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Pearl MS, Tsuchida TN, Oluigbo C, Kratimenos P, Anwar T, Kousa Y, Gaillard WD, Chang T. Definitive treatment of seizures due to hemimegalencephaly in neonates and young infants by transarterial embolization: technical considerations for 'endovascular embolic hemispherectomy'. J Neurointerv Surg 2023; 16:81-87. [PMID: 36302639 DOI: 10.1136/jnis-2022-019049] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 10/11/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND This case series describes the technical considerations and effectiveness of 'endovascular embolic hemispherectomy' for the treatment of medically intractable seizures in neonates and young infants with hemimegalencephaly (HME) and in whom surgical hemispherectomy is not a viable option. METHODS This is a descriptive review of the endovascular technique used to treat consecutive pediatric patients with serial transarterial embolization for intractable seizures due to HME between 2018 and 2022. Clinical presentation, endovascular procedural details and complications, and efficacy were examined. RESULTS Three infants (13-day-old, 13-week-old and 15-day-old) with HME and intractable seizures underwent a total of 10 transarterial embolizations. Anticipated intraprocedural events included vasospasm and focal subarachnoid hemorrhage in all three infants, effectively controlled endovascularly, and non-target embolization in one infant. No infants had symptomatic intracranial hemorrhage or femoral artery occlusion. EEG background quiescence and seizure cessation was achieved after the final stage of embolization in all patients. All infants were discharged home from the neonatal ICU (median length of stay 36 days, range 27-74 days) and remain seizure-free to date (4 years, 9 months, and 8 months). None have developed hydrocephalus, required surgical hemispherectomy or other neurosurgical interventions. CONCLUSION Endovascular hemispherectomy can be safely used to provide definitive treatment of HME-related epilepsy in neonates and young infants when intraprocedural events are managed effectively. This less invasive novel approach should be considered a feasible early alternative to surgical hemispherectomy. Further studies are needed to enhance the safety profile and to assess long-term neurodevelopmental outcome and durability of freedom from seizures.
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Affiliation(s)
- Monica S Pearl
- Radiology, Children's National Hospital, Washington, District of Columbia, USA
- Radiology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Tammy N Tsuchida
- Neurology, Children's National Hospital, Washington, District of Columbia, USA
- Neurology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Chima Oluigbo
- Neurology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
- Department of Neurosurgery, Children's National Health System, Washington, District of Columbia, USA
| | - Panagiotis Kratimenos
- Neonatology, Children's National Hospital, Washington, District of Columbia, USA
- Neonatology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Tayyba Anwar
- Neurology, Children's National Hospital, Washington, District of Columbia, USA
- Neurology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Youssef Kousa
- Neurology, Children's National Hospital, Washington, District of Columbia, USA
- Neurology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - William D Gaillard
- Neurology, Children's National Hospital, Washington, District of Columbia, USA
- Neurology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Taeun Chang
- Neurology, Children's National Hospital, Washington, District of Columbia, USA
- Neurology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
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Fortin O, Christoffel K, Kousa Y, Miller I, Leon E, Donoho K, Mulkey SB, Anwar T. Pearls & Oy-sters: Delayed Response to Pyridoxine in Pyridoxine-Dependent Epilepsy. Neurology 2023; 101:e1828-e1832. [PMID: 37580162 PMCID: PMC10634650 DOI: 10.1212/wnl.0000000000207829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/31/2023] [Indexed: 08/16/2023] Open
Abstract
Inborn errors of metabolism are a diverse group of genetic disorders including many that cause neonatal-onset epilepsy such as pyridoxine-dependent epilepsy (PDE). PDE occurs secondary to biallelic pathogenic variants in ALDH7A1 and can present with refractory neonatal seizures and status epilepticus. Neonatal seizures and encephalopathy are modifiable with pyridoxine (vitamin B6) supplementation. However, the clinical response to pyridoxine supplementation can be delayed. We present the case of a full-term neonate with PDE in which seizure cessation was seen a few hours after intravenous pyridoxine load, but the improvement in EEG background and level of clinical encephalopathy occurred 5 days later. We share this case to provide an example in which clinical improvement in PDE was gradual and required continuation of treatment for several days illustrating the necessity of continuing vitamin B6 supplementation in suspected cases until confirmatory genetic testing is obtained or an alternate cause is found.
