Browsing by Author "Cabrerizo, Maria"
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Publication Acute flaccid myelitis and Guillain-Barré syndrome in children: A comparative study with evaluation of diagnostic criteria(Wiley, 2022-02) Helfferich, Jelte; Roodbol, Joyce; de Wit, Marie-Claire; Brouwer, Oebele F; Jacobs, Bart C; 2016 Enterovirus D68 Acute Flaccid Myelitis Working Group; Dutch Pediatric GBS Study Group; Cabrerizo, Maria; Prinses Beatrix SpierfondsBackground and purpose: Differentiation between acute flaccid myelitis (AFM) and Guillain-Barré syndrome (GBS) can be difficult, particularly in children. Our objective was to improve the diagnostic accuracy by giving recommendations based on a comparison of clinical features and diagnostic criteria in children with AFM or GBS. Methods: A cohort of 26 children with AFM associated with enterovirus D68 was compared to a cohort of 156 children with GBS. The specificity of the Brighton criteria, used for GBS diagnosis, was evaluated in the AFM cohort and the specificity of the Centers for Disease Control and Prevention (CDC) AFM diagnostic criteria in the GBS cohort. Results: Children with AFM compared to those with GBS had a shorter interval between onset of weakness and nadir (3 vs. 8 days, p < 0.001), more often had asymmetric limb weakness (58% vs. 0%, p < 0.001), and less frequently had sensory deficits (0% vs. 40%, p < 0.001). In AFM, cerebrospinal fluid leukocyte counts were higher, whereas protein concentrations were lower. Spinal cord lesions on magnetic resonance imaging were only found in AFM patients. No GBS case fulfilled CDC criteria for definite AFM. Of the AFM cases, 8% fulfilled the Brighton criteria for GBS, when omitting the criterion of excluding an alternate diagnosis. Conclusions: Despite the overlap in clinical presentation, we found distinctive early clinical and diagnostic characteristics for differentiating AFM from GBS in children. Diagnostic criteria for AFM and GBS usually perform well, but some AFM cases may fulfill clinical diagnostic criteria for GBS. This underlines the need to perform diagnostic tests early to exclude AFM in children suspected of atypical GBS.Publication Acute flaccid paralysis (AFP) surveillance: challenges and opportunities from 18 years' experience, Spain, 1998 to 2015(European Centre for Disease Prevention and Control (ECDC), 2018) Masa-Calles, Josefa; Torner, Núria; Lopez-Perea, Noemi; Torres-de Mier, Maria de Viarce; Fernandez Martinez, Beatriz; Cabrerizo, Maria; Gallardo-García, Virtudes; Malo, Carmen; Margolles, Mario; Portell, Margarita; Abadía, Natividad; Blasco, Aniceto; García-Hernández, Sara; Marcos, Henar; Rabella, Núria; Marín, Celia; Fuentes, Amelia; Losada, Isabel; Gutiérrez, Juan García; Nieto, Alba; García Ortúzar, Visitación; Garcia-Cenoz, Manuel; Arteagoitia, José María; Blanco Martínez, Ángela; Rivas, Ana; Castrillejo, DanielAcute flaccid paralysis (AFP) surveillance is key for global polio eradication. It allows detecting poliovirus (PV) reintroductions from endemic countries. This study describes AFP surveillance in Spain from 1998 to 2015. During this time, 678 AFP cases were reported to the Spanish National Surveillance Network. The mean notification rate was 0.58 AFP cases/100,000 population under 15 years old (range: 0.45/100,000-0.78/100,000). Two periods (P) are described: P1 (1998-2006) with the AFP notification rate ranging from 0.66/100,000 to 0.78/100,000, peaking in 2001 (0.84/100,000); and P2 (2007-2015) when the AFP rate ranged from 0.43/100,000 to 0.57/100,000, with the lowest rate in 2009 (0.31/100,000). No poliomyelitis cases were caused by wild PV infections, although two Sabin-like PVs and one imported vaccine-derived PV-2 were detected. Overall, 23 (3.4%) cases met the hot case definition. Most cases were clinically diagnosed with Guillain-Barré syndrome (76.9%; 504/655). The adequate stool collection rate ranged from 33.3% (7/21) to 72.5% (29/40). The annual proportion of AFP cases with non-polio enterovirus findings varied widely across the study period. AFP surveillance with laboratory testing for non-polio enteroviruses must be maintained and enhanced both to monitor polio eradication and to establish sensitive surveillance for prompt detection of other enteroviruses causing serious symptoms.Publication An imported case of vaccine-derived poliovirus type 2, Spain in the context of the ongoing polio Public Health Emergency of International Concern, September 2021(European Centre for Disease Prevention and Control (ECDC), 2021-12) Chirlaque López, María Dolores; Cabrerizo, Maria; Guzmán Herrador, Bernardo R; Masa-Calles, Josefa; Alarcón-Linares, María Ester; Allende, Ana; Aznar Cano, Esteban; Barranco Boada, María Isabel; Cantero Gudino, Elena; Fernández-Balbuena, Sonia; Fernández Dueñas, Ana; Fernández-García, María Dolores; García Hernández, Laura; García