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Leon KE, Schubert RD, Casas-Alba D, Hawes IA, Ramachandran PS, Ramesh A, Pak JE, Wu W, Cheung CK, Crawford ED, Khan LM, Launes C, Sample HA, Zorn KC, Cabrerizo M, Valero-Rello A, Langelier C, Muñoz-Almagro C, DeRisi JL, Wilson MR. Genomic and serologic characterization of enterovirus A71 brainstem encephalitis. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:7/3/e703. [PMID: 32139440 PMCID: PMC7136061 DOI: 10.1212/nxi.0000000000000703] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 02/06/2020] [Indexed: 12/12/2022]
Abstract
Objective In 2016, Catalonia experienced a pediatric brainstem encephalitis outbreak caused by enterovirus A71 (EV-A71). Conventional testing identified EV in the periphery but rarely in CSF. Metagenomic next-generation sequencing (mNGS) and CSF pan-viral serology (VirScan) were deployed to enhance viral detection and characterization. Methods RNA was extracted from the CSF (n = 20), plasma (n = 9), stool (n = 15), and nasopharyngeal samples (n = 16) from 10 children with brainstem encephalitis and 10 children with meningitis or encephalitis. Pathogens were identified using mNGS. Available CSF from cases (n = 12) and pediatric other neurologic disease controls (n = 54) were analyzed with VirScan with a subset (n = 9 and n = 50) validated by ELISA. Results mNGS detected EV in all samples positive by quantitative reverse transcription polymerase chain reaction (qRT-PCR) (n = 25). In qRT-PCR-negative samples (n = 35), mNGS found virus in 23% (n = 8, 3 CSF samples). Overall, mNGS enhanced EV detection from 42% (25/60) to 57% (33/60) (p-value = 0.013). VirScan and ELISA increased detection to 92% (11/12) compared with 46% (4/12) for CSF mNGS and qRT-PCR (p-value = 0.023). Phylogenetic analysis confirmed the EV-A71 strain clustered with a neurovirulent German EV-A71. A single amino acid substitution (S241P) in the EVA71 VP1 protein was exclusive to the CNS in one subject. Conclusion mNGS with VirScan significantly increased the CNS detection of EVs relative to qRT-PCR, and the latter generated an antigenic profile of the acute EV-A71 immune response. Genomic analysis confirmed the close relation of the outbreak EV-A71 and neuroinvasive German EV-A71. A S241P substitution in VP1 was found exclusively in the CSF.
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Affiliation(s)
- Kristoffer E Leon
- From the Medical Scientist Training Program (K.E.L.), University of California, San Francisco; Biomedical Sciences Graduate Program (K.E.L., I.A.H.), University of California, San Francisco; Weill Institute for Neurosciences (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Department of Neurology (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Institut de Recerca Pediàtrica Hospital Sant Joan de Déu (D.C.-A., C.L., A.V.-R., C.M.-A.), Barcelona, Spain; Chan Zuckerberg Biohub (J.E.P., W.W., C.K.C., E.D.C., J.L.D.), San Francisco; Department of Biochemistry and Biophysics (L.M.K., H.A.S., K.C.Z., J.L.D.), University of California, San Francisco; CIBER Epidemiología y Salud Pública (CIBERESP) (C.L., M.C., C.M.-A.), Health Institute Carlos III; Department of Pediatrics (C.L.), Universitat de Barcelona, Barcelona; Enterovirus Unit (M.C.), Spanish National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain; Division of Infectious Diseases (C.L.), Department of Medicine, University of California, San Francisco; and Department of Medicine. Universitat Internacional de Catalunya (C.M.-A.), Barcelona, Spain
| | - Ryan D Schubert
- From the Medical Scientist Training Program (K.E.L.), University of California, San Francisco; Biomedical Sciences Graduate Program (K.E.L., I.A.H.), University of California, San Francisco; Weill Institute for Neurosciences (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Department of Neurology (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Institut de Recerca Pediàtrica Hospital Sant Joan de Déu (D.C.-A., C.L., A.V.-R., C.M.-A.), Barcelona, Spain; Chan Zuckerberg Biohub (J.E.P., W.W., C.K.C., E.D.C., J.L.D.), San Francisco; Department of Biochemistry and Biophysics (L.M.K., H.A.S., K.C.Z., J.L.D.), University of California, San Francisco; CIBER Epidemiología y Salud Pública (CIBERESP) (C.L., M.C., C.M.-A.), Health Institute Carlos III; Department of Pediatrics (C.L.), Universitat de Barcelona, Barcelona; Enterovirus Unit (M.C.), Spanish National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain; Division of Infectious Diseases (C.L.), Department of Medicine, University of California, San Francisco; and Department of Medicine. Universitat Internacional de Catalunya (C.M.-A.), Barcelona, Spain
