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Huang PN, Hsia SH, Huang KYA, Chen CJ, Wang ET, Shih SR, Lin TY. Reflecting on the 1998 enterovirus outbreak: A 25-year retrospective and learned lessons. Biomed J 2024:100715. [PMID: 38492637 DOI: 10.1016/j.bj.2024.100715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/13/2023] [Accepted: 03/06/2024] [Indexed: 03/18/2024] Open
Abstract
Enterovirus A71 (EV-A71) infections pose a significant public health concern in the Asia-Pacific region. EV-A71 is primarily responsible for causing hand, foot, and mouth disease (HFMD) in children. However, this virus can also lead to severe and potentially fatal neurological consequences in affected individuals. This review aims to provide a comprehensive understanding of the molecular virology, epidemiology, and recombination events associated with EV-A71. The literature extensively covers the clinical manifestations and neurological symptoms that accompany EV-A71 infections. One of the complications explored in this review is brainstem encephalitis, which can arise as a result of EV-A71 infections. Brainstem encephalitis refers to inflammation of the brainstem, a critical region responsible for various bodily functions. The review examines the underlying mechanisms, diagnostic criteria, treatment options, and prognosis for central nervous system infections involving EV-A71. Neurological complications associated with EV-A71 infections are diverse and can have severe consequences. These complications may include aseptic meningitis, acute flaccid paralysis, and acute transverse myelitis. The review delves into the pathophysiology of these complications, shedding light on the molecular mechanisms through which EV-A71 affects the central nervous system. Accurate diagnosis of EV-A71 infections is crucial for appropriate management and treatment. Treatment options for EV-A71 infections primarily focus on supportive care, as there are currently no specific antiviral drugs available for this virus. The review highlights the importance of managing symptoms, such as fever, dehydration, and pain relief, to alleviate the burden on affected individuals. Prognosis for individuals with central nervous system (CNS) infections involving EV-A71 can vary depending on the severity of the complications. The review provides insights into the long-term outcomes and potential neurological sequelae associated with EV-A71 infections. In conclusion, EV-A71 infections have emerged as a major public health concern in the Asia-Pacific region. This review aims to enhance our understanding of the molecular virology, epidemiology, and neurological complications associated with EV-A71. By examining the underlying mechanisms, diagnostic criteria, treatment options, and prognosis, this review contributes to the development of effective strategies for the prevention, diagnosis, and management of EV-A71 infections. The paper presents a comprehensive analysis of worldwide data pertaining to outbreaks of EV-A71 and HFMD. The subsequent discourse delves into the advancement and strategic formulation pertaining to the creation of vaccines targeting EV-A71. In summary, this study provides a comprehensive examination of the potential obstacles and considerations involved in the management and treatment of EV-A71 infections. Additionally, it proposes suggestions for future research and development endeavors with the objective of formulating efficacious treatment approaches for this viral infection.
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Affiliation(s)
- Peng-Nien Huang
- Research Center for Emerging Viral Infections, Chang Gung University, Taoyuan, Taiwan; Division of Infectious Diseases, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shao-Hsuan Hsia
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Department of Pediatric Respiratory Therapy, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kuan-Ying Arthur Huang
- Research Center for Emerging Viral Infections, Chang Gung University, Taoyuan, Taiwan; Division of Infectious Diseases, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Jung Chen
- Research Center for Emerging Viral Infections, Chang Gung University, Taoyuan, Taiwan; Division of Infectious Diseases, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - En-Tzu Wang
- Division of Acute Infectious Diseases, Centers for Disease Control, Ministry of Health and Welfare, Taiwan
| | - Shin-Ru Shih
- Research Center for Emerging Viral Infections, Chang Gung University, Taoyuan, Taiwan; Department of Medical Biotechnology and Laboratory Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; Research Center for Chinese Herbal Medicine, Research Center for Food and Cosmetic Safety, and Graduate Institute of Health Industry Technology, College of Human Ecology, Chang Gung University of Science and Technology, Taoyuan, Taiwan
| | - Tzou-Yien Lin
- Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Pediatrics, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Activation of Host Cellular Signaling and Mechanism of Enterovirus 71 Viral Proteins Associated with Hand, Foot and Mouth Disease. Viruses 2022; 14:v14102190. [PMID: 36298746 PMCID: PMC9609926 DOI: 10.3390/v14102190] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 11/07/2022] Open
Abstract
Enteroviruses are members of the Picornaviridae family consisting of human enterovirus groups A, B, C, and D as well as nonhuman enteroviruses. Human enterovirus type 71 (EV71) has emerged as a major cause of viral encephalitis, known as hand, foot, and mouth disease (HFMD), in children worldwide, especially in the Asia-Pacific region. EV71 and coxsackievirus A16 are the two viruses responsible for HFMD which are members of group A enteroviruses. The identified EV71 receptors provide useful information for understanding viral replication and tissue tropism. Host factors interact with the internal ribosome entry site (IRES) of EV71 to regulate viral translation. However, the specific molecular features of the respective viral genome that determine virulence remain unclear. Although a vaccine is currently approved, there is no effective therapy for treating EV71-infected patients. Therefore, understanding the host-pathogen interaction could provide knowledge in viral pathogenesis and further benefits to anti-viral therapy development. The aim of this study was to investigate the latest findings about the interaction of viral ligands with the host receptors as well as the activation of immunerelated signaling pathways for innate immunity and the involvement of different cytokines and chemokines during host-pathogen interaction. The study also examined the roles of viral proteins, mainly 2A and 3C protease, interferons production and their inhibitory effects.
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Nayak G, Bhuyan SK, Bhuyan R, Sahu A, Kar D, Kuanar A. Global emergence of Enterovirus 71: a systematic review. BENI-SUEF UNIVERSITY JOURNAL OF BASIC AND APPLIED SCIENCES 2022; 11:78. [PMID: 35730010 PMCID: PMC9188855 DOI: 10.1186/s43088-022-00258-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 05/29/2022] [Indexed: 02/06/2023] Open
Abstract
Background Hand, foot, and mouth disease (HFMD) is a viral infection caused by a virus from the enterovirus genus of picornavirus family that majorly affects children. Though most cases of HFMD do not cause major problems, the outbreaks of Enterovirus 71 (EV71) can produce a high risk of neurological sequelae, including meningoencephalitis, lung difficulties, and mortality. In Asia, HFMD caused by EV71 has emerged as an acutely infectious disease of highly pathogenic potential, which demands the attention of the international medical community.
