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Gaume L, Chabrolles H, Bisseux M, Lopez-Coqueiro I, Dehouck L, Mirand A, Henquell C, Gosselet F, Archimbaud C, Bailly JL. Enterovirus A71 crosses a human blood-brain barrier model through infected immune cells. Microbiol Spectr 2024; 12:e0069024. [PMID: 38752731 PMCID: PMC11237604 DOI: 10.1128/spectrum.00690-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 04/16/2024] [Indexed: 06/06/2024] Open
Abstract
Enterovirus A71 (EV-A71) is associated with neurological conditions such as acute meningitis and encephalitis. The virus is detected in the bloodstream, and high blood viral loads are associated with central nervous system (CNS) manifestations. We used an in vitro blood-brain barrier (BBB) model made up of human brain-like endothelial cells (hBLECs) and brain pericytes grown in transwell systems to investigate whether three genetically distinct EV-A71 strains (subgenogroups C1, C1-like, and C4) can cross the human BBB. EV-A71 poorly replicated in hBLECs, which released moderate amounts of infectious viruses from their luminal side and trace amounts of infectious viruses from their basolateral side. The barrier properties of hBLECs were not impaired by EV-A71 infection. We investigated the passage through hBLECs of EV-A71-infected white blood cells. EV-A71 strains efficiently replicated in immune cells, including monocytes, neutrophils, and NK/T cells. Attachment to hBLECs of immune cells infected with the C1-like virus was higher than attachment of cells infected with C1-06. EV-A71 infection did not impair the transmigration of immune cells through hBLECs. Overall, EV-A71 targets different white blood cell populations that have the potential to be used as a Trojan horse to cross hBLECs more efficiently than cell-free EV-A71 particles.IMPORTANCEEnterovirus A71 (EV-A71) was first reported in the USA, and numerous outbreaks have since occurred in Asia and Europe. EV-A71 re-emerged as a new multirecombinant strain in 2015 in Europe and is now widespread. The virus causes hand-foot-and-mouth disease in young children and is involved in nervous system infections. How the virus spreads to the nervous system is unclear. We investigated whether white blood cells could be infected by EV-A71 and transmit it across human endothelial cells mimicking the blood-brain barrier protecting the brain from adverse effects. We found that endothelial cells provide a strong roadblock to prevent the passage of free virus particles but allow the migration of infected immune cells, including monocytes, neutrophils, and NK/T cells. Our data are consistent with the potential role of immune cells in the pathogenesis of EV-A71 infections by spreading the virus in the blood and across the human blood-brain barrier.
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Affiliation(s)
- Léa Gaume
- Laboratoire Microorganismes: Génome et Environnement (LMGE), CNRS UMR 6023, Clermont Auvergne Université, Clermont-Ferrand, France
| | - Hélène Chabrolles
- Laboratoire Microorganismes: Génome et Environnement (LMGE), CNRS UMR 6023, Clermont Auvergne Université, Clermont-Ferrand, France
- Laboratoire de Virologie, Centre National de Référence des Entérovirus et Parechovirus, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Maxime Bisseux
- Laboratoire Microorganismes: Génome et Environnement (LMGE), CNRS UMR 6023, Clermont Auvergne Université, Clermont-Ferrand, France
- Laboratoire de Virologie, Centre National de Référence des Entérovirus et Parechovirus, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Igor Lopez-Coqueiro
- Laboratoire Microorganismes: Génome et Environnement (LMGE), CNRS UMR 6023, Clermont Auvergne Université, Clermont-Ferrand, France
| | - Lucie Dehouck
- Laboratoire de la Barrière Hémato-Encéphalique (LBHE), Université d’Artois, Lens, France
| | - Audrey Mirand
- Laboratoire Microorganismes: Génome et Environnement (LMGE), CNRS UMR 6023, Clermont Auvergne Université, Clermont-Ferrand, France
- Laboratoire de Virologie, Centre National de Référence des Entérovirus et Parechovirus, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Cécile Henquell
- Laboratoire Microorganismes: Génome et Environnement (LMGE), CNRS UMR 6023, Clermont Auvergne Université, Clermont-Ferrand, France
- Laboratoire de Virologie, Centre National de Référence des Entérovirus et Parechovirus, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Fabien Gosselet
- Laboratoire de la Barrière Hémato-Encéphalique (LBHE), Université d’Artois, Lens, France
| | - Christine Archimbaud
- Laboratoire Microorganismes: Génome et Environnement (LMGE), CNRS UMR 6023, Clermont Auvergne Université, Clermont-Ferrand, France
- Laboratoire de Virologie, Centre National de Référence des Entérovirus et Parechovirus, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean-Luc Bailly
- Laboratoire Microorganismes: Génome et Environnement (LMGE), CNRS UMR 6023, Clermont Auvergne Université, Clermont-Ferrand, France
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Huang PN, Hsia SH, Huang KYA, Chen CJ, Wang ET, Shih SR, Lin TY. Reflecting on the 1998 enterovirus outbreak: A 25-year retrospective and learned lessons. Biomed J 2024:100715. [PMID: 38492637 DOI: 10.1016/j.bj.2024.100715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/13/2023] [Accepted: 03/06/2024] [Indexed: 03/18/2024] Open
Abstract
Enterovirus A71 (EV-A71) infections pose a significant public health concern in the Asia-Pacific region. EV-A71 is primarily responsible for causing hand, foot, and mouth disease (HFMD) in children. However, this virus can also lead to severe and potentially fatal neurological consequences in affected individuals. This review aims to provide a comprehensive understanding of the molecular virology, epidemiology, and recombination events associated with EV-A71. The literature extensively covers the clinical manifestations and neurological symptoms that accompany EV-A71 infections. One of the complications explored in this review is brainstem encephalitis, which can arise as a result of EV-A71 infections. Brainstem encephalitis refers to inflammation of the brainstem, a critical region responsible for various bodily functions. The review examines the underlying mechanisms, diagnostic criteria, treatment options, and prognosis for central nervous system infections involving EV-A71. Neurological complications associated with EV-A71 infections are diverse and can have severe consequences. These complications may include aseptic meningitis, acute flaccid paralysis, and acute transverse myelitis. The review delves into the pathophysiology of these complications, shedding light on the molecular mechanisms through which EV-A71 affects the central nervous system. Accurate diagnosis of EV-A71 infections is crucial for appropriate management and treatment. Treatment options for EV-A71 infections primarily focus on supportive care, as there are currently no specific antiviral drugs available for this virus. The review highlights the importance of managing symptoms, such as fever, dehydration, and pain relief, to alleviate the burden on affected individuals. Prognosis for individuals with central nervous system (CNS) infections involving EV-A71 can vary depending on the severity of the complications. The review provides insights into the long-term outcomes and potential neurological sequelae associated with EV-A71 infections. In conclusion, EV-A71 infections have emerged as a major public health concern in the Asia-Pacific region. This review aims to enhance our understanding of the molecular virology, epidemiology, and neurological complications associated with EV-A71. By examining the underlying mechanisms, diagnostic criteria, treatment options, and prognosis, this review contributes to the development of effective strategies for the prevention, diagnosis, and management of EV-A71 infections. The paper presents a comprehensive analysis of worldwide data pertaining to outbreaks of EV-A71 and HFMD. The subsequent discourse delves into the advancement and strategic formulation pertaining to the creation of vaccines targeting EV-A71. In summary, this study provides a comprehensive examination of the potential obstacles and considerations involved in the management and treatment of EV-A71 infections. Additionally, it proposes suggestions for future research and development endeavors with the objective of formulating efficacious treatment approaches for this viral infection.
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Affiliation(s)
- Peng-Nien Huang
- Research Center for Emerging Viral Infections, Chang Gung University, Taoyuan, Taiwan; Division of Infectious Diseases, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shao-Hsuan Hsia
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Department of Pediatric Respiratory Therapy, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kuan-Ying Arthur Huang
- Research Center for Emerging Viral Infections, Chang Gung University, Taoyuan, Taiwan; Division of Infectious Diseases, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Jung Chen
- Research Center for Emerging Viral Infections, Chang Gung University, Taoyuan, Taiwan; Division of Infectious Diseases, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - En-Tzu Wang
- Division of Acute Infectious Diseases, Centers for Disease Control, Ministry of Health and Welfare, Taiwan
| | - Shin-Ru Shih
- Research Center for Emerging Viral Infections, Chang Gung University, Taoyuan, Taiwan; Department of Medical Biotechnology and Laboratory Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; Research Center for Chinese Herbal Medicine, Research Center for Food and Cosmetic Safety, and Graduate Institute of Health Industry Technology, College of Human Ecology, Chang Gung University of Science and Technology, Taoyuan, Taiwan
| | - Tzou-Yien Lin
- Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Pediatrics, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Hu YL, Chen CM, Wang ET, Kuo HW, Shih WL, Fang CT, Liu DP, Chang LY. The secular trend of enterovirus A71 after the implementation of preventive measures in Taiwan. BMC Public Health 2022; 22:1483. [PMID: 35927656 PMCID: PMC9351194 DOI: 10.1186/s12889-022-13916-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/29/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Enterovirus A71 (EV A71) is one of the most important enteroviruses related to morbidity and mortality in children worldwide. This study aimed to analyse the secular trend of EV A71 in Taiwan from 1998 to 2020 and to evaluate the effectiveness of infection control measures. METHODS We collected the epidemiological data of EV A71 from disease surveillance systems in Taiwan. We analysed the association between the secular trend of EV A71 and preventive measures such as hand washing, case isolation, and suspension of classes. RESULTS The incidence of enterovirus infections with severe complications (EVSC) decreased from 16.25 per 100,000 children under six in 1998 to less than 9.73 per 100,000 children under six after 2012 (P = 0.0022). The mortality rate also decreased significantly, from 3.52 per 100,000 children under six in 1998 to 0 per 100,000 children under six in 2020 (P < 0.0001). The numbers of EVSC and fatalities were significantly higher in the years when EV A71 accounted for more than 10% of the annual predominant serotypes (p < 0.05). After the implementation of many non-pharmaceutical interventions in 2012, the incidence of EVSC and mortality rate decreased significantly (p < 0.001). CONCLUSIONS After implementing active enterovirus surveillance and preventive measures, we found that the incidence of EVSC and fatalities due to EV A71 in Taiwan decreased significantly from 1998 to 2020. Continuous surveillance and strengthened infection control policies are still needed in the future.
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Affiliation(s)
- Ya-Li Hu
- Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan.,Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 8, Chung Shan S. Rd., Taipei, 10041, Taiwan.,Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University and Infectious Diseases Research and Education Center, Ministry of Health and Welfare and National Taiwan University, Taipei, Taiwan
| | - Chiu-Mei Chen
- Epidemic Intelligence Center, Centers for Disease Control, No. 6, Linsen S. Rd., Taipei, 10050, Taiwan
| | - En-Tzu Wang
- Epidemic Intelligence Center, Centers for Disease Control, No. 6, Linsen S. Rd., Taipei, 10050, Taiwan
| | - Hung-Wei Kuo
- Epidemic Intelligence Center, Centers for Disease Control, No. 6, Linsen S. Rd., Taipei, 10050, Taiwan
| | - Wei-Liang Shih
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University and Infectious Diseases Research and Education Center, Ministry of Health and Welfare and National Taiwan University, Taipei, Taiwan
| | - Chi-Tai Fang
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University and Infectious Diseases Research and Education Center, Ministry of Health and Welfare and National Taiwan University, Taipei, Taiwan
| | - Ding-Ping Liu
- Epidemic Intelligence Center, Centers for Disease Control, No. 6, Linsen S. Rd., Taipei, 10050, Taiwan.
| | - Luan-Yin Chang
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 8, Chung Shan S. Rd., Taipei, 10041, Taiwan.
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Lin CY, Huang SY, Jiang CB, Peng CC, Chi H, Chiu NC. Enteroviral Rhombencephalitis with Abducens Nerve Palsy and Cardio-Pulmonary Failure in a 2-Year-Old Boy. CHILDREN 2022; 9:children9050643. [PMID: 35626820 PMCID: PMC9139552 DOI: 10.3390/children9050643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/21/2022] [Accepted: 04/27/2022] [Indexed: 11/16/2022]
Abstract
Enterovirus infection is endemic in many areas, especially in Southeast Asia. Enterovirus infection with severe complications (EVSC) is life-threatening, and timely diagnosis and management are crucial for successful management. Here, we report on a 2-year-old boy with hand, foot, and mouth disease. Myoclonic jerks developed and left abducens nerve palsy followed. Brain magnetic resonance imaging (MRI) showed rhombencephalitis. Pulmonary edema and cardiopulmonary failure developed, and intravenous immunoglobulin and extracorporeal membrane oxygenation were administered. He had a tracheostomy with home ventilator use after 64 days of hospitalization. At a 5-year follow-up, his neurodevelopment was normal with complete recovery from the abducens nerve palsy. The progress of EVSC may be rapid and fulminant, and timely diagnosis is critical for patient prognosis and outcomes. The presence of abducens nerve palsy is an indicator of enteroviral rhombencephalitis, and immediate and appropriate management is suggested.
