Emerging Subspecialties in Neurology: Neuroinfectious diseases
John J. Millichap, MD and
Leon G. Epstein, MD
From the Division of Neurology, Children's Memorial Hospital, Northwestern University Medical School, Chicago, IL.
Address correspondence and reprint requests to Dr. John J. Millichap, Division of Neurology, Children's Memorial Hospital, 2300 Children's Plaza, Box 51, Chicago, IL 60614 jmillichap{at}childrensmemorial.org
Infection as a cause of neurologic disease is a prominent featurein the history of medicine. The training of the practitionercalled to care for these patients has changed throughout theyears. To understand the history of infectious disease in neurologicpractice, consider the relative infancy of the specialty ofneurology in the United States. Neurology as an independentspecialty board did not emerge from the cloak of neuropsychiatryand internal medicine until after World War II and the foundingof the American Academy of Neurology (AAN). Neuropathology wasan integral part of the curriculum, and neuroinfectious diseaseswere taught primarily from the pathologic perspective. In 1964,H. Merritt1 thought infectious disease was sufficiently importantto be the subject of the first chapter in the third editionof his Textbook of Neurology. The increasing importance of infectiousdisease in neurology is evident from the more recent publicationof dedicated textbooks on both pediatric and general neuroinfectiousdisorders.2–4
Early practitioners in the field of neurology were first recognizedfor their work with neuroinfections. A major purpose of thePasteur institute that opened in Paris in 1888 was to care forthe multitude of patients with rabies.5 In the same year, thefirst neurologist at Johns Hopkins' was noted to be involvedin the treatment of tabes dorsalis.6 The 20th century saw severalinfectious diseases of epidemic proportions with significantneurologic sequelae. In 1917, Constantin von Economo describedencephalitis lethargica related to the influenza epidemic.1Anterior poliomyelitis was widespread in the 1940s–1950s.Complications of these diseases that required long-term neurologiccare included postencephalitic parkinsonism and postpolio syndrome.1AIDS, the present-day epidemic, has complications such as HIV-associateddementia studied by neurologists since the 1980s.7
Nonepidemic viral infections constitute the majority of infectionsaffecting the nervous system today.8 Chronic neurologic diseaseas a sequel to infection is a relatively new and developingarea of both pediatric and adult neurology research. Chief amongthese disorders is the role of postinfectious brain inflammationin epileptogenesis.9
In addition to nonepidemic viral infections, modern neurologistswith expertise in infectious diseases care for patients witha variety of infections and their sequelae in multiple clinicalsettings. Acute CNS infection may require intensive care forthe management of increased intracranial pressure and statusepilepticus.4 Immunosuppression for cancer, organ transplant,and autoimmune disorders increases the number of patients atrisk for opportunistic neuroinfections.8,10 Patients with HIVmay develop lymphoma and neuropathy. Other conditions with infectiousassociations include prion and autoimmune disorders.4
TRAINING OPPORTUNITIES IN NEUROINFECTIOUS DISEASES
During the 2008 meeting of the AAN Section on NeuroinfectiousDiseases (aan.com/go/about/sections/disease), a proposal wasvoted forward to develop a subspecialty fellowship accreditedby the United Council for Neurological Subspecialties (UCNS).The UCNS currently accredits many emerging subspecialties includingneurocritical care and headache (ucns.org). Board certificationin both neurology and infectious disease is not a practicalroute for most subspecialists in the field. However, this optionmay be possible for child neurologists. Since most obtain boardcertification in pediatrics, they would then be eligible forconventional fellowships in pediatric infectious diseases aftercompletion of neurology training.
Non-accredited subspecialty fellowship training is currentlyavailable in this field at several institutions. Representativeprograms were located by Internet search of university Web sitesand are listed in the table. The amount of time devoted to researchand clinical varies between centers, and some institutions focusonly on AIDS or virology. Interested trainees may also acquireexpertise in infectious diseases in a neurology program activein research or closely associated with an established infectiousdisease service. Subspecialists practicing neuroinfectious diseasesalso list training in neurovirology at NIH in Bethesda, MD,and in neuroinfectious diseases at Indiana University in Indianapolis.Successful training in neuroinfectious diseases, as in otherspecialties, requires a close identification with a mentor inthe field.
