Author
Ian J Hart
Other affiliations: Royal Liverpool and Broadgreen University Hospital NHS Trust
Bio: Ian J Hart is an academic researcher from Royal Liverpool University Hospital. The author has contributed to research in topics: Meningitis & Viral meningitis. The author has an hindex of 13, co-authored 28 publications receiving 970 citations. Previous affiliations of Ian J Hart include Royal Liverpool and Broadgreen University Hospital NHS Trust.
Topics: Meningitis, Viral meningitis, Hepatitis B, Chlamydia trachomatis, HBsAg
Papers
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01 May 2022
TL;DR: The longitudinal clinical course of monkeypox in a high-income setting, coupled with viral dynamics, and any adverse events related to novel antiviral therapies are described, to highlight the urgent need for prospective studies of antivirals for this disease.
590 citations
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TL;DR: A group of clinicians met in Liverpool in February 2008 to begin the development process for clinical care guidelines based around a similar simple algorithm, supported by an evidence base, whose implementation is hoped would improve the management of patients with suspected encephalitis.
312 citations
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TL;DR: The Liverpool approach to the investigation and treatment of adults with suspected viral encephalitis is discussed, and the Liverpool algorithm for investigation and Treatment of immunocompetent adults with suspicions of viral encephalitis is introduced.
Abstract: The management of patients with suspected viral encephalitis has been revolutionised in recent years with improved imaging and viral diagnostics, better antiviral and immunomodulatory therapies, and enhanced neurointensive care. Despite this, disasters in patient management are sadly not uncommon. While some patients are attacked with all known antimicrobials with little thought to investigation of the cause of their illness, for others there are prolonged and inappropriate delays before treatment is started. Although viral encephalitis is relatively rare, patients with suspected central nervous system (CNS) infections, who might have viral encephalitis, are not. In addition, the increasing number of immunocompromised patients who may have viral CNS infections, plus the spread of encephalitis caused by arthropod-borne viruses, present new challenges to clinicians. This article discusses the Liverpool approach to the investigation and treatment of adults with suspected viral encephalitis, and introduces the Liverpool algorithm for investigation and treatment of immunocompetent adults with suspected viral encephalitis (available at www.liv.ac.uk/braininfections).
172 citations
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University of Liverpool1, University Hospitals Bristol NHS Foundation Trust2, Royal Liverpool and Broadgreen University Hospital NHS Trust3, Boston Children's Hospital4, Nottingham University Hospitals NHS Trust5, Salford Royal NHS Foundation Trust6, University College London Hospitals NHS Foundation Trust7, Central Manchester University Hospitals NHS Foundation Trust8, Belfast Health and Social Care Trust9, Leeds Teaching Hospitals NHS Trust10
TL;DR: This surveillance study described a cohort of adults and children with neurological manifestations of influenza in adults andChildren in the United Kingdom from February 2011, with the majority of cases due to H1N1.
Abstract: Background The emergence of influenza A(H1N1) 2009 was met with increased reports of associated neurological manifestations. We aimed to describe neurological manifestations of influenza in adults and children in the United Kingdom that presented at this time. Methods A 2-year surveillance study was undertaken through the British adult and pediatric neurological surveillance units from February 2011. Patients were included if they met clinical case definitions within 1 month of proven influenza infection. Results Twenty-five cases were identified: 21 (84%) in children and 4 (16%) in adults. Six (29%) children had preexisting neurological disorders. Polymerase chain reaction of respiratory secretions identified influenza A in 21 (81%; 20 of which [95%] were H1N1) and influenza B in 4 (15%). Twelve children had encephalopathy (1 with movement disorder), 8 had encephalitis, and 1 had meningoencephalitis. Two adults had encephalopathy with movement disorder, 1 had encephalitis, and 1 had Guillain-Barre syndrome. Seven individuals (6 children) had specific acute encephalopathy syndromes (4 acute necrotizing encephalopathy, 1 acute infantile encephalopathy predominantly affecting the frontal lobes, 1 hemorrhagic shock and encephalopathy, 1 acute hemorrhagic leukoencephalopathy). Twenty (80%) required intensive care, 17 (68%) had poor outcome, and 4 (16%) died. Conclusions This surveillance study described a cohort of adults and children with neurological manifestations of influenza. The majority were due to H1N1. More children than adults were identified; many children had specific encephalopathy syndromes with poor outcomes. None had been vaccinated, although 8 (32%) had indications for this. A modified classification system is proposed based on our data and the increasing spectrum of recognized acute encephalopathy syndromes.
134 citations
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TL;DR: The high prevalence of hepatitis/HIV coinfections may impact on treatment with antiretroviral therapy, especially if there are unintended interruptions of therapy, and studies are needed to document the possible clinical impact on ART programmes.
