- Email: [email protected]
Respiratory presentation of patients infected with enterovirus D68 in Taiwan
Journal Pre-proof Respiratory Presentation of Patients Infected with Enterovirus D68 in Taiwan Hui-Hsien Pan, Chi-Ren Tsai, Pei-Ju Ting, Fang-Liang Huang, Li-Chung Wang, ChinFu Lin, Jiunn-Liang Ko, Ko-Huang Lue, Po-Yen Chen PII:
S1875-9572(19)30502-9
DOI:
https://doi.org/10.1016/j.pedneo.2019.09.006
Reference:
PEDN 966
To appear in:
Pediatrics & Neonatology
Received Date: 24 July 2018 Revised Date:
27 May 2019
Accepted Date: 6 September 2019
Please cite this article as: Pan H-H, Tsai C-R, Ting P-J, Huang F-L, Wang L-C, Lin C-F, Ko J-L, Lue KH, Chen P-Y, Respiratory Presentation of Patients Infected with Enterovirus D68 in Taiwan, Pediatrics and Neonatology, https://doi.org/10.1016/j.pedneo.2019.09.006. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Copyright © 2019, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. All rights reserved.
PEDN_2018_424_After Eng edited_final
Category : original article Title: Respiratory Presentation of Patients Infected with Enterovirus D68 in Taiwan
Short title: Respiratory presentation and EV-D68 in Taiwan
Hui-Hsien Pan a,b,c, Chi-Ren Tsai d, Pei-Ju Ting d, Fang-Liang Huang d,e, Li-Chung Wang f, Chin-Fu Lin f, Jiunn-Liang Ko a,b,g, Ko-Huang Lue a,b,c,*, Po-Yen Chen c,d,*
Affiliations: a
Department of Pediatrics, Chung-Shan Medical University Hospital, Taichung City,
Taiwan b
Institute of Medicine, Chung Shan Medical University, Taichung City, Taiwan
c
School of Medicine, Chung Shan Medical University, Taichung City, Taiwan
d
Department of Pediatrics, Taichung Veterans General Hospital, Taichung City,
Taiwan e
Hung Kuang University, Taichung, Taiwan
f
Microbiology Section of the Medical Laboratory Department, Taichung Veterans
General Hospital, Taichung, Taiwan 1
g
Department of Medical Oncology and Chest Medicine, Chung Shan Medical
University Hospital, Taichung, Taiwan
*Correspondence: 1. Po-Yen Chen (Corresponding author) Division of Pediatric Infectious Disease, Department of Pediatrics, Taichung Veterans General Hospital, Taichung, Taiwan, 1650 Taiwan Boulevard Sect. 4, Taichung, Taiwan 40705, ROC Phone: +886-4-23592525 ext. 5913 Email: [email protected] 2. Ko-Huang Lue (Corresponding author) Department of Pediatrics, Chung Shan Medical University Hospital; School of Medicine, Chung Shan Medical University; Institute of Medicine, Chung Shan Medical University, No. 110, Sec. 1, Jianguo N. Road, Taichung City 40201, Taiwan R.O.C Phone: +88-642-4739595 ext.11011 Email: [email protected]
2
Abstract Background /Purpose: Enterovirus-D68 (EV-D68) has been endemic in Taiwan for some years with a small number of positive cases. Detailed information about respiratory presentation is lacking. This study characterized the clinical course in children admitted to the medical center and regional hospital in Taichung during 2015. Methods: Retrospective chart review of patients with confirmed EV-D68 infection admitted to the medical center and regional hospital in Taichung with respiratory symptoms in the second half of 2015. Past medical history, clinical presentation, management, and course in hospital were collected and analyzed. Simple demographic data and clinical symptoms were also collected from patients confirmed with EV-D68 infection who visited clinics in Taichung. Results: Six children were included. Two patients had a prior history of asthma or recurrent dyspnea, and one had other preexisting medical comorbidities. One child was admitted to the pediatric intensive care unit. All the patients were cured. Cough, rhinorrhea, tachypnea and fever were the most common clinical symptoms among inpatients, while influenza-like illness (ILI) was prevalent in outpatients. Conclusion: EV-D68 infection resulted in respiratory presentations of asthma-like illness in the hospitalized pediatric population. Patients with a prior history of asthma or recurrent dyspnea appear to be more severely affected. 3
Key words Enterovirus D68; Respiratory presentation; Taiwan
4
1. Introduction Enterovirus D68 (EV-D68), a viral pathogen belonging to the species Enterovirus D, genus Enterovirus, family Picornaviridae, and order Picornavirales was first found in 1962 by Schieble et al.1 EV-D68 is a non-enveloped, positive sense, single-stranded RNA virus, and it is classified into three genetic groups, Clades A, B, and C, on the basis of the VP1 nucleotide sequence.2 EV-D68 shares biological characteristics with rhinoviruses (RVs), including acid sensitivity and growth at lower optimal temperature than other EVs, and it binds specifically to α2-6 sialic acid instead of to α2-3 sialic acid, which is the receptor of the other EVs.3,4 EV-D68 outbreaks were observed in August 2014 in the United States and different countries worldwide, which reported an increased number of respiratory diseases due to EV-D68.5—7 EVD-68 presented as upper respiratory tract infection, pneumonia, bronchiolitis, bronchitis, and asthma exacerbations.8,9 Children appear to be disproportionately affected and may present with severe respiratory disease.8,10 EV-D68 has been endemic in Taiwan for years although the number of positive case is small. Surveillance data revealed limited information about the clinical presentation collected by the physicians and reference laboratories at the beginning.11 The current study seeks to characterize cases of EV-D68 in Taiwan. We delineate the patient demographics, clinical presentation, management at our institution, and underlying 5
characteristics.
