101
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Sun J, Hu XY, Yu XF. Current Understanding of Human Enterovirus D68. Viruses 2019; 11:v11060490. [PMID: 31146373 PMCID: PMC6631698 DOI: 10.3390/v11060490] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/08/2019] [Accepted: 05/13/2019] [Indexed: 12/20/2022] Open
Abstract
Human enterovirus D68 (EV-D68), a member of the species Enterovirus D of the Picornaviridae family, was first isolated in 1962 in the United States. EV-D68 infection was only infrequently reported until an outbreak occurred in 2014 in the US; since then, it has continued to increase worldwide. EV-D68 infection leads to severe respiratory illness and has recently been reported to be linked to the development of the neurogenic disease known as acute flaccid myelitis (AFM), mostly in children, seriously endangering public health. Hitherto, treatment options for EV-D68 infections were limited to supportive care, and as yet there are no approved, specific antiviral drugs or vaccines. Research on EV-D68 has mainly focused on its epidemiology, and its virologic characteristics and pathogenesis still need to be further explored. Here, we provide an overview of current research on EV-D68, including the genotypes and genetic characteristics of recent epidemics, the mechanism of infection and virus-host interactions, and its relationship to acute flaccid myelitis (AFM), in order to broaden our understanding of the biological features of EV-D68 and provide a basis for the development of effective antiviral agents.
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Affiliation(s)
- Jing Sun
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education), School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang, China.
| | - Xiao-Yi Hu
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education), School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang, China.
| | - Xiao-Fang Yu
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education), School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang, China.
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102
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Wells AI, Coyne CB. Enteroviruses: A Gut-Wrenching Game of Entry, Detection, and Evasion. Viruses 2019; 11:v11050460. [PMID: 31117206 PMCID: PMC6563291 DOI: 10.3390/v11050460] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 05/08/2019] [Accepted: 05/19/2019] [Indexed: 12/13/2022] Open
Abstract
Enteroviruses are a major source of human disease, particularly in neonates and young children where infections can range from acute, self-limited febrile illness to meningitis, endocarditis, hepatitis, and acute flaccid myelitis. The enterovirus genus includes poliovirus, coxsackieviruses, echoviruses, enterovirus 71, and enterovirus D68. Enteroviruses primarily infect by the fecal–oral route and target the gastrointestinal epithelium early during their life cycles. In addition, spread via the respiratory tract is possible and some enteroviruses such as enterovirus D68 are preferentially spread via this route. Once internalized, enteroviruses are detected by intracellular proteins that recognize common viral features and trigger antiviral innate immune signaling. However, co-evolution of enteroviruses with humans has allowed them to develop strategies to evade detection or disrupt signaling. In this review, we will discuss how enteroviruses infect the gastrointestinal tract, the mechanisms by which cells detect enterovirus infections, and the strategies enteroviruses use to escape this detection.
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Affiliation(s)
- Alexandra I Wells
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
- Center for Microbial Pathogenesis, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA.
| | - Carolyn B Coyne
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
- Center for Microbial Pathogenesis, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA.
- Richard K. Mellon Institute for Pediatric Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA.
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103
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Nath RK, Somasundaram C. Functional Improvement of Upper and Lower Extremity After Decompression and Neurolysis and Nerve Transfer in a Pediatric Patient with Acute Flaccid Myelitis. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:668-673. [PMID: 31073115 PMCID: PMC6523989 DOI: 10.12659/ajcr.915235] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Patient: Female, 5 Final Diagnosis: Enterovirus infection Symptoms: Weakness in all 4 limbs Medication: — Clinical Procedure: Nerve decompression • neurolysis and nerve transfer Specialty: Neurosurgery
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Affiliation(s)
- Rahul Kumar Nath
- Department of Surgical Research, Texas Nerve and Paralysis Institute, Houston, TX, USA
| | - Chandra Somasundaram
- Department of Surgical Research, Texas Nerve and Paralysis Institute, Houston, TX, USA
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104
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Acute flaccid myelitis associated with enterovirus D68 in a non-epidemic setting. IDCases 2019; 17:e00549. [PMID: 31193053 PMCID: PMC6515126 DOI: 10.1016/j.idcr.2019.e00549] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 04/30/2019] [Accepted: 04/30/2019] [Indexed: 01/28/2023] Open
Abstract
Acute flaccid myelitis (AFM) is a recently defined clinical disease accompanied by the national outbreak of enterovirus D68 (EV-D68) in the United States during the late summer/fall of 2014; 258 cases of EV-D68 and 59 cases of AFM were reported in Japan during the late summer/fall of 2015. Subsequently, there have been no epidemics of AFM or EV-D68. However, we encountered a patient who had AFM associated with EV-D68 in 2017. This is the first case of AFM caused by EV-D68 after the 2015 epidemic, and the only reported case in 2017. This report indicates that AFM caused by EV-D68 can arise even in non-epidemic situations. If a patient presents with paralysis, AFM caused by EV-D68 should be included in the differential diagnosis, regardless of the absence of an epidemic of EV-D68 infection.
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105
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Okumura A, Mori H, Fee Chong P, Kira R, Torisu H, Yasumoto S, Shimizu H, Fujimoto T, Tanaka-Taya K. Serial MRI findings of acute flaccid myelitis during an outbreak of enterovirus D68 infection in Japan. Brain Dev 2019; 41:443-451. [PMID: 30594353 DOI: 10.1016/j.braindev.2018.12.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 11/21/2018] [Accepted: 12/06/2018] [Indexed: 12/31/2022]
Abstract
OBJECIVE To clarify the neuroimaging findings of children with acute flaccid myelitis during an outbreak of EV-D68 infection. METHODS We performed a detailed review of the spinal and cranial MRI results of 54 children with acute flaccid myelitis. We focused on the range of longitudinal lesions, the localization and appearance of lesions within a horizontal section, Gadolinium-enhancement, and changes over time. RESULTS All children had longitudinal spinal lesions involving central gray matter. Twenty-six children had lesions spanning the entire spine. Six of them had weakness in all limbs, whereas seven had weakness of only one limb. Thirty-eight children had lesions in both gray and white matter and limb weakness tended to be more severe in these children. During the acute period, spinal lesions showed bilateral ill-defined widespread T2 hyperintensity. During the subacute period, lesions were well defined and confined to the anterior horn. The distribution of limb weakness was correlated with the appearance of lesions during the subacute period. Gadolinium enhancement was performed in 37 children, and enhancement was seen in the cauda equina in 29 children. Enhancement was infrequent within 2 days after onset but was seen in almost all children thereafter. Twenty-two children had brainstem lesions continuous with spinal lesions. CONCLUSION Extensive longitudinal spinal lesions were characteristic in children with acute flaccid myelitis. Lesions were usually bilateral and widespread during the acute period, whereas localization to the anterior horn could become obvious. Although enhancement of the cauda equina was often observed, its appearance was sometimes delayed.
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Affiliation(s)
- Akihisa Okumura
- Department of Pediatrics, Aichi Medical University, Nagakute, Aichi, Japan.
| | - Harushi Mori
- Department of Radiology, Graduate School and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Pin Fee Chong
- Department of Pediatric Neurology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Ryutaro Kira
- Department of Pediatric Neurology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Hiroyuki Torisu
- Department of Pediatrics, Fukuoka Dental College Medical and Dental Hospital, Fukuoka, Japan
| | - Sawa Yasumoto
- Medical Education Center, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Hiroyuki Shimizu
- Department of Virology II, National Institute of Infectious Diseases, Tokyo, Japan
| | - Tsuguto Fujimoto
- Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - Keiko Tanaka-Taya
- Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo, Japan
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106
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Fatemi Y, Chakraborty R. Acute Flaccid Myelitis: A Clinical Overview for 2019. Mayo Clin Proc 2019; 94:875-881. [PMID: 31054607 DOI: 10.1016/j.mayocp.2019.03.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/09/2019] [Accepted: 03/13/2019] [Indexed: 11/19/2022]
Abstract
Acute flaccid myelitis (AFM) is characterized by flaccid paralysis of one or more limbs, often following a viral illness, with magnetic resonance imaging findings consistent with inflammation of the spinal cord gray matter. It is unclear whether all patients with AFM will have full recovery of neurologic function. Since 2014, there have been several clusters of AFM in the United States, with a 3-fold increase in reported AFM cases recorded in 2018 compared with the previous year. Epidemiological evidence supports a temporal association between respiratory enteroviral illness, particularly with enteroviruses D68 and A71, and clustering of AFM cases. However, causality has yet to be established. Treatment of AFM is primarily supportive. Adjunctive therapies such as intravenous immunoglobulin, corticosteroids, plasmapheresis, and fluoxetine have not been found to improve long-term outcomes. Further research is urgently needed to characterize and optimize management of this emerging, yet poorly understood, condition.
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Affiliation(s)
- Yasaman Fatemi
- Division of General Pediatric and Adolescent Medicine, Department of Pediatrics and Adolescent Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.
| | - Rana Chakraborty
- Division of Pediatric Infectious Diseases, Department of Pediatrics and Adolescent Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
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107
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Moline H, Kalaskar A, Pomputius WF, Lopez A, Routh J, Kenyon C, Griffith J. Notes from the Field: Six Cases of Acute Flaccid Myelitis in Children - Minnesota, 2018. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2019; 68:356-358. [PMID: 30998669 PMCID: PMC6476059 DOI: 10.15585/mmwr.mm6815a4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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108
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Abstract
Since 2014, acute flaccid myelitis (AFM), a long-recognized condition associated with polioviruses, nonpolio enteroviruses, and various other viral and nonviral causes, has been reemerging globally in epidemic form. This unanticipated reemergence is ironic, given that polioviruses, once the major causes of AFM, are now at the very threshold of global eradication and cannot therefore explain any aspect of AFM reemergence. Instead, the new AFM epidemic has been temporally associated with reemergences of nonpolio enteroviruses such as EV-D68, until recently thought to be an obscure virus of extremely low endemicity. This perspective reviews the enigmatic epidemiologic, virologic, and diagnostic aspects of epidemic AFM reemergence; examines current options for clinical management; discusses future research needs; and suggests that the AFM epidemic offers important clues to mechanisms of viral disease emergence.
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109
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Rouhani AA, Lai S. Increase in Acute Flaccid Myelitis—United States, 2018. Ann Emerg Med 2019. [DOI: 10.1016/j.annemergmed.2019.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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110
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Kujawski SA, Midgley CM, Rha B, Lively JY, Nix WA, Curns AT, Payne DC, Englund JA, Boom JA, Williams JV, Weinberg GA, Staat MA, Selvarangan R, Halasa NB, Klein EJ, Sahni LC, Michaels MG, Shelley L, McNeal M, Harrison CJ, Stewart LS, Lopez AS, Routh JA, Patel M, Oberste MS, Watson JT, Gerber SI. Enterovirus D68-Associated Acute Respiratory Illness - New Vaccine Surveillance Network, United States, July-October, 2017 and 2018. MMWR. MORBIDITY AND MORTALITY WEEKLY REPORT 2019; 68:277-280. [PMID: 30921299 PMCID: PMC6448985 DOI: 10.15585/mmwr.mm6812a1] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In the fall of 2014, an outbreak of enterovirus D68 (EV-D68)-associated acute respiratory illness (ARI) occurred in the United States (1,2); before 2014, EV-D68 was rarely reported to CDC (2,3). In the United States, reported EV-D68 detections typically peak during late summer and early fall (3). EV-D68 epidemiology is not fully understood because testing in clinical settings seldom has been available and detections are not notifiable to CDC. To better understand EV-D68 epidemiology, CDC recently established active, prospective EV-D68 surveillance among pediatric patients at seven U.S. medical centers through the New Vaccine Surveillance Network (NVSN) (4). This report details a preliminary characterization of EV-D68 testing and detections among emergency department (ED) and hospitalized patients with ARI at all NVSN sites during July 1-October 31, 2017, and the same period in 2018. Among patients with ARI who were tested, EV-D68 was detected in two patients (0.8%) in 2017 and 358 (13.9%) in 2018. Continued active, prospective surveillance of EV-D68-associated ARI is needed to better understand EV-D68 epidemiology in the United States.
