Neonatal coxsackie B virus infection-a treatable disease?

Seasonal Testing, Results, and Effect of the Pandemic on Coxsackievirus Serum Studies

Coxsackieviruses (CVs) are common causes of infections and can be life-threatening. Unfortunately, rigorous studies guiding the clinician in interpreting CV serum antibody titer testing is lacking. To explore the epidemiology of circulating CVs and the serological test utility in aiding diagnosis of CV infections in our community, we obtained results of CV immunologic diagnostic tests between 2018 and 2022 from a regional healthcare database. For CV type A, rare individuals had positive CF (complement fixation) tests whereas all 16 individuals with IFA testing showed at least one positive serotype. For CV type B CF testing, 52.2% of 222 patients had at least one serotype positive, with B5 being most common and also the most common with higher titers (14.8% with ≥1:32). We found a significant reduction in seropositivity rate during the pandemic in 2020 compared to 2018, which continued through 2022 (OR: 0.2, 95% CI: 0.08-0.49, p-value < 0.001). During the pandemic, the seasonal pattern of positive tests varied from the pre-pandemic pattern. Testing for CVs was increased after the first year of the pandemic. Overall, the variability by month and seasonal change in our data support that CF testing can be used to identify recent CVB infection.

Severe neonatal enterovirus infection in twins with different outcomes: A case report

Enteroviruses are among the most common causes of acute viral illness worldwide, and in neonates, the clinical course of these infections is heterogeneous. Severe complications, such as myocarditis, are associated with high mortality rates. In this case report, we present the clinical course of premature twins born at 35 weeks of gestational age, suffering from a severe neonatal enterovirus infection with cardiac involvement, which proved fatal in one of the twins. This course led to prompt identification in the other twin and facilitated timely transfer to a neonatal intensive care unit with neonatal hemodynamic expertise, and facilitated the timely transfer to a neonatal intensive care nit with hemodynamic expertise and immediate availability of AZCMO would it have been indicated. Early supportive therapy in the other twin contributed to a positive outcome. Therefore, we emphasize the importance of early recognition in averting adverse consequences. As a recommendation, we propose routine screening of enterovirus in viral panels for febrile newborns.

Therapeutics for fulminant hepatitis caused by enteroviruses in neonates

Neonatal infection with nonpolio enteroviruses (EVs) causes nonspecific febrile illnesses and even life-threatening multiorgan failure. Hepatitis, which often results in hepatic necrosis followed by disseminated intravascular coagulopathy, is one of the most severe and frequent fatal neonatal EV infection complications. Coxsackievirus B (CVB) 1–5 and many echoviruses have been most commonly identified. Neonatal EV infection treatment has usually involved initial supportive care. Studies for CVB and echovirus infection treatments were developed for more than thirty years. Intravenous immunoglobulin and pleconaril therapy was performed in some clinical trials. Additionally, other studies demonstrated antiviral and/or anti-inflammatory pathogenesis mechanisms of neonatal EV hepatitis in in vitro or in vivo models. These treatments represented promising options for the clinical practice of neonatal EV hepatitis. However, further investigation is needed to elucidate the whole therapeutic potential and safety problems.

Syntheses, Characterizations, and Inhibition Activities Against Coxsackievirus B3 of Iodobenzoic Hydrazide Functionalized Hexamolybdates

A class of iodobenzoyldiazenido-functionalized POMs (TBA)₃ [Mo₆O₁₈(=N=NCOAr)] (Ar = Ph-o-I (1); Ph-m-I (2); Ph-p-I (3); Ph-3,4-I₂(4); Ph-2,3,5-I₃(5) (TBA = tetrabutylammonium) were prepared via the refluxing reaction of α-octamolybdates, DCC, and corresponding hydrazides in dry acetonitrile. Their structures were determined by Fourier-transform infrared spectroscopy, ultraviolet–visible spectra, X-ray photoelectron spectroscopy, hydrogen-1 nuclear magnetic resonance, and high-resolution mass spectrometry. Research on the biological activity of title compounds shows that L3, L5, 3, and 5 demonstrate potent inhibitory activity against coxsackievirus B3 and low in vitro cytotoxic activity against Hep-2 cell lines. The covalent linkage between the iodobenzoyldiazenido components and POMs can enhance the molecular inhibitory efficiency of iodobenzohydrazides.

