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Zika virus persists in serum for more than 2 months in newborns
Zika virus infections can persist for more than 2 months after birth in congenitally infected infants, indicating that viral shedding of Zika can take several weeks, according to an Aug. 24, 2016 research letter to the New England Journal of Medicine.
The case study described in the letter involves a male child born after 40 weeks’ gestation in Brazil to a mother who presented with Zika-like symptoms during the 26th week of pregnancy. The child was born with microcephaly – head circumference of 32.5 centimeters – but no signs of neurological abnormalities during the initial postnatal physical examination. Additionally, cerebrospinal fluid, ophthalmologic, and otoacoustic analyses were all deemed normal.
However, low brain parenchyma in the frontal and parietal lobes, along with calcification in the subcortical area and compensatory dilatation of the infratentorial supraventricular system was found via MRI. Furthermore, testing of serum, saliva, and urine at 54 days of age via quantitative real-time polymerase chain reaction assay came back positive for Zika virus. Serum tested at 67 days postbirth also was positive for Zika virus. Testing at day 216, however, showed no signs of Zika virus in serum.
“When the infant was examined on day 54, he had no obvious illness or evidence of any immunocompromising condition,” wrote lead author Danielle B.L. Oliveira, PhD, of the Universidade de São Paulo and her colleagues. “However, by 6 months of age, he showed neuropsychomotor developmental delay, with global hypertonia and spastic hemiplegia, with the right dominant side more severely affected.”
The report comes on the heels of a Florida Department of Health (DOH) announcement that the Zika virus has been found in a pregnant woman residing in Pinellas County, the first such case in that area, making it the third region of Florida in which Zika virus infection has been discovered. As of now, it is the only case of Zika virus in that area.
“DOH has begun door-to-door outreach in Pinellas County and mosquito abatement and reduction activities are also taking place,” the DOH announced in a statement. “DOH still believes ongoing transmission is only taking place within the small identified areas in Wynwood and Miami Beach in Miami-Dade County.”
Zika virus infections can persist for more than 2 months after birth in congenitally infected infants, indicating that viral shedding of Zika can take several weeks, according to an Aug. 24, 2016 research letter to the New England Journal of Medicine.
The case study described in the letter involves a male child born after 40 weeks’ gestation in Brazil to a mother who presented with Zika-like symptoms during the 26th week of pregnancy. The child was born with microcephaly – head circumference of 32.5 centimeters – but no signs of neurological abnormalities during the initial postnatal physical examination. Additionally, cerebrospinal fluid, ophthalmologic, and otoacoustic analyses were all deemed normal.
However, low brain parenchyma in the frontal and parietal lobes, along with calcification in the subcortical area and compensatory dilatation of the infratentorial supraventricular system was found via MRI. Furthermore, testing of serum, saliva, and urine at 54 days of age via quantitative real-time polymerase chain reaction assay came back positive for Zika virus. Serum tested at 67 days postbirth also was positive for Zika virus. Testing at day 216, however, showed no signs of Zika virus in serum.
“When the infant was examined on day 54, he had no obvious illness or evidence of any immunocompromising condition,” wrote lead author Danielle B.L. Oliveira, PhD, of the Universidade de São Paulo and her colleagues. “However, by 6 months of age, he showed neuropsychomotor developmental delay, with global hypertonia and spastic hemiplegia, with the right dominant side more severely affected.”
The report comes on the heels of a Florida Department of Health (DOH) announcement that the Zika virus has been found in a pregnant woman residing in Pinellas County, the first such case in that area, making it the third region of Florida in which Zika virus infection has been discovered. As of now, it is the only case of Zika virus in that area.
“DOH has begun door-to-door outreach in Pinellas County and mosquito abatement and reduction activities are also taking place,” the DOH announced in a statement. “DOH still believes ongoing transmission is only taking place within the small identified areas in Wynwood and Miami Beach in Miami-Dade County.”
Zika virus infections can persist for more than 2 months after birth in congenitally infected infants, indicating that viral shedding of Zika can take several weeks, according to an Aug. 24, 2016 research letter to the New England Journal of Medicine.
The case study described in the letter involves a male child born after 40 weeks’ gestation in Brazil to a mother who presented with Zika-like symptoms during the 26th week of pregnancy. The child was born with microcephaly – head circumference of 32.5 centimeters – but no signs of neurological abnormalities during the initial postnatal physical examination. Additionally, cerebrospinal fluid, ophthalmologic, and otoacoustic analyses were all deemed normal.
However, low brain parenchyma in the frontal and parietal lobes, along with calcification in the subcortical area and compensatory dilatation of the infratentorial supraventricular system was found via MRI. Furthermore, testing of serum, saliva, and urine at 54 days of age via quantitative real-time polymerase chain reaction assay came back positive for Zika virus. Serum tested at 67 days postbirth also was positive for Zika virus. Testing at day 216, however, showed no signs of Zika virus in serum.
“When the infant was examined on day 54, he had no obvious illness or evidence of any immunocompromising condition,” wrote lead author Danielle B.L. Oliveira, PhD, of the Universidade de São Paulo and her colleagues. “However, by 6 months of age, he showed neuropsychomotor developmental delay, with global hypertonia and spastic hemiplegia, with the right dominant side more severely affected.”
The report comes on the heels of a Florida Department of Health (DOH) announcement that the Zika virus has been found in a pregnant woman residing in Pinellas County, the first such case in that area, making it the third region of Florida in which Zika virus infection has been discovered. As of now, it is the only case of Zika virus in that area.
“DOH has begun door-to-door outreach in Pinellas County and mosquito abatement and reduction activities are also taking place,” the DOH announced in a statement. “DOH still believes ongoing transmission is only taking place within the small identified areas in Wynwood and Miami Beach in Miami-Dade County.”
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Zika virus pits pregnant women against time, knowledge gaps
ANNAPOLIS, MD. – The scramble to learn exactly how and when after infection the Zika virus affects the developing fetus has put pregnant women at the center of an unprecedented infectious disease emergency response.
“It’s the most complicated infectious disease response we’ve ever done,” Dana Meaney-Delman, MD, of the Centers for Disease Control and Prevention, told an audience at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology. “It’s also the first time an emergency response team has included an ob.gyn.”
Although research into Zika virus is happening at breakneck speed, every finding seems to lead to still more questions. “It’s hard to keep up,” said Dr. Meaney-Delman, who is a Clinical Deputy on the Pregnancy and Birth Defects Task Force, part of the CDC’s Zika virus response.
What is known
What is known is that Zika virus is primarily vector-borne, either manifesting as a mild illness or remaining subclinical. The virus is also communicable through male-to-female sex, female-to-female sex, blood donation, and organ transplantation. Once infected, one is immune; if symptomatic, the presentation clears within a couple of weeks. If a woman is infected during pregnancy, it can be transmitted to the developing fetus, including at the time of birth, according to Dr. Meaney-Delman.
“We know transmission can occur in any trimester. We’ve seen it in the placenta, in amniotic fluid, in the brain, as well as in the brains of infants who have died,” she said.
Whether the virus poses a risk to the fetus around the time of conception is not clear, but Dr. Meaney-Delman said that since other infections such as rubella and cytomegalovirus do pose a risk, the CDC is issuing Zika guidance accordingly.
Despite an initial theory that pregnant women were more susceptible to Zika infection, there is no evidence to date confirming this, but “the combination of mosquitoes and sexual transmission really puts a woman of reproductive age at risk,” said Catherine Y. Spong, MD, who also spoke during the meeting. Dr. Spong is acting director of the National Institute of Child Health and Human Development, part of the National Institutes of Health.
Based on data derived from other flaviviruses, the “good news” is that infected nonpregnant women who later want to conceive do not have a higher risk of bearing a child with Zika-related complications, according to Dr. Meaney-Delman.
Abnormalities seen and unseen
During the initial stages of the Zika outbreak in Brazil, the spiking rate of babies born with microcephaly attracted the most attention; yet it is now apparent that children were also born with a growing list of other Zika-associated pregnancy outcomes that likely were missed at the time, according to Dr. Spong.
“That’s not to say that a child that doesn’t have microcephaly does or doesn’t have some of these other complications. We don’t know; they weren’t studied because they didn’t have the microcephaly,” Dr Spong said. “To get the data right, you need to follow all the children.”
Brain abnormalities such as ventriculomegaly and intracranial calcifications, as well as a range of growth abnormalities, miscarriage, and stillbirth are increasingly associated with infants born to infected women. Data is also beginning to link Zika virus to limb abnormalities, hypertonia, hearing loss, damage to the eyes and central nervous system, and seizures.
The World Health Organization has also noted the involvement of the cardiac, genitourinary, and digestive systems in babies born to infected mothers in Panama and Colombia. “The caveat [to these data], is that all these women were symptomatic,” Dr. Spong said, noting that in Brazil, where the outbreak was first documented, 80% of the infected pregnant women were asymptomatic during the pregnancy.
“Just because the mother has no symptoms, she’s fine? That doesn’t make any sense to me,” Dr. Spong said. “We know that infections in pregnancy can result in long-term outcomes in kids that you don’t have the ability to diagnose at birth. We need to be cognizant of this and we need to study it.”
Although initial theories were that viremia in symptomatic women was likely higher, thus imparting a higher risk of infection in their fetus, Dr. Meaney-Delman said the number of asymptomatic women whose fetuses are affected has debunked this line of thinking.
Risk of infection during pregnancy
As to what the actual risk of Zika virus infection is during pregnancy, “honestly we don’t know,” said Dr. Spong. “There are modeling estimates that [it’s] between 1% and 13% in a first trimester infection, but we don’t have the hard and fast data.”