123 citations
Cited by
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Erasmus University Rotterdam1, University of Pennsylvania2, Bethel University3, McMaster Children's Hospital4, National Institutes of Health5, Children's Hospital at Westmead6, University of California, San Francisco7, Kaiser Permanente Oakland Medical Center8, Claude Bernard University Lyon 19, Medical University of Vienna10, Kitasato University11, John Radcliffe Hospital12, Charité13, Cleveland Clinic14, Innsbruck Medical University15, Witten/Herdecke University16, Johns Hopkins University School of Medicine17, Catalan Institution for Research and Advanced Studies18
TL;DR: Through logical differential diagnosis, levels of evidence for autoimmune encephalitis (possible, probable, or definite) are achieved, which can lead to prompt immunotherapy.
Abstract: Summary Encephalitis is a severe inflammatory disorder of the brain with many possible causes and a complex differential diagnosis. Advances in autoimmune encephalitis research in the past 10 years have led to the identification of new syndromes and biomarkers that have transformed the diagnostic approach to these disorders. However, existing criteria for autoimmune encephalitis are too reliant on antibody testing and response to immunotherapy, which might delay the diagnosis. We reviewed the literature and gathered the experience of a team of experts with the aims of developing a practical, syndrome-based diagnostic approach to autoimmune encephalitis and providing guidelines to navigate through the differential diagnosis. Because autoantibody test results and response to therapy are not available at disease onset, we based the initial diagnostic approach on neurological assessment and conventional tests that are accessible to most clinicians. Through logical differential diagnosis, levels of evidence for autoimmune encephalitis (possible, probable, or definite) are achieved, which can lead to prompt immunotherapy.
2,391 citations
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University of Southampton1, University Hospital Southampton NHS Foundation Trust2, University of Newcastle3, National Institute for Health Research4, Walton Centre5, University of Liverpool6, King's College London7, University of Utah8, UCL Institute of Neurology9, University of Cambridge10, University of Edinburgh11, Manchester Academic Health Science Centre12, University of Oxford13, University College London14, Royal Victoria Infirmary15
TL;DR: This is the first nationwide, cross-specialty surveillance study of acute neurological and psychiatric complications of COVID-19 and provides valuable and timely data that are urgently needed by clinicians, researchers, and funders.
990 citations
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TL;DR: The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is of a scale not seen since the 1918 influenza pandemic and the proportion of infections leading to neurological disease will probably remain small.
Abstract: Summary Background The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is of a scale not seen since the 1918 influenza pandemic. Although the predominant clinical presentation is with respiratory disease, neurological manifestations are being recognised increasingly. On the basis of knowledge of other coronaviruses, especially those that caused the severe acute respiratory syndrome and Middle East respiratory syndrome epidemics, cases of CNS and peripheral nervous system disease caused by SARS-CoV-2 might be expected to be rare. Recent developments A growing number of case reports and series describe a wide array of neurological manifestations in 901 patients, but many have insufficient detail, reflecting the challenge of studying such patients. Encephalopathy has been reported for 93 patients in total, including 16 (7%) of 214 hospitalised patients with COVID-19 in Wuhan, China, and 40 (69%) of 58 patients in intensive care with COVID-19 in France. Encephalitis has been described in eight patients to date, and Guillain-Barre syndrome in 19 patients. SARS-CoV-2 has been detected in the CSF of some patients. Anosmia and ageusia are common, and can occur in the absence of other clinical features. Unexpectedly, acute cerebrovascular disease is also emerging as an important complication, with cohort studies reporting stroke in 2–6% of patients hospitalised with COVID-19. So far, 96 patients with stroke have been described, who frequently had vascular events in the context of a pro-inflammatory hypercoagulable state with elevated C-reactive protein, D-dimer, and ferritin. Where next? Careful clinical, diagnostic, and epidemiological studies are needed to help define the manifestations and burden of neurological disease caused by SARS-CoV-2. Precise case definitions must be used to distinguish non-specific complications of severe disease (eg, hypoxic encephalopathy and critical care neuropathy) from those caused directly or indirectly by the virus, including infectious, para-infectious, and post-infectious encephalitis, hypercoagulable states leading to stroke, and acute neuropathies such as Guillain-Barre syndrome. Recognition of neurological disease associated with SARS-CoV-2 in patients whose respiratory infection is mild or asymptomatic might prove challenging, especially if the primary COVID-19 illness occurred weeks earlier. The proportion of infections leading to neurological disease will probably remain small. However, these patients might be left with severe neurological sequelae. With so many people infected, the overall number of neurological patients, and their associated health burden and social and economic costs might be large. Health-care planners and policy makers must prepare for this eventuality, while the many ongoing studies investigating neurological associations increase our knowledge base.
