Encephalitis with reversible splenial and deep cerebral white matter lesions associated with Epstein–Barr virus infection in adults
Identifieur interne : 000920 ( Pmc/Curation ); précédent : 000919; suivant : 000921Encephalitis with reversible splenial and deep cerebral white matter lesions associated with Epstein–Barr virus infection in adults
Auteurs : Yanjun Guo [République populaire de Chine] ; Shuhui Wang [République populaire de Chine] ; Bin Jiang [République populaire de Chine] ; Jianle Li [République populaire de Chine] ; Lei Liu [République populaire de Chine] ; Jiawei Wang [République populaire de Chine] ; Weiqin Zhao [République populaire de Chine] ; Jianping Jia [République populaire de Chine]Source :
- Neuropsychiatric Disease and Treatment [ 1176-6328 ] ; 2017.
Abstract
Approximately 200 cases of mild encephalitis with reversible splenial (MERS) and deep cerebral white matter lesions have been reported since MERS was first defined in 2004. MERS occurs more frequently in children; in adults, only ~60 cases have been reported. Until now, only four cases of MERS in adults have been associated with Epstein–Barr virus (EBV).
We report three adult cases of MERS associated with EBV infection in China. For all three patients, cranial magnetic resonance imaging (MRI) indicated solitary reversible splenial and/or perilateral ventricle white matter lesions with reduced diffusion. In the present report, all patients were adults presenting with high fever, headache, apathy, and confusion, as well as significant signs of meningeal inflammation. These symptoms peaked 10–14 days after disease onset, with serious hyponatremia (112–129 mmol/L), an elevated cerebrospinal fluid white blood cell count (80–380/mm3), and significantly increased protein levels (1,010–1,650 mg/dL). Cranial MRI indicated abnormal signal intensity in the splenium of corpus callosum and symmetrically reversible lesions scattered in the thalamus and deep cerebral white matter. The clinical symptoms tended to improve after ~10–14 days of antiviral treatment. However, these patients recovered more slowly than patients with viral meningitis.
MERS associated with EBV infection in adults occurs less frequently but with more severe symptoms than in children. EBV infection should be considered for patients with MERS symptoms. MERS has a good prognosis.
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DOI: 10.2147/NDT.S135510
PubMed: 28831257
PubMed Central: 5548266
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Encephalitis with reversible splenial and deep cerebral white matter lesions associated with Epstein–Barr virus infection in adults</title><author><name sortKey="Guo, Yanjun" sort="Guo, Yanjun" uniqKey="Guo Y" first="Yanjun" last="Guo">Yanjun Guo</name><affiliation wicri:level="1"><nlm:aff id="af1-ndt-13-2085">Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing, China</nlm:aff><country xml:lang="fr">République populaire de Chine</country><wicri:regionArea>Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing</wicri:regionArea></affiliation></author><author><name sortKey="Wang, Shuhui" sort="Wang, Shuhui" uniqKey="Wang S" first="Shuhui" last="Wang">Shuhui Wang</name><affiliation wicri:level="1"><nlm:aff id="af1-ndt-13-2085">Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing, China</nlm:aff><country xml:lang="fr">République populaire de Chine</country><wicri:regionArea>Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing</wicri:regionArea></affiliation></author><author><name sortKey="Jiang, Bin" sort="Jiang, Bin" uniqKey="Jiang B" first="Bin" last="Jiang">Bin Jiang</name><affiliation wicri:level="1"><nlm:aff id="af1-ndt-13-2085">Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing, China</nlm:aff><country xml:lang="fr">République populaire de Chine</country><wicri:regionArea>Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing</wicri:regionArea></affiliation></author><author><name sortKey="Li, Jianle" sort="Li, Jianle" uniqKey="Li J" first="Jianle" last="Li">Jianle Li</name><affiliation wicri:level="1"><nlm:aff id="af1-ndt-13-2085">Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing, China</nlm:aff><country xml:lang="fr">République populaire de Chine</country><wicri:regionArea>Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing</wicri:regionArea></affiliation></author><author><name sortKey="Liu, Lei" sort="Liu, Lei" uniqKey="Liu L" first="Lei" last="Liu">Lei