2. Material and Methods 2.1 Specimen collection This observational study was conducted from Jan 2015 to Dec 2015 at a 1500-bed tertiary teaching hospital in central Taiwan. The specimens were collected from children in the medical center, contracted reginal hospitals in Taichung, or contracted clinics in Taichung. In the medical center, all departments were involved in the specimen collection; pediatric departments were involved in the contracted reginal hospitals; internal medicine, otolaryngology, and pediatric clinics were also involved. Virus culture from a respiratory tract specimen was recommended based on an established case definition: patients with sign/symptoms of respiratory infection, which included cough, rhinorrhea, sore throat, increased work of breathing, and need for supplemental oxygen or continuous albuterol. However, the clinical provider ordered the test at their discretion. Otherwise, the EV-D68 infection with neurologic presentations might be left out under certain collection criteria. Testing was performed in the outpatient clinics, urgent care/emergency department and inpatient wards. Centers for Disease Control, Taiwan (Taiwan CDC) set up a laboratory-based surveillance system named the Taiwan Virology Reference Laboratory Network (TVRLN) from 1999. TVRLN collected throat swabs or rectal swabs from patients 6
with respiratory infection or suspected enterovirus infections by designated physicians in every township (N = 368).12 2.2 Virus identification Virus isolation followed the standard protocols for the surveillance system was conducted by Taiwan CDC as previously described.13 The isolates were then identified by immunofluorescence assay (IFA) using commercial antibodies against enterovirus (Light Diagnostic, USA). All IFA-untypable enterovirus isolates were reported as non-polio enterovirus in the laboratory of Taichung Veterans General Hospital (TCVGH), and then collected by Taiwan Centers for Disease Control (Taiwan CDC) for further identification. After traditional RT-PCR and sequencing, and then an enterovirus COnsensus-DEgenerate Hybrid Oligonucleotide Primers (CODEHOP) method, EV-D68 strains were confirmed.14,15 Testing for EV-D68 was done retrospectively in our study. In other words, further sequence analysis was done after being informed of EVD-68 strains by Taiwan CDC. 2.3 RNA extraction, RT-PCR amplification and Sequence analysis We extracted the RNA from the confirmed isolates with QIAamp Viral RNA Mini Kit(Qiagen, Santa Clara, CA, USA) according to the manufacturer’s instruction. The VP1 region was amplified by RT-PCR with primer sets 053/222 and 292/485 as previously described.4,16 Finch TV was used for aligning the nucleotide and deduced 7
amino acid sequences of VP1 region. We used the Basic Local Alignment Search Tool (BLAST) for virus classification and genotyping with the reference sequence database in GenBank. 2.4 Clinical data and chart review of EV-D68-positive patients All the cases in our study were virologically confirmed. We collected the clinical data from medical records in the TVRLN surveillance system, which included the records of patients’ age, sex, and clinical symptoms. The clinical symptoms include fever, headache, myalgia, malaise, rhinorrhea, cough, sore throat and vomiting. Patients from the medical center and the contracted regional hospital in Taichung were included for chart review analysis. We obtained history of presenting illness, past medical history, medications at time of admission, physical examination findings, interventions received in the hospital and discharge diagnoses. This study was approved by the Institutional Review Board (IRB) (IRB No. CE16092A).
3. Results Six samples positive for EV-D68 were collected from July to December. The 6 EV-D68-positive patients (1 males, 5 females) (nos. 1–6 in Table 1) belonged to different age groups: 0–11 months, 2 years, 3 years, 7 years, 11 years, and 12 years. All patients showed signs of lower respiratory tract infections and were diagnosed 8
with the following: bronchopneumonia (16.7%), asthmatic bronchitis (33.3%), bronchitis (16.7%), and ILI (33.3%). Of the 6 EV-D68-positive patients, one patient had co-infections of EV-D68 with Haemophilus influenza (H. Influenzae). None of the patients described in this paper had symptoms of neurological disease or paralysis. The main symptoms for the 6 EV-D68 patients were cough (100%) and fever (83%). Among inpatients, cough (100%), rhinorrhea (75%), tachypnea (75%) and fever (75%) were the most common clinical symptoms, while ILI (100%) was prevalent in outpatients. Table 1 shows the demographic and clinical manifestation of the patients with EV-D68 infection. The clinical presentations of the inpatients are described below. Case 1
A previously healthy 8-month-old boy presented with fever, productive
cough and decreased appetite. At admission, his physical examination showed that the child was febrile and alert but had an injected throat. Blood examination showed normal white blood cell count and elevated C-Reactive Protein (CRP) (13.92 mg/dL). Chest x-ray (CXR) revealed mild bilateral haziness. Adenovirus rapid test was negative. The patient was then treated with hydration and discharged 2 days later. Case 2
A 2-year-3-month-old girl with the past history of atopic dermatitis and
asthma presented with shortness of breath with room air SpO2 88%. Sore throat and vomiting were also noted. One day earlier, she had cough and rhinorrhea. At 9
emergency room (ER), her physical examination showed that the child had injected throat, postnasal drip, bilateral coarse breath sound with diffuse wheezing and subcostal and suprasternal retraction. Blood examination showed leukocytosis (23760/uL) with left shift and normal CRP. CXR revealed diffuse haziness especially at perihilar region and left upper zone. The patient was then treated with β-agonist inhalation. Despite therapy, shortness of breath with subcostal and suprasternal retraction was still noted, so the child was transferred to our Pediatric Intensive Care Unit (PICU); at admission he was diagnosed with asthmatic bronchitis with respiratory distress. Inhalation was prescribed and intravenous hydrocortisone was administered. After 2 days of treatment, the signs and symptoms of respiratory distress significantly reduced, and the child was transferred to our pediatric ward. Discharge was arranged 3 days later with improvement in appetite. Case 3
A 3-year-10-month-old girl with past history of dyspnea twice in the
previous year presented with audible wheezing and shortness of breath with room air SpO2 94%. At ER, her physical examination showed that the child had bilateral decreased breathing sound with subcostal and suprasternal retraction. Blood examination showed normal white blood cell count. CXR revealed bilateral hilar haziness. The patient was then treated with β-agonist inhalation. After treatment, the signs and symptoms of asthmatic bronchitis were reduced. Discharge with oral 10
β-agonist and prednisolone was arranged. Case 4
An 8-year-old girl with the underlying disease of primary
hypercholesterolemia presented with mild shortness of breath. One week earlier, she had cough and rhinorrhea with sticky yellowish discharge. Fever and sore throat was noted two days earlier. At admission, his physical examination showed that the child had injected throat and tonsil grade II with pus coating , post-nasal drip and bilateral coarse breathing sound. Blood examination showed leukocytosis (15630/uL) with left shift and elevated CRP (3.00 mg/dL). CXR revealed diffuse haziness. Under the impression of 1. Bronchopneumonia 2. Acute purulent tonsillitis and 3. Acute sinusitis, the patient was then treated with intravenous ampicillin/sulbactam and symptomatic medication. Sputum culture found H. Influenzae with resistance to ampicillin, amoxicillin/clavulanic acid and ampicillin/ sulbactam. After 6 days of treatment, the signs and symptoms improved. Among the inpatients, 75% of the patients had the clinical manifestation of tachypnea, 50% of them with chest indwelling and SpO2 values of < 95%, and 25% of the patients were admitted to the PICU. The clinical course was rapidly stabilized, and they were admitted for 3—6 days. Fifty percent of them had the history of asthma or recurrent dyspnea. Phylogenetic analysis showed that all eight EV-D68 sequences belonged to Clade 11
B3 as previously described.12 These eight sequences were 95% identical to the strains previously identified in other Asian areas of China,17 Hong Kong,18,19 Japan20 and Vietnam,21 and in Europe and USA.22 All the isolates in 2015 were 97—98% homologous to the Taiwan isolations in 2014. The sequences of the identified EV-D68 strains have been submitted to the GenBank database under accession numbers from MH341107 to MH341110, MH341112 and MH341113.
