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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Acute encephalitis is an infrequent neurologic emergency that can have devastating consequences&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is an illness characterised by neurologic impairment due to the inflammation of the cerebral parenchyma&#44; which may be due to various causes&#46; In the paediatric population&#44; it is usually caused by viral infection&#44; although the aetiology is not established in up to 62&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> We present the case of a toddler that received a diagnosis of tick-borne encephalitis &#40;TBE&#44; also known as Central European encephalitis&#41;&#46; We emphasise the need to include this disease in the differential diagnosis&#44; especially in children from endemic regions&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a boy aged 2 years that was unvaccinated due to parental refusal&#44; brought to the emergency department on account of somnolence and fever of 7 days&#8217; duration associated with headache and light and sound sensitivity with onset 5 days after returning to Spain from a 2-month trip to a rural area in north-east Austria&#46; The patient had experienced a few tick bites during the trip and a self-limited episode of fever without source a month before the current episode&#44; after which he had been asymptomatic for 3 weeks&#46; At admission&#44; he exhibited somnolence &#40;12 points in the Glasgow comma scale&#41; accompanied by irritability&#44; nuchal rigidity and ataxic gait&#46; Blood tests revealed leucocytosis &#40;21&#8239;200&#8239;cells&#47;mm<span class="elsevierStyleSup">3</span>&#41; with neutrophilia &#40;18&#8239;000&#8239;neutrophils&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#44; lymphopenia &#40;1900&#8239;lymphocytes&#47;mm<span class="elsevierStyleSup">3</span>&#41; and normal C-reactive protein and procalcitonin levels&#46; The findings of neuroimaging &#40;TC y RM&#41; normal&#46; The cerebrospinal fluid &#40;CSF&#41; analysis evinced lymphocytic pleocytosis &#40;125&#8239;lymphocytes&#47;mm<span class="elsevierStyleSup">3</span>&#44; 95&#37; mononuclear cells&#41; and increased protein levels in CSF &#40;47&#8239;mg&#47;dL&#41; with normal glucose levels&#46; A meningitis&#47;encephalitis panel&#44; FilmArray&#8482; &#40;bioM&#233;rieux&#44; Madrid&#44; Spain&#41;&#44; ruled out the main bacterial&#44; viral and fungal agents involved in central nervous system infections&#46; Suspicion of aseptic encephalitis of possible viral aetiology led to initiation of empirical treatment with acyclovir until a negative polymerase chain reaction &#40;PCR&#41; test ruled out the presence of herpes simplex virus&#46; The enterovirus PCR test was negative for the rectal swab and nasopharyngeal samples&#44; as were serologic tests for <span class="elsevierStyleItalic">Borrelia burgdorferi</span> and <span class="elsevierStyleItalic">Rickettsia conorii</span>&#46; The SARS-CoV-2 antibody test was positive for IgG and negative for IgM&#46; Due to the epidemiological history and the biphasic course of illness&#44; compatible with TBE&#44; tests were ordered to assess for this disease&#46; The immunohistochemical analysis of CSF &#40;EUROIMMUN&#44; L&#252;beck&#44; Germany&#41; did not detect antibodies against the virus&#44; and a generic real-time PRC test for detection of Flavivirus species was also negative&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However&#44; we found a four-fold increase of TBE-specific IgG antibodies compared to paired serum samples&#44; with positive IgM antibodies and no cross-reactivity to other flaviviruses&#44; such as West Nile virus or Japanese encephalitis virus&#44; which fulfilled the laboratory criteria for a confirmed case according to European guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In the first 48&#8239;h of the hospital stay&#44; the patient continued to be lethargic and ataxic&#44; with no other focal neurologic deficits&#46; At 72&#8239;h from admission&#44; the patient started to exhibit progressive improvement&#44; achieving full neurologic recovery by day 5&#46; The patient did not receive steroids or immunoglobulin therapy&#46; In the follow-up after discharge&#44; he remained asymptomatic and the neurologic examination was normal&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Tick-borne encephalitis is an infectious disease caused by a virus of the Flaviviridae family&#44; transmitted through the bite of ticks of species in the <span class="elsevierStyleItalic">Ixodes</span> genus&#44; of which 4 subtypes are known&#58; European&#44; Far-Eastern and Siberian&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> It is an important cause of encephalitis in Eastern and Central European countries&#44; northern China&#44; Mongolia and Russia&#46; However&#44; in recent years it has become an international public health problem due to the increase of travel to endemic areas&#44; with trips to high-risk rural areas in the Spring and Summer&#44; although there have also been reports of cases of secondary infection through the consumption of unpasteurised milk