Emerging Infectious Diseases Volume 16 Issue 2

2010·4.3 MB·English

by  CDC

Peer-Reviewed Journal Tracking and Analyzing Disease Trends pages 183–372
EDITOR-IN-CHIEF
D. Peter Drotman
Managing Senior Editor EDITORIAL BOARD
Polyxeni Potter, Atlanta, Georgia, USA
Dennis Alexander, Addlestone Surrey, United Kingdom
Senior Associate Editor Barry J. Beaty, Ft. Collins, Colorado, USA
Brian W.J. Mahy, Atlanta, Georgia, USA Ermias Belay, Atlanta, GA, USA
Martin J. Blaser, New York, New York, USA
Associate Editors
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Carolyn Bridges, Atlanta, GA, USA
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David Bell, Atlanta, Georgia, USA
Kenneth C. Castro, Atlanta, Georgia, USA
Charles H. Calisher, Ft. Collins, Colorado, USA
Thomas Cleary, Houston, Texas, USA
Michel Drancourt, Marseille, France
Anne DeGroot, Providence, Rhode Island, USA
Paul V. Effl er, Perth, Australia
Vincent Deubel, Shanghai, China
David Freedman, Birmingham, AL, USA
Ed Eitzen, Washington, DC, USA
K. Mills McNeill, Kampala, Uganda
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Patrice Nordmann, Paris, France
David L. Heymann, London, UK
Tanja Popovic, Atlanta, Georgia, USA
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Emerging Infectious Diseases
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Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 16, No. 2, February 2010
February 2010
On the Cover Human Hendra Virus Encephalitis
Ellis Wilson (1899–1977) and Equine Outbreak, Australia, 2008 ........219
Caribbean Bird Vendor (1953) E.G. Playford et al.
Oil on canvas (91.44 cm × 60.96 cm) Emergence of this virus is a serious medical,
Hampton University Museum, veterinary, and public health challenge.
Hampton, Virginia, USA
Cost-effectiveness of
About the Cover p. 369
Pharmaceutical-based Pandemic
Mitigation Strategies ....................................224
A.T. Newall et al.
Prepandemic vaccine and antiviral treatment may
be effective.
Domestic Animals and Visceral
Perspective Leishmaniasis, Nepal ...................................231
N.R. Bhattarai et al.
Coronavirus Infections in Children .............183 Proximity of Leishmania donovani–positive goats is
N. Principi et al. a risk factor for human infection.
Viruses should be monitored to prevent spread of
virulent strains. Tularemia Outbreak, Germany ....................238
A.M. Hauri et al.
Research Infectious aerosols can contribute to transmission
during processing of dead hares.
Imported MRSA, Sweden .............................189
M. Stenhem et al.
Infl uenza Vaccination Program
Knowledge of different risks for infection will
for Children, Hawaii ......................................244
improve control measures.
P.V. Effl er et al.
p. 240 Nearly half of students in participating elementary
CME ACTIVITY
and middle schools were vaccinated.
Community-associated Clostridium
diffi cile Infection, North Carolina ................197 Cryptococcus gattii, British Columbia,
P.K. Kutty et al. Canada, 1999–2007.......................................251
Antimicrobial drug exposure remains the most E. Galanis and L. MacDougall
common modifi able risk factor.
Incidence is high, but the predominant strain does
not cause greater illness or death than other strains.
Household Responses to p. 262
Pandemic (H1N1) 2009–related Tropheryma whipplei in Patients
School Closures, Australia ..........................205 with Pneumonia ............................................258
P.V. Effl er et al. S. Bousbia et al.
Results will determine the appropriateness and This bacterium may be an etiologic agent of
effi cacy of this mitigation measure. pneumonia.
Employment and Compliance with Increased Resistance in
Pandemic Infl uenza Mitigation Tuberculosis Despite Treatment
Recommendations .......................................212 Adherence, South Africa ..............................264
K.D. Blake et al. A.D. Calver et al.
Noncompliance may result from job insecurity and Rapid diagnostics and pharmacokinetic studies to
fi nancial problems. optimize dosages are needed.
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 16, No. 2, February 2010
Association Between
Mycobacterium tuberculosis
Strains and Phenotypes...............................272 February 2010
T. Brown et al.
335 Enterocytozoon bieneusi Infection, Czech
These fi ndings can be used as a model of pathogen Republic
global diversity. B. Sak et al.
