Severe Acute Kidney Injury Secondary to Immunoglobulin Infusion in Life-Threatening Guillain Barre Syndrome.

Immunoglobulin infusion (IVIG) is one of the first line therapy in Guillain Barre Syndrome (GBS). Several medical complications are associated with GBS (pneumonia, sepsis, deep vein thrombosis, dysautonomy). Acute kidney injury (AKI) is an uncommon complication during IVIG infusion. Several risk factors were associated with AKI during IVIG. These are an older age, previous renal disease, concomitant use of nephrotoxic agents, diabetes mellitus, hypovolemia, sepsis or using of IVIG that contained in its preparation sucrose or mannitol as stabilizers to avoid precipitation and aggregation. Infusion rate and total dose play a determinant role. The most important pathophysiological mechanism of AKI are the osmotic stress applied to the epithelium of proximal tubules and glomeruli. The osmotic overload is principally generated by IVIG stabilizers (sucrose). In general, AKI is reversible but approximately 30% hemodialysis is necessary. It is essential to respect doses, infusion rates and closely monitoring renal function parameters during IVIG infusion.

Molecular characterization and epidemiological aspects of non-polio enteroviruses isolated from acute flaccid paralysis in Brazil: a historical series (2005-2017).

Due to the advanced stage of polio eradication, the possible role of non-polio enteroviruses (NPEVs) associated to acute flaccid paralysis (AFP) cases has been highlighted. In this study, we described epidemiological aspects of NPEVs infections associated to AFP and explore the viral genetic diversity, information still scarce in Brazil. From 2005 to 2017, 6707 stool samples were collected in the scope of the Brazilian Poliomyelitis Surveillance Program. NPEVs were isolated in 359 samples (5.3%) and 341 (94.9%) were genotyped. About 46 different NPEV types were identified with the following detection pattern EV-B > EV-A > EV-C. The major EV-types were CVA2, CV4, EV-A71, CVB3, CVB5, E6, E7, E11, CVA13 and EV-C99, which corresponds to 51.6% of the total. Uncommon types, such as CVA12, EV-90 and CVA11, were also identified. Different E6 genogroups were observed, prevailing the GenIII, despite periods of co-circulation, and replacement of genogroups along time. CVA2 sequences were classified as genotype C and data suggested its dispersion in South-American countries. CVA13 viruses belonged to cluster B and Venezuelan viruses composed a new putative cluster. This study provides extensive information on enterovirus diversity associated with AFP, reinforcing the need of tailoring current surveillance strategies to timely monitor emergence/re-emergence of NPEVs.

Large Outbreak of Guillain-Barré Syndrome, Peru, 2019.

Outbreaks of Guillain-Barré syndrome (GBS) are uncommon. In May 2019, national surveillance in Peru detected an increase in GBS cases in excess of the expected incidence of 1.2 cases/100,000 population. Several clinical and epidemiologic findings call into question the suggested association between this GBS outbreak and Campylobacter.

Cryptococcal meningitis presenting as acute flaccid paralysis: A case report.

Cryptococcus is a cosmopolitan fungus with tropism for the nervous system and a higher prevalence of infection in immunosuppressed patients. Neurological compromise caused by this microorganism mainly debuts as a meningeal syndrome (headache, fever, neck stiffness) with predominant encephalic involvement. In this report we present the rare case of a non-HIV patient with flaccid paralysis and peripheral nerve involvement due to crytpococcal meningitis. This is a 53-years-old woman, with a past-medical history of diabetes, who presented with dysarthria, unilateral peripheral facial paralysis, asymmetric ascending quadriparesis, generalized hyporeflexia and urinary retention. Neuroimaging was initially reported as negative for vascular or demyelinating diseases. Electrophysiological studies were performed, and acute flaccid paralysis of undetermined etiology was defined as a temporal clinical diagnosis. Cerebrospinal fluid molecular analysis confirmed the presence of Cryptococcus neoformans var. gatti; posteriorly, antifungal treatment with amphotericin B and fluconazole was started. Polyneuroradiculopathy symptoms significantly improved over the in-hospital stay. In conclusion, spinal cord and peripheral nerve involvement by Cryptococcus is an infrequent cause of acute flaccid paralysis that should be considered in the differential diagnosis even in HIV-negative patients.