The Zika in Infants and Pregnancy (ZIP) study, recently launched by the NIH, will provide a prospective look at birth outcomes in 10,000 women aged 15 years and older who will be followed throughout their pregnancies to determine if they become infected with Zika virus, and if so, how infection impacts birth outcomes.
The international, multi-site study will help clarify the timing of risk, Dr. Spong said, and is intended to elucidate pregnancy risks in symptomatic vs. asymptomatic women. The study will also help indicate whether nutritional, socioeconomic status, and other cofactors such as Dengue infection are implicated. Once born, all children in the study will be observed for a year. “Even if they have no abnormalities, after birth there could be developmental delays, or more subtle consequences later on in the child’s life,” Dr. Meaney-Delman said.
Meanwhile, researchers are attempting to map how varying levels of viremia affect transmission. Zika virus has been found in semen after 90 days in at least two studies, “and we don’t know if Zika can be transmitted through other bodily fluids,” Dr. Spong said.
Surveillance data from the CDC’s Zika Pregnancy Registry has shown viremia in symptomatic women can last up to 46 days after onset of symptoms. In at least one asymptomatic pregnant woman, viremia was detected 53 days after exposure. Another study found prolonged viremia – 10 weeks – in a patient who had Zika infection in her first trimester; imaging showed the fetus was developing normally until week 20, when signs of severe brain abnormalities were detected.
The emerging picture of Zika’s potential for prolonged viremia has prompted the CDC to recommend clinicians use reverse transcription–polymerase chain reaction (RT-PCR) testing rather than serologic testing, as it is more sensitive and helps rule out other flavivirus infections, which require different management, Dr. Meaney-Delman said.
Potential mechanisms of action
“It’s clear that the virus does directly infect human cortical neural progenitor cells with very high efficiency, and in doing so, stunts their growth, dysregulates transcription, and causes cell death,” Dr. Spong said.
Researchers have also found that Zika replicates in subgroups of trophoblasts and endothelial cells, and in primary human placental macrophages, resulting in vascular damage and growth restriction. Other research suggests the virus spreads from basal and parietal decidua to chorionic villi and amniochorionic membranes, leading to the theory that uterine-placental suppression of the viral entry cofactor TIM1 could stop transmission to the fetus.
Prevention and management
CDC officials expect the current outbreak to mimic past flavivirus outbreaks which were contained locally in portions of the South and U.S. territories, Dr. Meaney-Delman said. Still, she emphasized that clinicians should screen patients, regardless of location. “Each pregnant women should be assessed for [vector] exposure, travel, and sexual exposure and asked about symptoms consistent with Zika virus,” Dr. Meaney-Delman said.
She also emphasized the importance of patients consistently using insect repellent and using condoms during pregnancy, as Zika has been detected in semen for as long as 6 months. “It’s been very hard to invoke this behavioral change in women, but it’s very effective.”
The CDC continues to update guidance, including how to evaluate newborns for Zika-related defects.
As for what resources might be needed in future to help affected families, in an interview Dr. Meaney-Delman said that depends on information still unknown. “Zika is a public health concern that we should be factoring in long term, but what we do about it will depend upon the outcomes,” she said. “If there are children that are born normal but who have lab evidence of Zika, then we will probably not do much. I don’t think we have a projection yet.”
On Twitter @whitneymcknight
ANNAPOLIS, MD. – The scramble to learn exactly how and when after infection the Zika virus affects the developing fetus has put pregnant women at the center of an unprecedented infectious disease emergency response.
“It’s the most complicated infectious disease response we’ve ever done,” Dana Meaney-Delman, MD, of the Centers for Disease Control and Prevention, told an audience at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology. “It’s also the first time an emergency response team has included an ob.gyn.”
Although research into Zika virus is happening at breakneck speed, every finding seems to lead to still more questions. “It’s hard to keep up,” said Dr. Meaney-Delman, who is a Clinical Deputy on the Pregnancy and Birth Defects Task Force, part of the CDC’s Zika virus response.
What is known
What is known is that Zika virus is primarily vector-borne, either manifesting as a mild illness or remaining subclinical. The virus is also communicable through male-to-female sex, female-to-female sex, blood donation, and organ transplantation. Once infected, one is immune; if symptomatic, the presentation clears within a couple of weeks. If a woman is infected during pregnancy, it can be transmitted to the developing fetus, including at the time of birth, according to Dr. Meaney-Delman.
“We know transmission can occur in any trimester. We’ve seen it in the placenta, in amniotic fluid, in the brain, as well as in the brains of infants who have died,” she said.
Whether the virus poses a risk to the fetus around the time of conception is not clear, but Dr. Meaney-Delman said that since other infections such as rubella and cytomegalovirus do pose a risk, the CDC is issuing Zika guidance accordingly.
Despite an initial theory that pregnant women were more susceptible to Zika infection, there is no evidence to date confirming this, but “the combination of mosquitoes and sexual transmission really puts a woman of reproductive age at risk,” said Catherine Y. Spong, MD, who also spoke during the meeting. Dr. Spong is acting director of the National Institute of Child Health and Human Development, part of the National Institutes of Health.
Based on data derived from other flaviviruses, the “good news” is that infected nonpregnant women who later want to conceive do not have a higher risk of bearing a child with Zika-related complications, according to Dr. Meaney-Delman.
Abnormalities seen and unseen
During the initial stages of the Zika outbreak in Brazil, the spiking rate of babies born with microcephaly attracted the most attention; yet it is now apparent that children were also born with a growing list of other Zika-associated pregnancy outcomes that likely were missed at the time, according to Dr. Spong.
“That’s not to say that a child that doesn’t have microcephaly does or doesn’t have some of these other complications. We don’t know; they weren’t studied because they didn’t have the microcephaly,” Dr Spong said. “To get the data right, you need to follow all the children.”
Brain abnormalities such as ventriculomegaly and intracranial calcifications, as well as a range of growth abnormalities, miscarriage, and stillbirth are increasingly associated with infants born to infected women. Data is also beginning to link Zika virus to limb abnormalities, hypertonia, hearing loss, damage to the eyes and central nervous system, and seizures.
The World Health Organization has also noted the involvement of the cardiac, genitourinary, and digestive systems in babies born to infected mothers in Panama and Colombia. “The caveat [to these data], is that all these women were symptomatic,” Dr. Spong said, noting that in Brazil, where the outbreak was first documented, 80% of the infected pregnant women were asymptomatic during the pregnancy.
“Just because the mother has no symptoms, she’s fine? That doesn’t make any sense to me,” Dr. Spong said. “We know that infections in pregnancy can result in long-term outcomes in kids that you don’t have the ability to diagnose at birth. We need to be cognizant of this and we need to study it.”
Although initial theories were that viremia in symptomatic women was likely higher, thus imparting a higher risk of infection in their fetus, Dr. Meaney-Delman said the number of asymptomatic women whose fetuses are affected has debunked this line of thinking.
Risk of infection during pregnancy
As to what the actual risk of Zika virus infection is during pregnancy, “honestly we don’t know,” said Dr. Spong. “There are modeling estimates that [it’s] between 1% and 13% in a first trimester infection, but we don’t have the hard and fast data.”
The Zika in Infants and Pregnancy (ZIP) study, recently launched by the NIH, will provide a prospective look at birth outcomes in 10,000 women aged 15 years and older who will be followed throughout their pregnancies to determine if they become infected with Zika virus, and if so, how infection impacts birth outcomes.
The international, multi-site study will help clarify the timing of risk, Dr. Spong said, and is intended to elucidate pregnancy risks in symptomatic vs. asymptomatic women. The study will also help indicate whether nutritional, socioeconomic status, and other cofactors such as Dengue infection are implicated. Once born, all children in the study will be observed for a year. “Even if they have no abnormalities, after birth there could be developmental delays, or more subtle consequences later on in the child’s life,” Dr. Meaney-Delman said.
Meanwhile, researchers are attempting to map how varying levels of viremia affect transmission. Zika virus has been found in semen after 90 days in at least two studies, “and we don’t know if Zika can be transmitted through other bodily fluids,” Dr. Spong said.
Surveillance data from the CDC’s Zika Pregnancy Registry has shown viremia in symptomatic women can last up to 46 days after onset of symptoms. In at least one asymptomatic pregnant woman, viremia was detected 53 days after exposure. Another study found prolonged viremia – 10 weeks – in a patient who had Zika infection in her first trimester; imaging showed the fetus was developing normally until week 20, when signs of severe brain abnormalities were detected.
The emerging picture of Zika’s potential for prolonged viremia has prompted the CDC to recommend clinicians use reverse transcription–polymerase chain reaction (RT-PCR) testing rather than serologic testing, as it is more sensitive and helps rule out other flavivirus infections, which require different management, Dr. Meaney-Delman said.
Potential mechanisms of action
“It’s clear that the virus does directly infect human cortical neural progenitor cells with very high efficiency, and in doing so, stunts their growth, dysregulates transcription, and causes cell death,” Dr. Spong said.
Researchers have also found that Zika replicates in subgroups of trophoblasts and endothelial cells, and in primary human placental macrophages, resulting in vascular damage and growth restriction. Other research suggests the virus spreads from basal and parietal decidua to chorionic villi and amniochorionic membranes, leading to the theory that uterine-placental suppression of the viral entry cofactor TIM1 could stop transmission to the fetus.
Prevention and management
CDC officials expect the current outbreak to mimic past flavivirus outbreaks which were contained locally in portions of the South and U.S. territories, Dr. Meaney-Delman said. Still, she emphasized that clinicians should screen patients, regardless of location. “Each pregnant women should be assessed for [vector] exposure, travel, and sexual exposure and asked about symptoms consistent with Zika virus,” Dr. Meaney-Delman said.
She also emphasized the importance of patients consistently using insect repellent and using condoms during pregnancy, as Zika has been detected in semen for as long as 6 months. “It’s been very hard to invoke this behavioral change in women, but it’s very effective.”