Liu</name><affiliation wicri:level="1"><nlm:aff id="af2-ndt-13-2085">Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China</nlm:aff><country xml:lang="fr">République populaire de Chine</country><wicri:regionArea>Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing</wicri:regionArea></affiliation></author><author><name sortKey="Wang, Jiawei" sort="Wang, Jiawei" uniqKey="Wang J" first="Jiawei" last="Wang">Jiawei Wang</name><affiliation wicri:level="1"><nlm:aff id="af2-ndt-13-2085">Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China</nlm:aff><country xml:lang="fr">République populaire de Chine</country><wicri:regionArea>Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing</wicri:regionArea></affiliation></author><author><name sortKey="Zhao, Weiqin" sort="Zhao, Weiqin" uniqKey="Zhao W" first="Weiqin" last="Zhao">Weiqin Zhao</name><affiliation wicri:level="1"><nlm:aff id="af1-ndt-13-2085">Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing, China</nlm:aff><country xml:lang="fr">République populaire de Chine</country><wicri:regionArea>Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing</wicri:regionArea></affiliation></author><author><name sortKey="Jia, Jianping" sort="Jia, Jianping" uniqKey="Jia J" first="Jianping" last="Jia">Jianping Jia</name><affiliation wicri:level="1"><nlm:aff id="af1-ndt-13-2085">Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing, China</nlm:aff><country xml:lang="fr">République populaire de Chine</country><wicri:regionArea>Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing</wicri:regionArea></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">28831257</idno><idno type="pmc">5548266</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5548266</idno><idno type="RBID">PMC:5548266</idno><idno type="doi">10.2147/NDT.S135510</idno><date when="2017">2017</date><idno type="wicri:Area/Pmc/Corpus">000920</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000920</idno><idno type="wicri:Area/Pmc/Curation">000920</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Curation">000920</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Encephalitis with reversible splenial and deep cerebral white matter lesions associated with Epstein–Barr virus infection in adults</title><author><name sortKey="Guo, Yanjun" sort="Guo, Yanjun" uniqKey="Guo Y" first="Yanjun" last="Guo">Yanjun Guo</name><affiliation wicri:level="1"><nlm:aff id="af1-ndt-13-2085">Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing, China</nlm:aff><country xml:lang="fr">République populaire de Chine</country><wicri:regionArea>Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing</wicri:regionArea></affiliation></author><author><name sortKey="Wang, Shuhui" sort="Wang, Shuhui" uniqKey="Wang S" first="Shuhui" last="Wang">Shuhui Wang</name><affiliation wicri:level="1"><nlm:aff id="af1-ndt-13-2085">Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing, China</nlm:aff><country xml:lang="fr">République populaire de Chine</country><wicri:regionArea>Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing</wicri:regionArea></affiliation></author><author><name sortKey="Jiang, Bin" sort="Jiang, Bin" uniqKey="Jiang B" first="Bin" last="Jiang">Bin Jiang</name><affiliation wicri:level="1"><nlm:aff id="af1-ndt-13-2085">Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing, China</nlm:aff><country xml:lang="fr">République populaire de Chine</country><wicri:regionArea>Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing</wicri:regionArea></affiliation></author><author><name sortKey="Li, Jianle" sort="Li, Jianle" uniqKey="Li J" first="Jianle" last="Li">Jianle Li</name><affiliation wicri:level="1"><nlm:aff id="af1-ndt-13-2085">Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing, China</nlm:aff><country xml:lang="fr">République populaire de Chine</country><wicri:regionArea>Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing</wicri:regionArea></affiliation></author><author><name sortKey="Liu, Lei" sort="Liu, Lei" uniqKey="Liu L" first="Lei" last="Liu">Lei Liu</name><affiliation wicri:level="1"><nlm:aff id="af2-ndt-13-2085">Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China</nlm:aff><country xml:lang="fr">République populaire de Chine</country><wicri:regionArea>Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing</wicri:regionArea></affiliation></author><author><name sortKey="Wang, Jiawei" sort="Wang, Jiawei" uniqKey="Wang