Characterization of oral virome and microbiome revealed distinctive microbiome disruptions in paediatric patients with hand, foot and mouth disease.

While the underlying determinants are unclear, hand, foot and mouth disease (HFMD) presents a wide spectrum of clinical manifestations with varying severity in different individuals. Recently, many studies identified the human microbiome as a critical factor in the pathogenesis of various diseases. Therefore, we here investigated the ecological dynamics of the oral microbiome changes during the HFMD infection. After targeted enrichment of all known vertebrate viruses, the virome profiles of symptomatic and asymptomatic HFMD patients were examined and revealed to be significantly altered from those of healthy individuals, with nine discriminative viruses detected. Further characterization of the prokaryotic microbiome revealed an elevated level of Streptococcus sp. as the most important signature of the symptomatic HFMD cohort, positively correlating to the level of enterovirus A RNA. In addition, we found that while coxsackievirus A5 is detected in saliva RNA of all asymptomatic cases, coxsackievirus A6 dominates the majority of the symptomatic cohort.

Enfermedad de mano-pie-boca atípica causada por virus Coxsackie A6 en Argentina, 2015 / Atypical hand, foot, and mouth disease caused by Coxsackievirus A6 in Argentina in 2015

We present two groups of cases of atypical hand, foot, and mouth disease (HFMD) caused by Coxsackievirus A6 (CV-A6) detected in Argentina in 2015. The first group involved 14 patients from Chubut province and the second group affected 12 patients from San Luis province. Molecular analysis of the complete VP1 protein gene revealed the circulation of E2 sublineage, the most predominant worldwide. To our knowledge, this is the first report of CV-A6 infections associated with atypical HFMD in Argentina and South America.

Se describen dos grupos de casos de enfermedad de mano-pie-boca (HFMD) atípica causada por el virus Coxsackie A6 (Coxsackievirus A6, CV-A6) detectados en Argentina en el año 2015. El primero de los grupos involucró a 14 pacientes de Chubut y el segundo a 12 pacientes de San Luis. El análisis molecular del gen de la proteína VP1 completa reveló la circulación del sublinaje E2, el predominante a nivel global. Hasta donde sabemos, este es el primer reporte de infecciones CV-A6 asociadas con HFMD atípica en Argentina y Sudamérica.

Clinical characteristics and managements of severe hand, foot and mouth disease caused by enterovirus A71 and coxsackievirus A16 in Shanghai, China.

BACKGROUND: Hand, foot and mouth disease (HFMD) is a transmissible infectious disease caused by human enteroviruses (EV). Here, we described features of children with severe HFMD caused by EV-A71 or coxsackievirus A16 (CV-A16) in Shanghai, China. METHODS: Severe EV-A71 or CV-A16 caused HFMD children admitted to the Xinhua Hospital from January 2014 and December 2016, were recruited retrospectively to the study. Symptoms and findings at the time of hospitalization, laboratory tests, treatments, length of stay and residual findings at discharge were systematically recorded and analyzed. RESULTS: Of 19,995 children visited clinic service with probable HFMD, 574 children (2.87%) were admitted, 234 children (40.76%) were confirmed with EV-A71 (90/574) or CV-A16 (144/574) disease. Most (91.02%) of the patients were under 5 years. Initial clinical symptoms of EV-A71 and CV-A16 cases were: fever > 39 °C in 81 (90%) and 119 (82.63%), vomiting in 31 (34.44%) and 28 (19.44%), myoclonic twitching in 19 (21.11%) and 11(7.64%), startle in 21 (23.33%) and 20 (13.69%), respectively. Serum levels of interleukin-1ß (IL-1ß), IL-2, IL-6, IL-8, interferon-γ (IFN-γ), tumor necrosis factor-α (TNF-α) were significantly upregulated in severe HFMD subjects. Forty-seven children (20.08%) treated with intravenous gamma globulin (IVIG) showed decreased duration of illness episodes. All children were discharged without complications. CONCLUSIONS: EV-A71 and CV-A16 accounted 40.76% of admitted HFMD during 2014 to 2016 in Xinhua Hospital. IVIG appeared to be beneficial in shortening the duration of illness episodes of severe HFMD.

