Human parechoviruses (HPeVs) are widespread pathogens belonging to the Picornavirus family. The aim of the present study was to assess the prevalence and genetic diversity of HPeV in Shanghai, China, during a HPeV screening program in 2008 and 2009. Of 300 stool samples from children under the age of 5 years with acute diarrhea seen at Children's Hospital, Fudan University, Shanghai, China, 165 (55%) were HPeV-positive. The median age of infected children was 3 months. The prevalence of HPeV was high (57%) in infants up to 2 years old but dropped to 30.4% in children between 2 and 5 years old. The prevalence did not differ by sex. Infections were present throughout the year but peaked in July and August. The most predominant genotype was HPeV1. Of the 139 strains, 4 were found in 9 samples: HPeV4 (n = 4), HPeV5 (n = 1), HPeV6 (n = 1), and HPeV8 (n= 3). This study provided useful data on the epidemiology of HPeV infection by documenting the distribution of genotypes, age of infection, and seasonal patterns in Shanghai, China.

Between April 1999 and March 2008, a total of 4,976 stool specimens collected from patients with suspected viral infection through infectious agent surveillance in Aichi, Japan, were tested for the presence of human parechoviruses (HPeVs). We detected HPeVs in 110 samples by either cell culture, reverse transcriptase PCR (RT-PCR), or both. Serotyping either by neutralization test or by nucleotide sequence determination and phylogenetic analysis of the VP1 region and 5' untranslated region (5'UTR) regions revealed that 63 were HPeV type 1 (HPeV-1), followed by 44 HPeV-3 strains, 2 HPeV-4 strains, and 1 HPeV-6 strain. The high nucleotide and amino acid sequence identities of the Japanese HPeV-3 isolates in 2006 to the strains previously reported from Canada and Netherlands confirmed the worldwide prevalence of HPeV-3 infection. Ninety-seven percent of the HPeV-positive patients were younger than 3 years, and 86.2% younger than 12 months. The clinical diagnoses of HPeV-positive patients were gastroenteritis, respiratory illness, febrile illness, exanthema,"hand, foot, and mouth disease," aseptic meningitis, and herpangina. Among 49 HPeV-positive patients with gastroenteritis, 35 were positive with HPeV-1 and 12 with HPeV-3, and out of 25 with respiratory illness, 11 were positive with HPeV-1 and 14 with HPeV-3. HPeV-3 seemed to be an important etiological agent of respiratory infection of children. While HPeV-1 was detected predominantly during fall and winter, the majority of the HPeV-3 cases were detected during summer and fall. A different pattern of clinical manifestations as well as seasonality suggested that there are different mechanisms of pathogenesis between HPeV-1 and HPeV-3 infections.

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BACKGROUND: From December 1987 through August 2004, lung tissue, nasopharyngeal swabs, and colon swab specimens obtained during 1263 autopsies of infants and young children were examined to assess the role of viruses in deaths of children aged <2 years. METHODS: Multiple cell cultures were used to isolate viruses. With 4 exceptions, virus isolates were identified by neutralization, immunofluorescence assay, or enzyme immunoassay. RNA extracted from these 4 isolates and associated autopsy specimens was tested using parechovirus-specific real-time polymerase chain reaction (RT-PCR) and sequencing assays. RESULTS: Specimens from 426 (34%) autopsies were positive for at least 1 virus; enteroviruses and adenoviruses were the most commonly identified. Human parechoviruses (HPeVs) were identified antigenically in isolates from 18 decedents (all HPeV type 1) and by RT-PCR in isolates and multiple autopsy specimens from 4 decedents with untypeable virus isolates. Sequencing of the VP1 region identified these 4 HPeVs as HPeV type 3 (n = 3) and HPeV type 6 (n = 1). Despite the detection of HPeV, the deaths of decedents 3 and 4 were determined to have been from noninfectious causes. CONCLUSIONS: These are the first confirmed HPeV type 3 and HPeV type 6 detections in the United States. This is also the initial report of fatal cases with associated HPeV type 3 infection. These results support prior findings associating HPeVs with serious disease in young children. Clinical testing for HPeVs and routine HPeV surveillance by public health laboratories will help determine the burden of disease caused by HPeVs.

