Clinical and Neurodevelopmental Characteristics of Enterovirus and Parechovirus Meningitis in Neonates

Mimickers of Hypoxic Ischemic Encephalopathy

Although neonatal encephalopathy is most often caused by hypoxic-ischemic injury, there are many other causes. A careful history and clinical examination allow clinicians to identify neonates with these mimickers, so prompt intervention and support ensue to allow the best developmental outcome.

State-of-the-art cranial ultrasound in clinical scenarios for infants born at term and near-term

Neonates admitted to the intensive care unit are at risk of brain injury. Importantly, infants with signs of neurological impairment need prompt diagnosis to guide intervention. Cranial ultrasound (CUS) is the first-line imaging tool for infants born preterm. New developments in this technology, which now incorporates high-resolution equipment, have notably improved the performance of CUS in infants born at term and near-term. On the other hand, the potential of CUS as a diagnostic tool in older infants is less established. The lack of studies focusing on this topic, local protocol variability among clinical sites, and divergent opinions on CUS patterns of disease entities are the main constraints. This review provides an overview of state-of-the-art CUS as a decision-making tool under different clinical scenarios, such as neonatal encephalopathy, seizures, and suspected central nervous system infection. The CUS features that characterize several patterns supporting a diagnosis are detailed, focusing on haemorrhage and infection.

Neurological Disorders and Use of Healthcare Services After Enteroviral Meningitis in Childhood: A Nationwide, Population-Based Cohort Study

BACKGROUND

Nervous system infections are associated with long-term risks of neurological disorders and healthcare service utilization, but little data exist on the long-term risks of enteroviral meningitis in childhood.

METHODS

We performed a population-based, nationwide registry-based matched cohort study (1997-2021). We included 925 children with enteroviral meningitis aged <17 years, a comparison cohort, and a cohort of siblings of all individuals. To illustrate short- and long-term risks of neurological disorders, we calculated 1-year cumulative incidences and age- and sex-adjusted hazard ratios (aHRs) with 95% confidence intervals (95% CIs) during years 1-20 of follow-up. We further calculated the annual proportion of individuals using antiepileptic medication and healthcare services.

RESULTS

Young infants (0 to <90 days) and older children (≥90 days to <17 years) had slightly increased short- and long-term risks of neurological disorders after enteroviral meningitis compared to comparison cohort members (1-year cumulative incidence: 1.4% vs 0.6%, and 1.5% vs 0.4%, 1-20-year adjusted hazard ratio: 2.0 [95% CI: 1.2-3.2] and 1.7 [95% CI: 1.0-2.8]). Older children had increased use of antiepileptic medication, as well as the use of health care services both before and after enteroviral meningitis, with a similar trend among their siblings.

CONCLUSIONS

Enteroviral meningitis in childhood appears to be associated with increased risk of short- and long-term neurological morbidity, though our estimates in older children may be confounded by prior neurological morbidity or increased healthcare-seeking behavior. Our findings suggest a generally good prognosis after enteroviral meningitis, though clinicians should be aware of the risk of neurological disorders in selected patients.

