The role of respiratory virus infection in suspected pertussis: A prospective study.

BACKGROUND: Infections caused by Bordetella pertussis are frequent and responsible for cases of huge severity in unvaccinated young infants. However, clinical manifestations vary and mimic other respiratory diseases as respiratory viruses. METHODS: A prospective cohort study was performed with infants under 1 old, hospitalized with suspected pertussis. All infants were submitted to etiological research to identify Bordetella pertussis (nasopharynx swab for culture and/or PCR) and respiratory viruses (nasopharyngeal aspirate for indirect immunofluorescence). Clinical and demographic data were collected. RESULTS: Among 59 infants, an etiological agent was identified in 37 (62.8%). Respiratory virus was identified in 19 (32%) and Bordetella pertussis in 14 (23.7%) as sole agent. Codetection was found in 4 (7%). Younger age, absence of fever, lack of BP immunization, leukocytosis > 20,000/mm3, lymphocytosis >10,000/mm3 were associated to a greater chance of pertussis. Wheezing and living with siblings were associated with viral infection. After adjustment for confounders, the most important predictors were presence of wheezing for respiratory virus and leukocytosis for pertussis. The severity of infections by RV and BP were similar. CONCLUSION: Respiratory virus infections are frequent in cases of clinical suspicion of pertussis and may actually exceed the prevalence of BP. Clinical/laboratory characteristics may suggest the etiology, but they are not pathognomonic, which stresses the need for respiratory virus and Bordetella pertussis research in this clinical situation.

Tick-Borne Encephalitis: A Differential Pattern of Intrathecal Humoral Immune Response and Inflammatory Cell Composition Compared with Other Viral CNS Infections.

To investigate whether and how cerebrospinal fluid (CSF) findings can contribute to distinguish tick-borne encephalitis (TBE) from herpes simplex virus (HSV) and varicella zoster virus (VZV) induced central nervous system (CNS) infections (HSV-I, VZV-I). Chart review and identification of TBE, HSV- I, and VZV-I was carried out, fulfilling the following criteria: (1) clinical signs of encephalitis and/or meningitis, (2) complete CSF analysis and confirmed viral etiology by either PCR or antibody testing in CSF, (3) hospitalized patients, and (4) available brain magnetic resonance imaging (MRI). Fifty-nine patients with 118 CSF/serum pairs were included. These comprised 21 with TBE (35 CSF/serum pairs), 20 (40 CSF/serum pairs) with HSV-I, and 18 (43 CSF/serum pairs) with VZV-I. In contrast to HSV-I and VZV-I, CSF cell differentiation in TBE showed more often an increased (>20%) proportion of granulocytes (p < 0.01) and a more frequent quantitative intrathecal IgM synthesis (p = 0.001 and p < 0.01, respectively), while the second was even more pronounced when follow-up CSF analyses were included (p < 0.001). CSF findings help to distinguish TBE from other viral infections. In cases with CSF pleocytosis and a positive history for a stay in or near an endemic area, TBE antibodies in CSF and serum should be determined, especially if granulocytes in CSF cell differentiation and/or an intrathecal IgM synthesis is present.

Epidemiological and clinical characteristics of 1663 hospitalized patients infected with COVID-19 in Wuhan, China: a single-center experience.