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Affiliation(s)
- Olivier Fortin
- From the Prenatal Pediatrics Institute (O.F., K.C., Y.K., S.B.M.), Children's National Hospital; Department of Neurology (Y.K., S.B.M., T.A.), and Department of Pediatrics (Y.K., K.D., S.B.M., T.A.), The George Washington University School of Medicine and Health Sciences; Division of Neurology (Y.K., T.A.), Division of Medical Genetics (I.M., E.L.), Rare Disease Institute (I.M., E.L.), and Division of Neonatology (K.D.), Children's National Hospital, Washington, DC.
| | - Kelsey Christoffel
- From the Prenatal Pediatrics Institute (O.F., K.C., Y.K., S.B.M.), Children's National Hospital; Department of Neurology (Y.K., S.B.M., T.A.), and Department of Pediatrics (Y.K., K.D., S.B.M., T.A.), The George Washington University School of Medicine and Health Sciences; Division of Neurology (Y.K., T.A.), Division of Medical Genetics (I.M., E.L.), Rare Disease Institute (I.M., E.L.), and Division of Neonatology (K.D.), Children's National Hospital, Washington, DC
| | - Youssef Kousa
- From the Prenatal Pediatrics Institute (O.F., K.C., Y.K., S.B.M.), Children's National Hospital; Department of Neurology (Y.K., S.B.M., T.A.), and Department of Pediatrics (Y.K., K.D., S.B.M., T.A.), The George Washington University School of Medicine and Health Sciences; Division of Neurology (Y.K., T.A.), Division of Medical Genetics (I.M., E.L.), Rare Disease Institute (I.M., E.L.), and Division of Neonatology (K.D.), Children's National Hospital, Washington, DC
| | - Ilana Miller
- From the Prenatal Pediatrics Institute (O.F., K.C., Y.K., S.B.M.), Children's National Hospital; Department of Neurology (Y.K., S.B.M., T.A.), and Department of Pediatrics (Y.K., K.D., S.B.M., T.A.), The George Washington University School of Medicine and Health Sciences; Division of Neurology (Y.K., T.A.), Division of Medical Genetics (I.M., E.L.), Rare Disease Institute (I.M., E.L.), and Division of Neonatology (K.D.), Children's National Hospital, Washington, DC
| | - Eyby Leon
- From the Prenatal Pediatrics Institute (O.F., K.C., Y.K., S.B.M.), Children's National Hospital; Department of Neurology (Y.K., S.B.M., T.A.), and Department of Pediatrics (Y.K., K.D., S.B.M., T.A.), The George Washington University School of Medicine and Health Sciences; Division of Neurology (Y.K., T.A.), Division of Medical Genetics (I.M., E.L.), Rare Disease Institute (I.M., E.L.), and Division of Neonatology (K.D.), Children's National Hospital, Washington, DC
| | - Kelsey Donoho
- From the Prenatal Pediatrics Institute (O.F., K.C., Y.K., S.B.M.), Children's National Hospital; Department of Neurology (Y.K., S.B.M., T.A.), and Department of Pediatrics (Y.K., K.D., S.B.M., T.A.), The George Washington University School of Medicine and Health Sciences; Division of Neurology (Y.K., T.A.), Division of Medical Genetics (I.M., E.L.), Rare Disease Institute (I.M., E.L.), and Division of Neonatology (K.D.), Children's National Hospital, Washington, DC
| | - Sarah B Mulkey
- From the Prenatal Pediatrics Institute (O.F., K.C., Y.K., S.B.M.), Children's National Hospital; Department of Neurology (Y.K., S.B.M., T.A.), and Department of Pediatrics (Y.K., K.D., S.B.M., T.A.), The George Washington University School of Medicine and Health Sciences; Division of Neurology (Y.K., T.A.), Division of Medical Genetics (I.M., E.L.), Rare Disease Institute (I.M., E.L.), and Division of Neonatology (K.D.), Children's National Hospital, Washington, DC