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Affiliation(s)
- Chien-Yu Lin
- Department of Pediatrics, Hsinchu MacKay Memorial Hospital, Hsinchu 30071, Taiwan;
- Department of Medicine, MacKay Medical College, New Taipei 25160, Taiwan; (C.-B.J.); (C.-C.P.); (H.C.)
| | - Shih-Yu Huang
- Department of Internal Medicine, Hsinchu MacKay Memorial Hospital, Hsinchu 30071, Taiwan;
| | - Chuen-Bin Jiang
- Department of Medicine, MacKay Medical College, New Taipei 25160, Taiwan; (C.-B.J.); (C.-C.P.); (H.C.)
- Department of Pediatrics, MacKay Children’s Hospital, Taipei 10449, Taiwan
| | - Chun-Chih Peng
- Department of Medicine, MacKay Medical College, New Taipei 25160, Taiwan; (C.-B.J.); (C.-C.P.); (H.C.)
- Department of Pediatrics, MacKay Children’s Hospital, Taipei 10449, Taiwan
| | - Hsin Chi
- Department of Medicine, MacKay Medical College, New Taipei 25160, Taiwan; (C.-B.J.); (C.-C.P.); (H.C.)
- Department of Pediatrics, MacKay Children’s Hospital, Taipei 10449, Taiwan
| | - Nan-Chang Chiu
- Department of Medicine, MacKay Medical College, New Taipei 25160, Taiwan; (C.-B.J.); (C.-C.P.); (H.C.)
- Department of Pediatrics, MacKay Children’s Hospital, Taipei 10449, Taiwan
- Correspondence:
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Abstract
PURPOSE OF REVIEW Understanding the pathophysiology of COVID-19 and the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus that causes the disease has demonstrated the complexity of acute respiratory viruses that can cause neurologic manifestations. This article describes the most common respiratory viruses that have neurologic manifestations, with a focus on SARS-CoV-2 and COVID-19. RECENT FINDINGS In vitro and in vivo studies have better elucidated the neurotropism of various respiratory viruses. Understanding host cell receptors that mediate viral binding and entry not only demonstrates how viruses enter host cells but also provides possible mechanisms for therapeutic interventions. Elucidation of SARS-CoV-2 binding and fusion with host cells expressing the angiotensin-converting enzyme 2 (ACE2) receptor may also provide greater insights into its systemic and neurologic sequelae. Respiratory virus neurotropism and collateral injury due to concurrent inflammatory cascades result in various neurologic pathologies, including Guillain-Barré syndrome, encephalopathy, encephalitis, ischemic stroke, intracerebral hemorrhage, and seizures. SUMMARY Numerous respiratory viruses can infect the cells of the peripheral and central nervous systems, elicit inflammatory cascades, and directly and indirectly cause various neurologic manifestations. Patients with neurologic manifestations from respiratory viruses are often critically ill and require mechanical ventilation. Neurologists and neurointensivists should be familiar with the common neurologic manifestations of respiratory viruses and the unique and still-evolving sequelae associated with COVID-19.
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Tee HK, Zainol MI, Sam IC, Chan YF. Recent advances in the understanding of enterovirus A71 infection: a focus on neuropathogenesis. Expert Rev Anti Infect Ther 2021; 19:733-747. [PMID: 33183118 DOI: 10.1080/14787210.2021.1851194] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Hand, foot, and mouth disease caused by enterovirus A71 (EV-A71) is more frequently associated with neurological complications and deaths compared to other enteroviruses.Areas covered: The authors discuss current understanding of the neuropathogenesis of EV-A71 based on various clinical, human, and animal model studies. The authors discuss the important advancements in virus entry, virus dissemination, and neuroinvasion. The authors highlight the role of host immune system, host genetic factors, viral quasispecies, and heparan sulfate in EV-A71 neuropathogenesis.Expert opinion: Comparison of EV-A71 with EV-D68 and PV shows similarity in primary target sites and dissemination to the central nervous system. More research is needed to understand cellular tropisms, persistence of EV-A71, and other possible invasion routes. EV-A71 infection has varied clinical manifestations which may be attributed to multiple receptors usage. Future development of antivirals and vaccines should target neurotropic enteroviruses. Repurposing drug and immunomodulators used in combination could reduce the severity of EV-A71 infection. Only a few drugs have been tested in clinical trials, and in the absence of antiviral and vaccines (except China), active virus surveillance, good hand hygiene, and physical distancing should be advocated. A better understanding of EV-A71 neuropathogenesis is critical for antiviral and multivalent vaccines development.
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Affiliation(s)
- Han Kang Tee
- Department of Medical Microbiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mohd Izwan Zainol
- Department of Medical Microbiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - I-Ching Sam
- Department of Medical Microbiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Yoke Fun Chan
- Department of Medical Microbiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Toczylowski K, Wieczorek M, Bojkiewicz E, Wietlicka-Piszcz M, Gad B, Sulik A. Pediatric Enteroviral Central Nervous System Infections in Bialystok, Poland: Epidemiology, Viral Types, and Drivers of Seasonal Variation. Viruses 2020; 12:v12080893. [PMID: 32824117 PMCID: PMC7472221 DOI: 10.3390/v12080893] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/09/2020] [Accepted: 08/11/2020] [Indexed: 12/15/2022] Open
Abstract
Enteroviruses are common causes of infections of the central nervous system (CNS) that in temperate climates tend to peak in the summer. The aim of the study was to describe epidemiology, drivers of seasonality, and types of enteroviruses causing infections of the CNS in children in Northeastern Poland. We prospectively collected data on children hospitalized with infection of the CNS attributed to enteroviruses in Bialystok, Poland, from January 2015 to December 2019. In total, 224 children were included. Nineteen different enterovirus types were identified in isolates collected from 188 children. Coxsackie B5 (32%), echovirus 30 (20%), and echovirus 6 (14%) were the three most common types. Enteroviruses were more prevalent during the summer–fall season. Infections caused by echovirus 30 peaked early in June and coxsackievirus B5 in July, whereas echovirus 6 peaked late in October. Phylogenetic analyses of these three enterovirus types showed multiple lineages co-circulating in this region. Mean air temperatures and precipitation rates were independently associated with monthly number of cases. Considering lack of effective treatment or vaccine, easy transmission of enteroviruses between susceptible individuals, their high mutation rate and prolonged time of viral shedding, continued monitoring and surveillance are imperative to recognize enteroviral infections of the CNS and the changes in circulation of enteroviruses in Poland.
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Affiliation(s)
- Kacper Toczylowski
- Department of Pediatric Infectious Diseases, Medical University of Bialystok, Waszyngtona 17, 15-274 Bialystok, Poland; (E.B.); (A.S.)
- Correspondence: ; Tel.: +48-857-450-680
| | - Magdalena Wieczorek
- Department of Virology, National Institute of Public Health—National Institute of Hygiene, Chocimska 24, 00-791 Warsaw, Poland; (M.W.); (B.G.)
| | - Ewa Bojkiewicz
- Department of Pediatric Infectious Diseases, Medical University of Bialystok, Waszyngtona 17, 15-274 Bialystok, Poland; (E.B.); (A.S.)
| | - Magdalena Wietlicka-Piszcz
- Department of Theoretical Foundations of Biomedical Sciences and Medical Computer Science, Nicolaus Copernicus University in Torun, L. Rydygier Collegium Medicum in Bydgoszcz, 9 M. Skłodowska-Curie St., 85-094 Bydgoszcz, Poland;
| | - Beata Gad
- Department of Virology, National Institute of Public Health—National Institute of Hygiene, Chocimska 24, 00-791 Warsaw, Poland; (M.W.); (B.G.)
| | - Artur Sulik
- Department of Pediatric Infectious Diseases, Medical University of Bialystok, Waszyngtona 17, 15-274 Bialystok, Poland; (E.B.); (A.S.)
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Chen SD, Ju YT, Wei YJ, Hsieh ML, Liu CC, Wu JM, Wang JN. Timing of Endotracheal Intubation in Patients with Fulminant Enterovirus 71 Infection. MEDICINA-LITHUANIA 2020; 56:medicina56040203. [PMID: 32344662 PMCID: PMC7230837 DOI: 10.3390/medicina56040203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/17/2020] [Accepted: 04/21/2020] [Indexed: 11/16/2022]
Abstract
Background and objective: Enterovirus 71 (EV 71) infections may result in the rapid progression of cardiopulmonary failure. Early endotracheal intubation is considered to be of primary importance. However, the appropriate timing for this is still not known. The aim of this study is to investigate the timing of intubation of children with fulminant EV71 infection. Material and Methods: From March 1998 to May 2012, patients with severe EV71 infection who were admitted to the pediatric intensive care unit of the National Cheng Kung University Hospital were enrolled in this study. Medical records were retrospectively reviewed. The patients were classified into three groups in accordance with the outcome of intubation. We used rhombencephalitis grading to describe the neurological presentation of these patients. The study was approved by the institutional review board. Results: There were a total of 105 patients enrolled. Of these, 77 patients were in Grade I, and only three of them needed intubation, who were, however, soon extubated within 24 h. There were 10 patients in Grade II; nine of them needed intubation. In total, 18 patients belonged to Grade III, and all of them need to be intubated. We then compared the outcome of intubation of grades II and III. There was only one patient out of the nine patients in grade II who experienced failed extubation due to the progression of the disease. Among grade III patients, only four patients were successfully extubated. We also listed clinical parameters to determine which one could be a sign that indicated intubation. Comparing the favorable outcomes, cranial nerve involvement was a good indicator for the timing of intubation. Conclusions: This study showed that early intubation in Grade II provides favorable outcomes and improves morbidity and mortality. We also found that if cranial nerve involvement was present, then early intubation is indicated.
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Affiliation(s)
- Shen-Dar Chen
- Department of Pediatrics, Dalin Tzu Chi hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi 62247, Taiwan;
| | - Ying-Tzu Ju
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70421, Taiwan; (Y.-T.J.); (Y.-J.W.); (M.-L.H.); (C.-C.L.); (J.-M.W.)
| | - Yu-Jen Wei
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70421, Taiwan; (Y.-T.J.); (Y.-J.W.); (M.-L.H.); (C.-C.L.); (J.-M.W.)
| | - Min-Ling Hsieh
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70421, Taiwan; (Y.-T.J.); (Y.-J.W.); (M.-L.H.); (C.-C.L.); (J.-M.W.)
| | - Ching-Chuan Liu
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70421, Taiwan; (Y.-T.J.); (Y.-J.W.); (M.-L.H.); (C.-C.L.); (J.-M.W.)
| | - Jing-Ming Wu
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70421, Taiwan; (Y.-T.J.); (Y.-J.W.); (M.-L.H.); (C.-C.L.); (J.-M.W.)
| | - Jieh-Neng Wang
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70421, Taiwan; (Y.-T.J.); (Y.-J.W.); (M.-L.H.); (C.-C.L.); (J.-M.W.)
- Correspondence: ; Tel.: +886-6-2353535 (ext. 4189)
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Yang X, Li Y, Zhang C, Zhan W, Xie J, Hu S, Chai H, Liu P, Zhao H, Tang B, Chen K, Yu J, Yin A, Luo M. Clinical features and phylogenetic analysis of severe hand-foot-and-mouth disease caused by Coxsackievirus A6. INFECTION GENETICS AND EVOLUTION 2020; 77:104054. [DOI: 10.1016/j.meegid.2019.104054] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 09/24/2019] [Accepted: 09/27/2019] [Indexed: 12/17/2022]
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10
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Tseng JJ, Lin CH, Lin MC. Long-Term Outcomes of Pediatric Enterovirus Infection in Taiwan: A Population-Based Cohort Study. Front Pediatr 2020; 8:285. [PMID: 32596191 PMCID: PMC7303813 DOI: 10.3389/fped.2020.00285] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 05/06/2020] [Indexed: 12/12/2022] Open
Abstract
Introduction: The major burden of diseases in childhood has shifted from infectious diseases to chronic health conditions in recent decades. Although the rates of infectious diseases have decreased, the incidence of chronic diseases stemming from infectious agents continues to grow. Enterovirus is a major infectious disease of childhood and has been linked to numerous chronic diseases. We analyzed population-based data from Taiwan's National Health Insurance Research Database (NHIRD) to investigate the correlations between enterovirus infection and major chronic health conditions in children. Method: Children diagnosed with enterovirus (EV) infection during 1999-2003 were identified from the Longitudinal Health Insurance Database 2000 (LHID 2000), a subdataset of Taiwan's National Health Insurance Research Database (NHIRD). A total of 14,168 patients were selected after excluding patients with existing chronic diseases and missing data. Another 14,168 children matched by age and sex were selected as the control group. Five primary outcomes, including attention deficit and hyperactivity disorder (ADHD), epilepsy, asthma, allergic rhinitis, and atopic dermatitis, were recorded. Results: The risks of ADHD, asthma, allergic rhinitis, and epilepsy were significantly increased in the EV group compared with the control group. The risk of atopic dermatitis was significantly increased in the crude model. However, there were no significant differences in the adjusted model. The risks of ADHD, asthma, allergic rhinitis, and epilepsy were also significantly increased in patients with severe EV infection compared with patients with non-severe EV infection. Conclusion: Chronic diseases, such as ADHD, epilepsy, asthma, allergic rhinitis, and atopic dermatitis were shown to be associated with enterovirus infection during childhood. EV infection during early childhood might have long-term public health implications and thus prevention strategies should be implemented.
