MedPage today story.
Public health officials are reviewing reports of a small potential increase in neurological complications of influenza in children, especially a rapidly progressing and dangerous condition called acute necrotizing encephalopathy (ANE).
Adrienne Randolph, MD, MS, of Boston Children's Hospital, said she has reported 12 potential cases of influenza-related ANE to the Centers for Disease Control and Prevention's National Center for Immunization and Respiratory Diseases (NCIRD) over the past few weeks.
Randolph's position as a leader Pediatric Influenza Intensive Care Network gives her special insight into what is happening with flu complications in children across the country.
“There is not a single study that confirms that all of these cases are in fact acute necrotizing encephalopathy,” Randolph said. MedPage todayurging caution regarding preliminary conclusions. “That's why I notified the CDC of potential cases in the United States that I became aware of. They can investigate.”
She noted that the diagnosis of ANE can be challenging to make, requiring specific clinical features as well as imaging findings. That's why “whatever is done must be done systematically, with cases being scrutinized by experts,” she said.
However, Randolph said she doesn't remember seeing any flu-related ANEs in her areas last year.
A CDC spokesperson said this. MedPage today that the agency is “aware of isolated reports” of ANE associated with influenza A in children. “We do not have active surveillance of ANE, but we are reviewing the situation and will provide updates.”
Randolph said her NCIRD contacts “asked me smart questions and I sent them more information, and that was it.”
A doctor from one of the American centers spoke about this. MedPage today that a child died from influenza-related ANE at their facility this year. “Everything moved very quickly and she [went into a coma] and died due to complications,” said the source, whose name and location are being withheld to protect patient privacy. Before this, the child was healthy.
Andrew Silverman, MD, MHS, and Keith Van Haren, MD, of Stanford University School of Medicine in California, said they are aware of at least 10 cases of influenza-associated ANE in their state alone during last year's and current flu seasons.
“Although ANE is not a specifically reportable disease, it appears to be a genuine increase in cases,” Silverman said. MedPage today. Last year they treated a child for influenza-related ANE at Lucile Packard Children's Hospital at Stanford and published case report in Neurology.
That case was followed by “an unusual cluster of additional cases over the next few weeks, which sparked interest in a larger case series,” Van Haren said. MedPage today.
Silverman and Van Haren are collecting cases of influenza-related ANE and recently submitted a request to the International Society of Infectious Diseases' ProMED email listserv. Silverman said they are also seeking recommendations for enhanced surveillance of the disease, with the help of the California Department of Public Health.
Symptoms of ANE can include seizures and changes in mental status, and patients can slip into a coma, says Sue Hong Routson, MD, a pediatric neurointensivist at Johns Hopkins Children's Center in Baltimore.
“This is a type of fulminant cerebral edema in which the brain swells very quickly and in a very short period of time,” Routson said. MedPage today. “A child can come to the hospital and within a day or two his brain will swell so much that he will lose all his function.
Classic imaging findings in ANE include bilateral thalamic involvement, deep gray matter involvement, and sometimes brainstem involvement, she said.
Routson said her institution has had one case of ANE this year, as well as four other cases in children with neurological complications from influenza who did not have classic ANE findings on MRI or clinical progression.
Typically, she said she sees maybe one case of influenza with neurological complications each year: “I think we're seeing a lot more brain-related problems this year than I've seen in the past,” she said.
She noted that this is a “very active flu season” with “many flu-related illnesses.” [intensive care unit] reception” is happening right now.
Indeed, data from the Centers for Disease Control and Prevention (CDC) shows that flu incidence rates are as high as record highsurpassing even the 2009-2010 H1N1 pandemic season, said a CDC source who requested anonymity. MedPage today. “The percentage of outpatient visits associated with influenza-like illness as of the week ending February 1 is the highest ever, including higher than during the 2009 H1N1 pandemic,” the source said.
It's unclear whether the overall surge in flu cases could lead to an increase in rare complications, experts say. There is also the possibility of fewer vaccinations or perhaps less immunity as children may have been less exposed to the flu during the COVID-19 pandemic.
However, last year, Italian researchers reported an outbreak of influenza with ANE at the Meyer Children's Hospital in Florence, Italy. Seven children developed illness ranging from mild encephalopathy to ANE with coma and multiple organ failure. they are described in detail in the journal of the European CDC, Eurosupervision.
One of the children died, another remained minimally conscious, and the rest made a good or complete recovery.
The authors reported that all of the children tested positive for the 2009 pandemic strain of H1N1, although it is unclear what exactly caused the cluster of cases.
Clinicians have been on alert as H5N1 avian influenza spreads through dairy and poultry herds across the United States, with the total number of human cases reaching 68. according to the latest CDC data.
However, Randolph noted that any potential increase in neurological complications from influenza this year does not appear to be related to H5N1. Some of the 12 cases she reported to the CDC did have subtypes, she said, and turned out to be the 2009 pandemic H1N1 strain.
However, CDC sources said they feel in the dark about flu surveillance because they have not been allowed to communicate with key partners such as health care organizations.
“Normally we would be talking quite a bit with our clinical and other partners right now, but we can't talk to any of them because the new executive branch administration has ordered us to resign,” the source said.
Regarding H5N1 in particular, the source said the CDC isn't getting enough information about testing or subtyping, “so we don't have a good understanding of the situation.”
Randolph and Routson said that treatment for ANE, because it is considered an overreaction of the immune system, includes steroids, intravenous immunoglobulin and other immunomodulators such as anakinra (Kineret) and tocilizumab (Actemra).
They noted that disseminating information about a potential increase in cases could help local doctors better identify and treat the disease.