BACKGROUND:: Human parechoviruses (HPeVs) and enteroviruses (EVs) belong to the family Picornaviridae. EVs are known to cause a wide range of disease such as meningitis, encephalitis, and sepsis. HPeV1 and 2 have been associated with mild gastrointestinal or respiratory symptoms in young children. HPeV3 is associated with more severe neonatal infection. Little is known about the epidemiology and pathology of HPeV4-6 in children. METHODS:: We evaluated the clinical symptoms of the children with an HPeV 4, 5, or 6 infection. The patients with positive HPeV4-6 in stool samples were selected and available plasma or cerebrospinal fluid samples from these patients were tested for HPeV. Data on clinical symptoms, diagnosis, presence and duration of fever, medical history, mean age, use of antibiotics of the children infected with HPeV4-6 were retrospectively documented. RESULTS:: HPeV4-6 were found in 31 of the 277 HPeV positive children (11%). Coinfection with EV was seen in 8 patients. Fever was seen in 13 (42%) patients. Of the HPeV4-6 positive patients, 20 of the 31 children (64%) presented with gastrointestinal complaints and 18 of 31 (58%) patients had respiratory symptoms. The mean age was 14 months, 58% of the patients had an underlying disorder such as bronchomalacia or a cardiac disorder. CONCLUSIONS:: Symptomatic HPeV4-6 infections are seen in relative young children and are associated with respiratory and/or gastrointestinal symptoms. HPeV type 4 was detected more frequently than HPeV types 5 and 6.

Background. Human parechoviruses (HPeVs), along with human enteroviruses (HEVs), are associated with neonatal sepsis and meningitis. We determined the relative importance of these viruses and the specific HPeV types involved in the development of central nervous system-associated disease. Methods. A total of 1575 cerebrospinal fluid (CSF) samples obtained during 2006-2008 were screened for HPeV by means of nested polymerase chain reaction. All samples for which results were positive were typed by sequencing of viral protein (VP) 3/VP1. Screening for HEV was performed in parallel, as was detection of HPeV in respiratory and fecal surveillance samples, to identify virus types circulating in the general population. Results. HPeV was detected in 14 CSF samples obtained exclusively from young infants (age,<3 months) with sepsis or pyrexia. The frequency of detection of HPeVs varied greatly by year, with the highest frequency (7.2%) noted in 2008 exceeding that of HEVs. Direct typing of CSF samples revealed that all infections were caused by HPeV type 3, a finding that is in contrast to the predominant circulation of HPeV1 in contemporary respiratory and fecal surveillance samples. Conclusion. HPeV was a significant cause of severe sepsis and fever with central nervous system involvement in young infants, rivaling enteroviruses. The specific targeting of young infants by HPeV type 3 may reflect a difference in tissue tropism between virus types or a lack of protection of young infants by maternal antibody consequent to the recent emergence of HPeV.

Human parechoviruses (HPeVs) are members of the large and growing family of Picornaviridae. Although originally described as echovirus 22 and 23 within human enteroviruses because of their clinical and morphological properties, they have since been shown to be distinct from this and other picornavirus groups in several features of their genome organisation, structure and replication. Human parechoviruses show genetic and antigenic heterogeneity and a number of distinct HPeV types are known to circulate widely in human populations throughout the world. Although the majority of HPeV infections occur early in life without specific symptoms, disease manifestations associated with many of the currently described types have been described, ranging from gastroenteritis and respiratory infections to neurological disease, particularly in neonates. Although HPeV diagnosis has historically been made by virus isolation, a new generation of sensitive and specific molecular tests for HPeV RNA promises to greatly improve the effectiveness of HPeV detection and type identification, as well as providing a greater understanding its molecular epidemiology. By this means, we will learn much more about the clinical relevance of HPeVs and the association of different HPeV types with specific disease presentations.

