CASE REPORT published: 24 May 2019 doi: 10.3389/fneur.2019.00548 Excellent Response to Plasma Exchange in Three Patients With Enterovirus-71 Neurological Disease Elba Pascual-Goñi 1 , Maria Josa 2 , Cristian Launes 3 , Luis Querol 1*, Marga del Cuerpo 4 , M. Alba Bosch 5 , Iolanda Jordan 3,6 and Eulàlia Turón-Viñas 2 1 Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain, 2 Department of Pediatrics, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain, 3 Pediatric Infectious Diseases Research Group, CIBER of Epidemiology and Public Health (CB15/00067 Group), Institut de Recerca Pediàtrica Sant Joan de Déu, Esplugues, Spain, 4 Department of Microbiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain, 5 Banc de Sang i Teixits, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain, 6 Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, Esplugues de Llobregat, Spain The clinical spectrum of Enterovirus-71-associated neurological disease includes acute flaccid paralysis, encephalomyelitis, or brainstem encephalitis with autonomic Edited by: dysfunction. As no specific antiviral treatments are available, intravenous human Avindra Nath, National Institute of Neurological immunoglobulin is used in early stages of the illness, decreasing serum proinflammatory Disorders and Stroke (NINDS), cytokines, and improving clinical outcomes. Plasma exchange aims to eliminate United States pathogenic autoantibodies and proinflammatory cytokines, and is used in diverse Reviewed by: Silvia Noemi Tenembaum, immune-mediated neurologic conditions. However, its effect in Enterovirus-71 infections Garrahan Hospital, Argentina is unknown. We report three cases of severe Enterovirus-71 neurological disease treated Kyung Yeon Lee, with plasma exchange during an outbreak in Catalonia (Spain) in 2016. We observed Ulsan University Hospital, South Korea a striking improvement in all three patients within 48 h of starting plasma exchange. *Correspondence: Patients received four to six sessions every other day. Good outcomes were confirmed at Luis Querol the 1-year follow-up visit. Our observations suggest that plasma exchange is an effective lquerol@santpau.cat complementary therapy for severe Enterovirus-71 neurological disease. Specialty section: Keywords: enterovirus, EV71, encephalomyelitis, brainstem encephalitis with cardiorespiratory failure, plasma This article was submitted to exchange, immunotherapy Neuroinfectious Diseases, a section of the journal Frontiers in Neurology INTRODUCTION Received: 17 October 2018 Accepted: 07 May 2019 Enterovirus-71 (EV-71) belongs to the human enterovirus A species of the Picornaviridae family. Published: 24 May 2019 It is an emergent pathogen responsible for a broad spectrum of infectious syndromes. EV-71 is Citation: a well-known cause of hand, foot and mouth disease (HFMD) in children, and is usually a self- Pascual-Goñi E, Josa M, Launes C, limiting infection (1). Rarely, some patients develop severe neurological disease, defined as the Querol L, del Cuerpo M, Bosch MA, presence of acute flaccid paralysis, encephalomyelitis, or brainstem encephalitis with autonomic Jordan I and Turón-Viñas E (2019) dysfunction (2) that may be fatal in 7% of patients (3). Since EV-71-associated neurologic disease Excellent Response to Plasma Exchange in Three Patients With was first described in California in 1969 (4), several outbreaks have since been reported in the Enterovirus-71 Neurological Disease. Asia-Pacific region and in Europe. An outbreak of brainstem encephalitis and encephalomyelitis Front. Neurol. 10:548. occurred in Catalonia in 2016, and involved a new recombinant strain: EV-71 subgenogroup doi: 10.3389/fneur.2019.00548 C1 (5, 6). This strain is highly neurotropic, and neurological involvement is often present. Frontiers in Neurology | www.frontiersin.org 1 May 2019 | Volume 10 | Article 548 Pascual-Goñi et al. Plasma Exchange in Enterovirus-71 Neurological Disease No specific antiviral treatment has shown any benefit to PATIENT 2 date. Since EV-71 (7) has been associated with a cytokine- mediated inflammatory response, patients with severe neurologic An 8-month-old infant with a viral exanthema presented with involvement receive immunomodulatory treatments such as lethargy and hemodynamic instability requiring mechanical intravenous human immunoglobulin (IVIg). When administered ventilation. An echocardiography showed reduced ejection in the early stages, IVIg may improve outcomes by decreasing fraction (40%). Brain and a spinal cord MRI (Figures 1E–G) plasmatic cytokines (2). Despite current treatments, however, demonstrated dorsal brainstem and cervical diffuse and neurological