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  • Updated 06.19.2023
  • Released 01.24.1996
  • Expires For CME 06.19.2026

Acute necrotizing hemorrhagic leukoencephalitis



Acute hemorrhagic leukoencephalitis of Weston Hurst is at the extreme end of the spectrum of demyelinating diseases. It typically follows a viral upper respiratory infection and evolves rapidly to coma and death. "Ball and ring" hemorrhages appear in the centrum semiovale of the brain, associated with mononuclear and neutrophil infiltrates, surrounded by demyelination spreading out from fibrin-filled venules. In this article, the author addresses these issues and suggests that IL-17, a cytokine that attracts neutrophils, may be important in pathogenesis. Hemorrhages, neutrophils, and the cytokine profile differentiate it from ADEM.

Key points

• Acute necrotizing hemorrhagic leukoencephalitis is a devastating disorder that often follows a virus or mycoplasma infection.

• COVID-19 infection induces acute necrotizing hemorrhagic leukoencephalitis.

• Lesions are hemorrhagic, with fibrinoid necrosis and polymorphonuclear neutrophil infiltration that is associated with demyelination.

• The devastating immune response may be from excess sensitization to one or more unknown antigens.

• Therapy is difficult, and most of those affected will die. Several therapies are suggested to deactivate the immune response.

Historical note and terminology

E. Weston Hurst was the first to clearly define acute necrotizing hemorrhagic leukoencephalitis and to suggest that it was a demyelinating disease (22). He described the abrupt onset of neurologic symptoms following a nonspecific upper respiratory infection in three patients: a 43-year-old housewife, a 33-year-old munitions worker, and a 37-year-old accountant. Death occurred in several days, and autopsies of two of these patients showed identical hemorrhagic lesions in the white matter. Other authors, such as Gayet, Leyden, Strümpell, Bückler, Leichtenstern, Brie, Oppenheim, de Faro, Baker, Levy, Adams, and Crawford described similar encephalitic conditions with petechial hemorrhage and inflammation, as early as 1875 (30).

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