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van Ackeren V, Schmutz S, Pichler I, Ziltener G, Zaheri M, Kufner V, Huber M. Retrospective Genotyping of Enteroviruses Using a Diagnostic Nanopore Sequencing Workflow. Pathogens 2024; 13:390. [PMID: 38787241 PMCID: PMC11124337 DOI: 10.3390/pathogens13050390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/29/2024] [Accepted: 05/02/2024] [Indexed: 05/25/2024] Open
Abstract
Enteroviruses are among the most common viruses pathogenic to humans. They are associated with various forms of disease, ranging from mild respiratory illness to severe neurological diseases. In recent years, an increasing number of isolated cases of children developing meningitis or encephalitis as a result of enterovirus infection have been reported, as well as discrete enterovirus D68 outbreaks in North America in 2014 and 2016. We developed an assay to rapidly genotype enteroviruses by sequencing a region within the VP1 gene using nanopore Flongles. We retrospectively analyzed enterovirus-/rhinovirus-positive clinical samples from the Zurich, Switzerland area mainly collected during two seasons in 2019/2020 and 2021/2022. Respiratory, cerebrospinal fluid, and stool samples were analyzed. Whole-genome sequencing was performed on samples with ambiguous genotyping results and enterovirus D68-positive samples. Out of 255 isolates, a total of 95 different genotypes were found. A difference in the prevalence of enterovirus and rhinovirus infections was observed for both sample type and age group. In particular, children aged 0-4 years showed a higher frequency of enterovirus infections. Comparing the respiratory seasons, a higher prevalence was found, especially for enterovirus A and rhinovirus A after the SARS-CoV-2 pandemic. The enterovirus genotyping workflow provides a rapid diagnostic tool for individual analysis and continuous enterovirus surveillance.
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Affiliation(s)
| | | | | | | | | | | | - Michael Huber
- Institute of Medical Virology, University of Zurich, 8057 Zurich, Switzerland; (V.v.A.); (S.S.); (I.P.); (G.Z.); (M.Z.); (V.K.)
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2
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Leung R, Yiu EM. Practical approach to the child presenting with acute generalised weakness. J Paediatr Child Health 2024; 60:41-46. [PMID: 38545899 DOI: 10.1111/jpc.16536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/03/2023] [Accepted: 03/18/2024] [Indexed: 04/17/2024]
Abstract
Acute generalised muscle weakness in children is a paediatric emergency with a broad differential diagnosis. A careful history and neurologic examination guides timely investigation and management. We review some of the more common causes of acute generalised muscle weakness in children, highlighting key history and examination findings, along with an approach to lesion localisation to guide differential diagnosis and further investigation.
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Affiliation(s)
- Rebecca Leung
- Department of Neurology and Metabolics, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Eppie M Yiu
- Department of Neurology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Neuroscience Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
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3
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Dai W, Li X, Liu Z, Zhang C. Identification of four neutralizing antigenic sites on the enterovirus D68 capsid. J Virol 2023; 97:e0160023. [PMID: 38047678 PMCID: PMC10734511 DOI: 10.1128/jvi.01600-23] [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: 10/16/2023] [Accepted: 11/14/2023] [Indexed: 12/05/2023] Open
Abstract
IMPORTANCE Enterovirus D68 (EV-D68) is an emerging respiratory pathogen associated with acute flaccid myelitis. Currently, no approved vaccines or antiviral drugs are available. Here, we report four functionally independent neutralizing antigenic sites (I to IV) by analyses of neutralizing monoclonal antibody (MAb)-resistant mutants. Site I is located in the VP1 BC loop near the fivefold axis. Site II resides in the VP2 EF loop, and site III is situated in VP1 C-terminus; both sites are located at the south rim of the canyon. Site IV is composed of residue in VP2 βB strand and residues in the VP3 BC loop and resides around the threefold axis. The developed MAbs targeting the antigenic sites can inhibit viral binding to cells. These findings advance the understanding of the recognition of EV-D68 by neutralizing antibodies and viral evolution and immune escape and also have important implications for the development of novel EV-D68 vaccines.
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Affiliation(s)
- Wenlong Dai
- Department of Pharmaceutics, National Vaccine Innovation Platform, School of Pharmacy, Nanjing Medical University, Nanjing, China
| | - Xue Li
- Shanghai Institute of Infectious Disease and Biosecurity, Fudan University, Shanghai, China
- Shanghai Institute of Immunity and Infection, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Shanghai, China
| | - Zeyu Liu
- Shanghai Institute of Immunity and Infection, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Shanghai, China
| | - Chao Zhang
- Shanghai Institute of Infectious Disease and Biosecurity, Fudan University, Shanghai, China
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4
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Caceres JA, Saucier L, Murphy OC, Gordon-Lipkin EM, Santoro JD, Van Haren K, Pardo CA, Hopkins S. Brain Magnetic Resonance Imaging Abnormalities in Acute Flaccid Myelitis. Pediatr Neurol 2023; 149:56-62. [PMID: 37797356 DOI: 10.1016/j.pediatrneurol.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 07/03/2023] [Accepted: 08/14/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Acute flaccid myelitis (AFM) presents with acute onset of flaccid paralysis with involvement of the gray matter on magnetic resonance imaging (MRI) of the spinal cord. Studies have reported brain MRI abnormalities, but the characteristics have not been fully defined. In this multicenter study, we assessed the acute features and evolution of brain MRI abnormalities in AFM. METHODS We reviewed brain MRIs of patients with AFM who presented to four referral hospitals between 2012 and 2018. Cases met established criteria for AFM. We analyzed the initial and follow-up brain MRIs. Areas were divided into supratentorial, infratentorial, and subdivisions within those regions. RESULTS A total of 66 patients were included. Brain MRI abnormalities were present in 34 (52%). Infratentorial abnormalities were more common, occurring in 33 (97%) cases with the dorsal pons being the most frequently affected area (88%). Abnormalities were also present in the medulla (74%), cerebellum (41%), and midbrain (38%). Nine subjects (26%) exhibited both supratentorial and infratentorial abnormalities, whereas isolated supratentorial changes were present in only one (3%). Contrast-enhancing abnormalities were encountered in 9% of cases and meningeal involvement in 6%. On follow-up, most abnormalities, 20 of 24 (83%), were stable, improving, or had resolved. CONCLUSIONS Brain MRI abnormalities occur in about half of the cases of AFM and commonly resolve with time. Dorsal pontine involvement is a characteristic MRI feature, whereas isolated supratentorial abnormalities are rare. Clinicians should consider that brain imaging abnormalities do not exclude a diagnosis of AFM in patients with typical presentations.
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Affiliation(s)
- J Alfredo Caceres
- Kennedy Krieger Institute, Baltimore, Maryland; Johns Hopkins University, Baltimore, Maryland.
| | - Laura Saucier
- Children's Hospital Los Angeles, Los Angeles, California
| | | | - Eliza M Gordon-Lipkin
- National Human Genome Research Institute (NHGRI), Bethesda, Maryland; National Institutes of Health, Bethesda, Maryland
| | | | - Keith Van Haren
- Stanford University Hospitals & Clinics, Stanford, California
| | | | - Sarah Hopkins
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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5
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Olum S, Scolding C, Omona V, Jackson K, Scolding N. Acute flaccid myelitis: not uncommon in rural Uganda? Brain Commun 2023; 5:fcad246. [PMID: 37860825 PMCID: PMC10584080 DOI: 10.1093/braincomms/fcad246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/01/2023] [Accepted: 10/13/2023] [Indexed: 10/21/2023] Open
Abstract
Acute Flaccid Myelitis is a paralytic illness with significant similarities to poliomyelitis, and which affects predominantly children. It was first fully delineated only in 2014 in the USA, occurring in epidemic clusters with a likely overall increasing incidence. It has subsequently rapidly been identified in Europe, the UK, and Australasia and the Far East, confirming it to be an emerging, global, infectious neurological disease. It has, however, been very little studied in low- and middle-income countries-reflecting partly of the global imbalance in science and medical research, and partly the extremely low provision of neurological care in most low- and middle-income countries: Uganda currently has no specialized neurology services outside the capital Kampala. During extended visits over a 2-year period with involvement in acute adult and paediatric internal medicine, one of us (NS) encountered at least six new patients with acute flaccid myelitis, suggesting that both the geographical reach and the frequency of the disorder may be significantly greater than previously thought. Here, these cases are described together with their clinical features and, where available, course and (limited) investigation results. These observations have significant implications concerning the current, and potentially the future geographical spread of the disease, and its clinical phenomenology. In addition, they highlight serious problems concerning the global applicability of the current Acute Flaccid Myelitis diagnostic criteria.
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Affiliation(s)
- Sam Olum
- Department of Internal Medicine, Gulu Medical School, Gulu University, Gulu, Uganda
- St Mary’s Hospital, Lacor, Gulu, Uganda
| | - Charlotte Scolding
- Department of Internal Medicine, Gulu Medical School, Gulu University, Gulu, Uganda
- St Mary’s Hospital, Lacor, Gulu, Uganda
- THS, Faculty of Medicine, University of Bristol, Bristol, BS10 5NB, UK
- Royal United Hospital, Bath, BA1 3NG, UK
| | - Venice Omona
- Department of Internal Medicine, Gulu Medical School, Gulu University, Gulu, Uganda
- St Mary’s Hospital, Lacor, Gulu, Uganda
| | - Kansiime Jackson
- Department of Internal Medicine, Gulu Medical School, Gulu University, Gulu, Uganda
- St Mary’s Hospital, Lacor, Gulu, Uganda
| | - Neil Scolding
- Department of Internal Medicine, Gulu Medical School, Gulu University, Gulu, Uganda
- St Mary’s Hospital, Lacor, Gulu, Uganda
- Royal United Hospital, Bath, BA1 3NG, UK
- Gloucestershire Hospitals NHS Trust, Cheltenham, GL53 7AN, UK
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6
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Singh B, Arora S, Sandhu N. Emerging trends and insights in acute flaccid myelitis: a comprehensive review of neurologic manifestations. Infect Dis (Lond) 2023; 55:653-663. [PMID: 37368373 DOI: 10.1080/23744235.2023.2228407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 06/08/2023] [Accepted: 06/18/2023] [Indexed: 06/28/2023] Open
Abstract
Acute Flaccid Myelitis (AFM) is a neurological condition in the anterior portion of the spinal cord and can be characterised as paraplegia (paralysis of the lower limbs), and cranial nerve dysfunction. These lesions are caused by the infection due to Enterovirus 68 (EV-D68); a member of the Enterovirus (EV) family belongs to the Enterovirus species within the Picornavirus family and a Polio-like virus. In many cases, the facial, axial, bulbar, respiratory, and extraocular muscles were affected, hence reducing the overall quality of the patient's life. Moreover, severe pathological conditions demand hospitalisation and can cause mortality in a few cases. The data from previous case studies and literature suggest that the prevalence is high in paediatric patients, but careful clinical assessment and management can decrease the risk of mortality and paraplegia. Moreover, the clinical and laboratory diagnosis can be performed by Magnetic resonance imaging (MRI) of the spinal cord followed by Reverse transcription polymerase chain reaction (rRT-PCR) and VP1 seminested PCR assay of the cerebrospinal fluid (CSF), stool, and serum samples can reveal the disease condition to an extent. The primary measure to control the outbreak is social distancing as advised by public health administrations, but more effective ways are yet to discover. Nonetheless, vaccines in the form of the whole virus, live attenuated, sub-viral particles, and DNA vaccines can be an excellent choice to treat these conditions. The review discusses a variety of topics, such as epidemiology, pathophysiology, diagnosis/clinical features, hospitalisation/mortality, management/treatment, and potential future developments.
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Affiliation(s)
- Baljinder Singh
- Centre for Pharmaceutical Innovation, University of South Australia, North Terrace, Adelaide, SA, Australia
| | - Sanchit Arora
- Department of Pharmaceutics, Delhi Institute of Pharmaceutical Sciences and Research (DIPSAR), Delhi Pharmaceutical Sciences and Research University (DPSRU), New Delhi, India
| | - Navjot Sandhu
- Department of Quality Assurance, ISF College of Pharmacy, Moga, Affiliated to IK Gujral Punjab Technical University, Jalandhar, India
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Lane TR, Fu J, Sherry B, Tarbet B, Hurst BL, Riabova O, Kazakova E, Egorova A, Clarke P, Leser JS, Frost J, Rudy M, Tyler KL, Klose T, Volobueva AS, Belyaevskaya SV, Zarubaev VV, Kuhn RJ, Makarov V, Ekins S. Efficacy of an isoxazole-3-carboxamide analog of pleconaril in mouse models of Enterovirus-D68 and Coxsackie B5. Antiviral Res 2023; 216:105654. [PMID: 37327878 PMCID: PMC10527014 DOI: 10.1016/j.antiviral.2023.105654] [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: 04/27/2023] [Revised: 06/05/2023] [Accepted: 06/13/2023] [Indexed: 06/18/2023]
Abstract
Enteroviruses (EV) cause a number of life-threatening infectious diseases. EV-D68 is known to cause respiratory illness in children that can lead to acute flaccid myelitis. Coxsackievirus B5 (CVB5) is commonly associated with hand-foot-mouth disease. There is no antiviral treatment available for either. We have developed an isoxazole-3-carboxamide analog of pleconaril (11526092) which displayed potent inhibition of EV-D68 (IC50 58 nM) as well as other enteroviruses including the pleconaril-resistant Coxsackievirus B3-Woodruff (IC50 6-20 nM) and CVB5 (EC50 1 nM). Cryo-electron microscopy structures of EV-D68 in complex with 11526092 and pleconaril demonstrate destabilization of the EV-D68 MO strain VP1 loop, and a strain-dependent effect. A mouse respiratory model of EV-D68 infection, showed 3-log decreased viremia, favorable cytokine response, as well as statistically significant 1-log reduction in lung titer reduction at day 5 after treatment with 11526092. An acute flaccid myelitis neurological infection model did not show efficacy. 11526092 was tested in a mouse model of CVB5 infection and showed a 4-log TCID50 reduction in the pancreas. In summary, 11526092 represents a potent in vitro inhibitor of EV with in vivo efficacy in EV-D68 and CVB5 animal models suggesting it is worthy of further evaluation as a potential broad-spectrum antiviral therapeutic against EV.
