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Fisher KS, Illner A, Kannan V. Pediatric neuroinflammatory diseases in the intensive care unit. Semin Pediatr Neurol 2024; 49:101118. [PMID: 38677797 DOI: 10.1016/j.spen.2024.101118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/12/2024] [Accepted: 01/28/2024] [Indexed: 04/29/2024]
Abstract
Inflammatory disorders of the central nervous system (CNS) include a wide spectrum of autoimmune, autoinflammatory, and paraneoplastic diseases. While many affected patients require acute hospital admission, a subset may present with severe neurological symptoms requiring intensive care unit (ICU) escalation due to disordered consciousness, respiratory failure, status epilepticus, intracranial hypertension, and/or severe autonomic dysregulation.
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Affiliation(s)
- Kristen S Fisher
- Department of Pediatrics, Section of Neurology and Developmental Neuroscience, Baylor College of Medicine, Houston, Texas.
| | - Anna Illner
- Department of Radiology, Baylor College of Medicine at Texas Children's Hospital, Houston, Texas
| | - Varun Kannan
- Division of Pediatric Neurology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
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2
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Hooi YT, Balasubramaniam VRMT. In vitro and in vivo models for the study of EV-D68 infection. Pathology 2023; 55:907-916. [PMID: 37852802 DOI: 10.1016/j.pathol.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/03/2023] [Accepted: 08/14/2023] [Indexed: 10/20/2023]
Abstract
Enterovirus D68 (EV-D68) is one of hundreds of non-polio enteroviruses that typically cause cold-like respiratory illness. The first EV-D68 outbreak in the United States in 2014 aroused widespread concern among the public and health authorities. The infection was found to be associated with increased surveillance of acute flaccid myelitis, a neurological condition that causes limb paralysis in conjunction with spinal cord inflammation. In vitro studies utilising two-dimensional (2D) and three-dimensional (3D) culture systems have been employed to elucidate the pathogenic mechanism of EV-D68. Various animal models have also been developed to investigate viral tropism and distribution, pathogenesis, and immune responses during EV-D68 infection. EV-D68 infections have primarily been investigated in respiratory, intestinal and neural cell lines/tissues, as well as in small-size immunocompetent rodent models that were limited to a young age. Some studies have implemented strategies to overcome the barriers by using immunodeficient mice or virus adaptation. Although the existing models may not fully recapitulate both respiratory and neurological disease observed in human EV-D68 infection, they have been valuable for studying pathogenesis and evaluating potential vaccine or therapeutic candidates. In this review, we summarise the methodologies and findings from each experimental model and discuss their applications and limitations.
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Affiliation(s)
- Yuan Teng Hooi
- Infection and Immunity Research Strength, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia.
| | - Vinod R M T Balasubramaniam
- Infection and Immunity Research Strength, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia.
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3
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Singh B, Arora S, Sandhu N. Emerging trends and insights in acute flaccid myelitis: a comprehensive review of neurologic manifestations. Infect Dis (Lond) 2023; 55:653-663. [PMID: 37368373 DOI: 10.1080/23744235.2023.2228407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 06/08/2023] [Accepted: 06/18/2023] [Indexed: 06/28/2023] Open
Abstract
Acute Flaccid Myelitis (AFM) is a neurological condition in the anterior portion of the spinal cord and can be characterised as paraplegia (paralysis of the lower limbs), and cranial nerve dysfunction. These lesions are caused by the infection due to Enterovirus 68 (EV-D68); a member of the Enterovirus (EV) family belongs to the Enterovirus species within the Picornavirus family and a Polio-like virus. In many cases, the facial, axial, bulbar, respiratory, and extraocular muscles were affected, hence reducing the overall quality of the patient's life. Moreover, severe pathological conditions demand hospitalisation and can cause mortality in a few cases. The data from previous case studies and literature suggest that the prevalence is high in paediatric patients, but careful clinical assessment and management can decrease the risk of mortality and paraplegia. Moreover, the clinical and laboratory diagnosis can be performed by Magnetic resonance imaging (MRI) of the spinal cord followed by Reverse transcription polymerase chain reaction (rRT-PCR) and VP1 seminested PCR assay of the cerebrospinal fluid (CSF), stool, and serum samples can reveal the disease condition to an extent. The primary measure to control the outbreak is social distancing as advised by public health administrations, but more effective ways are yet to discover. Nonetheless, vaccines in the form of the whole virus, live attenuated, sub-viral particles, and DNA vaccines can be an excellent choice to treat these conditions. The review discusses a variety of topics, such as epidemiology, pathophysiology, diagnosis/clinical features, hospitalisation/mortality, management/treatment, and potential future developments.
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Affiliation(s)
- Baljinder Singh
- Centre for Pharmaceutical Innovation, University of South Australia, North Terrace, Adelaide, SA, Australia
| | - Sanchit Arora
- Department of Pharmaceutics, Delhi Institute of Pharmaceutical Sciences and Research (DIPSAR), Delhi Pharmaceutical Sciences and Research University (DPSRU), New Delhi, India
| | - Navjot Sandhu
- Department of Quality Assurance, ISF College of Pharmacy, Moga, Affiliated to IK Gujral Punjab Technical University, Jalandhar, India
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4
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Aguglia G, Coyne CB, Dermody TS, Williams JV, Freeman MC. Contemporary enterovirus-D68 isolates infect human spinal cord organoids. mBio 2023; 14:e0105823. [PMID: 37535397 PMCID: PMC10470749 DOI: 10.1128/mbio.01058-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 06/05/2023] [Indexed: 08/04/2023] Open
Abstract
Enterovirus D68 (EV-D68) is a nonpolio enterovirus associated with severe respiratory illness and acute flaccid myelitis (AFM), a polio-like illness causing paralysis in children. AFM outbreaks have been associated with increased circulation and genetic diversity of EV-D68 since 2014, although the virus was discovered in the 1960s. The mechanisms by which EV-D68 targets the central nervous system are unknown. Since enteroviruses are human pathogens that do not routinely infect other animal species, establishment of a human model of the central nervous system is essential for understanding pathogenesis. Here, we describe two human spinal cord organoid (hSCO)-based models for EV-D68 infection derived from induced, pluripotent stem cell (iPSC) lines. One hSCO model consists primarily of spinal motor neurons, while the another model comprises multiple neuronal cell lineages, including motor neurons, interneurons, and glial cells. These hSCOs can be productively infected with contemporary strains, but not a historic strain, of EV-D68 and produce extracellular virus for at least 2 weeks without appreciable cytopathic effect. By comparison, infection with hSCO with another enterovirus, echovirus 11, causes significant structural destruction and apoptosis. Together, these findings suggest that EV-D68 infection is not the sole mediator of neuronal cell death in the spinal cord in those with AFM and that secondary injury from the immune response likely contributes to pathogenesis. IMPORTANCE AFM is a rare condition that causes significant morbidity in affected children, often contributing to life-long sequelae. It is unknown how EV-D68 causes paralysis in children, and effective therapeutic and preventative strategies are not available. Mice are not native hosts for EV-D68, and thus, existing mouse models use immunosuppressed or neonatal mice, mouse-adapted viruses, or intracranial inoculations. To complement existing models, we report two hSCO models for EV-D68 infection. These three-dimensional, multicellular models comprised human cells and include multiple neural lineages, including motor neurons, interneurons, and glial cells. These new hSCO models for EV-D68 infection will contribute to understanding how EV-D68 damages the human spinal cord, which could lead to new therapeutic and prophylactic strategies for this virus.
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Affiliation(s)
- Gabrielle Aguglia
- Department of Pediatrics, Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Carolyn B. Coyne
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Terence S. Dermody
- Department of Pediatrics, Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Institute for Infection, Inflammation, and Immunity (i4Kids), UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - John V. Williams
- Department of Pediatrics, Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Institute for Infection, Inflammation, and Immunity (i4Kids), UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Megan Culler Freeman
- Department of Pediatrics, Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Institute for Infection, Inflammation, and Immunity (i4Kids), UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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5
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Lane TR, Fu J, Sherry B, Tarbet B, Hurst BL, Riabova O, Kazakova E, Egorova A, Clarke P, Leser JS, Frost J, Rudy M, Tyler KL, Klose T, Volobueva AS, Belyaevskaya SV, Zarubaev VV, Kuhn RJ, Makarov V, Ekins S. Efficacy of an isoxazole-3-carboxamide analog of pleconaril in mouse models of Enterovirus-D68 and Coxsackie B5. Antiviral Res 2023; 216:105654. [PMID: 37327878 PMCID: PMC10527014 DOI: 10.1016/j.antiviral.2023.105654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/05/2023] [Accepted: 06/13/2023] [Indexed: 06/18/2023]
Abstract
Enteroviruses (EV) cause a number of life-threatening infectious diseases. EV-D68 is known to cause respiratory illness in children that can lead to acute flaccid myelitis. Coxsackievirus B5 (CVB5) is commonly associated with hand-foot-mouth disease. There is no antiviral treatment available for either. We have developed an isoxazole-3-carboxamide analog of pleconaril (11526092) which displayed potent inhibition of EV-D68 (IC50 58 nM) as well as other enteroviruses including the pleconaril-resistant Coxsackievirus B3-Woodruff (IC50 6-20 nM) and CVB5 (EC50 1 nM). Cryo-electron microscopy structures of EV-D68 in complex with 11526092 and pleconaril demonstrate destabilization of the EV-D68 MO strain VP1 loop, and a strain-dependent effect. A mouse respiratory model of EV-D68 infection, showed 3-log decreased viremia, favorable cytokine response, as well as statistically significant 1-log reduction in lung titer reduction at day 5 after treatment with 11526092. An acute flaccid myelitis neurological infection model did not show efficacy. 11526092 was tested in a mouse model of CVB5 infection and showed a 4-log TCID50 reduction in the pancreas. In summary, 11526092 represents a potent in vitro inhibitor of EV with in vivo efficacy in EV-D68 and CVB5 animal models suggesting it is worthy of further evaluation as a potential broad-spectrum antiviral therapeutic against EV.
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Affiliation(s)
- Thomas R Lane
- Collaborations Pharmaceuticals Inc., Raleigh, NC, USA
| | - Jianing Fu
- Department of Biological Sciences, Purdue University, West Lafayette, IN, USA
| | - Barbara Sherry
- Department of Molecular Biomedical Sciences, North Carolina State University, College of Veterinary Medicine, Raleigh, NC, USA
| | - Bart Tarbet
- Institute for Antiviral Research, Utah State University, Logan, UT, USA; Department of Animal, Dairy and Veterinary Sciences, Utah State University, Logan, UT, USA
| | - Brett L Hurst
- Institute for Antiviral Research, Utah State University, Logan, UT, USA; Department of Animal, Dairy and Veterinary Sciences, Utah State University, Logan, UT, USA
| | - Olga Riabova
- Research Center of Biotechnology RAS, 33-1 Leninsky prospect, 119071, Moscow, Russia
| | - Elena Kazakova
- Research Center of Biotechnology RAS, 33-1 Leninsky prospect, 119071, Moscow, Russia
| | - Anna Egorova
- Research Center of Biotechnology RAS, 33-1 Leninsky prospect, 119071, Moscow, Russia
| | - Penny Clarke
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - J Smith Leser
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Joshua Frost
- Department of Immunology and Microbiology, Infectious Disease, Medicine and Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Kenneth L Tyler
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Veterans Affairs, Aurora, CO, USA
| | - Thomas Klose
- Department of Biological Sciences, Purdue University, West Lafayette, IN, USA
| | | | | | - Vladimir V Zarubaev
- Saint Petersburg Pasteur Institute, 14 Mira Street, 197101, Saint Petersburg, Russia
| | - Richard J Kuhn
- Department of Biological Sciences, Purdue University, West Lafayette, IN, USA
| | - Vadim Makarov
- Research Center of Biotechnology RAS, 33-1 Leninsky prospect, 119071, Moscow, Russia
| | - Sean Ekins
- Collaborations Pharmaceuticals Inc., Raleigh, NC, USA.
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6
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Yoshida K, Muramatsu M, Shimizu H. Neutralizing activity of intravenous immune globulin products against enterovirus D68 strains isolated in Japan. BMC Infect Dis 2023; 23:481. [PMID: 37464326 PMCID: PMC10394975 DOI: 10.1186/s12879-023-08429-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/28/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Enterovirus D68 (EV-D68), belonging to Enterovirus D, is a unique human enterovirus mainly associated with common respiratory diseases. However, EV-D68 can cause severe respiratory diseases, and EV-D68 endemic is epidemiologically linked to current global epidemic of acute flaccid myelitis. METHODS In this study, we measured neutralizing antibody titers against six clinical EV-D68 isolates in nine intravenous immune globulin (IVIG) products commercially available in Japan to assess their potential as therapeutic options for severe EV-D68 infection. RESULTS Seven IVIG products manufactured from Japanese donors contained high neutralizing antibody titers (IC50 = 0.22-85.01 µg/mL) against all six EV-D68 strains. Apparent differences in neutralizing titers among the six EV-D68 strains were observed for all IVIG products derived from Japanese and non-Japanese blood donors. CONCLUSIONS High levels of EV-D68-neutralizing antibodies in IVIG products manufactured from Japanese donors suggest that anti-EV-D68 antibodies are maintained in the Japanese donor population similarly as found in foreign blood donors. Apparent differences in neutralizing antibody titers against the six EV-D68 strains suggest distinct antigenicity among the strains used in this study regardless of the genetic similarity of EV-D68.