| | - Tayyba Anwar
- From the Prenatal Pediatrics Institute (O.F., K.C., Y.K., S.B.M.), Children's National Hospital; Department of Neurology (Y.K., S.B.M., T.A.), and Department of Pediatrics (Y.K., K.D., S.B.M., T.A.), The George Washington University School of Medicine and Health Sciences; Division of Neurology (Y.K., T.A.), Division of Medical Genetics (I.M., E.L.), Rare Disease Institute (I.M., E.L.), and Division of Neonatology (K.D.), Children's National Hospital, Washington, DC
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3
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Steiner JP, Bachani M, Malik N, Li W, Tyagi R, Sampson K, Abrams RPM, Kousa Y, Solis J, Johnson TP, Nath A. Neurotoxic properties of the Zika virus envelope protein. Exp Neurol 2023; 367:114469. [PMID: 37327963 PMCID: PMC10527427 DOI: 10.1016/j.expneurol.2023.114469] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/31/2023] [Accepted: 06/11/2023] [Indexed: 06/18/2023]
Abstract
Prenatal Zika virus (ZIKV) infection is a serious global concern as it can lead to brain injury and many serious birth defects, collectively known as congenital Zika syndrome. Brain injury likely results from viral mediated toxicity in neural progenitor cells. Additionally, postnatal ZIKV infections have been linked to neurological complications, yet the mechanisms driving these manifestations are not well understood. Existing data suggest that the ZIKV envelope protein can persist in the central nervous system for extended periods of time, but it is unknown if this protein can independently contribute to neuronal toxicity. Here we find that the ZIKV envelope protein is neurotoxic, leading to overexpression of poly adenosine diphosphate -ribose polymerase 1, which can induce parthanatos. Together, these data suggest that neuronal toxicity resulting from the envelope protein may contribute to the pathogenesis of post-natal ZIKV-related neurologic complications.
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Affiliation(s)
- Joseph P Steiner
- Translational Neuroscience Center, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States of America
| | - Muznabanu Bachani
- Translational Neuroscience Center, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States of America
| | - Nasir Malik
- Translational Neuroscience Center, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States of America
| | - Wenxue Li
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States of America
| | - Richa Tyagi
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States of America
| | - Kevon Sampson
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States of America
| | - Rachel P M Abrams
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States of America
| | - Youssef Kousa
- Division of Neurology, Children's National Hospital, Washington, DC 20010, USA; Department of Genomics and Precision Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC 20052, USA
| | - Jamie Solis
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States of America
| | - Tory P Johnson
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States of America
| | - Avindra Nath
- Translational Neuroscience Center, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States of America; Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States of America.
