Fetal, neonatal, and infant outcomes associated with maternal Zika virus infection during pregnancy: A systematic review and meta-analysis

The occurrence of fetal and neonatal disorders in pregnant women with Zika virus infection in the literature is not consistent. This study aims to estimate the prevalence rate of these disorders in fetuses/neonates of pregnant women with confirmed or probable infection by Zika virus. A systematic review with meta-analysis was conducted in November 2020. Cohort studies that contained primary data on the prevalence of unfavorable outcomes in fetuses or neonates of women with confirmed or probable Zika virus infection during pregnancy were included. A total of 21 cohort studies were included, with a total of 35,568 pregnant women. The meta-analysis showed that central nervous system abnormalities had the highest prevalence ratio of 0.06 (95% CI 0.03-0.09). Intracranial calcifications had a prevalence ratio of 0.01 (95% CI 0.01-0.02), and ventriculomegaly 0.01 (95% CI 0.01-0.02). The prevalence ratio of microcephaly was 0.03 (95% CI 0.02-0.05), fetal loss (miscarriage and stillbirth) was 0.04 (95% CI 0.02-0.06), Small for Gestational Age was 0.04 (95% CI 0.00-0,09), Low Birth Weight was 0.05 (95% CI 0.03-0.08) and Prematurity was 0.07 (95% CI 0.04-0.10). The positivity in RT-PCR for ZIKV performed in neonates born to infected mothers during pregnancy was 0.25 (95% CI 0.06-0.44). We also performed the meta-analysis of meta-analysis for microcephaly with the prevalence ratios from other two previously systematic reviews: 0.03 (95% CI 0.00-0.25). Our results contribute to measuring the impact of Zika virus infection during pregnancy on children's health. The continuous knowledge of this magnitude is essential for the implementation development of health initiatives and programs, in addition to promoting disease prevention, especially in the development of a vaccine for Zika virus. PROSPERO protocol registration: http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42019125543.

Hydrocephalus and arthrogryposis in an immunocompetent mouse model of ZIKA teratogeny: A developmental study

The teratogenic mechanisms triggered by ZIKV are still obscure due to the lack of a suitable animal model. Here we present a mouse model of developmental disruption induced by ZIKV hematogenic infection. The model utilizes immunocompetent animals from wild-type FVB/NJ and C57BL/6J strains, providing a better analogy to the human condition than approaches involving immunodeficient, genetically modified animals, or direct ZIKV injection into the brain. When injected via the jugular vein into the blood of pregnant females harboring conceptuses from early gastrulation to organogenesis stages, akin to the human second and fifth week of pregnancy, ZIKV infects maternal tissues, placentas and embryos/fetuses. Early exposure to ZIKV at developmental day 5 (second week in humans) produced complex manifestations of anterior and posterior dysraphia and hydrocephalus, as well as severe malformations and delayed development in 10.5 days post-coitum (dpc) embryos. Exposure to the virus at 7.5-9.5 dpc induces intra-amniotic hemorrhage, widespread edema, and vascular rarefaction, often prominent in the cephalic region. At these stages, most affected embryos/fetuses displayed gross malformations and/or intrauterine growth restriction (IUGR), rather than isolated microcephaly. Disrupted conceptuses failed to achieve normal developmental landmarks and died in utero. Importantly, this is the only model so far to display dysraphia and hydrocephalus, the harbinger of microcephaly in humans, as well as arthrogryposis, a set of abnormal joint postures observed in the human setting. Late exposure to ZIKV at 12.5 dpc failed to produce noticeable malformations. We have thus characterized a developmental window of opportunity for ZIKV-induced teratogenesis encompassing early gastrulation, neurulation and early organogenesis stages. This should not, however, be interpreted as evidence for any safe developmental windows for ZIKV exposure. Late developmental abnormalities correlated with damage to the placenta, particularly to the labyrinthine layer, suggesting that circulatory changes are integral to the altered phenotypes.

Cerebrospinal fluid shunt malfunction not associated with ventricular enlargement. A case report and literature review

Substantiation of the shunt failure diagnosis and subsequent consideration of indications for surgical elimination of the malfunction is a laborious and challenging process. Identification of a malfunction in doubtful cases requires, in addition to standard examinations, extra diagnostic procedures, which may delay making a decision for several weeks to several months. The article describes a case of mechanical CSF shunt malfunction (breakage and failure of a peritoneal catheter in a 7-year-old girl) with intracranial hypertension symptoms, but without typical enlargement of the brain ventricles. According to the medical history, congenital hydrocephalus in the child was accompanied by an inflammatory process of bacterial and viral etiology. The absence of brain ventricle enlargement was shown not to exclude a probability of shunt malfunction. In this case, a specific phenomenon, an intraparenchymatous cerebrospinal fluid "lake" surrounding a ventricular catheter, was observed. Shunting recovery did not lead to a significant reduction in the phenomenon size. Causes underlying this phenomenon require further investigation.