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Affiliation(s)
- Thomas R Lane
- Collaborations Pharmaceuticals Inc., Raleigh, NC, USA
| | - Jianing Fu
- Department of Biological Sciences, Purdue University, West Lafayette, IN, USA
| | - Barbara Sherry
- Department of Molecular Biomedical Sciences, North Carolina State University, College of Veterinary Medicine, Raleigh, NC, USA
| | - Bart Tarbet
- Institute for Antiviral Research, Utah State University, Logan, UT, USA; Department of Animal, Dairy and Veterinary Sciences, Utah State University, Logan, UT, USA
| | - Brett L Hurst
- Institute for Antiviral Research, Utah State University, Logan, UT, USA; Department of Animal, Dairy and Veterinary Sciences, Utah State University, Logan, UT, USA
| | - Olga Riabova
- Research Center of Biotechnology RAS, 33-1 Leninsky prospect, 119071, Moscow, Russia
| | - Elena Kazakova
- Research Center of Biotechnology RAS, 33-1 Leninsky prospect, 119071, Moscow, Russia
| | - Anna Egorova
- Research Center of Biotechnology RAS, 33-1 Leninsky prospect, 119071, Moscow, Russia
| | - Penny Clarke
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - J Smith Leser
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Joshua Frost
- Department of Immunology and Microbiology, Infectious Disease, Medicine and Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Kenneth L Tyler
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Veterans Affairs, Aurora, CO, USA
| | - Thomas Klose
- Department of Biological Sciences, Purdue University, West Lafayette, IN, USA
| | | | | | - Vladimir V Zarubaev
- Saint Petersburg Pasteur Institute, 14 Mira Street, 197101, Saint Petersburg, Russia
| | - Richard J Kuhn
- Department of Biological Sciences, Purdue University, West Lafayette, IN, USA
| | - Vadim Makarov
- Research Center of Biotechnology RAS, 33-1 Leninsky prospect, 119071, Moscow, Russia
| | - Sean Ekins
- Collaborations Pharmaceuticals Inc., Raleigh, NC, USA.
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8
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Helfferich J, Neuteboom RF, de Lange MMA, Benschop KSM, Van Leer-Buter CC, Meijer A, Bakker DP, de Bie E, Braakman HMH, Brandsma R, Niks EH, Niermeijer JM, Roelfsema V, Schoenmaker N, Sie LT, Niesters HG, Te Wierik MJM, Jacobs BC, Brouwer OF. Pediatric acute flaccid myelitis: Evaluation of diagnostic criteria and differentiation from other causes of acute flaccid paralysis. Eur J Paediatr Neurol 2023; 44:28-36. [PMID: 36996587 DOI: 10.1016/j.ejpn.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/20/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND Acute flaccid paralysis (AFP) is characterized by rapidly progressive limb weakness with low muscle tone. It has a broad differential diagnosis, which includes acute flaccid myelitis (AFM), a rare polio-like condition that mainly affects young children. Differentiation between AFM and other causes of AFP may be difficult, particularly at onset of disease. Here, we evaluate the diagnostic criteria for AFM and compare AFM to other causes of acute weakness in children, aiming to identify differentiating clinical and diagnostic features. METHODS The diagnostic criteria for AFM were applied to a cohort of children with acute onset of limb weakness. An initial classification based on positive diagnostic criteria was compared to the final classification, based on application of features suggestive for an alternative diagnosis and discussion with expert neurologists. Cases classified as definite, probable, or possible AFM or uncertain, were compared to cases with an alternative diagnosis. RESULTS Of 141 patients, seven out of nine patients initially classified as definite AFM, retained this label after further classification. For probable AFM, this was 3/11, for possible AFM 3/14 and for uncertain 11/43. Patients initially classified as probable or possible AFM were most commonly diagnosed with transverse myelitis (16/25). If the initial classification was uncertain, Guillain-Barré syndrome was the most common diagnosis (31/43). Clinical and diagnostic features not included in the diagnostic criteria, were often used for the final classification. CONCLUSION The current diagnostic criteria for AFM usually perform well, but additional features are sometimes required to distinguish AFM from other conditions.
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Affiliation(s)
- Jelte Helfferich
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - Rinze F Neuteboom
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marit M A de Lange
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Kimberley S M Benschop
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Coretta C Van Leer-Buter
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Adam Meijer
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Dewi P Bakker
- Department of Paediatric Neurology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Eva de Bie
- Department of Paediatric Neurology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Hilde M H Braakman
- Department of Paediatric Neurology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Rick Brandsma
- Department of Paediatric Neurology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Erik H Niks
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Vincent Roelfsema
- Department of Paediatrics, Martini Hospital, Groningen, the Netherlands
| | | | - Lilian T Sie
- Department of Paediatric Neurology, Haga Hospital, the Hague, the Netherlands
| | - Hubert G Niesters
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Margreet J M Te Wierik
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Bart C Jacobs
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Oebele F Brouwer
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Lu E, Sinha A, Freeman MC. Clinical progress note: Enterovirus D68 and acute flaccid myelitis. J Hosp Med 2023; 18:435-438. [PMID: 36938975 DOI: 10.1002/jhm.13085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 03/21/2023]
Affiliation(s)
- Elise Lu
- Department of Pediatrics, Paul C. Gaffney Division of Pediatric Hospital Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Amit Sinha
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Megan Culler Freeman
- Department of Pediatrics, Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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10
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Bigi S, Ramette A, Barbani MT, Bieri A, Hoffmann A, Aebi C. Acute flaccid myelitis in Switzerland - association with enterovirus D68. Swiss Med Wkly 2023; 153:40045. [PMID: 36787499 DOI: 10.57187/smw.2023.40045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
Abstract
Poliomyelitis-like acute flaccid myelitis associated with enterovirus D68 (EV-D68) has emerged globally during the past decade. Here we describe the first documented case reported from Switzerland, and a second, suspected case occurring in temporal association. AFM occurs primarily in children, is usually heralded by a febrile, respiratory prodrome followed by acute-onset, usually asymmetrical, limb weakness with some predilection for the upper extremities, and respiratory muscle compromise in one third of reported cases. There is no specific therapy and the majority of cases result in permanent neurological sequelae. A comprehensive diagnostic workup and timely reporting to the health authorities are essential. Surveillance of respiratory and stool samples for EV-D68 and other neurotropic enteroviruses is in place in several European countries and warrants consideration in Switzerland. This could entail the extension of the poliomyelitis surveillance program of the Federal Office of Public Health by monitoring and enteroviral typing of respiratory samples from patients with acute flaccid paralysis.
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Affiliation(s)
- Sandra Bigi
- Institute of Social and Preventive Medicine, University of Bern, Switzerland.,Department of Neurology, Bern University Hospital, Inselspital, University of Bern, Switzerland
| | - Alban Ramette
- Institute for Infectious Diseases, University of Bern, Switzerland
| | | | - Andreas Bieri
- Department of Paediatrics, Cantonal Hospital Aarau, Switzerland
| | - Angelika Hoffmann
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Christoph Aebi
- Division of Paediatric Infectious Diseases, Department of Paediatrics, Bern University Hospital, Inselspital, University of Bern, Switzerland
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11
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Acute Flaccid Myelitis: Review of Clinical Features, Diagnosis, and Management with Nerve Transfers. Plast Reconstr Surg 2023; 151:85e-98e. [PMID: 36219869 DOI: 10.1097/prs.0000000000009788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Acute flaccid myelitis (AFM) is a devastating neurologic condition in children, manifesting as acute limb weakness and/or paralysis. Despite increased awareness of AFM following initiation of U.S. surveillance in 2014, no treatment consensus exists. The purpose of this systematic review was to summarize the most current knowledge regarding AFM epidemiology, cause, clinical features, diagnosis, and supportive and operative management, including nerve transfer. METHODS The authors systematically reviewed the literature based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using multiple databases to search the keywords ("acute flaccid myelitis"), ('acute flaccid myelitis'/exp OR 'acute flaccid myelitis'), and (Acute AND flaccid AND myelitis). Included articles reported on (1) AFM diagnosis and (2) patient-specific data regarding epidemiology, cause, clinical features, diagnostic features, or management of AFM. RESULTS Ninety-nine articles were included in this review. The precise cause and pathophysiologic mechanism of AFM remain undetermined, but AFM is strongly associated with nonpolio enterovirus infections. Clinical presentation typically comprises preceding viral prodrome, pleocytosis, spinal cord lesions on T2-weighted magnetic resonance imaging, and acute onset of flaccid weakness/paralysis with hyporeflexia in at least one extremity. Supportive care includes medical therapy and rehabilitation. Early studies of nerve transfer for AFM have shown favorable outcomes for patients with persistent weakness. CONCLUSIONS Supportive care and physical therapy are the foundation of a multidisciplinary approach to managing AFM. For patients with persistent limb weakness, nerve transfer has shown promise for improving function in distal muscle groups. Surgeons must consider potential spontaneous recovery, patient selection, donor nerve availability, recipient nerve appropriateness, and procedure timing.
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12
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Dinov D, Donowitz JR. Acute flaccid myelitis a review of the literature. Front Neurol 2022; 13:1034607. [PMID: 36605787 PMCID: PMC9807762 DOI: 10.3389/fneur.2022.1034607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
Acute flaccid myelitis (AFM) is a rare neurological disorder that first rose to national attention in 2014. This neurological disorder has a biennial presentation with every other even year being a peak year. Most patients present in childhood 5 days after a prodromal infection. Patients usually present with muscle weakness and hypo or areflexia in the summer or fall months. Clinical outcomes are variable however most patients do not improve. Currently there are no definitive prognostic factors or etiologies found. However, it is thought that enterovirus-D68 (EV-D68) could be a potential component in the pathobiology of AFM. Treatment options are limited with variable options and no consensus. Supportive therapy has been shown to be the most effective thus far. With our review of the literature, we highlight the recent growing evidence of a possible relationship between EV-D68 and AFM. Additionally, we identify the knowledge gaps in AFM with treatment and prognostic factors.
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Affiliation(s)
- Darina Dinov
- Department of Neurology, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, United States,*Correspondence: Darina Dinov ✉
| | - Jeffrey R. Donowitz
- Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, United States
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Helfferich J, de Lange MMA, Benschop KSM, Jacobs BC, Van Leer-Buter CC, Meijer A, Bakker DP, de Bie E, Braakman HMH, Brandsma R, Neuteboom RF, Niks EH, Niermeijer JM, Roelfsema V, Schoenmaker N, Sie LT, Niesters HG, Brouwer OF, te Wierik MJM. Epidemiology of acute flaccid myelitis in children in the Netherlands, 2014 to 2019. Euro Surveill 2022; 27:2200157. [PMID: 36268734 PMCID: PMC9585879 DOI: 10.2807/1560-7917.es.2022.27.42.2200157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Acute flaccid myelitis (AFM) is a polio-like condition affecting mainly children and involving the central nervous system (CNS). AFM has been associated with different non-polio-enteroviruses (EVs), in particular EV-D68 and EV-A71. Reliable incidence rates in European countries are not available. Aim To report AFM incidence in children in the Netherlands and its occurrence relative to EV-D68 and EV-A71 detections. Methods In 10 Dutch hospitals, we reviewed electronic health records of patients diagnosed with a clinical syndrome including limb weakness and/or CNS infection and who were < 18 years old when symptoms started. After excluding those with a clear alternative diagnosis to AFM, those without weakness, and removing duplicate records, only patients diagnosed in January 2014–December 2019 were retained and further classified according to current diagnostic criteria. Incidence rates were based on definite and probable AFM cases. Cases’ occurrences during the study period were co-examined with laboratory-surveillance detections of EV-D68 and EV-A71. Results Among 143 patients included, eight were classified as definite and three as probable AFM. AFM mean incidence rate was 0.06/100,000 children/year (95% CI: −0.03 to 0.14). All patient samples were negative for EV-A71. Of respiratory samples in seven patients, five were EV-D68 positive. AFM cases clustered in periods with increased EV-D68 and EV-A71 detections. Conclusions AFM is rare in children in the Netherlands. The temporal coincidence of EV-D68 circulation and AFM and the detection of this virus in several cases’ samples support its association with AFM. Increased AFM awareness among clinicians, adequate diagnostics and case registration matter to monitor the incidence.
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Affiliation(s)
- Jelte Helfferich
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Marit MA de Lange
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Kimberley SM Benschop
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Bart C Jacobs
- Department of Neurology and Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Coretta C Van Leer-Buter
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Adam Meijer
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Dewi P Bakker
- Department of Paediatric Neurology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Eva de Bie
- Department of Paediatric Neurology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Hilde MH Braakman
- Department of Paediatric Neurology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Rick Brandsma
- Department of Paediatric Neurology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Rinze F Neuteboom
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Erik H Niks
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Vincent Roelfsema
- Department of Paediatrics, Martini Hospital, Groningen, the Netherlands
| | | | - Lilian T Sie
- Department of Paediatric Neurology, Haga Hospital, the Hague, the Netherlands
| | - Hubert G Niesters
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Oebele F Brouwer
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Margreet JM te Wierik
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
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Abstract
Human enterovirus D68 (EV-D68) is a globally reemerging respiratory pathogen that is associated with the development of acute flaccid myelitis (AFM) in children. Currently, there are no approved vaccines or treatments for EV-D68 infection, and there is a paucity of data related to the virus and host-specific factors that predict disease severity and progression to the neurologic syndrome. EV-D68 infection of various animal models has served as an important platform for characterization and comparison of disease pathogenesis between historic and contemporary isolates. Still, there are significant gaps in our knowledge of EV-D68 pathogenesis that constrain the development and evaluation of targeted vaccines and antiviral therapies. Continued refinement and characterization of animal models that faithfully reproduce key elements of EV-D68 infection and disease is essential for ensuring public health preparedness for future EV-D68 outbreaks.
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15
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Andrés C, Vila J, Creus-Costa A, Piñana M, González-Sánchez A, Esperalba J, Codina MG, Castillo C, Martín MC, Fuentes F, Rubio S, García-Comuñas K, Vásquez-Mercado R, Saubi N, Rodrigo C, Pumarola T, Antón A. Enterovirus D68 in Hospitalized Children, Barcelona, Spain, 2014-2021. Emerg Infect Dis 2022; 28:1327-1331. [PMID: 35731133 PMCID: PMC9239859 DOI: 10.3201/eid2807.220264] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
To determine molecular epidemiology and clinical features of enterovirus D68 (EV-D68) infections, we reviewed EV-D68–associated respiratory cases at a hospital in Barcelona, Spain, during 2014–2021. Respiratory samples were collected from hospitalized patients or outpatients with symptoms of acute respiratory tract infection or suggestive of enterovirus infection. Enterovirus detection was performed by real-time multiplex reverse transcription PCR and characterization by phylogenetic analysis of the partial viral protein 1 coding region sequences. From 184 patients with EV-D68 infection, circulating subclades were B3 (80%), D1 (17%), B2 (1%), and A (<1%); clade proportions shifted over time. EV-D68 was detected mostly in children (86%) and biennially (2016, 2018, 2021). In patients <16 years of age, the most common sign/symptom was lower respiratory tract infection, for which 11.8% required pediatric intensive care unit admission and 2.3% required invasive mechanical ventilation; neurologic complications developed in 1. The potential neurotropism indicates that enterovirus surveillance should be mandatory.
