Encefalopatia neonatal por COVID-19 con estatus convulsivo / COVID-19 neonatal encephalopathy and convulsive status

We present a patient with laboratory-confirmed coronavirus disease who subsequently developed encephalopathy. The patient was brought to a primary care center due to slight symptoms, however the patient presented a seizure with generalized tonic-clonic movements with respiratory depression and reversible cardiorespiratory arrest, requiring orotracheal intubation and midazolam. After that the patient was transferred to the NICU where he was admitted with signs of dehydration, and he presented another reversible cardiac arrest. Given an inadequate response to weaning from mechanical ventilation, troponin increasing and chest X-ray suggestive of a pneumonic process, ampicillin sulbactam was considered. and took a tracheal secretion cultures and COVID-19 test, finding and methicillin sensitive , as well as a COVID-19 positive PCR test antibiotic management for bacterial pneumonia was started. It is to highlight the importance of recognizing that acute encephalitis is one of the most serious complications of pediatric viral infections, since it can lead to motor and intellectual sequelae, and even epilepsy in some cases.

Presentamos el caso de un paciente de 6 meses que presentó cuadro clínico de emesis, convulsiones tónico-clónicas generalizadas y dos paradas cardiorrespiratorias, requiriendo intubación orotraqueal y soporte inotrópico en la UCIN. Se obtuvo prueba de PCR COVID-19 positiva, se realizó el diagnóstico de encefalitis viral aguda y se inició manejo con antiepiléptico intravenoso, sedoanalgesia, soporte inotrópico, corticoide intravenoso, inmunoglobulina humana, N-acetilcisteína y tromboprofilaxis. Debido a la instauración atípica de la infección por COVID-19 en este grupo de edad, discutimos el espectro de presentación de la encefalitis viral en pediatría y su manejo desafiante.

Decompressive Craniectomy for Viral Encephalitis: Two Case Reports

A decompressive craniectomy is a therapeuticmodality not commonly used in cases of refractory intracranial hypertension due to viral encephalitis. In this article the authors present two cases of patients with viral encephalitis that have undergone decompressive craniectomy to control intracranial pressure. Both evolved with Glasgow outcome score of 4. The main clinical data for the surgical decision are Glasgow coma scale and the pupils of the patient associated with the imaging tests showing a large necrotic area and perilesional edema. The evolution of the patients undergoing decompression was satisfactory in 92.3% of cases.

Presentación del síndrome de Wernicke-Korsakoff secundario a encefalitis por citomegalovirus, a propósito de un caso / Wernicke-Korsakoff syndrome secondary to cytomegalovirus encephalitis: A case report

Resumen El citomegalovirus (CMV) es uno de los microorganismos oportunistas con mayor prevalencia en pacientes inmunocomprometidos, aunque su reactivación ha descendido después de la introducción de la terapia antirretroviral altamente activa (Highly Active Antiretroviral Therapy, HAART). En las coinfecciones, la encefalitis se ha reportado como una de las condiciones más frecuentes. Se presenta el caso de un paciente adulto joven con infección por virus de la inmunodeficiencia humana (HIV) que tuvo un rápido deterioro neurológico evidenciado en síntomas y signos clínicos clásicos del síndrome de Wernicke-Korsakoff y que no presentaba factores de riesgo para deficiencia de tiamina. En las imágenes de la resonancia magnética cerebral, se detectaron hallazgos típicos del síndrome, y se identificó citomegalovirus (CMV) en el líquido cefalorraquídeo. Con el tratamiento específico para el CMV, se logró el control de los síntomas, aunque hubo secuelas neurológicas que mejoraron. Este es uno de los pocos casos reportados a nivel mundial de síndrome de Wernicke secundario a encefalitis por citomegalovirus.

Abstract Cytomegalovirus (CMV) is one of the opportunistic microorganisms with the highest prevalence in immunocompromised patients. Reactivation has decreased after the introduction of highly active antiretroviral therapy (HAART). Encephalitis has been reported in the coinfection as one of the most frequent presentations. We present the case of a young adult patient with HIV infection and rapid neurological deterioration due to classic clinical symptoms and signs of the Wernicke-Korsakoff syndrome, with no risk factors for thiamine deficiency, with images by nuclear magnetic resonance typical of the syndrome, and identification of cytomegalovirus in cerebrospinal fluid. The specific treatment for CMV managed to control the symptoms with neurological sequelae in progression towards improvement. This is one of the few cases reported in the literature of Wernicke syndrome secondary to cytomegalovirus encephalitis.