Human parechoviruses (HPeVs) are frequent pathogens with seroprevalance of over 90% in adults. Recent studies on these viruses have increased the number of HPeV types to 6. Here we analyse the complete genome of one clinical isolate, PicoBank/HPeV1/a, and VP1 and 3D protein sequences of PicoBank/HPeV6/a, isolated from the same individual 13 months later. The sequences indicate that this individual was first infected with an HPeV1 strain, and then an HPeV6 strain, showing that the first infection was not cross-protecting. PicoBank/HPeV1/a is closely related to another recent HPeV1 isolate, BNI-788St, but is distinct from the HPeV1 Harris prototype isolated 50 years ago. The availability of an increasing number of HPeV sequences has allowed a detailed analysis of these viruses. The results add weight to the observations that recombination plays a role in the generation of HPeV diversity. An important finding is the presence of unexpected conservation of codons utilised in part of the 3D-encoding region, some of which can be explained by the presence of a phylogenetically-conserved predicted secondary structure domain. This suggests that in addition to the cis-acting replication element, RNA secondary structure domains in coding regions may play a key role in picornavirus replication.

A survey of immunization status and serological immunity to polio was carried out in 5 parishes in Jamaica in 1985. A sample of 2,506 children and adolescents aged 1-19 years was chosen by selecting clusters of children in enumeration districts (EDs) in each parish from the 1980 Census. Immunization status was verified by examining immunization records. Serological assay for antibodies to Polio Types 1, 2, and 3 was done. A positive neutralization test at dilution of 1:8 was taken as immunity to the polio virus. Of the 1,819 children whose immunization status was confirmed, coverage with 3 or more doses of oral polio vaccine was highest in the 1-4 year age group with 79.7% and lowest in the 15-19-year age group with 37.4%. Of the 2,506 children 81.4%, 94.7% and 72.3% were seropositive for Polio Types 1, 2 and 3 respectively. There was a significant difference in the prevalence of seropositives between individuals with and those without a history of vaccinations. No urban/rural or sex differences were noted. The study indicated a higher level of immunization status than previous surveys and a high level of serological immunity to polio.

A random sample of 78 district midwives, representing 24% of all district midwives in the government health service, were interviewed to assess their knowledge and practice of domiciliary midwifery as part of the Jamaican Perinatal Morbidity and Mortality Survey in 1986. A standard questionnaire based on the WHO guidelines on appropriate technology for birth was used. Records of their two preceding home deliveries were examined and their delivery bags inspected for availability of basic supplies and equipment. A mean of 21.5 home deliveries was attended by each rural midwife in 1986 compared with 3.8 in the urban areas. Routine laboratory tests were not done on many mothers, and there were long delays in getting results. Midwives' knowledge was average overall with one-third of them showing poor knowledge of high-risk factors in infants and newborn care. Most midwives routinely shave and give enemas to mothers. Unavailability of equipment and supplies, including vitamin K and eye drops, is common; 24% of midwives made no prenatal home visit in the previous month, and 80% fell short of the set norm of 5 postnatal home visits; 84% of midwives put the baby to the mother's breast within one hour of delivery. Essential supplies and lab investigations need to be provided and measures taken to improve domiciliary midwifery through a programme of continuing education and better supervision of midwives. A strategy to promote home deliveries under specified conditions needs to be considered.