[Congenital cytomegaly in one twin - a case report]

A report on dichorionic/diamniotic pregnancy in which only one, female, fetus was infected with cytomegalovirus and presented with severe congenital diseases at birth. Infection of the fetus occurred after recurrent maternal infection. The second, male, fetus did not have CMV infection. The cesarean section was performed at the 38th week of gestation. The birth weight of the infected girl was 1680g, the main symptoms, beside dystrophy, concerned the central nervous system: microcephaly, brain atrophy, hydrocephalus, corpus callosum agenesis. She also had Turner syndrome symptoms. The viral load was highest in the urine 81.2 x10^6/ml, in the cerebro-spinal fluid 15.4x10^6/ml and lower in blood 0.38 x10^5/ml. The concentration of specific IgG was 308 U/ml. Specific IgM was not detected. Throughout hospitalization, the infection maintained only one viral genotype gB2. Despite treatment with ganciclovir (10 weeks) and foscarnet (2 weeks), the girl died at the age of 8 months. Novel molecular diagnostic techniques (nested and real time PCR) confirmed the congenital infection and were helpful in the monitoring of the infection and treatment efficacy.

[Late consequences of hemorrhagic fever with renal syndrome in a woman who had it during pregnancy]

The authors adduce a brief description of the features and outcomes of hemorrhagic fever with renal syndrome (HFRS) in 8 pregnant women. The results of the examination of a 54-year-old woman and her son, who suffered from a severe form of HERS 28 years ago during the 31st week of pregnancy, are presented in detail. Antibodies to Hantaan virus 1:32 were found; magnetic resonance tomography of the skull revealed sequelae of hypophysial hemorrhage with the formation of "partly empty ephippium". The antibodies were not found in the son; hydrocephalus, forehead cortex atrophy, and lateral ventricular asymmetry were revealed.

Lymphocytic choriomeningitis virus: emerging fetal teratogen

Lymphocytic choriomeningitis virus (LCMV), a rodent-borne arenavirus, is an often undiagnosed human fetal teratogen. We describe a neonate born with hydrocephalus and chorioretinitis after maternal second-trimester symptomatic LCMV infection. Previously reported affected infants are reviewed. We strongly suggest that obstetricians counsel their pregnant patients regarding the potential hazard that contact with infected pet, laboratory, and household mice and hamsters poses to pregnant women and their unborn children.

Lymphocytic choriomeningitis virus: an underdiagnosed cause of congenital chorioretinitis

PURPOSE

To elucidate the role and clinical spectrum of congenital lymphocytic choriomeningitis virus infection as a cause of chorioretinopathy, congenital hydrocephalus, and macrocephaly or microcephaly in the United States.

METHODS

We performed complete ophthalmologic surveys of all residents at Misericordia, a home for the severely mentally retarded in Chicago, and prospectively evaluated all patients with chorioretinitis or chorioretinal scars during a 36-month period at Children's Memorial Hospital, also located in Chicago. Sera for patients demonstrating chorioretinal scars (a sign of intrauterine infection) were tested for Toxoplasma gondii, rubella virus, cytomegalovirus, and herpes simplex virus and lymphocytic choriomeningitis virus antibodies.

RESULTS

Four of 95 patients examined at the home had chorioretinal scars, and two of these patients had normal T. gondii, rubella virus, cytomegalovirus, and herpes simplex virus titers and dramatically elevated titers for lymphocytic choriomeningitis virus. Three of 14 cases of chorioretinitis at the hospital had normal T. gondii, rubella virus, cytomegalovirus, and herpes sim-plex virus titers and elevated lymphocytic choriomeningitis virus antibody titers. (A fourth case, diagnosed in 1996, was reported 2 years ago.)

CONCLUSIONS

Lymphocytic choriomeningitis virus was responsible for visual loss in two of four children secondary to chorioretinitis in a population of severely retarded children. The six new cases of lymphocytic choriomeningitis virus chorioretinitis identified in these two populations over the last 3 years, compared with the total number ever reported in the United States (10 cases), suggests that lymphocytic choriomeningitis virus may be a more common cause of congenital chorioretinitis than previously believed. Because its consequences for visual and psychomotor development are devastating, we conclude that the workup for congenital chorioretinitis should include lymphocytic choriomeningitis virus serology, especially if T. gondii, rubella virus, cytomegalovirus, and herpes simplex virus titers are negative.