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Affiliation(s)
- Jui-Ju Tseng
- Children's Medical Center, Taichung Veterans General Hospital, Taichung, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chien-Heng Lin
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ming-Chih Lin
- Children's Medical Center, Taichung Veterans General Hospital, Taichung, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Food and Nutrition, Providence University, Taichung, Taiwan
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Chiu ML, Luo ST, Chen YY, Chung WY, Duong V, Dussart P, Chan YF, Perera D, Ooi MH, Thao NTT, Truong HK, Lee MS. Establishment of Asia-Pacific Network for Enterovirus Surveillance. Vaccine 2019; 38:1-9. [PMID: 31679864 DOI: 10.1016/j.vaccine.2019.09.111] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 09/16/2019] [Accepted: 09/30/2019] [Indexed: 12/11/2022]
Abstract
Enteroviruses (EV), the major pathogens of hand, foot, and mouth disease (HFMD) and herpangina, affect millions of children each year. Most human enteroviruses cause self-limited infections except polioviruses, enterovirus A71 (EV-A71), enterovirus D68 (EV-D68), and several echoviruses (Echo) and coxsackieviruses (CV). Especially, EV-A71 has repeatedly caused large-scale outbreaks in the Asia-Pacific region since 1997. Some Asian countries have experienced cyclical outbreaks of severe EV-A71 infections and initiated development of EV-A71 vaccines. Five EV-A71 vaccine candidates have been clinically evaluated and three of them were approved for marketing in China. However, none of the China-approved products seek marketing approval in other countries. This situation supports a role for collaboration among Asian countries to facilitate clinical trials and licensure of EV-A71 vaccines. Additionally, enterovirus D68 outbreaks have been reported in the US and Taiwan currently and caused severe complications and deaths. Hence, an Asia-Pacific Network for Enterovirus Surveillance (APNES) has been established to estimate disease burden, understand virus evolution, and facilitate vaccine development through harmonizing laboratory diagnosis and data collection. Founded in 2017, the APNES is comprised of internationally recognized experts in the field of enterovirus in Asian countries working to raise awareness of this potentially fatal and debilitating disease. This article demonstrated the summaries of the first expert meeting, 2017 International Workshop on Enterovirus Surveillance and Vaccine Development, held by APNES in Taipei, Taiwan, March 2017.
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Affiliation(s)
- Mu-Lin Chiu
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Zhunan, Taiwan
| | - Shu-Ting Luo
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Zhunan, Taiwan
| | - Ya-Yen Chen
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Zhunan, Taiwan
| | - Wan Yu Chung
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Zhunan, Taiwan
| | - Veasna Duong
- Virology Unit, Institut Pasteur du Cambodge, Cambodia
| | | | - Yoke-Fun Chan
- Department of Medical Microbiology, Faculty of Medicine, University Malaya, Malaysia
| | - David Perera
- Institute of Health & Community Medicine, Universiti Malaysia Sarawak, Malaysia
| | - Mong How Ooi
- Institute of Health & Community Medicine, Universiti Malaysia Sarawak, Malaysia; Sarawak General Hospital, Sarawak, Malaysia
| | | | - Huu Khanh Truong
- Department of Infectious Diseases, Children Hospital 1, Ho Chi Minh City, Viet Nam
| | - Min-Shi Lee
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Zhunan, Taiwan.
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12
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Chang LY, Lin HY, Gau SSF, Lu CY, Hsia SH, Huang YC, Huang LM, Lin TY. Enterovirus A71 neurologic complications and long-term sequelae. J Biomed Sci 2019; 26:57. [PMID: 31395054 PMCID: PMC6688366 DOI: 10.1186/s12929-019-0552-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 08/06/2019] [Indexed: 11/10/2022] Open
Abstract
During recent 20 years, enterovirus A71 (EV-A71) has emerged as a major concern among pediatric infectious diseases, particularly in the Asia-Pacific region. The clinical manifestations of EV-A71 include uncomplicated hand, foot, and mouth disease, herpanina or febrile illness and central nervous system (CNS) involvement such as aseptic meningitis, myoclonic jerk, polio-like syndrome, encephalitis, encephalomyelitis and cardiopulmonary failure due to severe rhombencephalitis. In follow-up studies of patients with EV-A 71 CNS infection, some still have hypoventilation and need tracheostomy with ventilator support, some have dysphagia and need nasogastric tube or gastrostomy feeding, some have limb weakness/astrophy, cerebellar dysfunction, neurodevelopmental delay, lower cognition, or attention deficiency hyperactivity disorder. Long term sequelae may be related to greater severity of CNS involvement or neuron damage, hypoxia and younger age of onset.
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Affiliation(s)
- Luan-Yin Chang
- Departments of Pediatrics, National Taiwan University Children's Hospital, College of Medicine, National Taiwan University, No. 8, Chung-Shan South Road, Taipei, Taiwan.
| | - Hsiang-Yuan Lin
- Psychiatry, National Taiwan University Children's Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Susan Shur-Fen Gau
- Psychiatry, National Taiwan University Children's Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chin-Yu Lu
- Departments of Pediatrics, National Taiwan University Children's Hospital, College of Medicine, National Taiwan University, No. 8, Chung-Shan South Road, Taipei, Taiwan
| | - Shao-Hsuan Hsia
- Departments of Pediatrics, Chang Gung Children's Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Yhu-Chering Huang
- Departments of Pediatrics, Chang Gung Children's Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Li-Min Huang
- Departments of Pediatrics, National Taiwan University Children's Hospital, College of Medicine, National Taiwan University, No. 8, Chung-Shan South Road, Taipei, Taiwan
| | - Tzou-Yien Lin
- Departments of Pediatrics, Chang Gung Children's Hospital, Chang Gung University, Taoyuan, Taiwan
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Aw‐Yong KL, NikNadia NMN, Tan CW, Sam I, Chan YF. Immune responses against enterovirus A71 infection: Implications for vaccine success. Rev Med Virol 2019; 29:e2073. [DOI: 10.1002/rmv.2073] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 05/24/2019] [Accepted: 05/31/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Kam Leng Aw‐Yong
- Department of Medical Microbiology, Faculty of MedicineUniversity of Malaya Kuala Lumpur Malaysia
| | - Nik Mohd Nasir NikNadia
- Department of Medical Microbiology, Faculty of MedicineUniversity of Malaya Kuala Lumpur Malaysia
| | - Chee Wah Tan
- Department of Medical Microbiology, Faculty of MedicineUniversity of Malaya Kuala Lumpur Malaysia
| | - I‐Ching Sam
- Department of Medical Microbiology, Faculty of MedicineUniversity of Malaya Kuala Lumpur Malaysia
| | - Yoke Fun Chan
- Department of Medical Microbiology, Faculty of MedicineUniversity of Malaya Kuala Lumpur Malaysia
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Taravilla CN, Pérez-Sebastián I, Salido AG, Serrano CV, Extremera VC, Rodríguez AD, Marín LL, Sanz MA, Traba OMS, González AS. Enterovirus A71 Infection and Neurologic Disease, Madrid, Spain, 2016. Emerg Infect Dis 2019; 25. [PMID: 30560775 PMCID: PMC6302576 DOI: 10.3201/eid2501.181089] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
For children with brainstem encephalitis or encephalomyelitis, clinicians should look for enterovirus and not limit testing to cerebrospinal fluid. We conducted an observational study from January 2016 through January 2017 of patients admitted to a reference pediatric hospital in Madrid, Spain, for neurologic symptoms and enterovirus infection. Among the 30 patients, the most common signs and symptoms were fever, lethargy, myoclonic jerks, and ataxia. Real-time PCR detected enterovirus in the cerebrospinal fluid of 8 patients, nasopharyngeal aspirate in 17, and anal swab samples of 5. The enterovirus was genotyped for 25 of 30 patients; enterovirus A71 was the most common serotype (21/25) and the only serotype detected in patients with brainstem encephalitis or encephalomyelitis. Treatment was intravenous immunoglobulins for 21 patients and corticosteroids for 17. Admission to the pediatric intensive care unit was required for 14 patients. All patients survived. At admission, among patients with the most severe disease, leukocytes were elevated. For children with brainstem encephalitis or encephalomyelitis, clinicians should look for enterovirus and not limit testing to cerebrospinal fluid.
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15
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Kuo KC, Yeh YC, Huang YH, Chen IL, Lee CH. Understanding physician antibiotic prescribing behavior for children with enterovirus infection. PLoS One 2018; 13:e0202316. [PMID: 30192893 PMCID: PMC6128467 DOI: 10.1371/journal.pone.0202316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 08/01/2018] [Indexed: 11/22/2022] Open
Abstract
Background Our previous study demonstrated that pediatricians prescribe antibiotics without proper clinical justification to patients with enterovirus infection, although antibiotics are not effective in treating the infections caused by these viruses. To improve the quality of healthcare, we aim to evaluate the association of clinical and demographic characteristics of patients and further to identify the determining factors for prescribing antibiotics to children experiencing enterovirus infection. Methods We retrospectively reviewed the medical records of children who were hospitalized between January 2008 and December 2016 with a diagnosis of herpangina or hand-foot-mouth disease (HFMD). We identified those children who were prescribed antibiotics for at least 24 hours during admission. We conducted a retrospective descriptive study to analyze data in order to determine the factors associated with pediatrician antibiotics prescribing for enterovirus infection. Results In the nine years of study period, the rate of antibiotics use was about 13% in these patients. A total of 3659 patients were enrolled during 2008~2012 and analyzed in detail. Elevated levels of C-reactive protein (CRP) and presence of leukocytosis in blood (WBC) were both significantly associated with pediatrician antibiotic prescribing for enterovirus infection (p<0.001). Between different specialistic devisions, there was significantly different proportion of antibiotics utilization for patients. In further analysis of antibiotics prescribing by Receiver operating characteristic (ROC) curve method, the level of CRP significantly had more the area under curve (0.708) compared with the count of WBC (p<0.05). Conclusions The present study indicates that higher serum level of CRP is strongly associated with pediatricians prescribing antibiotics for children experiencing herpangina or HFMD. Antibiotic prescribing is a complex process. Pediatricians should be more judicious in decision-making time by their specialistics. Our findings would shed new light on process and allay the concern about inappropriate antibiotics.
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Affiliation(s)
- Kuang-Che Kuo
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yi-Chun Yeh
- Department of Psychiatry, Kaohsiung Medical University Hospital, Department of Psychiatry, Faculty of Medicine, Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ying-Hsien Huang
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - I-Ling Chen
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chen-Hsiang Lee
- Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- * E-mail:
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16
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Pan YZ, Song CL, Guo YJ, Wang LL, Cui YJ, Ren YF. [Effects of L-carnitine on serum levels of brain natriuretic peptide and N-terminal pro-brain natriuretic peptide and cardiac function in children with severe hand-foot-mouth disease]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2018; 20:635-640. [PMID: 30111472 PMCID: PMC7389759 DOI: 10.7499/j.issn.1008-8830.2018.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 07/11/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To observe the effects of L-carnitine treatment on serum levels of brain natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) and cardiac function in children with heart dysfunction and severe hand-foot-mouth disease (HFMD). METHODS A total of 120 children with severe HFMD were enrolled and randomly and equally divided into routine treatment group and L-carnitine treatment group. Thirty healthy children served as the control group. HFMD patients were given anti-fever and antiviral treatment as the basic treatment, while the patients in the L-carnitine treatment group were given L-carnitine as an adjuvant treatment to the basic treatment. Treatment outcomes were observed in the two groups. For all the subjects, serum levels of BNP and NT-proBNP and cardiac function parameters including left ventricular ejection fraction (LVEF), fractional shortening (FS), and cardiac index (CI) were measured at different time points before and after treatment. RESULTS Before treatment, HFMD patients had significantly higher serum levels of BNP and NT-proBNP and heart rate but significantly lower LVEF, FS, and CI compared with the control group (P<0.05). After treatment, the L-carnitine treatment group had a significantly higher response rate than the routine treatment group (P<0.05). After 3 days of treatment, the serum levels of BNP and NT-proBNP, LVEF, FS, and CI were significantly reduced in the L-carnitine group (P<0.05); the L-carnitine group had significantly lower serum levels of BNP and NT-proBNP, LVEF, FS, and CI than the routine treatment group (P<0.05); there were no significant differences in the serum levels of BNP and NT-proBNP, LVEF, FS, or CI between the L-carnitine treatment and control groups (P>0.05). After 5 days of treatment, there were no significant differences in the serum levels of BNP and NT-proBNP, LVEF, FS, or CI between the L-carnitine treatment and routine treatment groups (P>0.05). Heart rate recovery was significantly slower in the routine treatment group than in the L-carnitine treatment group (P<0.05). CONCLUSIONS As an adjuvant therapy for severe HFMD, L-carnitine treatment has satisfactory short-term efficacy in reducing the serum levels of BNP and NT-proBNP and improving cardiac function, thus improving clinical outcomes.