The CDC continues to update guidance, including how to evaluate newborns for Zika-related defects.
As for what resources might be needed in future to help affected families, in an interview Dr. Meaney-Delman said that depends on information still unknown. “Zika is a public health concern that we should be factoring in long term, but what we do about it will depend upon the outcomes,” she said. “If there are children that are born normal but who have lab evidence of Zika, then we will probably not do much. I don’t think we have a projection yet.”
On Twitter @whitneymcknight
ANNAPOLIS, MD. – The scramble to learn exactly how and when after infection the Zika virus affects the developing fetus has put pregnant women at the center of an unprecedented infectious disease emergency response.
“It’s the most complicated infectious disease response we’ve ever done,” Dana Meaney-Delman, MD, of the Centers for Disease Control and Prevention, told an audience at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology. “It’s also the first time an emergency response team has included an ob.gyn.”
Although research into Zika virus is happening at breakneck speed, every finding seems to lead to still more questions. “It’s hard to keep up,” said Dr. Meaney-Delman, who is a Clinical Deputy on the Pregnancy and Birth Defects Task Force, part of the CDC’s Zika virus response.
What is known
What is known is that Zika virus is primarily vector-borne, either manifesting as a mild illness or remaining subclinical. The virus is also communicable through male-to-female sex, female-to-female sex, blood donation, and organ transplantation. Once infected, one is immune; if symptomatic, the presentation clears within a couple of weeks. If a woman is infected during pregnancy, it can be transmitted to the developing fetus, including at the time of birth, according to Dr. Meaney-Delman.
“We know transmission can occur in any trimester. We’ve seen it in the placenta, in amniotic fluid, in the brain, as well as in the brains of infants who have died,” she said.
Whether the virus poses a risk to the fetus around the time of conception is not clear, but Dr. Meaney-Delman said that since other infections such as rubella and cytomegalovirus do pose a risk, the CDC is issuing Zika guidance accordingly.
Despite an initial theory that pregnant women were more susceptible to Zika infection, there is no evidence to date confirming this, but “the combination of mosquitoes and sexual transmission really puts a woman of reproductive age at risk,” said Catherine Y. Spong, MD, who also spoke during the meeting. Dr. Spong is acting director of the National Institute of Child Health and Human Development, part of the National Institutes of Health.
Based on data derived from other flaviviruses, the “good news” is that infected nonpregnant women who later want to conceive do not have a higher risk of bearing a child with Zika-related complications, according to Dr. Meaney-Delman.
Abnormalities seen and unseen
During the initial stages of the Zika outbreak in Brazil, the spiking rate of babies born with microcephaly attracted the most attention; yet it is now apparent that children were also born with a growing list of other Zika-associated pregnancy outcomes that likely were missed at the time, according to Dr. Spong.
“That’s not to say that a child that doesn’t have microcephaly does or doesn’t have some of these other complications. We don’t know; they weren’t studied because they didn’t have the microcephaly,” Dr Spong said. “To get the data right, you need to follow all the children.”
Brain abnormalities such as ventriculomegaly and intracranial calcifications, as well as a range of growth abnormalities, miscarriage, and stillbirth are increasingly associated with infants born to infected women. Data is also beginning to link Zika virus to limb abnormalities, hypertonia, hearing loss, damage to the eyes and central nervous system, and seizures.
The World Health Organization has also noted the involvement of the cardiac, genitourinary, and digestive systems in babies born to infected mothers in Panama and Colombia. “The caveat [to these data], is that all these women were symptomatic,” Dr. Spong said, noting that in Brazil, where the outbreak was first documented, 80% of the infected pregnant women were asymptomatic during the pregnancy.
“Just because the mother has no symptoms, she’s fine? That doesn’t make any sense to me,” Dr. Spong said. “We know that infections in pregnancy can result in long-term outcomes in kids that you don’t have the ability to diagnose at birth. We need to be cognizant of this and we need to study it.”
Although initial theories were that viremia in symptomatic women was likely higher, thus imparting a higher risk of infection in their fetus, Dr. Meaney-Delman said the number of asymptomatic women whose fetuses are affected has debunked this line of thinking.
Risk of infection during pregnancy
As to what the actual risk of Zika virus infection is during pregnancy, “honestly we don’t know,” said Dr. Spong. “There are modeling estimates that [it’s] between 1% and 13% in a first trimester infection, but we don’t have the hard and fast data.”
The Zika in Infants and Pregnancy (ZIP) study, recently launched by the NIH, will provide a prospective look at birth outcomes in 10,000 women aged 15 years and older who will be followed throughout their pregnancies to determine if they become infected with Zika virus, and if so, how infection impacts birth outcomes.
The international, multi-site study will help clarify the timing of risk, Dr. Spong said, and is intended to elucidate pregnancy risks in symptomatic vs. asymptomatic women. The study will also help indicate whether nutritional, socioeconomic status, and other cofactors such as Dengue infection are implicated. Once born, all children in the study will be observed for a year. “Even if they have no abnormalities, after birth there could be developmental delays, or more subtle consequences later on in the child’s life,” Dr. Meaney-Delman said.
Meanwhile, researchers are attempting to map how varying levels of viremia affect transmission. Zika virus has been found in semen after 90 days in at least two studies, “and we don’t know if Zika can be transmitted through other bodily fluids,” Dr. Spong said.
Surveillance data from the CDC’s Zika Pregnancy Registry has shown viremia in symptomatic women can last up to 46 days after onset of symptoms. In at least one asymptomatic pregnant woman, viremia was detected 53 days after exposure. Another study found prolonged viremia – 10 weeks – in a patient who had Zika infection in her first trimester; imaging showed the fetus was developing normally until week 20, when signs of severe brain abnormalities were detected.
The emerging picture of Zika’s potential for prolonged viremia has prompted the CDC to recommend clinicians use reverse transcription–polymerase chain reaction (RT-PCR) testing rather than serologic testing, as it is more sensitive and helps rule out other flavivirus infections, which require different management, Dr. Meaney-Delman said.
Potential mechanisms of action
“It’s clear that the virus does directly infect human cortical neural progenitor cells with very high efficiency, and in doing so, stunts their growth, dysregulates transcription, and causes cell death,” Dr. Spong said.
Researchers have also found that Zika replicates in subgroups of trophoblasts and endothelial cells, and in primary human placental macrophages, resulting in vascular damage and growth restriction. Other research suggests the virus spreads from basal and parietal decidua to chorionic villi and amniochorionic membranes, leading to the theory that uterine-placental suppression of the viral entry cofactor TIM1 could stop transmission to the fetus.
Prevention and management
CDC officials expect the current outbreak to mimic past flavivirus outbreaks which were contained locally in portions of the South and U.S. territories, Dr. Meaney-Delman said. Still, she emphasized that clinicians should screen patients, regardless of location. “Each pregnant women should be assessed for [vector] exposure, travel, and sexual exposure and asked about symptoms consistent with Zika virus,” Dr. Meaney-Delman said.
She also emphasized the importance of patients consistently using insect repellent and using condoms during pregnancy, as Zika has been detected in semen for as long as 6 months. “It’s been very hard to invoke this behavioral change in women, but it’s very effective.”
The CDC continues to update guidance, including how to evaluate newborns for Zika-related defects.
As for what resources might be needed in future to help affected families, in an interview Dr. Meaney-Delman said that depends on information still unknown. “Zika is a public health concern that we should be factoring in long term, but what we do about it will depend upon the outcomes,” she said. “If there are children that are born normal but who have lab evidence of Zika, then we will probably not do much. I don’t think we have a projection yet.”
On Twitter @whitneymcknight
AT IDSOG
Local Zika virus transmission identified in second area of Miami
The Centers for Disease Control and Prevention has confirmed that a new pocket of local Zika virus transmission has emerged in Miami Beach, adding yet another area in southern Florida for travelers to avoid.
“We now recommend [that] pregnant women should avoid travel to the designated area of Miami Beach, in addition to the designated area of Wynwood,” CDC Director Tom Frieden, MD, MPH, said during a conference call.
The announcement of a second Miami neighborhood experiencing ongoing local transmission came within 24 hours of the Miami Beach area being identified as a potential hazard, according to Dr. Frieden. Public health officials notified the public in late July about Zika virus transmission in the Wynwood neighborhood; in addition, there have been at least four other cases of independent mosquito-borne transmission of the Zika virus, but the CDC noted that these are not indicative of the disease spreading or becoming locally transmitted to a significant extent.
For those living in or near the affected areas, Dr. Frieden urged that they “do everything they can to prevent mosquito bites,” including wearing clothing that covers as much of the body as possible and using bug repellent, among other things. Those who traveled to the Miami area on or after July 14 of this year should use protection while having sex with their partners to prevent transmitting the virus that way. Women should wait until at least 8 weeks after onset of Zika virus symptoms before attempting to get pregnant.
“More broadly and not just with respect to Florida, all pregnant women anywhere in the U.S. should be evaluated for possible Zika virus exposure during each prenatal care visit,” said Dr. Frieden. “These evaluations should include an assessment of the symptoms of Zika virus disease such as fever, rash, arthralgia, and conjunctivitis, their travel history, and their potential partners’ exposure to Zika virus.”
Dr. Frieden said that the CDC will continue monitoring the situation on a daily basis and make any further announcements, along with changes to current guidelines and recommendations, as necessary.
The Centers for Disease Control and Prevention has confirmed that a new pocket of local Zika virus transmission has emerged in Miami Beach, adding yet another area in southern Florida for travelers to avoid.
“We now recommend [that] pregnant women should avoid travel to the designated area of Miami Beach, in addition to the designated area of Wynwood,” CDC Director Tom Frieden, MD, MPH, said during a conference call.