4. Discussion During 2015, sixteen EV-D68 cases were identified in Taiwan under the surveillance system of the Taiwan Virology Reference Laboratory Network (TVRLN).12 Eight of them were isolated from the patients with the diagnosis as respiratory illness in the hospitals or local clinics in Taichung City, and six patients were children. We detailed the clinical manifestation among hospitalized children, and this is the first study to detail the clinical manifestation of EV-D68 infection in Taiwan. In our study, the median age was 6.3 years, which was in keeping with the 2014 outbreak as school-aged children were disproportionately affected,7,23 but it different from the previous EV-D68 outbreak, where 0-2 years of age were in the majority.9,24 Enterovirus has a pattern of seasonality in the late summer and autumn in the Northern Hemisphere, which was also described in enterovirus D68.25,26 Huang YP et 12
al11 found that no obvious correlation with seasonal distribution was observed in Taiwan, while Clade B viruses were more likely to be detected in the typical enterovirus season. All our viruses belonged to Clade B, and they were distributed from July to December, the typical enterovirus season. All outpatients in our study had the clinical manifestation of ILI, and were older than inpatients. In a systemic review, ILI accounts for 11% of the clinical symptoms in the children with EV-D68 infection.27 Under the ILI surveillance conducted in South Africa, the prevalence of enterovirus was 3.4%, and Enterovirus-D68 was one of the most prevalent genotypes.28 In the ILI study conducted in the Netherlands, EVD68 was detected in 57 out of 9979 patients (0.57%) with respiratory symptoms. In the under 20 age groups, the EV-D68 positive rate was higher in the cases aged 10—19 years than in children <10 years of age.25 With the admissions to the hospital (excluding the neonatal ICU), ICU and the ER at St. Louis Children’s Hospital in the United States, EV-D68 infection was characterized by findings of tachypnea (65%), wheezing (71%) and retractions (65%) on examination, and the most common discharge diagnosis was asthma exacerbation (55%).29 A systemic review revealed that the most common symptoms of EV-D68 infection were coughing (38%), fever (24%), wheezing (21%), chest indrawing (15%), difficulties breathing (13%), and pneumonia (clinically or radiograph proven) 13
(13%).27 Among our 4 hospitalized children, cough, rhinorrhea, tachypnea and fever were the most common clinical symptoms, followed by wheezing, chest retractions and sore throat. Two of the four inpatients had prior history of asthma or recurrent dyspnea. Previous study found that EV-D68 was detected in the nasopharyngeal samples of 74.3% patients with asthma attacks.10 Several studies reported that 31— 70% of children hospitalized with EV-D68 infection had a history of asthma.7,30 For the severe cases admitted to PICU, 68% of children had a history of asthma or wheezing.31 Children with a history of asthma or wheezing illnesses are more likely to develop severe EV-D68 infections. Co-detection of other pathogens in respiratory samples has been observed in prior EV-D68 outbreaks.32,33 In one case series, children admitted to the PICU were significantly more likely to have an identified respiratory co-pathogen.32 One of our patients had simultaneous H. influenza infection. In studies of healthy children, the colonization of H. influenza was around 25—64%.34 There is some evidence that bacterial colonization accompanying virus infection may contribute to the severity of the wheezing because of its impact on airway inflammation.35 Previous studies revealed co-detection of bacterial pathogens including Pseudomonas aeruginosa, Streptococcus pneumoniae and Mycoplasma pneumoniae on the EV-D68-positive patients.6,19 Association between role of co-infections and the disease severity cannot 14
be excluded. In Taiwan, subclade A1, A2 and B1 were prevalent from 2007 to 2013. Prominent genotype converted to subclade B3 after 2014.12 All EV-D68 cases in our study belonged to subclade B3, 97—98% identical to the 2014 strains in Taiwan. Subclade B3 was found in Japan, Hong Kong, China, and Taiwan from 2014 and emerged worldwide in 2016, including in Netherlands36 and Sweden.37 Severe neurological manifestations including AFM were seen among subclade B3-infected patients with the rate around 4%.12 Those B3 strains identified in Japan, China and Hong Kong were associated with respiratory illness, which included bronchitis, bronchiolitis, pneumonia, asthma exacerbation and febrile wheeze. All our isolates showed the clinical manifestation as respiratory infection. Several limitations were considered in this study. First, this was a retrospective study, and doing viral testing was the clinician’s decision. Second, we collected specimen from patients only with primarily respiratory presentations, which might result in missing neurological presentations. Finally, our sample size was small, and the inspection rate would be lower in the clinics, likely misjudging the severity of EV-D68 infection. In conclusion, as in North America and other countries, EV-D68 also seems to contribute to the development of sometimes severe lower respiratory tract infections 15
in Taiwan. In order to prepare appropriate preventive and therapeutic measures, further studies capable of better defining its epidemiological, genetic and pathogenetic characteristics are required.
Conflicts of interest All authors have no conflicts of interest to declare.
References 1. Schieble JH, Fox VL, Lennette EH. A probable new human picornavirus associated with respiratory diseases. American Journal of Epidemiology 1967; 85: 297—310. 2. Imamura T, Oshitani H. Global reemergence of enterovirus D68 as an important pathogen for acute respiratory infections. Rev Med Virol 2015; 25: 102—14. 3. Imamura T, Okamoto M, Nakakita S, Suzuki A, Saito M, Tamaki R, et al. Antigenic and receptor binding properties of enterovirus 68. J Virol 2014; 88: 2374— 84. 4. Oberste MS, Maher K, Schnurr D, Flemister MR, Lovchik JC, Peters H, et al. Enterovirus 68 is associated with respiratory illness and shares biological features with both the enteroviruses and the rhinoviruses. J Gen Virol 2004; 85: 2577—84. 5. Oermann CM, Schuster JE, Conners GP, Newland JG, Selvarangan R, Jackson MA. Enterovirus D68. A focused review and clinical highlights from the 2014 U.S. Outbreak. Ann Am Thorac Soc 2015; 12: 775—81. 6. Esposito S, Zampiero A, Ruggiero L, Madini B, Niesters H, Principi N. Enterovirus D68-associated community-acquired pneumonia in children living in Milan, Italy. J Clin Virol 2015; 68: 94—6. 7. Drews SJ, Simmonds K, Usman HR, Yee K, Fathima S, Tipples G, et al. Characterization of enterovirus activity, including that of enterovirus D68, in pediatric patients in Alberta, Canada, in 2014. J Clin Microbiol 2015; 53: 1042—5. 8. Imamura T, Fuji N, Suzuki A, Tamaki R, Saito M, Aniceto R, et al. Enterovirus 68 among children with severe acute respiratory infection, the Philippines. Emerg 16
Infect Dis 2011; 17: 1430—5. 9.
