Scientific letter
Human parechovirus sepsis induced coagulopathy in an infant
Sepsis por parechovirus humano que indujo coagulopatía en un lactante
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an infant" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "143" "paginaFinal" => "144" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Jean-Francois Bonnet, Tara M. Connelly, Guillermo H. Vega, Alfonso Rodriguez Herrera" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Jean-Francois" "apellidos" => "Bonnet" "email" => array:1 [ 0 => "jfbonnet@live.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Tara M." "apellidos" => "Connelly" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Guillermo H." 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Cases of encephalitis/sepsis due to HpeV have been reported in infants.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1,2</span></a> One possible consequence of the viral infection is acute coagulopathy.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> We hereby present the case of an infant with sepsis and coagulopathy who underwent the routine tests available at local level that could not confirm the source of infection. A larger virological study conducted at the national virology lab revealed infection due to HpeV. We recommend routine studies to rule out HpeV in infants with no obvious etiology of sepsis.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">One eight-week old infant without a significant personal history is assessed due to clinical manifestations of fever, irritability and diarrhea of one (1) day duration. The clinical examination shows one single blue macular exanthema on the infant's right thigh. The heart and respiratory rates are 220 beats and 50 breaths per minute, respectively. Temperature is 101.3<span class="elsevierStyleHsp" style=""></span>°F and the capillary refill time is over four (4) seconds – suggestive of poor peripheral perfusion and a situation of clinical sepsis. The additional tests conducted showed leukocyte counts of 4<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/l and CRP values of 23<span class="elsevierStyleHsp" style=""></span>mg/l, and lactate levels of 2.7<span class="elsevierStyleHsp" style=""></span>mmol/l. The INR was 1.5. Prothrombin time (PT) was 16.1<span class="elsevierStyleHsp" style=""></span>s (normal<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>8.7–2.7), and the activated partial thromboplastin time (aPTT) was 67<span class="elsevierStyleHsp" style=""></span>s (normal<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>8.7–2.7). The liver function tests showed ALT levels of 22<span class="elsevierStyleHsp" style=""></span>U/l; bilirubin levels of 7.1<span class="elsevierStyleHsp" style=""></span>μmol/l; ALP levels of 196<span class="elsevierStyleHsp" style=""></span>U/l; and GGT levels of 16<span class="elsevierStyleHsp" style=""></span>U/l, all within normal ranges. A complete screening for sepsis including lumbar puncture; blood cultures; urine cultures; and coprocultures was conducted followed by the administration of a triple empirical antibiotic therapy (amoxicilin, gentamicin, and cefotaxime) and due to an inadequate peripheral perfusion, boluses of crystalloid solutions are administered too. On day two, the diarrhea gets worse with presence of swelling in the infant's lower limbs and scrotum areas. The controls reveal that the APPT extends over 100<span class="elsevierStyleHsp" style=""></span>s. The preliminary results from the blood, fecal and urine samples tested negative and the lumbar puncture confirmed glycorrhachia levels of 2.9<span class="elsevierStyleHsp" style=""></span>mmol/l and proteinorrhachia levels of 0.29<span class="elsevierStyleHsp" style=""></span>g/l.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We conducted X-rays of the chest and the abdomen and pelvic and cranial ultrasound scans and they all looked normal. We added teicoplanin to the antibiotic therapy to treat possible MRSA due to the local epidemiological situation of a higher incidence rate of infections due to MRSA. The fact that there was no improvement following the multiple antibiotic therapy and that the active source of infection could not be identified was suggestive that the etiology of sepsis could be viral. For a more in-depth study, the samples collected were sent to the national virology lab where unlike the procedures conducted at hospital standard labs, the CRP testing to rule out the presence of HpeV is routine. On day three, the fever stops. The CRP tested positive for HpeV RNA in fecal, pharyngeal, blood, and CSF samples. On day four, the patient's vital signs went back to normal and the antibiotic therapy was withdrawn. The patient was discharged from the hospital on day eight.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The clinical presentation of HpeV goes from a self-limited fever disease to sepsis with high mortality rate.