Journal of Clinical Virology 61 (2014) 463465

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Journal of Clinical Virology

jou rn al hom epage: www.elsev ier .com/ locate / j cv

Case Report

Optic neuritis associated with inuenza B virus m

F.A. Vianellob,, S. Osnaghia, E.A. Laicinib, G.P. Milanib,, G. TaA.M. Cappellari c, G. Lunghid, C.V. Agostonie, E.F. Fossalib

a Foundation IRb Foundation IR n, Italc Foundation IR al Head Foundation IR , Milane Department o re Pol

a r t i c l

Article history:Received 12 AReceived in re17 SeptemberAccepted 19 S

Keywords:Inuenza B virOptic neuritisNeurological c

anifesiblese of

1. Introduction

Most of the inuenza virus infection symptoms are respiratoryor gastroinseveral neutations to a[13]. Opticresulting inaffected eyeboth in chilan inuenzchild with O

2. Why thi

Optic neing acute viwith a goo

Abbreviatioence Tomogra

CorresponItaly. Tel.: +39 CorresponTel.: +39 3407

E-mail addmilani.gregori

be difcult and delay the treatment. Clinicians should be awareof the possibility of ON among complications of inuenza virusesinfections.

http://dx.doi.o1386-6532/ testinal, associated with a good prognosis. However,rological complications, ranging from mild manifes-cute necrotising encephalopathy have been reported

neuritis (ON) consists of the optic nerve inammation, sudden painful vision loss or impaired function of the

[4]. It has been associated with inuenza vaccinationdren and adults [5]. Anecdotally, ON was reported aftera A virus infection, too [6]. We describe the case of aN following an inuenza B virus meningoencephalitis.

s case is important

uritis is an inammatory, demyelinating disease caus-sual loss. A prompt treatment in children is associatedd prognosis in most cases [4,7]. Diagnosis of ON can

ns: ON, optic neuritis; CSF, cerebrospinal uid; OCT, Optical Coher-phy; MS, multiple sclerosis.ding author at: Via della Commenda 9, 20122 Milan,

3498320575.ding author at: Via della Commenda 9, 20122 Milan, Italy,071964.resses: fede.via.89@hotmail.it (F.A. Vianello),op@gmail.com (G.P. Milani).

2.1. Case description

A 10-year-old boy was admitted to our paediatric emer-gency department for asthenia, drowsiness, leg tremors andmuscular pain for 24 h and fever, cough and rhinitis for4 days.

On admission vital signs were as follows: axillary temperature38.4 C, heart rate 120 beats/min, blood pressure 115/75 mmHg,respiratory rate 30 breaths/min, and oxygen saturation 98% whilebreathing ambient air.

On physical examination, the child was agitated, with deteri-orating consciousness and confusion. Three episodes of rhythmiclegs movements lasting 23 min occurred during clinical examina-tion. Brudzinski and Kernig signs were positive. No petechiae werepresent. A complete blood cell count revealed (reference rangesin brackets): 17.870 WBC/mm3 [4.80012.100 mm3] (80% neu-trophils, 9% lymphocytes and 11% monocytes), haemoglobin levelwas 12 g/dl [10.514.5 g/dl], haematocrit 34.1% [34.542.5%], andplatelet count was 551.000 mm3 [150.00450.00 mm3]. Inam-matory indices and coagulation panel values were normal. Serumglucose level was 87 mg/dl.

