OBJECTIVETo investigate the myocardial protective effect of L-carnitine in children with hand, foot and mouth disease (HFMD) caused by Coxsackie A16 virus and possible mechanisms.

METHODSA total of 60 HFMD children with abnormal myocardial enzyme after Coxsackie A16 virus infection were enrolled and randomly divided into L-carnitine group and fructose-1,6-diphosphate group (fructose group), with 30 children in each group. The two groups were given L-carnitine or fructose diphosphate in addition to antiviral and heat clearance treatment. Another 30 healthy children who underwent physical examination were enrolled as control group. The changes in myocardial zymogram, malondialdehyde (MDA), superoxide dismutase (SOD), and apoptosis factors sFas and sFasL after treatment were compared between groups.

RESULTSThere was no significant difference in treatment response between the L-carnitine group and the fructose group (P>0.05). One child in the fructose group progressed to critical HFMD, which was not observed in the L-carnitine group. Before treatment, the L-carnitine group and the fructose group had significantly higher indices of myocardial zymogram and levels of MDA, sFas, and sFasL and a significantly lower level of SOD than the control group (P<0.05), while there were no significant differences in these indices between the L-carnitine group and the fructose group (P>0.05). After treatment, the L-carnitine group and the fructose group had significant reductions in the indices of myocardial zymogram and levels of MDA, sFas, and sFasL and a significant increase in the level of SOD (P<0.05); the fructose group had a significantly higher level of creatine kinase (CK) than the control group and the L-carnitine group, and there were no significant differences in other myocardial enzyme indices, MDA, sFas, and sFasL between the L-carnitine group and the fructose group, as well as between the L-carnitine and fructose groups and the control group (P>0.05). SOD level was negatively correlated with aspartate aminotransferase, lactate dehydrogenase (LDH), CK, and creatine kinase-MB (CK-MB) (r=-0.437, -0.364, -0.397, and -0.519 respectively; P<0.05), and MDA level was positively correlated with LDH and CK-MB (r=0.382 and 0.411 respectively; P<0.05).

CONCLUSIONSL-carnitine exerts a good myocardial protective effect in children with HFMD caused by Coxsackie A16 virus, possibly by clearing oxygen radicals and inhibiting cardiomyocyte apoptosis.

Carnitine ; therapeutic use ; Child, Preschool ; Coxsackievirus Infections ; complications ; Female ; Hand, Foot and Mouth Disease ; drug therapy ; etiology ; metabolism ; Heart ; drug effects ; Humans ; Infant ; Male ; Malondialdehyde ; analysis ; Myocardium ; metabolism ; pathology ; Superoxide Dismutase ; metabolism

OBJECTIVETo investigate the pathogenic and clinical presentation and laboratory tests of bullous rash in hand, foot and mouth disease (HFMD) in Xi'an from January 2013 to December 2014 by retrospective analysis.

METHODA total of 224 specimens were collected from clinically diagnosed HFMD cases who were characterized by widespread mucocutaneous bullous reactions in Xi'an Children's Hospital from January 2013 to December 2014, the identification and subtyping of the isolates were conducted with real-time fluorescent quantitative RT-PCR. A retrospective analysis was performed to analyze the clinical presentation, laboratory tests and late follow-up problems of the HFMD.

