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Vol. 89. Num. 6.01 December 2018
Pages 323-386
Vol. 89. Num. 6.01 December 2018
Pages 323-386
Scientific Letter
DOI: 10.1016/j.anpede.2018.01.014
Open Access
Infection outbreak due to an enterovirus causing severe neurological complications in a tertiary hospital
Brote de infección por enterovirus causantes de afectación neurológica grave en un hospital terciario
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Andrea María Leal Barcelóa,
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andremar_5_@hotmail.com

Corresponding author.
, Paula Carrascosa Garcíaa, Elena María Rincón Lópezb, María Concepción Miranda Herreroc, María Luisa Navarrob
a Servicio de Pediatría, Hospital General Universitario Gregorio Marañón, Madrid, Spain
b Servicio de Enfermedades Infecciosas Pediátricas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
c Servicio de Neurología Pediátrica, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Table 1. Summary of clinical characteristics, diagnostic tests, treatment and outcomes for each patient.
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Enterovirus (EV) frequently causes outbreaks of infection in children in spring and summer. Although it usually produces mild illness, there are also cases with severe neurologic involvement (encephalitis, rhombencephalitis, acute flaccid paralysis and autonomic dysfunction with pulmonary oedema) that may cause lifelong sequelae or death. The serotypes associated with the most severe cases are A71 and D68.1–6 We describe the cases of the patients admitted to a tertiary care hospital in Madrid in May 2016 following the outbreak of EV infection with severe neurologic involvement in Catalonia in the same year.1

We conducted a prospective descriptive study of the clinical and epidemiological characteristics, the diagnostic tests performed and the outcomes of patients admitted with suspected EV infection and severe neurologic symptoms (Table 1).

Table 1.

Summary of clinical characteristics, diagnostic tests, treatment and outcomes for each patient.

  Patient 1  Patient 2  Patient 3  Patient 4  Patient 5  Patient 6  Patient 7  Patient 8  Patient 9  Patient 10  Patient 11 
Age (months)  25  49  26  22  29  32  25  48  14  11  26 
Sex  Female  Male  Male  Female  Male  Male  Female  Female  Female  Female  Male 
Systemic manifestations
Fever  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  No  Yes  Yes 
Irritability  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes 
Skin and mucosal involvement  No  No  Yes  Yes  Yes  Yes  No  Yes  Yes  Yes  Yes 
Hand-foot-mouth-like rash  No  No  Yes  No  Yes  Yes  No  Yes  No  No  Yes 
Enanthem  No  No  Yes  Yes  No  No  No  No  No  No  No 
Neurologic manifestations
Onset (days from onset of systemic symptoms) 
Somnolence  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  No 
Ataxia  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Leve 
Myoclonus  Yes  No  Yes  No  Yes  Yes  No  Yes  No  Yes  Yes 
Tremors  Yes  Yes  Yes  Yes  Yes  Yes  No  Yes  Yes  Yes  No 
Convulsive seizures  No  No  No  No  No  No  No  No  No  No  No 
Flaccid paralysis  Yes  No  No  No  No  No  No  No  No  Initial suspicion  No 
Involvement of cranial nerves III-XII  Yes  Yes  No  No  No  No  No  No  No  No  No 
Dysautonomia
Altered breathing pattern  Yes  Yes  No  No  No  No  No  No  No  Yes  No 
Neurogenic pulmonary oedema  Yes  Yes  No  No  No  No  No  No  No  No  No 
Cardiac dysfunction  Yes  Yes  No  No  No  No  No  No  No  No  No 
High blood pressure  No  No  Yes  No  No  No  No  No  No  No  No 
Brain and spine MRI  Involvement of hindbrain and spinal cord  Involvement of brainstem, medulla and cervical spinal cord  Cervical transverse myelitis  Involvement of cervical spine and conus medullaris  Involvement of dentate nucleus and spinal cord through segment D1  Possible but unclear hyperintensity at the level of the C3–C6 segments and periaqueductal white matter  Lesions in left thalamus and cerebral peduncles and cervical myelitis  Hyperintensity in cerebral peduncles, periaqueductal brain matter and cervical spine through segment C6  Tracer uptake in the cervical and dorsal spine and conus medullaris  Mild hyperintensity in dentate nucleus  Not performed 
Enterovirus serotype  Nontypeable  A 71  A 71  A 71  A 71  –  Echo 32  Nontypeable  A 71 
Treatment
Days from onset of symptoms  No treatment 
IVIG  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  No 
Corticoids  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  No 
Fluoxetine  Yes  Yes  Yes  No  No  No  No  No  No  Yes  No 
Outcome
PICU stay (days)  Yes (12)  Yes (11)  Yes (2)  No  No  No  No  No  No  Yes (2)  No 
Mechanical ventilation (days)  Yes (7)  Yes (7)  No  No  No  No  No  No  No  Yes (2)  No 
Length of stay (days)  26  25  10 
Early sequelae  Altered sleep and irritability  Tremors and irritability  No  No  No  No  No  No  No  No  No 

