Benign infantile convulsions associated with mild gastroenteritis: a retrospective study of 39 cases including virological tests and efficacy of anticonvulsants

The Frequency of Rotavirus Gastroenteritis in Children from West of Iran and Genotyping of Rotavirus Isolates: A Suggestion for Further Changes in Childhood Immunization Program

BACKGROUND

Rotavirus is the most common cause of gastroenteritis among children. Currently, four oral live-attenuated vaccines are available to prevent rotavirus infection. The World Health Organization (WHO) has recommended including rotavirus vaccination in national immunization programs; however, it has not been introduced to the Iranian national immunization program. The study aimed to assess the frequency of rotavirus gastroenteritis in the west of Iran and investigate the necessity of rotavirus vaccination. Study Design: A case series study.

METHODS

In this case series study, 284 cases under six years of age who presented with acute gastroenteritis from March 2021 to 2022 to a referral hospital in the west of Iran were evaluated. Data on baseline characteristics, clinical manifestations, results of stool test, ELISA for rotavirus detection, and polymerase chain reaction (PCR) test for genotyping of rotavirus-positive samples were recorded.

RESULTS

Results showed that the prevalence of rotavirus infection was 36.6%. The highest frequency was observed among children aged 6-12 months and during the autumn. According to the PCR results, G1P[8], G9P[8], G9P[4], and G1P [4] were the dominant genotypes, and 33.75% of samples were infected with multiple rotavirus genotypes.

CONCLUSION

The study highlights the considerable prevalence of rotavirus infection among cases of acute gastroenteritis in children under six years of age who were referred to a referral hospital in the west of Iran and the high diversity of rotavirus genotypes in the targeted community. Consequently, physicians and health policymakers should prioritize strategies for the prevention and control of this infection, particularly by considering the rotavirus vaccine as a priority for the Iranian national immunization program.

Spontaneous Remission of Epileptic Seizures Following Norovirus Infection in a Patient With DNM1 Encephalopathy

Epileptic seizures can be worsened by infections; however, they sometimes disappear or decrease after an acute viral infection, although this is rare. We report the spontaneous remission of epileptic seizures following norovirus-induced viral gastroenteritis in a boy with DNM1 encephalopathy. He had clonic seizures daily from the age of two months and developed epileptic spasms at 14 months of age; he was admitted to the hospital at this time. A physical examination revealed hypotonia, strabismus, tongue protrusion with drooping, and widely spaced teeth. Although brain magnetic resonance imaging was unremarkable, electroencephalography revealed frequent occipital spikes. Three days after admission, the patient developed frequent diarrhea without a fever. A rapid immunochromatographic test of norovirus in a stool sample was positive. Immediately after the appearance of diarrhea, the epileptic seizures disappeared. Currently, at the age of five years, the patient has a profound psychomotor developmental delay; he has no verbal expression and is unable to walk. He has experienced involuntary movements of the myoclonus since 10 months of age. Whole-exome sequencing of the patient's DNA revealed the presence of a heterozygous de novo variant of DNM1: c.709C>T (p.Arg237Trp). Although the findings from our patient suggest that underlying neural network abnormalities were ameliorated by immunological mechanisms as a result of the viral infection, further research is needed to clarify the mechanisms behind this spontaneous remission of seizures.

Changes in frequency of benign convulsions with mild gastroenteritis and their viral causes before and during the COVID-19 pandemic: a single-center study

BACKGROUND

Benign convulsions with mild gastroenteritis (CwG) are prevalent in young children during the winter. Early in the coronavirus disease 2019 (COVID-19) pandemic, viral gastroenteritis occurrence decreased and seasonal variation was lost, which can change CwG.

PURPOSE

Here we investigated changes in frequency, seasonal variation, and causative viruses of CwG during the COVID-19 pandemic.

METHODS

We screened 1134 patients (3-36 months) with "other and unspecified convulsions" treated at Chonnam National University Hospital between March 2017 and February 2023; of them, we enrolled 41 (3.6%) with CwG. We compared their medical records from period I (March 2017 to February 2020) to those from period II (March 2020 to February 2023). Publicly available viral gastroenteritis surveillance data from the Korea Disease Control and Prevention Agency (KDCA) were reviewed as reference.

RESULTS

Of the 41 patients with CwG, 18 (2.9% of 613) were affected in period I versus 23 (4.4% of 512) in period II (P=0.184). In period I, CwG mainly occurred in winter and spring (55.6% and 22.2%, respectively). In period II, there were fewer CwG cases (39.1%) in winter and more cases in summer and autumn (26.1% and 17.4%, respectively): the cases of norovirus genogroup II (GII)-associated CwG increased significantly in the summer (38.5% vs. 0%, P= 0.046). Norovirus GII was the most common virus (56.1% of isolates). Enteric adenovirus was the second most common (19.5%), with one case in period I and 7 cases in period II (P=0.059). The clinical characteristics of enteric adenovirus-associated CwG were similar to those of norovirus. Seasonal changes in and viral causes of CwG were consistent with those observed in the KDCA stool surveillance data.

CONCLUSION

During the COVID-19 pandemic, CwG frequency did not change, seasonal variation was unapparent, and enteric adenovirus-associated CwG frequency increased.

Norovirus-associated neurological manifestations: summarizing the evidence

Norovirus, a positive-stranded RNA virus, is one of the leading causes of acute gastroenteritis among all age groups worldwide. The neurological manifestations of norovirus are underrecognized, but several wide-spectrum neurological manifestations have been reported among infected individuals in the last few years. Our objective was to summarize the features of norovirus-associated neurological disorders based on the available literature. We used the existing PRISMA consensus statement. Data were collected from PubMed, EMBASE, Web of Science, and Scopus databases up to Jan 30, 2023, using pre-specified searching strategies. Twenty-one articles were selected for the qualitative synthesis. Among these, seven hundred and seventy-four patients with norovirus-associated neurological manifestations were reported. Most cases were seizure episodes, infection-induced encephalopathy, and immune-driven disorders. However, only a few studies have addressed the pathogenesis of norovirus-related neurological complications. The pathogenesis of these manifestations may be mediated by either neurotropism or aberrant immune-mediated injury, or both, depending on the affected system. Our review could help clinicians to recognize these neurological manifestations better and earlier while deepening the understanding of the pathogenesis of this viral infection.

Febrile seizures and convulsions with mild gastroenteritis: age-dependent acute symptomatic seizures

BACKGROUND

Febrile seizures (FS) and benign convulsions in children with mild gastroenteritis (CwG) are acute symptomatic seizures, transiently occurring in infants and young children, probably related to the immaturity of the brain. Our paper aims to review the literature data on patients with FS and CwG.

METHODS

A review of series of patients with FS and CwG was performed by literature search on PubMed January 1960 to October 2022. Several parameters were considered, including epidemiology, pathophysiology, clinical features, electroencephalographic findings and other diagnostic studies, and treatment.

RESULTS

FS and CwG share an age-dependent course, but they show significant differences in the pathophysiology, clinical features, diagnostic studies, and treatment.

CONCLUSION

Acute symptomatic seizures include seizures that are caused by acute structural brain pathologies, such as stroke, as well as seizures that are provoked by a reversible factor, such as hyponatraemia, although the two groups should be not equated. Furthermore, FS and CwG should be set apart as "age-dependent acute symptomatic seizures", reinforcing the concept of their self-limited course over a certain period.

Laboratory Findings of Benign Convulsions With Mild Gastroenteritis: A Meta-Analysis

Investigating factors associated with benign convulsions with mild gastroenteritis (CwG) is important for early detection and treatment. In previous studies, uric acid (UA) has been reported to be associated with CwG. However, the association between CwG and abnormal laboratory values remains inconclusive. We performed a meta-analysis of recent reports to determine the association between CwG and laboratory findings, including UA, in patients with acute gastroenteritis without convulsions. We conducted electronic searches of three databases (PubMed, EMBASE, and Cochrane Library) and one scholarly search engine (Google Scholar (Google, Inc., Mountain View, CA, USA)) up to February 2023 for studies on CwG. Eligible studies were observational studies that assessed patients with CwG, reported laboratory data, and stated the presence or absence of convulsions during illness episodes. Patients were children with mild gastroenteritis, with the exposure group developing convulsions and the control group not. The outcome was a comparison of laboratory data between the two groups. The effect size was calculated using the standardized mean difference (SMD), and random-effects models were used for the analysis because of high heterogeneity. In total, 148 articles were included in this study. After the screening, nine studies, including 8,367 patients, were selected for the meta-analysis. The most prevalent laboratory finding was an increased serum UA level, with an SMD of 1.42 (N = 6,411; 95% confidence interval (CI): (1.12, 1.72); Z = 9.242, p< 0.001; I ² = 81.68%, p= 0.002). The optimal serum UA cutoff value was 7.21 mg/dL, with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.827 (95% CI: (0.807, 0.846)). This meta-analysis suggests that CwG is strongly associated with increased serum UA levels. These results demonstrate that more attention should be paid when interpreting laboratory findings in pediatric patients with acute gastroenteritis.

