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Reports of more than a dozen cases of dangerous and often deadly viral sepsis in infants in Europe, along with increasing circulation of similar viruses that typically spike in the summer and early fall, have experts on edge. in Pediatric Infectious Diseases in the US
“We are all on pins and needles here in the United States,” said Dr. David Kimberlin, co-director of the division of pediatric infectious diseases at the University of Alabama at Birmingham.
Enteroviruses can severely affect newborns, whose immune systems are not mature enough to fight infection.
“Most enteroviruses cause very mild illness in the children they infect,” Dr. Mike Ryan, executive director of the World Health Organization’s health emergencies program, said at a briefing on Wednesday. “But in a small proportion, we see much more significant catastrophic disease.”
In May, the WHO drew attention to a group of a particular type of enterovirus, called echovirus-11. Nine babies in France within their first month of life had been infected and developed organ failure and sepsis. Seven died.
That is more than would be expected, a WHO spokesperson wrote in an email. “It is considered unusual due to the extremely rapid deterioration and associated case fatality rate among affected babies,” the spokesperson wrote. Echoviruses can be spread through fecal matter or by breathing in respiratory droplets and usually live in the digestive system.
twin baby boys in italy they were found to be infected with the same strain of echovirus-11. One was seriously ill and remained in intensive care. What’s more, UK health authorities reported a equally unusual increase in severe myocarditis, or inflammation of the heart, among 10 babies who had another enterovirus called coxsackievirus. At least one died.
The WHO is expected to update global reports of enterovirus-related neonatal sepsis later this week, a spokesman said on Wednesday.
There is no way to know if those specific strains are already in the US and making babies sick. The Centers for Disease Control and Prevention does not have an active reporting system for neonatal enteroviral disease or enterovirus in general. More than 100 types of enteroviruses can infect people, according to the CDC.
“While we don’t have routine enterovirus surveillance, CDC has other surveillance systems that we use to quickly monitor and assess for signs of outbreaks and increases in specific types of enteroviruses,” said Dr. Janell Routh, chief of the virus division. from the CDC. diseases, she said in a statement. “As viral circulation has been disrupted by the COVID-19 pandemic, we remain vigilant for any changes in enterovirus transmission.”
Summer is enterovirus season
Doctors interviewed across the country are seeing a small increase in enterovirus cases, especially among children. Most get a slight temperature, cough, sneeze, or have a sore throat, and recover without much fuss.
“We’re hearing reports from across the country that all of our children’s hospitals have some degree of significant enterovirus this summer,” said Dr. Buddy Creech, a pediatric infectious disease physician at Vanderbilt University Medical Center in Nashville, Tennessee.
However, the cases in Europe have led Creech and his colleagues to make sure that pediatricians and families with newborns are aware of the potential of enteroviruses.
“We have our systems on high alert,” Creech said.
Although enteroviruses are common, historically cases of neonatal enteroviral sepsis have been rare. But since the pandemic has wiped out all viral activity, the concern is that there could be an even bigger rise in enteroviruses this summer.
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When there are more enteroviruses circulating in a community, the chance that a newborn will be infected increases.
That’s why it’s critical that pediatricians keep an eye out for the possibility of serious illness in newborns, instead of “being behind the eight ball when things get better and get out of control,” said Dr. Kevin Messacar, a specialist in pediatric infectious diseases. at Children’s Hospital Colorado in Denver.
Creech’s team is already treating more newborns hospitalized with enterovirus than usual. The hospital system did not comment on the exact number.
“Usually these are children in the first days to a week or two of life who are exposed to an enterovirus and, for reasons that we don’t fully understand, become seriously ill from what usually causes nothing more than enterovirus-like symptoms. cold ones,” Creech said.
The babies are usually born healthy and go home from the hospital to their families. This is when they develop symptoms of enterovirus exposure, including:
- Fever.
- Not eating well.
- Difficulty breathing.
- Being very fussy or cold to the touch.
- Pale or blotchy skin.
Some can develop serious complications: meningitis, organ failure, myocarditis, and even bone marrow problems. Some babies’ tiny systems become “super inflamed” to the point that their immune responses are causing as much damage as the virus itself, Creech said.
Enterovirus Testing and Treatment
Enterovirus treatments are limited. Babies receive supportive care, such as intravenous fluids or help with breathing and blood pressure.
Many doctors also give babies intravenous immune globulin. That’s essentially a cocktail of antibodies meant to bind to whatever virus is causing the disease. Ideally, those antibodies work to calm inflammation and help prevent the virus from spreading further in the body.
No antiviral drugs are approved to treat those little babies.
“It’s disappointing that we don’t have more treatments,” said Dr. Shannon Ross, an infectious disease specialist at Children’s of Alabama in Birmingham. Ross has treated a baby this summer for viral sepsis. “That’s the hardest thing: having fewer options to treat these babies.”
It is not known what type of enterovirus led to severe illness in the babies cared for by Creech and Ross. Hospital systems don’t usually do that kind of testing, because doctors say it wouldn’t change the way they’re treated.
In fact, it’s hard to get a real range of the number of newborns who die or are hospitalized from an enterovirus infection, because the US doesn’t track such cases.
A research project aims to provide some clarity.
Kimberlin, of the University of Alabama at Birmingham, and Dr. Mark Abzug, a pediatric infectious disease physician at Children’s Hospital Colorado in Denver, launched a study in 2020 to analyze tissue samples from infants with neonatal enteroviral sepsis.
“Something that we are specifically looking at is to see if there are any viral laboratory or clinical markers that correlate well with morbidity and mortality,” Abzug said. It may turn out, for example, that the amount of virus circulating in babies’ bloodstreams is a sign that they are at risk of more serious illness.
That’s just a theory for now. The team will eventually sequence multiple strains of the viral samples — there are more than 110 — to learn more about how each affects the immature immune systems of newborns. The study is funded by the National Institutes of Health.
The ultimate goal of the research, Abzug said, is to find an effective antiviral drug.
“That’s the true unmet medical need. To do that, we’re trying to prospectively collect information that can inform the best study design for an antiviral as it becomes available for study,” Abzug said.
The answers are still far away; only 23 babies have signed up so far. But the research is applauded by doctors who treat the sickest babies.
Enteroviruses “are not recognized as a major player in the infectious disease world, in part because they have always been endemic,” Messacar said. “They have always existed.”
But they are also “one of the most common causes of meningitis, brain infections, heart infections and neonatal sepsis in our young babies,” he said. “We need to realize that enteroviruses are a major cause of morbidity and, unfortunately, mortality in the pediatric population.”