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111
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Gordon-Lipkin E, Muñoz LS, Klein JL, Dean J, Izbudak I, Pardo CA. Comparative quantitative clinical, neuroimaging, and functional profiles in children with acute flaccid myelitis at acute and convalescent stages of disease. Dev Med Child Neurol 2019; 61:366-375. [PMID: 30225922 DOI: 10.1111/dmcn.14030] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/31/2018] [Indexed: 01/25/2023]
Abstract
AIM To quantify characteristics in acute flaccid myelitis (AFM) at acute and convalescent stages. METHOD This was a retrospective case series of children with AFM evaluated at a single institution in the USA (2014-2017). Acute inflammatory/ischemic myelopathies were excluded. Neurological assessments and segmental quantitative analysis of signal abnormalities on magnetic resonance imaging (MRI) of the brain and spinal cord were performed. RESULTS Sixteen patients (11 males, five females) were evaluated. Median age at onset was 4 years (interquartile range [IQR] 3-6y). All had parainfectious acute-onset limb weakness, lower motor neuron examination, and spinal fluid pleocytosis. On acute spinal cord MRI, longitudinally extensive T2 hyperintensities were identified throughout the spinal cord mostly within grey matter; five out of 12 patients had dorsal brainstem T2 hyperintensities. At a median of 2 months follow-up (IQR 2-3mo), spinal cord MRI improved in seven out of nine patients although focal T2 hyperintensities persisted in cervical and lumbar grey matter. At a median follow-up of 4 months (IQR 2-6mo), Medical Research Council sum score rose from a median of 29 to 32; distal muscle groups improved more than proximal ones; four out of 16 patients were ventilator-dependent; and two out of 16 patients were quadriplegic. INTERPRETATION While patients may show marked improvement on neuroimaging from acute to convalescent stages, the majority of children with AFM have limited motor recovery and continued disability. Clinicians should consider the timing of clinical and neuroimaging exams when assessing diagnosis and prognosis. WHAT THIS PAPER ADDS During the 2014 to 2017 acute flaccid myelitis outbreak in the USA, clinical recovery was better in distal than proximal muscle groups. Lumbar spinal cord showed more residual abnormalities at convalescence.
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Affiliation(s)
- Eliza Gordon-Lipkin
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Laura S Muñoz
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jessica L Klein
- Department of Pediatrics, Division of Pediatric Neurology, Medical University of South Carolina, Charleston, SC, USA
| | - Janet Dean
- Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Izlem Izbudak
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carlos A Pardo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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112
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Cramer N, Munjal N, Ware D, Ramgopal S, Simon D, Freeman MC, Michaels MG, Stem C, Thakkar K, Williams JV, Panigrahy A, Neville DNW, Owusu-Ansah S. New Cluster of Acute Flaccid Myelitis in Western Pennsylvania. Ann Emerg Med 2019; 74:503-508. [PMID: 30826069 DOI: 10.1016/j.annemergmed.2019.01.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Indexed: 01/17/2023]
Abstract
Acute flaccid myelitis is a debilitating illness characterized by acute onset of limb weakness, with one or more spinal segments displaying magnetic resonance imaging-confirmed gray matter lesions. Since the first outbreak in 2014, tracking by the Centers for Disease Control and Prevention has demonstrated biennial epidemics in the United States, with a current outbreak occurring in 2018. The cases of 3 children with acute flaccid myelitis who were initially thought to have common nonneurologic diagnoses are presented. Emergency physicians need to be vigilant to recognize the subtleties of acute flaccid myelitis because the illness progression is rapid and therapy is nuanced.
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Affiliation(s)
- Natan Cramer
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Neil Munjal
- Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Sriram Ramgopal
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Dennis Simon
- Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Megan C Freeman
- Department of Pediatrics, Division of Pediatric Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Marian G Michaels
- Department of Pediatrics, Division of Pediatric Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Christopher Stem
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Kavita Thakkar
- Department of Pediatrics, Division of Child Neurology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - John V Williams
- Department of Pediatrics, Division of Pediatric Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Ashok Panigrahy
- Department of Pediatric Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Desiree N W Neville
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Sylvia Owusu-Ansah
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.
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113
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Hopkins SE, Elrick MJ, Messacar K. Acute Flaccid Myelitis-Keys to Diagnosis, Questions About Treatment, and Future Directions. JAMA Pediatr 2019; 173:117-118. [PMID: 30500054 DOI: 10.1001/jamapediatrics.2018.4896] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Sarah E Hopkins
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew J Elrick
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Kevin Messacar
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora
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114
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Elrick MJ, Gordon-Lipkin E, Crawford TO, Van Haren K, Messacar K, Thornton N, Dee E, Voskertchian A, Nance JR, Muñoz LS, Gorman MP, Benson LA, Thomas DL, Pardo CA, Milstone AM, Duggal P. Clinical Subpopulations in a Sample of North American Children Diagnosed With Acute Flaccid Myelitis, 2012-2016. JAMA Pediatr 2019; 173:134-139. [PMID: 30500056 PMCID: PMC6439600 DOI: 10.1001/jamapediatrics.2018.4890] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Acute flaccid myelitis (AFM) is an emerging poliolike illness of children whose clinical spectrum and associated pathogens are only partially described. The case definition is intentionally encompassing for epidemiologic surveillance to capture all potential AFM cases. Defining a restrictive, homogenous subpopulation may aid our understanding of this emerging disease. OBJECTIVE To evaluate the extent to which the US Centers for Disease Control and Prevention (CDC) case definition of AFM incorporates possible alternative diagnoses and to assess the plausibility of a case definition that enriches the biological homogeneity of AFM for inclusion in research studies. DESIGN, SETTING, AND PARTICIPANTS Retrospective case analysis of children younger than 18 years diagnosed as having AFM between 2012 and 2016 using the CDC case definition. Group 1 included patients recruited from the United States and Canada based on the CDC case definition of AFM. Group 2 included patients referred to the Johns Hopkins Transverse Myelitis Center for evaluation of suspected AFM. Patients' records and imaging data were critically reviewed by 3 neurologists to identify those cases with definable alternative diagnoses, and the remaining patients were categorized as having restrictively defined AFM (rAFM). Clinical characteristics were compared between patients with rAFM (cases) and those with alternative diagnoses, and a case description distinguishing these AFM groups was identified. Interrater reliability of this description was confirmed for a subset of cases by a fourth neurologist. Data were analyzed between May 2017 and November 2018. MAIN OUTCOMES AND MEASURES Proportion of patients with possible alternative diagnosis. RESULTS Of the 45 patients who met the CDC AFM case definition and were included, the mean age was 6.1 years; 27 were boys (60%); and 37 were white (82%), 3 were Asian (7%), 1 was Hispanic (2%), and 4 were mixed race/ethnicity (9%). Of the included patients, 34 were classified as having rAFM, and 11 had alternate diagnoses (including transverse myelitis, other demyelinating syndromes, spinal cord stroke, Guillain-Barre syndrome, Chiari I myelopathy, and meningitis). Factors differing between groups were primarily asymmetry of weakness, lower motor neuron signs, preceding viral syndrome, symptoms evolving over hours to days, absence of sensory deficits, and magnetic resonance imaging findings. A case description was able to reliably define the rAFM group. CONCLUSIONS AND RELEVANCE We present an approach for defining a homogeneous research population that may more accurately reflect the pathogenesis of the prototypical poliomyelitis-like subgroup of AFM. The definition of rAFM forms a blueprint for inclusion criteria in future research efforts, but more work is required for refinement and external validation.
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Affiliation(s)
- Matthew J. Elrick
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Thomas O. Crawford
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Keith Van Haren
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, California
| | - Kevin Messacar
- Department of Pediatrics, Children’s Hospital Colorado, the University of Colorado, Aurora
| | - Nicole Thornton
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Elizabeth Dee
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Annie Voskertchian
- Division of Infectious Disease, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jessica R. Nance
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Laura S. Muñoz
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark P. Gorman
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
| | - Leslie A. Benson
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
| | - David L. Thomas
- Division of Infectious Disease, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carlos A. Pardo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aaron M. Milstone
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland,Division of Infectious Disease, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Priya Duggal
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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115
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116
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An increase in reports of acute flaccid paralysis (AFP) in the United Kingdom, 1 January 2018-21 January 2019: early findings. Euro Surveill 2019; 24:1900093. [PMID: 30755296 PMCID: PMC6373064 DOI: 10.2807/1560-7917.es.2019.24.6.1900093] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 02/07/2019] [Indexed: 12/29/2022] Open
Abstract
During 2018, the United Kingdom experienced an increase in reports of cases of acute flaccid paralysis (AFP). As at 21 January 2019, 40 cases had been identified with a peak in October 2018. The increase was temporally associated with an upsurge in enterovirus (EV) D68 activity. Enterovirus was detected in 15 cases, mainly from respiratory tract samples; nine were typed as EV-D68. A national task force has been established and investigations are ongoing.
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117
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Messacar K, Pretty K, Reno S, Dominguez SR. Continued biennial circulation of enterovirus D68 in Colorado. J Clin Virol 2019; 113:24-26. [PMID: 30825833 DOI: 10.1016/j.jcv.2019.01.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 01/15/2019] [Accepted: 01/23/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Kevin Messacar
- Children's Hospital Colorado, Aurora, CO, USA; University of Colorado Denver, Aurora, CO, USA
| | | | | | - Samuel R Dominguez
- Children's Hospital Colorado, Aurora, CO, USA; University of Colorado Denver, Aurora, CO, USA.
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118
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Genomic Analyses of Acute Flaccid Myelitis Cases among a Cluster in Arizona Provide Further Evidence of Enterovirus D68 Role. mBio 2019; 10:mBio.02262-18. [PMID: 30670612 PMCID: PMC6343034 DOI: 10.1128/mbio.02262-18] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Enteroviruses frequently result in respiratory and gastrointestinal illness; however, multiple subtypes, including poliovirus, can cause severe neurologic disease. Recent biennial increases (i.e., 2014, 2016, and 2018) in cases of non-polio acute flaccid paralysis have led to speculations that other enteroviruses, specifically enterovirus D68 (EV-D68), are emerging to fill the niche that was left from poliovirus eradication. A cluster of 11 suspect cases of pediatric acute flaccid myelitis (AFM) was identified in 2016 in Phoenix, AZ. Multiple genomic analyses identified the presence of EV-D68 in the majority of clinical AFM cases. Beyond limited detection of herpesvirus, no other likely etiologies were found in the cluster. These findings strengthen the likelihood that EV-D68 is a cause of AFM and show that the rapid molecular assays developed for this study are useful for investigations of AFM and EV-D68. Enteroviruses are a common cause of respiratory and gastrointestinal illness, and multiple subtypes, including poliovirus, can cause neurologic disease. In recent years, enterovirus D68 (EV-D68) has been associated with serious neurologic illnesses, including acute flaccid myelitis (AFM), frequently preceded by respiratory disease. A cluster of 11 suspect cases of pediatric AFM was identified in September 2016 in Phoenix, AZ. To determine if these cases were associated with EV-D68, we performed multiple genomic analyses of nasopharyngeal (NP) swabs and cerebrospinal fluid (CSF) material from the patients, including real-time PCR and amplicon sequencing targeting the EV-D68 VP1 gene and unbiased microbiome and metagenomic sequencing. Four of the 11 patients were classified as confirmed cases of AFM, and an additional case was classified as probable AFM. Real-time PCR and amplicon sequencing detected EV-D68 virus RNA in the three AFM patients from which NP swabs were collected, as well as in a fourth patient diagnosed with acute disseminated encephalomyelitis, a disease that commonly follows bacterial or viral infections, including enterovirus. No other obvious etiological causes for AFM were identified by 16S or RNA and DNA metagenomic sequencing in these cases, strengthening the likelihood that EV-D68 is an etiological factor. Herpes simplex viral DNA was detected in the CSF of the fourth case of AFM and in one additional suspect case from the cluster. Multiple genomic techniques, such as those described here, can be used to diagnose patients with suspected EV-D68 respiratory illness, to aid in AFM diagnosis, and for future EV-D68 surveillance and epidemiology.
