Rotavirus is a non-enveloped double-stranded RNA virus that causes severe gastroenteritis in children, but complications are rarely reported. Some reports have shown that rotavirus can induce diverse complications of the central nervous system, such as seizures, encephalopathy with a reversible splenial lesion, encephalitis, cerebral white matter abnormalities, and cerebellitis. Here, we present a 2-year-old patient with seizures, who had an isolated splenial lesion in the corpus callosum on neuroimaging, and the rotavirus antigen detected in faeces. © Lietuvos mokslu akademija, 2019. Other Abstract: ROTAVIRUSO SUKELTI TRAUKULIAI IR LAIKINAS DIDZIOSIOS SMEGENU JUNGTIES PAZEIDIMAS: SantraukaRotavirusas yra dvigrandes RNR virusas be apvalkalo, sukeliantis sunku vaiku gastroenterita, taciau apie komplikacijas pranesama retai. Kai kurie atveju aprasymai rodo, kad rotavirusas gali sukelti ivairias centrines nervu sistemos komplikacijas, tokias kaip traukuliai, encefalopatija su trumpalaikiu didziosios smegenu jungties pazeidimu, encefalitas, smegenu baltosios medziagos anomalijos ir cerebelitas. Cia pristatome dveju metu pacienta su traukuliais, kuriam laikinas didziosios smegenu jungties pazeidimas buvo nustatytas neurovaizdinimo metu, o rotaviruso antigenas aptiktas ismatose.Raktazodziai: rotavirusas, vaiku traukuliai, rotaviruso komplikacijos.publishersversionPeer reviewe

Feemster, Kristen A.

Gardovska, Dace

Laizane, Gunta

Nokalna, Ieva

Smane, Liene

Acta medica Lituanica

English

Rotavirus is a non-enveloped double-stranded RNA virus that causes severe gastroenteritis in children, but complications are rarely reported. Some reports have shown that rotavirus can induce diverse complications of the central nervous system, such as seizures, encephalopathy with a reversible splenial lesion, encephalitis, cerebral white matter abnormalities, and cerebellitis. Here, we present a 2-year-old patient with seizures, who had an isolated splenial lesion in the corpus callosum on neuroimaging, and the rotavirus antigen detected in faeces. © Lietuvos mokslu akademija, 2019. Other Abstract: ROTAVIRUSO SUKELTI TRAUKULIAI IR LAIKINAS DIDZIOSIOS SMEGENU JUNGTIES PAZEIDIMAS: SantraukaRotavirusas yra dvigrandes RNR virusas be apvalkalo, sukeliantis sunku vaiku gastroenterita, taciau apie komplikacijas pranesama retai. Kai kurie atveju aprasymai rodo, kad rotavirusas gali sukelti ivairias centrines nervu sistemos komplikacijas, tokias kaip traukuliai, encefalopatija su trumpalaikiu didziosios smegenu jungties pazeidimu, encefalitas, smegenu baltosios medziagos anomalijos ir cerebelitas. Cia pristatome dveju metu pacienta su traukuliais, kuriam laikinas didziosios smegenu jungties pazeidimas buvo nustatytas neurovaizdinimo metu, o rotaviruso antigenas aptiktas ismatose.Raktazodziai: rotavirusas, vaiku traukuliai, rotaviruso komplikacijos.Peer reviewe