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> The pathogenesis that leads to coagulopathy in infections due to HpeV is different from that of disseminated intravascular coagulation (DIC). In the DIC, the tissue factor is released after vascular damage, or after the cytokine release. The DIC PT and aPTT are extended; the fibrinogen level is high, normal, or even reduced, and there is a rapidly decreasing plateletcrit. According to the diagnostic algorithm for the DIC created by the Scientific and Standardisation Committee on Disseminated Intravascular Coagulation that takes all the aforementioned parameters into consideration, scores ≥5 have 97 per cent specificity and 91 per cent sensitivity in the diagnosis of DIC. Our patient scored 1 only, with normal platelet and fibrinogen levels during the course of the sepsis.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> This made us consider the possibility of a viral etiology as the cause of the clinical manifestations. The take-away message here is that one situation of sepsis that does not improve with multiple antibiotic therapy or extended aPTT without use of fibrinogen concentrate should make the physician think of a viral infection. There are many viruses that can cause this activation of endothelial cells, which may activate the blood coagulation cascade, inducing the expression of the tissue factor. This is a multifactor process also mediated by the molecule-leukocyte adhesion. Similarly, the edema secondary to the inflammation leads to the activation of the intrinsic blood coagulation cascade. This has been the case of our patient's pattern of coagulation with PT and INR peaks on day 2, and aPTT peaks on day 4.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Since it is not studied on a routine basis, the true incidence of HpeV is unknown. One retrospective study of 5396 infants showed that 1 per cent of the infants hospitalized in the neonatal intensive care unit suffered from an infection, 39 per cent of whom tested positive for enterovirus or parechovirus.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> Although there are not many clinical guidelines on the management of HpeV, the detailed monitoring of the patients’ vital signs and organic functions is necessary to plan adequate support therapies, since cases of rapid progression of encephalitis or sepsis may be fatal. The rapid systematic study of the HpeV RNA through CRP testing could mean achieving the diagnosis within six (6) hours after hospital admission and thus limiting the use of unnecessary antibiotics.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Bonnet J-F, Connelly TM, Vega GH, Rodriguez Herrera A. Sepsis por parechovirus humano que indujo coagulopatía en un lactante. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 1 | 0 | 1 |
| 2024 October | 12 | 6 | 18 |
| 2024 September | 17 | 6 | 23 |
| 2024 August | 22 | 3 | 25 |
| 2024 July | 16 | 3 | 19 |
| 2024 June | 26 | 3 | 29 |
| 2024 May | 8 | 7 | 15 |
| 2024 April | 11 | 16 | 27 |
| 2024 March | 13 | 11 | 24 |
| 2024 February | 8 | 3 | 11 |
| 2024 January | 8 | 6 | 14 |
| 2023 December | 15 | 4 | 19 |
| 2023 November | 7 | 2 | 9 |
| 2023 October | 14 | 6 | 20 |
| 2023 September | 5 | 2 | 7 |
| 2023 August | 10 | 2 | 12 |
| 2023 July | 7 | 3 | 10 |
| 2023 June | 12 | 4 | 16 |
| 2023 May | 13 | 1 | 14 |
| 2023 April | 15 | 4 | 19 |
| 2023 March | 33 | 3 | 36 |
| 2023 February | 16 | 3 | 19 |
| 2023 January | 9 | 6 | 15 |
| 2022 December | 12 | 4 | 16 |
| 2022 November | 33 | 7 | 40 |
| 2022 October | 30 | 15 | 45 |
| 2022 September | 17 | 5 | 22 |
| 2022 August | 17 | 11 | 28 |
| 2022 July | 21 | 5 | 26 |
| 2022 June | 15 | 9 | 24 |
| 2022 May | 12 | 6 | 18 |
| 2022 April | 15 | 7 | 22 |
| 2022 March | 22 | 7 | 29 |
| 2022 February | 20 | 12 | 32 |
| 2022 January | 32 | 8 | 40 |
| 2021 December | 12 | 7 | 19 |
| 2021 November | 14 | 8 | 22 |
| 2021 October | 8 | 7 | 15 |
| 2021 September | 26 | 9 | 35 |
| 2021 August | 31 | 9 | 40 |
| 2021 July | 17 | 11 | 28 |
| 2021 June | 8 | 12 | 20 |
| 2021 May | 21 | 11 | 32 |
| 2021 April | 55 | 20 | 75 |
| 2021 March | 93 | 6 | 99 |
| 2021 February | 27 | 13 | 40 |
| 2021 January | 13 | 8 | 21 |
| 2020 December | 10 | 6 | 16 |
| 2020 November | 12 | 3 | 15 |
| 2020 October | 6 | 4 | 10 |
| 2020 September | 8 | 9 | 17 |
| 2020 August | 17 | 10 | 27 |
| 2020 July | 9 | 7 | 16 |
| 2020 June | 11 | 5 | 16 |
| 2020 May | 15 | 7 | 22 |
| 2020 April | 12 | 5 | 17 |
| 2020 March | 15 | 1 | 16 |
| 2020 February | 10 | 3 | 13 |
| 2020 January | 5 | 4 | 9 |
| 2019 December | 15 | 6 | 21 |
| 2019 November | 9 | 5 | 14 |
| 2019 October | 7 | 7 | 14 |
| 2019 September | 12 | 5 | 17 |
| 2019 August | 6 | 8 | 14 |
| 2019 July | 10 | 18 | 28 |
| 2019 June | 32 | 20 | 52 |
| 2019 May | 94 | 9 | 103 |
| 2019 April | 26 | 13 | 39 |
| 2019 February | 3 | 7 | 10 |
| 2019 January | 1 | 2 | 3 |
| 2018 December | 1 | 1 | 2 |
| 2018 November | 5 | 0 | 5 |
| 2018 October | 2 | 3 | 5 |
| 2018 September | 7 | 2 | 9 |
| 2018 August | 9 | 0 | 9 |
| 2018 February | 3 | 1 | 4 |
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