Letter to the Editor
HHV-6 meningoencephalitis in an immunocompetent patient with influenza virus co-infection
Meningoencefalitis por HHV-6 en un paciente inmunocompetente asociado a coinfección por virus de la gripe
R. Jiménez Bolaños
, A. Díaz Díaz, I. Sánchez-Miranda Román, J.P. Castellano Santana
Corresponding author
Servicio de Neurología, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
Read
2682
Timeswas read the article
359
Total PDF
2323
Total HTML
Share statistics
array:25 [ "pii" => "S2173580821000274" "issn" => "21735808" "doi" => "10.1016/j.nrleng.2020.06.006" "estado" => "S300" "fechaPublicacion" => "2021-05-01" "aid" => "1445" "copyright" => "Sociedad Española de Neurología" "copyrightAnyo" => "2020" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "cor" "cita" => "Neurologia. 2021;36:329-30" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:20 [ "pii" => "S0213485320302000" "issn" => "02134853" "doi" => "10.1016/j.nrl.2020.06.007" "estado" => "S300" "fechaPublicacion" => "2021-05-01" "aid" => "1445" "copyright" => "Sociedad Española de Neurología" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "cor" "cita" => "Neurologia. 2021;36:329-30" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "es" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta al Editor</span>" "titulo" => "Meningoencefalitis por HHV-6 en un paciente inmunocompetente asociado a coinfección por virus de la gripe" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "329" "paginaFinal" => "330" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "HHV-6 meningoencephalitis in an immunocompetent patient associated with influenza virus co-infection" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "R. Jiménez Bolaños, A. Díaz Díaz, I. Sánchez-Miranda Román, J.P. Castellano Santana" "autores" => array:4 [ 0 => array:2 [ "nombre" => "R." "apellidos" => "Jiménez Bolaños" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Díaz Díaz" ] 2 => array:2 [ "nombre" => "I." "apellidos" => "Sánchez-Miranda Román" ] 3 => array:2 [ "nombre" => "J.P." "apellidos" => "Castellano Santana" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173580821000274" "doi" => "10.1016/j.nrleng.2020.06.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173580821000274?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213485320302000?idApp=UINPBA00004N" "url" => "/02134853/0000003600000004/v1_202104210950/S0213485320302000/v1_202104210950/es/main.assets" ] ] "itemSiguiente" => array:20 [ "pii" => "S2173580821000262" "issn" => "21735808" "doi" => "10.1016/j.nrleng.2020.06.005" "estado" => "S300" "fechaPublicacion" => "2021-05-01" "aid" => "1444" "copyright" => "Sociedad Española de Neurología" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "cor" "cita" => "Neurologia. 2021;36:330-2" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Jansen-de Vries syndrome. First case diagnosed in Spain" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "330" "paginaFinal" => "332" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome de Jansen-de Vries. Primer caso diagnosticado en España" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 689 "Ancho" => 905 "Tamanyo" => 136982 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Small hands with brachydactyly (especially in distal phalanxes) and clinodactyly.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "D. Martín Fernández-Mayoralas, A.L. Fernández-Perrone, A. Jiménez De Domingo, A. Alba Menéndez, A. Fernández-Jaén" "autores" => array:5 [ 0 => array:2 [ "nombre" => "D." "apellidos" => "Martín Fernández-Mayoralas" ] 1 => array:2 [ "nombre" => "A.L." "apellidos" => "Fernández-Perrone" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Jiménez De Domingo" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Alba Menéndez" ] 4 => array:2 [ "nombre" => "A." "apellidos" => "Fernández-Jaén" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0213485320301997" "doi" => "10.1016/j.nrl.2020.06.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213485320301997?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173580821000262?idApp=UINPBA00004N" "url" => "/21735808/0000003600000004/v1_202105110731/S2173580821000262/v1_202105110731/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S2173580821000298" "issn" => "21735808" "doi" => "10.1016/j.nrleng.2020.06.008" "estado" => "S300" "fechaPublicacion" => "2021-05-01" "aid" => "1446" "copyright" => "Sociedad Española de Neurología" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "cor" "cita" => "Neurologia. 2021;36:327-9" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Periventricular heterotopia: broadening of the clinical spectrum of the clathrin 1 gene <span class="elsevierStyleItalic">(CLTC)</span> pathogenic variants" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "327" "paginaFinal" => "329" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Heterotopías periventriculares: ampliación del espectro clínico de las variantes patogénicas del gen de la clatrina 1 <span class="elsevierStyleItalic">(CLTC)</span>" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1205 "Ancho" => 905 "Tamanyo" => 194448 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Phenotype of the patient at the age of 11. Slightly elongated face, long palpebral fissures, midface hypoplasia, deep philtrum, and bulbous tip of the nose.