Fatal illness associated with pulmonary hypertension in a neonate caused by intrauterine echovirus 11 infection

Nonpolio enterovirus (NPEV) infections are known to cause a wide range of illnesses in the neonatal period. In most cases, NPEV is presumed to be contracted during birth. Intrauterine NPEV infections occur infrequently. A case of intrauterine echovirus 11 infection with pneumonia, persistent pulmonary hypertension of the newborn, and purpura fulminans is presented.

An outbreak of echovirus 13 meningitis in central Israel

Until recently, echovirus 13 has been a very rare cause of aseptic meningitis. We investigated an outbreak of echovirus 13 in central Israel during the summer of 2000 using a prospective case control study and a retrospective study. Echovirus 13 was isolated from 79 cerebrospinal fluid (CSF) specimens from different medical centres in central Israel. Patients' ages ranged from 10 days to 41 years (95% < 15 years, M/F ratio 62/38). A total of 128 patients with clinical aseptic meningitis were admitted to the Department of Pediatrics during the outbreak (aged 10 days to 18 years, mean 5.4 years), and 58 CSF samples were processed for viral cultures. Thirty of them did not grow any virus, 26 samples yielded echovirus 13, and 2 samples echovirus 7. The clinical features of patients with echovirus 13 in the CSF were similar to those in whom no virus was isolated or those infected with other enteroviral strains except for higher rate of fever on admission, and prolonged time with fever following the diagnosis in the echovirus 13 patients. CSF cell count varied from 4 to 2,333 cells/mm3 with polymorphonuclears (PMN) predominant in 90% of our patients. In a case-control study there was no significant difference between patients and matched controls with regard to parameters such as: day care attendance, recreation in summer camp, swimming pools and at the beach, and consumption of tap water. All the patients in our series recovered fully with no neurological abnormalities. The illness caused by echovirus 13 was benign and involved mainly patients younger than 15 year of age. Several features that characterized this outbreak include relatively high WBC in the blood and a minent CSF PMN response.

Echovirus 11 sepsis in a neonate: report of one case

Neonates infected with nonpolio enteroviruses are at high risk for developing significant illness, including sepsis-like illness, meningoencephalitis, myocarditis and/or hepatitis. Echoviruses and group B coxsackieviruses account for the majority of neonatal enterovirus infections. We reported a case of echovirus 11 infection in newborn associated with maternal infection. To our knowledge, this is the first reported fatal case of neonatal echovirus infection in Taiwan. Eventually, the baby expired because of severe sepsis-like illness, fulminant hepatitis, disseminated intravascular coagulation, and extensive hemorrhagic manifestations in spite of intensive care, intravenous immunoglobulin infusion and exchange transfusion.

Echovirus 7 infection and necrotizing enterocolitis-like symptoms in a premature infant

Echovirus type 7 has been previously recognized as a virulent serotype in the premature neonate. However, reports of fatal disseminated infections have often been perinatally acquired from symptomatic mothers at the time of delivery. Nosocomial outbreaks in full-term and premature infants have been reported from newborn intensive care units; however, deaths attributed to Echovirus 7 in convalescing prematures are rare in the literature. We report the case of a growing premature neonate presenting with an overwhelming sepsis-like syndrome, including symptoms consistent with necrotizing enterocolitis. Despite intensive supportive care including ventilatory support, cardiovascular pharmacotherapy, and blood product administration, the infant succumbed to overwhelming Echovirus 7 infection.

[Life-threatening echovirus 11 infection during first month of life]

Infection with Echovirus 11 is mostly asymptomatic, but it may cause a wide variety of clinical diseases, from gastroenteritis to serious diseases such as meningitis and myocarditis. In small infants, especially during the first days of life, echovirus infection may appear as a sepsis-like illness, and cause disseminated intravascular coagulopathy and shock. We present 2 infants with severe Echovirus 11 infections. A 3.5-month-old died within 24 hours of shock and probably myocarditis. The other, 6-days old, presented with meningitis, hepatitis and disseminated intravascular coagulopathy. It recovered after treatment with intravenous immunoglobulin. Echovirus 11 may cause life-threatening infections in small infants. Pediatricians should be alert to the special characteristics of this disease.

