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Neurological infections

What are the distinctive features of HEV-associated neuralgic amyotrophy?

Clinical phenotype and outcome of hepatitis E virus-associated neuralgic amyotrophy

van Eijk JJJ, Dalton HR, Ripellino P, et al.

Neurology 2017; 89:909-917.

Abstract

OBJECTIVE:

To determine the clinical phenotype and outcome in hepatitis E virus-associated neuralgic amyotrophy (HEV-NA).

METHODS:

Cases of NA were identified in 11 centers from 7 European countries, with retrospective analysis of demographics, clinical/laboratory findings, and treatment and outcome. Cases of HEV-NA were compared with NA cases without evidence of HEV infection.

RESULTS:

Fifty-seven cases of HEV-NA and 61 NA cases without HEV were studied. Fifty-six of 57 HEV-NA cases were anti-HEV IgM positive; 53/57 were IgG positive. In 38 cases, HEV RNA was recovered from the serum and in 1 from the CSF (all genotype 3). Fifty-one of 57 HEV-NA cases were anicteric; median alanine aminotransferase 259 IU/L (range 12-2,961 IU/L); in 6 cases, liver function tests were normal. HEV-NA cases were more likely to have bilateral involvement (80.0% vs 8.6%, p < 0.001), damage outside the brachial plexus(58.5% vs 10.5%, p < 0.01), including phrenic nerve and lumbosacral plexus injury (25.0% vs 3.5%, p = 0.01, and 26.4% vs 7.0%, p = 0.001), reduced reflexes (p = 0.03), sensory symptoms (p = 0.04) with more extensive damage to the brachial plexus. There was no difference in outcome between the 2 groups at 12 months.

CONCLUSIONS:

Patients with HEV-neuralgic amyotrophy are usually anicteric and have a distinct phenotype, with predominately bilateral asymmetrical involvement of, and more extensive damage to, the brachial plexus. Involvement outside the brachial plexus is more common in HEV-NA. The relationship between HEV and NA is likely to be causal, but is easily overlooked. Patients presenting with NA should be tested for HEV, irrespective of liver function test results. Prospective treatment/outcome studies of HEV-NA are warranted.

This reference is cited in the neurochecklist:

Hepatitis E virus (HEV) neurology

Abstract link

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Categories
Neurological infections

The 7 most devastating viral neurological infections

One may be forgiven for thinking that neurology is all about neuroinflammatory and neurodegenerative diseases. This is because these disorders seem to get a lot of attention. But nothing could be further from the truth-globally, infections impose a heavier burden on neurological practice than say Multiple Sclerosis (MS) or Parkinson’s disease (PD). And medical advances have done very little to deter all sorts of creatures from invading the nervous system.

Bacteria. Cesar Herada on Flikr. https://www.flickr.com/photos/worldworldworld/4095866396/

The major types of organisms that infect the nervous system are viruses and bacteria, but fungi and parasites also take their toll. In this blog we will focus on the 7 most devastating viral neurological infections.

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1.  Viral encephalitis

Encephalitis is infection of the brain substance, as opposed to meningitis which is infection of the covering of the brain. Viral encephalitis, for some reason, tends to favour the temporal lobes of the brain causing seizures and memory problems, amongst other symptoms. The main villain responsible for viral encephalitis is herpes simplex type 1 (HSV1), but almost every other virus can carry out the job with deadly precision. The list is long and includes geographically specific viruses as West Nile and Japanese B. Check out the full list of causes of viral encephalitis and its management.

Herpes Simplex Virus Type 1: Procapsid and Mature Capsid. NIH Image gallery on Flikr. https://www.flickr.com/photos/nihgov/28295539863

2. HIV associated neurological infections

No part of the nervous system is immune to the ravages of the dreaded HIV. The list includes HIV  associated neurocognitive disorders (HAND)myelopathiesneuropathies, drug-induced syndromes, and tumours. The worst aspect of HIV, of course, is that it opens the flood gates for opportunistic infections to invade the nervous system.

By BruceBlausOwn work, CC BY-SA 4.0, Link

3. Hepatitis E virus (HEV)

Hepatitis E virus is just emerging as a scourge of neurology. It is particularly villainous because of its protean manifestations, from Guillain Barre syndrome (GBS) to neuralgic amyotrophy (brachial neuritis), from transverse myelitis to idiopathic intracranial hypertension (IIH). Check out the full neurological manifestations of HEV.

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4. Influenza H1N1

Influenza is bad, and H1N1 is a particularly nasty variant. This subtype of Influenza A is epidemic in pigs and birds, and unleashes havoc when it crosses over to humans. Its nervous system manifestations include encephalopathyGuillain Barre syndrome (GBS), acute demyelinating encephalomyelopathy (ADEM), and stroke. Not one to be treated lightly at all. Check out everything about Influenza H1N1 and the different ways influenza affects the nervous system.

H1N1 influenza viral particles. NIAID on Flikr. https://www.flickr.com/photos/niaid/8414750984

5. Zika virus infection (ZIKV)

This new kid on the infection block is fast establishing itself as a menace. Apart from causing myelitis, meningoencephalitis, encephalitis, encephalomyelitis, Guillain-Barre syndrome (GBS), and myasthenia gravis (MG), it is responsible for a variety of congenital defects, particularly microcephaly. Zika virus pathology and management are extensively covered in neurochecklists. Or check out 20 things we now know for certain about the Zika virus on our sister blog, The Neurology Lounge.

By Manuel Almagro RivasOwn work, CC BY-SA 4.0, Link

6. Ebola virus disease (EVD)

This ancient virus gained recent notoriety when it ravaged a large section of West Africa, sending chilling waves across the world. It is an RNA filovirus whose main reservoir is bats. It causes, among other things, an encephalitis and meningoencephalitis. It appears to be on vacation in the meantme, but it will surely rear its ugly head sometime soon. Check out the comprehensive clinical features and management of Ebola virus disease on neurochecklists.

By Scientific Animations – http://www.scientificanimations.com/wiki-images/, CC BY-SA 4.0, Link

7. Varicella zoster virus (VZV)

The varicella virus must take the prize for the most diverse ways a virus affects the nervous system. Neurochecklists has listed >20 neurological manifestations of VZV, ranging from herpes zoster to post herpetic neuralgia (PHN), from meningitis to encephalitis. VZV also causes all forms of cranial and peripheral neropathy, and may result in stroke, aneurysms, and giant cell arteritis (GCA). Not to mention the curiously named progressive outer retinal necrosis (just don’t mention its acronym!). Check out the full VZV on neurochecklists.

 

Check out the other deadly viral neurological infections on neurochecklists:

Dengue virus infection (DENV)

West Nile virus (WNV) infection

Japanese encephalitis virus (JEV)

Rabies encephalitis