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "D. Martín Fernández-Mayoralas, N. Muñoz Jareño, A. Alba Menéndez, A. Fernández-Jaén" "autores" => array:4 [ 0 => array:2 [ "nombre" => "D." "apellidos" => "Martín Fernández-Mayoralas" ] 1 => array:2 [ "nombre" => "N." "apellidos" => "Muñoz Jareño" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Alba Menéndez" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Fernández-Jaén" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0213485320302012" "doi" => "10.1016/j.nrl.2020.06.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213485320302012?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173580821000298?idApp=UINPBA00004N" "url" => "/21735808/0000003600000004/v1_202105110731/S2173580821000298/v1_202105110731/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "HHV-6 meningoencephalitis in an immunocompetent patient with influenza virus co-infection" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "329" "paginaFinal" => "330" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "R. Jiménez Bolaños, A. Díaz Díaz, I. Sánchez-Miranda Román, J.P. Castellano Santana" "autores" => array:4 [ 0 => array:4 [ "nombre" => "R." "apellidos" => "Jiménez Bolaños" "email" => array:1 [ 0 => "rayco.jb.92@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Díaz Díaz" ] 2 => array:2 [ "nombre" => "I." "apellidos" => "Sánchez-Miranda Román" ] 3 => array:2 [ "nombre" => "J.P." "apellidos" => "Castellano Santana" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Neurología, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Meningoencefalitis por HHV-6 en un paciente inmunocompetente asociado a coinfección por virus de la gripe" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Primary infection with human herpesvirus 6 (HHV-6) typically affects the paediatric population and usually manifests with fever and sudden exanthema.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Manifestation as encephalitis is infrequent.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> After primary infection, the virus remains latent in the brain tissue, mononuclear cells, and salivary glands, and may be reactivated in the event of immunosuppression (for instance, following transplantation, HIV infection, or lymphoproliferative syndrome).<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Reactivation may be asymptomatic or may manifest with fever and skin rash, and in exceptional cases with pneumonia, hepatitis, or encephalitis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However, the literature includes cases of meningoencephalitis in immunocompetent patients, occasionally associated with co-infection with other pathogens.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of an immunocompetent adult presenting meningoencephalitis in the context of co-infection with HHV-6 and influenza B virus.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Our patient is a 57-year-old man, a carrier of the factor V Leiden mutation, with history of meningoencephalitis of unknown aetiology, diagnosed 13 years previously, and lacunar ischaemic stroke that left no sequelae. A week after the onset of flu-like symptoms, he presented a 24-h history of fever, headache, neck pain, confusion, and generalised tonic-clonic seizures with subsequent incomplete recovery. The patient was transferred to the emergency department, where the examination revealed stupor, limited speech, neck rigidity, and fever of up to 40 °C. An emergency cerebrospinal fluid (CSF) analysis revealed mild lymphocytic pleocytosis (10 cells/μL), high protein levels (55 mg/dL), and normal glucose levels; a non-contrast brain computed tomography study showed normal results. We started empirical antibiotic and antiviral treatment with ceftriaxone, vancomycin, doxycycline, and aciclovir, and antiepileptic treatment with levetiracetam. Further laboratory analyses and a magnetic resonance imaging (MRI) study performed during admission ruled out vascular, structural, toxic/metabolic, autoimmune, and paraneoplastic origin. A study to determine the aetiology of the infection, including the most frequent pathogens, did not identify the causal agent. Among the results of the remaining complementary tests, we can only highlight the detection of diffuse slowing in the electroencephalography study, without epileptic activity. After a slight initial improvement, the patient presented deterioration of the level of alertness; the CSF study was repeated and the aetiological study was broadened. This time, a study of the nasopharyngeal exudate confirmed the presence of influenza B virus, and the microbiological analysis of the CSF yielded positive PCR results for HHV-6; the bacteria culture and tests for the remaining viruses analysed yielded negative results. In the light of these findings, we changed treatment to ganciclovir and oseltamivir for 14 and 4 days, respectively. Progression was favourable, with complete symptom resolution.