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Reis R, Adragão F, Parente C, Nunes I, Ramos A, Nabais I, Silva I. A Seasonal Cause of Encephalitis: Influenza Virus A (H3N1) Infection. Eur J Case Rep Intern Med 2021; 8:002336. [PMID: 33768079 DOI: 10.12890/2021_002336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 02/08/2021] [Indexed: 11/05/2022] Open
Abstract
Influenza virus infection can have a range of presentations, from asymptomatic to life-threatening disease. We present the case of a 57-year-old woman with a known history of schizophrenia (controlled with medication) who presented to our emergency department in a coma after experiencing a seizure. She had reported flu-like symptoms in the previous week, which evolved to dyspnoea and altered mental status culminating in seizures and coma. Influenza virus A (H3N1) was identified in the cerebrospinal fluid. Although a rare cause of encephalitis, the influenza virus should be considered in the differential diagnosis, especially during epidemics. LEARNING POINTS Influenza virus encephalitis should be considered in some specific settings, such as during pandemics or seasonal epidemics.Altered mental status in a patient with a history of mental disease may be easily dismissed as secondary to prior disease or medication.Although rare, extrapulmonary manifestations of influenza virus infection can be serious and fatal.
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Affiliation(s)
- Rúben Reis
- Internal Medicine Department, Centro Hospitalar Barreiro-Montijo, Barreiro, Portugal
| | - Francisco Adragão
- Internal Medicine Department, Centro Hospitalar do Algarve, Algarve, Portugal
| | - Catarina Parente
- Internal Medicine Department, Centro Hospitalar Barreiro-Montijo, Barreiro, Portugal
| | - Inês Nunes
- Intensive Care Unit, Hospital de Cascais, Cascais, Portugal
| | - Armindo Ramos
- Intensive Care Unit, Hospital de Cascais, Cascais, Portugal
| | - Inês Nabais
- Internal Medicine Department, Hospital de Cascais, Cascais, Portugal
| | - Isa Silva
- Internal Medicine Department, Hospital de Cascais, Cascais, Portugal
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Abstract
A 50-year-old woman presented with coma and hemorrhagic shock. A rapid influenza antigen test revealed influenza A infection; other laboratory examinations ruled out any other suspected infections. She was diagnosed with hemorrhagic shock and encephalopathy syndrome (HSES) induced by influenza A. She was administered methylprednisolone pulse therapy and peramivir. Subsequently, she was discharged without any sequelae. Only a few cases of influenza-induced HSES have been reported, and the clinical outcomes were very poor. We herein report a successfully treated adult case of influenza-induced HSES and review this rare syndrome.
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Affiliation(s)
| | - Naohiro Uchida
- Division of Internal Medicine, Kyushu Rosai Hospital, Japan
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Howard A, Uyeki TM, Fergie J. Influenza-Associated Acute Necrotizing Encephalopathy in Siblings. J Pediatric Infect Dis Soc 2018; 7:e172-e177. [PMID: 29741717 PMCID: PMC6636323 DOI: 10.1093/jpids/piy033] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 03/20/2018] [Indexed: 11/13/2022]
Abstract
Encephalopathy is an important complication associated with influenza, most frequently observed in young children, with a wide range of severity. The most severe category of influenza-associated encephalopathy (IAE) is acute necrotizing encephalopathy (ANE), characterized by high frequency of neurologic sequelae and fatal outcomes. We report two young siblings who developed fever and seizures with altered mental status. Influenza A(H1N1)pdm09 virus infection was identified in upper respiratory tract specimens from both patients, and neuroimaging revealed bilateral inflammatory lesions, consistent with acute necrotizing encephalopathy. Neither child had received influenza vaccination. Both children progressed to critical illness and required invasive mechanical ventilation. In addition to critical care management, both patients received high-dose corticosteroids, mannitol, anticonvulsants, and antiviral treatment of influenza. The older child recovered fully and was discharged 2 weeks after illness onset, but the younger sibling developed severe brainstem edema and cerebellar tonsillar herniation, and died on illness day 11. Both children tested positive for Ran Binding Protein 2 (RANBP2) gene mutations. RANBP2 is a genetic polymorphism associated with recurrent episodes of necrotizing encephalitis with respiratory viral infections. Annual influenza vaccination is especially important for ANE survivors, with or without RANBP2 mutations, their household contacts, and caregivers. During influenza season, close monitoring of any child with a history of neurological complications associated with respiratory illness is indicated, with prompt initiation of antiviral treatment with onset of acute respiratory illness, and influenza testing performed by molecular assay.
