Post-infectious Disease Research Articles

Long-term outcomes of pediatric infections: from traditional infectious diseases tolongCovid.

There is limited evidence available on the long-term impact of SARS-CoV-2 infection in children. In this article, the authors analyze the recent evidence on pediatric long covid and lessons learnt from a pediatric post-covid unit in Rome, Italy. To gain a better understanding of the concerns raised by parents and physicians in relation to the potential long-term consequences of this novel infection, it is important to recognize that long-term effect of a post-infectious disease is not a new phenomenon.

Postinfectious autoimmune encephalitis with opsoclonus-myoclonus syndrome

Opsoclonus is irregular chaotic eye movements, accompanied by impaired gaze fixation, oscillopsia and associated visual impairment. It is combined with myoclonus of the extremities, trunk, change in gait. It occurs in many pathological conditions, most often in oncological and post-infectious diseases. The rarity and uncommonness of the clinical manifestations of the opsoclonus-myoclonus syndrome, as well as the poor awareness of doctors about this pathology, cause diagnostic difficulties and errors. This report presents the case of a 49-year-old patient, who developed unsteadiness when walking, opsoclonus, myoclonus, startle syndrome, exaggerated startle response 3 weeks after an acute intestinal infection. The diagnostic errors made were analyzed. The diagnosis Post-infection autoimmune encephalitis was proposed and substantiated. Paraneoplastic opsoclonus-myoclonus syndrome was excluded by prospective observation of the patient for 6 years. High efficiency of glucocorticoid treatment was noted.

Особенности этиологии и клинических проявлений бактериальных кишечных инфекций у взрослых пациентов в Республике Адыгея

Aim: To assess the structure of acute intestinal infections (AIIs) over the period of 2017–2021 and characterize the etiology and clinical course of bacterial AIIs in adult patients in the Republic of Adygeya. Patients and Methods: this retrospective cohort study used the following resources: 1) official statistical reports on viral and bacterial AIIs over the period of 2017–2021 in the Republic of Adygeya to assess trends in the morbidity rates and 2) medical records of 50 patients with bacterial AIIs who received treatment in 2020–2021 in the Adygeya Republican Infectious Diseases Hospital to identify clinical and laboratory findings associated with the bacterial causes of diarrhea. A complete blood cell count, biochemistry blood test, stool analysis and stool culture test were performed in the studied patients. First, the stool samples were inoculated onto an enrichment medium, and then elective nutrient media were used for the detection of pathogens. Results: over the last five years, 4,474 AII cases were reported in the Republic, and in 3,317 (74.14%) of them the etiology was not determined. In 2017–2019, bowel infections of viral etiology prevailed in the structure of AIIs. In 2020 and 2021, amid a significant decline in AII morbidity rates, the percentage of viral and bacterial AIIs was similar: 7.14% and 7.71% in 2020 and 1.11% and 3.05% in 2021, respectively. The median age of patients with verified AIIs of bacterial etiology was 34.5 years, most of the patients were females. Salmonellosis caused by Salmonella entеritidis constituted the highest percentage of bacterial AIIs. Most of the patients had moderate illnesses with enterocolitis symptoms and prevailing secretory diarrhea. Conclusion: over the last five years, 4,474 AII cases were reported in the Republic of Adygeya, and in most patients the etiology was not determined. In 2020 and 2021, amid a significant decline in AII morbidity rates, the percentage of viral and bacterial AIIs was similar. Salmonellosis was dominating in the structure of AIIs (moderate illnesses with enterocolitis symptoms and prevailing secretory diarrhea). Biochemistry tests are necessary for patients with bacterial AIIs to identify pathogenetic mechanisms implicated in the development of post- infectious disease syndrome and gastrointestinal diseases. KEYWORDS: acute intestinal infections, bacterial intestinal infections, etiology, post-infectious disease syndrome, irritable bowel syndrome, gastrointestinal diseases. FOR CITATION: Tlyustangelova R.K., Pshenichnaya N.Yu., Khaidarov S.S. The etiology and clinical characteristics of bacterial intestinal infections in adult patients in the Republic of Adygeya. Russian Medical Inquiry. 2022;6(11):608–611 (in Russ.). DOI: 10.32364/2587-6821- 2022-6-11-608-611.