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16
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Monitoring of Enterovirus D68 Outbreak in Israel by a Parallel Clinical and Wastewater Based Surveillance. Viruses 2022; 14:v14051010. [PMID: 35632752 PMCID: PMC9144596 DOI: 10.3390/v14051010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 04/30/2022] [Accepted: 05/03/2022] [Indexed: 11/16/2022] Open
Abstract
Enterovirus D68 (EVD68) was recently identified as an important cause of respiratory illness and acute flaccid myelitis (AFM), mostly in children. Here, we examined 472 pediatric patients diagnosed with severe respiratory illness and screened for EVD68 between April and October 2021. In parallel, samples collected from a wastewater treatment plant (WWTP) covering the residential area of the hospitalized patients were also tested for EVD68. Of the 472 clinical samples evaluated, 33 (7%) patients were positive for EVD68 RNA. All wastewater samples were positive for EVD68, with varying viral genome copy loads. Calculated EVD68 genome copies increased from the end of May until July 2021 and dramatically decreased at the beginning of August. A similar trend was observed in both clinical and wastewater samples during the period tested. Sequence analysis of EVD68-positive samples indicated that all samples originated from the same branch of subclade B3. This study is the first to use wastewater-based epidemiology (WBE) to monitor EVD68 dynamics by quantitative detection and shows a clear correlation with clinically diagnosed cases. These findings highlight the potential of WBE as an important tool for continuous surveillance of EVD68 and other enteroviruses.
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17
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Lazzarini LM, Werner JM, Perez IA, Seruya M, Ramos-Platt L, Tiongson E, Keens TG. Does acute flaccid myelitis cause respiratory failure in children? Pediatr Pulmonol 2022; 57:682-685. [PMID: 34910378 DOI: 10.1002/ppul.25789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 10/15/2021] [Accepted: 11/23/2021] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Acute flaccid myelitis (AFM) is a rare disease that affects spinal cord gray matter, results in acute flaccid weakness of one or more limbs and predominantly involves the cervical spinal cord, which places patients at higher risk for respiratory failure. Our study aims to describe respiratory failure in pediatric AFM patients with emphasis on the need for assisted ventilation and respiratory nerve involvement from an acute and long-term perspective. MATERIALS AND METHODS We reviewed the medical records of patients diagnosed with AFM seen in a multidisciplinary clinic for persistent limb weakness between 2016 and 2020. RESULTS We studied 54 patients, 35% were female. The median age of patients at illness onset was 5 years (range 7 months-19 years). The median age of patients at the time of study was 8.5 years (range 2-20 years). Eleven patients (20%) required assisted ventilation for acute respiratory failure. Of those that experienced acute respiratory failure, 81% developed chronic respiratory failure. Fifty-six percent of patients with chronic respiratory failure were able to wean off assisted ventilation by 1 year. All patients that experienced unilateral diaphragm impairment with AFM onset experienced acute and chronic respiratory failure. DISCUSSION Many patients with AFM may experience respiratory compromise and develop chronic respiratory failure. However, most of these patients can be weaned off ventilatory support by 1 year from illness onset. Most children with unilateral diaphragm impairment can sustain adequate ventilation without the need for long-term ventilatory support.
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Affiliation(s)
- Laura M Lazzarini
- Division of Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Julie M Werner
- Division of Rehabilitation Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA.,Institute for Nursing and Interprofessional Research, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Iris A Perez
- Division of Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA.,Department of Pediatrics, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Mitchel Seruya
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, California, USA.,Plastic and Reconstructive Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Leigh Ramos-Platt
- Department of Pediatrics, Keck School of Medicine of University of Southern California, Los Angeles, California, USA.,Division of Neurology, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Emmanuelle Tiongson
- Department of Pediatrics, Keck School of Medicine of University of Southern California, Los Angeles, California, USA.,Division of Neurology, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Thomas G Keens
- Division of Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA.,Department of Pediatrics, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
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18
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Daniels DK, Conners GP. A Review of the Diagnosis and Management of Acute Flaccid Myelitis in the Emergency Department. Pediatr Emerg Care 2022; 38:126-130. [PMID: 35226621 DOI: 10.1097/pec.0000000000002660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Since 2014, biennial rises in acute flaccid myelitis (AFM) have brought attention to this rare but debilitating condition. Children with AFM typically present with acute onset, flaccid weakness accompanied by longitudinally extensive gray matter injury demonstrated on magnetic resonance imaging. A clearer understanding of the epidemiology and suspected pathogenesis of AFM may result in increased recognition. The purpose of this review article is to guide emergency physicians in recognizing key clinical features, initiating diagnostic evaluation and providing appropriate interventions for children with suspected AFM.
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Affiliation(s)
| | - Gregory P Conners
- Stanley A. August Professor and Chair of Pediatrics, Executive Director, Upstate Golisano Children's Hospital, SUNY Upstate Medical University, Syracuse, NY
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19
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Fall A, Kenmoe S, Ebogo-Belobo JT, Mbaga DS, Bowo-Ngandji A, Foe-Essomba JR, Tchatchouang S, Amougou Atsama M, Yéngué JF, Kenfack-Momo R, Feudjio AF, Nka AD, Mbongue Mikangue CA, Taya-Fokou JB, Magoudjou-Pekam JN, Noura EA, Zemnou-Tepap C, Meta-Djomsi D, Maïdadi-Foudi M, Kame-Ngasse GI, Nyebe I, Djukouo LG, Kengne Gounmadje L, Tchami Ngongang D, Oyono MG, Demeni Emoh CP, Tazokong HR, Mahamat G, Kengne-Ndé C, Sadeuh-Mba SA, Dia N, La Rosa G, Ndip L, Njouom R. Global prevalence and case fatality rate of Enterovirus D68 infections, a systematic review and meta-analysis. PLoS Negl Trop Dis 2022; 16:e0010073. [PMID: 35134062 PMCID: PMC8824346 DOI: 10.1371/journal.pntd.0010073] [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: 06/24/2021] [Accepted: 12/08/2021] [Indexed: 11/23/2022] Open
Abstract
A substantial amount of epidemiological data has been reported on Enterovirus D68 (EV-D68) infections after the 2014 outbreak. Our goal was to map the case fatality rate (CFR) and prevalence of current and past EV-D68 infections. We conducted a systematic review (PROSPERO, CRD42021229255) with published articles on EV-68 infections in PubMed, Embase, Web of Science and Global Index Medicus up to January 2021. We determined prevalences using a model random effect. Of the 4,329 articles retrieved from the databases, 89 studies that met the inclusion criteria were from 39 different countries with apparently healthy individuals and patients with acute respiratory infections, acute flaccid myelitis and asthma-related diseases. The CFR estimate revealed occasional deaths (7/1353) related to EV-D68 infections in patients with severe acute respiratory infections. Analyses showed that the combined prevalence of current and past EV-D68 infections was 4% (95% CI = 3.1–5.0) and 66.3% (95% CI = 40.0–88.2), respectively. The highest prevalences were in hospital outbreaks, developed countries, children under 5, after 2014, and in patients with acute flaccid myelitis and asthma-related diseases. The present study shows sporadic deaths linked to severe respiratory EV-D68 infections. The study also highlights a low prevalence of current EV-D68 infections as opposed to the existence of EV-D68 antibodies in almost all participants of the included studies. These findings therefore highlight the need to implement and/or strengthen continuous surveillance of EV-D68 infections in hospitals and in the community for the anticipation of the response to future epidemics. Enterovirus D68 (EV-D68) infections represent a global public health concern. EV-D68 are detected in apparently healthy subjects and patients with acute respiratory illnesses, acute flaccid myelitis, and asthma-related illnesses. Enterovirus D68 was first described in 1962 and exhibited sporadic circulation until August 2014 when outbreaks of EV-D68 infections were reported in the USA and Canada mainly in children with acute flaccid myelitis and severe acute respiratory disease. We systematically reviewed the literature on EV-D68 infections globally in the present study to determine the case fatality rate and prevalence of current and past infections. Our results show sporadic deaths in patients with severe acute respiratory EV-D68 infections. Our data also show a low prevalence of EV-D68 in current infections unlike the presence of EV-D68 antibodies (past infections) in almost all individuals of all ages. EV-D68 infections were more prevalent in hospital outbreaks, industrialized countries, children < 5 years, and patients with acute flaccid myelitis and asthma-related diseases. These data highlight the need to strengthen the surveillance of EV-D68 infections.
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Affiliation(s)
- Amary Fall
- Virology Department, Institute Pasteur of Dakar, Dakar, Senegal
| | - Sebastien Kenmoe
- Virology Department, Centre Pasteur of Cameroon, Yaounde, Cameroon
- Department of Microbiology and Parasitology, University of Buea, Buea, Cameroon
- * E-mail: (SK); (RN)
| | - Jean Thierry Ebogo-Belobo
- Medical Research Centre, Institute of Medical Research and Medicinal Plants Studies, Yaounde, Cameroon
| | | | - Arnol Bowo-Ngandji
- Department of Microbiology, The University of Yaounde I, Yaounde, Cameroon
| | | | | | - Marie Amougou Atsama
- Centre de Recherche sur les Maladies Émergentes et Re-Emergentes, Institut de Recherches Médicales et d’Etudes des Plantes Médicinales, Yaounde, Cameroon
| | | | - Raoul Kenfack-Momo
- Department of Biochemistry, The University of Yaounde I, Yaounde, Cameroon
| | | | - Alex Durand Nka
- Virology Laboratory, Chantal Biya International Reference Center for Research on HIV/AIDS Prevention and Management, Yaounde, Cameroon
| | | | | | | | - Efietngab Atembeh Noura
- Medical Research Centre, Institute of Medical Research and Medicinal Plants Studies, Yaounde, Cameroon
| | | | - Dowbiss Meta-Djomsi
- Centre de Recherche sur les Maladies Émergentes et Re-Emergentes, Institut de Recherches Médicales et d’Etudes des Plantes Médicinales, Yaounde, Cameroon
| | - Martin Maïdadi-Foudi
- Centre de Recherche sur les Maladies Émergentes et Re-Emergentes, Institut de Recherches Médicales et d’Etudes des Plantes Médicinales, Yaounde, Cameroon
| | - Ginette Irma Kame-Ngasse
- Medical Research Centre, Institute of Medical Research and Medicinal Plants Studies, Yaounde, Cameroon
| | - Inès Nyebe
- Department of Microbiology, The University of Yaounde I, Yaounde, Cameroon
| | | | | | | | - Martin Gael Oyono
- Department of Animals Biology and Physiology, The University of Yaounde I, Yaounde, Cameroon
| | | | | | - Gadji Mahamat
- Department of Microbiology, The University of Yaounde I, Yaounde, Cameroon
| | - Cyprien Kengne-Ndé
- Research Monitoring and Planning Unit, National Aids Control Committee, Douala, Cameroon
| | | | - Ndongo Dia
- Virology Department, Institute Pasteur of Dakar, Dakar, Senegal
| | - Giuseppina La Rosa
- Department of Environment and Health, Istituto Superiore di Sanità, Rome, Italy
| | - Lucy Ndip
- Department of Microbiology and Parasitology, University of Buea, Buea, Cameroon
| | - Richard Njouom
- Virology Department, Centre Pasteur of Cameroon, Yaounde, Cameroon
- * E-mail: (SK); (RN)
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20
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Acute flaccid rhombencephalomyelitis with radiculitis in a child with an enterovirus A71 infection seen for the first time in Denmark: a case report. J Med Case Rep 2022; 16:32. [PMID: 35073972 PMCID: PMC8786451 DOI: 10.1186/s13256-021-03246-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 12/27/2021] [Indexed: 11/24/2022] Open
Abstract
Background Acute flaccid myelitis is a serious condition of the spinal cord. More than 80% of patients experience a mild respiratory illness or fever consistent with a viral infection prior to acute flaccid myelitis development. Enterovirus A71 is known to circulate in Denmark, and has previously been associated with severe neurological symptoms. In this case report we describe acute flaccid rhombencephalomyelitis with radiculitis in an infant with an enterovirus infection. Case presentation The 8-month-old male of Asian origin presented with fever and gastrointestinal symptoms, followed by severe neurological deficits such as flaccid paralysis of the neck and upper extremities. An initial magnetic resonance imaging scan of the brain was normal, and the boy was treated for encephalitis. A follow-up magnetic resonance imaging scan of the brain and spinal cord 1 week later showed the development of pathological symmetrical gray matter hyperintensity lesions on T2-weighted images in the brainstem and upper medulla spinalis, and nerve enhancement in the terminal thread of the spinal cord and the cervical roots; findings consistent with rhombencephalomyelitis with radiculitis causing flaccid paralysis. Enterovirus A71 was detected in both nasopharyngeal and fecal specimens. Other differential diagnostic etiologies of viral and bacterial encephalitis, including poliovirus, were excluded. Conclusions This is the first case in Denmark of a patient diagnosed with acute flaccid rhombencephalomyelitis strongly linked to an enterovirus A71 infection. This case emphasizes the diagnostic importance of combining a history of respiratory and/or gastrointestinal illness, fever, and delayed onset of varying degrees of paralysis with progressive characteristic spinal and brain lesions. Analysis of respiratory, fecal, and cerebrospinal samples for the presence of enterovirus, and eliminating other differential pathogens, is essential to confirm the diagnosis.
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21
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Setia A, Bhatia J, Bhattacharya S. An Overview of Acute Flaccid Myelitis. CNS & NEUROLOGICAL DISORDERS DRUG TARGETS 2022; 21:774-794. [PMID: 34823462 DOI: 10.2174/1871527320666211125101424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 04/19/2021] [Accepted: 06/20/2021] [Indexed: 06/13/2023]
Abstract
Acute Flaccid Myelitis is defined by the presence of Acute Flaccid Paralysis (AFP) and a spinal cord lesion on magnetic resonance imaging that is primarily limited to the grey matter. AFM is a difficult situation to deal with when you have a neurologic illness. According to the Centers for Disease Control and Prevention (CDC), a large number of cases were discovered in the United States in 2014, with 90% of cases occurring in children. Although the exact cause of AFM is unknown, mounting evidence suggests a link between AFM and enterovirus D68 (EV-D68). In 2014, an outbreak of AFM was discovered in the United States. The condition was initially linked to polioviruses; however, it was later found that the viruses were caused by non-polioviruses Enteroviruses D-68 (EV-D68). The number of cases has increased since 2014, and the disease has been declared pandemic in the United States. The sudden onset of muscle weakness, usually in an arm or leg, as well as pain throughout the body, the change in patient's facial expression (facial weakness), and shortness of breath, ingesting, and speaking are all common symptoms in patients suffering from neurologic disease. This article includes graphic and histogram representations of reported AFM incidents and criteria for causality, epidemiology, various diagnostic approaches, signs and symptoms, and various investigational guidelines. It also includes key statements about recent clinical findings related to AFM disease.
