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Wagner JN, Leibetseder A, Troescher A, Panholzer J, von Oertzen TJ. Characteristics and therapy of enteroviral encephalitis: case report and systematic literature review. Int J Infect Dis 2021; 113:93-102. [PMID: 34628025 DOI: 10.1016/j.ijid.2021.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/24/2021] [Accepted: 10/02/2021] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Enterovirus (EV) is a frequent cause of encephalitis. The optimal therapeutic approach remains a matter of debate. We present the case of an immunosuppressed patient with EV encephalitis treated successfully with intravenous immunoglobulin (IVIG) and report the results of a systematic review on the characteristics of EV encephalitis, as well as the safety and efficacy of IVIG therapy. METHODS A systematic review was conducted using the PubMed, Cochrane Database, BIOSIS Previews, and ClinicalTrials.gov databases to identify all reports on patients with EV encephalitis as of December 31, 2020. The main outcomes assessed were the efficacy and safety of the respective therapeutic approach. RESULTS A total of 73 articles were included: one prospective trial, one retrospective and prospective case series, one purely retrospective case series, and 70 case reports. The case reports included a total of 101 patients. Immunosuppressed patients were at higher risk of contracting EV encephalitis and experiencing a fatal course. Hypogammaglobulinaemia particularly predisposes to EV disease, even with a moderate reduction in serum IgG levels. IVIG therapy in the immunosuppressed may confer a survival advantage. CONCLUSIONS IVIG therapy is rarely associated with severe adverse events and may be considered in immunosuppressed patients with EV encephalitis. Future trials should investigate the optimal IVIG dosing and route of application, the benefit of antibody-enriched IVIG preparations, and the serum immunoglobulin level that should trigger prophylactic replacement.
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Affiliation(s)
- Judith N Wagner
- Department of Neurology 1, Kepler University Hospital, Johannes Kepler University Linz, Wagner-Jauregg-Weg 15, 4020 Linz, Austria.
| | - Annette Leibetseder
- Department of Neurology 1, Kepler University Hospital, Johannes Kepler University Linz, Wagner-Jauregg-Weg 15, 4020 Linz, Austria
| | - Anna Troescher
- Department of Neurology 1, Kepler University Hospital, Johannes Kepler University Linz, Wagner-Jauregg-Weg 15, 4020 Linz, Austria
| | - Juergen Panholzer
- Department of Neurology 1, Kepler University Hospital, Johannes Kepler University Linz, Wagner-Jauregg-Weg 15, 4020 Linz, Austria
| | - Tim J von Oertzen
- Department of Neurology 1, Kepler University Hospital, Johannes Kepler University Linz, Wagner-Jauregg-Weg 15, 4020 Linz, Austria
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Strenger V, Kessler HH, Stelzl E, Aberle SW, Keldorfer M, Zach K, Karastaneva A, Sperl D, Lackner H, Benesch M, Urban C, Dornbusch HJ. Enterovirus infections in pediatric hematologic/oncologic patients. Pediatr Blood Cancer 2019; 66:e27448. [PMID: 30270558 DOI: 10.1002/pbc.27448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 08/16/2018] [Accepted: 08/17/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND Enteroviruses (EV) are a large group of Picornaviruses associated with respiratory, gastrointestinal, and neurologic symptoms in the immunocompetent host. Little is known about the epidemiologic and clinical impact in pediatric hematologic/oncologic patients. PROCEDURE From 2001 through 2017, different clinical specimens were collected from pediatric hematologic/oncologic patients and were tested for enteroviral RNA. RESULTS Of 13 004 specimens collected from 761 patients, 38 (0.3%) obtained from 14 patients (1.8%) tested positive for EV RNA. Viral shedding was observed without viremia and vice versa. None of 80 cerebrospinal fluid specimens obtained from 60 patients with neurologic symptoms were positive for EV RNA. None of 14 patients positive for EV RNA showed EV-specific symptoms. In 11/14 patients, EV RNA was found to be negative in the follow-up specimen. The remaining patient with a severe primary immune deficiency showed repeated positive EV RNA results for >5 years. CONCLUSIONS In this pediatric hematologic/oncologic cohort, EV infection occurred rarely and without related symptoms. Specimens concurrently obtained from one patient are commonly not in accordance with each other. In the vast majority of patients, EV RNA appears to turn negative in the follow-up specimen. EV infections seem to have a low impact in this patient cohort.