The Basics of Infectious Diseases

Infectious Diseases result from exposure and contact between a host (human being) and an (uninvited) guest (micro-organism). Given the fact that billions of micro-organisms are in and around us at any time, overall, infectious diseases are comparatively rare; of the millions of different microbial species, only about 300 are known to cause human diseases. Besides exposure and contact, factors on the side of the host (genetic background, environment, underlying diseases and their therapy) and on the side of the micro-organisms (pathogenicity / virulence factors) are necessary to result in an infectious disease. “Colonization” means that a micro-organism can attach on skin or mucous membrane for some time or even indefinitely but does not invade host tissue and does not cause any symptoms. Colonizers may even induce an immune response. “Infection” is defined as a micro-organism invading through skin or mucous membranes the tissue of a host, leading to no disease (“asymptomatic infection”); or symptomatic disease. It is followed by health, disability, or death. Following the infection, microorganisms may persist in the body for a long time or even for life without causing any symptoms, which is called “latent infection”. Infectious diseases may not only be due to pathogenicity factors of a micro-organism, but may also result from (i.) direct destruction of host tissues (e.g., from viral replication); (ii.) the acute host (immune-) response; and from late immune responses resulting in immune-mediated “post-infectious diseases”. Some infections may cause an immune response that is directed against host-tissue, resulting in an “autoimmune-disease”. Given the increasing number of microbes, the increasing number of exposures, and the increasing number and fraction of susceptible/predisposed humans, it is obvious that infectious diseases will increase in the future. Vaccines and vaccination may help solve this problem.

Study on Guillain-Barré Syndrome in A Tertiary Level Military Hospital

Introduction: Guillain-Barre Syndrome (GBS) is an acute, frequently severe and fulminant polyradiculopathy that is autoimmune in nature and that causes acute neuromascular failure. The condition is quite common in Bangladesh. GBS is an autoimmune and post-infectious immune disease. Objectives: To see the different presentation and outcome of GBS in combined military hospital (CMH) Dhaka. Materials and Methods: This was a retrospective observational study conducted on all the GBS patients admitted in the Neurology Ward of CMH Dhaka from January 2005 to July 2010. Total 25 patients clinical and laboratory data including CSF analysis, electrophysiological study data were collected from patients’ case sheet. Results: Among the 25 GBS patients male was 22 (88%) and female 03(12%) and most common age group affected was 31-40 years comprising of 09(36%) patients. The most common types of GBS patients were acute inflammatory demyelinating polyneuropathy (AIDP) 17(68%) patients and 10(40%) patients were found to have history of upper respiratory tract infection (URTI). Albuminocytological dissociation was found in 20(80%) patients in CSF study. Intravenous immunoglobulin therapy was given to 13(52%) patients, of them 09(36%) patient needed mechanical ventilation; rest 12(48%) patients were treated conservatively. The final outcome was full recovery 22(88%) patients, 02(8%) patients had residual disability and only one patient died after 2 years of GBS. Conclusion: GBS is an important cause of peripheral neuropathy. Patient should be monitored carefully because a significant number of patients ultimately require mechanical ventilation for respiratory failure which may be of sudden onset. JAFMC Bangladesh. Vol 16, No 2 (December) 2020: 44-46

The Spectrum of Manifestations of Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV2) Infection in Children: What We Can Learn From Multisystem Inflammatory Syndrome in Children (MIS-C).