The announcement of a second Miami neighborhood experiencing ongoing local transmission came within 24 hours of the Miami Beach area being identified as a potential hazard, according to Dr. Frieden. Public health officials notified the public in late July about Zika virus transmission in the Wynwood neighborhood; in addition, there have been at least four other cases of independent mosquito-borne transmission of the Zika virus, but the CDC noted that these are not indicative of the disease spreading or becoming locally transmitted to a significant extent.
For those living in or near the affected areas, Dr. Frieden urged that they “do everything they can to prevent mosquito bites,” including wearing clothing that covers as much of the body as possible and using bug repellent, among other things. Those who traveled to the Miami area on or after July 14 of this year should use protection while having sex with their partners to prevent transmitting the virus that way. Women should wait until at least 8 weeks after onset of Zika virus symptoms before attempting to get pregnant.
“More broadly and not just with respect to Florida, all pregnant women anywhere in the U.S. should be evaluated for possible Zika virus exposure during each prenatal care visit,” said Dr. Frieden. “These evaluations should include an assessment of the symptoms of Zika virus disease such as fever, rash, arthralgia, and conjunctivitis, their travel history, and their potential partners’ exposure to Zika virus.”
Dr. Frieden said that the CDC will continue monitoring the situation on a daily basis and make any further announcements, along with changes to current guidelines and recommendations, as necessary.
The Centers for Disease Control and Prevention has confirmed that a new pocket of local Zika virus transmission has emerged in Miami Beach, adding yet another area in southern Florida for travelers to avoid.
“We now recommend [that] pregnant women should avoid travel to the designated area of Miami Beach, in addition to the designated area of Wynwood,” CDC Director Tom Frieden, MD, MPH, said during a conference call.
The announcement of a second Miami neighborhood experiencing ongoing local transmission came within 24 hours of the Miami Beach area being identified as a potential hazard, according to Dr. Frieden. Public health officials notified the public in late July about Zika virus transmission in the Wynwood neighborhood; in addition, there have been at least four other cases of independent mosquito-borne transmission of the Zika virus, but the CDC noted that these are not indicative of the disease spreading or becoming locally transmitted to a significant extent.
For those living in or near the affected areas, Dr. Frieden urged that they “do everything they can to prevent mosquito bites,” including wearing clothing that covers as much of the body as possible and using bug repellent, among other things. Those who traveled to the Miami area on or after July 14 of this year should use protection while having sex with their partners to prevent transmitting the virus that way. Women should wait until at least 8 weeks after onset of Zika virus symptoms before attempting to get pregnant.
“More broadly and not just with respect to Florida, all pregnant women anywhere in the U.S. should be evaluated for possible Zika virus exposure during each prenatal care visit,” said Dr. Frieden. “These evaluations should include an assessment of the symptoms of Zika virus disease such as fever, rash, arthralgia, and conjunctivitis, their travel history, and their potential partners’ exposure to Zika virus.”
Dr. Frieden said that the CDC will continue monitoring the situation on a daily basis and make any further announcements, along with changes to current guidelines and recommendations, as necessary.
CDC updates diagnostic guidelines for congenital Zika virus infection
All infants who either exhibit abnormal clinical or neuroimaging findings consistent with possible Zika infection, or who exhibit normal phenotypes but are born to mothers who are positive for Zika virus infection during pregnancy, should undergo laboratory testing for the virus, according to updated diagnostic guidance from the CDC.
All infants should undergo a comprehensive physical exam at birth, as well as a neurologic examination, postnatal head ultrasound, and standard hearing tests to determine any phenotypic signs of congenital Zika infections (MMWR. ePub: 2016 Aug 19. doi: 10.15585/mmwr.mm6533e2).
Laboratory samples should be collected within 2 days of birth. Molecular testing should be done via a real-time reverse transcription–polymerase chain reaction (rRT-PCR), while serologic testing should be carried out via IgM. If the former test is positive, then the infant is Zika positive; however, if the rRT-PCR is negative but the IgM is positive, then the conclusion can only be a “probable” congenital Zika infection.
For infants with laboratory-confirmed or probable congenital Zika infection, the CDC recommends outpatient management and follow-up. For those who are found negative for Zika despite having other symptoms consistent with infection, the CDC advises continued evaluation to determine the cause of any congenital anomalies.
If an infant has no overt symptoms of Zika virus but is found to have laboratory-confirmed or probable Zika, they should be given routine newborn care along with auditory brainstem response (ABR) testing and an opthalmology examination within 1 month of birth. Infants with no overt signs of Zika and a lab-confirmed negative result can resume standard newborn care with no additional monitoring.
Outpatient care should begin with clear establishment of a medical home, followed by monitoring the child’s growth and developmental screenings at every well child visit, according to the CDC. Vision screening should be repeated at all well child visits; ABR should be repeated 4-6 months after initial testing.
“Use a standardized, validated developmental screening tool at 9 months as currently recommended, or earlier for any parental or provider concerns,” according to lead author Kate Russell, MD, of the CDC’s Epidemic Intelligence Service, and her coauthors.
Cranial ultrasound should be performed on all infants, regardless of how normal any prenatal cranial ultrasounds were. Previously, the CDC advised that if a third trimester prenatal cranial ultrasound showed no abnormalities, a postnatal cranial ultrasound was not needed.
The CDC continues to advise that a multidisciplinary approach be taken to evaluation, diagnosis, and potential treatment of infants with congenital Zika virus infection.
“Because the types of services needed to care for infants with congenital Zika syndrome are complex, CDC recommends coordinated care through a multidisciplinary team and established medical home,” according to the guidance. “As a critical component of patient care and early identification of any delays, families should be empowered to be active participants in their child’s monitoring and care.”
All infants who either exhibit abnormal clinical or neuroimaging findings consistent with possible Zika infection, or who exhibit normal phenotypes but are born to mothers who are positive for Zika virus infection during pregnancy, should undergo laboratory testing for the virus, according to updated diagnostic guidance from the CDC.
All infants should undergo a comprehensive physical exam at birth, as well as a neurologic examination, postnatal head ultrasound, and standard hearing tests to determine any phenotypic signs of congenital Zika infections (MMWR. ePub: 2016 Aug 19. doi: 10.15585/mmwr.mm6533e2).
Laboratory samples should be collected within 2 days of birth. Molecular testing should be done via a real-time reverse transcription–polymerase chain reaction (rRT-PCR), while serologic testing should be carried out via IgM. If the former test is positive, then the infant is Zika positive; however, if the rRT-PCR is negative but the IgM is positive, then the conclusion can only be a “probable” congenital Zika infection.
For infants with laboratory-confirmed or probable congenital Zika infection, the CDC recommends outpatient management and follow-up. For those who are found negative for Zika despite having other symptoms consistent with infection, the CDC advises continued evaluation to determine the cause of any congenital anomalies.
If an infant has no overt symptoms of Zika virus but is found to have laboratory-confirmed or probable Zika, they should be given routine newborn care along with auditory brainstem response (ABR) testing and an opthalmology examination within 1 month of birth. Infants with no overt signs of Zika and a lab-confirmed negative result can resume standard newborn care with no additional monitoring.
Outpatient care should begin with clear establishment of a medical home, followed by monitoring the child’s growth and developmental screenings at every well child visit, according to the CDC. Vision screening should be repeated at all well child visits; ABR should be repeated 4-6 months after initial testing.
“Use a standardized, validated developmental screening tool at 9 months as currently recommended, or earlier for any parental or provider concerns,” according to lead author Kate Russell, MD, of the CDC’s Epidemic Intelligence Service, and her coauthors.
Cranial ultrasound should be performed on all infants, regardless of how normal any prenatal cranial ultrasounds were. Previously, the CDC advised that if a third trimester prenatal cranial ultrasound showed no abnormalities, a postnatal cranial ultrasound was not needed.
The CDC continues to advise that a multidisciplinary approach be taken to evaluation, diagnosis, and potential treatment of infants with congenital Zika virus infection.
“Because the types of services needed to care for infants with congenital Zika syndrome are complex, CDC recommends coordinated care through a multidisciplinary team and established medical home,” according to the guidance. “As a critical component of patient care and early identification of any delays, families should be empowered to be active participants in their child’s monitoring and care.”
All infants who either exhibit abnormal clinical or neuroimaging findings consistent with possible Zika infection, or who exhibit normal phenotypes but are born to mothers who are positive for Zika virus infection during pregnancy, should undergo laboratory testing for the virus, according to updated diagnostic guidance from the CDC.
All infants should undergo a comprehensive physical exam at birth, as well as a neurologic examination, postnatal head ultrasound, and standard hearing tests to determine any phenotypic signs of congenital Zika infections (MMWR. ePub: 2016 Aug 19. doi: 10.15585/mmwr.mm6533e2).
Laboratory samples should be collected within 2 days of birth. Molecular testing should be done via a real-time reverse transcription–polymerase chain reaction (rRT-PCR), while serologic testing should be carried out via IgM. If the former test is positive, then the infant is Zika positive; however, if the rRT-PCR is negative but the IgM is positive, then the conclusion can only be a “probable” congenital Zika infection.
For infants with laboratory-confirmed or probable congenital Zika infection, the CDC recommends outpatient management and follow-up. For those who are found negative for Zika despite having other symptoms consistent with infection, the CDC advises continued evaluation to determine the cause of any congenital anomalies.
If an infant has no overt symptoms of Zika virus but is found to have laboratory-confirmed or probable Zika, they should be given routine newborn care along with auditory brainstem response (ABR) testing and an opthalmology examination within 1 month of birth. Infants with no overt signs of Zika and a lab-confirmed negative result can resume standard newborn care with no additional monitoring.
Outpatient care should begin with clear establishment of a medical home, followed by monitoring the child’s growth and developmental screenings at every well child visit, according to the CDC. Vision screening should be repeated at all well child visits; ABR should be repeated 4-6 months after initial testing.
