- Email: [email protected]
Optic neuritis associated with influenza B virus meningoencephalitis
Journal of Clinical Virology 61 (2014) 463–465
Contents lists available at ScienceDirect
Journal of Clinical Virology journal homepage: www.elsevier.com/locate/jcv
Case Report
Optic neuritis associated with influenza B virus meningoencephalitis F.A. Vianello b,∗∗ , S. Osnaghi a , E.A. Laicini b , G.P. Milani b,∗ , G. Tardini b , A.M. Cappellari c , G. Lunghi d , C.V. Agostoni e , E.F. Fossali b Foundation IRCCS, Ca Granda Ospedale Maggiore Policlinico, Oculistic Department, Milan, Italy Foundation IRCCS, Ca Granda Ospedale Maggiore Policlinico, Pediatric Emergency Department, Milan, Italy c Foundation IRCCS, Ca Granda Ospedale Maggiore Policlinico, Department of Neuroscience and Mental Health, Milan, Italy d Foundation IRCCS, Ca Granda Ospedale Maggiore Policlinico, Laboratory Department, Virology Unit, Milan, Italy e Department of Clinical Sciences and Community Health, University of Milan, IRCCS Ospedale Maggiore Policlinico, Pediatric Clinic 2, Milan, Italy a
b
a r t i c l e
i n f o
Article history: Received 12 August 2014 Received in revised form 17 September 2014 Accepted 19 September 2014
a b s t r a c t Various postinfectious neurological manifestations have been described associated to influenza viruses. Optic neuritis is a serious, often reversible disease reported among several infectious diseases and vaccines complications. We report a case of optic neuritis following an influenza B virus infection in a 10-year-old male. © 2014 Elsevier B.V. All rights reserved.
Keywords: Influenza B virus Optic neuritis Neurological complications
1. Introduction Most of the influenza virus infection symptoms are respiratory or gastrointestinal, associated with a good prognosis. However, several neurological complications, ranging from mild manifestations to acute necrotising encephalopathy have been reported [1–3]. Optic neuritis (ON) consists of the optic nerve inflammation, resulting in sudden painful vision loss or impaired function of the affected eye [4]. It has been associated with influenza vaccination both in children and adults [5]. Anecdotally, ON was reported after an influenza A virus infection, too [6]. We describe the case of a child with ON following an influenza B virus meningoencephalitis. 2. Why this case is important Optic neuritis is an inflammatory, demyelinating disease causing acute visual loss. A prompt treatment in children is associated with a good prognosis in most cases [4,7]. Diagnosis of ON can
Abbreviations: ON, optic neuritis; CSF, cerebrospinal fluid; OCT, Optical Coherence Tomography; MS, multiple sclerosis. ∗ Corresponding author at: Via della Commenda 9, 20122 Milan, Italy. Tel.: +39 3498320575. ∗∗ Corresponding author at: Via della Commenda 9, 20122 Milan, Italy, Tel.: +39 3407071964. E-mail addresses: [email protected] (F.A. Vianello), [email protected] (G.P. Milani). http://dx.doi.org/10.1016/j.jcv.2014.09.010 1386-6532/© 2014 Elsevier B.V. All rights reserved.