J" first="Jiawei" last="Wang">Jiawei Wang</name><affiliation wicri:level="1"><nlm:aff id="af2-ndt-13-2085">Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China</nlm:aff><country xml:lang="fr">République populaire de Chine</country><wicri:regionArea>Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing</wicri:regionArea></affiliation></author><author><name sortKey="Zhao, Weiqin" sort="Zhao, Weiqin" uniqKey="Zhao W" first="Weiqin" last="Zhao">Weiqin Zhao</name><affiliation wicri:level="1"><nlm:aff id="af1-ndt-13-2085">Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing, China</nlm:aff><country xml:lang="fr">République populaire de Chine</country><wicri:regionArea>Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing</wicri:regionArea></affiliation></author><author><name sortKey="Jia, Jianping" sort="Jia, Jianping" uniqKey="Jia J" first="Jianping" last="Jia">Jianping Jia</name><affiliation wicri:level="1"><nlm:aff id="af1-ndt-13-2085">Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing, China</nlm:aff><country xml:lang="fr">République populaire de Chine</country><wicri:regionArea>Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing</wicri:regionArea></affiliation></author></analytic><series><title level="j">Neuropsychiatric Disease and Treatment</title><idno type="ISSN">1176-6328</idno><idno type="eISSN">1178-2021</idno><imprint><date when="2017">2017</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Background</title><p>Approximately 200 cases of mild encephalitis with reversible splenial (MERS) and deep cerebral white matter lesions have been reported since MERS was first defined in 2004. MERS occurs more frequently in children; in adults, only ~60 cases have been reported. Until now, only four cases of MERS in adults have been associated with Epstein–Barr virus (EBV).</p></sec><sec><title>Case presentation</title><p>We report three adult cases of MERS associated with EBV infection in China. For all three patients, cranial magnetic resonance imaging (MRI) indicated solitary reversible splenial and/or perilateral ventricle white matter lesions with reduced diffusion. In the present report, all patients were adults presenting with high fever, headache, apathy, and confusion, as well as significant signs of meningeal inflammation. These symptoms peaked 10–14 days after disease onset, with serious hyponatremia (112–129 mmol/L), an elevated cerebrospinal fluid white blood cell count (80–380/mm<sup>3</sup>), and significantly increased protein levels (1,010–1,650 mg/dL). Cranial MRI indicated abnormal signal intensity in the splenium of corpus callosum and symmetrically reversible lesions scattered in the thalamus and deep cerebral white matter. The clinical symptoms tended to improve after ~10–14 days of antiviral treatment. However, these patients recovered more slowly than patients with viral meningitis.</p></sec><sec><title>Conclusion</title><p>MERS associated with EBV infection in adults occurs less frequently but with more severe symptoms than in children. EBV infection should be considered for patients with MERS symptoms. MERS has a good prognosis.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Tada, H" uniqKey="Tada H">H Tada</name></author><author><name sortKey="Takanashi, J" uniqKey="Takanashi J">J Takanashi</name></author><author><name sortKey="Barkovich, Aj" uniqKey="Barkovich A">AJ Barkovich</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Takanashi, J" uniqKey="Takanashi J">J Takanashi</name></author><author><name sortKey="Tada, H" uniqKey="Tada H">H Tada</name></author><author><name sortKey="Maeda, M" uniqKey="Maeda M">M Maeda</name></author><author><name sortKey="Suzuki, M" uniqKey="Suzuki M">M Suzuki</name></author><author><name sortKey="Terada, H" uniqKey="Terada H">H Terada</name></author><author><name sortKey="Barkovich, Aj" uniqKey="Barkovich A">AJ Barkovich</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kosami, K" uniqKey="Kosami K">K 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Neuropsychiatr Dis Treat</journal-id><journal-id journal-id-type="iso-abbrev">Neuropsychiatr Dis Treat</journal-id><journal-id journal-id-type="publisher-id">Neuropsychiatric Disease and Treatment</journal-id><journal-title-group><journal-title>Neuropsychiatric Disease and Treatment</journal-title></journal-title-group><issn pub-type="ppub">1176-6328</issn><issn pub-type="epub">1178-2021</issn><publisher><publisher-name>Dove Medical