Multisystem Inflammatory Syndrome in Children (MIS-C) is defined as a clinically serious condition requiring hospitalization with fever, multi-system organ disfunction, inflammatory biomarkers increase. The syndrome develops in the context of a probable or ascertained Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV2) infection, but other possible etiologies should be ruled out for definitive diagnosis. On the clinical side, along with the multi-system involvement, myocarditis with heart failure and shock is the most striking feature. Capillary leak is another fundamental feature of MIS-C. In fact, shock and hemodynamic compromise in MIS-C can occur also in the absence of laboratory evidence of myocardial inflammation, with preserved cardiac function and rapid reversibility. Since the first observations of MIS-C patients, it was evident that there is a delay between the peak of adult cases of Coronavirus disease 19 (COVID-19) and the MIS-C peak. Moreover, SARS-Cov2 isolation in children with MIS-C is not always possible, due to low viral load, while positive serology is far more commonly observed. These observations lead to the interpretation of MIS-C as a post-infectious disease. Although the exact pathogenesis of MIS-C is far from being elucidated, it is clear that it is a hyperinflammatory disease with a different inflammatory response as compared to what is seen in acute SARS-CoV-2 infection and that the disease shares some, but not all, immunological features with Macrophage Activation Syndrome (MAS), Kawasaki Disease (KD), Hemophagocytic Lymphohistiocytosis (HLH), and Toxic Shock Syndrome (TSS). Different mechanisms have been hypothesized as being responsible, from molecular mimicry to antibody dependent enhancement (ADE). Some evidence has also been collected on the immunological profile of patients with MIS-C and their difference from COVID-19. This review is focused on critical aspects of MIS-C clinical presentation and pathogenesis, and different immunological profiles. We propose a model where this hyperinflammatory disease represents one manifestation of the SARS-CoV2 spectrum in children, going from asymptomatic carriers to the post-infectious MIS-C, through symptomatic children, a low number of which may suffer from a severe infection with hyperinflammation (pediatric Hyper-COVID).

Guillain-barré syndrome and COVID-19: An observational multicenter study

Single cases and series of Guillain-Barré syndrome (GBS) were reported during the SARS-CoV-2 outbreak worldwide. We aimed to evaluate the incidence and clinical features of GBS in a cohort of patients from two regions of northern Italy with the highest number of COVID-19 patients. GBS cases diagnosed in 12 referral hospitals in March and April 2020 were retrospectively collected. As a control population, GBS patients diagnosed in March and April 2019 in the same hospitals were considered. Incidence of GBS in March and April 2020 was 0.202/100,000 per month (estimated rate 2.43/100.000 per year; C.I. 0.140–0.282) versus 0.077/100.000 per month (estimated rate 0.93/100.000 per year; C.I.: 0.041–0.132) in March and April 2019 with a 2.6-fold increase. Estimated incidence of GBS in COVID-19 positive patients was 47.9/100,000 and in the COVID-19 positive hospitalized patients was 236/100,000. COVID-positive GBS were compared with COVID-negative patients and a higher frequency of demyelinating subtype (AIDP) (76.6% vs 35.3%; p. 0.005), a lower MRC sum score (26.33 +/− 18.31 vs 41.41 +/− 14.85; p 0.006) and more frequent admission to ICU (66.6% vs 17.6%; p 0.002) were observed. This study shows an increased incidence of GBS during the first COVID-19 wave in northern Italy. This might not be unexpected considering that GBS is unanimously considered a post-infectious disease with several new infectious agents even recently added as possible trigger for GBS, including Zika and Hepatitis E viruses. We suggested that a correlation might exist between the COVID-19 and the increase in GBS incidence.

Reader Response: Acute Necrotizing Encephalopathy With SARS-CoV-2 RNA Confirmed in Cerebrospinal Fluid.

Virhammar et al.1 present a case of acute necrotizing encephalopathy (ANE) in a patient with COVID-19 diagnosed by nasopharyngeal swab PCR1. SARS-CoV-2 PCR testing on 2 CSF specimens performed on days 9 and 12 after symptom onset was negative, whereas a third CSF specimen tested positive at a cycle threshold (Ct) of 34.29 at 21 days. Although interesting, these results do not indicate that SARS-CoV-2 is neurotropic. First, most experts consider Ct counts >40 to represent a negative test, and counts >34 may not represent meaningful disease.2 Because PCR testing can amplify contaminants, this result may be a false positive, particularly with negative initial CSF testing. Second, because ANE is typically a postinfectious disease, a biologically plausible causal link with a weakly positive CSF PCR at 21 days is not established. Third, a large series of patients with COVID-19 who had neurologic symptoms found SARS-CoV-2 PCR was negative in the CSF in 100% of patients.3 Although one study reportedly detected SARS-CoV-2 in a brain autopsy,4 no immunohistochemistry studies were performed, and rough endoplasmic reticulum may be mistaken for virions. Larger brain autopsy series using immunohistochemistry have not detected primary viral CNS invasion.5 Direct neurotropism of SARS-CoV-2 has yet to be definitively established.

Lyme arthritis: linking infection, inflammation and autoimmunity.

