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      Neurologic complications of acute hepatitis E virus infection

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          Abstract

          Objective

          To assess the prevalence and clinical features of neurologic involvement in patients with acute hepatitis E virus (HEV) infection in Southern Switzerland.

          Methods

          Among 1,940 consecutive patients investigated for acute hepatitis E, we identified 141 cases of acute of HEV infection (anti-HEV immunoglobulin M and immunoglobulin G both reactive and/or HEV RNA positive) between June 2014 and September 2017. Neurologic cases were followed up for 6 months. We compared patients with and without neurologic symptoms.

          Results

          Neurologic symptoms occurred in 43 acute HEV cases (30.4%) and consisted of neuralgic amyotrophy (NA, n = 15, 10.6%) and myalgia (n = 28, 19.8%). All NA cases were immunocompetent. Men had higher odds (OR = 5.2, CI 1.12–24.0, p = 0.03) of developing NA after infection with HEV, and in 3 couples simultaneously infected with HEV, only men developed NA. Bilateral involvement of NA was predominant (2:1) and occurred only in men. Seven NA cases were viremic (all genotype 3), but HEV was undetectable in their CSF. In the acute phase of NA, 9 patients were treated with intravenous immunoglobulin and 4 with prednisone, reporting no side effects and improvement in pain and strength. Myalgia occurred both without (n = 16) or with (n = 12) concomitant elevated serum creatinine kinase. Seven cases with myalgia in the shoulder girdle did not have muscle weakness (“forme fruste” of NA).

          Conclusions

          Neurologic symptoms occurred in one-third of acute HEV infections and consisted of NA and myalgia. NA seems to occur more frequently in men infected by HEV and has a predominant (but not exclusive) bilateral involvement.

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          Most cited references33

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          The clinical spectrum of neuralgic amyotrophy in 246 cases.

          We investigated the symptoms, course and prognosis of neuralgic amyotrophy (NA) in a large group of patients with idiopathic neuralgic amyotrophy (INA, n = 199) and hereditary neuralgic amyotrophy (HNA, n = 47) to gain more insight into the broad clinical spectrum of the disorder. Several findings from earlier smaller-scale studies were tested, and for the first time the potential differences between the hereditary and idiopathic phenotypes and between males and females were explored. Generally, the course of the pain manifests itself in three consecutive phases with an initial severe, continuous pain lasting for approximately 4 weeks on average. Sensory involvement was quite common and found in 78.4% of patients but was clinically less impairing than the initial pain and subsequent paresis. As a typically patchy disorder NA can affect almost any nerve in the brachial plexus, although damage in the upper and middle trunk distribution with involvement of the long thoracic and/or suprascapular nerve occurred most frequently (71.1%). We found no correlation between the distribution of motor and sensory symptoms. In INA recurrent attacks were found in 26.1% of the patients during an average 6 year follow-up. HNA patients had an earlier onset (28.4 versus 41.3 years), more attacks (mean 3.5 versus 1.5) and more frequent involvement of nerves outside the brachial plexus (55.8 versus 17.3%) than INA patients, and a more severe maximum paresis, with a subsequent poorer functional outcome. In males the initial pain tended to last longer than it did in females (45 versus 23 days). In females the middle or lower parts of the brachial plexus were involved more frequently (23.1 versus 10.5% in males), and their functional outcome was worse. Overall recovery was less favourable than usually assumed, with persisting pain and paresis in approximately two-thirds of the patients who were followed for 3 years or more.
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            Neuralgic amyotrophy: An update on diagnosis, pathophysiology, and treatment

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              Extrahepatic manifestations of hepatitis E virus.

              Hepatitis E virus can cause acute, fulminant and chronic hepatitis and has been associated with a range of extrahepatic manifestations. Guillain-Barré syndrome, neuralgic amyotrophy and encephalitis are the main neurological manifestations associated with acute and chronic hepatitis E virus infection. Renal injuries have been also reported, including membranoproliferative glomerulonephritis with or without cryoglobulinemia and membranous glomerulonephritis. Acute pancreatitis, haematological disorders and other autoimmune extrahepatic manifestations of hepatitis E virus, such as myocarditis and thyroiditis, have been also reported. In this comprehensive article, we review all published reports describing hepatitis E virus-associated extrahepatic manifestations.
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                Author and article information

                Contributors
                Journal
                Neurol Neuroimmunol Neuroinflamm
                Neurol Neuroimmunol Neuroinflamm
                nnn
                NEURIMMINFL
                Neurology® Neuroimmunology & Neuroinflammation
                Lippincott Williams & Wilkins (Hagerstown, MD )
                2332-7812
                January 2020
                05 December 2019
                05 December 2019
                : 7
                : 1
                : e643
                Affiliations
                From the Department of Neurology (P.R., G.M., C.S., C.Z., G.D., A.K.-L., C.G.), Neurocenter of Southern Switzerland, Lugano, CH; Laboratory of Microbiology EOLAB (E.P., G.M.), Bellinzona, CH; Faculty of Biomedical Sciences, USI (G.M., C.Z., A.K.-L., C.G.), Lugano, CH; Division of Gastroenterology and Hepatology, Lausanne University Hospital (M.F., D.M.), Lausanne, CH; Institute of Microbiology, Lausanne University Hospital (R.S.), Lausanne, CH; Laboratory of Immunology, Lausanne University Hospital (V.A.), CH; Department of Hepatology, Hospital of Bellinzona (F.B.), CH; Division of Infectious Diseases (E.B.), Hospital of Lugano, CH; Epatocentro Ticino (B.T.B.-P., A.C.), Lugano, CH; Queens Park (H.R.D.), London, UK; Synlab Ticino (C.Z.), Bioggio, CH; and Unilabs Ticino (B.M.), Lugano, CH.
                Author notes
                Correspondence Dr. Ripellino pao.ripe@ 123456hotmail.it

                Go to Neurology.org/NN for full disclosures. Funding information is provided at the end of the article.

                The Article Processing Charge was funded by the authors.

                Article
                NEURIMMINFL2019024166
                10.1212/NXI.0000000000000643
                6935854
                31806684
                cfc12137-61ae-4ba6-93d5-bfe3b9a4ef6b
                Copyright © 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.

                This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0 (CC BY-NC-ND), which permits downloading and sharing the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

                History
                : 16 September 2019
                : 11 October 2019
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