be difficult and delay the treatment. Clinicians should be aware of the possibility of ON among complications of influenza viruses infections. 2.1. Case description A 10-year-old boy was admitted to our paediatric emergency department for asthenia, drowsiness, leg tremors and muscular pain for 24 h and fever, cough and rhinitis for 4 days. On admission vital signs were as follows: axillary temperature 38.4 ◦ C, heart rate 120 beats/min, blood pressure 115/75 mmHg, respiratory rate 30 breaths/min, and oxygen saturation 98% while breathing ambient air. On physical examination, the child was agitated, with deteriorating consciousness and confusion. Three episodes of rhythmic legs movements lasting 2–3 min occurred during clinical examination. Brudzinski and Kernig signs were positive. No petechiae were present. A complete blood cell count revealed (reference ranges in brackets): 17.870 WBC/mm3 [4.800–12.100 mm−3 ] (80% neutrophils, 9% lymphocytes and 11% monocytes), haemoglobin level was 12 g/dl [10.5–14.5 g/dl], haematocrit 34.1% [34.5–42.5%], and platelet count was 551.000 mm−3 [150.00–450.00 mm−3 ]. Inflammatory indices and coagulation panel values were normal. Serum glucose level was 87 mg/dl. Cerebrospinal fluid (CSF) analysis revealed: WBC count of 70 cells/mm3 [<5 cells/mm3 ] (70% neutrophils and 30%
464
F.A. Vianello et al. / Journal of Clinical Virology 61 (2014) 463–465
Fig. 1. Right eye examination. Spectral domain – OCT showing the swollen optic disc in the infrared image (orange arrows) and in cross-sectional images (blue arrows), [left and central panels]. Visual field examination showing visual defect areas (black parts) [right panel]. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
lymphocytes), proteins level of 45 mg/dl [10–45 mg/dl] and glucose level of 49 mg/dl (40–70 mg/dl). Diagnosis of meningoencephalitis was made and the patient received normal saline, ceftriaxone and acyclovir intravenously administered. The day after the admission the child became alert and on day 3 fever and neurological findings resolved and a brain and medulla MRI revealed normal findings. Ceftriaxone and acyclovir were discontinued after the research for viruses (herpes simplex 1 and 2, Ebstein–Barr, cytomegalovirus, adenovirus, varicella-zoster, measles, mumps, parvovirus and entoroviruses) and bacteria (Streptococcus pneumoniae, Haemophilus influentiae type b and Neisseria meningitidis) in CSF resulted negative. Influenza B virus was detected from nasopharyngeal aspirate by RT MULTIPLE PCR (real-time multiple polymerase chain reaction), but not from CSF. No further antiviral treatment was administered considering the improvement of the clinical conditions. Yet, on day 10 he developed headache and painful eye movements with partial blindness in right eye. Eye examination revealed papilledema on the right eye and reduction of visual acuity (7/10), and left eye was completely normal with visual acuity of 10/10. Brain and medulla MRI showed altered signal of the right optic nerve with contrast enhancement. Oligoclonal bands were absent in serum and CSF. Aquaporin-4 antibodies were negative and serum angiotensin converting enzyme level within normal range. Clinical and diagnostic features pointed towards bulbar and retro-bulbar optic neuritis without any cerebral and medulla lesions. The diagnosis of ON was confirmed by visual field test and Spectral Domain – Optical Coherence Tomography (OCT), which showed a right swollen disc and a visual field defect (Fig. 1). Intravenous bolus methylprednisolone was administered for 5 days with rapid improvement of symptoms; oral prednisone was subsequently given with a slow taper over 4 weeks. One week after the onset of symptoms, eye examination and visual field were normal and visual acuity increased to 10/10. Six month after discharge, physical examination, eyes examination, Spectral Domain – OCT, brain and medulla MRI were normal.
H1N1 vaccine [11]. Until now, only one case of ON following influenza A virus infection in a 9-year-old Asian boy is described [7]. To our knowledge, we report the first case of ON associated with influenza B virus meningoencephalitis. In our case, CFS analysis revealed pleocytosis, with RT MULTIPLE PCR for influenza B being negative, yet nasopharyngeal aspirate was positive for influenza B virus. It is known that virus RNA is detectable in CSF over a very short period during encephalitis and nasopharyngeal samples are appropriate to detect the presence of the virus [3,12]. After recovery, the patient developed visual symptoms suggestive for ON and radiological imaging, Spectral Domain – OCT and visual field test confirmed the diagnosis of ON. In 2006, Lin et al. reported a 12% incidence of neurological manifestations with influenza B infection in children and Moon et al. in 2013 found a similar incidence (8%) [1,3]. Many neurological symptoms are described, the most common being febrile and afebrile seizure and encephalitis [1,3]. Extrapyramidal syndrome, Guillain–Barrè syndrome, myelitis and myositis have been described as other complications [3,12,13]. The viruses may activate a systemic autoimmune mechanism of demyelination as can occur following vaccinations [9]. Demyelination of optic nerve can also be the first manifestation of multiple sclerosis (MS) [14]. Corticosteroids may be effective in treatment of ON and a slow taper may prevent the occurrence of relapses [4,13]. The risk of MS following ON in children is much lower than in adults. Data on paediatric patients indicate that the risk is 13% after 10 years, 19% after 20 years, 22% after 30 years and 26% after 40 years, while in adults the risk is 38% after 10 years [12,13]. Our child did not report any sign of relapse or MS at follow-up 6 months later. In conclusion, this case of ON suggests an increased awareness about this complication in children after an influenza virus infection.
