Clinical Features of Guillain-Barré Syndrome With vs Without Zika Virus Infection, Puerto Rico, 2016

Long-term outcomes of patients affected by Guillain-Barré syndrome in Colombia after the Zika virus epidemic

BACKGROUND

Guillain-Barré Syndrome (GBS) can lead to significant functional impairments, yet little is understood about the recovery phase and long-term consequences for patients in low- and medium-income countries.

OBJECTIVE

To evaluate the functional status and identify factors influencing outcomes among patients with GBS in Colombia.

METHODS

Telephone interviews were conducted with GBS patients enrolled in the Neuroviruses Emerging in the Americas Study between 2016 and 2020. The investigation encompassed access to health services and functional status assessments, utilizing the modified Rankin Scale (mRS), GBS Disability Score (GDS), Barthel Index (BI), and International Classification of Functioning (ICF). Univariate analysis, principal component analysis, linear discriminant analysis, and linear regression were employed to explore factors influencing functional status.

RESULTS

Forty-five patients (mean age = 50[±22] years) with a median time from diagnosis of 28 months (IQR = 9-34) were included. Notably, 22% and 16% of patients did not receive rehabilitation services during the acute episode and post-discharge, respectively. Most patients demonstrated independence in basic daily activities (median BI = 100, IQR = 77.5-100), improvement in disability as the median mRS at follow-up was lower than at onset (1 [IQR = 0-3] vs. 4.5 [IQR = 4-5], p < 0.001), and most were able to walk without assistance (median GDS = 2, IQR = 0-2). A shorter period from disease onset to interview was associated with worse mRS (p = 0.015) and ICF (p = 0.019). Negative outcomes on GDS and ICF were linked to low socioeconomic status, ICF to the severity of weakness at onset, and BI to an older age.

CONCLUSIONS

This study underscores that the functional recovery of GBS patients in Colombia is influenced not only by the natural course of the disease but also by socioeconomic factors, emphasizing the crucial role of social determinants of health.

Current status of Guillain-Barré syndrome (GBS) in China: a 10-year comprehensive overview

Guillain-Barré syndrome (GBS) is an acute inflammatory polyradiculoneuropathy; a disease involving the peripheral nervous system which is the most common cause of acute flaccid paralysis worldwide. So far, it is still lack of a comprehensive overview and understanding of the national epidemiological, clinical characteristics, and the risk factors of GBS in China, as well as differences between China and other countries and regions in these respects. With the global outbreak of the coronavirus disease 2019 (COVID-19), an epidemiological or phenotypic association between severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection and GBS has attracted great attention. In this review, we outlined the current clinical data of GBS in China by retrieving literature, extracting and synthesizing the data of GBS in China from 2010 to 2021. Besides, we compared the characteristics of epidemiology, preceding events and clinical profiles of GBS between China and other countries and regions. Furthermore, in addition to conventional intravenous immunoglobulin (IVIG) and plasma exchange (PE) therapy, the potential therapeutic effects with novel medications in GBS, such as complement inhibitors, etc., have become the research focus in treatments. We found that epidemiological and clinical findings of GBS in China are approximately consistent with those in the International GBS Outcome Study (IGOS) cohort. We provided an overall picture of the present clinical status of GBS in China and summarized the global research progress of GBS, aiming to further understand the characteristics of GBS and improve the future work of GBS worldwide, especially in countries with the middle and low incomes.

Dengue, chikungunya and zika arbovirus infections in Caribbean children

PURPOSE OF REVIEW

Dengue, chikungunya and zika have caused significant epidemics in the Caribbean in recent years. This review highlights their impact in Caribbean children.

RECENT FINDINGS

Dengue has been increasingly intense and severe, seroprevalence is 80-100% in the Caribbean, children have increased attributable morbidity and mortality. Severe dengue, especially dengue with haemorrhage was significantly associated with haemoglobin SC disease and multiple organ-systems involved. These included the gastrointestinal and haematologic systems with extremely high lactate dehydrogenases and creatinine phosphokinases and severely abnormal bleeding indices. Despite appropriate interventions, mortality was highest within the first 48 h of admission. Chikungunya, a togavirus, affected 80% of some Caribbean populations. Paediatric presentations included high fever, skin, joint and neurological manifestations. Children less than 5 years of age had the highest morbidity and mortality. This maiden chikungunya epidemic was explosive and overwhelmed public health systems. Zika, another flavivirus, has a seroprevalence of 15% in pregnancy, so the Caribbean remains susceptible. Paediatric complications include pregnancy losses, stillbirths, Congenital Zika syndrome, Guillain-Barre syndrome, acute disseminated encephalomyelitis and transverse myelitis. Neurodevelopment stimulation programs for zika-exposed infants have been effective in improving language and positive behaviour scores.

SUMMARY

Caribbean children remain at risk for dengue, chikungunya and zika, with high attributable morbidity and mortality.

COVID-19-associated Guillain-Barré syndrome in the early pandemic experience in Lombardia (Italy)

OBJECTIVE

To estimate the incidence and describe clinical characteristics and outcome of GBS in COVID-19 patients (COVID19-GBS) in one of the most hit regions during the first pandemic wave, Lombardia.

METHODS

Adult patients admitted to 20 Neurological Units between 1/3-30/4/2020 with COVID19-GBS were included as part of a multi-center study organized by the Italian society of Hospital Neuroscience (SNO).

RESULTS

Thirty-eight COVID19-GBS patients had a mean age of 60.7 years and male frequency of 86.8%. CSF albuminocytological dissociation was detected in 71.4%, and PCR for SARS-CoV-2 was negative in 19 tested patients. Based on neurophysiology, 81.8% of patients had a diagnosis of AIDP, 12.1% of AMSAN, and 6.1% of AMAN. The course was favorable in 76.3% of patients, stable in 10.5%, while 13.2% worsened, of which 3 died. The estimated occurrence rate in Lombardia ranges from 0.5 to 0.05 GBS cases per 1000 COVID-19 infections depending on whether you consider positive cases or estimated seropositive cases. When we compared GBS cases with the pre-pandemic period, we found a reduction of cases from 165 to 135 cases in the 2-month study period in Lombardia.

CONCLUSIONS

We detected an increased incidence of GBS in COVID-19 patients which can reflect a higher risk of GBS in COVID-19 patients and a reduction of GBS events during the pandemic period possibly due to a lower spread of more common respiratory infectious diseases determined by an increased use of preventive measures.

Estimating Zika virus attack rates and risk of Zika virus-associated neurological complications in Colombian capital cities with a Bayesian model

Zika virus (ZIKV) is a mosquito-borne pathogen that caused a major epidemic in the Americas in 2015-2017. Although the majority of ZIKV infections are asymptomatic, the virus has been associated with congenital birth defects and neurological complications (NC) in adults. We combined multiple data sources to improve estimates of ZIKV infection attack rates (IARs), reporting rates of Zika virus disease (ZVD) and the risk of ZIKV-associated NC for 28 capital cities in Colombia. ZVD surveillance data were combined with post-epidemic seroprevalence data and a dataset on ZIKV-associated NC in a Bayesian hierarchical model. We found substantial heterogeneity in ZIKV IARs across cities. The overall estimated ZIKV IAR across the 28 cities was 0.38 (95% CrI: 0.17-0.92). The estimated ZVD reporting rate was 0.013 (95% CrI: 0.004-0.024), and 0.51 (95% CrI: 0.17-0.92) cases of ZIKV-associated NC were estimated to be reported per 10 000 ZIKV infections. When we assumed the same ZIKV IAR across sex or age group, we found important spatial heterogeneities in ZVD reporting rates and the risk of being reported as a ZVD case with NC. Our results highlight how additional data sources can be used to overcome biases in surveillance data and estimate key epidemiological parameters.

