Disseminated neonatal echovirus 11 disease following antenatal maternal infection with a virus-positive cervix and virus-negative gastrointestinal tract

Pulmonary hemorrhage due to Coxsackievirus B infection-A call to raise suspicion of this important complication as an end-stage of enterovirus sepsis in preterm twin neonates

BACKGROUND

Prematurity is an important risk factor for the fulminate form of neonatal enteroviral infection. Pulmonary hemorrhage is a morbid complication that should be anticipated and managed aggressively due to its fatal outcome.

OBJECTIVE

To emphasize the significance of pulmonary hemorrhage as a complication of severe enterovirus infection in preterm neonates.

STUDY DESIGN

This report is a description of the clinical history, medical management and clinical outcomes of two pairs of preterm twin newborns (30 weeks and 36 weeks) with fulminant infection due to Coxsackievirus B (CBV) infection.

RESULTS

Maternal fever was reported in both deliveries and it was a factor in the decision for urgent cesarean section of the 30-week twins. Three of the four infants failed to survive. Their clinical course involved multiple organ system failure complicated with profound disseminated intravascular coagulopathy and pulmonary hemorrhage. Pulmonary bleeding leading to hypovolemic shock and respiratory failure was the direct cause of death in two cases.

CONCLUSIONS

This small series of preterm neonates with the diagnosis of CBV sepsis highlights the importance of correct diagnosis of maternal enterovirus infection in order to extend pregnancy and allow the fetus time to passively acquire protective antibodies. This report emphasizes the morbid complication of pulmonary hemorrhage as a result of enterovirus infection that should be anticipated and managed aggressively due to its potentially fatal outcome. Moreover, evaluation and observation of the asymptomatic twin is recommended in order to detect early signs of infection and deterioration in that sibling as well.

A case of congenital Echovirus 11 infection acquired early in pregnancy

Enterovirus (EV) maternal infection during pregnancy and its relation to fetal developmental pathology are seldomly described. When reported, the main manifestations of EV congenital infections are myocarditis or intra-uterine fetal demise (IUFD). No information on intrauterine Echovirus 11 infection or the effect of transplacental Echovirus 11 infection on development of the fetus has been described in literature up to date (excluding late-pregnancy infections). We report here a case of an extreme form of pulmonary hypoplasia in a neonate, characterized by total failure of development of terminal respiratory units. This pregnancy was marked by spontaneous demise of a co-twin at 14 weeks of gestation (WG), as well as by positive PCR for EV (Echovirus 11 serotype) in the amniotic fluid, performed for moderate pericardial effusion at 22WG. No signs of cardiac disease were further observed, but at 32WG a bilateral abnormal lung development was noticed After spontaneous delivery at 38WG, the child could not be resuscitated, and died at one hour after birth. Pulmonary hypoplasia is usually described following decrease intrapulmonary pressure due to oligohydramnios or compression due to intrathoracic mass of variable cause. However, rare cases of primary pulmonary hypoplasia are also described and usually of unknown etiology. The coexistence in our case of a congenital EV infection and a severe primary pulmonary hypoplasia with congenital acinar aplasia, challenges our understanding of the pathogenesis of this severe pulmonary growth arrest.

Non-polio enteroviruses and their association with acute diarrhea in children in India

A causative agent in approximately 40% of diarrheal cases still remains unidentified. Though many enteroviruses (EVs) are transmitted through fecal-oral route and replicate in the intestinal cells, their association with acute diarrhea has not so far been recognized due to lack of detailed epidemiological investigations. This long-term, detailed molecular epidemiological study aims to conclusively determine the association of non-polio enteroviruses (NPEVs) with acute diarrhea in comparison with rotavirus (RV) in children. Diarrheal stool specimens from 2161 children aged 0-2 years and 169 children between 2 and 9 years, and 1800 normal stool samples from age-matched healthy children between 0 and 9 years were examined during 2008-2012 for enterovirus (oral polio vaccine strains (OPVs) and NPEVs). Enterovirus serotypes were identified by complete VP1 gene sequence analysis. Enterovirus and rotavirus were detected in 19.01% (380/2330) and 13.82% (322/2330) diarrheal stools. During the study period, annual prevalence of EV- and RV-associated diarrhea ranged between 8% and 22%, but with contrasting seasonal prevalence with RV predominating during winter months and NPEV prevailing in other seasons. NPEVs are associated with epidemics-like outbreaks during which they are detected in up to 50% of diarrheic children, and in non-epidemic seasons in 0-10% of the patients. After subtraction of OPV-positive diarrheal cases (1.81%), while NPEVs are associated with about 17% of acute diarrhea, about 6% of healthy children showed asymptomatic NPEV excretion. Of 37 NPEV serotypes detected in diarrheal children, seven echovirus types 1, 7, 11, 13, 14, 30 and 33 are frequently observed, with E11 being more prevalent followed by E30. In conclusion, NPEVs are significantly associated with acute diarrhea, and NPEVs and rotavirus exhibit contrasting seasonal predominance. This study signifies the need for a new direction of research on enteroviruses involving systematic analysis of their contribution to diarrheal burden.