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Affiliation(s)
- Aseem Setia
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, Punjab-142001, India
| | - Jasween Bhatia
- Department of Masters in Public Health Science, Symbiosis Institute of Health Science, Pune-411042, India
| | - Sankha Bhattacharya
- Department of Pharmaceutics, School of Pharmacy & Technology Management Shirpur, SVKM\'S NMIMS Deemed-to-be University, Shirpur, Maharashtra 425405, India
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22
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Rabinovich RV, Pino PA, Aversano M, Kozin SH, Zlotolow DA. Nerve Transfers for Restoration of Elbow Flexion in Patients With Acute Flaccid Myelitis. J Hand Surg Am 2022; 47:91.e1-91.e8. [PMID: 34020841 DOI: 10.1016/j.jhsa.2021.02.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 12/06/2020] [Accepted: 02/18/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to evaluate short- to midterm outcomes of patients with acute flaccid myelitis who underwent nerve transfers for restoration of elbow flexion. METHODS Patients with a minimum of 10 months of follow up after undergoing nerve transfers to restore elbow flexion were clinically assessed using the Active Movement Scale (AMS). They were evaluated for any postoperative complications, particularly weakness in the distribution of the donor nerve(s). Fifteen of 25 consecutive patients who were treated using this surgical technique were included in the final analysis. RESULTS All patients exhibited poor elbow flexion preoperatively (AMS 0 to 3). At a mean follow up of 17.3 months, 80% (15/25) of patients achieved excellent elbow flexion (AMS 6 or 7); 9 of these 15 had full active range of motion. Two patients achieved good elbow flexion (AMS 5) with antigravity movement to less than 50% of the passive range of motion. No cases of superficial or deep infection were reported, and all patients maintained identical motor function, relative to preoperative status, of the muscles innervated by the donor nerves. CONCLUSIONS Nerve transfer surgery has shown promising short- to midterm results for recovery of nerve and muscle function, particularly for the restoration of elbow flexion. We recommend this treatment option for patients not demonstrating clinical improvement after 6 to 9 months of incomplete recovery. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Remy V Rabinovich
- Department of Orthopaedic Surgery, Philadelphia Hand to Shoulder Center and Thomas Jefferson University Hospitals, Philadelphia, PA.
| | - Paula A Pino
- Department of Orthopaedic Surgery, Pontefical Catholic University of Chile, Santiago, Chile
| | - Michael Aversano
- Department of Orthopaedic Surgery, Shriners Hospital for Children - Philadelphia, PA
| | - Scott H Kozin
- Department of Orthopaedic Surgery, Shriners Hospital for Children - Philadelphia, PA
| | - Dan A Zlotolow
- Department of Orthopaedic Surgery, Shriners Hospital for Children - Philadelphia, PA
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23
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Toopchizadeh V, Barzegar M, Ranjbar-Kiyakalayeh S, Shahidzadeh A, Khakbiz S, Jahanshahi A, Jahanjoo F. Clinical presentation, electrodiagnostic findings and outcomes of acute flaccid myelitis: A brief review and case series. J Pediatr Rehabil Med 2022; 15:369-376. [PMID: 35634814 DOI: 10.3233/prm-200798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Acute flaccid myelitis (AFM) is an acute condition occurring mostly in children. Although affected patients can show a broad spectrum of symptoms, it is mainly characterized by the progressive onset of focal limb weakness, presenting over a period of hours to a week, with or without pain, and spinal cord gray matter involvement on magnetic resonance imaging (MRI). There is compelling evidence to support the role of viruses, in particular enteroviruses. Studies describing electrodiagnostic (EDX) abnormalities and long-term outcomes in AFM are limited. In this report, the clinical presentation, EDX and MRI findings, and long-term outcomes in three children with AFM who presented with progressive and asymmetric weakness of the limbs are described. MRI showed a long segment cervicothoracic lesion with vertical expansion in all three cases. Patients do recover in time, but many continue to have permanent muscle weakness in the worst affected part(s), and complete recovery is rare. Follow-up of these three cases at 18 months demonstrated a partial recovery in the motor system.
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Affiliation(s)
- Vahideh Toopchizadeh
- Physical Medicine and Rehabilitation Research Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammad Barzegar
- Pediatric Health Research Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sepideh Ranjbar-Kiyakalayeh
- Physical Medicine and Rehabilitation Research Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Azadeh Shahidzadeh
- Physical Medicine and Rehabilitation Research Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Saide Khakbiz
- Physical Medicine and Rehabilitation Research Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Amirreza Jahanshahi
- Department of Radiology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fatemeh Jahanjoo
- Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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24
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Involvement of RIG-I Pathway in Neurotropic Virus-Induced Acute Flaccid Paralysis and Subsequent Spinal Motor Neuron Death. mBio 2021; 12:e0271221. [PMID: 34781742 PMCID: PMC8593677 DOI: 10.1128/mbio.02712-21] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Poliomyelitis-like illness is a common clinical manifestation of neurotropic viral infections. Functional loss and death of motor neurons often lead to reduced muscle tone and paralysis, causing persistent motor sequelae among disease survivors. Despite several reports demonstrating the molecular basis of encephalopathy, the pathogenesis behind virus-induced flaccid paralysis remained largely unknown. The present study for the first time aims to elucidate the mechanism responsible for limb paralysis by studying clinical isolates of Japanese encephalitis virus (JEV) and Chandipura virus (CHPV) responsible for causing acute flaccid paralysis (AFP) in vast regions of Southeast Asia and the Indian subcontinent. An experimental model for studying virus-induced AFP was generated by intraperitoneal injection of 10-day-old BALB/c mice. Progressive decline in motor performance of infected animals was observed, with paralysis being correlated with death of motor neurons (MNs). Furthermore, we demonstrated that upon infection, MNs undergo an extrinsic apoptotic pathway in a RIG-I-dependent fashion via transcription factors pIRF-3 and pIRF-7. Both gene-silencing experiments using specific RIG-I-short interfering RNA and in vivo morpholino abrogated cellular apoptosis, validating the important role of pattern recognition receptor (PRR) RIG-I in MN death. Hence, from our experimental observations, we hypothesize that host innate response plays a significant role in deterioration of motor functioning upon neurotropic virus infections.
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25
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Benschop KS, Albert J, Anton A, Andrés C, Aranzamendi M, Armannsdóttir B, Bailly JL, Baldanti F, Baldvinsdóttir GE, Beard S, Berginc N, Böttcher S, Blomqvist S, Bubba L, Calvo C, Cabrerizo M, Cavallero A, Celma C, Ceriotti F, Costa I, Cottrell S, Del Cuerpo M, Dean J, Dembinski JL, Diedrich S, Diez-Domingo J, Dorenberg D, Duizer E, Dyrdak R, Fanti D, Farkas A, Feeney S, Flipse J, De Gascun C, Galli C, Georgieva I, Gifford L, Guiomar R, Hönemann M, Ikonen N, Jeannoël M, Josset L, Keeren K, López-Labrador FX, Maier M, McKenna J, Meijer A, Mengual-Chuliá B, Midgley SE, Mirand A, Montes M, Moore C, Morley U, Murk JL, Nikolaeva-Glomb L, Numanovic S, Oggioni M, Palminha P, Pariani E, Pellegrinelli L, Piralla A, Pietsch C, Piñeiro L, Rabella N, Rainetova P, Uceda Renteria SC, Romero MP, Reynders M, Roorda L, Savolainen-Kopra C, Schuffenecker I, Soynova A, Swanink CM, Ursic T, Verweij JJ, Vila J, Vuorinen T, Simmonds P, Fischer TK, Harvala H. Re-emergence of enterovirus D68 in Europe after easing the COVID-19 lockdown, September 2021. ACTA ACUST UNITED AC 2021; 26. [PMID: 34763750 PMCID: PMC8646978 DOI: 10.2807/1560-7917.es.2021.26.45.2100998] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
We report a rapid increase in enterovirus D68 (EV-D68) infections, with 139 cases reported from eight European countries between 31 July and 14 October 2021. This upsurge is in line with the seasonality of EV-D68 and was presumably stimulated by the widespread reopening after COVID-19 lockdown. Most cases were identified in September, but more are to be expected in the coming months. Reinforcement of clinical awareness, diagnostic capacities and surveillance of EV-D68 is urgently needed in Europe.
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Affiliation(s)
- Kimberley Sm Benschop
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - Jan Albert
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Andres Anton
- Respiratory Virus Unit, Microbiology Department, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Cristina Andrés
- Respiratory Virus Unit, Microbiology Department, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Maitane Aranzamendi
- Microbiology Department, Donostia University Hospital and Biodonostia Health Research Institute, San Sebastián, Spain
| | | | - Jean-Luc Bailly
- Université d'Auvergne, LMGE UMR CNRS 6023, Equipe EPIE - Epidémiologie et physiopathologie des infections à entérovirus, Faculté de Médecine, Clermont-Ferrand, France.,CHU Clermont-Ferrand, National Reference Centre for enteroviruses and parechoviruses - Associated laboratory, Clermont-Ferrand, France
| | - Fausto Baldanti
- Department of Clinical Surgical Diagnostic and Pediatric Sciences, Università degli Studi di Pavia, Pavia, Italy.,Microbiology and Virology Department, Fondazione IRCCS Policlinico San Matteo, Italy
| | | | - Stuart Beard
- UK Health Security Agency, Colindale, United Kingdom
| | - Natasa Berginc
- National laboratory of health, environment and food, Laboratory for public health virology, Ljubljana, Slovenia
| | - Sindy Böttcher
- National Reference Center for Poliomyelitis and Enteroviruses, Robert-Koch Institute, Berlin, Germany
| | - Soile Blomqvist
- National Institute for Health and Welfare, Helsinki, Finland
| | - Laura Bubba
- Department of Biomedical Sciences of Health, University of Milan, Milan, Italy
| | | | - Maria Cabrerizo
- National Centre for Microbiology, Instituto de Salud Carlos III, Enterovirus and Viral Gastroenteritis Unit/Polio National Lab, Madrid, Spain
| | - Annalisa Cavallero
- Laboratory of Microbiology, ASST Monza, San Gerardo Hospital, Monza (MB), Italy
| | | | - Ferruccio Ceriotti
- Virology Unit, Division of Clinical Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Inês Costa
- National Institute of Health (INSA), Lisbon, Portugal
| | | | - Margarita Del Cuerpo
- Microbiology Department Hospital Universitari de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jonathan Dean
- National Virus Reference Laboratory, University College Dublin, Dublin, Ireland
| | | | - Sabine Diedrich
- National Reference Center for Poliomyelitis and Enteroviruses, Robert-Koch Institute, Berlin, Germany
| | - Javier Diez-Domingo
- Center for Public Health Research (FISABIO-Public Health), Generalitat Valenciana, Valencia, Spain
| | | | - Erwin Duizer
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - Robert Dyrdak
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Diana Fanti
- Chemical-clinical and Microbiological Analyses, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Agnes Farkas
- National Public Health Center, Budapest, Hungary
| | - Susan Feeney
- Regional Virus Laboratory, Belfast Health and Social Care Trust (BHSCT, Royal Victoria Hospital, Belfast, United Kingdom
| | - Jacky Flipse
- Laboratory for Medical Microbiology and Immunology, Rijnstate, Velp, the Netherlands
| | - Cillian De Gascun
- National Virus Reference Laboratory, University College Dublin, Dublin, Ireland
| | - Cristina Galli
- Department of Biomedical Sciences of Health, University of Milan, Milan, Italy
| | - Irina Georgieva
- National Reference Laboratory for Enteroviruses, National Center of Infectious and Parasitic Diseases, Sofia, Bulgaria
| | | | | | - Mario Hönemann
- Institute of Medical Microbiology and Virology, University of Leipzig, Leipzig, Germany
| | - Niina Ikonen
- National Institute for Health and Welfare, Helsinki, Finland
| | - Marion Jeannoël
- National Reference Center for Enteroviruses and Parechoviruses, Institut des Agents Infectieux, Hospices Civils de Lyon, Lyon, France
| | - Laurence Josset
- National Reference Center for Enteroviruses and Parechoviruses, Institut des Agents Infectieux, Hospices Civils de Lyon, Lyon, France
| | - Kathrin Keeren
- Secretary of the commission for Polio Eradication in Germany, Robert-Koch Institute, Berlin, Germany
| | - F Xavier López-Labrador
- CIBERESP, Instituto de Salud Carlos III, Madrid, Spain.,Center for Public Health Research (FISABIO-Public Health), Generalitat Valenciana, Valencia, Spain
| | - Melanie Maier
- Institute of Medical Microbiology and Virology, University of Leipzig, Leipzig, Germany
| | - James McKenna
- Regional Virus Laboratory, Belfast Health and Social Care Trust (BHSCT, Royal Victoria Hospital, Belfast, United Kingdom
| | - Adam Meijer
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - Beatriz Mengual-Chuliá
- Center for Public Health Research (FISABIO-Public Health), Generalitat Valenciana, Valencia, Spain
| | - Sofie E Midgley
- The Danish WHO National Reference Laboratory for Poliovirus, Statens Serum Institut, Copenhagen, Denmark
| | - Audrey Mirand
- Université d'Auvergne, LMGE UMR CNRS 6023, Equipe EPIE - Epidémiologie et physiopathologie des infections à entérovirus, Faculté de Médecine, Clermont-Ferrand, France.,CHU Clermont-Ferrand, National Reference Centre for enteroviruses and parechoviruses - Associated laboratory, Clermont-Ferrand, France
| | - Milagrosa Montes
- Microbiology Department, Donostia University Hospital and Biodonostia Health Research Institute, San Sebastián, Spain
| | | | - Ursula Morley
- National Virus Reference Laboratory, University College Dublin, Dublin, Ireland
| | - Jean-Luc Murk
- Elisabeth Tweesteden Hospital, Tilburg, the Netherlands
| | - Lubomira Nikolaeva-Glomb
- National Reference Laboratory for Enteroviruses, National Center of Infectious and Parasitic Diseases, Sofia, Bulgaria
| | - Sanela Numanovic
- Department of Virology, Norwegian Institute of Public Health, Oslo, Norway
| | - Massimo Oggioni
- Virology Unit, Division of Clinical Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Elena Pariani
- Department of Biomedical Sciences of Health, University of Milan, Milan, Italy
| | - Laura Pellegrinelli
- Department of Biomedical Sciences of Health, University of Milan, Milan, Italy
| | - Antonio Piralla
- Microbiology and Virology Department, Fondazione IRCCS Policlinico San Matteo, Italy
| | - Corinna Pietsch
- Institute of Medical Microbiology and Virology, University of Leipzig, Leipzig, Germany
| | - Luis Piñeiro
- Microbiology Department, Donostia University Hospital and Biodonostia Health Research Institute, San Sebastián, Spain
| | - Núria Rabella
- Microbiology Department Hospital Universitari de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Sara Colonia Uceda Renteria
- Virology Unit, Division of Clinical Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - María P Romero
- Department of Biomedical Sciences of Health, University of Milan, Milan, Italy
| | | | | | | | - Isabelle Schuffenecker
- National Reference Center for Enteroviruses and Parechoviruses, Institut des Agents Infectieux, Hospices Civils de Lyon, Lyon, France
| | - Aysa Soynova
- National Reference Laboratory for Enteroviruses, National Center of Infectious and Parasitic Diseases, Sofia, Bulgaria
| | - Caroline Ma Swanink
- Laboratory for Medical Microbiology and Immunology, Rijnstate, Velp, the Netherlands
| | - Tina Ursic
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Jorgina Vila
- Pediatric Hospitalization Unit, Department of Pediatrics, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Tytti Vuorinen
- Clinical Microbiology, Turku University Hospital and Institute of Biomedicine, University of Turku, Turku, Finland
| | | | - Thea K Fischer
- Nordsjaellands Hospital, Hillerod, Denmark.,University of Sothern Denmark, Odense, Denmark
| | - Heli Harvala
- University College London (UCL), Department of infection and Immunity, London, United Kingdom.,NHS Blood and Transplant, Microbiology Services, Colindale, United Kingdom
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26
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Helfferich J, Roodbol J, de Wit MC, Brouwer OF, Jacobs BC. Acute flaccid myelitis and Guillain-Barré syndrome in children: A comparative study with evaluation of diagnostic criteria. Eur J Neurol 2021; 29:593-604. [PMID: 34747551 PMCID: PMC9299116 DOI: 10.1111/ene.15170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/03/2021] [Accepted: 11/01/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE Differentiation between acute flaccid myelitis (AFM) and Guillain-Barré syndrome (GBS) can be difficult, particularly in children. Our objective was to improve the diagnostic accuracy by giving recommendations based on a comparison of clinical features and diagnostic criteria in children with AFM or GBS. METHODS A cohort of 26 children with AFM associated with enterovirus D68 was compared to a cohort of 156 children with GBS. The specificity of the Brighton criteria, used for GBS diagnosis, was evaluated in the AFM cohort and the specificity of the Centers for Disease Control and Prevention (CDC) AFM diagnostic criteria in the GBS cohort. RESULTS Children with AFM compared to those with GBS had a shorter interval between onset of weakness and nadir (3 vs. 8 days, p < 0.001), more often had asymmetric limb weakness (58% vs. 0%, p < 0.001), and less frequently had sensory deficits (0% vs. 40%, p < 0.001). In AFM, cerebrospinal fluid leukocyte counts were higher, whereas protein concentrations were lower. Spinal cord lesions on magnetic resonance imaging were only found in AFM patients. No GBS case fulfilled CDC criteria for definite AFM. Of the AFM cases, 8% fulfilled the Brighton criteria for GBS, when omitting the criterion of excluding an alternate diagnosis. CONCLUSIONS Despite the overlap in clinical presentation, we found distinctive early clinical and diagnostic characteristics for differentiating AFM from GBS in children. Diagnostic criteria for AFM and GBS usually perform well, but some AFM cases may fulfill clinical diagnostic criteria for GBS. This underlines the need to perform diagnostic tests early to exclude AFM in children suspected of atypical GBS.