Platelets and viruses

Platelets play an essential role in maintaining vascular integrity after injury. In addition, platelets contribute to the immune response to pathogens. For instance, they express receptors that mediate binding of viruses, and toll-like receptors that activate the cell in response to pathogen-associated molecular patterns. Platelets can be beneficial and/or detrimental during viral infections. They reduce blood-borne viruses by engulfing the free virus and presenting the virus to neutrophils. However, platelets can also enhance inflammation and tissue injury during viral infections. Here, we discuss the roles of platelets in viral infection.

Host Cell Calpains Can Cleave Structural Proteins from the Enterovirus Polyprotein

Enteroviruses are small RNA viruses that cause diseases with various symptoms ranging from mild to severe. Enterovirus proteins are translated as a single polyprotein, which is cleaved by viral proteases to release capsid and nonstructural proteins. Here, we show that also cellular calpains have a potential role in the processing of the enteroviral polyprotein. Using purified calpains 1 and 2 in an in vitro assay, we show that addition of calpains leads to an increase in the release of VP1 and VP3 capsid proteins from P1 of enterovirus B species, detected by western blotting. This was prevented with a calpain inhibitor and was dependent on optimal calcium concentration, especially for calpain 2. In addition, calpain cleavage at the VP3-VP1 interface was supported by a competition assay using a peptide containing the VP3-VP1 cleavage site. Moreover, a mass spectrometry analysis showed that calpains can cleave this same peptide at the VP3-VP1 interface, the cutting site being two amino acids aside from 3C’s cutting site. Furthermore, we show that calpains cannot cleave between P1 and 2A. In conclusion, we show that cellular proteases, calpains, can cleave structural proteins from enterovirus polyprotein in vitro. Whether they assist polyprotein processing in infected cells remains to be shown.

Enteroviral infection in neonates

Enteroviruses generally cause mild and self-limited diseases, but they have been found to affect neonates much differently, and often more severely than older children. Clinical manifestations are difficult to differentiate from those of bacterial sepsis, such as fever, poor feeding, lethargy, respiratory distress and cardiovascular collapse. Severe life threatening complications, including hepatic necrosis with coagulopathy, meningoencephalitis and myocarditis, usually present during the first week of life. Factors affecting severity and outcome include virus serotype, mode of transmission, and presence or absence of passively acquired, serotype-specific maternal antibodies. Echoviruses and coxsackievirus B viruses are most common serotypes associated with the neonatal sepsis. An awareness of the clinical syndromes, recognition of the risk factors and monitoring parameters associated with severe cases and use of rapid reverse-transcriptase polymerase chain reaction test for viral load may help physicians in diagnosing severe cases in a timely manner. Prompt aggressive treatment including early intravenous immunoglobulin treatment may help in reducing morbidity and mortality. Enterovirus infections in neonates are common and should be routinely considered in the differential diagnosis of febrile neonates, particularly during enterovirus season. This article provides an overview of what is known about non-polio enteroviruses in neonates including epidemiology, transmission, clinical presentation, diagnosis, and treatment.

Enteroviruses and Parechoviruses

Infections with enteroviruses and human parechoviruses are highly prevalent, particularly in neonates, where they may cause substantial morbidity and mortality. Individuals with B-cell-related immunodeficiencies are at risk for severe enteroviral infections, usually a chronic and fatal meningoencephalitis. In transplant recipients and patients with malignancy, enterovirus infections typically involve the respiratory tract, but cases of severe, disseminated infection have been described. The mainstay of diagnosis for enterovirus and human parechovirus infections involves the use of molecular diagnostic techniques. However, routine nucleic acid-detection methods for enteroviruses will not detect human parechoviruses. Laboratory diagnosis of these viral infections is important in determining a patient's prognosis and guiding clinical management.