Seasonal Trends in the Prevalence and Incidence of Viral Encephalitis in Korea (2015-2019)

Viral infections are a common cause of encephalitis. This study investigated the relationship between the incidence of encephalitis and that of respiratory and enteric viral infections in all age groups from 2015 to 2019, using the Health Insurance Review and Assessment (HIRA) Open Access Big Data Platform. We identified monthly incidence patterns and seasonal trends using the autoregressive integrated moving average (ARIMA). The Granger causality test was used to analyze correlations between encephalitis incidence and the positive detection rate (PDR) at 1-month intervals. A total of 42,775 patients were diagnosed with encephalitis during the study period. The incidence of encephalitis was highest in the winter (26.8%). The PDRs for respiratory syncytial virus (HRSV) and coronavirus (HCoV) were associated with the trend in encephalitis diagnosis in all age groups, with a 1-month lag period. In addition, an association with norovirus was observed in patients aged over 20 years, and with influenza virus (IFV) in patients aged over 60 years. This study found that HRSV, HCoV, IFV, and norovirus tended to precede encephalitis by 1 month. Further research is required to confirm the association between these viruses and encephalitis.

Efficacy and safety of phenobarbital for benign convulsions with mild gastroenteritis: A prospective randomized controlled study

BACKGROUND

previous studies have shown that phenobarbital (PB) is a effective and safe drug in the treatment of benign convulsions with mild gastroenteritis (CwG), but there is a lack of large sample prospective randomized controlled study of different doses. This study was a prospective randomized controlled study on the efficacy and safety of different doses of phenobarbital for CwG. There has been no similar study.

METHODS

One hundred twenty CwG cases were included in this study. All of them were hospitalized in the Department of Neurology of Jiangxi Provincial Children's Hospital from January 2019 to August 2021. They were randomly divided into 10 mg/kg single dose group (Group A, n = 60) and 5 mg/kg single dose group (Group B, n = 60). The criteria for judging the efficacy of PB in our study were there was no convulsion in the course of acute gastroenteritis within 2 weeks after using PB.

RESULTS

The effective rate was 93.33% in group A and 80.00% in group B. There was significant difference between the 2 groups (P < .05). Drowsiness was the most frequent adverse reaction. 14 cases in group A and 7 cases in group B had drowsiness. There was no significant difference between the 2 groups in the incidence of adverse events such as somnolence, ataxia, abnormal liver function, anemia, abnormal leukocyte, respiratory depression, cognitive impairment, rash, abnormal platelet and abnormal renal function (P > .05). All side reaction were transient.

CONCLUSION

it is suggested that PB 10 mg/kg intravenously should be used as soon as possible for CwG, which has high effectiveness and safety.

Update on benign convulsions with mild gastroenteritis

Benign convulsions with mild gastroenteritis (CwG) are characterized by afebrile convulsions associated with viral gastroenteritis in previously healthy infants and children. The main causative pathogens are rotavirus and norovirus. CwG occurs frequently in both East Asian and Western countries. The prevalence of CwG was reportedly not decreased by the introduction of rotavirus vaccines, and the prevalence of norovirus-associated CwG has been increasing annually. Convulsions in CwG are usually clustered, do not last longer than 5 minutes, and are mostly generalized. Laboratory diagnostics, electroencephalography (EEG), and imaging findings are usually normal. There is a probability of mild, transient abnormal findings on EEG or imaging limited to the acute disease phase. Although several reports have suggested that pathogens that affect the central nervous system through direct or indirect mechanisms could be related to the pathophysiology of CwG, its mechanism is not fully understood. Several antiepileptic drugs are effective during convulsions; however, long-term antiepileptic treatment is not required as CwG usually has a good prognosis.

Global molecular prevalence and genotype distribution of Sapovirus in children with gastrointestinal complications: A systematic review and meta-analysis

Sapovirus (SaV) is an emerging cause of children gastrointestinal complications such as acute gastroenteritis (AGE). The aim of the present systematic review and meta-analysis was to estimate the global prevalence of the SaV in children and association of infection with SaVs and AGE in children based on case-control studies. Four international databases (PubMed, Scopus, Web of Sciences and Google Scholar) were used to retrieve English-language studies published between January 2000 and December 2020. Comprehensive Meta-Analysis software was applied to estimate the overall prevalence, publication bias and heterogeneity index. The pooled prevalence of SaV infection among children with gastroenteritis was 3.4% [95% confidence interval (CI): 2.9%-3.9%] based on a random-effects meta-analysis. Genogroup I was the dominant genogroup of SaV in children with gastroenteritis [2.2% (95% CI: 1.6%-3.0%)], association analysis showed that SaV was associated with gastroenteritis [OR: 1.843 (95% CI: 1.27-2.66)]. Given the significant prevalence of the virus in children, it is necessary to pay more attention to this situation. Therefore, preventive health measures in children should be a priority.

Norovirus Causes Pediatric Encephalopathy and Status Epilepticus: A Case Report and Review of the Literature

Norovirus is a common cause of acute gastroenteritis outbreaks worldwide. The disease can present with varying degrees of neurologic impairment from benign convulsions to rare cases of severe encephalopathy. In this article, we described a case report of a North American infant who presented with norovirus gastroenteritis, status epilepticus, severe encephalopathy, and abnormal but reversible diffusion restriction changes on magnetic resonance imaging of brain.

Epidemiology of Rotavirus Gastroenteritis and Rotavirus-Associated Benign Convulsions with Mild Gastroenteritis after the Introduction of Rotavirus Vaccines in South Korea: Nationwide Data from the Health Insurance Review and Assessment Service

Using nationwide data from the Health Insurance Review and Assessment service, we assessed the impact of rotavirus vaccines, introduced in South Korea, in 2007, on changes in the prevalence of factors (age, sex, and geographic location) associated with rotavirus gastroenteritis (RVGE) and rotavirus-associated benign convulsions with mild gastroenteritis (RaCwG). We analyzed health records of children younger than 3 years who visited clinical facilities and were diagnosed with RVGE or RaCwG between 2007 and 2019. The annual mid-year population (MYP) was obtained from the Korean Statistical Information Service. The annual prevalence of RVGE, RaCwG and associated factors were statistically analyzed. Overall, 219,686, and 4032, children were confirmed to have RVGE and RaCwG, respectively. Although the annual prevalence of RVGE decreased significantly, that of RaCwG did not. The annual ratio of RaCwG to RVGE was significantly high. Compared to the prevalence of RVGE, the prevalence of RaCwG was significantly lower in rural areas. The age of RaCwG patients was significantly lower than that of the MYP and that of RVGE patients. The decrease in the number of RaCwG patients after rotavirus vaccination was not as pronounced as the decrease in the number of RVGE patients.

Older Patients May Have More Frequent Seizures among Children Diagnosed as Benign Convulsions with Mild Gastroenteritis

PURPOSE

Benign convulsions with mild gastroenteritis (CwG) is a condition that does not usually require treatment. However, when the patient experiences multiple seizures or prolonged seizures, anticonvulsant treatment may be required. We investigated this study to identify the factors that may influence on the number or duration of seizures at CwG.

METHODS

We retrospectively analyzed the medical records of CwG patients who were admitted to the Department of Pediatrics at Sanggye Paik Hospital.

