Marzia Puccioni-Sohler

Dengue infection: neurological manifestations and cerebrospinal fluid (CSF) analysis

Neurological manifestation is considered a rare complication of dengue infection. Neurological and cerebrospinal fluid (CSF) findings of 13 patients with dengue infection were studied. Seven patients had encephalitis, two had myelitis and four showed Guillain-Barré syndrome (GBS). No alteration in CSF was found from 57% of those with encephalitis. Patients with GBS and myelitis showed a CSF-blood barrier dysfunction. The differences in the CSF may be related to the location of the lesion and multiple mechanisms of the disease in the nervous system.

Review of the etiologies of viral meningitis and encephalitis in a dengue endemic region.

OBJECTIVES To evaluate the etiology of viral meningitis and encephalitis in adults and adolescents living in areas affected by dengue. METHODS Over two years, adults and adolescents with diagnoses of viral encephalitis or meningitis were selected for study in Brazil. PCRs for dengue, enterovirus, HSV1 and 2 and cytomegalovirus were performed in CSF samples. Serum and CSF samples were tested for the presence of anti-dengue IgM antibodies. RESULTS The etiologies of encephalitis and meningitis were determined in 70% of cases (30/47). Dengue was the leading cause of encephalitis (47%) with normal CSF cellularity in 75% of these patients. HSV1 was found in 17.6% of the cases, two of which had mild encephalitis. Enterovirus was the most common cause of meningitis (50%), followed by HSV1 (15%), cytomegalovirus and dengue (10%, each). CONCLUSIONS We identified the viral agents causing encephalitis and meningitis in a higher proportion of cases than has been reported in other studies. Dengue was the most frequent cause of encephalitis, which surpassed HSV. In endemic areas, dengue should be investigated as an important cause of encephalitis. Normal CSF cellularity should not exclude dengue encephalitis. Enterovirus is known to be the leading cause of meningitis in children, but here we found it was also the main cause of the disease in adults. HSV1 should be investigated in patients with mild forms of encephalitis and meningitis.

Meningitis determined by oligosymptomatic dengue virus type 3 infection: Report of a case

Dengue infection is a mosquito-borne disease caused by a flavivirus, and is recognized in over 100 countries with 2.5 billion people living in areas of risk. Neurological manifestations such as encephalitis, myelitis, Guillain-Barré syndrome, cranial nerve palsies, neuromyelitis optica, and encephalomyelitis have been recognized as clinical consequences of dengue infection. Meningitis is a rare complication. We report the case of a 24-year-old woman who presented with fever, headache, and nuchal rigidity without the typical symptoms of dengue infection. Cerebrospinal fluid analysis showed lymphocytic pleocytosis with a normal glucose value and negative bacterial and fungal cultures. The etiology of meningitis was confirmed by positive dengue PCR in the serum. This case report highlights dengue infection as a potential cause of meningitis in endemic areas. Also, meningitis can be the first manifestation of the infection. Dengue should be investigated even in the absence of a typical picture of the infection.

Oligosymptomatic dengue infection: a potential cause of Guillain Barré syndrome

BACKGROUND Dengue infection may cause neurological manifestations such as encephalitis, myelitis, mononeuropathies, acute disseminated encephalomyelitis, and Guillain Barré syndrome (GBS). In endemic regions, the infection course can be oligosymptomatic making difficult the diagnosis of the neurological picture associated with dengue infection. OBJECTIVE To report dengue infection and GBS association, even in oligosymptomatic cases of this infection. METHOD During the dengue epidemic in Rio de Janeiro city we looked for GBS cases, testing IgM antibodies for dengue and dengue polymerase chain reaction (PCR) in the cerebrospinal fluid (CSF) and serum. RESULTS We report seven cases (46.6%), presenting dengue positive IgM in serum but with poor or without clinical symptoms of the previous infection. Two of them had also positive IgM antibodies in CSF. CONCLUSION These data show that search for dengue infection should be a routine in GBS cases living in endemic areas.

Neurological complications in dengue infection: a review for clinical practice

Dengue is an important global public health problem. The World Health Organization estimates that 2/5 of entire world population are in risk of dengue infection. Almost 50 millions cases occur annually, with at least 20 thousand deaths. The etiological agent of this acute febrile disease is a single-strand positive-sense RNA virus of Flavivirus genus. It is an arboviral disease transmitted by Aedes sp. mosquitoes (Aedes aegypti and A. albopictus). Most infected individuals present asymptomatic infection, but some may develop clinical signs. Therefore, a wide spectrum of illness can be observed, ranging from unapparent, mild disease, called dengue fever, to a severe and occasionally fatal dengue hemorrhagic fever/dengue shock syndrome. Currently, neurological manifestations related to dengue infections are increasingly been observed and appears as a challenge for medical practice. In this study the neurological complications of dengue infection will be reviewed, focusing a better understanding of the disease for the clinical practice.