338 Hendra Virus Outbreak with Novel Clinical
Historical Review
Features, Australia, 2008
H. Field et al.
Cause of Epidemic among Native
Americans, New England, 1616–1619.........281
Commentary
J.S. Marr and J.T. Cathey
This outbreak may have been leptospirosis 341 Permanent Specimens of Hosts and Vectors
complicated by Weil syndrome. in Public Health and Epidemiology
A.T. Peterson
Dispatches Another Dimension
287 Clonal Distribution of Invasive 368 Personal Log, Stardate 42552.6
Pneumococci, Czech Republic, 1996–2003 C. Kim
H. Žemličková et al. p. 291
Letters
290 White-Nose Syndrome Fungus in Bat, France
S.J. Puechmaille et al.
343 Perinatal Pandemic (H1N1) 2009 Infection,
294 Nontuberculous Mycobacteria, Taiwan, Thailand
2000–2008
344 Bronchial Casts and Pandemic (H1N1) 2009
C.-C. Lai et al.
Virus Infection
297 Bordetella pertussis Clones Identifi ed by
346 Methicillin-Resistant Staphylococcus
Multilocus Variable-Number Tandem-Repeat
aureus ST398, Italy
Analysis
J. Kurniawan et al. 348 Neisseria meningitidis Serogroup W135,
China
301 Plasmodium falciparum Malaria, Southern
Algeria, 2007 349 Avian Infl uenza (H5N1) among Wild Birds,
S.C. Boubidi et al. Russia, 2009
304 Pandemic (H1N1) 2009 Outbreak on Pig 351 Pandemic (H1N1) 2009 Virus in Patients
Farm, Argentina Treated with Oseltamivir
A. Pereda et al.
p. 305 352 Marburg Virus in Fruit Bat, Kenya
308 Sin Nombre Virus Infections in Field
354 Human African Trypanosomiasis in Areas
Workers, Colorado
without Surveillance
F. Torres-Pérez et al.
356 Using Museum Collections to Detect
311 Pandemic (H1N1) 2009 Cases, Buenos
Pathogens
Aires, Argentina
M. Echavarría et al. 357 Aggression and Rabid Coyotes,
Massachusetts
314 Mammalian Ancestry of Pandemic (H1N1)
2009 Virus 359 Neisseria meningitidis, Italy
N.A. Ilyushina et al. 360 Antiphospholipid Syndrome and Acute HIV
318 Concurrent Silicosis and Mycosis at Death Infection
Y. Iossifova et al. 362 Mycobacterium tuberculosis Beijing Strain,
321 Coccidioidiomycosis among College Mali
Students, Arizona 363 Hemorrhagic Fever with Renal Syndrome,
N.G. Stern and J.N. Galgiani Vietnam
324 Novel Human Bocavirus in Children with 365 Porcine Reproductive and Respiratory
Acute Respiratory Tract Infection Syndrome Virus, China
J-r. Song et al.
367 Evidence-based Tool for Triggering School
328 Lymphocytic Choriomeningitis Virus Closures during Infl uenza Outbreaks
Meningitis, New York, NY, 2009 (response)
D.S. Asnis et al.
About the Cover
331 Severe Leptospirosis in Hospitalized
Patients, Guadeloupe 369 Bird’s Eye View of Emerging Zoonoses
C. Herrmann-Storck et al.
Etymologia
286 Cryptococcus gattii
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 16, No. 2, February 2010
Effects of Coronavirus Infections
in Children
Nicola Principi, Samantha Bosis, and Susanna Esposito
The isolation of the coronavirus (CoV) identifi ed as the ports that suggested a possible relationship with the de-
cause of severe acute respiratory syndrome and the detec- velopment of extrarespiratory problems, including central
tion of 2 new human CoVs (HCoV-NL63 and HCoV-HKU1) nervous system (CNS) involvement, in which HCoVs can
have led to studies of the epidemiology and clinical and persist and play a role in causing chronic neurologic disor-
socioeconomic effects of infections caused by all HCoVs,
ders (4). Consequently, the circulation of HCoVs was not
including those known since the late 1960s (HCoV-229E
monitored, and no attempt was made to develop vaccines
and HCoV-OC43). HCoV infections can be associated with
or drugs that were active against the viruses.