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Twenty-nine Cases of Enterovirus-D68-associated Acute Flaccid Myelitis in Europe 2016: A Case Series and Epidemiologic Overview. Pediatr Infect Dis J 2019; 38:16-21. [PMID: 30234793 PMCID: PMC6296836 DOI: 10.1097/inf.0000000000002188] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Enterovirus-D68 (EV-D68) is a respiratory virus within the genus Enterovirus and the family of Picornaviridae. Genetically, it is closely related to rhinovirus that replicates in the respiratory tract and causes respiratory disease. Since 2014, EV-D68 has been associated with the neurologic syndrome of acute flaccid myelitis (AFM). METHODS In October 2016, questionnaires were sent out to a European network including 66 virologists and clinicians, to develop an inventory of EV-D68-associated AFM cases in Europe. Clinical and virologic information of case patients was requested. In addition, epidemiologic information on EV testing was collected for the period between March and October 2016. RESULTS Twenty-nine cases of EV-D68-associated AFM were identified, from 12 different European countries. Five originated from France, 5 from Scotland and 3 each from Sweden, Norway and Spain. Twenty-six were children (median age 3.8 years), 3 were adults. EV-D68 was detected in respiratory materials (n = 27), feces (n = 8) and/or cerebrospinal fluid (n = 2). Common clinical features were asymmetric flaccid limb weakness, cranial nerve deficits and bulbar symptoms. On magnetic resonance imaging, typical findings were hyperintensity of the central cord and/or brainstem; low motor amplitudes with normal conduction velocities were seen on electromyography. Full clinical recovery was rare (n = 3), and 2 patients died. The epidemiologic data from 16 European laboratories showed that of all EV-D68-positive samples, 99% was detected in a respiratory specimen. CONCLUSIONS For 2016, 29 EV-D68-related AFM cases were identified in mostly Western Europe. This is likely an underestimation, because case identification is dependent on awareness among clinicians, adequate viral diagnostics on respiratory samples and the capability of laboratories to type EVs.
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Affiliation(s)
- Sacha Stelzer-Braid
- Virology Research Laboratory, Prince of Wales Hospital, Sydney, NSW 2031, Australia
- School of Medical Sciences, and School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - William Rawlinson
- Virology Research Laboratory, Prince of Wales Hospital, Sydney, NSW 2031, Australia
- School of Medical Sciences, and School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- Serology and Virology Division (SAViD), Microbiology NSW Health Pathology Randwick, NSW 2031, Australia
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Sun S, Bian L, Gao F, Du R, Hu Y, Fu Y, Su Y, Wu X, Mao Q, Liang Z. A neonatal mouse model of Enterovirus D68 infection induces both interstitial pneumonia and acute flaccid myelitis. Antiviral Res 2018; 161:108-115. [PMID: 30503887 DOI: 10.1016/j.antiviral.2018.11.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 11/01/2018] [Accepted: 11/26/2018] [Indexed: 02/08/2023]
Abstract
Enterovirus D68 (EV-D68) is a causative agent of recent outbreaks of severe respiratory illness, pneumonia and acute flaccid myelitis (AFM) worldwide. The study of the pathogenesis, vaccines and anti-viral drugs for EV-D68 infection has been reported. Given the previously described mouse model of EV-D68, we sought to establish a neonatal mice model inducing both pneumonia and AFM. The neonatal BALB/c mice were inoculated intraperitoneally with the EV-D68 strain (named15296-virus) which was produced by the reverse genetics method. The infected mice displayed limb paralysis, tachypnea and even death, which were similar to the clinical symptoms of human infections. Moreover, the results of histopathologic examination and immunohistochemical staining showed acidophilic necrosis in the muscle, the spinal cord and alveolar wall thickening in the lung, indicating that EV-D68 exhibited strong tropism to the muscles, spinal cord and lung. Furthermore, the results of real-time PCR also suggested that the viral loads in the blood, spinal cord, muscles and lung were higher than those in other tissues at different time points post-infection. Additionally, the neonatal mouse model was used for evaluating the EV-D68 infection. The results of the anti-serum passive and maternal antibody protection indicated that the neonatal mice could be protected against the EV-D68 challenge, and displayed that both the serum of 15296-virus and prototype-virus (Fermon) were performing a certain cross-protective activity against the 15296-virus challenge. In summary, the above results proved that our neonatal mouse model possessed not only the interstitial pneumonia and AFM simultaneously but also a potentiality to evaluate the protective effects of EV-D68 vaccines and anti-viral drugs in the future.
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Affiliation(s)
- Shiyang Sun
- Institute of Medicinal Biotechnology Chinese Academy of Medical Sciences, Peking Union Medical College (PUMC), Beijing, China; National Institute for Food and Drug Control, Beijing, China.
| | - Lianlian Bian
- National Institute for Food and Drug Control, Beijing, China.
| | - Fan Gao
- National Institute for Food and Drug Control, Beijing, China.
| | - Ruixiao Du
- National Institute for Food and Drug Control, Beijing, China.
| | - Yalin Hu
- Hualan Biological Engineering Inc, Xinxiang, China.
| | - Ying Fu
- National Institute for Food and Drug Control, Beijing, China.
| | - Yao Su
- National Institute for Food and Drug Control, Beijing, China.
| | - Xing Wu
- National Institute for Food and Drug Control, Beijing, China.
| | - Qunying Mao
- National Institute for Food and Drug Control, Beijing, China.
| | - Zhenglun Liang
- National Institute for Food and Drug Control, Beijing, China.
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McKay SL, Lee AD, Lopez AS, Nix WA, Dooling KL, Keaton AA, Spence-Davizon E, Herlihy R, Clark TA, Hopkins SE, Pastula DM, Sejvar J, Oberste MS, Pallansch MA, Patel M, Routh JA. Increase in Acute Flaccid Myelitis - United States, 2018. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2018; 67:1273-1275. [PMID: 30439867 PMCID: PMC6290805 DOI: 10.15585/mmwr.mm6745e1] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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Cassidy H, Poelman R, Knoester M, Van Leer-Buter CC, Niesters HGM. Enterovirus D68 - The New Polio? Front Microbiol 2018; 9:2677. [PMID: 30483226 PMCID: PMC6243117 DOI: 10.3389/fmicb.2018.02677] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/19/2018] [Indexed: 12/20/2022] Open
Abstract
Enterovirus D68 (EV-D68) has emerged over the recent years, with large outbreaks worldwide. Increased occurrence has coincided with improved clinical awareness and surveillance of non-polio enteroviruses. Studies showing its neurotropic nature and the change in pathogenicity have established EV-D68 as a probable cause of Acute Flaccid Myelitis (AFM). The EV-D68 storyline shows many similarities with poliovirus a century ago, stimulating discussion whether EV-D68 could be ascertaining itself as the "new polio." Increasing awareness amongst clinicians, incorporating proper diagnostics and integrating EV-D68 into accessible surveillance systems in a way that promotes data sharing, will be essential to reveal the burden of disease. This will be a necessary step in preventing EV-D68 from becoming a threat to public health.
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Affiliation(s)
| | | | | | | | - Hubert G. M. Niesters
- Department of Medical Microbiology and Infection Prevention, Division of Clinical Virology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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Hübner J, Kruse B, Christen HJ, Weidenmann J, Weiner V, Schöne-Bake JC, Eichinger A, Diedrich S, Müller-Felber W. Acute Flaccid Myelitis in German Children in 2016-the Return of Polio? DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:551-557. [PMID: 28855045 DOI: 10.3238/arztebl.2017.0551] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 01/18/2017] [Accepted: 06/02/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Although poliomyelitis has almost been eradicated worldwide, cases of a polio-like disease with asymmetrical flaccid paralysis of variable severity have been seen repeatedly in recent years. METHODS Data were collected on children treated in hospitals in the German federal states of Bavaria and Lower Saxony in 2016. The frequency of disease across Germany was estimated on the basis of voluntary reporting to the Robert Koch Institute. 16 cases were registered there for the entire year 2016. RESULTS 7 children with flaccid paralysis of acute onset were treated in the participating hospitals in the summer and fall of 2016. We describe two illustrative cases, one with a mild course and one with a severe course. Rapid diagnosis requires not only clinical neurological assessment but also neurophysiological studies, magnetic resonance imaging (MRI), and targeted microbiological testing. The characteristic features include damage to the anterior horn of the spinal cord that can be seen on MRI and/or electrophysiologically demonstrable abnormalities indicating motor neuron damage. A pathogen can hardly ever be identified in the cerebrospinal fluid, but the epidemiological context and the detection of viruses in the stool or respiratory secretions indicate that entero - viruses may be responsible. CONCLUSION The prognosis of this disease cannot be reliably assessed at first, and no specific treatment is currently available.
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Affiliation(s)
- Johannes Hübner
- Dr. von Hauner Children's Hospital, Ludwig-Maximilians University of Munich, Germany; Neuropediatric Department, Helios-Klinikum Hildesheim, Germany; Children's and Youth Hospital "Auf der Bult," Hannover, Germany; National Reference Center for Poliomyelitis and Enteroviruses, Robert Koch Institute, Berlin, Germany; German Center for Infection Research, Munich site, Germany
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Messacar K, Sillau S, Hopkins SE, Otten C, Wilson-Murphy M, Wong B, Santoro JD, Treister A, Bains HK, Torres A, Zabrocki L, Glanternik JR, Hurst AL, Martin JA, Schreiner T, Makhani N, DeBiasi RL, Kruer MC, Tremoulet AH, Van Haren K, Desai J, Benson LA, Gorman MP, Abzug MJ, Tyler KL, Dominguez SR. Safety, tolerability, and efficacy of fluoxetine as an antiviral for acute flaccid myelitis. Neurology 2018; 92:e2118-e2126. [PMID: 30413631 DOI: 10.1212/wnl.0000000000006670] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 10/10/2018] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To determine the safety, tolerability, and efficacy of fluoxetine for proven or presumptive enterovirus (EV) D68-associated acute flaccid myelitis (AFM). METHODS A multicenter cohort study of US patients with AFM in 2015-2016 compared serious adverse events (SAEs), adverse effects, and outcomes between fluoxetine-treated patients and untreated controls. Fluoxetine was administered at the discretion of treating providers with data gathered retrospectively. The primary outcome was change in summative limb strength score (SLSS; sum of Medical Research Council strength in all 4 limbs, ranging from 20 [normal strength] to 0 [complete quadriparesis]) between initial examination and latest follow-up, with increased SLSS reflecting improvement and decreased SLSS reflecting worsened strength. RESULTS Fifty-six patients with AFM from 12 centers met study criteria. Among 30 patients exposed to fluoxetine, no SAEs were reported and adverse effect rates were similar to unexposed patients (47% vs 65%, p = 0.16). The 28 patients treated with >1 dose of fluoxetine were more likely to have EV-D68 identified (57.1% vs 14.3%, p < 0.001). Their SLSS was similar at initial examination (mean SLSS 12.9 vs 14.3, p = 0.31) but lower at nadir (mean SLSS 9.25 vs 12.82, p = 0.02) and latest follow-up (mean SLSS 12.5 vs 16.4, p = 0.005) compared with the 28 patients receiving 1 (n = 2) or no (n = 26) doses. In propensity-adjusted analysis, SLSS from initial examination to latest follow-up decreased by 0.2 (95% confidence interval [CI] -1.8 to +1.4) in fluoxetine-treated patients and increased by 2.5 (95% CI +0.7 to +4.4) in untreated patients (p = 0.015). CONCLUSION Fluoxetine was well-tolerated. Fluoxetine was preferentially given to patients with AFM with EV-D68 identified and more severe paralysis at nadir, who ultimately had poorer long-term outcomes. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that for patients with EV-D68-associated AFM, fluoxetine is well-tolerated and not associated with improved neurologic outcomes.
