Successful Treatment of Influenza-Associated Acute Necrotizing Encephalitis in an Adult Using High-Dose Oseltamivir and Methylprednisolone: Case Report and Literature Review

Ahmed Alsolami Kevin Shiley

Open Forum Infectious Diseases, Volume 4, Issue 3, 1 July 2017, ofx145,

07 August 2017

... Case Report

A 46-year-old male patient with no prior medical history presented in March 2016 with acute onset dry cough, sore throat, myalgia, and fever that developed 48 hours before admission. Family members reported that he became drowsy during the first day of illness, then more confused and weak the day after. There was no witnessed seizure activity at home or en route to the facility.
The patient resided with his wife and 3 children in Buffalo, New York. All household members had an influenza-like illness during the week. The patient worked in an office setting. He had no recent travel, contact with travelers, or animal exposures.
He took no medications except acetaminophen for fevers. He was never vaccinated against influenza....

In our case, several observations raise the possibility of a primary neurological insult from influenza infection. First, neurologic dysfunction ensued in the absence of other widespread organ dysfunction such as shock, multiple organ failure, DIC, or ARDS—making an overwhelming systemic insult an unlikely trigger for the rapid onset focal brain necrosis observed. Second, our patient failed to show improvement on standard doses of oseltamivir, but he improved shortly after using high-dose oseltamivir. Furthermore, symptoms recurred within 72 hours of discontinuation of high-dose oseltamivir, but they quickly resolved after restarting high-dose oseltamivir, which can indicate an ongoing viral brain insult. It is notable that the patient was still receiving steroids when the high-dose oseltamivir treatment was interrupted, but his second improvement phase occurred after restarting high-dose oseltamivir without reintroduction of steroids...