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Affiliation(s)
- Yan-Zhu Pan
- Department of Emergency and Critical Medicine, Children's Hospital of Zhengzhou University/Children's Hospital of Henan Province/Zhengzhou Children's Hospital/Zhengzhou Children's Key Laboratory of Critical Care Medicine, Zhengzhou 450003, China.
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17
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Abstract
PURPOSE OF REVIEW The focus of this review is on enterovirus (EV)-associated acute flaccid paralysis (AFP) due to spinal cord anterior horn cell disease. Emphasis is placed on the epidemiology, pathogenesis, diagnosis, treatment, and outcome of AFP caused by polioviruses, vaccine-derived polioviruses, EV-D68, and EV-A71. RECENT FINDINGS Since the launch of The Global Polio Eradication Initiative in 1988, the worldwide incidence of polio has been reduced by 99.9%, with small numbers of poliomyelitis cases being reported only in Afghanistan, Pakistan, and Nigeria. With the planned phaseout of oral polio vaccine, vaccine-associated poliomyelitis is also expected to be eliminated. In their place, other EVs, chiefly EV-D68 and EV-A71, have emerged as the principal causes of AFP. There is evidence that the emergence of EV-D68 as a cause of severe respiratory disease and AFP was due to recent genetic virus evolution. Antiviral medications targeting EV-D68, EV-A71, and other EVs will likely be available in the near future. An effective EV-A71 vaccine has been developed, and preliminary investigations suggest an EV-D68 vaccine could be on the horizon. The eradication of poliomyelitis and vaccine-associated poliomyelitis is near, after which other EVs, presently EV-D68 and EV-A71, will be the principle viral causes of AFP. Moving forward, it is essential that EV outbreaks, in particular those associated with neurologic complications, be investigated carefully and the causal strains identified, so that treatment and prevention efforts can be rapidly developed and implemented.
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Affiliation(s)
- Ari Bitnun
- Division of Infectious Diseases, The Hospital for Sick Children and Department of Pediatrics, University of Toronto, Toronto, ON, M5G 1X8, Canada.
| | - E Ann Yeh
- Division of Neurology, The Hospital for Sick Children and Department of Pediatrics, Division of Neurosciences and Mental Health, SickKids Research Institute, University of Toronto, Toronto, Canada
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18
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The Risk Factors of Acquiring Severe Hand, Foot, and Mouth Disease: A Meta-Analysis. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2018; 2018:2751457. [PMID: 30046361 PMCID: PMC6038695 DOI: 10.1155/2018/2751457] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 04/22/2018] [Indexed: 11/30/2022]
Abstract
Objectives The incidence of severe hand, foot, and mouth disease (HFMD) is not low, especially in mainland China in almost every year recently. In this study, we conducted a meta-analysis to generate large-scale evidence on the risk factors of severe HFMD to provide suggestions on prevention and controlling. Methods PubMed, Web of Science, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfang (Chinese) were searched to identify relevant articles. All analyses were performed using Stata 14.0. Results We conducted a meta-analysis of 11 separate studies. Fever (odds ratio (OR) 7.396, 95% confidence interval (CI) 3.565–15.342), fever for more than 3 days (OR 5.773, 95% CI 4.199–7.939), vomiting (OR 6.023, 95% CI 2.598–13.963), limb trembling (OR 42.348, 95% CI 11.765–152.437), dyspnea (OR 12.869, 95% CI 1.948–85.017), contact with HFMD children (OR 5.326, 95% CI 1.263–22.466), rashes on the hips (OR 1.650, 95% CI 1.303–2.090), pathologic reflexes (OR 3057.064, 95% CI 494.409–19000), Lethargy (OR 31.791, 95% CI 3.369–300.020), convulsions (OR 23.652, 95% CI 1.973–283.592), and EV71 infection (OR 9.056, 95% CI 4.102–19.996) were significantly related to the risk of severe HFMD. We did not find an association between female sex (OR 0.918, 95% CI 0.738–1.142), scatter-lived children (OR 1.347, 95% CI 0.245–7.397), floating population (OR 0.847, 95% CI 0.202–3.549), rash on the hands (OR 0.740, 95% CI 0.292–1.874), rash on the foot (OR 0.905, 95% CI 0.645–1.272), the level of the clinic visited first (below the country level) (OR 5.276, 95% CI 0.781–35.630), breast feeding (OR 0.523, 95% CI 0.167–1.643), and the risk of severe HFMD. Conclusions Fever, fever for more than 3 days, vomiting, limb trembling, dyspnea, contact with HFMD children, rashes on the hips, pathologic reflexes, lethargy, convulsions, and EV71 infection are risk factors for severe HFMD.
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Wang W, Song J, Wang J, Li Y, Deng H, Li M, Gao N, Zhai S, Dang S, Zhang X, Jia X. Cost-effectiveness of a national enterovirus 71 vaccination program in China. PLoS Negl Trop Dis 2017; 11:e0005899. [PMID: 28892475 PMCID: PMC5608421 DOI: 10.1371/journal.pntd.0005899] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 09/21/2017] [Accepted: 08/23/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND AIMS Enterovirus 71 (EV71) has caused great morbidity, mortality, and use of health service in children younger than five years in China. Vaccines against EV71 have been proved effective and safe by recent phase 3 trials and are now available in China. The purpose of this study was to evaluate the health impact and cost-effectiveness of a national EV71 vaccination program in China. METHODS Using Microsoft Excel, a decision model was built to calculate the net clinical and economic outcomes of EV71 vaccination compared with no EV71 vaccination in a birth cohort of 1,000,000 Chinese children followed for five years. Model parameters came from published epidemiology, clinical and cost data. RESULTS In the base-case, vaccination would annually avert 37,872 cases of hand, foot and mouth disease (HFMD), 2,629 herpangina cases, 72,900 outpatient visits, 6,363 admissions to hospital, 29 deaths, and 945 disability adjusted life years. The break-even price of the vaccine was $5.2/dose. When the price was less than $8.3 or $14.6/dose, the vaccination program would be highly cost-effective or cost-effective, respectively (incremental cost-effectiveness ratio less than or between one to three times China GDP per capita, respectively). In one-way sensitivity analyses, the HFMD incidence was the only influential parameter at the price of $5/dose. CONCLUSIONS Within the price range of current routine vaccines paid by the government, a national EV71 vaccination program would be cost-saving or highly cost-effective to prevent EV71 related morbidity, mortality, and use of health service among children younger than five years in China. Policy makers should consider including EV71 vaccination as part of China's routine childhood immunization schedule.
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Affiliation(s)
- Wenjun Wang
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Jianwen Song
- Department of Dermatology, Xi’an Children’s Hospital, Xi’an, China
| | - Jingjing Wang
- Department of Pediatrics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yaping Li
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Huiling Deng
- The Second Department of Infectious Diseases, Xi’an Children’s Hospital, Xi’an, China
| | - Mei Li
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Ning Gao
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Song Zhai
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Shuangsuo Dang
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- * E-mail:
| | - Xin Zhang
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Xiaoli Jia
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
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Casas-Alba D, de Sevilla MF, Valero-Rello A, Fortuny C, García-García JJ, Ortez C, Muchart J, Armangué T, Jordan I, Luaces C, Barrabeig I, González-Sanz R, Cabrerizo M, Muñoz-Almagro C, Launes C. Outbreak of brainstem encephalitis associated with enterovirus-A71 in Catalonia, Spain (2016): a clinical observational study in a children's reference centre in Catalonia. Clin Microbiol Infect 2017; 23:874-881. [PMID: 28344164 DOI: 10.1016/j.cmi.2017.03.016] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 03/15/2017] [Accepted: 03/18/2017] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To describe the characteristics of an outbreak of brainstem encephalitis and encephalomyelitis related to enterovirus (EV) infection in Catalonia (Spain), a setting in which these manifestations were uncommon. METHODS Clinical and microbiological data were analysed from patients with neurological symptoms associated with EV detection admitted to a reference paediatric hospital between April and June 2016. RESULTS Fifty-seven patients were included. Median age was 27.7 months (p25-p75 17.1-37.6). Forty-one (72%) were diagnosed with brainstem encephalitis, seven (12%) with aseptic meningitis, six (11%) with encephalitis, and three (5%) with encephalomyelitis (two out of three with cardiopulmonary failure). Fever, lethargy, and myoclonic jerks were the most common symptoms. Age younger than 12 months, higher white-blood-cell count, and higher procalcitonin levels were associated with cardiopulmonary failure. Using a PAN-EV real-time PCR, EV was detected in faeces and/or nasopharyngeal aspirate in all the patients, but it was found in cerebrospinal fluid only in patients with aseptic meningitis. EV was genotyped in 47 out of 57 and EV-A71 was identified in 40 out of 47, being the only EV type found in patients with brainstem symptoms. Most of the detected EV-A71 strains were subgenogroup C1. Intravenous immunoglobulins were used in 34 patients. Eight cases (14%) were admitted to the intensive care unit. All the patients but three, those with encephalomyelitis, showed a good clinical course and had no significant sequelae. No deaths occurred. CONCLUSIONS The 2016 outbreak of brainstem encephalitis in Catalonia was associated with EV-A71 subgenogroup C1. Despite the clinical manifestations of serious disease, a favourable outcome was observed in the majority of patients.
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Affiliation(s)
- D Casas-Alba
- Department of Paediatrics, Hospital Sant Joan de Deu (University of Barcelona), Spain
| | - M F de Sevilla
- Department of Paediatrics, Hospital Sant Joan de Deu (University of Barcelona), Spain; Paediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; CIBER en Epidemiología y Salud Pública, CIBERESP, Spain
| | - A Valero-Rello
- Paediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; Department of Molecular Microbiology, Hospital Sant Joan de Deu, Spain
| | - C Fortuny
- Department of Paediatrics, Hospital Sant Joan de Deu (University of Barcelona), Spain; Paediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; CIBER en Epidemiología y Salud Pública, CIBERESP, Spain
| | - J-J García-García
- Department of Paediatrics, Hospital Sant Joan de Deu (University of Barcelona), Spain; Paediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; CIBER en Epidemiología y Salud Pública, CIBERESP, Spain
| | - C Ortez
- Department of Paediatric Neurology, Hospital Sant Joan de Deu (University of Barcelona), Spain
| | - J Muchart
- Department of Diagnostic Imaging, Hospital Sant Joan de Deu (University of Barcelona), Spain
| | - T Armangué
- Department of Paediatric Neurology, Hospital Sant Joan de Deu (University of Barcelona), Spain
| | - I Jordan
- Paediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; CIBER en Epidemiología y Salud Pública, CIBERESP, Spain; Paediatric Intensive Care Unit, Hospital Sant Joan de Deu (University of Barcelona), Spain
| | - C Luaces
- Emergency Department, Hospital Sant Joan de Deu (University of Barcelona), Spain
| | - I Barrabeig
- Epidemiological Surveillance Unit of Health Region, Barcelona-South, Public Health Agency of Catalonia, Hospitalet de Llobregat, Spain
| | - R González-Sanz
- Enterovirus Unit, National Centre for Microbiology, Institute of Public Health "Carlos III", Madrid, Spain
| | - M Cabrerizo
- Enterovirus Unit, National Centre for Microbiology, Institute of Public Health "Carlos III", Madrid, Spain
| | - C Muñoz-Almagro
- Paediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; CIBER en Epidemiología y Salud Pública, CIBERESP, Spain; Emergency Department, Hospital Sant Joan de Deu (University of Barcelona), Spain; School of Medicine, Universitat Internacional de Catalunya, Barcelona, Spain
| | - C Launes
- Department of Paediatrics, Hospital Sant Joan de Deu (University of Barcelona), Spain; Paediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; CIBER en Epidemiología y Salud Pública, CIBERESP, Spain.
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Rao S, Elkon B, Flett KB, Moss AFD, Bernard TJ, Stroud B, Wilson KM. Long-Term Outcomes and Risk Factors Associated With Acute Encephalitis in Children. J Pediatric Infect Dis Soc 2017; 6:20-27. [PMID: 26553786 DOI: 10.1093/jpids/piv075] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 09/29/2015] [Indexed: 11/12/2022]
Abstract
BACKGROUND Factors associated with poor outcomes of children with encephalitis are not well known. We sought to determine whether electroencephalography (EEG) findings, magnetic resonance imaging (MRI) abnormalities, or the presence of seizures at presentation were associated with poor outcomes. METHODS A retrospective review of patients aged 0 to 21 years who met criteria for a diagnosis of encephalitis admitted between 2000 and 2010 was conducted. Parents of eligible children were contacted and completed 2 questionnaires that assessed current physical and emotional quality of life and neurological deficits at least 1 year after discharge. RESULTS During the study period, we identified 142 patients with an International Classification of Diseases 9th Revision diagnosis of meningitis, meningoencephalitis, or encephalitis. Of these patients, 114 met criteria for a diagnosis of encephalitis, and 76 of these patients (representing 77 hospitalizations) had complete data available. Forty-nine (64%) patients were available for follow-up. Patients admitted to the intensive care unit were more likely to have abnormal EEG results (P = .001). The presence of seizures on admission was associated with ongoing seizure disorder at follow-up. One or more years after hospitalization, 78% of the patients had persistent symptoms, including 35% with seizures. Four (5%) of the patients died. Abnormal MRI findings and the number of abnormal findings on initial presentation were associated with lower quality-of-life scores. CONCLUSIONS Encephalitis leads to significant morbidity and death, and incomplete recovery is achieved in the majority of hospitalized patients. Abnormal EEG results were found more frequently in critically ill children, patients with abnormal MRI results had lower quality-of-life scores on follow-up, and the presence of seizures on admission was associated with ongoing seizure disorder and lower physical quality-of-life scores.