Infectious agents can trigger autoimmune responses in a number of chronic inflammatory diseases. Lyme arthritis, which is caused by the tick-transmitted spirochaete Borrelia burgdorferi, is effectively treated in most patients with antibiotic therapy; however, in a subset of patients, arthritis can persist and worsen after the spirochaete has been killed (known as post-infectious Lyme arthritis). This Review details the current understanding of the pathogenetic events in Lyme arthritis, from initial infection in the skin, through infection of the joints, to post-infectious chronic inflammatory arthritis. The central feature of post-infectious Lyme arthritis is an excessive, dysregulated pro-inflammatory immune response during the infection phase that persists into the post-infectious period. This response is characterized by high amounts of IFNγ and inadequate amounts of the anti-inflammatory cytokine IL-10. The consequences of this dysregulated pro-inflammatory response in the synovium include impaired tissue repair, vascular damage, autoimmune and cytotoxic processes, and fibroblast proliferation and fibrosis. These synovial characteristics are similar to those in other chronic inflammatory arthritides, including rheumatoid arthritis. Thus, post-infectious Lyme arthritis provides a model for other chronic autoimmune or autoinflammatory arthritides in which complex immune responses can be triggered and shaped by an infectious agent in concert with host genetic factors.

Focused Workshops

The initial trigger leading to the immune tolerance breakdown is still unknown in most autoimmune encephalitites associated with antibodies targeting neuronal surface antigens. Nevertheless, prodromal symptoms compatible with mild infections are not infrequent, suggesting that some common and benign microbiological agents could act as triggers of the autoimmune reaction. Conversely, herpes simplex virus (HSV) encephalitis is now a well-characterized trigger of autoimmune encephalitis, and is particularly related to the development of anti- NMDAR antibodies, though other specificities have also been reported. Serological studies as well as an animal model further support the association between HSV and anti-NMDAR encephalitis, but the underlying pathogenesis is still obscure. However, a genetic predisposition involving the Toll-like receptor 3-pathway might exist at least in a subset of patients. In addition to HSV, anti-NMDAR and other autoimmune encephalitis have also been associated with other infections, chiefly Japanese encephalitis and HIV, but new epidemic and pandemic diseases such as COVID-19 are raising concern as potential triggers of autoimmune encephalitis. On the contrary, despite the recent description of anti-neural antibodies against different targets in some patients, solid evidence regarding the autoimmune pathogenesis is still lacking for several historically reported post-infectious neurological diseases, such as Sydenham chorea and von Economo's encephalitis lethargica. Interestingly, type 1 narcolepsy constitutes a good example of neurological autoimmunity triggered by infection in genetic susceptible subjects that might provide some clues for future research in autoimmune encephalitis.

Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with COVID-19: A Case Series Experience in a Tertiary Care Hospital of Southern Turkey.

ObjectiveAim of the study is to assess the clinical characteristics and treatment outcomes of Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with COVID-19.Study designThe study comprised 52 children with MIS-C admitted to University of Health Sciences Adana City Training and Research Hospital pediatric wards from September 2020 to April 2021. Demographic characteristics and clinical data were retrospectively collected from patient files.ResultsMedian age of patients was 9 (5-13) years. Fever (92.3%), abdominal pain (76.9%), rash (48.1%) and vomiting (48.1%) were the most common presenting symptoms. Fever duration was 8 (4.25-10) days in overall. Depressed left ventricular ejection fraction was found in 17.3% of patients. At admission, elevated levels of CRP, procalcitonine, ESR, D-dimer, ferritin were found in 98.1%, 96.2%, 75%, 84.6% and 69.2% of the patients, respectively. Lymphopenia, hyponatremia and hypoalbuminemia were found in 76.9%, 59.6%, 42.3% of the patients. Intravenous immunoglobulin was used in 96.2%, corticosteroids in 71.2% and anakinra in 3.8% of the patients. 28.8% of the patients were admitted to pediatric intensive care (PICU) and 17.3% received vasopressor support. Median duration of hospital length of stay was 12.5 days. Comorbidities were present in 19.2% of the patients. No mortality was recorded.ConclusionsWhile being rare and treatable, MIS-C is the ugly and mysterious face of the COVID-19 pandemic for children. The increasing number of MIS-C cases shows that this phenomenon is more common than thought. Comprehensive studies are required to understand the pathogenesis of the disease and determine the treatment regimens clearly.Lay SummaryWhile being rare and treatable, Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 is the ugly and mysterious face of the COVID-19 pandemic for children. MIS-C is now thought to be a post-infectious (SARS-CoV2) hyperinflammatory disease secondary to an abnormal immune response, rather than a complete obscurity. The increasing number of MIS-C cases and new case series reports from all over the world show that MIS-C is more common than thought. Despite our increasing experience, we may encounter a new finding every day in MIS-C patients. Therefore, we want to contribute to literature by presenting the MIS-C cases we treated in our clinic in detail. We have experienced that MIS-C patients can apply with similar but also different and unique characteristics. In case of delayed diagnosis or treatment, morbidity and mortality rates may increase. Therefore, the level of awareness and knowledge of all physicians, especially those dealing with pediatric patients, about MIS-C should be increased. Although the early effects of MIS-C are known, we don’t have enough information about the long-term consequences yet. Comprehensive studies are required to understand the pathogenesis of the disease and determine the treatment regimens clearly.