Press</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">28831257</article-id><article-id pub-id-type="pmc">5548266</article-id><article-id pub-id-type="doi">10.2147/NDT.S135510</article-id><article-id pub-id-type="publisher-id">ndt-13-2085</article-id><article-categories><subj-group subj-group-type="heading"><subject>Case Series</subject></subj-group></article-categories><title-group><article-title>Encephalitis with reversible splenial and deep cerebral white matter lesions associated with Epstein–Barr virus infection in adults</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Guo</surname><given-names>Yanjun</given-names></name><xref ref-type="aff" rid="af1-ndt-13-2085">1</xref><xref ref-type="corresp" rid="c1-ndt-13-2085"></xref></contrib><contrib contrib-type="author"><name><surname>Wang</surname><given-names>Shuhui</given-names></name><xref ref-type="aff" rid="af1-ndt-13-2085">1</xref></contrib><contrib contrib-type="author"><name><surname>Jiang</surname><given-names>Bin</given-names></name><xref ref-type="aff" rid="af1-ndt-13-2085">1</xref></contrib><contrib contrib-type="author"><name><surname>Li</surname><given-names>Jianle</given-names></name><xref ref-type="aff" rid="af1-ndt-13-2085">1</xref></contrib><contrib contrib-type="author"><name><surname>Liu</surname><given-names>Lei</given-names></name><xref ref-type="aff" rid="af2-ndt-13-2085">2</xref></contrib><contrib contrib-type="author"><name><surname>Wang</surname><given-names>Jiawei</given-names></name><xref ref-type="aff" rid="af2-ndt-13-2085">2</xref></contrib><contrib contrib-type="author"><name><surname>Zhao</surname><given-names>Weiqin</given-names></name><xref ref-type="aff" rid="af1-ndt-13-2085">1</xref></contrib><contrib contrib-type="author"><name><surname>Jia</surname><given-names>Jianping</given-names></name><xref ref-type="aff" rid="af1-ndt-13-2085">1</xref></contrib></contrib-group><aff id="af1-ndt-13-2085"><label>1</label>Department of Neurology, Beijing Friendship Hospital, Capital Medical University. Beijing, China</aff><aff id="af2-ndt-13-2085"><label>2</label>Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China</aff><author-notes><corresp id="c1-ndt-13-2085">Correspondence: Yanjun Guo, Department of Neurology, Beijing Friendship Hospital, Capital Medical University, No 95 Yongan Road, Beijing 100050, China, Tel +86 136 4130 4226, Fax +86 010 6313 9807, Email <email>littleguo_1999@163.com</email></corresp></author-notes><pub-date pub-type="collection"><year>2017</year></pub-date><pub-date pub-type="epub"><day>03</day><month>8</month><year>2017</year></pub-date><volume>13</volume><fpage>2085</fpage><lpage>2092</lpage><permissions><copyright-statement>© 2017 Guo et al. This work is published and licensed by Dove Medical Press Limited</copyright-statement><copyright-year>2017</copyright-year><license><license-p>The full terms of this license are available at <ext-link ext-link-type="uri" xlink:href="https://www.dovepress.com/terms.php">https://www.dovepress.com/terms.php</ext-link> and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc/3.0/">http://creativecommons.org/licenses/by-nc/3.0/</ext-link>). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.</license-p></license></permissions><abstract><sec><title>Background</title><p>Approximately 200 cases of mild encephalitis with reversible splenial (MERS) and deep cerebral white matter lesions have been reported since MERS was first defined in 2004. MERS occurs more frequently in children; in adults, only ~60 cases have been reported. Until now, only four cases of MERS in adults have been associated with Epstein–Barr virus (EBV).</p></sec><sec><title>Case presentation</title><p>We report three adult cases of MERS associated with EBV infection in China. For all three patients, cranial magnetic resonance imaging (MRI) indicated solitary reversible splenial and/or perilateral ventricle white matter lesions with reduced diffusion. In the present report, all patients were adults presenting with high fever, headache, apathy, and confusion, as well as significant signs of meningeal inflammation. These symptoms peaked 10–14 days after disease onset, with serious hyponatremia (112–129 mmol/L), an elevated cerebrospinal fluid white blood cell count (80–380/mm<sup>3</sup>), and significantly increased protein levels (1,010–1,650 mg/dL). Cranial MRI indicated abnormal signal intensity in the splenium of corpus callosum and symmetrically reversible lesions scattered in the thalamus and deep cerebral white matter. The clinical symptoms tended to improve after ~10–14 days of antiviral treatment. However, these patients recovered more slowly than patients with viral meningitis.