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Affiliation(s)
- Kevin Messacar
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC.
| | - Stefan Sillau
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Sarah E Hopkins
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Catherine Otten
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Molly Wilson-Murphy
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Brian Wong
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Jonathan D Santoro
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Andrew Treister
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Harlori K Bains
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Alcy Torres
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Luke Zabrocki
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Julia R Glanternik
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Amanda L Hurst
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Jan A Martin
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Teri Schreiner
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Naila Makhani
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Roberta L DeBiasi
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Michael C Kruer
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Adriana H Tremoulet
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Keith Van Haren
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Jay Desai
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Leslie A Benson
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Mark P Gorman
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Mark J Abzug
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Kenneth L Tyler
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Samuel R Dominguez
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
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Contemporary Circulating Enterovirus D68 Strains Have Acquired the Capacity for Viral Entry and Replication in Human Neuronal Cells. mBio 2018; 9:mBio.01954-18. [PMID: 30327438 PMCID: PMC6191546 DOI: 10.1128/mbio.01954-18] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Since the EV-D68 outbreak during the summer of 2014, evidence of a causal link to a type of limb paralysis (AFM) has been mounting. In this article, we describe a neuronal cell culture model (SH-SY5Y cells) in which a subset of contemporary 2014 outbreak strains of EV-D68 show infectivity in neuronal cells, or neurotropism. We confirmed the difference in neurotropism in vitro using primary human neuron cell cultures and in vivo with a mouse paralysis model. Using the SH-SY5Y cell model, we determined that a barrier to viral entry is at least partly responsible for neurotropism. SH-SY5Y cells may be useful in determining if specific EV-D68 genetic determinants are associated with neuropathogenesis, and replication in this cell line could be used as rapid screening tool for identification of neurotropic EV-D68 strains. This may assist with better understanding of pathogenesis and epidemiology and with the development of potential therapies. Enterovirus D68 (EV-D68) has historically been associated with respiratory illnesses. However, in the summers of 2014 and 2016, EV-D68 outbreaks coincided with a spike in polio-like acute flaccid myelitis/paralysis (AFM/AFP) cases. This raised concerns that EV-D68 could be the causative agent of AFM during these recent outbreaks. To assess the potential neurotropism of EV-D68, we utilized the neuroblastoma-derived neuronal cell line SH-SY5Y as a cell culture model to determine if differential infection is observed for different EV-D68 strains. In contrast to HeLa and A549 cells, which support viral infection of all EV-D68 strains tested, SH-SY5Y cells only supported infection by a subset of contemporary EV-D68 strains, including isolates from the 2014 outbreak. Viral replication and infectivity in SH-SY5Y were assessed using multiple assays: virus production, cytopathic effects, cellular ATP release, and VP1 capsid protein production. Similar differential neurotropism was also observed in differentiated SH-SY5Y cells, primary human neuron cultures, and a mouse paralysis model. Using the SH-SY5Y cell culture model, we determined that barriers to viral binding and entry were at least partly responsible for the differential infectivity phenotype. Transfection of genomic RNA into SH-SY5Y generated virions for all EV-D68 isolates, but only a single round of replication was observed from strains that could not directly infect SH-SY5Y. In addition to supporting virus replication and other functional studies, this cell culture model may help identify the signatures of virulence to confirm epidemiological associations between EV-D68 strains and AFM and allow for the rapid identification and characterization of emerging neurotropic strains.
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Messacar K, Asturias EJ, Hixon AM, Van Leer-Buter C, Niesters HGM, Tyler KL, Abzug MJ, Dominguez SR. Enterovirus D68 and acute flaccid myelitis-evaluating the evidence for causality. THE LANCET. INFECTIOUS DISEASES 2018; 18:e239-e247. [PMID: 29482893 PMCID: PMC6778404 DOI: 10.1016/s1473-3099(18)30094-x] [Citation(s) in RCA: 141] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 09/19/2017] [Accepted: 11/09/2017] [Indexed: 01/11/2023]
Abstract
Increased circulation of enterovirus D68 in 2014 and 2016 temporally and geographically coincided with increases in cases of acute flaccid myelitis, an uncommon condition of paralysis due to lesions in the anterior horn of the spinal cord. The identification of enterovirus D68 in respiratory specimens from cases of acute flaccid myelitis worldwide further supports an association, yet the absence of direct virus isolation from affected tissues, infrequent detection in cerebrospinal fluid, and the absence, until recently, of an animal model has left the causal nature of the relationship unproven. In this Personal View we evaluate epidemiological and biological evidence linking enterovirus D68 and acute flaccid myelitis. We applied the Bradford Hill criteria to investigate the evidence for a causal relationship and highlight the importance of comprehensive surveillance and research to further characterise the role of enterovirus D68 in acute flaccid myelitis and pursue effective therapies and prevention strategies.
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Abstract
PURPOSE OF REVIEW The focus of this review is on enterovirus (EV)-associated acute flaccid paralysis (AFP) due to spinal cord anterior horn cell disease. Emphasis is placed on the epidemiology, pathogenesis, diagnosis, treatment, and outcome of AFP caused by polioviruses, vaccine-derived polioviruses, EV-D68, and EV-A71. RECENT FINDINGS Since the launch of The Global Polio Eradication Initiative in 1988, the worldwide incidence of polio has been reduced by 99.9%, with small numbers of poliomyelitis cases being reported only in Afghanistan, Pakistan, and Nigeria. With the planned phaseout of oral polio vaccine, vaccine-associated poliomyelitis is also expected to be eliminated. In their place, other EVs, chiefly EV-D68 and EV-A71, have emerged as the principal causes of AFP. There is evidence that the emergence of EV-D68 as a cause of severe respiratory disease and AFP was due to recent genetic virus evolution. Antiviral medications targeting EV-D68, EV-A71, and other EVs will likely be available in the near future. An effective EV-A71 vaccine has been developed, and preliminary investigations suggest an EV-D68 vaccine could be on the horizon. The eradication of poliomyelitis and vaccine-associated poliomyelitis is near, after which other EVs, presently EV-D68 and EV-A71, will be the principle viral causes of AFP. Moving forward, it is essential that EV outbreaks, in particular those associated with neurologic complications, be investigated carefully and the causal strains identified, so that treatment and prevention efforts can be rapidly developed and implemented.
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Affiliation(s)
- Ari Bitnun
- Division of Infectious Diseases, The Hospital for Sick Children and Department of Pediatrics, University of Toronto, Toronto, ON, M5G 1X8, Canada.
| | - E Ann Yeh
- Division of Neurology, The Hospital for Sick Children and Department of Pediatrics, Division of Neurosciences and Mental Health, SickKids Research Institute, University of Toronto, Toronto, Canada
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Sun S, Gao F, Hu Y, Bian L, Wu X, Su Y, Du R, Fu Y, Zhu F, Mao Q, Liang Z. A cross-sectional seroepidemiology study of EV-D68 in China. Emerg Microbes Infect 2018; 7:99. [PMID: 29872035 PMCID: PMC5988671 DOI: 10.1038/s41426-018-0103-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/08/2018] [Accepted: 04/29/2018] [Indexed: 02/02/2023]
Abstract
Enterovirus 68 (EV-D68) is associated with respiratory diseases, such as acute upper respiratory tract infections (URTIs), lower respiratory tract infections (LRTIs), pneumonia, neurological diseases, and acute flaccid myelitis (AFM). In recent years, there have been global outbreaks of EV-D68 epidemics. However, there is no effective vaccine against EV-D68, and the understanding of the seroprevalence characteristics of EV-D68 is limited. To evaluate the epidemiological features of this emerging infection in mainland China, serum samples from 20 pairs of pregnant women and their neonates, 405 infants and children (ages 1 month-15 years), and 50 adults were collected to measure EV-D68 neutralizing antibodies (NtAbs). The results showed that the geometric mean titers (GMTs) of pregnant women and their neonates were 168 (95%CI: 93.6-301.7) and 162.3 (95%CI: 89.9-293.1), respectively. The seroprevalence rate of EV-D68 antibodies was negatively correlated with age in 1-month-old to 12-month-old infants (84% for 1-month-old infants vs 10% for 1-year-old infants), whereas it was positively correlated with age for 1-year-old to 15-year-old children (10% for 1-year-old children vs 92% for 15-year-old children). This study evaluated maternal antibodies against EV-D68 in neonates. Our results showed that if mothers had high levels of anti-EV-D68 NtAbs, the NtAbs titers in their neonates were also high. The GMTs and seroprevalence rates of each age group indicated that EV-D68 infection was very common in China. Periodical EV-D68 seroprevalence surveys and vaccination campaigns should be the top priority for preventing EV-D68 infection.
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Affiliation(s)
- Shiyang Sun
- National Institute for Food and Drug Control, Beijing, China
| | - Fan Gao
- National Institute for Food and Drug Control, Beijing, China
| | - Yalin Hu
- Hualan Biological Engineering Inc, Xinxiang, China
| | - Lianlian Bian
- National Institute for Food and Drug Control, Beijing, China
| | - Xing Wu
- National Institute for Food and Drug Control, Beijing, China
| | - Yao Su
- National Institute for Food and Drug Control, Beijing, China
| | - Ruixiao Du
- National Institute for Food and Drug Control, Beijing, China
| | - Ying Fu
- National Institute for Food and Drug Control, Beijing, China
| | - Fengcai Zhu
- Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, China
| | - Qunying Mao
- National Institute for Food and Drug Control, Beijing, China.
| | - Zhenglun Liang
- National Institute for Food and Drug Control, Beijing, China.
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Chong PF, Kira R, Mori H, Okumura A, Torisu H, Yasumoto S, Shimizu H, Fujimoto T, Hanaoka N, Kusunoki S, Takahashi T, Oishi K, Tanaka-Taya K. Clinical Features of Acute Flaccid Myelitis Temporally Associated With an Enterovirus D68 Outbreak: Results of a Nationwide Survey of Acute Flaccid Paralysis in Japan, August-December 2015. Clin Infect Dis 2018; 66:653-664. [PMID: 29028962 PMCID: PMC5850449 DOI: 10.1093/cid/cix860] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 10/04/2017] [Indexed: 12/26/2022] Open
Abstract
Background Acute flaccid myelitis (AFM) is an acute flaccid paralysis syndrome with spinal motor neuron involvement of unknown etiology. We investigated the characteristics and prognostic factors of AFM clusters coincident with an enterovirus D68 (EV-D68) outbreak in Japan during autumn 2015. Methods An AFM case series study was conducted following a nationwide survey from August to December 2015. Radiographic and neurophysiologic data were subjected to centralized review, and virology studies were conducted for available specimens. Results Fifty-nine AFM cases (58 definite, 1 probable) were identified, including 55 children and 4 adults (median age, 4.4 years). The AFM epidemic curve showed strong temporal correlation with EV-D68 detection from pathogen surveillance, but not with other pathogens. EV-D68 was detected in 9 patients: 5 in nasopharyngeal, 2 in stool, 1 in cerebrospinal fluid (adult case), and 1 in tracheal aspiration, nasopharyngeal, and serum samples (a pediatric case with preceding steroid usage). Cases exhibited heterogeneous paralysis patterns from 1- to 4-limb involvement, but all definite cases had longitudinal spinal gray matter lesions on magnetic resonance imaging (median, 20 spinal segments). Cerebrospinal fluid pleocytosis was observed in 50 of 59 cases (85%), and 8 of 29 (28%) were positive for antiganglioside antibodies, as frequently observed in Guillain-Barré syndrome. Fifty-two patients showed variable residual weakness at follow-up. Good prognostic factors included a pretreatment manual muscle strength test unit score >3, normal F-wave persistence, and EV-D68-negative status. Conclusions EV-D68 may be one of the causative agents for AFM, while host susceptibility factors such as immune response could contribute to AFM development.