RESULTS

A total of 105 children with CwG were enrolled. The mean age was 19.59 ± 7.09 months. The mean duration of seizure was 2.79 ± 5.51 minutes and mean number of seizure was 2.33 ± 1.70. Sixty-nine children had seizures less than twice, whereas 36 experienced three times or more. These groups differed significantly according to age in CwG (18.16 ± 7.08, vs. 22.33 ± 6.34 months, p < 0.05). When patients were divided into two groups based on age in CwG using a cut-off of 20 months, we found significant differences in seizure number (1.91 ± 1.27 vs. 3.11 ± 2.10, p < 0.05). There was also a positive correlation between patient age and frequency of seizures (R = 0.316, p = 0.001). Patients who received anticonvulsants were older (17.60 ± 6.87 vs. 22.04 ± 6.63 months, p < 0.05) and had more frequent (1.59 ± 1.37 vs. 3.26 ± 1.63, p < 0.05) and longer seizures (1.76 ± 2.75 vs. 4.07 ± 7.49 minutes, p < 0.05).

CONCLUSION

As the number of seizure in CwG was associated with age, treatment in older children may be required in acute stage.

Pathogen-specific risk of seizure in children with moderate-to-severe diarrhoea: Case control study with follow-up

OBJECTIVE

To determine the pathogen-specific risk of seizure in under-five children hospitalised with moderate-to-severe diarrhoea (MSD) in rural settings.

METHOD

This was a prospective case-control study with follow-up, conducted in a sentinel facility of Global Enteric Multicenter Study in Mirzapur, a rural community of Bangladesh between 2007 and 2010. Children aged 0-59 months who presented with MSD and seizure constituted the cases whereas those who did not have seizure comprised the controls. MSD was defined if the episodes were associated with dehydration or dysentery or required hospitalisation with diarrhoea or dysentery. All enrolled children were followed up at home within 50-90 days of enrolment. A total of 64 cases and 128 randomly selected controls formed the analysable dataset.

RESULTS

The result of logistic regression analysis after adjusting for potential confounders revealed that shigellosis (Shigella species, OR = 5.34, 95% CI = 2.37-12.04) particularly S. flexneri (OR = 3.34, 95% CI = 1.48-7.57), S. flexneri 6 (OR = 23.24, 95% CI = 2.79-193.85), S. sonnei (OR = 6.90, 95% CI = 2.34-19.85); norovirus (OR = 6.77, 95% CI = 1.69-27.11), fever (OR = 16.75, 95% CI = 1.81-154.70) and loss of consciousness (OR = 35.25, 95% CI = 1.71-726.20) were the independent risk factors for seizure in MSD children. At enrolment, cases had lower WHZ (P = 0.006) compared to their peers, follow-up anthropometrics showed significant improvement in WHZ (P < 0.001) and WAZ (P < 0.05), whereas deterioration in HAZ (P < 0.001) in both cases and controls.

CONCLUSION

Childhood MSD episodes particularly due to Shigella and norovirus are often associated with seizure. Prompt identification and appropriate management of children with shigellosis may reduce occurrence and adverse consequences of seizure linked with MSD.

Comparison of Clinical Characteristics Between Febrile and Afebrile Seizures Associated With Acute Gastroenteritis in Childhood

Background: Acute gastroenteritis (AGE) accompanied by seizures is not a rare scenario in childhood. We investigated the clinical features of children with febrile or afebrile seizures during AGE and aimed to identify the impact of fever in this situation-related seizure. Methods: We retrospectively reviewed the medical charts of children admitted due to seizures associated with mild AGE between January 2008 and December 2017. These consecutive patients were divided into two groups: an "afebrile group" whose diagnosis was compatible with "benign convulsion with mild gastroenteritis (CwG)" and a "febrile group" who had a fever within 24 h of the onset of an AGE-related seizure. We compared the two groups' clinical and laboratory characteristics, electroencephalograms (EEG), neuroimaging, and outcomes. Results: Of the children suffering from AGE and seizures, 41 were afebrile and 30 were febrile, with a mean age of 32.2 ± 27.6 months. The gender, seizure semiology, frequency, duration of seizures, the time interval between AGE symptoms onset and first seizure, and levels of serum sodium, and hepatic enzymes were significantly different between the two groups. The most frequently identified enteropathogen was rotavirus (33%), especially in the male and febrile subjects. Afebrile patients had more EEG abnormalities initially, but all returned to normal later. All cases had an uneventful outcome. Of note, seizure clusters (≥2 episodes) occurred more frequently in the afebrile patients who had a duration of AGE symptoms lasting 2 days or more, or white blood cell counts ≥ 10,000/μL (p-values: 0.05 and 0.04, respectively). In comparison with seven similar studies, all showed more seizure clusters, partial seizures, and a shorter interval between AGE onset and seizures in afebrile patients than in febrile patients. Contrarily, afebrile patients had longer seizure duration and lower serum hepatic transaminases than febrile patients. Conclusion: Although fever partially influenced the clinical features of AGE-related seizures, febrile CwG might have pathophysiology distinctly different from that of febrile seizures. Comprehensive knowledge in discerning febrile and afebrile CwG can help to avoid unnecessary diagnostics tests, and anticonvulsants use.

Does norovirus induce acute hepatitis?

Background

Norovirus is the commonest cause of acute viral gastroenteritis with significant morbidity. Extra intestinal manifestation following norovirus infection is rare and the mechanism is unknown.

Methods

We undertook a review of the English literature published from January 1967 to April 2019 to evaluate the risk of acute viral hepatitis due to norovirus gastroenteritis. Data sources included MEDLINE, EMBASE, Cochrane library, and references within identified articles.

Results

We identified 126 potential studies and included 5 publications involving 17 cases of norovirus induced hepatitis, and all had elevated ALT (31.7–458IU/l) and AST levels (45.6–1150IU/l). Majority of the cases were below the age of 18 (88%, n = 15) and almost two-third (64.7%, n = 11) had supportive treatment, mainly intravenous fluid administration. In cases reporting sex, there were more females than males (62.5%, 5/8 vs. 37.5%, 3/8). The duration of illness was longer, on average 10 days, compared to 3 days in those without elevated transaminitis and it took an average of 22.5 days for liver enzymes to settle. All patients recovered fully with no progression to chronic liver disease.

Conclusion

Norovirus gastroenteritis is a self-limiting illness with majority not requiring hospitalisation and invasive investigations. We recommend that clinicians should be aware of norovirus induced transaminitis, and to suspect this especially in children who are likely to have protracted illness and require hospitalisation due to norovirus acute hepatitis.

Elevated Serum Uric Acid in Benign Convulsions with Mild Gastroenteritis in Children

Background and Purpose

To identify whether serum uric acid levels are significantly higher in patients with benign convulsion associated with mild gastroenteritis (CwG) than in patients with acute gastroenteritis.

Methods

This retrospective study compared the serum levels of uric acid between CwG, acute gastroenteritis, and febrile seizure after correcting for the varying degree of mild dehydration using serum HCO₃⁻ levels. We also compared the serum uric acid levels between patients with CwG and febrile seizures in order to exclude the effect of seizures on uric acid.

Results

This study included 154 CwG patients (age range 0.73–3.19 years), 2,938 patients with acute gastroenteritis, and 154 patients with febrile seizure. The serum uric acid level was significantly higher in CwG patients than in patients with acute gastroenteritis [9.79±2.16 mg/dL vs. 6.04±2.3 mg/dL (mean±SD), p<0.001]. This difference was also significant after correcting for dehydration. The serum uric acid level was significantly higher in CwG patients than in dehydration-corrected acute gastroenteritis patients (9.79±2.16 mg/dL vs. 6.67±2.48 mg/dL, p<0.001). The serum uric acid level was not elevated in patients with febrile seizure.

Conclusions

We have confirmed that serum uric acid is elevated in CwG patients even after correcting for their dehydration status, and that this was not a postictal phenomenon. Highly elevated serum uric acid in CwG could be a useful clinical indicator of CwG in patients with acute gastroenteritis.

Efficacy of phenobarbital for benign convulsions with mild gastroenteritis: A randomized, placebo-controlled trial

OBJECTIVE

This study was performed to evaluate the efficacy and safety of intravenous phenobarbital (PB) for benign convulsions with mild gastroenteritis (CwG).

