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Edridge AWD, Abd-Elfarag G, Deijs M, Broeks MH, Cristella C, Sie B, Vaz FM, Jans JJM, Calis J, Verhoef H, Demir A, Poppert S, Nickel B, van Dam A, Sebit B, Titulaer MJ, Verweij JJ, de Jong MD, van Gool T, Faragher B, Verhoeven-Duif NM, Elledge SJ, van der Hoek L, Boele van Hensbroek M. Parasitic, bacterial, viral, immune-mediated, metabolic and nutritional factors associated with nodding syndrome. Brain Commun 2023; 5:fcad223. [PMID: 37731906 PMCID: PMC10507744 DOI: 10.1093/braincomms/fcad223] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 06/25/2023] [Accepted: 08/16/2023] [Indexed: 09/22/2023] Open
Abstract
Nodding syndrome is a neglected, disabling and potentially fatal epileptic disorder of unknown aetiology affecting thousands of individuals mostly confined to Eastern sub-Saharan Africa. Previous studies have identified multiple associations-including Onchocerca volvulus, antileiomodin-1 antibodies, vitamin B6 deficiency and measles virus infection-yet, none is proven causal. We conducted a case-control study of children with early-stage nodding syndrome (symptom onset <1 year). Cases and controls were identified through a household survey in the Greater Mundri area in South Sudan. A wide range of parasitic, bacterial, viral, immune-mediated, metabolic and nutritional risk factors was investigated using conventional and state-of-the-art untargeted assays. Associations were examined by multiple logistic regression analysis, and a hypothetical causal model was constructed using structural equation modelling. Of 607 children with nodding syndrome, 72 with early-stage disease were included as cases and matched to 65 household- and 44 community controls. Mansonella perstans infection (odds ratio 7.04, 95% confidence interval 2.28-21.7), Necator americanus infection (odds ratio 2.33, 95% confidence interval 1.02-5.3), higher antimalarial seroreactivity (odds ratio 1.75, 95% confidence interval 1.20-2.57), higher vitamin E concentration (odds ratio 1.53 per standard deviation increase, 95% confidence interval 1.07-2.19) and lower vitamin B12 concentration (odds ratio 0.56 per standard deviation increase, 95% confidence interval 0.36-0.87) were associated with higher odds of nodding syndrome. In a structural equation model, we hypothesized that Mansonella perstans infection, higher vitamin E concentration and fewer viral exposures increased the risk of nodding syndrome while lower vitamin B12 concentration, Necator americanus and malaria infections resulted from having nodding syndrome. We found no evidence that Onchocerca volvulus, antileiomodin-1 antibodies, vitamin B6 and other factors were associated with nodding syndrome. Our results argue against several previous causal hypotheses including Onchocerca volvulus. Instead, nodding syndrome may be caused by a complex interplay between multiple pathogens and nutrient levels. Further studies need to confirm these associations and determine the direction of effect.
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Affiliation(s)
- Arthur W D Edridge
- Amsterdam Centre for Global Child Health, Emma Children’s Hospital,
Amsterdam UMC, Location University of Amsterdam, 1105 AZ
Amsterdam, The Netherlands
- Department of Medical Microbiology and Infection Prevention, Amsterdam UMC,
Location University of Amsterdam, 1105 AZ
Amsterdam, The Netherlands
| | - Gasim Abd-Elfarag
- Amsterdam Centre for Global Child Health, Emma Children’s Hospital,
Amsterdam UMC, Location University of Amsterdam, 1105 AZ
Amsterdam, The Netherlands
- Department of Neurology & Psychiatry, College of Medicine, University
of Juba, P.O. Box 82, Juba, South Sudan
| | - Martin Deijs
- Department of Medical Microbiology and Infection Prevention, Amsterdam UMC,
Location University of Amsterdam, 1105 AZ
Amsterdam, The Netherlands
| | - Melissa H Broeks
- Department of Genetics, Section Metabolic Diagnostics, University Medical
Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Cosimo Cristella
- Department of Medical Microbiology and Infection Prevention, Amsterdam UMC,
Location University of Amsterdam, 1105 AZ
Amsterdam, The Netherlands
| | - Brandon Sie
- Division of Genetics, Brigham and Women’s Hospital, Howard Hughes Medical
Institute, Boston, MA 02115, USA
- Department of Genetics, Harvard Medical School,
Boston, MA 02115, USA
| | - Frédéric M Vaz
- Department of Clinical Chemistry, Amsterdam UMC, Location University of
Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Judith J M Jans
- Department of Genetics, Section Metabolic Diagnostics, University Medical
Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Job Calis
- Amsterdam Centre for Global Child Health, Emma Children’s Hospital,
Amsterdam UMC, Location University of Amsterdam, 1105 AZ