deficits remain in around 10% of patients (3). poorly defined T2-hyperintensities, compatible with For this reason, additional therapeutic strategies are needed. In encephalomyelitis. CSF showed pleocytosis and enterovirus this report, we describe three cases of EV-71-associated severe PCR was negative. EV-71 was isolated in throat and rectal neurological disease that showed a clear clinical improvement specimens. Methylprednisolone (30 mg/Kg/day, for 3 days), following treatment with plasma exchange (PEX). We postulate milrinone and IVIg (1 g/Kg/day for 2 days) were started at that PEX could be a complementary approach to eliminate the admission. Five days later he was extubated and examination humoral factors and modulate the inflammation involved in the revealed bulbar palsy and upper limb hyperreflexia. These pathogenesis of the EV-71 neurological disease. symptoms improved over the following week. He then presented with myoclonus, decreased movements and lethargy, leading to reintubation. Methylprednisolone (30 mg/Kg/day, for 3 days) CASE REPORTS and IVIg (1 g/Kg/day for 2 days) were restarted and a new brain MRI showed persistent brainstem T2-hyperintensities in We report three patients (Table 1) who presented EV-71 dorsal brainstem. On the other hand, hyperintense T2 signal severe neurological disease (two infants with brainstem of the anterior horn of the spinal cord was also observed encephalitis with cardiorespiratory failure and one adult with (Figure 1). Given the worsening of symptoms, PEX therapy encephalomyelitis) during the outbreak in Catalonia (Spain) was started, and four sessions were performed every other day. between April and June 2016 (5, 6). Clinical and MRI findings The consciousness status, muscular tone and motor function were compatible with encephalomyelitis. Enterovirus RNA improved notably from the second day. Two weeks later he was detected by polymerase chain reaction (PCR) in stool had axial hypotonia with lack of head control and tetraparesis and throat specimens, and EV-71 was isolated in cell cultures. (4/5 on the Medical Research Council scale in all limbs) with Diagnosis, disease severity stratification and treatment were hyperreflexia and mild hypertonia. During the follow-up a conducted according to local (8) and WHO guidelines (2). Due progressive improvement of the tetraparesis was observed. to the disease severity and rapid neurological deterioration At 3-month follow-up, mild hypertonia of the right arm and despite standard treatment, all three patients were treated with lack of full head control persisted (mRS = 3). At 12 months, PEX. During each PEX session, 1 to 1.5 total plasma volume cognitive and motor functions were normal except for mild axial was removed and replaced with albumin. The procedure was hypotonia (mRS = 1). performed every other day. Motor and cognitive outcomes were assessed and modified Rankin Scale score (mRS) was obtained at 3- and 12-month follow-up. PATIENT 3 PATIENT 1 A 37-year-old male, admitted to our hospital with severe headache, aphasia, focal motor seizures, and progressive A 9-month-old infant presented with lethargy and respiratory tetraparesis. The previous week he had developed fever and failure. He had been diagnosed of herpangina 4 days before oral ulcers. Two weeks earlier, his 3-year-old son had had admission. Initial examination revealed bulbar palsy and a febrile exanthema and EV-71 had been isolated in the flaccid tetraparesis. Brain and spinal cord MRI (Figures 1A–C) child’s stool. Neurological examination of patient 3 revealed showed dorsal brainstem and cervical T2-hyperintensities. CSF motor aphasia, right facial paralysis, flaccid tetraparesis and revealed pleocytosis, and enterovirus PCR was negative. EV- hyperreflexia. Brain MRI (Figure 1I) revealed a left frontal 71 was isolated in throat and rectal specimens. Although cortical thickening in fluid-attenuated inversion recovery methylprednisolone (30 mg/Kg/day, for 3 days) and IVIg (1 (FLAIR) images, hyperintense in diffusion weighted images g/Kg/day for 2 days) were started, a few hours later he (DWI), with leptomeningeal enhancement. Spinal cord MRI developed high fever, hemodynamic instability, and respiratory (Figures 1J,K) revealed cervical and lumbosacral lesions. failure requiring mechanical ventilation. Due to the dramatic CSF showed pleocytosis and enterovirus PCR was negative. evolution, PEX was started 48 h after onset. Twelve hours later, Enterovirus RNA was detected by PCR in stool specimens. Given a marked clinical response was observed and he was extubated the rapid deterioration and the signs of inflammation in the MRI, after a second PEX session. Six PEX sessions were performed PEX therapy was initiated 72 h from the onset of the neurological every other day. He continued to improve and no significant symptoms. A striking clinical improvement was observed within complications were observed. Two weeks later, he presented 24 h after first session. Five sessions of PEX were performed intention tremor that had disappeared at 3- and 12-month every other day and no complications were observed. At 3- and follow-up (mRS = 0). 