METHODS

A randomized, single-blind, placebo-controlled trial involving patients with CwG was conducted at the Japanese Red Cross Society Himeji Hospital. Patients with CwG who had experienced two or more seizures were eligible. Patients were excluded if any anticonvulsant was used before enrollment. Patients who were allocated to the PB group were administered 10 mg/kg of PB intravenously. Patients who were allocated to the placebo group were administered 20 ml of normal saline.

RESULTS

From April 2016 to October 2018, 13 of 24 patients with CwG were randomized (PB group, n = 7; placebo group, n = 6; age, 1-3 years). Five of six patients in the placebo group had seizures after administration of placebo. However, patients in the PB group had no seizures after administration of PB, with a significant difference in efficacy between the two groups (P = 0.005). Five patients who had seizures after administration of normal saline were administered 10 mg/kg of PB, and no patients had a seizure thereafter. No significant differences were found in heart rate, blood pressure, or saturation of percutaneous oxygen between the two groups.

CONCLUSION

This is the first randomized controlled trial to evaluate the efficacy of an anticonvulsant for CwG. Intravenous PB at 10 mg/kg is effective and well tolerated for CwG.

Clinical features of campylobacter-associated benign convulsions with mild gastroenteritis compared with rotavirus convulsions

PURPOSE

The aim of the present study was to compare the clinical features of campylobacter-associated benign convulsions with mild gastroenteritis (BCWG) with rotavirus-associated BCWG in China.

METHODS

The medical records of BCWG patients admitted to Children's Hospital of Jiangxi Province in China between January 2015 and January 2017 were reviewed in this retrospective study.

RESULTS

Ultimately, 318 patients were diagnosed with BCWG. Two hundred and two cases were tested for Campylobacter jejuni antigen, and seven (3.47%) were positive. A total of 248 cases were tested for rotavirus antigen, and 44 (17.74%) were positive. Campylobacter-associated BCWG occurred in summer and autumn. In contrast, rotavirus-associated BCWG mainly occurred in winter. In the campylobacter-associated BCWG group, five patients (71.43%) had two or more seizures. In one patient(14.29%), the seizure occurred on the first day of gastroenteritis; three patients (42.86%) had seizures on the second day, and three (42.86%) had seizures on the third day or later. Thirteen seizures were observed in the campylobacter-associated BCWG group; of these, 11 (84.62%) lasted less than 5 min, and 11 (84.62%) were generalized seizures. Phenobarbital (5 mg/kg/time) was effective in all 6 cases (100%) in which it was used. Other than the different seasonal distributions, the clinical features of campylobacter-associated BCWG and rotavirus-associated BCWG may be similar.

CONCLUSIONS

Campylobacter is one of the pathogens responsible for BCWG, especially in summer and autumn. Other than the different seasonal distributions, the clinical features of campylobacter-associated BCWG and rotavirus-associated BCWG may be similar.

A nationwide survey of norovirus-associated encephalitis/encephalopathy in Japan

BACKGROUND

Norovirus is a major pathogen of gastroenteritis and is known to cause encephalitis/encephalopathy. The aim of this national survey was to clarify the clinical features of norovirus-associated encephalitis/encephalopathy (NoVE) among children in Japan.

METHODS

A nationwide survey of children with NoVE was conducted using a structured research form. The initial survey asked pediatricians about children with NoVE treated between January 2011 and March 2016. The second survey obtained patient information from two sources: hospitals that responded to the initial survey and those identified as having treated cases from a literature search.

RESULTS

Clinical information was available for 29 children. Their median age was 2 y 8 m. The outcome was good in 13 patients and poor in 15. The interval between the onset of gastrointestinal symptoms and that of encephalitis/encephalopathy was significantly shorter in those with a poor outcome. At the onset of an elevated serum creatinine level and an abnormal blood glucose level were correlated with a poor outcome. Regarding the subtypes of encephalitis/encephalopathy, acute encephalopathy with biphasic seizures and late reduced diffusion and hemorrhagic shock and encephalopathy syndrome were frequent.

CONCLUSION

The outcome of children with NoVE was poor. Early onset of neurological symptoms, an elevated serum creatinine level, and an abnormal blood glucose level were associated with a poor outcome. No effective treatment was identified and this should be the subject of future studies.

Reversible splenial lesion syndrome in children with benign convulsions associated with mild gastroenteritis: A retrospective study of five cases

OBJECTIVE

To assess the clinical and imaging features of reversible splenial lesion syndrome (RESLES) with benign convulsions associated with mild gastroenteritis (CwG) in children.

PATIENTS AND METHODS

We retrospectively reviewed the clinical course, blood and stool examinations, cerebrospinal fluid (CSF) examination, magnetic resonance imaging (MRI), electroencephalography (EEG) findings, therapy and prognosis of five children with RESLES associated with CwG.

RESULTS

Five previously healthy patients, four girls and one boy, with mean age 26.4 ± 8.1 months, had clusters of general tonic-clonic or clonic seizures within the first two days of gastroenteritis. Rotavirus antigen was positive in the stool of one case. Interictal EEG was normal except in one case, which showed occipital slow wave. The initial MRI was performed within five days of onset, four patients had an isolated lesion in the splenium of the corpus callosum (SCC), and one patient had lesions extending outside the SCC that involved the genu of the corpus callosum. The follow-up MRI was performed 10-15 days after onset, and all lesions had completely disappeared. All patients were treated with antiviral, rehydration and anticonvulsant therapy in the acute phase. They had good prognosis and normal psychomotor development, with no neurological sequelae after 26-30 months of follow-up.

CONCLUSIONS

CwG and RESLES can coexist in young children. The patients present with clusters of general tonic-clonic or clonic seizures in the acute phase. Brain MRI shows focal lesion in the SCC with high signal intensity on T2-weighted and FLAIR sequences. It has good prognosis and excessive treatment is not necessary.

Clinical characteristics and follow-up of benign convulsions with mild gastroenteritis among children

Benign convulsions with mild gastroenteritis have a high incidence in the North China, previous reports it has been caused by rotavirus infection, which is a non-febrile convulsion. In recent years, we observed that norovirus infection gradually increased all the years round and most of them are febrile convulsion.Retrospective analysis was performed on 55 pediatric patients with benign convulsions with mild gastroenteritis (CWG) who were admitted between January 2010 and January 2015.The median age of the norovirus infection group was greater than that of the rotavirus infection group. Norovirus infection has no obvious seasonality. The peak age of benign CWG onset was less than 3 years (74.5%). In 69.1% of all cases, the temperature was less than 38 °C. In 70.9% of cases, children had experienced more than 2 episodes. In 96.4% of all cases, convulsive episodes were shorter than 5 min. Convulsions mostly occurred within the first 2 days (78.2%) after gastroenteritis tract symptoms. Most episodes featured generalized tonic-clonic seizure (87.3%). Serum Na+ levels were lower while other biochemical test results were normal. Follow-up 2 years attack again (16.8%), intelligence quotient was not reduced.CWG febrile or afebrile occurs most frequently among young children. In addition to the rotavirus, the norovirus might also cause this syndrome. The prognosis is favorable and long-term anti-seizure treatment is considered to be unnecessary.

Acetaminophen and Febrile Seizure Recurrences During the Same Fever Episode

OBJECTIVES

To confirm the safety of using acetaminophen for febrile seizures (FSs) and to assess its efficacy in preventing FS recurrence during the same fever episode.

METHODS

In this single-center, prospective, open, randomized controlled study, we included children and infants (age range: 6-60 months) with FSs who visited our hospital between May 1, 2015, and April 30, 2017. The effectiveness of acetaminophen was examined by comparing the recurrence rates of patients in whom rectal acetaminophen (10 mg/kg) was administered every 6 hours until 24 hours after the first convulsion (if the fever remained >38.0°C) to the rates of patients in whom no antipyretics were administered. No placebo was administered to controls. The primary outcome measure was FS recurrence during the same fever episode.

RESULTS

We evaluated 423 patients; of these, 219 were in the rectal acetaminophen group, and 204 were in the no antipyretics group. In the univariate analysis, the FS recurrence rate was significantly lower in the rectal acetaminophen group (9.1%) than in the no antipyretics group (23.5%; P < .001). Among the variables in the final multiple logistic regression analysis, rectal acetaminophen use was the largest contributor to the prevention of FS recurrence during the same fever episode (odds ratio: 5.6; 95% confidence interval: 2.3-13.3).