RESULTIn the clinically diagnosed HFMD cases who were characterized by widespread mucocutaneous bullous reactions, 207 were caused by coxsackievirus A6 (CA6), accounting for 92. 4% of all cases with bullous, 4 were caused by enterovirus 71 (EV71), accounting for 1.8%, 10 were caused by coxsackievirus A16 (CA16), accounting for 4. 5%; 4 cases were negative for these viruses. In the cases positive for intestinal virus-nucleic acid, 130 were male, 90 were female; male to female ratio was 1. 44: 1, 203 were <5 years old, accounting for 92. 3%. Leukocytosis was found in 75 cases (34. 1%); high-sensitivity C-reactive protein (hsCRP) increased in 200 cases (90. 9%); elevated myocardial enzyme CK-MB was found in 35 cases (15. 9%), alanine aminotransferase increased in 15 cases (6. 8%); 187 cases had fever (85. 0%). None of the cases had serious complications such as encephalitis or myocarditis. In the course of the critical phase bullous rash or large vesicle-like changes, obvious itching, and facial rash appeared. After the fluid in the bullae was absorbed or the bullae ruptured or became ulcerated, scar formation and large areas of exfoliation occurred, with no effusion on the newly formed epithelium in the base, without significant pigmentation on later follow-up. In the late follow up process, 52 cases in CA6-positive patients (25. 1%) developed onychomadesis within 2-4 weeks after onset, 1 to 8 nails, an average of 4. 3 fell off, new nails grew, the nail bed showed no structural abnormalities and hyperplasia after falling off, the surface was smooth, had no hypertrophy, left no sequelae.

CONCLUSIONThe pathogen in HFMD characterized by widespread bullous reactions was mainly the CA6, this kind of HFMD was mainly mild type, with significant itching, later the bullae may have scar formation and skin exfoliation, in some cases onychomadesis may occur.

Child ; Enterovirus A, Human ; Enterovirus Infections ; pathology ; Exanthema ; pathology ; Female ; Fever ; Hand, Foot and Mouth Disease ; pathology ; Humans ; Male ; Pruritus ; Retrospective Studies

OBJECTIVETo investigate the etiology of hand, foot and mouth disease (HFMD) in Beijing during 2013, and study the clinical characteristics of HFMD caused by the main serotypes of enterovirus in the study.

METHODClinical data and 128 stool samples were collected from 128 hospitalized children with HFMD in Beijing Ditan Hospital during 2013. One step RT-PCR method was used for enterovirus genotyping to investigate the etiology of HFMD. Clinical characteristics of HFMD caused by the main serotypes of enterovirus were analyzed. And VP1 segments of the main virus were amplified to construct phylogenetic tree for the phylogenetic analysis.

RESULTA total of 128 hospitalized children with HFMD were included. HFMD was more likely developed in children under 2 years of age (81.6%, 102/125); 11 different enteroviruses were genotyped, with a total enterovirus positive rate of 76.6% (98/128); the positive rate of coxsackievirus A6 (CA6), 43.0% ( 55/128), was the highest, followed by enterovirus 71 (EV71), accounting for 14.8% (19/128). HFMD caused by CA6 was atypical, the rashes of which involved the perioral, trunk, limbs, face and neck (47%, 26/55), besides the common parts. Of the 55 cases caused by CA6, 6 children had clinical manifestations of nervous system involvement, one of whom even displayed type 2 respiratory failure. Mental status change more likely to occur in EV71-infected children than in CA6-infected ones (42% (8/19) vs. 11% (6/55) (χ(2)=7.041, P=0.008)); 13 children displayed onychomadesis, including 12 CA6 cases (23%, 12/53) and 1 CA10 cases (17%, 1/6), in the convalescence of hand, foot and mouth disease, and the correlation between onychomadesis and CA6 infection was significant (χ(2)=9.297, P=0.002). Phylogenetic analysis of 33 CA6 VP1 showed that the CA6 isolates of this study were highly similar to that of Taiwan and the nucleotide similarity was 95.91%-98.89%.

CONCLUSIONCA6 was the major pathogen of hospitalized children with hand, foot and mouth disease in Beijing during 2013, followed by EV71. The rashes caused by CA6 involved a wide range of skin sites and patients with CA6 infection displayed manifestations of neurological involvement or pulmonary edema similar to EV71 infection. Mental status change more likely occurred in EV71-infected children when neurological system was involved..

