pediatrneurol.2013.06.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Revised: 05/29/2013] [Accepted: 06/01/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND Influenza virus-associated neurological complications are rare, though well-documented, especially in children. Encephalopathy and seizures are the most common complications and are typically associated with influenza A infection. Cerebellar mutism has been rarely reported in association with influenza B infection. PATIENT We describe a 3-year-old boy who presented with cough, fever, altered mental status, seizure, hypotonia, and mutism. He tested positive for influenza B virus. His brain magnetic resonance imaging showed reversible cytotoxic edema limited to the middle cerebellar peduncles and the dentate nuclei. Other viral, vascular, toxic, and metabolic causes were ruled out. CONCLUSION Our patient represents a case of cerebellar mutism associated with influenza B encephalopathy in which the brain magnetic resonance imaging scan showed reversible cytotoxic edema limited to the middle cerebellar peduncles and the dentate nuclei. This clinicoradiological correlation supports other reports in which the dentate nuclei play a major rule in the pathogenesis of cerebellar mutism.
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Affiliation(s)
- Farouq I Thabet
- Department of Pediatrics and Human Development, Michigan State University, Lansing, Michigan.
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Kyan Y, Ueda Y, Yoshida M, Sasahara K, Shinya K. Transcriptome profiling of brain edemas caused by influenza infection and lipopolysaccharide treatment. J Med Virol 2013; 86:905-11. [PMID: 24306925 DOI: 10.1002/jmv.23801] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2013] [Indexed: 12/11/2022]
Abstract
Influenza A virus-associated encephalopathy triggered by influenza virus infection often occurs in children aged five and younger in Japan. However, the mechanisms behind Influenza A virus-associated encephalopathy are not yet well understood. This study developed an Influenza A virus-associated encephalopathy-like model using mice infected with Influenza A virus and given lipopolysaccharide treatment. The results showed that the mice used in the model suffered from brain edemas nearly three times more severe, as well as having higher cytokine levels in sera compared to those of the control groups. Using gene expression profiling, cytokine-related genes were found not to be up-regulated in the brain in situ, while protein coding genes, which are known to be involved in blood-brain barrier disruption, were up-regulated. Categorizing the functional groups using gene ontology revealed the terms "ion channels," "calcium oscillation," and "membrane transporter activities." The blood-brain barrier disruption found in this Influenza A virus-associated encephalopathy model can therefore be assumed to be due to a cellular electrolyte imbalance of the neuronal tissue, in addition to a cytokine storm.
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Affiliation(s)
- Yukihiro Kyan
- Graduate School of Medicine, Kobe University, Hyogo, Japan
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Severe form of encephalopathy associated with 2009 pandemic influenza A (H1N1) in Japan. J Clin Virol 2012; 56:25-30. [PMID: 23107158 DOI: 10.1016/j.jcv.2012.10.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Revised: 10/08/2012] [Accepted: 10/10/2012] [Indexed: 11/20/2022]
Abstract
BACKGROUND Every year, an estimated 200-500 children in Japan develop influenza-associated encephalopathy (IAE), and 10-30% of these children die. OBJECTIVE To clarify the clinical features of a severe form of acute encephalopathy seen with 2009 pandemic influenza A (H1N1). STUDY DESIGN This retrospective survey examined 20 children with acute encephalopathy associated with the 2009 pandemic influenza A (H1N1) who died or were in a prolonged deep coma with a flat electroencephalogram tracing and loss of spontaneous respiration. We obtained demographic, clinical, laboratory, and neuroimaging data through interviews with the attending physicians and chart reviews. RESULTS Subjects were 13 boys and seven girls. Their median age was 45 (range 11-200) months. Five patients had one or more pre-existing conditions. Acute encephalopathy developed within 2 days after influenza onset in 16 patients. As the initial neurological symptom, delirious behavior was seen in six children, and brief seizures in six. Eighteen patients were comatose within 6h of the onset of encephalopathy. Marked brain edema on computed tomography (CT) was seen in all but one patient. Brainstem lesions on CT were recognized in 12 patients. Sixteen patients died 0-45 (median 2.5) days after the onset of acute encephalopathy, and the others remained in deep comas without spontaneous respiration. CONCLUSIONS The clinical course of the patients was characterized by an onset with mild neurological symptoms and rapid deterioration of consciousness into coma. Head CT revealed marked cerebral edema, often associated with brainstem lesions.