Ortúzar, Visitación; Lopez-Perea, Noemi; Martínez-Salcedo, Eduardo; Moreno-Docón, Antonio; Ordobás Gavín, María; Rodero Garduño, Inmaculada; Sierra Moros, Maria José; Simón Soria, Fernando; Limia Sánchez, Aurora; Suárez Rodríguez, BertaThe monthly retrospective search for unreported acute flaccid paralysis (AFP) cases conducted as a complementary component of the Spanish AFP surveillance system identified a case of AFP in a child admitted in Spain from Senegal during August 2021. Vaccine-derived poliovirus 2 was identified in the stool in September 2021. We present public health implications and response undertaken within the framework of the National Action Plan for Polio Eradication and the Public Health Emergency of International Concern.Publication Analytical data as a predictor of duration of hospital admission in human parechovirus infections(Elsevier, 2024-02) Gómez-Anca, Silvia; Fresno Jorge, Paula; Cabrerizo, Maria; de Ceano-Vivas La Calle, María; Calvo, Cristina; Instituto de Salud Carlos IIIPublication Brotes epidémicos y situaciones de alerta sanitaria de probable etiología vírica en el Centro Nacional de Microbiología durante el período 2012-2013.(Ministerio de Sanidad y Consumo (España), 2016-03-23) Echevarria, Jose Manuel; Avellón, Ana; Cabrerizo, Maria; Casas Flecha, Inmaculada; Echevarria, Juan Emilio; De Ory, Fernando de; Negredo, Anabel; Pozo Sanchez, Francisco; Sánchez-Seco, María Paz; Tarrago Asensio, David; Trallero, GloriaLos Planes Nacionales de erradicación o eliminación de la poliomielitis, el sarampión y la rubéola congénita establecen el papel a jugar por el Centro Nacional de Microbiología (CNM) en la vigilancia de esas enfermedades víricas. Además, el Sistema de Vigilancia de la Gripe en España el Real Decreto 1940/2004 sobre Vigilancia de las Zoonosis y el Plan de Contingencia contra la Rabia lo hacen también en lo relativo a la gripe y a las zoonosis víricas. Los resultados derivados de estas actividades se comunican con mayor o menor amplitud y regularidad.Publication Características epidemiológicas y clínicas de los lactantes hospitalizados por infecciones por parechovirus humanos. Estudio prospectivo en España(Elsevier, 2018-02) Martín Del Valle, Fernando; Calvo, Cristina; Martinez-Rienda, Inés; Cilla, Amaia; Romero, María P; Menasalvas, Ana Isabel; Reis-Iglesias, Leticia; Roda, Diana; Pena, María J; Rabella, Nuria; Portugués de la Red, María Del Mar; Megías, Gregoria; Moreno-Docón, Antonio; Otero, Almudena; Cabrerizo, Maria; Grupo de Estudio de las infecciones por enterovirus y parechovirus en niños; Instituto de Salud Carlos III[ES] Introducción: Los parechovirus humanos (HPeV) son virus de la familia Picornaviridae, recientemente descritos, a los que se atribuyen cuadros de fiebre sin foco (FSF), sepsis clínica, gastroenteritis, meningitis o encefalitis fundamentalmente en lactantes pequeños. Nuestro objetivo fue describir la epidemiología y las características clínicas de las infecciones por HPeV en nuestro medio. Pacientes y métodos: Estudio multicéntrico prospectivo, llevado a cabo en 12 hospitales a nivel nacional, entre 2013-2015, en niños < 3 años con FSF, sepsis clínica o patología neurológica. Se realizó determinación de HPeV mediante RT-PCR en el Centro Nacional de Microbiología en suero, heces o líquido cefalorraquídeo. Resultados: Se analizan 47 infecciones por HPeV de un total de 850 muestras (5,52%), siendo HPeV-3 el más frecuente (29 casos), con predominio en mayo y julio, con una distribución bienal. El 57% eran neonatos y solo 2 > 3 meses. Todos los pacientes presentaron fiebre, el 45% irritabilidad, el 18,6% exantema y el 14% diarrea. No se observa ninguna alteración específica en las pruebas bioquímicas. El diagnóstico final más frecuente fue FSF (61%) seguido de sepsis clínica (29%). Aunque un 29% de los niños precisaron ingreso en cuidados intensivos, solo un paciente presentó secuelas. Conclusiones: Los HPeV circulan en nuestro país, afectando fundamentalmente a lactantes < 2 meses y se asocian a FSF y sepsis clínica, con un predominio en primavera y verano. Sería de interés implementar las técnicas moleculares de diagnóstico en todos los hospitales para reconocer y manejar adecuadamente estas infecciones. [EN] Introduction: Human parechovirus (HPeV) is one of the recently described picornaviridae viruses that have been associated with fever of unknown origin (FUO), clinical sepsis, gastroenteritis, meningitis, or encephalitis in very young infants. The aim of this study is to describe the epidemiology and clinical features of these viruses. Patients and methods: A prospective multicentre 3-year study was conducted in 12 hospitals in Spain. Out of 850 specimens examined, 47 were positive (5.52%), with HPeV-3 being the most frequent (29 cases). Infections occurred throughout the year, but mainly in May and July, and a biennial distribution was observed. More than half (57%) were neonates, and only 2 children