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Affiliation(s)
- Kazuhiro Yoshida
- Department of Virology 2, National Institute of Infectious Diseases, Tokyo, Japan.
| | - Masamichi Muramatsu
- Department of Virology 2, National Institute of Infectious Diseases, Tokyo, Japan
- Department of Infectious Disease Research, Institute of Biomedical Research and Innovation, Foundation for Biomedical Research and Innovation at Kobe, Kobe, Hyogo, Japan
| | - Hiroyuki Shimizu
- Department of Virology 2, National Institute of Infectious Diseases, Tokyo, Japan
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7
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Frost J, Rudy MJ, Leser JS, Tan H, Hu Y, Wang J, Clarke P, Tyler KL. Telaprevir Treatment Reduces Paralysis in a Mouse Model of Enterovirus D68 Acute Flaccid Myelitis. J Virol 2023; 97:e0015623. [PMID: 37154751 PMCID: PMC10231134 DOI: 10.1128/jvi.00156-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/09/2023] [Indexed: 05/10/2023] Open
Abstract
In 2014, 2016, and 2018, the United States experienced unprecedented spikes in pediatric cases of acute flaccid myelitis (AFM), which is a poliomyelitis-like paralytic illness. Accumulating clinical, immunological, and epidemiological evidence has identified enterovirus D68 (EV-D68) as a major causative agent of these biennial AFM outbreaks. There are currently no available FDA-approved antivirals that are effective against EV-D68, and the treatment for EV-D68-associated AFM is primarily supportive. Telaprevir is an food and drug administration (FDA)-approved protease inhibitor that irreversibly binds the EV-D68 2A protease and inhibits EV-D68 replication in vitro. Here, we utilize a murine model of EV-D68 associated AFM to show that early telaprevir treatment improves paralysis outcomes in Swiss Webster (SW) mice. Telaprevir reduces both viral titer and apoptotic activity in both muscles and spinal cords at early disease time points, which results in improved AFM outcomes in infected mice. Following intramuscular inoculation in mice, EV-D68 infection results in a stereotypic pattern of weakness that is reflected by the loss of the innervating motor neuron population, in sequential order, of the ipsilateral (injected) hindlimb, the contralateral hindlimb, and then the forelimbs. Telaprevir treatment preserved motor neuron populations and reduced weakness in limbs beyond the injected hindlimb. The effects of telaprevir were not seen when the treatment was delayed, and toxicity limited doses beyond 35 mg/kg. These studies are a proof of principle, provide the first evidence of benefit of an FDA-approved antiviral drug with which to treat AFM, and emphasize both the need to develop better tolerated therapies that remain efficacious when administered after viral infections and the development of clinical symptoms. IMPORTANCE Recent outbreaks of EV-D68 in 2014, 2016, and 2018 have resulted in over 600 cases of a paralytic illness that is known as AFM. AFM is a predominantly pediatric disease with no FDA-approved treatment, and many patients show minimal recovery from limb weakness. Telaprevir is an FDA-approved antiviral that has been shown to inhibit EV-D68 in vitro. Here, we demonstrate that a telaprevir treatment that is given concurrently with an EV-D68 infection improves AFM outcomes in mice by reducing apoptosis and viral titers at early time points. Telaprevir also protected motor neurons and improved paralysis outcomes in limbs beyond the site of viral inoculation. This study improves understanding of EV-D68 pathogenesis in the mouse model of AFM. This study serves as a proof of principle for the first FDA-approved drug that has been shown to improve AFM outcomes and have in vivo efficacy against EV-D68 as well as underlines the importance of the continued development of EV-D68 antivirals.
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Affiliation(s)
- Joshua Frost
- Department of Immunology & Microbiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michael J. Rudy
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - J. Smith Leser
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Haozhou Tan
- Department of Medicinal Chemistry, Ernest Mario School of Pharmacy, Rutgers, the State University of New Jersey, Piscataway, New Jersey, USA
| | - Yanmei Hu
- Department of Medicinal Chemistry, Ernest Mario School of Pharmacy, Rutgers, the State University of New Jersey, Piscataway, New Jersey, USA
| | - Jun Wang
- Department of Medicinal Chemistry, Ernest Mario School of Pharmacy, Rutgers, the State University of New Jersey, Piscataway, New Jersey, USA
| | - Penny Clarke
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kenneth L. Tyler
- Department of Immunology & Microbiology, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
- Division of Infectious Disease, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Neurology Service, Rocky Mountain VA Medical Center, Aurora, Colorado, USA
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8
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Helfferich J, Neuteboom RF, de Lange MMA, Benschop KSM, Van Leer-Buter CC, Meijer A, Bakker DP, de Bie E, Braakman HMH, Brandsma R, Niks EH, Niermeijer JM, Roelfsema V, Schoenmaker N, Sie LT, Niesters HG, Te Wierik MJM, Jacobs BC, Brouwer OF. Pediatric acute flaccid myelitis: Evaluation of diagnostic criteria and differentiation from other causes of acute flaccid paralysis. Eur J Paediatr Neurol 2023; 44:28-36. [PMID: 36996587 DOI: 10.1016/j.ejpn.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/20/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND Acute flaccid paralysis (AFP) is characterized by rapidly progressive limb weakness with low muscle tone. It has a broad differential diagnosis, which includes acute flaccid myelitis (AFM), a rare polio-like condition that mainly affects young children. Differentiation between AFM and other causes of AFP may be difficult, particularly at onset of disease. Here, we evaluate the diagnostic criteria for AFM and compare AFM to other causes of acute weakness in children, aiming to identify differentiating clinical and diagnostic features. METHODS The diagnostic criteria for AFM were applied to a cohort of children with acute onset of limb weakness. An initial classification based on positive diagnostic criteria was compared to the final classification, based on application of features suggestive for an alternative diagnosis and discussion with expert neurologists. Cases classified as definite, probable, or possible AFM or uncertain, were compared to cases with an alternative diagnosis. RESULTS Of 141 patients, seven out of nine patients initially classified as definite AFM, retained this label after further classification. For probable AFM, this was 3/11, for possible AFM 3/14 and for uncertain 11/43. Patients initially classified as probable or possible AFM were most commonly diagnosed with transverse myelitis (16/25). If the initial classification was uncertain, Guillain-Barré syndrome was the most common diagnosis (31/43). Clinical and diagnostic features not included in the diagnostic criteria, were often used for the final classification. CONCLUSION The current diagnostic criteria for AFM usually perform well, but additional features are sometimes required to distinguish AFM from other conditions.
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Affiliation(s)
- Jelte Helfferich
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - Rinze F Neuteboom
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marit M A de Lange
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Kimberley S M Benschop
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Coretta C Van Leer-Buter
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Adam Meijer
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Dewi P Bakker
- Department of Paediatric Neurology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Eva de Bie
- Department of Paediatric Neurology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Hilde M H Braakman
- Department of Paediatric Neurology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Rick Brandsma
- Department of Paediatric Neurology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Erik H Niks
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Vincent Roelfsema
- Department of Paediatrics, Martini Hospital, Groningen, the Netherlands
| | | | - Lilian T Sie
- Department of Paediatric Neurology, Haga Hospital, the Hague, the Netherlands
| | - Hubert G Niesters
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Margreet J M Te Wierik
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Bart C Jacobs
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Oebele F Brouwer
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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9
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Hayes LH, Hopkins SE, Liu S, Pardo CA, Garcia-Dominguez MA, Oleszek J, Yea C, Ciftci-Kavaklioglu B, Yeh EA, Dean J, Sadowsky CL, Desai J, Wiegand S, Farias-Moeller R, Nash K, Thakur KT, Vargas WS, Hong-Routson SJ, Yeshokumar A, Zhou MS, Makhani N, Wilson-Murphy M, Bove R, Zhang B, Benson LA. Challenges in the Clinical Recognition of Acute Flaccid Myelitis and its Implications. J Pediatr 2023; 253:55-62.e4. [PMID: 36115622 DOI: 10.1016/j.jpeds.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 09/07/2022] [Accepted: 09/09/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To explore the challenges in diagnosing acute flaccid myelitis (AFM) and evaluate clinical features and treatment paradigms associated with under recognition. STUDY DESIGN This was a retrospective multicenter study of pediatric patients (≤18 years) who were diagnosed with AFM from 2014 to 2018 using the Centers for Disease Control and Prevention's case definition. RESULTS In 72% of the cases (126 of 175), AFM was not considered in the initial differential diagnosis (n = 108; 61.7%) and/or the patient was not referred for acute care (n = 90; 51.4%) at the initial clinical encounter, and this did not improve over time. Although many features of the presentation were similar in those initially diagnosed with AFM and those who were not; preceding illness, constipation, and reflexes differed significantly between the 2 groups. Patients with a non-AFM initial diagnosis more often required ventilatory support (26.2% vs 12.2%; OR, 0.4; 95% CI, 0.2-1.0; P = .05). These patients received immunomodulatory treatment later (3 days vs 2 days after neurologic symptom onset; 95% CI, -2 to 0; P = .05), particularly intravenous immunoglobulin (5 days vs 2 days; 95% CI, -4 to -2; P < .001). CONCLUSIONS Delayed recognition of AFM is concerning because of the risk for respiratory decompensation and need for intensive care monitoring. A non-AFM initial diagnosis was associated with delayed treatment that could have a clinical impact, particularly as new treatment options emerge.
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Affiliation(s)
- Leslie H Hayes
- Department of Neurology, Boston Children's Hospital, Boston, MA
| | - Sarah E Hopkins
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, MA
| | - Shanshan Liu
- Department of Neurology and Institutional Centers for Clinical and Translational Research Biostatistics and Research Design Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Carlos A Pardo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MA
| | | | - Joyce Oleszek
- Department of Physical Medicine & Rehabilitation, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Carmen Yea
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - E Ann Yeh
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Janet Dean
- Department of Physical Medicine and Rehabilitation, International Center for Spinal Cord Injury, Johns Hopkins School of Medicine, Kennedy Krieger Institute, Baltimore, MD
| | - Cristina L Sadowsky
- Department of Physical Medicine and Rehabilitation, International Center for Spinal Cord Injury, Johns Hopkins School of Medicine, Kennedy Krieger Institute, Baltimore, MD
| | - Jay Desai
- Department of Neurology, Children's Hospital Los Angeles, Los Angeles, CA
| | - Sarah Wiegand
- Department of Neurology, Children's Hospital Los Angeles, Los Angeles, CA
| | - Raquel Farias-Moeller
- Division of Child Neurology, Department of Neurology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI
| | - Kendall Nash
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA
| | - Kiran T Thakur
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY
| | - Wendy S Vargas
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY
| | - Sue J Hong-Routson
- Division of Critical Care, Departments of Pediatrics & Neurology, Lurie Children's Hospital of Chicago, Chicago, IL
| | - Anusha Yeshokumar
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Melissa S Zhou
- Department of Pediatrics, Yale School of Medicine, New Haven, CT; Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Naila Makhani
- Department of Pediatrics, Yale School of Medicine, New Haven, CT; Department of Neurology, Yale School of Medicine, New Haven, CT
| | | | - Riley Bove
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA
| | - Bo Zhang
- Department of Neurology and Institutional Centers for Clinical and Translational Research Biostatistics and Research Design Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Leslie A Benson
- Department of Neurology, Boston Children's Hospital, Boston, MA.
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10
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Beardsley J, McCoy A, Freeman M, Cramer N, Neville D, Owusu-Ansah S, Houtrow A, Sinha A. The complete acute and post-acute care course of children affected by acute flaccid myelitis in Western Pennsylvania: A case series. J Pediatr Rehabil Med 2023; 16:401-413. [PMID: 36776079 DOI: 10.3233/prm-210120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
Acute flaccid myelitis (AFM) is a "polio-like" neurologic disorder of the spinal cord gray matter characterized by asymmetric, flaccid limb weakness of rapid onset following prodromal viral illness. It has affected the pediatric population of the United States since 2014, but there is a paucity of literature describing the post-acute comprehensive rehabilitation management that maximizes functional outcomes for patients. This case series attempts to mitigate this by describing the complete acute and post-acute care course of six children diagnosed with AFM in Western Pennsylvania. It is critical that pediatric rehabilitation medicine providers be knowledgeable about the complex medical and rehabilitation management for patients with AFM.
