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Srichawla BS, Manan MR, Kipkorir V, Dhali A, Diebel S, Sawant T, Zia S, Carrion-Alvarez D, Suteja RC, Nurani K, Găman MA. Neuroinvasion of emerging and re-emerging arboviruses: A scoping review. SAGE Open Med 2024; 12:20503121241229847. [PMID: 38711470 PMCID: PMC11072077 DOI: 10.1177/20503121241229847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 01/16/2024] [Indexed: 05/08/2024] Open
Abstract
Background Arboviruses are RNA viruses and some have the potential to cause neuroinvasive disease and are a growing threat to global health. Objectives Our objective is to identify and map all aspects of arbovirus neuroinvasive disease, clarify key concepts, and identify gaps within our knowledge with appropriate future directions related to the improvement of global health. Methods Sources of Evidence: A scoping review of the literature was conducted using PubMed, Scopus, ScienceDirect, and Hinari. Eligibility Criteria: Original data including epidemiology, risk factors, neurological manifestations, neuro-diagnostics, management, and preventive measures related to neuroinvasive arbovirus infections was obtained. Sources of evidence not reporting on original data, non-English, and not in peer-reviewed journals were removed. Charting Methods: An initial pilot sample of 30 abstracts were reviewed by all authors and a Cohen's kappa of κ = 0.81 (near-perfect agreement) was obtained. Records were manually reviewed by two authors using the Rayyan QCRI software. Results A total of 171 records were included. A wide array of neurological manifestations can occur most frequently, including parkinsonism, encephalitis/encephalopathy, meningitis, flaccid myelitis, and Guillain-Barré syndrome. Magnetic resonance imaging of the brain often reveals subcortical lesions, sometimes with diffusion restriction consistent with acute ischemia. Vertical transmission of arbovirus is most often secondary to the Zika virus. Neurological manifestations of congenital Zika syndrome, include microcephaly, failure to thrive, intellectual disability, and seizures. Cerebrospinal fluid analysis often shows lymphocytic pleocytosis, elevated albumin, and protein consistent with blood-brain barrier dysfunction. Conclusions Arbovirus infection with neurological manifestations leads to increased morbidity and mortality. Risk factors for disease include living and traveling in an arbovirus endemic zone, age, pregnancy, and immunosuppressed status. The management of neuroinvasive arbovirus disease is largely supportive and focuses on specific neurological complications. There is a need for therapeutics and currently, management is based on disease prevention and limiting zoonosis.
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Affiliation(s)
- Bahadar S Srichawla
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | | | - Vincent Kipkorir
- Department of Human Anatomy and Physiology, University of Nairobi, Nairobi, Kenya
| | - Arkadeep Dhali
- Department of Internal Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sebastian Diebel
- Department of Family Medicine, Northern Ontario School of Medicine University, Sudbury, ON, Canada
| | - Tirtha Sawant
- Department of Neurology, Spartan Health Sciences University, Spartan Drive St, Saint Lucia
| | - Subtain Zia
- Department of Infectious Diseases, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | | | - Richard C Suteja
- Faculty of Medicine, Udayana University, Kampus Bukit, Jl, Raya Kampus Unud Jimbaran, Kec, Kuta Sel, Kabupaten Badung, Bukit Jimbaran, Bali, Indonesia
| | - Khulud Nurani
- Department of Human Anatomy and Physiology, University of Nairobi, Nairobi, Kenya
| | - Mihnea-Alexandru Găman
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, București, Romania
- Bucharest, Romania and Department of Hematology, Center of Hematology and Bone Marrow Transplantation, Fundeni Clinical Institute, București, Romania
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2
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Zubair AS, McAlpine LS, Gobeske KT. Virology, ecology, epidemiology, pathology, and treatment of eastern equine encephalitis. J Neurol Sci 2024; 457:122886. [PMID: 38278094 DOI: 10.1016/j.jns.2024.122886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/27/2023] [Accepted: 01/11/2024] [Indexed: 01/28/2024]
Abstract
Eastern equine encephalitis (EEE) was one of the first-recognized neuroinvasive arboviral diseases in North America, and it remains the most lethal. Although EEE is known to have periodic spikes in infection rates, there is increasing evidence that it may be undergoing a change in its prevalence and its public health burden. Numerous factors shape the scope of EEE in humans, and there are important similarities with other emergent viral diseases that have surfaced or strengthened in recent years. Because environmental and ecological conditions that broadly influence the epidemiology of arboviral diseases also are changing, and the frequency, severity, and scope of outbreaks are expected to worsen, an expanded understanding of EEE will have untold importance in coming years. Here we review the factors shaping EEE transmission cycles and the conditions leading to outbreaks in humans from an updated, multidomain perspective. We also provide special consideration of factors shaping the virology, host-vector-environment relationships, and mechanisms of pathology and treatment as a reference for broadening audiences.
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Affiliation(s)
- Adeel S Zubair
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | | | - Kevin T Gobeske
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
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Ruiz C, Gibson G, Rojas S, Friend K. Eastern Equine Encephalitis Virus: A Case Report and Brief Literature Review of Current Therapeutic and Preventative Strategies. Vector Borne Zoonotic Dis 2024; 24:118-121. [PMID: 37870590 DOI: 10.1089/vbz.2023.0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023] Open
Abstract
Background: Eastern equine encephalitis virus (EEEV) is a rare mosquito-borne illness exhibiting rapid neurological deterioration and permanent damage. Despite its >30% mortality and >60% long-term neurological damage, EEEV has no approved antiviral medication or vaccination. This report uniquely aims to describe a rare case of EEEV and provide a current literature review of therapeutic and preventative options from the clinical perspective to guide clinicians and public health workers, along with informing them about its impact and current knowledge gaps. Methods: A retrospective chart review of the electronic medical record was performed for a patient's 10-day hospital admission in July 2021. In addition, PubMed was searched using relevant keywords for a literature review of EEEV. Results: A 61-year-old woman presented with dysarthria and right-sided facial droop. Acute ischemic stroke was ruled out, and empiric intravenous (IV) antibiotics were initiated for possible infectious etiology. The patient developed worsening mental status and fever and was intubated, with antibiotics broadened with concern for meningitis along with tick-borne illness. The patient remained encephalopathic and febrile, and lumbar serologies were consistent with viral meningoencephalitis or acute disseminated encephalomyelitis. Several days after collection, quantitative antibody testing returned positive for EEEV. The patient was pronounced dead on hospital day 10. On review of the literature regarding EEEV, supportive care and prevention remain the cornerstone of management. Although early IV immunoglobulin and high-dose steroids have shown potential as treatments to reduce morbidity and mortality, no vaccines have been approved to date. Conclusion: Prospective trials and further investigations into treatment and preventative options may be useful in reducing the morbidity and mortality associated with EEEV.