Background: Emergent cricothyroidotomy remains an uncommon, but life-saving, core procedural training requirement for emergency medicine (EM) physician training. We hypothesized that, although most cricothyroidotomies occur in the emergency department (ED), they are rarely performed by EM physicians. Methods: We conducted a retrospective analysis of all emergent cricothyroidotomies performed at two large level one trauma centers over 10 years. Operators and assistants for all procedures were identified, as well as mechanism of injury and patient demographics were examined. Results: Fifty-four cricothyroidotomies were performed. Patients were: mean age of 50, 80% male and 90% blunt trauma. The most common primary operator was a surgeon (n = 47, 87%), followed by an Emergency Medical Services (EMS) provider (n = 6, 11%) and a EM physician (n = 1, 2%). In all cases, except those performed by EMS, the operator or assistant was an attending surgeon. All EMS procedures resulted in serious complications compared to in-hospital procedures (p < 0.0001).Conclusions: 1. Pre-hospital cricothyroidotomy results in serious complications. 2. Despite the ubiquitous presence of emergency medicine physicians in the ED, all crico-thyroidotomies were performed by a surgeon, which may represent a serious emergency medicine training deficiency.

Testicular dislocation after blunt perineal trauma is a rare event and a diagnosis that can be easily overlooked. Careful examination can help facilitate early and appropriate treatment. Timely diagnosis and surgical management are of paramount importance to preserve normal spermatogenic function in the dislocated testicle. We describe a case of testicular dislocation and discuss some of the issues surrounding diagnosis and treatment.

STUDY DESIGN Pictorial review. OBJECTIVES To illustrate MRI signs of acute and subacute injury with emphasis on evidence-based links to clinical outcome and implications for treatment. METHODS Description of important aspects of MRI techniques and illustration of critical MRI signs important in the assessment of spinal cord injury following trauma, in the acute and subacute stages. CONCLUSIONS Familiarity with cord MRI appearances has an important impact on planning the management of the acutely spinal cord injured patient and also identifying complications in the subacute phase particularly in the presence of neurological deterioration.

AIM The aim of this study was to describe the effect of player positional groups on the nature of tackles that result in tackle-related injuries in professional rugby league matches. METHODS Prospective observational epidemiology analyses for tackle-related injuries and video analyses for the nature of tackles were conducted for a single team in the National Rugby League (NRL) throughout the 2007 and 2008 competitions for a total of 48 games. Risk ratios (RR) were calculated for comparisons between positional groups (adjustable, hit-up forwards or outside backs). RESULTS The total missed match tackle-related injury rate was 57.8 per 1 000 player hours. Hit-up forwards recorded significantly more total tackle-related injuries than outside backs (RR: 1.3; P=0.049), but not more than adjustables (RR: 1.0; P=0.922). Hit-up forwards recorded significantly more chest-back tackle-related injuries than adjustables (RR: 6.0; P=0.008). Outside backs recorded significantly more tackle injuries as the ball carrier than the tackler (RR: 2.4; P=0.015) while adjustables recorded significantly more tackle injuries as the tackler than the ball carrier (RR: 1.8; P<0.001). Hit-up forwards had a higher incidence of contusions, and sprains while adjustables had a higher incidence of fracture/dislocations. There were no differences in injury severity between the positional groups. CONCLUSION Player positional group had an effect on tackle-related injury type and injury site. Hit-up forwards and outside backs recorded more tackle-related injuries as a ball carrier than as a tackler, while in contrast, adjustables recorded more tackle-related injuries as the tackler than the ball carrier.