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Kothari C, Srivastava S, Kousa Y, Izem R, Gierdalski M, Kim D, Good A, Dies KA, Geisel G, Morizono H, Gallo V, Pomeroy SL, Garden GA, Guay-Woodford L, Sahin M, Avillach P. Validation of a computational phenotype for finding patients eligible for genetic testing for pathogenic PTEN variants across three centers. J Neurodev Disord 2022; 14:24. [PMID: 35321655 PMCID: PMC8943944 DOI: 10.1186/s11689-022-09434-0] [Citation(s) in RCA: 1] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 03/04/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Computational phenotypes are most often combinations of patient billing codes that are highly predictive of disease using electronic health records (EHR). In the case of rare diseases that can only be diagnosed by genetic testing, computational phenotypes identify patient cohorts for genetic testing and possible diagnosis. This article details the validation of a computational phenotype for PTEN hamartoma tumor syndrome (PHTS) against the EHR of patients at three collaborating clinical research centers: Boston Children's Hospital, Children's National Hospital, and the University of Washington. METHODS A combination of billing codes from the International Classification of Diseases versions 9 and 10 (ICD-9 and ICD-10) for diagnostic criteria postulated by a research team at Cleveland Clinic was used to identify patient cohorts for genetic testing from the clinical data warehouses at the three research centers. Subsequently, the EHR-including billing codes, clinical notes, and genetic reports-of these patients were reviewed by clinical experts to identify patients with PHTS. RESULTS The PTEN genetic testing yield of the computational phenotype, the number of patients who needed to be genetically tested for incidence of pathogenic PTEN gene variants, ranged from 82 to 94% at the three centers. CONCLUSIONS Computational phenotypes have the potential to enable the timely and accurate diagnosis of rare genetic diseases such as PHTS by identifying patient cohorts for genetic sequencing and testing.
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Affiliation(s)
- Cartik Kothari
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, 02115, USA
| | - Siddharth Srivastava
- Department of Neurology, Rosamund Stone Zander Translational Neuroscience Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Youssef Kousa
- Division of Neurology, Children's National Hospital, Washington, DC, 20010, USA.,Department of Genomics and Precision Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, 20052, USA
| | - Rima Izem
- Division of Biostatistics and Study Methodology, Children's National Research Institute, Silver Spring, MD, 20910, USA
| | - Marcin Gierdalski
- Division of Biostatistics and Study Methodology, Children's National Hospital, Washington, DC, 20010, USA
| | - Dongkyu Kim
- Division of Biostatistics and Study Methodology, Children's National Hospital, Washington, DC, 20010, USA
| | - Amy Good
- Institute for Translational Health Sciences, University of Washington, Seattle, WA, 98195, USA
| | - Kira A Dies
- Department of Neurology, Rosamund Stone Zander Translational Neuroscience Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Gregory Geisel
- Department of Neurology, Rosamund Stone Zander Translational Neuroscience Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Hiroki Morizono
- Center for Genetic Medicine Research, Children's National Hospital, Washington, DC, 20010, USA.,Department of Genomics and Precision Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, 20052, USA
| | - Vittorio Gallo
- Center for Neuroscience Research, Children's National Research Institute, Children's National Hospital, Washington, DC, 20010, USA
| | - Scott L Pomeroy
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Gwenn A Garden
- Department of Neurology and Center on Human Development and Disability, University of Washington, Seattle, WA, 98195, USA.,Department of Neurology, University of North Carolina, Chapel Hill, NC, 27599, USA
| | - Lisa Guay-Woodford
- Center for Translational Research, Children's National Hospital, Washington, DC, 20010, USA
| | - Mustafa Sahin
- Department of Neurology, Rosamund Stone Zander Translational Neuroscience Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Paul Avillach
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, 02115, USA.
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Mulkey SB, Arroyave-Wessel M, Peyton C, Bulas D, Vezina G, Fourzali Y, Morales A, Swisher C, Cristante C, Russo S, Kousa Y, Jiang J, Msall M, McCarter R, du Plessis A, Cure C, DeBiasi R. 1872. Neurodevelopment in Apparently Normal Infants from Zika Virus Positive Pregnancies. Open Forum Infect Dis 2019. [PMCID: PMC6809385 DOI: 10.1093/ofid/ofz359.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Congenital Zika syndrome (CZS) is seen in 5–12% of newborns from Zika virus (ZIKV)-infected pregnancies and includes severe neurologic abnormalities. However, the majority of ZIKV-exposed newborns do not have CZS. The risk for neurodevelopmental impairment for infants without CZS following in utero ZIKV is not well known. The objective was to determine whether infants without CZS exposed to ZIKV in utero, have normal neurodevelopment.