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Affiliation(s)
- Suchitra Rao
- Division of Hospital Medicine and Infectious Diseases.,Department of Pediatrics, Children's Hospital Colorado, Aurora
| | - Benjamin Elkon
- Department of Pediatrics, Children's Hospital Colorado, Aurora
| | - Kelly B Flett
- Division of Pediatric Infectious Diseases, Department of Medicine, Boston Children's Hospital, Massachusetts
| | - Angela F D Moss
- Adult and Child Center for Health Outcomes and Delivery Science, University of Colorado School of Medicine, and
| | - Timothy J Bernard
- Department of Pediatrics, Children's Hospital Colorado, Aurora.,Divisions of Neurology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora
| | - Britt Stroud
- Department of Neurology, Lee Memorial Health System, Fort Myers, Florida
| | - Karen M Wilson
- Hospital Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora
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A Case-control Study on Risk Factors for Severe Hand, Foot and Mouth Disease. Sci Rep 2017; 7:40282. [PMID: 28084311 PMCID: PMC5233949 DOI: 10.1038/srep40282] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 12/02/2016] [Indexed: 11/29/2022] Open
Abstract
The objective of this study was to identify potential risk factors for severe hand, foot and mouth disease (HFMD). In this case-control study, 459 severe HFMD patients and 246 mild HFMD patients from Guangdong province and Henan province, China were included. Data comprising demographic characteristics, clinical symptoms and signs, laboratory findings and other factors were collected. Univariate analysis revealed 30 factors associated with severe cases. Further multivariate analysis indicated four independent risk factors: fatigue (p < 0.01, odd ratio [OR] = 204.7), the use of glucocorticoids (p = 0.03, OR = 10.44), the use of dehydrant drugs (p < 0.01, OR = 73.7) and maculopapular rash (p < 0.01, OR = 84.4); and one independent protective factor: herpes or ulcers in mouth (p = 0.01, OR = 0.02). However, more systematic research and validation are needed to understand the underlying risk factors for severe HFMD.
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23
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Lee KY. Enterovirus 71 infection and neurological complications. KOREAN JOURNAL OF PEDIATRICS 2016; 59:395-401. [PMID: 27826325 PMCID: PMC5099286 DOI: 10.3345/kjp.2016.59.10.395] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Revised: 10/14/2015] [Accepted: 10/14/2015] [Indexed: 11/27/2022]
Abstract
Since the outbreak of the enterovirus 71 (EV71) infection in Malaysia in 1997, large epidemics of EV71 have occurred in the Asia-Pacific region. Many children and infants have died from serious neurological complications during these epidemics, and EV71 infection has become a serious public health problem in these areas. EV71 infection causes hand, foot and mouth disease (HFMD) in children, and usually resolves spontaneously. However, EV71 occasionally involves the central nervous system (CNS), and induces diverse neurological complications such as brainstem encephalitis, aseptic meningitis, and acute flaccid paralysis. Among those complications, brainstem encephalitis is the most critical neurological manifestation because it can cause neurogenic pulmonary hemorrhage/edema leading to death. The characteristic clinical symptoms such as myoclonus and ataxia, cerebrospinal fluid (CSF) pleocytosis, and brainstem lesions on magnetic resonance imaging, in conjunction with the skin rash of HFMD and the isolation of EV71 from a stool, throat-swab, or CSF sample are typical findings indicating CNS involvement of EV71 infection. Treatment with intravenous immunoglobulin and milrinone are recommended in cases with severe neurological complications from EV71 infection, such as brainstem encephalitis. Despite the recent discovery of receptors for EV71 in human cells, such as the scavenger receptor B2 and P-selection glycoprotein ligand 1, it is not known why EV71 infection predominantly involves the brainstem. Recently, 3 companies in China have completed phase III clinical trials of EV71 vaccines. However, the promotion and approval of these vaccines in various countries are problems yet to be resolved.
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Affiliation(s)
- Kyung Yeon Lee
- Department of Pediatrics, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
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Lee KY, Lee MS, Kim DB. Neurologic Manifestations of Enterovirus 71 Infection in Korea. J Korean Med Sci 2016; 31:561-7. [PMID: 27051240 PMCID: PMC4810339 DOI: 10.3346/jkms.2016.31.4.561] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 12/18/2015] [Indexed: 11/29/2022] Open
Abstract
Enterovirus 71 frequently involves the central nervous system and may present with a variety of neurologic manifestations. Here, we aimed to describe the clinical features, magnetic resonance imaging (MRI) findings, and cerebrospinal fluid (CSF) profiles of patients presenting with neurologic complications of enterovirus 71 infection. We retrospectively reviewed the records of 31 pediatric patients hospitalized with acute neurologic manifestations accompanied by confirmed enterovirus 71 infection at Ulsan University Hospital between 2010 and 2014. The patients' mean age was 2.9 ± 5.5 years (range, 18 days to 12 years), and 80.6% of patients were less than 4 years old. Based on their clinical features, the patients were classified into 4 clinical groups: brainstem encephalitis (n = 21), meningitis (n = 7), encephalitis (n = 2), and acute flaccid paralysis (n = 1). The common neurologic symptoms included myoclonus (58.1%), lethargy (54.8%), irritability (54.8%), vomiting (48.4%), ataxia (38.7%), and tremor (35.5%). Twenty-five patients underwent an MRI scan; of these, 14 (56.0%) revealed the characteristic increased T2 signal intensity in the posterior region of the brainstem and bilateral cerebellar dentate nuclei. Twenty-six of 30 patients (86.7%) showed CSF pleocytosis. Thirty patients (96.8%) recovered completely without any neurologic deficits; one patient (3.2%) died due to pulmonary hemorrhage and shock. In the present study, brainstem encephalitis was the most common neurologic manifestation of enterovirus 71 infection. The characteristic clinical symptoms such as myoclonus, ataxia, and tremor in conjunction with CSF pleocytosis and brainstem lesions on MR images are pathognomonic for diagnosis of neurologic involvement by enterovirus 71 infection.
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Affiliation(s)
- Kyung Yeon Lee
- Department of Pediatrics, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Myoung Sook Lee
- Department of Pediatrics, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Dong Bin Kim
- Department of Pediatrics, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
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Ong KC, Wong KT. Understanding Enterovirus 71 Neuropathogenesis and Its Impact on Other Neurotropic Enteroviruses. Brain Pathol 2015; 25:614-24. [PMID: 26276025 PMCID: PMC8029433 DOI: 10.1111/bpa.12279] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 06/19/2015] [Indexed: 01/27/2023] Open
Abstract
Enterovirus A71 (EV-A71) belongs to the species group A in the Enterovirus genus within the Picornaviridae family. EV-A71 usually causes self-limiting hand, foot and mouth disease or herpangina but rarely causes severe neurological complications such as acute flaccid paralysis and encephalomyelitis. The pathology and neuropathogenesis of these neurological syndromes is beginning to be understood. EV-A71 neurotropism for motor neurons in the spinal cord and brainstem, and other neurons, is mainly responsible for central nervous system damage. This review on the general aspects, recent developments and advances of EV-A71 infection will focus on neuropathogenesis and its implications on other neurotropic enteroviruses, such as poliovirus and the newly emergent Enterovirus D68. With the imminent eradication of poliovirus, EV-A71 is likely to replace it as an important neurotropic enterovirus of worldwide importance.
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Affiliation(s)
- Kien Chai Ong
- Department of Biomedical ScienceFaculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Kum Thong Wong
- Department of PathologyFaculty of MedicineUniversity of MalayaKuala LumpurMalaysia
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Chou IC, Lin CC, Kao CH. Enterovirus Encephalitis Increases the Risk of Attention Deficit Hyperactivity Disorder: A Taiwanese Population-based Case-control Study. Medicine (Baltimore) 2015; 94:e707. [PMID: 25906098 PMCID: PMC4602682 DOI: 10.1097/md.0000000000000707] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 02/02/2015] [Accepted: 02/17/2015] [Indexed: 12/02/2022] Open
Abstract
Enterovirus (EV) infection is a major public health issue throughout the world with potential neurological complications. This study evaluated the relationship between attention deficit hyperactivity disorder (ADHD) and EV encephalitis in children.Data of reimbursement claims from the National Health Insurance Research Database of Taiwan were used in a population-based case-control design. The study comprised 2646 children with ADHD who were matched according to sex, age, urbanization level of residence, parental occupation, and baseline year, to people without ADHD at a ratio of 1:10. The index date of the ADHD group was the ADHD date of diagnosis. Histories of EV infections before the index dates were collected and recategorized according to the severity of infection.Compared with children without EV infection, the children with mild EV infection had a 1.16-fold increased risk of ADHD (odds ratio [OR] = 1.16, 95% confidence interval [CI] = 1.07-1.26), and the children with severe EV infection had a greater risk of ADHD (OR = 2.82, 95% CI = 1.05-7.57). The results also revealed a significant correlation between ADHD and the severity of EV infection (P for trend = 0.0001).Patients with EV encephalitis have an increased risk of developing ADHD. Although most EV encephalitis in children has a favorable prognosis, it may be associated with significant long-term neurological sequelae, even in children considered fully recovered at discharge. Neuropsychological testing should be recommended for survivors of childhood EV encephalitis. The causative factors between EV encephalitis and the increased risk of ADHD require further investigation.
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Affiliation(s)
- I-Ching Chou
- From the Department of Pediatrics, China Medical University Hospital (I-CC), Graduate Institute of Integrated Medicine, College of Chinese Medicine (I-CC), Management Office for Health Data, China Medical University Hospital (C-CL), College of Medicine (C-CL), Graduate Institute of Clinical Medical Science and School of Medicine, College of Medicine (C-HK), Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung, Taiwan (C-HK)
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27
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Chea S, Cheng YB, Chokephaibulkit K, Chotpitayasunondh T, Rogier van Doorn H, Hafy Z, Kawichai S, Liu CC, Nam NT, Ooi MH, Wolbers M, Zeng M. Workshop on use of intravenous immunoglobulin in hand, foot and mouth disease in Southeast Asia. Emerg Infect Dis 2015; 21:e140992. [PMID: 25531166 PMCID: PMC4285270 DOI: 10.3201/eid2101.140992] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The South East Asia Infectious Disease Clinical Research Network convened subject matter experts at a workshop to make consensus recommendations for study design of a clinical trial for use of intravenous immunoglobulin (IVIg) in severe hand, foot and mouth disease (HFMD). HFMD is a highly contagious emerging infection among children in the region, a small proportion of whom develop neurologic and cardiopulmonary complications with high case-fatality rates. The use of IVIg for treatment of severe disease is widespread and a part of local, national, and international guidelines, but no clinical evidence warrants the use of this drug, which is expensive and has potentially serious side effects. During a 2-day workshop in March 2014, a group of HFMD experts reviewed the current evidence related to use of IVIg in HFMD and discussed potential study design, feasibility, inclusion and exclusion criteria, sample size, primary and secondary endpoints, and subsidiary studies for a randomized, placebo-controlled trial.
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Predicting severe enterovirus 71 infection: Age, comorbidity, and parental behavior matter. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2014; 50:10-16. [PMID: 25678038 DOI: 10.1016/j.jmii.2014.11.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 11/07/2014] [Accepted: 11/17/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Enterovirus 71 (EV71) is one of the major pathogens that cause severe enteroviral infections. Our aim was to study the behavioral and household risk factors for its serious complications. METHODS Between May 2011 and November 2012, we enrolled children who had symptoms of EV71 infection from six hospitals in Taiwan. The caregivers of each patient were interviewed to determine their hand hygiene habits in relation to EV71 infection. The severity of EV71 infection was classified as follows: Stage 1, hand-foot-mouth disease or herpangina; Stage 2, meningitis or myoclonic jerk; Stage 3A, encephalitis; Stage 3B, cardiopulmonary failure. Stages 2 to 3B were defined as severe EV71 infection. Children with Stages 3A and 3B infection were designated as the critical group. RESULTS A total of 399 patients had laboratory-confirmed EV71 infection. Three risks factors were associated with the different degrees of severity in EV71 infection. Children <2 years old had much greater risks for severe EV71 infection [odds ratio (OR) 1.8; 95% confidence interval (CI), 1.2-2.8], delayed medical evaluation for critical infection (OR 9.4; 95% CI, 3.6-24.1), and developmental retardation for cardiopulmonary failure (OR 8.3; 95% CI, 2.0-33.7). Among all the habits and household factors, caregivers in the critical group had a significantly lower rate in terms of cleaning the faucet after washing their hands (OR 2.63; 95% CI, 1.14-6.08). CONCLUSIONS Children <2 years old, developmental retardation, and delayed medical intervention were associated with severe EV71 infection. Cleaning water faucets after hand washing was a protective habit that reduced the risk of complications.