Clinical and cerebrospinal fluid findings contribute to the early differentiation between infectious and noninfectious encephalitis.

Early recognition and prompt specific treatment are crucial factors influencing the outcome of patients with acute encephalitis. The aim of this study was to determine the main causes of acute encephalitis in our population and to find predictors that may lead to specific diagnosis. Adult patients admitted to our hospital with suspected diagnosis of encephalitis in the period 2006-2013 were included. One hundred and five medical records were analyzed. Eighty-two patients with infectious encephalitis were identified (78% of total cases), 53 (65%) men and 29 (35%) women, mean age 47.8 years. The most common microorganisms identified were: HSV-1 (11%), VZV (10%), HSV-2 (5%) and EBV (5%). Twenty-three patients (22% of the series) had non-infectious encephalitis. Headache (p < 0.0001) and fever (p = 0.008) were more frequent in encephalitis of infectious origin. Protein levels and white blood cell counts in the cerebrospinal fluid were significantly higher in patients affected by infectious encephalitis than in those affected by noninfectious encephalitis (OR 95% CI 12.3 [2.9-51.7] and OR 95% CI 7.4 [2-27], respectively). Identifying specific causal agents of acute encephalitis remains a major challenge. Cerebrospinal fluid markers, as well as specific clinical findings, may however contribute to initial differentiation between infectious and noninfectious causes.

Dynamic of CSF and serum biomarkers in HIV-1 subtype C encephalitis with CNS genetic compartmentalization-case study.

Despite the effective suppression of viremia with antiretroviral therapy, HIV can still replicate in the central nervous system (CNS). This was a longitudinal study of the cerebrospinal fluid (CSF) and serum dynamics of several biomarkers related to inflammation, the blood-brain barrier, neuronal injury, and IgG intrathecal synthesis in serial samples of CSF and serum from a patient infected with HIV-1 subtype C with CNS compartmentalization.The phylogenetic analyses of plasma and CSF samples in an acute phase using next-generation sequencing and F-statistics analysis of C2-V3 haplotypes revealed distinct compartmentalized CSF viruses in paired CSF and peripheral blood mononuclear cell samples. The CSF biomarker analysis in this patient showed that symptomatic CSF escape is accompanied by CNS inflammation, high levels of cell and humoral immune biomarkers, CNS barrier dysfunction, and an increase in neuronal injury biomarkers with demyelization. Independent and isolated HIV replication can occur in the CNS, even in HIV-1 subtype C, leading to compartmentalization and development of quasispecies distinct from the peripheral plasma. These immunological aspects of the HIV CNS escape have not been described previously. To our knowledge, this is the first report of CNS HIV escape and compartmentalization in HIV-1 subtype C.

[Wernicke-Korsakoff syndrome secondary to cytomegalovirus encephalitis: A case report].

Cytomegalovirus (CMV) is one of the opportunistic microorganisms with the highest prevalence in immunocompromised patients. Reactivation has decreased after the introduction of highly active antiretroviral therapy (HAART). Encephalitis has been reported in the coinfection as one of the most frequent presentations.We present the case of a young adult patient with HIV infection and rapid neurological deterioration due to classic clinical symptoms and signs of the Wernicke-Korsakoff syndrome, with no risk factors for thiamine deficiency, with images by nuclear magnetic resonance typical of the syndrome, and identification of cytomegalovirus in cerebrospinal fluid. The specific treatment for CMV managed to control the symptoms with neurological sequelae in progression towards improvement.This is one of the few cases reported in the literature of Wernicke syndrome secondary to cytomegalovirus encephalitis.

Longitudinal assessment of subcortical gray matter volume, cortical thickness, and white matter integrity in HIV-positive patients.

