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Acute myelitis due to Zika - The Lancet

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In January, 2016, a 15-year-old girl with a history only of an ovarian cyst was admitted to hospital in Pointe-à-Pitre, Guadeloupe, with left hemiparesis. 7 days previously she had presented to the emergency department with left arm pain, frontal headaches, and conjunctival hyperaemia, but no fever, signs of meningeal irritation, or sensory or motor deficits. The day of admission, she developed acute lower back pain, paraesthesia on the left side of her body, and weakness in her left arm. On admission she had slight left-sided weakness and proximal pain of the left arm and leg, exacerbated on movement, but no fever or signs of meningism, and Glasgow Coma Score (GCS) 15.

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On day 2, she developed dysuria and urinary retention needing catheterisation, but no abnormal urinary frequency or urgency. The left-sided hemiparesis and pain worsened, and we noted loss of temperature sensation below the T2 dermatome on the left and T4 on the right, and bilateral Hoffman signs. Spinal MRI showed lesions of the cervical and thoracic spinal cord. The cervical lesion was enlarged, suggesting oedema (figure). Conus medullaris and lumbar roots were normal, suggesting the bladder dysfunction could be linked to spinal damage. Electromyography and cerebrospinal fluid examination (including isoelectric focusing protein profile) were normal. We detected high concentrations of Zika virus on specific real-time reverse PCR (Eurobio, Les Ulis, France) in serum, urine, and cerebrospinal fluid on the second day of her admission (9 days after symptom onset). PCR for varicella zoster and herpes simplex viruses, Legionella, and Mycoplasma pneumoniae in her cerebrospinal fluid were negative. She had no serological signs of acute infection with cytomegalovirus, Epstein-Barr, chikungunya or dengue viruses, syphilis, or Lyme disease; tests for HIV and human T-cell lymphotropic virus (HTLV) were negative; and aquaporin-A antibodies, a marker of neuromyelitis optica, were absent.

Thumbnail image of Figure. Opens large image

Figure

Magnetic resonance imaging (MRI) showing myelitis in Zika virus infection

(A) T2 sequences showing hypersignal in the thoracic cord T5–T8 (arrow) and enlargement of the cervical spinal cord. (B) Sagittal short time inversion recovery (STIR) sequences showing hypersignal in the cervical spinal cord C4–C7 (arrow).

 

 

We started methylprednisolone 1 g daily for 5 days. On the seventh day of admission her neurological condition improved and we could remove the catheter. 1 month after admission she had moderate weakness in both legs but was able to walk unaided. Repeat MRI showed reduced cervical spinal oedema (appendix).

The Zika virus epidemic that started in Brazil in May, 2015, spread to 28 countries in February, 2016, including the French Caribbean Islands of Martinique and Guadeloupe. Like dengue, Zika is an arthropod-borne virus of the Flaviviridae family transmitted by Aedes mosquitoes. Until recently, Zika was thought to cause benign infections in humans.1 The presence of Zika virus in the cerebrospinal fluid of our patient with acute myelitis suggests that this virus might be neurotropic. In addition to the usual clinical picture of myelitis she had severe pain. Absence of intrathecal immunoglobulins and normal brain MRI excluded acute disseminated encephalomyelitis. The neurotropism of flaviviruses such as dengue, Japanese encephalitis, and West Nile viruses, which might be responsible for invasive encephalitis and transverse or extensive myelitis,2, 3 is well documented. West Nile virus might also affect lumbosacral nerve roots in addition to the spinal cord,4 and retrograde axonal transport from infected peripheral nerves has been shown.5 Zika virus infection should be considered in patients with acute myelitis living in or travelling from endemic areas, and further study should clarify the spectrum and incidence of neurological associations.

Contributors

SM, CH, PP, T-HT, ND, GM, ALand, SB, and ALann managed the patient. ALann, SM, and SB wrote the report. Consent to publication was obtained.

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References

  1. Fauci, AS and Morens, DM. Zika virus in the Americas—yet another arbovirus threat. N Engl J Med.2016374601–604

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1st case of acute myelitis in a patient infected with Zika virus

08.03.2016 - PRESS RELEASE

 

A first case of acute myelitis following infection with Zika virus has been reported for the first time by a research team from Inserm Unit 1127 Brain and Spinal Cord Institute (Inserm/CNRS/Sorbonne University) and neurologists at Pointe-à-Pitre University Hospital and the University of the Antilles. A young patient in the acute phase of an infection by Zika virus presented motor deficiency in the 4 limbs, associated with very intense pain and acute urinary retention. The presence of the virus was confirmed in the cerebrospinal fluid, blood and urine.
This case was the subject of a Case report published in The Lancet on 3 March 2016.