Bacterial Meningoencephalitis in Newborns

Bacterial meningoencephalitis in newborns is a severe and life-threatening pathology, which results from meningeal infection and the subsequent involvement of the brain parenchyma. The severity of the acute onset of symptoms and the risk of neurodevelopmental adverse sequelae in children strongly depend on the timing of the infection, the immunological protection transmitted by the mother to the fetus during pregnancy, and the neonate's inflammatory and immune system response after birth. Although the incidence of neonatal meningitis and meningoencephalitis and related mortality declined in the past twenty years with the improvement of prenatal care and with the introduction of intrapartum antibiotic prophylaxis against Streptococcus beta Hemolyticus group B (Streptococcus Agalactiae) in the 1990s, bacterial meningitis remains the most common form of cerebrospinal fluid infection in pediatric patients. To date, the rate of unfavorable neurological outcomes is still from 20% to 60%, and the possibility of containing its rate strongly depends on early diagnosis, therapy, and a multidisciplinary approach, which involves neonatologists, neurologists, neuroradiologists, and physiotherapists. Neonatal meningitis remains difficult to diagnose because the responsible bacteria vary with gestational age at birth, age at presentation, and environmental context. The clinical presentation, especially in the newborn, is very ambiguous. From a clinical point of view, the definitive test for diagnosis is lumbar puncture in patients with symptoms suggestive of neurological involvement. Therefore, neuroimaging is key for raising clinical suspicion of meningitis or corroborating the diagnosis based on clinical and laboratory data. Our pictorial review offers a practical approach to neonatal meningoencephalitis by describing the epidemiology, the pathophysiology of bacterial meningoencephalitis, defining the indications and suggesting optimized protocols for neuroimaging techniques, and showing the main neuroimaging findings to reach the diagnosis and offering proper follow-up of bacterial meningitis. Moreover, we tried identifying some peculiar MRI patterns related to some bacteria.

Clinical presentation and management of enterovirus and parechovirus infection in children: A single-centre study in regional Australia

OBJECTIVE

This study aims to analyse the clinical presentation caused by enterovirus (EV) and/or human parechovirus (HPeV) infection in children, as well as the management of such cases admitted to a regional hospital in Australia.

METHODS

Retrospective study reviewing medical records.

SETTING

Single hospital in regional Australia.

PARTICIPANTS

All children under 18 years admitted over the 5-year period beginning from 1 January 2017 with confirmed EV and/or HPeV infection. Cases with clinically insignificant EV/HPeV isolation were excluded.

MAIN OUTCOME MEASURES

Data collected included demographic data, signs and symptoms present, specimens of EV/HPeV isolation, co-occurring pathogens, peak C-reactive protein (CRP), antibiotic therapy, discharge diagnosis and follow-up after discharge.

RESULTS

Overall, 27 patients fulfilled the inclusion criteria; 81.5% of the patients were ≤3 months of age with a median of 2 months (interquartile range 1-3); 74.1% were males. The most common clinical features were a fever ≥38°C and irritability/lethargy/high-pitched cry. 29.6% of the patients had co-occurring pathogens detected, and a CRP ≤10 mg/L was observed in 77.8% of cases. All but two children were treated with antibiotics while awaiting polymerase chain reaction results. The most common discharge diagnosis was meningitis. In all, 74.1% of the children attended follow-up appointments.

CONCLUSIONS

EV and HPeV should be considered as a possible aetiology of fever and irritability/lethargy/high-pitched cry in children under 3 months.

Respiratory Arrest in a Late Preterm Infant Presenting for a 2-Week Well-Visit

A 13-day-old, late preterm male, born appropriate for gestational age, presented to the pediatric clinic for his routine 2-week well visit with less than 1-day history of decreased oral intake and lethargy. During the baby's well exam, he acutely decompensated and required resuscitation and transfer to the emergency department, where he was intubated for frequent apneic events. He was admitted to the NICU for management and further workup. Physical examination and initial laboratory tests were unremarkable. An EEG demonstrated electrographic and clinical seizures. His initial MRI was unremarkable, and infection studies revealed the diagnosis. We review the patient's initial presentation, evaluation, hospital course, and the long-term implications of his diagnosis.

Molecular epidemiology and characterization of enteroviruses detected in cerebrospinal fluid and respiratory samples in Slovenia, 2014-2023