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Affiliation(s)
- Jelte Helfferich
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Joyce Roodbol
- Department of Neurology and Pediatric Neurology, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marie-Claire de Wit
- Department of Pediatric Neurology, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Oebele F Brouwer
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bart C Jacobs
- Department of Neurology and Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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27
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Yeh EA, Yea C, Bitnun A. Infection-Related Myelopathies. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2021; 17:141-158. [PMID: 34637338 DOI: 10.1146/annurev-pathmechdis-040121-022818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Recent years have seen growing attention to inflammatory and infectious disorders of the spinal cord, not only due to the discovery of autoantibody-mediated disorders of the spinal cord [e.g., aquaporin-4 immunoglobulin G (IgG) antibodies and myelin oligodendrocyte glycoprotein IgG antibodies], but also due to the emergence of clusters of infection-related myelopathy, now known as acute flaccid myelitis. We review the spectrum of infection-related myelopathies and outline a nosological classification system based on association with infection. We describe the epidemiology and definitions of myelopathies, with a discussion of clinical presentation and neuroimaging features, and then turn to specific discussion of myelopathies due to direct pathogen invasion and those considered to be post- or parainfectious. Expected final online publication date for the Annual Review of Pathology: Mechanisms of Disease, Volume 17 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- E Ann Yeh
- Division of Neurology, Department of Pediatrics, and Division of Neuroscience and Mental Health, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada; , .,Faculty of Medicine, University of Toronto, Toronto, Ontario M5G 1X8, Canada;
| | - Carmen Yea
- Division of Neurology, Department of Pediatrics, and Division of Neuroscience and Mental Health, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada; ,
| | - Ari Bitnun
- Division of Infectious Diseases, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario M5G 1X8, Canada;
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28
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Ebada MA, Fayed N, Alkanj S, Allah AW. Enterovirus D-68 Molecular Virology, Epidemiology, and Treatment: an Update and Way Forward. Infect Disord Drug Targets 2021; 21:320-327. [PMID: 32669078 DOI: 10.2174/1871526520666200715101230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 05/19/2020] [Accepted: 05/20/2020] [Indexed: 11/22/2022]
Abstract
Enterovirus D68 (EV-D68) is a single-stranded positive-sense RNA virus, and it is one of the family members of Picornaviridae. Except for EV-D68, the entire family Picornaviridae has been illustrated in literature. EV-D68 was first discovered and isolated in California, USA, in 1962. EV-D68 has resulted in respiratory disorders' outbreaks among children worldwide, and it has been detected in cases of various neurological diseases such as acute flaccid myelitis (AFM). A recent study documented a higher number of EV-D68 cases associated with AFM in Europe in 2016 compared to the 2014 outbreak. EV-D68 is mainly diagnosed by quantitative PCR, and there is an affirmative strategy for EV-D68 detection by using pan-EV PCR on the untranslated region and/or the VP1 or VP2, followed by sequencing of the PCR products. Serological tests are limited due to cross-reactivity of the antigens between the different serotypes. Many antiviral drugs for EV-D68 have been evaluated and showed promising results. In our review, we discuss the current knowledge about EV-D68 and its role in the development of AFM.
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Affiliation(s)
| | - Notila Fayed
- Faculty of Medicine, Zagazig University, Zagazig, El-Sharkia, Egypt
| | - Souad Alkanj
- Faculty of Medicine, Zagazig University, Zagazig, El-Sharkia, Egypt
| | - Ahmed Wadaa Allah
- Biochemistry Department, Faculty of Science, Ain Shams University, Cairo, Egypt
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29
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Keeren K, Böttcher S, Diedrich S. Enterovirus Surveillance (EVSurv) in Germany. Microorganisms 2021; 9:2005. [PMID: 34683328 PMCID: PMC8538599 DOI: 10.3390/microorganisms9102005] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/17/2021] [Accepted: 09/17/2021] [Indexed: 01/22/2023] Open
Abstract
The major aim of the enterovirus surveillance (EVSurv) in Germany is to prove the absence of poliovirus circulation in the framework of the Global Polio Eradication Program (GPEI). Therefore, a free-of-charge enterovirus diagnostic is offered to all hospitals for patients with symptoms compatible with a polio infection. Within the quality proven laboratory network for enterovirus diagnostic (LaNED), stool and cerebrospinal fluid (CSF) samples from patients with suspected aseptic meningitis/encephalitis or acute flaccid paralysis (AFP) are screened for enterovirus (EV), typing is performed in all EV positive sample to exclude poliovirus infections. Since 2006, ≈200 hospitals from all 16 German federal states have participated annually. On average, 2500 samples (70% stool, 28% CSF) were tested every year. Overall, the majority of the patients studied are children <15 years. During the 15-year period, 53 different EV serotypes were detected. While EV-A71 was most frequently detected in infants, E30 dominated in older children and adults. Polioviruses were not detected. The German enterovirus surveillance allows monitoring of the circulation of clinically relevant serotypes resulting in continuous data about non-polio enterovirus epidemiology.
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Affiliation(s)
- Kathrin Keeren
- Secretary of the National Commission for Polio Eradication in Germany, Robert Koch Institute, 13353 Berlin, Germany;
| | - Sindy Böttcher
- National Reference Centre for Poliomyelitis and Enteroviruses, Robert Koch Institute, 13353 Berlin, Germany;
| | | | - Sabine Diedrich
- National Reference Centre for Poliomyelitis and Enteroviruses, Robert Koch Institute, 13353 Berlin, Germany;
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30
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Update on Viral Infections Involving the Central Nervous System in Pediatric Patients. CHILDREN-BASEL 2021; 8:children8090782. [PMID: 34572214 PMCID: PMC8470393 DOI: 10.3390/children8090782] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/28/2021] [Accepted: 08/30/2021] [Indexed: 12/18/2022]
Abstract
Infections of the central nervous system (CNS) are mainly caused by viruses, and these infections can be life-threatening in pediatric patients. Although the prognosis of CNS infections is often favorable, mortality and long-term sequelae can occur. The aims of this narrative review were to describe the specific microbiological and clinical features of the most frequent pathogens and to provide an update on the diagnostic approaches and treatment strategies for viral CNS infections in children. A literature analysis showed that the most common pathogens worldwide are enteroviruses, arboviruses, parechoviruses, and herpesviruses, with variable prevalence rates in different countries. Lumbar puncture (LP) should be performed as soon as possible when CNS infection is suspected, and cerebrospinal fluid (CSF) samples should always be sent for polymerase chain reaction (PCR) analysis. Due to the lack of specific therapies, the management of viral CNS infections is mainly based on supportive care, and empiric treatment against herpes simplex virus (HSV) infection should be started as soon as possible. Some researchers have questioned the role of acyclovir as an empiric antiviral in older children due to the low incidence of HSV infection in this population and observed that HSV encephalitis may be clinically recognizable beyond neonatal age. However, the real benefit-risk ratio of selective approaches is unclear, and further studies are needed to define appropriate indications for empiric acyclovir. Research is needed to find specific therapies for emerging pathogens. Moreover, the appropriate timing of monitoring neurological development, performing neuroimaging evaluations and investigating the effectiveness of rehabilitation during follow-up should be evaluated with long-term studies.
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31
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Chong PF, Torisu H, Yasumoto S, Okumura A, Mori H, Sato T, Kimura J, Ohga S, Tanaka-Taya K, Kira R. Clinical and electrophysiological features of acute flaccid myelitis: A national cohort study. Clin Neurophysiol 2021; 132:2456-2463. [PMID: 34454273 DOI: 10.1016/j.clinph.2021.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 07/06/2021] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To summarize the neurophysiological properties of acute flaccid myelitis (AFM) and evaluate limb-based motor outcomes. METHODS Nerve conduction studies (NCS) in 49 patients (21 females, 28 males; median age = 52 m) with AFM (median = 7 d after onset; range 1-122 d) were reviewed. Neurophysiological findings, together with treatment and prognosis, and neurophysiology-neuroimaging correlations were analyzed. RESULTS The findings indicated that 64% of paralytic limbs during the acute stage (≤14 d after onset) showed diminished or absent compound muscle action potentials (CMAPs), 79% showed normal motor nerve conduction velocities, 55% showed decreased persistence or absent F-waves, and 95% showed normal sensory nerve conduction velocities. The rate of CMAP abnormalities increased from 41% on days 1-2 to 83% on days 13-14. The reduction in CMAP amplitude was correlated with weaker muscle strength at both the peak neurological deficit and the last follow-up. The baseline limb-based muscle strength at nadir and anterior horn-localized magnetic resonance imaging lesions at recovery stage (>14 d) were strong predictors of outcome at the last follow-up. CONCLUSIONS AFM typically shows neurophysiological features of neuronopathy. SIGNIFICANCE NCS is probably useful in the diagnosis and evaluation of AFM.
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Affiliation(s)
- Pin Fee Chong
- Department of Pediatric Neurology, Fukuoka Children's Hospital, Fukuoka, Japan; Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroyuki Torisu
- Section of Pediatrics, Department of Medicine, Fukuoka Dental College, Fukuoka, Japan
| | - Sawa Yasumoto
- Medical Education Center, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Akihisa Okumura
- Department of Pediatrics, Aichi Medical University, Nagakute, Aichi, Japan
| | - Harushi Mori
- Department of Radiology, Jichi Medical University, Tochigi, Japan
| | - Tatsuharu Sato
- Department of Pediatrics, Nagasaki University Hospital, Nagasaki, Japan
| | - Jun Kimura
- Division of Clinical Electrophysiology, Department of Neurology, University of Iowa Health Care, Iowa City, IA, USA
| | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keiko Tanaka-Taya
- Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - Ryutaro Kira
- Department of Pediatric Neurology, Fukuoka Children's Hospital, Fukuoka, Japan.
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32
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Harvala H, Benschop KSM, Berginc N, Midgley S, Wolthers K, Simmonds P, Feeney S, Bailly JL, Mirand A, Fischer TK. European Non-Polio Enterovirus Network: Introduction of Hospital-Based Surveillance Network to Understand the True Disease Burden of Non-Polio Enterovirus and Parechovirus Infections in Europe. Microorganisms 2021; 9:microorganisms9091827. [PMID: 34576722 PMCID: PMC8469463 DOI: 10.3390/microorganisms9091827] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/18/2021] [Accepted: 08/25/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Non-polio enteroviruses (EVs) and human parechoviruses (PeVs) cause a wide range of human infections. Limited data on their true disease burden exist as standardized European-wide surveillance is lacking. AIMS Our aim is to estimate the disease burden of EV and PeV infections in Europe via establishment of standardized surveillance for hand, foot and mouth disease (HFMD) and respiratory and neurological infections caused by these viruses. We will also assess the sensitivity of assays implemented in the network of participating laboratories so that all EV and PeV types are adequately detected. Plan. The European Non-Polio Enterovirus Network (ENPEN) has developed standardized protocols for a prospective, multi-center and cross-sectional hospital-based pilot study. Protocols include guidance for diagnosis, case definition, detection, characterization and reporting of EV and PeV infections associated with HFMD and respiratory and neurological diseases. Over 30 sites from 17 European countries have already registered to this one pilot study, likely to be commenced in 2022. BENEFITS This surveillance will allow European-wide comparison of data on EV and PeV infection. These data will also be used to determine the burden of EV and PeV infections, which is needed to guide the further prevention measures and policies.