“Use a standardized, validated developmental screening tool at 9 months as currently recommended, or earlier for any parental or provider concerns,” according to lead author Kate Russell, MD, of the CDC’s Epidemic Intelligence Service, and her coauthors.
Cranial ultrasound should be performed on all infants, regardless of how normal any prenatal cranial ultrasounds were. Previously, the CDC advised that if a third trimester prenatal cranial ultrasound showed no abnormalities, a postnatal cranial ultrasound was not needed.
The CDC continues to advise that a multidisciplinary approach be taken to evaluation, diagnosis, and potential treatment of infants with congenital Zika virus infection.
“Because the types of services needed to care for infants with congenital Zika syndrome are complex, CDC recommends coordinated care through a multidisciplinary team and established medical home,” according to the guidance. “As a critical component of patient care and early identification of any delays, families should be empowered to be active participants in their child’s monitoring and care.”
FROM MMWR
Zika in pregnant women: CDC reports 189 new cases
The number of pregnant women with laboratory evidence of Zika virus infection jumped by 189 during the week ending Aug. 11, with most of the increase coming in the U.S. territories, according to the Centers for Disease Control and Prevention.
The territories reported 170 new cases of Zika infection for that week, while the 50 states and the District of Columbia had 19 new cases in pregnant women. There have been 1,220 cases in pregnant women in the United States so far: 691 in the territories and 529 in the states and D.C. Among all Americans, there have been 10,295 cases of Zika: 8,035 in the territories and 2,260 in the states/D.C., the CDC reported.
The number of Zika-related poor outcomes did not change during the week ending Aug. 11. The number of liveborn infants born with birth defects stayed at 16 in the states/D.C. and 1 in the territories, and the number of pregnancy losses with birth defects held at 5 in the states/D.C. and 1 in the territories, the CDC said. State- or territorial-level data are not being reported to protect the privacy of affected women and children.
The figures for states, territories, and D.C. reflect reporting to the U.S. Zika Pregnancy Registry; data for Puerto Rico are reported to the U.S. Zika Active Pregnancy Surveillance System.
Zika virus–related birth defects recorded by the CDC could include microcephaly, calcium deposits in the brain indicating possible brain damage, excess fluid in the brain cavities and surrounding the brain, absent or poorly formed brain structures, abnormal eye development, or other problems resulting from brain damage that affect nerves, muscles, and bones. The pregnancy losses encompass any miscarriage, stillbirth, and termination with evidence of birth defects.
The number of pregnant women with laboratory evidence of Zika virus infection jumped by 189 during the week ending Aug. 11, with most of the increase coming in the U.S. territories, according to the Centers for Disease Control and Prevention.
The territories reported 170 new cases of Zika infection for that week, while the 50 states and the District of Columbia had 19 new cases in pregnant women. There have been 1,220 cases in pregnant women in the United States so far: 691 in the territories and 529 in the states and D.C. Among all Americans, there have been 10,295 cases of Zika: 8,035 in the territories and 2,260 in the states/D.C., the CDC reported.
The number of Zika-related poor outcomes did not change during the week ending Aug. 11. The number of liveborn infants born with birth defects stayed at 16 in the states/D.C. and 1 in the territories, and the number of pregnancy losses with birth defects held at 5 in the states/D.C. and 1 in the territories, the CDC said. State- or territorial-level data are not being reported to protect the privacy of affected women and children.
The figures for states, territories, and D.C. reflect reporting to the U.S. Zika Pregnancy Registry; data for Puerto Rico are reported to the U.S. Zika Active Pregnancy Surveillance System.
Zika virus–related birth defects recorded by the CDC could include microcephaly, calcium deposits in the brain indicating possible brain damage, excess fluid in the brain cavities and surrounding the brain, absent or poorly formed brain structures, abnormal eye development, or other problems resulting from brain damage that affect nerves, muscles, and bones. The pregnancy losses encompass any miscarriage, stillbirth, and termination with evidence of birth defects.
The number of pregnant women with laboratory evidence of Zika virus infection jumped by 189 during the week ending Aug. 11, with most of the increase coming in the U.S. territories, according to the Centers for Disease Control and Prevention.
The territories reported 170 new cases of Zika infection for that week, while the 50 states and the District of Columbia had 19 new cases in pregnant women. There have been 1,220 cases in pregnant women in the United States so far: 691 in the territories and 529 in the states and D.C. Among all Americans, there have been 10,295 cases of Zika: 8,035 in the territories and 2,260 in the states/D.C., the CDC reported.
The number of Zika-related poor outcomes did not change during the week ending Aug. 11. The number of liveborn infants born with birth defects stayed at 16 in the states/D.C. and 1 in the territories, and the number of pregnancy losses with birth defects held at 5 in the states/D.C. and 1 in the territories, the CDC said. State- or territorial-level data are not being reported to protect the privacy of affected women and children.
The figures for states, territories, and D.C. reflect reporting to the U.S. Zika Pregnancy Registry; data for Puerto Rico are reported to the U.S. Zika Active Pregnancy Surveillance System.
Zika virus–related birth defects recorded by the CDC could include microcephaly, calcium deposits in the brain indicating possible brain damage, excess fluid in the brain cavities and surrounding the brain, absent or poorly formed brain structures, abnormal eye development, or other problems resulting from brain damage that affect nerves, muscles, and bones. The pregnancy losses encompass any miscarriage, stillbirth, and termination with evidence of birth defects.
Candida auris in Venezuela outbreak is triazole-resistant, opportunistic
BOSTON – An investigation into 18 nosocomial Candida auris infections at a tertiary care center in Venezuela showed that isolates of the emerging fungal pathogen obtained during the outbreak were resistant to fluconazole and voriconazole. However, the isolates were intermediately susceptible to amphotericin B and susceptible to 5-fluorocitosine, and demonstrated high susceptibility to the candin antifungal anidulafungin.
Dr. Belinda Calvo, an infectious disease specialist at the University of Maracaibo, Venezuela, and her collaborators reported these findings, related to a 2012-2013 C. auris outbreak at the hospital. Dr. Calvo and her coinvestigators noted that other invasive C. auris outbreaks have been reported in India, Korea, and South Africa, but that “the real prevalence of this organism may be underestimated,” since common rapid microbial identification techniques may misidentify the species.
In a poster session at the annual meeting of the American Society of Microbiology, Dr. Calvo and her collaborators reported that the 18 patients involved in the Venezuelan outbreak were critically ill, of whom 11 were pediatric, and all had central venous catheter placement. All but two of the pediatric patients were neonates, and all had serious underlying morbidities; several had significant congenital anomalies. The median patient age was 26 days (range, 2 days to 72 years), reflecting the high number of neonates affected. One of the adult patients had esophageal carcinoma. Overall, 10/18 patients (56%) had undergone surgical procedures, and all had received antibiotics.
As has been reported in other C. auris outbreaks, isolates from blood cultures of affected individuals were initially reported as C. haemulonii by the Vitek 2 C automated microbial identification system. Molecular identification was completed by sequencing the internal transcribed spacer (ITS) of the rDNA gene, with analysis aided by the National Institutes of Health’s GenBank and the Netherland’s CBS Fungal Diversity Centre , in order to confirm the identity of the fungal isolates as C. auris. Dr. Calvo and her associates were able to generate a dendrogram of the 18 isolates, showing high clonality, a trait shared with other nosocomial C. auris outbreaks.
Susceptibility testing of the C. auris cultured from blood samples of the affected patients showed that fluconazole had a minimum inhibitory concentration to inhibit the growth of 50% of the organisms (MIC50) of greater than 64 mcg/mL. For fluconazole, the MIC90, range, and geometric mean were all also above 64 mcg/mL, indicating a high level of resistance. For voriconazole, the MICs, range, and mean were all 4 mcg/mL. For amphotericin B, the MIC50 was 1 mcg/mL, the MIC90 was 2 mcg/mL, the range was 1-2, and the geometric mean was 1.414 mcg/mL.
The high number of pediatric patients affected, as well as early pathogen identification with speedy and appropriate antifungal therapy and prompt removal of central venous catheters, likely contributed to the relatively low 30-day crude mortality rate of 28%, said Dr. Calvo and her coauthors.
“C. auris should be considered an emergent multiresistant species,” wrote Dr. Calbo and her collaborators, noting that the opportunistic pathogen has a “high potential for nosocomial horizontal transmission.”
In June 2016, the Centers for Disease Control issued a clinical alert to U.S. healthcare facilities regarding the global emergence of invasive infections caused by C. auris.
The study authors reported no external sources of funding and no conflicts of interest.
On Twitter @karioakes
BOSTON – An investigation into 18 nosocomial Candida auris infections at a tertiary care center in Venezuela showed that isolates of the emerging fungal pathogen obtained during the outbreak were resistant to fluconazole and voriconazole. However, the isolates were intermediately susceptible to amphotericin B and susceptible to 5-fluorocitosine, and demonstrated high susceptibility to the candin antifungal anidulafungin.
Dr. Belinda Calvo, an infectious disease specialist at the University of Maracaibo, Venezuela, and her collaborators reported these findings, related to a 2012-2013 C. auris outbreak at the hospital. Dr. Calvo and her coinvestigators noted that other invasive C. auris outbreaks have been reported in India, Korea, and South Africa, but that “the real prevalence of this organism may be underestimated,” since common rapid microbial identification techniques may misidentify the species.
In a poster session at the annual meeting of the American Society of Microbiology, Dr. Calvo and her collaborators reported that the 18 patients involved in the Venezuelan outbreak were critically ill, of whom 11 were pediatric, and all had central venous catheter placement. All but two of the pediatric patients were neonates, and all had serious underlying morbidities; several had significant congenital anomalies. The median patient age was 26 days (range, 2 days to 72 years), reflecting the high number of neonates affected. One of the adult patients had esophageal carcinoma. Overall, 10/18 patients (56%) had undergone surgical procedures, and all had received antibiotics.