Funding 2.2. Similar and contrasting cases in the literature and discussion None. Up to 50% of cases of paediatric ON are postinfectious or postvaccination [4]. ON can follow many viral infections (adenovirus, pertussis, mononucleosis, measles, mumps and chickenpox) and other infectious causes (bartonella, lyme, meningococcus, syphilis, toxocara and toxoplasma) [4,8]. Influenza virus live vaccines have also been advocated in association to ON [9,10] and recently after
Competing interests None.
F.A. Vianello et al. / Journal of Clinical Virology 61 (2014) 463–465
Ethical approval Not done for this observational case report. References [1] Lin CH, Huang YC, Chiu CH, Huang CG, Tsao KC, Lin TY. Neurologic manifestations in children with influenza B virus infection. Pediatr Infect Dis J 2006;25:1081–3. [2] Newland JG, Romero JR, Varman M, Drake C, Holst A, Safranek T, et al. Encephalitis associated with influenza B virus infection in 2 children and a review of the literature. Clin Infect Dis 2003;36:e87–95. [3] Moon J-H, Na J-Y, Kim J-H, Yum MK, Oh JW, Kim CR, et al. Neurological and muscular manifestations associated with influenza B infection in children. Pediatr Neurol 2013;49:97–101. [4] Collinge JE, Sprunger DT. Update in pediatric optic neuritis. Curr Opin Ophthalmol 2013;24:448–52. [5] Karussis D, Petrou P. The spectrum of post-vaccination inflammatory CNS demyelinating syndromes. Autoimmun Rev 2014;13: 215–24.
465
[6] El-Dairi MA, Ghasia F, Bhatti MT. Pediatric optic neuritis. Int Ophthalmol Clin 2012;52:29–49. [7] Lai C-C. Acute anterior uveitis and optic neuritis as ocular complications of influenza A infection in an 11-year-old boy. J Pediatr Ophthalmol Strabismus 2011;48:e30–3. [8] Dass Hazarika R, Deka NM, Khyriem AB, Lyngdoh WV, Barman H, Duwarah SG, et al. Invasive meningococcal infection: analysis of 110 cases from a Tertiary Care Centre in North East India. Indian J Pediatr 2013;80:359–64. [9] Lucchinetti CF, Kiers L, O’Duffy A, Gomez MR, Cross S, Leavitt JA, et al. Risk factors for developing multiple sclerosis after childhood optic neuritis. Neurology 1997;49:1413–8. [10] Riikonen R. The role of infection and vaccination in the genesis of optic neuritis and multiple sclerosis in children. Acta Neurol Scand 1989;80:425–31. [11] Lapphra K, Juh L, Scheifele DW. Adverse neurologic reactions after both doses of pandemic H1N1 influenza vaccine with optic neuritis and demyelination. Pediatr Infect Dis J 2011;30:84–6. [12] Studahl M. Influenza virus and CNS manifestations. J Clin Virol 2003;28:225–32. [13] Boomer JA, Siatkowski RM. Optic neuritis in adults and children. Semin Ophthalmol 2003;18:174–80. [14] Wilejto M, Shroff M, Buncic JR, Kennedy J, Goia C, Banwell B. The clinical features, MRI findings, and outcome of optic neuritis in children. Neurology 2006;67:258–62.