</p></sec><sec><title>Conclusion</title><p>MERS associated with EBV infection in adults occurs less frequently but with more severe symptoms than in children. EBV infection should be considered for patients with MERS symptoms. MERS has a good prognosis.</p></sec></abstract><kwd-group><title>Keywords</title><kwd>mild encephalitis with reversible splenial lesions</kwd><kwd>Epstein-Barr virus</kwd><kwd>apathy</kwd><kwd>hyponatremia</kwd><kwd>corpus fluid</kwd></kwd-group></article-meta></front><floats-group><fig id="f1-ndt-13-2085" position="float"><label>Figure 1</label><caption><p>MRI of case 1.</p><p><bold>Notes:</bold> On the day of admission, abnormal signal intensity in the splenium of corpus callosum with iso-signal intensity on T1-weighted images, mild hypersignal intensity on T2-weighted images and without contrast enhancement of splenial lesions, and hypersignal intensity on FLAIR and DWI images were observed. After 21 days of treatment, second cranial MRI indicated significant absorption of splenial lesions compared with the first scan and obviously decreased area of enhancement of the cerebral pia mater.</p><p><bold>Abbreviations:</bold> FLAIR, fluid-attenuated inversion recovery; DWI, diffusion-weighted imaging; MRI, magnetic resonance imaging.</p></caption><graphic xlink:href="ndt-13-2085Fig1"></graphic></fig><fig id="f2-ndt-13-2085" position="float"><label>Figure 2</label><caption><p>Magnetic resonance imaging of case 2.</p><p><bold>Notes:</bold> On the day of admission, abnormal signal intensity in the splenium of corpus callosum with iso-signal intensity on T1-weighted images, mild hypersignal intensity on T2-weighted images, mild enhancement of the meninges and lack of contrast enhancement of splenial lesions, and hypersignal intensity on DWI and FLAIR images were observed. On day 26, splenium of bilateral corpus callosum lesions in the splenium of corpus callosum almost disappeared; however, abnormal signal intensity was observed in bilateral periventricular white matter. The abnormal enhancement of meninges decreased. On day 35, abnormal signal intensity in the bilateral periventricular white matter almost disappeared.</p><p><bold>Abbreviations:</bold> FLAIR, fluid-attenuated inversion recovery; DWI, diffusion-weighted imaging.</p></caption><graphic xlink:href="ndt-13-2085Fig2"></graphic></fig><fig id="f3-ndt-13-2085" position="float"><label>Figure 3</label><caption><p>MRI of case 3.</p><p><bold>Notes:</bold> At 7 days after admission, cranial MRI showed abnormal signal intensity in the bilateral thalamus, para-lateral ventricle white matter, and splenium of corpus callosum; iso-signal intensity on T1-weighted images; mild hypersignal intensity on T2-weighted images; significant contrast enhancement of the cerebral pia mater and tentorium of right cerebellum; hypersignal intensity in bilateral periventricular white matter and splenium of corpus callosum on DWI and FLAIR images. On day 30, cranial MRI showed that lesions in the splenium of corpus callosum almost disappeared. Abnormal signal intensity in bilateral periventricle white matter reduced. Contrast enhancement of the cerebral pia mater significantly decreased. The enhancement of the tentorium of right cerebellum mildly decreased.</p><p><bold>Abbreviations:</bold> FLAIR, fluid-attenuated inversion recovery; DWI, diffusion-weighted imaging; MRI, magnetic resonance imaging.</p></caption><graphic xlink:href="ndt-13-2085Fig3"></graphic></fig><table-wrap id="t1-ndt-13-2085" position="float"><label>Table 1</label><caption><p>Characteristics of the three adult cases of MERS associated with EBV infection</p></caption><table frame="hsides" rules="groups"><thead><tr><th valign="top" align="left" rowspan="1" colspan="1">Characteristic</th><th valign="top" align="left" rowspan="1" colspan="1">Case 1</th><th valign="top" align="left" rowspan="1" colspan="1">Case 2</th><th valign="top" align="left" rowspan="1" colspan="1">Case 3</th></tr></thead><tbody><tr><td valign="top" align="left" rowspan="1" colspan="1">Sex</td><td valign="top" align="left" rowspan="1" colspan="1">Male</td><td valign="top" align="left" rowspan="1" colspan="1">Male</td><td