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Affiliation(s)
- Ashley Howard
- Department of Pediatrics, Driscoll Children’s Hospital, Corpus Christi, Texas
| | - Timothy M. Uyeki
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jaime Fergie
- Department of Pediatric Infectious Disease, Driscoll Children’s Hospital, Corpus Christi, Texas;,Department of Pediatrics, Texas A&M University College of Medicine, Bryan
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Okuno H, Yahata Y, Tanaka-Taya K, Arai S, Satoh H, Morino S, Shimada T, Sunagawa T, Uyeki TM, Oishi K. Characteristics and Outcomes of Influenza-Associated Encephalopathy Cases Among Children and Adults in Japan, 2010-2015. Clin Infect Dis 2018; 66:1831-1837. [PMID: 29293894 PMCID: PMC5982813 DOI: 10.1093/cid/cix1126] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 12/26/2017] [Indexed: 12/14/2022] Open
Abstract
Background Influenza-associated encephalopathy (IAE) can result in severe neurologic disease with high mortality. Most IAE cases are reported among children worldwide. Understanding of IAE among adults is limited. Methods Data were collected on IAE cases reported through the National Epidemiological Surveillance of Infectious Diseases database in Japan from 2010 through 2015. IAE cases were stratified by age category and analyzed using descriptive statistics to assess differences in characteristics and outcomes. Results Among 385 IAE cases, median age at diagnosis was 7 years (range, 0-90), and 283 (74%) were aged <18 years. Mean seasonal incidence of IAE cases among children and adults (aged ≥18 years) was 2.83 and 0.19 cases per 1000000 population, respectively. IAE incidence did not vary by predominant influenza A virus subtype. IAE frequency was highest in school-aged (5-12 years) children (38%), followed by children aged 2-4 years (21%) and adults aged 18-49 years (11%). The proportion of cases with seizures was more common in children. There were more cases with cerebrospinal fluid pleocytosis among adults than in children (P < .01), especially among those aged 18-49 (17%) and 50-64 (19%) years. Case fatality proportion was highest in those aged 40-64 (17%) and ≥65 (20%) years. Conclusions We found differences in the clinical features of IAE between adults and children in Japan. Although IAE incidence was higher in children, mortality was higher in adults. Efforts are needed to prevent and improve survival of patients with IAE, especially in adults.
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Affiliation(s)
- Hideo Okuno
- Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo
- Department of Epidemiology for Infectious Diseases, Osaka University, Graduate School of Medicine, Japan
| | - Yuichiro Yahata
- Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo
| | - Keiko Tanaka-Taya
- Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo
| | - Satoru Arai
- Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo
| | - Hiroshi Satoh
- Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo
| | - Saeko Morino
- Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo
| | - Tomoe Shimada
- Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo
| | - Tomimasa Sunagawa
- Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo
| | - Timothy M Uyeki
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kazunori Oishi
- Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo
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Achiriloaie A, Michelson D, Lei L, Denham L, Oberg K, Raghavan R. Acute Postviral Encephalopathy: Pathologic and Radiologic Correlation in an Atypical Case. Child Neurol Open 2016; 3:2329048X16658845. [PMID: 28503611 PMCID: PMC5417279 DOI: 10.1177/2329048x16658845] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/28/2016] [Accepted: 06/05/2016] [Indexed: 12/02/2022] Open
Abstract
The authors report a case of fatal acute encephalopathy following influenza infection, with slightly atypical pathological and imaging findings. A healthy 8-year-old boy with probable recent influenza A/B infection admitted for refractory seizures was placed on phenobarbital coma and later developed hemodynamic instability. Magnetic resonance imaging revealed bilateral cerebral and cerebellar white matter lesions and microhemorrhages. Following his demise, the autopsy revealed a large area of necrosis in the right centrum semiovale with similar lesions in the temporal and cerebellar regions. Microscopically, there was extensive coagulative necrosis, compatible with necrotizing white matter encephalopathy, and neuronal loss suggesting superimposed hypoxic–ischemia. The acute progressive neurologic deterioration was partly reminiscent on acute necrotizing encephalopathy, a condition recently associated with influenza A. In acute necrotizing encephalopathy, typical brain findings are characterized by bilateral thalamic necrosis/petechiae with variable white matter edema. The somewhat atypical findings in our case can relate to superadded cardiovascular collapse and hypoxic–ischemic effects.
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Affiliation(s)
- Adina Achiriloaie
- Department of Radiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - David Michelson
- Department of Neurology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Li Lei
- Department of Pathology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Laura Denham
- Department of Pathology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Kerby Oberg
- Department of Pathology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Ravi Raghavan
- Department of Pathology, Loma Linda University Medical Center, Loma Linda, CA, USA
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Azumagawa K, Kashiwagi M, Shimakawa S, Tanabe T, Tamai H. Delirious behavior or mild reduction of consciousness mimicking influenza-associated encephalopathy. Pediatr Int 2014; 56:244-7. [PMID: 24467485 DOI: 10.1111/ped.12240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 08/01/2013] [Accepted: 08/26/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND During the A/H1N1 pandemic, patients suffered from impaired consciousness. They were suspected of or diagnosed as having influenza-associated encephalopathy (IAE) in an emergency situation. Their symptoms resembled those of a recently described 'unique clinical group', which were reported to have a favorable prognosis. METHODS We retrospectively examined 46 patients and divided them into two groups. Group IC contained the 26 patients with persisting impaired consciousness. The remainder of the patients were categorized into group R, consisting of patients with only neurological symptoms without impaired consciousness. RESULTS Male predominance (22 male/four female) was noted in group IC. Patient age ranged from 5 to 12 years old (mean ± SD, 7.7 ± 2.3 years). Impaired consciousness such as delirious behavior or mild reduction of consciousness lasted continuously or intermittently from 5 min to 2.5 days. On electroencephalogram, semi-rhythmic high-voltage slow waves in the parieto-occipital regions and diffuse high-voltage slow waves were observed in eight and in two patients, respectively. In group R, there was no gender predominance. Patient age ranged from 1 to 9 years old (mean ± SD, 4.1 ± 2.5 years). All group R patients were clinically diagnosed with febrile seizure. CONCLUSIONS Some of the characteristics in group IC resembled those of the unique clinical group, and are part of a continuous clinical spectrum. Some patients may have favorable outcome without specific treatment.
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