La patología infecciosa ocupa una gran parte de la actividad, tanto asistencial como preventiva, que realizamos los pediatras desde las consultas de Atención Primaria. Cada día valoramos, diagnosticamos y tratamos a niños cuyos síntomas pueden corresponder a procesos infecciosos. En ocasiones se trata de situaciones difíciles por presentar una clínica no habitual o compleja como ocurre en los casos de patología importada, o aquellos de manejo inicialmente hospitalario.
Las enfermedades exantemáticas son frecuentes en los niños. Solo algunas de ellas presentan datos que permiten identificar su etiología y aunque suelen tener una evolución favorable, algunas circunstancias del niño o el entorno (contacto con embarazadas), hacen necesario orientar su diagnóstico de forma precoz. Presentamos también un caso clínico.
Enterovirus 71 frequently involves the central nervous system and may present with a variety of neurologic manifestations. Here, we aimed to describe the clinical features, magnetic resonance imaging (MRI) findings, and cerebrospinal fluid (CSF) profiles of patients presenting with neurologic complications of enterovirus 71 infection. We retrospectively reviewed the records of 31 pediatric patients hospitalized with acute neurologic manifestations accompanied by confirmed enterovirus 71 infection at Ulsan University Hospital between 2010 and 2014. The patients’ mean age was 2.9 ± 5.5 years (range, 18 days to 12 years), and 80.6% of patients were less than 4 years old. Based on their clinical features, the patients were classified into 4 clinical groups: brainstem encephalitis (n = 21), meningitis (n = 7), encephalitis (n = 2), and acute flaccid paralysis (n = 1). The common neurologic symptoms included myoclonus (58.1%), lethargy (54.8%), irritability (54.8%), vomiting (48.4%), ataxia (38.7%), and tremor (35.5%). Twenty-five patients underwent an MRI scan; of these, 14 (56.0%) revealed the characteristic increased T2 signal intensity in the posterior region of the brainstem and bilateral cerebellar dentate nuclei. Twenty-six of 30 patients (86.7%) showed CSF pleocytosis. Thirty patients (96.8%) recovered completely without any neurologic deficits; one patient (3.2%) died due to pulmonary hemorrhage and shock. In the present study, brainstem encephalitis was the most common neurologic manifestation of enterovirus 71 infection. The characteristic clinical symptoms such as myoclonus, ataxia, and tremor in conjunction with CSF pleocytosis and brainstem lesions on MR images are pathognomonic for diagnosis of neurologic involvement by enterovirus 71 infection.
Hace 24h saltó la alarma en la prensa tras un comunicado del Departament de Salut que expresaba que en las últimas semanas se habían conocido unos cuarenta casos entre niños menores de 6 años de una enfermedad vírica que evoluciona con síntomas neurológicos...
We have developed and evaluated a real-time reverse transcriptase PCR (RT-PCR) assay for the detection of human enterovirus D68 (EV-D68) in clinical specimens. This assay was developed in response to the unprecedented 2014 nationwide EV-D68 outbreak in the United States associated with severe respiratory illness. As part of our evaluation of the outbreak, we sequenced and published the genome sequence of the EV-D68 virus circulating in St. Louis, MO. This sequence, along with other GenBank sequences from past EV-D68 occurrences, was used to computationally select a region of EV-D68 appropriate for targeting in a strain-specific RT-PCR assay. The RT-PCR assay amplifies a segment of the VP1 gene, with an analytic limit of detection of 4 copies per reaction, and it was more sensitive than commercially available assays that detect enteroviruses and rhinoviruses without distinguishing between the two, including three multiplex respiratory panels approved for clinical use by the FDA. The assay did not detect any other enteroviruses or rhinoviruses tested and did detect divergent strains of EV-D68, including the first EV-D68 strain (Fermon) identified in California in 1962. This assay should be useful for identifying and studying current and future outbreaks of EV-D68 viruses.