| | - Didac Casas-Alba
- From the Medical Scientist Training Program (K.E.L.), University of California, San Francisco; Biomedical Sciences Graduate Program (K.E.L., I.A.H.), University of California, San Francisco; Weill Institute for Neurosciences (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Department of Neurology (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Institut de Recerca Pediàtrica Hospital Sant Joan de Déu (D.C.-A., C.L., A.V.-R., C.M.-A.), Barcelona, Spain; Chan Zuckerberg Biohub (J.E.P., W.W., C.K.C., E.D.C., J.L.D.), San Francisco; Department of Biochemistry and Biophysics (L.M.K., H.A.S., K.C.Z., J.L.D.), University of California, San Francisco; CIBER Epidemiología y Salud Pública (CIBERESP) (C.L., M.C., C.M.-A.), Health Institute Carlos III; Department of Pediatrics (C.L.), Universitat de Barcelona, Barcelona; Enterovirus Unit (M.C.), Spanish National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain; Division of Infectious Diseases (C.L.), Department of Medicine, University of California, San Francisco; and Department of Medicine. Universitat Internacional de Catalunya (C.M.-A.), Barcelona, Spain
| | - Isobel A Hawes
- From the Medical Scientist Training Program (K.E.L.), University of California, San Francisco; Biomedical Sciences Graduate Program (K.E.L., I.A.H.), University of California, San Francisco; Weill Institute for Neurosciences (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Department of Neurology (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Institut de Recerca Pediàtrica Hospital Sant Joan de Déu (D.C.-A., C.L., A.V.-R., C.M.-A.), Barcelona, Spain; Chan Zuckerberg Biohub (J.E.P., W.W., C.K.C., E.D.C., J.L.D.), San Francisco; Department of Biochemistry and Biophysics (L.M.K., H.A.S., K.C.Z., J.L.D.), University of California, San Francisco; CIBER Epidemiología y Salud Pública (CIBERESP) (C.L., M.C., C.M.-A.), Health Institute Carlos III; Department of Pediatrics (C.L.), Universitat de Barcelona, Barcelona; Enterovirus Unit (M.C.), Spanish National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain; Division of Infectious Diseases (C.L.), Department of Medicine, University of California, San Francisco; and Department of Medicine. Universitat Internacional de Catalunya (C.M.-A.), Barcelona, Spain
| | - Prashanth S Ramachandran
- From the Medical Scientist Training Program (K.E.L.), University of California, San Francisco; Biomedical Sciences Graduate Program (K.E.L., I.A.H.), University of California, San Francisco; Weill Institute for Neurosciences (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Department of Neurology (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Institut de Recerca Pediàtrica Hospital Sant Joan de Déu (D.C.-A., C.L., A.V.-R., C.M.-A.), Barcelona, Spain; Chan Zuckerberg Biohub (J.E.P., W.W., C.K.C., E.D.C., J.L.D.), San Francisco; Department of Biochemistry and Biophysics (L.M.K., H.A.S., K.C.Z., J.L.D.), University of California, San Francisco; CIBER Epidemiología y Salud Pública (CIBERESP) (C.L., M.C., C.M.-A.), Health Institute Carlos III; Department of Pediatrics (C.L.), Universitat de Barcelona, Barcelona; Enterovirus Unit (M.C.), Spanish National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain; Division of Infectious Diseases (C.L.), Department of Medicine, University of California, San Francisco; and Department of Medicine. Universitat Internacional de Catalunya (C.M.-A.), Barcelona, Spain
| | - Akshaya Ramesh