Methods
We performed a longitudinal study of neurodevelopment in Colombia for infants exposed to ZIKV in utero who had a normal fetal brain MRI (Mulkey et al, JAMA Peds 2019) and normal head circumference at birth. Infant development was assessed by the Warner Initial Developmental Evaluation of Adaptive and Functional Skills (WIDEA) and the Alberta Infant Motor Scale (AIMS) between 6 and 18 months of age. In-person training was done by a neurologist. The AIMS were video-recorded and scored centrally. Interrater reliability for the novel method of video-based AIMS was determined. WIDEA and AIMS scores were converted to Z-scores compared with normative samples. We also compared development between infants with normal and nonspecific findings on cranial ultrasound (US).
Results
Seventy-two non-CZS infants had neurodevelopmental tests; 40 were at a mean (SD) of 5.7 (0.9) months and 66 were at 13.5 (3.2) months of age. Thirty-four had two assessments. The total WIDEA, social cognition, and mobility domain scores became more abnormal with postnatal age (figure). The AIMS scores were similar to the normative sample. Three infants had an AIMS score < 2 SD’s below the norm. On cranial US, 19 infants (26%) had a nonspecific finding (lenticulostriate vasculopathy, choroid plexus cysts, subependymal cysts, and/or calcification). Infants with a US finding had a lower WIDEA mobility score than infants with normal US (P = .054). There was a trend toward lower AIMS scores in infants with US findings compared with infants with normal US (P = .26). AIMS Interrater agreement on video-based scoring was good (ICC = 0.73, 95% CI 0.42, 0.87).
Conclusion
ZIKV-exposed infants without CZS are at risk for neurodevelopmental delay. Nonspecific cranial US findings may represent mild ZIKV-related injury. Long-term neurodevelopmental follow-up is important for all ZIKV-exposed infants.
Disclosures
All Authors: No reported Disclosures.
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Affiliation(s)
| | | | - Colleen Peyton
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Dorothy Bulas
- Children’s National Health System, Rockville, Maryland
| | | | | | | | | | | | | | - Youssef Kousa
- Children’s National Health System, Rockville, Maryland
| | - Jiji Jiang
- Children’s National Health System, Rockville, Maryland
| | - Michael Msall
- University of Chicago Early Intervention Center, Chicago, Illinois
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Mulkey SB, Vezina G, Bulas DI, Khademian Z, Blask A, Kousa Y, Cristante C, Pesacreta L, du Plessis AJ, DeBiasi RL. Response to the Letter by Sora Yasri. Pediatr Neurol 2018; 81:55-56. [PMID: 29661494 DOI: 10.1016/j.pediatrneurol.2018.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Sarah B Mulkey
- Division of Fetal and Transitional Medicine, Children's National Health System, Washington, DC; Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC; Department of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, DC.