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Affiliation(s)
- Christian Ruiz
- Department of Pharmacy, Novant Health Huntersville Medical Center, Huntersville, North Carolina, USA
| | - Geneen Gibson
- Department of Pharmacy, St. Joseph's/Candler Health System, Savannah, Georgia, USA
| | - Scott Rojas
- Department of Infectious Disease, St. Joseph's/Candler Health System, Savannah, Georgia, USA
| | - Kimberly Friend
- Department of Pharmacy, St. Joseph's/Candler Health System, Savannah, Georgia, USA
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4
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Williams JA, Long SY, Zeng X, Kuehl K, Babka AM, Davis NM, Liu J, Trefry JC, Daye S, Facemire PR, Iversen PL, Bavari S, Pitt ML, Nasar F. Eastern equine encephalitis virus rapidly infects and disseminates in the brain and spinal cord of cynomolgus macaques following aerosol challenge. PLoS Negl Trop Dis 2022; 16:e0010081. [PMID: 35533188 PMCID: PMC9084534 DOI: 10.1371/journal.pntd.0010081] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 12/09/2021] [Indexed: 11/18/2022] Open
Abstract
Eastern equine encephalitis virus (EEEV) is mosquito-borne virus that produces fatal encephalitis in humans. We recently conducted a first of its kind study to investigate EEEV clinical disease course following aerosol challenge in a cynomolgus macaque model utilizing the state-of-the-art telemetry to measure critical physiological parameters. Here, we report the results of a comprehensive pathology study of NHP tissues collected at euthanasia to gain insights into EEEV pathogenesis. Viral RNA and proteins as well as microscopic lesions were absent in the visceral organs. In contrast, viral RNA and proteins were readily detected throughout the brain including autonomic nervous system (ANS) control centers and spinal cord. However, despite presence of viral RNA and proteins, majority of the brain and spinal cord tissues exhibited minimal or no microscopic lesions. The virus tropism was restricted primarily to neurons, and virus particles (~61–68 nm) were present within axons of neurons and throughout the extracellular spaces. However, active virus replication was absent or minimal in majority of the brain and was limited to regions proximal to the olfactory tract. These data suggest that EEEV initially replicates in/near the olfactory bulb following aerosol challenge and is rapidly transported to distal regions of the brain by exploiting the neuronal axonal transport system to facilitate neuron-to-neuron spread. Once within the brain, the virus gains access to the ANS control centers likely leading to disruption and/or dysregulation of critical physiological parameters to produce severe disease. Moreover, the absence of microscopic lesions strongly suggests that the underlying mechanism of EEEV pathogenesis is due to neuronal dysfunction rather than neuronal death. This study is the first comprehensive investigation into EEEV pathology in a NHP model and will provide significant insights into the evaluation of countermeasure. EEEV is an arbovirus endemic in parts of North America and is able to produce fatal encephalitis in humans and domesticated animals. Despite multiple human outbreaks during the last 80 years, there are still no therapeutic or vaccines to treat or prevent human disease. One critical obstacle in the development of effective countermeasure is the lack of insights into EEEV pathogenesis in a susceptible animal host. We recently conducted a study in cynomolgus macaques to investigate the disease course by measuring clinical parameters relevant to humans. Following infection, these parameters were rapidly and profoundly altered leading to severe disease. In this study, we examined the potential mechanisms that underlie pathogenesis to cause severe disease. The virus was present in many parts of the brain and spinal cord, however, minimal or no pathological lesions as well as active virus replication were observed. Additionally, neurons were the predominant target of EEEV infection and virus transport was facilitated via axonal transport system to spread neuron-to-neuron throughout the brain and spinal cord. These data show that EEEV likely hijacks essential transport system to rapidly spread in the brain and local/global neuronal dysfunction rather than neuronal death is the principal cause of severe disease.
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Affiliation(s)
- Janice A. Williams
- Pathology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, Maryland, United States of America
| | - Simon Y. Long
- Pathology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, Maryland, United States of America
| | - Xiankun Zeng
- Pathology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, Maryland, United States of America
| | - Kathleen Kuehl
- Pathology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, Maryland, United States of America
| | - April M. Babka
- Pathology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, Maryland, United States of America
| | - Neil M. Davis
- Pathology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, Maryland, United States of America
| | - Jun Liu
- Pathology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, Maryland, United States of America
| | - John C. Trefry
- Virology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, Maryland, United States of America
| | - Sharon Daye
- Pathology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, Maryland, United States of America
| | - Paul R. Facemire
- Pathology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, Maryland, United States of America
| | - Patrick L. Iversen
- Therapeutics Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, Maryland, United States of America
| | - Sina Bavari
- Office of the Commander, United States Army Medical Research Institute of Infectious Diseases, Frederick, Maryland, United States of America
| | - Margaret L. Pitt
- Virology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, Maryland, United States of America
- Office of the Commander, United States Army Medical Research Institute of Infectious Diseases, Frederick, Maryland, United States of America
- * E-mail: (MLP); , (FN)
| | - Farooq Nasar
- Virology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, Maryland, United States of America
- * E-mail: (MLP); , (FN)
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5
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Montalvo M, Ayoub D, McGary M, Byrd K, Mahmoud L, Mermel L, Thompson B, Wendell L. Eastern Equine Encephalitis: Case Series in Southern New England and Review of the Literature. Neurol Clin Pract 2021; 11:e714-e721. [PMID: 34840888 DOI: 10.1212/cpj.0000000000001079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 12/14/2020] [Indexed: 11/15/2022]
Abstract
Purpose of Review To describe the clinical presentation, diagnosis, management, and outcomes of 4 confirmed Eastern equine encephalitis (EEE) cases and a review of the literature. Recent Findings There was a sharp rise in the number of EEE cases in the United States in 2019, with 38 confirmed cases and 15 deaths. Our institution cared for 10% of patients with neuroinvasive EEE nationwide. These were the first cases seen locally since 2010. Summary EEE virus causes one of the most lethal types of arboviral encephalitis in the United States with a mortality of 30%-40%. Manifestations of EEE infections can range from mild encephalopathy to coma. Common findings include CSF pleocytosis and involvement of the basal ganglia on MRI. Given the rarity of this disease and nonspecific findings, diagnosis can be challenging, and a high clinical suspicion is important. Management is mainly supportive, and the use of IV immunoglobulin remains controversial. Two of our 4 patients died; these patients had coma within 48 hours, hyponatremia, involvement of bilateral thalami and brainstem, status epilepticus, and severe brain dysfunction in EEG.