BACKGROUND The Glasgow Blatchford Score (GBS) is increasingly being used to predict intervention and outcome following upper gastrointestinal haemorrhage (UGIH). AIM To compare the GBS with both the admission and full Rockall scores in predicting specific clinical end-points following UGIH. PATIENTS AND METHODS Data on consecutive patients presenting to four UK hospitals were collected. Admission history, clinical and laboratory data, endoscopic findings, treatment and clinical follow-up were recorded. Using ROC curves, we compared the three scores in the prediction of death, endoscopic or surgical intervention and transfusion. Results  A total of 1555 patients (mean age 56.7years) presented with UGIH during the study period. Seventy-four (4.8%) died, 223 (14.3%) had endoscopic or surgical intervention and 363 (23.3%) required transfusion. The GBS was similar at predicting death compared with both the admission Rockall (area under ROC curve 0.804 vs. 0.801) and full Rockall score (AUROC 0.741 vs. 0.790). In predicting endo-surgical intervention, the GBS was superior to the admission Rockall (AUROC 0.858 vs. 0.705; P<0.00005) and similar to the full Rockall score (AUROC 0.822 vs. 0.797). The GBS was superior to both admission Rockall (AUROC 0.944 vs. 0.756; P<0.00005) and full Rockall scores (AUROC 0.935 vs. 0.792; P<0.00005) in predicting need for transfusion. CONCLUSIONS Despite not incorporating age, the GBS is as effective as the admission and full Rockall scores in predicting death after UGIH. It is superior to both the admission and full Rockall scores in predicting need for transfusion, and superior to the admission Rockall score in predicting endoscopic or surgical intervention.

King et al. reported that of 5 941 moderate to serious claims resulting in medical treatment for rugby league injuries, the knee, shoulder, and head and neck body sites and soft tissue and fracture-dislocation injuries were most frequent and costly in the New Zealand national no-fault injury compensation corporation database during 1999 to 2007. However, additional analyses of knee, shoulder and head and neck body sites by soft tissue and fracture-dislocation injury types was required to enable a greater understanding of the nature of injuries most likely to be seen by sports medical personnel dealing with rugby league players. From 1999 to 2007 the injury claims and costs for head and neck soft tissue, fracture-dislocations, shoulders soft tissue significantly increased. Knee soft tissue injury claims and costs significantly decreased from 1999 to 2007. There was no significant difference in knee fracture-dislocation injury claims but there was a significant increase in knee fracture-dislocation injury costs from 1999 to 2007. Changes in the nature of injuries may be related to changes in defensive techniques employed in rugby league during this time. Sports medical personnel dealing with rugby league players should focus their injury prevention strategies on reducing musculoskeletal injuries to the head and shoulder. There should be a focus on increasing awareness of correct tackling technique, head injury awareness and management of suspected cervical spine injuries.

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Evaluation of the primary etiologic agents that cause aseptic meningitis outbreaks may provide valuable information regarding the prevention and management of aseptic meningitis. In Korea, an outbreak of aseptic meningitis caused by echovirus type 30 (E30) occurred from May to October in 2008. In order to determine the etiologic agent, CSF and/or stool specimens from 140 children hospitalized for aseptic meningitis at Soonchunhyang University Cheonan Hospital between June and October of 2008 were tested for virus isolation and identification. E30 accounted for 61.7%(37 cases) and echovirus 6 accounted for 21.7%(13 cases) of all the human enteroviruses (HEVs) isolates (60 cases in total). For the molecular characterization of the isolates, the VP1 gene sequence of 18 Korean E30 isolates was compared pairwise using the MegAlign with 34 reference strains from the GenBank database. The pairwise comparison of the nucleotide sequences of the VP1 genes demonstrated that the sequences of the Korean strains differed from those of lineage groups A, B, C, D, E, F and G. Reconstruction of the phylogenetic tree based on the complete VP1 nucleotide sequences resulted in a monophyletic tree, with eight clustered lineage groups. All Korean isolates were segregated from other lineage groups, thus suggesting that the Korean strains were a distinct lineage of E30, and a probable cause of this outbreak. This manuscript is the first report, to the best of our knowledge, of the molecular characteristics of E30 strains associated with an aseptic meningitis outbreak in Korea, and their respective phylogenetic relationships.