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Chen J, Xu L, Sun S, Zhang H, Ma T, Su W, Jiang C. Identification of cinobufagin and resibufogenin as inhibitors of enterovirus 71 infection. Chem Res Chin Univ 2014. [DOI: 10.1007/s40242-014-4133-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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30
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Shen FH, Shen TJ, Chang TM, Su IJ, Chen SH. Early dexamethasone treatment exacerbates enterovirus 71 infection in mice. Virology 2014; 464-465:218-227. [PMID: 25104614 DOI: 10.1016/j.virol.2014.07.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Revised: 06/23/2014] [Accepted: 07/14/2014] [Indexed: 11/26/2022]
Abstract
Enterovirus 71 (EV71) infection can induce encephalitis. Overt immune responses is suspected to cause severe symptoms, so anti-inflammatory agents, corticosteroids have been recommended for treatment. However, one clinical study reported that treatment with glucocorticoids, dexamethasone (Dex) exacerbates disease severity. Here we investigated Dex treatment on EV71 infection using the murine model and found that both long-term (14-day) and short-term (4-day) Dex treatment starting from 1 or 3 days postinfection increased the mortality and disease severity of infected mice. Dex treatment starting from 4 or 8 days postinfection did not affect mouse mortality and disease severity. Early Dex treatment starting from 1 day postinfection caused atrophy and enhanced apoptosis in lymphoid organs to decrease the numbers of lymphocytes (CD4(+) T cells, CD8(+) T cells, and CD19(+) B cells) and to increase viral loads in infected tissues of mice. Our results demonstrate that Dex treatment has no beneficial effect on EV71 infection.
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Affiliation(s)
- Fang-Hsiu Shen
- Department of Microbiology and Immunology, College of Medicine, National Cheng Kung University, Tainan, Taiwan 701, Republic of China
| | - Ting-Jing Shen
- Department of Microbiology and Immunology, College of Medicine, National Cheng Kung University, Tainan, Taiwan 701, Republic of China
| | - Tung-Miao Chang
- Statistical Analysis Laboratory, Department of International Business Management, Tainan University of Technology, Tainan, Taiwan 710, Republic of China
| | - Ih-Jen Su
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Tainan, Taiwan 701, Republic of China.
| | - Shun-Hua Chen
- Department of Microbiology and Immunology, College of Medicine, National Cheng Kung University, Tainan, Taiwan 701, Republic of China; Center of Infectious Disease and Signaling Research, National Cheng Kung University, Tainan, Taiwan 701, Republic of China.
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Cheng HY, Huang YC, Yen TY, Hsia SH, Hsieh YC, Li CC, Chang LY, Huang LM. The correlation between the presence of viremia and clinical severity in patients with enterovirus 71 infection: a multi-center cohort study. BMC Infect Dis 2014; 14:417. [PMID: 25069383 PMCID: PMC4133623 DOI: 10.1186/1471-2334-14-417] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 07/18/2014] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Enterovirus 71 (EV71) is a great disease burden across the whole world, particularly in Southeast Asia. However, in recent decades, the pathogenesis of severe EV71 infection was not well understood. This study was aimed to investigate the correlation between the presence of viremia and the clinical severity of EV71 infection. METHODS We organized a prospective cohort study and enrolled laboratory-confirmed EV71 cases in six tertiary care hospitals in Taiwan during the EV71 epidemic from 2011 to 2012. Blood samples were collected once in the acute stage, on the first day of admission. We used real-time RT-PCR to detect EV71 viremia. Demographical and clinical data were collected and the clinical severity was categorized into four grades. Data analysis was performed to identify the risk factors of viremia and the correlation between viremia and clinical severity of EV71 infection. RESULTS Of the total 224 enrolled patients, 59 (26%) patients were confirmed to have viremia. Two-thirds (68%) of viremic cases were detected within the first three days of infection. Viremia occurred more frequently in children under the age of one year old (odds ratios [OR] 4.82, p < 0.001) but the association between the presence of viremia and complicated EV71 infection was not found (OR 1.02, p = 0.96). In the viremia group, patients had significantly more severe complications if viremia was detected after the third day of disease onset (26% vs. 5%, p = 0.03). CONCLUSIONS Viremia occurred more frequently in children under the age of one year and viremia detected beyond three days after the onset of disease correlated with more severe disease in EV71 patients.
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Affiliation(s)
- Hao-Yuan Cheng
- />Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yi-Chuan Huang
- />Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ting-Yu Yen
- />Department of Pediatrics, Children’s Hospital, China Medical University and Hospitals, Taichung, Taiwan
| | - Shao-Hsuan Hsia
- />Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yu-Chia Hsieh
- />Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chung-Chen Li
- />Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Luan-Yin Chang
- />Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Li-Min Huang
- />Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
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The cytokine and chemokine profiles in patients with hand, foot and mouth disease of different severities in Shanghai, China, 2010. PLoS Negl Trop Dis 2013; 7:e2599. [PMID: 24367714 PMCID: PMC3868519 DOI: 10.1371/journal.pntd.0002599] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Accepted: 11/06/2013] [Indexed: 11/19/2022] Open
Abstract
Background and purpose Systemic upregulation of inflammatory cytokines is characteristic of critical severe hand, foot, and mouth disease (HFMD) with pulmonary edema. Thus, immunomodulatory medicines such as steroids, including methylprednisolone, have been proposed to treat patients with severe HFMD in China, because it is postulated that inflammatory cytokines play a role in the development of severe complications. This study is to further investigate the inflammatory response in the relatively mild HFMD patients, and whether steroid treatment has a beneficial effect on the suppression of inflammation in HFMD patients. Method We measured the levels of 50 kinds of chemokines, cytokines, growth factors and soluble receptors in serum samples from control patients without HFMD and the HFMD patients with or without prior treatment of intravenous methylprednisolone. Results Our present study found that even relatively mild HFMD patients without central nervous system (CNS) complications had elevated serum levels of inflammatory cytokines, including interleukin (IL)-3, IL-6, IL-12p40, and tumor necrosis factor (TNF)-α, which suggested systemic inflammation. In contrast, these patients also have decreased levels of other serum biomarkers, including IL-1Ra, IL-8, IL-16, soluble ICAM-1, CXCL-1, and CCL27. The dysregulation of cytokine and chemokine expression may be involved in CNS complications and unbalanced circulating leukocytes in HFMD patients. Surprisingly, patients treated with methylprednisolone had no difference in the expression levels of HFMD-associated biomarkers instead had slightly increased levels of IL-17A, which was not associated with the occurrence of HFMD. Conclusion Whether steroid treatment has any beneficial effect on the prognosis of HFMD patients requires to be further investigated. Systemic inflammation is characteristic of severe hand, foot, and mouth disease (HFMD). Steroids are considered immunomodulators and have been officially recommended to treat the severe HFMD patients with CNS complications in China. So far, it is uncertain whether steroid treatment has an immunomodulatory role in inflammation in HFMD patients and has a real beneficial effect on their prognosis. This study revealed that even relatively mild HFMD patients without CNS complications had elevated inflammation. Unexpectedly, the inflammatory cytokine levels in patients treated with methylprednisolone, one kind of steroid, were not significantly different from those in patients without the treatment. Rather, the treated patients tended to have elevated levels of IL-17A, whose expression levels were actually not significantly associated with the presence of HFMD. IL-17A is known to play a role in the pathogenesis of CNS-related inflammatory diseases. Altogether, our study does not support the presumption that steroids have beneficial effect on the prognosis of HFMD patients by inhibiting systemic inflammation.
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Wang YR, Sun LL, Xiao WL, Chen LY, Wang XF, Pan DM. Epidemiology and clinical characteristics of hand foot, and mouth disease in a Shenzhen sentinel hospital from 2009 to 2011. BMC Infect Dis 2013; 13:539. [PMID: 24225231 PMCID: PMC3829808 DOI: 10.1186/1471-2334-13-539] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Accepted: 11/12/2013] [Indexed: 11/10/2022] Open
Abstract
Background We investigated the epidemiological and clinical data of all hand, foot, and mouth disease (HFMD) cases in a sentinel hospital of Shenzhen, China from 2009 to 2011. Methods HFMD cases diagnosed in our institution were assessed from 2009 to 2011. Both epidemiological and clinical features were analyzed retrospectively. All the fatal cases were reported. Results A total of 12132 patients were diagnosed with HFMD, of which 2944 (24.3%) were hospitalized. Of the 2944 hospitalized patients, the highest proportion of diagnosed cases were admitted in May and July (989/2944, 33.6%). In 2009 all severe HFMD cases were diagnosed with enterovirus 71 (EV71). In 2010 and 2011, some of the severe HFMD were diagnosed with Coxsackievirus A16 (CA16). Incidence was highest in 0-4-year old children, with males being predominant. There were sporadic cases with HFMD the whole year except in February. All cases were cured in 2009. Six deaths were reported during 2010 and 2011. Conclusions EV71 can cause severe complications and deaths in our region. HFMD is an important public health problem in Shenzhen in spite of stringent measures taken in preschool centers. A high degree of vigilance should be maintained over the disease situation.
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Affiliation(s)
- Yan-rong Wang
- Department of Pediatrics, the Affiliated Shenzhen Third Hospital, Guangdong Medical College, Shenzhen 518020, China.
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Milrinone therapy for enterovirus 71-induced pulmonary edema and/or neurogenic shock in children: a randomized controlled trial. Crit Care Med 2013; 41:1754-60. [PMID: 23685637 DOI: 10.1097/ccm.0b013e31828a2a85] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Enterovirus 71-induced brainstem encephalitis with pulmonary edema and/or neurogenic shock (stage 3B) is associated with rapid mortality in children. In a small pilot study, we found that milrinone reduced early mortality compared with historical controls. This prospective, randomized control trial was designed to provide more definitive evidence of the ability of milrinone to reduce the 1-week mortality of stage 3B enterovirus 71 infections. DESIGN Prospective, unicenter, open-label, randomized, controlled study. SETTING Inpatient ward of a large tertiary teaching hospital in Ho Chi Minh City, Vietnam. PATIENTS Children (≤ 18 yr old) admitted with proven enterovirus 71-induced pulmonary edema and/or neurogenic shock. INTERVENTIONS Patients were randomly assigned to receive intravenous milrinone (0.5 μg/kg/min) (n = 22) or conventional management (n = 19). Both groups received dopamine or dobutamine and intravenous immunoglobulin. MEASUREMENTS AND MAIN RESULTS The primary endpoint was 1-week mortality. The secondary endpoints included length of ventilator dependence and hospital stay and adverse events. The median age was 2 years with a predominance of boys in both groups. The 1-week mortality was significantly lower, 18.2% (4/22) in the milrinone compared with 57.9% (11/19) in the conventional management group (relative risk = 0.314 [95% CI, 0.12-0.83], p = 0.01). The median duration of ventilator-free days was longer in the milrinone treatment group (p = 0.01). There was no apparent neurologic sequela in the survivors in either group, and no drug-related adverse events were documented. CONCLUSIONS Milrinone significantly reduced the 1-week mortality of enterovirus 71-induced pulmonary edema and/or neurogenic shock without adverse effects. Further studies are needed to determine whether milrinone might be useful to prevent progression of earlier stages of brainstem encephalitis.
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Gantt S, Yao L, Kollmann TR, Casper C, Zhang J, Self SG. Implications of Age-Dependent Immune Responses to Enterovirus 71 Infection for Disease Pathogenesis and Vaccine Design. J Pediatric Infect Dis Soc 2013; 2:162-70. [PMID: 26619463 DOI: 10.1093/jpids/pit017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 01/31/2013] [Indexed: 12/31/2022]
Abstract
Epidemics of enterovirus serotype 71 (EV71) infection in Asia appear to be increasing in size and severity, and there is increasing concern for pandemic spread. Efforts are underway to develop an effective EV71 vaccine. However, the immunologic correlates of protection against EV71 infection are not fully understood, and studies suggest that severe complications may result from a combination of pathological immune responses and direct viral effects. Severe disease and death typically occur only in young children, which is likely due in part to a lack of EV71-specific adaptive immunity but possibly also due to age-dependent hyperactive innate immune responses. Infants are the primary targets of EV71 vaccination strategies. Therefore, studies are needed to understand the interplay between age, immunopathology, and severity of EV71 infection to distinguish protective from harmful immune responses and to guide the development of effective EV71 vaccines. This review summarizes our current understanding and outlines the next steps forward.