On August 19, 2014, CDC was notified by Children's Mercy Hospital in Kansas City, Missouri, of an increase (relative to the same period in previous years) in patients examined and hospitalized with severe respiratory illness, including some admitted to the pediatric intensive care unit. An increase also was noted in detections of rhinovirus/enterovirus by a multiplex polymerase chain reaction assay in nasopharyngeal specimens obtained during August 5–19. On August 23, CDC was notified by the University of Chicago Medicine Comer Children's Hospital in Illinois of an increase in patients similar to those seen in Kansas City. To further characterize these two geographically distinct observations, nasopharyngeal specimens from most of the patients with recent onset of severe symptoms from both facilities were sequenced by the CDC Picornavirus Laboratory. Enterovirus D68* (EV-D68) was identified in 19 of 22 specimens from Kansas City and in 11 of 14 specimens from Chicago. Since these initial reports, admissions for severe respiratory illness have continued at both facilities at rates higher than expected for this time of year. Investigations into suspected clusters in other jurisdictions are ongoing.
Cada año, millones de niños en los Estados Unidos contraen enterovirus que pueden causar tos, estornudos y fiebre. En el 2014, el enterovirus que con más frecuencia causó enfermedad respiratoria en los niños en todo el país fue el enterovirus D68 (EV-D68). Tome medidas básicas para que su hijo no contraiga ni propague el EV-D68.
Las infecciones por enterovirus son comunes en los Estados Unidos durante el verano y el otoño. En agosto del 2014 un par de estados empezaron a observar más niños en los hospitales con enfermedad respiratoria grave causada por el EV-D68. En los meses después de este hallazgo, los CDC y los estados hicieron más pruebas y descubrieron que el EV-D68 estaba enfermando a personas en casi todos los estados. La mayoría de esos casos se presentaron en niños, muchos de los cuales tenían asma o antecedentes de sibilancias. El EV-D68 no es nuevo, pero en el pasado no fue tan frecuente como en el 2014. Aunque el 2014 fue un año en que se presentaron gran cantidad de infecciones por EV-D68, los CDC no pueden predecir si el enterovirus D68 será un tipo común de enterovirus causante de enfermedad en las temporadas futuras. Esto se debe a que anualmente circulan una mezcla de tipos de enterovirus, y diferentes tipos pueden ser comunes en años distintos.
R: El enterovirus D68 (EV-D68) es uno de más de 100 tipos de enterovirus no-polio. El virus se identificó por primera vez en California en 1962. P: ¿Cuáles son los síntomas de la infección por el EV-D68?
R: El EV-D68 puede causar enfermedad respiratoria de leve a grave.
Los síntomas de la forma leve pueden incluir fiebre, secreción nasal, estornudos, tos y dolores corporales y musculares. Los síntomas graves pueden incluir sibilancias y dificultad para respirar. Toda persona con una enfermedad respiratoria debe contactar a su médico si presenta dificultades para respirar, o si sus síntomas empeoran.
The primary aim of the Danish enterovirus (EV) surveillance system is to document absence of poliovirus infection. The conflict in Syria has left many children unvaccinated and movement from areas with polio cases to Europe calls for increased awareness to detect and respond to virus-transmission in a timely manner. We evaluate the national EV laboratory surveillance, to generate recommendations for system strengthening. The system was analysed for completeness of viral typing analysis and clinical information and timeliness of specimen collection, laboratory results and reporting of clinical information. Of 23,720 specimens screened, 2,202 (9.3%) were EV-positive. Submission of cerebrospinal fluid and faecal specimens from primary diagnostic laboratories was 79.5% complete (845/1,063), and varied by laboratory and patient age. EV genotypes were determined in 68.5% (979/1,430) of laboratory-confirmed cases, clinical information was available for 63.1% (903/1,430). Primary diagnostic results were available after a median of 1.4 days, typing results after 17 days, detailed clinical information after 33 days. The large number of samples typed demonstrated continued monitoring of EV-circulation in Denmark. The system could be strengthened by increasing the collection of supplementary faecal specimens, improving communication with primary diagnostic laboratories, adapting the laboratory typing methodology and collecting clinical information with electronic forms.