Virus myocarditis in a 1-month-old boy presenting as two types of paroxysmal supraventricular tachycardia

Herein we describe the case of a 1-month-old boy with acute viral myocarditis, who presented with two kinds of paroxysmal supraventricular tachycardia, and who was cured after medical treatment. He was brought to the emergency room with poor feeding due to fever. On the third day of hospitalization, a narrow QRS tachycardia (180-200 beats/min) was detected. Echocardiography showed a high echoic area at the atrial septum around the atrioventricular node. The patient was clinically diagnosed with acute myocarditis. The narrow QRS tachycardia was diagnosed as incessant junctional ectopic tachycardia. The patient was treated with propranolol and landiolol. The frequency of the tachycardia decreased, but a different narrow QRS tachycardia was detected on the 15th day of hospitalization on electrocardiogram (220 beats/min), which was ascribed to atrioventricular nodal re-entrant tachycardia. Atenolol was effective for the tachycardia. At 2 years follow up, cardiac function was normal and tachycardia had not recurred.

Severe Enterovirus Infections in Hospitalized Children in the South of England: Clinical Phenotypes and Causative Genotypes

BACKGROUND

Most enterovirus surveillance studies lack detailed clinical data, which limits their clinical usefulness. This study aimed to describe the clinical spectrum and outcome of severe enterovirus infections in children, and to determine whether there are associations between causative enterovirus genotypes and clinical phenotypes.

METHODS

Retrospective analysis of microbiological and clinical data from a tertiary children's hospital in the South of England over a 17-month period (2012-2013).

RESULTS

In total, 30 patients were identified, comprising sepsis (n = 9), myocarditis (n = 8), meningitis (n = 8) and encephalitis (n = 5). Cases with sepsis or myocarditis were significantly younger than those with central nervous system disease (median age 21 and 15 days vs. 79 days; P = 0.0244 and P = 0.0310, respectively). There was considerable diversity in the causative genotypes in each of the clinical phenotypes, with some predominance of echoviruses in the meningitis group, and coxsackie B viruses in the myocarditis group. Thirteen cases required mechanical ventilation, 11 cases inotropic support, 3 cases dialysis and 3 cases extracorporal membrane oxygenation. The overall mortality was 10% (sepsis group, n = 1; myocarditis group, n = 2). Of the survivors, 5 (19%) had long-term sequelae (myocardial dysfunction, n = 2; neurological sequelae, n = 3). Patients with encephalitis had the longest hospital stay (median: 16 days), compared with 9, 6 and 3 days in patients with myocarditis, sepsis and meningitis, respectively (P = 0.005).

CONCLUSIONS

Enterovirus infections, particularly enteroviral myocarditis and encephalitis, can cause significant morbidity and mortality. The results show that there are currently no strong associations between clinical phenotypes and particular causative enterovirus genotypes in the South of England.

Pharmacokinetic considerations in the use of antivirals in neonates

INTRODUCTION

Neonatal patients, because of the inability of their immune system to properly respond to microbial challenge, are highly susceptible to viral infections. Immunoglobulins, monoclonal antibody and antiviral drugs are used for prophylaxis and treatment of viral diseases in neonates. Neonates and, especially, preterm infants differ in drug absorption, distribution, metabolism and excretion from adults and older children.

AREAS COVERED

This review will evaluate deficiencies of neonatal immune responses to microbial challenge that predispose newborns to viral infections, clinical manifestations and the treatment of viral diseases in neonates. We focus on published studies describing antiviral drug pharmacokinetics in neonates and make recommendations on the dosing of these drugs, allowing achievement of maximal clinical benefits in neonates.