The gut microbiota of hand, foot and mouth disease patients demonstrates down-regulated butyrate-producing bacteria and up-regulated inflammation-inducing bacteria.

AIM: This study explored the gut microbiota of children with hand, foot and mouth disease (HFMD). METHODS: We enrolled 15 cases with HFMD admitted to the West China Second Hospital, Sichuan University, China, from July to September 2016 at a median age of three years. The controls were 15 healthy children of a similar age who underwent routine health examinations at the hospital during the same period. Gut microbiota was analysed using high throughput 16S ribosomal deoxyribonucleic acid sequencing. RESULTS: The gut microbiota in the HFMD patients was distinct from the controls. Compared with the controls, the composition of gut microbiota in the HFMD cases represented a reduction of two butyrate-producing bacteria, Ruminococcus (0.73 ± 1.28 versus 7.78 ± 20.01, p = 0.026) and Roseburia (0.67 ± 1.69 versus 1.61 ± 3.27, p = 0.024) and an up-regulation of Escherichia (5.26 ± 10.50 versus 1.59 ± 5.90,p < 0.01) and Enterococcus (4.12 ± 12.49 versus 0.12 ± 0.41, p = 0.015). CONCLUSION: The dysbiosis of gut microbiota of the HFMD cases included a reduction of butyrate-producing bacteria and an up-regulation of inflammation-inducing bacteria. These may have impaired the intestinal biological mucosal barrier and host immune functions, promoting the invasion of the enterovirus.

Spatiotemporal decomposition and risk determinants of hand, foot and mouth disease in Henan, China.

Hand, foot and mouth disease (HFMD) remains an increasing public health concern. The spatiotemporal variation of HFMD can be represented from multiple-perspectives, and it may be driven by different dominant factors. In this study, the HFMD cases in children under the age of five years in each county in Henan province, China, from 2009 to 2013 were assessed to explore the integrative spatiotemporal patterns of HFMD and investigate their driving factors. The empirical orthogonal function was applied to identify representative spatiotemporal patterns. Then, GeoDetector was used to quantify the determinant powers of driving factors to the disease. The results indicated that the most prominent spatiotemporal pattern explained 56.21% of the total variance, presented in big cities, e.g. capital city and municipal districts. The dominant factors of this pattern were per capita gross domestic product and relative humidity, with determinant powers of 62% and 42%, respectively. The secondary spatiotemporal pattern explained 10.52% of the total variance, presented in the counties around big cities. The dominant factors for this pattern were the ratio of urban to rural population and precipitation, with determinant powers of 26% and 41%, respectively. These findings unveiled the key spatiotemporal features and their determinants related to the disease; this will be helpful in establishing accurate spatiotemporal preventing of HFMD.

Enfermedades exantemáticas virales: aspectos clinicoepidemiológicos y de laboratorio / Exanthematous viral diseases: clinical and laboratory aspects

Los cuadros exantemáticos tienen frecuentemente origen infeccioso; los virus son una causa importante de exantema. Los exantemas más relevantes son, entre los maculopapulosos, el sarampión, la rubéola, el eritema infeccioso y el exantema súbito y, entre los vesiculoampollosos, la varicela, el zóster y la enfermedad boca-mano-pie. Algunas de las anteriores, y otras infecciones virales, causan exantemas purpúricos que pueden ser de mayor gravedad. El diagnóstico de laboratorio se realiza de forma directa, mediante el aislamiento, la detección de antígenos o la detección del ácido nucleico viral, siendo esta última la aproximación más adecuada; o, serológicamente, por detección de IgM específica, que proporciona diagnóstico temprano, o de seroconversión. En general, ambas herramientas metodológicas se complementan para mejorar el rendimiento diagnóstico. La caracterización molecular es una importante actividad de laboratorio, especialmente para los virus del sarampión y de la rubéola, en el contexto del plan de eliminación de estas enfermedades (AU)