The myotonic disorders, including the myotonic dystrophies (myotonic dystrophy type 1, DM1; myotonic dystrophy type 2, DM2/PROMM/PDM), the muscle channelopathies or non-dystrophic myotonias (chloride, sodium, calcium and potassium channelopathies) are all characterized by myotonia and muscle weakness despite different pathophysiology involved in these disorders. Myotonia may affect the eye, facial and jaw muscles as well as the hands and legs. It may be painful and disabling. Muscle weakness may be episodical as in the paralytic attacks of the sodium and calcium channelopathies or culminate in permanent muscle weakness as in the calcium channelopathies and some sodium channelopathies associated to specific point mutations. The severity of myotonia may fluctuate in the myotonic dystrophies, but weakness is usually fixed, affecting neck flexors, facial and jaw muscles as well as proximal and distal muscles of the limbs. Despite the recent progress in molecular genetics the precise mechanisms responsible for myotonia and weakness are not fully understood and there is no standardized treatment strategy. We present a review of selected treatment trials in the myotonic disorders and the muscle channelopathies, and discuss our experience in the treatment of myotonia and muscle weakness, with reference to the limits and advantages of treatment trials in this field.

An outbreak of aseptic meningitis due to echovirus 30 occurred in Ankara and Antalya in Turkey, during June to September 1999, with 176 cases fitting the clinical case definition. Cases were ascertained from attendees of the three hospitals in Ankara and one in Antalya. Medical files were reviewed and evaluated retrospectively. Clinical presentation and laboratory findings were typical of viral meningitis. Cerebrospinal fluid and/or stool samples of 86 patients were cultured for enteroviruses. Echovirus type 30 was isolated in 38 patients (44%). This is the first report and epidemiologic data about an aseptic meningitis outbreak due to echovirus type 30 from Turkey.

Echovirus type 33 (E33) is a relatively uncommon enterovirus. An E33 outbreak during the winter of 2000 in New Zealand led to 75 virologically-confirmed cases of E33 infection (2.6 cases per 100,000 individuals). Sixty-six (88%) of the 75 patients were aged <30 years, with the highest rates of infection recorded in Maori and Pacific ethnic groups. Overall, 47 (84%) of 56 patients whose cases were analyzed had either aseptic meningitis or encephalitis. Central nervous system involvement was more common after infancy (43 of 45 non-infant patients vs. 4 of 11 infants [relative risk, 2.6; 95% CI, 1.5-4.3]). Two infants died, including a neonate with fulminant hepatitis. Independent of symptom duration, neutrophil-predominant pleocytosis was detected in 17 (41%) of 41 cerebrospinal fluid specimens. Virus isolates could not be definitively typed by antibody neutralization testing but were identified as E33 by partial sequencing of the VP-1 capsid gene. The isolates were closely related to strains from Australia and Oman. Molecular typing, together with a serotype-specific E33 PCR, improved the speed and effectiveness of the outbreak investigation.

Bickerstaff reported eight patients who, in addition to acute ophthalmoplegia and ataxia, showed drowsiness, extensor plantar responses or hemisensory loss. This condition has been named Bickerstaff's brainstem encephalitis (BBE). One patient had gross flaccid weakness in the four limbs. Presumably because of the rarity of this disorder, there has been no reported study on a large number of patients with BBE. To clarify its clinical features, we reviewed detailed clinical profiles and laboratory findings for 62 cases of BBE diagnosed by the strict criteria of progressive, relatively symmetrical external ophthalmoplegia and ataxia by 4 weeks, and disturbance of consciousness or hyperreflexia. Ninety-two per cent of the patients involved had had an antecedent illness. Besides ophthalmoplegia and ataxia, disturbance of consciousness was frequent (74%), and facial diplegia (45%), Babinski's sign (40%) and pupillary abnormality and bulbar palsy (34%) were present. Almost all the patients had a monophasic remitting course and generally a good outcome. Serum anti-GQ1b IgG antibody was positive in 66%, and MRI showed brain abnormality in 30% of the patients. Another striking feature was the association with flaccid symmetrical tetraparesis, seen in 60% of the patients. An autopsy study of a BBE patient clearly showed the presence of definite inflammatory changes in the brainstem: there was perivascular lymphocytic infiltration with oedema and glial nodules. Electrodiagnostic study results suggested peripheral motor axonal degeneration. Limb weakness in the BBE cases studied was considered the result of overlap with the axonal subtype of Guillain-Barré syndrome. These findings confirm that BBE constitutes a clinical entity and provide additional clinical and laboratory features of BBE. A considerable number of BBE patients have associated axonal Guillain-Barré syndrome, indicative that the two disorders are closely related and form a continuous spectrum.