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Affiliation(s)
- Mayra Montalvo
- Department of Neurology (M. Montalvo), Mayo Clinic, Rochester, MN; Rhode Island Hospital (DA, L. Mahmoud), Providence; and Brown University (M. McGary, KB, L. Mermel, BT, LW), Providence, RI
| | - Dana Ayoub
- Department of Neurology (M. Montalvo), Mayo Clinic, Rochester, MN; Rhode Island Hospital (DA, L. Mahmoud), Providence; and Brown University (M. McGary, KB, L. Mermel, BT, LW), Providence, RI
| | - Michael McGary
- Department of Neurology (M. Montalvo), Mayo Clinic, Rochester, MN; Rhode Island Hospital (DA, L. Mahmoud), Providence; and Brown University (M. McGary, KB, L. Mermel, BT, LW), Providence, RI
| | - Katrina Byrd
- Department of Neurology (M. Montalvo), Mayo Clinic, Rochester, MN; Rhode Island Hospital (DA, L. Mahmoud), Providence; and Brown University (M. McGary, KB, L. Mermel, BT, LW), Providence, RI
| | - Leana Mahmoud
- Department of Neurology (M. Montalvo), Mayo Clinic, Rochester, MN; Rhode Island Hospital (DA, L. Mahmoud), Providence; and Brown University (M. McGary, KB, L. Mermel, BT, LW), Providence, RI
| | - Leonard Mermel
- Department of Neurology (M. Montalvo), Mayo Clinic, Rochester, MN; Rhode Island Hospital (DA, L. Mahmoud), Providence; and Brown University (M. McGary, KB, L. Mermel, BT, LW), Providence, RI
| | - Bradford Thompson
- Department of Neurology (M. Montalvo), Mayo Clinic, Rochester, MN; Rhode Island Hospital (DA, L. Mahmoud), Providence; and Brown University (M. McGary, KB, L. Mermel, BT, LW), Providence, RI
| | - Linda Wendell
- Department of Neurology (M. Montalvo), Mayo Clinic, Rochester, MN; Rhode Island Hospital (DA, L. Mahmoud), Providence; and Brown University (M. McGary, KB, L. Mermel, BT, LW), Providence, RI
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6
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Case of fatal eastern equine encephalitis. IDCases 2021; 26:e01288. [PMID: 34646732 PMCID: PMC8496102 DOI: 10.1016/j.idcr.2021.e01288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 09/22/2021] [Indexed: 11/20/2022] Open
Abstract
Eastern Equine Encephalitis (EEE) is a rare and very serious arbovirus that is transmitted to humans through the bite of infected mosquitoes. When symptomatic, patients with this condition are typically seriously ill and the fatality rate is high. We present a fatal case of EEE that exhibited classic symptoms and findings. Included are high quality MRI images that show the classic radiographic findings of this infection. In addition to confirmatory laboratory findings, the case report includes pathologic specimens from brain tissue obtained at autopsy. Perhaps due to climate change and human encroachment on mosquito habitat, there is a westward spread of EEE in the United States.
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7
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The utilization of advance telemetry to investigate critical physiological parameters including electroencephalography in cynomolgus macaques following aerosol challenge with eastern equine encephalitis virus. PLoS Negl Trop Dis 2021; 15:e0009424. [PMID: 34138849 PMCID: PMC8259972 DOI: 10.1371/journal.pntd.0009424] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 07/06/2021] [Accepted: 04/29/2021] [Indexed: 11/19/2022] Open
Abstract
Most alphaviruses are mosquito-borne and can cause severe disease in humans and domesticated animals. In North America, eastern equine encephalitis virus (EEEV) is an important human pathogen with case fatality rates of 30–90%. Currently, there are no therapeutics or vaccines to treat and/or prevent human infection. One critical impediment in countermeasure development is the lack of insight into clinically relevant parameters in a susceptible animal model. This study examined the disease course of EEEV in a cynomolgus macaque model utilizing advanced telemetry technology to continuously and simultaneously measure temperature, respiration, activity, heart rate, blood pressure, electrocardiogram (ECG), and electroencephalography (EEG) following an aerosol challenge at 7.0 log10 PFU. Following challenge, all parameters were rapidly and substantially altered with peak alterations from baseline ranged as follows: temperature (+3.0–4.2°C), respiration rate (+56–128%), activity (-15-76% daytime and +5–22% nighttime), heart rate (+67–190%), systolic (+44–67%) and diastolic blood pressure (+45–80%). Cardiac abnormalities comprised of alterations in QRS and PR duration, QTc Bazett, T wave morphology, amplitude of the QRS complex, and sinoatrial arrest. An unexpected finding of the study was the first documented evidence of a critical cardiac event as an immediate cause of euthanasia in one NHP. All brain waves were rapidly (~12–24 hpi) and profoundly altered with increases of up to 6,800% and severe diffuse slowing of all waves with decreases of ~99%. Lastly, all NHPs exhibited disruption of the circadian rhythm, sleep, and food/fluid intake. Accordingly, all NHPs met the euthanasia criteria by ~106–140 hpi. This is the first of its kind study utilizing state of the art telemetry to investigate multiple clinical parameters relevant to human EEEV infection in a susceptible cynomolgus macaque model. The study provides critical insights into EEEV pathogenesis and the parameters identified will improve animal model development to facilitate rapid evaluation of vaccines and therapeutics. In North America, EEEV causes the most severe mosquito-borne disease in humans highlighted by fatal encephalitis and permeant debilitating neurological sequelae in survivors. The first confirmed human cases were reported more than 80 years ago and since then multiple sporadic outbreaks have occurred including one of the largest in 2019. Unfortunately, most human infections are diagnosed at the on-set of severe neurological symptoms and consequently a detailed disease course in humans is lacking. This gap in knowledge is a significant obstacle in the development of appropriate animal models to evaluate countermeasures. Here, we performed a cutting-edge study by utilizing a new telemetry technology to understand the course of EEEV infection in a susceptible macaque model by measuring multiple physiological parameters relevant to human disease. Our study demonstrates that the infection rapidly produces considerable alterations in many critical parameters including the electrical activity of the heart and the brain leading to severe disease. The study also highlights the extraordinary potential of new telemetry technology to develop the next generation of animal models to comprehensively investigate pathogenesis as well as evaluate countermeasures to treat and/or prevent EEEV disease.
