Rotavirus meningoencephalitis in a previously healthy child and a review of the literature

Shotgun metagenomics to investigate unknown viral etiologies of pediatric meningoencephalitis

INTRODUCTION

Meningoencephalitis in children poses a diagnostic challenge, as etiology remains unknown for most of patients. Viral metagenomics by shotgun sequencing represents a powerful tool for investigating unknown viral infections related to these cases.

PATIENTS AND METHODS

In a two-year, reference-centre, retrospective study, we investigated the usefulness of viral metagenomics of cerebrospinal fluid (CSF) for the diagnosis of viral infectious meningoencephalitis in forty seven pediatric patients, forty of them previously tested negative with a routine neurologic panel of viral targets that included herpesvirus 1-3 and enterovirus. We enhanced the detection by targeting viral sequences by hybrid capture. Raw sequence data was analysed using three bioinformatics pipelines.

RESULTS

Out of forty remaining children with meningoencephalitis of unknown viral etiology, a significant detection of viral nucleic acid by shotgun sequencing was found in twenty one, which was confirmed in ten of them by specific PCR: seven human endogenous retrovirus K113 (HER K113), one parechovirus 3, one human herpesvirus 5 (HHV5); one enterovirus B (Echovirus 9). The remaining eleven CSF were not confirmed by PCR: three rotavirus, one human herpesvirus 7 (HHV7), one influenza A, one mastadenovirus C, one sindbis virus, one torque teno virus, one human immunodeficiency virus 1 (HIV-1), one human alphaherpesvirus 3 (HHV3), one human alphaherpesvirus 2 (HHV2).

CONCLUSIONS

Underutilization of currently available meningitis-encephalitis diagnostic techniques such as BioFire® FilmArray® is the main cause of undiagnosed cases of meningoencephalitis. However, in this study we detected uncommon viruses that should be considered, including virus, rotavirus, sindbis virus, influenza A virus and HHV7. No other viral sequences that could be readily linked to CNS inflammation were detected. Some findings may stem from reagent or sample contamination, as seen with papillomavirus; for others, the clinical relevance of the virus remains uncertain and should be substantiated by further studies, as is the case with endogenous retrovirus K113 virus. Online bioinformatics pipeline CZID represents a valuable tool for analysing shotgun sequencing data in cases of neurological conditions with unknown etiology. Altogether, this study highlights the potential of shotgun sequencing in identifying previously unknown viral neuropathogens and sheds light on the interpretation issues related to its application in clinical microbiology.

Rotavirus infection-associated central nervous system complications: clinicoradiological features and potential mechanisms

Despite the introduction of vaccines in 2006, rotavirus remains one of the most common causes of pediatric gastroenteritis worldwide. While many studies have conclusively shown that rotavirus infection causes gastroenteritis and is associated with various extraintestinal manifestations including central nervous system (CNS) complications, extraintestinal manifestations due to rotavirus infection have been relatively overlooked. Rotavirus infection-associated CNS complications are common in children and present with diverse clinicoradiological features. Rotavirus infection-associated CNS complications can be classified based on clinical features and brain magnetic resonance imaging findings, particularly lesion location on diffusion-weighted imaging. Common clinicoradiological features of rotavirus infection-associated CNS complications include: (1) benign convulsions with mild gastroenteritis; (2) acute encephalopathies/encephalitis, such as mild encephalopathy with a reversible splenial lesion, acute encephalopathy with biphasic seizures and late reduced diffusion, and acute necrotizing encephalopathy; (3) acute cerebellitis; and (4) neonatal rotavirus-associated leukoencephalopathy. The precise mechanism underlying the development of these complications remains unknown despite a number of clinical and laboratory studies. Here we review the diverse clinicoradiological features of rotavirus infection-associated CNS complications and propose a hypothesis of their pathophysiology.

Rotavirus Meningitis in an adult with transient aphasia

We identified an additional case of documented Rotavirus meningitis in an adult with full medical history. A previously healthy 37 years old patient presented herself for a transient aphasia associated with fever and headaches at the end of a one-week history of gastro-enteritis. CSF analysis revealed a lymphocytic meningitis and Aciclovir was initiated. Rotavirus A RT-PCR was positive in CSF as well as in the patient's stools, in favor of Rotavirus meningitis. Testing for other viruses was negative. MRI showed no signs of encephalitis. Aphasia was resolutive in less than 12 hours, and no neurological symptoms relapsed. All symptoms evolved favorably despite Aciclovir discontinuation. Viral sequencing methods have recently identified unexpected viruses as potential causative agents in meningitis, including Rotavirus. We confirm the detectability of Rotavirus in analysis of CSF in the context of Rotavirus gastroenteritis in an adult. This case suggest post-viral HaNDL syndrome may be linked to previously undetected direct viral infection of central nervous system. Clinicians should consider Rotavirus meningitis in the diagnosis of meningitis associated with gastroenteritis in adults.

Clinical Features and Outcomes of Children Admitted to the PICU due to Rotavirus Infection

OBJECTIVES

In this study, we aimed to evaluate the clinical and laboratory features of the patients with rotavirus (RV) antigen positivity on or following admission to the pediatric intensive care unit (PICU).

METHODS

Patients admitted to the PICU due to community-acquired rotavirus (CA-RV) or hospital-acquired rotavirus (HA-RV)-induced gastroenteritis between January 1, 2013, and December 31, 2019 were evaluated.

