H5N1

Guillain-Barré syndrome associated with COVID-19 infection: A case report

Via ScienceDirect, a report in the Journal of Clinical Neuroscience: Guillain Barre syndrome associated with COVID-19 infection: A case report. This brings back very unhappy memories of Zika virus. The highlights and abstract:

Highlights 

• A novel coronavirus (COVID-19) was detected in Wuhan City, Hubei Province of China.  

• The most symptoms of disease have reported fever, cough, dyspnea, myalgia, headache, and diarrhea.  

• We described GBS symptoms in one infected patient with COVID-19, for the first time. 

• The patient revealed quadriplegia and facial paresis bilaterally, two weeks after COVID-19 infection. 

• The electrodiagnostic findings of patient demonstrated acute motor sensory axonal polyneuropathy. 

Abstract 

Novel outbreak with coronavirus 2019 began since 31 December 2019. Coronaviruses can cause multiple systemic infections that respiratory complications are the most obvious symptoms. In this report, we describe the symptoms of Guillain-Barré syndrome (GBS) in one infected patient with COVID-19, for the first time. We reported a 65-year-old male patient with complaints of acute progressive symmetric ascending quadriparesis. 

Two weeks prior to hospitalization, the patient suffered from cough, fever, and RT-PCR was reported positive for COVID-19 infection. The electrodiagnostic test showed that the patient is an AMSAN variant of GBS. COVID-19 stimulates inflammatory cells and produces various inflammatory cytokines and as a result, it creates immune-mediated processes. GBS is an immune-mediated disorder and molecular mimicry as a mechanism of autoimmune disorder plays an important role in creating it. 

It is unclear whether COVID-19 induces the production of antibodies against specific gangliosides. Further investigations should be conducted about the mechanism of GBS in patients with COVID-19, in the future.

ECDC: CDTR, week 25

ECDC has published Communicable disease threats report, 16-22 June 2019, week 25. The summary:

The ECDC Communicable Disease Threats Report (CDTR) is a weekly bulletin for epidemiologists and health professionals on active public health threats. This issue covers the period from 16-22 June 2019 and includes updates on Ebola virus disease, West Nile virus infection, chikungunya virus disease and acute neurological syndrome in Peru.

The acute neurological syndrome is Guillain-Barré; Peru has reported 548 cases as of June 13, twice last year's number.

Acute flaccid paralysis (AFP) surveillance: Challenges and opportunities from 18 years’ experience, Spain, 1998 to 2015

Via Eurosurveillance: Acute flaccid paralysis (AFP) surveillance: challenges and opportunities from 18 years’ experience, Spain, 1998 to 2015. The abstract:

Acute flaccid paralysis (AFP) surveillance is key for global polio eradication. It allows detecting poliovirus (PV) reintroductions from endemic countries. This study describes AFP surveillance in Spain from 1998 to 2015. During this time, 678 AFP cases were reported to the Spanish National Surveillance Network. 

The mean notification rate was 0.58 AFP cases/100,000 population under 15 years old (range: 0.45/100,000–0.78/100,000). Two periods (P) are described: P1 (1998–2006) with the AFP notification rate ranging from 0.66/100,000 to 0.78/100,000, peaking in 2001 (0.84/100,000); and P2 (2007–2015) when the AFP rate ranged from 0.43/100,000 to 0.57/100,000, with the lowest rate in 2009 (0.31/100,000). No poliomyelitis cases were caused by wild PV infections, although two Sabin-like PVs and one imported vaccine-derived PV-2 were detected. 

Overall, 23 (3.4%) cases met the hot case definition. Most cases were clinically diagnosed with Guillain–Barré syndrome (76.9%; 504/655). The adequate stool collection rate ranged from 33.3% (7/21) to 72.5% (29/40). The annual proportion of AFP cases with non-polio enterovirus findings varied widely across the study period. 

AFP surveillance with laboratory testing for non-polio enteroviruses must be maintained and enhanced both to monitor polio eradication and to establish sensitive surveillance for prompt detection of other enteroviruses causing serious symptoms.

Peru: Hospitals on alert for Guillain-Barré syndrome

A May 8 news release from the Ministry of Health: .Hospitales del país en alerta por Sindrome de Guillain-Barré. Excerpt, with my translation:

Frente al brote de más de 15 casos sospechosos de Síndrome de Guillain Barré en La Libertad y 4 en Lima, el Ministerio de Salud (Minsa) declaró la alerta epidemiológica nacional, a fin de que todos los establecimientos asistenciales del país refuercen sus acciones de vigilancia y bioseguridad en sus servicios, de manera tal que de presentarse otros casos similares los notifiquen de inmediato al Sistema Nacional de Salud. 