884 citations
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Valley Hospital1, University College London2, UCL Institute of Neurology3, University of Liverpool4, Wexham Park Hospital5, University of Tübingen6, University of Oxford7, University College London Hospitals NHS Foundation Trust8, Mahosot Hospital9, Watford General Hospital10, University of Cambridge11, John Radcliffe Hospital12, Northwick Park Hospital13, University of Hertfordshire14, Imperial College Healthcare15, Queen Mary University of London16, Guy's and St Thomas' NHS Foundation Trust17
TL;DR: A case series of 43 patients with neurological complications of SARS-CoV-2 infection includes encephalopathies, encephalitis, acute disseminated encephalomyelitis with haemorrhagic change, transverse myelitis, ischaemic stroke, and Guillain-Barré syndrome.
Abstract: Preliminary clinical data indicate that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with neurological and neuropsychiatric illness. Responding to this, a weekly virtual coronavirus disease 19 (COVID-19) neurology multi-disciplinary meeting was established at the National Hospital, Queen Square, in early March 2020 in order to discuss and begin to understand neurological presentations in patients with suspected COVID-19-related neurological disorders. Detailed clinical and paraclinical data were collected from cases where the diagnosis of COVID-19 was confirmed through RNA PCR, or where the diagnosis was probable/possible according to World Health Organization criteria. Of 43 patients, 29 were SARS-CoV-2 PCR positive and definite, eight probable and six possible. Five major categories emerged: (i) encephalopathies (n = 10) with delirium/psychosis and no distinct MRI or CSF abnormalities, and with 9/10 making a full or partial recovery with supportive care only; (ii) inflammatory CNS syndromes (n = 12) including encephalitis (n = 2, para- or post-infectious), acute disseminated encephalomyelitis (n = 9), with haemorrhage in five, necrosis in one, and myelitis in two, and isolated myelitis (n = 1). Of these, 10 were treated with corticosteroids, and three of these patients also received intravenous immunoglobulin; one made a full recovery, 10 of 12 made a partial recovery, and one patient died; (iii) ischaemic strokes (n = 8) associated with a pro-thrombotic state (four with pulmonary thromboembolism), one of whom died; (iv) peripheral neurological disorders (n = 8), seven with Guillain-Barre syndrome, one with brachial plexopathy, six of eight making a partial and ongoing recovery; and (v) five patients with miscellaneous central disorders who did not fit these categories. SARS-CoV-2 infection is associated with a wide spectrum of neurological syndromes affecting the whole neuraxis, including the cerebral vasculature and, in some cases, responding to immunotherapies. The high incidence of acute disseminated encephalomyelitis, particularly with haemorrhagic change, is striking. This complication was not related to the severity of the respiratory COVID-19 disease. Early recognition, investigation and management of COVID-19-related neurological disease is challenging. Further clinical, neuroradiological, biomarker and neuropathological studies are essential to determine the underlying pathobiological mechanisms that will guide treatment. Longitudinal follow-up studies will be necessary to ascertain the long-term neurological and neuropsychological consequences of this pandemic.
839 citations
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Johns Hopkins University School of Medicine1, Brown University2, Vanderbilt University3, University of Michigan4, Centers for Disease Control and Prevention5, University of Toronto6, Public Health Agency of Canada7, Global Alliance for Rabies Control8, Boston University9, University of Alabama10, University of Sydney11, Public Health England12, University College London13, Newcastle University14, University of Manitoba15, Chinese Center for Disease Control and Prevention16, California Health and Human Services Agency17
TL;DR: A consensus document is presented that proposes a standardized case definition and diagnostic guidelines for evaluation of adults and children with suspected encephalitis and will serve as a practical aid to clinicians evaluating patients with suspectedEncephalitis.
Abstract: Background Encephalitis continues to result in substantial morbidity and mortality worldwide. Advances in diagnosis and management have been limited, in part, by a lack of consensus on case definitions, standardized diagnostic approaches, and priorities for research. Methods In March 2012, the International Encephalitis Consortium, a committee begun in 2010 with members worldwide, held a meeting in Atlanta to discuss recent advances in encephalitis and to set priorities for future study. Results We present a consensus document that proposes a standardized case definition and diagnostic guidelines for evaluation of adults and children with suspected encephalitis. In addition, areas of research priority, including host genetics and selected emerging infections, are discussed. Conclusions We anticipate that this document, representing a synthesis of our discussions and supported by literature, will serve as a practical aid to clinicians evaluating patients with suspected encephalitis and will identify key areas and approaches to advance our knowledge of encephalitis.
740 citations