of infected goats&#44; sheep or cows&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Although ticks of <span class="elsevierStyleItalic">Ixodes</span> species are distributed throughout Europe&#44; including Spain&#44; there have been no reports of cases of TBE in Spain until April 2020&#44; when the first case of imported TBE due to consumption of contaminated milk was reported in a patient aged 18 years after a trip to Estonia&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The typical course of disease is biphasic&#46; After an incubation period of approximately 8 days&#44; the initial phase manifests with nonspecific symptoms such as fever&#44; asthenia or myalgia&#46; After 1&#8211;3 weeks of absent symptoms&#44; a third of infected individuals develop neurologic manifestations compatible with meningoencephalitis or encephalomyelitis&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Disease severity increases with age&#44; and the Far-Eastern subtype is associated with the poorest outcomes&#44; with a mortality of 20&#37;&#8211;40&#37; compared to 1&#37;&#8211;2&#37; for the European subtype&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> At present&#44; there is no specific treatment for TBE&#44; and management consists of supportive care&#46; Vaccination is the most effective method of prevention&#44; and has been recommended in Spain since 2008 for individuals that travel to endemic regions for outdoor activities&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Here&#44; we describe the second known case of imported TBE in Spain&#44; which highlights the importance of epidemiological surveillance of emerging endemic infectious diseases and the need of vaccination as highly effective tools for the prevention of diseases like TBE&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Izurieta-Pacheco AC&#44; Nou-Fontanet L&#44; Nascimento A&#44; Mart&#237;nez MJ&#44; Velasco-Arnaiz E&#46; Encefalitis centroeuropea&#46; Descripci&#243;n del primer caso importado en Espa&#241;a en un paciente pedi&#225;trico&#46; An Pediatr &#40;Barc&#41;&#46; 2022&#59;96&#58;68&#8211;69&#46;</p>"
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Scientific Letter
Tick-borne encephalitis. Description of the first imported case in Spain in a paediatric patient
Encefalitis centroeuropea. Descripción del primer caso importado en España en un paciente pediátrico
Ana Carolina Izurieta-Pachecoa,
Corresponding author
anacaroizurieta@gmail.com

Corresponding author.
, Laia Nou-Fontaneta, Andrés Nascimentob, Miguel J. Martínezc,d, Eneritz Velasco-Arnaize
a Servicio de Pediatría, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
b Servicio de Neurología Pediátrica, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
c Servicio de Microbiología, Hospital Clínic, Barcelona, Spain
d Instituto de Salud Global de Barcelona (Isglobal), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
e Unidad de Infectología, Servicio de Pediatría, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Acute encephalitis is an infrequent neurologic emergency that can have devastating consequences&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is an illness characterised by neurologic impairment due to the inflammation of the cerebral parenchyma&#44; which may be due to various causes&#46; In the paediatric population&#44; it is usually caused by viral infection&#44; although the aetiology is not established in up to 62&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> We present the case of a toddler that received a diagnosis of tick-borne encephalitis &#40;TBE&#44; also known as Central European encephalitis&#41;&#46; We emphasise the need to include this disease in the differential diagnosis&#44; especially in children from endemic regions&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a boy aged 2 years that was unvaccinated due to parental refusal&#44; brought to the emergency department on account of somnolence and fever of 7 days&#8217; duration associated with headache and light and sound sensitivity with onset 5 days after returning to Spain from a 2-month trip to a rural area in north-east Austria&#46; The patient had experienced a few tick bites during the trip and a self-limited episode of fever without source a month before the current episode&#44; after which he had been asymptomatic for 3 weeks&#46; At admission&#44; he exhibited somnolence &#40;12 points in the Glasgow comma scale&#41; accompanied by irritability&#44; nuchal rigidity and ataxic gait&#46; Blood tests revealed leucocytosis &#40;21&#8239;200&#8239;cells&#47;mm<span class="elsevierStyleSup">3</span>&#41; with neutrophilia &#40;18&#8239;000&#8239;neutrophils&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#44; lymphopenia &#40;1900&#8239;lymphocytes&#47;mm<span class="elsevierStyleSup">3</span>&#41; and normal C-reactive protein and procalcitonin levels&#46; The findings of neuroimaging &#40;TC y RM&#41; normal&#46; The cerebrospinal fluid &#40;CSF&#41; analysis evinced lymphocytic pleocytosis &#40;125&#8239;lymphocytes&#47;mm<span class="elsevierStyleSup">3</span>&#44; 95&#37; mononuclear cells&#41; and increased protein levels in CSF &#40;47&#8239;mg&#47;dL&#41; with