Facing an outbreak of over 15 suspected cases of Guillain-Barré syndrome in La Libertad and four more in Lima, the Ministry of Health has declared a national epidemiological alert. The purpose is ensure that all health services in the country reinforce their surveillance and biosecurity so that they can immediately notify the National Health System if they encounter similar cases.

La Viceministra de Salud Pública del Minsa, María del Carmen Calle, precisó que desde el primer momento su Sector tomó las acciones necesarias para atender oportunamente a los pacientes que presentan síntomas relacionados con síndrome de Guillain Barré, así como para dar inicio a las investigaciones científicas que logren establecer un diagnóstico certero de los casos presentados en las últimas semanas.  

Vice-Minister of Public Health María del Carmen Calle said that from the first moment her sector took needed actions to attend promptly to patients presenting symptoms of Guillain-Barré syndrome, and launched scientific investigations to establish a reliable diagnosis of the cases presented in recent weeks.

En conferencia de prensa, la viceministra Calle, sostuvo que los pacientes con síntomas compatibles a esta enfermedad inmunológica vienen recibiendo el tratamiento adecuado en base al suministro del medicamento inmunoglobulina, solo 4 personas reciben respiración asistida, señaló. 

In a news conference, Vice-Minister Calle said the patients with symptoms compatible with this immunologic illness continue to receive adequate treatment based on the supply of immunoglobulin. Only four persons are on assisted respiration, she said.

A la fecha, los estudios de laboratorio realizados a muestras de secreciones, sangre, heces y orina, identificaron un probable tipo de enterovirus, que ataca al intestino vía fecal e ingresa por la boca o aparato respiratorio por falta de higiene luego de ir al baño. Este microorganismo suele producir síntomas como resfrío, vómitos, diarreas y frecuentemente dolores ascendentes y descendentes en las extremidades. 

To date, lab tests on samples of secretions, blood, stool and urine have identified a probably enterovirus that attacks the intestine through fecal matter received orally or nasally due to poor hygiene after going to the bathroom. This micro-organism usually causes symptoms such as chills, vomiting, diarrhea, and often pains going up and down the extremities.

Por su parte, el jefe del Instituto Nacional de Salud (INS), Hans Vásquez, explicó que su institución ha detectado de manera preliminar la presencia de un enterovirus en muestras de secreción de líquido cefalorraquídeo y heces de pacientes con problemas neurológicos y “en los próximos días se espera tener la identificación exacta tras un proceso de genotipificación de algunos exámenes adicionales que se están realizando”.

For his part, the chief of the National Health Institute, Hans Vásquez, explained that his institution has preliminary evidence of an enterovirus in samples of cerebrospinal fluid and stools of patients with neurological problems: "In the coming days we hope to have an exact identification after a genotyping process for some additional tests being conducted."

Zika virus in French Polynesia 2013–14: Anatomy of a completed outbreak

Via The Lancet Infectious Diseases: Zika virus in French Polynesia 2013–14: anatomy of a completed outbreak. The summary:

The Zika virus crisis exemplified the risk associated with emerging pathogens and was a reminder that preparedness for the worst-case scenario, although challenging, is needed. 

Herein, we review all data reported during the unexpected emergence of Zika virus in French Polynesia in late 2013. We focus on the new findings reported during this outbreak, especially the first description of severe neurological complications in adults and the retrospective description of CNS malformations in neonates, the isolation of Zika virus in semen, the potential for blood-transfusion transmission, mother-to-child transmission, and the development of new diagnostic assays. 

We describe the effect of this outbreak on health systems, the implementation of vector-borne control strategies, and the line of communication used to alert the international community of the new risk associated with Zika virus. 

This outbreak highlighted the need for careful monitoring of all unexpected events that occur during an emergence, to implement surveillance and research programmes in parallel to management of cases, and to be prepared to the worst-case scenario.

US study sheds light on how Zika causes nerve disorder

Via Reuters: U.S. study sheds light on how Zika causes nerve disorder. Excerpt:

A new study sheds light on how the mosquito-borne Zika virus causes a rare neurological condition, and the findings could have implications for companies working on Zika vaccines, U.S. researchers said on Wednesday.  

The Zika outbreak that swept through the Americas in 2015 and 2016 showed the virus could, in rare cases, cause Guillain-Barre, an autoimmune disorder in which the body attacks itself in the aftermath of an infection.  

Since the Zika virus attacks nerve cells, scientists were not sure whether the Guillain-Barre cases they had seen in Zika patients were caused by an autoimmune response to the Zika infection or a direct attack by the virus on nerve cells.  