CONCLUSIONS

Acetaminophen is a safe antipyretic against FSs and has the potential to prevent FS recurrence during the same fever episode.

Incidence and characteristics of norovirus-associated benign convulsions with mild gastroenteritis, in comparison with rotavirus ones

BACKGROUND AND PURPOSE

Rotavirus was detected in 40-50% of patients with benign convulsions with mild gastroenteritis (CwG) before the rotavirus vaccine was introduced in late 2000. However, the rate of rotavirus positivity has decreased since 2010 while the prevalence of norovirus has gradually increased. We investigated the incidence of norovirus-associated CwG during a recent 3-year period and additionally compared the characteristics of norovirus-associated CwG with those of rotavirus-associated CwG.

METHODS

The medical records of CwG patients admitted to our hospital between March 2014 and February 2017 were reviewed, including the results of stool virus tests. For comparing norovirus- and rotavirus-associated CwG, data obtained between March 2005 and February 2014 that included sufficient numbers of patients with rotavirus-associated CwG were additionally reviewed. Data were collected on clinical characteristics (age, sex, seasonal distribution, enteric symptoms, and the interval to seizure onset), seizure characteristics (frequency, duration, type, and electroencephalographic findings), and laboratory findings.

RESULTS

CwG was diagnosed in 42 patients during the 3-year study period. Stool viruses were checked in 40 (95.2%) patients and were detected in 32 (80.0%) patients. Norovirus genogroup II was detected in 27 (67.5%) of the 40 patients, rotavirus was detected in 3 patients, and adenovirus was detected in 2 patients. In total, 140 CwG patients were enrolled between March 2005 and February 2017. The patients with norovirus-associated CwG (N = 44) and rotavirus-associated CwG (N = 26) were aged 18.66 ± 5.57 and 19.31 ± 7.37 months (mean ± standard deviation), respectively (P > 0.05). Norovirus-associated CwG was less prevalent than rotavirus-associated CwG during spring (13.6% vs. 34.6%, P = 0.04), while the prevalence of both types of CwG peaked during winter (63.6% and 46.2%, respectively). Vomiting was more prevalent in norovirus- than rotavirus-associated CwG (97.7% vs. 80.8%, P = 0.02) and the interval between enteric symptom onset and seizure onset was shorter in norovirus-associated CwG (2.00 ± 1.06 vs. 2.58 ± 1.21 days, P = 0.04). Most cases in both groups had seizures that lasted for less than 5 min (95.5% vs. 92.3%). Clustered seizures seemed to occur more frequently in the norovirus group (79.5% vs. 57.7%), although with borderline significance (P = 0.05). Posterior slowing was observed more frequently in norovirus-associated CwG (34.9% vs. 11.5%, P = 0.03).

CONCLUSION

The most common viral pathogen of CwG was norovirus during the analyzed 3-year period, with an incidence of 67.5%. In comparison with rotavirus-associated CwG, norovirus-associated CwG was less frequent during spring, more frequently seen with vomiting, had a shorter interval from enteric symptom onset to seizure onset, and more frequently showed posterior slowing in electroencephalography.

Clinical outcome of recurrent afebrile seizures in children with benign convulsions associated with mild gastroenteritis

PURPOSE

To assess the clinical outcome and evolution of recurrent afebrile seizures in children initially diagnosed with benign convulsions associated with mild gastroenteritis (CwG).

METHODS

We reviewed and analyzed the medical records of 37 patients who were diagnosed as CwG at onset, followed by recurrent afebrile seizures and followed up for at least 24 months.

RESULTS

The follow-up period ranged from 2 to 7 years (median, 40.1 months).Three patterns of recurrent afebrile seizures were recorded: afebrile seizures associated with gastrointestinal infection (AS-GI, n = 25), afebrile seizures associated with non-gastrointestinal infection (AS-nGI, n = 9), and unprovoked seizures (US, n = 3). Twenty eight patients (75.7%) had a second episode within 6 months after the first seizures. Five cases (13.5%) suffered three episodes of afebrile seizures. Seizure characteristics of the three patterns were similar, manifesting as clustered seizures in the majority. Focal epileptic activities in interictal EEG were found in 3 cases (9.4%) at onset, 10 cases (28.6%) at the second episode, respectively. Six patients were prescribed anti-epileptic drugs with apparently good responses. During at least 2 years' follow-up, all the cases showed normal psychomotor development. Only one patient was diagnosed with epilepsy.

CONCLUSIONS

All the recurrent afebrile seizures initially diagnosed as CwG, irrespective of the kinds and frequency of relapses, showed favorable prognoses. CwG maybe falls within the category of situation-related seizures, rather than epilepsy.

Comparative Effectiveness of Levetiracetam vs Phenobarbital for Infantile Epilepsy

IMPORTANCE

More than half of infants with new-onset epilepsy have electroencephalographic and clinical features that do not conform to known electroclinical syndromes (ie, nonsyndromic epilepsy). Levetiracetam and phenobarbital are the most commonly prescribed medications for epilepsy in infants, but their comparative effectiveness is unknown.

OBJECTIVE

To compare the effectiveness of levetiracetam vs phenobarbital for nonsyndromic infantile epilepsy.

DESIGN, SETTING, AND PARTICIPANTS

The Early Life Epilepsy Study-a prospective, multicenter, observational cohort study conducted from March 1, 2012, to April 30, 2015, in 17 US medical centers-enrolled infants with nonsyndromic epilepsy and a first afebrile seizure between 1 month and 1 year of age.

EXPOSURES

Use of levetiracetam or phenobarbital as initial monotherapy within 1 year of the first seizure.

MAIN OUTCOMES AND MEASURES

The binary outcome was freedom from monotherapy failure at 6 months, defined as no second prescribed antiepileptic medication and freedom from seizures beginning within 3 months of initiation of treatment. Outcomes were adjusted for demographics, epilepsy characteristics, and neurologic history, as well as for observable selection bias using propensity score weighting and for within-center correlation using generalized estimating equations.

RESULTS

Of the 155 infants in the study (81 girls and 74 boys; median age, 4.7 months [interquartile range, 3.0-7.1 months]), those treated with levetiracetam (n = 117) were older at the time of the first seizure than those treated with phenobarbital (n = 38) (median age, 5.2 months [interquartile range, 3.5-8.2 months] vs 3.0 months [interquartile range, 2.0-4.4 months]; P < .001). There were no other significant bivariate differences. Infants treated with levetiracetam were free from monotherapy failure more often than those treated with phenobarbital (47 [40.2%] vs 6 [15.8%]; P = .01). The superiority of levetiracetam over phenobarbital persisted after adjusting for covariates, observable selection bias, and within-center correlation (odds ratio, 4.2; 95% CI, 1.1-16; number needed to treat, 3.5 [95% CI, 1.7-60]).

CONCLUSIONS AND RELEVANCE

Levetiracetam may have superior effectiveness compared with phenobarbital for initial monotherapy of nonsyndromic epilepsy in infants. If 100 infants who received phenobarbital were instead treated with levetiracetam, 44 would be free from monotherapy failure instead of 16 by the estimates in this study. Randomized clinical trials are necessary to confirm these findings.

Clinical characteristics and complications of rotavirus gastroenteritis in children in east London: A retrospective case-control study

Background

Rotavirus is the leading cause of acute gastroenteritis in children and is associated with neurological complications such as seizures and encephalopathy. The aim of this study was to investigate the presentation and complications of rotavirus compared to non-rotavirus gastroenteritis in UK children.

Methods

This was a retrospective, case-control, hospital-based study conducted at three sites in east London, UK. Cases were children aged 1 month to 16 years diagnosed with acute gastroenteritis between 1 June 2011 and 31 December 2013, in whom stool virology investigations confirmed presence of rotavirus by PCR. They were matched by age, gender and month of presentation to controls with rotavirus-negative gastroenteritis.

