Clinical and virological features of severe neonatal echovirus 11 infection.

In recent studies, euro monitoring The journal described a serious and fatal infection in newborns caused by a new echovirus 11 (E-11) variant in France.

study: Severe and fatal neonatal infections associated with new variants of echovirus 11, France, July 2022 to April 2023. Image credit: KomsanLoonprom/Shutterstock.com

Background

Enteroviruses commonly cause infections in newborns. Clinical manifestations range from asymptomatic to severe illness or death. From July 2022 to April 2023, nine neonates with liver failure were reported in France.

Of these, seven deaths were reported. They were all associated with his new E-11 variant. In the current study, the researchers described the characteristics of this surge in severe neonatal infections.

Case description

All nine patients, all male, from three major French metropolitan areas, were admitted to the pediatric intensive care unit with suspected sepsis.

Eight patients had twin pregnancies, and only one singleton pregnancy was delivered to term. All were born between 31 and 36 weeks of gestation and had been admitted to the neonatal department before symptoms appeared.

The first symptoms (fever and apnea) appeared 3-5 days after birth. Early symptoms were soon followed by signs of septic shock requiring aggressive resuscitation.

Acute hepatocellular failure with severe cytolysis was observed in all patients on the day of admission. Quick factor, fibrinogen, and coagulation factors II, V, VII, and X were undetectable in all cases.

The patient showed hyperammonemia. Three were treated with hemodialysis, five with sodium benzoate, and one died before starting treatment. Thrombocytopenia was observed in all patients. Seven required plasma, platelets, and tranexamic acid.

Two patients presented with enteritis, three with meningoencephalitis, and one with myocarditis. All patients had acute renal failure at onset.

Five patients had normal findings on transfondral ultrasonography, while two patients had grade III bilateral intraventricular hemorrhages and the other two had some hyperechogenicity in the white matter. showed lesions.

Seven patients had negative blood cultures for bacteria within 48 hours of symptom onset.However, one patient tested positive Staphylococcus epidermis, and another was positive Escherichia coli.

Enterovirus genomes were detected in all specimens, including cerebrospinal fluid, blood, stool, dried blood stains, postmortem biopsy, nasopharyngeal, throat, and rectal swabs. Next-generation sequencing identified E-11 as the causative agent in all cases.

Five mothers had gastrointestinal symptoms at or before delivery and four perinatal blood samples were available.

A sample from the mother was enterovirus positive, later identified as E-11. All patients started empirical antibiotic treatment at the onset of symptoms. Pocapavir was used for treatment in 3 cases and intravenous polyvalent immunoglobulin was given in 7 cases.

Of the 9 cases, 7 patients died between 5 and 40 days of age. Two patients survived without sequelae.

Molecular characterization and monitoring

The researchers performed a phylogenetic analysis of E-11 sequences from samples collected in France from 2010 to 2023 and samples from other countries available in GenBank.

The E-11 strains sequenced in 2022 and 2023 split into two distinct lineages (1 and 2), distinct from the E-11 strains prior to 2022. Lineage 1 contained sequences associated with non-neonatal infections and less severe neonatal infections.

Lineage 2 included the remaining French E-11 sequences from 2022, related to sequences isolated in China in 2018-2019. Similarity plot analysis revealed an implicated recombination origin in both lineages.

From January 2022 to April 2023, more than 2,000 cases of enterovirus infection were reported in France. Of these, 24.5% were neonates, and E-11 was the most common enterovirus type among neonates and non-neonatals.

E-11 has been detected consistently in France since April 2022. From 2022 to 2023, 28 neonatal cases presented with severe enteroviral infection. Of these, 14 were identified as E-11.

In contrast, 62 severe neonatal cases were documented between 2016 and 2021, with E-11 detected in 6.2% of cases. In addition, there was a higher proportion of male neonates with severe enterovirus or her E-11 cases.

Conclusion

Taken together, this study suggests that a new E-11 variant associated with severe neonatal infections and increased mortality is prevalent in France. Clinicians should be vigilant about the possible involvement of enteroviruses in severe neonatal symptoms.

Newborns with unexplained sepsis with signs of liver failure (with cytolysis) and myocarditis should be evaluated for enteroviral infection, especially if the mother was symptomatic prenatally, and treated with pocapavir or immunoglobulin. should be considered for treatment with