In pregnant women, the virus infects fetal brain cells, resulting in the birth defect known as microcephaly. 

To study the nerve disorder, Dr. Tyler Sharp of the U.S. Centers for Disease Control and Prevention’s Dengue Branch in San Juan and colleagues in Puerto Rico examined the rare case of a 78-year-old man from San Juan who had been infected with Zika in 2016, developed Guillain-Barre and subsequently died. 

An autopsy showed inflammation and erosion of the protective sheath known as myelin in two nerves, but no evidence of the Zika virus in nerve cells. 

“In this case, it looks like it was antibodies that led to destruction of that myelin sheath,” said Sharp, whose study was published in Emerging Infectious Diseases, the CDC’s public health journal. 

Although it was just a single case, Sharp said it suggested the mechanism that causes Guillain-Barre after a Zika infection was the same as in other cases of the nerve disorder. 

Sharp said the study raised a caution flag, however, for companies testing experimental Zika vaccines. Although Guillain-Barre typically occurs in the aftermath of an infection, it has been known to occur in response to a vaccine.  

“Vaccine manufacturers do need to be thinking about Guillain-Barre as a potential outcome of vaccination against Zika,” he said.

The article doesn't seem to have been posted on EID's site yet.

Zika virus in French Polynesia 2013–14: Anatomy of a completed outbreak

Via The Lancet: Zika virus in French Polynesia 2013–14: anatomy of a completed outbreak. The summary:

The Zika virus crisis exemplified the risk associated with emerging pathogens and was a reminder that preparedness for the worst-case scenario, although challenging, is needed. Herein, we review all data reported during the unexpected emergence of Zika virus in French Polynesia in late 2013. 

We focus on the new findings reported during this outbreak, especially the first description of severe neurological complications in adults and the retrospective description of CNS malformations in neonates, the isolation of Zika virus in semen, the potential for blood-transfusion transmission, mother-to-child transmission, and the development of new diagnostic assays. 

We describe the effect of this outbreak on health systems, the implementation of vector-borne control strategies, and the line of communication used to alert the international community of the new risk associated with Zika virus. 

This outbreak highlighted the need for careful monitoring of all unexpected events that occur during an emergence, to implement surveillance and research programmes in parallel to management of cases, and to be prepared for the worst-case scenario.

After the epidemic: Zika virus projections for Latin America and the Caribbean

Via PLOS Neglected Tropical Diseases: After the epidemic: Zika virus projections for Latin America and the Caribbean. Read it carefully: the principal findings are disturbing. The abstract:

Background  

Zika is one of the most challenging emergent vector-borne diseases, yet its future public health impact remains unclear. Zika was of little public health concern until recent reports of its association with congenital syndromes. By 3 August 2017 ∼217,000 Zika cases and ∼3,400 cases of associated congenital syndrome were reported in Latin America and the Caribbean. Some modelling exercises suggest that Zika virus infection could become endemic in agreement with recent declarations from the The World Health Organisation. 

Methodology/Principal findings  

We produced high-resolution spatially-explicit projections of Zika cases, associated congenital syndromes and monetary costs for Latin America and the Caribbean now that the epidemic phase of the disease appears to be over. In contrast to previous studies which have adopted a modelling approach to map Zika potential, we project case numbers using a statistical approach based upon reported dengue case data as a Zika surrogate. 

Our results indicate that ∼12.3 (0.7–162.3) million Zika cases could be expected across Latin America and the Caribbean every year, leading to ∼64.4 (0.2–5159.3) thousand cases of Guillain-Barré syndrome and ∼4.7 (0.0–116.3) thousand cases of microcephaly. The economic burden of these neurological sequelae are estimated to be USD ∼2.3 (USD 0–159.3) billion per annum. 

Conclusions/Significance 

Zika is likely to have significant public health consequences across Latin America and the Caribbean in years to come. Our projections inform regional and federal health authorities, offering an opportunity to adapt to this public health challenge.

CIDRAP: Brazilian study sheds new light on Zika neuro complications in adults

Every new research finding gives us something else to detest about Zika, and this report by CIDRAP's Lisa Schnirring is no exception: Brazilian study sheds new light on Zika neuro complications in adults. Excerpt:

In adults, Zika virus infection can cause a diverse array of serious neurologic complications, according to a case series of patients during Brazil's outbreak who were treated at a neurology referral hospital in Rio de Janeiro. 

In other developments, another research group from Brazil reported a reduction in the birth rate in one of the country's biggest cities and the US Food and Drug Administration (FDA) recently issued an emergency use authorization (EUA) for the first test that can simultaneously assess for Zika, all dengue serotypes, chikungunya, and West Nile virus.  