12-month follow-ups he was asymptomatic (mRS = 0). Frontiers in Neurology | www.frontiersin.org 2 May 2019 | Volume 10 | Article 548 Pascual-Goñi et al. Plasma Exchange in Enterovirus-71 Neurological Disease TABLE 1 | Clinical and laboratory features of patients. Patient 1 Patient 2 Patient 3 Age 9 months 8 months 37 years Sex Male Male Male Past medical history None None Smoker Symptoms/signs Lethargy (GCS = 10), bulbar palsy, Lethargy (GCS = 10), viral exantema, Headache, aphasia, focal motor tetraparesis, and hypercarbic respiratory bulbar palsy, tetraparesis, and seizures, tetraparesis, and urinary failure hemodynamic instability retention EV71 isolation throat and rectal swabs throat and rectal swabs rectal swabs CSF cell count 44 cells/mm3 100 leucocytes/mm3 22 cells/mm3 (90% lymphocytes) (95% lymphocytes) (93% neutrophils) Negative oligoclonal bands MRI T2- hyperintensities in dorsal brainstem and T2- hyperintensities in dorsal brainstem Left frontal cortical thickening, cervical spinal cord and cervical spinal cord leptomeningeal enhancement, cervical, and lumbosacral lesions with contrast enhancement Diagnosis Brainstem encephalitis with cardiorespiratory Brainstem encephalitis with Encephalomyelitis failure plus myelitis cardiorespiratory failure plus myelitis Conventional IVIg, methylprednisonlone, milrinone IVIg, methylprednisonlone, milrinone No treatments Time from neurological 48 h 7 days 72 h disease onset to start PEX Number of PEX 6 4 5 sessions Time from PEX to 12 h 48 h 24 h clinical improvement Outcomes (1-yr Asymptomatic (mRS = 0) Mild axial hypotonia (mRS = 1) Asymptomatic (mRS = 0) follow-up) 3-month Follow-up MRI Mild T2-hyperintensity in dorsal brainstem, Persistent lesions in dorsal brainstem and Brain MRI: Resolution of previous disappearance of the cervical lesion anterior cervical spinal cord lesions CSF, cerebrospinal fluid; GCS, Glasgow Coma Scale; IVIg, intravenous human immunoglobulin; mRS, modified Rankin Scale score. DISCUSSION known about their benefits and mechanisms of action. Milrinone has been used in cases of autonomic dysfunction due to its We report three cases of severe neurological disease associated anti-inflammatory effect and its well-known inotropic properties with EV-71 that responded to plasma exchange despite poor (12). And third, IVIg has been used in EV-71 neurologic disease response to conventional treatment. A clinical response was according to WHO guidelines (2) that recommend starting IVIg observed within 24–48 h after the first PEX session. We in patients with autonomic dysfunction or encephalitis plus acute did not detect any relevant side effects associated with this flaccid paralysis. IVIg has shown to modulate inflammation procedure. The positive response to PEX suggested a role of in EV-71 neurological syndromes by decreasing plasmatic a deleterious inflammatory response in the pathophysiology of pro-inflammatory cytokines (13). Cytokine removal from these syndromes. plasma could also prevent EV-71 neurological complications All three patients presented serious EV-71 complications, with (7). Cytokine and other inflammatory humoral factors can autonomic dysfunction in two cases. Autonomic dysfunction be removed with PEX. By this procedure, blood from the is of major concern in EV-71 neurological disease. In such patient is passed through a medical device that separates and cases, it has been hypothesized that cytokine release injures the removes plasma, replacing it with albumin, or donor’s plasma. vasomotor center of the brainstem, increasing pulmonary vessel This procedure is safe when performed in critically ill and permeability and leading to pulmonary edema (9). Interestingly, pediatric patients at experienced centers (14, 15). Good results Shao et al. (10) showed that levels of proinflammatory cytokines have been observed in neurological immune-mediated diseases and chemokines (except IL-8 and IL-4) in plasma were higher and post-infectious disorders such as steroid-unresponsive in patients with encephalitis plus cardiorespiratory failure than acute disseminated encephalomyelitis and Guillain-Barré in those with encephalitis alone. Given the role of cytokines syndrome (16, 