Encefalitis como complicación neurológica por dengue / Encephalitis as neurological complication due dengue

Resumen Se presenta el caso de un varón de 32 años, previamente sano, que consultó por fiebre de cinco días, cefalea, dolor retro-ocular, rash, petequias, mialgias, artralgias y dolor abdominal. Presentaba leucopenia, trombocitopenia intensa, transaminitis y tiempo de coagulación prolongado. Se diagnosticó un dengue grave con coagulopatía que requirió manejo en Unidad de Cuidados Intensivos. Evolucionó con alteración del estado de conciencia, agitación psicomotora y agresividad. Se descartaron alteraciones estructurales, isquémicohemorrágicas, infecciones bacterianas y micóticas. Se confirmó finalmente una encefalitis por dengue por una RPC para virus dengue positiva en LCR. Se brindaron medidas de soporte con una evolución favorable. La encefalitis es la complicación neurológica más grave tras la infección por virus del dengue.

Abstract We present the case of a 32-year-old male, previously healthy, with a 5-day history of fever, frontal-occipital headache, retro-ocular pain, rash, petechiae, myalgia, arthralgia, and abdominal pain. Blood tests with leukopenia, severe thrombocytopenia, transaminitis, long clotting times. Severe dengue with associated coagulopathy was diagnosed, indicating transfer to ICU. Presents torpid evolution, altered state of consciousness, psychomotor agitation, and aggressiveness. Structural, ischemic-hemorrhagic alterations, bacterial and fungal infections were ruled out. Finally diagnosing dengue encephalitis, confirmed by DENV PCR in CSF. Support measures are provided with favorable evolution. Encephalitis is the most serious neurological complication after dengue virus infection.

Infecciones del sistema nervioso: nuevas herramientas diagnósticas / Central nervous system infections: new diagnostic tools

Las infecciones del sistema nervioso constituyen un problema emergente de salud. Su pronóstico es desfavorable si el tratamiento no es el adecuado, por lo que, para comenzar rápidamente con una apropiada estrategia terapéutica, es necesario establecer el diagnóstico de forma precisa. Sin embargo, esto representa un verdadero desafío. El rendimiento relativo de los métodos de diagnóstico por imágenes es bien conocido: mientras la tomografía computada (TC) permite una valoración inicial general de la estructura, la resonancia magnética (RM) es el procedimiento de elección, a pesar de su baja especificidad. No obstante, en los últimos anos ˜ esto se ha visto sustancialmente modificado por la introducción en la práctica diaria de nuevas modalidades de resonancia que permiten un análisis estructural y funcional más preciso, brindando, además, información fundamental para el diagnóstico. Así, gracias a las técnicas de difusión, perfusión y espectroscopia (entre otras), se puede realizar un análisis más profundo que, junto con la clínica y los estudios de laboratorio, mejora significativamente la sensibilidad y especificidad del método en este complejo grupo de pacientes. Revisamos las formas de presentación de las patologías infecciosas más frecuentes del sistema nervioso, destacando los aportes de las técnicas funcionales o de las secuencias convencionales modificadas.

Central nervous system infections are an emerging health problem with poor prognosis if treatment is not adequate. Thus, establishing a correct diagnosis is necessary to quickly start the appropriate treatment. This is a real challenge for the radiologist, as it frequently requires a multidisciplinary approach. The relatively low performance of diagnostic imaging is well known. While computed tomography (CT) is limited only to an initial structural assessment, with magnetic resonance imaging (MRI) being the method of choice, although it has a low specificity. However, this has been substantially modified in recent years with the introduction into daily practice of new magnetic resonance sequences that allow precise structural and functional analysis, and provide essential additional information for final diagnosis. Now, due to the techniques of diffusion, perfusion, and spectroscopy, among others, a more detailed analysis can be made in conjunction with clinical and laboratory studies that signifi- cantly improve the sensitivity and specificity of MRI in this complex patient group. The patterns of the most common infectious diseases of the nervous system are reviewed here, highlighting the contributions of functional sequences in these complex patients.

