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Case Report/Case Series |

Elevated CSF Cytokines in the Jarisch-Herxheimer Reaction of General Paresis

Larry E. Davis, MD1; Ryan Oyer, MD2; J. David Beckham, MD2,3; Kenneth L. Tyler, MD2,3
[+] Author Affiliations
1Department of Neurology Service, New Mexico VA Health Care System, Albuquerque
2Division of Infectious Diseases, Department of Medicine, University of Colorado School of Medicine, Aurora
3Division of Infectious Diseases, Departments of Neurology, Medicine, and Microbiology, University of Colorado School of Medicine, Aurora
JAMA Neurol. 2013;70(8):1060-1064. doi:10.1001/jamaneurol.2013.2120.
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Importance  The Jarisch-Herxheimer reaction (JHR) is a well-recognized transient worsening of signs and symptoms occurring soon after the first dose of an appropriate antibiotic for several spirochetal infections. The pathogenesis of this reaction is poorly understood. In this case study of cerebrospinal fluid (CSF) cytokines, we aimed to improve understanding of the pathogenesis of JHR in patients with neurosyphilis who develop transient neurologic signs.

Observations  Four hours after receiving penicillin for general paresis, a 55-year-old man developed a severe JHR characterized by fever, tachycardia, hypertension, obtundation, seizures, and a neutrophilia lasting 18 hours. Cerebrospinal fluid obtained at the peak of the JHR demonstrated a switch from a mild lymphophilia to a moderate neutrophilia. He had markedly elevated CSF interleukin (IL) 8 and likely elevated IL-1β, IL-10, and IL-15 levels, which returned to normal in follow-up CSF examination results.

Conclusions and Relevance  To our knowledge, this is the first report of elevated CSF cytokines in a patient with a JHR, which possibly contributed to the neurologic signs of JHR. Further studies on the innate inflammatory response during episodes of acute infection and inflammation are needed to develop targeted therapies to modulate this system, which could, in turn, improve future outcomes and modify the JHR.

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Figure 1.
Magnetic Resonance Images (MRIs) of Patient

A, T1-weighted MRI of the patient in 2009. B, T1-weighted MRI of patient in 2011 showing severe generalized brain atrophy.

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Figure 2.
Increases in Cerebrospinal Fluid Interleukins

Increases in cerebrospinal fluid (CSF) interleukins (ILs) during Jarisch-Herxheimer reaction compared with 7 months later.

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