Contents lists available at ScienceDirect
Journal of Clinical Virology journal homepage: www.elsevier.com/locate/jcv
Case Report
Optic neuritis associated with influenza B virus meningoencephalitis F.A. Vianello b,∗∗ , S. Osnaghi a , E.A. Laicini b , G.P. Milani b,∗ , G. Tardini b , A.M. Cappellari c , G. Lunghi d , C.V. Agostoni e , E.F. Fossali b Foundation IRCCS, Ca Granda Ospedale Maggiore Policlinico, Oculistic Department, Milan, Italy Foundation IRCCS, Ca Granda Ospedale Maggiore Policlinico, Pediatric Emergency Department, Milan, Italy c Foundation IRCCS, Ca Granda Ospedale Maggiore Policlinico, Department of Neuroscience and Mental Health, Milan, Italy d Foundation IRCCS, Ca Granda Ospedale Maggiore Policlinico, Laboratory Department, Virology Unit, Milan, Italy e Department of Clinical Sciences and Community Health, University of Milan, IRCCS Ospedale Maggiore Policlinico, Pediatric Clinic 2, Milan, Italy a
b
a r t i c l e
i n f o
Article history: Received 12 August 2014 Received in revised form 17 September 2014 Accepted 19 September 2014
a b s t r a c t Various postinfectious neurological manifestations have been described associated to influenza viruses. Optic neuritis is a serious, often reversible disease reported among several infectious diseases and vaccines complications. We report a case of optic neuritis following an influenza B virus infection in a 10-year-old male. © 2014 Elsevier B.V. All rights reserved.
Keywords: Influenza B virus Optic neuritis Neurological complications
1. Introduction Most of the influenza virus infection symptoms are respiratory or gastrointestinal, associated with a good prognosis. However, several neurological complications, ranging from mild manifestations to acute necrotising encephalopathy have been reported [1–3]. Optic neuritis (ON) consists of the optic nerve inflammation, resulting in sudden painful vision loss or impaired function of the affected eye [4]. It has been associated with influenza vaccination both in children and adults [5]. Anecdotally, ON was reported after an influenza A virus infection, too [6]. We describe the case of a child with ON following an influenza B virus meningoencephalitis. 2. Why this case is important Optic neuritis is an inflammatory, demyelinating disease causing acute visual loss. A prompt treatment in children is associated with a good prognosis in most cases [4,7]. Diagnosis of ON can
Abbreviations: ON, optic neuritis; CSF, cerebrospinal fluid; OCT, Optical Coherence Tomography; MS, multiple sclerosis. ∗ Corresponding author at: Via della Commenda 9, 20122 Milan, Italy. Tel.: +39 3498320575. ∗∗ Corresponding author at: Via della Commenda 9, 20122 Milan, Italy, Tel.: +39 3407071964. E-mail addresses: [email protected] (F.A. Vianello), [email protected] (G.P. Milani). http://dx.doi.org/10.1016/j.jcv.2014.09.010 1386-6532/© 2014 Elsevier B.V. All rights reserved.