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Affiliation(s)
- Soren Gantt
- University of Washington Seattle Children's Hospital, and
| | - Lena Yao
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Corey Casper
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Jing Zhang
- Chinese Center for Disease Control and Prevention, Beijing, People's Republic of China
| | - Steven G Self
- Fred Hutchinson Cancer Research Center, Seattle, Washington
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Zhou XB, Lu JJ, Jiang YS, Huo Y, Wang JF, Zhou KF, Li B. A safety study of inactivated Enterovirus 71 vaccine. Hum Vaccin Immunother 2013; 9:1430-7. [PMID: 23571172 DOI: 10.4161/hv.24395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Enterovirus 71 (EV71) is one of the major causative agents for hand, foot and mouth disease (HFMD) in childhood. Nowadays, HFMD or EV71 infections have already become an important public health issue throughout the world. Vaccination may be the most effective measure to control the transmission of the virus. Therefore, to pave EV71 vaccine into human clinical trial, in the present study a comprehensive preclinical safety assessment of inactivated EV71 vaccine including single- and repeat-dose toxicity studies were conducted in rats and cynomolgus monkeys. No abnormal findings were observed in rats following single intramuscular administration with EV71 vaccine (640 U). The results also showed no obvious systemic toxicities from four repetitive intramuscular injections, with a 14-d interval, of two dosages of EV71 vaccine in the two animal species. Antinuclear antibody response was not detected after the repeated administrations. Histopathological examination demonstrated the minimal to severe inflammatory changes in muscle tissues of the injection sites in EV71 vaccine-injected animals and most of findings have been improved over time. Furthermore, test article could induce highly EV71-specfic neutralizing antibody response in both animal species. Taken together, these data suggested a favorable safety profile for inactivated EV71 vaccine and supported this product to enter human phase I clinical trial.
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Affiliation(s)
- Xiao-bing Zhou
- Graduate School of Peking Union Medical College; Dongcheng District, Beijing, P.R. China; National Center for Safety Evaluation of Drugs; National Institutes for Food and Drug Control; Beijing, P.R. China
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Kim SJ, Kim JH, Kang JH, Kim DS, Kim KH, Kim KH, Kim YH, Chung JY, Bin JH, Jung DE, Kim JH, Kim HM, Cheon DS, Kang BH, Seo SY. Risk factors for neurologic complications of hand, foot and mouth disease in the Republic of Korea, 2009. J Korean Med Sci 2013; 28:120-7. [PMID: 23341722 PMCID: PMC3546090 DOI: 10.3346/jkms.2013.28.1.120] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Accepted: 10/24/2012] [Indexed: 12/03/2022] Open
Abstract
In 2009, the first outbreak of hand, foot and mouth disease (HFMD) or herpangina (HP) caused by enterovirus 71 occurred in the Republic of Korea. This study inquired into risk factors associated with complications of HFMD or HP. A retrospective medical records review was conducted on HFMD or HP patients for whom etiologic viruses had been verified in 2009. One hundred sixty-eight patients were examined for this investigation. Eighty patients were without complications while 88 were accompanied by complications, and 2 had expired. Enterovirus 71 subgenotype C4a was the most prevalent in number with 67 cases (54.9%). In the univariate analysis, the disease patterns of HFMD rather than HP, fever longer than 4 days, peak body temperature over 39℃, vomiting, headache, neurologic signs, serum glucose over 100 mg/dL, and having an enterovirus 71 as a causative virus were significant risk factors of the complications. After multiple logistic analysis, headache (Odds ratio [OR], 10.75; P < 0.001) and neurologic signs (OR, 42.76; P < 0.001) were found to be the most significant factors. Early detection and proper management of patients with aforementioned risk factors would be necessary in order to attain a better clinical outcome.
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Affiliation(s)
- Seong Joon Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong-Hyun Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin-Han Kang
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong Soo Kim
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Ki Hwan Kim
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung-Hyo Kim
- Department of Pediatrics, Ewha Womans University School of Medicine, Seoul, Korea
| | - Young-Hoon Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ju-Young Chung
- Department of Pediatrics, Inje University College of Medicine, Busan, Korea
| | - Joong Hyun Bin
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Da Eun Jung
- Department of Pediatrics, School of Medicine, Ajou University, Suwon, Korea
| | - Ji Hong Kim
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Hwang Min Kim
- Department of Pediatrics, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Doo-Sung Cheon
- Division of Hepatitis and Enteric Viruses, Korea Centers for Disease Control and Prevention, Cheongwon, Korea
| | - Byung Hak Kang
- Division of Hepatitis and Enteric Viruses, Korea Centers for Disease Control and Prevention, Cheongwon, Korea
| | - Soon Young Seo
- Division of Epidemic Intelligence Service, Korea Centers for Disease Control and Prevention, Cheongwon, Korea
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Shang L, Xu M, Yin Z. Antiviral drug discovery for the treatment of enterovirus 71 infections. Antiviral Res 2012; 97:183-94. [PMID: 23261847 DOI: 10.1016/j.antiviral.2012.12.005] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Revised: 12/05/2012] [Accepted: 12/06/2012] [Indexed: 12/17/2022]
Abstract
Enterovirus 71 (EV71) is a small, positive-sense, single-stranded RNA virus in the genus Enterovirus, family Picornavirus. It causes hand, foot and mouth disease in infants and children, which in a small percentage of cases progresses to central nervous system infection, ranging from aseptic meningitis to fatal encephalitis. Sporadic cases of EV71 infection occur throughout the world, but large epidemics have occurred recently in Southeast Asia and China. There are currently no approved vaccines or antiviral therapies for the prevention or treatment of EV71 infection. This paper reviews efforts to develop antiviral therapies against EV71.
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Affiliation(s)
- Luqing Shang
- College of Pharmacy, Nankai University, Tianjin, PR China
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Use of intravenous immunoglobulin compared with standard therapy is associated with improved clinical outcomes in children with acute encephalitis syndrome complicated by myocarditis. Pediatr Cardiol 2012; 33:1370-6. [PMID: 22588459 DOI: 10.1007/s00246-012-0350-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2012] [Accepted: 04/25/2012] [Indexed: 01/08/2023]
Abstract
Although an autoimmune mechanism has been postulated for acute encephalitis syndrome (AES) complicated by myocarditis, immunomodulatory treatment strategies are still under investigation. To study the role of intravenous immunoglobulin (IVIG) in AES complicated by myocarditis in children age 2-12 years. This nonrandomized study was conducted in a tertiary care teaching hospital from July 2008 to January 2010. A total of 83 consecutive children with AES complicated by myocarditis were enrolled. Diagnosis of myocarditis was based on clinical, electrocardiogram, and echocardiogram findings. Patients were allocated to the two groups based on the days of the week: Those presenting on Monday and Friday were allocated to IVIG treatment (group I), and those presenting on the other days of the week to standard care (group II). Group I (n = 26) patients received IVIG at a dose of 400 mg/kg/day for 5 days in addition to standard care. All baseline and outcome data were recorded prospectively in a prestructured performa. The primary outcomes were mortality and improvement of left-ventricular dysfunction. A total of 83 children were studied: 26 in group I and 57 in group II. The mean (SD) age of the enrolled children was 4.6 years (3.1). The baseline characteristics were comparable between the two groups. A viral etiology could be established in 14 children, with the 2 most common agents isolated being Coxackie virus and enterovirus. Mortality was lower in the IVIG group [n = 1 (3.8 %)] patients compared with the standard care group [n = 13 (22.8 %)] with a relative risk of 0.17 (95 % CI = 0.02, 1.22). The difference in mortality reached borderline significance (p = 0.05). At discharge, mean (SD) ejection fraction improved from 32.8 % (6.31 %) to 49.5 % (9.04 %) in group I patients, which was significantly greater than that of group II (p = 0.001). Use of IVIG seemed to have a beneficial effect in terms of improved clinical outcomes in children with AES complicated by myocarditis. Our findings need further validation before IVIG can be incorporated into the treatment protocol of these children.
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Chiang PS, Huang ML, Luo ST, Lin TY, Tsao KC, Lee MS. Comparing molecular methods for early detection and serotyping of enteroviruses in throat swabs of pediatric patients. PLoS One 2012; 7:e48269. [PMID: 23133580 PMCID: PMC3484998 DOI: 10.1371/journal.pone.0048269] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2012] [Accepted: 09/21/2012] [Indexed: 01/29/2023] Open
Abstract
Background Enteroviruses include over 100 serotypes and usually cause self-limited infections with non-specific symptoms in children, with the exceptions of polioviruses and enterovirus 71 which frequently cause neurologic complications. Therefore, early detection and serotyping of enteroviruses are critical in clinical management and disease surveillance. Traditional methods for detection and serotyping of enteroviruses are virus isolation and immunofluorescence assay, which are time-consuming. In this study, we compare virus isolation and two molecular tests for detection and serotyping of enteroviruses in clinical samples. Methods One hundred and ten throat swabs were collected from pediatric outpatients with enterovirus-like illnesses (hand-foot-mouth disease, herpangina, and non-specific febrile illness). Virus isolation was conducted using multiple cell lines and isolated viruses were serotyped using immunofluorescent assay. In the molecular tests, a semi-nested RT-PCR and a novel CODEHOP platform were used to detect the 5′UTR and VP1 genes of enteroviruses, respectively. Amplified nucleotides were sequenced and genotyped. Results Among the 110 cases, 39(35%), 52(47%), and 46(42%) were tested positive with these three tests, respectively. Using the consensus results of these three tests as the gold standard, agreement of the VP1 CODEHOP test was 96%, which is higher than those of the virus isolation (89%) and the 5′-UTR test (88%). The VP1 CODEHOP test also has the best performance on serotyping confirmed with serum neutralization tests. Conclusions The VP1 CODEHOP test performed well for detection and serotyping of enteroviruses in clinical specimens and could reduce unnecessary hospitalization cares during enterovirus seasons.
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Affiliation(s)
- Pai-Shan Chiang
- National Institutes of Infectious Diseases and Vaccinology, National Health Research Institutes, Taiwan
| | - Mei-Liang Huang
- National Institutes of Infectious Diseases and Vaccinology, National Health Research Institutes, Taiwan
| | - Shu-Ting Luo
- National Institutes of Infectious Diseases and Vaccinology, National Health Research Institutes, Taiwan
| | - Tzou-Yien Lin
- Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kuo-Chien Tsao
- Department of Medical Biotechnology and Laboratory Science, Chang Gung University, Taoyuan, Taiwan
- Department of Clinical Pathology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Min-Shi Lee
- National Institutes of Infectious Diseases and Vaccinology, National Health Research Institutes, Taiwan
- * E-mail:
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CD4 T-cell-independent antibody response reduces enterovirus 71 lethality in mice by decreasing tissue viral loads. Clin Dev Immunol 2012; 2012:580696. [PMID: 23133489 PMCID: PMC3486008 DOI: 10.1155/2012/580696] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Revised: 09/09/2012] [Accepted: 09/10/2012] [Indexed: 11/17/2022]
Abstract
Enterovirus 71 (EV71) has induced fatal encephalitis in hundreds of thousands of infants and young children in the Asia-Pacific region since the past decade. Lymphocyte and antibody responses have been suspected to aggravate EV71-induced neurological symptoms, so anti-inflammatory agents have been used to treat patients with neurological symptoms. In the present study, we found that mice deficient in CD4+ T cells were resistant to EV71 infection as wild-type mice, whereas mice deficient in B cells were highly susceptible to viral infection. Compensation of CD4 T-cell function by other immune cells was not likely, because wild-type mice depleted of CD4+ T cells were also resistant to viral infection. Infected CD4 T-cell-deficient mice produced virus-specific neutralizing antibodies, IgM and IgG. Moreover, adoptive transfer of the virus-specific antibody produced by infected CD4 T-cell-deficient mice protected B-cell-deficient mice from infection by reducing tissue viral loads. Collectively, our results show that the CD4 T-cell-independent antibody response promotes the survival of EV71-infected mice and suggest great potential for the use of vaccines and neutralizing antibodies to reduce fatal symptoms in patients.
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Xin KW, Huimin Y, Alonso S. Enterovirus 71: pathogenesis, control and models of disease. Future Virol 2012. [DOI: 10.2217/fvl.12.89] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Enterovirus 71 (EV71) is one of the major agents responsible for hand, foot and mouth disease. The increasing incidence of hand, foot and mouth disease outbreaks, epidemics due to EV71 infection in South East Asia and the propensity of EV71 strains to cause severe neurological complications in young children underscore the need to further our knowledge and understanding of the mechanisms involved in EV71 pathogenesis; such knowledge could then be translated to the identification of biomarkers of disease severity, and the development of effective therapeutics and vaccines. This article reviews the current knowledge of EV71 pathogenesis, control measures and models of infection.