BACKGROUND: The COVID-19 outbreak in late December 2019 has quickly emerged into pandemic in 2020. We aimed to describe the epidemiology and clinical characteristics of hospitalized COVID-19 patients, and to investigate the potential risk factors for COVID-19 severity. METHOD: 1663 hospitalized patients with laboratory-confirmed diagnosed COVID-19 from Tongji Hospital between January 14, 2020, and February 28, 2020 were included in the present study. Demographic information, exposure history, medical history, comorbidities, signs and symptoms, chest computed tomography (CT) scanning, severity of COVID-19 and laboratory findings on admission were collected from electronic medical records. Multivariable logistic regression was used to explore the association between potential risk factors with COVID-19 severity. RESULTS: In the present study, the majority (79%) of 1663 COVID-19 patients were aged over 50 years old. A total of 2.8% were medical staff, and an exposure history of Huanan seafood market was document in 0.7%, and 7.4% were family infection. Fever (85.8%), cough (36.0%), fatigue (23.6%) and chest tightness (11.9%) were the most common symptoms in COVID-19 patients. As of February 28, 2020, of the 1663 patients included in this study, 26.0% were discharged, 10.2% were died, and 63.8% remained hospitalized. More than 1/3 of the patients had at least one comorbidity. Most (99.8%) patients had abnormal results Chest CT, and the most common manifestations of chest CT were local patchy shadowing (70.7%) and ground-glass opacity (44.8%). On admission, lymphocytopenia was present in 51.1% of the patients, mononucleosis in 26.6%, and erythrocytopenia in 61.3%. Most of the patients had increased levels of C-reactive protein (80.4%) and D-dimer (64.4%). Compared with non-severe patients, severe patients had more obvious abnormal laboratory results related to inflammation, coagulation disorders, liver and kidney damage (all P < 0.05). Older age (OR = 2.37, 95% CI: 1.47-3.83), leukocytosis (OR = 2.37, 95% CI: 1.47-3.83), and increased creatine kinase (OR = 2.37, 95% CI: 1.47-3.83) on admission were significantly associated with COVID-19 severity. CONCLUSION: Timely medical treatment and clear diagnosis after the onset might be beneficial to control the condition of COVID-19. Severe patients were more likely to be to be elder, and tended to have higher proportion of comorbidities and more prominent laboratory abnormalities. Older age, leukocytosis, and increased creatine kinase might help clinicians to identify severe patients with COVID-19.

Comparison of tick-borne encephalitis between children and adults-analysis of 669 patients.

The aim of our study was to compare the course of TBE in children and adults. A retrospective analysis of the medical records of 669 patients was performed. The patients were categorized into 2 groups: Group I with 68 children and group II with 601 adults. TBE symptoms in children were milder compared with adults, with meningitis in 97% of cases. In adults, meningoencephalitis and meningoencephalomyelitis made up 49.26% of cases. Nausea and vomiting are more frequent in children, while neurological manifestations are more frequent in adults. There were no differences in CSF pleocytosis at the onset of disease in both groups, while CSF protein concentration was higher in adults. Children treated with corticosteroids over 7 days had higher checkup pleocytosis than pleocytosis at the onset of disease compared with adults. Corticosteroid use prolongs the disease duration but does not influence the development of TBE sequelae. Children had more favourable outcomes than adult patients.

Prognostic Value of Leukocytosis and Lymphopenia for Coronavirus Disease Severity.

To evaluate lymphopenia as a marker for coronavirus disease severity, we conducted a meta-analysis of 10 studies. Severe illness was associated with lower lymphocyte and higher leukocyte counts. Using these markers for early identification of patients with severe disease may help healthcare providers prioritize the need to obtain therapy.

West Nile virus neuroinvasive disease associated with rituximab therapy.

West Nile virus neuroinvasive disease (WNVND) manifests with meningitis, encephalitis, and/or acute flaccid paralysis. It represents less than 1% of the clinical syndromes associated with West Nile virus (WNV) infection in immunocompetent patients. Immunosuppressive therapy is associated with increased risk of WNVND and worse prognosis. We present a patient with WNVND during therapy with rituximab, and a review of the literature for previous similar cases with the goal to describe the clinical spectrum of WNVND in patients treated specifically with rituximab. Our review indicates that the most common initial complaints are fever and altered mental status, brain magnetic resonance imaging often shows bilateral thalamic hyperintensities, and cerebrospinal analysis consistently reveals mild lymphocytic pleocytosis with elevated protein, positive WNV polymerase chain reaction, and negative WNV antibodies. Treatment is usually supportive care, with intravenous immunoglobulins (IVIG) plus corticosteroids and WNV-specific IVIG also used. The disease is usually fatal despite intervention. Our patient's presentation was very similar to prior reports, however demonstrated spontaneous improvement with supportive management only. WNVND is a rare and serious infection with poor prognosis when associated with rituximab therapy. Diagnosis is complicated by absent or delayed development of antibodies. The presence of bilateral thalamic involvement is a diagnostic clue for WNVND. There is insufficient evidence to recommend the use of corticosteroids or IVIG.

Infectious causes and outcomes in patients presenting with cerebral spinal fluid pleocytosis.