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Affiliation(s)
| | - Andrew McCoy
- UPMC Physical Medicine and Rehabilitation, Pittsburgh, PA, USA
| | - Megan Freeman
- Pediatric Infectious Disease, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Natan Cramer
- Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Desiree Neville
- Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Silvia Owusu-Ansah
- Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Amy Houtrow
- Pediatric Rehabilitation Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Amit Sinha
- Pediatric Rehabilitation Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
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11
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Neutralizing Antibody Given after Paralysis Onset Reduces the Severity of Paralysis Compared to Nonspecific Antibody-Treated Controls in a Mouse Model of EV-D68-Associated Acute Flaccid Myelitis. Antimicrob Agents Chemother 2022; 66:e0022722. [PMID: 35894595 PMCID: PMC9380545 DOI: 10.1128/aac.00227-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Enterovirus D68 (EV-D68) can cause mild to severe respiratory illness and is associated with a poliomyelitis-like paralytic syndrome called acute flaccid myelitis (AFM). Most cases of EV-D68-associated AFM occur in young children who are brought to the clinic after the onset of neurologic symptoms. There are currently no known antiviral therapies for AFM, and it is unknown whether antiviral treatments will be effective if initiated after the onset of neurologic symptoms (when patients are likely to present for medical care). We developed a "clinical treatment model" for AFM, in which individual EV-D68-infected mice are tracked and treated with an EV-D68-specific human-mouse chimeric monoclonal antibody after the onset of moderate paralysis. Mice treated with antibody had significantly better paralysis outcomes compared to nonspecific antibody-treated controls. Treatment did not reverse paralysis that was present at the time of treatment initiation but did slow the further loss of function, including progression of weakness to other limbs, as well as reducing viral titer in the muscle and spinal cords of treated animals. We observed the greatest therapeutic effect in EV-D68 isolates which were neutralized by low concentrations of antibody, and diminishing therapeutic effect in EV-D68 isolates which required higher doses of antibody for neutralization. This work supports the use of virus-specific immunotherapy for the treatment of AFM. It also suggests that patients who present with AFM should be treated as soon as possible if recent infection with EV-D68 is suspected.
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12
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Abstract
Human enterovirus D68 (EV-D68) is a globally reemerging respiratory pathogen that is associated with the development of acute flaccid myelitis (AFM) in children. Currently, there are no approved vaccines or treatments for EV-D68 infection, and there is a paucity of data related to the virus and host-specific factors that predict disease severity and progression to the neurologic syndrome. EV-D68 infection of various animal models has served as an important platform for characterization and comparison of disease pathogenesis between historic and contemporary isolates. Still, there are significant gaps in our knowledge of EV-D68 pathogenesis that constrain the development and evaluation of targeted vaccines and antiviral therapies. Continued refinement and characterization of animal models that faithfully reproduce key elements of EV-D68 infection and disease is essential for ensuring public health preparedness for future EV-D68 outbreaks.
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13
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Daniels DK, Conners GP. A Review of the Diagnosis and Management of Acute Flaccid Myelitis in the Emergency Department. Pediatr Emerg Care 2022; 38:126-130. [PMID: 35226621 DOI: 10.1097/pec.0000000000002660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Since 2014, biennial rises in acute flaccid myelitis (AFM) have brought attention to this rare but debilitating condition. Children with AFM typically present with acute onset, flaccid weakness accompanied by longitudinally extensive gray matter injury demonstrated on magnetic resonance imaging. A clearer understanding of the epidemiology and suspected pathogenesis of AFM may result in increased recognition. The purpose of this review article is to guide emergency physicians in recognizing key clinical features, initiating diagnostic evaluation and providing appropriate interventions for children with suspected AFM.
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Affiliation(s)
| | - Gregory P Conners
- Stanley A. August Professor and Chair of Pediatrics, Executive Director, Upstate Golisano Children's Hospital, SUNY Upstate Medical University, Syracuse, NY
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14
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Helfferich J, Roodbol J, de Wit MC, Brouwer OF, Jacobs BC. Acute flaccid myelitis and Guillain-Barré syndrome in children: A comparative study with evaluation of diagnostic criteria. Eur J Neurol 2021; 29:593-604. [PMID: 34747551 PMCID: PMC9299116 DOI: 10.1111/ene.15170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/03/2021] [Accepted: 11/01/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE Differentiation between acute flaccid myelitis (AFM) and Guillain-Barré syndrome (GBS) can be difficult, particularly in children. Our objective was to improve the diagnostic accuracy by giving recommendations based on a comparison of clinical features and diagnostic criteria in children with AFM or GBS. METHODS A cohort of 26 children with AFM associated with enterovirus D68 was compared to a cohort of 156 children with GBS. The specificity of the Brighton criteria, used for GBS diagnosis, was evaluated in the AFM cohort and the specificity of the Centers for Disease Control and Prevention (CDC) AFM diagnostic criteria in the GBS cohort. RESULTS Children with AFM compared to those with GBS had a shorter interval between onset of weakness and nadir (3 vs. 8 days, p < 0.001), more often had asymmetric limb weakness (58% vs. 0%, p < 0.001), and less frequently had sensory deficits (0% vs. 40%, p < 0.001). In AFM, cerebrospinal fluid leukocyte counts were higher, whereas protein concentrations were lower. Spinal cord lesions on magnetic resonance imaging were only found in AFM patients. No GBS case fulfilled CDC criteria for definite AFM. Of the AFM cases, 8% fulfilled the Brighton criteria for GBS, when omitting the criterion of excluding an alternate diagnosis. CONCLUSIONS Despite the overlap in clinical presentation, we found distinctive early clinical and diagnostic characteristics for differentiating AFM from GBS in children. Diagnostic criteria for AFM and GBS usually perform well, but some AFM cases may fulfill clinical diagnostic criteria for GBS. This underlines the need to perform diagnostic tests early to exclude AFM in children suspected of atypical GBS.
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Affiliation(s)
- Jelte Helfferich
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Joyce Roodbol
- Department of Neurology and Pediatric Neurology, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marie-Claire de Wit
- Department of Pediatric Neurology, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Oebele F Brouwer
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bart C Jacobs
- Department of Neurology and Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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15
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Yeh EA, Yea C, Bitnun A. Infection-Related Myelopathies. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2021; 17:141-158. [PMID: 34637338 DOI: 10.1146/annurev-pathmechdis-040121-022818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Recent years have seen growing attention to inflammatory and infectious disorders of the spinal cord, not only due to the discovery of autoantibody-mediated disorders of the spinal cord [e.g., aquaporin-4 immunoglobulin G (IgG) antibodies and myelin oligodendrocyte glycoprotein IgG antibodies], but also due to the emergence of clusters of infection-related myelopathy, now known as acute flaccid myelitis. We review the spectrum of infection-related myelopathies and outline a nosological classification system based on association with infection. We describe the epidemiology and definitions of myelopathies, with a discussion of clinical presentation and neuroimaging features, and then turn to specific discussion of myelopathies due to direct pathogen invasion and those considered to be post- or parainfectious. Expected final online publication date for the Annual Review of Pathology: Mechanisms of Disease, Volume 17 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- E Ann Yeh
- Division of Neurology, Department of Pediatrics, and Division of Neuroscience and Mental Health, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada; , .,Faculty of Medicine, University of Toronto, Toronto, Ontario M5G 1X8, Canada;
| | - Carmen Yea
- Division of Neurology, Department of Pediatrics, and Division of Neuroscience and Mental Health, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada; ,
| | - Ari Bitnun
- Division of Infectious Diseases, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario M5G 1X8, Canada;
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16
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Filipe IC, Guedes MS, Zdobnov EM, Tapparel C. Enterovirus D: A Small but Versatile Species. Microorganisms 2021; 9:1758. [PMID: 34442837 PMCID: PMC8400195 DOI: 10.3390/microorganisms9081758] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 12/13/2022] Open
Abstract
Enteroviruses (EVs) from the D species are the causative agents of a diverse range of infectious diseases in spite of comprising only five known members. This small clade has a diverse host range and tissue tropism. It contains types infecting non-human primates and/or humans, and for the latter, they preferentially infect the eye, respiratory tract, gastrointestinal tract, and nervous system. Although several Enterovirus D members, in particular EV-D68, have been associated with neurological complications, including acute myelitis, there is currently no effective treatment or vaccine against any of them. This review highlights the peculiarities of this viral species, focusing on genome organization, functional elements, receptor usage, and pathogenesis.
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Affiliation(s)
- Ines Cordeiro Filipe
- Department of Microbiology and Molecular Medicine, University of Geneva, 1206 Geneva, Switzerland;
| | - Mariana Soares Guedes
- Department of Microbiology and Molecular Medicine, University of Geneva, 1206 Geneva, Switzerland;
| | - Evgeny M. Zdobnov
- Department of Genetic Medicine and Development, Switzerland and Swiss Institute of Bioinformatics, University of Geneva, 1206 Geneva, Switzerland;
| | - Caroline Tapparel
- Department of Microbiology and Molecular Medicine, University of Geneva, 1206 Geneva, Switzerland;
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17
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Weber EL, Werner JM, Johnson MB, Kim G, Tiongson E, Ramos-Platt L, Seruya M. Characteristics of Upper Extremity Recovery in Acute Flaccid Myelitis: A Case Series. Plast Reconstr Surg 2021; 147:645-655. [PMID: 33009334 DOI: 10.1097/prs.0000000000007583] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Clinical characteristics and timing associated with nonsurgical recovery of upper extremity function in acute flaccid myelitis are unknown. METHODS A single-institution retrospective case series was analyzed to describe clinical features of acute flaccid myelitis diagnosed between October of 2013 and December of 2016. Patients were consecutively sampled children with a diagnosis of acute flaccid myelitis who were referred to a hand surgeon. Patient factors and initial severity of paralysis were compared with upper extremity muscle strength outcomes using the Medical Research Council scale every 3 months up to 18 months after onset. RESULTS Twenty-two patients with acute flaccid myelitis (aged 2 to 16 years) were studied. Proximal upper extremity musculature was more frequently and severely affected, with 56 percent of patients affected bilaterally. Functional recovery of all muscle groups (≥M3) in an individual limb was observed in 43 percent of upper extremities within 3 months. Additional complete limb recovery to greater than or equal to M3 after 3 months was rarely observed. Extraplexal paralysis, including spinal accessory (72 percent), glossopharyngeal/hypoglossal (28 percent), lower extremity (28 percent), facial (22 percent), and phrenic nerves (17 percent), was correlated with greater severity of upper extremity paralysis and decreased spontaneous recovery. There was no correlation between severity of paralysis or recovery and patient characteristics, including age, sex, comorbidities, prodromal symptoms, or time to paralysis. CONCLUSIONS Spontaneous functional limb recovery, if present, occurred early, within 3 months of the onset of paralysis. The authors recommend that patients without signs of early recovery warrant consideration for early surgical intervention and referral to a hand surgeon or other specialist in peripheral nerve injury. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
- Erin L Weber
- From the Keck School of Medicine, University of Southern California; and the Children's Hospital Los Angeles
| | - Julie M Werner
- From the Keck School of Medicine, University of Southern California; and the Children's Hospital Los Angeles
| | - Maxwell B Johnson
- From the Keck School of Medicine, University of Southern California; and the Children's Hospital Los Angeles
| | - Gina Kim
- From the Keck School of Medicine, University of Southern California; and the Children's Hospital Los Angeles
| | - Emmanuelle Tiongson
- From the Keck School of Medicine, University of Southern California; and the Children's Hospital Los Angeles
| | - Leigh Ramos-Platt
- From the Keck School of Medicine, University of Southern California; and the Children's Hospital Los Angeles
| | - Mitchel Seruya
- From the Keck School of Medicine, University of Southern California; and the Children's Hospital Los Angeles
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18
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Hu Y, Kitamura N, Musharrafieh R, Wang J. Discovery of Potent and Broad-Spectrum Pyrazolopyridine-Containing Antivirals against Enteroviruses D68, A71, and Coxsackievirus B3 by Targeting the Viral 2C Protein. J Med Chem 2021; 64:8755-8774. [PMID: 34085827 PMCID: PMC9179928 DOI: 10.1021/acs.jmedchem.1c00758] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The enterovirus genus of the picornavirus family contains many important human pathogens. EV-D68 primarily infects children, and the disease manifestations range from respiratory illnesses to neurological complications such as acute flaccid myelitis (AFM). EV-A71 is a major pathogen for the hand, foot, and mouth disease (HFMD) in children and can also lead to AFM and death in severe cases. CVB3 infection can cause cardiac arrhythmias, acute heart failure, as well as type 1 diabetes. There is currently no FDA-approved antiviral for any of these enteroviruses. In this study, we report our discovery and development of pyrazolopyridine-containing small molecules with potent and broad-spectrum antiviral activity against multiple strains of EV-D68, EV-A71, and CVB3. Serial viral passage experiments, coupled with reverse genetics and thermal shift binding assays, suggested that these molecules target the viral protein 2C. Overall, the pyrazolopyridine inhibitors represent a promising class of candidates for the urgently needed nonpolio enterovirus antivirals.
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Affiliation(s)
- Yanmei Hu
- Department of Pharmacology and Toxicology, College of Pharmacy, The University of Arizona, Tucson, Arizona 85721, United States
| | - Naoya Kitamura
- Department of Pharmacology and Toxicology, College of Pharmacy, The University of Arizona, Tucson, Arizona 85721, United States
| | - Rami Musharrafieh
- Department of Pharmacology and Toxicology, College of Pharmacy, The University of Arizona, Tucson, Arizona 85721, United States
| | - Jun Wang
- Department of Pharmacology and Toxicology, College of Pharmacy, The University of Arizona, Tucson, Arizona 85721, United States
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19
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Abstract
Acute flaccid myelitis (AFM) is an incompletely understood neurologic disorder occurring in epidemic fashion causing weakness ranging from mild paresis to devastating paralysis in children and some adults. This article reviews the case definition of AFM as well as its epidemiology and association with enteroviral infection. The clinical presentation, diagnostic investigation with particular attention to electrodiagnostics, acute management, and surgical options are described. Clinical outcomes and considerations for acute and long-term rehabilitation management are discussed extensively based on review of current literature, highlighting avenues for further study.