PhotoCP Zika

(c) Fotolia

In January 2016, a 15-year old girl was admitted to the Pointe-à-Pitre University Hospital in Guadeloupe, with left-side hemiplegia. The girl showed urinary retention on her second day in hospital. The left-side hemiplegia and pain became worse and the doctors recorded a loss of sensation in the legs.

The researchers detected high concentrations of Zika virus in the serum and cerebrospinal fluid on the second day after admission (9 days after the symptoms began). Tests for shingles, chickenpox, herpes virus, legionellosis and mycoplasma pneumonia were negative.

The patient was treated with methylprednisolone (1 g), an anti-inflammatory drug, from the first day and daily for 5 days. Seven days after admission, her neurological condition had improved. At present, the patient is still in hospital but she is out of danger. She has signs of moderate weakness in both legs but is walking unaided again.

For the researchers, “this case strengths the hypothesis regarding the neurotropic nature of the Zika virus. It highlights the existence of neurological complications in the acute phase of the infection, while Guillain Barré syndromes are post-infectious complications. Furthermore, this is a single case. Future studies will be needed.”

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WEDNESDAY, MARCH 9, 2016

Zika 'link' to new, paralysing disease: report

 

 

315847-01-02.jpg

A child suffering from microcephaly at Obras Socias Irma Dulce Hospital in Salvador, Brazil, on January 28, 2016. The mosquito-borne virus usually causes mild symptoms in adults, with a low fever, headaches and joint pain, but the virus' quick spread has caused alarm due to an observed association with more serious health problems. AFP PHOTO | CHRISTOPHE SIMON 

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By AFP
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Suspected of causing brain damage in babies and a rare neurological ailment in adults, the Zika virus was linked by researchers Tuesday to a third disorder: paralysis-causing myelitis.

French experts reported that a 15-year-old girl diagnosed on the French Caribbean island of Guadeloupe with acute myelitis in January had high levels of Zika in her cerebrospinal fluid, blood and urine.

"This is the first published case to offer proof of a link" between myelitis and the virus sweeping Latin America and the Caribbean, Annie Lannuzel of the University Hospital Center Pointe-a-Pitre in Guadeloupe told AFP.

The case had been described in a report published by The Lancet medical journal.

"Until recently, Zika was thought to cause benign infections in humans," Lannuzel and a team wrote in the case report.

Instead, the "presence of Zika virus in the cerebrospinal fluid of our patient with acute myelitis suggests that this virus might be neurotropic" — something that attacks the nervous system.

The mosquito-borne virus usually causes mild symptoms in adults, with a low fever, headaches and joint pain, but the virus' quick spread has caused alarm due to an observed association with more serious health problems.

There have been fewer than a handful of reported cases of sexual transmission.

Last week, scientists said they had found the first evidence of a biological link between Zika and microcephaly, which causes severe deformation of the brains of unborn babies.

Laboratory tests found that Zika targeted key cells involved in brain development in the womb and then destroyed or disabled them, they said.

A separate study, also last week, offered evidence that Zika may cause Guillain-Barre, a rare condition in which the body's immune system attacks a part of the nervous system that controls muscle strength.

Myelitis is an inflammation of the spinal cord which can affect limb movement and cause paralysis by interrupting communication between the spinal cord and the rest of the body.

'NOT BENIGN'

Some patients are left with permanent damage.

There is no effective cure, and treatment general consists of cortisone injections in strong doses.

In the reported case, a teenaged girl was admitted to the Pointe-a-Pitre hospital with partial paralysis, limb weakness, and intense pain.

OTHER POTENTIAL CAUSES RULED OUT

Nine days after the symptoms began, doctors found high levels of Zika virus in her blood, spinal fluid and urine, said a statement from France's Inserm medical research institute.

Other potential causes of myelitis were ruled out, including shingles, chicken pox, herpes and other viruses.

The girl's condition has since improved and she is now out of danger, said the statement.

"My message is that Zika does not only affect pregnant women, and is not necessarily benign," said Lannuzel.

The team underlined this was a single case, and "future studies will be needed" to determine wether Zika does indeed cause myelitis.

Brazil has been hardest hit by the Zika outbreak, with some 1.5 million people infected and 641 confirmed cases of microcephaly in children born to women infected with the virus while pregnant.

According to the World Health Organisation, 41 countries or territories have reported transmission of Zika within their borders since last year, and eight have reported an increase in Guillain-Barre cases.

A rise in microcephaly and other baby malformations has so far "only been reported in Brazil and French Polynesia", according to the WHO, which has declared this a health emergency.

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