COVID-19 Vaccination a Cause of Guillain-Barré Syndrome? A Case Series

Guillain-Barré syndrome (GBS) is a rare autoimmune neuropathic disorder of peripheral nerves usually following an infection or on rarer occasions following vaccinations, but the exact underlying pathophysiology is still unclear. The most common etiology of GBS is a bacterial infection caused by Campylobacter jejuni. Viral infections like Zika virus, Epstein-Barr virus, and Cytomegalovirus also add to the list of GBS etiology. COVID-19 (SARS-CoV-2) has also been reported to cause GBS. Vaccines like the rabies vaccine, influenza vaccine, and poliovirus vaccine account for a very small fraction of Guillain-Barré syndrome. GBS as an adverse effect of COVID-19 vaccination was not reported by the Vaccine Adverse Event Reporting System (VAERS), but an update was later released in the course of the pandemic from FDA news, reporting several patients developing GBS after receiving the COVID-19 vaccine. In this case series, we discuss five cases that developed the GBS post-COVID-19 AstraZeneca vaccine, along with its pathophysiology, management, and outcome.

Zika Virus Exploits Lipid Rafts to Infect Host Cells

Several flaviviruses such as Hepatitis C virus, West Nile virus, Dengue virus and Japanese Encephalitis virus exploit the raft platform to enter host cells whereas the involvement of lipid rafts in Zika virus–host cell interaction has not yet been demonstrated. Zika virus disease is caused by a flavivirus transmitted by Aedes spp. Mosquitoes, although other mechanisms such as blood transfusion, sexual and maternal–fetal transmission have been demonstrated. Symptoms are generally mild, such as fever, rash, joint pain and conjunctivitis, but neurological complications, including Guillain-Barré syndrome, have been associated to this viral infection. During pregnancy, it can cause microcephaly and other congenital abnormalities in the fetus, as well as pregnancy complications, representing a serious health threat. In this study, we show for the first time that Zika virus employs cell membrane lipid rafts as a portal of entry into Vero cells. We previously demonstrated that the antifungal drug Amphotericin B (AmphB) hampers a microbe–host cell interaction through the disruption of lipid raft architecture. Here, we found that Amphotericin B by the same mechanism of action inhibits both Zika virus cell entry and replication. These data encourage further studies on the off-label use of Amphotericin B in Zika virus infections as a new and alternate antiviral therapy.

Etiological profile of peripheral neuropathies in an academic hospital in southern Morocco

Background

Peripheral neuropathies constitute a common complaint in general and neurology practice, and are a source of handicap to patients. Epidemiological data in the Middle East and North Africa region as well as in the African continent are sparse. Nevertheless, regional etiological profiles are crucial in navigating the diagnostic maze of neuropathies. This study outlines the etiological profile of peripheral neuropathies in an academic hospital in southern Morocco.

Results

A total of 180 cases were recorded in a span of 8 years (22.5 cases per year). The mean age of patients was 42.35 years. Male gender was predominant (68.88%), with a sex ratio of 2.2. Motor symptoms were the most frequently reported (86.6%). The axonal form (40.56%) was the most frequently encountered electrophysiologic form. The most frequent etiologies in the study were diabetes (26.7%), acute polyradiculoneuropathy (26.1%) and amyotrophic lateral sclerosis (16.1%). Alcohol neuropathy was found in 2.2% of the cohort. No cause was found in 5% of cases. Outcome was mostly favorable under treatment, although 10 deaths due to acute polyradiculoneuropathy were recorded (mortality = 21.3%).

Conclusions

Knowledge of the etiological profile of peripheral neuropathies should guide clinicians to an early diagnosis and aid in an adapted management of patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41983-022-00531-4.

The acute motor axonal neuropathy variant of Guillain-Barré Syndrome diagnosed after ankle trauma

A case of Guillain-Barré syndrome (GBS) was diagnosed in a patient admitted to the emergency department (ED) after ankle trauma was presented. GBS is generally defined as immune-mediated peripheral neuropathy that develops after an infection. Our patient presented to ED with ankle trauma that developed after fatigue. Lateral, medial, and posterior malleolar fractures were detected in the ankle. The patient with loss of motor strength in the distal muscles was diagnosed with acute motor axonal neuropathy variant of GBS. After GBS treatment, the patient's loss of muscle strength regressed, and then surgical treatment was performed. We aimed to present this case report, which emphasizes the systematic approach of the emergency physician without having a large differential diagnosis list.

Demographic, clinical, investigational characteristics of COVID-19 related Guillain-Barré syndrome with differences from typical and another virus-related Guillain-Barré syndrome

BACKGROUNDS

SARS-CoV-2 infection typically presents with fever and respiratory symptoms. Besides this, COVID-19 related central and peripheral nervous system manifestations are emerging.

OBJECTIVES

This study summarises the demographics, clinical profile, laboratory findings, management strategies, and outcomes in a large number of patients with COVID-19 related GBS and its variants. We also compared its clinical profile with Zika and dengue virus-related GBS.

METHODS

Authors carried out a literature search up to Dec 31, 2020, in MEDLINE, PubMed, SCOPUS, Cochrane database, and Google Scholar for all published articles.

RESULTS

The study identified 54 different types of articles consisting of 70 cases from 17 countries worldwide. Maximum cases 15 (21.4%) were identified from Italy, followed by USA 12 (17.1%), Spain 11 (15.7%), and Iran 10 (14.3%). The age group more than 60 years had most cases with 32 (45.7%) cases followed by age group 40-60 with cases 25 (35.7%) with male and female ratio 2. Maximum cases were treated with IVIG infusion 58 (82.9%), followed by Plasma exchange 13 (18.6%) cases. Out of 70 cases, 7 (10%) cases were manifested as Miller-Fisher syndrome. The most predominant electrodiagnostic variant was demyelinating neuropathy in 41 (73.21%) cases. The outcome reported in 67 cases was survival in 63 (90%) cases and the death of 4 (5.7%) cases.

CONCLUSION

Covid 19 related GBS were reported worldwide with a better outcome. Both postinfectious or parainfectious patterns were reported. Early recognition with prompt management of GBS can prevent further severe morbidity and mortality.

Peculiarities of Zika Immunity and Vaccine Development: Lessons from Dengue and the Contribution from Controlled Human Infection Model

The Zika virus (ZIKV) was first isolated from a rhesus macaque in the Zika forest of Uganda in 1947. Isolated cases were reported until 2007, when the first major outbreaks of Zika infection were reported from the Island of Yap in Micronesia and from French Polynesia in 2013. In 2015, ZIKV started to circulate in Latin America, and in 2016, ZIKV was considered by WHO to be a Public Health Emergency of International Concern due to cases of Congenital Zika Syndrome (CZS), a ZIKV-associated complication never observed before. After a peak of cases in 2016, the infection incidence dropped dramatically but still causes concern because of the associated microcephaly cases, especially in regions where the dengue virus (DENV) is endemic and co-circulates with ZIKV. A vaccine could be an important tool to mitigate CZS in endemic countries. However, the immunological relationship between ZIKV and other flaviviruses, especially DENV, and the low numbers of ZIKV infections are potential challenges for developing and testing a vaccine against ZIKV. Here, we discuss ZIKV vaccine development with the perspective of the immunological concerns implicated by DENV-ZIKV cross-reactivity and the use of a controlled human infection model (CHIM) as a tool to accelerate vaccine development.

Acute neurologic emerging flaviviruses

The COVID-19 pandemic has shed light on the challenges we face as a global society in preventing and containing emerging and re-emerging pathogens. Multiple intersecting factors, including environmental changes, host immunological factors, and pathogen dynamics, are intimately connected to the emergence and re-emergence of communicable diseases. There is a large and expanding list of communicable diseases that can cause neurological damage, either through direct or indirect routes. Novel pathogens of neurotropic potential have been identified through advanced diagnostic techniques, including metagenomic next-generation sequencing, but there are also known pathogens which have expanded their geographic distribution to infect non-immune individuals. Factors including population growth, climate change, the increase in animal and human interface, and an increase in international travel and trade are contributing to the expansion of emerging and re-emerging pathogens. Challenges exist around antimicrobial misuse giving rise to antimicrobial-resistant infectious neurotropic organisms and increased susceptibility to infection related to the expanded use of immunomodulatory treatments. In this article, we will review key concepts around emerging and re-emerging pathogens and discuss factors associated with neurotropism and neuroinvasion. We highlight several neurotropic pathogens of interest, including West Nile virus (WNV), Zika Virus, Japanese Encephalitis Virus (JEV), and Tick-Borne Encephalitis Virus (TBEV). We emphasize neuroinfectious diseases which impact the central nervous system (CNS) and focus on flaviviruses, a group of vector-borne pathogens that have expanded globally in recent years and have proven capable of widespread outbreak.