EXPERT OPINION

While some efforts were undertaken to study pharmacokinetics and pharmacodynamics of antiviral drugs, much more needs to be done. Current data indicate that the pharmacokinetics of antiviral drugs may vary significantly depending on gestational age, maturation processes of drug-metabolizing enzymes and renal clearance. Specifics of pharmacokinetics of antiviral drugs need to be taken into consideration when they are prescribed to neonates and infants.

Effect of intravenous immunoglobulin for neonates with severe enteroviral infections with emphasis on the timing of administration

BACKGROUND

The benefits of intravenous immunoglobulin (IVIG) therapy for severe neonatal enterovirus infections are still controversial.

OBJECT

To evaluate whether timing of IVIG administration might affect clinical outcomes of neonates with severe enteroviral infections.

STUDY DESIGNS

We retrospectively analyzed 67 neonates with culture-confirmed severe enteroviral infection, defined as hepatitis with coagulopathy and thrombocytopenia. Clinical features, outcomes and the usage of IVIG therapy were collected and analyzed. IVIG administered within 3 days of illness onset was classified as early IVIG therapy.

RESULTS

Of the 67 cases, 38 (57%) were male, 27 (40%) were premature, 57 (85%) had disease onset within 7 days of life and all but 2 cases were caused by coxsackievirus B group. Ten infants (15%) had clinically evident myocarditis. 41 infants (61%) received IVIG therapy and 29 were early IVIG therapy. Fifteen infants (22%) eventually died, without IVIG therapy for 7 infants. The deceased had a significantly higher peak serum aspartate aminotransferase (AST) level than the survivors (3539 vs. 866 IU/L, p<0.01). The timing of IVIG therapy was highly correlated with the timing of peak AST level in patients with early IVIG therapy. Multiple logistic regression analysis showed that a higher nadir hemoglobin level (adjusted odds ratio 2.8, 95% confidence interval: 1.4-5.4), no concurrent myocarditis (42.6 [3.4-5289]) and early IVIG therapy (14.7 [1.3-163]) were independently associated with a favorable prognosis.

CONCLUSIONS

In defined severe neonatal enterovirus infections, serum AST level correlated with the disease severity. Early IVIG therapy, if needed, may be beneficial for survival.

First report of a Chinese strain of coxsackie B3 virus infection in a newborn in Germany in 2011: a case report

INTRODUCTION

Enteroviruses commonly encounter babies and children and infections present in a wide variety of symptoms ranging from asymptomatic infection, benign illness, and aseptic meningitis, hand-foot-and-mouth disease to severe life-threatening disease. Some newborns develop severe disease in the first 2 weeks of life and long-term sequelae may occur among survivors.

CASE PRESENTATION

We present a case report of a Caucasian newborn baby boy with severe encephalitis and systemic coxsackievirus B3 infection. The coincidence of maternal infection as well as previous mild respiratory illness in his sister suggests either prenatal or horizontal postnatal transmission. An electroencephalogram showed a severe pathologic pattern with theta-delta-rhythm and spike-wave complexes on both hemispheres. We also observed an unusual prolonged viremia for a period of 6 weeks. Due to the lack of specific antiviral treatment options, the supportive management included ventilation and medical treatment of seizures. Phylogenetic analysis revealed a genogroup D2 virus previously exclusively detected in China and now described in Europe for the first time.

CONCLUSIONS

Enteroviral infection is an important differential diagnosis in neonatal encephalitis. Prolonged viremia must be taken into account and might correlate with disease severity. The newly observed enterovirus genotype D2 is spreading from Asia to other continents.

Coxsackievirus B4 myocarditis and meningoencephalitis in newborn twins

Coxsackievirus B4 (CB4) is a picornavirus associated with a variety of human diseases, including neonatal meningoencephalitis, myocarditis and type 1 diabetes. We report the pathological findings in twin newborns who died during an acute infection. The twins were born 1 month premature but were well and neurologically intact at birth. After a week they developed acute lethal neonatal sepsis and seizures. Histopathology demonstrated meningoencephalitis and severe myocarditis, as well as pancreatitis, adrenal medullitis and nephritis. Abundant CB4 sequences were identified in nucleic acid extracted from the brain and heart. In situ hybridization with probes to CB4 demonstrated infection of neurons, myocardiocytes, endocrine pancreas and adrenal medulla. The distribution of infected cells and immune response is consistent with reported clinical symptomatology where systemic and neurological diseases are the result of CB4 infection of select target cells.