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Affiliation(s)
- William Ide
- Department of Pediatric Rehabilitation, Kennedy Krieger Institute, 707 North Broadway, Ste. 232, Baltimore, MD 21205, USA; Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine
| | - Michelle Melicosta
- Department of Pediatric Rehabilitation, Kennedy Krieger Institute, 707 North Broadway, Ste. 232, Baltimore, MD 21205, USA; Department of Pediatrics, Johns Hopkins University School of Medicine
| | - Melissa K Trovato
- Department of Pediatric Rehabilitation, Kennedy Krieger Institute, 707 North Broadway, Ste. 232, Baltimore, MD 21205, USA; Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine.
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20
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Kaur R, Kumar K. Synthetic and medicinal perspective of quinolines as antiviral agents. Eur J Med Chem 2021; 215:113220. [PMID: 33609889 PMCID: PMC7995244 DOI: 10.1016/j.ejmech.2021.113220] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 12/17/2020] [Accepted: 01/18/2021] [Indexed: 12/20/2022]
Abstract
In current scenario, various heterocycles have come up exhibiting crucial role in various medicinal agents which are valuable for mankind. Out of diverse range of heterocycle, quinoline scaffold have been proved to play an important role in broad range of biological activities. Several drug molecules bearing a quinoline molecule with useful anticancer, antibacterial activities etc have been marketed such as chloroquine, saquinavir etc. Owing to their broad spectrum biological role, various synthetic strategies such as Skraup reaction, Combes reaction etc. has been developed by the researchers all over the world. But still the synthetic methods are associated with various limitations as formation of side products, use of expensive metal catalysts. Thus, several efforts to develop an efficient and cost effective synthetic protocol are still carried out till date. Moreover, quinoline scaffold displays remarkable antiviral activity. Therefore, in this review we have made an attempt to describe recent synthetic protocols developed by various research groups along with giving a complete explanation about the role of quinoline derivatives as antiviral agent. Quinoline derivatives were found potent against various strains of viruses like zika virus, enterovirus, herpes virus, human immunodeficiency virus, ebola virus, hepatitis C virus, SARS virus and MERS virus etc.
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Affiliation(s)
- Ramandeep Kaur
- Department of Pharmaceutical Chemistry, Indo-Soviet Friendship College of Pharmacy (ISFCP), Moga, Punjab, 142001, India
| | - Kapil Kumar
- School of Pharmacy and Technology Management, SVKM's NMIMS, Hyderabad, Telangana, 509301, India.
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21
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Murphy OC, Messacar K, Benson L, Bove R, Carpenter JL, Crawford T, Dean J, DeBiasi R, Desai J, Elrick MJ, Farias-Moeller R, Gombolay GY, Greenberg B, Harmelink M, Hong S, Hopkins SE, Oleszek J, Otten C, Sadowsky CL, Schreiner TL, Thakur KT, Van Haren K, Carballo CM, Chong PF, Fall A, Gowda VK, Helfferich J, Kira R, Lim M, Lopez EL, Wells EM, Yeh EA, Pardo CA. Acute flaccid myelitis: cause, diagnosis, and management. Lancet 2021; 397:334-346. [PMID: 33357469 PMCID: PMC7909727 DOI: 10.1016/s0140-6736(20)32723-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 09/15/2020] [Accepted: 09/17/2020] [Indexed: 12/20/2022]
Abstract
Acute flaccid myelitis (AFM) is a disabling, polio-like illness mainly affecting children. Outbreaks of AFM have occurred across multiple global regions since 2012, and the disease appears to be caused by non-polio enterovirus infection, posing a major public health challenge. The clinical presentation of flaccid and often profound muscle weakness (which can invoke respiratory failure and other critical complications) can mimic several other acute neurological illnesses. There is no single sensitive and specific test for AFM, and the diagnosis relies on identification of several important clinical, neuroimaging, and cerebrospinal fluid characteristics. Following the acute phase of AFM, patients typically have substantial residual disability and unique long-term rehabilitation needs. In this Review we describe the epidemiology, clinical features, course, and outcomes of AFM to help to guide diagnosis, management, and rehabilitation. Future research directions include further studies evaluating host and pathogen factors, including investigations into genetic, viral, and immunological features of affected patients, host-virus interactions, and investigations of targeted therapeutic approaches to improve the long-term outcomes in this population.
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Affiliation(s)
- Olwen C Murphy
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kevin Messacar
- Department of Pediatric Infectious Diseases, Children's Hospital Colorado, Aurora, CO, USA
| | - Leslie Benson
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Riley Bove
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Jessica L Carpenter
- Department of Neurology, Children's National Health System, Washington, DC, USA
| | - Thomas Crawford
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Janet Dean
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Roberta DeBiasi
- Department of Pediatric Infectious Diseases, Children's National Health System, Washington, DC, USA
| | - Jay Desai
- Division of Neurology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Matthew J Elrick
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Raquel Farias-Moeller
- Department of Neurology, Children's Hospital of Wisconsin and the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Grace Y Gombolay
- Department of Neurology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Benjamin Greenberg
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Matthew Harmelink
- Department of Neurology, Children's Hospital of Wisconsin and the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sue Hong
- Division of Pediatric Critical Care, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sarah E Hopkins
- Division of Neurology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joyce Oleszek
- Department of Physical Medicine and Rehabilitation, Children's Hospital Colorado, Aurora, CO, USA
| | - Catherine Otten
- Department of Pediatric Neurology, Seattle Children's Hospital, Seattle, WA, USA
| | - Cristina L Sadowsky
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA; International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Teri L Schreiner
- Department of Child Neurology, Children's Hospital Colorado, Aurora, CO, USA
| | - Kiran T Thakur
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Keith Van Haren
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Carolina M Carballo
- Department of Infectious Diseases, Hospital de Niños "Ricardo Gutiérrez", Buenos Aires, Argentina
| | - Pin Fee Chong
- Department of Pediatric Neurology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Amary Fall
- Institut Pasteur de Dakar, Département de Virologie, Dakar, Senegal
| | - Vykuntaraju K Gowda
- Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India
| | - Jelte Helfferich
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Ryutaro Kira
- Department of Pediatric Neurology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Ming Lim
- Children's Neuroscience Center, Evelina London Children's Hospital, Guy's and St Thomas' NHS Trust, and Faculty of Life Sciences, King's College, London, UK
| | - Eduardo L Lopez
- Department of Infectious Diseases, Hospital de Niños "Ricardo Gutiérrez", Buenos Aires, Argentina
| | - Elizabeth M Wells
- Department of Neurology, Children's National Health System, Washington, DC, USA
| | - E Ann Yeh
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada
| | - Carlos A Pardo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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22
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Jheng JR, Chen YS, Horng JT. Regulation of the proteostasis network during enterovirus infection: A feedforward mechanism for EV-A71 and EV-D68. Antiviral Res 2021; 188:105019. [PMID: 33484748 DOI: 10.1016/j.antiviral.2021.105019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 01/12/2021] [Accepted: 01/16/2021] [Indexed: 10/25/2022]
Abstract
The proteostasis network guarantees successful protein synthesis, folding, transportation, and degradation. Mounting evidence has revealed that this network maintains proteome integrity and is linked to cellular physiology, pathology, and virus infection. Human enterovirus A71 (EV-A71) and EV-D68 are suspected causative agents of acute flaccid myelitis, a severe poliomyelitis-like neurologic syndrome with no known cure. In this context, further clarification of the molecular mechanisms underlying EV-A71 and EV-D68 infection is paramount. Here, we summarize the components of the proteostasis network that are intercepted by EV-A71 and EV-D68, as well as antivirals that target this network and may help develop improved antiviral drugs.
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Affiliation(s)
- Jia-Rong Jheng
- Department of Biochemistry and Molecular Biology, College of Medicine, Chang Gung University, Kweishan, Taoyuan, Taiwan
| | - Yuan-Siao Chen
- Department of Biochemistry and Molecular Biology, College of Medicine, Chang Gung University, Kweishan, Taoyuan, Taiwan
| | - Jim-Tong Horng
- Department of Biochemistry and Molecular Biology, College of Medicine, Chang Gung University, Kweishan, Taoyuan, Taiwan; Research Center for Industry of Human Ecology and Graduate Institute of Health Industry Technology, Chang Gung University of Science and Technology, Taoyuan, Taiwan; Research Center for Emerging Viral Infections, College of Medicine, Chang Gung University, Kweishan, Taoyuan, Taiwan; Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
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23
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Ünver O, Türkdoğan D, Güler S, Kipoğlu O, Güngör M, Paketçi C, Çarman KB, Öztürk G, Genç HM, Özkan M, Dündar NO, Işık U, Karatoprak E, Kılıç B, Özkale M, Bayram E, Yarar C, Sözen HG, Sağer G, Güneş AS, Kahraman Koytak P, Karadağ Saygı E, Ekinci G, Saltık S, Çalışkan M, Kara B, Yiş U, Aydınlı N. Acute flaccid myelitis outbreak through 2016-2018: A multicenter experience from Turkey. Eur J Paediatr Neurol 2021; 30:113-120. [PMID: 33218883 DOI: 10.1016/j.ejpn.2020.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/04/2020] [Accepted: 10/30/2020] [Indexed: 10/23/2022]
Abstract
AIM We aim to describe the demographic characteristics, etiology, neurophysiology, imaging findings, treatment, prognosis, and prognostic factors of acute flaccid myelitis. METHODS The clinical data, laboratory test and, magnetic resonance imaging (MRI) results of pediatric patients diagnosed with acute flaccid myelitis according to the Centers for Disease Control criteria between August 1, 2016, and December 31, 2018, from 13 centers in Turkey were reviewed. RESULTS Of the 34 cases identified, 31 were confirmed (91.2%). Eighteen patients (55.9%) were boys. The median patient age was 4 years (interquartile range 2.5-6.9 years). Most of the patients were admitted in 2018 (n = 27). A preceding history of a febrile illness was reported in all patients, with a median of 4 days (interquartile range 3-7 days) before symptom onset. Thirty-one patients had T2 hyperintensity on spinal MRI, and 18 patients had cerebrospinal fluid pleocytosis. The most common infectious agents were entero/rhinoviruses (n = 5) in respiratory specimens. All patients except one received immunotherapy either alone or in combination. Among 27 patients with follow-up data 24 had persistent weakness. Involvement of four limbs together with an abnormal brain MRI at onset were associated with a poor prognosis. CONCLUSION The number of patients with acute flaccid myelitis increased since 2012, spiking with every 2-year interval, largely in the pediatric population. The median age decreases with every outbreak. Clinicians should be aware of the clinical picture for early collection of specimens and early start of rehabilitation programs. Further studies are needed to better characterize the etiology, pathogenesis, risk factors, and treatment of this rare condition.
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Affiliation(s)
- Olcay Ünver
- Division of Pediatric Neurology, Department of Pediatrics, Marmara University School of Medicine, İstanbul, Turkey.