Exanthematous diseases frequently have an infectious origin; viruses are a major cause of rashes. The most notable maculopapular rashes are measles, rubella, infectious erythema and exanthem subitum, while the vesicular rashes include varicella (and zoster) and hand-foot-and-mouth disease. Some of the above and other viral infections cause purpuric rashes, which may be more severe. Laboratory diagnosis is performed directly, by viral isolation, antigen detection or viral nucleic acid detection, the latter being the best approach; or serologically, by detection of specific IgM (providing rapid diagnosis) or seroconversion. Both methodological tools generally complement each other to improve diagnostic performance. Molecular characterization is an important laboratory procedure, especially for the measles and rubella viruses, in the context of the plan for the elimination of these diseases (AU)

Short-term impacts of floods on enteric infectious disease in Qingdao, China, 2005-2011.

The current study aimed to examine the relationship between floods and the three enteric infectious diseases, namely bacillary dysentery (BD), hand-foot-mouth disease (HFMD) and other infectious diarrhoea (OID) in Qingdao, China. Relative risks (RRs) and 95% confidence intervals (CIs) of floods on BD, HFMD and OID were calculated using a quasi-Poisson generalized linear model, adjusting for daily average temperature, daily average relative humidity, and seasonal and long-term temporal trends. Two separate models within two different periods were designed. Model 1 for the summer period showed that floods were positively associated with BD for 4- to 12-day lags, with the greatest effects for 7-day (RR 1·41, 95% CI 1·22-1·62) and 11-day (RR 1·42, 95% CI 1·22-1·64) lags. Similar findings were found in model 2 for the whole study period for 5- to 12-day lags. However, HFMD and OID were not significantly associated with floods in both models. Results from this study will provide insight into the health risks associated with floods and may help inform public health precautionary measures for such disasters.

An outbreak of Kingella kingae infections associated with hand, foot and mouth disease/herpangina virus outbreak in Marseille, France, 2013.

BACKGROUND: Outbreaks of invasive Kingella kingae infections recently emerged as a new public health concern in daycare centers in Europe, USA and Israel. Despite this, no trigger factor has been yet identified, preventing the setting up of rational measures of control and prevention. We report an outbreak of K. kingae infections associated with hand, foot and mouth disease/herpangina outbreak, and we define the research and policy priorities. METHODS: From April 22 to May 07, 2013, 5 toddlers presented successive osteo-articular infections in a daycare center in Marseille, France. Real-time polymerase chain reaction targeting the cpn60 gene of K. kingae was used to investigate suspected cases and the prevalence of oropharyngeal K. kingae carriage of their close contacts. RESULTS: The attack rate of the K. kingae infections outbreak was 23.7% (5/21) with no fatality. Positive real-time polymerase chain reaction targeting the cpn60 gene of K. kingae confirmed the diagnosis in 3 cases and revealed a rate of K. kingae oropharynx carriage in the index classroom of 94.4% (17/18) among daycare attendees not given antibiotic during the previous month, and of 76.9% (10/13) among staff in close contact. The eradication rate of K. kingae was 21.4% (3/14) among classmates after oral administration of rifampicin, and eradication occurred spontaneously in 83.3% (5/6) of the staff. Clinical and epidemiological features of the herpangina outbreak were consistent with that of an emerging European Coxsackievirus-A6 outbreak. CONCLUSIONS: Hand, foot and mouth disease/herpangina virus outbreak enables triggering a K. kingae infections outbreak. Our findings offer support for new guidelines of K. kingae infections outbreaks management and emphasize the need for further research.

Epidemiological and clinical characteristics of children who died from hand, foot and mouth disease in Vietnam, 2011.

