Influenza B-associated encephalitis with rapid improvement with oseltamivir
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Influenza B-associated encephalitis with rapid improvement with oseltamivir Jessica Yen 1
&
Ali Al Moamen 1 & Jason Margolesky 1
Received: 28 May 2020 / Accepted: 3 October 2020 # Fondazione Società Italiana di Neurologia 2020
Abstract A 25-year-old female veterinarian presented with 1-week of flu-like symptoms followed by progressive encephalopathy. She was originally from Nicaragua and had been in the USA for 4 months. In the emergency department, she was confused and non-verbal with meningismus and facial myoclonus, but with an otherwise non-focal neurological exam. MRI brain abnormalities were consistent with viral encephalitides. Influenza B was detected via nasopharyngeal swab PCR. Mental status improved rapidly with oseltamivir. In such presentations, especially during flu season, influenza encephalitis must be considered, to facilitate early recognition of this entity and allow for targeted treatment. Keywords Encephalitis . Neuroinfectious disease . Influenza
We present a 25-year-old female veterinarian with no significant medical history who was brought in by family with a 1week history of progressive confusion and generalized weakness. She was in her usual state of health when she developed rhinorrhea and pharyngitis followed by fevers and meningismus. One month prior to this presentation, she suffered a cat scratch and subsequent febrile illness, which resolved without treatment. She was originally from Nicaragua and had been in the USA for 4 months. She had no history of tuberculosis. In the emergency room, she was febrile (39.4 °C) and was hypotensive (88/58 mmHg). She was encephalopathic, nonverbal, and not following commands. Facial myoclonic movements were observed. Urinalysis, complete blood count, chest X-ray, and non-contrast-enhanced brain CT were unremarkable. Influenza B was positive in the
* Jessica Yen [email protected] Ali Al Moamen [email protected] Jason Margolesky [email protected] 1
Department of Neurology, University of Miami/Jackson Memorial Hospital, 1120 NW 14th Street, Ste. #1383, Miami, FL 33136, USA
nasopharyngeal swab PCR. MRI brain with and without contrast, electroencephalogram (EEG), and lumbar puncture were recommended; and she was started on broad spectrum antibiotics (vancomycin, ampicillin, doxycycline (for possible Bartonella), ceftriaxone) as well as oseltamivir. Cerebrospinal fluid, obtained after 1 day of empiric treatment, showed 0 WBCs, 0 RBCs, normal glucose, and elevated protein (124 mg/dL). Meningitis/encephalitis PCR panel, which included Listeria, Neisseria meningitidis, Streptococcus agalactiae/pneumoniae, CMV, Enterovirus, HSV 1 and 2, HHV-6, VZV, and Cryptococcus, was negative. Bartonella serology was negative. Cytology was negative for malignancy and flow cytometry was normal. EEG showed diffuse, bifrontal predominant 2–3 Hz delta slowing with intermittent superimposed 5–6 Hz frequencies, consistent with encephalopathy. FLAIR changes on MRI Brain are shown in Fig. 1. The patient had a dramatic improvemen
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