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International audience; PURPOSE: Infectious encephalitis (IE) is a severe disease which requires intensive care unit (ICU) admission in up to 50% of cases. We aimed to describe characteristics, management and outcomes of IE patients who required ICU admission. MATERIALS AND METHODS: Ancillary study focusing on patients with ICU admission within the ENCEIF cohort, a French prospective observational multicentre study. The primary criteria for outcome was the functional status at hospital discharge, categorized using the Glasgow outcome scale (GOS). Logistic regression model was used to identify risk factors for poor outcome, defined as a GOS ≤ 3. RESULTS: We enrolled 198 ICU patients with IE. HSV was the primary cause (n = 72, 36% of all IE, 53% of IE with microbiological documentation). Fifty-two patients (26%) had poor outcome at hospital discharge, including 22 deaths (11%). Immunodeficiency, supratentorial focal signs on admission, lower cerebrospinal fluid (CSF) white cells count (2 days were independent predictors of poor outcome. CONCLUSION: HSV is the primary cause of IE requiring ICU admission. IE patients admitted in ICU have a poor prognosis with 11% of in-hospital mortality and 15% of severe disabilities in survivors at discharge.

Background New diagnostic tools have been developed to improve the diagnosis of infectious encephalitis. Using a prospective cohort of encephalitis patients, our objective was to identify possible clusters of patients with similar patterns among encephalitis of unknown cause (EUC) and to describe to what extent a patient’s initial presentation may be predictive of encephalitis etiology, particularly herpes simplex virus (HSV) and varicella-zoster virus (VZV). Methods The National Cohort of Infectious Encephalitis in France is an ongoing prospective cohort study implemented in France in 2016. Patients who present with documented or suspected acute infectious encephalitis were included. Focusing on the variables that describe the initial presentation, we performed a factor analysis of mixed data (FAMD) to investigate a pattern of association between the initial presentation of a patient and the etiologic pathogen. Results As of 1 August 2018, data from 349 patients were analyzed. The most frequent pathogens were HSV (25%), VZV (11%), tick-borne encephalitis virus (6%), Listeria (5%), influenza virus (3%), and EUC (34%). Using the FAMD, it was not possible to identify a specific pattern related to the group of EUC. Age, temporal or hemorrhagic lesions, and cerebral spinal fluid lymphocytosis were significantly associated with HSV/VZV encephalitis. Conclusions No initial clinical/imaging/biology pattern was identified at admission among EUC, despite the improvement in diagnostic tools. In this context, the recommendation for a universal, early, probabilistic, initial treatment against HSV and VZV is still relevant, regardless of the initial clinical presentation of the encephalitis.

Background: 5-Fluorouracil (5-FU) and its oral prodrug capecitabine have been rarely but consistently associated with acute central nervous system toxicity, including transient leukoencephalopathies involving the splenium of the corpus callosum. Methods: We performed a retrospective search in the French Pharmacovigilance database (FPDB) (January 1985−July 2020) for adult patients affected by solid cancers who developed acute toxic leukoencephalopathies with splenial lesions following treatment with 5-FU or capecitabine. A comprehensive review of the literature helped to circumstantiate our findings. Results: Our research in the FPDB identified six patients who, within 3days from their first cycle of 5-FU or capecitabine, developed acute neurological symptoms, including gait ataxia (n=4), dysarthria (n=3), dysmetria (n=2), headache (n=2), and confusion (n=2). Brain magnetic resonance imaging (MRI) showed T2/FLAIR (fluid-attenuated inversion recovery) hyperintensities in the corpus callosum, with diffusion restriction and no contrast enhancement, generally accompanied by additional alterations in the bilateral supratentorial white matter (n=5). All patients discontinued the agent supposedly responsible for the toxicity and experienced full recovery after a median of 8.5days from symptom onset. Control MRI showed a progressive normalization of acute MRI abnormalities. Literature review identified 26 cases with similar clinical and paraclinical characteristics. A single patient from the literature resumed 5-FU at a lower dose, with no recurrent toxicity. Conclusions: 5-FU and capecitabine might be responsible for acute leukoencephalopathies with transient splenial lesions that are generally reversible upon drug discontinuation. Resuming the agent responsible for toxicity might be feasible in selected cases, after having excluded dihydropyrimidine dehydrogenase deficiency, if expected benefits outweigh the risks.

Introduction La neuroborreliose de Lyme apparait en phase secondaire de la maladie dans 3 a 15 % des cas et est caracterisee par des douleurs neuropathiques, une meningoradiculite et l’atteinte des nerfs crâniens dans la majorite des cas. Observation Nous rapportons le cas d’une patiente de 77 ans avec cervicalgie et nevralgies C5 bilaterales d’installation brutale, intense et necessitant des morphiniques suivies d’un deficit moteur proximal et symetrique des deux membres superieurs sans amyotrophie. L’IRM cervicale realisee en urgence n’a pas montre d’infarctus medullaire anterieur ni de conflit disco-radiculaire. La ponction lombaire (PL) retrouvait une meningite lymphocytaire (45 elements/mm3) et une hyperproteinorachie a 1,05 g/l. L’EMG etait en faveur d’une atteinte radiculaire C5 bilaterale plus marquee a droite sans signe de demyelinisation en stimulodetection. L’IRM des plexus brachiaux a montre une modification moderee diffuse du signal STIR des deux plexus brachiaux avec rehaussement lineaire proximal de C5 droit et dans moindre mesure des troncs superieurs et intermediaires gauches, compatible avec une atteinte inflammatoire mais non infiltrative. La serologie de Lyme est revenue positive dans le sang (confirmee en Immun blot) et le LCR. Un traitement antibiotique par ceftriaxone a permis d’ameliorer rapidement les douleurs neuropathiques. Le suivi a 3 mois a confirme la bonne evolution clinique avec une recuperation motrice complete. Discussion Une diplegie brachiale douloureuse revelatrice d’une maladie de Lyme est exceptionnelle. Dans le cas present, le diagnostic de certitude a pu etre pose sur les resultats de la PL, la serologie positive dans le sang et le LCR et une excellente reponse aux antibiotiques. L’IRM des plexus brachiaux a permis en outre d’orienter vers une atteinte inflammatoire/infectieuse avant meme le retour des serologies. Conclusion La neurroborreliose de Lyme peut revetir de multiples formes. Face a une diplegie brachiale douloureuse, un infarctus medullaire, une infiltration neoplasique (lymphome) voir un syndrome de Parsonage–Turner bilateral doivent etre evoque et elimine.