Hydrocephalus: a fatal late consequence of mumps encephalitis

Common and usually self-limited diseases may occasionally have fatal consequences. Hydrocephalus is a very rare complication of mumps, with just a few cases reported in the literature. Here we report a fatal case of hydrocephalus presenting 19 years after mumps encephalitis. The long latency period between encephalitis and hydrocephalus-associated symptoms makes this case particularly interesting.

Experimental mumps virus-induced hydrocephalus: viral neurotropism and neuronal maturity

In order to elucidate the relationship between virus neurotropism and neuronal maturity, two experiments were performed. First, mumps virus infectivity was compared among the different developmental stages of hamster brains inoculated with mumps virus by examining the immunohistochemical distribution of mumps virus antigen. Second, brain lesions resulting from mumps virus infection during the period of neuronal migration were histologically and ultrastructurally analyzed. Three groups of Syrian hamsters, Group E12 (fetuses on the 12th day of gestation), and Groups P2 and P30 (2 and 30 days old, respectively), were injected with mumps virus intraplacentally or intracerebrally. In Group P30, mumps virus antigen was observed specifically in ependymal cells and the choroid plexus. In addition to these areas, in Group P2, some neurons in layers II and III of the cerebral cortex also showed virus antigen immunoreactivity. In Group E12, mumps virus antigen accumulated primarily in the neuroepithelial cells within the ventricular zone. Neither specific intranuclear changes related to viral replication nor the formation of complete virions and nucleocapsids was observed. We conclude that mumps virus neurotropism to hamster brains is dependent on the degree of neuronal maturity and that mumps virus can induce an abortive infection and resultant neuronal cell necrosis in the immature developing hamster brain.

[Meningo-encephalitis and hydrocephalus caused by Epstein-Barr virus]

In a 35-year-old woman who presented with acute somnolence, confusion and slow irregular breathing, Epstein-Barr virus (EBV) meningoencephalitis was diagnosed after serological testing and a polymerase chain reaction of the cerebrospinal fluid. She developed papilloedema and bilateral nervus abducens paresis. A CT scan showed generalized oedema of the brain and triventricular hydrocephalus. Treatment with a ventriculoperitoneal shunt and ganciclovir led to complete recovery. Meningoencephalitis is a not uncommon, yet rarely reported complication of infectious mononucleosis. It usually runs a mild course with spontaneous and full recovery. Hydrocephalus secondary to aqueduct stenosis is a complication of Epstein-Barr virus (EBV) meningoencephalitis which has not been reported in adults before. The disease should be considered whenever the clinical condition deteriorates or neurological symptoms increase.

Hydrocephalus in mice infected with a Theiler's murine encephalomyelitis virus variant

The etiology of hydrocephalus is never established in the majority of clinical cases, while various agents, nutritional deficiencies, and genetic factors have been shown to play a role. Viral infection has been recognized as one of the causative factors in the development of hydrocephalus. The wild-type DA strain of Theiler's murine encephalomyelitis virus (TMEV), which belongs to the family Picornaviridae, causes a chronic demyelinating disease in mice with viral persistence that resembles multiple sclerosis. We found that a DA virus variant, hydrocephalus 101 virus (H101 virus), caused hydrocephalus in mice, a condition previously never described for TMEV. To clarify the relationship between DA virus infection and hydrocephalus, we compared H101 virus and wild-type DA virus infection in mice. Using immunohistochemistry and terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick-end labeling (TUNEL), we found that during the acute phase of infection, H101 virus caused macrocephaly and meningitis with the presence of apoptosis, while parenchymal involvement was not evident. In contrast, wild-type DA virus caused an acute polioencephalomyelitis with parenchymal infection and apoptosis. During the chronic phase, H101 virus infection caused communicating hydrocephalus without viral persistence. No demyelination and little or no anti-TMEV antibodies were observed in H101 virus-infected mice. Sequence analysis revealed that H101 virus had mutations in the 5'UTR and capsid protein coding region. Characterization of this new hydrocephalus model gives insight into the possible viral involvement in human hydrocephalus cases of obscure etiology.