To evaluate the infectious etiologies, clinical features, and outcomes of patients with CNS infections at a tertiary care center. Patients that present with a pleocytosis in the cerebral spinal fluid (CSF), defined as a CSF WBC count > 5 cells/mm3, from July 2015 to June 2016 at a tertiary care hospital were analyzed for this report. Data from patients with confirmed (n = 43) and presumed (n = 51) CNS infections were analyzed. CNS infection was the leading known cause of CSF pleocytosis (n = 43, 18% of all patients with a pleocytosis in the CSF), and HSV-2 was identified as the leading causative pathogen (n = 10) followed by varicella zoster virus (n = 5). Fifty-three percent of patients with a pleocytosis in the CSF did not receive a diagnosis. In the patients that did not receive a diagnosis, CNS infection was presumed to be the cause in 51 patients (21% of patients with CSF pleocytosis). The mean time to diagnosis for patients with confirmed CNS infection was 16 days, but time to diagnosis was highly variable depending on the causative pathogen. There was a significant overlap in CSF parameters and peripheral white blood cell counts in patients diagnosed with a viral, bacterial, or fungal infection. Neuroimaging changes were present in only 44% of CNS infections. The overall mortality was 7% for CNS infections, and 17% of patients with a CNS infection had a severe neurologic deficit at presentation while only 3% had a severe deficit at the last neurologic assessment. This study provides new insights into the infectious causes of disease in a cohort of patients with pleocytosis in the CSF. The study provides new insights into the time to diagnosis and outcomes in patients that present with pleocytosis in the CSF.

Clinical features and laboratory findings in children hospitalized with acute Epstein-Barr virus infection: a crosssectional study in a tertiary care hospital.

Çaglar I, Topal S, Çokboz M, Düzgöl M, Kara A, Bayram SN, Apa H, Devrim I. Clinical features and laboratory findings in children hospitalized with acute Epstein-Barr virus infection: a cross-sectional study in a tertiary care hospital. Turk J Pediatr 2019; 61: 368-373. Epstein-Barr virus (EBV) is widespread all over the world. It causes infectious mononucleosis (IM) mostly in adolescents and adults. Although IM is considered to be rare in younger children and infants, acute EBV infection may have various manifestations in this age group. We aimed to describe the clinical features and laboratory findings of children hospitalized with acute EBV infection. All children hospitalized at Dr. Behçet Uz Children`s Hospital, between January 2010 and January 2017, who tested positive by presence of EBV-specific antibodies and had the diagnosis of acute EBV infection, were included (n=66). Thirty four of the patients (51.5%) were under 6 years of age, and 23 (34.8%) children were below 3 years of age. The most common physical finding was fever (92.4%) followed by cervical lymphadenopathy and tonsillopharyngitis. Leukocytosis (65.1%) and lymphocytosis (42.4%) were the most common laboratory findings. Reactive and atypical lymphocytes were present in 77.2% of the patients. Fifty-three (80.3%) of the patients had a doctor visit before hospitalization, and the ratio of patients using antibiotics was 77.3%. Skin rash was observed in 14 (27.4%) of the patients who used antibiotic treatment and in 2 (13.3%) of the patients who did not (p > 0.05). EBV infection resulting in admission to hospital is common in younger children, even in pre-school period. Serological tests for EBV specific antibody responses and peripheral blood smear evaluation are important diagnostic tools. In addition, rapid streptococcal antigen test and throat culture should be performed in patients presenting with tonsillopharyngitis in order to exclude Group A beta-hemolytic streptococci and reduce unnecessary antibiotic consumption.

Enterovirus and parechovirus infections in children: differences in clinical presentation, mechanisms for meningitis without pleocytosis and mechanisms involved in the neurological outcome.

Enterovirus (EV) and Parechovirus (HPeV) are a frequent cause of infection in children. This review gives an overview of possible causes for differences in clinical presentation. EV and HPeV can cause a meningitis with or without pleocytosis. Different possible mechanisms for meningitis without pleocytosis are given. Little is known about the prognosis and long-term effects of EV and HPeV meningitis in children. Only some studies with a small number of children with EV or HPeV meningitis are reported. The different possible mechanisms involved in the neurological outcome after EV or HPeV meningitis will be discussed.

Cerebrospinal fluid features in adults with enteroviral nervous system infection.