Main body of the abstract Some online databases including NCBI, PubMed, Google Scholar, ProQuest, Scopus, and EBSCO were also accessed using keywords relating to the topic for data mining. The paid articles were accessed through the Centre Library facility of Siksha O Anusandhan University. This work describes the structure, outbreak, molecular epidemiology of Enterovirus 71 along with different EV71 vaccines. Many vaccines have been developed such as inactivated whole-virus live attenuated, subviral particles, and DNA vaccines to cure the patients. In Asia–Pacific nations, inactivated EV71 vaccination still confronts considerable obstacles in terms of vaccine standardization, registration, price, and harmonization of pathogen surveillance and measurements. Short conclusion HFMD has emerged as a severe health hazard in Asia–Pacific countries in recent decades. In Mainland China and other countries with high HFMD prevalence, the inactivated EV71 vaccination will be a vital tool in safeguarding children's health. When creating inactivated EV71 vaccines, Mainland China ensured maintaining high standards of vaccine quality. The Phase III clinical studies were used to confirm the safety and effectiveness of vaccinations. Graphical Abstract ![]()
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Affiliation(s)
- Gayatree Nayak
- Centre for Biotechnology, Siksha O Anusandhan (Deemed to Be) University, Kalinga Nagar, Ghatikia, Bhubaneswar, Odisha 751003 India
| | - Sanat Kumar Bhuyan
- Institute of Dental Sciences, Siksha 'O' Anusandhan (Deemed to Be) University, Bhubaneswar, Odisha 751003 India
| | - Ruchi Bhuyan
- Department of Medical Research, Health Science, IMS and SUM Hospital, Siksha O Anusandhan (Deemed to Be) University, Bhubaneswar, Odisha 751003 India
| | - Akankshya Sahu
- Centre for Biotechnology, Siksha O Anusandhan (Deemed to Be) University, Kalinga Nagar, Ghatikia, Bhubaneswar, Odisha 751003 India
| | - Dattatreya Kar
- Department of Medical Research, Health Science, IMS and SUM Hospital, Siksha O Anusandhan (Deemed to Be) University, Bhubaneswar, Odisha 751003 India
| | - Ananya Kuanar
- Centre for Biotechnology, Siksha O Anusandhan (Deemed to Be) University, Kalinga Nagar, Ghatikia, Bhubaneswar, Odisha 751003 India
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Toczylowski K, Wieczorek M, Bojkiewicz E, Wietlicka-Piszcz M, Gad B, Sulik A. Pediatric Enteroviral Central Nervous System Infections in Bialystok, Poland: Epidemiology, Viral Types, and Drivers of Seasonal Variation. Viruses 2020; 12:v12080893. [PMID: 32824117 PMCID: PMC7472221 DOI: 10.3390/v12080893] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/09/2020] [Accepted: 08/11/2020] [Indexed: 12/15/2022] Open
Abstract
Enteroviruses are common causes of infections of the central nervous system (CNS) that in temperate climates tend to peak in the summer. The aim of the study was to describe epidemiology, drivers of seasonality, and types of enteroviruses causing infections of the CNS in children in Northeastern Poland. We prospectively collected data on children hospitalized with infection of the CNS attributed to enteroviruses in Bialystok, Poland, from January 2015 to December 2019. In total, 224 children were included. Nineteen different enterovirus types were identified in isolates collected from 188 children. Coxsackie B5 (32%), echovirus 30 (20%), and echovirus 6 (14%) were the three most common types. Enteroviruses were more prevalent during the summer–fall season. Infections caused by echovirus 30 peaked early in June and coxsackievirus B5 in July, whereas echovirus 6 peaked late in October. Phylogenetic analyses of these three enterovirus types showed multiple lineages co-circulating in this region. Mean air temperatures and precipitation rates were independently associated with monthly number of cases. Considering lack of effective treatment or vaccine, easy transmission of enteroviruses between susceptible individuals, their high mutation rate and prolonged time of viral shedding, continued monitoring and surveillance are imperative to recognize enteroviral infections of the CNS and the changes in circulation of enteroviruses in Poland.
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Affiliation(s)
- Kacper Toczylowski
- Department of Pediatric Infectious Diseases, Medical University of Bialystok, Waszyngtona 17, 15-274 Bialystok, Poland; (E.B.); (A.S.)
- Correspondence: ; Tel.: +48-857-450-680
| | - Magdalena Wieczorek
- Department of Virology, National Institute of Public Health—National Institute of Hygiene, Chocimska 24, 00-791 Warsaw, Poland; (M.W.); (B.G.)
| | - Ewa Bojkiewicz
- Department of Pediatric Infectious Diseases, Medical University of Bialystok, Waszyngtona 17, 15-274 Bialystok, Poland; (E.B.); (A.S.)
| | - Magdalena Wietlicka-Piszcz
- Department of Theoretical Foundations of Biomedical Sciences and Medical Computer Science, Nicolaus Copernicus University in Torun, L. Rydygier Collegium Medicum in Bydgoszcz, 9 M. Skłodowska-Curie St., 85-094 Bydgoszcz, Poland;
| | - Beata Gad
- Department of Virology, National Institute of Public Health—National Institute of Hygiene, Chocimska 24, 00-791 Warsaw, Poland; (M.W.); (B.G.)
| | - Artur Sulik
- Department of Pediatric Infectious Diseases, Medical University of Bialystok, Waszyngtona 17, 15-274 Bialystok, Poland; (E.B.); (A.S.)
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Chen SD, Ju YT, Wei YJ, Hsieh ML, Liu CC, Wu JM, Wang JN. Timing of Endotracheal Intubation in Patients with Fulminant Enterovirus 71 Infection. MEDICINA-LITHUANIA 2020; 56:medicina56040203. [PMID: 32344662 PMCID: PMC7230837 DOI: 10.3390/medicina56040203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/17/2020] [Accepted: 04/21/2020] [Indexed: 11/16/2022]
Abstract
Background and objective: Enterovirus 71 (EV 71) infections may result in the rapid progression of cardiopulmonary failure. Early endotracheal intubation is considered to be of primary importance. However, the appropriate timing for this is still not known. The aim of this study is to investigate the timing of intubation of children with fulminant EV71 infection. Material and Methods: From March 1998 to May 2012, patients with severe EV71 infection who were admitted to the pediatric intensive care unit of the National Cheng Kung University Hospital were enrolled in this study. Medical records were retrospectively reviewed. The patients were classified into three groups in accordance with the outcome of intubation. We used rhombencephalitis grading to describe the neurological presentation of these patients. The study was approved by the institutional review board. Results: There were a total of 105 patients enrolled. Of these, 77 patients were in Grade I, and only three of them needed intubation, who were, however, soon extubated within 24 h. There were 10 patients in Grade II; nine of them needed intubation. In total, 18 patients belonged to Grade III, and all of them need to be intubated. We then compared the outcome of intubation of grades II and III. There was only one patient out of the nine patients in grade II who experienced failed extubation due to the progression of the disease. Among grade III patients, only four patients were successfully extubated. We also listed clinical parameters to determine which one could be a sign that indicated intubation. Comparing the favorable outcomes, cranial nerve involvement was a good indicator for the timing of intubation. Conclusions: This study showed that early intubation in Grade II provides favorable outcomes and improves morbidity and mortality. We also found that if cranial nerve involvement was present, then early intubation is indicated.
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Affiliation(s)
- Shen-Dar Chen
- Department of Pediatrics, Dalin Tzu Chi hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi 62247, Taiwan;
| | - Ying-Tzu Ju
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70421, Taiwan; (Y.-T.J.); (Y.-J.W.); (M.-L.H.); (C.-C.L.); (J.-M.W.)
| | - Yu-Jen Wei
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70421, Taiwan; (Y.-T.J.); (Y.-J.W.); (M.-L.H.); (C.-C.L.); (J.-M.W.)
| | - Min-Ling Hsieh
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70421, Taiwan; (Y.-T.J.); (Y.-J.W.); (M.-L.H.); (C.-C.L.); (J.-M.W.)
| | - Ching-Chuan Liu
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70421, Taiwan; (Y.-T.J.); (Y.-J.W.); (M.-L.H.); (C.-C.L.); (J.-M.W.)
| | - Jing-Ming Wu
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70421, Taiwan; (Y.-T.J.); (Y.-J.W.); (M.-L.H.); (C.-C.L.); (J.-M.W.)
| | - Jieh-Neng Wang
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70421, Taiwan; (Y.-T.J.); (Y.-J.W.); (M.-L.H.); (C.-C.L.); (J.-M.W.)