were older than 3 months. Fever was present in all children, with irritability in 45%, rash in 18.6%, and diarrhoea in 14%. The results of biochemical tests were all in normal range. The most common final diagnosis was FUO (61%), followed by clinical sepsis (29%). Up to 29% of infants were admitted to the intensive care unit, but only one patient had sequelae. Results: Out of 850 specimens examined, 47 were positive (5.52%) for HPeV, with HPeV-3 being the most frequent (29 cases). Infections occurred throughout the year, but mainly in May and July, and a biennial distribution was observed. More than half (57%) were neonates, and only 2 children were older than 3 months. Fever was present in all children, with irritability in 45%, rash in 18.6%, and diarrhoea in 14%. The results of biochemical tests were all in normal range. The most common final diagnosis was FUO (61%), followed by clinical sepsis (29%). Up to 29% of infants were admitted to the intensive care unit, but only one patient had sequelae. Conclusions: HPeV circulates in our country, mainly during spring and summer, and affects young infants with a FUO and clinical sepsis. Molecular diagnostic techniques in all hospitals could help in improving the management of patients with these infections.Publication Comparison of epidemiology and clinical characteristics of infections by human parechovirus vs. those by enterovirus during the first month of life(Springer, 2015-11) Cabrerizo, Maria; Trallero, Gloria; Pena, María José; Cilla, Amaia; Megias, Gregoria; Muñoz-Almagro, Carmen; Del Amo, Eva; Roda, Diana; Mensalvas, Ana Isabel; Moreno-Docón, Antonio; García-Costa, Juan; Rabella, Nuria; Omeñaca, Manuel; Romero, María Pilar; Sanbonmatsu-Gámez, Sara; Pérez-Ruiz, Mercedes; Santos-Muñoz, María José; Calvo, Cristina; Study Group of Enterovirus and parechovirus infections in children under 3 years-old, Spain; Instituto de Salud Carlos IIIHuman parechoviruses (HPeV) have been recently recognized as important viral agents in paediatric infections. The aims of this study were to investigate the HPeV infection prevalence in infants <1 month in Spain and, secondly, to analyse the clinical and epidemiological characteristics of the infected patients compared with those infected by enterovirus (EV). Infants <1 month with neurological or systemic symptoms were included in a multicentre prospective study. EV and HPeV detection by RT-PCR and genotyping were performed in cerebrospinal fluids (CSF), sera or throat swabs. Out of the total of 84 infants studied during 2013, 32 were EV positive (38 %) and 9 HPeV positive (11 %). HPeV-3 was identified in eight cases and HPeV-5 in one. Mean age of HPeV-positive patients was 18 days. Diagnoses were fever without source (FWS) (67 %), clinical sepsis (22 %) and encephalitis (11 %). Leukocytes in blood and CSF were normal. Pleocytosis (p = 0.03) and meningitis (p = 0.001) were significantly more frequent in patients with EV infections than with HPeV. Conclusions: Although HPeV-3 infections were detected less frequently than EV, they still account for approximately 10 % of the cases analysed in infants younger than 1 month. HPeV-3 was mainly associated with FWS and without leukocytosis and pleocytosis in CSF. In these cases, HPeV screening is desirable to identify the aetiologic agent and prevent unnecessary treatment and prolonged hospitalization.Publication Detección de SARS-CoV-2 en aguas residuales como herramienta de vigilancia y alerta rápida(2020-06-01) Cabrerizo, Maria; Fernandez-Garcia, Maria Dolores; Gonzalez-de-Audicana, Jon; Plaza-Ramos, Jose A.; Molina, Pampa; Alvarez-del Arco, Debora; Grupo de Análisis Científico de Coronavirus del ISCIII (GACC-ISCIII)El tracto gastrointestinal puede verse afectado por el coronavirus SARS-CoV-2, según apuntan diversos estudios realizados hasta la fecha, que señalan que el material genético del virus está presente en heces de pacientes con COVID-19 y que puede ser excretado durante largos periodos de tiempo. A pesar de que es posible que el SARS-CoV-2 se transmita por vía fecal-oral, se necesitan más estudios para determinar las condiciones que podrían favorecer este tipo de transmisión. La detección del virus en muestras de aguas residuales es una herramienta útil ya conocida para la vigilancia epidemiológica de virus que se está utilizando en el marco de la pandemia actual de coronavirus, ya que supone un indicador de circulación del virus entre la población. La capacidad que tiene la vigilancia de las aguas residuales para detectar casos leves o asintomáticos es una de sus principales ventajas y puede ser una herramienta de alerta temprana para identificar de forma precoz la presencia del SARS-CoV-2 tanto en el momento actual como en posibles rebrotes o segundas oleadas de la infección. Este acercamiento a la vigilancia medioambiental no sería nuevo en España, ya que el análisis de muestras de aguas residuales