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Post-marketing assessment of neuropsychiatric adverse events in influenza patients treated with oseltamivir: an updated review. Adv Ther 2012; 29:826-48. [PMID: 23054689 DOI: 10.1007/s12325-012-0050-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Indexed: 10/27/2022]
Abstract
A 2008 review by our group concluded that the risk of neuropsychiatric adverse events (NPAEs) in influenza patients was not increased by oseltamivir exposure, and did not identify any mechanism by which oseltamivir or its metabolites could cause or worsen such events. The current article reviews new information on this topic. Between September 16, 2007 and May 15, 2010, 1,805 spontaneously-reported NPAEs were identified in 1,330 patients receiving oseltamivir: 767 (42.5%) from Japan, 296 (16.4%) from the USA, and 742 (41.1%) from other countries. NPAEs were more common in children: 1,072 (59.4%) events were in those aged ≤16 years. NPAEs often occurred within 48 h of treatment initiation (953 events; 52.8%). Nearly half of the events were serious in nature (838; 46.4%). The three largest categories of events were abnormal behavior (457 events, 25.3%), miscellaneous psychiatric events (370; 20.5%), and delusions/perceptual disturbances (316 events, 17.5%). A total of 1,545 events (85.6%) in eight different categories were considered to be delirium or delirium-like. Twenty-eight suicide-related events were reported. A US healthcare claims database analysis showed that the risk of NPAEs in 7,798 oseltamivir-treated patients was no higher than that in 10,411 patients not on antivirals, but a study on oseltamivir and abnormal behavior in Japan was less conclusive. NPAE frequency in oseltamivir-exposed Japanese and Taiwanese children with influenza was the same as in unexposed children. New analysis of the UK General Practice Research Database showed that the relative adjusted risk of NPAEs in influenza patients was 2.18-times higher than in the general population. Other epidemiology studies report frequent occurrence of encephalitis and similar disorders in influenza patients independently of oseltamivir exposure. The new data support the findings of the original assessment. Evidence suggests that influenza-related encephalopathies are caused by influenza-induced inflammatory responses, but more work is needed to confirm the underlying mechanisms.
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Abstract
Neurologic complications associated with influenza infection represent rare, but often underappreciated, manifestations of both seasonal and global pandemic influenza. Seizures are the most common neurologic complication, occurring as febrile seizures, as exacerbations in patients with epilepsy, or as symptoms of other influenza-induced neurologic disorders. Encephalopathy is the second most common neurologic complication associated with influenza. A wide spectrum of conditions ranging from coma with severe long-term morbidity or mortality and more mild altered mental states that resolve with minimal-to-no sequelae have been reported. Other less common neurologic complications that have been described include stroke, focal neurologic deficits, Guillain-Barré syndrome, acute disseminated encephalomyelitis, and transverse myelitis.