SARS-CoV-2-associated Guillain-Barré syndrome is a para-infectious disease

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been linked to the Guillain-Barré syndrome (GBS). The objective of the present study is to identify specific clinical features of cases of GBS reported in the literature associated with SARS-CoV-2 infection. We searched Pubmed, and included single case reports and case series with full text in English, reporting original data of patients with GBS and a confirmed recent SARS-CoV-2 infection. Clinical data were extracted. We identified 28 articles (22 single case reports and 6 case series), reporting on a total of 44 GBS patients with confirmed SARS-CoV-2 infection. SARS-CoV-2 infection was confirmed through serum reverse transcriptase-polymerase chain reaction in 72.7% of cases. A total of 40 patients (91%) had symptoms compatible with SARS-CoV-2 infection before the onset of the GBS. The median period between the onset of symptoms of SARS-CoV-2 infection and symptoms of the GBS was 11.2 days (range, 2-23). The most common clinical features were: leg weakness (61.4%), leg paresthesia (50%), arm weakness (50.4%), arm paresthesia (50.4%), hyporeflexia/areflexia (48%) and ataxia (22.7%). In total, 38.6% (n = 17) were found to have facial paralysis. Among 37 patients in whom nerve-conduction studies and electromyography were performed, of which 26 patients (59.1%) were consistent with the acute inflammatory demyelinating polyneuropathy subtype of the GBS. The present retrospective analysis support the role of the SARS-CoV-2 infection in the development of the GBS, may trigger GBS as para-infectious disease, and lead to SARS-CoV-2-associated GBS.

Global, regional, and national burden of Guillain-Barré syndrome and its underlying causes from 1990 to 2019

Background

This article presents the first detailed analysis of the prevalence and disability burden of Guillain–Barré syndrome (GBS) from 1990 to 2019 by cause, age, sex, and Socio-demographic Index (SDI) in 204 countries and territories.

Methods

Data from the Global Burden of Diseases Study (GBD) 2019 were used. GBD 2019 modelled the prevalence of GBS using hospital and claims data. Years lived with disability (YLDs) were estimated as the product of the GBS prevalence and the disability weight. This article also reported proportions in the age-standardised prevalence rate that were due to six underlying causes of GBS.

Results

In 2019, there were 150,095 [95% uncertainty intervals (UI) 119,924 to 188,309] total cases of GBS worldwide, which resulted in 44,407 (95% UI 28,016 to 64,777) YLDs. Globally, there was a 6.4% (95% UI 3.6 to 9.5) increase in the age-standardised prevalence of GBS per 100,000 population between 1990 and 2019. High-income Asia Pacific [1.9 (95% UI: 1.5 to 2.4)] and East Asia [0.8 (95% UI: 0.6 to 1.0)] had the highest and lowest age-standardised prevalence rates (per 100,000), respectively, in 2019. Nationally, Japan [6.4 (95% UI: 5.3 to 7.7)] and China [0.8 (95% UI: 0.6 to 1.0)] had the highest and lowest age-standardised prevalence rates (per 100,000). The age-standardised burden of GBS increased with increasing age and was higher in males in all age groups. Furthermore, the age-standardised prevalence of GBS (per 100,000) had a positive association with the level of development, as measured by SDI, although this association was not strong. Upper respiratory infections and unknown causes accounted for the highest proportions of underlying causes.

Conclusions

Globally, the prevalence of GBS continues to increase. Geographical differences and strategies aimed at preventing infectious diseases should be considered in future health policy planning and decision-making processes. This study had several limitations, such as using the same disability weight for all causes and a reliance on hospital- and self-reported data, which should be addressed in future research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12974-021-02319-4.

Clinical-epidemiological characteristics associated with discharge outcomes and seasonality among surviving patients with Guillain-Barré syndrome in a national third-level hospital, Lima, Peru

BACKGROUND

Guillain-Barré syndrome (GBS) is an autoimmune disease that affects the peripheral nervous system. Severe motor deficit (SMD), respiratory impairment, cranial nerve involvement and autonomic dysfunction are associated with a poor prognosis.

OBJECTIVE

To investigate the association between the clinical-epidemiological characteristics and the discharge results among Peruvian patients with GBS.

METHODS

We carried out a retrospective observational study on patients with GBS who survived until discharge. We used the Brighton Collaboration's criteria and considered Hughes Severity Scale (HSS) scores greater than two to be SMD. We defined the discharge results as an improvement if the HSS score decreased by at least one point from admission to hospital discharge and defined hospital stay as prolonged if > 14 days.

RESULTS

We analyzed 92 patients, among whom 70.7% were male. Quadriparesis (81.1%) and hyporeflexia (86.8%) were the most characteristic manifestations. We observed that more than half of the cases were in summer and winter. Gastrointestinal infections were associated with a higher proportion of prolonged stays. The proportion of improvement was lower among patients who had an SMD at hospital admission. We confirmed these results through fitting in multivariate models.

CONCLUSIONS

The prolonged stay was related to previous gastrointestinal infection, while a less improvement in SMD individuals at admission. Prospective multicenter surveillance systems are needed for monitoring GBS cases in low-income settings like Peru.

Clinical manifestations and health outcomes associated with Zika virus infections in adults: A systematic review

Background

Zika virus (ZIKV) has generated global interest in the last five years mostly due to its resurgence in the Americas between 2015 and 2016. It was previously thought to be a self-limiting infection causing febrile illness in less than one quarter of those infected. However, a rise in birth defects amongst children born to infected pregnant women, as well as increases in neurological manifestations in adults has been demonstrated. We systemically reviewed the literature to understand clinical manifestations and health outcomes in adults globally.

Methods

This review was registered prospectively with PROPSERO (CRD 42018096558). We systematically searched for studies in six databases from inception to the end of September 2020. There were no language restrictions. Critical appraisal was completed using the Joanna Briggs Institute Critical Appraisal Tools.

Findings

We identified 73 studies globally that reported clinical outcomes in ZIKV-infected adults, of which 55 studies were from the Americas. For further analysis, we considered studies that met 70% of critical appraisal criteria and described subjects with confirmed ZIKV. The most common symptoms included: exanthema (5,456/6,129; 89%), arthralgia (3,809/6,093; 63%), fever (3,787/6,124; 62%), conjunctivitis (2,738/3,283; 45%), myalgia (2,498/5,192; 48%), headache (2,165/4,722; 46%), and diarrhea (337/2,622; 13%). 36/14,335 (0.3%) of infected cases developed neurologic sequelae, of which 75% were Guillain-Barré Syndrome (GBS). Several subjects reported recovery from peak of neurological complications, though some endured chronic disability. Mortality was rare (0.1%) and hospitalization (11%) was often associated with co-morbidities or GBS.

Conclusions

The ZIKV literature in adults was predominantly from the Americas. The most common systemic symptoms were exanthema, fever, arthralgia, and conjunctivitis; GBS was the most prevalent neurological complication. Future ZIKV studies are warranted with standardization of testing and case definitions, consistent co-infection testing, reporting of laboratory abnormalities, separation of adult and pediatric outcomes, and assessing for causation between ZIKV and neurological sequelae.