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8
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LaRovere KL, Riggs BJ, Poussaint TY, Young CC, Newhams MM, Maamari M, Walker TC, Singh AR, Dapul H, Hobbs CV, McLaughlin GE, Son MBF, Maddux AB, Clouser KN, Rowan CM, McGuire JK, Fitzgerald JC, Gertz SJ, Shein SL, Munoz AC, Thomas NJ, Irby K, Levy ER, Staat MA, Tenforde MW, Feldstein LR, Halasa NB, Giuliano JS, Hall MW, Kong M, Carroll CL, Schuster JE, Doymaz S, Loftis LL, Tarquinio KM, Babbitt CJ, Nofziger RA, Kleinman LC, Keenaghan MA, Cvijanovich NZ, Spinella PC, Hume JR, Wellnitz K, Mack EH, Michelson KN, Flori HR, Patel MM, Randolph AG. Neurologic Involvement in Children and Adolescents Hospitalized in the United States for COVID-19 or Multisystem Inflammatory Syndrome. JAMA Neurol 2021; 78:536-547. [PMID: 33666649 DOI: 10.1001/jamaneurol.2021.0504] [Citation(s) in RCA: 262] [Impact Index Per Article: 87.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Coronavirus disease 2019 (COVID-19) affects the nervous system in adult patients. The spectrum of neurologic involvement in children and adolescents is unclear. Objective To understand the range and severity of neurologic involvement among children and adolescents associated with COVID-19. Setting, Design, and Participants Case series of patients (age <21 years) hospitalized between March 15, 2020, and December 15, 2020, with positive severe acute respiratory syndrome coronavirus 2 test result (reverse transcriptase-polymerase chain reaction and/or antibody) at 61 US hospitals in the Overcoming COVID-19 public health registry, including 616 (36%) meeting criteria for multisystem inflammatory syndrome in children. Patients with neurologic involvement had acute neurologic signs, symptoms, or diseases on presentation or during hospitalization. Life-threatening involvement was adjudicated by experts based on clinical and/or neuroradiologic features. Exposures Severe acute respiratory syndrome coronavirus 2. Main Outcomes and Measures Type and severity of neurologic involvement, laboratory and imaging data, and outcomes (death or survival with new neurologic deficits) at hospital discharge. Results Of 1695 patients (909 [54%] male; median [interquartile range] age, 9.1 [2.4-15.3] years), 365 (22%) from 52 sites had documented neurologic involvement. Patients with neurologic involvement were more likely to have underlying neurologic disorders (81 of 365 [22%]) compared with those without (113 of 1330 [8%]), but a similar number were previously healthy (195 [53%] vs 723 [54%]) and met criteria for multisystem inflammatory syndrome in children (126 [35%] vs 490 [37%]). Among those with neurologic involvement, 322 (88%) had transient symptoms and survived, and 43 (12%) developed life-threatening conditions clinically adjudicated to be associated with COVID-19, including severe encephalopathy (n = 15; 5 with splenial lesions), stroke (n = 12), central nervous system infection/demyelination (n = 8), Guillain-Barré syndrome/variants (n = 4), and acute fulminant cerebral edema (n = 4). Compared with those without life-threatening conditions (n = 322), those with life-threatening neurologic conditions had higher neutrophil-to-lymphocyte ratios (median, 12.2 vs 4.4) and higher reported frequency of D-dimer greater than 3 μg/mL fibrinogen equivalent units (21 [49%] vs 72 [22%]). Of 43 patients who developed COVID-19-related life-threatening neurologic involvement, 17 survivors (40%) had new neurologic deficits at hospital discharge, and 11 patients (26%) died. Conclusions and Relevance In this study, many children and adolescents hospitalized for COVID-19 or multisystem inflammatory syndrome in children had neurologic involvement, mostly transient symptoms. A range of life-threatening and fatal neurologic conditions associated with COVID-19 infrequently occurred. Effects on long-term neurodevelopmental outcomes are unknown.
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Affiliation(s)
- Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Becky J Riggs
- Division of Pediatric Anesthesiology and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Tina Y Poussaint
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts
| | - Cameron C Young
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Margaret M Newhams
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Mia Maamari
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern, Children's Health Medical Center Dallas
| | - Tracie C Walker
- Department of Pediatrics, University of North Carolina at Chapel Hill Children's Hospital, Chapel Hill
| | - Aalok R Singh
- Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla
| | - Heda Dapul
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, New York University Grossman School of Medicine, New York
| | - Charlotte V Hobbs
- Division of Infectious Diseases, Department of Pediatrics, Department of Microbiology, University of Mississippi Medical Center, Jackson
| | - Gwenn E McLaughlin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida
| | - Mary Beth F Son
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Aline B Maddux
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora
| | - Katharine N Clouser
- Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack, New Jersey
| | - Courtney M Rowan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis
| | - John K McGuire
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle
| | - Julie C Fitzgerald
- Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Shira J Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Saint Barnabas Medical Center, Livingston, New Jersey
| | - Steven L Shein
- Division of Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Alvaro Coronado Munoz
- Pediatric Critical Care Division, Department of Pediatrics, University of Texas Health Science Center at Houston, Houston
| | - Neal J Thomas
- Department of Pediatrics, Penn State Hershey Children's Hospital, Pennsylvania State University College of Medicine, Hershey
| | - Katherine Irby
- Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock
| | - Emily R Levy
- Divisions of Pediatric Infectious Diseases and Pediatric Critical Care Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mary A Staat
- Department of Pediatrics, University of Cincinnati, Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mark W Tenforde
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia.,Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Leora R Feldstein
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia.,Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Natasha B Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John S Giuliano
- Division of Critical Care, Yale University School of Medicine, New Haven, Connecticut
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham
| | | | - Jennifer E Schuster
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
| | - Sule Doymaz
- Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University, Brooklyn
| | - Laura L Loftis
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Houston
| | - Keiko M Tarquinio
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | | | - Ryan A Nofziger
- Division of Critical Care Medicine, Akron Children's Hospital, Akron, Ohio
| | - Lawrence C Kleinman
- Division of Population Health, Quality, and Implementation Sciences (PopQuIS), Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Michael A Keenaghan
- Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital, Brooklyn, New York
| | - Natalie Z Cvijanovich
- Division of Critical Care Medicine, University of California, San Francisco, Benioff Children's Hospital, Oakland
| | - Philip C Spinella
- Division of Critical Care, Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Janet R Hume
- Division of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital, Minneapolis