[Intrathecal interferon therapy in chronic echovirus meningoencephalitis in Bruton type agammaglobulinemia]

A 9-year-old body with X-linked agammaglobulinemia developed chronic enteroviral meningoencephalitis (CEMA) caused by echovirus type 6. Intravenous treatment with selected immunoglobulin charges containing high titers against echovirus type 6 or combination with beta-interferon did not result in improvement. After implantation of a Rickham reservoir and periodical administration of intraventricular and intravenous immunoglobulin the virus recurred rapidly each time treatment was stopped. After 20 months of treatment the patient received a combined therapy with beta-interferon and selected immunoglobulin. Both drugs were given by lumbar puncture, intravenously and via Rickham reservoir. Subsequently echovirus type 6 could not be isolated in culture or PCR. Cerebrospinal fluid pleocytosis disappeared. The remission is lasting for more than three years. Intrathecal and intraventricular beta-interferon therapy for CEMA is being reported for the first time. Facing the unfavourable prognosis of the disease this mode of treatment is a new therapeutic approach following failure of other therapies.

Septic shock in an elderly patient: unusual presentation of echovirus infection

We have described a case of fulminant echovirus infection that progressed rapidly to purpura and septic shock. To our knowledge, this is a previously unreported presentation of acute echovirus infection in an immunocompetent adult.

Conservative management of an echovirus 11 outbreak in a neonatal unit

Two babies in a neonatal unit presented on the same day with meningitis due to echovirus 11, which was thought to have been introduced by staff. At this time echovirus 11 was also isolated from the stools of eight other babies; five of them did not have signs of infection. No intervention was made except to emphasise the importance of handwashing. There was evidence of secondary spread to two babies who were both clinically well. The attack rate was twelve (29%) of forty-one babies exposed. Seven of the twelve infected babies were born before 30 weeks' gestation and would have had little or no maternal antibody, yet only two of the seven babies had signs of infection. Despite lack of special measures, all babies recovered. Most cases of horizontally acquired neonatal echovirus infection are mild: extreme measures in the management of outbreaks are unnecessary.

Intraventricular gamma-globulin for the management of enterovirus encephalitis

Although bacterial infections predominate in patients with hypogammaglobulinemia, patients who do not produce normal amounts of immunoglobulin also have an increased incidence of viral infections. This is particularly true of infections with enteroviruses. Echovirus encephalitis has been a major problem for patients with hypogammaglobulinemia. Neurologic damage, frequently resulting in death, has been common in such patients. Because there is an obligatory extracellular phase in the cell to cell spread of enteroviruses, therapy with immunoglobulin has been attempted. In certain patients intravenous and intrathecal gammaglobulin has temporarily halted progression of the disease, but no patients have been cured by this approach. In this report we detail treatment of three children with X-linked hypogammaglobulinemia who had encephalitis caused by echovirus infections. Despite doses of intravenous immunoglobulin that maintained the patients' IgG levels within the normal range, their condition deteriorated in all cases. Treatment with intraventricular immunoglobulin was then tried. In all three cases cerebrospinal fluid protein levels and cell counts returned to normal after this treatment and the echoviruses can no longer be isolated from the cerebrospinal fluid. Follow-up time has ranged from 18 months to 4 years. Ommaya reservoirs were placed into the lateral ventricle of each patient and concentrated (6%) immunoglobulin (Sandoglobulin) was injected into the reservoir on a daily basis. On Days 1 through 7 of the regimen patients were given 120, 300, 450, 510, 540 and 600 mg of IgG, respectively. Patients then received 300 mg daily for periods ranging from 1 week to 1 month. Cultures of cerebrospinal fluid removed from the reservoir were repeatedly analyzed to determine the need for further treatment. Clinically the patients improved markedly.(ABSTRACT TRUNCATED AT 250 WORDS)

Uses of immune globulins in the prophylaxis and treatment of viral infections

Immune globulin preparations clearly provide safe and effective passive prophylaxis in a variety of viral infections: hepatitis A, hepatitis B, primary varicella zoster, measles, rubella, and rabies. When available, specific preparations (HBIG, VZIG, RIG) should be used. The use of CMVIG remains controversial at this time. Only recently have immunoglobulins been used for therapy of viral infections; however, their use in Kawasaki disease, AIDS, and echovirus in patients with hypogammaglobulinemia appears promising.