| | - Dilşad Türkdoğan
- Division of Pediatric Neurology, Department of Pediatrics, Marmara University School of Medicine, İstanbul, Turkey
| | - Serhat Güler
- Division of Pediatric Neurology, Department of Pediatrics, İstanbul University Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Osman Kipoğlu
- Division of Pediatric Neurology, Department of Pediatrics, İstanbul University Faculty of Medicine, İstanbul, Turkey
| | - Mesut Güngör
- Division of Pediatric Neurology, Department of Pediatrics, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Cem Paketçi
- Division of Pediatric Neurology, Department of Pediatrics, Dokuz Eylül University Medical Faculty, İzmir, Turkey
| | - Kürşat Bora Çarman
- Division of Pediatric Neurology, Department of Pediatrics, Eskişehir Osmangazi University Medical Faculty, Eskişehir, Turkey
| | - Gülten Öztürk
- Division of Pediatric Neurology, Department of Pediatrics, Marmara University School of Medicine, İstanbul, Turkey
| | - Hülya Maraş Genç
- Division of Pediatric Neurology, Department of Pediatrics, Ümraniye Training and Research Hospital, İstanbul, Turkey
| | - Mehpare Özkan
- Division of Pediatric Neurology, Department of Pediatrics, Bahçeşehir University Medical Faculty, İstanbul, Turkey
| | - Nihal Olgaç Dündar
- Division of Pediatric Neurology, Department of Pediatrics, Izmir Katip Çelebi University Medical Faculty, İzmir, Turkey
| | - Uğur Işık
- Division of Pediatric Neurology, Department of Pediatrics, Acıbadem University School of Medicine, İstanbul, Turkey
| | - Elif Karatoprak
- Division of Pediatric Neurology, Department of Pediatrics, Medeniyet University School of Medicine, İstanbul, Turkey
| | - Betül Kılıç
- Division of Pediatric Neurology, Department of Pediatrics, Medipol University School of Medicine, İstanbul, Turkey
| | - Murat Özkale
- Division of Pediatric Intensive Care Unit, Department of Pediatrics, Başkent University School of Medicine, Adana, Turkey
| | - Erhan Bayram
- Division of Pediatric Neurology, Department of Pediatrics, Dokuz Eylül University Medical Faculty, İzmir, Turkey
| | - Coşkun Yarar
- Division of Pediatric Neurology, Department of Pediatrics, Eskişehir Osmangazi University Medical Faculty, Eskişehir, Turkey
| | - Hatice Gülhan Sözen
- Division of Pediatric Neurology, Department of Pediatrics, Ümraniye Training and Research Hospital, İstanbul, Turkey
| | - Güneş Sağer
- Division of Pediatric Neurology, Department of Pediatrics, Marmara University School of Medicine, İstanbul, Turkey
| | - Ayfer Sakarya Güneş
- Division of Pediatric Neurology, Department of Pediatrics, Kocaeli University School of Medicine, Kocaeli, Turkey
| | | | - Evrim Karadağ Saygı
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, İstanbul, Turkey
| | - Gazanfer Ekinci
- Department of Radiology, Yeditepe University School of Medicine, İstanbul, Turkey
| | - Sema Saltık
- Division of Pediatric Neurology, Department of Pediatrics, İstanbul University Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Mine Çalışkan
- Division of Pediatric Neurology, Department of Pediatrics, İstanbul University Faculty of Medicine, İstanbul, Turkey; İstanbul University Institute of Child Health, İstanbul, Turkey
| | - Bülent Kara
- Division of Pediatric Neurology, Department of Pediatrics, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Uluç Yiş
- Division of Pediatric Neurology, Department of Pediatrics, Dokuz Eylül University Medical Faculty, İzmir, Turkey
| | - Nur Aydınlı
- Division of Pediatric Neurology, Department of Pediatrics, İstanbul University Faculty of Medicine, İstanbul, Turkey
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Elrick MJ, Pekosz A, Duggal P. Enterovirus D68 molecular and cellular biology and pathogenesis. J Biol Chem 2021; 296:100317. [PMID: 33484714 PMCID: PMC7949111 DOI: 10.1016/j.jbc.2021.100317] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 12/13/2022] Open
Abstract
In recent years, enterovirus D68 (EV-D68) has advanced from a rarely detected respiratory virus to a widespread pathogen responsible for increasing rates of severe respiratory illness and acute flaccid myelitis (AFM) in children worldwide. In this review, we discuss the accumulating data on the molecular features of EV-D68 and place these into the context of enterovirus biology in general. We highlight similarities and differences with other enteroviruses and genetic divergence from own historical prototype strains of EV-D68. These include changes in capsid antigens, host cell receptor usage, and viral RNA metabolism collectively leading to increased virulence. Furthermore, we discuss the impact of EV-D68 infection on the biology of its host cells, and how these changes are hypothesized to contribute to motor neuron toxicity in AFM. We highlight areas in need of further research, including the identification of its primary receptor and an understanding of the pathogenic cascade leading to motor neuron injury in AFM. Finally, we discuss the epidemiology of the EV-D68 and potential therapeutic approaches.
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Affiliation(s)
- Matthew J Elrick
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
| | - Andrew Pekosz
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Priya Duggal
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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25
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Hopkins SE, Desai J, Benson L. Acute Flaccid Myelitis: A Call for Vigilance and an Update on Management. Pediatr Neurol 2021; 114:26-28. [PMID: 33190069 PMCID: PMC7481844 DOI: 10.1016/j.pediatrneurol.2020.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 08/30/2020] [Accepted: 09/05/2020] [Indexed: 01/19/2023]
Affiliation(s)
- Sarah E. Hopkins
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Communications should be addressed to: Dr. Hopkins; Division of Neurology; Children’s Hospital of Philadelphia; Perelman School of Medicine at the University of Pennsylvania; 3501 Civic Center Boulevard; Philadelphia, PA 19104
| | - Jay Desai
- Division of Neurology, Children’s Hospital of Los Angeles, Los Angeles, California
| | - Leslie Benson
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
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26
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Hardy D, Hopkins S. Update on acute flaccid myelitis: recognition, reporting, aetiology and outcomes. Arch Dis Child 2020; 105:842-847. [PMID: 32041735 DOI: 10.1136/archdischild-2019-316817] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 01/08/2020] [Accepted: 01/17/2020] [Indexed: 12/31/2022]
Abstract
Acute flaccid myelitis, defined by acute flaccid limb weakness in the setting of grey matter lesions of the spinal cord, became increasingly recognised in 2014 following outbreaks in Colorado and California, temporally associated with an outbreak of enterovirus D68 respiratory disease. Since then, there have been biennial increases in late summer/early fall. A viral infectious aetiology, most likely enteroviral, is strongly suspected, but a definitive connection has yet to be established. Patients typically present with asymmetric weakness, maximal proximally, in the setting of a febrile illness. MRI demonstrates T2/FLAIR abnormalities in the central grey matter of the spinal cord, and cerebrospinal fluid typically shows a lymphocytic pleocytosis with variable elevation in protein. The weakness may be progressive over several days and involve respiratory muscles, making early recognition and close monitoring essential. Other complications in the acute period may include autonomic instability and bowel/bladder involvement. There is no clear recommended treatment at this time, although intravenous immunoglobulin, steroids and plasma exchange have been used. Intensive therapies and rehab services have shown benefit in maximising function, and surgical interventions may be considered in cases without optimal response to therapies. Close attention should also be paid to psychosocial factors. Prognosis is generally guarded, and additional factors that predict final outcome, including host factors and treatment effects, have yet to be elucidated. Multicentre collaborative efforts will be required to provide answers about this rare but serious disorder.
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Affiliation(s)
- Duriel Hardy
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sarah Hopkins
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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27
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Enterovirus infection and acute flaccid myelitis. Curr Opin Virol 2020; 40:55-60. [PMID: 32711392 DOI: 10.1016/j.coviro.2020.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 06/12/2020] [Accepted: 06/17/2020] [Indexed: 12/16/2022]
Abstract
Recent outbreaks of limb paralysis similar to poliomyelitis, termed acute flaccid myelitis (AFM), have prompted intense investigation into potential etiology. Peaks of AFM were seen in the United States in 2012, 2014, 2016 and 2018, coincident with peaks in enterovirus transmission, particularly EV-D68. Similar peaks of AFM and EV-D68 circulation were reported in other parts of the world. The causal relationship between EV-D68 is still not widely accepted as it is for poliovirus and EV-A71, the latter of which is endemic in the US. Recent in vitro and mouse model data as well as enhanced-sensitivity diagnostic assays have provided further evidence linking the causal relationship between EV-D68 and AFM. In addition, an outbreak of EV-A71-associated AFM was recently described, highlighting the possibility of an additional emerging non-polio enterovirus of public health concern. As AFM is a devastating disease with poor prognosis in many children, particularly those with EV-D68, recent studies call for increased surveillance, pursuit of novel therapeutics and strategies to prevent transmission before the next outbreak.
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28
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Abstract
Enterovirus D68 (EV-D68) is an RNA virus that causes respiratory illnesses mainly in children. In severe cases, it can lead to neurological complications such as acute flaccid myelitis (AFM). EV-D68 belongs to the enterovirus genera of the Picornaviridae family, which also includes many other significant human pathogens such as poliovirus, enterovirus A71, and rhinovirus. There are currently no vaccines or antivirals against EV-D68. In this review, we present the current understanding of the link between EV-D68 and AFM, the mechanism of viral replication, and recent progress in developing EV-D68 antivirals by targeting various viral proteins and host factors that are essential for viral replication. The future directions of EV-D68 antiviral drug discovery and the criteria for drugs to reach clinical trials are also discussed.
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Affiliation(s)
- Yanmei Hu
- Department of Pharmacology and Toxicology, College of Pharmacy, The University of Arizona, Tucson, USA, 85721
| | - Rami Musharrafieh
- Department of Pharmacology and Toxicology, College of Pharmacy, The University of Arizona, Tucson, USA, 85721
| | - Madeleine Zheng
- Department of Pharmacology and Toxicology, College of Pharmacy, The University of Arizona, Tucson, USA, 85721
| | - Jun Wang
- Department of Pharmacology and Toxicology, College of Pharmacy, The University of Arizona, Tucson, USA, 85721
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29
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Omura S, Sato F, Park AM, Fujita M, Khadka S, Nakamura Y, Katsuki A, Nishio K, Gavins FNE, Tsunoda I. Bioinformatics Analysis of Gut Microbiota and CNS Transcriptome in Virus-Induced Acute Myelitis and Chronic Inflammatory Demyelination; Potential Association of Distinct Bacteria With CNS IgA Upregulation. Front Immunol 2020; 11:1138. [PMID: 32733435 PMCID: PMC7358278 DOI: 10.3389/fimmu.2020.01138] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 05/11/2020] [Indexed: 02/05/2023] Open
Abstract
Virus infections have been associated with acute and chronic inflammatory central nervous system (CNS) diseases, e.g., acute flaccid myelitis (AFM) and multiple sclerosis (MS), where animal models support the pathogenic roles of viruses. In the spinal cord, Theiler's murine encephalomyelitis virus (TMEV) induces an AFM-like disease with gray matter inflammation during the acute phase, 1 week post infection (p.i.), and an MS-like disease with white matter inflammation during the chronic phase, 1 month p.i. Although gut microbiota has been proposed to affect immune responses contributing to pathological conditions in remote organs, including the brain pathophysiology, its precise role in neuroinflammatory diseases is unclear. We infected SJL/J mice with TMEV; harvested feces and spinal cords on days 4 (before onset), 7 (acute phase), and 35 (chronic phase) p.i.; and examined fecal microbiota by 16S rRNA sequencing and CNS transcriptome by RNA sequencing. Although TMEV infection neither decreased microbial diversity nor changed overall microbiome patterns, it increased abundance of individual bacterial genera Marvinbryantia on days 7 and 35 p.i. and Coprococcus on day 35 p.i., whose pattern-matching with CNS transcriptome showed strong correlations: Marvinbryantia with eight T-cell receptor (TCR) genes on day 7 and with seven immunoglobulin (Ig) genes on day 35 p.i.; and Coprococcus with gene expressions of not only TCRs and IgG/IgA, but also major histocompatibility complex (MHC) and complements. The high gene expression of IgA, a component of mucosal immunity, in the CNS was unexpected. However, we observed substantial IgA positive cells and deposition in the CNS, as well as a strong correlation between CNS IgA gene expression and serum anti-TMEV IgA titers. Here, changes in a small number of distinct gut bacteria, but not overall gut microbiota, could affect acute and chronic immune responses, causing AFM- and MS-like lesions in the CNS. Alternatively, activated immune responses would alter the composition of gut microbiota.
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Affiliation(s)
- Seiichi Omura
- Department of Microbiology, Kindai University Faculty of Medicine, Osaka, Japan
- Department of Microbiology and Immunology, Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA, United States
| | - Fumitaka Sato
- Department of Microbiology, Kindai University Faculty of Medicine, Osaka, Japan
- Department of Microbiology and Immunology, Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA, United States
| | - Ah-Mee Park
- Department of Microbiology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Mitsugu Fujita
- Department of Microbiology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Sundar Khadka
- Department of Microbiology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Yumina Nakamura
- Department of Microbiology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Aoshi Katsuki
- Department of Microbiology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Kazuto Nishio
- Department of Genome Biology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Felicity N. E. Gavins
- Department of Molecular and Cellular Physiology, Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA, United States
- Department of Biosciences, College of Health and Life Sciences, Brunel University London, Uxbridge, United Kingdom
| | - Ikuo Tsunoda
- Department of Microbiology, Kindai University Faculty of Medicine, Osaka, Japan
- Department of Microbiology and Immunology, Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA, United States
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30
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Vogt MR, Fu J, Kose N, Williamson LE, Bombardi R, Setliff I, Georgiev IS, Klose T, Rossmann MG, Bochkov YA, Gern JE, Kuhn RJ, Crowe JE. Human antibodies neutralize enterovirus D68 and protect against infection and paralytic disease. Sci Immunol 2020; 5:5/49/eaba4902. [PMID: 32620559 DOI: 10.1126/sciimmunol.aba4902] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 06/12/2020] [Indexed: 12/17/2022]
Abstract
Enterovirus D68 (EV-D68) causes outbreaks of respiratory illness, and there is increasing evidence that it causes outbreaks of acute flaccid myelitis (AFM). There are no licensed therapies to prevent or treat EV-D68 infection or AFM disease. We isolated a panel of EV-D68-reactive human monoclonal antibodies that recognize diverse antigenic variants from participants with prior infection. One potently neutralizing cross-reactive antibody, EV68-228, protected mice from respiratory and neurologic disease when given either before or after infection. Cryo-electron microscopy studies revealed that EV68-228 and another potently neutralizing antibody (EV68-159) bound around the fivefold or threefold axes of symmetry on virion particles, respectively. The structures suggest diverse mechanisms of action by these antibodies. The high potency and effectiveness observed in vivo suggest that antibodies are a mechanistic correlate of protection against AFM disease and are candidates for clinical use in humans with EV-D68 infection.