normal glucose levels&#46; A meningitis&#47;encephalitis panel&#44; FilmArray&#8482; &#40;bioM&#233;rieux&#44; Madrid&#44; Spain&#41;&#44; ruled out the main bacterial&#44; viral and fungal agents involved in central nervous system infections&#46; Suspicion of aseptic encephalitis of possible viral aetiology led to initiation of empirical treatment with acyclovir until a negative polymerase chain reaction &#40;PCR&#41; test ruled out the presence of herpes simplex virus&#46; The enterovirus PCR test was negative for the rectal swab and nasopharyngeal samples&#44; as were serologic tests for <span class="elsevierStyleItalic">Borrelia burgdorferi</span> and <span class="elsevierStyleItalic">Rickettsia conorii</span>&#46; The SARS-CoV-2 antibody test was positive for IgG and negative for IgM&#46; Due to the epidemiological history and the biphasic course of illness&#44; compatible with TBE&#44; tests were ordered to assess for this disease&#46; The immunohistochemical analysis of CSF &#40;EUROIMMUN&#44; L&#252;beck&#44; Germany&#41; did not detect antibodies against the virus&#44; and a generic real-time PRC test for detection of Flavivirus species was also negative&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However&#44; we found a four-fold increase of TBE-specific IgG antibodies compared to paired serum samples&#44; with positive IgM antibodies and no cross-reactivity to other flaviviruses&#44; such as West Nile virus or Japanese encephalitis virus&#44; which fulfilled the laboratory criteria for a confirmed case according to European guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In the first 48&#8239;h of the hospital stay&#44; the patient continued to be lethargic and ataxic&#44; with no other focal neurologic deficits&#46; At 72&#8239;h from admission&#44; the patient started to exhibit progressive improvement&#44; achieving full neurologic recovery by day 5&#46; The patient did not receive steroids or immunoglobulin therapy&#46; In the follow-up after discharge&#44; he remained asymptomatic and the neurologic examination was normal&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Tick-borne encephalitis is an infectious disease caused by a virus of the Flaviviridae family&#44; transmitted through the bite of ticks of species in the <span class="elsevierStyleItalic">Ixodes</span> genus&#44; of which 4 subtypes are known&#58; European&#44; Far-Eastern and Siberian&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> It is an important cause of encephalitis in Eastern and Central European countries&#44; northern China&#44; Mongolia and Russia&#46; However&#44; in recent years it has become an international public health problem due to the increase of travel to endemic areas&#44; with trips to high-risk rural areas in the Spring and Summer&#44; although there have also been reports of cases of secondary infection through the consumption of unpasteurised milk of infected goats&#44; sheep or cows&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Although ticks of <span class="elsevierStyleItalic">Ixodes</span> species are distributed throughout Europe&#44; including Spain&#44; there have been no reports of cases of TBE in Spain until April 2020&#44; when the first case of imported TBE due to consumption of contaminated milk was reported in a patient aged 18 years after a trip to Estonia&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The typical course of disease is biphasic&#46; After an incubation period of approximately 8 days&#44; the initial phase manifests with nonspecific symptoms such as fever&#44; asthenia or myalgia&#46; After 1&#8211;3 weeks of absent symptoms&#44; a third of infected individuals develop neurologic manifestations compatible with meningoencephalitis or encephalomyelitis&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Disease severity increases with age&#44; and the Far-Eastern subtype is associated with the poorest outcomes&#44; with a mortality of 20&#37;&#8211;40&#37; compared to 1&#37;&#8211;2&#37; for the European subtype&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> At present&#44; there is no specific treatment for TBE&#44; and management consists of supportive care&#46; Vaccination is the most effective method of prevention&#44; and has been recommended in Spain since 2008 for individuals that travel to endemic regions for outdoor activities&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Here&#44; we describe the second known case of imported TBE in Spain&#44; which highlights the importance of epidemiological surveillance of emerging endemic infectious diseases and the need of vaccination as highly effective tools for the prevention of diseases like TBE&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Izurieta-Pacheco AC&#44; Nou-Fontanet L&#44; Nascimento A&#44; Mart&#237;nez MJ&#44; Velasco-Arnaiz E&#46; Encefalitis centroeuropea&#46; Descripci&#243;n del primer caso importado en Espa&#241;a en un paciente pedi&#225;trico&#46; An Pediatr &#40;Barc&#41;&#46; 2022&#59;96&#58;68&#8211;69&#46;</p>"
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Article information
ISSN: 23412879
Original language: English
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