OBJECTIVES: The aim of this study was to investigate the clinical and laboratory features of adults with nervous system infections caused by enteroviruses, with special emphasis on cerebrospinal fluid (CSF). METHODS: The data of 46 patients who were PCR-positive for enteroviruses in the CSF between 2002 and 2017 were evaluated. RESULTS: Meningitis was the most common clinical manifestation (89%), followed by encephalitis (7%) and isolated cranial nerve involvement (4%). Twenty percent of patients reported a sudden onset of severe headache that led to the initial suspected diagnosis of subarachnoid haemorrhage. General signs of infection, such as fever, elevated C-reactive protein, and an elevated white blood cell count, were found in only 61%. Most patients exhibited consistent inflammatory CSF changes, with elevated cell counts (85%) and blood-CSF barrier dysfunction (83%). Patients with normal CSF cell counts were significantly older, less frequently presented with meningitis, and exhibited lower peripheral white blood cell counts. Sequencing revealed species Enterovirus B in all patients, with most sequences related to echovirus 30. CONCLUSIONS: The absence of CSF pleocytosis, isolated cranial nerve involvement, and only infrequent general signs of infection may impede the diagnosis of enteroviral nervous system infections. A thorough CSF analysis including PCR is essential for a reliable diagnosis.

Systemic Epstein-Barr virus-positive T-cell lymphoproliferative disorders of childhood with fulminant leukocytosis and tumor lysis: a case report with autopsy findings.

Systemic Epstein-Barr virus (EBV)-positive T-cell lymphoproliferative disorders (T-LPD) of childhood is an extremely rare disease characterized by an aggressive clinical course and very poor prognosis. We report an adolescent male with systemic EBV-positive T-LPD of childhood after primary EBV infection, resulting in a fatal clinical course within 9 days, along with autopsy findings. A 19-year-old male without an immunocompromised status presented with an acute onset of high fever, and was hospitalized for persistent fever, vomiting and diarrhea on the 5th day from onset. Laboratory data showed severe thrombocytopenia, increased ferritin level, liver dysfunction, disseminated intravascular coagulation, and anti-EBV-IgM positivity. Peripheral blood smears identified a number of atypical lymphocytes. Bone marrow aspiration revealed many atypical various-sized lymphocytes with apparent nucleoli and hemophagocytosis. Atypical lymphocytes displayed a CD8+ T-cell phenotype with monoclonal rearrangement of T-cell receptors. EBV-encoded RNA was also observed in lymphoid cells by in situ hybridization. The patient received dexamethasone and cyclosporine with no improvement, and died of tumor lysis by leukocytosis on the 9th day from onset.

Hematologic, hepatic, and renal function changes in hospitalized patients with Middle East respiratory syndrome coronavirus.

BACKGROUND: There are no longitudinal data on the changes in hematologic, hepatic, and renal function findings in patients with Middle East respiratory syndrome coronavirus (MERS-CoV) infection. METHODS: This is a retrospective cohort study of 16 MERS-CoV patients, to describe the hematological, hepatic, and renal findings of patients with MERS-CoV. RESULTS: During the 21 days of observation, there was no significant change in the hepatic panel or creatinine tests. There was a significant increase in the mean ± SD of the white blood cell count from 8.3 ± 4.6 to 14.53 ± 7 (P value = 0.001) and an increase in mean ± SD of the absolute neutrophil count from 6.33 ± 4.2 to 12 ± 5.5 (P value = 0.015). Leukocytosis was observed in 31% (5/16) of the patients on day 1 and in 80% (4/5) on day 21. Transient leukopenia developed in 6% (1/16) of the patients on day 1 and in 13% (1/8) on day 8. None of the patients had neutropenia. Lymphopenia was a prominent feature with a rate of 44% (7/16) of the patients on day 1 and 60% (3/5) on day 21. Lymphocytosis was not a feature of MERS-CoV infection. Thrombocytopenia developed in 31% (5/16) of the patients on day 1 and 40% (2/5) on day 21. Thrombocytosis was not a prominent feature and was observed in 6% (1/16) of the patients on day 1 and 17% (1/6) on day 9. CONCLUSIONS: Patients with MERS-CoV infection showed variable hematologic parameters over time. Lymphocytosis and neutropenia were not features of MERS-CoV infection.

Chemokine Receptor Ccr7 Restricts Fatal West Nile Virus Encephalitis.