Successful treatment of echovirus meningoencephalitis in sex-linked agammaglobulinaemia by intrathecal and intravenous injection of high titre gammaglobulin

A 7-year-old boy with sex-linked agammaglobulinaemia developed meningoencephalitis caused by echovirus type 11. He had convulsions, right hemiplegia, cortical motor aphasia, left abducens nerve paralysis, left hypoglossal nerve paralysis, and later became unconscious. Treatment by intravenous injection of conventional gammaglobulin and intrathecal alpha-interferon brought no clinical improvement, but intrathecal administration together with intravenous injection of gammaglobulin containing a high titre of anti-echovirus type 11 antibody was associated with a dramatic improvement in his clinical symptoms. After subsequent periodical (once or twice a week) administration of specific gammaglobulin for 8 months, the echovirus in his cerebrospinal fluid was no longer detected. These findings suggest that intrathecal injection combined with intravenous injection of high titre anti-echovirus type 11 antibody was effective in treating this case of echovirus meningoencephalitis in sex-linked agammaglobulinaemia.

Echovirus polymyositis in patients with hypogammaglobulinemia. Failure of high-dose intravenous gammaglobulin therapy and review of the literature

A 29-year-old man with X-linked hypogammaglobulinemia was treated with prednisone and methotrexate for polymyositis. Subsequently, it was established that disseminated echovirus 11 infection was causing the polymyositis. Treatment with large doses of intravenous gammaglobulin did not result in improvement. Viral cultures of blood, urine, and cerebrospinal fluid gave positive results throughout treatment and at postmortem examination. Multiple cultures of other tissues, including muscle, also gave positive results at postmortem examination. Severity of infection and treatment with prednisone and methotrexate prior to referral, diagnosis, and gammaglobulin treatment may explain the lack of response. A review of 23 cases of echovirus infection in patients with hypogammaglobulinemia revealed that the infection in these patients may cause meningoencephalitis or a polymyositis-like syndrome or both. Treatment with immunosuppressive agents, the standard therapy for polymyositis, is contraindicated, and intravenous or intraventricular gammaglobulin or both may be helpful.

Echovirus meningomyeloencephalitis with administration of intrathecal immunoglobulin

Echovirus meningomyeloencephalitis was treated with cerebral intraventricular immunoglobulin. This case includes a complete examination of the central nervous system (CNS) supported by viral culture studies, immunoperoxidase staining and electron microscopy. Neuronal loss was most severe in the cerebellum and spinal cord. This may lead to the ataxia and a poliomyelitis-like syndrome often seen in cases of echovirus meningomyeloencephalitis. Focal encephalitic lesions, antigen-antibody reactions and live virus were found at numerous levels of the CNS in spite of intrathecal and intravenous immunoglobulin therapy. This mode of therapy and the electron microscopic features noted in echovirus infections are discussed.

Fatal ECHO 24 infection in a patient with hypogammaglobulinemia: relationship to dermatomyositis-like syndrome

Patients with deficient antibody-mediated immunity may develop a rare "dermatomyositis-like" syndrome, which is usually progressive and fatal. We have observed a child with hypogammaglobulinemia in whom a dermatomyositis-like syndrome was associated with a fatal, disseminated ECHO 24 infection. This association suggests that in some immunodeficient patients the fatal dermatomyositis-like syndrome is a manifestation of a viral infection in a compromised host. The use of maternal plasma, with a high titer of ECHO 24 neutralizing activity, was unsuccessful in arresting the progress of the infection.