Outbreak of Enterovirus Infection with Neurological Presentations in a Pediatric Population in Northern Spain: A Clinical Observational Study

Abstract

Objective The study aimed to describe the cases of neurological disease related to the outbreak of enterovirus (EV) in three regions in Northern Spain during 2016. Materials and Methods Multicenter retrospective observational study. Clinical, radiological, and microbiological data were analyzed from patients younger than 15 years with confirmed EV-associated neurological disease admitted to 10 hospitals of Asturias, Cantabria, and Castile and Leon between January 1 and December 31, 2016. Results Fifty-five patients were included. Median age was 24 months (interquartile range = 18.5 months). Fifteen patients were classified as aseptic meningitis (27.3%). In total, 37 cases presented brainstem encephalitis (67.3%), 25 of them due to EV-A71 with excellent prognosis (84.6% asymptomatic 2 months following the onset). Three cases of acute flaccid myelitis (5.5%) by EV-D68 were reported and presented persistent paresis 2 months following the onset. Microbiological diagnosis by reverse transcriptase polymerase chain reaction was performed in all cases, finding EV in cerebrospinal fluid in meningitis, but not in brainstem encephalitis and acute flaccid myelitis, where EV was found in respiratory or rectal samples. Step therapy was administrated with intravenous immunoglobulin (IVIG; 32.7%), methylprednisolone (10%), and plasmapheresis (3.6%). Four patients received fluoxetine (7.3%). Twenty patients needed to be admitted to pediatric intensive care unit (36.4%). Conclusion Clinical, microbiological, and radiological diagnosis is essential in outbreaks of EV neurological disease, taking into account that it can be difficult to identify EV-A71 and EV-D68 in CSF, requiring throat or rectal samples. There is not specific treatment to these conditions and the efficacy and understanding of the mechanism of action of immune-modulatory treatment (IVIG, corticosteroids, and plasmapheresis) is limited.

Clinical and epidemiological characteristics of acute flaccid myelitis cases in children registered in the Russian Federation in 2015–2019

“…Знание об этом синдроме позволит заподозрить наличие ОВМ и обеспечить быстрый сбор образцов для диагностики (ЦСЖ, носоглоточные смывы, кал, сыворотка крови) и своевременное лечение. Следует отметить, что эффективность и понимание механизма действия иммуномодулирующего лечения (внутривенные иммуноглобулины, глюкокортикостероиды и плазмаферез) ограничены [18,19]. На мышиных моделях инфекции нервной системы EV-D68 раннее введение внутривенного имму-ноглобулина уменьшало паралич, тогда как лечение глюкокортикостероидами приводило к увеличению титра вируса в ЦСЖ и ухудшению результатов [19].…”

“…Следует отметить, что эффективность и понимание механизма действия иммуномодулирующего лечения (внутривенные иммуноглобулины, глюкокортикостероиды и плазмаферез) ограничены [18,19]. На мышиных моделях инфекции нервной системы EV-D68 раннее введение внутривенного имму-ноглобулина уменьшало паралич, тогда как лечение глюкокортикостероидами приводило к увеличению титра вируса в ЦСЖ и ухудшению результатов [19]. По данным литературы, в случаях критического отека с вторичным сдавлением спинного мозга использовались глюкокортикостероиды, но индивидуальная польза в таких ситуациях неясна [14].…”

The Enigma of Childhood Predisposition in Enteroviral Infections

“…We read with great interest the article by Hedrera-Fernandez et al describing the spectrum of neurological presentations of enteroviral infections in a cohort of Spanish children over 1 year (2016). 1 Authors vividly describe the neurological manifestations, their management, and the outcome of the cohort. Enterovirus A71 (EV-A71) and EV-D68 were the common enteroviral infections and neurological manifestations ranged from aseptic meningitis, brainstem encephalitis, and acute flaccid myelitis (AFM).…”