Age-dependent susceptibility in mumps-associated hydrocephalus: neuropathologic features and brain barriers

Central nervous system susceptibility to viral infection is often age dependent for unclear reasons. In this study, we examined the age-dependent susceptibility of the brain in mumps virus-induced hydrocephalus in hamsters, and evaluated the relationship between neuropathologic features and brain barriers using glial fibrillary acidic protein and zonula occludentes 1 (ZO-1) immunohistochemistry. In a group intracerebrally inoculated with mumps virus at 2 days of age, pathologic findings such as periventricular edema, ependymal cell loss, and ventricular dilation were more prominent and the distribution of mumps virus antigen was wider than in a group inoculated at 30 days of age. ZO-1-immunoreactive tight junctions in the hydrocephalic brains of the 2-day group were severely damaged in the choroid plexus and ependyma, and in white matter capillaries as early as 3 days after inoculation. These changes were not apparent in the hydrocephalic brains of the 30-day group. Prominent cortical dissemination of virus in the 2-day group was related to underdeveloped perivascular glial foot processes in brain parenchyma. Periventricular edema in the 2-day group was linked to ependymal and blood-brain barrier tight-junction permeability. Our results suggest that tight junctions in the early postnatal period are more immature and fragile than in the adult. We concluded that brain susceptibility in mumps virus-induced hydrocephalus is intimately related to the maturity of brain barriers.

Ovine fetal malformations induced by in utero inoculation with Main Drain, San Angelo, and LaCrosse viruses

The teratogenic potential of three bunyaviruses, two California serogroup bunyaviruses, LaCrosse virus and San Angelo virus, and a Bunyamwera serogroup member, Main Drain virus, in sheep was studied following in utero inoculation of ewes in early gestation. Although Main Drain virus appeared to be most teratogenic, all three viruses induced a range of lesions including arthrogryposis, hydrocephalus, fetal death, axial skeletal deviations, anasarca, and oligohydramnios. The teratogenic effects of these viruses are identical to those described in ovine infections by Cache Valley and Akabane viruses. Demonstration of a common bunyaviral tropism for fetal tissue infection that results in congenital brain and musculoskeletal malformations provides evidence that human in utero infection by bunyaviruses could result in similar malformations in human infants.

Unusual manifestations of postnatally acquired cytomegalovirus infection: findings on CT and MR

An infant with unusual CT and MRI manifestations of postnatally acquired cytomegalovirus (CMV) infection is presented. The child exhibited extensive inflammatory lesions in the periventricular area and at the level of the quadrigeminal plate with the formation of a pseudotumour at this level. The latter produced aqueduct obstruction resulting in hydrocephalus. These findings have not previously been described in the literature.

An association between fetal parvovirus B19 infection and fetal anomalies: a report of two cases

The association between fetal parvovirus B19 infection and hydrops was first reported in 1984. The virus has a predilection for the erythroid cell line, which in the fetus may produce anemia. Recent cases of parvovirus infection in other fetal cell lines have raised concern that the infection may induce fetal anomalies in rare cases. We report two pregnancies complicated by parvovirus B19 infection. In each instance the patient had normal second trimester ultrasounds but subsequently developed fetal abnormalities--disruptions of normal structure. One infant has myocardial infarction, splenic calcifications, and mild hydrocephalus. The other had moderate hydrocephalus with central nervous system scarring. There are two possible mechanisms in which parvovirus may induce fetal anomalies. Both direct infection of fetal organs and vascular inflammation have been documented in association with B19 parvovirus. Although fetal abnormalities associated with parvovirus are rare, continued study of this organism may indicate a greater pathologic potential than is now thought.

Hydrocephalus induction in mice infected with herpes simplex virus type 2 after antiviral treatment

By using antiviral chemotherapy to moderate the lethal effect of wild-type herpes simplex virus type 2 (HSV-2), a new mouse model for herpes simplex virus (HSV)-induced hydrocephalus was developed. Groups of BALB/c mice were infected either intracerebrally (i.c.) or intraperitoneally (i.p.) with a lethal dose of HSV-2. The antiviral agent 2'-fluoro-5-methylarabinosyluracil (FMAU) was administered i.p. 2 days after virus inoculation. By day 21, 80 and 71.4% of the mice infected i.c. or i.p., respectively, survived. The surviving animals were randomly subdivided into different groups and some were challenged i.c. or i.p. with a lethal or superlethal dose of homologous virus. The mice were sacrificed at 2 or 3 months after the initial virus infection. Neuropathological changes of the brains were assessed. Dilation of lateral and third ventricles was noted in the animals initially inoculated i.c., especially in all the animals inoculated i.c. and challenged i.c. with a superlethal virus inoculum, but not in those inoculated i.p. Microscopic examination of hydrocephalic brains revealed evidence of viral meningoencephalitis. Two different mechanisms of ventricular enlargement in this animal model are proposed. This model is relevant since HSV-induced cases of hydrocephalus have been reported to occur in humans and in particular neonates. Issues of virus persistence and expression, long-term evaluation for disease progression, and intervention strategies could be examined with this model.