Results

Data were collected from 116 children (50 cases and 66 controls). Children with rotavirus gastroenteritis tended to present more frequently with metabolic acidosis (pH 7.30 vs 7.37, P = 0.011) and fever (74% versus 46%; P = 0.005) and were more likely to require hospitalisation compared to children with non-rotavirus gastroenteritis (93% versus 73%; P = 0.019). Neurological complications were the most common extra-intestinal manifestations, but did not differ significantly between children with rotavirus-positive gastroenteritis (RPG) and rotavirus-negative gastroenteritis (RNG) (24% versus 15%, respectively; P = 0.24). Encephalopathy occurred only in children with rotavirus infection (n = 3, 6%).

Conclusion

Rotavirus causes longer and more severe disease compared to other viral pathogens. Seizures and milder neurological signs were surprisingly common and associated with multiple pathogens, but encephalopathy occurred only in children with rotavirus gastroenteritis. Rotavirus vaccination may reduce seizures and presentation to hospital, but vaccines against other pathogens causing gastroenteritis are required.

Clinical Characteristics and Risk Factors for Seizures Associated With Norovirus Gastroenteritis in Childhood

Norovirus has become increasingly recognized as causing viral gastroenteritis in children. Few data are available on the characteristics of children admitted to pediatric emergency departments with norovirus gastroenteritis and accompanying seizures. Our aim in this study was to describe the clinical features of, and risk factors for, seizures accompanying norovirus gastroenteritis. We collected 6359 stool samples from patients with gastroenteritis, of whom 1444 (22.71%) had laboratory-confirmed norovirus gastroenteritis. Of all patients, 108 (7.48%) children exhibited norovirus gastroenteritis and seizures; 49 (45.4%) were febrile, and 59 (54.6%) afebrile. The mean patient age was 2.31 ± 2.12 years; most were <5 years of age (92.6%). The afebrile group had a significantly higher incidence of 2 or more seizures than the febrile subjects ( P = .004). Early recognition and prompt treatment of convulsions associated with norovirus gastroenteritis in children are important. Future studies might explore the long-term prognoses of these patients.

Clinical Epidemiology and Treatment of Febrile and Afebrile Convulsions With Mild Gastroenteritis: A Multicenter Study

BACKGROUND

We investigated features and responses to treatment in patients with febrile and afebrile convulsions with mild gastroenteritis and characterized convulsions with rotavirus and norovirus gastroenteritis.

METHODS

We conducted a prospective, observational study to evaluate patients with febrile and afebrile convulsions with mild gastroenteritis who were hospitalized between November 2011 and March 2014 at 13 facilities in the National Hospital Organization. We classified the patients into two groups: presence or absence of fever. We investigated the background, clinical and laboratory characteristics, viral antigen in stool, and efficacy of anticonvulsant drugs.

RESULTS

Of 126 patients enrolled in this study, 50 were febrile (Fc group) and 76 were afebrile (aFc group). A family history of febrile seizures was significantly more frequent in the Fc group than in the aFc group (28.0% vs 9.2%, P = 0.005). Clinical characteristics were similar between the rotavirus and norovirus groups, but fever was significantly more frequent in the rotavirus group (46.2% vs 8.3%, P < 0.001). Serum sodium levels were significantly negatively related to the number of seizures in the aFc group (β = -0.13; 95% confidence interval, -0.24, -0.03; P = 0.01). Carbamazepine was significantly more efficacious than diazepam suppositories in the aFc group (odds ratio = 49.3, 95% confidence interval, 2.35, 1037; P = 0.01).

CONCLUSION

Febrile convulsions with mild gastroenteritis show characteristics of both febrile seizures and convulsions with mild gastroenteritis. Carbamazepine is optimal for convulsions with mild gastroenteritis. Clinical features of convulsions with rotavirus and norovirus gastroenteritis are similar, except for fever. Serum sodium levels may play a major role in the onset of convulsions with mild gastroenteritis.

Norovirus in benign convulsions with mild gastroenteritis

BACKGROUND

Benign convulsions with gastroenteritis (CwG) are defined as afebrile convulsions accompanying symptoms of gastroenteritis without evidence of laboratory derangement. Although the main pathogen has been known as rotavirus, since the introduction of rotavirus vaccine, associated viruses with CwG may have changed. Thus, we evaluated the viral association of CwG for patients admitting for recent 2.5 years.

METHODS

All patients hospitalized for CwG between November 2012 and May 2015 were included in our study. Stool specimens were tested with reverse transcription polymerase chain reaction for detecting norovirus and astrovirus and with enzyme immunoassay for rotavirus and enteric adenovirus. Clinical data was gathered via chart review.

RESULTS

Fifty patients were included. Except four patients who failed to collect stool samples, 46 patients were tested. Causative diarrheal viruses were detected in 38 patients and they were 29 norovirus, four rotavirus, four adenovirus, and one astrovirus. Norovirus was commonly identified during the months of November and December. No difference of the clinical characteristics and laboratory value was noted according to the number of seizure episodes.

CONCLUSIONS

Norovirus is a common pathogen in CwG. Understanding the viral associations can facilitate recognition of CwG.

Complicated norovirus infection and assessment of severity by a modified Vesikari disease score system in hospitalized children

Background

Norovirus (NoV) GII.4 is the most common genotype for norovirus gastroenteritis worldwide. New variants or subgenotypes are continuously emerging, thus posing a serious threat to child health.

Methods

We compared retrospectively the clinical manifestations and complications of norovirus gastroenteritis in children from April, 2004 through December, 2012. NoV variants were analyzed to investigate the association of circulating viral strains with the complications. A modified disease severity score system based on Vesikari score system was devised and to evaluate disease severity.

Results

Compared to the outbreak in 2004/2005 winter, significant higher incidence of complications in the later periods are: convulsive disorder (p < 0.001) in 2006/2007 winter gastrointestinal hemorrhage (p = 0.047) and severe abdominal pain or irritability (p = 0.033) in 2008/09/10 winter; gastrointestinal hemorrhage (p = 0.030), severe abdominal pain or irritability (p = 0.014), and prominent hyperthermia (fever >39 °C, p = 0.001) in 2011/2012 winter. GII.4 Den_Haag_2006b, GII.4 2010, GII.4 Sydney 2012, and GII.4 2012b were the predominant strains in the outbreaks after 2006. By the modified severity score system, severe norovirus disease occurred in 28.5 %, 32 %, 33.3 %, and 30.2 % of the patients in the four periods. A longer duration of hospitalization (p = 0.02) were found in those with high score irrespective of the year of admission.

Conclusions

Our study demonstrated NoV outbreaks in northern Taiwan caused by different GII.4 variants that were associated with specific complications and uncommon clinical presentations. A modified severity score system first proposed in this study was able to identify severe cases with a longer hospital stay in NoV-infected children.

Benign convulsions in children with mild gastroenteritis

BACKGROUND

Benign convulsions with mild gastroenteritis (CwG) is a clinical condition characterized by convulsions occurring in otherwise healthy children, usually in the absence of fever and in the presence of mild acute gastroenteritis. Until now, CwG had not been fully recognized as an epileptic syndrome, and several aspects of this condition are not clearly defined, especially its pathogenesis.

METHODS

The main aim of this paper is to discuss after the review of the literature what is known about CwG to facilitate its recognition and treatment.

RESULTS

CwG is a benign condition that has several clinical and prognostic similarities with febrile seizures. The disease occurs in infants and in children who are 1 month to 3 years old, during the winter and early spring when rotavirus and norovirus are circulating. In most cases, seizures follow gastrointestinal symptoms. In a minority of patients, the seizures and gastrointestinal symptoms occur before or simultaneously with the development of diarrhoea. Even if convulsions are mostly described as generalized tonic-clonic, the ictal recordings have always demonstrated a focal origin. Electroencephalography, lumbar punctures, and radiological examinations are not useful because they are normal in these patients; and when alterations are present, they disappear in a relatively short time. Only prolonged seizures, which are usually not common, require antiepileptic treatments in the acute phase.

CONCLUSION

Knowledge of CwG characteristics is essential for paediatricians to avoid useless hospitalization, examinations and, above all, drug administration, as the drugs have potential side effects.