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Affiliation(s)
- Khong Wei Xin
- Yong Loo Lin School of Medicine, Department of Microbiology, Life Sciences Institute, Immunology Programme, National University of Singapore, Singapore
| | - Yeo Huimin
- Yong Loo Lin School of Medicine, Department of Microbiology, Life Sciences Institute, Immunology Programme, National University of Singapore, Singapore
| | - Sylvie Alonso
- Yong Loo Lin School of Medicine, Department of Microbiology, Life Sciences Institute, Immunology Programme, National University of Singapore, Singapore
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Yang T, Xu G, Dong H, Ye M, He T. A case-control study of risk factors for severe hand-foot-mouth disease among children in Ningbo, China, 2010-2011. Eur J Pediatr 2012; 171:1359-64. [PMID: 22527564 DOI: 10.1007/s00431-012-1731-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 03/20/2012] [Accepted: 03/23/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND A small fraction of hand-foot-mouth disease (HFMD) progression from the onset of severity to fatality may be remarkably rapid. Early recognition of children at risk of severity is critical to increase treatment effectiveness and reduce acute mortality. METHODS A frequency-matched case-control study was conducted between January 2010 and June 2011 in Ningbo to identify risk factors associated with the occurrence of severity in children with HFMD. Data including demographic characteristics, clinical features, and laboratory test results were collected by trained interviewers through retrospective medical record review and/or face-to-face interviews with children's parents using a standardized questionnaire. RESULTS Eighty-nine cases with severe HFMD and 267 controls with mild HFMD were recruited in this study. Palm rashes (OR = 0.004, 95%CI = 0.000-0.039, p < 0.001), oral ulcers or herpes (OR = 0.001, 95%CI = 0.000-0.009, p < 0.001) were significantly associated with protection against severity, and an increased risk of severity was significantly associated with the presence of, e.g., a high fever of over 39°C for more than 3 days (OR = 2.217, 95%CI = 1.082-4.541, p = 0.030), leg trembling (OR = 29.008, 95%CI = 1.535-548.178, p = 0.025), papule rash (OR = 4.622, 95%CI = 1.110-19.252, p = 0.035), a raised WBC count > 10.8 × 10(9)/L (OR = 4.495, 95%CI = 1.311-15.415, p = 0.017), and human enterovirus 71 infection (OR = 39.172, 95%CI = 9.803-156.522, p < 0.001). CONCLUSION Clinicians should pay increased attention to children diagnosed as HFMD with the independent risk factors above.
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Affiliation(s)
- Tianchi Yang
- Section of Communicable Diseases Prevention and Management, Ningbo Municipal Center for Disease Control and Prevention, No.237, Yongfeng Road, Ningbo, Zhejiang 315010, China.
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Chang SC, Li WC, Chen GW, Tsao KC, Huang CG, Huang YC, Chiu CH, Kuo CY, Tsai KN, Shih SR, Lin TY. Genetic characterization of enterovirus 71 isolated from patients with severe disease by comparative analysis of complete genomes. J Med Virol 2012; 84:931-9. [PMID: 22499017 DOI: 10.1002/jmv.23287] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Enterovirus 71 (EV71) which causes mild illness in children is also associated with severe neurological complications. This study analyzed the complete genomes of EV71 strains derived from mild and severe diseases in order to determine whether the differences of EV71 genomes were responsible for different clinical presentations. Compared to complete genomes of EV71 strains derived from mild cases (less virulent strains), nucleotide differences in EV71 strains isolated from severe cases (more virulent strains) were observed primarily in the internal ribosomal entry site (IRES) of the 5'-untranslated region (UTR), which is vital for the cap-independent translation of viral proteins. In the protein-coding region, an E-Q substitution at amino acid position 145 of structural protein VP1 that occurred in more than one of more virulent strains was observed. This site is known to be related functionally to receptor binding and virulence in mice. Overall, strains (Group III) isolated from patients with fatal or severe sequelae outcomes had greater sequence substitutions in the 5'-UTR and/or protein-coding region and exhibited a relatively low-average homology to less virulent strains across the entire genome, indicating the possibility of significant genomic diversity in the most virulent EV71 strains. Further studies of EV71 pathogenesis should examine the significance of genomic diversity and the effects of multiple mutations in a viral population.
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Affiliation(s)
- Shih-Cheng Chang
- Research Center for Emerging Viral Infections, Chang Gung University, Taoyuan, Taiwan
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Huang HI, Weng KF, Shih SR. Viral and host factors that contribute to pathogenicity of enterovirus 71. Future Microbiol 2012; 7:467-79. [DOI: 10.2217/fmb.12.22] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The single-stranded RNA virus enterovirus 71 (EV71), which belongs to the Picornaviridae family, has caused epidemics worldwide, particularly in the Asia–Pacific region. Most EV71 infections result in mild clinical symptoms, including herpangina and hand, foot and mouth disease. However, serious pathological complications have also been reported, especially for young children. The mechanisms of EV71 disease progression remain unclear. The pathogenesis of adverse clinical outcomes may relate to many factors, including cell tropism, cell death and host immune responses. This article reviews the recent advances in the identification of factors determining EV71 cell tropism, the associated mechanisms of viral infection-induced cell death and the interplay between EV71 and immunity.
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Affiliation(s)
- Hsing-I Huang
- Research Center for Emerging Viral Infections, Chang Gung University, Kwei-Shan Tao-Yuan, Taiwan, Republic of China
- Department of Medical Biotechnology & Laboratory Science, Chang Gung University, Kwei-Shan Tao-Yuan, Taiwan, Republic of China
| | - Kuo-Feng Weng
- Research Center for Emerging Viral Infections, Chang Gung University, Kwei-Shan Tao-Yuan, Taiwan, Republic of China
- The Center for Molecular & Clinical Immunology, Chang Gung University, Kwei-Shan Tao-Yuan, Taiwan, Republic of China
| | - Shin-Ru Shih
- Research Center for Emerging Viral Infections, Chang Gung University, Kwei-Shan Tao-Yuan, Taiwan, Republic of China
- Department of Medical Biotechnology & Laboratory Science, Chang Gung University, Kwei-Shan Tao-Yuan, Taiwan, Republic of China
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Tian H, Yang QZ, Liang J, Dong SY, Liu ZJ, Wang LX. Clinical features and management outcomes of severe hand, foot and mouth disease. Med Princ Pract 2012; 21:355-9. [PMID: 22188681 DOI: 10.1159/000334619] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Accepted: 10/23/2011] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE This study was designed to describe the clinical features and management outcomes of severe hand, foot and mouth disease (HFMD). SUBJECTS AND METHODS Data on 147 severe HFMD patients during an outbreak in 2009 were analyzed. RESULTS Most patients were under 3 years of age; 102 (69.4%) were boys. All had skin rashes and fever of ≥38°C. All (n = 147, 100%) showed signs of central nervous system involvement, such as lethargy (n = 124, 84.4%), myoclonic jerks (n = 76, 51.7%), or drowsiness (n = 34, 23.1%). Respiratory symptoms were mainly tachypnea (n = 112, 76.2%) or bradypnea (n = 21, 14.3%). Common cardiovascular symptoms included tachycardia (n = 134, 91.2%) and hypertension (n = 23, 15.5%). Chest X-ray showed increased markings in 76 (51.7%) or consolidation in 44 (29.9%). Hyperglycemia and elevated blood lactic acid levels were found in 127 (86.4%) and 130 (88.4%), respectively. Positive enterovirus EV71-PCR was found in 113 (76.9%). All patients were treated with mechanical ventilation for 61.2 ± 12.8 h (range, 40-96 h), as well as mannitol, dexamethasone, gamma globulin and ribavirin. Dopamine, dobutamine or amrinone was administered in 58.5, 51.0 and 21.8%, respectively. Three patients (2%) died during hospitalization. All others had a full recovery and were discharged after 14.2 ± 1.6 days (range, 12-17 days). CONCLUSION Central nervous and cardiorespiratory systems were involved in the patients with severe HFMD. Fasting blood glucose and lactic acid levels increased in the majority of patients. Mechanical ventilation and supportive pharmacotherapy were associated with a good clinical outcome in these patients.
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Affiliation(s)
- Hui Tian
- Department of Intensive Care, Liaocheng People's Hospital and Liaocheng Clinical School of Taishan Medical University, Liaocheng, PR China
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Anti-enteroviral Activity of Microalgal Extracts Probed by Bionanohybrids of Quantum Dots and Viruses. BIONANOSCIENCE 2011. [DOI: 10.1007/s12668-011-0019-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Epidemiology of hand, foot, and mouth disease in children in Shanghai 2007–2010. Epidemiol Infect 2011; 140:1122-30. [DOI: 10.1017/s0950268811001622] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
SUMMARYWe retrospectively analysed the epidemiological data of all hand, foot, and mouth disease (HFMD) cases from the largest paediatric infectious diseases centre in Shanghai between 2007 and 2010. A total of 28 058 outpatients were diagnosed with HFMD, of which 3948 (14·07%) were hospitalized, 730 (2·60%) had complications with neurological disorders and pulmonary oedema/haemorrhage, and 11 (0·04%) died. The peak season was the summer months. Boys were more affected than girls. Since 2008, the major population group affected has shifted from native Shanghainese children attending preschool to migrant children and younger children cared for at home. Children aged 1–4 years constituted 82·27% of cases. EV-A71 was tested in clinical samples taken from severe cases in 2009 and 2010, and from most inpatients in 2010. EV-A71 was positive in 99·17% and 86·31% of severe cases, respectively in 2009 and 2010. All 12 cases with pulmonary oedema or haemorrhage were infected with EV-A71. Ten (90·90%) of 11 fatal cases were attributable to EV-A71 infection. In 2010, EV-A71-positive cases accounted for 54·12% of inpatients. The dominant circulation of EV-A71 led to the outbreak of HFMD and occurrence of severe and fatal cases.
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Hsu CH, Lu CY, Shao PL, Lee PI, Kao CL, Chung MY, Chang LY, Huang LM. Epidemiologic and clinical features of non-polio enteroviral infections in northern Taiwan in 2008. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2011; 44:265-73. [PMID: 21524954 DOI: 10.1016/j.jmii.2011.01.029] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Revised: 04/20/2010] [Accepted: 08/12/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Non-polio enteroviruses may cause different diseases, including herpangina, hand-foot-mouth disease (HFMD), meningitis, and nonspecific febrile illness; and cause epidemic outbreak annually. This study delineates the diversity of clinical presentations based on different serotypes and different groups [human enterovirus (HEV)-A and HEV-B] of enteroviruses (EVs) during the 2008 epidemic in National Taiwan University Hospital (NTUH). METHODS We retrospectively identified patients younger than 18 years who had positive isolates of non-polio EV in throat swabs, rectal swabs, or cerebrospinal fluid, in NTUH from January 1 to December 31, 2008. For serotyping, immunofluorescence assay and polymerase chain reaction followed by viral structure protein-1 sequencing were applied. We analyzed and compared their clinical features among different serotypes and different groups of EVs. RESULTS Among 172 patients who were enrolled, 16 serotypes were identified. The major serotype in NTUH was EV71 (25.6%) followed by coxsackievirus A (CA)16 and coxsackievirus B (CB)4. EV71 manifested mostly as HFMD (89%) and was complicated with encephalomyelitis in three patients. Serotypes of HFMD included EV71 (70%), CA16 (27%), CA4, and CA6. Serotypes of herpangina were heterogeneous, and the major serotype was CA2 (35.7%) followed by CB4 (23.8%). Aseptic meningitis was entirely caused by HEV-B and mostly infected by echovirus 30 (50%). Among children with EV-related respiratory tract infection, CB4 (32%) was dominant in upper respiratory tract infection, whereas echovirus 4 (71%) was the major cause of lower respiratory tract infection. Cases of HEV-A were significantly younger than the cases of HEV-B (p = 0.04). Multivariate analysis revealed that the most significant factor associated with hospitalization is HEV-B (odds ratio, 2.2; 95% confidence interval, 1.1-4.2; p = 0.02). CONCLUSIONS At least 16 serotypes circulated in northern Taiwan in 2008. EV71 is the predominant strain in this outbreak. All patients with HFMD were infected by HEV-A, but HEV-B was associated with a higher rate of hospitalization and aseptic meningitis, which should be a cause of alert regarding public health.
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Affiliation(s)
- Chien-Hui Hsu
- Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
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Abstract
Although poliomyelitis has been mostly eradicated worldwide, large outbreaks of the related enterovirus 71 have been seen in Asia-Pacific countries in the past 10 years. This virus mostly affects children, manifesting as hand, foot, and mouth disease, aseptic meningitis, poliomyelitis-like acute flaccid paralysis, brainstem encephalitis, and other severe systemic disorders, including especially pulmonary oedema and cardiorespiratory collapse. Clinical predictors of severe disease include high temperature and lethargy, and lumbar puncture might reveal pleocytosis. Many diagnostic tests are available, but PCR of throat swabs and vesicle fluid, if available, is among the most efficient. Features of inflammation, particularly in the anterior horns of the spinal cord, the dorsal pons, and the medulla can be clearly seen on MRI. No established antiviral treatment is available. Intravenous immunoglobulin seems to be beneficial in severe disease, perhaps through non-specific anti-inflammatory mechanisms, but has not been tested in any formal trials. Milrinone might be helpful in patients with cardiac dysfunction.
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