be difficult and delay the treatment. Clinicians should be aware of the possibility of ON among complications of influenza viruses infections. 2.1. Case description A 10-year-old boy was admitted to our paediatric emergency department for asthenia, drowsiness, leg tremors and muscular pain for 24 h and fever, cough and rhinitis for 4 days. On admission vital signs were as follows: axillary temperature 38.4 ◦ C, heart rate 120 beats/min, blood pressure 115/75 mmHg, respiratory rate 30 breaths/min, and oxygen saturation 98% while breathing ambient air. On physical examination, the child was agitated, with deteriorating consciousness and confusion. Three episodes of rhythmic legs movements lasting 2–3 min occurred during clinical examination. Brudzinski and Kernig signs were positive. No petechiae were present. A complete blood cell count revealed (reference ranges in brackets): 17.870 WBC/mm3 [4.800–12.100 mm−3 ] (80% neutrophils, 9% lymphocytes and 11% monocytes), haemoglobin level was 12 g/dl [10.5–14.5 g/dl], haematocrit 34.1% [34.5–42.5%], and platelet count was 551.000 mm−3 [150.00–450.00 mm−3 ]. Inflammatory indices and coagulation panel values were normal. Serum glucose level was 87 mg/dl. Cerebrospinal fluid (CSF) analysis revealed: WBC count of 70 cells/mm3 [<5 cells/mm3 ] (70% neutrophils and 30%
464
F.A. Vianello et al. / Journal of Clinical Virology 61 (2014) 463–465
Fig. 1. Right eye examination. Spectral domain – OCT showing the swollen optic disc in the infrared image (orange arrows) and in cross-sectional images (blue arrows), [left and central panels]. Visual field examination showing visual defect areas (black parts) [right panel]. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
lymphocytes), proteins level of 45 mg/dl [10–45 mg/dl] and glucose level of 49 mg/dl (40–70 mg/dl). Diagnosis of meningoencephalitis was made and the patient received normal saline, ceftriaxone and acyclovir intravenously administered. The day after the admission the child became alert and on day 3 fever and neurological findings resolved and a brain and medulla MRI revealed normal findings. Ceftriaxone and acyclovir were discontinued after the research for viruses (herpes simplex 1 and 2, Ebstein–Barr, cytomegalovirus, adenovirus, varicella-zoster, measles, mumps, parvovirus and entoroviruses) and bacteria (Streptococcus pneumoniae, Haemophilus influentiae type b and Neisseria meningitidis) in CSF resulted negative. Influenza B virus was detected from nasopharyngeal aspirate by RT MULTIPLE PCR (real-time multiple polymerase chain reaction), but not from CSF. No further antiviral treatment was administered considering the improvement of the clinical conditions. Yet, on day 10 he developed headache and painful eye movements with partial blindness in right eye. Eye examination revealed papilledema on the right eye and reduction of visual acuity (7/10), and left eye was completely normal with visual acuity of 10/10. Brain and medulla MRI showed altered signal of the right optic nerve with contrast enhancement. Oligoclonal bands were absent in serum and CSF. Aquaporin-4 antibodies were negative and serum angiotensin converting enzyme level within normal range. Clinical and diagnostic features pointed towards bulbar and retro-bulbar optic neuritis without any cerebral and medulla lesions. The diagnosis of ON was confirmed by visual field test and Spectral Domain – Optical Coherence Tomography (OCT), which showed a right swollen disc and a visual field defect (Fig. 1). Intravenous bolus methylprednisolone was administered for 5 days with rapid improvement of symptoms; oral prednisone was subsequently given with a slow taper over 4 weeks. One week after the onset of symptoms, eye examination and visual field were normal and visual acuity increased to 10/10. Six month after discharge, physical examination, eyes examination, Spectral Domain – OCT, brain and medulla MRI were normal.
H1N1 vaccine [11]. Until now, only one case of ON following influenza A virus infection in a 9-year-old Asian boy is described [7]. To our knowledge, we report the first case of ON associated with influenza B virus meningoencephalitis. In our case, CFS analysis revealed pleocytosis, with RT MULTIPLE PCR for influenza B being negative, yet nasopharyngeal aspirate was positive for influenza B virus. It is known that virus RNA is detectable in CSF over a very short period during encephalitis and nasopharyngeal samples are appropriate to detect the presence of the virus [3,12]. After recovery, the patient developed visual symptoms suggestive for ON and radiological imaging, Spectral Domain – OCT and visual field test confirmed the diagnosis of ON. In 2006, Lin et al. reported a 12% incidence of neurological manifestations with influenza B infection in children and Moon et al. in 2013 found a similar incidence (8%) [1,3]. Many neurological symptoms are described, the most common being febrile and afebrile seizure and encephalitis [1,3]. Extrapyramidal syndrome, Guillain–Barrè syndrome, myelitis and myositis have been described as other complications [3,12,13]. The viruses may activate a systemic autoimmune mechanism of demyelination as can occur following vaccinations [9]. Demyelination of optic nerve can also be the first manifestation of multiple sclerosis (MS) [14]. Corticosteroids may be effective in treatment of ON and a slow taper may prevent the occurrence of relapses [4,13]. The risk of MS following ON in children is much lower than in adults. Data on paediatric patients indicate that the risk is 13% after 10 years, 19% after 20 years, 22% after 30 years and 26% after 40 years, while in adults the risk is 38% after 10 years [12,13]. Our child did not report any sign of relapse or MS at follow-up 6 months later. In conclusion, this case of ON suggests an increased awareness about this complication in children after an influenza virus infection.