| | - Kari Wellnitz
- Division of Pediatric Critical Care, Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Elizabeth H Mack
- Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston
| | - Kelly N Michelson
- Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Heidi R Flori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mott Children's Hospital and University of Michigan, Ann Arbor
| | - Manish M Patel
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia.,Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Adrienne G Randolph
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Departments of Anaesthesia and Pediatrics, Harvard Medical School, Boston, Massachusetts
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9
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Albe JR, Ma H, Gilliland TH, McMillen CM, Gardner CL, Boyles DA, Cottle EL, Dunn MD, Lundy JD, O’Malley KJ, Salama N, Walters AW, Pandrea I, Teichert T, Klimstra WB, Reed DS, Hartman AL. Physiological and immunological changes in the brain associated with lethal eastern equine encephalitis virus in macaques. PLoS Pathog 2021; 17:e1009308. [PMID: 33534855 PMCID: PMC7886169 DOI: 10.1371/journal.ppat.1009308] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 02/16/2021] [Accepted: 01/12/2021] [Indexed: 11/18/2022] Open
Abstract
Aerosol exposure to eastern equine encephalitis virus (EEEV) can trigger a lethal viral encephalitis in cynomolgus macaques which resembles severe human disease. Biomarkers indicative of central nervous system (CNS) infection by the virus and lethal outcome of disease would be useful in evaluating potential medical countermeasures, especially for therapeutic compounds. To meet requirements of the Animal Rule, a better understanding of the pathophysiology of EEEV-mediated disease in cynomolgus macaques is needed. In this study, macaques given a lethal dose of clone-derived EEEV strain V105 developed a fever between 2-3 days post infection (dpi) and succumbed to the disease by 6 dpi. At the peak of the febrile phase, there was a significant increase in the delta electroencephalography (EEG) power band associated with deep sleep as well as a sharp rise in intracranial pressure (ICP). Viremia peaked early after infection and was largely absent by the onset of fever. Granulocytosis and elevated plasma levels of IP-10 were found early after infection. At necropsy, there was a one hundred- to one thousand-fold increase in expression of traumatic brain injury genes (LIF, MMP-9) as well as inflammatory cytokines and chemokines (IFN-γ, IP-10, MCP-1, IL-8, IL-6) in the brain tissues. Phenotypic analysis of leukocytes entering the brain identified cells as primarily lymphoid (T, B, NK cells) with lower levels of infiltrating macrophages and activated microglia. Massive amounts of infectious virus were found in the brains of lethally-infected macaques. While no infectious virus was found in surviving macaques, quantitative PCR did find evidence of viral genomes in the brains of several survivors. These data are consistent with an overwhelming viral infection in the CNS coupled with a tremendous inflammatory response to the infection that may contribute to the disease outcome. Physiological monitoring of EEG and ICP represent novel methods for assessing efficacy of vaccines or therapeutics in the cynomolgus macaque model of EEEV encephalitis.
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Affiliation(s)
- Joseph R. Albe
- Center for Vaccine Research, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Henry Ma
- Center for Vaccine Research, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Department of Infectious Diseases and Microbiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Theron H. Gilliland
- Center for Vaccine Research, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Cynthia M. McMillen
- Center for Vaccine Research, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Department of Infectious Diseases and Microbiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Christina L. Gardner
- Center for Vaccine Research, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Devin A. Boyles
- Center for Vaccine Research, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Emily L. Cottle
- Center for Vaccine Research, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Matthew D. Dunn
- Center for Vaccine Research, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Jeneveve D. Lundy
- Center for Vaccine Research, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Katherine J. O’Malley
- Center for Vaccine Research, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Noah Salama
- Department of Infectious Diseases and Microbiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Aaron W. Walters
- Center for Vaccine Research, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Department of Infectious Diseases and Microbiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Ivona Pandrea
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Tobias Teichert
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - William B. Klimstra
- Center for Vaccine Research, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Department of Immunology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- * E-mail: (WBK); (DSR); (ALH)
| | - Douglas S. Reed
- Center for Vaccine Research, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Department of Immunology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- * E-mail: (WBK); (DSR); (ALH)
| | - Amy L. Hartman
- Center for Vaccine Research, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Department of Infectious Diseases and Microbiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- * E-mail: (WBK); (DSR); (ALH)
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10
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Wilcox DR, Collens SI, Solomon IH, Mateen FJ, Mukerji SS. Eastern equine encephalitis and use of IV immunoglobulin therapy and high-dose steroids. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:e917. [PMID: 33172962 PMCID: PMC7713729 DOI: 10.1212/nxi.0000000000000917] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 09/28/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine the clinical presentation and patient outcomes after treatment with IV immunoglobulin (IVIG), high-dose steroids, or standard of care alone in Eastern equine encephalitis (EEE), a mosquito-borne viral infection with significant neurologic morbidity and mortality. METHODS A retrospective observational study of patients admitted to 2 tertiary academic medical centers in Boston, Massachusetts, with EEE from 2005 to 2019. RESULTS Of 17 patients (median [IQR] age, 63 [36-70] years; 10 (59%) male, and 16 (94%) White race), 17 patients had fever (100%), 15 had encephalopathy (88%), and 12 had headache (71%). Eleven of 14 patients with CSF cell count differential had a neutrophil predominance (mean = 60.6% of white blood cells) with an elevated protein level (median [IQR], 100 mg/dL [75-145]). Affected neuroanatomic regions included the basal ganglia (n = 9/17), thalamus (n = 7/17), and mesial temporal lobe (n = 7/17). A total of 11 patients (65%) received IVIG; 8 (47%) received steroids. Of the patients who received IVIG, increased time from hospital admission to IVIG administration correlated with worse long-term disability as assessed by the modified Rankin Scale (mRS) (r = 0.72, p = 0.02); steroid use was not associated with the mRS score. The mortality was 12%. CONCLUSIONS Clinicians should suspect EEE in immunocompetent patients with early subcortical neuroimaging abnormalities and CSF neutrophilic predominance. This study suggests a lower mortality than previously reported, but a high morbidity rate in EEE. IVIG as an adjunctive to standard of care may be considered early during hospitalization.
