[A case of polyradiculoneuritis associated with disseminated herpes zoster].

A 34-year-old man developed right-dominant lower limb paraplegia, and then upper limb paresis with radicular pain following disseminated herpes zoster (HZ) in his right forehead, back of the trunk, and lumbar and right lower limb regions. Cerebrospinal fluid (CSF) findings revealed an increase in lymphocytes (32 cells/µl) and protein content (50 mg/dl), and polymerase chain reaction (PCR) for varicella-zoster virus (VZV) DNA was negative in CSF, but VZV antigen was positive in the patient's vesicle smear. Lumbar root MRI using 3D Nerve VIEW (Philips) imaging showed high-intensity lesions on the L2-L5 spinal roots with contrast enhancements, and cervical MRI showed similar findings on both sides at the C4-Th1. Peripheral nerve conduction study revealed prolonged distal latency to 4.9 ms, decreased MCV to 38 m/s, and complete loss of F-wave was seen in the right peroneal nerve study. Minimal F-wave latency was prolonged in the right tibial nerve. Thus, the patient was diagnosed with VZV polyradiculoneuritis caused by disseminated HZ. Regarding the possible pathogenesis of polyradiculoneuritis in this patient with disseminated HZ, we speculate that VZV reached by retrograde transmission from the involved peripheral nerves to the spinal ganglia, which, then, produced polyradiculoneuritis.

Polirradiculoneuritis aguda asociada a infección por Virus Herpes Humano 7 en un paciente adulto inmunocompetente / Acute polyradiculoneuropathy associated with human Herpes Virus 7 in an immunocompetent patient: case report

Human herpes virus 7 (HHV-7) is a cause of encephalitis, meningitis and myeloradiculoneuropathy in adults who are immunocompetent or with immunosuppression. The involvement of the peripheral nervous system is always associated with myelitis. We report a case of acute polyradiculoneuropathy due to HHV-7, without involvement of central nervous system, in an immunocompetent patient. A 35-years-old man complained of lumbar pain radiating to both buttocks. On examination muscle strength and tendon reflexes were normal. He had asymmetric pinprick and light touch saddle hypoesthesia and also in the perineal region, dorsum and lateral aspect of the left foot. Magnetic resonance imaging showed mild thickening and contrast enhancement of cauda equina nerve roots. Polymerase chain reaction performed on cerebrospinal fluid was positive for HVV-7. Other inflammatory, infectious and neoplastic etiologies were ruled out. Lumbar pain and hypoesthesia improved progressively and neurological examination was normal after one month. He did not receive antiviral therapy.

[Acute polyradiculoneuropathy associated with human Herpes Virus 7 in an immunocompetent patient. Case report]. / Polirradiculoneuritis aguda asociada a infección por Virus Herpes Humano 7 en un paciente adulto inmunocompetente.

Human herpes virus 7 (HHV-7) is a cause of encephalitis, meningitis and myeloradiculoneuropathy in adults who are immunocompetent or with immunosuppression. The involvement of the peripheral nervous system is always associated with myelitis. We report a case of acute polyradiculoneuropathy due to HHV-7, without involvement of central nervous system, in an immunocompetent patient. A 35-years-old man complained of lumbar pain radiating to both buttocks. On examination muscle strength and tendon reflexes were normal. He had asymmetric pinprick and light touch saddle hypoesthesia and also in the perineal region, dorsum and lateral aspect of the left foot. Magnetic resonance imaging showed mild thickening and contrast enhancement of cauda equina nerve roots. Polymerase chain reaction performed on cerebrospinal fluid was positive for HVV-7. Other inflammatory, infectious and neoplastic etiologies were ruled out. Lumbar pain and hypoesthesia improved progressively and neurological examination was normal after one month. He did not receive antiviral therapy.

Neurological impairment and arthritis in an immunocompetent child with human parvovirus B19 chronic infection.

Human parvovirus B19 (HPV-B19) is usually a self-limiting infection in immunocompetent children. In this case report, instead, we describe an immunocompotent child with evidence of persistent HPV-B19 infection, arthritis and neurological impairment. He was first admitted to hospital for HPV-B19 infection and sent home in good clinical condition after anti-inflammatory therapy. Eight months later he was re-admitted to hospital for episodes of arthritis and weakness, myalgia, tremors in his legs and hands, and was unable to walk unaided. In both plasma and serum, HPV-B19 DNA, detected by polymerase chain reaction, was still present. For neurological symptoms, he underwent magnetic resonance, which showed increased signal intensity at the spinal roots in the lumbar region, compatible with polyradiculoneuritis. After immunoglobulin therapy he had an excellent response in clinical and radiological terms, suggesting an association between neurological impairment and HPV-B19 infection. Eleven months after the second admission, the patient was still in good clinical condition.

Multiorgan involvement due to cytomegalovirus infection in AIDS.