In 2014, the United States (US) experienced a nationwide outbreak of enterovirus D68 (EV-D68) infection with 1,152 cases reported mainly in hospitalised children with severe asthma or bronchiolitis. Following the US alert, 11 laboratories of the French enterovirus (EV) surveillance network participated in an EV-D68 survey. A total of 6,229 respiratory samples, collected from 1 July to 31 December 2014, were screened for EV-D68 resulting in 212 EV-D68-positive samples. These 212 samples corresponded to 200 EV-D68 cases. The overall EV-D68 positivity rates among respiratory samples were of 5% (184/3,645) and 1.1% (28/2,584) in hospitalised children and adults respectively. The maximum weekly EV-D68 positivity rates were of 16.1% for children (n = 24/149; week 43) and 2.6% for adults (n = 3/115; week 42). Of 173 children with EV-D68 infection alone, the main symptoms were asthma (n = 83; 48.0%) and bronchiolitis (n = 37; 21.4%). One child developed acute flaccid paralysis (AFP) following EV-D68-associated pneumonia. Although there was no significant increase in severe respiratory tract infections reported to the French public health authorities, 10.7% (19/177) of the EV-D68 infected children and 14.3% (3/21) of the EV-D68 infected adults were hospitalised in intensive care units. Phylogenetic analysis of the viral protein 1 (VP1) sequences of 179 EV-D68 cases, revealed that 117 sequences (65.4%), including that of the case of AFP, belonged to the B2 variant of clade B viruses. Continuous surveillance of EV-D68 infections is warranted and could benefit from existing influenza-like illness and EV surveillance networks.
Objective: The purpose of this study was to evaluate the clinical characteristics of nervous system damage caused by enterovirus 71 (EV71) infection in pediatric patients.
Study Design: Clinical data and outcomes were retrospectively analyzed for 134 cases of laboratory confirmed pediatric EV71 infection admitted to the Children’s Hospital of Chongqing Medical University from January to December 2013.
Results: EV71 infection was significantly more common in patients 1–4 years of age, in males and during the months of April–July. Fifty-six cases complicated by hand, foot and mouth disease were diagnosed. Fever was the most common symptom (128 of 134 patients) and lasted on average 5.3 ± 2.1 days. The most common neurologic complication was aseptic meningitis (n = 74), followed by brain stem encephalitis (n = 24), acute flaccid paralysis (AFP; n = 20), acute parencephalitis (n = 12) and encephalomyelitis (n = 4). Each was characterized by a unique profile of clinical symptoms. Damage to the pons and medulla oblongata was apparent in 28 brain magnetic resonance images. Lesions associated with AFP were concentrated in the cervical spinal cord and thoracic 8. The anterior root of the spinal anterior horn was a specific lesion. Fourteen of the AFP patients had unilateral or bilateral femoral nerve involvement. None of the patients died, and in 132 of 134 patients, follow-up visits showed that their physical and neuropsychologic abilities had returned to normal.
Conclusions: Most children infected with EV71 have a good prognosis if they are diagnosed early and receive proper supportive treatment.
If you haven't heard of enterovirus D68 yet, the chances are you will soon. In 2014, an outbreak of acute flaccid myelitis (AFM) leading to lower limb paralysis affecting about 50 children in the US and Canada caused great concern; the typical prodrome of a febrile respiratory illness led to suspicions of a viral cause, and an enterovirus seemed a liked candidate because of its known predilection for attacking neural tissue. …
Urinary tract infections (UTIs) are some of the most common infections in both community and hospital settings infections. With their high rate of incidence, recurrence, complications, diverse etiologic agents, as well as growing antibiotic resistance, UTIs have proven to be a serious challenge for medical professionals. The aim of this study was to obtain data on the susceptibility patterns of pathogens responsible for UTIs in Poland to currently used antibiotics. A total of 396 bacterial isolates were collected between March and May 2013 from 41 centers in all regions of Poland. The majority of isolates were from adult patients (96.2 %); 144 (37.8 %) patients were diagnosed with uncomplicated UTI, while the remaining 237 (62.2 %) had a complicated infection. The most prevalent pathogen was Escherichia coli (71.4 %), followed by Klebsiella spp. (10.8 %) and the Proteae group (7.6 %). Escherichia coli was responsible for 80.6 % of cases of uncomplicated and 65.8 % of complicated infections. Only 65.8 % of E. coli isolates were susceptible to ciprofloxacin (uncomplicated 75.9 %, complicated 58.3 %), 64.0 % to nitrofurantoin (67.2 %, 62.8 %), 65.1 % to trimethoprim/sulfamethoxazole (68.1 %, 62.8 %), and 66.4 % to fosfomycin (77.6 %, 62.2 %). Among E. coli isolates from all UTIs, only 43.4 % were susceptible to ampicillin, with 47.4 % from uncomplicated compared with 40.4 % from complicated infections; 88.2 % to amoxicillin/clavulanic acid (91.4 % vs. 85.9 % complicated); 90.1 % to cefuroxime (93.1 %, 87.8 %); and 94.1 % to cefotaxime (98.2 %, 91.0 %). Thirty-five strains (10.4 %) were capable of producing extended-spectrum β-lactamases (ESBLs). This study demonstrates an increase in multidrug-resistant strains, especially among the leading pathogens associated with UTIs, including E. coli, Klebsiella spp., and Proteus spp.