Patient series finds diverse problems, unusual features 

In the neurologic complication study, researchers reported on 40 adults who were hospitalized with acute-onset neurologic symptoms who were evaluated for Zika infection Dec 5, 2015, and May 10, 2016. The team published its findings today in JAMA Neurology.  

Of the 40 patients, 35 had evidence of recent Zika infection in blood or cerebrospinal fluid (CSF). Of those who were positive for Zika virus, 27 had Guillain-Barre syndrome (GBS), 5 had encephalitis, 2 had transverse myelitis, and 1 had chronic inflammatory demyelinating polyneuropathy.  

Among the 27 with GBS, 13 had cranial nerve involvement and three had facial numbness or trouble swallowing. Of the patients with encephalitis, two had accompanying neuromuscular findings, seen with other flavivirus neurologic complications.  

Serum and CSF were tested for Zika virus using real-time reverse-transcriptase polymerase chain reaction (rRT-PCR) and IgM antibody assays. Researchers also recorded clinical data, radiographic and electrophysiological test findings, and 3-month function outcomes. 

Nine of the patients required intensive care unit treatment and five required mechanical ventilation. 

The authors found Zika IgM in the CSF of many of the patients, often at significantly higher levels than in blood, which they said is a sign of direct Zika virus penetration. Two patients tested positive for dengue on serum but not CSF samples. 

When they compared the number of complications with baseline[MS1]  levels in Brazil, they found that the incidences of GBS and encephalitis rose 6-fold and 3.5-fold compared with the period before the outbreak.  

They concluded that Zika infection is linked to a diverse array of serious neurologic disorders and that serologic and molecular tests on blood and CSF can be useful as a less expensive and more accessible alternative to plaque reduction neutralization testing in developing countries.

US: Houston braces for another brush with the peril of Zika

Via The New York Times: Houston Braces for Another Brush With the Peril of Zika. Excerpt:

With 4.5 million people in a hot, muggy metropolis built atop a bayou, America’s fourth-largest city, Houston, is a perfect target for the mosquito-borne Zika virus. But it may be better prepared than any other urban center to stop an outbreak. 

The city last year increased its mosquito-control budget by 33 percent. Officials are testing new high-tech traps and have plans to release genetically modified mosquitoes that produce short-lived offspring, reducing the population. 

Should the virus start spreading here, officials are prepared to follow Miami’s example, beginning aerial spraying and house-to-house inspections to clear standing water in which mosquitoes breed. 

“We’re much better prepared this year than we were last year,” said Mustapha Debboun, mosquito control director of Harris County, which includes Houston.  

Almost everywhere, Year 2 of Zika is looking much less threatening than Year 1. But the risk posed by this virus is far from gone.

According to the Pan American Health Organization, the number of infections has declined precipitously in the Americas, except for Peru, Ecuador and Argentina.  

Zika infections are down by more than 90 percent in the Caribbean, Central America and Mexico. Cases of Guillain-Barré syndrome paralysis, linked to infection with the virus, are also down to pre-epidemic levels. 

Fewer infections overseas should mean fewer travelers returning to the United States with live virus in their blood, reducing the likelihood of an outbreak here.  

Dr. Scott C. Weaver, a Zika expert at the University of Texas Medical Branch in nearby Galveston, described himself as “cautiously optimistic” that the epidemic was fading out.  

Still, he warned, “it’s premature to conclude that the danger is over.” Data is limited on infections just over the border in Mexico, and the rainy season — prime time for mosquito breeding — has just begun in Central America and the Caribbean.  

Still, it’s a far cry from the situation last year, when a surge of babies born with abnormally small heads in Brazil sowed an international panic. The birth defects were shown to be linked to infection with the Zika virus, transmitted to pregnant women by common household mosquitoes.  

As the epidemic crept northward with warming weather, drug companies began testing more than 20 vaccines. The Obama White House fought a bitter battle with congressional Republicans over emergency funding, and the Gulf Coast, where similar mosquitoes had previously caused outbreaks of dengue and chikungunya, braced for the worst. 

Ultimately, the country recorded about 5,100 cases, of which about 4,800 were acquired by travelers overseas. Florida reported 218 cases of locally acquired Zika infection, however, mostly in Miami. Texas recorded only six, all in the Brownsville area, abutting Mexico. 

Thus far, 216 babies with severe Zika-related birth defects have been born or have died in the womb, 88 of them in the United States and 128 in its territories, mostly in Puerto Rico, according to the Centers for Disease Control and Prevention.  

As winter returned, the disease receded from the headlines. This summer, there is no panic in cities like Houston, only uncertainty.