Neuromyelitis optica spectrum disorder associated with Zika virus infection

Abstract

, a healthy 35-year-old Brazilian man with a medical history of dengue fever 18 months prior (confirmed by serology at the time) developed fever, a sore throat, myalgia, and arthralgia. Four days later, he was hospitalized with urinary retention, proximal paraparesis (Medical Research Council [MRC] grade 4), and paresthesias in lower limbs and face. On the first day of hospitalization, sagittal short T1 inversion recovery (STIR) spine MRI showed hyperintense, nonenhancing lesions between T1-T4 and T6-T9 compatible with an acute myelitis (figure, A). Brain MRI was normal. Lumbar puncture revealed 1/mm 3 cells, 56 mg/dL protein, 60 mg/dL glucose, and presence of oligoclonal bands. Immunoglobulin G (IgG) index was 0.55. Zika virus (ZIKV) PCR was positive in CSF, blood, urine, and saliva. PCR in the CSF for other viruses, including herpes, dengue (DENV), chikungunya, yellow fever, West Nile, and Saint Louis encephalitis, were all negative. Blood aquaporin-4 IgG (AQP4-IgG) was negative. Rheumatologic disease and other infections, including syphilis, hepatitis, HIV, cytomegalovirus, Epstein-Barr virus, and tuberculosis, were all negative in serologic testing. Methylprednisolone (1 g/d IV for 5 days) was started on the second day of hospitalization. One day later, the patient deteriorated, with increased weakness of the legs (MRC 1), bilateral Babinski sign and ankle clonus, a T2 sensory level, oscillatory vertigo with central pattern nystagmus, constipation, vomiting, somnolence, and discrete hearing loss. Brain MRI 7 days after admission revealed hyperintensity in the pons, superior and middle left cerebellar peduncle, and periependymal lesions on T2-weighted fluid-attenuated inversion recovery (FLAIR) sequences (figure, B). At this time, the patient met the criteria 1 for NMOSD with negative AQP4-IgG based on the presence of acute brainstem syndrome with periependymal lesion and acute myelitis with a compatible MRI (intramedullary lesion extending over 3 segments). After corticosteroid therapy, he received IV immunoglobulin for 5 days (2 g/ kg total dose) and was discharged with minor sensory impairment and partial recovery of bladder and bowel control, and was able to walk using a walker. The day after discharge, however, the patient returned with visual impairment, dyschromatopsia, afferent pupillary defect, and pain in the right eye (day 27). Another brain MRI showed hyperintense T2 signs of the right optic nerve and an extensive T1 gadolinium-enhancing lesion compromising at least 50% of the nerve length, compatible with optic neuritis (figure, C). Another methylprednisolone course was administered, and his visual acuity improved. Maintenance treatment with oral prednisone (60 mg/d) was started. After remaining stable for 1 month, the patient developed tactile and temperature allodynia of both arms (day 63). Sagittal STIR spinal MRI showed hyperintensities at C3 to C6 segments (figure, D). AQP4-IgG and ZIKV PCR in blood were negative. Anti-MOG was not available for testing. He received a third course of methylpre...

Does a patient with acquired arbovirus infection have a hearing impairment? A scoping review of hearing changes in an adult with Dengue, Chikungunya, and Zika

“…The studies were published between the years 2003 18 and 2022, 20 and most of them were produced in Brazil (n = 7 articles). 5 , 6 , 13 , 18 , 19 , 22 , 23 The most frequent study design was a case report in eight studies. 5 , 6 , 12 , 13 , 19 , 20 , 22 , 24 The sample size and mean age ranged in the studies from 1 5 , 12 , 19 , 20 , 22 to 227 25 participants and from 23 13 to 60 5 years of age.…”

“…Two studies mentioned neurological alterations associated with the researched arboviruses, one relating CHIKV 24 in a case of encephalitis in the brainstem and another pertinent to ZIKV 22 in a case of acute myelitis. However, the neurological issue was not assessed and was directly associated with the hearing alterations presented.…”

The clinical spectrum and immunopathological mechanisms underlying ZIKV-induced neurological manifestations

“…Another possible outcome of ZIKV infection is the occurrence of neuromyelitis optica spectrum disorder (NMOSD), recently characterized in a single patient [ 50 ]. NMOSD is a severe and debilitating condition that mostly affects the spinal cord.…”

Molecular mimicry between Zika virus and central nervous system inflammatory demyelinating disorders: the role of NS5 Zika virus epitope and PLP autoantigens

“…1 In addition, ZikV was detected by serology in cerebrospinal fluid (CSF), molecular and histopathological analysis of the brain, and amniotic fluid of microcephalic fetuses. 2,3 ZikV has also been associated with central nervous system (CNS) inflammatory demyelinating disorders (IDD) including optic neuritis, 4 neuromyelitis optica spectrum disorders (NMOSD), 5 transverse myelitis and acute disseminated encephalomyelitis (ADEM). 2 Our group has recently published a case in which the coexistence of the virus in the CNS of an MS patient led to the development of an ADEM-like episode.…”