- Correspondence: ; Tel.: +886-6-2353535 (ext. 4189)
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Hsia SH, Lin JJ, Chan OW, Lin TY. Cardiopulmonary failure in children infected with Enterovirus A71. J Biomed Sci 2020; 27:53. [PMID: 32299443 PMCID: PMC7161201 DOI: 10.1186/s12929-020-00650-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 03/31/2020] [Indexed: 11/10/2022] Open
Abstract
Enterovirus A71 (EV-A71) is one of the causative pathogens of hand, foot, and mouth disease (HFMD), which may cause severe neurological and cardiopulmonary complications in children. In this review, we discuss the pathogenesis, clinical manifestations, management strategy, and clinical outcomes of cardiopulmonary failure (CPF) in patients with EV-A71 infection. The pathogenesis of CPF involves both catecholamine-related cardiotoxicity following brainstem encephalitis and vasodilatory shock due to cytokine storm. Sympathetic hyperactivity, including tachycardia and hypertension, are the early clinical manifestations of cardiopulmonary involvement, which may progress to pulmonary edema/hemorrhage and/or CPF. The management strategy comprises multidisciplinary supportive treatment, including fluid management, positive pressure ventilation support, and use of milrinone, vasopressors, and inotropes. Some patients may require extracorporeal membrane oxygenation. Major neurological sequelae are almost inevitable once a child develops life-threatening illness. Long-term care of these children is an important medico-social issue.
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Affiliation(s)
- Shao-Hsuan Hsia
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Pediatric Respiratory Therapy, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Pediatric Respiratory Therapy, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Oi-Wa Chan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tzou-Yien Lin
- Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, No. 5, Fuxing Street, Guishan District, Taoyuan, 333, Taiwan.
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Clinical Value of Dorsal Medulla Oblongata Involvement Detected With Conventional Magnetic Resonance Imaging for Prediction of Outcome in Children With Enterovirus 71-Related Brainstem Encephalitis. Pediatr Infect Dis J 2019; 38:99-103. [PMID: 29624567 DOI: 10.1097/inf.0000000000002041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Brainstem encephalitis is the most common neurologic complication after enterovirus 71 infection. The involvement of brainstem, especially the dorsal medulla oblongata, can cause severe sequelae or death in children with enterovirus 71 infection. We aimed to determine the prevalence of dorsal medulla oblongata involvement in children with enterovirus 71-related brainstem encephalitis (EBE) by using conventional magnetic resonance imaging (MRI) and to evaluate the value of dorsal medulla oblongata involvement in outcome prediction. METHODS Forty-six children with EBE were enrolled in the study. All subjects underwent a 1.5 Tesla MRI examination of the brain. The disease distribution and clinical data were collected. Dichotomized outcomes (good vs. poor) at longer than 6 months were available for 28 patients. Logistic regression was used to determine whether the MRI-confirmed dorsal medulla oblongata involvement resulted in improved clinical outcome prediction when compared with other location involvement. RESULTS Of the 46 patients, 35 had MRI evidence of dorsal medulla oblongata involvement, 32 had pons involvement, 10 had midbrain involvement and 7 had dentate nuclei involvement. Patients with dorsal medulla oblongata involvement or multiple area involvement were significantly more often in the poor outcome group than in the good outcome group. Logistic regression analysis showed that dorsal medulla oblongata involvement was the most significant single variable in outcome prediction (predictive accuracy, 90.5%), followed by multiple area involvement, age and initial Glasgow Coma Scale score. CONCLUSIONS Dorsal medulla oblongata involvement on conventional MRI correlated significantly with poor outcomes in EBE children, improved outcome prediction when compared with other clinical and disease location variables, and was most predictive when combined with multiple area involvement, Glasgow Coma Scale score and age.
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Jan SL, Lin MC, Chan SC, Lee HF, Chen PY, Huang FL. Urine catecholamines in children with severe Enterovirus A71 infection: comparison with paediatric septic shock. Biomarkers 2018; 24:277-285. [PMID: 30521401 DOI: 10.1080/1354750x.2018.1556339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose: Hypercatecholaminemia-related heart failure has been proposed as the main cause of enterovirus A71-related (EV-A71) early mortality. The purpose of this study was to measure urine catecholamine concentrations in severe EV-A71-infected children. Methods: A total of 35 children, aged 2.5 ± 2.1 years, were divided into three groups. Group I: 15 septic shock patients, group II: 17 EV-A71-stage-2 patients, and group III: 3 EV-A71-stage-4 patients. The laboratory results, cardiac biomarkers and urine catecholamine concentrations were statistically analysed. Results: Group I had the highest C-reactive protein (CRP) levels and group II had the lowest B-type natriuretic peptide (BNP) and its N-terminal prohormone among the groups (p = 0.039, <0.01 and <0.01, respectively). Group III patients had significantly higher urine catecholamine and troponin-I values among the groups. If urine epinephrine (Epi) >134 ug/gCr, norepinephrine (NE) >176 ug/gCr and vanillylmandelic acid (VMA) >11.7 mg/gCr were used as the cutoff points to differentiate groups II and III, the sensitivities and specificity were all 100%. Conclusions: The significantly elevated urine catecholamine concentrations in EV-A71-stage-4 patients support the hypothesis that hypercatecholaminemia-related heart failure is involved in severe EV-A71 infection. Urine catecholamines could be used as reliable biomarkers for differentiation of severe EV-A71 infection with or without heart failure and septic shock.
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Affiliation(s)
- Sheng-Ling Jan
- a Department of Paediatrics, Children's Medical Center , Taichung Veterans General Hospital , Taichung , Taiwan , ROC.,b Department of Paediatrics, School of Medicine , National Yang-Ming University , Taipei , Taiwan , ROC.,c Department of Paediatrics, School of Medicine , Kaohsiung Medical University , Kaohsiung , Taiwan , ROC
| | - Ming-Chih Lin
- a Department of Paediatrics, Children's Medical Center , Taichung Veterans General Hospital , Taichung , Taiwan , ROC.,b Department of Paediatrics, School of Medicine , National Yang-Ming University , Taipei , Taiwan , ROC
| | - Sheng-Ching Chan
- d Department of Nursing, Ta-Jen University , Pingtung City , Taiwan , ROC
| | - Hsiu-Fen Lee
- a Department of Paediatrics, Children's Medical Center , Taichung Veterans General Hospital , Taichung , Taiwan , ROC
| | - Po-Yen Chen
- a Department of Paediatrics, Children's Medical Center , Taichung Veterans General Hospital , Taichung , Taiwan , ROC
| | - Fang-Liang Huang
- a Department of Paediatrics, Children's Medical Center , Taichung Veterans General Hospital , Taichung , Taiwan , ROC
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Chang YK, Chen KH, Chen KT. Hand, foot and mouth disease and herpangina caused by enterovirus A71 infections: a review of enterovirus A71 molecular epidemiology, pathogenesis, and current vaccine development. Rev Inst Med Trop Sao Paulo 2018; 60:e70. [PMID: 30427405 PMCID: PMC6223252 DOI: 10.1590/s1678-9946201860070] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 10/09/2018] [Indexed: 01/28/2023] Open
Abstract
Enterovirus A71 (EV-A71) infections are one of the main etiological agents of hand, foot and mouth disease (HFMD) and herpangina worldwide. EV-A71 infection is a life-threatening communicable disease and there is an urgent global need for the development of vaccines for its prevention and control. The morbidity rate of EV-A71 infection differs between countries. The pathogen’s genetic lineages are undergoing rapid evolutionary changes. An association between the occurrence of EV-A71 infection and the circulation of different genetic strains of EV-A71 virus has been identified around the world. In this review, we present and discuss the molecular epidemiology and pathogenesis of the human disease caused by EV-A71 infection, as well as current prospects for the development of an EV-A71 vaccine.