Enterovirus RNA shedding in the genital tract of childbearing-aged women living in Central Africa

Enteroviruses (EVs) (Picornaviridae) in the female genital tract may constitute possible sources of antenatal or perinatal infection. The presence of EV genomes in the acellular part of cervicovaginal lavages of 119 non-pregnant childbearing-aged African women was determined using a semiquantitative RT-PCR and hybridization detection assay. EV-specific cervicovaginal IgA and IgG antibodies were also detected by immunocapture ELISA assays. Of 119 CVS samples tested, only 10 (8%) were positive for the detection of EV RNA, demonstrating an genital shedding of EVs in African woman. EV-RNA positivity was not associated with the HIV serostatus or with the presence of semen traces in female genital secretion. The microwell hybridization assay of EV amplified RT-PCR products indicated the presence of low levels of EV genomes, ranging from 50 to 100 RNA copies per ml of genital fluids. EV-specific cervicovaginal IgA or IgG antibodies were detected only in two hemoglobin-positive cervicovaginal secretions samples from women without genital EVs. The lack of EV specific IgA or IgG antibody secretion by the cervicovaginal mucosa supported the hypothesis of genital shedding of EVs without ongoing viral replication in the female genital tract. In conclusion, the findings demonstrated the presence of EV genomes in nearly 10% of childbearing-aged women living in Central Africa, and provided the basis of possible antenatal or perinatal transmission of EV from mother-to-child.

Adrenal infections

Adrenal infections are an important but under-recognized clinical entity. The adrenal gland can be infected by a myriad of pathogens including fungi, viruses, parasites, and bacteria. Infection can directly or indirectly cause tissue damage and alteration in endocrine function. Direct damage occurs via microbial replication and local production of toxic compounds, such as endotoxins. Indirect damage results from alterations in the regulation of a host's immunologic and endocrine mediators in response to damage by a microbe at a distant site. Variations in pathogen tropism, adrenal anatomy, and host immune integrity contribute to the progression of active disease and discernable adrenal dysfunction. Early recognition and intervention in the case of adrenal infection can significantly improve outcome, demonstrating the need for increased clinical suspicion in the appropriate clinical setting.

Presentation, diagnosis, and management of enterovirus infections in neonates

The nonpoliovirus enteroviruses commonly infect newborns, with consequences ranging from asymptomatic infection and benign illness, to severe, life-threatening disease. Frequently occurring symptoms include fever, irritability, lethargy, anorexia, and rash. Although most illnesses are mild, severe disease develops in a subset of newborns infected in the first 2 weeks of life. Severe disease may consist of sepsis, meningoencephalitis, myocarditis, pneumonia, hepatitis, and/or coagulopathy. Substantial mortality rates have been reported, and long-term sequelae may occur among survivors. Risk factors and clinical features associated with severe disease include absence of neutralizing antibody to the infecting serotype, maternal illness prior to or at delivery, prematurity, illness onset within the first few days of life, multiorgan disease, severe hepatitis, positive serum viral culture, and specific infecting serotype (e.g. group B coxsackieviruses and echovirus 11). Whereas the mainstay of diagnosis has traditionally been viral isolation in tissue culture, the polymerase chain reaction has been demonstrated to be more sensitive than culture, highly specific, and rapid. Immunoglobulin has been used as a therapeutic agent for neonates with enterovirus disease; however, clinical efficacy has not been proven. Specific antiviral therapy for enteroviruses is in development. Pleconaril is an investigational agent that inhibits viral attachment to host cell receptors and uncoating of viral nucleic acid. It has broad and potent anti-enterovirus activity, excellent oral bioavailability, and is well tolerated. Some clinical trials have demonstrated benefit in children and adults with enterovirus meningitis, and in adults with upper respiratory tract infections caused by picornaviruses (rhinoviruses or enteroviruses). Data summarizing compassionate use for severe enterovirus diseases (including neonatal sepsis) also suggest possible benefit. Limited pharmacokinetic data are available in infants and neonates. A multicenter, placebo-controlled, randomized trial of pleconaril in neonates with severe hepatitis, coagulopathy, and/or myocarditis is currently being conducted.