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Affiliation(s)
- Volker Strenger
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Harald H Kessler
- Molecular Diagnostics Laboratory, Diagnostic and Research Center for Molecular Biomedicine, Medical University of Graz, Graz, Austria
| | - Evelyn Stelzl
- Molecular Diagnostics Laboratory, Diagnostic and Research Center for Molecular Biomedicine, Medical University of Graz, Graz, Austria
| | - Stephan W Aberle
- Center for Virology, Medical University of Vienna, Vienna, Austria
| | - Markus Keldorfer
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Klara Zach
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Anna Karastaneva
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Daniela Sperl
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Herwig Lackner
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Martin Benesch
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Christian Urban
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Hans Jürgen Dornbusch
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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Madakshira MG, Bhardwaj S, Gupta K, Chander Y, Bhalla A. A fatal case of enterovirus infection with secondary hemophagocytosis-case report with review of literature. APMIS 2018; 126:877-882. [PMID: 30357959 DOI: 10.1111/apm.12892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 09/25/2018] [Indexed: 11/28/2022]
Abstract
Enterovirus is a common viral infection, which can affect multiple organ systems with an array of clinical presentation such as meningitis, encephalitis, myocarditis, and disseminated infections. The illness is usually asymptomatic and self-limited but few cases can be severe and life-threatening especially when associated with hemophagocytosis. We discuss a fatal case of disseminated enterovirus infection and the histomorphological features of the infection.
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Affiliation(s)
- Manoj Gopal Madakshira
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunny Bhardwaj
- Department of Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kirti Gupta
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Yogesh Chander
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Bhalla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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4
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Dixon SB, Lane A, O'Brien MM, Burns KC, Mangino JL, Breese EH, Absalon MJ, Perentesis JP, Phillips CL. Viral surveillance using PCR during treatment of AML and ALL. Pediatr Blood Cancer 2018; 65. [PMID: 28792686 DOI: 10.1002/pbc.26752] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/24/2017] [Accepted: 07/15/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND While viral surveillance of cytomegalovirus (CMV), Epstein-Barr virus (EBV), and adenovirus using PCR is routine in patients undergoing hematopoetic stem cell transplant and solid organ transplant, the utility in the nontransplant pediatric leukemia population is unknown. Our institution screens patients with acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) for viral DNAemia by PCR as part of clinical care. PROCEDURE This retrospective chart review included patients treated for newly diagnosed or relapsed AML or ALL between April 2010 and September 2014. We retrieved data for viral PCR screening, detection and quantification, duration of positivity, and prophylaxis or treatment. RESULTS One hundred eleven patients were included in analyses. Forty (36.0%) had at least one blood PCR positive for EBV, CMV, or adenovirus. Patients with ALL had significantly higher rates of persistent viral detection and treatment than those with AML (P < 0.02, P < 0.01, respectively). International patients had significantly higher rates of viral detection (P < 0.01), persistence (P < 0.01), any treatment (P < 0.03), and antiviral treatment (P < 0.01); 16.9% of patients who received intravenous immunoglobulin (IVIG) prophylactically had viral detection compared to 63% of patients who did not receive prophylactic IVIG (P = 0.0008). CONCLUSIONS Patients with ALL were more susceptible than those with AML to viral reactivation that was persistent or resulted in treatment. Patients with relapsed ALL, refractory ALL, or infantile ALL are most likely to benefit from asymptomatic screening for CMV and adenovirus. International patients are at higher risk for reactivation and may merit screening. EBV reactivation was not significant and does not warrant screening.