- From the Medical Scientist Training Program (K.E.L.), University of California, San Francisco; Biomedical Sciences Graduate Program (K.E.L., I.A.H.), University of California, San Francisco; Weill Institute for Neurosciences (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Department of Neurology (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Institut de Recerca Pediàtrica Hospital Sant Joan de Déu (D.C.-A., C.L., A.V.-R., C.M.-A.), Barcelona, Spain; Chan Zuckerberg Biohub (J.E.P., W.W., C.K.C., E.D.C., J.L.D.), San Francisco; Department of Biochemistry and Biophysics (L.M.K., H.A.S., K.C.Z., J.L.D.), University of California, San Francisco; CIBER Epidemiología y Salud Pública (CIBERESP) (C.L., M.C., C.M.-A.), Health Institute Carlos III; Department of Pediatrics (C.L.), Universitat de Barcelona, Barcelona; Enterovirus Unit (M.C.), Spanish National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain; Division of Infectious Diseases (C.L.), Department of Medicine, University of California, San Francisco; and Department of Medicine. Universitat Internacional de Catalunya (C.M.-A.), Barcelona, Spain
| | - John E Pak
- From the Medical Scientist Training Program (K.E.L.), University of California, San Francisco; Biomedical Sciences Graduate Program (K.E.L., I.A.H.), University of California, San Francisco; Weill Institute for Neurosciences (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Department of Neurology (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Institut de Recerca Pediàtrica Hospital Sant Joan de Déu (D.C.-A., C.L., A.V.-R., C.M.-A.), Barcelona, Spain; Chan Zuckerberg Biohub (J.E.P., W.W., C.K.C., E.D.C., J.L.D.), San Francisco; Department of Biochemistry and Biophysics (L.M.K., H.A.S., K.C.Z., J.L.D.), University of California, San Francisco; CIBER Epidemiología y Salud Pública (CIBERESP) (C.L., M.C., C.M.-A.), Health Institute Carlos III; Department of Pediatrics (C.L.), Universitat de Barcelona, Barcelona; Enterovirus Unit (M.C.), Spanish National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain; Division of Infectious Diseases (C.L.), Department of Medicine, University of California, San Francisco; and Department of Medicine. Universitat Internacional de Catalunya (C.M.-A.), Barcelona, Spain
| | - Wesley Wu
- From the Medical Scientist Training Program (K.E.L.), University of California, San Francisco; Biomedical Sciences Graduate Program (K.E.L., I.A.H.), University of California, San Francisco; Weill Institute for Neurosciences (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Department of Neurology (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Institut de Recerca Pediàtrica Hospital Sant Joan de Déu (D.C.-A., C.L., A.V.-R., C.M.-A.), Barcelona, Spain; Chan Zuckerberg Biohub (J.E.P., W.W., C.K.C., E.D.C., J.L.D.), San Francisco; Department of Biochemistry and Biophysics (L.M.K., H.A.S., K.C.Z., J.L.D.), University of California, San Francisco; CIBER Epidemiología y Salud Pública (CIBERESP) (C.L., M.C., C.M.-A.), Health Institute Carlos III; Department of Pediatrics (C.L.), Universitat de Barcelona, Barcelona; Enterovirus Unit (M.C.), Spanish National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain; Division of Infectious Diseases (C.L.), Department of Medicine, University of California, San Francisco; and Department of Medicine. Universitat Internacional de Catalunya (C.M.-A.), Barcelona, Spain
| | - Carly K Cheung
- From the Medical Scientist Training Program (K.E.L.), University of California, San Francisco; Biomedical Sciences Graduate Program (K.E.L., I.A.H.), University of California, San Francisco; Weill Institute for Neurosciences (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Department of Neurology (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Institut de Recerca Pediàtrica Hospital Sant Joan de Déu (D.C.-A., C.L., A.V.-R., C.M.-A.), Barcelona, Spain; Chan Zuckerberg Biohub (J.E.P., W.W., C.K.C., E.D.C., J.L.D.), San Francisco; Department of Biochemistry and Biophysics (L.M.K., H.A.S., K.C.Z., J.L.D.), University of California, San Francisco; CIBER Epidemiología y Salud Pública (CIBERESP) (C.L., M.C., C.M.-A.), Health Institute Carlos III; Department of Pediatrics (C.L.), Universitat de Barcelona, Barcelona; Enterovirus Unit (M.C.), Spanish National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain; Division of Infectious Diseases (C.L.), Department of Medicine, University of California, San Francisco; and Department of Medicine. Universitat Internacional de Catalunya (C.M.-A.), Barcelona, Spain