PURPOSE: To longitudinally evaluate the cortical thickness and deep gray matter structures volume, measured from T1 three-dimensional (3D) Gradient echo-weighted imaging, and white matter integrity, assessed from diffusion tensor imaging (DTI) of HIV-positive patients. MATERIALS AND METHODS: Twenty-one HIV-positive patients on stable highly active antiretroviral therapy (HAART) with CD4+ T lymphocytes count >200 cells/mL and viral load <50 copies/mL underwent two magnetic resonance imaging (MRI) scans with a median interval of 26.6 months. None of the patients had HIV-related dementia. T1 3D magnetization prepared rapid gradient echo-weighted imaging and DTI along 30 noncolinear directions were performed using a 1.5 Tesla MR scanner. FreeSurfer was used to perform cortical volumetric reconstruction and segmentation of deep gray matter structures. For tract-based spatial statistics analysis, a white matter skeleton was created, and a permutation-based inference with 5000 permutations, with a threshold of P < 0.05 was used to identify abnormalities in fractional anisotropy (FA). The median, radial, and axial diffusivities were also projected onto the mean FA skeleton. RESULTS: There were no significant differences in cortical thickness, deep gray matter structures volumes or diffusivity parameters between scans at the two time points (considering P < 0.05). CONCLUSION: No longitudinal differences in cortical thickness, deep gray matter volumes, or white matter integrity were observed in an HIV-positive population on stable HAART, with undetectable viral load and high CD4+ T lymphocytes count. J. Magn. Reson. Imaging 2016;44:1262-1269.

Febrile infection-related epilepsy syndrome: a study of 12 patients.

PURPOSE: To analyze the electroclinical features, neuroimaging findings, treatment, and outcome of 12 patients with febrile infection-related epilepsy syndrome (FIRES). METHODS: This is a retrospective study of 12 children with FIRES with a mean time of follow-up of 6.5 years carried out at the Garrahan Hospital of Buenos Aires between 1997 and 2012. RESULTS: Eight males and four females had focal status epilepticus preceded by febrile infection with a mean age at presentation of 8.5 years. In the acute period, the treatment included antiepileptic drugs (AEDs) in all cases, immunotherapy in 10 cases, and burst-suppression coma in eight. The ketogenic diet was tried in two, plasmapheresis in one, and rituximab in one. Two patients treated with IVIG and one patient given steroids had a good response, but in this phase only three patients had a prolonged good response to IVIG and a ketogenic diet. No patients died in this period. In the chronic epilepsy phase, all children had seizures arising from neocortical regions. All patients had refractory epilepsy, and most mental retardation, and behavioral disturbances. All received different AEDs and in this phase a third patient was put on a ketogenic diet. One patient was operated without good results. Only two cases had a good outcome after 2 and 10 years of follow-up. CONCLUSION: FIRES is a well-defined severe epileptic syndrome, probably in the group of epileptic encephalopathies, characterized by focal or multifocal seizures arising from the neocortical regions with an unknown etiology. Immunoglobulin and the ketogenic diet may be considered a potentially efficacious treatment.

Viral encephalitis: current treatments and future perspectives.

Several viruses may cause central nervous system infections that lead to a broad range of clinical manifestations. The course of the viral encephalitis can be acute, sub acute, or chronic. Some viruses have the ability to enter into the brain and cause direct injury, while others activate inflammatory cells that attack the central nervous system (CNS) secondarily. Some types of viral encephalitis occur in previously healthy individuals, while others affect immunocompromised patients. The epidemiology of viral encephalitis has undergone changes in recent years. Factors such as evolving lifestyles and ecological changes have had a considerable impact on the epidemiology of some types of viral encephalitis. The result is a change in the etiology spectrum of viral encephalitis, with new types of encephalitis arising or returning from time to time. Many scientific achievements in neuroimaging, molecular diagnosis, antiviral therapy, immunomodulatory treatments, and neurointensive care have allowed more precise and earlier diagnoses and more efficient treatments, resulting in improved outcomes. Despite these advances, there is still considerable morbidity and mortality related to these disorders. This aim of this article is to review the current knowledge of the current drugs used in the management of the most important viral encephalitis, focusing on the mechanisms of action, efficacy, and side effects of the drugs. In addition, future perspectives in this area will be addressed. Despite the technological advances, much effort has yet to be undertaken to reduce the impact of these potentially devastating diseases.