CSF, cerebrospinal fluid; IVIG, intravenous immunoglobulin; MRI, magnetic resonance imaging; PICU, paediatric intensive care unit.

We analyzed 11 cases, of which 10 were confirmed, defined as presenting with acute neurologic manifestations of encephalitis, rhombencephalitis and/or acute paralysis with compatible findings on MRI examination and detection of enterovirus by PCR analysis of a nasopharyngeal or rectal swab sample in the absence of evidence of a different aetiological agent. One was a probable case, suspected based on compatible clinical manifestations and results from diagnostic tests, but without microbiological confirmation.

All the patients were previously healthy. The median age was 26 months (interquartile range [IQR], 22–32) and there was a predominance of the female sex (6/11). We did not find an apparent epidemiological association between the different cases. The symptoms at onset were irritability (11/11), fever (10/11) and skin and mucosal involvement (8/11). Neurologic symptoms developed a median of 3 days after the onset of systemic symptoms (IQR, 2–4), and the most common were ataxia (11/11), somnolence (10/11), tremors (9/11) and myoclonus during sleep (7/11). Only 2 patients had symptoms of brainstem involvement, while flaccid paralysis was initially suspected in 1 (due to areflexia and need for mechanical ventilation) but eventually ruled out due to the quick resolution of symptoms within 24h. Four patients were admitted to the PICU due to dysautonomia and cardiac dysfunction.

All patients underwent a lumbar puncture, and subsequent examination of the sample revealed pleocytosis in the cerebrospinal fluid in 9 out of 11 patients, with lymphocytic predominance in 7. A MRI scan was performed in 10 patients, revealing rhombencephalitis in 8 (associated with myelitis in 7) and isolated myelitis in 2 (Fig. 1). Since a high proportion of patients presented with somnolence and irritability, an encephalogram (EEG) was performed in 10, revealing slow wave activity in 9. The results of 9 brainstem auditory evoked response tests in patients with manifestations or MRI evidence of brainstem involvement and the 3 electromyograms performed in patients with significant spinal cord involvement were normal.

Figure 1.
(0.66MB).

T2-weighted and FLAIR MR images showing hindbrain involvement with myelitis. T2-weighed images showing hyperintensity on at the level of the cervical spine until segment C6 in patient 2 (A) and significant thickening of the conus medullaris in patient 4 (B). Hyperintensity on T2-weighted and FLAIR MR images at the level of the posterior pons and surrounding the fourth ventricle in patient 2 (C–F).