ya se realiza desde hace tiempo para realizar el seguimiento de la posible circulación de otros virus, como el de la polio, en la población. El Laboratorio de Enterovirus del Centro Nacional de Microbiología, que actúa como Laboratorio Nacional de Polio acreditado por la OMS, lleva a cabo esta labor desde hace más de 20 años gracias a un convenio con el Canal de Isabel II, que gestiona las aguas en la Comunidad de Madrid. España ya está desarrollando algunos estudios en torno a la presencia de SARS-CoV-2 en aguas residuales. El CSIC, la Universidad de Barcelona y el Centro Nacional de Microbiología, entre otros, están trabajando en este ámbito y ya disponen de resultados preliminares que muestran la detección del virus en parte de las muestras analizadas.Publication Enterovirus D68-associated respiratory and neurological illness in Spain, 2014-2018(Taylor & Francis, 2019) Gonzalez-Sanz, Ruben; Taravillo, Irene; Reina, Jordi; Navascués, Ana; Moreno-Docón, Antonio; Aranzamendi, Maitane; Romero, María Pilar; Del Cuerpo, Margarita; Pérez-González, Carmen; Pérez-Castro, Sonia; Otero, Almudena; Cabrerizo, Maria; Instituto de Salud Carlos IIIDuring 2014, enterovirus D68 (EV-D68) outbreaks were described globally, causing severe respiratory diseases in children and, in some cases, subsequent paralysis. In this study, the type characterization of enterovirus (EV) detected in respiratory illnesses and the epidemiology and clinical association of EV-D68 infections in Spain over a five-year period were described. A total of 546 EV-positive samples from hospitalized patients with respiratory infections were included. EV-D68 was the most frequently detected type (46.6%, 191/410 typed EV). Other EV from species A (25.1%), B (27.8%) and C (0.5%) were also identified. EV-D68 infections were more associated with bronchitis while EV-A/B types were more frequent in upper respiratory illness (p < 0.01). EV-D68 was also detected in patients with neurological symptoms (nine meningitis/meningoencephalitis and eight acute flaccid paralysis cases). Phylogenetic analysis of 3'-VP1 region showed most Spanish EV-D68 sequences from 2014 to 2016 belonged to subclades B2/B3, as other American and European strains circulating during the same period. However, those detected in 2017 and 2018 clustered to the emerged subclade D1. In summary, different EV can cause respiratory infections but EV-D68 was the most prevalent, with several strains circulating in Spain at least since 2014. Association between EV-D68 infection and neurological disease was also described.Publication Epidemiology of Echovirus 30 Infections Detected in a University Hospital in Catalonia, Spain, in 1995-2020(Multidisciplinary Digital Publishing Institute (MDPI), 2022-03-09) Cuerpo Casas, Margarita del; Gonzalez-de-Audicana, Jon; Fernandez-Garcia, Maria Dolores; Marín, Pilar; Esteban, Montserrat; Español, Montserrat; Cabrerizo, Maria; Rabella, NúriaThere is a growing interest in echovirus 30 (E30), an enterovirus responsible for neurological disease and hospitalization. There are multiple studies of outbreaks, but few that study the epidemiology over long periods of time. Our study aims to describe the clinical, epidemiological and microbiological characteristics of a series of E30 infections detected over 26 years. Data were retrospectively collected from a database of all enterovirus infections identified in our laboratory. They were detected by viral isolation or nucleic acid detection in patients presenting with respiratory or neurological infections, rash, sepsis-like syndrome, or gastroenteritis. Enterovirus genotyping was performed by amplification of the VP1 gene using RT-nested PCR, followed by sequencing and BLAST analysis. Of the 2402 enterovirus infections detected, 1619 were linked to at least one genotype and 173 were caused by E30. Clinical information was available for 158 (91.3%) patients. E30 was associated with neurological infection in 107 (67.8%) cases and it was detected almost every year. Phylogenetic analysis was performed with 67 sequences. We observed that E30 strains circulating in Catalonia from 1996 to 2016 belong to two lineages (E and F), although the majority cluster was in F. In 2018, lineage I emerged as the dominant lineage.Publication Genomic and serologic characterization of enterovirus A71 brainstem encephalitis(Lippincott Williams & Wilkins (LWW), 2020-05) Leon, Kristoffer E; Schubert, Ryan D; Casas-Alba, Didac; Hawes, Isobel A; Ramachandran, Prashanth S; Ramesh, Akshaya; Pak, John E; Wu, Wesley; Cheung, Carly K; Crawford, Emily D; Khan, Lillian M; Launes, Cristian; Sample, Hannah A; Zorn, Kelsey C; Cabrerizo, Maria; Valero-Rello, Ana; Langelier, Charles; Muñoz-Almagro, Carmen; DeRisi, Joseph L; Wilson, Michael R; Instituto de Salud Carlos III; European Regional Development FundOBJECTIVE: In 2016, Catalonia experienced a pediatric brainstem encephalitis outbreak