Prognosis for neonates with enterovirus hepatitis and coagulopathy

BACKGROUND

Neonatal enterovirus hepatitis and coagulopathy (EHC) can be a severe, life-threatening infection. However, the case-fatality rate of EHC and the prognosis for survivors are not well-defined.

METHODS

A search of a hospital medical records database and the investigator's files for the period 1983 to 2000 was performed. Patients with onset of enterovirus-associated illness at age < or = 30 days and either (1) aspartate aminotransferase or alanine aminotransferase > 3 times the upper limit of normal or (2) platelet count < 100 000 plus an abnormal coagulation profile were included.

RESULTS

Sixteen cases were identified. Symptoms began at a mean of 3.8 days (range, 1 to 7 days). Frequent clinical and laboratory findings included jaundice, lethargy, anorexia, hepatomegaly, thrombocytopenia, clotting time prolongation, elevated transaminase and bilirubin values and decreased fibrinogen and albumin concentrations. Five patients had myocarditis and 4 had encephalitis. Hemorrhagic complications occurred in 10 (intracranial hemorrhage in 5). Five (31%) patients died. Features discriminating patients who died from survivors were concomitant myocarditis (5 of 5 vs. 0 of 11, P < 0.001), encephalitis (3 of 5 vs. 1 of 11, P = 0.06), prothrombin time > 30 s (4 of 5 vs. 1 of 9, P = 0.02) and intracranial hemorrhage (4 of 5 vs. 1 of 8, P = 0.03). Follow-up of 6 survivors revealed normalization of liver function and platelet counts, satisfactory growth and absence of significant medical problems.

CONCLUSIONS

The case-fatality rate of 31% is evidence of the potentially devastating nature of EHC. Concomitant EHC and myocarditis are especially serious, but the prognosis for children who survive neonatal EHC is generally excellent.

Direct in situ transcriptase polymerase chain reaction for the detection of Enterovirus genome in liver tissues

Adolescent female mice were inoculated intraperitoneally with coxsackievirus B3 Nancy strain, sacrificed 3 and 5 days later and the livers harvested. A protocol for direct reverse transcriptase in situ PCR (RT-ISPCR) detection of enteroviral RNA in paraffin-embedded liver tissues was developed. The optimal conditions for the assay were determined. The best results were obtained when the tissue was fixed in formalin, prior to being embedded in paraffin, then cut in 5 micron thick sections, and mounted onto silanized slides. After deparaffination the slides were incubated in 1 microgram/m1 Proteinase K for 10 min and cDNA synthesis was carried out. For successful RT-ISPCR 40-50 cycles of amplification were necessary. The optimal concentrations of dNTP, primers and Taq Polymerase for RT-ISPCR were determined by serial dilution assays. Primers were selected from highly conserved sequences in the 5' non-coding region (5'NTR). To detect the viral RNA in the liver, digoxigenin-dUTP was incorporated during amplification, subsequently bound with an antidigoxigenin antibody conjugated to alkaline phosphatase (AP), followed by colorimetric detection with nitroblue tetrazolium salt (NBT) and 5-brom-4chloro-3indolyl-phosphate (BCIP). The result was a blue precipitate in the cytoplasm of hepatocytes from infected mice. Fibroblasts, endothelial cells, lymphocytes and the nuclei of hepatocytes were negative. Thus, RT-ISPCR is a specific method for the detection of enterovirus RNA in the hepatocytes of infected mice, and can be of use for the determination of EV liver disease in man.

Coxsackievirus-positive cervices in women with febrile illnesses during the third trimester in pregnancy

Coxsackievirus B5 infection was demonstrated in five of seven third-trimester pregnant women with undifferentiated febrile illnesses or aseptic meningitis. Coxsackievirus B5 was recovered from the cervix and throat in four women and from the rectum in three. No obvious illnesses were evident in the babies. These findings suggest that previously unrecognized cervical enterovirus carriage or infection is common in infected pregnant women in the last trimester and that subsequent neonatal infection at delivery may result.