Interest in Zika virus (ZIKV) has increased in the last decade due to its emergence and rapid spread in the Americas. In this review, we examine ZIKV clinical manifestations and sequelae in adults. Among studies reporting subjects with confirmed ZIKV and critical appraisal scores of at least 70%, symptoms reported include exanthema, fever, arthralgia, conjunctivitis, myalgia, headache, and diarrhea. Neurological sequelae in this group occurred in 0.3% of subjects, of which 75% were Guillain-Barré Syndrome (GBS). Recovery from GBS was variable: some patients returned to health and others endured chronic disability. Mortality was rare (0.1%). Hospitalization (11%) was often associated co-morbidities or GBS; this percentage perhaps reflects studies in which all reported subjects were hospitalized. Synthesizing reported data is challenging given the wide range of case definitions and ZIKV testing practices.

Autoimmune Neurogenic Dysphagia

Autoimmune neurogenic dysphagia refers to manifestation of dysphagia due to autoimmune diseases affecting muscle, neuromuscular junction, nerves, roots, brainstem, or cortex. Dysphagia is either part of the evolving clinical symptomatology of an underlying neurological autoimmunity or occurs as a sole manifestation, acutely or insidiously. This opinion article reviews the autoimmune neurological causes of dysphagia, highlights clinical clues and laboratory testing that facilitate early diagnosis, especially when dysphagia is the presenting symptom, and outlines the most effective immunotherapeutic approaches. Dysphagia is common in inflammatory myopathies, most prominently in inclusion body myositis, and is frequent in myasthenia gravis, occurring early in bulbar-onset disease or during the course of progressive, generalized disease. Acute-onset dysphagia is often seen in Guillain–Barre syndrome variants and slowly progressive dysphagia in paraneoplastic neuropathies highlighted by the presence of specific autoantibodies. The most common causes of CNS autoimmune dysphagia are demyelinating and inflammatory lesions in the brainstem, occurring in patients with multiple sclerosis and neuromyelitis optica spectrum disorders. Less common, but often overlooked, is dysphagia in stiff-person syndrome especially in conjunction with cerebellar ataxia and high anti-GAD autoantibodies, and in gastrointestinal dysmotility syndromes associated with autoantibodies against the ganglionic acetyl-choline receptor. In the setting of many neurological autoimmunities, acute-onset or progressive dysphagia is a potentially treatable condition, requiring increased awareness for prompt diagnosis and early immunotherapy initiation.

Descriptive analysis of surveillance data for Zika virus disease and Zika virus-associated neurological complications in Colombia, 2015-2017

Zika virus (ZIKV) is a mosquito-borne pathogen that recently caused a major epidemic in the Americas. Although the majority of ZIKV infections are asymptomatic, the virus has been associated with birth defects in fetuses and newborns of infected mothers as well as neurological complications in adults. We performed a descriptive analysis on approximately 106,000 suspected and laboratory-confirmed cases of Zika virus disease (ZVD) that were reported during the 2015-2017 epidemic in Colombia. We also analyzed a dataset containing patients with neurological complications and recent febrile illness compatible with ZVD. Females had higher cumulative incidence of ZVD than males. Compared to the general population, cases were more likely to be reported in young adults (20 to 39 years of age). We estimated the cumulative incidence of ZVD in pregnant females at 3,120 reported cases per 100,000 population (95% CI: 3,077-3,164), which was considerably higher than the incidence in both males and non-pregnant females. ZVD cases were reported in all 32 departments. Four-hundred and eighteen patients suffered from ZIKV-associated neurological complications, of which 85% were diagnosed with Guillain-Barré syndrome. The median age of ZIKV cases with neurological complications was 12 years older than that of ZVD cases. ZIKV-associated neurological complications increased with age, and the highest incidence was reported among individuals aged 75 and older. Even though neurological complications and deaths due to ZIKV were rare in this epidemic, better risk communication is needed for people living in or traveling to ZIKV-affected areas.

The Neurobiology of Modern Viral Scourges: ZIKV and COVID-19

The interactions of viruses with the nervous system were thought to be well understood until the recent outbreaks of Zika and SARS-CoV-2. In this review, we consider these emerging pathogens, the range and mechanisms of the neurological disease in humans, and how the biomedical research enterprise has pivoted to answer questions about viral pathogenesis, immune response, and the special vulnerability of the nervous system. ZIKV stands out as the only new virus in a generation, associating with congenital brain defects, neurological manifestations of microcephaly in newborns, and radiculopathy in adults. COVID-19, the disease caused by SARS-CoV-2, has swept the planet in an unprecedented manner and is feared worldwide for its effect on the respiratory system, but recent evidence points to important neurological sequelae. These can include anosmia, vasculopathy, paresthesias, and stroke. Evidence of ZIKV and SARS-CoV-2 genetic material from neural tissue, and evidence of infection of neural cells, raises questions about how these emerging viruses produce disease, and where new therapies might emerge.

Guillain-Barré syndrome spectrum associated with COVID-19: an up-to-date systematic review of 73 cases

Since coronavirus disease-2019 (COVID-19) outbreak in January 2020, several pieces of evidence suggested an association between the spectrum of Guillain-Barré syndrome (GBS) and severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Most findings were reported in the form of case reports or case series, whereas a comprehensive overview is still lacking. We conducted a systematic review and searched for all published cases until July 20th 2020. We included 73 patients reported in 52 publications. A broad age range was affected (mean 55, min 11-max 94 years) with male predominance (68.5%). Most patients showed respiratory and/or systemic symptoms, and developed GBS manifestations after COVID-19. However, asymptomatic cases for COVID-19 were also described. The distributions of clinical variants and electrophysiological subtypes resemble those of classic GBS, with a higher prevalence of the classic sensorimotor form and the acute inflammatory demyelinating polyneuropathy, although rare variants like Miller Fisher syndrome were also reported. Cerebrospinal fluid (CSF) albuminocytological dissociation was present in around 71% cases, and CSF SARS-CoV-2 RNA was absent in all tested cases. More than 70% of patients showed a good prognosis, mostly after treatment with intravenous immunoglobulin. Patients with less favorable outcome were associated with a significantly older age in accordance with previous findings regarding both classic GBS and COVID-19. COVID-19-associated GBS seems to share most features of classic post-infectious GBS and possibly the same immune-mediated pathogenetic mechanisms. Nevertheless, more extensive epidemiological studies are needed to clarify these issues.

Measuring the global burden of chikungunya and Zika viruses: A systematic review

Throughout the last decade, chikungunya virus (CHIKV) and Zika virus (ZIKV) infections have spread globally, causing a spectrum of disease that ranges from self-limited febrile illness to permanent severe disability, congenital anomalies, and early death. Nevertheless, estimates of their aggregate health impact are absent from the literature and are currently omitted from the Global Burden of Disease (GBD) reports. We systematically reviewed published literature and surveillance records to evaluate the global burden caused by CHIKV and ZIKV between 2010 and 2019, to calculate estimates of their disability-adjusted life year (DALY) impact. Extracted data on acute, chronic, and perinatal outcomes were used to create annualized DALY estimates, following techniques outlined in the GBD framework. This study is registered with PROSPERO (CRD42020192502). Of 7,877 studies identified, 916 were screened in detail, and 21 were selected for inclusion. Available data indicate that CHIKV and ZIKV caused the average yearly loss of over 106,000 and 44,000 DALYs, respectively, between 2010 and 2019. Both viruses caused substantially more burden in the Americas than in any other World Health Organization (WHO) region. This unequal distribution is likely due to a combination of limited active surveillance reporting in other regions and the lack of immunity that left the previously unexposed populations of the Americas susceptible to severe outbreaks during the last decade. Long-term rheumatic sequelae provided the largest DALY component for CHIKV, whereas congenital Zika syndrome (CZS) contributed most significantly for ZIKV. Acute symptoms and early mortality accounted for relatively less of the overall burden. Suboptimal reporting and inconsistent diagnostics limit precision when determining arbovirus incidence and frequency of complications. Despite these limitations, it is clear from our assessment that CHIKV and ZIKV represent a significant cause of morbidity that is not included in current disease burden reports. These results suggest that transmission-blocking strategies, including vector control and vaccine development, remain crucial priorities in reducing global disease burden through prevention of potentially devastating arboviral outbreaks.