Cerebrospinal uid (CSF) analysis revealed: WBC countof 70 cells/mm3 [

464 F.A. Vianello et al. / Journal of Clinical Virology 61 (2014) 463465

Fig. 1. Right e ed imand central pa el]. (Freader is refer

lymphocyteglucose levgoencephalceftriaxone

The dayday 3 fevermedulla MRwere disconand 2, Ebstemeasles, m(Streptococcseria menin

InuenzRT MULTIPLbut not fromconsidering

Yet, on dments withpapilledemand left eyeBrain and mnerve with in serum anangiotensin

Clinical retro-bulbalesions. TheSpectral Doshowed a ri

Intravendays with rsubsequentthe onset ofmal and vis

Six montion, Spectr

2.2. Similar

Up to 50vaccinationpertussis, mother infecttoxocara analso been a

vaccza A

our ueur car insitiv

able arynus [3r recr ONeld 006statin 20

symebril, Guied a

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Datars, 1whilye examination. Spectral domain OCT showing the swollen optic disc in the infrarnels]. Visual eld examination showing visual defect areas (black parts) [right panred to the web version of this article.)

s), proteins level of 45 mg/dl [1045 mg/dl] andel of 49 mg/dl (4070 mg/dl). Diagnosis of menin-itis was made and the patient received normal saline,

and acyclovir intravenously administered. after the admission the child became alert and on

and neurological ndings resolved and a brain andI revealed normal ndings. Ceftriaxone and acyclovirtinued after the research for viruses (herpes simplex 1inBarr, cytomegalovirus, adenovirus, varicella-zoster,umps, parvovirus and entoroviruses) and bacteriaus pneumoniae, Haemophilus inuentiae type b and Neis-gitidis) in CSF resulted negative.a B virus was detected from nasopharyngeal aspirate byE PCR (real-time multiple polymerase chain reaction),

CSF. No further antiviral treatment was administered the improvement of the clinical conditions.ay 10 he developed headache and painful eye move-

partial blindness in right eye. Eye examination revealeda on the right eye and reduction of visual acuity (7/10),

was completely normal with visual acuity of 10/10.edulla MRI showed altered signal of the right optic

contrast enhancement. Oligoclonal bands were absentd CSF. Aquaporin-4 antibodies were negative and serum

converting enzyme level within normal range.and diagnostic features pointed towards bulbar andr optic neuritis without any cerebral and medulla

diagnosis of ON was conrmed by visual eld test andmain Optical Coherence Tomography (OCT), whichght swollen disc and a visual eld defect (Fig. 1).

H1N1 inuen[7]. Towith in

In oPCR fowas podetectnasophthe vir

Aftetive fovisual

In 2manifeet al. ilogicaland afdromedescrib

Thedemyetion ofsclerosON and

Theadults.10 yeayears, ous bolus methylprednisolone was administered for 5apid improvement of symptoms; oral prednisone wasly given with a slow taper over 4 weeks. One week after

symptoms, eye examination and visual eld were nor-ual acuity increased to 10/10.th after discharge, physical examination, eyes examina-al Domain OCT, brain and medulla MRI were normal.

and contrasting cases in the literature and discussion

% of cases of paediatric ON are postinfectious or post- [4]. ON can follow many viral infections (adenovirus,ononucleosis, measles, mumps and chickenpox) andious causes (bartonella, lyme, meningococcus, syphilis,d toxoplasma) [4,8]. Inuenza virus live vaccines havedvocated in association to ON [9,10] and recently after

child did nolater.

In conclness aboutinfection.

Funding

None.

Competing

None.age (orange arrows) and in cross-sectional images (blue arrows), [leftor interpretation of the references to colour in this gure legend, the

ine [11]. Until now, only one case of ON following virus infection in a 9-year-old Asian boy is describedknowledge, we report the rst case of ON associatednza B virus meningoencephalitis.se, CFS analysis revealed pleocytosis, with RT MULTIPLEuenza B being negative, yet nasopharyngeal aspiratee for inuenza B virus. It is known that virus RNA isin CSF over a very short period during encephalitis andgeal samples are appropriate to detect the presence of,12].overy, the patient developed visual symptoms sugges-

and radiological imaging, Spectral Domain OCT andtest conrmed the diagnosis of ON., Lin et al. reported a 12% incidence of neurologicalons with inuenza B infection in children and Moon13 found a similar incidence (8%) [1,3]. Many neuro-ptoms are described, the most common being febrilee seizure and encephalitis [1,3]. Extrapyramidal syn-llainBarr syndrome, myelitis and myositis have beens other complications [3,12,13].ses may activate a systemic autoimmune mechanism ofion as can occur following vaccinations [9]. Demyelina-c nerve can also be the rst manifestation of multipleS) [14]. Corticosteroids may be effective in treatment ofow taper may prevent the occurrence of relapses [4,13].