Rahamat-Langendoen J, Riezebos-Brilman A, Borger R, van der Heide R,
Brandenburg A, Scholvinck E, et al. Upsurge of human enterovirus 68 infections in patients with severe respiratory tract infections. J Clin Virol 2011; 52: 103—6. 10. Hasegawa S, Hirano R, Okamoto-Nakagawa R, Ichiyama T, Shirabe K. Enterovirus 68 infection in children with asthma attacks: virus-induced asthma in Japanese children. Allergy 2011; 66: 1618—20. 11. Huang YP, Lin TL, Lin TH, Wu HS. Molecular and epidemiological study of enterovirus D68 in Taiwan. J Microbiol Immunol Infect 2017; 50: 411—7. 12. Wei HY, Yeh TK, Hsieh JY, Lin IP, Yang JY. Updates on the molecular epidemiology of Enterovirus D68 after installation of screening test among acute flaccid paralysis patients in Taiwan. J Microbiol Immunol Infect 2018; 51: 688—91. 13. Huang YP, Lin TL, Hsu LC, Chen YJ, Tseng YH, Hsu CC, et al. Genetic diversity and C2-like subgenogroup strains of enterovirus 71, Taiwan, 2008. Virol J 2010 22: 277. 14. Nix WA, Oberste MS, Pallansch MA. Sensitive, seminested PCR amplification of VP1 sequences for direct identification of all enterovirus serotypes from original clinical specimens. J Clin Microbiol 2006; 44: 2698—704. 15. Tseng FC, Huang HC, Chi CY, Lin TL, Liu CC, Jian JW, et al. Epidemiological survey of enterovirus infections occurring in Taiwan between 2000 and 2005: analysis of sentinel physician surveillance data. J Med Virol 2007; 79: 1850—60. 16. Oberste MS, Maher K, Kilpatrick DR, Pallansch MA. Molecular evolution of the human enteroviruses_correlation of serotype with VP1 sequence and application to picornavirus classification. J Virol 1999 73: 1941—8. 17. Chen L, Shi L, Yang H, Gu DY, Meng J, Xu YQ, et al. Identification and whole-genome sequencing of four Enterovirus D68 strains in Southern China in late 2015. Genome Announc 2016; 4. 18. Lau SK, Yip CC, Zhao PS, Chow WN, To KK, Wu AK, et al. Enterovirus D68 infections associated with severe respiratory illness in elderly patients and emergence of a novel clade in Hong Kong. Sci Rep 2016; 6: 25147. 19. Yip CCY, Lo JYC, Sridhar S, Lung DC, Luk S, Chan KH, et al. First report of a fatal case associated with EV-D68 infection in Hong Kong and emergence of an interclade recombinant in China revealed by genome analysis. Int J Mol Sci 2017; 18. 20. Kaida A, Iritani N, Yamamoto SP, Kanbayashi D, Hirai Y, Togawa M, et al. Distinct genetic clades of enterovirus D68 detected in 2010, 2013, and 2015 in Osaka City, Japan. PLoS One 2017; 12: e0184335. 21. Ny NTH, Anh NT, Hang VTT, Nguyet LA, Thanh TT, Ha DQ, et al. Enterovirus D68 in Viet Nam (2009—2015). Wellcome Open Research 2017; 2. 17
22. Wang G, Zhuge J, Huang W, Nolan SM, Gilrane VL, Yin C, et al. Enterovirus D68 subclade B3 strain circulating and causing an outbreak in the United States in 2016. Sci Rep 2017; 7: 1242. 23. Schuster JE, Selvarangan R, Hassan F, Briggs KB, Hays L, Miller JO, et al. Clinical course of Enterovirus D68 in hospitalized children. Pediatr Infect Dis J 2017; 36: 290—5. 24. Khetsuriani N, Lamonte-Fowlkes A, Oberst S, Pallansch MA, Prevention CfDCa. Enterovirus surveillance--United States, 1970—2005. MMWR Surveill Summ 2006; 55: 1—20. 25. Meijer A, van der Sanden S, Snijders BE, Jaramillo-Gutierrez G, Bont L, van der Ent CK, et al. Emergence and epidemic occurrence of enterovirus 68 respiratory infections in The Netherlands in 2010. Virology 2012; 423: 49—57. 26. Ikeda T, Mizuta K, Abiko C, Aoki Y, Itagaki T, Katsushima F, et al. Acute respiratory infections due to enterovirus 68 in Yamagata, Japan between 2005 and 2010. Microbiol Immunol 2012; 56: 139—43. 27. Holm-Hansen CC, Midgley SE, Fischer TK. Global emergence of enterovirus D68: a systematic review. The Lancet Infectious Diseases 2016; 16: e64—75. 28. Hellferscee O, Tempia S, Walaza S, Variava E, Dawood H, Wolter N, et al. Enterovirus genotypes among patients with severe acute respiratory illness, influenza-like illness, and asymptomatic individuals in South Africa, 2012—2014. J Med Virol 2017; 89: 1759—67. 29. Orvedahl A, Padhye A, Barton K, O'Bryan K, Baty J, Gruchala N, et al. Clinical characterization of children presenting to the hospital with Enterovirus D68 infection during the 2014 outbreak in St. Louis. Pediatr Infect Dis J 2016; 35: 481—7. 30. Mertz D, Alawfi A, Pernica JM, Rutherford C, Luinstra K, Smieja M. Clinical severity of pediatric respiratory illness with enterovirus D68 compared with rhinovirus or other enterovirus genotypes. CMAJ 2015 187: 1279—84. 31. Schuster JE, Miller JO, Selvarangan R, Weddle G, Thompson MT, Hassan F, et al. Severe enterovirus 68 respiratory illness in children requiring intensive care management. J Clin Virol 2015; 70: 77—82. 32. Martin G, Li R, Cook VE, Carwana M, Tilley P, Sauve L, et al. Respiratory presentation of pediatric patients in the 2014 Enterovirus D68 outbreak. Can Respir J 2016; 2016: 8302179. 33. Linsuwanon P, Puenpa J, Suwannakarn K, Auksornkitti V, Vichiwattana P, Korkong S, et al. Molecular epidemiology and evolution of human enterovirus serotype 68 in Thailand, 2006—2011. PLoS One 2012; 7: e35190. 34. Ortiz-Romero MDM, Espejo-García MP, Alfayate-Miguelez S, Ruiz-López FJ, Zapata-Hernandez D, Gonzalez-Pacanowska AJ, et al. Epidemiology of 18
nasopharyngeal carriage by Haemophilus influenzae in healthy children: a study in the Mediterranean coast region. Pediatr Infect Dis J 2017; 36: 919—23. 35. Yu D, Wei L, Zhengxiu L, Jian L, Lijia W, Wei L, et al. Impact of bacterial colonization on the severity, and accompanying airway inflammation, of virus-induced wheezing in children. Clinical Microbiology and Infection 2010; 16: 1399—404. 36. Knoester M, Scholvinck EH, Poelman R, Smit S, Vermont CL, Niesters HG, et al. Upsurge of Enterovirus D68, the Netherlands, 2016. Emerg Infect Dis 2017; 23: 140—3. 37.
Dyrdak R, Grabbe M, Hammas B, Ekwall J , Hansson KE, Luthander J, et al.
Outbreak of enterovirus D68 of the new B3 lineage in Stockholm, Sweden, August to September 2016. Euro surveillance : bulletin Europeen sur les maladies transmissibles = European communicable disease bulletin 2016; 21. pii: 30403.
19
Table 1 Characteristics of study subjects. Patient
Age/sex
Month
Clinical information
Underlying disease
CXR
22y4mo/M
Jun
Fever, cough, rhinorrhea, sore
NA
NA
No
Mild bilateral
no. 1
throat, myalgia, prostration, ILI 2
0y8mo/M
July
Fever, cough
haziness 3
8y0mo/F
July
Fever, cough, rhinorrhea, sore
Primary
throat, purulent tonsillitis,
hypercholesterolemia
Diffuse haziness
tachypnea 4
12y0mo/F
Aug
Fever, cough, sore throat
NA
NA
Outcome
headache, ILI 5
11y1mo/F
Aug
Fever, cough, sore throat
NA
NA
headache, myalgia, ILI 6
18y5mo/M
Nov
ILI
NA
NA
7
2y3mo/F
Nov
Fever, cough, rhinorrhea, sore
Atopic dermatitis,
Diffuse haziness
throat, wheezing, tachypnea, chest
asthma
indrawing 8
3y10mo/F
Dec
Cough, rhinorrhea, audible wheezing, tachypnea, chest indrawing
ILI, influenza-like illness; NA, not available
Recurrent dyspnea
Bilateral hilar haziness
S1875-9572(19)30502-9
DOI:
https://doi.org/10.1016/j.pedneo.2019.09.006
Reference:
PEDN 966
To appear in:
Pediatrics & Neonatology
Received Date: 24 July 2018 Revised Date:
27 May 2019
Accepted Date: 6 September 2019
Please cite this article as: Pan H-H, Tsai C-R, Ting P-J, Huang F-L, Wang L-C, Lin C-F, Ko J-L, Lue KH, Chen P-Y, Respiratory Presentation of Patients Infected with Enterovirus D68 in Taiwan, Pediatrics and Neonatology, https://doi.org/10.1016/j.pedneo.2019.09.006. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Copyright © 2019, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. All rights reserved.