valign="top" align="left" rowspan="1" colspan="1">Male</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Age (years)</td><td valign="top" align="left" rowspan="1" colspan="1">46</td><td valign="top" align="left" rowspan="1" colspan="1">33</td><td valign="top" align="left" rowspan="1" colspan="1">23</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1"><bold>On admission</bold></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Body temperature</td><td valign="top" align="left" rowspan="1" colspan="1">39°C</td><td valign="top" align="left" rowspan="1" colspan="1">40°C</td><td valign="top" align="left" rowspan="1" colspan="1">39.3°C</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Clinical symptoms</td><td valign="top" align="left" rowspan="1" colspan="1">Fever, headache, and vomiting for 10 days</td><td valign="top" align="left" rowspan="1" colspan="1">Fever, headache, and vomiting for 10 days</td><td valign="top" align="left" rowspan="1" colspan="1">Fever, headache, and vomiting for 14 days</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Physical examination</td><td valign="top" align="left" rowspan="1" colspan="1">– Apathy and slow reactions<break></break>– Positive signs of meningeal inflammation sign<break></break>– Neck rigidity and a chin-sternum distance of 4 fingers</td><td valign="top" align="left" rowspan="1" colspan="1">– Apathy<break></break>– Positive signs of meningeal inflammation<break></break>– Neck rigidity and a chin-sternum distance of 4 fingers<break></break>– Kernig’s sign (+)<break></break>– Brudzinski’s sign (−)<break></break>– Multiple enlarged lymph nodes palpable in the bilateral posterior neck, axillae, and inguinal grooves</td><td valign="top" align="left" rowspan="1" colspan="1">– Apathy<break></break>– Positive signs of meningeal inflammation<break></break>– Neck rigidity and a chin-sternum distance of 4 fingers<break></break>– Kernig’s sign (+)<break></break>– Brudzinski’s sign (−)</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1"><bold>Blood</bold></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Sodium (mmol/L)</td><td valign="top" align="left" rowspan="1" colspan="1">112</td><td valign="top" align="left" rowspan="1" colspan="1">125</td><td valign="top" align="left" rowspan="1" colspan="1">128</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Chloride (mmol/L)</td><td valign="top" align="left" rowspan="1" colspan="1">81</td><td valign="top" align="left" rowspan="1" colspan="1">91.8</td><td valign="top" align="left" rowspan="1" colspan="1">117</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1"><bold>CSF</bold></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">WBC (×10<sup>6</sup>/L)</td><td valign="top" align="left" rowspan="1" colspan="1">250 (75% monocytes, 25% neutrophils)</td><td valign="top" align="left" rowspan="1" colspan="1">80 (60% monocytes, 40% neutrophils)</td><td valign="top" align="left" rowspan="1" colspan="1">380 (80% monocytes, 20% neutrophils)</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Protein (mg/L)</td><td valign="top" align="left" rowspan="1" colspan="1">1,418</td><td valign="top" align="left" rowspan="1" colspan="1">1,050</td><td valign="top" align="left" rowspan="1" colspan="1">1,630</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Virus detection</td><td valign="top" align="left" rowspan="1" colspan="1">EBV IgM (+)<break></break>PCR not done</td><td valign="top" align="left" rowspan="1" colspan="1">EBV IgM/VCA positive (1:5) (day 1)<break></break>EBV IgM/VCA: positive (1:10) (day 14)<break></break>EBV IgM/VCA: positive (1:5) (day 30)<break></break>EBV IgG/VCA 1:10 (for the three times)<break></break>EBV IgA/VCA (−) (for the three times)<break></break>EBV IgA/EA (−) (for the three times)<break></break>EBV PCR not done</td><td valign="top" align="left" rowspan="1" colspan="1">EBV (day 2)<break></break>EBV IgM/VCA: positive (1:10)<break></break>EBV IgG/VCA: positive (1:10)<break></break>EBV IgA/VCA: negative<break></break>EBV IgM/EA: negative<break></break>EBV PCR 3.2×10<sup>3</sup> copies/L</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1"><bold>Other</bold></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1">Biopsy from lymph nodes indicated atypical inflammation</td><td valign="top" align="left" rowspan="1" colspan="1">LDH, 251 U/L; CK, 314 U/L</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1"><bold>Therapy</bold></td><td valign="top" align="left" rowspan="1" colspan="1">Day 