RESULTS

Thirty-four patients with a mean age of 14.00 ± 19.17 months were enrolled. Fortyfour percent were girls. Twenty (58.8%) patients had a history of chronic diseases. Nine (26.5%) patients had CA-RV and 25 (73.5%) patients had HA-RV infection. RV antigens were simultaneously found in 44.1% (n = 14) of the other patients at the time of diagnosis. In the study sample, 5 patients had hyponatremia, 8 had hypernatremia, 6 had hypokalemia, 4 had hypoalbuminemia, 21 had leukocytosis, 2 had leukopenia and 3 had thrombocytopenia, and 17 had elevatedC-reactive protein (CRP) levels. Three patients had seizures, 1 patient had cardiac arrest, and 2 patients had secondary bacteremia. The mean (SD) PICU length of stay was 6 (6.02) with CA-RV gastroenteritis. All CA-RV patients survived, but 8 of the HA-RV patients succumbed to causes other than RV.

CONCLUSION

RV-related PICU admission is not rare, and occasional severe clinical consequences occur, especially in young children, with both CA-RV and HA-RV gastroenteritis. Appropriate timely intervention and meticulous follow-up improve survival.

Viral capture sequencing detects unexpected viruses in the cerebrospinal fluid of adults with meningitis

OBJECTIVES

Many patients with meningitis have no aetiology identified leading to unnecessary antimicrobials and prolonged hospitalisation. We used viral capture sequencing to identify possible pathogenic viruses in adults with community-acquired meningitis.

METHODS

Cerebrospinal fluid (CSF) from 73 patients was tested by VirCapSeq-VERT, a probe set designed to capture viral targets using high throughput sequencing. Patients were categorised as suspected viral meningitis - CSF pleocytosis, no pathogen identified (n = 38), proven viral meningitis - CSF pleocytosis with a pathogen identified (n = 15) or not meningitis - no CSF pleocytosis (n = 20).

RESULTS

VirCapSeq-VERT detected virus in the CSF of 16/38 (42%) of those with suspected viral meningitis, including twelve individual viruses. A potentially clinically relevant virus was detected in 9/16 (56%). Unexpectedly Toscana virus, rotavirus and Saffold virus were detected and assessed to be potential causative agents.

CONCLUSION

VirCapSeq-VERT increases the probability of detecting a virus. Using this agnostic approach we identified Toscana virus and, for the first time in adults, rotavirus and Saffold virus, as potential causative agents in adult meningitis. Further work is needed to determine the prevalence of atypical viral candidates as well as the clinical impact of using sequencing methods in real time. This knowledge can help to reduce antimicrobial use and hospitalisations leading to both patient and health system benefits.

Occurrence of speech-language disorders in the acute phase following pediatric acquired brain injury: results from the Ghent University Hospital

AIMS

This study investigated the occurrence of speech-language disorders during the acute phase of recovery in children with acquired brain injury (ABI) with an age between 0 and 16 years.

METHODS

A retrospective chart analysis was performed including 228 children (n = 118 boys, n = 110 girls) who consecutively presented with ABI over a 10-year period (2006-2016) at the children's rehabilitation center at Ghent University Hospital. Descriptive statistical analyses were applied.

RESULTS

71.1% (162/228) of the children who were admitted to the rehabilitation center presented with a speech-language disorder. Within this sample (n = 162), results demonstrated the occurrence of acquired disorders in language (48.9%), speech (35.1%), learning (33.3%), swallowing (21.5%), and early communicative functions (17.4%). The proportion of children presenting with disturbances in early communicative functions differed by ABI cause. More than half (10/18, 58.8%) of the children who presented with ABI following inflammatory processes demonstrated disorders in early communicative functions.

CONCLUSIONS

Especially in young children who present with inflammatory processes as the ABI cause, speech-language pathologists (SLPs) must be aware of disorders in early speech-language development. The present findings allow the SLP to appropriately plan research, education, and clinical management.

Molecular characterization of rotaviruses obtained from patients with rotavirus-associated encephalitis/encephalopathy

Group A rotavirus (RVA) rarely causes severe complications such as encephalitis/encephalopathy. However, the pathophysiology of this specific complication remains unclear. Next-generation sequence analysis was used to compare the entire genome sequences of RVAs detected in patients with encephalitis/encephalopathy and gastroenteritis. This study enrolled eight patients with RVA encephalitis/encephalopathy and 10 with RVA gastroenteritis who were treated between February 2013 and July 2014. Viral RNAs were extracted from patients' stool, and whole-genome sequencing analysis was carried out to identify the specific gene mutations in RVA obtained from patients with severe neurological complications. Among the eight encephalitis/encephalopathy cases, six strains were DS-1-like G1P[8] and the remaining two were Wa-like G1P[8] (G1-P[8]-I1-R1-C1-M1-A1-N1-T1-E1-H1). Meanwhile, eight of the 10 viruses detected in rotavirus gastroenteritis patients were DS-1-like G1P[8], and the remaining two were Wa-like G1P[8]. These strains were further characterized by conducting phylogenetic analysis. No specific clustering was demonstrated in RVAs detected from encephalitis/encephalopathy patients. Although the DS-1-like G1P[8] strain was predominant in both groups, no specific molecular characteristics were detected in RVAs from patients with severe central nervous system complications.