Since accredited fellowships are still in the developing stage,entry to this field may take many forms. A career in this subspecialtywould necessarily be located in a university affiliated hospitalor large neurology clinic, with opportunities for clinical orbasic laboratory research. A position in an established practiceis preferable to creating a niche in this area at a local facility.The latter may be plausible for an individual in the form ofan intermittent specialty clinic in addition to general practice.A search of the AAN directory provides a list of approximately90 members of the Section on Neuroinfectious Diseases (aan.com/go/about/sections/disease).In addition to the list of institutions in the table, IndianaUniversity in Indianapolis (http://neurology.medicine.iu.edu/body.cfm?id=3078&oTopID=3022),Mayo Clinic in Rochester, MN (mayoclinic.org/neurology-rst/neuroid.html),and the University of Kentucky in Lexington (ukhealthcare.uky.edu/KNI/clinic_infectious.htm)also advertise specialist clinics in neuroinfectious diseases.A list of practitioners with expertise in neuro-AIDS is availableon The Neurologic AIDS Research Consortium (NARC) Web site (narc.wustl.edu/narc/default.aspx).
A neuroinfectious disease specialist in a hospital or clinicwould act as consultant to the infectious disease service, especiallyfor acute presentations and complications. Another importantrole for the neuroinfectious disease specialist is the diagnosisand management of chronic neuroinfectious disorders, includingpostinfectious epilepsy.8,9 New diagnostic tools using molecularmethods and the development of new antimicrobial and antiinflammatoryagents is an important area of future research. Membership andactive participation in the AAN Section on Neuroinfectious Diseaseand the Infectious Diseases Society of America (idsociety.org)is vital to career development.
The development of neuroinfectious diseases as a subspecialtyis essential for the care of large numbers of patients alreadyaffected by today's most important pathogens and to preparefor tomorrow's.6,8 Collaboration with internal medicine–or pediatrics-based infectious diseases specialists is an importantpart of this practice.10 Despite the long history of infectionsaffecting the nervous system, the prospect of a formal subspecialtyfellowship and certification combining these 2 fields remainsa work in progress. Neurologists have the unique understandingof this complex organ system and how certain infections maycause damage. As more neuropathogens emerge, medicine will needmore neurologists with subspecialty training, experience, andinterest in infectious disorders to develop new diagnostic,preventative, and therapeutic options for these patients.6
Barton LL, Friedman NR, eds. The Neurological Manifestations of Pediatric Infectious Diseases and Immunodeficiency Syndromes. Totowa, NJ: Humana Press;
Johnson RT. Viral Infections of the Nervous System. Philadelphia: Lippincott Williams & Wilkins;
Roos KL, ed. Principles of Neurologic Infectious Diseases: Principles and Practice. New York: McGraw-Hill;
Neuroinfections: celebrating the past, discussing the present. Lancet Neurol 2008;7:975.[Medline]
Griffin JW. Neurologists don't do windows Nat Clin Pract Neurol 2006;2:1.[Medline]
Epstein LG, Sharer LR, Cho ES, Myenhofer M, Navia B, Price RW. HTLV-III/LAV-like retrovirus particles in the brains of patients with AIDS encephalopathy. AIDS Res 1984-1985;1:447–454.
Tan K, Patel S, Gandhi N, Chow F, Rumbaugh J, Nath A. Burden of neuroinfectious diseases on the neurology service in a tertiary care center. Neurology 2008;71:1160–1166.[Abstract/Free Full Text]
Singh G, Prabhakar S. The association between central nervous system (CNS) infections and epilepsy: epidemiological approaches and microbiological and epileptological perspectives. Epilepsia 2008;49:2–7.
Butcher J. Profile: Karen Roos: treating neuroinfections in Indiana. Lancet Neurol 2007;6:760.[Medline]
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