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Aseptic Meningitis Epidemic During a West Nile Virus Avian Epizootic Kathleen G

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Aseptic Meningitis Epidemic During a West Nile Virus Avian Epizootic Kathleen G RESEARCH Aseptic Meningitis Epidemic during a West Nile Virus Avian Epizootic Kathleen G. Julian,* James A. Mullins,† Annette Olin,‡ Heather Peters,§ W. Allan Nix,† M. Steven Oberste,† Judith C. Lovchik,¶ Amy Bergmann,§ Ross J. Brechner,§ Robert A. Myers,§ Anthony A. Marfin,* and Grant L. Campbell* While enteroviruses have been the most commonly ance of emerging infectious agents such as West Nile virus identified cause of aseptic meningitis in the United States, (WNV), warrants periodic reevaluation. the role of the emerging, neurotropic West Nile virus (WNV) WNV infection is usually asymptomatic but may cause is not clear. In summer 2001, an aseptic meningitis epidem- a wide range of syndromes including nonspecific febrile ic occurring in an area of a WNV epizootic in Baltimore, illness, meningitis, and encephalitis. In recent WNV epi- Maryland, was investigated to determine the relative contri- butions of WNV and enteroviruses. A total of 113 aseptic demics in which neurologic manifestations were promi- meningitis cases with onsets from June 1 to September 30, nent (Romania, 1996 [5]; United States, 1999–2000 [6,7]; 2001, were identified at six hospitals. WNV immunoglobu- and Israel, 2000 [8]), meningitis was the primary manifes- lin M tests were negative for 69 patients with available tation in 16% to 40% of hospitalized patients with WNV specimens; however, 43 (61%) of 70 patients tested disease. However, because WNV meningitis has nonspe- enterovirus-positive by viral culture or polymerase chain cific clinical manifestations and requires laboratory testing reaction. Most (76%) of the serotyped enteroviruses were for a definitive diagnosis, case ascertainment and testing echoviruses 13 and 18. Enteroviruses, including previously practices can affect the number of cases diagnosed. rarely detected echoviruses, likely caused most aseptic Because WNV testing in U.S. surveillance programs has meningitis cases in this epidemic. No WNV meningitis cases were identified. Even in areas of WNV epizootics, focused on patients with encephalitis of undetermined enteroviruses continue to be important causative agents of cause (9), the role of WNV as a cause of aseptic meningi- aseptic meningitis. tis in the United States is not clear. A 2001 investigation in Baltimore provided an oppor- tunity to evaluate the role of WNV in the epidemiology of hen national surveillance for aseptic meningitis was aseptic meningitis and to assess WNV surveillance. From Wconducted in the United States, the Centers for Baltimore City and County, 118 cases of aseptic meningi- Disease Control and Prevention (CDC) received reports of tis with onsets from June 1 to September 30, 2001, were 7,000 to 14,000 cases of aseptic meningitis per year from reported to Maryland’s Department of Health and Mental 1984 to 1994 (1). Enteroviruses are the leading identifiable Hygiene (DHMH), compared to an average of 39 cases cause of aseptic meningitis in children and adults, particu- during the same summer season in 1997–2000. larly in summer and autumn (2). In smaller proportions, Approximately 95% of these 2001 cases were reported mumps virus (primarily in studies before 1980), her- without known cause. Simultaneously, an intense WNV pesviruses, lymphocytic choriomeningitis virus, arbovirus- epizootic among birds was detected in the Baltimore area es, Leptospira, and many other viral and nonviral agents (288 WNV-infected dead birds and 14 WNV-infected have been identified in etiologic studies of aseptic menin- mosquito pools were collected before September 30, gitis in the United States (3,4). However, the epidemiolo- 2001). Early in the summer, nearly 100% of dead crows gy of aseptic meningitis is not static and, with the appear- collected from some sections of Baltimore City tested positive for WNV. When the investigation of aseptic meningitis was initiated in mid-September, one case of *Centers for Disease Control and Prevention, Fort Collins, Colorado, USA; †Centers for Disease Control and Prevention, human WNV encephalitis had been reported from Atlanta, Georgia, USA; ‡St. Matthew’s School of Medicine, Grand Baltimore. The investigation’s objectives included 1) Caymans, British West Indies; §Maryland Department of Health identification of the predominant cause(s) of the aseptic and Mental Hygiene, Baltimore, Maryland, USA; and ¶University of meningitis epidemic, emphasizing the relative contribu- Maryland Medical Center, Baltimore, Maryland, USA 1082 Emerging Infectious Diseases • Vol. 9, No. 9, September 2003 RESEARCH tions of WNV and enteroviruses and 2) evaluation of hos- For each case, a standardized form was used to abstract pital-based–WNV