As has been reported in other C. auris outbreaks, isolates from blood cultures of affected individuals were initially reported as C. haemulonii by the Vitek 2 C automated microbial identification system. Molecular identification was completed by sequencing the internal transcribed spacer (ITS) of the rDNA gene, with analysis aided by the National Institutes of Health’s GenBank and the Netherland’s CBS Fungal Diversity Centre , in order to confirm the identity of the fungal isolates as C. auris. Dr. Calvo and her associates were able to generate a dendrogram of the 18 isolates, showing high clonality, a trait shared with other nosocomial C. auris outbreaks.
Susceptibility testing of the C. auris cultured from blood samples of the affected patients showed that fluconazole had a minimum inhibitory concentration to inhibit the growth of 50% of the organisms (MIC50) of greater than 64 mcg/mL. For fluconazole, the MIC90, range, and geometric mean were all also above 64 mcg/mL, indicating a high level of resistance. For voriconazole, the MICs, range, and mean were all 4 mcg/mL. For amphotericin B, the MIC50 was 1 mcg/mL, the MIC90 was 2 mcg/mL, the range was 1-2, and the geometric mean was 1.414 mcg/mL.
The high number of pediatric patients affected, as well as early pathogen identification with speedy and appropriate antifungal therapy and prompt removal of central venous catheters, likely contributed to the relatively low 30-day crude mortality rate of 28%, said Dr. Calvo and her coauthors.
“C. auris should be considered an emergent multiresistant species,” wrote Dr. Calbo and her collaborators, noting that the opportunistic pathogen has a “high potential for nosocomial horizontal transmission.”
In June 2016, the Centers for Disease Control issued a clinical alert to U.S. healthcare facilities regarding the global emergence of invasive infections caused by C. auris.
The study authors reported no external sources of funding and no conflicts of interest.
On Twitter @karioakes
BOSTON – An investigation into 18 nosocomial Candida auris infections at a tertiary care center in Venezuela showed that isolates of the emerging fungal pathogen obtained during the outbreak were resistant to fluconazole and voriconazole. However, the isolates were intermediately susceptible to amphotericin B and susceptible to 5-fluorocitosine, and demonstrated high susceptibility to the candin antifungal anidulafungin.
Dr. Belinda Calvo, an infectious disease specialist at the University of Maracaibo, Venezuela, and her collaborators reported these findings, related to a 2012-2013 C. auris outbreak at the hospital. Dr. Calvo and her coinvestigators noted that other invasive C. auris outbreaks have been reported in India, Korea, and South Africa, but that “the real prevalence of this organism may be underestimated,” since common rapid microbial identification techniques may misidentify the species.
In a poster session at the annual meeting of the American Society of Microbiology, Dr. Calvo and her collaborators reported that the 18 patients involved in the Venezuelan outbreak were critically ill, of whom 11 were pediatric, and all had central venous catheter placement. All but two of the pediatric patients were neonates, and all had serious underlying morbidities; several had significant congenital anomalies. The median patient age was 26 days (range, 2 days to 72 years), reflecting the high number of neonates affected. One of the adult patients had esophageal carcinoma. Overall, 10/18 patients (56%) had undergone surgical procedures, and all had received antibiotics.
As has been reported in other C. auris outbreaks, isolates from blood cultures of affected individuals were initially reported as C. haemulonii by the Vitek 2 C automated microbial identification system. Molecular identification was completed by sequencing the internal transcribed spacer (ITS) of the rDNA gene, with analysis aided by the National Institutes of Health’s GenBank and the Netherland’s CBS Fungal Diversity Centre , in order to confirm the identity of the fungal isolates as C. auris. Dr. Calvo and her associates were able to generate a dendrogram of the 18 isolates, showing high clonality, a trait shared with other nosocomial C. auris outbreaks.
Susceptibility testing of the C. auris cultured from blood samples of the affected patients showed that fluconazole had a minimum inhibitory concentration to inhibit the growth of 50% of the organisms (MIC50) of greater than 64 mcg/mL. For fluconazole, the MIC90, range, and geometric mean were all also above 64 mcg/mL, indicating a high level of resistance. For voriconazole, the MICs, range, and mean were all 4 mcg/mL. For amphotericin B, the MIC50 was 1 mcg/mL, the MIC90 was 2 mcg/mL, the range was 1-2, and the geometric mean was 1.414 mcg/mL.
The high number of pediatric patients affected, as well as early pathogen identification with speedy and appropriate antifungal therapy and prompt removal of central venous catheters, likely contributed to the relatively low 30-day crude mortality rate of 28%, said Dr. Calvo and her coauthors.
“C. auris should be considered an emergent multiresistant species,” wrote Dr. Calbo and her collaborators, noting that the opportunistic pathogen has a “high potential for nosocomial horizontal transmission.”
In June 2016, the Centers for Disease Control issued a clinical alert to U.S. healthcare facilities regarding the global emergence of invasive infections caused by C. auris.
The study authors reported no external sources of funding and no conflicts of interest.
On Twitter @karioakes
AT ASM 2016
Key clinical point: Isolates in an outbreak of nosocomially acquired Candida auris were fluconazole-resistant.
Major finding: All C. auris isolates were resistant to fluconazole, with geometric mean minimum inhibitory concentrations greater than 64 mcg/mL.
Data source: Retrospective, single-center study of 18 pediatric and adult patients with C. auris infections at a tertiary care center in Venezuela.
Disclosures: The study investigators reported no outside sources of funding and no disclosures.
CDC reports two new cases of Zika-related birth defects
Two live-born infants with Zika virus–related birth defects were reported the week ending Aug. 4, 2016, bringing the U.S. total to 17, the Centers for Disease Control and Prevention reported.
One of the two infants was born in the 50 states and the District of Columbia, and the other was the first live-born infant with Zika-related birth defects born in the U.S. territories. State- or territorial-level data are not being reported to protect the privacy of affected women and children, the CDC said.
There were no new pregnancy losses among Zika-infected women in the territories, keeping the total at one for the year, but the CDC seems to have adjusted the number of pregnancy losses for the states and D.C., as the most recent total for the year is now five, after six were reported the previous week.
A total of 59 new cases of Zika infection in pregnant women were reported for the week ending Aug. 4: 31 new cases in the states/D.C. and 28 in the territories. For the year, there have been 510 cases of pregnant women with laboratory evidence of Zika infection in the states/D.C. and 521 in the territories, for a U.S. total of 1,031, the CDC reported.
The figures for states, territories, and D.C. reflect reporting to the U.S. Zika Pregnancy Registry; data for Puerto Rico are reported to the U.S. Zika Active Pregnancy Surveillance System.
Zika virus–related birth defects recorded by the CDC could include microcephaly, calcium deposits in the brain indicating possible brain damage, excess fluid in the brain cavities and surrounding the brain, absent or poorly formed brain structures, abnormal eye development, or other problems resulting from brain damage that affect nerves, muscles, and bones. The pregnancy losses encompass any miscarriage, stillbirth, and termination with evidence of birth defects.
Two live-born infants with Zika virus–related birth defects were reported the week ending Aug. 4, 2016, bringing the U.S. total to 17, the Centers for Disease Control and Prevention reported.
One of the two infants was born in the 50 states and the District of Columbia, and the other was the first live-born infant with Zika-related birth defects born in the U.S. territories. State- or territorial-level data are not being reported to protect the privacy of affected women and children, the CDC said.
There were no new pregnancy losses among Zika-infected women in the territories, keeping the total at one for the year, but the CDC seems to have adjusted the number of pregnancy losses for the states and D.C., as the most recent total for the year is now five, after six were reported the previous week.
A total of 59 new cases of Zika infection in pregnant women were reported for the week ending Aug. 4: 31 new cases in the states/D.C. and 28 in the territories. For the year, there have been 510 cases of pregnant women with laboratory evidence of Zika infection in the states/D.C. and 521 in the territories, for a U.S. total of 1,031, the CDC reported.
The figures for states, territories, and D.C. reflect reporting to the U.S. Zika Pregnancy Registry; data for Puerto Rico are reported to the U.S. Zika Active Pregnancy Surveillance System.
Zika virus–related birth defects recorded by the CDC could include microcephaly, calcium deposits in the brain indicating possible brain damage, excess fluid in the brain cavities and surrounding the brain, absent or poorly formed brain structures, abnormal eye development, or other problems resulting from brain damage that affect nerves, muscles, and bones. The pregnancy losses encompass any miscarriage, stillbirth, and termination with evidence of birth defects.
Two live-born infants with Zika virus–related birth defects were reported the week ending Aug. 4, 2016, bringing the U.S. total to 17, the Centers for Disease Control and Prevention reported.
One of the two infants was born in the 50 states and the District of Columbia, and the other was the first live-born infant with Zika-related birth defects born in the U.S. territories. State- or territorial-level data are not being reported to protect the privacy of affected women and children, the CDC said.
There were no new pregnancy losses among Zika-infected women in the territories, keeping the total at one for the year, but the CDC seems to have adjusted the number of pregnancy losses for the states and D.C., as the most recent total for the year is now five, after six were reported the previous week.
A total of 59 new cases of Zika infection in pregnant women were reported for the week ending Aug. 4: 31 new cases in the states/D.C. and 28 in the territories. For the year, there have been 510 cases of pregnant women with laboratory evidence of Zika infection in the states/D.C. and 521 in the territories, for a U.S. total of 1,031, the CDC reported.
The figures for states, territories, and D.C. reflect reporting to the U.S. Zika Pregnancy Registry; data for Puerto Rico are reported to the U.S. Zika Active Pregnancy Surveillance System.