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Affiliation(s)
- Stephanie B Dixon
- Department of Pediatric Hematology and Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Adam Lane
- Division of Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Maureen M O'Brien
- Cancer and Blood Diseases Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Karen C Burns
- Cancer and Blood Diseases Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jennifer L Mangino
- Cancer and Blood Diseases Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Erin H Breese
- Cancer and Blood Diseases Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michael J Absalon
- Cancer and Blood Diseases Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - John P Perentesis
- Cancer and Blood Diseases Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Christine L Phillips
- Cancer and Blood Diseases Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Abstract
Infections with enteroviruses and human parechoviruses are highly prevalent, particularly in neonates, where they may cause substantial morbidity and mortality. Individuals with B-cell-related immunodeficiencies are at risk for severe enteroviral infections, usually a chronic and fatal meningoencephalitis. In transplant recipients and patients with malignancy, enterovirus infections typically involve the respiratory tract, but cases of severe, disseminated infection have been described. The mainstay of diagnosis for enterovirus and human parechovirus infections involves the use of molecular diagnostic techniques. However, routine nucleic acid-detection methods for enteroviruses will not detect human parechoviruses. Laboratory diagnosis of these viral infections is important in determining a patient's prognosis and guiding clinical management.
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Abstract
Though the treatment of pediatric cancers has come a long way, acute and chronic effects of cancer are still affecting the life of many children. These effects may be caused not only by the malignancy itself but also by the interventions used for the purpose of treatment. This article focuses primarily on the indirect effects of pediatric cancers and their treatment on the central and peripheral nervous system. Chemotherapy, radiation, and stem cell transplantation cause an immune-compromised state and place the patient at risk of infection, the leading cause of mortality in pediatric cancer. The underlying cancer and the treatments also cause neurovascular changes that may lead to neurological sequelae immediately or many years in the future. Chemotherapy and radiation have both immediate and long-term neurotoxic effects on the central and peripheral nervous system. Cancers may also trigger an immune response that damages nervous system components, leading to altered mental status, seizures, abnormal movements, and even psychosis. Knowledge of these effects can help the practitioner be more vigilant for the signs and symptoms of potential neurological complications during the management of pediatric cancers.
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Affiliation(s)
- Lauren Weaver
- From the Section of Neurology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA
| | - Ayman Samkari
- Section of Oncology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA.
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7
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Grisariu S, Vaxman I, Gatt M, Elias S, Avni B, Arad A, Pasvolsky O, Raanani P, Paltiel O. Enteroviral infection in patients treated with rituximab for non-Hodgkin lymphoma: a case series and review of the literature. Hematol Oncol 2016; 35:591-598. [DOI: 10.1002/hon.2365] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 08/23/2016] [Accepted: 09/08/2016] [Indexed: 11/11/2022]
Affiliation(s)
- S. Grisariu
- Department of Hematology; Hadassah-Hebrew University Medical Center; Jerusalem Israel
| | - I. Vaxman
- Hematology Division Davidoff Cancer Center; Beilinson Hospital; Rabin Medical Center; Israel
- Sackler School of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - M. Gatt
- Department of Hematology; Hadassah-Hebrew University Medical Center; Jerusalem Israel
| | - S. Elias
- Department of Hematology; Hadassah-Hebrew University Medical Center; Jerusalem Israel
| | - B. Avni
- Department of Hematology; Hadassah-Hebrew University Medical Center; Jerusalem Israel
| | - A. Arad
- Department of Hematology; Hadassah-Hebrew University Medical Center; Jerusalem Israel
| | - O. Pasvolsky
- Hematology Division Davidoff Cancer Center; Beilinson Hospital; Rabin Medical Center; Israel
- Sackler School of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - P. Raanani
- Hematology Division Davidoff Cancer Center; Beilinson Hospital; Rabin Medical Center; Israel
- Sackler School of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - O. Paltiel
- Department of Hematology; Hadassah-Hebrew University Medical Center; Jerusalem Israel
- School of Public Health; Hadassah-Hebrew University Medical Center; Jerusalem Israel
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8
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Moschovi M, Adamaki M, Vlahopoulos SA. Progress in Treatment of Viral Infections in Children with Acute Lymphoblastic Leukemia. Oncol Rev 2016; 10:300. [PMID: 27471584 PMCID: PMC4943096 DOI: 10.4081/oncol.2016.300] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 06/29/2016] [Indexed: 02/08/2023] Open
Abstract
In children, the most commonly encountered type of leukemia is acute lymphoblastic leukemia (ALL). An important source of morbidity and mortality in ALL are viral infections. Even though allogeneic transplantations, which are often applied also in ALL, carry a recognized risk for viral infections, there are multiple factors that make ALL patients susceptible to viral infections. The presence of those factors has an influence in the type and severity of infections. Currently available treatment options do not guarantee a positive outcome for every case of viral infection in ALL, without significant side effects. Side effects can have very serious consequences for the ALL patients, which include nephrotoxicity. For this reason a number of strategies for personalized intervention have been already clinically tested, and experimental approaches are being developed. Adoptive immunotherapy, which entails administration of ex vivo grown immune cells to a patient, is a promising approach in general, and for transplant recipients in particular. The ex vivo grown cells are aimed to strengthen the immune response to the virus that has been identified in the patients' blood and tissue samples. Even though many patients with weakened immune system can benefit from progress in novel approaches, a viral infection still poses a very significant risk for many patients. Therefore, preventive measures and supportive care are very important for ALL patients.