caused by enterovirus A71 (EV-A71). Conventional testing identified EV in the periphery but rarely in CSF. Metagenomic next-generation sequencing (mNGS) and CSF pan-viral serology (VirScan) were deployed to enhance viral detection and characterization. METHODS: RNA was extracted from the CSF (n = 20), plasma (n = 9), stool (n = 15), and nasopharyngeal samples (n = 16) from 10 children with brainstem encephalitis and 10 children with meningitis or encephalitis. Pathogens were identified using mNGS. Available CSF from cases (n = 12) and pediatric other neurologic disease controls (n = 54) were analyzed with VirScan with a subset (n = 9 and n = 50) validated by ELISA. RESULTS: mNGS detected EV in all samples positive by quantitative reverse transcription polymerase chain reaction (qRT-PCR) (n = 25). In qRT-PCR-negative samples (n = 35), mNGS found virus in 23% (n = 8, 3 CSF samples). Overall, mNGS enhanced EV detection from 42% (25/60) to 57% (33/60) (p-value = 0.013). VirScan and ELISA increased detection to 92% (11/12) compared with 46% (4/12) for CSF mNGS and qRT-PCR (p-value = 0.023). Phylogenetic analysis confirmed the EV-A71 strain clustered with a neurovirulent German EV-A71. A single amino acid substitution (S241P) in the EVA71 VP1 protein was exclusive to the CNS in one subject. CONCLUSION: mNGS with VirScan significantly increased the CNS detection of EVs relative to qRT-PCR, and the latter generated an antigenic profile of the acute EV-A71 immune response. Genomic analysis confirmed the close relation of the outbreak EV-A71 and neuroinvasive German EV-A71. A S241P substitution in VP1 was found exclusively in the CSF.Publication Genomic surveillance of enterovirus associated with aseptic meningitis cases in southern Spain, 2015-2018(Nature Publishing Group, 2021-11-02) Gámbaro, Fabiana; Pérez, Ana Belén; Agüera, Eduardo; Prot, Matthieu; Martínez-Martínez, Luis; Cabrerizo, Maria; Simon-Loriere, Etienne; Fernandez-Garcia, Maria Dolores; Regional Government of Andalusia (España); Instituto de Salud Carlos III; Nvidia CorporationNew circulating Enterovirus (EV) strains often emerge through recombination. Upsurges of recombinant non-polio enteroviruses (NPEVs) associated with neurologic manifestations such as EVA71 or Echovirus 30 (E30) are a growing public health concern in Europe. Only a few complete genomes of EVs circulating in Spain are available in public databases, making it difficult to address the emergence of recombinant EVs, understand their evolutionary relatedness and the possible implication in human disease. We have used metagenomic (untargeted) NGS to generate full-length EV genomes from CSF samples of EV-positive aseptic meningitis cases in Southern Spain between 2015 and 2018. Our analyses reveal the co-circulation of multiple Enterovirus B (EV-B) types (E6, E11, E13 and E30), including a novel E13 recombinant form. We observed a genetic turnover where emergent lineages (C1 for E6 and I [tentatively proposed in this study] for E30) replaced previous lineages circulating in Spain, some concomitant with outbreaks in other parts of Europe. Metagenomic sequencing provides an effective approach for the analysis of EV genomes directly from PCR-positive CSF samples. The detection of a novel, disease-associated, recombinant form emphasizes the importance of genomic surveillance to monitor spread and evolution of EVs.Publication Hybrid capture shotgun sequencing detected unexpected viruses in the cerebrospinal fluid of children with acute meningitis and encephalitis(Springer, 2024-03-04) Launes, Cristian; Camacho, Juan; Pons-Espinal, Marina; López-Labrador, F Xavier; Esteva, Cristina; Cabrerizo, Maria; Fernandez-Garcia, Maria Dolores; Fogeda, Marta; Masa-Calles, Josefa; Lopez-Perea, Noemi; Echevarria, Juan Emilio; Muñoz-Almagro, Carmen; Tarrago Asensio, David; Conferencia de Rectores de las Universidades Españolas; Consejo Superior de Investigaciones Científicas (España); Centro de Investigación Biomédica en Red - CIBERESP (Epidemiología y Salud Pública)Purpose: Investigation of undiagnosed cases of infectious neurological diseases, especially in the paediatric population, remains a challenge. This study aimed to enhance understanding of viruses in CSF from children with clinically diagnosed meningitis and/or encephalitis (M/ME) of unknown aetiology using shotgun sequencing enhanced by hybrid capture (HCSS). Methods: A single-centre prospective study was conducted at Sant Joan de Déu University Hospital, Barcelona, involving 40 M/ME episodes of unknown aetiology, recruited from May 2021 to July 2022. All participants had previously tested negative with the FilmArray Meningitis/Encephalitis Panel. HCSS was used to detect viral nucleic acid in the patients' CSF. Sequencing was performed on Illumina NovaSeq platform. Raw sequence data were analysed using CZ ID metagenomics and PikaVirus bioinformatics pipelines. Results: Forty