Zika virus–related birth defects recorded by the CDC could include microcephaly, calcium deposits in the brain indicating possible brain damage, excess fluid in the brain cavities and surrounding the brain, absent or poorly formed brain structures, abnormal eye development, or other problems resulting from brain damage that affect nerves, muscles, and bones. The pregnancy losses encompass any miscarriage, stillbirth, and termination with evidence of birth defects.
West Nile testing underutilized in endemic areas
Testing for West Nile virus (WNV) is underutilized in areas where the disease is endemic, according to Jakapat Vanichanan, MD, and his associates.
In a sample of 751 patients admitted to Houston hospitals for meningitis or encephalitis, 390 patients experienced onset of symptoms during the WNV peak season between June and October, but only 281 of the 751 patients received WNV testing. Of the 281 patients tested for WNV, 32 were diagnosed with acute infection.
Patients tested for WNV were more likely to have acute focal neurologic deficits, be of older age, require an MRI, be prescribed antiviral therapy, have worse clinical outcomes, and experience concomitant testing for mycobacterial, fungal, or other viral infections. Of the 32 patients diagnosed with WNV, 16 were admitted with meningitis and 16 were admitted with encephalitis.
“Although supportive treatment remains the standard of care for patients with WNND [West Nile neuroinvasive diseases], performing appropriate WNV testing may yield several benefits. An accurate diagnosis more precisely defines disease burden and epidemiology, an ongoing surveillance deficiency. Moreover, identifying WNV may lead to early detection of long-term neurologic and neurocognitive sequelae after WNND and thus enable earlier intervention,” the investigators said.
Find the full study in Emerging Infectious Diseases (doi: 10.3201/eid2209.152050).
Testing for West Nile virus (WNV) is underutilized in areas where the disease is endemic, according to Jakapat Vanichanan, MD, and his associates.
In a sample of 751 patients admitted to Houston hospitals for meningitis or encephalitis, 390 patients experienced onset of symptoms during the WNV peak season between June and October, but only 281 of the 751 patients received WNV testing. Of the 281 patients tested for WNV, 32 were diagnosed with acute infection.
Patients tested for WNV were more likely to have acute focal neurologic deficits, be of older age, require an MRI, be prescribed antiviral therapy, have worse clinical outcomes, and experience concomitant testing for mycobacterial, fungal, or other viral infections. Of the 32 patients diagnosed with WNV, 16 were admitted with meningitis and 16 were admitted with encephalitis.
“Although supportive treatment remains the standard of care for patients with WNND [West Nile neuroinvasive diseases], performing appropriate WNV testing may yield several benefits. An accurate diagnosis more precisely defines disease burden and epidemiology, an ongoing surveillance deficiency. Moreover, identifying WNV may lead to early detection of long-term neurologic and neurocognitive sequelae after WNND and thus enable earlier intervention,” the investigators said.
Find the full study in Emerging Infectious Diseases (doi: 10.3201/eid2209.152050).
Testing for West Nile virus (WNV) is underutilized in areas where the disease is endemic, according to Jakapat Vanichanan, MD, and his associates.
In a sample of 751 patients admitted to Houston hospitals for meningitis or encephalitis, 390 patients experienced onset of symptoms during the WNV peak season between June and October, but only 281 of the 751 patients received WNV testing. Of the 281 patients tested for WNV, 32 were diagnosed with acute infection.
Patients tested for WNV were more likely to have acute focal neurologic deficits, be of older age, require an MRI, be prescribed antiviral therapy, have worse clinical outcomes, and experience concomitant testing for mycobacterial, fungal, or other viral infections. Of the 32 patients diagnosed with WNV, 16 were admitted with meningitis and 16 were admitted with encephalitis.
“Although supportive treatment remains the standard of care for patients with WNND [West Nile neuroinvasive diseases], performing appropriate WNV testing may yield several benefits. An accurate diagnosis more precisely defines disease burden and epidemiology, an ongoing surveillance deficiency. Moreover, identifying WNV may lead to early detection of long-term neurologic and neurocognitive sequelae after WNND and thus enable earlier intervention,” the investigators said.
Find the full study in Emerging Infectious Diseases (doi: 10.3201/eid2209.152050).
FROM EMERGING INFECTIOUS DISEASES
Study evaluates Zika syndrome with joint contractures
Congenital Zika syndrome should be added to the differential diagnosis of congenital infections and arthrogryposis (joint contractures), results from a case series study in Brazil suggest.
“Brain impairment in the presence of microcephaly is the main characteristic of a congenital Zika virus syndrome,” researchers led by Vanessa van der Linden, MD, wrote in a study published online Aug. 9 in the BMJ. “However, little is still known about this condition and its clinical spectrum, which also concerns newborns with a normal head circumference. Two studies have described the association between arthrogryposis and microcephaly in newborns presumed to have congenital Zika virus infection [See Morb Mortal Wkly. Rep. 2016;65:59-62 and Ultrasound Obstet Gynecol. 2016;47:6-7].” The authors went on to note that while arthrogryposis might be considered more of a sign than a specific disease, “it might be associated with several disorders. However, there are no reports in the literature about other congenital infections in humans associated with arthrogryposis.”
Dr. van der Linden, a pediatric neurologist with the Association for Assistance of Disabled Children, Recife, Brazil, and her associates retrospectively evaluated the medical records of seven patients with arthrogryposis associated with congenital infection believed to be caused by Zika virus, during the Brazilian microcephaly epidemic (BMJ. 2016;354:i3899). The main outcomes of interest were clinical, radiologic, and electromyographic findings, and likely collaboration between clinical and primary neurological abnormalities.
The researchers reported that brain images of all seven children revealed characteristics of congenital infection and arthrogryposis. Two children (29%) tested positive for IgM antibody for Zika virus in the cerebrospinal fluid, while arthrogryposis was present in the arms and legs of six children (86%) and in the legs of one child (14%). In addition, hip x-rays showed bilateral dislocation in all seven children and subluxation of the knee associated with genu valgus in three (43%). No evidence of abnormalities was seen on high-definition ultrasonography of the joints, but moderate signs of remodeling of the motor units and a reduced recruitment pattern were found on needle electromyography. Results from brain computed tomography conducted in all seven patients and magnetic resonance imaging conducted in five revealed malformations of cortical development, calcifications predominantly in the cortex and subcortical white matter, reduction in brain volume, ventriculomegaly, and hypoplasia of the brainstem and cerebellum. Spinal MRI conducted in four children showed apparent thinning of the cord and reduced ventral roots.
“Further research is needed with a larger number of cases to study the neurological abnormalities behind arthrogryposis, including histopathology of autopsy samples or tissues from stillborn babies,” the researchers concluded. “As we do not know the potential implications of congenital Zika virus infection as it evolves, children must receive orthopedic follow-up, even those with a standard first orthopedic evaluation, because they could develop musculoskeletal deformities secondary to neurological impairment, central or peripheral, or both, as these occur in patients with cerebral palsy and other chronic encephalopathies.”
The researchers reported having no financial disclosures.
Congenital Zika syndrome should be added to the differential diagnosis of congenital infections and arthrogryposis (joint contractures), results from a case series study in Brazil suggest.
“Brain impairment in the presence of microcephaly is the main characteristic of a congenital Zika virus syndrome,” researchers led by Vanessa van der Linden, MD, wrote in a study published online Aug. 9 in the BMJ. “However, little is still known about this condition and its clinical spectrum, which also concerns newborns with a normal head circumference. Two studies have described the association between arthrogryposis and microcephaly in newborns presumed to have congenital Zika virus infection [See Morb Mortal Wkly. Rep. 2016;65:59-62 and Ultrasound Obstet Gynecol. 2016;47:6-7].” The authors went on to note that while arthrogryposis might be considered more of a sign than a specific disease, “it might be associated with several disorders. However, there are no reports in the literature about other congenital infections in humans associated with arthrogryposis.”
Dr. van der Linden, a pediatric neurologist with the Association for Assistance of Disabled Children, Recife, Brazil, and her associates retrospectively evaluated the medical records of seven patients with arthrogryposis associated with congenital infection believed to be caused by Zika virus, during the Brazilian microcephaly epidemic (BMJ. 2016;354:i3899). The main outcomes of interest were clinical, radiologic, and electromyographic findings, and likely collaboration between clinical and primary neurological abnormalities.
The researchers reported that brain images of all seven children revealed characteristics of congenital infection and arthrogryposis. Two children (29%) tested positive for IgM antibody for Zika virus in the cerebrospinal fluid, while arthrogryposis was present in the arms and legs of six children (86%) and in the legs of one child (14%). In addition, hip x-rays showed bilateral dislocation in all seven children and subluxation of the knee associated with genu valgus in three (43%). No evidence of abnormalities was seen on high-definition ultrasonography of the joints, but moderate signs of remodeling of the motor units and a reduced recruitment pattern were found on needle electromyography. Results from brain computed tomography conducted in all seven patients and magnetic resonance imaging conducted in five revealed malformations of cortical development, calcifications predominantly in the cortex and subcortical white matter, reduction in brain volume, ventriculomegaly, and hypoplasia of the brainstem and cerebellum. Spinal MRI conducted in four children showed apparent thinning of the cord and reduced ventral roots.
“Further research is needed with a larger number of cases to study the neurological abnormalities behind arthrogryposis, including histopathology of autopsy samples or tissues from stillborn babies,” the researchers concluded. “As we do not know the potential implications of congenital Zika virus infection as it evolves, children must receive orthopedic follow-up, even those with a standard first orthopedic evaluation, because they could develop musculoskeletal deformities secondary to neurological impairment, central or peripheral, or both, as these occur in patients with cerebral palsy and other chronic encephalopathies.”