Cutaneous Findings in SARS-CoV-2-Associated Multisystem Inflammatory Disease in Children.

Rash is a common feature of multisystem inflammatory syndrome in children (MIS-C), a postinfectious hyperinflammatory disease associated with prior severe acute respiratory syndrome coronavirus 2 infection. Because the differential diagnosis of fever and rash in children is broad, understanding clinical characteristics of MIS-C may assist with diagnosis. Here we describe the cutaneous findings observed in a series of children with MIS-C-associated rash.

Immune determinants of COVID-19 disease presentation and severity.

COVID-19, caused by SARS-CoV-2 infection, is mild to moderate in the majority of previously healthy individuals, but can cause life-threatening disease or persistent debilitating symptoms in some cases. The most important determinant of disease severity is age, with individuals over 65 years having the greatest risk of requiring intensive care, and men are more susceptible than women. In contrast to other respiratory viral infections, young children seem to be less severely affected. It is now clear that mild to severe acute infection is not the only outcome of COVID-19, and long-lasting symptoms are also possible. In contrast to severe acute COVID-19, such 'long COVID' is seemingly more likely in women than in men. Also, postinfectious hyperinflammatory disease has been described as an additional outcome after SARS-CoV-2 infection. Here I discuss our current understanding of the immunological determinants of COVID-19 disease presentation and severity and relate this to known immune-system differences between young and old people and between men and women, and other factors associated with different disease presentations and severity.

Guillain-Barre syndrome during COVID-19 pandemic: experience from a referral healthcare center in Mexico.

To describe clinical characteristics and electrophysiological variants of GBS cases during the pandemic, we carried out a comparative analysis between SARS-CoV2 related GBS and non-SARS-CoV2 patients and then compared to the 2019 cases. We carried out a cross-sectional study of GBS patients diagnosed according to Asbury and Cornblath criteria. We collected information on clinical and paraclinical variables. We defined a SARS-CoV-2 related GBS case according to the description of Ellul et al. We used Hadden criteria to classify the electrophysiological variants. We performed a comparative analysis between groups. Fourty-two patients were diagnosed with GBS in 2020, men 64.2%, age 46 ± 17.4 years, patients with obesity/overweight 42.8%, previous diarrhea 31%, history of respiratory tract infection 14.2%. Guillain Barre Disability Scale = 3 points 71.4% and, cranial nerve involvement 69%. The most frequent electrophysiological variant was acute inflammatory demyelinating polyradiculoneuropathy (AIDP) 53.5%. Seven (16.6%) cases were SARS-CoV2 related, four men, age 43.4 ± 13.4 years. When comparing patients with GBS in 2020 vs patients in 2019, we observed a decrease in the previous infection history during 2020 (45.2% vs 73.3%, p-value = 0.005) and a decrease in previous respiratory infection (14.2% vs 33.3%, p = 0.045), as well as a higher frequency of cranial nerve involvement, and albuminocytologic dissociation. SARS-CoV2 virus infection preventive measures may be impacting the presentation of post-infectious diseases such as GBS. We did not observe an increase in GBS cases during 2020. Also, the AIDP variant were more frequent in our population in the COVID-19 pandemic.