In the present study, the sensitivities of HEp-2 (human epithelioma), RD (rhabdomyosarcoma) and L20B (mouse cells, that have receptors for human polioviruses) cell cultures have been evaluated and compared, for the isolation and identification of enteroviruses from the stool and cerebrospinal fluid samples of patients with acute flask paralysis and aseptic meningitis, which were examined between the years 1999-2000, in Refik Saydam Institute of Hygiene Center, Virology, Tissue Culture and Enterovirus Laboratory. Of a total of 1663 samples, 131 viral strains were isolated, and 120 of them were identified as enteroviruses, and 11 as adenoviruses. The isolation rates of 48 Sabin-like polioviruses from HEp-2, RD and L20B cell lines were found similar, as 83.3%, 87.5% and 91.6%, respectively. All of 47 Echovirus strains were isolated from RD cells, all of 13 Coxsackie type B strains were isolated from HEp-2 cells, and all of 12 non-polio enteroviruses were isolated from RD cells. All of 11 adenovirus strains that have been grown in Hep-2 cells, were thought to be occasionally isolated due to the passage of viruses to gastrointestinal tract, and excreted via stool, thus having no clinical significance for these patients. As a result, it was concluded that, all of these three cell lines and especially L20B were sensitive for polioviruses, RD cell line being more sensitive for Echovirus, and HEp-2 cell line being more sensitive for Coxsackie type B virus strains.

BACKGROUND: In August and September 2002 an outbreak of West Nile virus (WNV) infection occurred in southern Ontario. We encountered a number of seriously ill patients at our hospitals. In this article we document the clinical characteristics of these cases. METHODS: We conducted a retrospective chart review of patients who came to the attention of infectious disease or neurology consultants or the microbiology laboratories at 7 hospitals in the municipalities of Toronto, Peel and Halton, Ont. Patients were included if they had been admitted to hospital or stayed overnight in the emergency department, had serological evidence of WNV infection and had clinical evidence of WNV fever, aseptic meningitis, encephalomyelitis or motor neuronopathy. RESULTS: In all, 64 patients met the inclusion criteria; 57 had encephalitis or neuromuscular weakness or both, 5 had aseptic meningitis, and 2 had WNV fever. The mean age was 61 years (range 26-87). The patients were predominantly active, middle-aged or elderly people living independently in the community. Seven patients were immunocompromised A febrile prodromal illness preceded the neurological symptoms in almost all cases. The most common neurological abnormality was decreased level of consciousness; this frequently evolved to severe lower motor neuron neuromuscular weakness. Ataxia and swallowing disorders were frequent and important problems. Sixteen patients (25%) required intubation and mechanical ventilation because of a decreased level of consciousness, inability to clear secretions or respiratory muscle weakness; 9 others had disabling muscle weakness of one or more limbs. Ten patients died. The study patients were in hospital a total of 1856 patient-days, including 532 patient-days in an intensive care unit. Only 28%(13/47) of the patients who survived encephalitis or neuromuscular weakness, or both, were discharged home without additional support. Slow turnaround time for serological test results resulted in delayed diagnosis. INTERPRETATION: The 2002 WNV infection outbreak in Ontario caused serious morbidity and mortality in the subset of patients who had encephalitis or neuromuscular weakness severe enough to require hospital admission.