Viral Sepsis in Children

Sepsis in children is typically presumed to be bacterial in origin until proven otherwise, but frequently bacterial cultures ultimately return negative. Although viruses may be important causative agents of culture-negative sepsis worldwide, the incidence, disease burden and mortality of viral-induced sepsis is poorly elucidated. Consideration of viral sepsis is critical as its recognition carries implications on appropriate use of antibacterial agents, infection control measures, and, in some cases, specific, time-sensitive antiviral therapies. This review outlines our current understanding of viral sepsis in children and addresses its epidemiology and pathophysiology, including pathogen-host interaction during active infection. Clinical manifestation, diagnostic testing, and management options unique to viral infections will be outlined.

A novel group A rotavirus associated with acute illness and hepatic necrosis in pigeons (Columba livia), in Australia

Cases of vomiting and diarrhoea were reported in racing pigeons in Western Australia in May, 2016. Morbidity and mortality rates were high. Similar clinical disease was seen in Victoria in December and by early 2017 had been reported in all states except the Northern Territory, in different classes of domestic pigeon–racing, fancy and meat bird–and in a flock of feral pigeons. Autopsy findings were frequently unremarkable; histological examination demonstrated significant hepatic necrosis as the major and consistent lesion, often with minimal inflammatory infiltration. Negative contrast tissue suspension and thin section transmission electron microscopy of liver demonstrated virus particles consistent with a member of the Reoviridae. Inoculation of trypsin-treated Vero, MDBK and MA-104 cell lines resulted in cytopathic changes at two days after infection. Next generation sequencing was undertaken using fresh liver samples and a previously undescribed group A rotavirus (genotype G18P[17]) of avian origin was identified and the virus was isolated in several cell lines. A q-RT-PCR assay was developed and used to screen a wider range of samples, including recovered birds. Episodes of disease have continued to occur and to reoccur in previously recovered lofts, with variable virulence reported. This is the first report of a rotavirus associated with hepatic necrosis in any avian species.

Group A Rotavirus Associated with Encephalitis in Red Fox

In 2011, a group A rotavirus was isolated from the brain of a fox with encephalitis and neurologic signs, detected by rabies surveillance in Italy. Intracerebral inoculation of fox brain homogenates into mice was fatal. Genome sequencing revealed a heterologous rotavirus of avian origin, which could provide a model for investigating rotavirus neurovirulence.

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

Background

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

Methods

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

Results

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

Conclusion

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

Survey of rotavirus-associated severe complications in Aichi Prefecture

BACKGROUND

Rotavirus can, rarely, cause severe complications such as encephalopathy/encephalitis, myocarditis, sudden death, urinary stone, and gastrointestinal (GI) bleeding; and the incidence of these severe complications remains unclear. Additionally, it has not been determined whether rotavirus (RV) vaccine could reduce cases of severe complications or not.

METHODS

A two-part questionnaire was designed to determine the number and clinical features of severe complications between 1 September 2008 and 31 August 2015, including the observation periods before and after RV vaccine introduction in Aichi Prefecture.

RESULTS

Twenty-four cases of encephalitis/encephalopathy, eight cases of sudden death, three cases of urinary tract stone, and three cases of GI bleeding were reported during the 2008/2009 season and the 2012/2013 seasons. Although five cases of encephalitis/encephalopathy were reported, no other cases of severe complications were reported during the 2013/2014 and 2014/2015 seasons. No age difference was noted according to type of complication. Although onset of encephalitis/encephalopathy and of sudden death was around day 2 of illness, that of urinary tract stone and GI bleeding was slightly later (day 6 and day 4). In addition to the eight sudden deaths, fatal outcome was also noted in four cases (13.8%) of encephalitis/encephalopathy, and in one case of GI bleeding.

CONCLUSION

According to the questionnaire survey in Aichi Prefecture, the incidence of the four severe RV-associated complications appears to have declined as the vaccination rate has increased.

Neurodevelopmental outcomes in newborns with neonatal seizures caused by rotavirus-associated leukoencephalopathy

PURPOSE

Rotavirus infection has recently been reported to be associated with seizures accompanied by leukoencephalopathy in newborns. We aimed to determine long-term outcomes and prognostic factors in newborns with neonatal seizures caused by rotavirus-associated leukoencephalopathy.

METHODS

We retrospectively reviewed the records and brain magnetic resonance (MR) images of 32 patients who fulfilled the following criteria: (1) neonatal seizures, (2) distinctive symmetric cerebral white matter lesions on diffusion-weighted MR images (DWI), (3) rotavirus infection, (4) absence of a specific etiology of seizures, except for the aforementioned DWI lesions, and (5) Korean Bayley Scales of Infant Development II (K-BSID-II) assessment after 12 months of age.

RESULTS

The mean age at seizure onset was 4.7 ± 0.8 days. The median age of the patients at the time of K-BSID-II assessment was 22 months. Fourteen patients (43.8%) showed normal or accelerated performance in the mental and motor scales, while 18 patients (56.2%) had delayed performance in the mental and/or motor scales. Seven patients (21.9%) had significantly delayed performances on the mental and/or motor scales. The percentage of volume of diffusion-restricted lesions based on total brain volume was significantly negatively correlated with the mental developmental index (MDI) score (r = -0.507, p = .003), but not with the psychomotor developmental index (PDI) score (r = -0.324, p = .071).