BACKGROUND: In 2011, a large outbreak of hand, foot and mouth disease (HFMD) in Vietnam resulted in 113,121 children seeking medical attention, of whom170 died. Understanding the epidemiology of fatal HFMD may improve treatment and help targeting prevention activities for vulnerable populations. We describe epidemiological and clinical characteristics of children who died from HFMD in Vietnam in 2011. METHODS: Clinical data were obtained through reviewing medical records of the deaths occurring from January through December 2011 in all hospitals in Vietnam. Hospitals reported any deaths among patients with laboratory-confirmed enterovirus (EV) infection to the Ministry of Health. Data were extracted from the national database. RESULTS: Of the 169 deaths reviewed for whom records were available, 87% were 3-year-old or younger, 69% were male, 18% attended daycare, 89% lived in Southern Vietnam, and 85% of the deaths occurred between May-October 2011. One hundred thirty (77%) cases sought treatment in a hospital within three days of onset of illness. Symptoms at admission included fever (98%), myoclonus (66%), vomiting (53%), oral ulcers (50%) and vesicular erythema (50%). One hundred six (75%) cases had leukocytosis and 91 (54%) had hyperglycemia. One hundred three (61%) tested positive for EV, of which 84 (82%) were positive for EV71. CONCLUSIONS: Deaths associated with HFMD occurred throughout 2011 among males three years or younger who were cared for at home. The HFMD control program should focus on interventions at the household level. Clinicians should be alerted to symptoms suggestive of severe HFMD including fever, myoclonus, vomiting, oral ulcers and vesicles with high white blood cell count especially in young children.

[Experimental studies on infant Tupaia belangeri chineses with EV71 infection].

Tupaia belangeri are small mammals with a squirrel-like appearance; they were formerly classified under the primates order despite the lack of derived features characteristic of primates. Given that T. belangeri are easy to raise, cheap to maintain, and have a small body size, a high reproductive rate, and close affinity to primates, these animals would be used as an alternative to primates in biomedical research. Three-month old T. belangeri chineses were infected with enterovirus 71 (EV71) via three different routes, namely, oral administration, nasal dripping, and tail intravenous injection, to study the infection in infant T. belangeri and find a feasible scheme to make them an ideal animal model of EV71 in place of primates. Daily activities were regularly observed, body temperatures were measured, and blood tests were conducted. Blood and fecal samples were regularly collected. The infection was examined via the neutralizing antibody test, reverse transcription polymerase chain reaction (RT-PCR), Real-Time PCR, and pathological analysis. The temperature, as well as the white blood cell count and the number of lymphocytes, increased four days after infection. Virus loads were determined in all three groups, and the peak appeared on, before, or after the tenth day, respectively. Thus, oral administration proved to be the best route. The highest serum antibody titer obtained was 1:16. Acute paralysis with urinary retention manifested after about two weeks, and pathological changes were observed in the brain, heart, lung, spleen, kidney, and other tissues. In conclusion, T. belangeri chineses can infected with EV71 via oral administration, nasal dripping, and tail intravenous injection. Therefore, T. belangeri are potential EV71 animal models for further studies on the mechanism of pathogenesis or vaccine evaluation.

Serum microRNA expression profile distinguishes enterovirus 71 and coxsackievirus 16 infections in patients with hand-foot-and-mouth disease.

Altered circulating microRNA (miRNA) profiles have been noted in patients with microbial infections. We compared host serum miRNA levels in patients with hand-foot-and-mouth disease (HFMD) caused by enterovirus 71 (EV71) and coxsackievirus 16 (CVA16) as well as in other microbial infections and in healthy individuals. Among 664 different miRNAs analyzed using a miRNA array, 102 were up-regulated and 26 were down-regulated in sera of patients with enteroviral infections. Expression levels of ten candidate miRNAs were further evaluated by quantitative real-time PCR assays. A receiver operating characteristic (ROC) curve analysis revealed that six miRNAs (miR-148a, miR-143, miR-324-3p, miR-628-3p, miR-140-5p, and miR-362-3p) were able to discriminate patients with enterovirus infections from healthy controls with area under curve (AUC) values ranged from 0.828 to 0.934. The combined six miRNA using multiple logistic regression analysis provided not only a sensitivity of 97.1% and a specificity of 92.7% but also a unique profile that differentiated enterovirial infections from other microbial infections. Expression levels of five miRNAs (miR-148a, miR-143, miR-324-3p, miR-545, and miR-140-5p) were significantly increased in patients with CVA16 versus those with EV71 (p<0.05). Combination of miR-545, miR-324-3p, and miR-143 possessed a moderate ability to discrimination between CVA16 and EV71 with an AUC value of 0.761. These data indicate that sera from patients with different subtypes of enteroviral infection express unique miRNA profiles. Serum miRNA expression profiles may provide supplemental biomarkers for diagnosing and subtyping enteroviral HFMD infections.