| | - Gilbert Vezina
- Division of Radiology, Children's National Health System, Washington, DC
| | - Dorothy I Bulas
- Division of Fetal and Transitional Medicine, Children's National Health System, Washington, DC; Division of Radiology, Children's National Health System, Washington, DC
| | - Zarir Khademian
- Division of Radiology, Children's National Health System, Washington, DC
| | - Anna Blask
- Division of Radiology, Children's National Health System, Washington, DC
| | - Youssef Kousa
- Division of Neurology, Children's National Health System, Washington, DC
| | - Caitlin Cristante
- Division of Fetal and Transitional Medicine, Children's National Health System, Washington, DC
| | - Lindsay Pesacreta
- Division of Fetal and Transitional Medicine, Children's National Health System, Washington, DC
| | - Adre J du Plessis
- Division of Fetal and Transitional Medicine, Children's National Health System, Washington, DC; Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC; Department of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Roberta L DeBiasi
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC; Division of Infectious Diseases, Children's National Health System, Washington, DC; Department of Microbiology, Immunology and Tropical Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC
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Mulkey SB, Vezina G, Bulas DI, Khademian Z, Blask A, Kousa Y, Cristante C, Pesacreta L, du Plessis AJ, DeBiasi RL. Neuroimaging Findings in Normocephalic Newborns With Intrauterine Zika Virus Exposure. Pediatr Neurol 2018; 78:75-78. [PMID: 29167058 DOI: 10.1016/j.pediatrneurol.2017.10.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [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: 08/29/2017] [Revised: 10/13/2017] [Accepted: 10/14/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Congenital Zika infection can result in a spectrum of neurological abnormalities in the newborn. Newborns exposed to Zika virus in utero often have neuroimaging as part of their clinical evaluation. METHODS Through the Congenital Zika Program at Children's National Health System in Washington DC, we performed fetal or neonatal neuroimaging, including magnetic resonance imaging and ultrasound, on over 70 fetuses or neonates with intrauterine Zika exposure. Novel findings on neonatal brain magnetic resonance imaging were observed in two instances. RESULTS Gadolinium-contrast magnetic resonance imaging showed enhancement of multiple cranial nerves at three days of age on one infant. Another infant underwent magnetic resonance imaging at 16 days of age and was shown to have a chronic ischemic cerebral infarction. This infant had previously normal fetal magnetic resonance imaging. CONCLUSION Cranial nerve enhancement and cerebral infarction may be among the expanding list of neurological findings in congenital Zika infection. Postnatal brain magnetic resonance imaging should be considered for newborns exposed to Zika virus in utero.
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Affiliation(s)
- Sarah B Mulkey
- Division of Fetal and Transitional Medicine, Children's National Health System, Washington, District of Columbia; Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia; Department of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.
| | - Gilbert Vezina
- Division of Radiology, Children's National Health System, Washington, District of Columbia
| | - Dorothy I Bulas
- Division of Fetal and Transitional Medicine, Children's National Health System, Washington, District of Columbia; Division of Radiology, Children's National Health System, Washington, District of Columbia
| | - Zarir Khademian
- Division of Radiology, Children's National Health System, Washington, District of Columbia
| | - Anna Blask
- Division of Radiology, Children's National Health System, Washington, District of Columbia
| | - Youssef Kousa
- Division of Neurology, Children's National Health System, Washington, District of Columbia
| | - Caitlin Cristante
- Division of Fetal and Transitional Medicine, Children's National Health System, Washington, District of Columbia
| | - Lindsay Pesacreta
- Division of Fetal and Transitional Medicine, Children's National Health System, Washington, District of Columbia
| | - Adre J du Plessis
- Division of Fetal and Transitional Medicine, Children's National Health System, Washington, District of Columbia; Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia; Department of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Roberta L DeBiasi
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia; Division of Infectious Diseases, Children's National Health System, Washington, District of Columbia; Department of Microbiology, Immunology and Tropical Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
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8