A case of myocarditis following neonatal meningitis caused by coxsackievirus B1 in spite of intravenous immunoglobulin treatment

Enteroviral infection is one of the most common neonatal infections, and most patients recover without complications. This report describes a neonate who experienced meningitis followed by myocarditis. A 4-day-old boy was admitted with fever, diagnosed with enteroviral meningitis and treated with intravenous immunoglobulin (IVIG). However, myocarditis was subsequently diagnosed in spite of IVIG treatment, and coxsackievirus B1 (CXB1) was revealed as a cause. A left ventricular aneurysm persisted even though the patient recovered with repeated high-dose IVIG treatment and cardiac supportive care. This report describes a rare case where myocarditis developed several days after a diagnosis of CXB1 meningitis in spite of IVIG treatment. It is important to pay attention to the patient's clinical condition until the end of the second viremia of enterovirus and to consider high-dose IVIG treatment when treating enteroviral infections for neonates.

Antenatal and postnatal diagnosis of coxsackie b4 infection: case series

Enteroviruses are a common cause of neonatal infection. In particular, Coxsackie B viruses are often associated with severe, fatal disease. The antenatal diagnosis of Coxsackie B viral infections is uncommon. We present a unique case of Coxsackie B4 virus ventriculitis and myocarditis causing fetal hydrops at 22 weeks gestation. Transmission was inferred by viral isolation from the amniotic fluid and by placental pathology. We also describe two additional cases of fatal neonatal Coxsackie B4 infection complicated by myocarditis and encephalitis with cerebral necrosis in a 4-day-old female and by myocarditis, spinal leptomeningitis, and hepatitis in a 4-day-old male. Transplacental acquisition of infection carries a poor prognosis. We propose that Coxsackie B virus should be considered in the investigation of nonimmune hydrops, particularly in the presence of cardiac dysfunction.

Experimental SSM-CVB3 infection in macaques

OBJECTIVE

To evaluate the pathogenicity of SSM-CVB3 in a macaque model.

METHODS

The clinical symptoms of macaques were recorded; hematological, biochemical and histopathological evaluations were completed; viral titers and neutralization titers (NT-titers) in sera were tested; and the mRNA levels of SSM-CVB3, coxsackievirus and adenovirus receptor (CAR) and decay accelerating factor (DAF) were determined.

RESULTS

After SSM-CVB3 infection, the macaques showed a lack of activity, a poor appetite, a higher body temperature, and severe diarrhea. The macaques also developed hematuria and albuminuria at 4 to 10 days post-inoculation. Virus titers (5.1-6.5 LogTCID(50)/mL) were higher at 6 to 10 days post-inoculation, and NT-titers (6.5-7.3 Log2) reached plateaus at 8 to 14 days post-inoculation. The infected macaques developed serious anemia with decreased RBC and WBC, but the percentages of LYM were increased. The levels of CK, CK-MB, AST and ALT in the sera were 84-169 U/L, 87.6-271.1 U/L, 43-87 U/L and 43-82 U/L, respectively, and all of those were higher than normal. Histological analysis showed obvious cardiac, hepatic and renal damages in the infected macaques and the mRNA contents of SSM-CVB3, CAR and DAF in the heart, liver and kidneys of infected macaques were higher (P<0.05).

CONCLUSION

This was the first report on experimental SSM-CVB3 infections in macaques with serious hepatic and renal damage, except for myocarditis. The information obtained from this study suggests that the SSM-CVB3 strain and this macaque model could be used for studying CVB3-induced cardiac, hepatic or renal diseases.