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Affiliation(s)
- Douglas R Wilcox
- From the Division of Neuroimmunology and Neuro-Infectious Diseases (D.R.W., S.I.C., F.J.M., S.S.M.), Department of Neurology, Massachusetts General Hospital; Department of Neurology (D.R.W.), Brigham and Women's Hospital; Department of Pathology (I.H.S.), Brigham and Women's Hospital; and Department of Neurology (D.R.W., F.J.M., S.S.M.), Harvard Medical School, Boston, MA.
| | - Sarah I Collens
- From the Division of Neuroimmunology and Neuro-Infectious Diseases (D.R.W., S.I.C., F.J.M., S.S.M.), Department of Neurology, Massachusetts General Hospital; Department of Neurology (D.R.W.), Brigham and Women's Hospital; Department of Pathology (I.H.S.), Brigham and Women's Hospital; and Department of Neurology (D.R.W., F.J.M., S.S.M.), Harvard Medical School, Boston, MA
| | - Isaac H Solomon
- From the Division of Neuroimmunology and Neuro-Infectious Diseases (D.R.W., S.I.C., F.J.M., S.S.M.), Department of Neurology, Massachusetts General Hospital; Department of Neurology (D.R.W.), Brigham and Women's Hospital; Department of Pathology (I.H.S.), Brigham and Women's Hospital; and Department of Neurology (D.R.W., F.J.M., S.S.M.), Harvard Medical School, Boston, MA
| | - Farrah J Mateen
- From the Division of Neuroimmunology and Neuro-Infectious Diseases (D.R.W., S.I.C., F.J.M., S.S.M.), Department of Neurology, Massachusetts General Hospital; Department of Neurology (D.R.W.), Brigham and Women's Hospital; Department of Pathology (I.H.S.), Brigham and Women's Hospital; and Department of Neurology (D.R.W., F.J.M., S.S.M.), Harvard Medical School, Boston, MA
| | - Shibani S Mukerji
- From the Division of Neuroimmunology and Neuro-Infectious Diseases (D.R.W., S.I.C., F.J.M., S.S.M.), Department of Neurology, Massachusetts General Hospital; Department of Neurology (D.R.W.), Brigham and Women's Hospital; Department of Pathology (I.H.S.), Brigham and Women's Hospital; and Department of Neurology (D.R.W., F.J.M., S.S.M.), Harvard Medical School, Boston, MA
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11
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Abstract
Viral encephalitis is difficult to treat. Herpes simplex encephalitis has been successfully treated with acyclovir, but is still a cause for significant morbidity even with that treatment. A rare form of autoimmune encephalitis related to NMDA receptor antibody after infection by herpes simplex can be treated with corticosteroid therapy. Arthropod-borne encephalitides, such as West Nile virus encephalitis and Eastern equine encephalitis, are primarily treated with supportive measures. Attempts have been made to use immunoglobulin therapy with limited effects. Progressive multifocal leukoencephalopathy has been treated with an emerging immune activation therapy in a limited number of patients with incomplete success.
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Affiliation(s)
- Allen J Aksamit
- Department of Neurology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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12
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Pouch SM, Katugaha SB, Shieh WJ, Annambhotla P, Walker WL, Basavaraju SV, Jones J, Huynh T, Reagan-Steiner S, Bhatnagar J, Grimm K, Stramer SL, Gabel J, Lyon GM, Mehta AK, Kandiah P, Neujahr DC, Javidfar J, Subramanian RM, Parekh SM, Shah P, Cooper L, Psotka MA, Radcliffe R, Williams C, Zaki SR, Staples JE, Fischer M, Panella AJ, Lanciotti RS, Laven JJ, Kosoy O, Rabe IB, Gould CV. Transmission of Eastern Equine Encephalitis Virus From an Organ Donor to 3 Transplant Recipients. Clin Infect Dis 2020; 69:450-458. [PMID: 30371754 DOI: 10.1093/cid/ciy923] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 10/25/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In fall 2017, 3 solid organ transplant (SOT) recipients from a common donor developed encephalitis within 1 week of transplantation, prompting suspicion of transplant-transmitted infection. Eastern equine encephalitis virus (EEEV) infection was identified during testing of endomyocardial tissue from the heart recipient. METHODS We reviewed medical records of the organ donor and transplant recipients and tested serum, whole blood, cerebrospinal fluid, and tissue from the donor and recipients for evidence of EEEV infection by multiple assays. We investigated blood transfusion as a possible source of organ donor infection by testing remaining components and serum specimens from blood donors. We reviewed data from the pretransplant organ donor evaluation and local EEEV surveillance. RESULTS We found laboratory evidence of recent EEEV infection in all organ recipients and the common donor. Serum collected from the organ donor upon hospital admission tested negative, but subsequent samples obtained prior to organ recovery were positive for EEEV RNA. There was no evidence of EEEV infection among donors of the 8 blood products transfused into the organ donor or in products derived from these donations. Veterinary and mosquito surveillance showed recent EEEV activity in counties nearby the organ donor's county of residence. Neuroinvasive EEEV infection directly contributed to the death of 1 organ recipient and likely contributed to death in another. CONCLUSIONS Our investigation demonstrated EEEV transmission through SOT. Mosquito-borne transmission of EEEV to the organ donor was the likely source of infection. Clinicians should be aware of EEEV as a cause of transplant-associated encephalitis.