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Affiliation(s)
- Yu-Kang Chang
- Chi-Mei Medical Center, Liouying Campus, Department of Radiology, Tainan, Taiwan
| | - Kou-Huang Chen
- Sanming University, School of Mechanical & Electronic Engineering, Sanming, Fujian Province, China
| | - Kow-Tong Chen
- Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), Department of Occupational Medicine, Tainan, Taiwan.,National Cheng Kung University, College of Medicine, Department of Public Health, Tainan, Taiwan
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Jones E, Pillay TD, Liu F, Luo L, Bazo-Alvarez JC, Yuan C, Zhao S, Chen Q, Li Y, Liao Q, Yu H, Rogier van Doorn H, Sabanathan S. Outcomes following severe hand foot and mouth disease: A systematic review and meta-analysis. Eur J Paediatr Neurol 2018; 22:763-773. [PMID: 29778429 PMCID: PMC6148319 DOI: 10.1016/j.ejpn.2018.04.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 02/23/2018] [Accepted: 04/09/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Hand, foot and mouth disease (HFMD) caused by enterovirus A71 (EV-A71) is associated with acute neurological disease in children. This study aimed to estimate the burden of long-term sequelae and death following severe HFMD. METHODS This systematic review and meta-analysis pooled all reports from English and Chinese databases including MEDLINE and Wangfang on outbreaks of clinically diagnosed HFMD and/or laboratory-confirmed EV-A71 with at least 7 days' follow-up published between 1st January 1966 and 19th October 2015. Two independent reviewers assessed the literature. We used a random effects meta-analysis to estimate cumulative incidence of neurological sequelae or death. Studies were assessed for methodological and reporting quality. PROSPERO registration number: 10.15124/CRD42015021981. FINDINGS 43 studies were included in the review, and 599 children from 9 studies were included in the primary analysis. Estimated cumulative incidence of death or neurological sequelae at maximum follow up was 19.8% (95% CI:10.2%, 31.3%). Heterogeneity (Iˆ2) was 88.57%, partly accounted for by year of data collection and reporting quality of studies. Incidence by acute disease severity was 0.00% (0.00, 0.00) for grade IIa; 17.0% (7.9, 28.2) for grade IIb/III; 81.6% (65.1, 94.5) for grade IV (p = 0.00) disease. CONCLUSIONS HFMD with neurological involvement is associated with a substantial burden of long-term neurological sequelae. Grade of acute disease severity was a strong predictor of outcome. Strengths of this study include its bilingual approach and clinical applicability. Future prospective and interventional studies must use rigorous methodology to assess long-term outcomes in survivors. FUNDING There was no specific funding for this study. See below for researcher funding.
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Affiliation(s)
- Eben Jones
- University Hospital Lewisham, National Health Service, London, UK
| | - Timesh D Pillay
- University Hospital Lewisham, National Health Service, London, UK.
| | - Fengfeng Liu
- Division of Infectious Disease, Key Laboratory of Surveillance and Early Warning on Infectious Disease, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Li Luo
- Division of Infectious Disease, Key Laboratory of Surveillance and Early Warning on Infectious Disease, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Juan Carlos Bazo-Alvarez
- Methodology Research Group, Department of Primary Care and Population Health, University College London (UCL), London, UK
| | - Chen Yuan
- Zhoushan Center for Disease Control and Prevention, Zhoushan, Zhejiang, China
| | - Shanlu Zhao
- Hunan Provincial Center for Disease Control and Prevention, Changsha, Hunan, China
| | - Qi Chen
- Hubei Provincial Center for Disease Control and Prevention, Changsha, Hunan, China
| | - Yu Li
- Division of Infectious Disease, Key Laboratory of Surveillance and Early Warning on Infectious Disease, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Qiaohong Liao
- Division of Infectious Disease, Key Laboratory of Surveillance and Early Warning on Infectious Disease, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Hongjie Yu
- School of Public Health, Fudan University, Key Laboratory of Public Health Safety, Ministry of Education, Shanghai, China
| | - H Rogier van Doorn
- Oxford University Clinical Research Unit, Ha Noi, Viet Nam; Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, Oxford University, Oxford, UK
| | - Saraswathy Sabanathan
- Oxford University Clinical Research Unit, Ha Noi, Viet Nam; Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, Oxford University, Oxford, UK
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11
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Liu G, Xu Y, Wang X, Zhuang X, Liang H, Xi Y, Lin F, Pan L, Zeng T, Li H, Cao X, Zhao G, Xia H. Developing a Machine Learning System for Identification of Severe Hand, Foot, and Mouth Disease from Electronic Medical Record Data. Sci Rep 2017; 7:16341. [PMID: 29180702 PMCID: PMC5703994 DOI: 10.1038/s41598-017-16521-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 11/13/2017] [Indexed: 11/21/2022] Open
Abstract
Children of severe hand, foot, and mouth disease (HFMD) often present with same clinical features as those of mild HFMD during the early stage, yet later deteriorate rapidly with a fulminant disease course. Our goal was to: (1) develop a machine learning system to automatically identify cases with high risk of severe HFMD at the time of admission; (2) compare the effectiveness of the new system with the existing risk scoring system. Data on 2,532 HFMD children admitted between March 2012 and July 2015, were collected retrospectively from a medical center in China. By applying a holdout strategy and a 10-fold cross validation method, we developed four models with the random forest algorithm using different variable sets. The prediction system HFMD-RF based on the model of 16 variables from both the structured and unstructured data, achieved 0.824 sensitivity, 0.931 specificity, 0.916 accuracy, and 0.916 area under the curve in the independent test set. Most remarkably, HFMD-RF offers significant gains with respect to the commonly used pediatric critical illness score in clinical practice. As all the selected risk factors can be easily obtained, HFMD-RF might prove to be useful for reductions in mortality and complications of severe HFMD.
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Affiliation(s)
- Guangjian Liu
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yi Xu
- Department of Infectious Diseases, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Xinming Wang
- School of Computer, South China Normal University, Guangzhou, China
| | - Xutian Zhuang
- School of Computer, South China Normal University, Guangzhou, China
| | - Huiying Liang
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yun Xi
- School of Computer, South China Normal University, Guangzhou, China
| | - Fangqin Lin
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Liyan Pan
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Taishan Zeng
- School of Mathematical Sciences, South China Normal University, Guangzhou, China
| | - Huixian Li
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Xiaojun Cao
- Department of Research, Education and Data Management, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Gansen Zhao
- School of Computer, South China Normal University, Guangzhou, China.
| | - Huimin Xia
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.
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Huang WC, Chen HL, Chen HY, Peng KP, Lee Y, Huang LM, Chang LY, Liu FT. Galectin-3 and Its Genetic Variation rs4644 Modulate Enterovirus 71 Infection. PLoS One 2016; 11:e0168627. [PMID: 28002441 PMCID: PMC5176291 DOI: 10.1371/journal.pone.0168627] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 12/02/2016] [Indexed: 11/18/2022] Open
Abstract
Galectin-3, a chimeric type β-galactoside-binding protein, is known to modulate viral infection; however, its role in enterovirus 71 (EV71) infection has not been investigated. We generated galectin-3 null rhabdomyosarcoma (RD) cells and evaluated whether EV71 infection would be affected. In galectin-3 null cells, the released and intracellular EV71 viral loads were suppressed after 24 h of infection, and cell death rates were significantly lower, while cell proliferation remained unaltered. In addition, RD cells expressing a nonsynonymous genetic variant of galectin-3, rs4644 (LGALS3 +191C/A, P64H), produced lower virus titers than those with wild-type galectin-3 (C allele). To clarify whether the in vitro viral load reduction correlates with clinical severity, we enrolled children with laboratory-confirmed EV71 infection. Since hyperglycemia is an indicator of severe EV71 infection in children, 152 of 401 enrolled children had glucose examinations at admission, and 59 subjects had serum glucose levels ≥ 150 mg/dL. In comparison to the rs4644 AA genotype (2.2 ± 0.06 log10 mg/dL), serum glucose levels during EV71 infection were higher in patients with CC (2.4 ± 0.17 log10 mg/dL, p = 0.03) and CA (2.4 ± 0.15 log10 mg/dL, p = 0.02) genotypes, respectively. These findings suggest that the rs4644 AA genotype of galectin-3 might exert a protective effect. In summary, galectin-3 affects EV71 replication in our cellular model and its variant, rs4644, is associated with hyperglycemia in the clinical setting. The underlying mechanism and its potential therapeutic application warrant further investigation.