Child, Hospitalized ; Child, Preschool ; Enterovirus ; classification ; Enterovirus Infections ; diagnosis ; virology ; Exanthema ; pathology ; Genotype ; Hand, Foot and Mouth Disease ; diagnosis ; virology ; Hospitals ; Humans ; Infant ; Phylogeny ; Pulmonary Edema ; pathology ; Skin ; pathology ; Taiwan

OBJECTIVE: To explore the distribution of inflammatory cells and positive expression of P-se- lectin glycoprotein ligand-1 (PSGL-1) in infant brainstem tissue from hand-foot-mouth disease related fatal brainstem encephalitis. METHODS: Twenty brainstem samples from infants suffered from brainstem en- cephalitis were collected as the experimental group. Ten brainstem samples from infants died of non- brain diseases and injuries were collected as the control group. The distribution of inflammatory cells and the expression of PSGL-1 in the two groups were examined by immunohistochemical method. The characteristics of the positive cells were observed. RESULTS: In brainstem tissue of the experimental group, there were sleeve infiltrations of inflammatory cells around the vessels and in the glial nodule. Microglia was the most and following was neutrophils around the vessels and in the glial nodule. There was a significant statistical difference among microglias, neutrophils and lymphocytes (P < 0.05). There was no sleeve infiltration in the control group. PSGL-1 protein was expressed widely in inflammatory cells in the experimental group, especially in the inflammatory cells around the vessels and in the glial nodule. But PSGL-1 positive staining could be observed significantly less in the control group comparing with the experimental group (P < 0.05). CONCLUSION Microglia is the main type of inflammatory cells involved in the progress of the fatal disease. Moreover, PSGL-1 could participate in the pathogenesis of hand-foot-mouth disease related fatal brainstem encephalitis.
Brain Stem/pathology* ; Encephalitis/pathology* ; Hand, Foot and Mouth Disease/pathology* ; Humans ; Infant ; Membrane Glycoproteins/metabolism* ; Microglia/pathology* ; Neutrophils/pathology*

OBJECTIVETo understand the clinical and epidemiological characteristics of hand-foot-and-mouth disease (HFMD) deceased cases.

METHODInformation of demographics, diagnosis and treatment, clinical symptoms and signs, laboratory test results, and epidemiological contact history of 72 HFMD cases who died between May 2008 and September 2011, in Zhejiang Province, were collected and analyzed.

RESULTThe average age of the 72 cases was 1.8 years, 45 were males, accounting for 62.5%, 63 (87.5%) of the cases were scattered children. Eighteen counties reported 2 or more deaths, accounting for 46.1% (18/39) among the counties where the deaths were reported. The deaths occurred mainly in April to August, the peak occurred in May and June. Fever (98.4%, 63/64) and rash (95.1%, 58/61) were the most common symptoms, but the rash was not obvious at the first diagnosis. Fever occurred before the rash (79.0%, 49/62), persisted for 4 days in average. Vomiting (71.9%, 46/64), dyspnea (65.6%, 42/64), cyanosis (53.1%, 34/64) and impaired consciousness (51.6%, 33/64) were often seen among the cases; 53.1% (34/64) cases went to see the doctor on the first day, but 82.5%(52/63)cases were misdiagnosed. Time to diagnosis of HFMD was in average 3 days. About 3 to 4 days after the onset, the disease deteriorated sharply, deaths occurred within 1 day after admission in 78.9%(45/57)of the deceased cases; 85.0% (34/40) cases had high white blood cells level, mainly neutrophils increased, the ratio of neutrophil was more than 70% in 55.6% (15/27) of cases. Enterovirus 71 (EV71) infection was found in 93.3% (56/60) cases, the deceased cases often died of pulmonary hemorrhage (42.9%, 21/49) and encephalitis (34.7%, 17/49). The sanitary conditions of the cases' family were poor (65.5%, 36/55), but 73.3% (33/45) cases had no exposure history.

CONCLUSIONThe HFMD deceased cases were mostly younger aged boys, scattered children, nonlocal-residents, and had poor sanitation. They were often infected with EV71, had high fever but had no typical rash, no clear exposure history, they had increased leukocyte, and were often misdiagnosed. Three or 4 days after onset, the disease deteriorated abruptly, most cases died within 1 week after onset. To decrease the HFMD mortality, early detection of severe cases should be stressed, and relative measures should be taken. The guardian should be aware of having good sanitary situation and healthy habits.