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Affiliation(s)
- Stephanie M Pouch
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Shalika B Katugaha
- Infectious Diseases Physicians, Inc, Inova Fairfax Hospital Heart and Vascular Institute, Falls Church, Virginia
| | - Wun-Ju Shieh
- Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Pallavi Annambhotla
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - William L Walker
- Division of Vector-Borne Diseases, NCEZID, CDC, Fort Collins, Colorado.,Epidemic Intelligence Service, Center for Surveillance, Epidemiology and Laboratory Services, CDC, Atlanta, Georgia
| | - Sridhar V Basavaraju
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Jefferson Jones
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Thanhthao Huynh
- Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Sarah Reagan-Steiner
- Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Julu Bhatnagar
- Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Kacie Grimm
- American Red Cross, Gaithersburg, Maryland, Emory University School of Medicine, Atlanta, Georgia
| | - Susan L Stramer
- American Red Cross, Gaithersburg, Maryland, Emory University School of Medicine, Atlanta, Georgia
| | - Julie Gabel
- Georgia Department of Public Health, Emory University School of Medicine, Atlanta, Georgia
| | - G Marshall Lyon
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Aneesh K Mehta
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Prem Kandiah
- Department of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - David C Neujahr
- Division of Pulmonary Allergy and Critical Care Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Jeffrey Javidfar
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Ram M Subramanian
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Samir M Parekh
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Palak Shah
- Department of Heart Failure and Transplantation, Inova Fairfax Hospital Heart and Vascular Institute, Falls Church, Virginia
| | - Lauren Cooper
- Department of Heart Failure and Transplantation, Inova Fairfax Hospital Heart and Vascular Institute, Falls Church, Virginia
| | - Mitchell A Psotka
- Department of Heart Failure and Transplantation, Inova Fairfax Hospital Heart and Vascular Institute, Falls Church, Virginia
| | - Rachel Radcliffe
- Division of Acute Disease Epidemiology, South Carolina Department of Health and Environmental Control, Columbia
| | | | - Sherif R Zaki
- Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - J Erin Staples
- Division of Vector-Borne Diseases, NCEZID, CDC, Fort Collins, Colorado
| | - Marc Fischer
- Division of Vector-Borne Diseases, NCEZID, CDC, Fort Collins, Colorado
| | - Amanda J Panella
- Division of Vector-Borne Diseases, NCEZID, CDC, Fort Collins, Colorado
| | | | - Janeen J Laven
- Division of Vector-Borne Diseases, NCEZID, CDC, Fort Collins, Colorado
| | - Olga Kosoy
- Division of Vector-Borne Diseases, NCEZID, CDC, Fort Collins, Colorado
| | - Ingrid B Rabe
- Division of Vector-Borne Diseases, NCEZID, CDC, Fort Collins, Colorado
| | - Carolyn V Gould
- Division of Vector-Borne Diseases, NCEZID, CDC, Fort Collins, Colorado
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13
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Sandrock C, Aziz SR. Travel/Tropical Medicine and Pandemic Considerations for the Global Surgeon. Oral Maxillofac Surg Clin North Am 2020; 32:407-425. [PMID: 32473858 PMCID: PMC7205681 DOI: 10.1016/j.coms.2020.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
International travel goes hand in hand with medical delivery to underserved communities. The global health care worker can be exposed to a wide range of infectious diseases during their global experiences. A pretravel risk assessment visit and all appropriate vaccinations and education must be performed. Universal practices of water safety, food safety, and insect avoidance will prevent most travel-related infections and complications. Region-specific vaccinations will further reduce illness risk. An understanding of common travel-related illness signs and symptoms is helpful. Emerging pathogens that can cause a pandemic should be understood to avoid health care worker infection and spread.
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Affiliation(s)
- Christian Sandrock
- UC Davis School of Medicine, 4150 V street, Suite 3400, Sacramento, CA 95817, USA.
| | - Shahid R Aziz
- Rutgers School of Dental Medicine, 110 Bergen Street, Room B854, Newark, NJ 07103, USA
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14
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Ma H, Lundy JD, Cottle EL, O’Malley KJ, Trichel AM, Klimstra WB, Hartman AL, Reed DS, Teichert T. Applications of minimally invasive multimodal telemetry for continuous monitoring of brain function and intracranial pressure in macaques with acute viral encephalitis. PLoS One 2020; 15:e0232381. [PMID: 32584818 PMCID: PMC7316240 DOI: 10.1371/journal.pone.0232381] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 05/28/2020] [Indexed: 12/17/2022] Open
Abstract
Alphaviruses such as Venezuelan equine encephalitis virus (VEEV) and Eastern equine encephalitis virus (EEEV) are arboviruses that can cause severe zoonotic disease in humans. Both VEEV and EEEV are highly infectious when aerosolized and can be used as biological weapons. Vaccines and therapeutics are urgently needed, but efficacy determination requires animal models. The cynomolgus macaque (Macaca fascicularis) provides a relevant model of human disease, but questions remain whether vaccines or therapeutics can mitigate CNS infection or disease in this model. The documentation of alphavirus encephalitis in animals relies on traditional physiological biomarkers and behavioral/neurological observations by veterinary staff; quantitative measurements such as electroencephalography (EEG) and intracranial pressure (ICP) can recapitulate underlying encephalitic processes. We detail a telemetry implantation method suitable for continuous monitoring of both EEG and ICP in awake macaques, as well as methods for collection and analysis of such data. We sought to evaluate whether changes in EEG/ICP suggestive of CNS penetration by virus would be seen after aerosol exposure of naïve macaques to VEEV IC INH9813 or EEEV V105 strains compared to mock-infection in a cohort of twelve adult cynomolgus macaques. Data collection ran continuously from at least four days preceding aerosol exposure and up to 50 days thereafter. EEG signals were processed into frequency spectrum bands (delta: [0.4 - 4Hz); theta: [4 - 8Hz); alpha: [8-12Hz); beta: [12-30] Hz) and assessed for viral encephalitis-associated changes against robust background circadian variation while ICP data was assessed for signal fidelity, circadian variability, and for meaningful differences during encephalitis. Results indicated differences in delta, alpha, and beta band magnitude in infected macaques, disrupted circadian rhythm, and proportional increases in ICP in response to alphavirus infection. This novel enhancement of the cynomolgus macaque model offers utility for timely determination of onset, severity, and resolution of encephalitic disease and for the evaluation of vaccine and therapeutic candidates.