CONCLUSIONS

Rotavirus-associated leukoencephalopathy in newborns around 5 days of age can cause adverse neurodevelopmental outcomes with a wide range of severity. The extent of white matter lesion on initial DWI can predict neurocognitive outcome.

Interrelationship of rotavirus infection and Creatine Kinase-MB isoenzyme levels in children hospitalized with acute gastroenteritis in Guangzhou, China, 2012-2015

Elevated levels of Creatine Kinase-MB (CK-MB) Isoenzyme are a common phenomenon among rotavirus (RV) diarrhea. However, few studies have addressed this issue using large sample size. In current study, 1,118 children (age <5 years) hospitalized with diarrhea in Guangzhou Women and Children’s Medical Center from 2012 to 2015 were finally included. Changing pattern of CK-MB and its relationship with RV-infection were analyzed and characterized. Multivariate linear regression models showed that RV-positive cases had a 28% rise in CK-MB compared to RV-negative cases (OR = 1.28, 95% CI: 1.15 to 1.41, P < 0.01) after controlling for age, gender, season of admission, and weight. The pattern of change showed that CK-MB level of RV-positive group started to rise immediately at the 1^st day of diarrhea, reached the peak on days 2 to 4, declined during 4–9 days, and then reached a relatively stable level when compared to the RV-negative group. Mediation analyses showed that indirect effect of RV infection on the increase of CK-MB via Vesikari score was significant (β = 8.01, P < 0.01), but direct effect was not (β = 9.96, P = 0.12). Thus, elevated CK-MB value is a common finding in RV-infection and completely mediated by the severity of diarrhea. CK-MB monitoring may help to identify children with more severe viral infection.

Escherichia coli Meningitis after Rotavirus Gastroenteritis in an Infant

Although rotavirus gastroenteritis is quite common in the pediatric population, secondary bacterial sepsis following rotavirus infection is a rare clinical entity. Gram-negative bacilli are the fifth most common cause of meningitis in infants but this infection rarely occurs after gastroenteritis. Here, we report a 2.5-month-old infant who developed Escherichia coli (E. coli) meningitis after acute rotavirus gastroenteritis. The 2.5-month-old male infant with fever, vomiting, and watery diarrhea that started 1 day earlier was admitted to the hospital. Rotavirus antigen in stool sample was positive. He was hospitalized, and fever was measured at 39.5°C on the second day. Lumbar puncture was done for suspicion of meningitis, and cerebrospinal fluid (CSF) findings suggested meningitis. Intravenous vancomycin and cefotaxime were started empirically. Since E. coli reproduction was seen in blood culture and CSF culture, treatment was continued with cefotaxime. The patient was discharged with minimal midlevel hydrocephalus findings in cranial ultrasonography and magnetic resonance imaging following 21 days of antibiotics treatment. Septicemia development following rotavirus gastroenteritis is an extremely rare clinical condition. It is vital to start prompt antibiotic treatment as soon as the diagnosis of secondary bacterial infection is made because of high mortality and morbidity rates.

Systemic features of rotavirus infection

A growing body of evidence warrants a revision of the received/conventional wisdom of rotavirus infection as synonymous with acute gastroenteritis. Rotavirus vaccines have boosted our interest and knowledge of this virus, but also importantly, they may have changed the landscape of the disease. Extraintestinal spread of rotavirus is well documented, and the clinical spectrum of the disease is widening. Furthermore, the positive impact of current rotavirus vaccines in reducing seizure hospitalization rates should prompt a reassessment of the actual burden of extraintestinal manifestations of rotavirus diseases. This article discusses current knowledge of the systemic extraintestinal manifestations of rotavirus infection and their underlying mechanisms, and aims to pave the way for future clinical, public health and research questions.

Role of matrix metalloproteinases in the pathogenesis of childhood gastroenteritis

Matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) have been implicated in the pathogenesis of gastrointestinal diseases, such as rotavirus gastroenteritis (GE). Kinetics of these biomarkers were examined in paired serum samples collected from bacterial enteritis patients with Campylobacter (n = 2) and Salmonella (n = 4) and viral GE patients with rotavirus (n = 27), norovirus (n = 25), and adenovirus (n = 11). At the time of hospital admission, all viral GE patients demonstrated increased MMP-9 and decreased MMP-2 and TIMP-2 serum levels. In contrast to viral GE patients, serum MMP-9 levels were not elevated at the time of hospital admission but elevated at the time of discharge; serum MMP-2 and TIMP-2 levels were decreased both at the time of admission and discharge in bacterial enteritis patients. Interestingly, the kinetics of serum MMP-2, MMP-9, and TIMP-2 levels were similar among the viral GE patients but distinct from bacterial enteritis patients. Thus, the involvement of MMPs and TIMPs in the pathophysiology of gastrointestinal symptoms likely varies depending on the etiological agent. Further studies are required to verify whether the extent of the bacterial enteritis or age of the patients influences these serum biomarkers. J. Med. Virol. 88:1341-1346, 2016. © 2016 Wiley Periodicals, Inc.

Encephalitis in Australian children: contemporary trends in hospitalisation

OBJECTIVE

The clinical epidemiology of childhood encephalitis in Australia is inadequately understood. We aimed to describe recent trends in childhood encephalitis-related hospitalisation.