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Affiliation(s)
- Matthew R Vogt
- Department of Pediatrics (Infectious Diseases), Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jianing Fu
- Department of Biological Sciences and Purdue Institute of Inflammation, Immunology, and Infectious Disease, Purdue University, West Lafayette, IN, USA
| | - Nurgun Kose
- Vanderbilt Vaccine Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lauren E Williamson
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robin Bombardi
- Vanderbilt Vaccine Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ian Setliff
- Program in Chemical and Physical Biology, Vanderbilt University, Nashville, TN, USA
| | - Ivelin S Georgiev
- Vanderbilt Vaccine Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Thomas Klose
- Department of Biological Sciences and Purdue Institute of Inflammation, Immunology, and Infectious Disease, Purdue University, West Lafayette, IN, USA
| | - Michael G Rossmann
- Department of Biological Sciences and Purdue Institute of Inflammation, Immunology, and Infectious Disease, Purdue University, West Lafayette, IN, USA
| | - Yury A Bochkov
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, USA
| | - James E Gern
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, USA.,Department of Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Richard J Kuhn
- Department of Biological Sciences and Purdue Institute of Inflammation, Immunology, and Infectious Disease, Purdue University, West Lafayette, IN, USA
| | - James E Crowe
- Department of Pediatrics (Infectious Diseases), Vanderbilt University Medical Center, Nashville, TN, USA. .,Vanderbilt Vaccine Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA.,Program in Chemical and Physical Biology, Vanderbilt University, Nashville, TN, USA
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31
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Bastemur M, Gocmen R, Parlak S, Yuksel D, Arslan EA, Okten AY, Iscan A, Ekici B, Anlar B. Pontine Tegmentum Lesions Accompanying Myelitis During an Enterovirus Outbreak: Differential Diagnosis and Outcome. J Child Neurol 2020; 35:501-508. [PMID: 32507080 DOI: 10.1177/0883073820911737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AIM To investigate etiology and prognostic significance of pontine tegmentum lesions accompanying a cluster of acute flaccid myelitis. METHOD We retrospectively examined patients from 6 centers in Turkey who manifested encephalitis or myelitis associated with dorsal pontine lesions on magnetic resonance imaging (MRI) between July 2018 and February 2019. RESULTS Twenty-two patients were evaluated. Ten of 22 (45%) presented with acute paralysis and 12 of 22 (55%) with brainstem symptoms only. Reverse transcription polymerase chain reaction for enterovirus was positive in 2 patients' respiratory tract. Other etiologic factors were detected in 10 cases. On follow-up, patients presenting with symptoms of myelitis developed motor sequalae although spinal cord lesions on MRI resolved in 5 of 9 (55%). Encephalitic symptoms, present in 17 cases, recovered in 13 (76%), and brain MRI showed complete or near-complete resolution in 11 of 14 (78%). CONCLUSION Various etiologic agents can be detected in patients with pontine involvement, even in a series collected during an outbreak of EV-D68. Encephalitis has a fair outcome but clinical recovery is slow and motor sequalae are frequent in spinal involvement, irrespective of follow-up spinal MRI findings.
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Affiliation(s)
- Mehmet Bastemur
- Department of Pediatric Neurology, Ihsan Doğramaci Children's Hospital, Faculty of Medicine, Hacettepe University, Ankara
| | - Rahsan Gocmen
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Safak Parlak
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Deniz Yuksel
- Department of Pediatric Neurology, Dr. Sami Ulus Children's Hospital, Ankara, Turkey
| | - Elif Acar Arslan
- Department of Pediatric Neurology, Karadeniz Technical University Trabzon, Turkey
| | | | - Akin Iscan
- Department of Pediatric Neurology, Faculty of Medicine, Bezmialem Vakıf University, Istanbul, Turkey
| | | | - Banu Anlar
- Department of Pediatric Neurology, Ihsan Doğramaci Children's Hospital, Faculty of Medicine, Hacettepe University, Ankara
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32
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Downey R, McElvain D, Murphey DK, Bailey A, Patel B, Fernandez M, Loftis L, Carreno CG, Eger L, Aguilera EA, Wootton S, Castagnini LA, Hauger SB. Acute Flaccid Myelitis Among Hospitalized Children in Texas, 2016. Pediatr Neurol 2020; 106:50-55. [PMID: 32192819 DOI: 10.1016/j.pediatrneurol.2020.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 01/13/2020] [Accepted: 01/21/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Acute flaccid myelitis is characterized by acute-onset flaccid limb weakness with predominantly gray matter lesions in the spinal cord spanning one or more segments. Rates of full recovery are poor, and there is no standard treatment or definitive cause. METHODS This is a retrospective review of children diagnosed with acute flaccid myelitis in Texas during 2016. Patients were identified through a Texas collaborative of six hospitals in four major metropolitan areas. Data abstraction included health history, illness presentation, medical treatments, laboratory studies, imaging data, recovery, and ability to perform activities of daily living up to approximately two years from illness onset. RESULTS Among all sites, 21 patients met inclusion criteria. Treatments varied with the most common being intravenous immunoglobulin, high-dose methylprednisolone, and plasmapheresis. No differences were seen in response to medical treatments. A potential etiology was found in 12 (57%) cases, including four with enterovirus D68. Five cases recovered fully. Of the 16 patients without full recovery, abilities ranged from (1) able to perform all activities of daily living for age independently (n = 5), (2) mild deficits (n = 5), and (3) substantial reliance on caregivers for activities of daily living (n = 6). CONCLUSION Many reports describe symptoms and outcomes of acute flaccid myelitis, but limited data are available on long-term functional outcomes. We were unable to make a strong case for any single cause or treatment modality. Fortunately, the majority of patients (15, 71%) were able to perform activities of daily living with complete independence or only mild deficits.
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Affiliation(s)
- Rachel Downey
- Pediatric Infectious Diseases, Dell Children's Medical Group, Austin, Texas; Dell Children's Medical Center of Central Texas, Austin, Texas.
| | - Dawn McElvain
- Dell Children's Medical Center of Central Texas, Austin, Texas; Pediatric Neurology, Child Neurology Consultants of Austin, Austin Texas
| | - Donald K Murphey
- Pediatric Infectious Diseases, Dell Children's Medical Group, Austin, Texas; Dell Children's Medical Center of Central Texas, Austin, Texas; The University of Texas at Austin Dell Medical School, Austin, Texas
| | - Ann Bailey
- Infection Prevention, Dell Children's Medical Center of Central Texas, Austin, Texas
| | - Bhairav Patel
- Dell Children's Medical Center of Central Texas, Austin, Texas; Neuroradiology, Austin Radiological Association, Austin Texas
| | - Marisol Fernandez
- Pediatric Infectious Diseases, Dell Children's Medical Group, Austin, Texas; Dell Children's Medical Center of Central Texas, Austin, Texas; The University of Texas at Austin Dell Medical School, Austin, Texas
| | - Laura Loftis
- Pediatrics and Medical Ethics, Baylor College of Medicine, Section of Pediatric Critical Care, Texas Children's Hospital, Houston, Texas
| | | | - Lynne Eger
- Infectious Diseases, Cook Children's Medical Center, Fort Worth, Texas
| | - Elizabeth A Aguilera
- Pediatrics, Infectious Diseases, The University of Texas, McGovern Medical School, Houston Texas
| | - Susan Wootton
- Pediatrics, Infectious Diseases, The University of Texas, McGovern Medical School, Houston Texas
| | - Luis A Castagnini
- Pediatrics, Baylor College of Medicine, Section Chief of Pediatric Infectious Diseases, San Antonio, Texas; Children's Hospital of San Antonio, San Antonio, Texas
| | - Sarmistha B Hauger
- Pediatric Infectious Diseases, Dell Children's Medical Group, Austin, Texas; Dell Children's Medical Center of Central Texas, Austin, Texas; The University of Texas at Austin Dell Medical School, Austin, Texas
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33
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Hu YL, Chang LY. Current status of enterovirus D68 worldwide and in Taiwan. Pediatr Neonatol 2020; 61:9-15. [PMID: 31706947 DOI: 10.1016/j.pedneo.2019.09.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 07/09/2019] [Accepted: 09/10/2019] [Indexed: 10/26/2022] Open
Abstract
Enterovirus D68 was first identified in 1962 and caused a worldwide outbreak starting from the North America in 2014. Enterovirus D68 has been in continuous circulation among many countries recently, including Taiwan. Reports also reveal high seroprevalence, which indicates that the disease burden of enterovirus D68 may be underestimated via viral culture or polymerase chain reaction results. Although most infected cases have mild respiratory illness, severe complications including acute flaccid myelitis and acute respiratory distress syndrome have also been reported. In the position of an emerging pathogen, enterovirus D68 poses a threat to public health and may cause devastating diseases. Diverse severity of neurological sequelae remains inevitable among acute flaccid myelitis patients, but no curable treatment is available currently. According to the management suggestions of the American Centers of Disease Control, uses of corticosteroids and plasmapheresis are either preferred or avoided and intravenous immunoglobulin also has no clear indication in the treatment for acute flaccid myelitis. In this review article, we provide information about the epidemiology, clinical recognition and treatment strategy of enterovirus D68. Better understanding of this disease is the foothold for advanced investigation and monitoring in the future.
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Affiliation(s)
- Ya-Li Hu
- Department of Pediatrics, New Taipei City Hospital, New Taipei City, Taiwan
| | - Luan-Yin Chang
- Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Bubba L, Broberg EK, Jasir A, Simmonds P, Harvala H. Circulation of non-polio enteroviruses in 24 EU and EEA countries between 2015 and 2017: a retrospective surveillance study. THE LANCET. INFECTIOUS DISEASES 2019; 20:350-361. [PMID: 31870905 DOI: 10.1016/s1473-3099(19)30566-3] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/10/2019] [Accepted: 09/11/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Enteroviruses can cause severe infections, especially in young children. Non-polio enterovirus infections are not notifiable in most countries in the EU and European Economic Area (EEA) region, and surveillance varies substantially between countries. We collected and analysed available enterovirus data across EU and EEA countries to assess the current epidemiological situation and need for standardising surveillance. METHODS Aggregated data on any enterovirus detected between Jan 1, 2015, and Dec 31, 2017, through national enterovirus reference laboratories were requested from representatives in all 31 EU and EEA countries. Information collected included enterovirus types detected by month, patient age group, symptom, and specimen type. We also collected sequence data on viral capsid sequences for the three most clinically relevant enterovirus types, as identified from the data. FINDINGS Aggregated data were provided by representatives from 24 (77%) of 31 countries. 9914 (66%) of 14 999 enterovirus infections with information about age were in children younger than 5 years, and 3197 (45%) of 7139 individuals for whom symptoms were reported had neurological symptoms. Other symptoms were non-specific fever (in 1607 [23%] patients), respiratory symptoms (in 1197 [17%] patients), hand, foot, and mouth disease (in 528 [7% patients), and myocarditis (in 39 [1%] patients). 68 deaths were temporally associated with enterovirus infection. Typing for 11 559 (67%) of 17 136 specimens revealed 66 enterovirus types. Coxsackievirus A6 was the most frequently detected enterovirus type (in 1556 [13%] of 11 559 typed enteroviruses), and 292 (65%) of 448 patients with coxsackievirus A6 infection with available clinical data presented with hand, foot, and mouth disease. Echovirus 30 was the second most frequently detected enterovirus type, representing 1412 (12%) of 11 559 typed enteroviruses, and 384 (82%) of 467 individuals with echovirus 30 infection with available clinical data had neurological symptoms. Sequences available from 18 countries showed circulation of newly emerging strains of enterovirus A71 and enterovirus D68. INTERPRETATION To our knowledge, this study is the largest investigation of enterovirus circulation in EU and EEA countries and confirms the availability of non-polio enterovirus data in the region. Our study highlights the wide circulation of non-polio enteroviruses in Europe, mostly affecting young children and leading to neurological symptoms. Collecting data on morbidity and mortality related to enterovirus infections, as well as harmonising case definition for surveillance, should be encouraged. FUNDING None.
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Affiliation(s)
- Laura Bubba
- Bacteriology Reference Department, Public Health England, London, UK; European Programme for Public Health Microbiology Training, Solna, Sweden
| | - Eeva K Broberg
- European Centre for Disease Prevention and Control, Solna, Sweden
| | - Aftab Jasir
- European Centre for Disease Prevention and Control, Solna, Sweden
| | - Peter Simmonds
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Heli Harvala
- Microbiology Services, National Health Service (NHS) Blood and Transplant, London, UK; Division of Infection and Immunity, University College London, London, UK.
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Bauer L, Manganaro R, Zonsics B, Strating JRPM, El Kazzi P, Lorenzo Lopez M, Ulferts R, van Hoey C, Maté MJ, Langer T, Coutard B, Brancale A, van Kuppeveld FJM. Fluoxetine Inhibits Enterovirus Replication by Targeting the Viral 2C Protein in a Stereospecific Manner. ACS Infect Dis 2019; 5:1609-1623. [PMID: 31305993 PMCID: PMC6747591 DOI: 10.1021/acsinfecdis.9b00179] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
![]()
Enteroviruses
(family Picornaviridae) comprise a large group of
human pathogens against which no licensed antiviral therapy exists.
Drug-repurposing screens uncovered the FDA-approved drug fluoxetine
as a replication inhibitor of enterovirus B and D species. Fluoxetine
likely targets the nonstructural viral protein 2C, but detailed mode-of-action
studies are missing because structural information on 2C of fluoxetine-sensitive
enteroviruses is lacking. We here show that broad-spectrum anti-enteroviral
activity of fluoxetine is stereospecific concomitant with binding
to recombinant 2C. (S)-Fluoxetine inhibits with a
5-fold lower 50% effective concentration (EC50) than racemic
fluoxetine. Using a homology model of 2C of the fluoxetine-sensitive
enterovirus coxsackievirus B3 (CVB3) based upon a recently elucidated
structure of a fluoxetine-insensitive enterovirus, we predicted stable
binding of (S)-fluoxetine. Structure-guided mutations
disrupted binding and rendered coxsackievirus B3 (CVB3) resistant
to fluoxetine. The study provides new insights into the anti-enteroviral
mode-of-action of fluoxetine. Importantly, using only (S)-fluoxetine would allow for lower dosing in patients, thereby likely
reducing side effects.