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Affiliation(s)
- Henry Ma
- Center for Vaccine Research, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Jeneveve D. Lundy
- Center for Vaccine Research, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Emily L. Cottle
- Center for Vaccine Research, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Katherine J. O’Malley
- Center for Vaccine Research, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Anita M. Trichel
- Center for Vaccine Research, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - William B. Klimstra
- Center for Vaccine Research, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Amy L. Hartman
- Center for Vaccine Research, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Douglas S. Reed
- Center for Vaccine Research, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Tobias Teichert
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
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15
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Kapadia RK, Chauhan L, Piquet AL, Tyler KL, Pastula DM. An Overview of Eastern Equine Encephalitis (EEE). Neurohospitalist 2020; 10:161-162. [PMID: 32549937 DOI: 10.1177/1941874420905762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Ronak K Kapadia
- Neuro-Infectious Diseases Group, Department of Neurology and Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lakshmi Chauhan
- Neuro-Infectious Diseases Group, Department of Neurology and Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, USA
| | - Amanda L Piquet
- Neuro-Infectious Diseases Group, Department of Neurology and Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kenneth L Tyler
- Neuro-Infectious Diseases Group, Department of Neurology and Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Immunology-Microbiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Daniel M Pastula
- Neuro-Infectious Diseases Group, Department of Neurology and Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
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16
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Cho JJ, Wong JK, Henkel J, DeJesus RO, Nazario-Lopez B. Acute Seroconversion of Eastern Equine Encephalitis Coinfection With California Serogroup Encephalitis Virus. Front Neurol 2019; 10:242. [PMID: 30941092 PMCID: PMC6433933 DOI: 10.3389/fneur.2019.00242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 02/25/2019] [Indexed: 11/13/2022] Open
Abstract
Eastern equine encephalitis (EEE) is a severe arboviral neuroinvasive disease with high mortality and neurological sequelae. Treatment for EEE is primarily supportive. Intravenous immunoglobulin (IVIg) and high-dose steroids have been used as empirical therapy for EEE with some case reports of benefit. We report a case of a patient who presented with encephalopathy with initial cerebrospinal spinal fluid (CSF) serology analysis showing California serogroup encephalitis virus IgG positivity. However, the rapid clinical deterioration of the patient into a comatose state prompted a second CSF serology analysis that showed seroconversion of high titer Eastern Equine Encephalitis virus IgM and positive titer of California serogroup encephalitis virus IgG. The patient completed a 5-day course of empiric IVIg without concurrent corticosteroid therapy but did not show significant clinical improvement.
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Affiliation(s)
- Jonathan J Cho
- Department of Neurology, McKnight Brain Institute, College of Medicine, University of Florida, Gainesville, FL, United States.,Department of Anatomy and Cell Biology, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Joshua K Wong
- Department of Neurology, McKnight Brain Institute, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Jacqueline Henkel
- Department of Radiology, University of Florida, Gainesville, FL, United States
| | - Reordan O DeJesus
- Department of Radiology, University of Florida, Gainesville, FL, United States
| | - Bernadette Nazario-Lopez
- Department of Neurology, McKnight Brain Institute, College of Medicine, University of Florida, Gainesville, FL, United States
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17
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Solomon IH, Ciarlini PDSC, Santagata S, Ahmed AA, De Girolami U, Prasad S, Mukerji SS. Fatal Eastern Equine Encephalitis in a Patient on Maintenance Rituximab: A Case Report. Open Forum Infect Dis 2017; 4:ofx021. [PMID: 28480291 PMCID: PMC5414020 DOI: 10.1093/ofid/ofx021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 02/06/2017] [Indexed: 11/15/2022] Open
Abstract
A 63-year-old woman on rituximab maintenance for follicular lymphoma presented with headaches, vomiting, and fever, and was diagnosed with eastern equine encephalomyelitis by cerebrospinal fluid polymerase chain reaction. Eastern equine encephalomyelitis immunoglobulin (Ig)G/IgM remained negative due to rituximab treatment, and magnetic resonance imaging showed minimal abnormalities, making this a diagnostically challenging case. Despite therapy with intravenous Ig, the patient rapidly declined and died on hospital day 12. Autopsy revealed perivascular and parenchymal chronic inflammation, with an absence of B lymphocytes, and virally infected neurons throughout the central nervous system.
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Affiliation(s)
| | | | | | - Asim A Ahmed
- Department of Medicine, Division of Infectious Diseases, Boston Children's Hospital, Harvard Medical School, Massachusetts
| | | | - Sashank Prasad
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Shibani S Mukerji
- Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
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18
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Garlick J, Lee TJ, Shepherd P, Linam WM, Pastula DM, Weinstein S, Schexnayder SM. Locally Acquired Eastern Equine Encephalitis Virus Disease, Arkansas, USA. Emerg Infect Dis 2016; 22:2216-2217. [PMID: 27662563 PMCID: PMC5189158 DOI: 10.3201/eid2212.160844] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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19
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Shah KJ, Cherabuddi K. Case of eastern equine encephalitis presenting in winter. BMJ Case Rep 2016; 2016:bcr-2016-215270. [PMID: 27165999 DOI: 10.1136/bcr-2016-215270] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 50-year-old man was admitted in midwinter with fever, altered mental status and new onset generalised tonic-clonic seizure with urinary incontinence. Cerebrospinal fluid (CSF) analysis revealed an opening pressure of 14.5 cm of water, normal glucose and protein 82 mg/dL (reference range: 15-45 mg/dL). Cell count showed: red cells 11 (reference range: <5 mm(3)), white cell count 1 (reference range: <5 mm(3)). The patient's blood and CSF cultures had no growth. MRI of the brain with and without gadolinium contrast showed abnormal T2 and fluid-attenuated inversion recovery signals within bilateral ventricular nuclei, hippocampi, left frontal and parietal regions. Eastern equine encephalitis (EEE) antibody, IgG titre was 1:64 and IgM titre was <1:16. Three weeks later, his repeat/convalescent titres increased to 1:1024 and 1:32, respectively. Hence, a diagnosis of EEE was established. The patient was treated with supportive care. He recovered well with mildly impaired memory but no other cognitive deficits.
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Affiliation(s)
- Kairav J Shah
- Department of Medicine, Division of Infectious Diseases, University of Florida, Gainesville, Florida, USA
| | - Kartikeya Cherabuddi
- Department of Medicine, Division of Infectious Diseases, University of Florida, Gainesville, Florida, USA
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Mukerji SS, Lam AD, Wilson MR. Eastern Equine Encephalitis Treated With Intravenous Immunoglobulins. Neurohospitalist 2016; 6:29-31. [PMID: 26740855 DOI: 10.1177/1941874415578533] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We report the case of a 68-year-old man from southeastern Massachusetts presenting with encephalitis due to eastern equine encephalitis (EEE) virus. Despite the high morbidity and mortality rate of EEE, the patient made a near complete recovery in the setting of receiving early intravenous immunoglobulins.
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Affiliation(s)
- Shibani S Mukerji
- Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Alice D Lam
- Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael R Wilson
- Department of Neurology, University of California, San Francisco School of Medicine, San Francisco, CA, USA
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Abstract
Mosquito-borne diseases affect horses worldwide. Mosquito-borne diseases generally cause encephalomyelitis in the horse and can be difficult to diagnose antemortem. In addition to general disease, and diagnostic and treatment aspects, this review article summarizes the latest information on these diseases, covering approximately the past 5 years, with a focus on new equine disease encroachments, diagnostic and vaccination aspects, and possible therapeutics on the horizon.
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