episodes of M/ME of unknown aetiology in 39 children were analysed by HCSS. A significant viral detection in 30 CSF samples was obtained, including six parechovirus A, three enterovirus ACD, four polyomavirus 5, three HHV-7, two BKV, one HSV-1, one VZV, two CMV, one EBV, one influenza A virus, one rhinovirus, and 13 HERV-K113 detections. Of these, one sample with BKV, three with HHV-7, one with EBV, and all HERV-K113 were confirmed by specific PCR. The requirement for Intensive Care Unit admission was associated with HCSS detections. Conclusion: This study highlights HCSS as a powerful tool for the investigation of undiagnosed cases of M/ME. Data generated must be carefully analysed and reasonable precautions must be taken before establishing association of clinical features with unexpected or novel virus findings.Publication Impact of the bacterial nasopharyngeal microbiota on the severity of genus enterovirus lower respiratory tract infection in children: A case-control study(Wiley, 2023-06) Penela-Sánchez, Daniel; Rocafort, Muntsa; Henares, Desiree; Jordan, Iolanda; Brotons, Pedro; Cabrerizo, Maria; Launes, Cristian; Muñoz-Almagro, Carmen; Instituto de Salud Carlos III; Unión Europea. Fondo Europeo de Desarrollo Regional (FEDER/ERDF)Introduction: Rhinoviruses (RV) and enteroviruses (EV) are among the main causative etiologies of lower respiratory tract infection (LRTI) in children. The clinical spectrum of RV/EV infection is wide, which could be explained by diverse environmental, pathogen-, and host-related factors. Little is known about the nasopharyngeal microbiota as a risk factor or disease modifier for RV/EV infection in pediatric patients. This study describes distinct nasopharyngeal microbiota profiles according to RV/EV LRTI status in children. Methods: Cross-sectional case-control study, conducted at Hospital Sant de Déu (Barcelona, Spain) from 2017 to 2020. Three groups of children <5 years were included: healthy controls without viral detection (Group A), mild or asymptomatic controls with RV/EV infection (Group B), and cases with severe RV/EV infection admitted to the pediatric intensive care unit (PICU) (Group C). Nasopharyngeal samples were collected from participants for viral DNA/RNA detection by multiplex-polymerase chain reaction and bacterial microbiota characterization by 16S rRNA gene sequencing. Results: A total of 104 subjects were recruited (A = 17, B = 34, C = 53). Children's nasopharyngeal microbiota composition varied according to their RV/EV infection status. Richness and diversity were decreased among children with severe infection. Nasopharyngeal microbiota profiles enriched in genus Dolosigranulum were related to respiratory health, while genus Haemophilus was specifically predominant in children with severe RV/EV LRTI. Children with mild or asymptomatic RV/EV infection showed an intermediate profile. Conclusions: These results suggest a close relationship between the nasopharyngeal microbiota and different clinical presentations of RV/EV infection.Publication La importancia de la vigilancia epidemiológica de los enterovirus emergentes(Elsevier, 2019) Amado Puentes, Alfonso; Cabrerizo, MariaPublication Lower Respiratory Tract Infection and Genus Enterovirus in Children Requiring Intensive Care: Clinical Manifestations and Impact of Viral Co-Infections(Multidisciplinary Digital Publishing Institute (MDPI), 2021-10-14) Penela-Sánchez, Daniel; Gonzalez-de-Audicana, Jon; Armero, Georgina; Henares, Desiree; Esteva, Cristina; de-Sevilla, Mariona-Fernández; Ricart, Silvia; Jordan, Iolanda; Brotons, Pedro; Cabrerizo, Maria; Muñoz-Almagro, Carmen; Launes, Cristian; Instituto de Salud Carlos III; Sociedad Española de Enfermedades Infecciosas y Microbiología ClínicaInfection by rhinovirus (RV) and enterovirus (EV) in children ranges from asymptomatic infection to severe lower respiratory tract infection (LRTI). This cohort study evaluates the clinical impact of RV/EV species, alone or in codetection with other viruses, in young children with severe LRTI. Seventy-one patients aged less than 5 years and admitted to the Paediatric Intensive Care Unit (PICU) of a reference children's hospital with RV or EV (RV/EV) LRTI were prospectively included from 1/2018 to 3/2020. A commercial PCR assay for multiple respiratory pathogens was performed in respiratory specimens. In 22/71, RV/EV + respiratory syncytial virus (RSV) was found, and 18/71 had RV/EV + multiple viral detections. Patients with single RV/EV detection required invasive mechanical ventilation (IMV) as frequently as those with RSV codetection, whereas none of those with multiple viral codetections required IMV. Species were determined in 60 samples, 58 being RV. No EV-A, EV-C, or EV-D68 were detected. RV-B and EV-B were only found in patients with other respiratory virus codetections. There were not any associations between RV/EV species and severity