The researchers reported having no financial disclosures.
Congenital Zika syndrome should be added to the differential diagnosis of congenital infections and arthrogryposis (joint contractures), results from a case series study in Brazil suggest.
“Brain impairment in the presence of microcephaly is the main characteristic of a congenital Zika virus syndrome,” researchers led by Vanessa van der Linden, MD, wrote in a study published online Aug. 9 in the BMJ. “However, little is still known about this condition and its clinical spectrum, which also concerns newborns with a normal head circumference. Two studies have described the association between arthrogryposis and microcephaly in newborns presumed to have congenital Zika virus infection [See Morb Mortal Wkly. Rep. 2016;65:59-62 and Ultrasound Obstet Gynecol. 2016;47:6-7].” The authors went on to note that while arthrogryposis might be considered more of a sign than a specific disease, “it might be associated with several disorders. However, there are no reports in the literature about other congenital infections in humans associated with arthrogryposis.”
Dr. van der Linden, a pediatric neurologist with the Association for Assistance of Disabled Children, Recife, Brazil, and her associates retrospectively evaluated the medical records of seven patients with arthrogryposis associated with congenital infection believed to be caused by Zika virus, during the Brazilian microcephaly epidemic (BMJ. 2016;354:i3899). The main outcomes of interest were clinical, radiologic, and electromyographic findings, and likely collaboration between clinical and primary neurological abnormalities.
The researchers reported that brain images of all seven children revealed characteristics of congenital infection and arthrogryposis. Two children (29%) tested positive for IgM antibody for Zika virus in the cerebrospinal fluid, while arthrogryposis was present in the arms and legs of six children (86%) and in the legs of one child (14%). In addition, hip x-rays showed bilateral dislocation in all seven children and subluxation of the knee associated with genu valgus in three (43%). No evidence of abnormalities was seen on high-definition ultrasonography of the joints, but moderate signs of remodeling of the motor units and a reduced recruitment pattern were found on needle electromyography. Results from brain computed tomography conducted in all seven patients and magnetic resonance imaging conducted in five revealed malformations of cortical development, calcifications predominantly in the cortex and subcortical white matter, reduction in brain volume, ventriculomegaly, and hypoplasia of the brainstem and cerebellum. Spinal MRI conducted in four children showed apparent thinning of the cord and reduced ventral roots.
“Further research is needed with a larger number of cases to study the neurological abnormalities behind arthrogryposis, including histopathology of autopsy samples or tissues from stillborn babies,” the researchers concluded. “As we do not know the potential implications of congenital Zika virus infection as it evolves, children must receive orthopedic follow-up, even those with a standard first orthopedic evaluation, because they could develop musculoskeletal deformities secondary to neurological impairment, central or peripheral, or both, as these occur in patients with cerebral palsy and other chronic encephalopathies.”
The researchers reported having no financial disclosures.
FROM BMJ
Key clinical point: The differential diagnosis of congenital infections and arthrogryposis should include congenital Zika syndrome.
Major finding: All seven children revealed characteristics of congenital infection and arthrogryposis. Two children (29%) tested positive for IgM antibody for Zika virus in the cerebrospinal fluid, while arthrogryposis was present in the arms and legs of six children (86%) and in the legs of one child (14%).
Data source: A retrospective case series study of seven children with arthrogryposis associated with congenital infection believed to be caused by Zika virus.
Disclosures: The researchers reported having no financial disclosures.
Blood viral RNA may indicate severity of MERS coronavirus clinical course
The presence of blood viral RNA in patients presenting with possible Middle East respiratory syndrome coronavirus (MERS-CoV) may be a very reliable indicator of the severity of the infection’s clinical course, according to a new study published in Emerging Infectious Diseases.
“Our study aimed to evaluate the diagnostic utility of blood specimens for MERS-CoV infection by using large numbers of patients with a single viral origin and to determine the relationship between blood viral detection and clinical characteristics,” wrote the authors, led by So Yeon Kim, MD, of the National Medical Center in Seoul, South Korea.
The investigators recruited 21 MERS-CoV patients within South Korea, all of whom had been previously diagnosed by the Korea Centers for Disease Control and Prevention via respiratory samples and were of “a single viral origin.” All subjects contributed ethylenediaminetetraacetic acid (EDTA)-treated whole blood and serum specimens, from which viral RNA was extracted (Emerg Infect Dis. 2016 Oct 15;22[10]. doi: 10.3201/eid2210.160218).
Viral RNA was detected in 6 of 21 whole blood samples and 6 of 21 serum samples at hospital admission. However, because two patients were viral positive in either specimen subtype of EDTA-treated whole blood or serum, the overall detection rate for the population was 7 of 21 (33%). Being positive for blood viral RNA at admission was found to be associated with a fever of higher than 37.5 °C (99.5 °F) on the date of sample collection (P = .007), being placed on mechanical ventilation at some point during the clinical course (P = .003), extracorporeal membrane oxygenation (P = .025), and death (P = .025).
However, “between the blood viral RNA-positive and -negative groups, we found no differences in age, duration from symptom onset to diagnosis of MERS-CoV infection, or an invasive procedure before the specimens were obtained,” the investigators noted.
The takeaway, the authors underscore, is that although early blood viral RNA presence may not be a useful diagnostic tool, it “might be a good prognostic indicator of severe outcome” due to its high association with worse clinical course.
The research was funded by the National Medical Center Research Institute.
The presence of blood viral RNA in patients presenting with possible Middle East respiratory syndrome coronavirus (MERS-CoV) may be a very reliable indicator of the severity of the infection’s clinical course, according to a new study published in Emerging Infectious Diseases.
“Our study aimed to evaluate the diagnostic utility of blood specimens for MERS-CoV infection by using large numbers of patients with a single viral origin and to determine the relationship between blood viral detection and clinical characteristics,” wrote the authors, led by So Yeon Kim, MD, of the National Medical Center in Seoul, South Korea.
The investigators recruited 21 MERS-CoV patients within South Korea, all of whom had been previously diagnosed by the Korea Centers for Disease Control and Prevention via respiratory samples and were of “a single viral origin.” All subjects contributed ethylenediaminetetraacetic acid (EDTA)-treated whole blood and serum specimens, from which viral RNA was extracted (Emerg Infect Dis. 2016 Oct 15;22[10]. doi: 10.3201/eid2210.160218).
Viral RNA was detected in 6 of 21 whole blood samples and 6 of 21 serum samples at hospital admission. However, because two patients were viral positive in either specimen subtype of EDTA-treated whole blood or serum, the overall detection rate for the population was 7 of 21 (33%). Being positive for blood viral RNA at admission was found to be associated with a fever of higher than 37.5 °C (99.5 °F) on the date of sample collection (P = .007), being placed on mechanical ventilation at some point during the clinical course (P = .003), extracorporeal membrane oxygenation (P = .025), and death (P = .025).
However, “between the blood viral RNA-positive and -negative groups, we found no differences in age, duration from symptom onset to diagnosis of MERS-CoV infection, or an invasive procedure before the specimens were obtained,” the investigators noted.
The takeaway, the authors underscore, is that although early blood viral RNA presence may not be a useful diagnostic tool, it “might be a good prognostic indicator of severe outcome” due to its high association with worse clinical course.
The research was funded by the National Medical Center Research Institute.
The presence of blood viral RNA in patients presenting with possible Middle East respiratory syndrome coronavirus (MERS-CoV) may be a very reliable indicator of the severity of the infection’s clinical course, according to a new study published in Emerging Infectious Diseases.
“Our study aimed to evaluate the diagnostic utility of blood specimens for MERS-CoV infection by using large numbers of patients with a single viral origin and to determine the relationship between blood viral detection and clinical characteristics,” wrote the authors, led by So Yeon Kim, MD, of the National Medical Center in Seoul, South Korea.
The investigators recruited 21 MERS-CoV patients within South Korea, all of whom had been previously diagnosed by the Korea Centers for Disease Control and Prevention via respiratory samples and were of “a single viral origin.” All subjects contributed ethylenediaminetetraacetic acid (EDTA)-treated whole blood and serum specimens, from which viral RNA was extracted (Emerg Infect Dis. 2016 Oct 15;22[10]. doi: 10.3201/eid2210.160218).
Viral RNA was detected in 6 of 21 whole blood samples and 6 of 21 serum samples at hospital admission. However, because two patients were viral positive in either specimen subtype of EDTA-treated whole blood or serum, the overall detection rate for the population was 7 of 21 (33%). Being positive for blood viral RNA at admission was found to be associated with a fever of higher than 37.5 °C (99.5 °F) on the date of sample collection (P = .007), being placed on mechanical ventilation at some point during the clinical course (P = .003), extracorporeal membrane oxygenation (P = .025), and death (P = .025).
However, “between the blood viral RNA-positive and -negative groups, we found no differences in age, duration from symptom onset to diagnosis of MERS-CoV infection, or an invasive procedure before the specimens were obtained,” the investigators noted.
The takeaway, the authors underscore, is that although early blood viral RNA presence may not be a useful diagnostic tool, it “might be a good prognostic indicator of severe outcome” due to its high association with worse clinical course.
The research was funded by the National Medical Center Research Institute.
FROM EMERGING INFECTIOUS DISEASES
Key clinical point: Checking for blood viral RNA at hospital admission may be a reliable indicator of the severity of MERS coronavirus infection clinical course.
Major finding: Blood viral RNA positivity at admission was associated with fever higher than 37.5 °C on the sampling date (P = .007), requirement for mechanical ventilation during the following clinical course (P = .003), extracorporeal membrane oxygenation (P = .025), and patient death (P = .025).
Data source: Prospective analysis of 21 patients with Middle East respiratory syndrome coronavirus (MERS-CoV).
Disclosures: The research was funded by the National Medical Center Research Institute.