Chikungunya and Zika are 2 mosquito-borne viral diseases that can cause both acute symptoms and long-term, debilitating complications in infected individuals. Chikungunya is best known as a cause of persistent arthritis in otherwise recovered patients and Zika as a cause of cognitive, motor, and sensory anomalies in newborn children. Both diseases emerged in the Americas within the last decade and have since spread rapidly throughout the region. Despite their widespread transmission there and throughout much of the world, chikungunya and Zika remain neglected diseases. One of the most significant obstacles to address their spread is a lack of data involving their burden. We searched the published literature and surveillance reports to collect information about the incidence, mortality, and morbidity associated with each of these diseases to estimate their regional and global burden during the last decade. Our estimates confirm that chikungunya and Zika caused substantial burden throughout this time frame and place them among the most problematic mosquito-borne viral diseases worldwide. We found that the largest proportion of global burden linked to each disease between 2010 and 2019 occurred in the Americas, although this observation is likely due to limited reporting in other regions.

Purinergic Signaling of ATP in COVID-19 Associated Guillain-Barré Syndrome

Declared as a global public health emergency, coronavirus disease 2019 (COVID-19) is presented as a disease of the respiratory tract, although severe cases can affect the entire organism. Several studies have shown neurological symptoms, ranging from dizziness and loss of consciousness to cerebrovascular and neurodegenerative diseases. In this context, Guillain-Barré syndrome, an immune-mediated inflammatory neuropathy, has been closely associated with critical cases of infection with "severe acute respiratory syndrome of coronavirus 2" (SARS-CoV-2), the etiological agent of COVID-19. Its pathophysiology is related to a generalized inflammation that affects the nervous system, but neurotropism was also revealed by the new coronavirus, which may increase the risk of neurological sequel, as well as the mortality of the disease. Thus, considering the comorbidities that SARS-CoV-2 infection can promote, the modulation of purinergic signaling can be applied as a potential therapy. In this perspective, given the role of adenosine triphosphate (ATP) in neural intercommunication, the P2X7 receptor (P2X7R) acts on microglia cells and its inhibition may be able to reduce the inflammatory condition of neurodegenerative diseases. Finally, alternative measures to circumvent the reality of the COVID-19 pandemic need to be considered, given the severity of critical cases and the viral involvement of multiple organs.

Guillain-Barré syndrome during the Zika virus outbreak in Northeast Brazil: An observational cohort study

OBJECTIVE

To determine the clinical phenotype of Guillain-Barré syndrome (GBS) after Zika virus (ZIKV) infection, the anti-glycolipid antibody signature, and the role of other circulating arthropod-borne viruses, we describe a cohort of GBS patients identified during ZIKV and chikungunya virus (CHIKV) outbreaks in Northeast Brazil.

METHODS

We prospectively recruited GBS patients from a regional neurology center in Northeast Brazil between December 2014 and February 2017. Serum and CSF were tested for ZIKV, CHIKV, and dengue virus (DENV), by RT-PCR and antibodies, and serum was tested for GBS-associated antibodies to glycolipids.

RESULTS

Seventy-one patients were identified. Forty-eight (68%) had laboratory evidence of a recent arbovirus infection; 25 (52%) ZIKV, 8 (17%) CHIKV, 1 (2%) DENV, and 14 (29%) ZIKV and CHIKV. Most patients with a recent arbovirus infection had motor and sensory symptoms (72%), a demyelinating electrophysiological subtype (67%) and a facial palsy (58%). Patients with a recent infection with ZIKV and CHIKV had a longer hospital admission and more frequent mechanical ventilation compared to the other patients. No specific anti-glycolipid antibody signature was identified in association with arbovirus infection, although significant antibody titres to GM1, GalC, LM1, and GalNAc-GD1a were found infrequently.

CONCLUSION

A large proportion of cases had laboratory evidence of a recent infection with ZIKV or CHIKV, and recent infection with both viruses was found in almost one third of patients. Most patients with a recent arbovirus infection had a sensorimotor, demyelinating GBS. We did not find a specific anti-glycolipid antibody signature in association with arbovirus-related GBS.

Burden of Disease of Guillain-Barré Syndrome in Brazil before and during the Zika virus epidemic 2014-2016

OBJECTIVE

To estimate the burden of disease of Guillain-Barré syndrome (GBS) in Brazil in 2014, 1 year before the Zika virus epidemic, and in 2015 and 2016 during the epidemic.

METHODS

The burden of disease of GBS was estimated using the summary measure of population health: Disability Adjusted Life Years (DALY), that combines both mortality (Years of Life Lost YLLs) and morbidity (Years Lived with Disability) components. The study population was composed of GBS hospitalised cases and deaths from the information systems of the Brazilian Unified Health System.

RESULTS

The GBS incidence rate in 2014, 2015 and 2016 was 0.74, 0.96, 1.02/100 000 respectively, and the mortality rate in the same period was 0.08, 0.009 and 0.11/100 000 habitants. The DALYs calculated using the point estimate of GBS disability weight and its values of the confidence interval (0.198 and 0.414) were 5725.90 (5711.79-5742.89) in 2014, 6054.61 (6035.57-6077.54) in 2015 and 7588.49 (7570.20-7610.51) in 2016. The DALYs were high among the male population and in age groups between 20 and 50 years.

CONCLUSIONS

The increase in DALYs in the years 2015 and 2016 compared to 2014 probably resulted from the introduction of ZIKV in Brazil, reinforcing the importance of investments in the prevention of ZIKV infection and in the care of GBS patients.

Epidemiologic and spatiotemporal trends of Zika Virus disease during the 2016 epidemic in Puerto Rico

Background

After Zika virus (ZIKV) emerged in the Americas, laboratory-based surveillance for arboviral diseases in Puerto Rico was adapted to include ZIKV disease.

Methods and findings

Suspected cases of arboviral disease reported to Puerto Rico Department of Health were tested for evidence of infection with Zika, dengue, and chikungunya viruses by RT-PCR and IgM ELISA. To describe spatiotemporal trends among confirmed ZIKV disease cases, we analyzed the relationship between municipality-level socio-demographic, climatic, and spatial factors, and both time to detection of the first ZIKV disease case and the midpoint of the outbreak. During November 2015–December 2016, a total of 71,618 suspected arboviral disease cases were reported, of which 39,717 (55.5%; 1.1 cases per 100 residents) tested positive for ZIKV infection. The epidemic peaked in August 2016, when 71.5% of arboviral disease cases reported weekly tested positive for ZIKV infection. Incidence of ZIKV disease was highest among 20–29-year-olds (1.6 cases per 100 residents), and most (62.3%) cases were female. The most frequently reported symptoms were rash (83.0%), headache (64.6%), and myalgia (63.3%). Few patients were hospitalized (1.2%), and 13 (<0.1%) died. Early detection of ZIKV disease cases was associated with increased population size (log hazard ratio [HR]: -0.22 [95% confidence interval -0.29, -0.14]), eastern longitude (log HR: -1.04 [-1.17, -0.91]), and proximity to a city (spline estimated degrees of freedom [edf] = 2.0). Earlier midpoints of the outbreak were associated with northern latitude (log HR: -0.30 [-0.32, -0.29]), eastern longitude (spline edf = 6.5), and higher mean monthly temperature (log HR: -0.04 [-0.05, -0.03]). Higher incidence of ZIKV disease was associated with lower mean precipitation, but not socioeconomic factors.

Conclusions

During the ZIKV epidemic in Puerto Rico, 1% of residents were reported to public health authorities and had laboratory evidence of ZIKV disease. Transmission was first detected in urban areas of eastern Puerto Rico, where transmission also peaked earlier. These trends suggest that ZIKV was first introduced to Puerto Rico in the east before disseminating throughout the island.