outcomes. To conclude, RV/EV detection alone was observed in young children with severe disease, while multiple viral codetections may result in reduced clinical severity. Differences in pathogenicity between RV and EV species could not be drawn.Publication Metagenomic sequencing, molecular characterization, and Bayesian phylogenetics of imported type 2 vaccine-derived poliovirus, Spain, 2021(Frontiers Media, 2023-05) Fernandez-Garcia, Maria Dolores; Faye, Martin; Díez-Fuertes, Francisco; Moreno-Docón, Antonio; Chirlaque-López, Maria Dolores; Faye, Ousmane; Cabrerizo, Maria; Instituto de Salud Carlos IIIIntroduction: In 2021, a type 2 vaccine-derived poliovirus (VDPV2) was isolated from the stool of a patient with acute flaccid paralysis (AFP) admitted to Spain from Senegal. A virological investigation was conducted to characterize and trace the origin of VDPV2. Methods: We used an unbiased metagenomic approach for the whole-genome sequencing of VDPV2 from the stool (pre-treated with chloroform) and from the poliovirus-positive supernatant. Phylogenetic analyses and molecular epidemiological analyses relying on the Bayesian Markov Chain Monte Carlo methodology were used to determine the geographical origin and estimate the date of the initiating dose of the oral poliovirus vaccine for the imported VDPV2. Results: We obtained a high percentage of viral reads per total reads mapped to the poliovirus genome (69.5% for pre-treated stool and 75.8% for isolate) with a great depth of sequencing coverage (5,931 and 11,581, respectively) and complete genome coverage (100%). The two key attenuating mutations in the Sabin 2 strain had reverted (A481G in the 5'UTR and Ile143Thr in VP1). In addition, the genome had a recombinant structure between type-2 poliovirus and an unidentified non-polio enterovirus-C (NPEV-C) strain with a crossover point in the protease-2A genomic region. VP1 phylogenetic analysis revealed that this strain is closely related to VDPV2 strains circulating in Senegal in 2021. According to Bayesian phylogenetics, the most recent common ancestor of the imported VDPV2 could date back 2.6 years (95% HPD: 1.7-3.7) in Senegal. We suggest that all VDPV2s circulating in 2020-21 in Senegal, Guinea, Gambia, and Mauritania have an ancestral origin in Senegal estimated around 2015. All 50 stool samples from healthy case contacts collected in Spain (n = 25) and Senegal (n = 25) and four wastewater samples collected in Spain were poliovirus negative. Discussion: By using a whole-genome sequencing protocol with unbiased metagenomics from the clinical sample and viral isolate with high sequence coverage, efficiency, and throughput, we confirmed the classification of VDPV as a circulating type. The close genomic linkage with strains from Senegal was consistent with their classification as imported. Given the scarce number of complete genome sequences for NPEV-C in public databases, this protocol could help expand poliovirus and NPEV-C sequencing capacity worldwide.Publication Molecular characterization of enterovirus detected in cerebrospinal fluid and wastewater samples in Monastir, Tunisia, 2014-2017(BioMed Central (BMC), 2022-03-18) Rmadi, Yosra; Elargoubi, Aida; Gonzalez-Sanz, Ruben; Mastouri, Maha; Cabrerizo, Maria; Aouni, Mahjoub; Ministry of Higher Education and Scientific Research (Túnez)Background: Enteroviruses (EVs) are considered the main causative agents responsible for aseptic meningitis worldwide. This study was conducted in the Monastir region of Tunisia in order to know the prevalence of EV infections in children with meningitis symptoms. Detected EV types were compared to those identified in wastewater samples. Methods: Two hundred CSF samples collected from hospitalized patients suspected of having aseptic meningitis for an EV infection between May 2014 and May 2017 and 80 wastewater samples collected in the same time-period were analyzed. EV detection and genotyping were performed using PCR methods followed by sequencing. Phylogenetic analyses in the 3'-VP1 region were also carried-out. Results: EVs were detected in 12% (24/200) CSF and in 35% (28/80) wastewater samples. EV genotyping was reached in 50% (12/24) CSF-positive samples and in 64% (18/28) sewage. Most frequent types detected in CSF were CVB3, E-30 and E-9 (25% each). In wastewater samples, the same EVs were identified, but also other types non-detected in CSF samples, such as E-17,CVA9 and CVB1 from EV species B, and EV-A71 and CVA8 from EV-A, suggesting their likely lower pathogenicity. Phylogenetic analysis showed that within the same type, different strains circulate in Tunisia. For some of the EV types such as E-9, E-11 or CVB3, the same strains were detected in CSF and wastewater samples. Conclusions: Epidemiological studies are important for the surveillance of the EV infections and to better understand the emergence of certain types and variants.Publication