Los exantemas eritematomaculopapulosos se caracterizan por un rash cutáneo eritematoso, máculas planas coloreadas casi siempre eritematosas y/o pápulas sobreelevadas. La lesión elemental predominante puede ser: mácula (lesión plana caracterizada por cambio de coloraci ón), pápula (elevación circunscrita de la piel con un diámetro inferior a 10 mm, si es mayor de 1 cm se denomina placa ), eritema o eritrodermia (enrojecimiento inflamatorio de grandes zonas o la t otalidad de la piel), habón (pápulas o placas rosa pálido edematosas que en oca siones se unen formando lesiones anulares o serpigin osas con evolución cambiante, duran < 24 h en una localización). En general son manifestaciones cu táneas de aparición brusca. Constituyen el grupo más amplio de las enfermedades exantemáticas. Acompañan a muchas enfermedades, la mayoría infecciosas de origen viral y autolimitadas. Otras causas: bacterias, Rickettsias, fármacos, paravirales, enfermedades sistémicas 1 . Algunas entidades coexisten con lesiones vesiculosas y/o petequiales, por lo que se describen también en los algoritmos respectivos.
En el Boletín Epidemiológico Semanal de Aragón (Semana 01/2016), publicado el 14 de enero de 2016, se informa de la detección, por primera vez en España, de un enterovirus D68 (EV D68) asociado a un caso de parálisis flácida aguda (PFA).
Se trata de un niño de 4 años, residente en la ciudad de Zaragoza, correctamente vacunado frente a la polio, que ingresó en un hospital local el pasado 3 de diciembre de 2015. El 16 de diciembre, el Laboratorio Nacional de Poliovirus (Centro Nacional de Microbiología) confirmó la detección de un EV D68 y la ausencia de poliovirus en las muestras estudiadas. El niño permanece gravemente afectado por una polineuropatía axonal motora difusa.
Since its discovery in California in 1962, reports of enterovirus D68 have been infrequent. Before 2014, infections were confirmed in only 699 people worldwide. In August, 2014, two paediatric hospitals in the USA reported increases in the number of patients with severe respiratory illness, with an over-representation in children with asthma. Shortly after, the authorities recognised a nationwide outbreak, which then spread to Canada, Europe, and Asia. In 2014, more than 2000 cases of enterovirus D68 were reported in 20 countries. Concurrently, clusters of children with acute flaccid paralysis of unknown cause were reported in several US states and in Europe. Enterovirus D68 infection was confirmed in some of the paralysed children, but not all. Complications in patients who were severely neurologically affected resemble those caused by poliomyelitis. In this paper we systematically review reports on enterovirus D68 to estimate its global epidemiology and its ability to cause respiratory infections and neurological damage in children. We extracted data from 70 papers to report on prevalence, symptoms, hospitalisation and mortality, and complications of enterovirus D68, both before and during the large outbreak of 2014. The magnitude and severity of the enterovirus D68 outbreak underscores a need for improved diagnostic work-up of paediatric respiratory illness, not only to prevent unnecessary use of antibiotics, but also to ensure better surveillance of diseases. Existing surveillance systems should be assessed in terms of capacity and ability to detect and report any upsurge of respiratory viruses such as enterovirus D68 in a timely manner, and focus should be paid to development of preventive measures against these emerging enteroviruses that have potential for severe disease.
Enterovirus D68 (EV-D68), also known as enterovirus 68 (EV-68 or EV68), is a non-poliovirus, nonenveloped, positive-sense single-stranded RNA virus that belongs to the Picornaviridae family. See the images below. EV-D68 is transmitted person to person by contact with respiratory and gastrointestinal secretions.