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Affiliation(s)
- Maria Moschovi
- Hematology-Oncology Unit, First Department of Pediatrics, University of Athens, Aghia Sophia Children's Hospital , Athens, Greece
| | - Maria Adamaki
- Hematology-Oncology Unit, First Department of Pediatrics, University of Athens, Aghia Sophia Children's Hospital , Athens, Greece
| | - Spiros A Vlahopoulos
- Hematology-Oncology Unit, First Department of Pediatrics, University of Athens, Aghia Sophia Children's Hospital , Athens, Greece
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Murk JL, de Vries AC, GeurtsvanKessel CH, Aron G, Osterhaus AD, Wolthers KC, Fraaij PL. Persistent spiking fever in a child with acute myeloid leukemia and disseminated infection with enterovirus. J Clin Virol 2014; 61:453-5. [PMID: 25281281 DOI: 10.1016/j.jcv.2014.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 09/08/2014] [Accepted: 09/14/2014] [Indexed: 11/16/2022]
Abstract
We here report a 7 year old acute myeloid leukemia patient with persistent spiking fever likely caused by chronic echovirus 20 infection. After immunoglobulin substitution fevers subsided and the virus was cleared. Enterovirus infection should be considered in immunocompromised patients with unexplained persistent fever.
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Affiliation(s)
- J L Murk
- Department of Viroscience, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - A C de Vries
- Department of Pediatric Oncology/Hematology, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - C H GeurtsvanKessel
- Department of Viroscience, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - G Aron
- Department of Viroscience, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - A D Osterhaus
- Department of Viroscience, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - K C Wolthers
- Laboratory of Clinical Virology, Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands
| | - P L Fraaij
- Department of Viroscience, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Pediatrics, Subdivision of Infectious Diseases and Immunology, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
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10
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Růžek D, Dobler G, Niller HH. May early intervention with high dose intravenous immunoglobulin pose a potentially successful treatment for severe cases of tick-borne encephalitis? BMC Infect Dis 2013; 13:306. [PMID: 23822550 PMCID: PMC3710210 DOI: 10.1186/1471-2334-13-306] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 07/02/2013] [Indexed: 12/18/2022] Open
Abstract
Background Arthropod-borne viral encephalitis of diverse origins shows similar clinical symptoms, histopathology and magnetic resonance imaging, indicating that the patho mechanisms may be similar. There is no specific therapy to date. However, vaccination remains the best prophylaxis against a selected few. Regardless of these shortcomings, there are an increasing number of case reports that successfully treat arboviral encephalitis with high doses of intravenous immunoglobulins. Discussion To our knowledge, high dose intravenous immunoglobulin has not been tested systematically for treating severe cases of tick-borne encephalitis. Antibody-dependent enhancement has been suspected, but not proven, in several juvenile cases of tick-borne encephalitis. Although antibody-dependent enhancement during secondary infection with dengue virus has been documented, no adverse effects were noticed in a controlled study of high dose intravenous immunoglobulin therapy for dengue-associated thrombocytopenia. The inflammation-dampening therapeutic effects of generic high dose intravenous immunoglobulins may override the antibody-dependent enhancement effects that are potentially induced by cross-reactive antibodies or by virus-specific antibodies at sub-neutralizing levels. Summary Analogous to the increasing number of case reports on the successful treatment of other arboviral encephalitides with high dose intravenous immunoglobulins, we postulate whether it may be possible to also treat severe cases of tick-borne encephalitis with high dose intravenous immunoglobulins as early in the course of the disease as possible.