Oral Norovirus Infection Is Blocked in Mice Lacking Peyer's Patches and Mature M Cells

A critical early step in murine norovirus (MNV) pathogenesis is crossing the intestinal epithelial barrier to reach the target cells for replication, i.e., macrophages, dendritic cells, and B cells. Our previous work showed that MNV replication decreases in the intestines of mice conditionally depleted of microfold (M) cells. To define the importance of Peyer's patch (PP) M cells during MNV pathogenesis, we used a model of BALB/c mice deficient in recombination-activating gene 2 (Rag2) and the common gamma chain (γc) (Rag-γc(-/-)), which lack gut-associated lymphoid tissues (GALT), such as Peyer's patches, and mature GP2(+) M cells. Rag-γc(-/-) mice were infected intraperitoneally or perorally with MNV-1 or CR3 for 24 or 72 h. Although the intestinal laminae propriae of Rag-γc(-/-) mice have a higher frequency of certain MNV target cells (dendritic cells and macrophages) than those of wild-type mice and lack others (B cells), Rag-γc(-/-) and wild-type BALB/c mice showed relatively similar viral loads in the intestine following infection by the intraperitoneal route, which provides direct access to target cells. However, Rag-γc(-/-) mice were not productively infected with MNV by the oral route, in which virions must cross the intestinal epithelial barrier. These data are consistent with a model whereby PP M cells are the primary route by which MNV crosses the intestinal epithelia of BALB/c mice.

IMPORTANCE

Noroviruses (NoVs) are prevalent pathogens that infect their hosts via the intestine. Identifying key factors during the initial stages of virus infection in the host may provide novel points of intervention. Microfold (M) cells, antigen-sampling cells in the intestine, were previously shown to provide a gateway for murine NoV (MNV) into the host, but the relative importance of this uptake pathway remained unknown. Here we show that the absence of gut-associated lymphoid tissues (GALT), such as Peyer's patches, which contain high numbers of mature M cells, renders BALB/c mice refractory to oral infection with MNV. These findings are consistent with the model that M cells represent the primary route by which MNV crosses the intestinal epithelial barrier and infects underlying immune cells during a productive infection.

Incidence of benign convulsions with mild gastroenteritis after introduction of rotavirus vaccine

BACKGROUND AND PURPOSE

Rotavirus was the most common virus in benign convulsions with mild gastroenteritis (CwG), with an incidence of 40-50%. As rotavirus gastroenteritis has decreased since introduction of rotavirus vaccine, we investigated the incidence of CwG and rotavirus positivity after introduction of the vaccine.

METHODS

We retrospectively reviewed the medical records of 987 patients aged between 3months and 3years who were admitted to the Chonnam National University Hospital between March 2005 and February 2014 due to their first seizures and enrolled 102 patients with CwG. The incidences of CwG among seizure patients and stool rotavirus positivity in CwG patients were compared between two periods: period I (March 2005-February 2010) and period II (March 2010-February 2014). Other viruses in stools were also reviewed.

RESULTS

The incidence of CwG were 8.47% (45 among 531 patients) in period I and 12.50% (57 among 456 patients) in period II (P=0.018). Stool rotavirus was checked in 85.29% (87 patients): 82.22% (37 patients) in period I and 87.72% (50 patients) in period II (P=0.166). The positivity of rotavirus was 40.54% (15 patients) in period I and 16.00% (8 patients) in period II (P=0.01). In the patients without rotavirus gastroenteritis, 30 patients were test for other viruses. Norovirus was the most common (56.67%, 17 patients) and was more frequent in period II than I (71.43% versus 22.22%, P=0.018).

CONCLUSION

After introduction of rotavirus vaccine, rotavirus-associated CwG has decreased but the incidence of CwG has increased due to an increase of norovirus.

Severity of rotavirus gastroenteritis in an Indian population: report from a 3 year surveillance study

This study investigated the severity of rotavirus gastroenteritis (RVGE) in hospitalized children less than 60 months of age and compared severity in the first five months of life to severity in children 6 to 23 months of age. Results from a 3 year surveillance study show an early peak of rotavirus disease, with 117 (31%) RVGE hospitalizations in children <6 months old. Higher incidence of severe dehydration, acidemia and acidosis at admission and prolonged hospitalization >7 days were seen in infants 0-5 months of age. The findings support the need for consideration of timely immunization or an accelerated immunization schedule with a birth dose to protect this vulnerable age.

The molecular pathology of noroviruses

Norovirus infection in humans typically results in acute gastroenteritis but may also occur in many animal species. Noroviruses are recognized as one of the most common causes of acute gastroenteritis in the world, being responsible for almost 20% of all cases. Despite their prevalence and impact, our knowledge of the norovirus life cycle and the pathological processes associated with norovirus-induced disease is limited. Whilst infection of the intestine is the norm, extraintestinal spread and associated pathologies have also been described. In addition, long-term chronic infections are now recognized as a significant cause of morbidity and mortality in the immunocompromised. This review aims to summarize the current state of knowledge with respect to norovirus pathology and the underlying mechanisms that have been characterized to date.

Norovirus-associated encephalitis in a previously healthy 2-year-old girl

We describe the case of 2-year-old girl with encephalitis associated with norovirus infection. The viral genome was detected in cerebrospinal fluid and stool by reverse transcription polymerase chain reaction. This is the first time in Spain and the second worldwide that the genome of norovirus from the stool sample and 2 cerebrospinal fluid samples were genetically characterized and matched.

Clinical characteristics of seizures associated with viral gastroenteritis in children

OBJECTIVE

We analyzed the clinical features of seizures during gastroenteritis in children by comparing the norovirus and rotavirus pathogen, and the impact of fever, if present, during the seizure episodes.

METHODS

Retrospective analysis was performed on 293 consecutive pediatric patients admitted with viral gastroenteritis to Osaka General Hospital between November 2007 and May 2009. Eighteen patients developed seizures, 12 of whom were positive for norovirus and six for rotavirus, as revealed by antigen detection. Of these 18 seizure patients, eight presented without fever (the aFS group) and 10 presented with febrile episodes (FS group).

RESULTS

Seizure patients in the rotavirus group (83%) were more likely to be febrile than those in the norovirus group (58%). Compared with the aFS group, 90% of patients in the FS group presented seizures at an early stage of gastroenteritis. The frequency of clustered seizures in the FS group was considerably higher than that of febrile seizures in general and was also as high as that of "convulsions with mild gastroenteritis (CwG)". All seizure patients, whether febrile or afebrile, presented with generalized tonic clonic seizures (GTCS), complex partial seizures (CPS), or both. Diazepam (DZP) was less effective and carbamazepine (CBZ) was completely effective for the cessation of seizures in the FS group, similar to the drug response observed in CwG.

CONCLUSIONS

The causative pathogen (norovirus or rotavirus) affected the frequency of febrile episodes during gastroenteritis, but fever had little effect on the clinical features of seizures. However, seizures occurred earlier during gastroenteritis in the FS group. On the whole, the clinical features of febrile seizures during viral gastroenteritis may closely resemble those of "convulsions with mild gastroenteritis" (CwG) than those of febrile seizures in general with respect to the frequency of clustered seizures and the antiepileptic drug responses and may have a pathogenic mechanism distinct from those of febrile seizures due to other causes.

Marked Elevation of Excitatory Amino Acids in Cerebrospinal Fluid Obtained From Patients With Rotavirus-Associated Encephalopathy

Rotavirus is the most common cause of severe gastroenteritis in young children; however, its pathogenesis and immunity are not completely understood. Even less well recognized is rotavirus-induced central nervous system (CNS) involvement, which has been associated with seizure, encephalopathy and death, among others. To elucidate the host response to rotavirus infection, we retrospectively examined neurotransmitter amino acids in the cerebrospinal fluid (CSF) of 19 children with CNS involvement associated with rotavirus infection. Subjects were classified into two groups: those with encephalopathy followed by prolonged seizure (encephalopathy group) and those who had experienced afebrile, brief cluster of seizures without encephalopathy (cluster group). The levels of glutamate, glycine, and taurine in the encephalopathy group were significantly higher than those in the cluster group. Increased levels of excitatory amino acids in the CSF may induce neurological disorders and be related to disorder severity. To the best of our knowledge, this is the first report regarding amino acids in the CSF obtained from patients with rotavirus-induced CNS involvement. Further study is necessary to elucidate the role of CSF amino acid levels in rotavirus-induced CNS involvement.