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Affiliation(s)
- Pin Fee Chong
- Department of Pediatric Neurology, Fukuoka Children’s Hospital
| | - Ryutaro Kira
- Department of Pediatric Neurology, Fukuoka Children’s Hospital
| | - Harushi Mori
- Department of Radiology, Graduate School and Faculty of Medicine, University of Tokyo
| | - Akihisa Okumura
- Department of Pediatrics, Aichi Medical University, Nagakute
| | - Hiroyuki Torisu
- Department of Pediatrics, Fukuoka Dental College Medical and Dental Hospital
| | - Sawa Yasumoto
- Medical Education Center, Fukuoka University School of Medicine
| | | | - Tsuguto Fujimoto
- Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo
| | - Nozomu Hanaoka
- Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo
| | - Susumu Kusunoki
- Department of Neurology, Kindai University Faculty of Medicine, Osaka-Sayama
| | - Toshiyuki Takahashi
- Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kazunori Oishi
- Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo
| | - Keiko Tanaka-Taya
- Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo
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131
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Zhang C, Zhang X, Dai W, Liu Q, Xiong P, Wang S, Geng L, Gong S, Huang Z. A Mouse Model of Enterovirus D68 Infection for Assessment of the Efficacy of Inactivated Vaccine. Viruses 2018; 10:v10020058. [PMID: 29385753 PMCID: PMC5850365 DOI: 10.3390/v10020058] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 01/27/2018] [Accepted: 01/29/2018] [Indexed: 12/15/2022] Open
Abstract
In recent years, enterovirus D68 (EVD68) has been reported increasingly to be associated with severe respiratory tract infections and acute flaccid myelitis (AFM) in children all over the world. Yet, no effective vaccines or antiviral drugs are currently available for EVD68. Although several experimental animal models have been developed, immunogenicity and protective efficacy of inactivated EVD68 vaccines has not been fully evaluated. To promote the development of vaccines, we established an Institute of Cancer Research (ICR) suckling mouse model of EVD68 infection in this study. The results showed that ICR neonatal mice up to about nine days of age were susceptible to infection with EVD68 clinical strain US/MO/14-18947 by intraperitoneal injection. The infected mice exhibited progressive limb paralysis prior to death and the mortality of mice was age- and virus dose-dependent. Tissue viral load analysis showed that limb muscle and spinal cord were the major sites of viral replication. Moreover, histopathologic examination revealed the severe necrosis of the limb and juxtaspinal muscles, suggesting that US/MO/14-18947 has a strong tropism toward muscle tissues. Additionally, β-propiolactone-inactivated EVD68 vaccine showed high purity and quality and induced robust EVD68-specific neutralizing antibody responses in adult mice. Importantly, results from both antisera transfer and maternal immunization experiments clearly showed that inactivated EVD68 vaccine was able to protect against lethal viral infection in the mouse model. In short, these results demonstrate the successful establishment of the mouse model of EVD68 infection for evaluating candidate vaccines against EVD68 and also provide important information for the development of inactivated virus-based EVD68 vaccines.
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Affiliation(s)
- Chao Zhang
- Joint Center for Infection and Immunity, Guangzhou Institute of Pediatrics, Department of Gastroenterology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou 510623, China; (C.Z.); (L.G.)
- Unit of Vaccinology & Antiviral Strategies, CAS Key Laboratory of Molecular Virology & Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Shanghai 200031, China; (X.Z); (W.D.); (Q.L.); (P.X.); (S.W)
| | - Xueyang Zhang
- Unit of Vaccinology & Antiviral Strategies, CAS Key Laboratory of Molecular Virology & Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Shanghai 200031, China; (X.Z); (W.D.); (Q.L.); (P.X.); (S.W)
| | - Wenlong Dai
- Unit of Vaccinology & Antiviral Strategies, CAS Key Laboratory of Molecular Virology & Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Shanghai 200031, China; (X.Z); (W.D.); (Q.L.); (P.X.); (S.W)
| | - Qingwei Liu
- Unit of Vaccinology & Antiviral Strategies, CAS Key Laboratory of Molecular Virology & Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Shanghai 200031, China; (X.Z); (W.D.); (Q.L.); (P.X.); (S.W)
| | - Pei Xiong
- Unit of Vaccinology & Antiviral Strategies, CAS Key Laboratory of Molecular Virology & Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Shanghai 200031, China; (X.Z); (W.D.); (Q.L.); (P.X.); (S.W)
| | - Shuxia Wang
- Unit of Vaccinology & Antiviral Strategies, CAS Key Laboratory of Molecular Virology & Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Shanghai 200031, China; (X.Z); (W.D.); (Q.L.); (P.X.); (S.W)
| | - Lanlan Geng
- Joint Center for Infection and Immunity, Guangzhou Institute of Pediatrics, Department of Gastroenterology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou 510623, China; (C.Z.); (L.G.)
| | - Sitang Gong
- Joint Center for Infection and Immunity, Guangzhou Institute of Pediatrics, Department of Gastroenterology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou 510623, China; (C.Z.); (L.G.)
- Correspondence: (Z.H.); (S.G.)
| | - Zhong Huang
- Joint Center for Infection and Immunity, Guangzhou Institute of Pediatrics, Department of Gastroenterology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou 510623, China; (C.Z.); (L.G.)
- Unit of Vaccinology & Antiviral Strategies, CAS Key Laboratory of Molecular Virology & Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Shanghai 200031, China; (X.Z); (W.D.); (Q.L.); (P.X.); (S.W)
- Correspondence: (Z.H.); (S.G.)
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132
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Dyda A, Stelzer-Braid S, Adam D, Chughtai AA, MacIntyre CR. The association between acute flaccid myelitis (AFM) and Enterovirus D68 (EV-D68) - what is the evidence for causation? Euro Surveill 2018; 23:17-00310. [PMID: 29386095 PMCID: PMC5792700 DOI: 10.2807/1560-7917.es.2018.23.3.17-00310] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BackgroundEnterovirus D68 (EV-D68) has historically been a sporadic disease, causing occasional small outbreaks of generally mild infection. In recent years, there has been evidence of an increase in EV-D68 infections globally. Large outbreaks of EV-D68, with thousands of cases, occurred in the United States, Canada and Europe in 2014. The outbreaks were associated temporally and geographically with an increase in clusters of acute flaccid myelitis (AFM).
Aims: We aimed to evaluate a causal association between EV-D68 and AFM.
Methods: Using data from the published and grey literature, we applied the Bradford Hill criteria, a set of nine principles applied to examine causality, to evaluate the relationship between EV-D68 and AFM. Based on available evidence, we defined the Bradford Hill Criteria as being not met, or met minimally, partially or fully.
Results: Available evidence applied to EV-D68 and AFM showed that six of the Bradford Hill criteria were fully met and two were partially met. The criterion of biological gradient was minimally met. The incidence of EV-D68 infections is increasing world-wide. Phylogenetic epidemiology showed diversification from the original Fermon and Rhyne strains since the year 2000, with evolution of a genetically distinct outbreak strain, clade B1. Clade B1, but not older strains, is associated with AFM and is neuropathic in animal models.
Conclusion: While more research is needed on dose-response relationship, application of the Bradford Hill criteria supported a causal relationship between EV-D68 and AFM.
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Affiliation(s)
- Amalie Dyda
- School of Public Health and Community Medicine, University of New South Wales (UNSW), Sydney, New South Wales (NSW), Australia
| | - Sacha Stelzer-Braid
- School of Medical Sciences, University of New South Wales (UNSW), Sydney, New South Wales (NSW), Australia,Division of Serology and Virology, South Eastern Area Laboratory Services, Prince of Wales Hospital, Sydney, Australia
| | - Dillon Adam
- School of Public Health and Community Medicine, University of New South Wales (UNSW), Sydney, New South Wales (NSW), Australia
| | - Abrar A Chughtai
- School of Public Health and Community Medicine, University of New South Wales (UNSW), Sydney, New South Wales (NSW), Australia
| | - C Raina MacIntyre
- School of Public Health and Community Medicine, University of New South Wales (UNSW), Sydney, New South Wales (NSW), Australia,College of Public Service and Community Solutions and College of Health Solutions, Arizona State University, Tempe, Arizona, United States
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133
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Moline HL, Karachunski PI, Strain A, Griffith J, Kenyon C, Schleiss MR. Acute Transverse Myelitis Caused by Echovirus 11 in a Pediatric Patient: Case Report and Review of the Current Literature. Child Neurol Open 2018; 5:2329048X17751526. [PMID: 29372173 PMCID: PMC5772484 DOI: 10.1177/2329048x17751526] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 10/30/2017] [Accepted: 11/21/2017] [Indexed: 11/16/2022] Open
Abstract
A 12-year-old boy presented with acute flaccid weakness of the right upper extremity and was found to have acute flaccid myelitis with transverse myelitis involving the cervical cord (C1-T1). An interdisciplinary team-based approach was undertaken, including input from a generalist, an infectious diseases physician, and a pediatric neurologist. Consultation was sought from the Minnesota Department of Health to investigate for a potential etiology and source of the responsible infection. Evaluation for an infectious etiology demonstrated infection with human echovirus 11. The patient recovered with some disability. Echovirus 11 is among the more common etiologies of acute flaccid myelitis and should be considered in the differential diagnosis of this increasingly recognized pediatric infection.
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Affiliation(s)
- Heidi L Moline
- Department of Pediatrics, University of Minnesota Masonic Children's Hospital, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Peter I Karachunski
- Department of Pediatrics, University of Minnesota Masonic Children's Hospital, University of Minnesota Medical School, Minneapolis, MN, USA.,Department of Neurology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Anna Strain
- Epidemiology and Control Division, Infectious Diseases, Minnesota Department of Health, Saint Paul, MN, USA
| | - Jayne Griffith
- Epidemiology and Control Division, Infectious Diseases, Minnesota Department of Health, Saint Paul, MN, USA
| | - Cynthia Kenyon
- Epidemiology and Control Division, Infectious Diseases, Minnesota Department of Health, Saint Paul, MN, USA
| | - Mark R Schleiss
- Department of Pediatrics, University of Minnesota Masonic Children's Hospital, University of Minnesota Medical School, Minneapolis, MN, USA
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134
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Morrey JD, Wang H, Hurst BL, Zukor K, Siddharthan V, Van Wettere AJ, Sinex DG, Tarbet EB. Causation of Acute Flaccid Paralysis by Myelitis and Myositis in Enterovirus-D68 Infected Mice Deficient in Interferon αβ/γ Receptor Deficient Mice. Viruses 2018; 10:E33. [PMID: 29329211 PMCID: PMC5795446 DOI: 10.3390/v10010033] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 01/04/2018] [Accepted: 01/08/2018] [Indexed: 11/16/2022] Open
Abstract
Enterovirus D68 (EV-D68) caused a large outbreak in the summer and fall of 2014 in the United States. It causes serious respiratory disease, but causation of associated paralysis is controversial, because the virus is not routinely identified in cerebrospinal fluid. To establish clinical correlates with human disease, we evaluated EV-D68 infection in non-lethal paralysis mouse models. Ten-day-old mice lacking interferon responses were injected intraperitoneally with the virus. Paralysis developed in hindlimbs. After six weeks of paralysis, the motor neurons were depleted due to viral infection. Hindlimb muscles were also infected and degenerating. Even at the earliest stage of paralysis, muscles were still infected and were degenerating, in addition to presence of virus in the spinal cord. To model natural respiratory infection, five-day-old mice were infected intranasally with EV-D68. Two of the four infected mice developed forelimb paralysis. The affected limbs had muscle disease, but no spinal cord infection was detected. The unique contributions of this study are that EV-D68 causes paralysis in mice, and that causation by muscle disease, with or without spinal cord disease, may help to resolve the controversy that the virus can cause paralysis, even if it cannot be identified in cerebrospinal fluid.
