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Acute Hemorrhagic Leukoencephalitis: A Rare Complication of Influenza H3N2 FREE TO VIEW

Elizabeth Yu, MD; Tine Vindenes, MD; Mithila Vullaganti, MD; Maher Tabba, MD
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Tufts Medical Center, Boston, MA

Chest. 2015;148(4_MeetingAbstracts):271A. doi:10.1378/chest.2275545
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SESSION TITLE: Critical Care Student/Resident Case Report Posters II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: We describe a patient who presented with influenza H3N2 complicated by multiple intra-parenchymal hemorrhages consistent with acute hemorrhagic leukoencephalitis (AHLE).

CASE PRESENTATION: A 40 year-old man presented with septic shock and hypoxic respiratory failure requiring pressors and mechanical ventilation. His labs showed WBC 2,600/ul, creatinine 2.23 mg/dl, bicarbonate 14 mEq/l, lactate 4.0 mEq/l. Chest X-ray and CT showed multi-lobar pneumonia. He received broad-spectrum antibiotics and oseltamivir. Viral panel showed influenza A/H3 and sputum cultures grew group A streptococcus. He received methylprednisolone and IV immunoglobulin for possible toxic shock syndrome. His hospitalization was complicated by fluid overload requiring dialysis, atrial fibrillation, and thrombocytopenia (13,000/ul). As his sedation was weaned he was noted to have altered mentation. CT showed bilateral intra-parenchymal hemorrhages. MRI/MRA did not show abscesses or vasculitis. Echocardiograms disclosed no vegetations. CSF showed lymphocytic cell predominance, normal protein and glucose levels, and negative gram stain and culture. He suffered generalized tonic-clonic seizures treated with phenytoin and levetiracetam. Ultimately, tracheostomy and gastric tubes were placed. Neurologic function improved and at discharge he was moving his extremities on command.

DISCUSSION: This patient presented in septic shock secondary to influenza H3N2 complicated by streptococcus pneumonia and toxic shock syndrome. The etiology of multiple intra-parenchymal hemorrhages may be due to a single, monophasic, inflammatory hemorrhagic event that occurred in the setting of thrombocytopenia, such as AHLE. AHLE is a rare and severe form of acute disseminated encephalomyelitis, typically associated with inflammation of the white matter with necrotizing venulitis and perivascular hemorrhage. A preceding infection (typically upper respiratory) is noted in approximately 50% of cases. Pathogenesis is unclear, but thought to be a hyperacute, autoimmune form of post-infectious encephalomyelitis. Its diagnosis may be confirmed at autopsy since the majority of cases are fatal (1, 2, 3). However, aggressive treatment of underlying illness, early therapy with steroids, and immunoglobulin may be life saving.

CONCLUSIONS: AHLE is a rare, potentially fatal, form of acute disseminated encephalomyelitis. Early treatment with steroids and immunoglobulin may be life saving.

Reference #1: Jeganathan, N., Fox, M., Schneider, J., Gurka, D., Bleck, T. Acute Hemorrhagic Leukoencephalopathy Associated with Influenza A (H1N1) Virus. Neurocrit Care. 2013.

Reference #2: Takeda, H., Isono, M., Kobayashi, H. Possible Acute Hemorrhagic Leukoencephalitis Manifesting as Intracerebral Hemorrhage on Computed Tomography. Neurol Med Chir. 2002.

Reference #3: Abou Zeid, N.E., Burns, J.D., Wijdicks, E.F., Giannini, C., Keegan, B.M. Atypical Acute Hemorrhagic Leukoencephalitis (Hurst’s disease) Presenting With Focal Hemorrhagic Brainstem Lesion. Neurocrit Care. 2010.

DISCLOSURE: The following authors have nothing to disclose: Elizabeth Yu, Tine Vindenes, Mithila Vullaganti, Maher Tabba

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