West Nile virus (WNV) is a mosquito-transmitted flavivirus that can cause debilitating encephalitis. To delineate the mechanisms behind this pathology, we studied Ccr7-deficient mice, which afforded us the capacity to study infection in mice with disrupted peripheral cellular trafficking events. The loss of Ccr7 resulted in an immediate pan-leukocytosis that remained elevated throughout the infection. This leukocytosis resulted in a significant enhancement of leukocyte accumulation within the central nervous system (CNS). Despite an excess of virus-specific T cells in the CNS, Ccr7-deficient mice had significantly higher CNS viral loads and mortality rates than wild-type animals. Mechanistically, the elevated trafficking of infected myeloid cells into the brain in Ccr7-deficient mice resulted in increased levels of WNV in the CNS, thereby effectively contributing to neuroinflammation and lowering viral clearance. Combined, our experiments suggest that during WNV infection, Ccr7 is a gatekeeper for nonspecific viral transference to the brain.IMPORTANCE In this study, we show that Ccr7 is required for the sufficient migration of dendritic cells and T cells into the draining lymph node immediately following infection and for the restriction of leukocyte migration into the brain. Further, the severe loss of dendritic cells in the draining lymph node had no impact on viral replication in this organ, suggesting that WNV may migrate from the skin into the lymph node through another mechanism. Most importantly, we found that the loss of Ccr7 results in a significant leukocytosis, leading to hypercellularity within the CNS, where monocytes/macrophages contribute to CNS viremia, neuroinflammation, and increased mortality. Together, our data point to Ccr7 as a critical host defense restriction factor limiting neuroinflammation during acute viral infection.

Severe Chikungunya infection in Northern Mozambique: a case report.

BACKGROUND: Although Chikungunya virus has rapidly expanded to several countries in sub-Saharan Africa, little attention has been paid to its control and management. Until recently, Chikungunya has been regarded as a benign and self-limiting disease. In this report we describe the first case of severe Chikungunya disease in an adult patient in Pemba, Mozambique. CASE PRESENTATION: A previously healthy 40 year old male of Makonde ethnicity with no known past medical history and resident in Pemba for the past 11 years presented with a severe febrile illness. Despite administration of broad spectrum intravenous antibiotics the patient rapidly deteriorated and became comatose while developing anaemia, thrombocytopenia and later, melaena. Laboratory testing revealed IgM antibodies against Chikungunya virus. Malaria tests were consistently negative. CONCLUSIONS: This report suggests that Chikungunya might cause unsuspected severe disease in febrile patients in Mozambique and provides insights for the improvement of national protocols for management of febrile patients in Mozambique. We recommend that clinicians should consider Chikungunya in the differential diagnosis of febrile illness in locations where Aedes aegypti mosquitos are abundant.

Acyclovir resistance in herpes simplex virus type I encephalitis: a case report.

Acyclovir resistance is rarely seen in herpes simplex virus (HSV) type I encephalitis. Prevalence rates vary between 0.5 % in immunocompetent patients (Christophers et al. 1998; Fife et al. 1994) and 3.5-10 % in immunocompromised patients (Stranska et al. 2005). We report a 45-year-old, immunocompetent (negative HIV antigen/antibody testing), female patient, without previous illness who developed-after a febrile prodromal stage-aphasia and psychomotor slowing. Cerebral magnetic resonance imaging (cMRI) showed right temporal and insular T2-hyperintense lesions with spreading to the contralateral temporal lobe. Cerebrospinal fluid (CSF) analysis yielded lymphocytic pleocytosis and elevated protein level. Polymerase chain reaction testing for HSV type I showed a positive result in repeat lumbar puncture. HSV type I encephalitis was diagnosed and intravenous acyclovir treatment was initiated (750 mg t.i.d.). Acyclovir treatment was intensified to 1000 mg t.i.d., due to clinical deterioration, ongoing pleocytosis and progression on cMRI 5 days after initiation of antiviral therapy. In parallel, acyclovir resistance testing showed mutation of thymidine kinase gene at position A156V prompting foscarnet therapy (60 mg t.i.d.). Patient's condition improved dramatically over 2 weeks. Acyclovir resistance is rare but should be considered in case of clinical worsening of patient's condition. To our knowledge, this is the first report of acyclovir resistance in HSV type I encephalitis of an immunocompetent and previously healthy patient in Austria.

Biomarkers of chemotaxis and inflammation in cerebrospinal fluid and serum in individuals with HIV-1 subtype C versus B.