Sentinel surveillance for enterovirus 71, Taiwan, 1998.

Outbreaks of enterovirus 71 have been reported around the world since 1969. The most recent outbreak occurred in Taiwan during April-July 1998. This hand, foot, and mouth disease epidemic was detected by a sentinel surveillance system in April at the beginning of the outbreak, and the public was alerted.

Complete nucleotide sequence of a coxsackie B5 virus and its relationship to swine vesicular disease virus.

We report the first complete nucleotide sequence of the picornavirus coxsackievirus B5 (CB5), strain 1954/UK/85, an isolate from a case of hand-foot-and-mouth disease. We have compared the sequence with those of other coxsackie B viruses, coxsackievirus A9, poliovirus and swine vesicular disease virus (SVDV). The genes encoding the three major capsid proteins are most closely related to those of SVDV but the 5' and 3' noncoding regions and the P3 gene are more similar to the corresponding regions in the other coxsackie B viruses than to those of SVDV. These observations are considered in the light of the antigenic and biochemical relationships between SVDV and CB5.

Outbreak of enterovirus 71 infection in Victoria, Australia, with a high incidence of neurologic involvement.

An outbreak of infections caused by enterovirus 71 occurred in southeastern Australia during the winter of 1986. Infection was confirmed by virus isolation or serology in 114 patients, 65 of whom were admitted to hospital. Fifty-one percent of inpatients were infants younger than 12 months old and 85% were younger than 5 years old. Many cases of hand, foot and mouth disease occurred in the community during the epidemic, but 51% (33 of 65) of patients admitted to hospital had central nervous system involvement, often associated with severe symptoms. Six patients had encephalitis and one had a poliomyelitis-like paralytic illness. Various skin manifestations other than hand, foot and mouth disease occurred, especially in young children, and 25 patients had significant respiratory disease including at least 7 with pneumonia. Enterovirus 71 is one of very few viruses that cause hand, foot and mouth disease as well as a variety of other clinical manifestations. The most important of these is meningoencephalitis, which causes significant morbidity, especially in infants and young children.

Protective effect of interferon on infections with hand, foot, and mouth disease virus in newborn mice.

The protective effect of interferon on infection with coxsackievirus type A 16 (CA-16) or enterovirus type 71 (EV-71) in newborn mice was examined. Subcutaneous administration of murine interferon (MuIFN-alpha/beta) into the infected mice produced a protective effect against infection with CA-16 or EV-71. It was found that the time of administration of MuIFN was important in relation to the cycle of infection. Protection was observed when MuIFN was given once daily for several days, from one day before or after infection with the lethal dose of CA-16 or EV-71. These results suggest that interferon may directly suppress infection with CA-16 and not indirectly suppress it by the medium of macrophages, natural killer cells, and T cells.

Oligonucleotide fingerprint analysis of coxsackievirus A10 isolated in Japan.

Eight coxsackievirus A10 strains isolated in 1978 and in 1981 and 1982 from patients with hand, foot-and-mouth disease and with herpangina at a dispensary in Matsue city were compared by RNA fingerprinting techniques. The oligonucleotide maps of the four 1978 isolates were related to each other by 85 to 93% with respect to their large T1 oligonucleotides. In contrast, the oligonucleotide maps of the four 1981 and 1982 isolates were very different from each other. Co-electrophoresis experiments revealed that the 1981 and 1982 strains shared only 17 to 34% of their large oligonucleotides. In addition, some large oligonucleotides were found in most of the fingerprint maps of isolates from 1978 to 1982, suggesting that there are regions in the genome of coxsackievirus A10 which are not subject to mutational changes.