Influenza A-associated acute necrotising encephalopathy

A previously healthy woman in her 20s was brought to the emergency department with a convulsive seizure. Over the preceding 24 hours, she had developed flu-like symptoms, including cough, headache and fever (39°C). She was started on lorazepam with a loading dose of levetiracetam and given empirical intravenous acyclovir and ceftriaxone. A CT scan of the head and blood tests for inflammatory markers, full blood count and renal and liver profile were normal. She was intubated and admitted to the medical intensive care unit due to a persistently low Glasgow coma scale score (7–8) and recurrent seizures. Cerebrospinal fluid (CSF) examination showed two white cells/µL (≤5), glucose 4.06 mmol/L (2.5–4.4) and protein 0.96 g/L (0.15–0.45); Gram stain, culture, viral PCR panel and cytology were negative. Electroencephalogram showed severe diffuse theta-delta slowing consistent with encephalopathy. A nasopharyngeal swab tested positive for influenza A, H3N2 subtype. Blood and …