Electroencephalographic findings in Bickerstaff’s brainstem encephalitis: A possible reflection of the dysfunction of the ascending reticular activating system

ObjectivesBickerstaff’s brainstem encephalitis (BBE) is a rare post-infectious inflammatory disease, which causes impaired consciousness by the dysfunction of the ascending reticular activating system (ARAS). We aimed to clarify EEG changes possibly caused by the dysfunction of the ARAS in BBE. MethodsWe retrospectively investigated 15 EEGs from 5 patients with definite BBE (i.e., the positivity for serum IgG anti-GQ1b antibodies was mandatory for the diagnosis) admitted to our hospital from January 2014 through December 2019, particularly focusing on whether N1 and N2 sleep patterns were maintained. ResultsAll of the 10 EEGs recorded when patients had consciousness disturbance were abnormal. Stereotypical EEG changes correlating with their level of consciousness were identified: poorly organized posterior dominant rhythms with maintenance of sleep patterns in patients with mild consciousness disturbance (n = 5); predominant N1 and/or N2 sleep patterns even with external stimuli, including spindle coma pattern, in patients with moderate consciousness disturbance (“unarousable sleep-like” EEG) (n = 4); and generalized slow waves without N1 and N2 sleep patterns in patients with severe consciousness disturbance (n = 1). Among 5 patients, 3 (60%) had “unarousable sleep-like” EEG in their clinical course. ConclusionsPatients with BBE showed stereotypical EEG changes correlating with their level of consciousness, mostly with maintenance of N1 and N2 sleep patterns, and often exhibited characteristic “unarousable sleep-like” EEG. SignificanceThis study revealed characteristic EEG changes possibly caused by the dysfunction of the ARAS, which can be a diagnostic clue for BBE.

Human Pluripotent Stem Cell-Derived Neural Cells and Brain Organoids Reveal SARS-CoV-2 Neurotropism Predominates in Choroid Plexus Epithelium.

Neurological complications are common in patients with COVID-19. Although severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causal pathogen of COVID-19, has been detected in some patient brains, its ability to infect brain cells and impact their function is not well understood. Here, we investigated the susceptibility of human induced pluripotent stem cell (hiPSC)-derived monolayer brain cells and region-specific brain organoids to SARS-CoV-2 infection. We found that neurons and astrocytes were sparsely infected, but choroid plexus epithelial cells underwent robust infection. We optimized a protocol to generate choroid plexus organoids from hiPSCs and showed that productive SARS-CoV-2 infection of these organoids is associated with increased cell death and transcriptional dysregulation indicative of an inflammatory response and cellular function deficits. Together, our findings provide evidence for selective SARS-CoV-2 neurotropism and support the use of hiPSC-derived brain organoids as a platform to investigate SARS-CoV-2 infection susceptibility of brain cells, mechanisms of virus-induced brain dysfunction, and treatment strategies.

Disease of the Year: COVID-19 and Its Neuro-ophthalmic Complications.

Disease of the Year: COVID-19 and Its Neuro-ophthalmic Complications.

Limited improvement and high rate of complication in patients undergoing reverse total shoulder arthroplasty for previous native shoulder infection

The outcomes of reverse total shoulder arthroplasty (RTSA) surgery for the sequelae of former septic native joint shoulder arthritis are unknownbut might be inferior to patients without prior bacterial arthritis. We performed a single-center case-control study embedded in our prospective RTSA cohort. We matched all patients withprior infections in a 1:1 ratio with patients who underwent RTSA for other indications. The matching variables wereindication for surgery, age, sex, dominant/nondominant shoulder, and body mass index. We evaluated outcomes by Constant score and active function. Among 1249 patients in the RTSA cohort, 14 were operated for sequelae of previous native shoulder joint infections. Although both groups significantly improved from preoperative to postoperative values, the outcome of postinfectious patients was clearly inferior in comparison with the control group (absolute [38 ± 17 vs. 75 ± 8, P < .01], relative Constant score [47 ± 19 vs. 88 ± 9, P< .01], Constant pain score [11.0 ± 3.1 vs. 14.3 ± 1.3, P < .01], subjective shoulder value [43 ± 26 vs. 85 ± 10, P < .01], abduction [70 ± 43 vs. 148 ± 29°, P = .001], and elevation [82 ± 49° to 131 ± 16°, P = .02]). Moreover, in the postinfectious group, overall surgical complications occurred in 36%, with the need for revision in 21%. There was, however, no recurrence of infection in any of the patients' shoulders. RTSA for end-stage postinfectious joint disease is associated with a high number of complications and reoperations. Clinical outcomes are inferior to those without past infection.