Treatment of viral encephalitis.

Several viruses may cause central nervous system diseases with a broad range of clinical manifestations. The time course of the viral encephalitis can be acute, subacute, or chronic. Pathologically there are encephalitis with direct viral entry into the CNS in which brain parenchyma exhibits neuronal damaging and viral antigens and there are postinfectious autoimmune encephalitis associated with systemic viral infections with brain tissue presenting perivascular aggregation of immune cells and myelin damaging. Some virus affect previously healthy individuals while others produce encephalitis among imunocompromised ones. Factors such evolving lifestyles and ecological changes have had a considerable impact on the epidemiology of some viral encephalitis [e.g. West-Nile virus, and Japanese B virus]. Citomegalovirus and JC virus are examples of infections of the brain that have been seen more frequently because they occur in immunocompromised patients. In the other hand many scientific achievements in neuroimaging, molecular diagnosis, antiviral therapy, immunomodulatory treatments, and neurointensive care have allowed more precise and earlier diagnoses and more efficient treatments, resulting in improved outcomes. In this article, we will present the current drug options in the management of the main acute and chronic viral infection of the central nervous system of immunocompetent and immunocompromised adults, focusing on drugs mechanisms of action, efficacy, and side effects. The early diagnosis and correct management of such diseases can reduce mortality and neurological sequelae; however, even with recent treatment advances, potentially devastating outcomes are still possible.

Management of acute viral encephalitis in Brazil

The appropriate management of acute viral encephalitis is a challenge. Clinical picture includes general symptoms and a wide range of neurological signs. Etiological diagnosis cannot be performed only by clinical means and depends on neuroimaging studies and cerebrospinal fluid molecular analyses. It is recommended since some of these viruses are treatable and that the prognoses of these infections depend on the prompt administration of antiviral and/or immunomodulatory drugs. The management of acute viral encephalitis in Brazil has some peculiarities. First, the etiological distribution of the viral encephalitis may differ from what is found in other countries. Some viruses, such as dengue virus, are more common in Brazil than in developed countries while others, like West Nile virus, are not found here. Second, there are some regions in Brazil where neuroimaging and laboratorial methods are not available, and a clinical-based decision is the only therapeutic approach. As most of the guidelines in the literature are based on complimentary methods, it is relevant to establish an alternative approach compatible with the Brazilian health system reality. The goal of this study was to review the recent advances in the field of the acute viral encephalitis, to discuss the diagnosis and the treatment of the main etiologies of acute viral encephalitis found in Brazil, and to propose a viable guideline for the evaluation of the suspected acute viral encephalitis cases in the emergence room in Brazil.

Management of acute viral encephalitis in Brazil.

The appropriate management of acute viral encephalitis is a challenge. Clinical picture includes general symptoms and a wide range of neurological signs. Etiological diagnosis cannot be performed only by clinical means and depends on neuroimaging studies and cerebrospinal fluid molecular analyses. It is recommended since some of these viruses are treatable and that the prognoses of these infections depend on the prompt administration of antiviral and/or immunomodulatory drugs. The management of acute viral encephalitis in Brazil has some peculiarities. First, the etiological distribution of the viral encephalitis may differ from what is found in other countries. Some viruses, such as dengue virus, are more common in Brazil than in developed countries while others, like West Nile virus, are not found here. Second, there are some regions in Brazil where neuroimaging and laboratorial methods are not available, and a clinical-based decision is the only therapeutic approach. As most of the guidelines in the literature are based on complimentary methods, it is relevant to establish an alternative approach compatible with the Brazilian health system reality. The goal of this study was to review the recent advances in the field of the acute viral encephalitis, to discuss the diagnosis and the treatment of the main etiologies of acute viral encephalitis found in Brazil, and to propose a viable guideline for the evaluation of the suspected acute viral encephalitis cases in the emergence room in Brazil.

[Acute cerebellitis caused by Epstein-Barr virus: case report]. / Cerebelite aguda causada por vírus Epstein-Barr: relato de caso.