Riga Stradins university

ACTA MEDICA LITUANICA. 2019. Vol. 26. No. 2. P. 113–117© Lietuvos mokslų akademija, 2019Rotavirus-associated seizures and reversible corpus callosum lesion*Correspondence to: Gunta Laizane, Department of Infectiology, Children’s Clinical University Hospital, Vienibas gatve 45, Riga 1004, Latvia. Email: gunta.laizane@rsu.lvGunta Laizane1, 2, Liene Smane2, Ieva Nokalna1, 2, Dace Gardovska1, 2, Kristen A. Feemster31 Riga Stradins University, Riga, Latvia2 Department of Infectiology, Children’s Clinical University Hospital, Riga, Latvia3 Children’s Hospital of Philadelphia, Philadelphia Department of Public Health Philadelphia, USARotavirus is a non-enveloped double-stranded RNA virus that causes severe gastroenteritis in children, but complications are rarely reported. Some reports have shown that rotavirus can in-duce diverse complications of the central nervous system, such as seizures, encephalopathy with a reversible splenial lesion, enceph-alitis, cerebral white matter abnormalities, and cerebellitis. Here, we present a 2-year-old patient with seizures, who had an isolated splenial lesion in the corpus callosum on neuroimaging, and the rotavirus antigen detected in faeces.KEYWORDS: rotavirus, paediatric, seizures, rotavirus complica-tionsCASE PRESENTATIONA previously healthy 2-year-old boy was hospital-ized in the Emergency Department (ED) of the Children’s Clinical University Hospital in Riga, af-ter suffering several consecutive generalized tonic seizures that lasted approximately three minutes each and were followed by disturbance of con-sciousness in which the patient initially did not recognize his parents and had difficulties speak-ing. The seizures were preceded by a 24-hour history of mild diarrhoea, vomiting, and a fever. The patient was afebrile during seizure episode. The patient’s younger sister also had diarrhoea, vomiting, and a fever. He was completely immu-nized according to the recommendations of the National Immunization Programme (with the ex-ception of the Rotavirus vaccine). On admission, 114 Gunta Laizane, Liene Smane, Ieva Nokalna, Dace Gardovska, Kristen A. Feemsterbody temperature was 37.4°C, the heart rate 150 beats/min, the respiratory rate 26–30 breaths/min, and SpO2 was 99%. Signs of mild dehydra-tion were present, the abdomen was soft by pal-pation and meteorized, active bowel sounds were auscultated. There were no significant changes in patient’s full blood count and formula, cerebro-spinal fluid and levels of electrolytes that were performed on admission. Neurological exami-nation did not reveal any focal abnormality, and the boy was transferred to the ward of infectious diseases where supportive therapy was initiated. While the boy was in the hospital, he had anoth-er afebrile generalized tonic seizure episode fol-lowed by disturbance of consciousness, and after the second episode he was transferred to the ICU. After 24 hours of observation in the ICU, the boy was transferred back to the ward. At recommen-dations of a neurologist, treatment with furosem-ide and phenobarbital was initiated, and MRI and EEG were prescribed. After the therapy was initi-ated, the patient had a short episode of facial mus-cle spasms but no further neurological symptoms developed. The rotavirus antigen was detected in the stool sample at the time of presentation to the ED. Electroencephalography was without pathol-ogy. MRI showed a transient intensified signal on the splenium of corpus callosum (Fig. 1). The patient was evaluated by an ophthalmologist and a  neurologist and neither examination revealed any abnormalities. The patient was discharged five days later in stable overall condition, with recommendations to stay under the supervision of a general practitioner and to continue therapy with phenobarbital for four days. Repeat MRI was recommended after two months. Follow-up MRI revealed no pathology, and no signs of neurologic complications were evident upon discharge or af-ter two months (Fig. 2).DISCUSSIONGroup A rotavirus infection is the leading cause of severe acute gastroenteritis in children (3). While infection is generally not associated with extra- gastrointestinal complications, rotavirus gastro-enteritis has been reported to be accompanied by neurological manifestations, such as febrile sei-zures, afebrile seizures, encephalopathy, meningo-encephalitis, or cerebellitis (1). Transient corpus callosum lesions, similar to the lesion found in our patient, have been reported in the cases of neuro-logical manifestations associated with influenza A virus, parainfluenza virus, mumps, Epstein-Barr virus, rotavirus, and adenovirus infections (4–9). These lesions are described in association with many Fig. 1. Axial diffusion-weighted magnetic resonance images (DWI) demonstrate high signal intensity on the sple nium of the corpus callosum on day 2 of hospitalization115Rotavirus-associated seizures and