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Affiliation(s)
- Daniel Růžek
- Academy of Sciences of the Czech Republic, Biology Centre, Institute of Parasitology, Branisovska: 31, CZ-37005 Ceske Budejovice, Czech Republic
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Lim BK, Ju ES, Lao DH, Yun SH, Lee YJ, Kim DK, Jeon ES. Development of a enterovirus diagnostic assay system for diagnosis of viral myocarditis in humans. Microbiol Immunol 2013; 57:281-7. [DOI: 10.1111/1348-0421.12028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 12/26/2012] [Accepted: 01/09/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Byung-Kwan Lim
- Division of Cardiology, Samsung Medical Center, Samsung Biomedical Research Institute; Sungkyunkwan University School of Medicine; 50 Irwon dong, Gangnam-gu, Seoul, 135-710; Korea
| | - Eun-Seon Ju
- Division of Cardiology, Samsung Medical Center, Samsung Biomedical Research Institute; Sungkyunkwan University School of Medicine; 50 Irwon dong, Gangnam-gu, Seoul, 135-710; Korea
| | - Dieu Hung Lao
- Department of Medicine; University of California, San Diego Department of Cardiology; San Diego, California; USA
| | - Soo-Hyeon Yun
- Research and Development Center; Celltrion, 13-6 Songdo-dong, Yeonsu-gu, Incheon 406-840; Korea
| | - Yoo-Jung Lee
- Division of Cardiology, Samsung Medical Center, Samsung Biomedical Research Institute; Sungkyunkwan University School of Medicine; 50 Irwon dong, Gangnam-gu, Seoul, 135-710; Korea
| | - Duk-Kyung Kim
- Division of Cardiology, Samsung Medical Center, Samsung Biomedical Research Institute; Sungkyunkwan University School of Medicine; 50 Irwon dong, Gangnam-gu, Seoul, 135-710; Korea
| | - Eun-Seok Jeon
- Division of Cardiology, Samsung Medical Center, Samsung Biomedical Research Institute; Sungkyunkwan University School of Medicine; 50 Irwon dong, Gangnam-gu, Seoul, 135-710; Korea
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12
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Santos H, Isidoro L, Leite A, Costa C, Santos F. Rombencefalitis por enterovirus. An Pediatr (Barc) 2012; 76:243-5. [DOI: 10.1016/j.anpedi.2011.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2011] [Revised: 10/11/2011] [Accepted: 10/31/2011] [Indexed: 10/14/2022] Open
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13
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Licciardello M, Pegoraro A, Cesaro S. Prophylaxis and therapy of viral infections in pediatric patients treated for malignancy. Pediatr Rep 2011; 3:e5. [PMID: 21647278 PMCID: PMC3103130 DOI: 10.4081/pr.2011.e5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Accepted: 12/22/2010] [Indexed: 11/23/2022] Open
Abstract
Infections are still an important cause of mortality and morbidity in pediatric cancer patients. Most of the febrile episodes in immunocompromised patients are classified as a fever of unknown origin (FUO) while bacteria are the more frequent causes of documented infections. Viral infections are also feared during chemotherapy but less data are available on their incidence and morbidity. We reviewed the literature on incidence, morbidity, and mortality of viral infections in children undergoing chemotherapy and discussed the evidence concerning the prophylaxis and the therapy.