Cytomegalovirus (CMV) infection is a relatively late complication of AIDS. Like other viruses contributing to co-morbidity of HIV infection, cytomegalovirus has the propensity to cause multiorgan involvement. We report the case of a 34-year-old seropositive man who presented with bilateral lower limb weakness and symptomatic pallor. He was already on antiretroviral drugs for a month prior to presentation. Detailed clinical examination and laboratory investigations revealed cytomegalovirus polyradiculoneuropathy associated with bone marrow dysplasia. Dysplasia of haematopoeitic cell lines occurs in 30% to 70% of HIV infected patients, and is often indistinguishable from myelodysplastic syndrome. However, in our case, the bone marrow picture reverted back to normal with treatment of the CMV infection, pointing to a possible role of CMV as the causative agent of bone marrow dysplasia. Moreover, CMV has been incriminated as a pathogen producing the immune reconstitution inflammatory syndrome. The onset of the disease in our case one month after initiation of HAART strongly raises the possibility of this being a case of CMV related IRIS. This is the first reported case where IRIS has presented with CMV polyradiculoneuropathy and bone marrow dysplasia. We would like to highlight that in today's era of HIV care, clinicians should be aware of the possibility of multiorgan involvement by CMV, for appropriate management of this disease in the background of AIDS.

Multiorgan involvement due to cytomegalovirus infection in AIDS

Cytomegalovirus (CMV) infection is a relatively late complication of AIDS. Like other viruses contributing to co-morbidity of HIV infection, cytomegalovirus has the propensity to cause multiorgan involvement. We report the case of a 34-year-old seropositive man who presented with bilateral lower limb weakness and symptomatic pallor. He was already on antiretroviral drugs for a month prior to presentation. Detailed clinical examination and laboratory investigations revealed cytomegalovirus polyradiculoneuropathy associated with bone marrow dysplasia. Dysplasia of haematopoeitic cell lines occurs in 30 percent to 70 percent of HIV infected patients, and is often indistinguishable from myelodysplastic syndrome. However, in our case, the bone marrow picture reverted back to normal with treatment of the CMV infection, pointing to a possible role of CMV as the causative agent of bone marrow dysplasia. Moreover, CMV has been incriminated as a pathogen producing the immune reconstitution inflammatory syndrome. The onset of the disease in our case one month after initiation of HAART strongly raises the possibility of this being a case of CMV related IRIS. This is the first reported case where IRIS has presented with CMV polyradiculoneuropathy and bone marrow dysplasia. We would like to highlight that in today's era of HIV care, clinicians should be aware of the possibility of multiorgan involvement by CMV, for appropriate management of this disease in the background of AIDS.

The spectrum of antecedent infections in Guillain-Barré syndrome: a case-control study.

OBJECTIVE: To determine which antecedent infections are specifically associated with the Guillain-Barré syndrome (GBS). BACKGROUND: Infections with many agents have been reported preceding GBS. Some infections are related to specific clinical and immunologic subgroups in GBS. Most agents were reported in case reports and uncontrolled small series of GBS patients only, and their relation to GBS and its subgroups remains unclear. METHOD: A serologic study for 16 infectious agents in 154 GBS patients and 154 sex- and age-matched controls with other neurologic diseases. Acute phase, pretreatment samples were used from clinically well-defined GBS patients. The seasonal distribution of serum sampling in the GBS and control group was the same. RESULTS: Multivariate analysis showed that in GBS patients, infections with Campylobacter jejuni (32%), cytomegalovirus (13%), and Epstein-Barr virus (10%) were significantly more frequent than in controls. Mycoplasma pneumoniae infections occurred more often in GBS patients (5%) than in controls in univariate analysis. Infections with Haemophilus influenzae (1%), parainfluenza 1 virus (1%), influenza A virus (1%), influenza B virus (1%), adenovirus (1%), herpes simplex virus (1%), and varicella zoster virus (1%) were also demonstrated in GBS patients, but not more frequently than in controls. C. jejuni infections were associated with antibodies to the gangliosides GM1 and GD1b and with a severe pure motor form of GBS. Cytomegalovirus infections were associated with antibodies to the ganglioside GM2 and with severe motor sensory deficits. Other infections were not related to specific antiganglioside antibodies and neurologic patterns. CONCLUSIONS: Recent infections with C. jejuni, cytomegalovirus, Epstein-Barr virus, and M. pneumoniae are specifically related to GBS. The variety of infections may contribute to the clinical and immunologic heterogeneity of GBS.

Rare adverse events associated with oral poliovirus vaccine in Brazil.

Oral poliovirus vaccine (OPV) developed by A. Sabin has been effectively used to control poliomyelitis in Brazil, and the last case with the isolation of a wild poliovirus strain occurred in March 1989. Although the vaccine controlled the circulation of wild strains and poliomyelitis cases associated with these strains were not detected during the last eight years, rare cases classified as vaccine-associated paralytic poliomyelitis (VAPP) have been detected. Molecular characterization studies of poliovirus strains isolated from VAPP cases and from healthy contacts have confirmed that the isolates are derived from the Sabin vaccine strains and also detected genomic modifications known or suspected to increase neurovirulence such as mutations and recombination. The molecular characterization of polioviruses isolated during the last eight years from paralysis cases classified as Guillain-Barré (GBS) syndrome and transverse myelitis (TM), and from facial paralysis (FP) cases also confirmed the vaccine origin of the strains and demonstrated mutations known to increase neurovirulence. Analysis of the epidemiologic data of these GBS, TM and FP cases demonstrated that in most of them the last OPV dose was given months or years before the onset of the disease and the isolation of the polioviruses. The temporal association between the isolation of these strains and the GBS, TM and FP suggested that the Sabin vaccine-derived poliovirus strains could also rarely trigger the diseases.