PEDN_2018_424_After Eng edited_final
Category : original article Title: Respiratory Presentation of Patients Infected with Enterovirus D68 in Taiwan
Short title: Respiratory presentation and EV-D68 in Taiwan
Hui-Hsien Pan a,b,c, Chi-Ren Tsai d, Pei-Ju Ting d, Fang-Liang Huang d,e, Li-Chung Wang f, Chin-Fu Lin f, Jiunn-Liang Ko a,b,g, Ko-Huang Lue a,b,c,*, Po-Yen Chen c,d,*
Affiliations: a
Department of Pediatrics, Chung-Shan Medical University Hospital, Taichung City,
Taiwan b
Institute of Medicine, Chung Shan Medical University, Taichung City, Taiwan
c
School of Medicine, Chung Shan Medical University, Taichung City, Taiwan
d
Department of Pediatrics, Taichung Veterans General Hospital, Taichung City,
Taiwan e
Hung Kuang University, Taichung, Taiwan
f
Microbiology Section of the Medical Laboratory Department, Taichung Veterans
General Hospital, Taichung, Taiwan 1
g
Department of Medical Oncology and Chest Medicine, Chung Shan Medical
University Hospital, Taichung, Taiwan
*Correspondence: 1. Po-Yen Chen (Corresponding author) Division of Pediatric Infectious Disease, Department of Pediatrics, Taichung Veterans General Hospital, Taichung, Taiwan, 1650 Taiwan Boulevard Sect. 4, Taichung, Taiwan 40705, ROC Phone: +886-4-23592525 ext. 5913 Email: [email protected] 2. Ko-Huang Lue (Corresponding author) Department of Pediatrics, Chung Shan Medical University Hospital; School of Medicine, Chung Shan Medical University; Institute of Medicine, Chung Shan Medical University, No. 110, Sec. 1, Jianguo N. Road, Taichung City 40201, Taiwan R.O.C Phone: +88-642-4739595 ext.11011 Email: [email protected]
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Abstract Background /Purpose: Enterovirus-D68 (EV-D68) has been endemic in Taiwan for some years with a small number of positive cases. Detailed information about respiratory presentation is lacking. This study characterized the clinical course in children admitted to the medical center and regional hospital in Taichung during 2015. Methods: Retrospective chart review of patients with confirmed EV-D68 infection admitted to the medical center and regional hospital in Taichung with respiratory symptoms in the second half of 2015. Past medical history, clinical presentation, management, and course in hospital were collected and analyzed. Simple demographic data and clinical symptoms were also collected from patients confirmed with EV-D68 infection who visited clinics in Taichung. Results: Six children were included. Two patients had a prior history of asthma or recurrent dyspnea, and one had other preexisting medical comorbidities. One child was admitted to the pediatric intensive care unit. All the patients were cured. Cough, rhinorrhea, tachypnea and fever were the most common clinical symptoms among inpatients, while influenza-like illness (ILI) was prevalent in outpatients. Conclusion: EV-D68 infection resulted in respiratory presentations of asthma-like illness in the hospitalized pediatric population. Patients with a prior history of asthma or recurrent dyspnea appear to be more severely affected. 3
Key words Enterovirus D68; Respiratory presentation; Taiwan
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1. Introduction Enterovirus D68 (EV-D68), a viral pathogen belonging to the species Enterovirus D, genus Enterovirus, family Picornaviridae, and order Picornavirales was first found in 1962 by Schieble et al.1 EV-D68 is a non-enveloped, positive sense, single-stranded RNA virus, and it is classified into three genetic groups, Clades A, B, and C, on the basis of the VP1 nucleotide sequence.2 EV-D68 shares biological characteristics with rhinoviruses (RVs), including acid sensitivity and growth at lower optimal temperature than other EVs, and it binds specifically to α2-6 sialic acid instead of to α2-3 sialic acid, which is the receptor of the other EVs.3,4 EV-D68 outbreaks were observed in August 2014 in the United States and different countries worldwide, which reported an increased number of respiratory diseases due to EV-D68.5—7 EVD-68 presented as upper respiratory tract infection, pneumonia, bronchiolitis, bronchitis, and asthma exacerbations.8,9 Children appear to be disproportionately affected and may present with severe respiratory disease.8,10 EV-D68 has been endemic in Taiwan for years although the number of positive case is small. Surveillance data revealed limited information about the clinical presentation collected by the physicians and reference laboratories at the beginning.11 The current study seeks to characterize cases of EV-D68 in Taiwan. We delineate the patient demographics, clinical presentation, management at our institution, and underlying 5
characteristics.
2. Material and Methods 2.1 Specimen collection This observational study was conducted from Jan 2015 to Dec 2015 at a 1500-bed tertiary teaching hospital in central Taiwan. The specimens were collected from children in the medical center, contracted reginal hospitals in Taichung, or contracted clinics in Taichung. In the medical center, all departments were involved in the specimen collection; pediatric departments were involved in the contracted reginal hospitals; internal medicine, otolaryngology, and pediatric clinics were also involved. Virus culture from a respiratory tract specimen was recommended based on an established case definition: patients with sign/symptoms of respiratory infection, which included cough, rhinorrhea, sore throat, increased work of breathing, and need for supplemental oxygen or continuous albuterol. However, the clinical provider ordered the test at their discretion. Otherwise, the EV-D68 infection with neurologic presentations might be left out under certain collection criteria. Testing was performed in the outpatient clinics, urgent care/emergency department and inpatient wards. Centers for Disease Control, Taiwan (Taiwan CDC) set up a laboratory-based surveillance system named the Taiwan Virology Reference Laboratory Network (TVRLN) from 1999. TVRLN collected throat swabs or rectal swabs from patients 6
with respiratory infection or suspected enterovirus infections by designated physicians in every township (N = 368).12 2.2 Virus identification Virus isolation followed the standard protocols for the surveillance system was conducted by Taiwan CDC as previously described.13 The isolates were then identified by immunofluorescence assay (IFA) using commercial antibodies against enterovirus (Light Diagnostic, USA). All IFA-untypable enterovirus isolates were reported as non-polio enterovirus in the laboratory of Taichung Veterans General Hospital (TCVGH), and then collected by Taiwan Centers for Disease Control (Taiwan CDC) for further identification. After traditional RT-PCR and sequencing, and then an enterovirus COnsensus-DEgenerate Hybrid Oligonucleotide Primers (CODEHOP) method, EV-D68 strains were confirmed.14,15 Testing for EV-D68 was done retrospectively in our study. In other words, further sequence analysis was done after being informed of EVD-68 strains by Taiwan CDC. 2.3 RNA extraction, RT-PCR amplification and Sequence analysis We extracted the RNA from the confirmed isolates with QIAamp Viral RNA Mini Kit(Qiagen, Santa Clara, CA, USA) according to the manufacturer’s instruction. The VP1 region was amplified by RT-PCR with primer sets 053/222 and 292/485 as previously described.4,16 Finch TV was used for aligning the nucleotide and deduced 7
amino acid sequences of VP1 region. We used the Basic Local Alignment Search Tool (BLAST) for virus classification and genotyping with the reference sequence database in GenBank. 2.4 Clinical data and chart review of EV-D68-positive patients All the cases in our study were virologically confirmed. We collected the clinical data from medical records in the TVRLN surveillance system, which included the records of patients’ age, sex, and clinical symptoms. The clinical symptoms include fever, headache, myalgia, malaise, rhinorrhea, cough, sore throat and vomiting. Patients from the medical center and the contracted regional hospital in Taichung were included for chart review analysis. We obtained history of presenting illness, past medical history, medications at time of admission, physical examination findings, interventions received in the hospital and discharge diagnoses. This study was approved by the Institutional Review Board (IRB) (IRB No. CE16092A).