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Affiliation(s)
- Heli Harvala
- NHS Blood and Transplant, Microbiology Services, Colindale, London NW9 5BG, UK
- Department of Infection, University College London (UCL), London WC1E 6BT, UK
- Correspondence: ; Tel.: +44-77-47096974
| | | | - Natasa Berginc
- Laboratory for Public Health Virology, 1000 Ljubljana, Slovenia;
| | - Sofie Midgley
- The WHO National Reference Laboratory for Poliovirus, Statens Serum Institute, DK-2300 Copenhagen, Denmark;
| | - Katja Wolthers
- Amsterdam University Medical Center, 1105 AZ Amsterdam, The Netherlands;
| | - Peter Simmonds
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 3SY, UK;
| | - Susan Feeney
- Regional Virus Laboratory, Royal Victoria Hospital, Belfast BT12 6BA, Northern Ireland, UK;
| | - Jean-Luc Bailly
- CHU Clermont-Ferrand, National Reference Centre for Enteroviruses and Parechoviruses–Associated Laboratory, 63000 Clermont-Ferrand, France; (J.-L.B.); (A.M.)
| | - Audrey Mirand
- CHU Clermont-Ferrand, National Reference Centre for Enteroviruses and Parechoviruses–Associated Laboratory, 63000 Clermont-Ferrand, France; (J.-L.B.); (A.M.)
| | - Thea K. Fischer
- Department of Clinical Research, Nordsjaellands University Hospital, DK-3400 Hilleroed, Denmark;
- Department of Public Health and Department of International Health, University of Copenhagen, DK-1353 Copenhagen, Denmark
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33
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Development of an experimental inactivated vaccine from Vero cell adapted Enterovirus D68. Virus Res 2021; 304:198528. [PMID: 34339771 DOI: 10.1016/j.virusres.2021.198528] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/10/2021] [Accepted: 07/22/2021] [Indexed: 11/24/2022]
Abstract
Enterovirus D68 is an emerging respiratory disease pathogen causing multiple outbreaks worldwide. Enterovirus D68 strain US/KY/14-18953 was adapted to propagate in Vero cells resulting alteration of seven amino acids. The Vero cell adapted virus was inactivated with Formalin and immunized in mice. Formalin inactivated vaccine elicited high virus specific IgG antibody titer and neutralization titer. Avidity of the IgG antibodies elicited by two different doses of formalin inactivated vaccine is moderately high which got augmented by alum adjuvanted formulations. Formalin inactivated unadjuvanted vaccine elicited a balanced IgG1 type and IgG2a type antibody indicating a more balanced Th2/Th1 type immune response while alum formulated formalin inactivated antigen elicited significantly high IgG1 antibody in immunized sera and Th2 cytokines in mice splenocytes denoting Th2 type T cell immune response. Additionally, the formalin inactivated vaccine formulations has displayed excellent serum mediated invivo protective efficacy. These data suggested that formalin inactivated Enterovirus D68 is a promising vaccine candidate.
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Lerner AM, DeRocco AJ, Yang L, Robinson DA, Eisinger RW, Bushar ND, Nath A, Erbelding E. Unraveling the Mysteries of Acute Flaccid Myelitis: Scientific Opportunities and Priorities for Future Research. Clin Infect Dis 2021; 72:2044-2048. [PMID: 32964217 DOI: 10.1093/cid/ciaa1432] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/18/2020] [Indexed: 11/12/2022] Open
Abstract
Since 2014, cases of acute flaccid myelitis (AFM) have been reported in the United States in increasing numbers biennially, occurring in the late summer and early fall. Although there is unlikely to be a single causative agent of this syndrome, non-polio enteroviruses, including enterovirus D-68 (EV-D68), have had epidemiological and laboratory associations with AFM. Much remains to be known about AFM and AFM-associated enteroviruses, including disease pathogenesis and the best strategies for development of therapeutics or preventive modalities including vaccines. To catalyze research that addresses these scientific and clinical gaps, the National Institute of Allergy and Infectious Diseases convened a workshop entitled "AFM Preparedness: Addressing EV-D68 and Other AFM-Associated Enteroviruses" on 19-20 February 2020.
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Affiliation(s)
- Andrea M Lerner
- Office of the Director, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Amanda J DeRocco
- Office of the Director, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Linda Yang
- Office of the Director, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Daphne A Robinson
- Office of the Director, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Robert W Eisinger
- Office of the Director, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Nicholas D Bushar
- Office of the Director, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Avindra Nath
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Emily Erbelding
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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Sanjay RE, Sabeena S, Robin S, Shaji JT, Jayakrishnan MP, Suresh EKK, Michael CJ, Aswathyraj S, Josmi J, Shahin S, Anup J, Arunkumar G. Genetic analysis of Enterovirus D68 associated with pneumonia in children from South India. J Med Microbiol 2021; 70. [PMID: 33999799 DOI: 10.1099/jmm.0.001356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
EV-D68 is an emerging enterovirus infection associated with severe acute respiratory illness (SARI), acute flaccid myelitis (AFM) and acute flaccid paralysis (AFP). While EV-D68 outbreaks and sporadic cases are reported globally, a single case has been reported from India. The present study aims to investigate the molecular epidemiology and clinical characteristics of EV-D68-associated SARI cases from South India. We screened influenza-negative archived throat swab specimens from Influenza-Like Illness (ILI) and SARI cases (n=959; 2016 to 2018 period) for enteroviruses by pan-enterovirus real-time RT-PCR. Thirteen samples positive for enteroviruses were typed by PCR and sequencing based on VPI, VP2 and/or 5'NCR regions. One EV-D68 RNA sample was subjected to next-generation sequencing for whole genome characterisation. Among 13 enterovirus cases, four were ECHO-11, three EV-D68, two CV-A16 and one each EV-71, CV-B1, CV-B2 and CV-A9. All three cases of EV-D68 infection were reported in children below 2 years of age from Kerala state of South India during June and July 2017. The patients developed pneumonia without any neurological complications. Sequencing based on VPI and 5'NCR regions showed that EV-D68 strains belong to the novel subclade B3. The EV-D68 complete genome identified with two unique amino acid substitutions in VP1 (T-246-I) and 3D (K-344-R) regions. This study reiterates the EV-D68 novel subclade B3 circulation in India and indicates the urgent need for structured EV-D68 surveillance in the country to describe the epidemiology.
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Affiliation(s)
- Ramachandran Erathodi Sanjay
- Manipal Institute of Virology, Manipal Academy of Higher Education (Deemed to be University), Manipal, Karnataka, India
| | - Sasidharanpillai Sabeena
- Manipal Institute of Virology, Manipal Academy of Higher Education (Deemed to be University), Manipal, Karnataka, India
| | - Sudandiradas Robin
- Manipal Institute of Virology, Manipal Academy of Higher Education (Deemed to be University), Manipal, Karnataka, India
| | - John T Shaji
- Department of Paediatrics & Neonatology, Baby Memorial Hospital, Kozhikode, Kerala, India
| | - M P Jayakrishnan
- Department of Paediatrics, Government Medical College, Kozhikode, Kerala, India
| | - E K Kumar Suresh
- Department of Paediatrics, Aster MIMS Hospital, Kozhikode, Kerala, India
| | - C J Michael
- Department of ENT, Government General Hospital, Kozhikode, Kerala, India
| | - S Aswathyraj
- Manipal Institute of Virology, Manipal Academy of Higher Education (Deemed to be University), Manipal, Karnataka, India
| | - Joseph Josmi
- Manipal Institute of Virology, Manipal Academy of Higher Education (Deemed to be University), Manipal, Karnataka, India
| | - Sheik Shahin
- Manipal Institute of Virology, Manipal Academy of Higher Education (Deemed to be University), Manipal, Karnataka, India
| | - Jayaram Anup
- Manipal Institute of Virology, Manipal Academy of Higher Education (Deemed to be University), Manipal, Karnataka, India
| | - Govindakarnavar Arunkumar
- Present address: Consultant at World Health Organisation- country office for Nepal, Nepal, India.,Manipal Institute of Virology, Manipal Academy of Higher Education (Deemed to be University), Manipal, Karnataka, India
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Abstract
Acute flaccid myelitis (AFM) is an incompletely understood neurologic disorder occurring in epidemic fashion causing weakness ranging from mild paresis to devastating paralysis in children and some adults. This article reviews the case definition of AFM as well as its epidemiology and association with enteroviral infection. The clinical presentation, diagnostic investigation with particular attention to electrodiagnostics, acute management, and surgical options are described. Clinical outcomes and considerations for acute and long-term rehabilitation management are discussed extensively based on review of current literature, highlighting avenues for further study.
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Affiliation(s)
- William Ide
- Department of Pediatric Rehabilitation, Kennedy Krieger Institute, 707 North Broadway, Ste. 232, Baltimore, MD 21205, USA; Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine
| | - Michelle Melicosta
- Department of Pediatric Rehabilitation, Kennedy Krieger Institute, 707 North Broadway, Ste. 232, Baltimore, MD 21205, USA; Department of Pediatrics, Johns Hopkins University School of Medicine
| | - Melissa K Trovato
- Department of Pediatric Rehabilitation, Kennedy Krieger Institute, 707 North Broadway, Ste. 232, Baltimore, MD 21205, USA; Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine.
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37
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Zhang C, Xu C, Dai W, Wang Y, Liu Z, Zhang X, Wang X, Wang H, Gong S, Cong Y, Huang Z. Functional and structural characterization of a two-MAb cocktail for delayed treatment of enterovirus D68 infections. Nat Commun 2021; 12:2904. [PMID: 34006855 PMCID: PMC8131599 DOI: 10.1038/s41467-021-23199-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 04/14/2021] [Indexed: 02/03/2023] Open
Abstract
Enterovirus D68 (EV-D68) is an emerging pathogen associated with respiratory diseases and/or acute flaccid myelitis. Here, two MAbs, 2H12 and 8F12, raised against EV-D68 virus-like particle (VLP), show distinct preference in binding VLP and virion and in neutralizing different EV-D68 strains. A combination of 2H12 and 8F12 exhibits balanced and potent neutralization effects and confers broader protection in mice than single MAbs when given at onset of symptoms. Cryo-EM structures of EV-D68 virion complexed with 2H12 or 8F12 show that both antibodies bind to the canyon region of the virion, creating steric hindrance for sialic acid receptor binding. Additionally, 2H12 binding can impair virion integrity and trigger premature viral uncoating. We also capture an uncoating intermediate induced by 2H12 binding, not previously described for picornaviruses. Our study elucidates the structural basis and neutralizing mechanisms of the 2H12 and 8F12 MAbs and supports further development of the 2H12/8F12 cocktail as a broad-spectrum therapeutic agent against EV-D68 infections in humans.
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MESH Headings
- Animals
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/immunology
- Antibodies, Monoclonal/metabolism
- Antibodies, Neutralizing/administration & dosage
- Antibodies, Neutralizing/immunology
- Antibodies, Neutralizing/metabolism
- Cell Line, Tumor
- Cryoelectron Microscopy
- Enterovirus D, Human/drug effects
- Enterovirus D, Human/immunology
- Enterovirus D, Human/physiology
- Enterovirus Infections/drug therapy
- Enterovirus Infections/immunology
- Enterovirus Infections/virology
- Female
- Humans
- Mice, Inbred BALB C
- Protein Binding/drug effects
- Receptors, Cell Surface/immunology
- Receptors, Cell Surface/metabolism
- Time-to-Treatment
- Treatment Outcome
- Virion/drug effects
- Virion/immunology
- Virion/metabolism
- Virion/ultrastructure
- Virus Uncoating/drug effects
- Mice
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Affiliation(s)
- Chao Zhang
- Joint Center for Infection and Immunity, Guangzhou Institute of Pediatrics, Department of Gastroenterology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
- CAS Key Laboratory of Molecular Virology & Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Shanghai, China
| | - Cong Xu
- State Key Laboratory of Molecular Biology, National Center for Protein Science Shanghai, Shanghai Institute of Biochemistry and Cell Biology, Center for Excellence in Molecular Cell Science, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Shanghai, China
| | - Wenlong Dai
- CAS Key Laboratory of Molecular Virology & Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Shanghai, China
| | - Yifan Wang
- State Key Laboratory of Molecular Biology, National Center for Protein Science Shanghai, Shanghai Institute of Biochemistry and Cell Biology, Center for Excellence in Molecular Cell Science, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Shanghai, China
| | - Zhi Liu
- CAS Key Laboratory of Molecular Virology & Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Shanghai, China
| | - Xueyang Zhang
- CAS Key Laboratory of Molecular Virology & Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Shanghai, China
| | - Xuesong Wang
- CAS Key Laboratory of Molecular Virology & Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Shanghai, China
| | - Haikun Wang
- CAS Key Laboratory of Molecular Virology & Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Shanghai, China
| | - Sitang Gong
- Joint Center for Infection and Immunity, Guangzhou Institute of Pediatrics, Department of Gastroenterology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.
| | - Yao Cong
- State Key Laboratory of Molecular Biology, National Center for Protein Science Shanghai, Shanghai Institute of Biochemistry and Cell Biology, Center for Excellence in Molecular Cell Science, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Shanghai, China.
- Shanghai Science Research Center, Chinese Academy of Sciences, Shanghai, China.
| | - Zhong Huang
- CAS Key Laboratory of Molecular Virology & Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Shanghai, China.
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38
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Direct Diagnosis of Echovirus 12 Meningitis Using Metagenomic Next Generation Sequencing. Pathogens 2021; 10:pathogens10050610. [PMID: 34067526 PMCID: PMC8156364 DOI: 10.3390/pathogens10050610] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/02/2021] [Accepted: 05/12/2021] [Indexed: 11/17/2022] Open
Abstract
The current point-of-care diagnosis of enterovirus meningitis does not identify the viral genotype, which is prognostic. In this case report, more than 81% of an Echovirus 12 genome were detected and identified by metagenomic next-generation sequencing, directly from the cerebrospinal fluid collected in a 6-month-old child with meningeal syndrome and meningitis: introducing Echovirus 12 as an etiological agent of acute meningitis in the pediatric population.
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39
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Vawter-Lee M, Peariso K, Frey M, Bolikal P, Schaffzin JK, Schwentker A, O'Brien WT, Zamor R, Kerrey BT. Acute Flaccid Myelitis: A Multidisciplinary Protocol to Optimize Diagnosis and Evaluation. J Child Neurol 2021; 36:421-431. [PMID: 33258719 DOI: 10.1177/0883073820975230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Acute flaccid myelitis is an emerging neurologic disease, first described in 2014 and predominantly affecting young children. Acute flaccid myelitis cases tend to spike every 2 years, in the late summer to fall, and the next peak is expected in 2020. The diagnosis of acute flaccid myelitis is often delayed, leading to suboptimal evaluation, including incomplete laboratory assessment. Acute and chronic morbidity are high, and a standardized, multidisciplinary approach to evaluation and treatment is essential to optimizing outcomes. In a review of acute flaccid myelitis patients treated in 2018 at our institution, we noted considerable variability in days to presentation, evaluation, and treatment. In response, the authors developed a protocol for the evaluation and management of pediatric patients suspected of having acute flaccid myelitis. The protocol was developed using local experience/case review, expert consensus, and the relevant literature. The protocol spans the spectrum of care, from initial evaluation in a primary care or emergency setting, to acute hospital management and evaluation and long-term inpatient and rehabilitation settings. The purpose of this report is both to share the findings from our 2018 case review and to disseminate our acute flaccid myelitis protocol. Our hope is that publication of our protocol will both inform the development of a standardized approach to acute flaccid myelitis and to encourage other centers to form a multidisciplinary acute flaccid myelitis team to provide expert care throughout the disease process, from presentation to recovery.