Benign convulsion with mild gastroenteritis

Benign convulsion with mild gastroenteritis (CwG) is a type of afebrile seizure that occurs in children. CwG is defined as a convulsion in a previously healthy child with no known central nervous system infection or encephalopathy, accompanying mild diarrhea without fever, electrolyte imbalance, or moderate to severe dehydration. Convulsions in CwG are characterized by multiple brief episodes of generalized or focal seizures. Although the etiology and pathophysiology have yet to be fully explained, many pathogenic mechanisms have been proposed including the possibility of direct invasion of the central nervous system by a gastrointestinal virus such as rotavirus or the possibility of indirect influence by the production and effects of certain mediators. The electroencephalogram findings are benign and long-term antiepileptic treatment is typically not required. Long-term prognosis has been favorable with normal psychomotor development. This review provides a general overview of CwG with the goal of allowing physicians practicing in the field of pediatrics to better recognize this unique entity and, ultimately, to minimize unnecessary evaluation and treatment.

Serum and CSF biomarkers in acute pediatric neurological disorders

BACKGROUND

There have been numerous reports regarding serum or cerebrospinal fluid (CSF) biomarkers in various disorders; however, the validities of such biomarkers for more precise diagnoses and prognosis estimates remain to be determined, especially in pediatric patients with neurological disorders.

METHODS

Serum/CSF S100B, neuron-specific enolase, and total tau (tTau) were measured in various acute pediatric neurological disorders, and their usefulness for diagnostic and prognostic predictions was validated using receiver operating characteristic curves and area under the curve (AUC) analysis.

RESULTS

A total of 336 serum and 200 CSF specimens from 313 patients were examined, and we identified statistically significant differences that were relevant from diagnostic and prognostic viewpoints. CSF and serum tTau levels could be good predictors for diagnosis (CSF tTau; AUC=0.76) and prognosis (serum tTau; AUC=0.78).

CONCLUSIONS

Both CSF and serum tTau levels could be useful for precise diagnostic and prognostic estimations in acute pediatric neurological disorders. Further studies are needed to clarify the clinical significance of such biomarkers.

Are afebrile seizures associated with minor infections a single seizure category? A hospital-based prospective cohort study on outcomes of first afebrile seizure in early childhood

OBJECTIVE

To explore if afebrile seizures associated with minor infections are a single category of seizure, or a set of different kinds of seizures.

METHODS

We conducted this prospective cohort study on three kinds of first afebrile seizure: first afebrile seizure associated with gastrointestinal infection (AS-GI), first afebrile seizure associated with nongastrointestinal infection (AS-nGI), and first unprovoked seizure (US). The Kaplan-Meier estimate risks of recurrent seizures were analyzed and compared pairwise. The characteristics of recurrent seizures were also compared pairwise.

RESULTS

The Kaplan-Meier estimate risks of recurrent seizure at 2 years of the AS-GI, AS-nGI, and US groups were 6.9%, 23.7%, and 37.8%, respectively. The pairwise differences were significant between the AS-GI and US groups (p < 0.001) and between the AS-GI and AS-nGI groups (p = 0.001), but not significant between the US and AS-nGI groups (p = 0.066). Among unprovoked subsequent seizures in patients with recurrence, the pairwise differences were significant between the AS-GI and US groups (p < 0.001) and between the AS-GI and AS-nGI groups (p = 0.005), but not significant between the US and AS-nGI groups (p = 0.417).

SIGNIFICANCE

Afebrile seizures associated with minor infections are indeed of two distinguishable kinds: AS-GI, if free of risk factors such as a family history of epilepsy, had a better prognosis and should be categorized as an acute symptomatic seizure, whereas patients with first AS-nGI, like patients with first US, may have recurrent unprovoked seizures, which suggests this category's essential difference from AS-GI.

Rotavirus antigenemia in children is associated with more severe clinical manifestations of acute gastroenteritis

BACKGROUND

Rotavirus (RV) antigenemia and RNAemia are common findings in rotavirus-infected children. Sporadic associations between RV antigenemia and extraintestinal manifestations of RV infection have been observed. We examined the clinical severity of RV gastroenteritis in patients with and without RV antigenemia or RNAemia.

METHODS

Stool, serum and whole blood samples were collected from children seen with acute gastroenteritis in Tampere University Hospital and studied for RV using reverse transcription polymerase chain reaction and enzyme-linked immunosorbent assay. Only exclusively RV-positive specimens were included into this study. The patients were divided into groups according to RV findings from stool, serum and blood specimens. Clinical manifestations were graded according to 20-point Vesikari scoring system.

RESULTS

Of 374 children, 155 (41%) had RV in their stools. Of these 155 children, 105 (67%) were found to have RV RNA in the serum; of those, 94 (90%) had also RV enzyme-linked immunosorbent assay antigen. Thus antigenemia occurred in 61% (94 cases) of RV-infected children all of whom had concomitant RNAemia. Neither antigenemia nor RNAemia were detected in 85 patients with non-RV gastroenteritis. Patients who had RV RNA and RV antigen in both serum and stools were more likely to have a higher level of fever and more severe vomiting than patients who had RV only in stools. G1 genogroup RV was more often associated with RNAemia and antigenemia than other genogroups combined.

CONCLUSION

Rotavirus antigenemia and viremia are commonly detected in children hospitalized for RV gastroenteritis and may be associated with increased severity of fever and vomiting.

A comparative study of febrile and afebrile seizures associated with mild gastroenteritis

PURPOSE

Seizures associated with mild gastroenteritis have been increasingly reported. We analyzed the clinical characteristics of febrile and afebrile seizures associated with mild gastroenteritis, and attempted to determine the influence of fever in these two groups.

METHODS

We reviewed the medical records of 59 children presenting with seizures during a mild gastroenteritis episode. They were classified into an afebrile group (n=27) and a febrile group (n=32). We compared the age of onset, sex, seizure semiology, frequency, duration, family history, and prior history of seizures between the two groups.

RESULTS

The mean age, family history, seizure semiology, and frequency of seizures were not significantly different between the two groups. However, more patients in the afebrile group experienced ≥ 2 seizures/day than in the febrile group (63% vs. 38%, p=0.051). The febrile patients had a tendency of experiencing prolonged seizures lasting ≥ 5 min compared with the afebrile group (34% vs. 11%, p=0.063). Prior febrile seizures were noted in 5 of the 32 patients (15.6%) in the febrile group, while none of the 27 patients in the afebrile group had a history of prior seizures (p=0.056).

CONCLUSIONS

It seems that the presence of fever may influence the clinical characteristics of seizures associated with mild gastroenteritis. We suggest that afebrile seizures associated with gastroenteritis may be regarded as a distinct condition from those associated with fever, and it needs to be clarified by a further large sample study.

Genetic analysis of PRRT2 for benign infantile epilepsy, infantile convulsions with choreoathetosis syndrome, and benign convulsions with mild gastroenteritis

PURPOSE

PRRT2 mutations were recently identified in benign familial infantile epilepsy (BFIE) and infantile convulsions with paroxysmal choreoathetosis (ICCA) but no abnormalities have so far been identified in their phenotypically similar seizure disorder of benign convulsions with mild gastroenteritis (CwG), while mutations in KCNQ2 and KCNQ3 have been recognized in benign familial neonatal epilepsy (BFNE). The aim of this study was to identify PRRT2 mutations in infantile convulsions in Asian families with BFIE and ICCA, CwG and BFNE.

METHODS

We recruited 26 unrelated Japanese affected with either BFIE or non-familial benign infantile seizures and their families, including three families with ICCA. A total of 17 Japanese and Taiwanese with CwG, 50 Japanese with BFNE and 96 healthy volunteers were also recruited. Mutations of PRRT2 were sought using direct sequencing.

RESULTS

Heterozygous truncation mutation (c.649dupC) was identified in 15 of 26 individuals with benign infantile epilepsy (52.1%). All three families of ICCA harbored the same mutation (100%). Another novel mutation (c.1012+2dupT) was found in the proband of a family with BFIE. However, no PRRT2 mutation was found in either CwG or BFNE.

CONCLUSIONS

The results confirm that c.649dupC, a truncating mutation of PRRT2, is a hotspot mutation resulting in BFIE or ICCA regardless of the ethnic background. In contrast, PRRT2 mutations do not seem to be associated with CwG or BFNE. Screening for PRRT2 mutation might be useful in early-stage differentiation of BFIE from CwG.