niman Posted March 10, 2016 Report Posted March 10, 2016 CORRESPONDENCEZika Virus Associated with MeningoencephalitisMarch 9, 2016DOI: 10.1056/NEJMc1602964http://www.nejm.org/doi/full/10.1056/NEJMc1602964
niman Posted March 10, 2016 Author Report Posted March 10, 2016 (edited) Guillaume Carteaux, M.D., Ph.D.Assistance Publique–Hôpitaux de Paris, Créteil, France [email protected]Marianne Maquart, Ph.D.French Armed Forces Biomedical Research Institute, Marseille, FranceArmand Mekontso Dessap, M.D., Ph.D.Université Paris Est Créteil, Créteil, FranceAlexandre Bedet, M.D.Damien Contou, M.D.Pierre Brugières, M.D.Slim Fourati, M.D., Ph.D.Laurent Cleret de Langavant, M.D., Ph.D.Assistance Publique–Hôpitaux de Paris, Créteil, FranceThomas de Broucker, M.D.Centre Hospitalier de Saint-Denis, Saint-Denis, FranceChristian Brun-Buisson, M.D.Assistance Publique–Hôpitaux de Paris, Créteil, FranceIsabelle Leparc-Goffart, Ph.D.French Armed Forces Biomedical Research Institute, Marseille, FranceDisclosure forms provided by the authors are available with the full text of this letter at NEJM.org.This letter was published on March 9, 2016, at NEJM.org. Edited March 10, 2016 by niman
niman Posted March 10, 2016 Author Report Posted March 10, 2016 To the Editor:Zika virus (ZIKV) is currently spreading widely, while its clinical spectrum remains a matter of investigation. Evidence of a relationship between ZIKV infection and cerebral birth abnormalities1,2is growing.3 An increased incidence of some peripheral nervous syndromes among adults was reported during outbreaks in French Polynesia4,5 and Brazil,1,2 but no formal link with ZIKV infection was shown. We describe a case of central nervous system infection with ZIKV that was associated with meningoencephalitis in an adult.An 81-year-old man was admitted to the intensive care unit (ICU) 10 days after he had been on a 4-week cruise in the area of New Caledonia, Vanuatu, the Solomon Islands, and New Zealand; he was reported to have been in perfect health during that time. On medical examination, he was febrile (39.1°C) and comatose (Glasgow Coma Scale score of 6 on a scale from 3 to 15, with lower scores indicating a reduced level of consciousness) with hemiplegia of the left side, paresis of the right upper limb, a normal response to tendon reflexes, and a Babinski sign on the left side. The patient’s trachea was intubated and mechanical ventilation begun; a transient rash was observed within the next 48 hours.Magnetic resonance imaging (MRI) of the brain was suggestive of meningoencephalitis. There were asymmetric subcortical white-matter hyperintensities on fluid-attenuated inversion recovery (FLAIR) imaging, multiple punctuated hyperintensities on diffusion-weighted sequences that were evocative of ischemic foci, and a slight hyperintensity of the right rolandic fissure that was evocative of meningitis (Figure 1FIGURE 1Imaging of the Brain.). Computed tomographic angiography revealed an irregular narrowing of the right callosomarginal artery.A lumbar puncture was performed on day 1, and findings on analysis of cerebrospinal fluid (CSF) were suggestive of meningitis: the leukocyte count was 41 per cubic millimeter (with 98% polymorphonuclear leukocytes), the protein level was 76 mg per deciliter, and the ratio of CSF to blood glucose was 0.75. The patient was initially treated with amoxicillin, cefotaxime, gentamicin, and acyclovir, but these antimicrobial agents were stopped on day 5. Investigations in both CSF and blood for other infections were unrevealing (see the Supplementary Appendix, available with the full text of this letter at NEJM.org), except for a positive result for ZIKV on reverse-transcriptase–polymerase-chain-reaction assay of the CSF (cycle threshold, 34). ZIKV was grown in culture from the CSF on a Vero cell line (see the Supplementary Appendix). These findings all support the diagnosis of ZIKV-associated meningoencephalitis.Several electroencephalograms showed no direct signs that were suggestive of epilepsy during levetiracetam therapy (which was administered for the first time in the ICU because seizure had been suspected as one of the mechanisms of the initial consciousness disorder). Spontaneous arousal occurred within 24 hours after intubation, and mechanical ventilation was weaned on day 2. At that time, the patient was awake but had spatial delusion with visual and kinesthetic hallucinations and a persisting weakness (2/5) of the left arm. His neurologic condition continued to improve without specific treatment. He was discharged from the ICU on day 17, and his cognitive function was fully recovered by day 38. He had a residual weakness (4/5) of the left arm. Clinicians should be aware that ZIKV may be associated with meningoencephalitis.
niman Posted March 10, 2016 Author Report Posted March 10, 2016 5 References1Fauci AS, Morens DM. Zika virus in the Americas — yet another arbovirus threat. N Engl J Med 2016;374:601-604Free Full Text | Medline2Latest Zika virus situation reports. Geneva: World Health Organization, 2016 (http://www.who.int/emergencies/zika-virus/situation-report/en/).3Mlakar J, Korva M, Tul N, et al. Zika virus associated with microcephaly. N Engl J Med 2016;374:951-958Full Text4Ioos S, Mallet H-P, Leparc Goffart I, Gauthier V, Cardoso T, Herida M. Current Zika virus epidemiology and recent epidemics. Med Mal Infect 2014;44:302-307CrossRef | Web of Science | Medline5Oehler E, Watrin L, Larre P, et al. Zika virus infection complicated by Guillain-Barre syndrome — case report, French Polynesia, December 2013. Euro Surveill 2014;19CrossRef
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