Amsterdam, The Netherlands
- Department of Paediatrics and Child Health, Kamuzu University of Health
Sciences, P.O. Box 95, Blantyre, Malawi
| | - Hans Verhoef
- Division of Human Nutrition and Health, Wageningen
University, 6701 AR Wageningen, The Netherlands
| | - Ayse Demir
- Laboratory for Clinical Chemistry and Hematology, Meander Medical
Centre, 3813 TZ Amersfoort, The Netherlands
| | - Sven Poppert
- Diagnostic Centre, Swiss Tropical and Public Health
Institute, University of Basel, 4123 Allschwil,
Switzerland
- University of Basel, 4056 Basel,
Switzerland
| | - Beatrice Nickel
- Diagnostic Centre, Swiss Tropical and Public Health
Institute, University of Basel, 4123 Allschwil,
Switzerland
- University of Basel, 4056 Basel,
Switzerland
| | - Alje van Dam
- Department of Medical Microbiology and Infection Prevention, Amsterdam UMC,
Location University of Amsterdam, 1105 AZ
Amsterdam, The Netherlands
| | - Boy Sebit
- Department of Neurology & Psychiatry, College of Medicine, University
of Juba, P.O. Box 82, Juba, South Sudan
| | - Maarten J Titulaer
- Department of Neurology, Erasmus MC University Medical
Center, 3000 CA Rotterdam, The Netherlands
| | - Jaco J Verweij
- Microvida Laboratory for Medical Microbiology and Immunology,
Elisabeth-Tweesteden Hospital, 5022 GC Tilburg,
The Netherlands
| | - Menno D de Jong
- Department of Medical Microbiology and Infection Prevention, Amsterdam UMC,
Location University of Amsterdam, 1105 AZ
Amsterdam, The Netherlands
| | - Tom van Gool
- Department of Medical Microbiology and Infection Prevention, Amsterdam UMC,
Location University of Amsterdam, 1105 AZ
Amsterdam, The Netherlands
| | - Brian Faragher
- Department of Clinical Sciences, Liverpool School of Tropical
Medicine, Liverpool L3 5QA, UK
| | - Nanda M Verhoeven-Duif
- Department of Genetics, Section Metabolic Diagnostics, University Medical
Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Stephen J Elledge
- Division of Genetics, Brigham and Women’s Hospital, Howard Hughes Medical
Institute, Boston, MA 02115, USA
| | - Lia van der Hoek
- Department of Medical Microbiology and Infection Prevention, Amsterdam UMC,
Location University of Amsterdam, 1105 AZ
Amsterdam, The Netherlands
| | - Michael Boele van Hensbroek
- Amsterdam Centre for Global Child Health, Emma Children’s Hospital,
Amsterdam UMC, Location University of Amsterdam, 1105 AZ
Amsterdam, The Netherlands
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Edridge AWD, Abd-Elfarag G, Deijs M, Jebbink MF, Boele van Hensbroek M, van der Hoek L. Divergent Rhabdovirus Discovered in a Patient with New-Onset Nodding Syndrome. Viruses 2022; 14:v14020210. [PMID: 35215803 PMCID: PMC8880091 DOI: 10.3390/v14020210] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/14/2022] [Accepted: 01/16/2022] [Indexed: 12/15/2022] Open
Abstract
A divergent rhabdovirus was discovered in the bloodstream of a 15-year-old girl with Nodding syndrome from Mundri West County in South Sudan. Nodding syndrome is a progressive degenerative neuropathy of unknown cause affecting thousands of individuals in Sub-Saharan Africa. The index case was previously healthy until she developed head-nodding seizures four months prior to presentation. Virus discovery by VIDISCA-NGS on the patient’s plasma detected multiple sequence reads belonging to a divergent rhabdovirus. The viral load was 3.85 × 103 copies/mL in the patient’s plasma and undetectable in her cerebrospinal fluid. Further genome walking allowed for the characterization of full coding sequences of all the viral proteins (N, P, M, U1, U2, G, U3, and L). We tentatively named the virus “Mundri virus” (MUNV) and classified it as a novel virus species based on the high divergence from other known viruses (all proteins had less than 43% amino acid identity). Phylogenetic analysis revealed that MUNV forms a monophyletic clade with several human-infecting tibroviruses prevalent in Central Africa. A bioinformatic machine-learning algorithm predicted MUNV to be an arbovirus (bagged prediction strength (BPS) of 0.9) transmitted by midges (BPS 0.4) with an artiodactyl host reservoir (BPS 0.9). An association between MUNV infection and Nodding syndrome was evaluated in a case–control study of 72 patients with Nodding syndrome (including the index case) matched to 65 healthy households and 48 community controls. No subject, besides the index case, was positive for MUNV RNA in their plasma. A serological assay detecting MUNV anti-nucleocapsid found, respectively, in 28%, 22%, and 16% of cases, household controls and community controls to be seropositive with no significant differences between cases and either control group. This suggests that MUNV commonly infects children in South Sudan yet may not be causally associated with Nodding syndrome.