3. Results Six samples positive for EV-D68 were collected from July to December. The 6 EV-D68-positive patients (1 males, 5 females) (nos. 1–6 in Table 1) belonged to different age groups: 0–11 months, 2 years, 3 years, 7 years, 11 years, and 12 years. All patients showed signs of lower respiratory tract infections and were diagnosed 8
with the following: bronchopneumonia (16.7%), asthmatic bronchitis (33.3%), bronchitis (16.7%), and ILI (33.3%). Of the 6 EV-D68-positive patients, one patient had co-infections of EV-D68 with Haemophilus influenza (H. Influenzae). None of the patients described in this paper had symptoms of neurological disease or paralysis. The main symptoms for the 6 EV-D68 patients were cough (100%) and fever (83%). Among inpatients, cough (100%), rhinorrhea (75%), tachypnea (75%) and fever (75%) were the most common clinical symptoms, while ILI (100%) was prevalent in outpatients. Table 1 shows the demographic and clinical manifestation of the patients with EV-D68 infection. The clinical presentations of the inpatients are described below. Case 1
A previously healthy 8-month-old boy presented with fever, productive
cough and decreased appetite. At admission, his physical examination showed that the child was febrile and alert but had an injected throat. Blood examination showed normal white blood cell count and elevated C-Reactive Protein (CRP) (13.92 mg/dL). Chest x-ray (CXR) revealed mild bilateral haziness. Adenovirus rapid test was negative. The patient was then treated with hydration and discharged 2 days later. Case 2
A 2-year-3-month-old girl with the past history of atopic dermatitis and
asthma presented with shortness of breath with room air SpO2 88%. Sore throat and vomiting were also noted. One day earlier, she had cough and rhinorrhea. At 9
emergency room (ER), her physical examination showed that the child had injected throat, postnasal drip, bilateral coarse breath sound with diffuse wheezing and subcostal and suprasternal retraction. Blood examination showed leukocytosis (23760/uL) with left shift and normal CRP. CXR revealed diffuse haziness especially at perihilar region and left upper zone. The patient was then treated with β-agonist inhalation. Despite therapy, shortness of breath with subcostal and suprasternal retraction was still noted, so the child was transferred to our Pediatric Intensive Care Unit (PICU); at admission he was diagnosed with asthmatic bronchitis with respiratory distress. Inhalation was prescribed and intravenous hydrocortisone was administered. After 2 days of treatment, the signs and symptoms of respiratory distress significantly reduced, and the child was transferred to our pediatric ward. Discharge was arranged 3 days later with improvement in appetite. Case 3
A 3-year-10-month-old girl with past history of dyspnea twice in the
previous year presented with audible wheezing and shortness of breath with room air SpO2 94%. At ER, her physical examination showed that the child had bilateral decreased breathing sound with subcostal and suprasternal retraction. Blood examination showed normal white blood cell count. CXR revealed bilateral hilar haziness. The patient was then treated with β-agonist inhalation. After treatment, the signs and symptoms of asthmatic bronchitis were reduced. Discharge with oral 10
β-agonist and prednisolone was arranged. Case 4
An 8-year-old girl with the underlying disease of primary
hypercholesterolemia presented with mild shortness of breath. One week earlier, she had cough and rhinorrhea with sticky yellowish discharge. Fever and sore throat was noted two days earlier. At admission, his physical examination showed that the child had injected throat and tonsil grade II with pus coating , post-nasal drip and bilateral coarse breathing sound. Blood examination showed leukocytosis (15630/uL) with left shift and elevated CRP (3.00 mg/dL). CXR revealed diffuse haziness. Under the impression of 1. Bronchopneumonia 2. Acute purulent tonsillitis and 3. Acute sinusitis, the patient was then treated with intravenous ampicillin/sulbactam and symptomatic medication. Sputum culture found H. Influenzae with resistance to ampicillin, amoxicillin/clavulanic acid and ampicillin/ sulbactam. After 6 days of treatment, the signs and symptoms improved. Among the inpatients, 75% of the patients had the clinical manifestation of tachypnea, 50% of them with chest indwelling and SpO2 values of < 95%, and 25% of the patients were admitted to the PICU. The clinical course was rapidly stabilized, and they were admitted for 3—6 days. Fifty percent of them had the history of asthma or recurrent dyspnea. Phylogenetic analysis showed that all eight EV-D68 sequences belonged to Clade 11
B3 as previously described.12 These eight sequences were 95% identical to the strains previously identified in other Asian areas of China,17 Hong Kong,18,19 Japan20 and Vietnam,21 and in Europe and USA.22 All the isolates in 2015 were 97—98% homologous to the Taiwan isolations in 2014. The sequences of the identified EV-D68 strains have been submitted to the GenBank database under accession numbers from MH341107 to MH341110, MH341112 and MH341113.