respiratory and extrarespiratory manifestations, including
The identifi cation of SARS-CoV and the isolation
central nervous system involvement. Furthermore, unlike
of 2 novel HCoVs in humans (HCoV-NL63 and HCoV-
other RNA viruses, HCoVs can easily mutate and recombine
when different strains infect the same cells and give rise to a HKU1) (5,6) have led to several studies of the epidemiol-
novel virus with unpredictable host ranges and pathogenic- ogy and clinical and socioeconomic effects of HCoV in-
ity. Thus, circulating HCoVs should be closely monitored to fections, which were greatly facilitated by the availability
detect the spread of particularly virulent strains in the com- of modern molecular biology methods that enable direct
munity at an early stage and to facilitate the development of viral identifi cation in respiratory secretions (7–26). Interest
adequate preventive and therapeutic measures. was strengthened by the demonstration that SARS could
be considered a zoonotic infection because, after it was
Human coronaviruses (HCoVs) have been known since described and the causative agent identifi ed from patients
the late 1960s as a group of viruses capable of infecting in the People’s Republic of China, SARS-CoV–like viruses
humans and animals (1). In a wide variety of animals, they were isolated from caged animals, including palm civets
cause respiratory, enteric, hepatic, and neurologic diseases and raccoon dogs in wildlife markets of the same Chinese
that, in some cases (especially when they infect the young), province (27). This fi nding and the subsequent independent
can be severe (1). However, until the pathogen identifi ed discovery of SARS-CoV–like viruses in horseshoe bats in-
as the cause of severe acute respiratory syndrome (SARS) dicated that wild animals could be the reservoir of these vi-
was isolated (2), the previously known HCoVs (HCoV- ruses and that, in a suitable environment, they could infect
229E and HCoV-OC43) were considered to play a marginal humans and cause epidemics. New data concerning old and
clinical role in pediatrics. This conclusion was made main- the new HCoVs raise the question of whether HCoVs may
ly because, on the basis of the data available at the time, be more clinically important in children than was previous-
HCoVs were believed to cause only mild upper respiratory ly thought, thus indicating the need for a systematic evalu-
tract infections (URTIs) in children and that only in pre- ation of their circulation and the availability of preventive
mature infants and children with a chronic underlying dis- and therapeutic measures.
ease could severe lower respiratory tract infections (LRTIs)
develop (3). Moreover, no importance was placed on re- Epidemiology of HCoV Infections in Children
A profound difference exists between the epidemiol-
Author affi liations: University of Milan, Milan, Italy; and Fondazione ogy of the infections caused by SARS-CoV and that of all
Istituto Di Ricovero e Cura a Carattere Scientifi co “Ospedale Mag- other HCoV infections. SARS-CoV emerged in November
giore Policlinico, Mangiagalli e Regine Elena,” Milan 2002 and disappeared in April 2004 (28). During these 18
months, it was isolated in many countries, some of which
DOI: 10.3201/eid1602.090469
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 16, No. 2, February 2010 183
PERSPECTIVE
were very distant from each other. However, the total of 42.9%–50.0% of children 6–12 months of age (32) and in
8,098 cases of SARS diagnosed worldwide (28) is substan- 65% of those 2.5–3.5 years of age (33). Similarly, in 75%
tially fewer than the number usually found during epidem- of the cases, children 2.5–3.5 years of age had antibodies
ics of the most common respiratory viruses, such as respi- against HCoV-NL63 (33). All these factors can explain
ratory syncytial virus (RSV) and infl uenza viruses (18). why the lowest incidences of HCoV-229E and HCoV-
Furthermore, seroepidemiologic studies of high-risk OC43 infections are usually found when the study popula-
and low-risk residential areas have clearly shown that the tion includes older children or adolescents, patients with
prevalence of immunoglobulin G against SARS-CoV was underlying severe chronic diseases or hospitalized patients,
low in children and adults (29); this result indicates that when only highly symptomatic infections are considered,
SARS-CoV not only had a restricted period of circulation and when the study is conducted during the whole year.
but also that it had limited spread. Proportionally fewer Moreover, what has been clearly shown is that the
children were involved: <5% of all cases were diagnosed original HCoVs are commonly detected in childhood and
in patients <18 years of age (28). The biology of SARS and frequently isolated in the nasopharyngeal secretions of
its low level of transmissibility seem to be the main rea- children with respiratory infection. In some cases, co-in-
sons for the low risk for contagion in children. In most of fections with other respiratory viruses, mainly RSV, infl u-
the areas in which outbreaks occurred, healthcare workers enza viruses, and human metapneumovirus, have also been
and adult patients were mainly involved and, because they found (4,7–23). However, the real incidence of HCoV-
were immediately hospitalized, the risk for the infection 229E and HCoV-OC43 co-infections with other respiratory
spreading to children was greatly reduced because they are pathogens has not yet been defi ned because only a few of
not usually allowed to visit hospitals (28). This hypothesis the published studies were planned to identify all the main
seems to be further supported by the fact that the early de- respiratory viruses.