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Affiliation(s)
- Wen-Chan Huang
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
- Ph.D. Program in Translational Medicine, National Taiwan University and Academia Sinica, Taipei, Taiwan
| | - Hung-Lin Chen
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Huan-Yuan Chen
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Kuan-Po Peng
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yungling Lee
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
| | - Li-Min Huang
- Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Luan-Yin Chang
- Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
- * E-mail: (FTL); (LYC)
| | - Fu-Tong Liu
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
- Department of Dermatology, University of California Davis, Sacramento, California, United States of America
- * E-mail: (FTL); (LYC)
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13
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Chang PC, Chen SC, Chen KT. The Current Status of the Disease Caused by Enterovirus 71 Infections: Epidemiology, Pathogenesis, Molecular Epidemiology, and Vaccine Development. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:E890. [PMID: 27618078 PMCID: PMC5036723 DOI: 10.3390/ijerph13090890] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 08/16/2016] [Accepted: 09/01/2016] [Indexed: 12/22/2022]
Abstract
Enterovirus 71 (EV71) infections have a major public health impact in the Asia-Pacific region. We reviewed the epidemiology, pathogenesis, and molecular epidemiology of EV71 infection as well as EV71 vaccine development. Previous studies were found using the search terms "enterovirus 71" and "epidemiology" or "pathogenesis" or "molecular epidemiology" or "vaccine" in Medline and PubMed. Articles that were not published in the English language, manuscripts without an abstract, and opinion articles were excluded from the review. The reported epidemiology of cases caused by EV71 infection varied from country to country; seasonal variations in incidence were observed. Most cases of EV71 infection that resulted in hospitalization for complications occurred in children less than five years old. The brainstem was the most likely major target of EV71 infection. The emergence of the EV71 epidemic in the Asia-Pacific region has been associated with the circulation of different genetic lineages (genotypes B3, B4, C1, C2, and C4) that appear to be undergoing rapid evolutionary changes. The relationship between the gene structure of the EV71 virus and the factors that ensure its survival, circulation, and evasion of immunity is still unknown. EV71 infection has emerged as an important global public health problem. Vaccine development, including the development of inactivated whole-virus live attenuated, subviral particles, and DNA vaccines, has been progressing.
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Affiliation(s)
- Ping-Chin Chang
- Division of Infectious Disease, Department of Internal Medicine, Chi-Mei Medical Center, Liouying, Tainan 736, Taiwan.
| | - Shou-Chien Chen
- Department of Family Medicine, Da-Chien General Hospital, Miaoli 237, Taiwan.
- General Education Center, Ta Tung University, Taipei 104, Taiwan.
| | - Kow-Tong Chen
- Department of Occupational Medicine, Tainan Municipal Hospital, Tainan 701, Taiwan.
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan.
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Predicting severe enterovirus 71 infection: Age, comorbidity, and parental behavior matter. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2014; 50:10-16. [PMID: 25678038 DOI: 10.1016/j.jmii.2014.11.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 11/07/2014] [Accepted: 11/17/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Enterovirus 71 (EV71) is one of the major pathogens that cause severe enteroviral infections. Our aim was to study the behavioral and household risk factors for its serious complications. METHODS Between May 2011 and November 2012, we enrolled children who had symptoms of EV71 infection from six hospitals in Taiwan. The caregivers of each patient were interviewed to determine their hand hygiene habits in relation to EV71 infection. The severity of EV71 infection was classified as follows: Stage 1, hand-foot-mouth disease or herpangina; Stage 2, meningitis or myoclonic jerk; Stage 3A, encephalitis; Stage 3B, cardiopulmonary failure. Stages 2 to 3B were defined as severe EV71 infection. Children with Stages 3A and 3B infection were designated as the critical group. RESULTS A total of 399 patients had laboratory-confirmed EV71 infection. Three risks factors were associated with the different degrees of severity in EV71 infection. Children <2 years old had much greater risks for severe EV71 infection [odds ratio (OR) 1.8; 95% confidence interval (CI), 1.2-2.8], delayed medical evaluation for critical infection (OR 9.4; 95% CI, 3.6-24.1), and developmental retardation for cardiopulmonary failure (OR 8.3; 95% CI, 2.0-33.7). Among all the habits and household factors, caregivers in the critical group had a significantly lower rate in terms of cleaning the faucet after washing their hands (OR 2.63; 95% CI, 1.14-6.08). CONCLUSIONS Children <2 years old, developmental retardation, and delayed medical intervention were associated with severe EV71 infection. Cleaning water faucets after hand washing was a protective habit that reduced the risk of complications.
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Shen FH, Shen TJ, Chang TM, Su IJ, Chen SH. Early dexamethasone treatment exacerbates enterovirus 71 infection in mice. Virology 2014; 464-465:218-227. [PMID: 25104614 DOI: 10.1016/j.virol.2014.07.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Revised: 06/23/2014] [Accepted: 07/14/2014] [Indexed: 11/26/2022]
Abstract
Enterovirus 71 (EV71) infection can induce encephalitis. Overt immune responses is suspected to cause severe symptoms, so anti-inflammatory agents, corticosteroids have been recommended for treatment. However, one clinical study reported that treatment with glucocorticoids, dexamethasone (Dex) exacerbates disease severity. Here we investigated Dex treatment on EV71 infection using the murine model and found that both long-term (14-day) and short-term (4-day) Dex treatment starting from 1 or 3 days postinfection increased the mortality and disease severity of infected mice. Dex treatment starting from 4 or 8 days postinfection did not affect mouse mortality and disease severity. Early Dex treatment starting from 1 day postinfection caused atrophy and enhanced apoptosis in lymphoid organs to decrease the numbers of lymphocytes (CD4(+) T cells, CD8(+) T cells, and CD19(+) B cells) and to increase viral loads in infected tissues of mice. Our results demonstrate that Dex treatment has no beneficial effect on EV71 infection.
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Affiliation(s)
- Fang-Hsiu Shen
- Department of Microbiology and Immunology, College of Medicine, National Cheng Kung University, Tainan, Taiwan 701, Republic of China
| | - Ting-Jing Shen
- Department of Microbiology and Immunology, College of Medicine, National Cheng Kung University, Tainan, Taiwan 701, Republic of China
| | - Tung-Miao Chang
- Statistical Analysis Laboratory, Department of International Business Management, Tainan University of Technology, Tainan, Taiwan 710, Republic of China
| | - Ih-Jen Su
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Tainan, Taiwan 701, Republic of China.
| | - Shun-Hua Chen
- Department of Microbiology and Immunology, College of Medicine, National Cheng Kung University, Tainan, Taiwan 701, Republic of China; Center of Infectious Disease and Signaling Research, National Cheng Kung University, Tainan, Taiwan 701, Republic of China.