of MS following ON in children is much lower than in on paediatric patients indicate that the risk is 13% after9% after 20 years, 22% after 30 years and 26% after 40e in adults the risk is 38% after 10 years [12,13]. Our

t report any sign of relapse or MS at follow-up 6 months

usion, this case of ON suggests an increased aware- this complication in children after an inuenza virus

interests

F.A. Vianello et al. / Journal of Clinical Virology 61 (2014) 463465 465

Ethical approval

Not done for this observational case report.

References

[1] Lin CH, Huang YC, Chiu CH, Huang CG, Tsao KC, Lin TY. Neurologic man-ifestations in children with inuenza B virus infection. Pediatr Infect Dis J2006;25:10813.

[2] Newland JG, Romero JR, Varman M, Drake C, Holst A, Safranek T, et al. Encephali-tis associated with inuenza B virus infection in 2 children and a review of theliterature. Clin Infect Dis 2003;36:e8795.

[3] Moon J-H, Na J-Y, Kim J-H, Yum MK, Oh JW, Kim CR, et al. Neurological and mus-cular manifestations associated with inuenza B infection in children. PediatrNeurol 2013;49:97101.

[4] Collinge JE, Sprunger DT. Update in pediatric optic neuritis. Curr Opin Ophthal-mol 2013;24:44852.

[5] Karussis D, Petrou P. The spectrum of post-vaccination inam-matory CNS demyelinating syndromes. Autoimmun Rev 2014;13:21524.

[6] El-Dairi MA, Ghasia F, Bhatti MT. Pediatric optic neuritis. Int Ophthalmol Clin2012;52:2949.

[7] Lai C-C. Acute anterior uveitis and optic neuritis as ocular complications ofinuenza A infection in an 11-year-old boy. J Pediatr Ophthalmol Strabismus2011;48:e303.

[8] Dass Hazarika R, Deka NM, Khyriem AB, Lyngdoh WV, Barman H, Duwarah SG,et al. Invasive meningococcal infection: analysis of 110 cases from a TertiaryCare Centre in North East India. Indian J Pediatr 2013;80:35964.

[9] Lucchinetti CF, Kiers L, ODuffy A, Gomez MR, Cross S, Leavitt JA, et al. Risk fac-tors for developing multiple sclerosis after childhood optic neuritis. Neurology1997;49:14138.

[10] Riikonen R. The role of infection and vaccination in the genesis of optic neuritisand multiple sclerosis in children. Acta Neurol Scand 1989;80:42531.

[11] Lapphra K, Juh L, Scheifele DW. Adverse neurologic reactions after both dosesof pandemic H1N1 inuenza vaccine with optic neuritis and demyelination.Pediatr Infect Dis J 2011;30:846.

[12] Studahl M. Inuenza virus and CNS manifestations. J Clin Virol 2003;28:22532.[13] Boomer JA, Siatkowski RM. Optic neuritis in adults and children. Semin Oph-

thalmol 2003;18:17480.[14] Wilejto M, Shroff M, Buncic JR, Kennedy J, Goia C, Banwell B. The clinical

features, MRI ndings, and outcome of optic neuritis in children. Neurology2006;67:25862.

Optic neuritis associated with influenza B virus meningoencephalitis1 Introduction2 Why this case is important2.1 Case description2.2 Similar and contrasting cases in the literature and discussion

FundingCompeting interestsEthical approval

References