Parálisis fláccida aguda por enterovirus con resolución completa del cuadro neurológico. A propósito de un caso pediátrico / Acute flaccid paralysis related to enterovirus with complete resolution of the neurological symptoms. A pediatric case report

Desde la eliminación de la circulación del virus polio salvaje, disminuyeron los casos de parálisis fláccida aguda. Sin embargo, continúan ocurriendo casos asociados a otros enterovirus no polio y virus neurotropos. Se presenta el caso de una paciente de 9 años con diagnóstico de meningitis y mielitis con compromiso motor en los miembros inferiores y vejiga neurogénica asociado a enterovirus, con resolución completa del cuadro neurológico posterior a la administración de gammaglobulina hiperinmune.

Since the wild poliovirus no longer circulates, the number of cases of acute flaccid paralysis decreased. However, cases related to non-polio enteroviruses and neurotrope viruses continue to occur. We present a nine-year-old patient with meningitis and myelitis with motor involvement in the lower limbs and neurogenic bladder associated with enterovirus, with complete resolution of the neurological symptoms following the administration of hyperimmune gammaglobulin.

[Acute flaccid paralysis related to enterovirus with complete resolution of the neurological symptoms. A pediatric case report]. / Parálisis fláccida aguda por enterovirus con resolución completa del cuadro neurológico. A propósito de un caso pediátrico.

Since the wild poliovirus no longer circulates, the number of cases of acute flaccid paralysis decreased. However, cases related to non-polio enteroviruses and neurotrope viruses continue to occur. We present a nine-year-old patient with meningitis and myelitis with motor involvement in the lower limbs and neurogenic bladder associated with enterovirus, with complete resolution of the neurological symptoms following the administration of hyperimmune gammaglobulin.

Desde la eliminación de la circulación del virus polio salvaje, disminuyeron los casos de parálisis fláccida aguda. Sin embargo, continúan ocurriendo casos asociados a otros enterovirus no polio y virus neurotropos. Se presenta el caso de una paciente de 9 años con diagnóstico de meningitis y mielitis con compromiso motor en los miembros inferiores y vejiga neurogénica asociado a enterovirus, con resolución completa del cuadro neurológico posterior a la administración de gammaglobulina hiperinmune.

Hepatitis E virus is not detected in association with neurological disorders among Brazilian children.

Hepatitis E virus is increasingly being associated with idiopathic neurological disease. We tested 325 stool samples from Brazilian children presenting acute flaccid paralysis or Guillain-Barré syndrome using a broadly reactive and sensitive Reverse-transcription Polymerase chain reaction. Hepatitis E genome was not detected in any of the samples tested. Our results suggest that hepatitis E virus does not seem to be associated as the etiologic agent of acute flaccid paralysis and Guillain-Barré syndrome cases occurred in Brazilian children during the period of investigation (2010-2012).

Parálisis ácida aguda "polio-like" (Brote de 10 casos presentados en Buenos Aires - Argentina en 2016) / Acute acid paralysis "polio-like" (Outbreak of 10 cases presented in Buenos Aires - Argentina in 2016)