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Mulkey S, Vezina G, Fourzali Y, Bulas D, Arroyave-Wessel M, Cristante C, Swisher C, Kousa Y, Cure C, DeBiasi R, Plessis AD. Fetal and Postnatal Brain Imaging for the Detection of ZIKV Encephalopathy in the Fetus/Newborn. Open Forum Infect Dis 2017. [PMCID: PMC5632160 DOI: 10.1093/ofid/ofx162.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Up to 15% of pregnancies complicated by maternal ZIKV infection result in Zika-virus associated brain abnormalities in the fetus/newborn. Fetal ultrasound (feUS) is the standard imaging modality for the evaluation of fetal anatomy and for brain changes from congenital infection. Fetal MRI (feMRI) may be a useful adjunct. Methods We performed a prospective longitudinal neuroimaging study of fetuses/newborns of pregnant women with clinical and/or lab confirmed (RT-PCR and/or IgM/PRNT) diagnosis of Zika infection in Barranquilla, Colombia (endemic) and in Washington, DC, USA (travel-related). Gestational age (GA) at exposure and timing between ZIKV exposure/symptoms and imaging was documented. Subjects had one to two feMRIs and feUS, depending upon GA at enrollment. The feMRI and feUS protocols were standardized between sites and studies were centrally interpreted at Children’s National. Postnatally, infants received an unsedated brain MRI and head US. Results Forty-eight, ZIKV exposed/infected in first or second trimester pregnant women were enrolled (46 Colombia, 2 USA). Subjects had symptoms of ZIKV infection at mean of 8.4±5.7 week GA. The first feMRI and feUS were performed at 25.1±6.3 week GA. Thirty-six infants had a second feMRI and feUS at 31.1±4.2 week GA. Three of 48 (6%) cases had an abnormal feMRI: (1) heterotopias and abnormal cortical indent; (2) parietal encephalocele and Chiari II; (3) thin corpus callosum, dysplastic brainstem, temporal cysts, subependymal heterotopias, and generalized cerebral/cerebellar atrophy. FeUS in these three cases found (1) normal study; (2) parietal encephalocele and Chiari II; (3) significant ventriculomegaly with decreasing percentiles of head circumference from 32 to 36 week GA (38% to 3.6%). Postnatal head US revealed findings not seen on feUS: choroid plexus or germinal matrix cysts in nine infants and lenticulostriate vasculopathy in one infant. Conclusion FeMRI and feUS provide complimentary information in the assessment of fetal brain changes in ZIKV. In cases of abnormal brain structure, feMRI reveals more extensive areas of brain damage than is seen by US. Further studies are needed to determine whether cystic changes on postnatal head US are related to ZIKV infection, or are incidental findings. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Sarah Mulkey
- Fetal Medicine, Children’s National Health System, Washington, District of Columbia
| | - Gilbert Vezina
- Children’s National Health System, Washington, District of Columbia
| | | | - Dorothy Bulas
- Children’s National Health System, Washington, District of Columbia
| | | | | | | | - Youssef Kousa
- Children’s National Health System, Washington, District of Columbia
| | | | - Roberta DeBiasi
- Pedatrics (Infectious Disesaesand Microbiology, Immunology and Tropical Medicine, Childrens National Health System/GWU School of Medicine, Washington, District of Columbia
| | - Adre Du Plessis
- Fetal Medicine Institute, Children’s National Health System, Washington, District of Columbia
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Schuldt NJ, Aldhamen YA, Appledorn DM, Seregin SS, Kousa Y, Godbehere S, Amalfitano A. Vaccine platforms combining circumsporozoite protein and potent immune modulators, rEA or EAT-2, paradoxically result in opposing immune responses. PLoS One 2011; 6:e24147. [PMID: 21912619 PMCID: PMC3166157 DOI: 10.1371/journal.pone.0024147] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Accepted: 08/05/2011] [Indexed: 11/20/2022] Open
Abstract
Background Malaria greatly impacts the health and wellbeing of over half of the world's population. Promising malaria vaccine candidates have attempted to induce adaptive immune responses to Circumsporozoite (CS) protein. Despite the inclusion of potent adjuvants, these vaccines have limited protective efficacy. Conventional recombinant adenovirus (rAd) based vaccines expressing CS protein can induce CS protein specific immune responses, but these are essentially equivalent to those generated after use of the CS protein subunit based vaccines. In this study we combined the use of rAds expressing CS protein along with rAds expressing novel innate immune response modulating proteins in an attempt to significantly improve the induction of CS protein specific cell mediated immune (CMI) responses. Methods and Findings BALB/cJ mice were co-vaccinated with a rAd vectors expressing CS protein simultaneous with a rAd expressing either TLR agonist (rEA) or SLAM receptors adaptor protein (EAT-2). Paradoxically, expression of the TLR agonist uncovered a potent immunosuppressive activity inherent to the combined expression of the CS protein and rEA. Fortunately, use of the rAd vaccine expressing EAT-2 circumvented CS protein's suppressive activity, and generated a fivefold increase in the number of CS protein responsive, IFNγ secreting splenocytes, as well as increased the breadth of T cells responsive to peptides present in the CS protein. These improvements were positively correlated with the induction of a fourfold improvement in CS protein specific CTL functional activity in vivo. Conclusion Our results emphasize the need for caution when incorporating CS protein into malaria vaccine platforms expressing or containing other immunostimulatory compounds, as the immunological outcomes may be unanticipated and/or counter-productive. However, expressing the SLAM receptors derived signaling adaptor EAT-2 at the same time of vaccination with CS protein can overcome these concerns, as well as significantly improve the induction of malaria antigen specific adaptive immune responses in vivo.