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Affiliation(s)
- Arthur W. D. Edridge
- Laboratory of Experimental Virology, Department of Medical Microbiology and Infection Prevention, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (M.D.); (M.F.J.)
- Center for Global Child Health, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (G.A.-E.); (M.B.v.H.)
- Correspondence: (A.W.D.E.); (L.v.d.H.)
| | - Gasim Abd-Elfarag
- Center for Global Child Health, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (G.A.-E.); (M.B.v.H.)
| | - Martin Deijs
- Laboratory of Experimental Virology, Department of Medical Microbiology and Infection Prevention, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (M.D.); (M.F.J.)
| | - Maarten F. Jebbink
- Laboratory of Experimental Virology, Department of Medical Microbiology and Infection Prevention, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (M.D.); (M.F.J.)
| | - Michael Boele van Hensbroek
- Center for Global Child Health, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (G.A.-E.); (M.B.v.H.)
| | - Lia van der Hoek
- Laboratory of Experimental Virology, Department of Medical Microbiology and Infection Prevention, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (M.D.); (M.F.J.)
- Correspondence: (A.W.D.E.); (L.v.d.H.)
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Abd-Elfarag GOE, Edridge AWD, Spijker R, Sebit MB, van Hensbroek MB. Nodding Syndrome: A Scoping Review. Trop Med Infect Dis 2021; 6:tropicalmed6040211. [PMID: 34941667 PMCID: PMC8703395 DOI: 10.3390/tropicalmed6040211] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/06/2021] [Accepted: 12/08/2021] [Indexed: 12/23/2022] Open
Abstract
Nodding syndrome (NS) is a debilitating yet often neglected neurological disease affecting thousands of children in several sub-Saharan African countries. The cause of NS remains unknown, and effective treatment options are lacking. Moreover, knowledge regarding NS is scarce and is based on a limited number of publications, with no comprehensive overview published to date. Therefore, the aim of this scoping review was to summarise the current evidence and identify existing knowledge gaps in order to help clinicians, scientists, and policymakers develop guidelines for prioritising this severe condition. We searched the Medline (Ovid), Embase (Ovid), Scopus, and Global Health Library databases in accordance with the PRISMA extension for scoping review guidance and in accordance with the Joanna Briggs Institute guidelines and methodology for a scoping review, using keywords describing NS. We then extracted and presented the original data regarding the epidemiology, aetiology, pathophysiology, clinical features, diagnosis, management, and outcomes of NS, as well as community perceptions and the psychosocial and economic impact of NS. Out of 1470 identified articles, a total of 69 were included in this scoping review. Major gaps exist in understanding the aetiology and pathogenesis of NS. Future research is urgently needed not only to address these gaps, but also to study the treatment options, epidemiology, and psychosocial and economic impacts of NS. Innovative interventions and rehabilitation programmes designed to address the psychosocial and economic burdens associated with NS are also urgently needed.
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Affiliation(s)
- Gasim Omer Elkhalifa Abd-Elfarag
- Amsterdam Center for Global Health, Department of Pediatrics and Department of Global Health, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands; (A.W.D.E.); (M.B.v.H.)
- Correspondence:
| | - Arthur Wouter Dante Edridge
- Amsterdam Center for Global Health, Department of Pediatrics and Department of Global Health, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands; (A.W.D.E.); (M.B.v.H.)
- Laboratory of Experimental Virology, Department of Medical Microbiology, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands
| | - René Spijker
- Amsterdam Public Health, Medical Library, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands;
| | - Mohamed Boy Sebit
- Department of Psychiatry, College of Medicine, University of Juba, Juba P.O. Box 82, Sudan;
| | - Michaël B. van Hensbroek
- Amsterdam Center for Global Health, Department of Pediatrics and Department of Global Health, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands; (A.W.D.E.); (M.B.v.H.)
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