Resumen Objetivo Reportar un brote de 10 casos de mielopatías ácida aguda asimétrica por compromiso de la motoneurona espinal. Material y métodos: Relación V/M: 6/4 media de edad de 3 años, todos con parálisis ácida aguda, analizamos sus aspectos clínicos, etiológicos, neurorradiológicos, terapéuticos y evolutivos. Resultados: 8 presentaron parálisis áccida de miembros superiores asimétrica, 1 monoplejía de miembro inferior izquierdo, 1 hemiparesia, 5 sumaron compromiso de pares craneanos y 4 requirieron asistencia respiratoria mecánica. Todos coincidieron con catarro de vía aérea superior y/o ebre. La resonancia magnética medular fue anormal en todos, identi cando dos patrones de imágenes: uno lineal relacionado al compromiso del asta anterior y otro más heterogéneo con médula espinal engrosada, sin refuerzo con contraste, 5/10 presentaron además compromiso bulbo-protuberancial. Ninguno presento lesiones supratentoriales. En 4/10 identi camos enterovirus humano subtipo D68 HEV-D68) en secreciones de vía aérea y en 1/10 de ellos también en LCR. En el resto se detectaron otros enterovirus A, B y C, en uno rinovirus y otro In uenza. Nueve pacientes recibieron como tratamiento gammaglobulina y corticoides y 4 además recambio plasmático terapéutico sin mejoría clínica. Conclusiones: Ante una parálisis ácida aguda es importante descartar el HEV-D68. Consideramos los casos no detectados como "falsos negativos" dado que las muestras fueron tomadas tardíamente. Los otros virus identi cados no se han relacionado a mielopatías. Si bien la siopatología no es clara la ausencia de respuesta a tratamiento antin amatorio e inmunomodulador orienta a un mecanismo de agresión directa del virus. Se trata del primer reporte por HEV-D68 en Latinoamérica.

Abstract Objective: To report an outbreak of 10 cases of acute asymmetric accid myelopathy due to spinal motor neuron injury. Material and methods: Ten children, six male, with a mean age of 3 years presented with acute accid myelitis. We analyzed clinical features, etiology, neuroradiological images, treatment, and outcome. Results: Eight children had bilateral and asymmetric accid myelitis of the upper limbs, 1 had upper limb monoplegia, and 1 presented with hemiparesis. The cranial nerves were involved in 5 patients and 4 required mechanical ventilation. In all cases acute accid myelitis co-occurred with upper airway infection and/or fever. Spinal cord magnetic resonance imaging was abnormal in all, showing 2 di erent patterns: A linear pattern involving the anterior horns and another that was more heterogeneous showing spinal cord expansion. The lesions were non-enhancing in all. In 5/10 patients involvement of the medulla oblongata and pons was also observed. None of the patients presented with supratentorial lesions. In 4/10 children, the human enterovirus subtype D68 (HEV-D68) was identi ed in the airway and in 1/10 in the cerebrospinal uid as well. In the remaining patients di erent enterovirus species A, B, and C variants were detected, as well as rhinovirus in 1 and in uenza in another. Nine children received treatment with intravenous immunoglobulin and steroids and 4 of these children also underwent plasma exchange. Treatment did not lead to clinical improvement. Conclusions: In a patient with acute accid myelitis, HEV-D68 infection should be ruled out. Cases in which the virus was not detected were considered as "false negatives" as samples were collected late in course of the disease. The lack of response to anti-in ammatory and immunomodulatory treatment suggests a direct viral mechanism. This study is to our knowledge the rst on an HEV-D68-infection-related report in Latin America.

Infecciones por el virus EV-D68 en niños hospitalizados en un hospital de alta complejidad / EV-D68 virus infections in children admitted to a tertiary-care hospital

Introducción: Los reportes de infecciones por enterovirus D68 (EV-D68) han aumentado en los últimos años. Material y métodos: Cohorte prospectiva. Se realizó la búsqueda de EV-D68 en niños internados en el Hospital de Pediatría Juan P. Garrahan entre 1-5-2016 y 30-9-2016 con: infección respiratoria aguda baja (IRAB) que requirieran cuidados intensivos, parálisis aguda fláccida (PAF) asimétrica con compromiso de sustancia gris en resonancia magnética nuclear (RMN) o identificación de cualquier enterovirus con cuadro clínico compatible. La identificación de EV-D68 se realizó en el Servicio de Neurovirus, Instituto Nacional de Enfermedades Infecciosas INEI-ANLIS "Dr. CG. Malbrán". Resultados: n: 6. PAF: cuatro niños presentaron PAF asimétrica, con arreflexia y RMN compatible con mielitis. Requirieron ventilación mecánica en unidades de cuidados intensivos (UCI) dos de los 4 niños. Todos presentaron parálisis residual. Se identificó EV-D68 en secreciones nasofaríngeas (SNF) de todos ellos. En líquido cefalorraquídeo sólo en uno. Miocarditis: Una niña sana de 5 años se internó en UCI por disfunción miocárdica y fiebre. Presentaba además derrame pericárdico moderado. Recibió gamaglobulina e.v. con buena evolución. En SNF se identificaron virus sincicial respiratorio (VSR) y EV-D68. IRAB grave: se identificó EV-D68 en un paciente de 14 meses que permaneció en UCI por IRAB grave con requerimientos de ventilación no invasiva por 72 hs, con buena evolución posterior. Se constató coinfección VSR y EV-D68 en SNF. Conclusiones: Se reportan 6 pacientes internados con infección por EV-D68. La vigilancia epidemiológica activa es esencial para identificar la circulación, las características clínicas y el pronostico de las infecciones por virus emergentes (AU)