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Locuratolo N, Mannarelli D, Colonnese C, Pauletti C, Antonaci L, Ferretti G, Fattapposta F. Unusual posterior reversible encephalopathy syndrome in a case of influenza A/H1N1 infection. J Neurol Sci 2012; 321:114-6. [PMID: 22910147 DOI: 10.1016/j.jns.2012.07.063] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2012] [Revised: 07/25/2012] [Accepted: 07/26/2012] [Indexed: 12/09/2022]
Abstract
Central nervous system involvement is an uncommon though potentially a severe complication during influenza infection; the pathogenic mechanisms of the neurological syndromes described in humans are largely unknown. We describe a case of a 51-year-old man who presented with fever and behavioral changes but no focal neurological deficits. The next day, the condition rapidly evolved into a severe neurological syndrome with recurrent focal motor seizures with secondary generalization. At the brain MRI, FLAIR disclosed a slight area of increased signal in the left mesial frontal cortex extending to the frontopolar area and insula. At DWI, a mild hyperintensity was evident in the mesial-frontopolar cortex, with normal ADC values. MR perfusion was indicative of severe hypoperfusion. Fungal, bacterial and viral cultures in CSF, blood and urine were negative. The nasopharyngeal swab PCR was positive for the H1N1-influenza A virus. The patient was thus treated and by day five the neurological examination results had returned to normal. A follow-up MRI, performed two weeks later, only revealed a residual slight hyperintensity in the left medial frontal cortex. The onset of a rapidly evolving encephalopathy syndrome, its close association with a MRI brain pattern of acute vasogenic edema and favorable outcome support a diagnosis of PRES during influenza A infection. However, the topographic characteristics of the cerebral lesion seem to define a PRES with an atypical pattern.
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Fearnley RA, Lines SW, Lewington AJP, Bodenham AR. Influenza A-induced rhabdomyolysis and acute kidney injury complicated by posterior reversible encephalopathy syndrome. Anaesthesia 2011; 66:738-42. [PMID: 21539531 DOI: 10.1111/j.1365-2044.2011.06752.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We report a case of Influenza A-induced rhabdomyolysis causing acute kidney injury in a young adult female who required invasive ventilation and renal replacement therapy. This case was further complicated by posterior reversible encephalopathy syndrome. Although this represents an extremely rare neurological complication of Influenza A infection, an appreciation of the condition and its management is important, given the high numbers of critically ill patients recently affected by H1N1 Influenza A in intensive care units in the UK.
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Affiliation(s)
- R A Fearnley
- Department of Anaesthesia, Queen Elizabeth Hospital, Woolwich, South London Healthcare NHS Trust, London, UK.
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Akins PT, Belko J, Uyeki TM, Axelrod Y, Lee KK, Silverthorn J. H1N1 encephalitis with malignant edema and review of neurologic complications from influenza. Neurocrit Care 2011; 13:396-406. [PMID: 20811962 PMCID: PMC7100075 DOI: 10.1007/s12028-010-9436-0] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Influenza virus infection of the respiratory tract is associated with a range of neurologic complications. The emergence of 2009 pandemic influenza A (H1N1) virus has been linked to neurological complications, including encephalopathy and encephalitis. Methods Case report and literature review. Results We reviewed case management of a 20-year old Hispanic male who developed febrile upper respiratory tract signs and symptoms followed by a confusional state. He had rapid neurologic decline and his clinical course was complicated by refractory seizures and malignant brain edema. He was managed with oseltamavir and peramavir, corticosteroids, intravenous gamma globulin treatment, anticonvulsants, intracranial pressure management with external ventricular drain placement, hyperosmolar therapy, sedation, and mechanical ventilation. Reverse transcriptase polymerase chain reaction analysis of nasal secretions confirmed 2009 H1N1 virus infection; cerebrospinal fluid (CSF) was negative for 2009 H1N1 viral RNA. Follow-up imaging demonstrated improvement in brain edema but restricted diffusion in the basal ganglia. We provide a review of the clinical spectrum of neurologic complications of seasonal influenza and 2009 H1N1, and current approaches towards managing these complications. Conclusions 2009 H1N1-associated acute encephalitis and encephalopathy appear to be variable in severity, including a subset of patients with a malignant clinical course complicated by high morbidity and mortality. Since the H1N1 influenza virus has not been detected in the CSF or brain tissue in patients with this diagnosis, the emerging view is that the host immune response plays a key role in pathogenesis.
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Affiliation(s)
- Paul Taylor Akins
- Department of Neurosurgery, Permanente Medical Group, Kaiser Sacramento Medical Center, 2025 Morse Avenue, Sacramento, CA 95825, USA.
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