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16
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Cheng HY, Huang YC, Yen TY, Hsia SH, Hsieh YC, Li CC, Chang LY, Huang LM. The correlation between the presence of viremia and clinical severity in patients with enterovirus 71 infection: a multi-center cohort study. BMC Infect Dis 2014; 14:417. [PMID: 25069383 PMCID: PMC4133623 DOI: 10.1186/1471-2334-14-417] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 07/18/2014] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Enterovirus 71 (EV71) is a great disease burden across the whole world, particularly in Southeast Asia. However, in recent decades, the pathogenesis of severe EV71 infection was not well understood. This study was aimed to investigate the correlation between the presence of viremia and the clinical severity of EV71 infection. METHODS We organized a prospective cohort study and enrolled laboratory-confirmed EV71 cases in six tertiary care hospitals in Taiwan during the EV71 epidemic from 2011 to 2012. Blood samples were collected once in the acute stage, on the first day of admission. We used real-time RT-PCR to detect EV71 viremia. Demographical and clinical data were collected and the clinical severity was categorized into four grades. Data analysis was performed to identify the risk factors of viremia and the correlation between viremia and clinical severity of EV71 infection. RESULTS Of the total 224 enrolled patients, 59 (26%) patients were confirmed to have viremia. Two-thirds (68%) of viremic cases were detected within the first three days of infection. Viremia occurred more frequently in children under the age of one year old (odds ratios [OR] 4.82, p < 0.001) but the association between the presence of viremia and complicated EV71 infection was not found (OR 1.02, p = 0.96). In the viremia group, patients had significantly more severe complications if viremia was detected after the third day of disease onset (26% vs. 5%, p = 0.03). CONCLUSIONS Viremia occurred more frequently in children under the age of one year and viremia detected beyond three days after the onset of disease correlated with more severe disease in EV71 patients.
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Affiliation(s)
- Hao-Yuan Cheng
- />Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yi-Chuan Huang
- />Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ting-Yu Yen
- />Department of Pediatrics, Children’s Hospital, China Medical University and Hospitals, Taichung, Taiwan
| | - Shao-Hsuan Hsia
- />Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yu-Chia Hsieh
- />Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chung-Chen Li
- />Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Luan-Yin Chang
- />Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Li-Min Huang
- />Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
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17
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Abzug MJ. The enteroviruses: Problems in need of treatments. J Infect 2014; 68 Suppl 1:S108-14. [DOI: 10.1016/j.jinf.2013.09.020] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2013] [Indexed: 01/26/2023]
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Milrinone therapy for enterovirus 71-induced pulmonary edema and/or neurogenic shock in children: a randomized controlled trial. Crit Care Med 2013; 41:1754-60. [PMID: 23685637 DOI: 10.1097/ccm.0b013e31828a2a85] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Enterovirus 71-induced brainstem encephalitis with pulmonary edema and/or neurogenic shock (stage 3B) is associated with rapid mortality in children. In a small pilot study, we found that milrinone reduced early mortality compared with historical controls. This prospective, randomized control trial was designed to provide more definitive evidence of the ability of milrinone to reduce the 1-week mortality of stage 3B enterovirus 71 infections. DESIGN Prospective, unicenter, open-label, randomized, controlled study. SETTING Inpatient ward of a large tertiary teaching hospital in Ho Chi Minh City, Vietnam. PATIENTS Children (≤ 18 yr old) admitted with proven enterovirus 71-induced pulmonary edema and/or neurogenic shock. INTERVENTIONS Patients were randomly assigned to receive intravenous milrinone (0.5 μg/kg/min) (n = 22) or conventional management (n = 19). Both groups received dopamine or dobutamine and intravenous immunoglobulin. MEASUREMENTS AND MAIN RESULTS The primary endpoint was 1-week mortality. The secondary endpoints included length of ventilator dependence and hospital stay and adverse events. The median age was 2 years with a predominance of boys in both groups. The 1-week mortality was significantly lower, 18.2% (4/22) in the milrinone compared with 57.9% (11/19) in the conventional management group (relative risk = 0.314 [95% CI, 0.12-0.83], p = 0.01). The median duration of ventilator-free days was longer in the milrinone treatment group (p = 0.01). There was no apparent neurologic sequela in the survivors in either group, and no drug-related adverse events were documented. CONCLUSIONS Milrinone significantly reduced the 1-week mortality of enterovirus 71-induced pulmonary edema and/or neurogenic shock without adverse effects. Further studies are needed to determine whether milrinone might be useful to prevent progression of earlier stages of brainstem encephalitis.
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CD4 T-cell-independent antibody response reduces enterovirus 71 lethality in mice by decreasing tissue viral loads. Clin Dev Immunol 2012; 2012:580696. [PMID: 23133489 PMCID: PMC3486008 DOI: 10.1155/2012/580696] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Revised: 09/09/2012] [Accepted: 09/10/2012] [Indexed: 11/17/2022]
Abstract
Enterovirus 71 (EV71) has induced fatal encephalitis in hundreds of thousands of infants and young children in the Asia-Pacific region since the past decade. Lymphocyte and antibody responses have been suspected to aggravate EV71-induced neurological symptoms, so anti-inflammatory agents have been used to treat patients with neurological symptoms. In the present study, we found that mice deficient in CD4+ T cells were resistant to EV71 infection as wild-type mice, whereas mice deficient in B cells were highly susceptible to viral infection. Compensation of CD4 T-cell function by other immune cells was not likely, because wild-type mice depleted of CD4+ T cells were also resistant to viral infection. Infected CD4 T-cell-deficient mice produced virus-specific neutralizing antibodies, IgM and IgG. Moreover, adoptive transfer of the virus-specific antibody produced by infected CD4 T-cell-deficient mice protected B-cell-deficient mice from infection by reducing tissue viral loads. Collectively, our results show that the CD4 T-cell-independent antibody response promotes the survival of EV71-infected mice and suggest great potential for the use of vaccines and neutralizing antibodies to reduce fatal symptoms in patients.
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Huang HI, Weng KF, Shih SR. Viral and host factors that contribute to pathogenicity of enterovirus 71. Future Microbiol 2012; 7:467-79. [DOI: 10.2217/fmb.12.22] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The single-stranded RNA virus enterovirus 71 (EV71), which belongs to the Picornaviridae family, has caused epidemics worldwide, particularly in the Asia–Pacific region. Most EV71 infections result in mild clinical symptoms, including herpangina and hand, foot and mouth disease. However, serious pathological complications have also been reported, especially for young children. The mechanisms of EV71 disease progression remain unclear. The pathogenesis of adverse clinical outcomes may relate to many factors, including cell tropism, cell death and host immune responses. This article reviews the recent advances in the identification of factors determining EV71 cell tropism, the associated mechanisms of viral infection-induced cell death and the interplay between EV71 and immunity.
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Affiliation(s)
- Hsing-I Huang
- Research Center for Emerging Viral Infections, Chang Gung University, Kwei-Shan Tao-Yuan, Taiwan, Republic of China
- Department of Medical Biotechnology & Laboratory Science, Chang Gung University, Kwei-Shan Tao-Yuan, Taiwan, Republic of China
| | - Kuo-Feng Weng
- Research Center for Emerging Viral Infections, Chang Gung University, Kwei-Shan Tao-Yuan, Taiwan, Republic of China
- The Center for Molecular & Clinical Immunology, Chang Gung University, Kwei-Shan Tao-Yuan, Taiwan, Republic of China
| | - Shin-Ru Shih
- Research Center for Emerging Viral Infections, Chang Gung University, Kwei-Shan Tao-Yuan, Taiwan, Republic of China
- Department of Medical Biotechnology & Laboratory Science, Chang Gung University, Kwei-Shan Tao-Yuan, Taiwan, Republic of China
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Li Y, Zhu R, Qian Y, Deng J. The characteristics of blood glucose and WBC counts in peripheral blood of cases of hand foot and mouth disease in China: a systematic review. PLoS One 2012; 7:e29003. [PMID: 22235257 PMCID: PMC3250408 DOI: 10.1371/journal.pone.0029003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2011] [Accepted: 11/18/2011] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Outbreaks of Hand Foot and Mouth Disease (HFMD) have occurred in many parts of the world especially in China. We aimed to summarize the characteristics of the levels of blood glucose and white blood cell (WBC) counts in cases of HFMD in Mainland China and Taiwan, using meta-analysis based on systematic review of published articles. METHODS We systematically reviewed published studies, from the MEDLINE and WANFANG Data, about the levels of blood glucose and WBC counts in cases of HFMD until 15(th) June 2011, and quantitatively summarized the characteristics of them using meta-analysis. RESULTS In total, 37 studies were included in this review. In Mainland China and Taiwan, generally, the average level of blood glucose, the prevalence of hyperglycemia, WBC counts and the prevalence of leukocytosis increased with the severity of the illness. There was no significant difference in the prevalence of leukocytosis between ANS (autonomic nervous system dysregulation)/PE (pulmonary edema) group and CNS (central nervous system) group, and in the average level of blood glucose between healthy controls and mild cases of HFMD. WBC counts in cases infected by EV71 were less than those in cases infected by CA16. CONCLUSIONS our analyses indicated that blood glucose and WBC counts increased with the severity of HFMD disease, which would help doctors to manage patients efficiently.