Reversible splenial lesion on the corpus callosum in nonfulminant hepatitis A presenting as encephalopathy

Reversible focal lesions on the splenium of the corpus callosum (SCC) have been reported in patients with mild encephalitis/encephalopathy caused by various infectious agents, such as influenza, mumps, adenovirus, Varicella zoster, Escherichia coli, Legionella pneumophila, and Staphylococcus aureus. We report a case of a reversible SCC lesion causing reversible encephalopathy in nonfulminant hepatitis A. A 30-year-old healthy male with dysarthria and fever was admitted to our hospital. After admission his mental status became confused, and so we performed electroencephalography (EEG) and magnetic resonance imaging (MRI) of the brain, which revealed an intensified signal on diffusion-weighted imaging (DWI) at the SCC. His mental status improved 5 days after admission, and the SCC lesion had completely disappeared 15 days after admission.

Las encefalitis esquinas: Una Revisión / The equine encephalitis: a review

El grupo de las encefalitis Equina Venezolana, del Este, del Oeste y del Nilo Occidental (EEV, EEE, EEO y ENO respectivamente) son zoonosis transmitidas por mosquitos a humanos y equinos. Este grupo de enfermedades se mantienen en la naturaleza en ciclos enzoóticos de transmisión entre mosquitos y roedores silvestres o aves que son sus hospedadores naturales. La circulación de estos virus es enzoótica y ocurre en áreas geográficas definidas y tienen capacidad de causar epidemias/epizootias con morbilidad y mortalidad que puede ser de importancia significativa. Este artículo describe detalladamente todas las encefalitis virales que afectan a los équidos y sus aspectos clínicos, patológicos y diagnósticos.

The encephalitis of Venezuelan Equine, Eastern, Western and West Nile (VEE, EEE, WEE and ENO respectively) are zoonotic encephalitis transmitted by mosquitoes to humans and horses. This group of diseases is maintained in nature in cycle’s enzootic transmission between mosquitoes and wild rodents or birds are their natural hosts. The circulation of this virus is enzootic and occurs in defined geographical areas but is capable of causing epidemics / epizootics with morbidity and mortality can be significant importance. This article describes all viral encephalitis affecting equines and their clinical, pathological and diagnostic aspects.

Encefalopatía perdedora de sal en romboencefalitis por listeria / Cerebral salt wasting syndrome associated with Listeria monocytogenes encephalitis. Report of one case

Hyponatremia is common in patients with severe neurological diseases and is often secondary to a syndrome of inappropriate antidiuretic hormone secretion (SIADH). However, in some patients, hyponatremia is due to cerebral salt wasting syndrome (CSWS). SIADH and CSWS treatments are opposite and misdiagnosis can lead to increased morbidity and mortality. We report a 52 years old female with a rhom-boencephalitis caused by Listeria Monocytogenes (LM), ventriculitis and abscesses in cerebellum and brainstem. It was associated with hyponatremia, hypotension, increased natriuresis, hypouricemia, and low creatinine and blood urea nitrogen levels. Large amounts ofsodium were needed and the condition persisted after hospital discharge. Hyponatremia is common in central nervous system involvement by LM, however we are not aware of CSWS reports of this condition.

Cerebritis bifrontal y absceso cerebral por Streptococcus del grupo anginosus, en paciente previamente sano: Caso clínico / Bifrontal cerebritis and brain abscess caused by Sreptococcus anginosus group: Report of one case

The etiology of brain abscesses is mostly polymicrobial. Streptococci and anaerobic bacteria are the most commonly isolated pathogens. We report a previously healthy female without predisposingfactors, presenting with a bifrontal cerebritis caused by a Streptococcus anginosus group infection. The patient developed a brain abscess and a subdural collection with severe intracranial hypertension offatal evolution. The etiologic diagnosis was made culturing the material obtained from the subdural collection. It is presumed that, within the Streptococcus anginosus group, Streptococus intermedius could have been the causing bacteria, given its central nervous system tissue tropism and its predisposition to form brain abscesses.