Electron micrograph of a thin section of enterovirus D68 (EV-D68), showing the numerous, spherical viral particles. Courtesy of the CDC.
Electron micrograph of a thin section of numerous spherical enterovirus D68 (EV-D68) viral particles. Some of the particles appear to be "empty," missing their contents of single-stranded RNA. Courtesy of the CDC. While most of the approximately 100 species of enteroviruses primarily infect the gastrointestinal (GI) tract, EV-D68 has tropism for the respiratory tract. It causes acute respiratory disease ranging from mild upper respiratory tract symptoms to severe pneumonia. In an outpatient setting, EV-D68 disease has manifested most commonly among persons younger than 20 years and adults aged 50-59 years. Inpatients have predominately been children.[1, 2]
EV-D68 was first isolated in 4 pediatric patients with lower respiratory tract infection in California in 1962.
EV-D68, as with other enterovirus species, circulates seasonally in the summer and especially in fall months.[4, 5]
In August 2014, EV-D68 emerged as a cause of severe respiratory infections. Hospitals in Illinois and Missouri reported an increased incidence of rhinovirus and enterovirus infection, with 30 of 36 isolates from the nasopharyngeal secretions of patients with severe respiratory illness identified as EV-D68. Following these reports, an unusually high number of patients with severe respiratory illness were admitted to these facilities, presumably with EV-D68 infection.
Susceptible patients generally have underlying asthma and wheezing. In addition to respiratory illness, EV-D68 has also been associated with rare and lethal central nervous system (CNS) infection with polioviruslike manifestations.
Evite que su niño contraiga el ENTEROVIRUS D68 o que lo propague Evite el contacto cercano con personas enfermas. [Ilustración que muestra la importancia de evitar el contacto con las personas enfermas] Cúbrase la nariz y la boca cuando tosa y estornude. [Ilustración que muestra la importancia de cubrirse la nariz y la boca al toser y estornudar] Lávese las manos con agua y jabón. [Ilustración que muestra la importancia de lavarse las manos con agua y jabón] Limpie y desinfecte las superficies. [Ilustración que muestra la importancia de limpiar y desinfectar las superficies] Evite tocarse la cara sin haberse lavado las manos. [Ilustración que muestra la importancia de no tocarse la cara] Quédese en la casa si está enfermo.
Every year, millions of children in the United States catch enteroviruses that can cause coughing, sneezing, and fever. In 2014, the enterovirus that most commonly caused respiratory illness in children across the country was enterovirus D68 (EV-D68). Take basic steps to keep your child from getting and spreading EV-D68.
Infections with enteroviruses are common in the United States during summer and fall. In August 2014, a couple of states started seeing more children in hospitals with severe respiratory illness caused by EV-D68. In the months following this discovery, CDC and states did more testing and found that EV-D68 was making people sick in almost all states. Most of the cases were among children, many who had asthma or a history of wheezing. EV-D68 is not new, but it wasn’t as common in the past as it was in 2014. While 2014 was a big year for EV-D68 infections, CDC can’t predict whether EV-D68 will be a common type of enterovirus to cause sickness in future seasons. That’s because a mix of different enteroviruses types circulates every year, and different types can be common in different years.
Enterovirus D68 (EV-D68) is one of more than 100 non-polio enteroviruses. This virus was first identified in California in 1962.
What are the symptoms of EV-D68 infection?
EV-D68 can cause mild to severe respiratory illness.
Mild symptoms may include runny nose, sneezing, cough, and body and muscle aches. Severe symptoms may include wheezing and difficulty breathing. Anyone with respiratory illness should contact their doctor if they are having difficulty breathing or if their symptoms are getting worse.
Enterovirus D68 (EV-D68) has been recognised as a worldwide emerging pathogen associated with severe respiratory symptoms since 2009. We here report EV-D68 detection in hospitalised patients with acute respiratory infection admitted to three tertiary hospitals in Germany between January 2013 and December 2014. From a total of 14,838 respiratory samples obtained during the study period, 246 (1.7%) tested enterovirus-positive and, among these, 39 (15.9%) were identified as EV-D68. Infection was observed in children and teenagers (0–19 years; n=31), the majority (n=22) being under five years-old, as well as in adults > 50 years of age (n=8). No significant difference in prevalence was observed between the 2013 and 2014 seasons. Phylogenetic analyses based on viral protein 1 (VP1) sequences showed co-circulation of different EV-D68 lineages in Germany. Sequence data encompassing the entire capsid region of the genome were analysed to gain information on amino acid changes possibly relevant for immunogenicity and revealed mutations in two recently described pleconaril binding sites.