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Affiliation(s)
- Yuyun Li
- Laboratory of Virology, Capital Institute of Pediatrics, Beijing, China
| | - Runan Zhu
- Laboratory of Virology, Capital Institute of Pediatrics, Beijing, China
| | - Yuan Qian
- Laboratory of Virology, Capital Institute of Pediatrics, Beijing, China
- * E-mail:
| | - Jie Deng
- Laboratory of Virology, Capital Institute of Pediatrics, Beijing, China
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Abstract
Although poliomyelitis has been mostly eradicated worldwide, large outbreaks of the related enterovirus 71 have been seen in Asia-Pacific countries in the past 10 years. This virus mostly affects children, manifesting as hand, foot, and mouth disease, aseptic meningitis, poliomyelitis-like acute flaccid paralysis, brainstem encephalitis, and other severe systemic disorders, including especially pulmonary oedema and cardiorespiratory collapse. Clinical predictors of severe disease include high temperature and lethargy, and lumbar puncture might reveal pleocytosis. Many diagnostic tests are available, but PCR of throat swabs and vesicle fluid, if available, is among the most efficient. Features of inflammation, particularly in the anterior horns of the spinal cord, the dorsal pons, and the medulla can be clearly seen on MRI. No established antiviral treatment is available. Intravenous immunoglobulin seems to be beneficial in severe disease, perhaps through non-specific anti-inflammatory mechanisms, but has not been tested in any formal trials. Milrinone might be helpful in patients with cardiac dysfunction.
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Abstract
Over the past decade, Human enterovirus (HEV)71 has emerged as a highly significant cause of viral encephalitis in the south-east Asian region. A pattern of increased epidemic activity has been observable since 1997, the cause of which is unclear. Ongoing investigations into the molecular basis of HEV71 infection and virulence, in particular viral translation and replication, have confirmed similarities between HEV71 and other enteroviruses, including the prototype species Poliovirus, but more work is required in this field. Although several putative receptors for HEV71 have been identified, it remains likely that other, as yet unidentified, receptors exist. Work in several established animal models for HEV71 infection has confirmed the protective efficacy of several inactivated vaccines. As more information emerges regarding the molecular processes involved in HEV71 infection, further advances may lead to the development of more effective antiviral treatments and, ultimately, a vaccine protection strategy.
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Affiliation(s)
- Emily J Bek
- Infectious Diseases & Immunology, Sydney Medical School, Blackburn Building D06, The University of Sydney, NSW 2006, Australia
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Abstract
Hand, foot and mouth disease (HFMD) is generally a benign febrile exanthematous childhood disease caused by human enteroviruses. The route of transmission is postulated to be faeco-oral in developing areas but attributed more to respiratory droplet in developed areas. Transmission is facilitated by the prolonged environmental survival of these viruses and their greater resistance to biocides. Serious outbreaks with neurological and cardiopulmonary complications caused by human enterovirus 71 (HEV-71) seem to be commoner in the Asian Pacific region than elsewhere in the world. This geographical predilection is unexplained but could be related to the frequency of intra- and inter-typic genetic recombinations of the virus, the host populations' genetic predisposition, environmental hygiene, and standard of healthcare. Vaccine development could be hampered by the general mildness of the illness and rapid genetic evolution of the virus. Antivirals are not readily available; the role of intravenous immunoglobulin in the treatment of serious complications should be investigated. Monitoring of this disease and its epidemiology in the densely populated Asia Pacific epicentre is important for the detection of emerging epidemics due to enteroviruses.
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Jan SL, Lin SJ, Fu YC, Chi CS, Wang CC, Wei HJ, Chang Y, Hwang B, Chen PY, Huang FL, Lin MC. Extracorporeal life support for treatment of children with enterovirus 71 infection-related cardiopulmonary failure. Intensive Care Med 2009; 36:520-7. [PMID: 20033668 DOI: 10.1007/s00134-009-1739-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2009] [Accepted: 08/12/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE Enterovirus 71 (EV71) infection leading to cardiopulmonary failure (CPF) is rare, but usually fatal. In such cases, intensive cardiorespiratory support is essential for survival. In this study, we report our experience in the treatment of EV71-related CPF with extracorporeal life support (ECLS). METHODS This was a retrospective study of a total of 13 children, aged 16 +/- 10 months, with EV71-related hemodynamically unstable CPF, which was refractory to conventional treatments, who were rescued by transsternal ECLS from 2000 to 2008. The clinical manifestations and outcomes of the 13 children (present cohort) were compared with those of 10 children (past cohort) who had EV71-related CPF without ECLS between 1998 and 2000. RESULTS Among these 13 patients, 10 were successfully weaned off ECLS and survived. The myocardial recovery time was 71 +/- 28 (median, 69) h, and the ECLS duration was 93 +/- 33 (median, 93) h. Six surviving patients had a good neurological outcome at hospital discharge. All surviving patients had some neurological sequelae but showed improvement at follow-up, including dysphagia in nine, central hypoventilation in seven, limb weakness in six and seizure in three. The present cohort had better neurological outcomes (46 vs. 0%, P = 0.005) and a higher survival rate (77 vs. 30%, P = 0.024) than the past cohort, respectively. CONCLUSIONS Patients with EV71-related CPF supported by ECLS had a higher survival rate and fewer neurological sequelae than those who only received conventional treatments. ECLS is an effective alternative method for treatment of children with refractory EV71-related CPF.
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Affiliation(s)
- Sheng-Ling Jan
- Department of Paediatrics, Taichung Veterans General Hospital, Taichung 40705, Taiwan.
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Abstract
Enterovirus 71 (EV71) causes death and long-term neurologic sequelae in hundreds of thousands of young children, but its pathogenesis remains elusive. Dendritic cells (DCs) play a crucial role in antiviral immunity by functioning as professional antigen-presenting cells to prime T cells and by secreting cytokines to modulate immune responses. Here, we show that EV71 productively infected human immature DCs and expressed viral antigen in DCs. EV71 entry into DCs was partially mediated by DC-SIGN. Further analyses revealed that EV71 increased the viability, activation, release of cytokines, interleukin-6, interleukin-12, and tumor necrosis factor-α in DCs. Moreover, EV71 enabled DCs to stimulate T-cell proliferation. Collectively, these findings suggest that EV71 infection of human DCs in vivo is very likely to elicit protective immunity, because in infected mice, both T cells and IL-6 function to reduce mortality.
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Abstract
The purpose of this review was to explore the epidemiology, pathogenesis, virology, and management of enterovirus 71 (EV71) infection. Published literature was surveyed by Medline using the keyword "EV71." The reported incidence of cases of hand-foot-mouth disease/herpangina varied from year to year; seasonal variations in incidence were observed, with a peak in incidence during the summer season. Most cases of hand-foot-mouth disease/herpangina hospitalized for complications occurred in children less than 5 years old. The brainstem was the most likely major target of EV71 infection. Different enteroviruses cocirculate in the community annually. The emergence of the EV71 epidemic in the Asia Pacific region has been associated with the circulation of 5 genetic lineages (genotypes B3, B4, C1, C2, C4) that appear to be undergoing rapid evolutionary changes. The relationship between the gene structure of the EV71 virus and the factors that ensure its survival, ease of transmission, and evasion of immunity is still unclear. EV71 central nervous system involvement causes serious clinical illness, death, and long-term neurologic and psychiatric disorders in young children. EV71 infection has emerged as an important public health problem. Vaccine development is recommended for the prevention of EV71 infection in the future.
