Fatal Neonatal Echovirus 6 Infection: Autopsy Case Report and Review of the Literature

Abstract

A full-term, healthy male neonate was delivered by caesarian section to a 26-year-old primigravida woman who had a history of fever and upper respiratory tract infection. On the fourth day of life, the neonate developed a sepsis-like syndrome, acute respiratory and renal failure, and disseminated intravascular coagulopathy. He died 13 days after birth. Postmortem examination revealed jaundice, anasarca, massive hepatic necrosis, adrenal hemorrhagic necrosis, renal medullary hemorrhage, hemorrhagic noninflammatory pneumonia, and severe encephalomalacia. Echovirus type 6 was isolated from blood, liver, and lungs. Although uncommon, echovirus type 6 infection may produce a spectrum of pathologic findings similar to those seen with the more commonly virulent echovirus type 11. Echoviruses are single-stranded RNA viruses of the genus Enterovirus of the family Picornaviridae that may occasionally cause overwhelming disease and death in neonates (1, 2). Of the 31 types of echoviruses, type 11 is the most frequent cause of serious neonatal morbidity and mortality, often presenting as fulminant hepatitis, infection of the central nervous system, or both (3). Echovirus type 6 infection is an uncommon cause of neonatal mortality, with only a few reported cases of severe or fatal neonatal infection (3-7). We present the case of a newborn infant with fatal echovirus 6 infection and describe the unusual pathologic findings. We also review the literature about severe neonatal echovirus 6 infections. CASE REPORTA full-term boy appropriate for his gestational age was born via caesarian section to a 26-year-old G 1 P 0 Latin American woman who had a medical history of a well-controlled seizure disorder for which she was receiving carbamazepine. She had received regular prenatal care, with negative prenatal serologic tests for human immunodeficiency virus, hepatitis B virus, and syphilis. Two weeks before delivery, she experienced fever and an upper respiratory tract infection. At birth, the infant weighed 3838 g and had an Apgar score of 9. The neonate was put under an oxygen hood, then was later slowly weaned from it. On his fourth day of life, the neonate developed fever (38.6°C) and was observed to have decreased activity. An area of hyperemia and swelling was seen on the right shoulder. This area of swelling and redness increased in size during the next few days. He received ampicillin, gentamicin, ceftazidime, and acyclovir after blood was collected for viral and bacterial cultures. Cranial ultrasonography results were normal.On the fifth day of life, the neonate experienced respiratory difficulty, which required intubation and mechanical ventilation. He remained febrile and developed oliguria that later progressed to renal insufficiency. Sepsis and disseminated intravascular coagulopathy were suspected, and blood and blood products were provided. On the ninth day of life, he suffered cardiopulmonary arrest twice and remained neurologically compromised thereafter. He was transferred to the University of Texas Medical Branch ...

Clinical features of echovirus 6 and 9 infections in children

“…Although being considered as a self-limited disease, echoviruses 6 and 9 have been found to cause deaths in children, especially in neonates. [5][6][7][8][9][10][11][12][13] …”

Phylogenetic analysis of complete VP1 sequences of echoviruses 11 and 6: high genetic diversity and circulation of genotypes with a wide geographical and temporal range

“…The circulation of these genotypes throughout the world and over time has been studied to increase our understanding of the dynamics of their transmission, to evaluate their endemicity and to explain the extent of epidemics when they occur. Beyond type identification, sequencing of the VP1 region has also proved to be a reliable method for such molecular epidemiological studies.Echovirus 6 (E6) and echovirus 11 (E11) are among the most commonly isolated HEVs worldwide, and are frequently associated with outbreaks and sporadic cases of aseptic meningitis, as well as with several diseases ranging from mild non-specific illness to encephalitis, paralysis, myocarditis and severe systemic infections in neonates (Abe et al, 2000;Ashwell et al, 1996;Atkinson et al, 1998;Bahri et al, 2005;Belguith et al, 2007a;Boyd et al, 1987;Cabrerizo et al, 2008;Chomel et al, 2003;Druyts-Voets, 1997;El-Sageyer et al, 1998;Joo et al, 2005;Khetsuriani et al, 2006;Mao et al, 2010;Mirand et al, 2008;Miwa & Sawatari, 1994;Somekh et al, 2001;Ventura et al, 2001). However, despite their important impact on human health, studies of the molecular epidemiology of E6 and E11 remain limited.…”

A fatal course of neonatal meningo-encephalitis

“…[4][5][6][7] Only two case reports describe central nervous system involvement and a fatal course, as in our case. 4,6 Severe white matter injury and neurological sequelae in EV meningo-encephalitis were recently reported by VerboonMaciolek et al 8…”