reversible corpus callosum lesiondiverse clinical conditions including the use of an-tiepileptic drugs, hypoglycaemia, and are related to migraine with aura in children (10–12). Recent case reports illustrate that rotavirus RNA may be found in the cerebrospinal fluid (CSF) of patients with gastroenteritis and neurological symptoms (13, 14). However, the pathophysiology of the in-volvement of the central nervous system has not been explained yet. There are several hypotheses. Detection of rotavirus RNA or the antigen by PCR from CSF of rotavirus-positive patients with neu-rological manifestations supports the hypothesis of direct viral invasion (13, 14). Another explana-tion focuses on possible contamination at the time of lumbar puncture or in the testing laboratory, or carriage of rotavirus RNA in CSF lymphocytes (15), although the case reported by Lynch et al. (15) did not support this hypothesis. In their case report, the detection of rotavirus RNA in two CSF samples obtained three weeks apart makes fae-cal contamination unlikely. Rotavirus infection of neurons has been demonstrated in vitro and in vivo (16–18). However, the lack of evidence of rotavirus in the CSF in many cases of rotavirus-associated neurological manifestations suggests an alternative mechanism. Another possible explanation of neu-rological manifestations could be associated with secondary involvement of the CNS. During infec-tion, nonstructural protein-4 (NSP4) destroys en-terocytes and toxins entering the bloodstream via damaged intestinal epithelium. In addition, rotavi-rus infection destroys healthy intestinal brush bor-der enzymes. NSP4 has been shown to have direct toxic effects on the gastrointestinal epithelium and lamina propria (19). In this case report, the examination of the rota-virus antigen was not performed in CSF. However, imaging results support the association of rotavirus with corpus callosum lesions in children with se-vere acute gastroenteritis.CONCLUSIONSOur case report demonstrates encephalopathy as-sociated with rotavirus infection with transient corpus callosum lesion. The patient’s neurological symptoms resolved after therapy without any com-plications. This and other reported cases suggest that once the intensified signal of the splenium is detected, a mild course can be expected without major complications and a good prognosis.Received 9 April 2019 Accepted 4 June 2019Fig. 2. Normal axial diffusion-weighted magnetic resonance image (DWI) two months after discharge116 Gunta Laizane, Liene Smane, Ieva Nokalna, Dace Gardovska, Kristen A. FeemsterReferences 1. Dennehy PH. Rotavirus infection: an update on management and prevention. Adv Pediatr. 2012; 59(1): 47–74. 2. Takanashi J. Wide range of CNS manifestations of rotavirus infection. Brain Dev. 2011 Jan; 33(1): 9. 3. Dennehy PH. Rotavirus infection: a disease of the past? Infect Dis Clin North Am. 2015 Dec; 29(4): 617–35. 4. Iwata A, Matsubara K, Nigami H, Kamimura K, Fukaya T. Reversible splenial lesion associated with novel influenza A (H1N1) viral infection. Pediatr Neurol. 2010 Jun; 42(6): 447–50. 5. Abenhaim Halpern L, Agyeman P, Steinlin M, El-Koussy M, Grunt S. 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Microtubule-associated protein 2 appears in axons of cultured dorsal root ganglia and spinal cord neurons after rotavirus in-fection. J Neurosci Res. 1993 Oct 1; 36(2): 173–82. 18. Gregorio L, Sutton CL, Lee DA. Central pontine myelinolysis in a previously healthy 4-year-old child with acute rotavirus gastroenteritis. Pediatrics. 1997 May; 99(5): 738–43. 19. Rodríguez-Díaz J, Banasaz M, Istrate C, Buesa J, Lundgren O, Espinoza F, Sundqvist T, Rottenberg M, Svensson L. Role of nitric oxide during rotavirus infection. J Med Virol. 2006 Jul; 78(7): 979–85.117Rotavirus-associated seizures and reversible corpus callosum lesionGunta Laizane, Liene Smane, Ieva Nokalna, Dace Gardovska, Kristen A. FeemsterROTAVIRUSO SUKELTI TRAUKULIAI IR LAIKINAS DIDŽIOSIOS SMEGENŲ JUNGTIES PAŽEIDIMASSantraukaRotavirusas yra dvigrandės RNR virusas be apvalkalo, sukeliantis sunkų vaikų gastroenteritą, tačiau apie kom-plikacijas pranešama retai. Kai kurie atvejų aprašymai rodo, kad rotavirusas gali sukelti įvairias centrinės ner-vų sistemos komplikacijas, tokias kaip traukuliai, ence-falopatija su trumpalaikiu didžiosios smegenų jungties pažeidimu, encefalitas, smegenų baltosios medžiagos anomalijos ir cerebelitas. Čia pristatome dvejų metų pa-cientą su traukuliais, kuriam laikinas didžiosios smege-nų jungties pažeidimas buvo nustatytas neurovaizdini-mo metu, o rotaviruso antigenas aptiktas išmatose.Raktažodžiai: rotavirusas, vaikų traukuliai, rotavi-ruso komplikacijos

Rotavirus-associated seizures and reversible corpus callosum lesion

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Rotavirus-associated seizures and reversible corpus callosum lesion

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