| | - Emily D Crawford
- From the Medical Scientist Training Program (K.E.L.), University of California, San Francisco; Biomedical Sciences Graduate Program (K.E.L., I.A.H.), University of California, San Francisco; Weill Institute for Neurosciences (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Department of Neurology (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Institut de Recerca Pediàtrica Hospital Sant Joan de Déu (D.C.-A., C.L., A.V.-R., C.M.-A.), Barcelona, Spain; Chan Zuckerberg Biohub (J.E.P., W.W., C.K.C., E.D.C., J.L.D.), San Francisco; Department of Biochemistry and Biophysics (L.M.K., H.A.S., K.C.Z., J.L.D.), University of California, San Francisco; CIBER Epidemiología y Salud Pública (CIBERESP) (C.L., M.C., C.M.-A.), Health Institute Carlos III; Department of Pediatrics (C.L.), Universitat de Barcelona, Barcelona; Enterovirus Unit (M.C.), Spanish National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain; Division of Infectious Diseases (C.L.), Department of Medicine, University of California, San Francisco; and Department of Medicine. Universitat Internacional de Catalunya (C.M.-A.), Barcelona, Spain
| | - Lillian M Khan
- From the Medical Scientist Training Program (K.E.L.), University of California, San Francisco; Biomedical Sciences Graduate Program (K.E.L., I.A.H.), University of California, San Francisco; Weill Institute for Neurosciences (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Department of Neurology (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Institut de Recerca Pediàtrica Hospital Sant Joan de Déu (D.C.-A., C.L., A.V.-R., C.M.-A.), Barcelona, Spain; Chan Zuckerberg Biohub (J.E.P., W.W., C.K.C., E.D.C., J.L.D.), San Francisco; Department of Biochemistry and Biophysics (L.M.K., H.A.S., K.C.Z., J.L.D.), University of California, San Francisco; CIBER Epidemiología y Salud Pública (CIBERESP) (C.L., M.C., C.M.-A.), Health Institute Carlos III; Department of Pediatrics (C.L.), Universitat de Barcelona, Barcelona; Enterovirus Unit (M.C.), Spanish National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain; Division of Infectious Diseases (C.L.), Department of Medicine, University of California, San Francisco; and Department of Medicine. Universitat Internacional de Catalunya (C.M.-A.), Barcelona, Spain
| | - Cristian Launes
- From the Medical Scientist Training Program (K.E.L.), University of California, San Francisco; Biomedical Sciences Graduate Program (K.E.L., I.A.H.), University of California, San Francisco; Weill Institute for Neurosciences (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Department of Neurology (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Institut de Recerca Pediàtrica Hospital Sant Joan de Déu (D.C.-A., C.L., A.V.-R., C.M.-A.), Barcelona, Spain; Chan Zuckerberg Biohub (J.E.P., W.W., C.K.C., E.D.C., J.L.D.), San Francisco; Department of Biochemistry and Biophysics (L.M.K., H.A.S., K.C.Z., J.L.D.), University of California, San Francisco; CIBER Epidemiología y Salud Pública (CIBERESP) (C.L., M.C., C.M.-A.), Health Institute Carlos III; Department of Pediatrics (C.L.), Universitat de Barcelona, Barcelona; Enterovirus Unit (M.C.), Spanish National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain; Division of Infectious Diseases (C.L.), Department of Medicine, University of California, San Francisco; and Department of Medicine. Universitat Internacional de Catalunya (C.M.-A.), Barcelona, Spain
| | - Hannah A Sample
- From the Medical Scientist Training Program (K.E.L.), University of California, San Francisco; Biomedical Sciences Graduate Program (K.E.L., I.A.H.), University of California, San Francisco; Weill Institute for Neurosciences (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Department of Neurology (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Institut de Recerca Pediàtrica Hospital Sant Joan de Déu (D.C.-A., C.L., A.V.-R., C.M.-A.), Barcelona, Spain; Chan Zuckerberg Biohub (J.E.P., W.W., C.K.C., E.D.C., J.L.D.), San Francisco; Department of Biochemistry and Biophysics (L.M.K., H.A.S., K.C.Z., J.L.D.), University of California, San Francisco; CIBER Epidemiología y Salud Pública (CIBERESP) (C.L., M.C., C.M.-A.), Health Institute Carlos III; Department of Pediatrics (C.L.), Universitat de Barcelona, Barcelona; Enterovirus Unit (M.C.), Spanish National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain; Division of Infectious Diseases (C.L.), Department of Medicine, University of California, San Francisco; and Department of Medicine. Universitat Internacional de Catalunya (C.M.-A.), Barcelona, Spain