Animals ; Child, Preschool ; China ; epidemiology ; Disease Outbreaks ; Enterovirus A, Human ; isolation & purification ; Feces ; virology ; Female ; Fever ; etiology ; pathology ; Hand, Foot and Mouth Disease ; epidemiology ; mortality ; pathology ; Humans ; Infant ; Male ; Retrospective Studies ; Sex Distribution

Coxsackievirus A16 belongs to the family Picornaviridae, and is a major agent of hand-foot-and-mouth disease that infects mostly children, and to date no vaccines or antiviral therapies are available. 2A protease of enterovirus is a nonstructural protein and possesses both self-cleavage activity and the ability to cleave the eukaryotic translation initiation factor 4G. Here we present the crystal structure of coxsackievirus A16 2A protease, which interestingly forms hexamers in crystal as well as in solution. This structure shows an open conformation, with its active site accessible, ready for substrate binding and cleavage activity. In conjunction with a previously reported "closed" state structure of human rhinovirus 2, we were able to develop a detailed hypothesis for the conformational conversion triggered by two "switcher" residues Glu88 and Tyr89 located within the bll2-cII loop. Substrate recognition assays revealed that amino acid residues P1', P2 and P4 are essential for substrate specificity, which was verified by our substrate binding model. In addition, we compared the in vitro cleavage efficiency of 2A proteases from coxsackievirus A16 and enterovirus 71 upon the same substrates by fluorescence resonance energy transfer (FRET), and observed higher protease activity of enterovirus 71 compared to that of coxsackievirus A16. In conclusion, our study shows an open conformation of coxsackievirus A16 2A protease and the underlying mechanisms for conformational conversion and substrate specificity. These new insights should facilitate the future rational design of efficient 2A protease inhibitors.
Coxsackievirus Infections ; virology ; Crystallography, X-Ray ; Cysteine Endopeptidases ; chemistry ; genetics ; Fluorescence Resonance Energy Transfer ; Hand, Foot and Mouth Disease ; enzymology ; pathology ; virology ; Humans ; Picornaviridae ; chemistry ; enzymology ; genetics ; Protein Conformation ; Structure-Activity Relationship ; Substrate Specificity ; Viral Proteins ; chemistry ; genetics

OBJECTIVETo explore the development and prognosis of the acute flaccid paralysis (AFP) associated with enterovirus 71 (EV71) infection through clinical follow-up study for clinical and magnetic resonance imaging (MRI) features based on the research progress of virology and pathology.

METHODSixteen children with HFMD associated with AFP in hospital from May 1, 2011 to August 31, 2011 were investigated and the patients received intensive rehabilitation training. The 16 cases were divided into two groups (the recovery or the sequela) by if the muscle strength recovered to level 4 after intensive rehabilitation. The MRI findings of 15 children were analyzed and among them, 6 patients were reexamined after one month. The clinical markers were compared between groups including course of disease, WBC, WBC in cerebrospinal fluid (CSF), ventilator support, therapy, the worst muscle strength, the initial tendon reflex, the muscle atrophy, and multi-limb paralysis. The data were analyzed by t test and χ2 test with SPSS10.0.

RESULTAll the 16 children were infected with enterovirus 71 (EV71). The myodynamia of 7 children were level 0, 4 children had serious upper limbs paralysis. The neck muscle in 3 cases and the brain stem motor ruckus in 4 cases were involved. The ankle clonus of non-completely paralyzed limbs in 14 cases occurred during rehabilitation. Eight children had the better prognosis, the other 8 children had sequela. 0 level muscle strength (0 case vs. 7 cases, χ2=12.4), the initial tendon reflex (2 cases vs. 8 cases, χ2=9.6), obvious muscle atrophy (0 case vs. 8 cases, χ2=16), were significantly different in the children with the recovery when compared to the sequela (P<0.01). The severe upper limbs paralysis had the worse prognosis than the severe lower limbs paralysis. MR imaging showed signs of spinal nerve root inflammation and the bilateral hyperintense lesions, symmetrical in the posterior portions of the medulla, pons, and asymmetrical in the ventral horns of cervical spinal cord. Signal enhancement occurred only in the early MRI examination.