Enterovirus was detected in rectal swab samples (10/11) and nasopharyngeal swab samples (5/9) by PCR (GeneXpert®) in our hospital, and subsequently typed in samples submitted to the Centro Nacional de Microbiología. It was not detected in cerebrospinal fluid (CSF) or blood samples in any patient. The most frequent serotype was A71 (5/10), while serotype D68 was not detected in any case. The 10 patients classified as having moderate illness (significant somnolence) or severe illness (clinical manifestations or neuroimaging evidence of brainstem or spinal cord involvement) received early intravenous immunoglobulin (IVIG) therapy (within 24–48h from admission) in adherence with the treatment protocol applied in previous outbreaks.1,2 All of them received IVIG (1g/kg/day for 2 days), combined with administration of boluses of IV methylprednisolone (30mg/kg/day for 3 days) in patients with severe disease. Only patients admitted to the PICU received fluoxetine (0.3mg/kg/day), which was prescribed off-label on account of its in vitro activity and had no clear beneficial effects.

Two of the patients with severe disease had immediate sequelae that resolved after 3 months, and all patients remained asymptomatic at 12 months’ followup. The diagnostic tests repeated during followup included 4 EEGs that showed normalization of wave patterns and 2 MRI scans, of which 1 was unremarkable and 1 had features indicative of persistent myelitis.

In conclusion, we present a group of cases of EV infection with neurologic involvement linked in time, in which the most frequent type of involvement was rhombencephalitis. The clinical presentation was similar to the one described in other studies.1–3 The serotype detected most frequently was A71. As happened in the outbreak in Catalonia, while the initial presentation of some of the patients was severe, none died and all had favourable outcomes with no sequelae,1 which was not the case in other countries.2,3,6

Given the potential severity of neurologic involvement in enterovirus infection and that an outbreak of this magnitude had not been described in Spain until 2016, we believe that reporting the cases occurred in our country is relevant. This could help identify similar cases earlier, improving the initial management (especially supportive care) of an infection that can lead to death in the first 24h from the onset of neurologic symptoms.

References
[1]
D. Casas-Alba, M.F. de Sevilla, A. Valero-Rello, C. Fortuny, J.J. García-García, C. Ortez
Outbreak of brainstem encephalitis associated with enterovirus-A71 in Catalonia Spain (2016): a clinical observational study in a children's reference centre in Catalonia
Clin Microbiol Infect, 23 (2017), pp. 874-881
[2]
K.Y. Lee, M.S. Lee, D.B. Kim
Neurologic manifestations of enterovirus 71 infection in Korea
J Korean Med Sci, 31 (2016), pp. 561-567
[3]
H.L. Teoh, S.S. Mohammad, P.N. Britton, T. Kandula, M.S. Lorentzos, R. Booy
Clinical characteristics and functional motor outcomes of enterovirus 71 neurological disease in children
JAMA Neurol, 73 (2016), pp. 300-307
[4]
A. Macaya, A. Felipe-Rucián
Enterovirus y complicaciones neurológicas
An Pediatr, 86 (2017), pp. 107-109
[5]
M. Cabrerizo, J.P. García-Iñiguez, F. Munell, A. Amado, P. Madurga-Revilla, C. Rodrigo
First cases of severe flaccid paralysis associated with enterovirus D68 infection in Spain, 2015–2016
Pediatr Infect Dis J, 36 (2017), pp. 1214-1216
[6]
H. Chao-Ching, L. Ching-Chuan, C. Ying-Chao, C. Cheng-Yu, W. Shan-Tair, Y. Tsu-Fuh
Neurologic complications in children with enterovirus 71 infection
N Engl J Med, 341 (1999), pp. 936-942

Please cite this article as: Leal Barceló AM, Carrascosa García P, Rincón López EM, Miranda Herrero MC, Navarro ML. Brote de infección por enterovirus causantes de afectación neurológica grave en un hospital terciario. An Pediatr (Barc). 2018;89:378–381.

Previous presentation: This study was presented as an oral communication at the XX Annual Meeting of the Sociedad de Pediatría de Madrid y Castilla-La Mancha, September 30, 2016, Oropesa, Spain.

Copyright © 2017. Asociación Española de Pediatría
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