17). in EV-71 neurologic disease, several immunomodulatory Although the use of PEX is common in parainfectious treatments have been used, with varying results. Steroids, for immune-mediated disorders, EV-71 treatment guidelines (2) example, have been used extensively in viral and inflammatory do not include PEX as an alternative therapy in severe myelitis (11) and in EV-71 neurologic disease (3), but little is yet patients. According to our observations, severe patients could Frontiers in Neurology | www.frontiersin.org 3 May 2019 | Volume 10 | Article 548 Pascual-Goñi et al. Plasma Exchange in Enterovirus-71 Neurological Disease FIGURE 1 | Brain and spinal cord MRI findings. Patient 1 – (A–C): dorsal brainstem and cervical hyperintensities on T2-weighted images. (D): sagital FLAIR image shows disappearance of previous spinal cord hyperintensity. Patient 2—(E–G): dorsal brainstem and cervical diffuse and poorly defined T2-hyperintensities during the acute phase; (H): hyperintense T2 signal of the anterior horn of the cervical spinal cord one week later. Patient 3—(I–K): left frontal cortical hyperintensities (asterisk) in diffusion weighted images (DWI); cervical and lumbosacral hyperintensities on T2-weighted imaging with enhancement on post-gadolinium image. (L): axial DWI at 3 months shows resolution of the previous alterations. benefit from PEX therapy. In all three cases PEX seemed to ETHICS STATEMENT change a deteriorating clinical course. Interestingly, patient 3, primarily treated with PEX, recovered quickly after starting The patient or their parents provided written informed PEX. In our opinion, the natural history of the disease, consent agreeing to undergo treatment and allow the though frequently benign, does not account for this almost publication of the information that was described in the immediate improvement. We understand that our observations case report. are limited by the small sample size, uncontrolled design and the concomitant use of conventional treatments such as AUTHOR CONTRIBUTIONS methylprednisolone and IVIg that may have contributed to the clinical improvement. However, it is unlikely that clinical EP-G, LQ, and ET-V were involved in study conceptualization, trials will be available in EV-71 neurological complications data collection, drafting, analysis, and revising the manuscript and, thus, case reports and case series provide anecdotal but for intellectual content. MJ, CL, MdC, MB, and IJ were involved very valuable information to treat patients with potentially in data collection, drafting, and revising the manuscript for fatal complications. intellectual content. In conclusion, our observations suggest that PEX is a potential adjuvant therapy in patients with severe EV-71 neurological FUNDING disease. Clearly, however, larger series are needed to confirm the impact of PEX on the prognosis of the disease, and to assess This research did not receive any specific grant from funding timing and duration of the therapy. agencies in the public, commercial, or not-for-profit sectors. Frontiers in Neurology | www.frontiersin.org 4 May 2019 | Volume 10 | Article 548 Pascual-Goñi et al. Plasma Exchange in Enterovirus-71 Neurological Disease LQ receives funds from the PI16/000627 grant of the Fondo PI15CIII-00020] for the molecular epidemiology surveillance of de Investigaciones Sanitarias—Instituto de Salud Carlos III EV infections. (fondos FEDER), and personal grant SLT006/17/00131 of the Pla estratègic de Recerca i Innovació en Salut (PERIS), ACKNOWLEDGMENTS Departament de Salut, Generalitat de Catalunya. The Pediatric Infectious Diseases Research Group participates in a study To the Enterovirus Unit of the National Center for Microbiology of the Spanish National Health Institute [grant number (Madrid, Spain) for their support in typing the Case 2 infection. REFERENCES 10. Shao P, Wu X, Li H, Wu Z, Yang Z, Yao H. Clinical significance of inflammatory cytokine and chemokine expression in hand, foot and mouth 1. 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The use, distribution or Pathogenesis of enterovirus 71 brainstem encephalitis in pediatric reproduction in other forums is permitted, provided the original author(s) and the patients: roles of cytokines and cellular immune activation in patients copyright owner(s) are credited and that the original publication in this journal with pulmonary edema. J Infect Dis. (2003) 188:564–70. doi: 10.1086/ is cited, in accordance with accepted academic practice. No use, distribution or 376998 reproduction is permitted which does not comply with these terms. Frontiers in Neurology | www.frontiersin.org 5 May 2019 | Volume 10 | Article 548