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Table.  

Characteristic Patient
1 2 3 4 5 6 7
Age,y/sex 28/F 37/F 55/F 20/F 57/M 31/F 27/F
Days from illness onset 3 2 10 5 3 4 3
Medical history Uncontrolled hyperthyroidism Unremarkable Influenza A(H3N2) virus encephalitis in 2012 Treated for Russell−Silver syndrome Unremarkable Recent breast implants Unremarkable
Leukocyte count, cells/mm3 2 2 10 5 2 3 13
CSF
   Protein, g/L 0.143 0.270 2.305 0.251 0.313 0.162 7.156
   Glucose, g/L 0.61 0.50 0.74 1.07 0.55 0.71 1.22
   Chloride, g/L ND ND 7.60 6.78 7.10 6.80 7.02
Virus type B seq EPI_ISL_179707 B seq EPI_ISL_179711 B B B seq EPI_ISL_182519 B B seq EPI_ISL_182518
Cerebral imaging result MRI, abnormal† CT, normal MRI, abnormal‡ MRI, normal MRI, normal NA MRI, abnormal§
Diagnosis Confirmed encephalitis Possible encephalitis Confirmed encephalitis Confirmed encephalitis Possible encephalitis Cerebellar ataxia Confirmed encephalitis
Length of hospitalization, d 7 9 18 17 10 5 3
Outcome Died Complete resolution Complete resolution Complete resolution Complete resolution Complete resolution Died
Clinical findings Fever, headache, sleepiness, left upper limb motor deficit, coma, GCS score 3–4 Fever, headache, sleepiness, photophobia, vertigo, stiff neck, positive Romberg sign Fever, confusion, photophobia, dizziness, right facial paralysis, aphasia, stiff neck, coma, GCS score 8 Fever, agitation, nystagmus, stiff neck, coma, GCS score 9–10 Fever, headache, dysarthria, right side motor deficit, vomiting Fever, headache, vomiting, vertigo, photophobia, ataxia, positive Romberg sign, movement and balance disorder Fever, headache, vomiting, lethargy, aphasia, upward deviation of eyes, seizures, coma, GCS score 3

Table. Characteristics of 7 patients with neurologic complications of influenza B virus infection, Romania*

*All patients showed negative RT-PCR results for influenza B virus in CSF. CSF, cerebrospinal fluid; CT, computed tomography; GCS, Glasgow coma scale; MRI, magnetic resonance imaging; NA, not available; ND, not determined.
†MRI on day 3. See Figure 1 for a detailed description.
‡MRI on day 8. See Figure 2 for a detailed description.
§MRI on day 2 showed multiple areas of hyperintensities.

CME

Neurologic Complications of Influenza B Virus Infection in Adults, Romania

  • Authors: Corneliu Petru Popescu, MD; Simin Aysel Florescu, MD, PhD; Emilia Lupulescu, MD, PhD; Mihaela Zaharia, MD; Gratiela Tardei, MD, PhD; Mihaela Lazar, MD, PhD; Emanoil Ceausu, MD, PhD; Simona Maria Ruta, MD, PhD
  • CME Released: 3/16/2017
  • THIS ACTIVITY HAS EXPIRED FOR CREDIT
  • Valid for credit through: 3/16/2018, 11:59 PM EST
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Target Audience and Goal Statement

This activity is intended for infectious disease clinicians, neurologists, internists, intensivists, and other clinicians caring for patients with influenza B-related neurologic manifestations.

The goal of this activity is to describe neurologic complications of influenza B virus infection in adults, based on a case series from a tertiary facility in Romania.

Upon completion of this activity, participants will be able to:

  1. Recognize clinical and neurologic manifestations of influenza B virus infection in adults, based on a case series from a tertiary facility in Romania
  2. Determine the course and treatment of influenza B virus infection in adults with neurologic complications
  3. Identify laboratory and neuroimaging findings of influenza B virus infection in adults with neurologic complications


Disclosures

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Authors

  • Corneliu Petru Popescu, MD

    Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Dr Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Bucharest, Romania; ESCMID Study Group for Infectious Diseases of the Brain

    Disclosures

    Disclosure: Corneliu Petru Popescu, MD, has disclosed no relevant financial relationships.

  • Simin Aysel Florescu, MD, PhD

    Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Dr Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Bucharest, Romania

    Disclosures

    Disclosure: Simin Aysel Florescu, MD, PhD, has disclosed no relevant financial relationships.

  • Emilia Lupulescu, MD, PhD

    National Institute of Research Cantacuzino, Bucharest, Romania

    Disclosures

    Disclosure: Emilia Lupulescu, MD, PhD, has disclosed no relevant financial relationships.

  • Mihaela Zaharia, MD

    Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Bucharest, Romania; ESCMID Study Group for Infectious Diseases of the Brain

    Disclosures

    Disclosure: Mihaela Zaharia, MD, has disclosed no relevant financial relationships.