STUDY DESIGN

We identified encephalitis-related hospital admissions (2000-2012) in national datasets among children ≤14 years using ICD encephalitis codes. We calculated hospitalisation rates and analysed trends by year, age, gender, location, indigenous status and aetiology.

RESULTS

Rates of childhood encephalitis hospitalisations significantly declined over an 11-year period (2000-2012; average hospitalisation rate 3.2/100 000). Varicella encephalitis hospitalisations decreased significantly, associated with high levels of varicella vaccine coverage since 2006. Acute disseminated encephalomyelitis (ADEM) was the most common 'specified' cause of encephalitis hospitalisation (15%-17%), and its rate has significantly increased. The highest hospitalisation rates occurred in the <1 year age group (5.8/100 000) and varied by location (highest in Northern Territory). The majority (58.9%) of hospitalised encephalitis had no cause identified; this proportion was highest in the <1 year age group (77%). The most common specified infectious causes included: herpes simplex virus, enterovirus, bacterial meningoencephalitis and varicella. When aggregated, the proportion of childhood encephalitis coded as viral was 21.2%.

CONCLUSION

Hospitalisation of childhood encephalitis has slightly decreased in Australia. High rates of childhood immunisation have been associated with a reduction of varicella-associated encephalitis in Australian children. ADEM, an immune-mediated encephalitis, is the most common recognised cause of encephalitis in children. Young children (<1 year) have the highest admission rates. The high proportion of 'unspecified' encephalitis deaths and hospitalisations is an ongoing challenge.

Association of Rotavirus With Seizures Accompanied by Cerebral White Matter Injury in Neonates

We aimed to identify whether rotavirus, human parechovirus, or enterovirus are causative or associated viral pathogens of seizures accompanied by diffuse cerebral white matter injury in neonates. Thirty neonates who presented with seizures and diffusion-restriction in the widespread bilateral cerebral white matter on diffusion-weighted magnetic resonance imaging (MRI) were included in this study. All patients were tested for rotavirus, human parechovirus, and enterovirus by using reverse transcription PCR. Stool, cerebrospinal fluid, and serum samples were examined in 30, 25, and 20 patients, respectively. Rotavirus was detected in stool samples from all 30 patients (100%). Stool samples from 5 patients (16.7%) were also positive for enterovirus. Rotavirus or human parechovirus were not detected in any cerebrospinal fluid samples from 25 patients, but 1 patient tested positive for enterovirus. No virus was detected in any of 20 patient sera. This study indicated an association between rotavirus and seizures accompanied by diffuse cerebral white matter lesions in neonates.

Impact of Rotavirus Vaccination on Childhood Hospitalization for Seizures

BACKGROUND

Rotavirus vaccine (RV) might reduce the risk of hospitalization due to childhood seizures (CS). We aimed to identify and assess variations in the incidence of hospitalizations for CS among children <5 years of age before and after RV introduction.

METHODS

Annual hospitalization rates for any kind of CS, before and after RV introduction in 2007, were calculated using the official surveillance system for hospitalization data.

RESULTS

Our study cohort totaled 6149 children <5 years of age admitted to the hospital between 2003 and 2013 with any kind of CS (780.3* + 779.0* + 333.2* + 345* ICD-9-CM code). The annual hospitalization rates for any kind of CS in children <5 years of age were correlated with RV coverage (r = -0.673; P = 0.033) and rotavirus acute gastroenteritis admission rates (ρ = 0.506; P = 0.001), with decrease rates ranging from 16.2% (95% confidence interval: 8.3-23.5%) in 2007 to 34.0% (27.3-40.1%) in 2010, as compared with the median rate of the pre-vaccination period (2003 to 2006). Similarly, for convulsions (780.3*ICD-9-CM code), the decrease seen in children <5 years of age was significantly correlated with the increase in RV coverage (r = -0.747; P = 0.013) and rotavirus acute gastroenteritis admission rates (ρ = 0.543; P < 0.001), with decrease rates ranging from 18.7% (9.6-26.8%) in 2007 to 42.5% (35.3-48.9%) in 2012. Significant results were also obtained for infants <12 months and infants 1-2 years of age. In the remaining age groups or diagnostic categories analyzed, changes were either not significant or not related to vaccination changes or rotavirus acute gastroenteritis admission rates.

CONCLUSIONS

Our results show that rotavirus vaccination may have a significant impact in the decrease in seizure-related hospitalizations in childhood. This additional benefit of rotavirus vaccination seems more marked in the youngest infants.

Neonatal seizures accompanied by diffuse cerebral white matter lesions on diffusion-weighted imaging are associated with rotavirus infection

BACKGROUND AND AIMS

Some full-term neonates presenting seizures show diffusion-restricted lesions in the cerebral white matter on brain diffusion-weighted imaging (DWI). The purpose of this study was to describe the clinical characteristics and DWI findings in a group of neonates with seizures, white matter lesions on DWI, and a high incidence of rotavirus infection.

METHODS

Total 30 full-term neonates with seizures were admitted between 2008 and 2010. Of these, 13 (group A) had the following characteristics on brain DWI: (1) diffusion-restricted lesions in the diffuse symmetric cerebral white matter, including the corpus callosum, and (2) no cerebral cortical lesions. The remaining 17 patients (group B) did not exhibit the DWI findings. The clinical characteristics were compared between the 2 groups.