Hepatitis and Encephalitis due to Coxsackie Virus A9 in an Adult

Coxsackie virus infection most commonly manifests itself in the neonatal period as a multisystem disease. This life-threatening neonatal infection has been recently treated with a new anti-picornaviral drug, pleconaril. In contrast, in adults Coxsackie virus is an uncommon source of hepatitis, but Coxsackie virus type B has been described in case reports to cause hepatitis. This is the first case report of hepatitis and encephalitis secondary to Coxsackie virus type A9 in an adult. This virus was found in a culture of the cerebrospinal fluid and was confirmed by PCR. The patient recovered completely without specific treatment.

Reversible Atrioventricular Block and Junctional Ectopic Tachycardia in Coxsackievirus B3-Induced Fetal-Neonatal Myocarditis without Left Ventricular Dysfunction

We present a case of fetal-neonatal acute myocarditis caused by coxsackievirus B3 infection in a term neonate. The condition manifested as high-grade atrioventricular (A-V) block prenatally. After delivery, various arrhythmias such as high-grade A-V block, ventricular tachycardia, and junctional ectopic tachycardia appeared, and we had difficulty managing these arrhythmias. This is the first report describing a case of acute myocarditis due to coxsackievirus infection presenting with fetal A-V block. This case is also unique in that it is extremely rare that various arrhythmias occur serially in one patient without left ventricular dysfunction.

Survival of neonates with enteroviral myocarditis requiring extracorporeal membrane oxygenation

OBJECTIVES

Neonates infected with enteroviruses may present with severe myocarditis and medically refractory cardiopulmonary collapse. Extracorporeal membrane oxygenation (ECMO) has been used to support patients in this setting, but its efficacy has not been systematically studied. We sought to review the Extracorporeal Life Support Organization registry to determine survival rates and identify predictors of in hospital mortality for these neonates.

DESIGN

Retrospective cohort study using data reported to the Extracorporeal Life Support Organization registry.

SETTING

Multi-institutional data.

PATIENTS

Patients ≤ 15 days old with enteroviral myocarditis who required ECMO support between 2000 and 2008.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Twenty-four neonates with enteroviral myocarditis were reported to the Extracorporeal Life Support Organization registry during the study period. The survival to hospital discharge rate was 33% (n = 8). Multisystem organ dysfunction was more common in nonsurvivors than in survivors (75% vs. 0%, p < .01). In particular, nonsurvivors had a higher prevalence of renal dysfunction (50% vs. 0%, p = .02). Nonsurvivors also had a greater number of ECMO-related complications (5 vs. 3.5, p = .03).

CONCLUSIONS

Cardiopulmonary support with ECMO should be considered for neonates with severe enteroviral myocarditis that fails conventional medical therapies. Multisystem organ dysfunction, particularly with renal involvement, may portend a poor prognosis and is one of several factors that should be considered in the decision to initiate and/or continue mechanical support for these patients.

Enterovirus infections in neonates

Enteroviruses, which include echoviruses, coxsackie A and B viruses, polioviruses and the 'numbered' enteroviruses, are among the most common viruses causing disease in humans. A large proportion of enteroviral infections occur in neonates and infants. There is a wide spectrum of clinical manifestations that can be caused by enterovirus infection with varying degrees of severity. In the neonatal age group, enteroviral infections are associated with significant morbidity and mortality, particularly when infection occurs antenatally. This review provides a detailed overview of the epidemiology and clinical features of enterovirus infections in the neonatal period. In addition, laboratory features and diagnostic investigations are discussed. A review of the currently available data for prophylactic and therapeutic interventions, including antiviral therapy, is also presented.

Severe enterovirus disease in febrile neonates

INTRODUCTION

Fever in newborn infants may be due to an invasive infection with potential morbidity and mortality. Our aim was to describe the characteristics and outcome of group of febrile neonates with severe enterovirus infection compared to a group of neonates with severe bacterial infection.