A defective chemokine motif in the HIV-1 Tat protein has been hypothesized to alter central nervous system cellular trafficking and inflammation, rendering HIV-1 subtype C less neuropathogenic than B. To evaluate this hypothesis, we compared biomarkers of cellular chemotaxis and inflammation in cerebrospinal fluid (CSF) and serum in individuals infected with HIV-1 subtypes B (n = 27) and C (n = 25) from Curitiba, Brazil. None had opportunistic infections. Chemokines (MCP-1, MIP-1α, MIP-1ß, RANTES, IP-10) and cytokines (TNF-α, IFN-γ, IL-1ß, IL-2, IL-4, IL-6, IL-7, IL-10) were measured using the multiplex bead suspension array immunoassays or ELISA HD. CSF and serum biomarker concentrations were compared between subtype B and C groups and HIV-positive and HIV-negative subjects (N = 19) using an independent group t test (unadjusted analysis) and linear regression (adjusted analysis), controlling for nadir CD4 and CSF and plasma HIV RNA suppression. CSF levels of cytokines and chemokines were significantly (p < 0.05) elevated in HIV-positive versus HIV-negative participants for 7/13 biomarkers measured, but levels did not differ for subtypes B and C. Serum levels were significantly elevated for 4/13 markers, with no significant differences between subtypes B and C. Although pleocytosis was much more frequent in HIV-positive than in HIV-negative individuals (27 vs. 0 %), subtypes B and C did not differ (32 and 22 %; p = 0.23). We did not find molecular evidence to support the hypothesis that intrathecal chemotaxis and inflammation is less in HIV-1 subtype C than in subtype B. Biomarker changes in CSF were more robust than in serum, suggesting compartmentalization of the immunological response to HIV.

Performance of the XN-2000 WPC channel-flagging to differentiate reactive and neoplastic leukocytosis.

BACKGROUND: The distinction between reactive and neoplastic leukocytes, especially atypical lymphocytes suspected to be reactive or neoplastic, is a particular challenge in automated hematological cell differentiation. The aim of the study was to evaluate the performance of the XN analyzer supplemented with the WPC channel for differentiating between reactive and neoplastic leukocytosis. METHODS: Blood samples of 253 patients with viral infections, lymphoma or leukemia were analyzed by the Sysmex XN-2000 analyzer equipped with the WPC channel. The results were compared to routine leukocyte differentiation using the routine Sysmex XE-2100 analyzer and automated digital microscopy (DM96). The combined information from standard morphology, immune phenotyping and clinical diagnosis served as a reference. RESULTS: The XN WPC channel demonstrated an excellent performance for differentiating neoplastic (AUC=0.933) and reactive leukocytosis (AUC=0.900) as compared to morphological smear examination (AUC=0.949 and AUC=0.968, respectively) or to the differentiation results of our routine hematology analyzer (AUC=0.630 and AUC=0.635, respectively). CONCLUSIONS: Our data show that the combined WDF/WPC of the Sysmex XN-Series analyzer is advantageous in the automated differentiation of neoplastic and reactive leukocytosis, thus supporting the correct diagnostic decision in the daily laboratory routine.

Cerebrospinal fluid white cell count: discriminatory or otherwise for enteroviral meningitis in infants and young children?

Non-polio enteroviruses (EV) are the most common viruses causing aseptic meningitis in children. We aim to evaluate the cerebrospinal fluid (CSF) characteristics of neonates and children with EV meningitis with a view to determine whether it could be discriminatory or otherwise in making a positive diagnosis. We performed a 3-year (July 2008-July 2011) retrospective study of children ≤16 years, treated at a tertiary children's hospital, with positive CSF EV polymerase chain reaction (PCR) and negative blood and CSF bacterial cultures. A total of 206 children were studied. The median CSF white cell count was 79 cells/mm(3) (range 0-4608 cells/mm(3)). CSF pleocytosis was observed in 99/150 (66%) aged ≤90 days, 3/4 (75%) aged 90 days-1 year, and 49/52 (94%) children ≥3 years. There was a huge variability in CSF pleocytosis in infants ≤90 days, where 34% of them had no pleocytosis, while in 66%, a wide range of pleocytosis that might even suggest bacterial meningitis was noted. CSF red cells were low, and protein or sugar values were not discriminatory. CSF pleocytosis in relation to increasing age was found to be statistically significant (p < 0.001). Early lumbar puncture within 48 h of symptoms and absence of CSF pleocytosis was also statistically significant (p = 0.039). CSF pleocytosis in EV meningitis is commoner in older children. As there was a huge variability in CSF pleocytosis in infants ≤90 days particularly, CSF analysis including EV PCR could avoid unnecessary antibiotic therapy.