surveillance of patients with aseptic clinical information from the medical record. meningitis, including strategies used for diagnostic test- ing. Acute-Phase and Convalescent-Phase Specimens and Interviews Methods Acute-phase (<8 days after illness onset) CSF, serum, rectal swab, and nasopharyngeal specimens were collected Discharge Diagnoses Code Review if ordered by the patients’ physicians. Specimens were To confirm an increase in aseptic meningitis cases by a stored at hospital, DHMH, or private reference laboratories method independent of case reporting to DHMH, a dis- at temperatures ranging from 4°C to –70°C. During home charge diagnosis code review was conducted at the six visits to consenting patients >12 years of age who had had investigation hospitals. Included were patients with aseptic aseptic meningitis of unknown cause, convalescent-phase meningitis (including International Classification of (>7 days after illness onset) blood specimens were collect- Diseases [ICD]-9-CM codes 047.0, 047.1, 047.8, 047.9, ed and a standardized questionnaire was administered to 049.0, 049.1, 053.0, 054.72, 072.1) who were evaluated characterize symptoms and duration of illness. from June 1 to September 30, 1998–2001. Diagnostic Testing Case Definitions Hospitals performed routine cell counts, chemistries, The investigation was conducted at six hospitals that and bacterial cultures of CSF for patients with sufficient collectively reported to DHMH 76% of the 118 aseptic specimen quantity. Some patients’ physicians ordered meningitis cases from Baltimore City and County. A case additional tests. These tests commonly included, for CSF of aseptic meningitis was defined as an illness with onset specimens, latex agglutination screening tests for bacterial from June 1 to September 30, 2001; cerebrospinal fluid antigens, culture or PCR tests for enteroviruses or her- (CSF) cell count of >5 leukocytes per milliliter; negative pesviruses, and culture for fungi; for CSF or serum speci- CSF bacterial cultures; and no physician or laboratory doc- mens, Borrelia burgdorferi antibody, Venereal Disease umentation of bacterial, fungal, or parasitic central nerv- Research Laboratory test, and cryptococcal antigen test; ous system (CNS) disease, cerebral hemorrhage, carcino- and for nasopharyngeal and rectal swab specimens, culture matous meningitis, or cerebral vasculitis. Neonates who for enteroviruses. developed CSF abnormalities before first hospital dis- For available specimens from patients with aseptic charge were excluded, as were persons with a physician- meningitis of unknown cause, arbovirus serologic testing documented diagnosis of encephalitis, confusion, or was performed at DHMH laboratories, and WNV PCR obtundation. A case of enteroviral meningitis was defined tests were completed at DHMH laboratories or the as an illness meeting the criteria for aseptic meningitis and, Division of Vector-Borne Infectious Diseases, CDC. CSF in addition, a positive enterovirus culture of a CSF, rectal specimens were tested by ELISA for IgM antibodies to swab, or nasopharyngeal specimen, or a positive WNV and by TaqMan reverse transcriptase (RT-) PCR enterovirus polymerase chain reaction (PCR) test of a CSF tests for WNV (10,11). Serum specimens were tested at specimen. A case of WNV meningitis was defined as an ill- DHMH laboratories by ELISA for IgM antibodies to ness meeting the criteria for aseptic meningitis and, in WNV, and by immunofluorescence assay (IFA) for IgM addition, WNV immunoglobulin (Ig) M detected in a CSF and IgG antibodies to La Crosse, St. Louis encephalitis, specimen by enzyme-linked immunosorbent assay eastern equine encephalomyelitis, and western equine (ELISA), a greater than-four-fold rise of WNV-neutraliz- encephalomyelitis viruses. ing antibodies in acute- and convalescent-phase serum Available CSF and rectal swab specimens from patients specimens, or WNV nucleic acid detected in a CSF speci- with aseptic meningitis of unknown cause were tested by men by PCR. The investigation was limited to persons liv- enterovirus culture at the Respiratory and Enteric Viruses ing in Baltimore City or County who were evaluated at one Branch, CDC. Three cell lines were used at CDC for of the six investigation hospitals. enterovirus culture: RD (human rhabdomyosarcoma), HELF (human embryonic lung fibroblast), and LLC-MK2 Case Ascertainment (monkey kidney). Isolates were serotyped by RT-PCR Cases reported to DHMH as the code “viral meningitis” amplification and subsequent sequencing of an approxi- were reviewed. Depending on the resources of each hospi- mately 320-nt segment of the VP1 enterovirus gene (12). tal, additional cases were identified by computerized When available, enteroviruses already isolated by hospital queries for test results of >5–10 leukocytes per milliliter in laboratories from CSF, nasopharyngeal, or rectal swab
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