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Abstract
Hand, foot and mouth disease (HFMD) is generally a benign febrile exanthematous childhood disease caused by human enteroviruses. The route of transmission is postulated to be faeco-oral in developing areas but attributed more to respiratory droplet in developed areas. Transmission is facilitated by the prolonged environmental survival of these viruses and their greater resistance to biocides. Serious outbreaks with neurological and cardiopulmonary complications caused by human enterovirus 71 (HEV-71) seem to be commoner in the Asian Pacific region than elsewhere in the world. This geographical predilection is unexplained but could be related to the frequency of intra- and inter-typic genetic recombinations of the virus, the host populations' genetic predisposition, environmental hygiene, and standard of healthcare. Vaccine development could be hampered by the general mildness of the illness and rapid genetic evolution of the virus. Antivirals are not readily available; the role of intravenous immunoglobulin in the treatment of serious complications should be investigated. Monitoring of this disease and its epidemiology in the densely populated Asia Pacific epicentre is important for the detection of emerging epidemics due to enteroviruses.
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15
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Katsibardi K, Moschovi MA, Theodoridou M, Spanakis N, Kalabalikis P, Tsakris A, Tzortzatou-Stathopoulou F. Enterovirus-associated hemophagocytic syndrome in children with malignancy: report of three cases and review of the literature. Eur J Pediatr 2008; 167:97-102. [PMID: 17318619 DOI: 10.1007/s00431-007-0436-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2006] [Revised: 01/29/2007] [Accepted: 01/30/2007] [Indexed: 12/27/2022]
Abstract
Enteroviruses can cause severe manifestations in children with malignancy. Infection-associated hemophagocytic syndrome (IAHS) due to enterovirus is a rare entity in children. Patients with malignancy and IAHS due to enterovirus were retrospectively evaluated at the University of Athens' Hematology-Oncology pediatric unit within a 6-year period (2000-2006). IAHS occurred in three cases among 56 patients with documented enteroviral infection. The diagnosis of IAHS was confirmed by bone marrow aspiration and biopsy. Nested reverse transcriptase-polymerase chain reaction (RT-PCR), sequencing of the amplified alleles, and immunohistochemistry were performed to document the presence of enterovirus. The type of enterovirus was specified by indirect immunofluorescence assay. At the early phase of the disease, patients presented mild, non-specific viral symptoms, persistent unexplained fever, and pancytopenia. At the late phase, patients had more severe manifestations, such as persistent high fever, diarrhea, weight loss, hepatosplenomegaly, and hepatic dysfunction. The therapeutic approach consisted of supportive care, administration of immunoglobulin (400 mg/kg or 2 g/kg), and pleconaril. All patients had fatal outcome; two patients succumbed to multiorgan failure (MOF), while one patient succumbed to ventricular fibrillation. IAHS usually has fulminant course and leads to severe and life-threatening complications, such as liver failure and MOF. IAHS should always be included in the differential diagnosis of viral syndrome or unexplained fever. The therapeutic approach for IAHS should be administered as early as possible, before the progression to irreversible tissue damage. Early therapeutic intervention involving high doses of immunoglobulin might be beneficial for the patient's outcome.
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Affiliation(s)
- Katerina Katsibardi
- Hematology-Oncology Unit, First Department of Pediatrics, University of Athens, "Aghia Sophia" Children's Hospital, Thivon & Levadias Ave., Athens 11527, Greece
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16
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Frange P, Michon J, Fromantin I, Franck N, Safar E, Escande MC, Desguerre I, Orbach D. Enterovirus 71 meningoencephalitis during chemotherapy in a child with metastatic osteosarcoma. J Pediatr Hematol Oncol 2007; 29:566-8. [PMID: 17762499 DOI: 10.1097/mph.0b013e3180f61bbc] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Enterovirus meningoencephalitis is rare but can be severe. Very few cases of these infections have been reported in pediatric oncology. We report the case of a 10-year-old boy with tibial osteosarcoma and lung metastases who developed enterovirus 71 meningoencephalitis during aplasia. Clinical features comprised fever, hypotension, vesicular rash, generalized seizures, and altered consciousness. Diagnosis was confirmed by polymerase chain reaction on samples of cerebrospinal fluid and skin vesicles. The patient received treatment with intravenous immunoglobulins with an excellent outcome with no cutaneous or neurologic sequelae. Immunoglobulin therapy could be considered in cases of invasive enteroviral infection with such severity in pediatric oncology.
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Affiliation(s)
- Pierre Frange
- Pediatric Oncology Department, Hôpital Necker Enfants Malades, APHP, Paris, France
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