RESULTS

The 1-min and 5-min Apgar scores ranged between 7 and 10 in all group A patients, whereas the scores were more diverse in the group B patients. Patients' age at seizure onset was 4.6 ± 0.6 days (range, 4-6 days) in group A and 8.3 ± 7.4 days (range, 1-27 days) in group B. Twelve of 13 patients (92.3%) in group A tested positive for stool rotavirus antigen, while only 2 of 12 (16.7%) in group B tested positive (p < 0.001). Six of 10 group A patients showed normal neurodevelopment, but 4 had delayed development between 6 and 30 months.

CONCLUSIONS

Rotavirus infection should be considered in neonates with seizures accompanied by diffuse cerebral white matter lesions on DWI, particularly around 5 days of life.

Nationwide survey of rotavirus-associated encephalopathy and sudden unexpected death in Japan

BACKGROUND

Rotavirus can cause severe complications such as encephalopathy/encephalitis and sudden unexpected death. The incidence of rotavirus-associated encephalopathy/encephalitis or sudden unexpected death remains unknown. To clarify the clinical features of rotavirus-associated encephalitis/encephalopathy and sudden unexpected death, we conducted a nationwide survey in Japan.

METHOD

A two-part questionnaire was designed to determine the number of the cases and the clinical features of severe cases of rotavirus infection, including encephalitis/encephalopathy and sudden unexpected death, between 2009 and 2011.

RESULT

Of the 1365 questionnaires sent to hospitals, 963 (70.5%) were returned and eligible for analysis. We determined 58 cases of rotavirus-associated encephalitis/encephalopathy and 7 cases of sudden unexpected death. These patients were diagnosed with rotavirus infection by immunochromatography. Although 36/58 (62.1%) encephalitis/encephalopathy patients had no sequelae, 15/58 (25.9%) patients had neurological sequelae, and 7/58 (12.1%) patients had fatal outcomes. Pleocytosis was observed in 9/40 (22.5%) patients and cerebrospinal fluid protein levels were elevated in only 4/40 (10%) patients. Elevated lactate dehydrogenase (LDH) (>500 IU/L) or acidemia (pH<7.15) were related to a poor prognosis.

CONCLUSION

We estimate that annual cases of rotavirus-associated encephalitis/encephalopathy and sudden unexpected death were 44.0 and 4.9 cases in Japan, respectively. Elevated LDH (>500 IU/L) or acidemia (pH<7.15) were related to a poor prognosis of the encephalitis/encephalopathy.

Evidences and consequences of extra-intestinal spread of rotaviruses in humans and animals

Rotavirus is recognized as one of the main diarrheal pathogens in young children and animals. The prevailing central dogma of rotavirus infection states that the infection is confined in the gastrointestinal tract. However, increasing evidences indicate that rotavirus infection is systemic. Clinical case reports of systemic manifestations to rotavirus infection in children has continued to accumulate over the past years. The use of animal models provided pathological and molecular evidences for extra-intestinal infection of rotaviruses. The mechanism correlated with the extra-intestinal spread of rotavirus infection from the intestine is through cell-free and cell-associated viremia. The extent of the extra-intestinal spread of rotavirus infection has not yet been fully elucidated; whether it can only affect a limited number of organs and tissues or capable of involving the body as a whole. Moreover, the influence of systemic rotavirus infections remains to be determined. In this review, combination of previous and new data are outlined to help in better understanding of the extra-intestinal infections of rotaviruses.

Protective association between rotavirus vaccination and childhood seizures in the year following vaccination in US children

BACKGROUND

Rotavirus illness has been linked to childhood seizures. We investigated whether a protective association exists between receipt of rotavirus vaccine and being hospitalized or visiting the emergency department for seizures in the year after vaccination.

METHODS

We retrospectively analyzed a cohort of children born after 28 February 2006 (when rotavirus vaccine was licensed in the United States) and enrolled in the Vaccine Safety Datalink (VSD) through November 2009. Seizure rates from 4 to 55 weeks following last rotavirus vaccination were compared by vaccine exposure status (fully vaccinated and unvaccinated). A time-to-event analysis using a Cox proportional hazards model was performed, accounting for time-varying covariates. We calculated the relative incidence of seizure compared by vaccine exposure status during the postexposure interval.

RESULTS

Our cohort contained VSD data on 250 601 infants, including 186 502 children fully vaccinated (74.4%) and 64 099 (25.6%) not vaccinated with rotavirus vaccine. Rates of seizures were associated with rotavirus vaccination status. After adjusting for covariates (VSD site, age at last dose, sex, and calendar month of the index date), a statistically significant protective association was observed between a full course of rotavirus vaccination vs no vaccination for both first-ever seizures (risk ratio [RR] = 0.82; 95% confidence interval [CI], .73-.91) and all seizures (RR = 0.79; 95% CI, .71-.88).

CONCLUSIONS

A full course of rotavirus vaccination was statistically associated with an 18%-21% reduction in risk of seizure requiring hospitalization or emergency department care in the year following vaccination, compared with unvaccinated children. This reduction in childhood seizures complements the well-documented vaccine-related benefit of preventing US diarrhea hospitalizations.

Acute cerebellitis associated with rotavirus infection

BACKGROUND

Rotavirus infection is occasionally associated with central nervous system involvement, including cerebellitis. However, the precise clinical sequelae of central nervous system disorders and the usefulness of neuroradiological examination for clinical therapies, such as steroid pulse therapy, have not been clarified.