| | - Kelsey C Zorn
- From the Medical Scientist Training Program (K.E.L.), University of California, San Francisco; Biomedical Sciences Graduate Program (K.E.L., I.A.H.), University of California, San Francisco; Weill Institute for Neurosciences (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Department of Neurology (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Institut de Recerca Pediàtrica Hospital Sant Joan de Déu (D.C.-A., C.L., A.V.-R., C.M.-A.), Barcelona, Spain; Chan Zuckerberg Biohub (J.E.P., W.W., C.K.C., E.D.C., J.L.D.), San Francisco; Department of Biochemistry and Biophysics (L.M.K., H.A.S., K.C.Z., J.L.D.), University of California, San Francisco; CIBER Epidemiología y Salud Pública (CIBERESP) (C.L., M.C., C.M.-A.), Health Institute Carlos III; Department of Pediatrics (C.L.), Universitat de Barcelona, Barcelona; Enterovirus Unit (M.C.), Spanish National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain; Division of Infectious Diseases (C.L.), Department of Medicine, University of California, San Francisco; and Department of Medicine. Universitat Internacional de Catalunya (C.M.-A.), Barcelona, Spain
| | - Maria Cabrerizo
- From the Medical Scientist Training Program (K.E.L.), University of California, San Francisco; Biomedical Sciences Graduate Program (K.E.L., I.A.H.), University of California, San Francisco; Weill Institute for Neurosciences (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Department of Neurology (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Institut de Recerca Pediàtrica Hospital Sant Joan de Déu (D.C.-A., C.L., A.V.-R., C.M.-A.), Barcelona, Spain; Chan Zuckerberg Biohub (J.E.P., W.W., C.K.C., E.D.C., J.L.D.), San Francisco; Department of Biochemistry and Biophysics (L.M.K., H.A.S., K.C.Z., J.L.D.), University of California, San Francisco; CIBER Epidemiología y Salud Pública (CIBERESP) (C.L., M.C., C.M.-A.), Health Institute Carlos III; Department of Pediatrics (C.L.), Universitat de Barcelona, Barcelona; Enterovirus Unit (M.C.), Spanish National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain; Division of Infectious Diseases (C.L.), Department of Medicine, University of California, San Francisco; and Department of Medicine. Universitat Internacional de Catalunya (C.M.-A.), Barcelona, Spain
| | - Ana Valero-Rello
- From the Medical Scientist Training Program (K.E.L.), University of California, San Francisco; Biomedical Sciences Graduate Program (K.E.L., I.A.H.), University of California, San Francisco; Weill Institute for Neurosciences (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Department of Neurology (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Institut de Recerca Pediàtrica Hospital Sant Joan de Déu (D.C.-A., C.L., A.V.-R., C.M.-A.), Barcelona, Spain; Chan Zuckerberg Biohub (J.E.P., W.W., C.K.C., E.D.C., J.L.D.), San Francisco; Department of Biochemistry and Biophysics (L.M.K., H.A.S., K.C.Z., J.L.D.), University of California, San Francisco; CIBER Epidemiología y Salud Pública (CIBERESP) (C.L., M.C., C.M.-A.), Health Institute Carlos III; Department of Pediatrics (C.L.), Universitat de Barcelona, Barcelona; Enterovirus Unit (M.C.), Spanish National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain; Division of Infectious Diseases (C.L.), Department of Medicine, University of California, San Francisco; and Department of Medicine. Universitat Internacional de Catalunya (C.M.-A.), Barcelona, Spain
| | - Charles Langelier