Molecular Epidemiology and Evolutionary Trajectory of Emerging Echovirus 30, Europe(Centers for Disease Control and Prevention (CDC), 2021-06) Benschop, Kimberley S M; Broberg, Eeva K; Hodcroft, Emma; Schmitz, Dennis; Albert, Jan; Baicus, Anda; Bailly, Jean-Luc; Baldvinsdottir, Gudrun; Berginc, Natasa; Blomqvist, Soile; Böttcher, Sindy; Brytting, Mia; Bujaki, Erika; Cabrerizo, Maria; Celma, Cristina; Cinek, Ondrej; Claas, Eric C J; Cremer, Jeroen; Dean, Jonathan; Dembinski, Jennifer L; Demchyshyna, Iryna; Diedrich, Sabine; Dudman, Susanne; Dunning, Jake; Dyrdak, Robert; Emmanouil, Mary; Farkas, Agnes; De Gascun, Cillian; Fournier, Guillaume; Georgieva, Irina; Gonzalez-Sanz, Ruben; van Hooydonk-Elving, Jolanda; Jääskeläinen, Anne J; Jancauskaite, Ruta; Keeren, Kathrin; Fischer, Thea K; Krokstad, Sidsel; Nikolaeva-Glomb, Lubomira; Novakova, Ludmila; Midgley, Sofie E; Mirand, Audrey; Molenkamp, Richard; Morley, Ursula; Mossong, Joël; Muralyte, Svajune; Murk, Jean-Luc; Nguyen, Trung; Nordbø, Svein A; Österback, Riikka; Pas, Suzan; Pellegrinelli, Laura; Pogka, Vassiliki; Prochazka, Birgit; Rainetova, Petra; Van Ranst, Marc; Roorda, Lieuwe; Schuffenecker, Isabelle; Schuurman, Rob; Stoyanova, Asya; Templeton, Kate; Verweij, Jaco J; Voulgari-Kokota, Androniki; Vuorinen, Tytti; Wollants, Elke; Wolthers, Katja C; Zakikhany, Katherina; Neher, Richard; Harvala, Heli; Simmonds, Peter; Ministry of Health Welfare and Sport (Países Bajos); Unión Europea. Comisión Europea. H2020; Aristotle University of Thessaloniki (Grecia); Wellcome Trust; National Institute for Health and Disability Insurance (Bélgica)In 2018, an upsurge in echovirus 30 (E30) infections was reported in Europe. We conducted a large-scale epidemiologic and evolutionary study of 1,329 E30 strains collected in 22 countries in Europe during 2016-2018. Most E30 cases affected persons 0-4 years of age (29%) and 25-34 years of age (27%). Sequences were divided into 6 genetic clades (G1-G6). Most (53%) sequences belonged to G1, followed by G6 (23%), G2 (17%), G4 (4%), G3 (0.3%), and G5 (0.2%). Each clade encompassed unique individual recombinant forms; G1 and G4 displayed >2 unique recombinant forms. Rapid turnover of new clades and recombinant forms occurred over time. Clades G1 and G6 dominated in 2018, suggesting the E30 upsurge was caused by emergence of 2 distinct clades circulating in Europe. Investigation into the mechanisms behind the rapid turnover of E30 is crucial for clarifying the epidemiology and evolution of these enterovirus infections.Publication Molecular epidemiology of an enterovirus A71 outbreak associated with severe neurological disease, Spain, 2016(European Centre for Disease Prevention and Control (ECDC), 2019-02) Gonzalez-Sanz, Ruben; Casas-Alba, Didac; Launes, Cristian; Muñoz-Almagro, Carmen; Ruiz-García, Montserrat; Alonso, Mercedes; González-Abad, María José; Megías, Gregoria; Rabella, Nuria; Del Cuerpo, Margarita; Gozalo-Margüello, Mónica; González-Praetorius, Alejandro; Martínez-Sapiña, Ana; Goyanes-Galán, María José; Romero, María Pilar; Calvo, Cristina; Antón, Andrés; Imaz, Manuel; Aranzamendi, Maitane; Hernández-Rodríguez, Águeda; Moreno-Docón, Antonio; Rey-Cao, Sonia; Navascués, Ana; Otero, Almudena; Cabrerizo, MariaIntroductionEnterovirus A71 (EV-A71) is an emerging pathogen that causes a wide range of disorders including severe neurological manifestations. In the past 20 years, this virus has been associated with large outbreaks of hand, foot and mouth disease with neurological complications in the Asia-Pacific region, while in Europe mainly sporadic cases have been reported. In spring 2016, however, an EV-A71 outbreak associated with severe neurological cases was reported in Catalonia and spread further to other Spanish regions.AimOur objective was to investigate the epidemiology and clinical characteristics of the outbreak.MethodsWe carried out a retrospective study which included 233 EV-A71-positive samples collected during 2016 from hospitalised patients. We analysed the clinical manifestations associated with EV-A71 infections and performed phylogenetic analyses of the 3'-VP1 and 3Dpol regions from all Spanish strains and a set of EV-A71 from other countries.ResultsMost EV-A71 infections were reported in children (mean age: 2.6 years) and the highest incidence was between May and July 2016 (83%). Most isolates (218/233) were classified as subgenogroup C1 and 217 of them were grouped in one cluster phylogenetically related to a new recombinant variant strain associated with severe neurological diseases in Germany and France in 2015 and 2016. Moreover, we found a clear association of EV-A71-C1 infection with severe neurological disorders, brainstem encephalitis being the most commonly reported.ConclusionAn emerging recombinant variant of EV-A71-C1 was responsible for the large outbreak in 2016 in Spain that was associated with many severe neurological cases.