Acute cerebellitis can occur in association with varicella-zoster virus, enterovirus, mumps, mycoplasma, and other infective organisms. Acute cerebellitis is a rare complication of Epstein-Barr virus (EBV) infection. We report the case of a 21-year-old woman with a 12-day history of nausea and vomiting, gait and limbs ataxia, myoclonus, tremor of head and all four limbs, opsoclonus and cutaneous rash. Anti-EBV IgG and IgM antibodies against antiviral capsid were positive and anti-EBV against virus-associated nuclear antigen was also positive. EBV infection in association with neurological findings can occur without the classic signs and symptoms of infectious mononucleosis.

Application of competitive PCR to cerebrospinal fluid samples from patients with herpes simplex encephalitis.

The purpose of the present study was to determine if the quantity of herpes simplex virus (HSV) DNA in the cerebrospinal fluid (CSF) of patients with herpes encephalitis would be useful in establishing the prognosis of the disease and to determine the effect of antiviral therapy on the clearance of viral DNA from the CSF. Quantitation of HSV DNA was done by constructing an internal standard (IS) from the glycoprotein B amplicon which had a 25-bp deletion between primer annealing sites. Each CSF specimen was coamplified with the IS and the ratio of the amount of HSV/amount of IS was compared to the ratios on a standard curve constructed with the same IS plus known amounts of HSV DNA. CSF specimens were available from 16 patients who were treated with intravenous acyclovir, and the amount of HSV DNA ranged from < 25 to 18,000 copies per microliter in CSF obtained before or within 4 days of the initiation of acyclovir therapy. Patients with > 100 copies of HSV DNA per microliter were older, were found by computed tomography to have lesions, and had poorer outcomes than patients with < 100 copies. Follow-up CSF specimens were available from seven patients. In six of these seven patients, the HSV DNA levels decreased during therapy. One patient had a twofold increase in HSV DNA levels after 1 week of therapy and died on day 8. The application of this assay may be helpful in establishing the prognosis and in the monitoring of patients with herpes simplex encephalitis.

Encefalitis Viral / Viral Encephalitis

Los virus se constituyen en una causa importante de encefalitis y meningoencefalitis en la edad pediátrica. Entre los implicados están el del sarampión, parotiditis, adenovirus, arbovirus, familia herpes virus, rabia, rubeola, entre otros. La encefalitis se ha definido como la inflamación del cerebro y las manifestaciones clínicas son diversas, siendo el resultado de la respuesta a este proceso inflamatorio, con hallazgos neurológicos específicos de acuerdo a las áreas del parénquima cerebral afectadas y que dependen del tipo de virus y de la respuesta inmune del individuo. El diagnóstico está basado en la historia clínica y el examen físico, complementado con estudios del líquido cefalorraquídeo, imagenología y cerología. El tratamiento es en general inespecífico, empírico y su objetivo es el de mantener la vida del paciente, prevenir y manejar las complicaciones. Se busca de este modo, llamar la atención sobre esta enfermedad, ya que el diagnóstico precoz y el tratamiento oportuno y adecuado, mejoran el pronóstico, disminuyen las secuelas y la mortalidad

[Neonatal herpetic encephalitis. Current concepts concerning a case]. / Encefalitis herpética neonatal. Conceptos actuales a propósito de un caso.

We describe a newborn patient with herpes simplex infection localized to the central nervous system. The diagnosis was suspected on clinical grounds and it was corroborated by tissue culture isolation of the virus and by herpes simplex glycoprotein B DNA detection by PCR in cerebrospinal fluid. We describe the clinical manifestations of this patient and we present some considerations regarding pathogenesis, diagnosis, prognosis and treatment of this viral infection in the newborn period.

Encefalite por vírus herpes simples: consideraçöes diagnósticas e terapêuticas / Encephalitis by herpes simplex virus: diagnostic and therapeutic considerations

As meningoencefalites virais säo afecçöes relativamente comuns, sendo o vírus do herpes simplex o agente etiológico mais freqüente. O prognóstico das encefalites herpéticas alcançou melhora significativa a partir do advento do aciclovir. Os autores revisam, no presente artigo, os aspectos clínicos, diagnósticos e terapêuticos das encefalites virais, relatando o caso de uma paciente jovem, com boa evoluçäo clínica, a partir da instituiçäo precoce de terapêutica anti-viral.