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Affiliation(s)
- Marissa Vawter-Lee
- 2518University of Cincinnati, College of Medicine, Cincinnati, OH, USA.,Division of Neurology, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Katrina Peariso
- 2518University of Cincinnati, College of Medicine, Cincinnati, OH, USA.,Division of Neurology, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mary Frey
- Division of Emergency Medicine, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Priya Bolikal
- 2518University of Cincinnati, College of Medicine, Cincinnati, OH, USA.,Division of Physical Medicine and Rehabilitation, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Joshua K Schaffzin
- 2518University of Cincinnati, College of Medicine, Cincinnati, OH, USA.,Division of Infectious Diseases, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ann Schwentker
- 2518University of Cincinnati, College of Medicine, Cincinnati, OH, USA.,Division of Pediatric Plastic and Craniofacial Surgery, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - William T O'Brien
- 2518University of Cincinnati, College of Medicine, Cincinnati, OH, USA.,Division of Neuroradiology, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ronine Zamor
- 2518University of Cincinnati, College of Medicine, Cincinnati, OH, USA.,Division of Emergency Medicine, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Benjamin T Kerrey
- 2518University of Cincinnati, College of Medicine, Cincinnati, OH, USA.,Division of Emergency Medicine, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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40
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Abstract
PURPOSE OF REVIEW This article reviews infectious etiologies of spinal cord dysfunction, emphasizing the importance of recognizing common clinicoradiographic syndromes and interpreting them in the context of exposure risk and individual host susceptibilities. RECENT FINDINGS This article discusses the shifting spectrum of neurologic infectious diseases, the growing population of patients who are immunocompromised, and the emergence of effective antiretroviral therapies. In addition, it discusses new molecular and serologic tests that have the potential to enhance our ability to rapidly and accurately diagnose infectious diseases of the spine. SUMMARY When evaluating patients with suspected infectious myelopathies, it is imperative to narrow the range of pathogens under consideration. The geography, seasonality, and clinicoradiographic presentation and immunocompetence status of the patient define the range of potential pathogens and should guide testing and initial management.
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Murphy OC, Messacar K, Benson L, Bove R, Carpenter JL, Crawford T, Dean J, DeBiasi R, Desai J, Elrick MJ, Farias-Moeller R, Gombolay GY, Greenberg B, Harmelink M, Hong S, Hopkins SE, Oleszek J, Otten C, Sadowsky CL, Schreiner TL, Thakur KT, Van Haren K, Carballo CM, Chong PF, Fall A, Gowda VK, Helfferich J, Kira R, Lim M, Lopez EL, Wells EM, Yeh EA, Pardo CA. Acute flaccid myelitis: cause, diagnosis, and management. Lancet 2021; 397:334-346. [PMID: 33357469 PMCID: PMC7909727 DOI: 10.1016/s0140-6736(20)32723-9] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 09/15/2020] [Accepted: 09/17/2020] [Indexed: 12/20/2022]
Abstract
Acute flaccid myelitis (AFM) is a disabling, polio-like illness mainly affecting children. Outbreaks of AFM have occurred across multiple global regions since 2012, and the disease appears to be caused by non-polio enterovirus infection, posing a major public health challenge. The clinical presentation of flaccid and often profound muscle weakness (which can invoke respiratory failure and other critical complications) can mimic several other acute neurological illnesses. There is no single sensitive and specific test for AFM, and the diagnosis relies on identification of several important clinical, neuroimaging, and cerebrospinal fluid characteristics. Following the acute phase of AFM, patients typically have substantial residual disability and unique long-term rehabilitation needs. In this Review we describe the epidemiology, clinical features, course, and outcomes of AFM to help to guide diagnosis, management, and rehabilitation. Future research directions include further studies evaluating host and pathogen factors, including investigations into genetic, viral, and immunological features of affected patients, host-virus interactions, and investigations of targeted therapeutic approaches to improve the long-term outcomes in this population.
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Affiliation(s)
- Olwen C Murphy
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kevin Messacar
- Department of Pediatric Infectious Diseases, Children's Hospital Colorado, Aurora, CO, USA
| | - Leslie Benson
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Riley Bove
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Jessica L Carpenter
- Department of Neurology, Children's National Health System, Washington, DC, USA
| | - Thomas Crawford
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Janet Dean
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Roberta DeBiasi
- Department of Pediatric Infectious Diseases, Children's National Health System, Washington, DC, USA
| | - Jay Desai
- Division of Neurology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Matthew J Elrick
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Raquel Farias-Moeller
- Department of Neurology, Children's Hospital of Wisconsin and the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Grace Y Gombolay
- Department of Neurology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Benjamin Greenberg
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Matthew Harmelink
- Department of Neurology, Children's Hospital of Wisconsin and the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sue Hong
- Division of Pediatric Critical Care, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sarah E Hopkins
- Division of Neurology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joyce Oleszek
- Department of Physical Medicine and Rehabilitation, Children's Hospital Colorado, Aurora, CO, USA
| | - Catherine Otten
- Department of Pediatric Neurology, Seattle Children's Hospital, Seattle, WA, USA
| | - Cristina L Sadowsky
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA; International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Teri L Schreiner
- Department of Child Neurology, Children's Hospital Colorado, Aurora, CO, USA
| | - Kiran T Thakur
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Keith Van Haren
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Carolina M Carballo
- Department of Infectious Diseases, Hospital de Niños "Ricardo Gutiérrez", Buenos Aires, Argentina
| | - Pin Fee Chong
- Department of Pediatric Neurology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Amary Fall
- Institut Pasteur de Dakar, Département de Virologie, Dakar, Senegal
| | - Vykuntaraju K Gowda
- Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India
| | - Jelte Helfferich
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Ryutaro Kira
- Department of Pediatric Neurology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Ming Lim
- Children's Neuroscience Center, Evelina London Children's Hospital, Guy's and St Thomas' NHS Trust, and Faculty of Life Sciences, King's College, London, UK
| | - Eduardo L Lopez
- Department of Infectious Diseases, Hospital de Niños "Ricardo Gutiérrez", Buenos Aires, Argentina
| | - Elizabeth M Wells
- Department of Neurology, Children's National Health System, Washington, DC, USA
| | - E Ann Yeh
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada
| | - Carlos A Pardo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Hagen K, Porter C, Martin R, Dean J, Salorio C, Sadowsky C. Improvements in Function Following Inpatient Activity-Based Therapy for Children With Acute Flaccid Myelitis. Top Spinal Cord Inj Rehabil 2021; 26:275-282. [PMID: 33536733 PMCID: PMC7831282 DOI: 10.46292/sci20-00010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Acute flaccid myelitis (AFM) is an illness defined by rapid onset of flaccid paralysis in one or more limbs or bulbar muscles, with MRI findings of predominantly spinal cord gray matter abnormalities spanning one or more spinal segments following a viral illness. Individuals with AFM may require rehabilitation to promote recovery. Activity-based restorative therapy (ABRT) has previously been shown to result in positive outcomes in children with neurologic deficits related to AFM. OBJECTIVES This study examined functional changes in a group of children with AFM who participated in ABRT in an inpatient setting. METHODS Retrospective chart review of children with AFM admitted to a single inpatient rehabilitation unit from 2014 to 2018. Children were assessed using the Functional Independence Measure for Children (WeeFIM), Manual Muscle Testing (MMT), Spinal Cord Independence Measure (SCIM), and the Physical Abilities and Mobility Scale (PAMS) as part of routine clinical care; the Modified Rankin Scale for Neurologic Disability was completed retrospectively. RESULTS Children showed significant improvements across all outcome measures, with effect sizes ranging from moderate to large. Significant change was also seen across all muscle groups on MMT, with effect sizes ranging from small to large. Consistent with previous reports, children demonstrated better function in distal than proximal muscle groups at both admission and discharge. CONCLUSION Children with AFM who participated in ABRT increased muscle strength and made functional gains across all outcome measures. These results support the utility of rehabilitation in the long-term care of children with AFM and residual neurologic deficit.
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Affiliation(s)
- Kaitlin Hagen
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, Maryland
| | - Courtney Porter
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, Maryland
| | - Rebecca Martin
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, Maryland
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Janet Dean
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, Maryland
| | - Cynthia Salorio
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, Maryland
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Cristina Sadowsky
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, Maryland
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland
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43
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McLaren N, Lopez A, Kidd S, Zhang JX, Nix WA, Link-Gelles R, Lee A, Routh JA. Characteristics of Patients with Acute Flaccid Myelitis, United States, 2015-2018. Emerg Infect Dis 2021; 26. [PMID: 31961305 PMCID: PMC6986848 DOI: 10.3201/eid2602.191453] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Differences between years with and without increased activity suggest differences in viral etiologies. Observed peaks of acute flaccid myelitis (AFM) cases have occurred biennially since 2014 in the United States. We aimed to determine if AFM etiology differed between peak and nonpeak years, considering that clinical features of AFM differ by virus etiology. We compared clinical and laboratory characteristics of AFM cases that occurred during peak (2016 and 2018, n = 366) and nonpeak (2015 and 2017, n = 50) years. AFM patients in peak years were younger (5.2 years) than those in nonpeak years (8.3 years). A higher percentage of patients in peak years than nonpeak years had pleocytosis (86% vs. 60%), upper extremity involvement (33% vs. 16%), and an illness preceding limb weakness (90% vs. 62%) and were positive for enterovirus or rhinovirus RNA (38% vs. 16%). Enterovirus D68 infection was associated with AFM only in peak years. Our findings suggest AFM etiology differs between peak and nonpeak years.
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Ünver O, Türkdoğan D, Güler S, Kipoğlu O, Güngör M, Paketçi C, Çarman KB, Öztürk G, Genç HM, Özkan M, Dündar NO, Işık U, Karatoprak E, Kılıç B, Özkale M, Bayram E, Yarar C, Sözen HG, Sağer G, Güneş AS, Kahraman Koytak P, Karadağ Saygı E, Ekinci G, Saltık S, Çalışkan M, Kara B, Yiş U, Aydınlı N. Acute flaccid myelitis outbreak through 2016-2018: A multicenter experience from Turkey. Eur J Paediatr Neurol 2021; 30:113-120. [PMID: 33218883 DOI: 10.1016/j.ejpn.2020.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/04/2020] [Accepted: 10/30/2020] [Indexed: 10/23/2022]
Abstract
AIM We aim to describe the demographic characteristics, etiology, neurophysiology, imaging findings, treatment, prognosis, and prognostic factors of acute flaccid myelitis. METHODS The clinical data, laboratory test and, magnetic resonance imaging (MRI) results of pediatric patients diagnosed with acute flaccid myelitis according to the Centers for Disease Control criteria between August 1, 2016, and December 31, 2018, from 13 centers in Turkey were reviewed. RESULTS Of the 34 cases identified, 31 were confirmed (91.2%). Eighteen patients (55.9%) were boys. The median patient age was 4 years (interquartile range 2.5-6.9 years). Most of the patients were admitted in 2018 (n = 27). A preceding history of a febrile illness was reported in all patients, with a median of 4 days (interquartile range 3-7 days) before symptom onset. Thirty-one patients had T2 hyperintensity on spinal MRI, and 18 patients had cerebrospinal fluid pleocytosis. The most common infectious agents were entero/rhinoviruses (n = 5) in respiratory specimens. All patients except one received immunotherapy either alone or in combination. Among 27 patients with follow-up data 24 had persistent weakness. Involvement of four limbs together with an abnormal brain MRI at onset were associated with a poor prognosis. CONCLUSION The number of patients with acute flaccid myelitis increased since 2012, spiking with every 2-year interval, largely in the pediatric population. The median age decreases with every outbreak. Clinicians should be aware of the clinical picture for early collection of specimens and early start of rehabilitation programs. Further studies are needed to better characterize the etiology, pathogenesis, risk factors, and treatment of this rare condition.
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Affiliation(s)
- Olcay Ünver
- Division of Pediatric Neurology, Department of Pediatrics, Marmara University School of Medicine, İstanbul, Turkey.
| | - Dilşad Türkdoğan
- Division of Pediatric Neurology, Department of Pediatrics, Marmara University School of Medicine, İstanbul, Turkey
| | - Serhat Güler
- Division of Pediatric Neurology, Department of Pediatrics, İstanbul University Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Osman Kipoğlu
- Division of Pediatric Neurology, Department of Pediatrics, İstanbul University Faculty of Medicine, İstanbul, Turkey
| | - Mesut Güngör
- Division of Pediatric Neurology, Department of Pediatrics, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Cem Paketçi
- Division of Pediatric Neurology, Department of Pediatrics, Dokuz Eylül University Medical Faculty, İzmir, Turkey
| | - Kürşat Bora Çarman
- Division of Pediatric Neurology, Department of Pediatrics, Eskişehir Osmangazi University Medical Faculty, Eskişehir, Turkey
| | - Gülten Öztürk
- Division of Pediatric Neurology, Department of Pediatrics, Marmara University School of Medicine, İstanbul, Turkey
| | - Hülya Maraş Genç
- Division of Pediatric Neurology, Department of Pediatrics, Ümraniye Training and Research Hospital, İstanbul, Turkey
| | - Mehpare Özkan
- Division of Pediatric Neurology, Department of Pediatrics, Bahçeşehir University Medical Faculty, İstanbul, Turkey
| | - Nihal Olgaç Dündar
- Division of Pediatric Neurology, Department of Pediatrics, Izmir Katip Çelebi University Medical Faculty, İzmir, Turkey
| | - Uğur Işık
- Division of Pediatric Neurology, Department of Pediatrics, Acıbadem University School of Medicine, İstanbul, Turkey
| | - Elif Karatoprak
- Division of Pediatric Neurology, Department of Pediatrics, Medeniyet University School of Medicine, İstanbul, Turkey
| | - Betül Kılıç
- Division of Pediatric Neurology, Department of Pediatrics, Medipol University School of Medicine, İstanbul, Turkey
| | - Murat Özkale
- Division of Pediatric Intensive Care Unit, Department of Pediatrics, Başkent University School of Medicine, Adana, Turkey
| | - Erhan Bayram
- Division of Pediatric Neurology, Department of Pediatrics, Dokuz Eylül University Medical Faculty, İzmir, Turkey
| | - Coşkun Yarar
- Division of Pediatric Neurology, Department of Pediatrics, Eskişehir Osmangazi University Medical Faculty, Eskişehir, Turkey
| | - Hatice Gülhan Sözen
- Division of Pediatric Neurology, Department of Pediatrics, Ümraniye Training and Research Hospital, İstanbul, Turkey
| | - Güneş Sağer
- Division of Pediatric Neurology, Department of Pediatrics, Marmara University School of Medicine, İstanbul, Turkey
| | - Ayfer Sakarya Güneş
- Division of Pediatric Neurology, Department of Pediatrics, Kocaeli University School of Medicine, Kocaeli, Turkey
| | | | - Evrim Karadağ Saygı
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, İstanbul, Turkey
| | - Gazanfer Ekinci
- Department of Radiology, Yeditepe University School of Medicine, İstanbul, Turkey
| | - Sema Saltık
- Division of Pediatric Neurology, Department of Pediatrics, İstanbul University Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Mine Çalışkan
- Division of Pediatric Neurology, Department of Pediatrics, İstanbul University Faculty of Medicine, İstanbul, Turkey; İstanbul University Institute of Child Health, İstanbul, Turkey
| | - Bülent Kara
- Division of Pediatric Neurology, Department of Pediatrics, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Uluç Yiş
- Division of Pediatric Neurology, Department of Pediatrics, Dokuz Eylül University Medical Faculty, İzmir, Turkey
| | - Nur Aydınlı
- Division of Pediatric Neurology, Department of Pediatrics, İstanbul University Faculty of Medicine, İstanbul, Turkey
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Abstract
BACKGROUND Acute flaccid myelitis (AFM) syndrome consists of loss of lower motor neurons following a viral infection, with preserved sensory function. It usually affects the upper limbs asymmetrically, with proximal more than distal muscle involvement. METHODS Five cases were surgically treated with nerve transfers: spinal accessory to suprascapular nerve transfer (4 patients), branch of radial nerve to axillary nerve transfer (Somsak's procedure) (2 patients), and transfer of a fascicle of the ulnar nerve to the motor branch to the biceps (Oberlin's procedure) (1 patient). RESULTS Motor improvement was seen in three cases. Widespread motor involvement was associated with poor outcome. CONCLUSION This small series of cases reinforces that nerve transfers are a reliable option for treatment of selected children with AFM.