Echoviruses are the commonest cause of aseptic meningitis (AM). Echovirus type 13 (EV-13) was the second enterovirus serotype associated with different local outbreaks of AM in Spain between February and October 2000. It was the first time that an epidemic AM caused by this virus was recognized in Spain. The index case appeared in the Canary Islands (Canarias). The EV-13 virus was isolated from 135 patients, predominantly from cerebrospinal fluid (CSF). All isolates were from children under 13 years. The age specific peak incidence was in infants under 1 year. Most patients had fever, headache and other meningeal signs. This enterovirus serotype, not previously detected in Spain, caused severe illness with a high attack rate.

OBJECTIVE: We assessed epidemiologic, clinical and laboratory features of aseptic meningitis during one season of multiserotype enteroviral meningitis in East Germany in 70 consecutive patients with aseptic meningitis admitted to the Children's University Hospital Leipzig. RESULTS: Patients, age 1 to 16 years, typically presented with headache, emesis and fever, whereas signs of meningeal irritation were only moderately expressed in one-half of the patients. The median number of leukocytes in the CSF was 151 cells/mm(3)(range, 2 to 1,820) with a high percentage of polymorphonuclear cells (PMNs). Initial blood counts showed mild leukocytosis and pronounced PMN predominance (78.9 +/- 1.3%). The percentage of PMNs in the peripheral blood decreased in favor of mononuclear cells after 3 days to a pattern more compatible with viral infection as opposed to that suggestive for bacteria in the beginning. Mean cerebrospinal fluid values of protein, glucose and lactate and the C-reactive protein were mildly elevated or normal. Nonpolio enteroviruses were detected in 30 of 70 patients. Subsequent serotyping revealed echovirus type 13 (13 patients), type 6 (2), type 30 (1) and coxsackie B virus type 5 (2). There were no differences in demographic or clinical data between enterovirus positive and negative patients. CONCLUSIONS: Even though individual laboratory values do not solely allow discrimination between viral and bacterial meningitis, the combined epidemiologic, clinical and laboratory data facilitate the diagnosis of aseptic meningitis in most cases. Viral diagnostics, identifying echovirus type 13 that thus far has not been associated with epidemics of meningitis, adds important epidemiologic information.

A large outbreak of aseptic meningitis occurred from April to November 2001 in Taiwan. Of the 1,130 enterovirus-infected patients, echovirus 30 (E30) infection was diagnosed in 188 (16.6%), with the patients having various clinical manifestations including aseptic meningitis (73.9%), young infant fever (6.9%), respiratory symptoms or herpangina (13.3%), or others (5.9%). The majority of the E30-infected patients were between 3 and 10 years old. Of the 264 E30 strains identified, 94.3, 71, and 67.4% were isolated from RD, MRC-5, and A549 cells, respectively. Primary isolation of E30 required mean times of 3.7 days for RD cells and 4.1 days for MRC-5 and A549 cells. Among all E30-positive patients, virus was most frequently isolated from throat swab specimens (85.2%) and, to a lesser extent, stool (76.4%) or cerebrospinal fluid (70.1%) specimens. The virus isolates were initially identified as echovirus 4 (E4) on the basis of immunofluorescence staining with anti-E4 and anti-E30 (Bastianni prototype) monoclonal antibodies. However, upon performance of the neutralization test, E30-specific reverse transcription-PCR, and sequencing of the VP1 gene, the results identified these isolates as E30, not E4, indicating that the reagent used to type E30, which is produced with the Bastianni strain as the immunogen, is inadequate for the identification of recent E30 isolates in Taiwan. Phylogenetic analyses of the VP1 genes of these isolates showed that their sequences differed from those of E30 isolates from the GenBank database by 9.1 to 25.2%, suggesting that this outbreak was caused by a new variant strain of E30 introduced into Taiwan in 2000 that resulted in the widespread aseptic meningitis epidemic in 2001.