Worldwide emergence of enterovirus (EV) D68 causing severe respiratory illness particularly in children, between 2008 and 2014, has been described in numerous articles. In 2014, EV-D68 gained particular attention when a large outbreak in children, associated with severe respiratory illness and possible neurological illness, occurred in the United States [1-3]. This event triggered a number of surveillance activities in various countries, some of them published in Eurosurveillance [4-8]. In our current issue we present investigations into the occurrence of EV-D68 in two European countries namely France and Germany.
The articles present data from patients hospitalised or visiting hospital emergency departments with respiratory symptoms. Schuffenecker et al. report on samples collected by eleven laboratories of the French EV surveillance network from eight of 22 Regions over six months in 2014 . These eleven laboratories represent about one-third of the laboratories participating in the French EV network. Böttcher et al. analysed samples during two entire years, 2013 and 2014, at three large tertiary hospital laboratories in Germany . These laboratories, situated mainly in the western part of the country, contribute ca 25% of the EV-positive samples in the nationwide RespVir surveillance .
Enterovirus (EV) 71 has emerged as a primary cause of severe neurologic enterovirus infection in the aftermath of the global polio eradication effort. Eleven subgenotypes of EV71 exist, the C4 subgenotype being associated with large outbreaks in Asia with high mortality rates. This subgenotype has rarely been reported in Europe. In the period between 1 January 2009 and 31 December 2013 a total of 1,447 EV positive samples from 1,143 individuals were sent to the Statens Serum Institute (SSI), and 938 samples from 913 patients were genotyped at the Danish National World Health Organization Reference laboratory for Poliovirus at SSI. Echovirus 6 (E06) (n=141 patients), echovirus 30 (E30) (n=114), coxsackievirus A6 (CA06) (n=96) and EV71 (n=63) were the most prevalent genotypes. We observed a shift in circulating EV71 subgenotypes during the study period, with subgenotype C4 dominating in 2012. A total of 34 EV71 patients were found to be infected with strains of the C4 subgenotype, and phylogenetic analysis revealed that they belonged to the C4a lineage. In our study, the proportions of cases with cerebral and/or sepsis-like symptoms were similar in those affected by C4a (19/34) and those with C1 and C2 (15/35). The majority (n=30) of the 34 EV71 C4 cases were children ≤5 years of age, and males (n=22) were over-represented. Continued EV surveillance is required to monitor the spread of EV71 C4 in Denmark and the rest of Europe.
Enterovirus D68 (EV-D68), phylogenetic clade B was identified in nasopharyngeal specimens of two cases of severe acute flaccid myelitis. The cases were six and five years-old and occurred in September and November 2014. EV-D68 is increasingly associated with acute flaccid myelitis in children, most cases being reported in the United States. Awareness of this possible neurological complication of enterovirus D68 infection is needed.
Knowledge on Staphylococcus aureus colonization rates and epidemiology in hand eczema is limited. The aim of this study was to clarify some of these issues. Samples were collected by the “glove juice” method from the hands of 59 patients with chronic hand eczema and 24 healthy individuals. Swab samples were taken from anterior nares and throat from 43 of the 59 patients and all healthy individuals. S. aureus were spa typed and analysed by DNA-microarray-based genotyping. The extent of the eczema was evaluated by the hand eczema extent score (HEES). The colonization rate was higher on the hands of hand eczema patients (69 %) compared to healthy individuals (21 %, p < 0.001). This was also seen for bacterial density (p = 0.002). Patients with severe hand eczema (HEES ≥ 13) had a significantly higher S. aureus density on their hands compared to those with milder eczema (HEES = 1 to 12, p = 0.004). There was no difference between patients and healthy individuals regarding colonization rates in anterior nares or throat. spa typing and DNA-microarray-based genotyping indicated certain types more prone to colonize eczematous skin. Simultaneous colonization, in one individual, with S. aureus of different types, was identified in 60–85 % of the study subjects. The colonization rate and density indicate a need for effective treatment of eczema and may have an impact on infection control in healthcare.
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