CONCLUSIONIn the evolution of AFP due to EV71 infection, the upper motor neuron damage is common, the prognosis is related with the severity of early paralysis and neuron damage. MR imaging is helpful to understand the pathological mechanism of AFP.

Child, Preschool ; Enterovirus A, Human ; pathogenicity ; Female ; Follow-Up Studies ; Hand, Foot and Mouth Disease ; diagnosis ; pathology ; virology ; Humans ; Infant ; Magnetic Resonance Imaging ; Male ; Paralysis ; diagnosis ; pathology ; virology ; Prognosis

OBJECTIVE: To explore the mechanism that how human enterovirus 71 (EV71) invades the brainstem and how intercellular adhesion molecules-1 (ICAM-1) participates by analyzing the expression and distribution of human EV71, and ICAM-1 in brainstem of infants with brain stem encephalitis. METHODS: Twenty-two brainstem of infants with brain stem encephalitis were collected as the experimental group and 10 brainstems of fatal congenital heart disease were selected as the control group. The sections with perivascular cuffings were selected to observe EV71-VP1 expression by immunohistochemistry method and ICAM-1 expression was detected for the sections with EV71-VP1 positive expression. The staining image analysis and statistics analysis were performed. The experiment and control groups were compared. RESULTS: (1) EV71-VP1 positive cells in the experimental group were mainly astrocytes in brainstem with [dark]-brown particles, and the control group was negative. (2) ICAM-1 positive cells showed [dark]-brown. The expression in inflammatory cells (around blood vessels of brain stem and in glial nodules) and gliocytes increased. The results showed statistical difference comparing with control group (P < 0.05). CONCLUSION The brainstem encephalitis can be used to diagnose fatal EV71 infection in infants. EV71 can invade the brainstem via hematogenous route. ICAM-1 may play an important role in the pathogenic process.
Astrocytes/pathology* ; Brain Stem/virology* ; Case-Control Studies ; Encephalitis, Viral/virology* ; Enterovirus A, Human/metabolism* ; Female ; Hand, Foot and Mouth Disease/virology* ; Humans ; Immunohistochemistry ; Infant ; Intercellular Adhesion Molecule-1/metabolism* ; Male

OBJECTIVETo investigate the epidemiological and clinical features of hand, foot and mouth disease (HFMD) since several outbreaks of HFMD caused by enteroviruses were documented in China between 2007 and 2008.

METHODSHFMD cases reported to the National Infectious Disease Information Management System database between May 2008 and April 2009 were assessed. Clinical features in some of the severe and fatal cases were analyzed the etiology of the outbreaks was investigated.

RESULTS89.1% of reported HFMD cases were found in children<5 year-old with an age-specific incidence rate of 834.1/100 000 in the first year as the notifiable disease in China from May 2008 to April 2009. The incidence, mortality and percentage of severe cases were studied for three regions of China and found to be highest in the central region. The incidence of severe cases and mortality in rural population were significantly higher than those in urban population. Among the laboratory confirmed EV17 positive cases there were 52.6% mild, 83.5% severe, and 96.1% fatal cases. More myoclonic jerks were found in the severe case group than in group that died. Tachypnea, lip purpling, pink foaming and low limb temperature occurred more frequently in the fatal cases than in the severe cases.

CONCLUSIONThe epidemic of HFMD in China was characterized predominantly by EV71 infections, had relatively high mortality rates especially in the central region, and was most prevalent in young, rural populations.

Adolescent ; Adult ; Aged ; Aged, 80 and over ; Child ; Child, Preschool ; China ; epidemiology ; Hand, Foot and Mouth Disease ; epidemiology ; pathology ; Humans ; Infant ; Infant, Newborn ; Middle Aged ; Young Adult

Brain Edema ; etiology ; Brain Stem ; pathology ; Encephalitis ; etiology ; Female ; Hand, Foot and Mouth Disease ; complications ; therapy ; Humans ; Infant, Newborn