During epidemics of Zika virus disease in the Americas in 2015 and 2016, assessment of transmission dynamics was limited by inconsistent laboratory testing of patients with suspected Zika virus disease. This limitation was further complicated by co-circulation of dengue and chikungunya viruses, which cause illnesses clinically similar to Zika virus disease. In Puerto Rico, all reported suspect cases of arboviral disease were tested for Zika, dengue, and chikungunya virus infection throughout the epidemic, which allowed for fine-scale analysis of epidemiologic and spatiotemporal trends. In total, 39,717 cases of Zika virus disease were detected, or roughly 1% of all residents of Puerto Rico. Young adults and females were most affected. Disease was mostly mild, as only 1% of cases were hospitalized. Thirteen patients with Zika virus disease died, most of whom had Guillain-Barré syndrome or severe underlying illnesses. Early detection of Zika virus disease cases was associated with more populated areas of eastern Puerto Rico, where early detection of peak case numbers also occurred, particularly in warmer areas. These trends suggest that, in contrast to prior epidemics of dengue and chikungunya that started in the San Juan metropolitan region, the Zika virus epidemic appears to have begun in eastern Puerto Rico.

COVID-19 and Guillain-Barre Syndrome: a systematic review of case reports

Background: Guillain-Barre Syndrome (GBS) is a neurological autoimmune disease that can lead to respiratory failure and death. Whether COVID-19 patients are at high risk of GBS is unknown. Through a systematic review of case reports, we aimed to summarize the main features of patients with GBS and COVID-19. Methods: Without any restrictions, we searched MEDLINE, Embase, Global Health, Scopus, Web of Science and MedXriv (April 23 rd, 2020). Two reviewers screened and studied titles, abstracts and reports. We extracted information to characterize sociodemographic variables, clinical presentation, laboratory results, treatments and outcomes. Results: Eight reports (n=12 patients) of GBS and COVID-19 were identified; one was a Miller Fisher case. The age ranged between 23 and 77 years, and there were more men (9/102). GBS symptoms started between 5 and 24 days after those of COVID-19. The protein levels in cerebrospinal fluid samples ranged between 40 and 193 mg/dl. None of the cerebrospinal fluid samples tested positive for COVID-19. Six patients debuted with ascendant weakness and three with facial weakness. Five patients had favourable evolution, four remained with relevant symptoms or required critical care and one died; the Miller Fisher case had successful resolution. Conclusions: GBS is emerging as a disease that may appear in COVID-19 patients. Although limited, preliminary evidence appears to suggest that GBS occurs after COVID-19 onset. Practitioners and investigators should have GBS in mind as they look after COVID-19 patients and conduct research on novel aspects of COVID-19. Comparison with GBS patients in the context of another viral outbreak (Zika), revealed similarities and differences that deserves further scrutiny and epidemiological studies.

Guillain-Barré syndrome associated with Zika virus infection in Brazil: a cost-of-illness study

BACKGROUND

Guillain-Barré syndrome (GBS) is a serious, acute paralytic neuropathy of autoimmune aetiology, usually associated with a previous infection. The current study aims to estimate the costs of GBS associated with Zika virus (ZIKV) infection in Brazil.

METHODS

A cost-of-illness study was conducted from the perspective of the Brazilian public health system (Sistema Único de Saúde [SUS]) and Brazilian society for the year 2016. Direct and indirect costs were estimated by a mixed macrocosting and microcosting approach.

RESULTS

The total cost of ZIKV-associated GBS in Brazil was US$11 997 225.85, consisting of the costs of symptomatic ZIKV infection before onset of GBS (direct costs US$2011.51, indirect costs US$19 780.53) and the costs that followed development of GBS (direct costs US$4 722 980.89, indirect costs US$7 252 452.92). The cost of treatment with human immunoglobulin (US$3 263 210.50) and the cost of productivity losses associated with potential years of working life lost due to early mortality (US$4 398 551.72) were particularly noteworthy.

CONCLUSIONS

These findings suggest that ZIKV-associated GBS is costly to Brazil, especially due to productivity losses and hospitalization. This highlights the importance of investing in the prevention of ZIKV infection and in the care of patients with GBS.

COVID-19 and Guillain-Barre Syndrome: a systematic review of case reports

Background: Guillain-Barre Syndrome (GBS) is a neurological autoimmune disease that can lead to respiratory failure and death. Whether COVID-19 patients are at high risk of GBS is unknown. Through a systematic review of case reports, we aimed to summarize the main features of patients with GBS and COVID-19. Methods: Without any restrictions, we searched MEDLINE, Embase, Global Health, Scopus, Web of Science and MedXriv (April 23 rd, 2020). Two reviewers screened and studied titles, abstracts and reports. We extracted information to characterize sociodemographic variables, clinical presentation, laboratory results, treatments and outcomes. Results: Eight reports (n=12 patients) of GBS and COVID-19 were identified; one was a Miller Fisher case. Overall, the median age was 62.5 (interquartile range (IQR)=54.5-70.5) years, and there were more men (9/102). GBS symptoms started between 5 and 24 days after those of COVID-19. The median protein levels in cerebrospinal fluid samples was 101.5 mg/dl (IQR=51-145). None of the cerebrospinal fluid samples tested positive for COVID-19. Six patients debuted with ascendant weakness and three with facial weakness. Five patients had favourable evolution, four remained with relevant symptoms or required critical care and one died; the Miller Fisher case had successful resolution. Conclusions: GBS is emerging as a disease that may appear in COVID-19 patients. Although limited, preliminary evidence appears to suggest that GBS occurs after COVID-19 onset. Practitioners and investigators should have GBS in mind as they look after COVID-19 patients and conduct research on novel aspects of COVID-19. Comparison with GBS patients in the context of another viral outbreak (Zika), revealed similarities and differences that deserves further scrutiny and epidemiological studies.

SARS-CoV-2 Infection Leads to Neurological Dysfunction

A number of neurological disease complications have been seen following infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). While most person with COVID-19 respiratory disease demonstrate headache, nausea and vomiting, up to 40% present also experience dizziness, confusion, cerebrovascular disease, muscle pain, ataxia and seizures. Loss of taste and smell, defects in visual acuity and pain occur in parallel. Such central nervous system (CNS) signs and symptoms linked to laboratory-confirmed SARS-CoV-2 infection is often life threatening. Health care providers currently evaluating patients with neurologic symptoms need consider COVID-19 in any differential diagnosis. These considerations will facilitate prompt testing, isolation and prevention of viral transmission speeding best clinical outcomes.

Militão de Albuquerque MDF. Guillain-Barré syndrome related to Zika virus infection: A systematic review and meta-analysis of the clinical and electrophysiological phenotype

Background

The Zika virus (ZIKV) has been associated with Guillain-Barré syndrome (GBS) in epidemiological studies. Whether ZIKV-associated GBS is related to a specific clinical or electrophysiological phenotype has not been established. To this end, we performed a systematic review and meta-analysis of all published studies on ZIKV-related GBS.

Methods

We searched Pubmed, EMBASE and LILACS, and included all papers, reports or bulletins with full text in English, Spanish or Portuguese, reporting original data of patients with GBS and a suspected, probable or confirmed recent ZIKV infection. Data were extracted according to a predefined protocol, and pooled proportions were calculated.

Results

Thirty-five studies were included (13 single case reports and 22 case series, case-control or cohort studies), reporting on a total of 601 GBS patients with a suspected, probable or confirmed ZIKV infection. Data from 21 studies and 587 cases were available to be summarized. ZIKV infection was confirmed in 21%, probable in 22% and suspected in 57% of cases. ZIKV PCR was positive in 30% (95%CI 15–47) of tested patients. The most common clinical features were: limb weakness 97% (95%CI 93–99), diminished/absent reflexes 96% (95%CI 88–100), sensory symptoms 82% (95%CI 76–88), and facial palsy 51% (95%CI 44–58). Median time between infectious and neurological symptoms was 5–12 days. Most cases had a demyelinating electrophysiological subtype and half of cases were admitted to the Intensive Care Unit (ICU). Heterogeneity between studies was moderate to substantial for most variables.