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Affiliation(s)
- John D Morrey
- Institute for Antiviral Research, Department of Animal, Dairy, and Veterinary Sciences, 5600 Old Main Hill, Utah State University, Logan, UT 84322, USA.
| | - Hong Wang
- Institute for Antiviral Research, Department of Animal, Dairy, and Veterinary Sciences, 5600 Old Main Hill, Utah State University, Logan, UT 84322, USA.
| | - Brett L Hurst
- Institute for Antiviral Research, Department of Animal, Dairy, and Veterinary Sciences, 5600 Old Main Hill, Utah State University, Logan, UT 84322, USA.
| | - Katherine Zukor
- Institute for Antiviral Research, Department of Animal, Dairy, and Veterinary Sciences, 5600 Old Main Hill, Utah State University, Logan, UT 84322, USA.
| | - Venkatraman Siddharthan
- Institute for Antiviral Research, Department of Animal, Dairy, and Veterinary Sciences, 5600 Old Main Hill, Utah State University, Logan, UT 84322, USA.
| | - Arnaud J Van Wettere
- Utah Veterinary Diagnostics Laboratory, Department of Animal, Dairy, and Veterinary Sciences, 950 East 1400 North, Utah State University, Logan, UT 84341, USA.
| | - Donal G Sinex
- Department of Communication Disorders and Deaf Education, 2800 Old Main Hill, Utah State University, Logan, UT 84322, USA.
| | - E Bart Tarbet
- Institute for Antiviral Research, Department of Animal, Dairy, and Veterinary Sciences, 5600 Old Main Hill, Utah State University, Logan, UT 84322, USA.
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135
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Enterovirus D68 virus-like particles expressed in Pichia pastoris potently induce neutralizing antibody responses and confer protection against lethal viral infection in mice. Emerg Microbes Infect 2018; 7:3. [PMID: 29323105 PMCID: PMC5837163 DOI: 10.1038/s41426-017-0005-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/24/2017] [Accepted: 11/12/2017] [Indexed: 12/17/2022]
Abstract
Enterovirus D68 (EV-D68) has been increasingly associated with severe respiratory illness and neurological complications in children worldwide. However, no vaccine is currently available to prevent EV-D68 infection. In the present study, we investigated the possibility of developing a virus-like particle (VLP)-based EV-D68 vaccine. We found that co-expression of the P1 precursor and 3CD protease of EV-D68 in Pichia pastoris yeast resulted in the generation of EV-D68 VLPs, which were composed of processed VP0, VP1, and VP3 capsid proteins and were visualized as ~30 nm spherical particles. Mice immunized with these VLPs produced serum antibodies capable of specifically neutralizing EV-D68 infections in vitro. The in vivo protective efficacy of the EV-D68 VLP candidate vaccine was assessed in two challenge experiments. The first challenge experiment showed that neonatal mice born to the VLP-immunized dams were fully protected from lethal EV-D68 infection, whereas in the second experiment, passive transfer of anti-VLP sera was found to confer complete protection in the recipient mice. Collectively, these results demonstrate the proof-of-concept for VLP-based broadly effective EV-D68 vaccines.
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136
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Dai W, Zhang C, Zhang X, Xiong P, Liu Q, Gong S, Geng L, Zhou D, Huang Z. A virus-like particle vaccine confers protection against enterovirus D68 lethal challenge in mice. Vaccine 2018; 36:653-659. [DOI: 10.1016/j.vaccine.2017.12.057] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 12/16/2017] [Indexed: 01/07/2023]
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137
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Suresh S, Forgie S, Robinson J. Non-polio Enterovirus detection with acute flaccid paralysis: A systematic review. J Med Virol 2018; 90:3-7. [PMID: 28857219 DOI: 10.1002/jmv.24933] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 08/18/2017] [Indexed: 11/07/2022]
Abstract
Acute flaccid paralysis (AFP), as defined by the World Health Organization (WHO), is characterized by an acute onset of limb weakness. In the post-polio era, other enterovirus (EV) serotypes associated with AFP may become more prominent. This study aims to collate the data on the non-polio enteroviruses (NPEV) associated with AFP. A systematic review of published case reports, case series, and surveillance studies of AFP from 1960 through 2017 was undertaken. Data were collected including the country of the study, number of specimens positive for NPEV and available clinical data. The majority of studies originated from Asia. In surveillance studies, EV 71 (a serotype of Enterovirus A) was the most commonly detected serotype with AFP, followed by Enterovirus B serotype echovirus 11 and then Enterovirus B serotype echovirus 11. In case studies and case reports, EV 71 and EV 68 (a serotype of Enterovirus D), were the most commonly detected NPEV. As poliovirus eradication continues, there is a need to ensure that AFP surveillance will also detect other potentially vaccine preventable viruses.
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MESH Headings
- Adolescent
- Adult
- Asia/epidemiology
- Child
- Child, Preschool
- Enterovirus A, Human/genetics
- Enterovirus A, Human/immunology
- Enterovirus A, Human/isolation & purification
- Enterovirus A, Human/pathogenicity
- Enterovirus B, Human/genetics
- Enterovirus B, Human/immunology
- Enterovirus B, Human/isolation & purification
- Enterovirus B, Human/pathogenicity
- Enterovirus D, Human/genetics
- Enterovirus D, Human/immunology
- Enterovirus D, Human/isolation & purification
- Enterovirus D, Human/pathogenicity
- Enterovirus Infections/complications
- Enterovirus Infections/epidemiology
- Enterovirus Infections/virology
- Feces/virology
- Female
- Humans
- Male
- Nucleic Acid Amplification Techniques
- Paraplegia/epidemiology
- Paraplegia/etiology
- Paraplegia/virology
- Phylogeny
- Poliovirus
- Serogroup
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Affiliation(s)
- Sneha Suresh
- Department of Pediatrics, Stollery Children's Hospital and University of Alberta, Edmonton, Alberta, Canada
| | - Sarah Forgie
- Department of Pediatrics, Stollery Children's Hospital and University of Alberta, Edmonton, Alberta, Canada
| | - Joan Robinson
- Department of Pediatrics, Stollery Children's Hospital and University of Alberta, Edmonton, Alberta, Canada
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138
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Hixon AM, Clarke P, Tyler KL. Evaluating Treatment Efficacy in a Mouse Model of Enterovirus D68-Associated Paralytic Myelitis. J Infect Dis 2017; 216:1245-1253. [PMID: 28968718 DOI: 10.1093/infdis/jix468] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 09/07/2017] [Indexed: 12/17/2022] Open
Abstract
Background Enterovirus D68 (EV-D68)-associated acute flaccid myelitis (AFM) is a devastating neurological disease for which there are no treatments of proven efficacy. The unpredictable temporal and geographic distribution of cases and the rarity of the disease make it unlikely that data from randomized controlled trials will be available to guide therapeutic decisions. We evaluated the following 3 widely used empirical therapies for the ability to reduce the severity of paralysis in a mouse model of EV-D68 infection: (1) human intravenous immunoglobulin (hIVIG), (2) fluoxetine, and (3) dexamethasone. Methods Neonatal mice were injected intramuscularly with a human 2014 EV-D68 isolate that reliably induces paralysis in mice due to infection and loss of spinal cord motor neurons. Mice receiving treatments were evaluated for motor impairment, mortality, and spinal cord viral load. Results hIVIG, which contained neutralizing antibodies to EV-D68, reduced paralysis in infected mice and decreased spinal cord viral loads. Fluoxetine had no effect on motor impairment or viral loads. Dexamethasone treatment worsened motor impairment, increased mortality, and increased viral loads. Conclusion Results in this model of EV-D68-associated AFM provide a rational basis for selecting empirical therapy in humans and establish this model as a useful system for evaluating other potential therapies.
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Affiliation(s)
- Alison M Hixon
- Medical Scientist Training Program.,Neuroscience Program
| | | | - Kenneth L Tyler
- Department of Neurology.,Department of Medicine.,Department of Immunology and Microbiology, University of Colorado School of Medicine Aurora
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139
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Acute Flaccid Myelitis: Etiologic Challenges, Diagnostic and Management Considerations. Curr Treat Options Neurol 2017; 19:48. [PMID: 29181601 DOI: 10.1007/s11940-017-0480-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Purpose of review Acute flaccid myelitis is a polio-like illness defined by the acute onset of flaccid paralysis in the setting spinal MRI demonstrating a longitudinal lesion in the gray matter of the cord. This paper aims to review the current state of knowledge and key clinical points for the diagnosis and management of acute flaccid myelitis. RECENT FINDINGS Recent findings There were clusters of AFM noted in California and Colorado in 2014, with additional cases across the USA that year, and another spike in cases in 2016. Patients have been managed with classic treatments for transverse myelitis, but in general without benefit, although some colleagues have noted anecdotal improvement in individual patients. Our current practice at the Children's Hospital of Philadelphia is to initiate therapy with intravenous immunoglobulin (IVIG) upon recognition of acute flaccid myelitis in hopes of boosting humoral immunity, and to provide an emphasis on rehabilitation services, including physical and occupational therapy. There is some data that suggests a connection to the virus enterovirus D68 (EV D68), but there has been no definitive link. Publications regarding longer-term outcomes in these patients are early in development and, thus far, only provide data for 6 to 12 months from onset. Summary AFM is a serious illness with long-term consequences, and we have much to learn. Key areas in need of further investigation involve etiology, host susceptibilities, treatment options, and long-term outcome. Individual clinicians can assist in these efforts by the prompt reporting of cases of AFM to the US Centers for Disease Control and Prevention.
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140
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Itagaki T, Aoki Y, Matoba Y, Tanaka S, Ikeda T, Mizuta K, Matsuzaki Y. Clinical characteristics of children infected with enterovirus D68 in an outpatient clinic and the association with bronchial asthma. Infect Dis (Lond) 2017; 50:303-312. [PMID: 29119851 DOI: 10.1080/23744235.2017.1400176] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND All reports of increases in severe respiratory disease associated with human enterovirus D68 (EV-D68) are from hospital settings. However, there are few reports describing clinical characteristics in less severely affected populations. METHODS We conducted a retrospective observational study from January 2010 to December 2015 in Yamagata, Japan. Using regional passive surveillance, 5794 respiratory specimens were collected from children who initially presented to an outpatient clinic with acute respiratory symptoms. The collected samples were tested for EV-D68 by reverse transcription PCR. RESULTS EV-D68 was detected in 79 specimens mainly during the two epidemic periods in August-October 2010 and August-October 2015, when detection rates were 10.2% (31 of 304 specimens) and 16.3% (46 of 282 specimens), respectively. Among the 69 EV-D68-positive children, excluding those with viral coinfection, 39 (57%) had upper respiratory tract infections, 23 (33%) bronchiolitis or asthma attack, 5 (7%) bronchitis, 1 (1%) meningitis and 1 (1%) acute flaccid paralysis. In 23 children with wheezing, retraction was observed in 10 (43%), and six (26%) were diagnosed with asthma exacerbation. Six children required hospital admission, five (83%) because of asthma exacerbation. A history of asthma or wheezing was the most significant risk factor for the development of wheezing (odds ratio, 8.23; 95% CI, 2.65-25.50; p < .001). CONCLUSIONS The low rate of hospitalization (9%, 6 of 69) indicates that most cases with EV-D68 infection were managed as outpatients. A history of asthma or wheezing was a potential risk factor for wheezing, resulting in hospitalization due to a severe asthma attack.