METHODS

We present a case of rotavirus cerebellitis examined by magnetic resonance imaging (MRI), magnetic resonance spectroscopy, and single photon emission computed tomography.

RESULTS

MRI demonstrated abnormal intensities in the right cerebellum on fluid attenuated inversion recovery images and, much more obviously, on diffusion-weighted images, but not on T1- or T2-weighted images. Single photon emission computed tomography showed only mild hypoperfusion in the right cerebellum on the 15th day, while 4 weeks later the image showed remarkably low perfusion in the right cerebellum.

CONCLUSION

The findings of the reported case suggest the importance of performing radiological examinations at early phases of the disease, especially by new modalities such as diffusion weighted imaging, to make timely and appropriate therapeutic decisions.

Complications in hospitalized children with acute gastroenteritis caused by rotavirus: a retrospective analysis

Acute gastroenteritis (AGE) caused by rotavirus (RV) is a common disease among infants and toddlers, often leading to hospitalization and, in resource-poor countries, to death. However, little is known on specific complications of severe RV-positive (RV+) AGE and on the clinical course in chronically ill children. This was a retrospective analysis of data for children <5 years of age hospitalized due to AGE during six rotavirus seasons in three large German pediatric hospitals. The primary study end point was the incidence and type of complications in RV+ versus RV-negative (RV-) cases. A total of 6,884 episodes of AGE in hospitalized children aged <5 years were included in this analysis. Of the 4,880 stools tested for RV, 2,118 (43.4%) were RV+. Hypernatremia was significantly more common in RV+ AGE (P < 0.001) and was associated with severe disease, need for intensive care treatment, and longer duration of hospitalization. Metabolic disorders, particularly hypoglycemia, were more common in RV+ AGE. In contrast, symptoms such as respiratory infections, neurological, and abdominal symptoms were more common in children with RV- AGE.

CONCLUSIONS

Hypernatremia is a specific complication of RV+ AGE. RV would therefore appear to be the cause of infant toxicosis, the traditional descriptive term for severe dehydration and clinical deterioration following AGE.

Case report: detection of rotavirus RNA in the cerebrospinal fluid of a child with rotavirus gastroenteritis and meningism

Although case reports have described detection of rotavirus (RV) in extraintestinal sites such as the liver, kidney, and central nervous system (CNS) of children with RV gastroenteritis, CNS localization in RV infection seems to be rare. RT-PCR and nucleotide sequencing detected a G1P[8] strain in the stool and cerebrospinal fluid (CSF) samples of a patient with concurrent RV-associated enteritis and CNS signs. Upon sequence analysis, the viruses detected in the CSF was identical to the virus detected in the stools. In the VP7- and VP4-based phylogenetic dendograms the strain clustered within the G1-Ic sub-lineage and the P[8]-III lineage. This study supports the hypothesis that RV infection was able to spread from the intestinal tract to the CNS, and likely played a role in the onset of neurological disease.

Rotavirus cerebellitis: new aspects to an old foe?

Rotavirus infection is a significant cause of childhood morbidity and mortality worldwide. Although infection primarily causes gastroenteritis and dehydration, systemic signs and neurologic manifestations in rotavirus infection are widely recognized. The pathophysiologic origins of neurologic signs in rotavirus infection remain incompletely understood. We present a 4-year-old girl with clinical features of severe cerebellitis in association with abnormalities detected on magnetic resonance imaging. Rotavirus nucleic acid was demonstrated in both serum and cerebrospinal fluid. Severe neurologic sequelae remain after 2 years of follow-up. This report adds further evidence supporting a direct role for rotavirus in neurologic illness.

Antigenemia and cytokine expression in rotavirus gastroenteritis in children

BACKGROUND

Antigenemia is commonly found in children with rotavirus infection, although its clinical significance is undetermined. The aim of this study was to evaluate the association of antigenemia with clinical manifestations and cytokine profiles in children infected by rotavirus.

METHODS

In total, 68 children hospitalized with rotavirus gastroenteritis were enrolled. Serum samples were collected for detection of antigenemia and viremia. Clinical, laboratory and demographic data were analyzed. Proinflammatory, Th1 and Th2 cytokines were evaluated by bead-based flow cytometry.

RESULTS

Antigenemia and viremia were found in 45.6% (n = 31) and 5.9% (n = 4) of the 68 rotavirus-infected children, respectively. The mean age of the antigenemia group was significantly greater than that of the non-antigenemia group (43.5 vs. 27.3 months; p = 0.034). The antigenemia group had a significantly shorter length of hospitalization (4.8 vs. 5.8 days; p = 0.0354) in comparison with the non-antigenemia group, and antigenemia was inversely associated with the length of hospitalization (β = 0.31, p = 0.021). A significantly higher tumor necrosis factor (TNF)-β level was found in the patients with antigenemia than those without (236.7 vs. 29.2 pg/mL, p = 0.026). The severity of disease and the rate of extra-intestinal manifestations did not differ between the groups. Viremia was associated with a higher fever (p = 0.012).

CONCLUSIONS

Antigenemia was positively correlated with shorter hospital stay in children with rotavirus infection. Enhanced innate and T-cell-mediated immunity evidenced by up-regulation of TNF-β was found in patients with antigenemia.