Adult-onset Rasmussen’s encephalitis.

Rasmussen’s encephalitis (RE) is characterised by refractory focal seizures, unilateral cortical deficits, and progressive unihemispheric focal cortical atrophy of undetermined aetiology. A majority of these cases present in childhood, and three disease stages have been recognised: a ‘prodromal stage’, an ‘acute stage’ and a ‘residual stage’. Adult-onset and variant forms have also been described but are rare, and we report one such case with frequent refractory focal seizures, right-sided hemiparesis, aphasia, and marked atrophy of the left perisylvian cortex with a slow disease progression over 17 years. Immunotherapy with corticosteroids, IVIG, plasma exchange, and tacrolimus has been tried in RE with variable results. Hemispherectomy and disconnective techniques like functional hemispherectomy and hemispherotomy are effective in achieving seizure freedom in 62.5% to 85% cases, but carry a risk of motor and language deficits.

Etiology and outcome of non-traumatic coma in children admitted to pediatric intensive care unit

Non-traumatic coma is a relatively common condition in children that may cause considerable mortality and morbidity. The purpose of this study was to determine clinical presentation, etiology and outcome of non-traumatic coma in children. In a retrospective cross sectional study over a period of 5 years, files of 150 children aged between 1 month and 14 years admitted with non-traumatic coma to pediatric intensive care unit of Rasool Akram hospital were reviewed. Historical, presenting symptoms, clinical and laboratory data were collected. Etiology of coma was determined on the basis of clinical history and relevant investigations. The outcome was recorded as died or neurological condition at discharge as normal, mild or sever disability. Chi-square test was used to test the differences in categorical variables. There were 63 [42%] boys and 87 [58%] girls. The mean +/- SD age of patients was 2.7 +/- 2.35 years. Systemic presentations including nausea, vomiting, fever, lethargy and poor I feeding were more prominent in children under 2 years. Etiology of coma in 49 patients [32.7%] was infectious [meningitis, encephalitis, respiratory and systemic]. Other causes were status epilepticus 44 [29.4%], metabolic [diabetic ketoacidosis, inborn errors of metabolism] 11 [7.3%], intoxications 10 [6.7%], accidental [drowning, electrical shock, suffocation] 9 [6%], shunt dysfunction [secondary to congenital brain malformations] 7 [4.6%], others [acute disseminated encephalomyelitis, vasculitis, hypertensive encephalopathy] 11 [7.3%], unknown 9 [6%]. Infection occurred significantly [P=0.002] in children under 2 years of age, whereas accidents and intoxications were more prominent [P=0.004] in those between 2 and 6 years. Overall 25 children [16.6%] died. Of those survived 16 became severely disabled. Accidents and infections had higher mortality compared to other groups [P<0.001 and P=0.02 respectively]. Our results showed that infection was the most common cause of non-traumatic coma in childhood. Accidents and infection had higher mortality than other causes

Hyperammonemic coma presenting as Hashimoto's encephalopathy.

Hyperammonemia is commonly encountered in active liver disease. Evaluation of patients having hyperammonemia with normal liver function is difficult. We present a case referred to us as undiagnosed hyperammonemic coma with normal liver function, who was subsequently diagnosed to have Hashimoto's encephalopathy. In patients with hyperammonemia without hepatic dysfunction, one must search for the presence of hypothyroidism. Hashimoto's encephalopathy though described to be rare in literature, is often underlooked. In patients with undiagnosed coma, one must look for it as it is easy to diagnose and treat.

Phenytoin induced severe disabling osteomalacia in a young male with seizure disorder.

While the use of anti epileptic drugs (AEDs) for a long period is a known risk factor for bone loss and pathological fractures, yet the physicians are not yet sensitized to this possibility. It is now believed that the patients who have fractures due to long-term treatment with anticonvulsants have osteomalacia as the predominant lesion. This has been attributed to the alterations in the levels of circulating calcium and calcitropic hormones. Here we report a case of a young male who had been on anticonvulsants for 11 years and was admitted with us with severe bone pains, multiple pathological pseudo fractures and a severe degree of disability secondary to phenytoin induced osteomalacia.