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Affiliation(s)
- Nathaniel J. Schuldt
- Genetics Program, Michigan State University, East Lansing, Michigan, United States of America
| | - Yasser A. Aldhamen
- Department of Microbiology and Molecular Genetics, Michigan State University, East Lansing, Michigan, United States of America
| | - Daniel M. Appledorn
- Department of Microbiology and Molecular Genetics, Michigan State University, East Lansing, Michigan, United States of America
| | - Sergey S. Seregin
- Department of Microbiology and Molecular Genetics, Michigan State University, East Lansing, Michigan, United States of America
| | - Youssef Kousa
- Department of Biochemistry and Molecular Biology, Michigan State University, East Lansing, Michigan, United States of America
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, United States of America
| | - Sarah Godbehere
- Department of Microbiology and Molecular Genetics, Michigan State University, East Lansing, Michigan, United States of America
| | - Andrea Amalfitano
- Genetics Program, Michigan State University, East Lansing, Michigan, United States of America
- Department of Microbiology and Molecular Genetics, Michigan State University, East Lansing, Michigan, United States of America
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, United States of America
- Department of Pediatrics, Michigan State University, East Lansing, Michigan, United States of America
- * E-mail:
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10
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Appledorn DM, Kiang A, McBride A, Jiang H, Seregin S, Scott JM, Stringer R, Kousa Y, Hoban M, Frank MM, Amalfitano A. Wild-type adenoviruses from groups A-F evoke unique innate immune responses, of which HAd3 and SAd23 are partially complement dependent. Gene Ther 2008; 15:885-901. [PMID: 18288208 DOI: 10.1038/gt.2008.18] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Alternative human and non-human Ad serotype vectors are currently studied for gene therapy and/or vaccine applications to capitalize upon their likely ability to avoid pre-existing immunity to HAd5. However, relatively little attention has been given to the nature and scope of innate immune responses generated by alternative Ad serotypes. In this study, we characterized several innate immune responses after intravenous administration of wild-type Ad serotypes HAd31, HAd3, HAd5, HAd37, SAd23 and HAd41, representing groups A-F, respectively. Notably, biodistribution studies revealed significant differences between the serotypes, with high levels of HAd3 genomes found in the liver and lung, and HAd37 genomes found in the spleen after systemic administration. Relative to similar treatments with other Ad serotypes, HAd3 and SAd23 induced altered innate immune responses, illustrated by induction of higher levels of cellular gene transcription in several tissues, and higher plasma levels of cytokines and chemokines. We also investigated whether complement interactions have a role in HAd3- and SAd23-induced responses. We confirmed complement dependent gene transcription, plasma cytokine/chemokine responses, and liver toxicities incurred after administration of HAd3 and SAd23. This study highlights the potential benefits and/or limitations to the proposed use of alternative Ad serotypes for gene therapy or vaccine applications.
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Affiliation(s)
- D M Appledorn
- Department of Microbiology and Molecular Genetics, Michigan State University, East Lansing, MI 48823, USA
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