Rare adverse events associated with oral poliovirus vaccine in Brazil

Oral poliovirus vaccine (OPV) developed by A. Sabin has been effectively used to control poliomyelitis in Brazil, and the last case with the isolation of a wild poliovirus strain occourred in March 1989. Although the vaccine controlled the circulation ...

Genomic modifications in Sabin vaccine strains isolated from vaccination-associated cases, healthy contacts and healthy vaccinees.

The three attenuated strains developed by A.B. Sabin have been effectively used as an oral live poliovirus vaccine (OPV) to control poliomyelitis in many countries. Although rarely, vaccination-associated paralytic poliomyelitis (VAPP) cases occur with the type 2 and 3 strains, and less frequently with the type 1 strain. The greater number of attenuating mutations in the P1/Sabin strain is probably reflected in the higher safety of this strain in comparison to type 2 and 3 strains. For the P1/Sabin strain, many attenuating mutations were already identified in the 5'-non-coding region (5'NCR), in the capsid proteins coding region, in the 3Dpol coding region, and the 3'-non-coding region (3'NCR). For the P2/Sabin and P3/Sabin strains, one mutation in 5'NCR and another in the capsid proteins coding region have been demonstrated to be important determinations of attenuation, although it has been suggested that other mutations may also have some effect, though minor. Although reverting mutations in attenuating determinants, suppressor mutations, mutations in antigenic sites and genomic recombination have been observed in strains isolated from VAPP cases, the observation of similar genomic modifications in strains isolated from healthy contacts and from healthy vaccinees has supported the view that host factors are also involved in the establishment of the disease. Reverting mutations at nucleotides (nt) 480 (G-->A), 481 (A-->G) and 472 (U-->C) for the P1/Sabin, P2/Sabin and P3/Sabin strains, respectively, have been detected in almost all strains isolated from VAPP cases and also from healthy vaccinees. Although the Sabin vaccine strains have been implicated in rare VAPP cases, recent studies have suggested that the vaccine strains could also trigger the Guillain-Barré syndrome (GBS), transverse myelitis (TM) and facial paralysis.

[Painful bilateral lumbar radiculoplexopathy associated with Epstein-Barr virus infection]. / Radiculoplexopathie lombaire douloureuse bilatérale associée à une infection par le virus d'Epstein-Barr.

We report a case of polyneuropathy caused by primary Epstein Barr virus (EBV) infection in a 57-year-old patient. The primary EBV infection was confirmed by serology tests and EBNA (Epstein-Barr nuclear antigen) seroconversion. The main clinical sign was a highly painful subacute, bilateral lumbar radiculoplexopathy with amyotrophy which responded to corticosteroids and complement treatment within a few months. The association of left facial paralysis, neurophysiological signs of polyradiculopathy and elevated protein levels in the cerebrospinal fluid demonstrate the variability of peripheral neurological involvement in the same subject with EBV infection. This case also demonstrates the poorly limits of dysimmune polyneuropathies, including lumbar radiculoplexopathy which can be considered as an exceptional variant.

[Pathologic anatomy of cytomegalovirus encephalomyelitis and varicella-zona virus encephalomyelitis]. / Anatomie pathologique des encéphalomyélites à cytomégalovirus et à virus varicelle-zona.

Cytomegalovirus (CMV) infection of the nervous system is frequent in acquired immunodeficiency syndrome (AIDS) and can be responsible for encephalitis, encephalomyelitis, meningoradiculitis or polyradiculo-neuropathy. Encephalitis is characterized at microscopy by its periventricular and cerebellar location, and by the presence of cytomegalic cells, containing intranuclear and/or intracytoplasmic inclusions, microglial nodules and necrotic foci. The virus can infect almost all types of cells. Coexistence of CMV and HIV has been observed in giant cells of macrophagic origin. It has been suggested that the two viruses could act in synergy. The nervous system is seldom infected by the varicella-zoster virus (VZV) in AIDS. The infection can be responsible for multifocal leukoencephalitis, ventriculitis, vascular lesions associated or not with cerebral infarction, or with meningomyeloradiculitis. In almost all cell types Cowdry's type A intranuclear inclusions have been found. The virus can be demonstrated by immunohistochemistry or in situ hybridization. VZV antigens have been reported in the walls of vessels damaged by a non inflammatory obliterating vasculopathy or by a granulomatous angiitis. Coexistence of VZV and HIV has been observed in giant cells of macrophagic origin, and synergy between those two viruses has been suspected.