Funding 2.2. Similar and contrasting cases in the literature and discussion None. Up to 50% of cases of paediatric ON are postinfectious or postvaccination [4]. ON can follow many viral infections (adenovirus, pertussis, mononucleosis, measles, mumps and chickenpox) and other infectious causes (bartonella, lyme, meningococcus, syphilis, toxocara and toxoplasma) [4,8]. Influenza virus live vaccines have also been advocated in association to ON [9,10] and recently after
Competing interests None.
F.A. Vianello et al. / Journal of Clinical Virology 61 (2014) 463–465
Ethical approval Not done for this observational case report. References [1] Lin CH, Huang YC, Chiu CH, Huang CG, Tsao KC, Lin TY. Neurologic manifestations in children with influenza B virus infection. Pediatr Infect Dis J 2006;25:1081–3. [2] Newland JG, Romero JR, Varman M, Drake C, Holst A, Safranek T, et al. Encephalitis associated with influenza B virus infection in 2 children and a review of the literature. Clin Infect Dis 2003;36:e87–95. [3] Moon J-H, Na J-Y, Kim J-H, Yum MK, Oh JW, Kim CR, et al. Neurological and muscular manifestations associated with influenza B infection in children. Pediatr Neurol 2013;49:97–101. [4] Collinge JE, Sprunger DT. Update in pediatric optic neuritis. Curr Opin Ophthalmol 2013;24:448–52. [5] Karussis D, Petrou P. The spectrum of post-vaccination inflammatory CNS demyelinating syndromes. Autoimmun Rev 2014;13: 215–24.
465
[6] El-Dairi MA, Ghasia F, Bhatti MT. Pediatric optic neuritis. Int Ophthalmol Clin 2012;52:29–49. [7] Lai C-C. Acute anterior uveitis and optic neuritis as ocular complications of influenza A infection in an 11-year-old boy. J Pediatr Ophthalmol Strabismus 2011;48:e30–3. [8] Dass Hazarika R, Deka NM, Khyriem AB, Lyngdoh WV, Barman H, Duwarah SG, et al. Invasive meningococcal infection: analysis of 110 cases from a Tertiary Care Centre in North East India. Indian J Pediatr 2013;80:359–64. [9] Lucchinetti CF, Kiers L, O’Duffy A, Gomez MR, Cross S, Leavitt JA, et al. Risk factors for developing multiple sclerosis after childhood optic neuritis. Neurology 1997;49:1413–8. [10] Riikonen R. The role of infection and vaccination in the genesis of optic neuritis and multiple sclerosis in children. Acta Neurol Scand 1989;80:425–31. [11] Lapphra K, Juh L, Scheifele DW. Adverse neurologic reactions after both doses of pandemic H1N1 influenza vaccine with optic neuritis and demyelination. Pediatr Infect Dis J 2011;30:84–6. [12] Studahl M. Influenza virus and CNS manifestations. J Clin Virol 2003;28:225–32. [13] Boomer JA, Siatkowski RM. Optic neuritis in adults and children. Semin Ophthalmol 2003;18:174–80. [14] Wilejto M, Shroff M, Buncic JR, Kennedy J, Goia C, Banwell B. The clinical features, MRI findings, and outcome of optic neuritis in children. Neurology 2006;67:258–62.