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Affiliation(s)
| | - Yoko Aoki
- b Department of Microbiology , Yamagata Prefectural Institute of Public Health , Tokamachi , Japan
| | - Yohei Matoba
- b Department of Microbiology , Yamagata Prefectural Institute of Public Health , Tokamachi , Japan
| | - Shizuka Tanaka
- b Department of Microbiology , Yamagata Prefectural Institute of Public Health , Tokamachi , Japan
| | - Tatsuya Ikeda
- b Department of Microbiology , Yamagata Prefectural Institute of Public Health , Tokamachi , Japan
| | - Katsumi Mizuta
- b Department of Microbiology , Yamagata Prefectural Institute of Public Health , Tokamachi , Japan
| | - Yoko Matsuzaki
- c Department of Infectious Diseases , Yamagata University Faculty of Medicine , Iida-Nishi , Japan
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141
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Messacar K, Abzug MJ, Dominguez SR. The changing epidemiology of acute flaccid paralysis warrants a paradigm shift in surveillance. J Med Virol 2017; 90:1-2. [PMID: 29023852 DOI: 10.1002/jmv.24920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 08/22/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Kevin Messacar
- Department of Pediatrics, Section of Hospital Medicine, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado.,Department of Pediatrics, Section of Infectious Diseases, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado
| | - Mark J Abzug
- Department of Pediatrics, Section of Infectious Diseases, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado
| | - Samuel R Dominguez
- Department of Pediatrics, Section of Infectious Diseases, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado.,Department of Pathology and Laboratory Medicine, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado
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142
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Shaw J, Halsey NA, Weinberg A, Scott Schmid D, George KS, Weldon WC, Jordan M, Bryant PW, LaRussa PS, Bradshaw DY, Harrington T, Gershon A. Arm Paralysis After Routine Childhood Vaccinations: Application of Advanced Molecular Methods to the Causality Assessment of an Adverse Event After Immunization. J Pediatric Infect Dis Soc 2017; 6:e161-e164. [PMID: 28339574 PMCID: PMC6251534 DOI: 10.1093/jpids/piw084] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 12/02/2016] [Indexed: 12/27/2022]
Abstract
Post-licensure surveillance for adverse events following immunizations (AEFI) can identify rare complications of vaccinations and rigorous vaccine adverse event causality assessments can help to identify possible causal relationships. We report the development of arm paralysis after varicella vaccination in a 1-year-old child. Paralysis was initially presumed to be due to vOka because of the temporal relationship between vaccination and onset of arm weakness; however, molecular studies identified wild-type varicella zoster virus VZV (WT-VZV) in the CSF, leading the authors to conclude that WT-VZV was the probable cause. This case illustrates the complexity of assessing AEFI causality, and the importance of careful and complete evaluations when determining the most likely cause of an AEFI.
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Affiliation(s)
- Jana Shaw
- Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University, Golisano Children’s Hospital, Syracuse;,Correspondence: J. Shaw, MD, MPH, Associate Professor of Pediatrics, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University, Golisano Children’s Hospital, 750 East Adams Street, Syracuse, NY 13210 ()
| | - Neal A Halsey
- Institute for Vaccine Safety, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Adriana Weinberg
- Departments of Pediatrics, Medicine and Pathology, Director, Molecular and Virology Clinical Laboratories, University of Colorado Denver, Aurora
| | - D Scott Schmid
- National Center for Immunizations and Respiratory Diseases, Division of Viral Diseases, Atlanta, Georgia
| | - Kirsten St George
- Laboratory of Viral Diseases, Wadsworth Center, New York State Department of Health, Clinical Professor, Department of Biomedical Sciences, University at Albany, SUNY
| | - William C Weldon
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Michael Jordan
- Pediatrics, Divisions of Immunobiology, and Bone Marrow Transplantation and Immune Deficiency Cincinnati Children’s Hospital/University of Cincinnati, Ohio
| | - Patrick W Bryant
- Laboratory of Viral Diseases, Wadsworth Center, New York State Department of Health, Albany
| | - Philip S LaRussa
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Columbia University, New York, New York
| | | | - Theresa Harrington
- Centers for Disease Control and Prevention, National Center for Emerging, Zoonotic, and Infectious Diseases, Division of Healthcare Quality Promotion, Immunization Safety Office, Clinical Immunization Safety Assessment Project, Atlanta, Georgia
| | - Anne Gershon
- Columbia University College of Physicians and Surgeons, New York, New York
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Bonwitt J, Poel A, DeBolt C, Gonzales E, Lopez A, Routh J, Rietberg K, Linton N, Reggin J, Sejvar J, Lindquist S, Otten C. Acute Flaccid Myelitis Among Children - Washington, September-November 2016. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2017; 66:826-829. [PMID: 28796760 PMCID: PMC5687781 DOI: 10.15585/mmwr.mm6631a2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Iverson SA, Ostdiek S, Prasai S, Engelthaler DM, Kretschmer M, Fowle N, Tokhie HK, Routh J, Sejvar J, Ayers T, Bowers J, Brady S, Rogers S, Nix WA, Komatsu K, Sunenshine R. Notes from the Field: Cluster of Acute Flaccid Myelitis in Five Pediatric Patients - Maricopa County, Arizona, 2016. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2017; 66:758-760. [PMID: 28727681 PMCID: PMC5657946 DOI: 10.15585/mmwr.mm6628a4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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145
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Ny NTH, Anh NT, Hang VTT, Nguyet LA, Thanh TT, Ha DQ, Minh NNQ, Ha DLA, McBride A, Tuan HM, Baker S, Tam PTT, Phuc TM, Huong DT, Loi TQ, Vu NTA, Hung NV, Minh TTT, Xang NV, Dong N, Nghia HDT, Chau NVV, Thwaites G, van Doorn HR, Anscombe C, Le Van T. Enterovirus D68 in Viet Nam (2009-2015). Wellcome Open Res 2017. [PMID: 28852711 DOI: 10.12688/wellcomeopenres.11558.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Since 1962, enterovirus D68 (EV-D68) has been implicated in multiple outbreaks and sporadic cases of respiratory infection worldwide, but especially in the USA and Europe with an increasing frequency between 2010 and 2014. We describe the detection, associated clinical features and molecular characterization of EV-D68 in central and southern Viet Nam between 2009 and 2015. METHODS Enterovirus/rhinovirus PCR positive respiratory or CSF samples taken from children and adults with respiratory/central nervous system infections in Viet Nam were tested by an EV-D68 specific PCR. The included samples were derived from 3 different observational studies conducted at referral hospitals across central and southern Viet Nam between 2009 and 2015. Whole-genome sequencing was carried out using a MiSeq based approach. Phylogenetic reconstruction and estimation of evolutionary rate and recombination were carried out in BEAST and Recombination Detection Program, respectively. RESULTS EV-D68 was detected in 21/625 (3.4%) enterovirus/rhinovirus PCR positive respiratory samples but in none of the 15 CSF. All the EV-D68 patients were young children (age range: 11.8 - 24.5 months) and had moderate respiratory infections. Phylogenetic analysis suggested that the Vietnamese sequences clustered with those from Asian countries, of which 9 fell in the B1 clade, and the remaining sequence was identified within the A2 clade. One intra sub-clade recombination event was detected, representing the second reported recombination within EV-D68. The evolutionary rate of EV-D68 was estimated to be 5.12E -3 substitutions/site/year. Phylogenetic analysis indicated that the virus was imported into Viet Nam in 2008. CONCLUSIONS We have demonstrated for the first time EV-D68 has been circulating at low levels in Viet Nam since 2008, associated with moderate acute respiratory infection in children. EV-D68 in Viet Nam is most closely related to Asian viruses, and clusters separately from recent US and European viruses that were suggested to be associated with acute flaccid paralysis.
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Affiliation(s)
- Nguyen Thi Han Ny
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Ho Chi Minh City University of Science, Ho Chi Minh City, Vietnam
| | - Nguyen To Anh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Vu Thi Ty Hang
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Lam Anh Nguyet
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Tran Tan Thanh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Do Quang Ha
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Do Lien Anh Ha
- Murdoch Children's Research Institute, Melbourne, Australia
| | - Angela McBride
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Ha Manh Tuan
- Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Stephen Baker
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Tran My Phuc
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Dang Thao Huong
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Tran Quoc Loi
- Dong Thap General Hospital, Ban Me Thuot City, Vietnam
| | | | | | | | | | - Nguyen Dong
- Khanh Hoa General Hospital, Nha Trang City, Vietnam
| | - Ho Dang Trung Nghia
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Pham Ngoc Thach University, Ho Chi Minh City, Vietnam
| | | | - Guy Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - H Rogier van Doorn
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Tan Le Van
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
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146
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Ny NTH, Anh NT, Hang VTT, Nguyet LA, Thanh TT, Ha DQ, Minh NNQ, Ha DLA, McBride A, Tuan HM, Baker S, Tam PTT, Phuc TM, Huong DT, Loi TQ, Vu NTA, Hung NV, Minh TTT, Xang NV, Dong N, Nghia HDT, Chau NVV, Thwaites G, van Doorn HR, Anscombe C, Le Van T. Enterovirus D68 in Viet Nam (2009-2015). Wellcome Open Res 2017; 2:41. [PMID: 28852711 PMCID: PMC5553084 DOI: 10.12688/wellcomeopenres.11558.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2017] [Indexed: 11/30/2022] Open
Abstract
Background: Since 1962, enterovirus D68 (EV-D68) has been implicated in multiple outbreaks and sporadic cases of respiratory infection worldwide, especially in the USA and Europe with an increasing frequency between 2010 and 2014. We describe the detection, associated clinical features and molecular characterization of EV-D68 in central and southern Viet Nam between 2009 and 2015. Methods: Enterovirus/rhinovirus PCR positive respiratory or CSF samples taken from children and adults with respiratory/central nervous system infections in Viet Nam were tested by an EV-D68 specific PCR. The included samples were derived from 3 different observational studies conducted at referral hospitals across central and southern Viet Nam 2009 2015. Whole-genome sequencing was carried out using a MiSeq based approach. Phylogenetic reconstruction and estimation of evolutionary rate and recombination were carried out in BEAST and Recombination Detection Program, respectively. Results: EV-D68 was detected in 21/625 (3.4%) enterovirus/rhinovirus PCR positive respiratory samples but in none of the 15 CSF. All the EV-D68 patients were young children (age range: 11.8 – 24.5 months) and had moderate respiratory infections. Phylogenetic analysis suggested that the Vietnamese sequences clustered with those from Asian countries, of which 9 fell in the B1 clade, and the remaining sequence was identified within the A2 clade. One intra sub-clade recombination event was detected, representing the second reported recombination within EV-D68. The evolutionary rate of EV-D68 was estimated to be 5.12E
-3 substitutions/site/year. Phylogenetic analysis indicated that the virus was imported into Viet Nam in 2008. Conclusions: We have demonstrated for the first time EV-D68 has been circulating at low levels in Viet Nam since 2008, associated with moderate acute respiratory infection in children. EV-D68 in Viet Nam is most closely related to Asian viruses, and clusters separately from recent US and European viruses that were suggested to be associated with acute flaccid paralysis.
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Affiliation(s)
- Nguyen Thi Han Ny
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Ho Chi Minh City University of Science, Ho Chi Minh City, Vietnam
| | - Nguyen To Anh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Vu Thi Ty Hang
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Lam Anh Nguyet
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Tran Tan Thanh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Do Quang Ha
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Do Lien Anh Ha
- Murdoch Children's Research Institute, Melbourne, Australia
| | - Angela McBride
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Ha Manh Tuan
- Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Stephen Baker
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Tran My Phuc
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Dang Thao Huong
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Tran Quoc Loi
- Dong Thap General Hospital, Ban Me Thuot City, Vietnam
| | | | | | | | | | - Nguyen Dong
- Khanh Hoa General Hospital, Nha Trang City, Vietnam
| | - Ho Dang Trung Nghia
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Pham Ngoc Thach University, Ho Chi Minh City, Vietnam
| | | | - Guy Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - H Rogier van Doorn
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Tan Le Van
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
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147
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Martin JA, Messacar K, Yang ML, Maloney JA, Lindwall J, Carry T, Kenyon P, Sillau SH, Oleszek J, Tyler KL, Dominguez SR, Schreiner TL. Outcomes of Colorado children with acute flaccid myelitis at 1 year. Neurology 2017; 89:129-137. [PMID: 28615421 DOI: 10.1212/wnl.0000000000004081] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 03/27/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We describe long-term functional, neurodiagnostic, and psychosocial outcomes of a cohort of 12 children from Colorado diagnosed with acute flaccid myelitis (AFM) in 2014. METHODS Children were assessed every 3 months for 1 year or until clinical resolution. Assessments included neurologic examination, MRI, EMG/nerve conduction studies (NCS), functional measures (Assisting Hand Assessment, Hammersmith Functional Motor Scale), and Patient-Reported Outcomes Measurement Information System questionnaires. RESULTS Eight of 12 children completed the study. Six of 8 had persistent motor deficits at 1 year; 2 demonstrated full recovery. Four were not enrolled, 2 of whom reported full recovery. The 6 affected were weakest in proximal muscles, showing minimal to no improvement and significant atrophy at 1 year. All patients improved in distal muscle groups. Cranial nerve dysfunction resolved in 2 of 5 and improved in all. Four of 5 showed progressive functional improvement at 6 and 12 months. Two of 8 reported pain at 1 year. Three of 8 reported depressive symptoms. Repeat MRI was performed in 7 of 8 children a median of 7 months after onset and showed significant improvement or normalization in all but one child. Repeat EMG/NCS was performed on 4 children a median of 8 months after onset and showed ongoing denervation and chronic reinnervation in 3 children with persistent deficits. CONCLUSIONS At 1 year, children with AFM demonstrated functional gains but weakness persisted. EMG changes correlated with persistent deficits better than imaging. Despite improvements, AFM had substantial long-term functional effects on affected children.