Enterovirus (EV) infections have various symptoms and severe complications, including death. To determine EV prevalence and EV types in Slovenia, data on over 25 000 EV RNA tests for diagnostics and surveillance from 2014 to 2023 were analyzed. Altogether, 3733 cerebrospinal fluid (CSF) and 21 297 respiratory (sentinel and clinical) samples were tested for EV RNA. EV typing was performed on all residual EV-positive CSF samples and on subset of respiratory specimens. Altogether, 1238 samples tested positive for EV RNA: 238 (6.4%) CSF and 1000 (4.7%) respiratory samples. EV-positive patients were predominantly male (p < 0.001). Many EV-positive CSF samples were from infants under 3 months (33.1%), whereas most EV-positive respiratory samples were from children 1 to 2 years old (49.2%). Echovirus 30 (E-30) was most frequent in CSF (33.0%), followed by CV-B5 (13.8%) and E-6 (13.8%). CV-A6 was most frequent in respiratory samples (16.0%), followed by EV-D68 (7.6%) and CV-A5 (7.4%). EV types in CSF and respiratory samples show diverse dynamics, with some outbreaks indicated. A significant difference was found in the EV detection rate between CSF and respiratory samples by age. Various EV types were characterized, showing that some EV types are more neurotropic or cause more severe infections.

Clinical course and peculiarities of Parechovirus and Enterovirus central nervous system infections in newborns: a single-center experience

Parechovirus (HpEV) and Enterovirus (EV) infections in children mostly have a mild course but are particularly fearsome in newborns in whom they may cause aseptic meningitis, encephalitis, and myocarditis. Our study aimed to describe the clinical presentations and peculiarities of CNS infection by HpEV and EV in neonates. This is a single-center retrospective study at Istituto Gaslini, Genoa, Italy. Infants aged ≤ 30 days with a CSF RTq-PCR positive for EV or HpEV from January 1, 2022, to December 1, 2023, were enrolled. Each patient's record included demographic data, blood and CSF tests, brain MRI, therapies, length of stay, ICU admission, complications, and mortality. The two groups were compared to identify any differences and similarities. Twenty-five patients (15 EV and 10 HpEV) with a median age of 15 days were included. EV patients had a more frequent history of prematurity/neonatal respiratory distress syndrome (p = 0.021), more respiratory symptoms on admission (p = 0.012), and higher C-reactive protein (CRP) levels (p = 0.027), whereas ferritin values were significantly increased in HpEV patients (p = 0.001). Eight patients had a pathological brain MRI, equally distributed between the two groups. Three EV patients developed myocarditis and one HpEV necrotizing enterocolitis with HLH-like. No deaths occurred.  Conclusion: EV and HpEV CNS infections are not easily distinguishable by clinical features. In both cases, brain MRI abnormalities are not uncommon, and a severe course of the disease is possible. Hyper-ferritinemia may represent an additional diagnostic clue for HpEV infection, and its monitoring is recommended to intercept HLH early and initiate immunomodulatory treatment. Larger studies are needed to confirm our findings. What is Known: • Parechovirus and Enteroviruses are the most common viral pathogens responsible for sepsis and meningoencephalitis in neonates and young infants. • The clinical course and distinguishing features of Parechovirus and Enterovirus central nervous system infections are not well described. What is New: • Severe disease course, brain MRI abnormalities, and complications are not uncommon in newborns with Parechovirus and Enteroviruses central nervous system infections. • Hyper-ferritinemia may represent an additional diagnostic clue for Parechovirus infection and its monitoring is recommended.

Human parechovirus meningitis in children: state of the art

Human Parechovirus is a common cause of infection occurring especially during the first years of life. It may present with a broad spectrum of manifestations, ranging from a pauci-symptomatic infection to a sepsis-like or central nervous system disease. Aim of this study is to explore the knowledge on Parechovirus meningitis. According to the purpose of the study, a systematic review of the literature focusing on reports on central nervous system. Parechovirus infection of children was performed following PRISMA criteria. Out of the search, 304 papers were identified and 81 records were included in the revision dealing with epidemiology, clinical manifestations, laboratory findings, imaging, therapy and outcome. Parechovirus meningitis incidence may vary all over the world and outbreaks may occur. Fever is the most common symptom, followed by other non-specific signs and symptoms including irritability, poor feeding, skin rash or seizures. Although several reports describe favourable short-term neurodevelopmental outcomes at discharge after Parechovirus central nervous system infection, a specific follow up and the awareness on the risk of sequelae should be underlined in relation to the reported negative outcome. Evidence seems to suggest a correlation between magnetic imaging resonance alteration and a poor outcome.