BACKGROUND AND PURPOSE:Although microcephaly is the most prominent feature of congenital Zika syndrome, a spectrum with less severe cases is starting to be recognized. Our aim was to review neuroimaging of infants to detect cases without microcephaly and compare them with those with microcephaly.

IMPORTANCE Hydrocephalus is a treatable but potentially fatal complication that has not been previously described in congenital Zika syndrome (CZS).OBJECTIVE To describe the clinical features and imaging findings in 24 patients with congenital Zika syndrome (CZS) who developed hydrocephalus. DESIGN, SETTING, AND PARTICIPANTSThis case series included patients with hydrocephalus who were born in October and November 2015 and followed up until mid-2017 in the 2 largest national referral centers for CZS in Brazil. The participants included consecutively enrolled children with a clinical and laboratorial diagnosis of CZS who developed clinical and/or image findings suggestive of hydrocephalus and who were confirmed to experience increased intracranial hypertension during ventriculoperitoneal shunt procedures. MAIN OUTCOMES AND MEASURESTo retrospectively describe clinical and image findings in these 24 patients. RESULTS This multicenter cohort included 308 patients with CZS; 24 consecutive children were enrolled in this study. These children were aged between 3 to 18 months, and 13 of 24 (54%) were female. All patients presented with at least 1 positive test result for anti-Zika antibodies in cerebrospinal fluid or serum and had classic signs of CZS. At the time of hydrocephalus diagnosis, only 14 of 24 patients (58%) had symptoms and signs suggestive of hydrocephalus (mainly worsening seizures, vomiting, irritability, and/or sudden increase of head circumference percentile). Two of 24 patients (8%) had no symptoms suggestive of hydrocephalus but were found to have reduced brain volume on repeated imaging. Cerebellar or brainstem hypoplasia on baseline imaging were found in 18 of 23 patients (78%). At the second computed tomographic scan, all patients showed a marked increase of ventricular volume, compatible with communicating hydrocephalus, and reduction of brain tissue that was visibly worse than on baseline imaging for the 23 patients with repeated scans. CONCLUSIONS AND RELEVANCEWe present evidence that hydrocephalus is a complication of CZS in at least a proportion of patients. The clinical spectrum of this condition continues to evolve, but given that presenting signs and symptoms of hydrocephalus can be challenging to recognize in CZS, we provisionally recommend that high suspicion and appropriate monitoring for hydrocephalus should be part of the standard care of patients with CZS.

From January 1st up to September 30th 1990, 77 patients with leptospirosis confirmed by laboratory studies were admitted at the Infectious and Parasitic Diseases Service of the Hospital das Clínicas of the Universidade Federal de Pernambuco. Clinical manifestations had sudden onset with presence of fever, headache, chills and muscle pains. Plurisystemic involvement was observed both in the icteric and in the non-icteric patients. The neurological exam was abnormal in 70 of the patients (90.91%). Neurological findings were essentially variable. Though in a transitory form, they allowed the observation of the following clinical forms: meningoencephalitis and polyneuritis in association, meningoencephalitis, polyneuritis, and subarachnoid hemorrhage.

RESUMO -Entre 1-janeiro e 30-setembro-1990 foram estudados 77 pacientes com diagnóstico de leptospirose, admitidos no S D l P / U F P E . O exame neurológico foi anormal em 70 (90,91%) dos pacientes. O exame do LCR, realizado em 67 (87%) dos pacientes, foi anormal em 64 (95,52), tendo como achado mais freqüente a pleocitose. Não houve diferença significativa no comportamento do LCR nas diversas formas clínicas neurológicas observadas, nem quando comparadas as formas ictéricas com as não ictéricas. Bastante significativos foram os resultados da reação de microaglutinação para leptospirose no LCR.PALAVRAS-CHAVE: leptospirose, sistema nervoso, líquido cefalorraqueano, reação de microaglutinação. Involvement of the nervous system in leptospirosis: II Cerebrospinal fluid examination.SUMMARY -From January 1st up to September 30th 1990, 77 patients with leptospirosis diagnosis confirmed by laboratory studies were admitted at the Infectious and Parasitic Disease Service of the Hospital das Clínicas of the Universidade Federal de Pernambuco. The neurological exam was abnormal in 70 of the patients (90.91%). The cerebrospinal fluid (CSF) examination was carried out on 67 (87%) of the patients; it was abnormal in 64 (95.52%) yielding hypercytosis in the majority of cases. There was no difference in the CSF behavior in report to the several neurological forms nor in relation to the icteric or non-icteric forms of the disease. Significant were the results for the microscopic agglutination tests for leptospirosis in the CSF.