Complicaciones neurológicas de la infección por mycoplasma pneumoniae / Neurological complications related to mycoplasma pneumoniae infection

Las manifestaciones neurológicas asociadas a infecciones por M. Pneumoniae corresponden al 0,1 por ciento, siendo la encefalitis la manifestación más frecuente en los niños, que se caracteriza por presentar trastorno de conciencia, convulsiones y ocasionalmente ataxia y coreoatetosis, que regresan en forma espontánea, sin dejar secuelas en la gran mayoría de los casos. Sin embargo, existen algunos casos fatales.- Objetivo: Sensibilizar al pediatra general sobre esta patología y su oportuna derivación al especialista.- Caso clínico: Niño de 5 años que cursa con trastorno de conciencia, convulsiones, trastorno de la marcha, sin fiebre, concomitantemente con una neumonía lobar izquierda. IgM M. Pneumoniae, método Elisa rápido positivo. Tomografía axial computarizada cerebral normal. Se realiza tratamiento con anticonvulsivante endovenoso por 48 h., continuando con ácido valproico oral, el que se suspende luego de una semana, al obtener EEG normal. Se completa tratamiento con macrólido por 14 días resolviéndose la neumonía. Evoluciona con ataxia y trastorno del lenguaje, que se normalizan en el trascurso de una semana, sin repetir crisis convulsiva.- Conclusión: Se presenta este caso debido a la infrecuencia de esta complicación neurológica en niños e infecciones respiratorias por M. Pneumoniae, cuya causa aún se discute, siendo la teoría autoinmunitaria la más aceptada actualmente.

Brainstem encephalitis with Kikuchi-Fujimoto disease

A case of young woman is described who developed clinical and MRI features of brainstem encephalitis in the setting of fever and cervical lymphadenopathy. Lymph node biopsy revealed histiocytic necrotizing lymphadenitis [Kikuchi-Fujimoto disease], which may reflect host response to an unspecified immune insult

Kleine-Levin syndrome and encephalitis.

Kleine-Levin Syndrome is characterized by hypersomnolence, hyperphagia and sexual disinhibition. The article reported a case of 10-year-old boy with a two-week history of altered sensorium, irrelevant talks, markedly increasing appetite and tendency to sleep most of the times. Immediately preceding to it the child had been an episode of enteric fever confirmed by the serological tests.

Encefalite por Trypanosoma cruzi em paciente com Síndrome da Imunodeficiência adquirida - Relato de caso / Trypanosoma cruzi encephalitis in patient presenting the Acquired Immune Deficiency Syndrome (AIDS) - case report

É relatado um caso de reativaçäo de doença de Chagas, manifestada por encefalite, em uma paciente de 44 anos com Síndrme da Imunodeficiência Adquirida, que apresentou perda súbita de consciência, parestesia em membro superior direito, seguida de confusäo mental e sonolência. Ao exame neurológico, a paciente apresentou-se näonresponsiva aos estímulos verbais, reagindo aos estímulos dolorosos, com reflexos diminuídos globalmente e Babinski positivo. A tomografia computadorizada do crânio revelou lesöes anelares envolvidas por edema em lobo frontal direito, em lobo occipital esquerdo e outras na cortical perietal bilateral. As reaçöes de imunofluorescência, de hemaglutinaçäo e de fixaçäo de complemento para doença de Chagas foram positivas no soro. O exame do líquido cefalorraquiano (LCR) mostrou aspecto límpido, 2 leucócitos/ml, 4 hemáceas/ml, glicose 58 mg por cento, proteínas 54 mg por cento, ausência de fungos, BAAR ou bactérias, e presença de inúmeras formas tripomastigotas de Trypanosoma cruzi. A paciente foi submetida à terapêutica com benzonidazol na dose de 600 mg/dia. Realizou-se revisäo dos principais aspectos desta associaçäo.