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Affiliation(s)
- Lisa Bauer
- Virology Division, Department of Infectious Diseases and Immunology, Faculty of Veterinary Medicine, Utrecht University, Utrecht 3584CL, The Netherlands
| | - Roberto Manganaro
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, King Edward VII Avenue, Cardiff CF10 3NB, United Kingdom
| | - Birgit Zonsics
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, King Edward VII Avenue, Cardiff CF10 3NB, United Kingdom
| | - Jeroen R. P. M. Strating
- Virology Division, Department of Infectious Diseases and Immunology, Faculty of Veterinary Medicine, Utrecht University, Utrecht 3584CL, The Netherlands
| | - Priscila El Kazzi
- Architecture et Fonction des Macromolécules Biologiques, UMR 6098 Centre National de la Recherche Scientifique, Université de la Méditerranée and Université de Provence, Aix-Marseille Université, Case 925, 163 Avenue de Luminy, Marseille 3288 CEDEX 9, France
| | - Moira Lorenzo Lopez
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, King Edward VII Avenue, Cardiff CF10 3NB, United Kingdom
| | - Rachel Ulferts
- Virology Division, Department of Infectious Diseases and Immunology, Faculty of Veterinary Medicine, Utrecht University, Utrecht 3584CL, The Netherlands
| | - Clara van Hoey
- Department of Pharmaceutical Chemistry, Faculty of Life Sciences, University of Vienna, Althanstraße 14, Vienna A-1090, Austria
| | - Maria J. Maté
- Architecture et Fonction des Macromolécules Biologiques, UMR 6098 Centre National de la Recherche Scientifique, Université de la Méditerranée and Université de Provence, Aix-Marseille Université, Case 925, 163 Avenue de Luminy, Marseille 3288 CEDEX 9, France
| | - Thierry Langer
- Department of Pharmaceutical Chemistry, Faculty of Life Sciences, University of Vienna, Althanstraße 14, Vienna A-1090, Austria
| | - Bruno Coutard
- Architecture et Fonction des Macromolécules Biologiques, UMR 6098 Centre National de la Recherche Scientifique, Université de la Méditerranée and Université de Provence, Aix-Marseille Université, Case 925, 163 Avenue de Luminy, Marseille 3288 CEDEX 9, France
- Unité des Virus Emergents, UVE: Aix-Marseille Univ-IRD 190-Inserm 1207-IHU Méditerranée Infection, 13385 Marseille, CEDEX 5, France
| | - Andrea Brancale
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, King Edward VII Avenue, Cardiff CF10 3NB, United Kingdom
| | - Frank J. M. van Kuppeveld
- Virology Division, Department of Infectious Diseases and Immunology, Faculty of Veterinary Medicine, Utrecht University, Utrecht 3584CL, The Netherlands
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Hixon AM, Frost J, Rudy MJ, Messacar K, Clarke P, Tyler KL. Understanding Enterovirus D68-Induced Neurologic Disease: A Basic Science Review. Viruses 2019; 11:E821. [PMID: 31487952 PMCID: PMC6783995 DOI: 10.3390/v11090821] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 08/28/2019] [Accepted: 08/29/2019] [Indexed: 12/28/2022] Open
Abstract
In 2014, the United States (US) experienced an unprecedented epidemic of enterovirus D68 (EV-D68)-induced respiratory disease that was temporally associated with the emergence of acute flaccid myelitis (AFM), a paralytic disease occurring predominantly in children, that has a striking resemblance to poliomyelitis. Although a definitive causal link between EV-D68 infection and AFM has not been unequivocally established, rapidly accumulating clinical, immunological, and epidemiological evidence points to EV-D68 as the major causative agent of recent seasonal childhood AFM outbreaks in the US. This review summarizes evidence, gained from in vivo and in vitro models of EV-D68-induced disease, which demonstrates that contemporary EV-D68 strains isolated during and since the 2014 outbreak differ from historical EV-D68 in several factors influencing neurovirulence, including their genomic sequence, their receptor utilization, their ability to infect neurons, and their neuropathogenicity in mice. These findings provide biological plausibility that EV-D68 is a causal agent of AFM and provide important experimental models for studies of pathogenesis and treatment that are likely to be difficult or impossible in humans.
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Affiliation(s)
- Alison M Hixon
- Medical Scientist Training Program, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Joshua Frost
- Department of Immunology & Microbiology, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Michael J Rudy
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Kevin Messacar
- Hospital Medicine and Pediatric Infectious Disease Sections, Department of Pediatrics, University of Colorado, Aurora, CO 80045, USA.
- Children's Hospital Colorado, Aurora, CO 80045, USA.
| | - Penny Clarke
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO 80045, USA.
| | - Kenneth L Tyler
- Department of Immunology & Microbiology, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Division of Infectious Disease, Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Neurology Service, Rocky Mountain VA Medical Center, Aurora, CO 80045, USA
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Abstract
Acute flaccid myelitis is a disease that affects the anterior horn cells of the spinal cord, leading to rapid onset of flaccid paralysis. Recent biennial epidemics, beginning in the summer of 2014, have been associated with enterovirus D68, although the underlying pathophysiology is unknown. Patients present with asymmetric flaccid weakness of the extremities, with cranial neuropathy and without encephalopathy, and often have residual disability. Here we review the current literature on this disabling disease and discuss treatment modalities and ongoing research.
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Affiliation(s)
- Alison Christy
- 1 Alison Christy, Providence Health & Services, Pediatric Neurology, Portland, OR, USA
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Contemporary Circulating Enterovirus D68 Strains Infect and Undergo Retrograde Axonal Transport in Spinal Motor Neurons Independent of Sialic Acid. J Virol 2019; 93:JVI.00578-19. [PMID: 31167912 DOI: 10.1128/jvi.00578-19] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 06/01/2019] [Indexed: 12/25/2022] Open
Abstract
Enterovirus D68 (EV-D68) is an emerging virus that has been identified as a cause of recent outbreaks of acute flaccid myelitis (AFM), a poliomyelitis-like spinal cord syndrome that can result in permanent paralysis and disability. In experimental mouse models, EV-D68 spreads to, infects, and kills spinal motor neurons following infection by various routes of inoculation. The topography of virus-induced motor neuron loss correlates with the pattern of paralysis. The mechanism(s) by which EV-D68 spreads to target motor neurons remains unclear. We sought to determine the capacity of EV-D68 to spread by the neuronal route and to determine the role of known EV-D68 receptors, sialic acid and intracellular adhesion molecule 5 (ICAM-5), in neuronal infection. To do this, we utilized a microfluidic chamber culture system in which human induced pluripotent stem cell (iPSC) motor neuron cell bodies and axons can be compartmentalized for independent experimental manipulation. We found that EV-D68 can infect motor neurons via their distal axons and spread by retrograde axonal transport to the neuronal cell bodies. Virus was not released from the axons via anterograde axonal transport after infection of the cell bodies. Prototypic strains of EV-D68 depended on sialic acid for axonal infection and transport, while contemporary circulating strains isolated during the 2014 EV-D68 outbreak did not. The pattern of infection did not correspond with the ICAM-5 distribution and expression in either human tissue, the mouse model, or the iPSC motor neurons.IMPORTANCE Enterovirus D68 (EV-D68) infections are on the rise worldwide. Since 2014, the United States has experienced biennial spikes in EV-D68-associated acute flaccid myelitis (AFM) that have left hundreds of children paralyzed. Much remains to be learned about the pathogenesis of EV-D68 in the central nervous system (CNS). Herein we investigated the mechanisms of EV-D68 CNS invasion through neuronal pathways. A better understanding of EV-D68 infection in experimental models may allow for better prevention and treatment strategies of EV-D68 CNS disease.
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Kilmer M, Shreve M, Jarrett A. Clarifying the Diagnosis of Acute Flaccid Myelitis. J Nurse Pract 2019. [DOI: 10.1016/j.nurpra.2019.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Sun J, Hu XY, Yu XF. Current Understanding of Human Enterovirus D68. Viruses 2019; 11:v11060490. [PMID: 31146373 PMCID: PMC6631698 DOI: 10.3390/v11060490] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/08/2019] [Accepted: 05/13/2019] [Indexed: 12/20/2022] Open
Abstract
Human enterovirus D68 (EV-D68), a member of the species Enterovirus D of the Picornaviridae family, was first isolated in 1962 in the United States. EV-D68 infection was only infrequently reported until an outbreak occurred in 2014 in the US; since then, it has continued to increase worldwide. EV-D68 infection leads to severe respiratory illness and has recently been reported to be linked to the development of the neurogenic disease known as acute flaccid myelitis (AFM), mostly in children, seriously endangering public health. Hitherto, treatment options for EV-D68 infections were limited to supportive care, and as yet there are no approved, specific antiviral drugs or vaccines. Research on EV-D68 has mainly focused on its epidemiology, and its virologic characteristics and pathogenesis still need to be further explored. Here, we provide an overview of current research on EV-D68, including the genotypes and genetic characteristics of recent epidemics, the mechanism of infection and virus-host interactions, and its relationship to acute flaccid myelitis (AFM), in order to broaden our understanding of the biological features of EV-D68 and provide a basis for the development of effective antiviral agents.
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Affiliation(s)
- Jing Sun
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education), School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang, China.
| | - Xiao-Yi Hu
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education), School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang, China.
| | - Xiao-Fang Yu
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education), School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang, China.
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Dyrdak R, Mastafa M, Hodcroft EB, Neher RA, Albert J. Intra- and interpatient evolution of enterovirus D68 analyzed by whole-genome deep sequencing. Virus Evol 2019; 5:vez007. [PMID: 31037220 PMCID: PMC6482344 DOI: 10.1093/ve/vez007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Worldwide outbreaks of enterovirus D68 (EV-D68) in 2014 and 2016 have caused serious respiratory and neurological disease. To investigate diversity, spread, and evolution of EV-D68 we performed near full-length deep sequencing in fifty-four samples obtained in Sweden during the 2014 and 2016 outbreaks. In most samples, intrapatient variability was low and dominated by rare synonymous variants, but three patients showed evidence of dual infections with distinct EV-D68 variants from the same subclade. Interpatient evolution showed a very strong temporal signal, with an evolutionary rate of 0.0039 ± 0.0001 substitutions per site and year. Phylogenetic trees reconstructed from the sequences suggest that EV-D68 was introduced into Stockholm several times during the 2016 outbreak. Putative neutralization targets in the BC and DE loops of the VP1 protein were slightly more diverse within-host and tended to undergo more frequent substitution than other genomic regions. However, evolution in these loops did not appear to have been driven the emergence of the 2016 B3-subclade directly from the 2014 B1-subclade. Instead, the most recent ancestor of both clades was dated to 2009. The study provides a comprehensive description of the intra- and interpatient evolution of EV-D68, including the first report of intrapatient diversity and dual infections. The new data along with publicly available EV-D68 sequences are included in an interactive phylodynamic analysis on nextstrain.org/enterovirus/d68 to facilitate timely EV-D68 tracking in the future.
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Affiliation(s)
- Robert Dyrdak
- Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Microbiology, Tumor and Cell Biology, Karolinska Institute, Stockholm, Sweden
| | - Monika Mastafa
- Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Microbiology, Tumor and Cell Biology, Karolinska Institute, Stockholm, Sweden
| | - Emma B Hodcroft
- Biozentrum, University of Basel, Basel, Switzerland.,Swiss Institute of Bioinformatics, Basel, Switzerland
| | - Richard A Neher
- Biozentrum, University of Basel, Basel, Switzerland.,Swiss Institute of Bioinformatics, Basel, Switzerland
| | - Jan Albert
- Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Microbiology, Tumor and Cell Biology, Karolinska Institute, Stockholm, Sweden
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Musharrafieh R, Zhang J, Tuohy P, Kitamura N, Bellampalli SS, Hu Y, Khanna R, Wang J. Discovery of Quinoline Analogues as Potent Antivirals against Enterovirus D68 (EV-D68). J Med Chem 2019; 62:4074-4090. [PMID: 30912944 DOI: 10.1021/acs.jmedchem.9b00115] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Enterovirus D68 (EV-D68) is an atypical nonpolio enterovirus that mainly infects the respiratory system of humans, leading to moderate-to-severe respiratory diseases. In rare cases, EV-D68 can spread to the central nervous system and cause paralysis in infected patients, especially young children and immunocompromised individuals. There is currently no approved vaccine or antiviral available for the prevention and treatment of EV-D68. In this study, we aimed to improve the antiviral potency and selectivity of a previously reported EV-D68 inhibitor, dibucaine, through structure-activity relationship studies. In total, 60 compounds were synthesized and tested against EV-D68 using the viral cytopathic effect assay. Three compounds 10a, 12a, and 12c were identified to have significantly improved potency (EC50 < 1 μM) and a high selectivity index (>180) compared with dibucaine against five different strains of EV-D68 viruses. These compounds also showed potent antiviral activity in neuronal cells, such as A172 and SH-SY5Y cells, suggesting they might be further developed for the treatment of both respiratory infection as well as neuronal infection.