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Elrick MJ, Pekosz A, Duggal P. Enterovirus D68 molecular and cellular biology and pathogenesis. J Biol Chem 2021; 296:100317. [PMID: 33484714 PMCID: PMC7949111 DOI: 10.1016/j.jbc.2021.100317] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 12/13/2022] Open
Abstract
In recent years, enterovirus D68 (EV-D68) has advanced from a rarely detected respiratory virus to a widespread pathogen responsible for increasing rates of severe respiratory illness and acute flaccid myelitis (AFM) in children worldwide. In this review, we discuss the accumulating data on the molecular features of EV-D68 and place these into the context of enterovirus biology in general. We highlight similarities and differences with other enteroviruses and genetic divergence from own historical prototype strains of EV-D68. These include changes in capsid antigens, host cell receptor usage, and viral RNA metabolism collectively leading to increased virulence. Furthermore, we discuss the impact of EV-D68 infection on the biology of its host cells, and how these changes are hypothesized to contribute to motor neuron toxicity in AFM. We highlight areas in need of further research, including the identification of its primary receptor and an understanding of the pathogenic cascade leading to motor neuron injury in AFM. Finally, we discuss the epidemiology of the EV-D68 and potential therapeutic approaches.
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Affiliation(s)
- Matthew J Elrick
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
| | - Andrew Pekosz
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Priya Duggal
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Brown DM, Zhang Y, Scheuermann RH. Epidemiology and Sequence-Based Evolutionary Analysis of Circulating Non-Polio Enteroviruses. Microorganisms 2020; 8:microorganisms8121856. [PMID: 33255654 PMCID: PMC7759938 DOI: 10.3390/microorganisms8121856] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/13/2020] [Accepted: 11/17/2020] [Indexed: 02/07/2023] Open
Abstract
Enteroviruses (EVs) are positive-sense RNA viruses, with over 50,000 nucleotide sequences publicly available. While most human infections are typically associated with mild respiratory symptoms, several different EV types have also been associated with severe human disease, especially acute flaccid paralysis (AFP), particularly with endemic members of the EV-B species and two pandemic types—EV-A71 and EV-D68—that appear to be responsible for recent widespread outbreaks. Here we review the recent literature on the prevalence, characteristics, and circulation dynamics of different enterovirus types and combine this with an analysis of the sequence coverage of different EV types in public databases (e.g., the Virus Pathogen Resource). This evaluation reveals temporal and geographic differences in EV circulation and sequence distribution, highlighting recent EV outbreaks and revealing gaps in sequence coverage. Phylogenetic analysis of the EV genus shows the relatedness of different EV types. Recombination analysis of the EV-A species provides evidence for recombination as a mechanism of genomic diversification. The absence of broadly protective vaccines and effective antivirals makes human enteroviruses important pathogens of public health concern.
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Affiliation(s)
- David M Brown
- Department of Synthetic Biology, J. Craig Venter Institute, Rockville, MD 20850, USA
| | - Yun Zhang
- Department of Informatics, J. Craig Venter Institute, La Jolla, CA 92037, USA
| | - Richard H Scheuermann
- Department of Informatics, J. Craig Venter Institute, La Jolla, CA 92037, USA
- Department of Pathology, University of California San Diego, La Jolla, CA 92093, USA
- La Jolla Institute for Immunology, La Jolla, CA 92065, USA
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48
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Yea C, Bitnun A, Branson HM, Ciftci-Kavaklioglu B, Rafay MF, Fortin O, Moresoli P, Sébire G, Srour M, Decaluwe H, Marois L, Pelletier F, Barton M, Nouri MN, Brophy J, Venkateswaran S, Pohl D, Selby K, Jones K, Robinson J, Mineyko A, Licht C, Ertl-Wagner B, Yeh EA. Association of outcomes in acute flaccid myelitis with identification of enterovirus at presentation: a Canadian, nationwide, longitudinal study. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:828-836. [PMID: 33068549 DOI: 10.1016/s2352-4642(20)30176-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/21/2020] [Accepted: 05/27/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Acute flaccid myelitis (AFM) is characterised by rapid onset of limb weakness with spinal cord grey-matter abnormalities on MRI scan. We aimed to assess whether detection of enterovirus in respiratory or other specimens can help predict prognosis in children with AFM. METHODS In this nationwide, longitudinal study, we evaluated the significance of detection of enterovirus in any sample in predicting outcomes in a cohort of Canadian children younger than 18 years presenting with AFM to tertiary paediatric hospitals in Canada in 2014 and 2018. All patients fulfilled the 2015 US Centers for Disease Control and Prevention case definition for definite AFM or probable AFM. Clinical data, laboratory findings, treatment, and neuroimaging results were collected (follow up period up to 5 years). We assessed neurological function and motor outcomes using Kurtzke's Expanded Disability Status Scale (EDSS) and a Weakest Limb Score. FINDINGS 58 children with AFM (median age 5·1 years, IQR 3·8-8·3) were identified across five of Canada's ten provinces and three territories. 25 (43%) children had enterovirus detected in at least one specimen: 16 (64%) with EV-D68, two (8%) with EV-A71, two (8%) with coxsackievirus, 10 (40%) with untyped enterovirus. Children who were enterovirus positive were more likely than those that were negative to have had quadriparesis (12 [48%] of 25 vs four [13%] of 30; p=0·028), bulbar weakness (11 [44%] of 25 vs two [7%] of 30; p=0·028), bowel or bladder dysfunction (14 [56%] of 25 vs seven [23%] of 30; p=0·040), cardiovascular instability (nine [36%] of 25 vs one [3%] of 30; p=0·028), and were more likely to require intensive care unit admission (13 [52%] of 25 vs 5 [17%] of 30; p=0·028). On MRI, most children who were enterovirus positive showed brainstem pontine lesions (14 [61%] of 23), while other MRI parameters did not correlate with enterovirus status. Median EDSS of enterovirus positive (EV+) and enterovirus negative (EV-) groups was significantly different at all timepoints: baseline (EDSS 8·5, IQR 4·1-9·5 vs EDSS 4·0, IQR 3·0-6·0; p=0·0067), 3 months (EDSS 4·0, IQR 3·0-7·4 vs EDSS 3·0, IQR 1·5-4·3; p=0·0067), 6 months (EDSS 3·5, IQR 3·0-7·0 vs EDSS 3·0, IQR 1·0-4·0; p=0·029), and 12 months (EDSS 3·0, IQR 3·0-6·9 vs EDSS 2·5 IQR 0·3-3·0; p=0·0067). Kaplan-Meier survival analysis of a subgroup of patients showed significantly poorer motor recovery among children who tested positive for enterovirus than for those who tested negative (p=0·037). INTERPRETATION Detection of enterovirus in specimens from non-sterile sites at presentation correlated with more severe acute motor weakness, worse overall outcomes and poorer trajectory for motor recovery. These results have implications for rehabilitation planning as well as counselling of families of children with these disorders. The findings of this study support the need for early testing for enterovirus in non-CNS sites in all cases of AFM. FUNDING None.
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Affiliation(s)
- Carmen Yea
- SickKids Research Institute, Neuroscience and Mental Health Program, The Hospital for Sick Children, Toronto, ON, Canada
| | - Ari Bitnun
- Division of Infectious Diseases, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Helen M Branson
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Mubeen F Rafay
- Department of Pediatric and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
| | - Olivier Fortin
- McGill University Health Centre, Montreal Children's Hospital, Montréal, QC, Canada
| | - Paola Moresoli
- McGill University Health Centre, Montreal Children's Hospital, Montréal, QC, Canada
| | - Guillaume Sébire
- McGill University Health Centre, Montreal Children's Hospital, Montréal, QC, Canada
| | - Myriam Srour
- McGill University Health Centre, Montreal Children's Hospital, Montréal, QC, Canada
| | - Hélène Decaluwe
- Division of Immunology and Rheumatology, Department of Pediatrics, Sainte-Justine University Hospital Center, Université de Montréal, Montréal, QC, Canada
| | - Louis Marois
- Division of Immunology and Rheumatology, Department of Pediatrics, Sainte-Justine University Hospital Center, Université de Montréal, Montréal, QC, Canada
| | - Félixe Pelletier
- Division of Neurology, Department of Pediatrics, Sainte-Justine University Hospital Center, Université de Montréal, Montréal, QC, Canada
| | - Michelle Barton
- Department of Pediatrics, London Health Sciences Centre, London, ON, Canada
| | | | - Jason Brophy
- Division of Infectious Diseases, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Sunita Venkateswaran
- Division of Neurology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Daniela Pohl
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Kathryn Selby
- Division of Pediatric Neurology, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Kevin Jones
- Division of Neurology, Department of Pediatrics McMaster Children's Hospital, Hamilton, ON, Canada
| | - Joan Robinson
- Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Aleksandra Mineyko
- Section of Neurology, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | - Christoph Licht
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Birgit Ertl-Wagner
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada
| | - E Ann Yeh
- SickKids Research Institute, Neuroscience and Mental Health Program, The Hospital for Sick Children, Toronto, ON, Canada; Division of Neurology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada.
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49
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Mulroy E, Anderson NE. Altered mental status in "Guillain-Barré syndrome" -a noteworthy clinical clue. Ann Clin Transl Neurol 2020; 7:2489-2507. [PMID: 33136342 PMCID: PMC7732251 DOI: 10.1002/acn3.51226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/19/2020] [Accepted: 09/26/2020] [Indexed: 01/01/2023] Open
Abstract
Guillain‐Barré syndrome (GBS) is widely regarded as a “pure” peripheral nervous system disorder. However, this simplistic interpretation belies the fact that central nervous system involvement, often manifesting as derangements in mental status can occur as a complication of the “pure” form of the disorder, as part of GBS variants, as well as in a number of mimic disorders. Despite being common in clinical practice, there is no guidance in the literature as to how to approach such scenarios. Herein, we detail our approach to these cases.
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Affiliation(s)
- Eoin Mulroy
- UCL Queen Square Institute of Neurology, London, UK
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50
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Midgley SE, Benschop K, Dyrdak R, Mirand A, Bailly JL, Bierbaum S, Buderus S, Böttcher S, Eis-Hübinger AM, Hönemann M, Jensen VV, Hartling UB, Henquell C, Panning M, Thomsen MK, Hodcroft EB, Meijer A. Co-circulation of multiple enterovirus D68 subclades, including a novel B3 cluster, across Europe in a season of expected low prevalence, 2019/20. ACTA ACUST UNITED AC 2020; 25. [PMID: 31964463 PMCID: PMC6976881 DOI: 10.2807/1560-7917.es.2020.25.2.1900749] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Enterovirus D68 (EV-D68) was detected in 93 patients from five European countries between 1 January 2019 and 15 January 2020, a season with expected low circulation. Patients were primarily children (n = 67, median age: 4 years), 59 patients required hospitalisation and five had severe neurologic manifestations. Phylogenetic analysis revealed two clusters in the B3 subclade and subclade A2/D. This circulation of EV-D68 associated with neurological manifestations stresses the importance of surveillance and diagnostics beyond expected peak years.
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Affiliation(s)
- Sofie Elisabeth Midgley
- Department for Virus and Microbiological Special Diagnostics, Statens Serum Institut, Copenhagen, Denmark
| | - Kimberley Benschop
- Centre for Infectious Disease Research, Diagnostics and Laboratory Surveillance, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Robert Dyrdak
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Audrey Mirand
- Université Clermont Auvergne, CNRS, Laboratoire Microorganismes: Génome et Environnement, Clermont-Ferrand, France.,CHU Clermont-Ferrand, Centre National de Référence des entérovirus et parechovirus - Laboratoire Associé, Laboratoire de Virologie, Clermont-Ferrand, France
| | - Jean-Luc Bailly
- Université Clermont Auvergne, CNRS, Laboratoire Microorganismes: Génome et Environnement, Clermont-Ferrand, France
| | - Sibylle Bierbaum
- Institute of Virology, University of Freiburg, Freiburg, Germany
| | - Stefan Buderus
- Department of General Pediatrics, St.-Marien-Hospital, Bonn, Germany
| | - Sindy Böttcher
- National Reference Center for Poliomyelitis and Enteroviruses, Robert Koch-Institute, Berlin, Germany
| | | | - Mario Hönemann
- Institute of Virology, University of Leipzig, Leipzig, Germany
| | - Veronika Vorobieva Jensen
- Department for Virus and Microbiological Special Diagnostics, Statens Serum Institut, Copenhagen, Denmark
| | | | - Cécile Henquell
- CHU Clermont-Ferrand, Centre National de Référence des entérovirus et parechovirus - Laboratoire Associé, Laboratoire de Virologie, Clermont-Ferrand, France
| | - Marcus Panning
- Institute of Virology, University of Freiburg, Freiburg, Germany
| | | | - Emma B Hodcroft
- Swiss Institute of Bioinformatics, Basel, Switzerland.,Biozentrum, University of Basel, Basel, Switzerland
| | - Adam Meijer
- Centre for Infectious Disease Research, Diagnostics and Laboratory Surveillance, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
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