Introduction: Reports on enterovirus D68 (EV-D68) infections have increased over the past years. Material and methods: A prospective cohort study. A search for EV-D68 infection was conducted in children hospitalized at Hospital de Pediatría Juan P. Garrahan between 1-5-2016 and 30-9-2016 with: acute lower respiratory infection (ALRI) requiring intensive care unit (UCI) admission, acute flaccid paralysis (AFP), asymmetry with grey matter involvement on magnetic resonance imaging (MRI), or identification of any enterovirus associated with compatible features. The identification of EV-D68 was performed at the Department of Neuroviruses of the InstitutoNacional de EnfermedadesInfecciosas INEI-ANLIS "Dr. CG. Malbrán". Results: n: 6. AFP: four children had asymmetric AFP with areflexia and MRI compatible with myelitis. Two of four required mechanical ventilation in the ICU. All of them presented with residual paralysis. EV-D68 was identified in the nasopharyngeal swab (NPS) in all of them and in the cerebrospinal fluid in only one. Myocarditis: A 5-year-old healthy girl was admitted to the ICU because of myocardial dysfunction and fever associated with moderate pericardial effusion. She was put on IV gamma globulin with a good response. In the NPS respiratory syncytial virus (RSV) and EV-D68 were identified. Severe ALRI: EV-D68 was identified in a 14-month-old patient who was admitted to the UCU because of severe ALRI requiring non-invasive ventilation for 72 hours with a good outcome. A RSV and EV-D68 coinfection was found in the NPS. Conclusions: We report six inpatients with a EV-D68 infection. Active epidemiological surveillance is crucial to identify circulation of the virus, clinical features, and prognosis of emerging viruses (AU)

Acute flaccid paralysis laboratorial surveillance in a polio-free country: Brazil, 2005-2014.

The last case of paralytic poliomyelitis caused by wild poliovirus in Brazil occurred in 1989. The interruption of the indigenous poliovirus transmission was obtained through mass immunization campaigns to eligible children and an active epidemiological and laboratorial surveillance of all cases of acute flaccid paralysis (AFP) among children under 15 y of age. This paper describes and evaluates the performance of the AFP surveillance system in different geographic areas of Brazil between 2005 and 2014, using indicators recommended by WHO. AFP surveillance indicators as well as virological investigation of polio and non-polio enteroviruses in stool samples received in the laboratory were assessed from 2005-2014. During the period, 5463 cases of AFP were investigated. Of these, 55% were males and 45% were females. Those under 5 y of age represented 48% of all cases reported and investigated. AFP notification rate was within the acceptable values with mean value of 1.3 (North), 1.4 (Northeast), 1.1 (Southern), 1.0 (Southeast) and 1.4 (Midwest) cases of AFP per 100.000 population aged 15 y as well as the adequacy of fecal specimens received in the laboratory. Sabin- related polioviruses accounted for 1.7% of the isolates while, 6.7% were non-polio enterovirus with the values ranging from 5.0% to 8.9 %. No wild-type polio was found. The AFP epidemiological and laboratorial surveillance activities have been kept at appropriate levels in Brazil. These data are a very strong indication, which supports the status of country free of polio.

Zika Virus Infection and Guillain-Barré Syndrome in Three Patients from Suriname.