PATIENTS AND METHODS

Prospective study including all neonates (<29 days old) admitted to a teaching hospital for fever (>38 degrees C), with positive bacterial cultures or enterovirus detection in sterile samples, from September 2003 to December 2004. Clinical information, analytical data at admission (complete leukocyte count and C-reactive protein concentrations), blood, urine, and cerebrospinal fluid culture results, molecular detection of enterovirus by polymerase chain reaction (PCR), and outcome were recorded.

RESULTS

Invasive bacterial infections were observed in 62 patients: urinary tract infection (n=57, including 8 cases of bacteremia), sepsis (n=3), and meningitis (n=2). Molecular tests for enterovirus were positive in 10 patients. C-reactive protein values were significantly higher in neonates with bacterial infection than in those with enterovirus infection (62,3 versus 9mg/L, P=0,008). Two patients with Streptococcus agalactiae meningitis, 1 with Staphylococcus aureus sepsis and 3 with enterovirus infection (manifested as myocarditis, hepatitis, and meningoencephalitis) required admission to the pediatric intensive care unit. Among these, 1 newborn with S. agalactiae and 2 of the 3 with enterovirus infection died.

CONCLUSIONS

In our series, enterovirus infection was an important cause of severe invasive disease. Specific viral diagnosis can contribute to the management of febrile neonates.

Enteroviral sepsis and ischemic cardiomyopathy in a neonate: case report and review of literature

Neonatal entero-viral sepsis is a rare but fulminant infection with multisystem involvement, often presenting with hepatitis, meningo-encephalitis, disseminated intravascular coagulation (DIC), and myocarditis. Neonatal myocarditis often proves fatal. We report here a case of neonatal enteroviral myocarditis with multisystem organ failure and ischemic cardiomyopathy that was managed medically.

A case report of a premature infant with coxsackie B1 meningitis

This case report describes a 36-week gestational age infant diagnosed with coxsackie B1 meningitis at 20 days of age. A head ultrasound 5 days after diagnosis was consistent with cystic periventricular leukomalacia. The scientific literature does not clearly elucidate differences between bacterial and viral infections in infants. When difficulties arise, it is pertinent to consider a viral etiology for the underlying illness and obtain a detailed maternal and infant history focusing on clinical symptoms, seasonality, geographic location, exposure, and incubation period. Polymerase chain reaction is a rapid and sensitive diagnostic test for the identification of enteroviruses in cerebrospinal fluid, blood, urine, and throat specimens and should be performed as part of the general workup in the evaluation of a febrile infant with sepsis. In retrospect, it may have established an earlier diagnosis of meningitis, consequently preventing the unnecessary use of antibiotics, potentially decreasing the length of hospitalization, and eliminating the need for more detailed investigations to rule out other etiological factors. In addition, treatment with pleconaril may have affected the severity of the encephalitis. This article reviews the pathogenesis, clinical manifestations, and differential diagnoses of enteroviral infections, specifically focusing on the prevention, treatment, and prognosis of the disease and the implications for clinical practice.

Viral Load in Blood Is Correlated with Disease Severity of Neonatal Coxsackievirus B3 Infection: Early Diagnosis and Predicting Disease Severity Is Possible in Severe Neonatal Enterovirus Infection

We conducted a study during an outbreak of coxsackievirus B3 infection in 2005 and found that viral RNA could be detected in patients' blood specimens soon after the onset of fever, and the level of viral RNA was positively correlated with disease severity. Timely diagnosis is possible in severe neonatal enterovirus infection.