- From the Medical Scientist Training Program (K.E.L.), University of California, San Francisco; Biomedical Sciences Graduate Program (K.E.L., I.A.H.), University of California, San Francisco; Weill Institute for Neurosciences (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Department of Neurology (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Institut de Recerca Pediàtrica Hospital Sant Joan de Déu (D.C.-A., C.L., A.V.-R., C.M.-A.), Barcelona, Spain; Chan Zuckerberg Biohub (J.E.P., W.W., C.K.C., E.D.C., J.L.D.), San Francisco; Department of Biochemistry and Biophysics (L.M.K., H.A.S., K.C.Z., J.L.D.), University of California, San Francisco; CIBER Epidemiología y Salud Pública (CIBERESP) (C.L., M.C., C.M.-A.), Health Institute Carlos III; Department of Pediatrics (C.L.), Universitat de Barcelona, Barcelona; Enterovirus Unit (M.C.), Spanish National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain; Division of Infectious Diseases (C.L.), Department of Medicine, University of California, San Francisco; and Department of Medicine. Universitat Internacional de Catalunya (C.M.-A.), Barcelona, Spain
| | - Carmen Muñoz-Almagro
- From the Medical Scientist Training Program (K.E.L.), University of California, San Francisco; Biomedical Sciences Graduate Program (K.E.L., I.A.H.), University of California, San Francisco; Weill Institute for Neurosciences (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Department of Neurology (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Institut de Recerca Pediàtrica Hospital Sant Joan de Déu (D.C.-A., C.L., A.V.-R., C.M.-A.), Barcelona, Spain; Chan Zuckerberg Biohub (J.E.P., W.W., C.K.C., E.D.C., J.L.D.), San Francisco; Department of Biochemistry and Biophysics (L.M.K., H.A.S., K.C.Z., J.L.D.), University of California, San Francisco; CIBER Epidemiología y Salud Pública (CIBERESP) (C.L., M.C., C.M.-A.), Health Institute Carlos III; Department of Pediatrics (C.L.), Universitat de Barcelona, Barcelona; Enterovirus Unit (M.C.), Spanish National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain; Division of Infectious Diseases (C.L.), Department of Medicine, University of California, San Francisco; and Department of Medicine. Universitat Internacional de Catalunya (C.M.-A.), Barcelona, Spain
| | - Joseph L DeRisi
- From the Medical Scientist Training Program (K.E.L.), University of California, San Francisco; Biomedical Sciences Graduate Program (K.E.L., I.A.H.), University of California, San Francisco; Weill Institute for Neurosciences (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Department of Neurology (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Institut de Recerca Pediàtrica Hospital Sant Joan de Déu (D.C.-A., C.L., A.V.-R., C.M.-A.), Barcelona, Spain; Chan Zuckerberg Biohub (J.E.P., W.W., C.K.C., E.D.C., J.L.D.), San Francisco; Department of Biochemistry and Biophysics (L.M.K., H.A.S., K.C.Z., J.L.D.), University of California, San Francisco; CIBER Epidemiología y Salud Pública (CIBERESP) (C.L., M.C., C.M.-A.), Health Institute Carlos III; Department of Pediatrics (C.L.), Universitat de Barcelona, Barcelona; Enterovirus Unit (M.C.), Spanish National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain; Division of Infectious Diseases (C.L.), Department of Medicine, University of California, San Francisco; and Department of Medicine. Universitat Internacional de Catalunya (C.M.-A.), Barcelona, Spain
| | - Michael R Wilson
- From the Medical Scientist Training Program (K.E.L.), University of California, San Francisco; Biomedical Sciences Graduate Program (K.E.L., I.A.H.), University of California, San Francisco; Weill Institute for Neurosciences (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Department of Neurology (R.D.S., I.A.H., P.S.R., A.R., M.R.W.), University of California, San Francisco; Institut de Recerca Pediàtrica Hospital Sant Joan de Déu (D.C.-A., C.L., A.V.-R., C.M.-A.), Barcelona, Spain; Chan Zuckerberg Biohub (J.E.P., W.W., C.K.C., E.D.C., J.L.D.), San Francisco; Department of Biochemistry and Biophysics (L.M.K., H.A.S., K.C.Z., J.L.D.), University of California, San Francisco; CIBER Epidemiología y Salud Pública (CIBERESP) (C.L., M.C., C.M.-A.), Health Institute Carlos III; Department of Pediatrics (C.L.), Universitat de Barcelona, Barcelona; Enterovirus Unit (M.C.), Spanish National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain; Division of Infectious Diseases (C.L.), Department of Medicine, University of California, San Francisco; and Department of Medicine. Universitat Internacional de Catalunya (C.M.-A.), Barcelona, Spain.
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