  • Gratiela Tardei, MD, PhD

    Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Bucharest, Romania

    Disclosures

    Disclosure: Gratiela Tardei, MD, PhD, has disclosed no relevant financial relationships.

  • Mihaela Lazar, MD, PhD

    National Institute of Research Cantacuzino, Bucharest, Romania

    Disclosures

    Disclosure: Mihaela Lazar, MD, PhD, has disclosed no relevant financial relationships.

  • Emanoil Ceausu, MD, PhD

    Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Dr Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Bucharest, Romania

    Disclosures

    Disclosure: Emanoil Ceausu, MD, PhD, has disclosed the following relevant financial relationships:
    Received grants for clinical research from: MSD; Gilead

  • Simona Maria Ruta, MD, PhD

    Carol Davila University of Medicine and Pharmacy; Stefan S. Nicolau Institute of Virology, Bucharest, Romania

    Disclosures

    Disclosure: Simona Maria Ruta, MD, PhD, has disclosed no relevant financial relationships.

Editor

  • Thomas J. Gryczan, MS

    Copyeditor, Emerging Infectious Diseases

    Disclosures

    Disclosure: Thomas J. Gryczan, MS, has disclosed no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer, Medscape, LLC

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed the following relevant financial relationships:
    Owns stock, stock options, or bonds from: Pfizer

CME Reviewer

  • Robert Morris, PharmD

    Associate CME Clinical Director, Medscape, LLC

    Disclosures

    Disclosure: Robert Morris, PharmD, has disclosed no relevant financial relationships.


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CME

Neurologic Complications of Influenza B Virus Infection in Adults, Romania

Authors: Corneliu Petru Popescu, MD; Simin Aysel Florescu, MD, PhD; Emilia Lupulescu, MD, PhD; Mihaela Zaharia, MD; Gratiela Tardei, MD, PhD; Mihaela Lazar, MD, PhD; Emanoil Ceausu, MD, PhD; Simona Maria Ruta, MD, PhDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED FOR CREDIT

CME Released: 3/16/2017

Valid for credit through: 3/16/2018, 11:59 PM EST

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Abstract and Introduction

Abstract

We characterized influenza B virus–related neurologic manifestations in an unusually high number of hospitalized adults at a tertiary care facility in Romania during the 2014–15 influenza epidemic season. Of 32 patients with a confirmed laboratory diagnosis of influenza B virus infection, neurologic complications developed in 7 adults (median age 31 years). These complications were clinically diagnosed as confirmed encephalitis (4 patients), possible encephalitis (2 patients), and cerebellar ataxia (1 patient). Two of the patients died. Virus sequencing identified influenza virus B (Yam)-lineage clade 3, which is representative of the B/Phuket/3073/2013 strain, in 4 patients. None of the patients had been vaccinated against influenza. These results suggest that influenza B virus can cause a severe clinical course and should be considered as an etiologic factor for encephalitis.

Introduction

Influenza viruses are negative single-stranded RNA viruses belonging to the family Orthomyxoviridae and cause worldwide epidemics of influenza with high rates of illness and death. Human influenza A and B viruses cause a self-limited acute respiratory infection. This infection has an abrupt onset and causes fever, chills, headache, cough, and myalgia. Every year, different strains of influenza viruses emerge because of continuous antigenic drift and interspecies gene reassortment, which cause antigenic shifts. Severe complications of influenza can involve the lower respiratory tract (pneumonia), heart (myocarditis), and central nervous system (encephalitis, myelitis, meningitis, febrile and afebrile seizures, Guillain-Barré syndrome, cerebellar ataxia) and can lead to death.[1–3]

Although type A and B influenza viruses might induce neurologic complications, most published studies on virus neurotropism have focused on influenza A viruses, with an emphasis on the new A(H1N1)pdm09 virus strain after 2009.[4–7] Influenza B virus, which was isolated from a child in 1940, has steadily adapted to humans without a stable animal reservoir.[8–10] The earliest report of a case of influenza B viral encephalitis was in London, UK, in 1946,[11] but only sporadic cases with neurologic manifestations have been reported, especially in children and adolescents. Influenza B is generally considered a mild disease with less frequent neurologic complications than influenza A.[4–7]

There was major increased influenza activity in Romania during the 2014–15 influenza season: 3.5 times more cases of influenza-like illness (ILI) and acute respiratory infections than in the previous season. A total of 4,511 case-patients with ILI were reported, of which 1,709 (37.9%) were hospitalized; 3,297 (73.1%) were >14 years of age. Influenza B viruses prevailed (in 529 [56.4%] of the 938 laboratory-confirmed influenza cases), unlike the rest of Europe, where there was a predominance of type A influenza strains.[12] We characterized influenza B virus–related neurologic manifestations diagnosed at a tertiary care facility in Romania during the 2014–15 influenza season.