New-onset Seizures and Headache in Postpartum Woman: A Case Report

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New-onset Seizures and Headache in Postpartum Woman: A Case Report

A 22-year-old woman was presented with a new onset of seizures after delivering her first child. The headache moderately intense, non-positional, bifrontal, with a throbbing quality after one day. Her pregnancy was unremarkable, and she developed a cough, fever (39.6°) and tachycardia at the time of her delivery. She was also detected with influenza B virus infection on nasopharyngeal swab consistent with respiratory influenza. After seven days, she had generalised convulsions and right elbow flexion and head version to the left.

 

Which of the following syndrome explains the new onset of seizures and respiratory influenza infection?

  • Eclampsia

  • Posterior reversible encephalopathy syndrome (PRES)

  • Cerebral Thrombosis

  • Influenza-associated encephalitis

Introduction:

Influenza-associated encephalitis (IAE) is a complex neurological syndrome commonly reported in children and is associated with a high degree of morbidity and mortality. The incidence of IAE in adults is rare, with estimated prevalence rates of 0.21 per million population per year. Clinically, it is presented with fever (93%), seizures (27%), and altered mental status (23%) up to 3 weeks followed by respiratory influenza infection. In children, it can be presented with a severe form known as acute necrotising encephalopathy, characterised by symmetric lesions involving the brainstem, thalami, brainstem, corpus callosum and cerebellum. The aetiology of IAE is poorly understood, but it appears to include a hyperactivated cytokine response instead of direct viral invasion. It is supported by the fact that influenza virus may initiate the release of pro-inflammatory cytokines (interleukin-6, soluble tumour necrosis factor) in the brain that stimulates microglia to secrete inflammatory mediators. The inflammatory mediators cause direct neurotoxic effects, the breakdown of the blood-brain barrier and cerebral metabolic derangements.

The diagnosis and management of IAE is challenging due to the lack of clear diagnostic and clinical criteria. The patients with recent respiratory influenza infection are often diagnosed of IAE. Differentiating IAE from septic encephalopathy in patients with sepsis is difficult. The initial examination includes nasopharyngeal testing for influenza, magnetic resonance imaging (MRI) of the brain and lumbar puncture.

 

Medical History

The patient was suggestive of new focal-onset seizures with secondary generalisation. Her family history was unremarkable with normal development.

 

Examination and Laboratory Investigations:

Clinical diagnosis:

During her initial physical examination, her blood pressure was reported175/105 mm Hg and a heart rate was 81 beats per minute. She was alert without acute distress and nuchal rigidity. Funduscopic examination revealed no papilledema. Her verbal fluency was decreased with the absence of sensory and visual neglect. She had difficulty in following Luria-3 test. Comprehensive metabolic and coagulation studies were normal. Initial laboratory studies indicated proteinuria and a neutrophil-predominant leukocytosis.

Confirmatory diagnosis:

  • Cognitive examination indicated dysfunction in the frontal lobe

  • Luria test showed deficits in motor planning due to difficulty in performing hand motions

  • MRI with or without contrast suggested a T2/fluid-attenuated inversion recovery (FLAIR) hyperintensity in the right middle frontal gyrus with mild leptomeningeal enhancement

  • Magnetic resonance venography (MRV) showed no signs of venous thrombosis

  • Lumbar puncture and cerebrospinal fluid analysis (CSF) revealing

  • An opening pressure of 17 cm H2O

  • RBC count of 500/mm3 in tube 1 and 600/mm3 in tube 4

  • WBC count of 10/mm3 in tube 1 and 10/mm3 in tube 4 (39% monocytes, 33% lymphocytes, 28% neutrophils)

  • Protein 33 mg/dL, and glucose 65 mg/dL

  • Negative results for bacterial, fungal and broad viral infections including evaluation for West Nile virus, Herpes simplex virus (HSV), Epstein-Barr virus, Cytomegalovirus, and Arboviruses

  • Negative results for NMDA receptor antibodies, paraneoplastic workup, and influenza PCR

  • Rheumatological workup showing an erythrocyte sedimentation rate of 54 mm/h and C-reactive protein of 4.40 mg/dL

The patient’s clinical presentation confirmed respiratory influenza infection, and MRI abnormalities are consistent with IAE.

 

Management

The patient was initially treated with magnesium infusion for 24 hours, resolving her proteinuria and hypertension. She was also given levetiracetam 500 mg twice daily for the treatment of seizures. She was treated with a 7-day course of intravenous acyclovir and also oseltamivir for influenza infection. Her clinical condition was improved after ten days, and then she was discharged from the hospital. She was free of seizures with improvement in her cognitive deficits at follow up examination of 1 and four months. MRI scan showed improvement of T2/FLAIR hyperintensities after three months.

 

Discussion

The current case report presented a rare case of pregnant women diagnosed with influenza-associated encephalitis (IAE). It elucidates the diagnosis and management of IAE which is quite challenging. The initial diagnosis includes nasopharyngeal testing for influenza, MRI brain, and lumbar puncture. Most of the cases indicate abnormalities in MRI and constitute T2 hyperintensities in the brainstem, cerebellum, and subcortical white matter. The evaluation of cerebrospinal fluid (CSF) is also essential; however, it is positive in 16% of cases. A rise in the influenza antibody titers have been detected in a few case reports, but its frequency is not well-established. The management therapies for IAE are not well-organised. Seizures and cerebral oedema require immediate evaluation and supportive control. Oseltamivir and immunomodulation therapies have been proposed, but evidence to depict their efficacy is still lacking.

 

Learning

The diagnosis of IAE should be considered in all patients with encephalitis with recent respiratory illness due to its morbidity and mortality rates.

 

References:

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  9. Miejer WJ, Linn FH, Wensing AMJ, et al. Acute influenza virus-associated encephalitis and encephalopathy in adults: a challenging diagnosis. JMM Case Rep 2016;3: e005076.

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Exploratory, Acyclovir, Oseltamivir, Levetiracetam, Headache, Encephalitis, Seizures, Antiviral, Antiepileptic, Case study, Case report, MRI, CT scan, Intravenous
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