1<break></break>Acyclovir, 750 mg, i.v., t.i.d., for 2 weeks;<break></break>Sodium supplementation;<break></break>Day 10: Hydrocortisone, 100 mg/day, i.v. qd, for 1 week</td><td valign="top" align="left" rowspan="1" colspan="1">Day 1<break></break>Acyclovir, 750 mg, i.v., t.i.d., for 3 weeks; Sodium supplementation;<break></break>Day 10: Hydrocortisone 100 mg/day, i.v. via pump over 2 hours, for 1 week</td><td valign="top" align="left" rowspan="1" colspan="1">Day 2<break></break>Acyclovir, 0.85 mg, per 8 hours; Mannitol, 250 mL, per 8 hours; Moxifloxacin, 250 mg, qd<break></break>Sodium supplementation</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Time to clinical response</td><td valign="top" align="left" rowspan="1" colspan="1">7 days</td><td valign="top" align="left" rowspan="1" colspan="1">16 days</td><td valign="top" align="left" rowspan="1" colspan="1">14 days</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Time to resolution of lesions</td><td valign="top" align="left" rowspan="1" colspan="1">20 days</td><td valign="top" align="left" rowspan="1" colspan="1">3.5 months</td><td valign="top" align="left" rowspan="1" colspan="1">1 month</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1"><bold>Imaging</bold></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">First cranial MRI</td><td valign="top" align="left" rowspan="1" colspan="1">– Mild enhancement of the cerebral pia mater<break></break>–Abnormal signal intensity in the splenium of corpus callosum with<break></break>– Iso-signal intensity on T1-weighted images<break></break>– Mild hypersignal intensity on T2-weighted and FLAIR images<break></break>– Hypersignal intensity on DWI images<break></break>– Lack of contrast enhancement of splenial lesions</td><td valign="top" align="left" rowspan="1" colspan="1">– Mild enhancement of the meninges<break></break>– Abnormal signal intensity in the splenium of corpus callosum with<break></break>– Iso-signal intensity on T1-weighted images<break></break>– Mild hypersignal intensity on T2-weighted and FLAIR images<break></break>– Hypersignal intensity on DWI images<break></break>– Lack of contrast enhancement of splenial lesions</td><td valign="top" align="left" rowspan="1" colspan="1">– Abnormal signal intensity in the bilateral thalamus, para-lateral ventricle white matter and splenium of corpus callosum<break></break>– Iso-signal intensity on T1-weighted images<break></break>– Mild hypersignal intensity on T2-weighted and FLAIR images<break></break>– Hypersignal intensity on DWI images<break></break>– Significant contrast enhancement of the cerebral pia mater and tentorium of right cerebellum</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Second cranial MRI scan</td><td valign="top" align="left" rowspan="1" colspan="1">– Cranial MRI indicated a decreased area of enhancement of the cerebral pia mater and significant absorption of splenial lesions compared with the first scan</td><td valign="top" align="left" rowspan="1" colspan="1">– Abnormal signal intensity in the bilateral basal ganglia, thalamus, and splenium of bilateral corpus callosums<break></break>– Lesionsin the splenium of corpus callosum almost disappeared<break></break>– Decreased signal intensity on T2WI images and resolution of hypersignal intensity on DWI images compared with the first scan<break></break>– The meninges show decreased abnormal enhancement<break></break>– New lesions noted in the bilateral basal ganglia and thalamus</td><td valign="top" align="left" rowspan="1" colspan="1">– Cranial MRI showed abnormal signal intensity in the bilateral thalamus and para-lateral ventricle and white matter lesions<break></break>– Significant contrast enhancement of the cerebral pia mater<break></break>– Mild decrease in the enhancement of the tentorium of right cerebellum<break></break>– Lesionsin the splenium of corpus callosum almost disappeared</td></tr></tbody></table><table-wrap-foot><fn id="tfn1-ndt-13-2085"><p><bold>Abbreviations:</bold> CSF, cerebrospinal fluid; DWI, diffusion-weighted imaging; EBV, Epstein–Barr virus; EA, early antigen; FLAIR, fluid-attenuated inversion recovery; MRI, magnetic resonance imaging; PCR, polymerase chain reaction; VCA, viral capsid antigen; WBC, white blood cell.</p></fn></table-wrap-foot></table-wrap></floats-group></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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