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Affiliation(s)
- Jan A Martin
- From the Departments of Pediatrics (J.A. Martin, M.L.Y., T.L.S.), Infectious Diseases (K.M., S.R.D.), Hospital Medicine (K.M.), Radiology (J.A. Maloney), Child Psychiatry (J.L.), and Physical Medicine and Rehabilitation (T.C., P.K., J.O.), Section of Child Neurology, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora; and Departments of Neurology, Medicine, and Immunology-Microbiology and Neurology Service at the Denver Veterans Affairs Medical Center (S.H.S., K.L.T.), University of Colorado School of Medicine
| | - Kevin Messacar
- From the Departments of Pediatrics (J.A. Martin, M.L.Y., T.L.S.), Infectious Diseases (K.M., S.R.D.), Hospital Medicine (K.M.), Radiology (J.A. Maloney), Child Psychiatry (J.L.), and Physical Medicine and Rehabilitation (T.C., P.K., J.O.), Section of Child Neurology, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora; and Departments of Neurology, Medicine, and Immunology-Microbiology and Neurology Service at the Denver Veterans Affairs Medical Center (S.H.S., K.L.T.), University of Colorado School of Medicine
| | - Michele L Yang
- From the Departments of Pediatrics (J.A. Martin, M.L.Y., T.L.S.), Infectious Diseases (K.M., S.R.D.), Hospital Medicine (K.M.), Radiology (J.A. Maloney), Child Psychiatry (J.L.), and Physical Medicine and Rehabilitation (T.C., P.K., J.O.), Section of Child Neurology, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora; and Departments of Neurology, Medicine, and Immunology-Microbiology and Neurology Service at the Denver Veterans Affairs Medical Center (S.H.S., K.L.T.), University of Colorado School of Medicine
| | - John A Maloney
- From the Departments of Pediatrics (J.A. Martin, M.L.Y., T.L.S.), Infectious Diseases (K.M., S.R.D.), Hospital Medicine (K.M.), Radiology (J.A. Maloney), Child Psychiatry (J.L.), and Physical Medicine and Rehabilitation (T.C., P.K., J.O.), Section of Child Neurology, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora; and Departments of Neurology, Medicine, and Immunology-Microbiology and Neurology Service at the Denver Veterans Affairs Medical Center (S.H.S., K.L.T.), University of Colorado School of Medicine
| | - Jennifer Lindwall
- From the Departments of Pediatrics (J.A. Martin, M.L.Y., T.L.S.), Infectious Diseases (K.M., S.R.D.), Hospital Medicine (K.M.), Radiology (J.A. Maloney), Child Psychiatry (J.L.), and Physical Medicine and Rehabilitation (T.C., P.K., J.O.), Section of Child Neurology, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora; and Departments of Neurology, Medicine, and Immunology-Microbiology and Neurology Service at the Denver Veterans Affairs Medical Center (S.H.S., K.L.T.), University of Colorado School of Medicine
| | - Terri Carry
- From the Departments of Pediatrics (J.A. Martin, M.L.Y., T.L.S.), Infectious Diseases (K.M., S.R.D.), Hospital Medicine (K.M.), Radiology (J.A. Maloney), Child Psychiatry (J.L.), and Physical Medicine and Rehabilitation (T.C., P.K., J.O.), Section of Child Neurology, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora; and Departments of Neurology, Medicine, and Immunology-Microbiology and Neurology Service at the Denver Veterans Affairs Medical Center (S.H.S., K.L.T.), University of Colorado School of Medicine
| | - Patricia Kenyon
- From the Departments of Pediatrics (J.A. Martin, M.L.Y., T.L.S.), Infectious Diseases (K.M., S.R.D.), Hospital Medicine (K.M.), Radiology (J.A. Maloney), Child Psychiatry (J.L.), and Physical Medicine and Rehabilitation (T.C., P.K., J.O.), Section of Child Neurology, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora; and Departments of Neurology, Medicine, and Immunology-Microbiology and Neurology Service at the Denver Veterans Affairs Medical Center (S.H.S., K.L.T.), University of Colorado School of Medicine
| | - Stefan H Sillau
- From the Departments of Pediatrics (J.A. Martin, M.L.Y., T.L.S.), Infectious Diseases (K.M., S.R.D.), Hospital Medicine (K.M.), Radiology (J.A. Maloney), Child Psychiatry (J.L.), and Physical Medicine and Rehabilitation (T.C., P.K., J.O.), Section of Child Neurology, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora; and Departments of Neurology, Medicine, and Immunology-Microbiology and Neurology Service at the Denver Veterans Affairs Medical Center (S.H.S., K.L.T.), University of Colorado School of Medicine
| | - Joyce Oleszek
- From the Departments of Pediatrics (J.A. Martin, M.L.Y., T.L.S.), Infectious Diseases (K.M., S.R.D.), Hospital Medicine (K.M.), Radiology (J.A. Maloney), Child Psychiatry (J.L.), and Physical Medicine and Rehabilitation (T.C., P.K., J.O.), Section of Child Neurology, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora; and Departments of Neurology, Medicine, and Immunology-Microbiology and Neurology Service at the Denver Veterans Affairs Medical Center (S.H.S., K.L.T.), University of Colorado School of Medicine
| | - Kenneth L Tyler
- From the Departments of Pediatrics (J.A. Martin, M.L.Y., T.L.S.), Infectious Diseases (K.M., S.R.D.), Hospital Medicine (K.M.), Radiology (J.A. Maloney), Child Psychiatry (J.L.), and Physical Medicine and Rehabilitation (T.C., P.K., J.O.), Section of Child Neurology, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora; and Departments of Neurology, Medicine, and Immunology-Microbiology and Neurology Service at the Denver Veterans Affairs Medical Center (S.H.S., K.L.T.), University of Colorado School of Medicine
| | - Samuel R Dominguez
- From the Departments of Pediatrics (J.A. Martin, M.L.Y., T.L.S.), Infectious Diseases (K.M., S.R.D.), Hospital Medicine (K.M.), Radiology (J.A. Maloney), Child Psychiatry (J.L.), and Physical Medicine and Rehabilitation (T.C., P.K., J.O.), Section of Child Neurology, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora; and Departments of Neurology, Medicine, and Immunology-Microbiology and Neurology Service at the Denver Veterans Affairs Medical Center (S.H.S., K.L.T.), University of Colorado School of Medicine
| | - Teri L Schreiner
- From the Departments of Pediatrics (J.A. Martin, M.L.Y., T.L.S.), Infectious Diseases (K.M., S.R.D.), Hospital Medicine (K.M.), Radiology (J.A. Maloney), Child Psychiatry (J.L.), and Physical Medicine and Rehabilitation (T.C., P.K., J.O.), Section of Child Neurology, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora; and Departments of Neurology, Medicine, and Immunology-Microbiology and Neurology Service at the Denver Veterans Affairs Medical Center (S.H.S., K.L.T.), University of Colorado School of Medicine.
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148
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Acute Hypotonia in an Infant. J Emerg Med 2017; 52:e245-e247. [DOI: 10.1016/j.jemermed.2016.12.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/03/2016] [Accepted: 12/27/2016] [Indexed: 11/22/2022]
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149
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First Report of a Fatal Case Associated with EV-D68 Infection in Hong Kong and Emergence of an Interclade Recombinant in China Revealed by Genome Analysis. Int J Mol Sci 2017; 18:ijms18051065. [PMID: 28509856 PMCID: PMC5454976 DOI: 10.3390/ijms18051065] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 05/04/2017] [Accepted: 05/09/2017] [Indexed: 12/19/2022] Open
Abstract
A fatal case associated with enterovirus D68 (EV-D68) infection affecting a 10-year-old boy was reported in Hong Kong in 2014. To examine if a new strain has emerged in Hong Kong, we sequenced the partial genome of the EV-D68 strain identified from the fatal case and the complete VP1, and partial 5′UTR and 2C sequences of nine additional EV-D68 strains isolated from patients in Hong Kong. Sequence analysis indicated that a cluster of strains including the previously recognized A2 strains should belong to a separate clade, clade D, which is further divided into subclades D1 and D2. Among the 10 EV-D68 strains, 7 (including the fatal case) belonged to the previously described, newly emerged subclade B3, 2 belonged to subclade B1, and 1 belonged to subclade D1. Three EV-D68 strains, each from subclades B1, B3, and D1, were selected for complete genome sequencing and recombination analysis. While no evidence of recombination was noted among local strains, interclade recombination was identified in subclade D2 strains detected in mainland China in 2008 with VP2 acquired from clade A. This study supports the reclassification of subclade A2 into clade D1, and demonstrates interclade recombination between clades A and D2 in EV-D68 strains from China.
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150
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Messacar K, Robinson CC, Pretty K, Yuan J, Dominguez SR. Surveillance for enterovirus D68 in colorado children reveals continued circulation. J Clin Virol 2017; 92:39-41. [PMID: 28521212 DOI: 10.1016/j.jcv.2017.05.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 04/25/2017] [Accepted: 05/09/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND The largest, most widespread outbreak of enterovirus D68 respiratory disease occurred from August to December of 2014 in the United States with 1153 confirmed infections in 49 states. The epidemiology of enterovirus D68 following the 2014 outbreak is unknown. OBJECTIVES This study seeks to describe the epidemiology of enterovirus D68 circulation amongst Colorado children from 2014 to 2016. STUDY DESIGN This is a prospective observational surveillance study of enterovirus D68 infection amongst children tested for respiratory pathogens from July-October 2014-2016 at Children's Hospital Colorado (CHCO), a quaternary care children's hospital in Aurora, CO. RESULTS Amongst rhinovirus/enterovirus positive respiratory specimens from intensive care unit patients, ninety-eight of 314 (31.2%) in 2014, none of 307 (0%) specimens in 2015, and 19 of 240 (7.9%) specimens in 2016 were identified as enterovirus D68. Amongst respiratory specimens from all patients during the prospective active surveillance period, none of 1469 (0%) in 2015 and 46 of 1403 (3.3%) were positive for enterovirus D68. CONCLUSIONS Surveillance for enterovirus D68 amongst respiratory specimens at a quaternary care children's hospital revealed a seasonal pattern of circulation in the late summer to early fall of 2014 and 2016. Continued surveillance of respiratory specimens is necessary to define the circulation pattern and understand the epidemiology of this emerging pathogen.
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Affiliation(s)
- Kevin Messacar
- Children's Hospital Colorado, Aurora, CO, USA; University of Colorado Denver, Aurora, CO, USA
| | | | | | - Ji Yuan
- Children's Hospital Colorado, Aurora, CO, USA
| | - Samuel R Dominguez
- Children's Hospital Colorado, Aurora, CO, USA; University of Colorado Denver, Aurora, CO, USA.
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