Conclusions

The clinical phenotype of GBS associated with ZIKV infection reported in literature is generally a sensorimotor demyelinating GBS with frequent facial palsy and a severe disease course often necessitating ICU admittance. Time between infectious and neurological symptoms and negative PCR in most cases suggests a post-infectious disease mechanism. Heterogeneity between studies was considerable and results may be subject to reporting bias. This study was registered on the international Prospective Register of Systematic Reviews (CRD42018081959).

Guillain-Barré syndrome (GBS) is a rare but severe neurological disease, characterized by an acute onset flaccid paralysis. GBS is thought to be caused by an exaggerated immune response to common infections that damages the peripheral nerves. The Zika virus (ZIKV) is the most recent pathogen to be connected to GBS, when large outbreaks of ZIKV infection in French Polynesia and Latin America were followed by an increased incidence of GBS patients. To better understand the clinical features and outcome of ZIKV-related GBS, we have performed a systematic review and meta-analysis of all published studies on GBS related to ZIKV. We identified 35 studies, reporting on a total of 601 patients with GBS and a suspected, probable or confirmed Zika virus infection, and were able to summarize data of 587 patients from 21 studies in a pooled analysis. Our study shows that published cases with ZIKV-related GBS generally have both sensory and motor symptoms, facial palsy, demyelination on electrophysiological examination, and a severe disease course that often necessitates ICU admittance. The relatively long time between infectious and neurologic symptoms and the lack of detection of viral particles in bodily fluids in most patients suggest a post-infectious rather than an infectious pathogenesis. However, these results should be interpreted taking into account the heterogeneity between studies, which was considerable for many variables, and a possible reporting bias of more severe cases. Outbreaks of ZIKV and GBS may appear in the future and our study can help clinicians in diagnosing and managing GBS patients in ZIKV endemic areas, and increases our understanding of the neuropathology of ZIKV.

An optimized purified inactivated Zika vaccine provides sustained immunogenicity and protection in cynomolgus macaques

The recent spread of Zika virus (ZIKV) through the Americas and Caribbean and its devastating consequences for pregnant women and their babies have driven the search for a safe and efficacious ZIKV vaccine. Among the vaccine candidates, a first-generation ZIKV purified inactivated vaccine (ZPIV), adjuvanted with aluminum hydroxide, developed by the Walter Reed Army Institute of Research (WRAIR), has elicited high seroconversion rates in participants in three phase-I clinical trials. In collaboration with the WRAIR, Sanofi Pasteur (SP) optimized the production scale, culture and purification conditions, and increased the regulatory compliance, both of which are critical for clinical development and licensure of this vaccine. Using a clinical batch of the first-generation ZPIV as a benchmark, we report that different doses of the optimized vaccine (ZPIV-SP) elicited sustained neutralizing antibodies, specific T- and memory B-cells, and provided complete protection against a ZIKV challenge in cynomolgus macaques. These data provide evidence that the ZPIV-SP vaccine performs at least as well as the ZPIV vaccine, and provide support for continued development in the event of future ZIKV outbreaks.

Axonal variants of Guillain-Barré syndrome: an update

Axonal variants of Guillain-Barré syndrome (GBS) mainly include acute motor axonal neuropathy, acute motor and sensory axonal neuropathy, and pharyngeal-cervical-brachial weakness. Molecular mimicry of human gangliosides by a pathogen's lipooligosaccharides is a well-established mechanism for Campylobacter jejuni-associated GBS. New triggers of the axonal variants of GBS (axonal GBS), such as Zika virus, hepatitis viruses, intravenous administration of ganglioside, vaccination, and surgery, are being identified. However, the pathogenetic mechanisms of axonal GBS related to antecedent bacterial or viral infections other than Campylobacter jejuni remain unknown. Currently, autoantibody classification and serial electrophysiology are cardinal approaches to differentiate axonal GBS from the prototype of GBS, acute inflammatory demyelinating polyneuropathy. Newly developed technologies, including metabolite analysis, peripheral nerve ultrasound, and feature selection via artificial intelligence are facilitating more accurate diagnosis of axonal GBS. Nevertheless, some key issues, such as genetic susceptibilities, remain unanswered and moreover, current therapies bear limitations. Although several therapies have shown considerable benefits to experimental animals, randomized controlled trials are still needed to validate their efficacy.

Cerebrospinal fluid immunoglobulins are increased in neonates exposed to Zika virus during foetal life

OBJECTIVE

To compare immunoglobulin levels in cerebrospinal fluid (CSF) of neonates exposed to Zika virus (ZIKV) during foetal life (cases) with levels in CSF of control neonates.

METHODS

We identified 16 neonates who underwent lumbar puncture (LP), during the ZIKV epidemic (December/2015 to March/2016) whose mothers reported ZIKV clinical symptoms during gestation (cases). Congenital microcephaly was defined as head circumference ≤31.9 cm (boys) and ≤31.5 cm (girls) for term neonates, or ≤2 standard deviations below the mean for premature (<37 weeks) neonates. Subsequently, we identified neonates who underwent LP in the same lab and fulfilled criteria to be controls: age ≤4 days, CSF white blood cell count ≤8/mm³, CSF protein ≤132 mg/dL, CSF red blood cell count ≤1,000/mm³, neither central nervous system illness, nor congenital infection, nor microcephaly. CSF immunoglobulin concentrations were measured by mass spectrometry.

RESULTS

13 controls were included. IgM, IgA, IgG, IgK, and IgL were significantly higher among cases (p < 0.001). Eight (50%) ZIKV exposed infants had congenital microcephaly. These showed the strongest immunoglobulin elevation of the IgM and IgA classes.

CONCLUSION

Neonates exposed to ZIKV infection during gestation present with elevated distinct immunoglobulins in CSF, both in cases that developed microcephaly and in cases that did not.

High susceptibility, viral dynamics and persistence of South American Zika virus in New World monkey species

South American Zika virus (ZIKV) recently emerged as a novel human pathogen, linked with neurological disorders. However, comparative ZIKV infectivity studies in New World primates are lacking. Two members of the Callitrichidae family, common marmosets (Callithrix jacchus) and red-bellied tamarins (Saguinus labiatus), were highly susceptible to sub-cutaneous challenge with the Puerto Rico-origin ZIKV_PRVABC59 strain. Both exhibited rapid, high, acute viraemia with early neuroinvasion (3 days) in peripheral and central nervous tissue. ZIKV RNA levels in blood and tissues were significantly higher in New World hosts compared to Old World species (Macaca mulatta, Macaca fascicularis). Tamarins and rhesus macaques exhibited loss of zonal occludens-1 (ZO-1) staining, indicative of a compromised blood-brain barrier 3 days post-ZIKV exposure. Early, widespread dissemination across multiple anatomical sites distant to the inoculation site preceded extensive ZIKV persistence after 100 days in New and Old World lineages, especially lymphoid, neurological and reproductive sites. Prolonged persistence in brain tissue has implications for otherwise resolved human ZIKV infection. High susceptibility of distinct New World species underscores possible establishment of ZIKV sylvatic cycles in primates indigenous to ZIKV endemic regions. Tamarins and marmosets represent viable New World models for ZIKV pathogenesis and therapeutic intervention studies, including vaccines, with contemporary strains.

Zika virus infection as a cause of congenital brain abnormalities and Guillain-Barré syndrome: A living systematic review

Background: The Zika virus (ZIKV) caused a large outbreak in the Americas leading to the declaration of a Public Health Emergency of International Concern in February 2016. A causal relation between infection and adverse congenital outcomes such as microcephaly was declared by the World Health Organization (WHO) informed by a systematic review structured according to a framework of ten dimensions of causality, based on the work of Bradford Hill. Subsequently, the evidence has continued to accumulate, which we incorporate in regular updates of the original work, rendering it a living systematic review.

Methods: We present an update of our living systematic review on the causal relation between ZIKV infection and adverse congenital outcomes and between ZIKV and GBS for four dimensions of causality: strength of association, dose-response, specificity, and consistency. We assess the evidence published between January 18, 2017 and July 1, 2019.