4. Discussion During 2015, sixteen EV-D68 cases were identified in Taiwan under the surveillance system of the Taiwan Virology Reference Laboratory Network (TVRLN).12 Eight of them were isolated from the patients with the diagnosis as respiratory illness in the hospitals or local clinics in Taichung City, and six patients were children. We detailed the clinical manifestation among hospitalized children, and this is the first study to detail the clinical manifestation of EV-D68 infection in Taiwan. In our study, the median age was 6.3 years, which was in keeping with the 2014 outbreak as school-aged children were disproportionately affected,7,23 but it different from the previous EV-D68 outbreak, where 0-2 years of age were in the majority.9,24 Enterovirus has a pattern of seasonality in the late summer and autumn in the Northern Hemisphere, which was also described in enterovirus D68.25,26 Huang YP et 12
al11 found that no obvious correlation with seasonal distribution was observed in Taiwan, while Clade B viruses were more likely to be detected in the typical enterovirus season. All our viruses belonged to Clade B, and they were distributed from July to December, the typical enterovirus season. All outpatients in our study had the clinical manifestation of ILI, and were older than inpatients. In a systemic review, ILI accounts for 11% of the clinical symptoms in the children with EV-D68 infection.27 Under the ILI surveillance conducted in South Africa, the prevalence of enterovirus was 3.4%, and Enterovirus-D68 was one of the most prevalent genotypes.28 In the ILI study conducted in the Netherlands, EVD68 was detected in 57 out of 9979 patients (0.57%) with respiratory symptoms. In the under 20 age groups, the EV-D68 positive rate was higher in the cases aged 10—19 years than in children <10 years of age.25 With the admissions to the hospital (excluding the neonatal ICU), ICU and the ER at St. Louis Children’s Hospital in the United States, EV-D68 infection was characterized by findings of tachypnea (65%), wheezing (71%) and retractions (65%) on examination, and the most common discharge diagnosis was asthma exacerbation (55%).29 A systemic review revealed that the most common symptoms of EV-D68 infection were coughing (38%), fever (24%), wheezing (21%), chest indrawing (15%), difficulties breathing (13%), and pneumonia (clinically or radiograph proven) 13
(13%).27 Among our 4 hospitalized children, cough, rhinorrhea, tachypnea and fever were the most common clinical symptoms, followed by wheezing, chest retractions and sore throat. Two of the four inpatients had prior history of asthma or recurrent dyspnea. Previous study found that EV-D68 was detected in the nasopharyngeal samples of 74.3% patients with asthma attacks.10 Several studies reported that 31— 70% of children hospitalized with EV-D68 infection had a history of asthma.7,30 For the severe cases admitted to PICU, 68% of children had a history of asthma or wheezing.31 Children with a history of asthma or wheezing illnesses are more likely to develop severe EV-D68 infections. Co-detection of other pathogens in respiratory samples has been observed in prior EV-D68 outbreaks.32,33 In one case series, children admitted to the PICU were significantly more likely to have an identified respiratory co-pathogen.32 One of our patients had simultaneous H. influenza infection. In studies of healthy children, the colonization of H. influenza was around 25—64%.34 There is some evidence that bacterial colonization accompanying virus infection may contribute to the severity of the wheezing because of its impact on airway inflammation.35 Previous studies revealed co-detection of bacterial pathogens including Pseudomonas aeruginosa, Streptococcus pneumoniae and Mycoplasma pneumoniae on the EV-D68-positive patients.6,19 Association between role of co-infections and the disease severity cannot 14
be excluded. In Taiwan, subclade A1, A2 and B1 were prevalent from 2007 to 2013. Prominent genotype converted to subclade B3 after 2014.12 All EV-D68 cases in our study belonged to subclade B3, 97—98% identical to the 2014 strains in Taiwan. Subclade B3 was found in Japan, Hong Kong, China, and Taiwan from 2014 and emerged worldwide in 2016, including in Netherlands36 and Sweden.37 Severe neurological manifestations including AFM were seen among subclade B3-infected patients with the rate around 4%.12 Those B3 strains identified in Japan, China and Hong Kong were associated with respiratory illness, which included bronchitis, bronchiolitis, pneumonia, asthma exacerbation and febrile wheeze. All our isolates showed the clinical manifestation as respiratory infection. Several limitations were considered in this study. First, this was a retrospective study, and doing viral testing was the clinician’s decision. Second, we collected specimen from patients only with primarily respiratory presentations, which might result in missing neurological presentations. Finally, our sample size was small, and the inspection rate would be lower in the clinics, likely misjudging the severity of EV-D68 infection. In conclusion, as in North America and other countries, EV-D68 also seems to contribute to the development of sometimes severe lower respiratory tract infections 15
in Taiwan. In order to prepare appropriate preventive and therapeutic measures, further studies capable of better defining its epidemiological, genetic and pathogenetic characteristics are required.
Conflicts of interest All authors have no conflicts of interest to declare.
References 1. Schieble JH, Fox VL, Lennette EH. A probable new human picornavirus associated with respiratory diseases. American Journal of Epidemiology 1967; 85: 297—310. 2. Imamura T, Oshitani H. Global reemergence of enterovirus D68 as an important pathogen for acute respiratory infections. Rev Med Virol 2015; 25: 102—14. 3. Imamura T, Okamoto M, Nakakita S, Suzuki A, Saito M, Tamaki R, et al. Antigenic and receptor binding properties of enterovirus 68. J Virol 2014; 88: 2374— 84. 4. Oberste MS, Maher K, Schnurr D, Flemister MR, Lovchik JC, Peters H, et al. Enterovirus 68 is associated with respiratory illness and shares biological features with both the enteroviruses and the rhinoviruses. J Gen Virol 2004; 85: 2577—84. 5. Oermann CM, Schuster JE, Conners GP, Newland JG, Selvarangan R, Jackson MA. Enterovirus D68. A focused review and clinical highlights from the 2014 U.S. Outbreak. Ann Am Thorac Soc 2015; 12: 775—81. 6. Esposito S, Zampiero A, Ruggiero L, Madini B, Niesters H, Principi N. Enterovirus D68-associated community-acquired pneumonia in children living in Milan, Italy. J Clin Virol 2015; 68: 94—6. 7. Drews SJ, Simmonds K, Usman HR, Yee K, Fathima S, Tipples G, et al. Characterization of enterovirus activity, including that of enterovirus D68, in pediatric patients in Alberta, Canada, in 2014. J Clin Microbiol 2015; 53: 1042—5. 8. Imamura T, Fuji N, Suzuki A, Tamaki R, Saito M, Aniceto R, et al. Enterovirus 68 among children with severe acute respiratory infection, the Philippines. Emerg 16
Infect Dis 2011; 17: 1430—5. 9.