Guillain-Barré syndrome related to Zika virus infection: Asystematic review and meta-analysis of the clinical and electrophysiological phenotype.

BackgroundThe Zika virus (ZIKV) has been associated with Guillain-Barré syndrome (GBS) in epidemiological studies. Whether ZIKV-associated GBS is related to a specific clinical or electrophysiological phenotype has not been established. To this end, we performed a systematic review and meta-analysis of all published studies on ZIKV-related GBS.MethodsWe searched Pubmed, EMBASE and LILACS, and included all papers, reports or bulletins with full text in English, Spanish or Portuguese, reporting original data of patients with GBS and a suspected, probable or confirmed recent ZIKV infection. Data were extracted according to a predefined protocol, and pooled proportions were calculated.ResultsThirty-five studies were included (13 single case reports and 22 case series, case-control or cohort studies), reporting on a total of 601 GBS patients with a suspected, probable or confirmed ZIKV infection. Data from 21 studies and 587 cases were available to be summarized. ZIKV infection was confirmed in 21%, probable in 22% and suspected in 57% of cases. ZIKV PCR was positive in 30% (95%CI 15–47) of tested patients. The most common clinical features were: limb weakness 97% (95%CI 93–99), diminished/absent reflexes 96% (95%CI 88–100), sensory symptoms 82% (95%CI 76–88), and facial palsy 51% (95%CI 44–58). Median time between infectious and neurological symptoms was 5–12 days. Most cases had a demyelinating electrophysiological subtype and half of cases were admitted to the Intensive Care Unit (ICU). Heterogeneity between studies was moderate to substantial for most variables.ConclusionsThe clinical phenotype of GBS associated with ZIKV infection reported in literature is generally a sensorimotor demyelinating GBS with frequent facial palsy and a severe disease course often necessitating ICU admittance. Time between infectious and neurological symptoms and negative PCR in most cases suggests a post-infectious disease mechanism. Heterogeneity between studies was considerable and results may be subject to reporting bias. This study was registered on the international Prospective Register of Systematic Reviews (CRD42018081959).

Dengue and chikungunya infection in neurologic disorders from endemic areas in Brazil.

ObjectiveTo detect the frequency of dengue virus (DENV), Chikungunya virus (CHIKV), and Zika virus (ZIKV) in adult patients with suspected viral infection of the CNS or postinfectious syndromes living in the state of Rio de Janeiro, Brazil.MethodsDENV, CHIKV, and ZIKV RNA by reverse transcription PCR (RT-PCR) and specific IgM antibodies were investigated in 47 CSF and serum samples of 36 adult patients suspected with viral infection or postinfectious neurologic diseases. In addition, intrathecal synthesis of anti-DENV and anti-CHIKV IgG antibodies was also evaluated using a specific antibody index.ResultsOf the total group, neuroinvasive arbovirus was confirmed in 31% (11/36) of the cases: 6 (55%) by RT-PCR in CSF and/or serum, 1 (9%) by RT-PCR in CSF and/or serum and specific IgM in CSF, and 4 (36%) by specific IgM in CSF. Five cases had DENV infection, and 6 patients were positive for CHIKV. No sample amplified for ZIKV. In addition, 3 of 7 (42%) tested cases had intrathecal synthesis of DENV or CHIKV antibodies. The neurologic complications included encephalitis (7), Guillain-Barré syndrome (2), optic neuritis (1), neuromyelitis optica spectrum disorder (1), polyneuropathy, (1) and myelitis (1).ConclusionDENV and CHIKV are a frequent cause of emerging and reemerging infections. It increases the number of cases with neurologic complications worldwide. We demonstrated that the combined use of molecular and immunologic tests in CSF/serum might support more widely the diagnosis of neurologic disorders caused by arbovirus in endemic areas. The detection of intrathecal synthesis of specific IgG antibodies may be promising for the retrospective diagnosis of neuroinvasive disorders caused by arbovirus.