Results: We found that the strength of association between ZIKV infection and adverse outcomes from case-control studies differs according to whether exposure to ZIKV is assessed in the mother (OR 3.8, 95% CI: 1.7-8.7, I ²=19.8%) or the foetus/infant (OR 37.4, 95% CI: 11.0-127.1, I ²=0%). In cohort studies, the risk of congenital abnormalities was 3.5 times higher after ZIKV infection (95% CI: 0.9-13.5, I ²=0%). The strength of association between ZIKV infection and GBS was higher in studies that enrolled controls from hospital (OR: 55.8, 95% CI: 17.2-181.7, I ²=0%) than in studies that enrolled controls at random from the same community or household (OR: 2.0, 95% CI: 0.8-5.4, I ²=74.6%). In case-control studies, selection of controls from hospitals could have biased results.

Conclusions: The conclusions that ZIKV infection causes adverse congenital outcomes and GBS are reinforced with the evidence published between January 18, 2017 and July 1, 2019.

Incidence of Guillain-Barré Syndrome (GBS) in Latin America and the Caribbean before and during the 2015-2016 Zika virus epidemic: A systematic review and meta-analysis

BACKGROUND

A severe neurological disorder, Guillain-Barré syndrome (GBS) is the leading cause of acute flaccid paralysis. Enhanced surveillance of GBS in Latin America and the Caribbean (LAC) following the 2015-2016 Zika virus (ZIKV) epidemic presents an opportunity to estimate, for the first time, the regional incidence of GBS.

METHODS AND FINDINGS

For this systematic review and meta-analysis, we searched nine scientific databases and grey literature from January 1, 1980 to October 1, 2018. Sources with primary data on incident GBS cases in LAC within a well-defined population and timeframe, published in English, Spanish, Portuguese, or French, were included. We calculated the annual GBS incidence rates (IRs) and 95% confidence intervals (CIs) for each source based on published data. Following an assessment of heterogeneity, we used random-effects meta-analysis to calculate the pooled annual IR of GBS. The study is registered with PROSPERO, number CRD42018086659. Of the 6568 initial citation hits, 31 were eligible for inclusion. Background annual GBS IRs in Latin America ranged from 0.40 in Brazil to 2.12/100,000 in Chile. The pooled annual IR in the Caribbean was 1.64 (95% CI 1.29-2.12, I2<0.01, p = 0.44). During the ZIKV epidemic, GBS IRs ranged from 0.62 in Mexico to 9.35/100,000 in Martinique. GBS increased 2.6 (95% CI 2.3-2.9) times during ZIKV and 1.9 (95% CI 1.1-3.4) times during chikungunya outbreaks over background rates. A limitation of this review is that the studies included employed different methodologies to find and ascertain cases of GBS, which could contribute to IR heterogeneity. In addition, it is important to consider that data on GBS are lacking for many countries in the region.

CONCLUSIONS

Background IRs of GBS appear to peak during arboviral disease outbreaks. The current review contributes to an understanding of the epidemiology of GBS in the LAC region, which can inform healthcare system planning and preparedness, particularly during arboviral epidemics.

TRIAL REGISTRATION

Registered with PROSPERO: CRD42018086659.

Long-term outcomes of Guillain-Barré syndrome possibly associated with Zika virus infection

Background

This prospective cohort investigation analyzed the long-term functional and neurologic outcomes of patients with Zika virus-associated Guillain-Barré syndrome (GBS) in Barranquilla, Colombia.

Methods

Thirty-four Zika virus-associated GBS cases were assessed a median of 17 months following acute GBS illness. We assessed demographics, results of Overall Disability Sum Scores (ODSS), Hughes Disability Score (HDS), Zung Depression Scale (ZDS), and Health Related Quality of Life (HRQL) questionnaires; and compared outcomes indices with a normative sample of neighborhood-selected control subjects in Barranquilla without GBS.

Results

Median age at time of acute neurologic onset was 49 years (range, 10–80); 17 (50%) were male. No deaths occurred. At long-term follow-up, 25 (73%) patients had a HDS 0–1, indicating complete / near complete recovery. Among the group, HDS (mean 1.4, range 0–4), ODSS (mean 1.9, range 0–9) and ZDS score (mean 34.4, range 20–56) indicated mild / moderate ongoing disability. Adjusting for age and sex, Zika virus-associated GBS cases were similar to a population comparison group (n = 368) in Barranquilla without GBS in terms of prevalence of physical or mental health complaints, though GBS patients were more likely to have an ODSS of ≥ 1 (OR 8.8, 95% CI 3.2–24.5) and to suffer from moderate / moderate-severe depression (OR 3.89, 95% CI 1.23–11.17) than the comparison group.

Conclusions

Long-term outcomes of Zika virus-associated GBS are consistent with those associated with other antecedent antigenic stimuli in terms of mortality and ongoing long-term morbidity, as published in the literature. Persons with Zika virus-associated GBS more frequently reported disability and depression after approximately one year compared with those without GBS.

Human Schwann cells are susceptible to infection with Zika and yellow fever viruses, but not dengue virus

Zika virus (ZIKV) is a re-emerged flavivirus transmitted by Aedes spp mosquitoes that has caused outbreaks of fever and rash on islands in the Pacific and in the Americas. These outbreaks have been associated with neurologic complications that include congenital abnormalities and Guillain-Barré syndrome (GBS). The pathogenesis of ZIKV-associated GBS, a potentially life-threatening peripheral nerve disease, remains unclear. Because Schwann cells (SCs) play a central role in peripheral nerve function and can be the target for damage in GBS, we characterized the interactions of ZIKV isolates from Africa, Asia and Brazil with human SCs in comparison with the related mosquito-transmitted flaviviruses yellow fever virus 17D (YFV) and dengue virus type 2 (DENV2). SCs supported sustained replication of ZIKV and YFV, but not DENV. ZIKV infection induced increased SC expression of IL-6, interferon (IFN)β1, IFN-λ, IFIT-1, TNFα and IL-23A mRNAs as well as IFN-λ receptors and negative regulators of IFN signaling. SCs expressed baseline mRNAs for multiple potential flavivirus receptors and levels did not change after ZIKV infection. SCs did not express detectable levels of cell surface Fcγ receptors. This study demonstrates the susceptibility and biological responses of SCs to ZIKV infection of potential importance for the pathogenesis of ZIKV-associated GBS.

Guillain-Barré Syndrome Associated With Zika Virus Infection: A Prospective Case Series From Mexico

Background: On May 2016, anticipating the rainy season from June to October in Mexico, we expected an increase in cases of Zika virus (ZIKV) infections. With the goal of identifying cases of GBS associated with ZIKV infection, a prospective joint study was conducted by a reference center for neurological patients and the Secretary of Health in Mexico City from July 2016 to November 2016.

Methods: Serum, cerebrospinal fluid, urine, and saliva were tested by RT-PCR for ZIKV, dengue virus, and chikungunya virus in patients referred from states with reported transmissions of ZIKV infection, and with clinical symptoms of GBS according to the Brighton Collaboration criteria. Clinical, electrophysiological, and long-term disability data were collected.

Results: In the year 2016 twenty-eight patients with GBS were diagnosed at our institute. In five hospitalized patients with GBS, RT-PCR was positive to ZIKV in any collected specimen. Dengue and chikungunya RT-PCR results were negative. All five patients had areflexic flaccid weakness, and cranial nerves affected in three. Electrophysiological patterns were demyelinating in two patients and axonal in three. Three patients were discharged improved in 10 days or less, and two patients required intensive care unit admission, and completely recovered during follow-up.

Conclusion: Our results are similar to those reported from the state of Veracruz, Mexico, in which out of 33 samples of urine of patients with GBS two had a positive RT-PCR for ZIKV. Simultaneous processing of serum, CSF, urine, and saliva by RT-PCR may increase the success of diagnosis of GBS associated to ZIKV.