Rahamat-Langendoen J, Riezebos-Brilman A, Borger R, van der Heide R,
Brandenburg A, Scholvinck E, et al. Upsurge of human enterovirus 68 infections in patients with severe respiratory tract infections. J Clin Virol 2011; 52: 103—6. 10. Hasegawa S, Hirano R, Okamoto-Nakagawa R, Ichiyama T, Shirabe K. Enterovirus 68 infection in children with asthma attacks: virus-induced asthma in Japanese children. Allergy 2011; 66: 1618—20. 11. Huang YP, Lin TL, Lin TH, Wu HS. Molecular and epidemiological study of enterovirus D68 in Taiwan. J Microbiol Immunol Infect 2017; 50: 411—7. 12. Wei HY, Yeh TK, Hsieh JY, Lin IP, Yang JY. Updates on the molecular epidemiology of Enterovirus D68 after installation of screening test among acute flaccid paralysis patients in Taiwan. J Microbiol Immunol Infect 2018; 51: 688—91. 13. Huang YP, Lin TL, Hsu LC, Chen YJ, Tseng YH, Hsu CC, et al. Genetic diversity and C2-like subgenogroup strains of enterovirus 71, Taiwan, 2008. Virol J 2010 22: 277. 14. Nix WA, Oberste MS, Pallansch MA. Sensitive, seminested PCR amplification of VP1 sequences for direct identification of all enterovirus serotypes from original clinical specimens. J Clin Microbiol 2006; 44: 2698—704. 15. Tseng FC, Huang HC, Chi CY, Lin TL, Liu CC, Jian JW, et al. Epidemiological survey of enterovirus infections occurring in Taiwan between 2000 and 2005: analysis of sentinel physician surveillance data. J Med Virol 2007; 79: 1850—60. 16. Oberste MS, Maher K, Kilpatrick DR, Pallansch MA. Molecular evolution of the human enteroviruses_correlation of serotype with VP1 sequence and application to picornavirus classification. J Virol 1999 73: 1941—8. 17. Chen L, Shi L, Yang H, Gu DY, Meng J, Xu YQ, et al. Identification and whole-genome sequencing of four Enterovirus D68 strains in Southern China in late 2015. Genome Announc 2016; 4. 18. Lau SK, Yip CC, Zhao PS, Chow WN, To KK, Wu AK, et al. Enterovirus D68 infections associated with severe respiratory illness in elderly patients and emergence of a novel clade in Hong Kong. Sci Rep 2016; 6: 25147. 19. Yip CCY, Lo JYC, Sridhar S, Lung DC, Luk S, Chan KH, et al. First report of a fatal case associated with EV-D68 infection in Hong Kong and emergence of an interclade recombinant in China revealed by genome analysis. Int J Mol Sci 2017; 18. 20. Kaida A, Iritani N, Yamamoto SP, Kanbayashi D, Hirai Y, Togawa M, et al. Distinct genetic clades of enterovirus D68 detected in 2010, 2013, and 2015 in Osaka City, Japan. PLoS One 2017; 12: e0184335. 21. Ny NTH, Anh NT, Hang VTT, Nguyet LA, Thanh TT, Ha DQ, et al. Enterovirus D68 in Viet Nam (2009—2015). Wellcome Open Research 2017; 2. 17
22. Wang G, Zhuge J, Huang W, Nolan SM, Gilrane VL, Yin C, et al. Enterovirus D68 subclade B3 strain circulating and causing an outbreak in the United States in 2016. Sci Rep 2017; 7: 1242. 23. Schuster JE, Selvarangan R, Hassan F, Briggs KB, Hays L, Miller JO, et al. Clinical course of Enterovirus D68 in hospitalized children. Pediatr Infect Dis J 2017; 36: 290—5. 24. Khetsuriani N, Lamonte-Fowlkes A, Oberst S, Pallansch MA, Prevention CfDCa. Enterovirus surveillance--United States, 1970—2005. MMWR Surveill Summ 2006; 55: 1—20. 25. Meijer A, van der Sanden S, Snijders BE, Jaramillo-Gutierrez G, Bont L, van der Ent CK, et al. Emergence and epidemic occurrence of enterovirus 68 respiratory infections in The Netherlands in 2010. Virology 2012; 423: 49—57. 26. Ikeda T, Mizuta K, Abiko C, Aoki Y, Itagaki T, Katsushima F, et al. Acute respiratory infections due to enterovirus 68 in Yamagata, Japan between 2005 and 2010. Microbiol Immunol 2012; 56: 139—43. 27. Holm-Hansen CC, Midgley SE, Fischer TK. Global emergence of enterovirus D68: a systematic review. The Lancet Infectious Diseases 2016; 16: e64—75. 28. Hellferscee O, Tempia S, Walaza S, Variava E, Dawood H, Wolter N, et al. Enterovirus genotypes among patients with severe acute respiratory illness, influenza-like illness, and asymptomatic individuals in South Africa, 2012—2014. J Med Virol 2017; 89: 1759—67. 29. Orvedahl A, Padhye A, Barton K, O'Bryan K, Baty J, Gruchala N, et al. Clinical characterization of children presenting to the hospital with Enterovirus D68 infection during the 2014 outbreak in St. Louis. Pediatr Infect Dis J 2016; 35: 481—7. 30. Mertz D, Alawfi A, Pernica JM, Rutherford C, Luinstra K, Smieja M. Clinical severity of pediatric respiratory illness with enterovirus D68 compared with rhinovirus or other enterovirus genotypes. CMAJ 2015 187: 1279—84. 31. Schuster JE, Miller JO, Selvarangan R, Weddle G, Thompson MT, Hassan F, et al. Severe enterovirus 68 respiratory illness in children requiring intensive care management. J Clin Virol 2015; 70: 77—82. 32. Martin G, Li R, Cook VE, Carwana M, Tilley P, Sauve L, et al. Respiratory presentation of pediatric patients in the 2014 Enterovirus D68 outbreak. Can Respir J 2016; 2016: 8302179. 33. Linsuwanon P, Puenpa J, Suwannakarn K, Auksornkitti V, Vichiwattana P, Korkong S, et al. Molecular epidemiology and evolution of human enterovirus serotype 68 in Thailand, 2006—2011. PLoS One 2012; 7: e35190. 34. Ortiz-Romero MDM, Espejo-García MP, Alfayate-Miguelez S, Ruiz-López FJ, Zapata-Hernandez D, Gonzalez-Pacanowska AJ, et al. Epidemiology of 18
nasopharyngeal carriage by Haemophilus influenzae in healthy children: a study in the Mediterranean coast region. Pediatr Infect Dis J 2017; 36: 919—23. 35. Yu D, Wei L, Zhengxiu L, Jian L, Lijia W, Wei L, et al. Impact of bacterial colonization on the severity, and accompanying airway inflammation, of virus-induced wheezing in children. Clinical Microbiology and Infection 2010; 16: 1399—404. 36. Knoester M, Scholvinck EH, Poelman R, Smit S, Vermont CL, Niesters HG, et al. Upsurge of Enterovirus D68, the Netherlands, 2016. Emerg Infect Dis 2017; 23: 140—3. 37.
Dyrdak R, Grabbe M, Hammas B, Ekwall J , Hansson KE, Luthander J, et al.
Outbreak of enterovirus D68 of the new B3 lineage in Stockholm, Sweden, August to September 2016. Euro surveillance : bulletin Europeen sur les maladies transmissibles = European communicable disease bulletin 2016; 21. pii: 30403.
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Table 1 Characteristics of study subjects. Patient
Age/sex
Month
Clinical information
Underlying disease
CXR
22y4mo/M
Jun
Fever, cough, rhinorrhea, sore
NA
NA
No
Mild bilateral
no. 1
throat, myalgia, prostration, ILI 2
0y8mo/M
July
Fever, cough
haziness 3
8y0mo/F
July
Fever, cough, rhinorrhea, sore
Primary
throat, purulent tonsillitis,
hypercholesterolemia
Diffuse haziness
tachypnea 4
12y0mo/F
Aug
Fever, cough, sore throat
NA
NA
Outcome
headache, ILI 5
11y1mo/F
Aug
Fever, cough, sore throat
NA
NA
headache, myalgia, ILI 6
18y5mo/M
Nov
ILI
NA
NA
7
2y3mo/F
Nov
Fever, cough, rhinorrhea, sore
Atopic dermatitis,
Diffuse haziness
throat, wheezing, tachypnea, chest
asthma
indrawing 8
3y10mo/F
Dec
Cough, rhinorrhea, audible wheezing, tachypnea, chest indrawing
ILI, influenza-like illness; NA, not available
Recurrent dyspnea
Bilateral hilar haziness