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Messacar K, Tyler KL. Enterovirus D68-Associated Acute Flaccid Myelitis: Rising to the Clinical and Research Challenges. JAMA 2019; 321:831-832. [PMID: 30768149 DOI: 10.1001/jama.2019.1016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Kevin Messacar
- Hospital Medicine and Pediatric Infectious Disease Sections, Department of Pediatrics, University of Colorado, Aurora
- Children's Hospital Colorado, Aurora
| | - Kenneth L Tyler
- Neuroinfectious Disease Section, Department of Neurology, University of Colorado, Aurora
- Departments of Medicine and Immunology-Microbiology, University of Colorado, Aurora
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Kramer R, Lina B, Shetty J. Acute flaccid myelitis caused by enterovirus D68: Case definitions for use in clinical practice. Eur J Paediatr Neurol 2019; 23:235-239. [PMID: 30670331 DOI: 10.1016/j.ejpn.2019.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 12/17/2018] [Accepted: 01/04/2019] [Indexed: 01/05/2023]
Abstract
Acute flaccid myelitis (AFM) was increasingly detected in recent years, coinciding with upsurges of enterovirus D68 (EV-D68) infections. We reviewed the evidence for a causal relationship between both. Based on reported cases, we provide case definitions for AFM caused by EV-D68 infections to enable a standard procedure for affected patients. Current case definitions are focussing on epidemiological aspects but clinical case definitions are still missing. We propose the following case definitions to be used in clinical practice in order to mirror clinical realities and facilitate a common systematic approach in case management: A possible case is defined as a person presenting with either acute myelitis/paralysis or Guillain-Barré Syndrome (GBS), particularly during periods of EV-D68 circulation. A probable case is defined as a person presenting with symptoms of either acute myelitis/paralysis or GBS and at least one of the following criteria: i) MRI abnormality representing with T2 hyperintensity in spinal cord grey matter with or without hyperintensity at dorsal brain stem, ii) investigations showing an axonal neuropathy including reduced compound motor action potentials with normal conduction velocities and absence of conduction blocks compatible with anterior horn cell disease or iii) detection of enteroviruses in a respiratory specimen obtained from the lower respiratory tract during periods of EV-D68 circulation. A confirmed case is defined as a person presenting with acute flaccid myelitis/paralysis, MRI abnormality and detection of enterovirus-D68-specific nucleic acids in a respiratory specimen using a validated PCR assay targeting the VP1 gene with subsequent sequencing and typing.
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Affiliation(s)
- Rolf Kramer
- European Public Health Microbiology Training Programme (EUPHEM); Centre National de Référence des Enterovirus et Parechovirus, Laboratoire de Virologie, Institut des Agent Infectieux, HCL, Hôpital de la Croix-Rousse, Lyon, France.
| | - Bruno Lina
- Centre National de Référence des Enterovirus et Parechovirus, Laboratoire de Virologie, Institut des Agent Infectieux, HCL, Hôpital de la Croix-Rousse, Lyon, France; Virpath, CIRI, Université de Lyon, INSERM U1111, CNRS 5308, ENS de Lyon, UCBL, Lyon, France
| | - Jay Shetty
- Paediatric Neurosciences, Royal Hospital for Sick Children, Edinburgh, UK; Child Life and Health, University of Edinburgh, Edinburgh, UK
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Cramer N, Munjal N, Ware D, Ramgopal S, Simon D, Freeman MC, Michaels MG, Stem C, Thakkar K, Williams JV, Panigrahy A, Neville DNW, Owusu-Ansah S. New Cluster of Acute Flaccid Myelitis in Western Pennsylvania. Ann Emerg Med 2019; 74:503-508. [PMID: 30826069 DOI: 10.1016/j.annemergmed.2019.01.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Indexed: 01/17/2023]
Abstract
Acute flaccid myelitis is a debilitating illness characterized by acute onset of limb weakness, with one or more spinal segments displaying magnetic resonance imaging-confirmed gray matter lesions. Since the first outbreak in 2014, tracking by the Centers for Disease Control and Prevention has demonstrated biennial epidemics in the United States, with a current outbreak occurring in 2018. The cases of 3 children with acute flaccid myelitis who were initially thought to have common nonneurologic diagnoses are presented. Emergency physicians need to be vigilant to recognize the subtleties of acute flaccid myelitis because the illness progression is rapid and therapy is nuanced.
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Affiliation(s)
- Natan Cramer
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Neil Munjal
- Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Sriram Ramgopal
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Dennis Simon
- Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Megan C Freeman
- Department of Pediatrics, Division of Pediatric Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Marian G Michaels
- Department of Pediatrics, Division of Pediatric Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Christopher Stem
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Kavita Thakkar
- Department of Pediatrics, Division of Child Neurology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - John V Williams
- Department of Pediatrics, Division of Pediatric Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Ashok Panigrahy
- Department of Pediatric Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Desiree N W Neville
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Sylvia Owusu-Ansah
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.
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Hopkins SE, Elrick MJ, Messacar K. Acute Flaccid Myelitis-Keys to Diagnosis, Questions About Treatment, and Future Directions. JAMA Pediatr 2019; 173:117-118. [PMID: 30500054 DOI: 10.1001/jamapediatrics.2018.4896] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Sarah E Hopkins
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew J Elrick
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Kevin Messacar
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora
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Elrick MJ, Gordon-Lipkin E, Crawford TO, Van Haren K, Messacar K, Thornton N, Dee E, Voskertchian A, Nance JR, Muñoz LS, Gorman MP, Benson LA, Thomas DL, Pardo CA, Milstone AM, Duggal P. Clinical Subpopulations in a Sample of North American Children Diagnosed With Acute Flaccid Myelitis, 2012-2016. JAMA Pediatr 2019; 173:134-139. [PMID: 30500056 PMCID: PMC6439600 DOI: 10.1001/jamapediatrics.2018.4890] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Acute flaccid myelitis (AFM) is an emerging poliolike illness of children whose clinical spectrum and associated pathogens are only partially described. The case definition is intentionally encompassing for epidemiologic surveillance to capture all potential AFM cases. Defining a restrictive, homogenous subpopulation may aid our understanding of this emerging disease. OBJECTIVE To evaluate the extent to which the US Centers for Disease Control and Prevention (CDC) case definition of AFM incorporates possible alternative diagnoses and to assess the plausibility of a case definition that enriches the biological homogeneity of AFM for inclusion in research studies. DESIGN, SETTING, AND PARTICIPANTS Retrospective case analysis of children younger than 18 years diagnosed as having AFM between 2012 and 2016 using the CDC case definition. Group 1 included patients recruited from the United States and Canada based on the CDC case definition of AFM. Group 2 included patients referred to the Johns Hopkins Transverse Myelitis Center for evaluation of suspected AFM. Patients' records and imaging data were critically reviewed by 3 neurologists to identify those cases with definable alternative diagnoses, and the remaining patients were categorized as having restrictively defined AFM (rAFM). Clinical characteristics were compared between patients with rAFM (cases) and those with alternative diagnoses, and a case description distinguishing these AFM groups was identified. Interrater reliability of this description was confirmed for a subset of cases by a fourth neurologist. Data were analyzed between May 2017 and November 2018. MAIN OUTCOMES AND MEASURES Proportion of patients with possible alternative diagnosis. RESULTS Of the 45 patients who met the CDC AFM case definition and were included, the mean age was 6.1 years; 27 were boys (60%); and 37 were white (82%), 3 were Asian (7%), 1 was Hispanic (2%), and 4 were mixed race/ethnicity (9%). Of the included patients, 34 were classified as having rAFM, and 11 had alternate diagnoses (including transverse myelitis, other demyelinating syndromes, spinal cord stroke, Guillain-Barre syndrome, Chiari I myelopathy, and meningitis). Factors differing between groups were primarily asymmetry of weakness, lower motor neuron signs, preceding viral syndrome, symptoms evolving over hours to days, absence of sensory deficits, and magnetic resonance imaging findings. A case description was able to reliably define the rAFM group. CONCLUSIONS AND RELEVANCE We present an approach for defining a homogeneous research population that may more accurately reflect the pathogenesis of the prototypical poliomyelitis-like subgroup of AFM. The definition of rAFM forms a blueprint for inclusion criteria in future research efforts, but more work is required for refinement and external validation.
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Affiliation(s)
- Matthew J. Elrick
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Thomas O. Crawford
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Keith Van Haren
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, California
| | - Kevin Messacar
- Department of Pediatrics, Children’s Hospital Colorado, the University of Colorado, Aurora
| | - Nicole Thornton
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Elizabeth Dee
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Annie Voskertchian
- Division of Infectious Disease, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jessica R. Nance
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Laura S. Muñoz
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark P. Gorman
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
| | - Leslie A. Benson
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
| | - David L. Thomas
- Division of Infectious Disease, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carlos A. Pardo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aaron M. Milstone
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland,Division of Infectious Disease, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Priya Duggal
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Genomic Analyses of Acute Flaccid Myelitis Cases among a Cluster in Arizona Provide Further Evidence of Enterovirus D68 Role. mBio 2019; 10:mBio.02262-18. [PMID: 30670612 PMCID: PMC6343034 DOI: 10.1128/mbio.02262-18] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Enteroviruses frequently result in respiratory and gastrointestinal illness; however, multiple subtypes, including poliovirus, can cause severe neurologic disease. Recent biennial increases (i.e., 2014, 2016, and 2018) in cases of non-polio acute flaccid paralysis have led to speculations that other enteroviruses, specifically enterovirus D68 (EV-D68), are emerging to fill the niche that was left from poliovirus eradication. A cluster of 11 suspect cases of pediatric acute flaccid myelitis (AFM) was identified in 2016 in Phoenix, AZ. Multiple genomic analyses identified the presence of EV-D68 in the majority of clinical AFM cases. Beyond limited detection of herpesvirus, no other likely etiologies were found in the cluster. These findings strengthen the likelihood that EV-D68 is a cause of AFM and show that the rapid molecular assays developed for this study are useful for investigations of AFM and EV-D68. Enteroviruses are a common cause of respiratory and gastrointestinal illness, and multiple subtypes, including poliovirus, can cause neurologic disease. In recent years, enterovirus D68 (EV-D68) has been associated with serious neurologic illnesses, including acute flaccid myelitis (AFM), frequently preceded by respiratory disease. A cluster of 11 suspect cases of pediatric AFM was identified in September 2016 in Phoenix, AZ. To determine if these cases were associated with EV-D68, we performed multiple genomic analyses of nasopharyngeal (NP) swabs and cerebrospinal fluid (CSF) material from the patients, including real-time PCR and amplicon sequencing targeting the EV-D68 VP1 gene and unbiased microbiome and metagenomic sequencing. Four of the 11 patients were classified as confirmed cases of AFM, and an additional case was classified as probable AFM. Real-time PCR and amplicon sequencing detected EV-D68 virus RNA in the three AFM patients from which NP swabs were collected, as well as in a fourth patient diagnosed with acute disseminated encephalomyelitis, a disease that commonly follows bacterial or viral infections, including enterovirus. No other obvious etiological causes for AFM were identified by 16S or RNA and DNA metagenomic sequencing in these cases, strengthening the likelihood that EV-D68 is an etiological factor. Herpes simplex viral DNA was detected in the CSF of the fourth case of AFM and in one additional suspect case from the cluster. Multiple genomic techniques, such as those described here, can be used to diagnose patients with suspected EV-D68 respiratory illness, to aid in AFM diagnosis, and for future EV-D68 surveillance and epidemiology.
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Acute flaccid myelitis and enterovirus D68: lessons from the past and present. Eur J Pediatr 2019; 178:1305-1315. [PMID: 31338675 PMCID: PMC6694036 DOI: 10.1007/s00431-019-03435-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/11/2019] [Accepted: 07/16/2019] [Indexed: 12/20/2022]
Abstract
Acute flaccid myelitis is characterized by the combination of acute flaccid paralysis and a spinal cord lesion largely restricted to the gray matter on magnetic resonance imaging. The term acute flaccid myelitis was introduced in 2014 after the upsurge of pediatric cases in the USA with enterovirus D68 infection. Since then, an increasing number of cases have been reported worldwide. Whereas the terminology is new, the clinical syndrome has been recognized in the past in association with several other neurotropic viruses such as poliovirus.Conclusion: This review presents the current knowledge on acute flaccid myelitis with respect to the clinical presentation and its differential diagnosis with Guillain-Barré syndrome and acute transverse myelitis. We also discuss the association with enterovirus D68 and the presumed pathophysiological mechanism of this infection causing anterior horn cell damage. Sharing clinical knowledge and insights from basic research is needed to make progress in diagnosis, treatment, and prevention of this new polio-like disease. What is Known: • Acute flaccid myelitis (AFM) is a polio-like condition characterized by rapid progressive asymmetric weakness, together with specific findings on MRI • AFM has been related to different viral agents, but recent outbreaks are predominantly associated with enterovirus D68. What is New: • Improving knowledge on AFM must increase early recognition and adequate diagnostic procedures by clinicians. • The increasing incidence of AFM urges cooperation between pediatricians, neurologists, and microbiologists for the development of treatment and preventive options.
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