Rotavirus vaccines: update on global impact and future priorities

Early rotavirus vaccine adopter countries in the Americas, Europe, and in Australia have documented substantial declines in rotavirus disease burden following the introduction of vaccination.  However, the full public health impact of rotavirus vaccines has not been realized as they have not been introduced into routine immunization programs in countries of Africa and Asia with the highest rotavirus disease morbidity and mortality burden.  In this article, we review the epidemiology of rotavirus disease, the development and current status of rotavirus vaccines including newly available vaccine impact data from early-introducer countries, and future priorities for implementation and monitoring of rotavirus vaccination programs in developing countries.

Norovirus encephalopathy in a previously healthy child

Norovirus causes acute gastroenteritis in all age groups. Afebrile convulsion is an occasional neurologic complication in norovirus infection, but encephalitis is rare. We report the case of a previously healthy 15-month-old girl with norovirus encephalopathy who had a poor neurologic outcome. Norovirus (genogroup II) was detected in plasma and stool by real-time reverse transcription polymerase chain reaction, but the cerebrospinal fluid showed negative result for genome. Elevated concentrations of cerebrospinal fluid interleukin-6, interleukin-10, interferon-γ, and tumor necrosis factor-α were observed on the third day of illness. The encephalopathy in our patient may be related to hypercytokinemia rather than to direct viral invasion.

Two patients with acute rotavirus encephalitis associated with cerebellar signs and symptoms

Rotavirus, one of the major causes of severe gastroenteritis in children, occasionally causes central nervous system complications. Recently several patients with acute encephalitis/encephalopathy due to rotavirus associated with cerebellar signs and symptoms have been reported. The condition is characterized by disturbances of consciousness at onset and cerebellar signs and symptoms such as hypotonia, ataxia, dysmetria, and speech disorders, including mutism, slow speech, and dysarthria at convalescence. We report two patients (3-year-old girl, 2-year-old boy) who developed acute encephalitis due to rotavirus and showed cerebellar signs and symptoms. Both patients had characteristic history of consciousness disturbances subsequent to several days of diarrhea, vomiting and fever, and cerebellar symptoms such as hypotonia, ataxia, dysmetria, and speech disorders during the recovery period. Electroencephalography showed diffuse high-voltage delta wave activity in each patient. Brain magnetic resonance imaging showed cerebellar edema in the acute phase followed by cerebellar atrophy on follow-up images in both patients. In the first patient, diffusion-weighted images (DWI) revealed high signals at the left cerebellar peduncle region and apparent diffusion coefficient (ADC) maps showed decreased ADC values of the lesion in the acute phase. The first patient had dysmetria at 1-year follow-up. However, she had normal motor and cognitive functions and could lead her daily life without impairment. In the second patient, no further symptoms were apparent at 1-year follow-up. Acute encephalitis/encephalopathy due to rotavirus with cerebellar signs and symptoms might be diagnosed on DWI, by demonstrating decreased ADC values in acute phase.

Transient splenial lesion of the corpus callosum in a case of benign convulsion associated with rotaviral gastroenteritis

Transient magnetic resonance (MR) signal changes in the splenium of the corpus callosum (SCC) arise from many different conditions, including encephalopathy or encephalitis caused by infection, seizures, metabolic derangements, and asphyxia. Few case reports exist on reversible SCC lesions associated with rotavirus infection. A benign convulsion with mild gastroenteritis (CwG) is frequently associated with rotaviral infections. This entity is characterized by normal laboratory findings, electroencephalogram, neuroimaging, and good prognosis. We report a case of a 2.5-year-old Korean girl with rotavirus-associated CwG demonstrating a reversible SCC lesion on diffusion-weighted MR images. She developed 2 episodes of brief generalized tonic-clonic seizure with mild acute gastroenteritis without any other neurologic abnormality. Stool test for rotavirus antigen was positive. Brain MRI done on the day of admission showed a linear high signal intensity and decreased apparent diffusion coefficient values on the SCC. The lesion completely disappeared on follow-up MRI 6 days later. The patient fully recovered without any sequelae.

A critical review on a globally-licensed, live, orally-administrable, monovalent human rotavirus vaccine: Rotarix

Rotavirus is the major cause of severe gastroenteritis in children worldwide, and two, live, orally-administrable vaccines are licensed globally. They are Rotarix, a monovalent, human rotavirus-based vaccine (GlaxoSmithKline), and RotaTeq, a pentavalent, bovine-human reassortant vaccine (Merck). The RIX4414 strain, a G1P[8] virus, is contained in the Rotarix vaccine. It grows efficiently in the human intestine, as evidenced by vaccine virus shedding into faeces. Efficient multiplication of RIX4414 in the intestines may play a role in stimulating immune effectors other than neutralizing antibodies that may explain the protective immunity against fully heterotypic G2P[4] strains. The protective efficacy against severe rotavirus gastroenteritis afforded by Rotarix is consistently better against strains that share with RIX4414 both G and P serotypes (i.e., G1P[8]), or only P serotype (i.e., G3P[8], G4P[8] and G9P[8]). The Rotarix vaccine is safe regarding intussusception if its first dose is administered between 6 and 12 weeks of age and the last dose by 24 weeks of age with a minimum interval of 4 weeks between the two doses. The expansion by Advisory Committee on Immunization Practices, USA, of the age limit for the first dose to age <15 weeks, and the last dose by 8 months requires close monitoring.