We present three patients from Suriname who were diagnosed with Guillain-Barré syndrome (GBS) during the Zika virus (ZIKV) outbreak in this country. One patient had a positive ZIKV urine real-time RT-PCR (qRT-PCR) result. The other two patients had a negative ZIKV urine qRT-PCR but a positive virus neutralization test and presence of IgG antibodies against ZIKV in the serum. Considering the evidence of a past ZIKV infection and absence of evidence for recent infections with the most common preceding infections of GBS, it is very likely that these GBS cases were triggered by ZIKV.

Introduction of sequential inactivated polio vaccine-oral polio vaccine schedule for routine infant immunization in Brazil's National Immunization Program.

In August 2012, the Brazilian Ministry of Health introduced inactivated polio vaccine (IPV) as part of sequential polio vaccination schedule for all infants beginning their primary vaccination series. The revised childhood immunization schedule included 2 doses of IPV at 2 and 4 months of age followed by 2 doses of oral polio vaccine (OPV) at 6 and 15 months of age. One annual national polio immunization day was maintained to provide OPV to all children aged 6 to 59 months. The decision to introduce IPV was based on preventing rare cases of vaccine-associated paralytic polio, financially sustaining IPV introduction, ensuring equitable access to IPV, and preparing for future OPV cessation following global eradication. Introducing IPV during a national multivaccination campaign led to rapid uptake, despite challenges with local vaccine supply due to high wastage rates. Continuous monitoring is required to achieve high coverage with the sequential polio vaccine schedule.

Fortalecimiento de la vigilancia integrada de poliomielitis y otras enfermedades inmunoprevenibles en Angola basadas en la experiencia cubana / Strengthening of comprehensive surveillance of poliomyelitis and other immunopreventable diseases in Angola on the basis of the Cuban experience

Múltiples han sido los esfuerzos que se han llevado a cabo por la Organización Mundial de la Salud para la erradicación de la poliomielitis en el mundo, enfermedad que muestra una parálisis irreversible para toda la vida, acompañada de consecuencias económicas para la persona afectada y su entorno familiar. Por primera vez se lleva a cabo un proyecto de cooperación técnica entre países, fuera de las Américas, donde se puso de manifiesto una vez más la capacidad, fortaleza, entrega y potencialidad de la medicina cubana en el mundo. Participaron 20 médicos cubanos en una primera etapa (enero- julio 2008) y 7 en una segunda etapa (enero-abril 2009). El objetivo de esta colaboración se centró en el trabajo integral de grupo, en el fortalecimiento de la vigilancia, control de las enfermedades inmunoprevenibles, mejora de las coberturas de vacunación de rutina, formación de recursos humanos y apoyo en las campañas de vacunación. Se logró sensibilizar a una gran cantidad de personal de salud y a la comunidad para la identificación de las parálisis flácidas agudas, así como de otras enfermedades inmunoprevenibles; se fortaleció la búsqueda activa de casos y se reforzó la vigilancia, así como el apoyo y monitoreo de la calidad de las campañas de vacunación. Se trabajó por incrementar las coberturas de vacunación de rutina y la vigilancia integrada de estas dolencias. Una vez más se demuestra la incondicionalidad de los médicos cubanos para mitigar el dolor que causan estas enfermedades, acompañado del gran valor humano de la medicina cubana.

Many efforts have been made by the World Health Organization to eradicate poliomyelitis worldwide, a disease that causes irreversible paralysis for life in addition to adverse economic effects for the patient and his/her family as well. For the first time, there is a technical cooperation project between countries outside The Americas, in which the capabilities, strength, commitment and potentialities of the Cuban medicine was again stressed in the world. Twenty Cuban physicians were involved in the first phase (January-July 2008) and 7 in the second phase (January-April 2009). The objective of this cooperation was focused on comprehensive teamwork, strengthening of surveillance, control of immunopreventable diseases, improvement of regular vaccination coverage, formation of human resources and support to vaccination campaigns. It was possible to make a large amount of health workers and the community sensitive to the detection of acute flaccid paralysis as well as other immnopreventable diseases, to strengthen active search of cases, to reinforce surveillance and to support and monitor the quality of vaccination campaigns. The participants worked towards increasing the regular vaccination coverage and the comprehensive surveillance of these illnesses. Once again the full dedication of the Cuban physicians to relieve pain caused by these diseases and the great human value of the Cuban medicine was demonstrated.