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Lymphocyte and antibody responses reduce enterovirus 71 lethality in mice by decreasing tissue viral loads. J Virol 2009; 83:6477-83. [PMID: 19386699 DOI: 10.1128/jvi.00434-09] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Enterovirus 71 (EV71) infects the central nervous system and causes death and long-term neurological sequelae in hundreds of thousands of young children, but its pathogenesis remains elusive. Immunopathological mechanisms have been suspected to contribute to the pathogenesis of neurological symptoms, so anti-inflammatory agents have been used to treat patients with neurological symptoms. The present study was therefore designed to investigate the functions of lymphocyte and antibody responses in EV71 infection using a mouse model. Immunohistochemical staining analysis revealed virus and three types of lymphocytes, B cells, CD4 T cells, and CD8 T cells, in the spinal cord of an EV71-infected patient who died. A study of mice showed that the levels of virus and lymphocytes in brains and antibody titers in sera were elevated during the time when the mice succumbed to death in a phenomenon analogous to that observed in patients. Further studies demonstrated that after infection, the disease severity, mortality, and tissue viral loads of mice deficient in B, CD4 T, or CD8 T cells were significantly higher than those of wild-type mice. In addition, treatment with a virus-specific antibody, but not a control antibody, before or after infection significantly reduced the disease severity, mortality, and tissue viral loads of mice deficient in B cells. Our results show that both lymphocyte and antibody responses protect mice from EV71 infection. Our study suggests the use of vaccines and virus-specific antibodies to control fatal outbreaks and raises caution over the use of corticosteroids to treat EV71-infected patients with neurological symptoms.
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Huang KY, Zhang X, Chung PH, Tsao KC, Lin TY, Su LH, Chiu CH. Enterovirus 71 in Taiwan, 2004-2006: epidemiological and virological features. ACTA ACUST UNITED AC 2008; 40:571-4. [PMID: 18584550 DOI: 10.1080/00365540701799359] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
We report unusual cases of myocarditis caused by enterovirus 71 (EV71) and a declining trend in the incidence of EV71 in Taiwan since 2005. Furthermore, phylogenetic analysis of the 5' untranslated region, VP4, and VP1 genes of EV71 isolates in 2004-2005 revealed a divergent phylogeny from the previous Taiwanese isolates. No obvious phylogenetically distinct clones or clusters were found related to varying degrees of disease severity or clinical manifestations.
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Affiliation(s)
- Kuan-Ying Huang
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Chang Gung Children's Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
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Simmonds J, Cubitt D, Ashworth M, Burch M. Successful heart transplantation following neonatal necrotic enterovirus myocarditis. Pediatr Cardiol 2008; 29:834-7. [PMID: 18158605 DOI: 10.1007/s00246-007-9182-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2007] [Revised: 11/09/2007] [Accepted: 11/21/2007] [Indexed: 11/30/2022]
Abstract
Enterovirus myocarditis is a potentially devastating diagnosis in the neonatal setting, with an associated high mortality and risk for chronically impaired cardiac function. Transplantation may be a possible therapeutic option, but, due to the comparative scarcity of the presentation, the limited donor pool, and fears of viral persistence and recurrence of myocarditis (especially in the immunocompromised, post-transplant setting), there are no reported cases in the literature. This case report illustrates an encouraging one-year outcome following heart transplantation for necrotic enterovirus myocarditis in a neonate.
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Affiliation(s)
- Jacob Simmonds
- Department of Paediatric Cardiology, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK.
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Abzug MJ. The enteroviruses: an emerging infectious disease? The real, the speculative and the really speculative. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2008; 609:1-15. [PMID: 18193653 DOI: 10.1007/978-0-387-73960-1_1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Affiliation(s)
- Mark J Abzug
- Department of Pediatrics, (Pediatric Infectious Diseases), University of Colorado School of Medicine, The Children's Hospital, Denver, CO 80218, USA.
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Tsou YA, Cheng YK, Chung HK, Yeh YC, Lin CD, Tsai MH, Chang JS. Upper aerodigestive tract sequelae in severe enterovirus 71 infection: predictors and outcome. Int J Pediatr Otorhinolaryngol 2008; 72:41-7. [PMID: 18029029 DOI: 10.1016/j.ijporl.2007.09.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Revised: 07/20/2007] [Accepted: 09/14/2007] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Enterovirus 71 (EV71) infection sequelae can be severe and life-threatening, and long-term follow-up outcomes remain unknown. Therefore, we conducted a retrospective follow-up study to review airway and neurological sequelae development in patients with severe EV71 infection. We also studied the incidence and risk factors for tracheotomy and gastrostomy requirement. PATIENTS AND METHODS We investigated 202 EV71-infected children according to their disease stage. Seventy-two of them were diagnosed to have EV71 encephalitis, which was characterized by myoclonus, ataxia, nystagmus, oculomotor palsy and bulbar palsy or combinations of these conditions. All the 72 patients required endotracheal intubation due to respiratory failure or ventilator dependence; among these, 14 underwent tracheostomy and 10 underwent gastrostomy. All patients were followed-up for at least 3 years after discharge. Predictors of tracheostomy and gastrostomy requirement were age <2 years, body weight <10th percentile, pulmonary hemorrhage or edema, meningeal symptoms and magnetic resonance imaging (MRI) findings of upper spinal cord and brainstem. We determined outcome based on persistent tracheostomy or gastrostomy requirement and whether patients developed positive neurological sequelae. RESULTS Significant tracheostomy and gastrostomy predictors were age <2 years, pulmonary edema or hemorrhage, hypotension, hemiparesis and positive MRI findings. Statistical analysis revealed pulmonary edema and hypotension as index predictors of tracheostomy requirement and pulmonary edema as the significant risk factor for gastrostomy. CONCLUSIONS Long-term neuropsychological impact was observed on children who present the signs of the pulmonary edema or hypotension in the early onset of the EV71 infection. EV71-infected patients who develop neurological pulmonary edema or hypotension should be hemodynamically stabilized and undergo early tracheostomy to prevent further complications. This may improve the decannulation success rate after the brainstem function recovers.
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Affiliation(s)
- Yung-An Tsou
- Department of Otolaryngology, China Medical University Hospital, Taichung, Taiwan, ROC
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Frange P, Michon J, Fromantin I, Franck N, Safar E, Escande MC, Desguerre I, Orbach D. Enterovirus 71 meningoencephalitis during chemotherapy in a child with metastatic osteosarcoma. J Pediatr Hematol Oncol 2007; 29:566-8. [PMID: 17762499 DOI: 10.1097/mph.0b013e3180f61bbc] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Enterovirus meningoencephalitis is rare but can be severe. Very few cases of these infections have been reported in pediatric oncology. We report the case of a 10-year-old boy with tibial osteosarcoma and lung metastases who developed enterovirus 71 meningoencephalitis during aplasia. Clinical features comprised fever, hypotension, vesicular rash, generalized seizures, and altered consciousness. Diagnosis was confirmed by polymerase chain reaction on samples of cerebrospinal fluid and skin vesicles. The patient received treatment with intravenous immunoglobulins with an excellent outcome with no cutaneous or neurologic sequelae. Immunoglobulin therapy could be considered in cases of invasive enteroviral infection with such severity in pediatric oncology.
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Affiliation(s)
- Pierre Frange
- Pediatric Oncology Department, Hôpital Necker Enfants Malades, APHP, Paris, France
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