Probable intrafamilial transmission of coxsackievirus b3 with vertical transmission, severe early-onset neonatal hepatitis, and prolonged viral RNA shedding

Here we report a familial cluster of 3 cases of coxsackievirus B3 infection: a recent history of illness in a woman's 3-year-old son with a coxsackievirus B3-positive stool culture indicated that he probably infected his mother at home during her last week of pregnancy. Consequently, she delivered an infected neonate who developed severe hepatitis, disseminated intravascular coagulation, and bilateral intracranial hemorrhage. The neonate remained well for the first 2 days of life. On the third day, he developed fever (39 degrees C) and poor peripheral circulation. On the fourth day, he developed petechiae and bruises over his chest wall and extremities, and prolonged bleeding was observed over venipuncture sites. Investigations revealed severe thrombocytopenia (platelets: 41 x 10(9)/L) and a markedly deranged coagulation profile (prothrombin time: 19 seconds [reference: < 10 seconds]; activated partial thromboplastin time: > 120 seconds [reference: 24.2-37.0 seconds], serum D-dimers: 6722 ng/mL [reference: < 500 ng/mL]), suggestive of disseminated intravascular coagulopathy. Clinical examination revealed yellow sclera, hepatomegaly (5 cm), and splenomegaly (2 cm), consistent with hepatitis. Serial chest radiographs showed bilateral pleural effusions, and an ultrasound of the abdomen demonstrated ascites. An echocardiogram showed normal cardiac structure and good contractility of both ventricles. However, a cranial ultrasound revealed bilateral grade 2 intraventricular hemorrhages. Serum C-reactive protein increased to 33.9 mg/L. Liver-function tests were also markedly deranged at this time, with maximum values for serum alanine transferase, bilirubin, alkaline phosphatase, and ammonia concentration of 1354 IU/L, 258 micromol/L, 189 IU/L, and 147 micromol/L, respectively. Serum glucose levels were normal. Over the next 3 days, his fever subsided, and his liver function and clotting profile normalized by day 13 after onset of illness. A stool sample from the older brother, collected 14 days after his onset of illness at home, was positive for coxsackievirus B3 by both virus culture and enterovirus reverse-transcription polymerase chain reaction. He had neutralizing coxsackievirus B3 antibody titers of 1:2560 and 1:1280 on days 14 and 28 after his onset of illness, respectively. No virus was cultured from the mother's stool sample, collected 5 days after her onset of illness, but the enterovirus polymerase chain reaction was positive and maternal sera neutralized the coxsackievirus B3 isolated from the neonate. The maternal sera also showed a more than fourfold rise in antibody titer from 1:80 to 1:640 on days 5 and 16 after her onset of illness, respectively. Neonatal antibody titers also showed a more than fourfold rise from < 1:80 to 1:2560 on days 1 and 21 after his onset of illness, respectively. This demonstrates that both the mother and the neonate had had recent coxsackievirus B3 infections. Serially collected neonatal throat swab and stool samples were culture negative for enterovirus by 4 and 8 days after his onset of illness, respectively. However, enterovirus RNA remained detectable by reverse-transcription polymerase chain reaction in these samples for considerably longer, only becoming undetectable by 16, 23, and 41 days after his onset of illness. We show that even mild household infections may have potentially serious consequences for pregnant women and their infants.

Inhibitors of virus replication: recent developments and prospects

The search for inhibitors of viral replication is dependent on understanding the events taking place at the molecular level during viral infection. All the essential steps during the viral life cycle are potential targets for antiviral drugs. Classical inhibitors of herpesvirus replication cause chain termination during viral DNA replication. Similarly, the HIV reverse transcriptase is the major target of anti-HIV compounds. The broad-spectrum antiviral agent ribavirin affects viral nucleic acid replication by multiple mechanisms. Another major enzyme encoded by many viruses is a protease responsible for the processing of virus-encoded polyproteins. The HIV protease has been very successfully targeted, and hepatitis C virus and rhinovirus protease inhibitors are being actively developed. The complex series of interactions during virus entry is a rapidly emerging and promising target for inhibitors of HIV and many other viruses. New anti-influenza drugs inhibit virus release from infected cells. Several stages of the viral life cycle remain incompletely characterized and are therefore poorly exploited in antiviral strategies. These include, among others, the RNA capping reactions catalyzed by many viruses, as well as the membrane association of replication complexes which is common to all positive-strand RNA viruses.