</p><p id="par0020" class="elsevierStylePara elsevierViewall">HHV-6 is a neurotropic virus that is increasingly recognised as an emerging pathogen of the nervous system. HHV-6 encephalitis is a severe complication in immunocompromised patients, whereas only isolated cases have been reported in immunocompetent patients.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> HHV-6 viral load has been confirmed in 40% of patients with encephalitis of unknown origin; however, the clinical relevance of the presence of HHV-6 in the CSF of these patients has been questioned.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">According to the available literature, HHV-6 encephalitis most frequently affects young patients (median age, 29 years). Clinically, it manifests with behavioural disorders and altered level of consciousness, focal neurological signs, and epileptic seizures with occasional progression to status epilepticus, encephalomyelitis, or relapsing and remitting encephalitis, especially in immunocompromised individuals.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5–8</span></a> Patients may also present predominantly temporal MRI signal alterations that subsequently resolve. However, neuroimaging results may also be strictly normal.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> CSF usually shows variable lymphocytic pleocytosis (9-155 cells/μL) and eventually variable high protein and low glucose levels.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,7</span></a> Given the lack of randomised clinical trials, there is no current consensus on treatment. The clinical practice guidelines of the Infectious Diseases Society of America recommend ganciclovir, with a risk of developing resistance, or foscarnet; cases have been published in which both drugs were administered in combination.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,7</span></a> Prognosis is generally good.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In our case, the patient developed similar symptoms to those reported in the literature, with the peculiarity that he presented co-infection with influenza B virus, which made it impossible to exclusively attribute some manifestations to HHV-6. Seizures have been described in adult patients with influenza virus infection.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Cases of co-infection have been reported in a Japanese paediatric population,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> with ours being the first case in an immunocompetent adult, to our knowledge. It has been suggested that primary infection with influenza virus may cause a transient state of immunosuppression, thus triggering viral reactivation.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Despite its rareness, we must consider HHV-6 in the differential diagnosis of lymphocytic meningoencephalitis of unknown origin in immunocompetent adults, especially when the patient presents a trigger factor favouring reactivation, such as influenza virus infection.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Jiménez Bolaños R, Díaz Díaz A, Sánchez-Miranda Román I, Castellano Santana JP. Meningoencefalitis por HHV-6 en un paciente inmunocompetente asociado a coinfección por virus de la gripe. Neurología. 2021;36:329–330.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A rare and fatal case of viral encephalitis in an immunocompetent host" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P. Krishnan" 1 => "P. Ramadas" 2 => "R. Chakravarty" 3 => "B. Sah" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.amjms.2016.07.006" "Revista" => array:6 [ "tituloSerie" => "Am J Med Sci" "fecha" => "2017" "volumen" => "353" "paginaInicial" => "194" "paginaFinal" => "195" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28183425" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Human Herpesvirus 6 encephalitis in an immunocompetent pregnant patient and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Yilmaz" 1 => "C. Yasar" 2 => "S. Aydin" 3 => "O. Derin" 4 => "B. Polat" 5 => "G. Ertan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.clineuro.2018.05.026" "Revista" => array:6 [ "tituloSerie" => "Clin Neurol Neurosurg" "fecha" => "2018" "volumen" => "171" "paginaInicial" => "106" "paginaFinal" => "108" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29902636" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Influenza-associated encephalopathy: no evidence for neuroinvasion by influenza virus nor for reactivation of human herpesvirus 6 or 7" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J. van Zeijl" 1 => "J. Bakkers" 2 => "B. Wilbrink" 3 => "W. Melchers" 4 => "R. Mullaart" 5 => "J. Galama" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/427027" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2005" "volumen" => "40" "paginaInicial" => "483" "paginaFinal" => "485" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15668876" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Influenza encephalopathy associated with infection with human herpesvirus 6 and/or human herpesvirus 7" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "N. Sugaya" 1 => "T. Yoshikawa" 2 => "M. Miura" 3 => "T. Ishizuka" 4 => "C. Kawakami" 5 => "Y. Asano" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/338468" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2002" "volumen" => "34" "paginaInicial" => "461" "paginaFinal" => "466" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11797172" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Detection of human herpesvirus-6 in cerebrospinal fluid of patients with encephalitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K. Yao" 1 => "S. Honarmand" 2 => "A. Espinosa" 3 => "N. Akhyani" 4 => "C. Glaser" 5 => "S. Jacobson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ana.21611" "Revista" => array:5 [ "tituloSerie" => "Ann Neurol" "fecha" => "2009" "volumen" => "65" "paginaInicial" => "257" "paginaFinal" => "267" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "HHV-6 encephalitis presenting as status epilepticus in an immunocompetent patient" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "L. Shahani" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/bcr-2014-205880" "Revista" => array:2 [ "tituloSerie" => "BMJ Case Rep" "fecha" => "2014" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Severe encephalomyelitis in an immunocompetent adult with chromosomally integrated human herpesvirus 6 and clinical response to treatment with foscarnet plus ganciclovir" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S. Troy" 1 => "B. Blackburn" 2 => "K. Yeom" 3 => "A. Finley Caulfield" 4 => "M. Bhangoo" 5 => "J. Montoya" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/593315" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2008" "volumen" => "47" "paginaInicial" => "e93" "paginaFinal" => "e96" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18991511" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An adult case of relapsing human herpesvirus-6 encephalitis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Sawada" 1 => "S. Nakatani-Enomoto" 2 => "H. Aizawa" 3 => "T. Katayama" 4 => "T. Ito" 5 => "Y. Aburakawa" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2169/internalmedicine.46.0239" "Revista" => array:6 [ "tituloSerie" => "Intern Med" "fecha" => "2007" "volumen" => "46" "paginaInicial" => "1617" "paginaFinal" => "1620" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17878655" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Influenza-associated seizures in healthy adults: Report of 3 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. Ruisanchez-Nieva" 1 => "A. Martinez-Arroyo" 2 => "M. Gomez-Beldarrain" 3 => "J. Bocos Portillo" 4 => "J. Garcia-Monco" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ebcr.2017.01.003" "Revista" => array:6 [ "tituloSerie" => "Epilepsy Behav Case Rep" "fecha" => "2017" "volumen" => "8" "paginaInicial" => "12" "paginaFinal" => "13" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28652973" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735808/0000003600000004/v1_202105110731/S2173580821000274/v1_202105110731/en/main.assets" "Apartado" => array:4 [ "identificador" => "9409" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735808/0000003600000004/v1_202105110731/S2173580821000274/v1_202105110731/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173580821000274?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 19 | 0 | 19 |
| 2024 October | 64 | 11 | 75 |
| 2024 September | 60 | 4 | 64 |
| 2024 August | 58 | 10 | 68 |
| 2024 July | 93 | 10 | 103 |
| 2024 June | 62 | 9 | 71 |
| 2024 May | 67 | 5 | 72 |
| 2024 April | 45 | 9 | 54 |
| 2024 March | 88 | 10 | 98 |
| 2024 February | 107 | 6 | 113 |
| 2024 January | 110 | 9 | 119 |
| 2023 December | 119 | 12 | 131 |
| 2023 November | 152 | 9 | 161 |
| 2023 October | 144 | 9 | 153 |
| 2023 September | 104 | 3 | 107 |
| 2023 August | 95 | 4 | 99 |
| 2023 July | 90 | 5 | 95 |
| 2023 June | 83 | 8 | 91 |
| 2023 May | 106 | 12 | 118 |
| 2023 April | 82 | 1 | 83 |
| 2023 March | 76 | 11 | 87 |
| 2023 February | 49 | 9 | 58 |
| 2023 January | 37 | 9 | 46 |
| 2022 December | 54 | 6 | 60 |
| 2022 November | 30 | 10 | 40 |
| 2022 October | 26 | 9 | 35 |
| 2022 September | 23 | 9 | 32 |
| 2022 August | 23 | 12 | 35 |
| 2022 July | 16 | 7 | 23 |
| 2022 June | 23 | 13 | 36 |
| 2022 May | 38 | 6 | 44 |
| 2022 April | 23 | 7 | 30 |
| 2022 March | 14 | 7 | 21 |
| 2022 February | 15 | 5 | 20 |
| 2022 January | 10 | 8 | 18 |
| 2021 December | 11 | 10 | 21 |
| 2021 November | 18 | 8 | 26 |
| 2021 October | 20 | 10 | 30 |
| 2021 September | 13 | 6 | 19 |
| 2021 August | 15 | 12 | 27 |
| 2021 July | 9 | 5 | 14 |
| 2021 June | 11 | 6 | 17 |
| 2021 May | 16 | 8 | 24 |
| 2021 April | 5 | 15 | 20 |
| 2021 March | 0 | 5 | 5 |
Show all