Factors associated to the positive cerebrospinal fuid culture in the tuberculous meningitis

Central nervous system involvement is the most common neurological complication in the course of tuberculosis. The lack of rapid and sensitive tests delays the early diagnosis. Here, we retrospectively reviewed the cerebrospinal fluid (CSF) examination of 30 patients with tuberculous meningitis confirmed by bacteriological tests (culture and/or polymerase chain reaction). The purpose of the present study was to determine the CSF parameters associated to the positive CSF culture for Mycobacterium tuberculosis in tuberculous meningitis. We found higher frequency of positive CSF culture in patients infected with HIV as well in patients with high number of neutrophils and high protein content (characteristic in the early or acute-stage patients), which suggests that the positive culture found in these patients may be associated with the presence of high bacillary load in CSF occurring in these stages.

HAM/TSP: association between white matter lesions on magnetic resonance imaging, clinical and cerebrospinal fluid findings

OBJECTIVE To investigate the association between clinical data, white matter lesions and inflammatory cerebrospinal fluid (CSF) findings in HTLV-1 associated myelopathy/tropical spastic paraparesis (HAM/TSP). METHOD We studied brain and cervical spinal cord on magnetic resonance imaging (MRI) and CSF examinations of 28 Brazilian HAM/TSP patients. RESULTS The majority of patients had severe neurological incapacity with EDSS median of 6.5 (3-8). The brain MRI showed white matter lesions (75%) and atrophy (14%). The preferential brain location was periventricular. Cervical demyelination lesions occurred in 11% of the cases, and cervical atrophy in 3.5%. One patient had enhancement lesions on T1 cervical spinal cord MRI. Cases with spinal cord lesions had signs of acute CSF inflammation. The brain white matter lesions predominated in the patients with higher age. CONCLUSION Our data suggest that an active inflammatory process is associated with the cervical spinal cord lesions in HAM/TSP. The brain abnormalities are not related to the clinical picture of HAM/TSP.

Complicações neurológicas da síndrome de imunodeficiência adquirida experiência do HUCFF - UFRJ: experience at HUCFF-UFRJ.

The frequency of neurological manifestations was evaluated in 653 HIV infected patients admitted in a university hospital in Rio de Janeiro city, Brazil, in the 1985-1989 period. A total of 172 (26%) patients developed neurological symptoms. Central nervous system complications included: cerebral toxoplasmosis (80), cryptococcal meningitis (57), subacute encephalitis (17), tuberculosis (8) and aseptic meningitis (2), progressive multifocal leukoencephalopathy (2) and vacuolar mielopathy (6). Peripheral neuropathy occurred in three cases. The clinical and tomographic aspects were analysed. The majority of the patients died within six months after the onset of the neurological disease.The frequency of neurological manifestations was evaluated in 653 HIV infected patients admitted in a university hospital in Rio de Janeiro city, Brazil, in the 1985-1989 period. A total of 172 (26%) patients developed neurological symptoms. Central nervous system complications included: cerebral toxoplasmosis (80), cryptococcal meningitis (57), subacute encephalitis (17), tuberculosis (8) and aseptic meningitis (2), progressive multifocal leukoencephalopathy (2) and vacuolar myelopathy (6). Peripheral neuropathy occurred in three cases. The clinical and tomographic aspects were analysed. The majority of the patients died within six months after the onset of the neurological disease.

Implications of HAM/TSP functional incapacity in the quality of life

OBJECTIVE To identify the functional status and quality of life of HAM/TSP patients. METHOD We evaluated prospectively 30 HAM/TSP patients (20 females) seen in the Neuroinfection Clinic of the HUGG. The functional capacity was analyzed by the functional independence measure (FIM), the expanded disability status (EDSS) scale and the Osames motor disability score (OMDS). The quality of life was assessed by the Short-Form Health Survey 36 (SF-36)TM. RESULTS All patients need assistance device. The FIM, OMDS and EDSS scores classified 70%, 67% and 67% of the patients as dependent, respectively. The lowest scores of the SF-36 survey were found in the domains related to the physical health (D1, D2), role-emotional functioning (D7) and social functioning (D6). CONCLUSION Our data suggest that the HAM/TSP physical impairment has an impact in the emotional and social issues, considering the limitation in the daily activities.

Multiple sclerosis: clinical and laboratorial correlation

The clinical and demographic characteristics of 86 Brazilian patients with clinically definite multiple sclerosis (MS) were compared to the cerebrospinal fluid (CSF) findings. The disease course was relapsing-remitting in 71% and chronic progressive in 29% of the cases. The IgG index was increased in 76% in the chronic progressive status and 46% and 49% during the bout and remission, respectively (p < 0.005). Only 36% of the MS patients using corticosteroids had increased IgG index, in comparison to the 64% of the patients without immunosupressive treatment. Oligoclonal IgG bands were detected in the CSF of 77% and 88% of the MS corticosteroids users and non-users, respectively. The quantitative study of intrathecal synthesis of IgG contributes to demonstrate the immunological differences between the two forms of MS, the relapsing-remitting and the chronic progressive. The treatment with corticosteroids decreases quantitatively the intrathecal synthesis of IgG but not the presence of oligoclonal bands.