tection and isolation of symptomatic patients were the most Similar conclusions can be drawn in relation to the
important measures in controlling the SARS epidemic. more recently identifi ed HCoVs. HCoV-NL63, which can
Unlike SARS-CoV, HCoV-229E, HCoV-OC43, be found in 1.0%–9.3% of nasopharyngeal aspirates from
HCoV-NL63, and HCoV-HKU1 have been in continuous patients with RTIs (7–23), circulates throughout the world
circulation since their fi rst isolation and every year cause (predominantly during the winter in temperate regions), in-
a large number of infections that more frequently involve fects mainly younger children and subjects with underlying
children than adults (3,5–26). In particular, the data re- severe chronic diseases, and is more frequently found in
garding the earlier-appearing HCoVs indicate that they are nonhospitalized children (online Appendix Table, www.
distributed throughout the world and mainly circulate dur- cdc.gov/EID/content/16/2/183-appT.htm). Although it was
ing the winter and early spring, with outbreaks occurring not isolated until 2000, HCoV-NL63 has probably been
every 2–4 years (3). Whenever HCoVs have been sought circulating for some time because one of the fi rst detec-
in studies of respiratory infections in infants and children, tions occurred in a sample of nasopharyngeal secretions
they have been found, although generally less frequently collected from a child with pneumonia that had been kept
than other respiratory viruses such as RSV and infl uenza in a freezer since January 2003 before evaluation (5).
(18,30). However, the real importance of HCoV-229E and HCoV-HKU1 was identifi ed in 2005 and has once
HCoV-OC43 in clinical practice has not been fully defi ned again been found in nasopharyngeal secretions of children
because the collected data are often discordant. In 1974, and adults with respiratory infections in countries that are
McIntosh et al. found that the global incidence of LRTIs very distant from each other. Its incidence varies from
due to HCoV-229 and HCoV-OC43 in hospitalized children <1% to 6% (Table) (6,20,24–26), and seroepidemiologic
was no higher than 3.8% (31). Later studies have shown that surveys based on antibodies reacting with the recombinant
when all respiratory infections are considered, the etiologic HKU1 nucleocapsid protein suggest that infection may be
prevalence of these pathogens in pediatric patients can be relatively common in humans, although generally asymp-
signifi cantly higher, varying from ≈5% to >30% (7,15). tomatic (32,33). HCoV-NL63 and HCoV-HKU1 are often
An overall evaluation of the available data suggests associated with co-infections with other respiratory viruses,
that these differences can be attributed to differences in mainly RSV and infl uenza viruses (7–26).
research methods. The infections caused by these viruses
are more common from November through March; more Clinical Manifestations of HCoV
frequently affect children <5 years of age, those examined Infections in Children
in the community, and those without underlying risk fac-
tors; and are more often identifi ed with serologic methods Respiratory Problems
(32,33). In this regard, 2 recent surveys that used serologic It is well known that all HCoVs cause respiratory in-
methods alone found previous HCoV-229E infection in fections. SARS-CoV is the most aggressive, although the
184 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 16, No. 2, February 2010
Coronavirus Infections in Children
Table. Main studies of the epidemiology and clinical relevance of HCoV-HKU1 in infants and children*
No. No. (%) patients
samples with positive test
Study Location and period Population tested results Comments
Lau et al. (20) Hong Kong; 629 children with RTIs, 6 629 10 (1.6) 11 patients with URTIs, 1
2004 Apr–2005 Mar mo–5 y; inpatients with pneumonia, 1 with
bronchiolitis, 5 with febrile
seizures; 3 with underlying
disease
Vabret et al. (24) Canada; 83 children with RTIs, <5 y; 83 5 (6.0) 3 patients with
2005 Feb–Mar negative for RSV, influenza gastroenteritis, 1 with febrile
A/B, PIV 1–3, adenovirus; seizures; mean age 26 mo
inpatients
Sloots et al. (25) Australia; 259 children with RTIs, <5 y; 259 10 (3.8) 1 patient with co-infection
2004 May–Aug inpatients and outpatients
Talbot et al. (34) USA; 1,055 children with RTIs, <5 1,055 4 (0.4) Mild episodes
2001 Oct–2003 Sep y; inpatients
*HCoV, human coronavirus; RTI, respiratory tract infection; URTI, upper respiratory tract infection; RSV, respiratory syncytial virus; PIV, parainfluenza
virus.
disease seems to be substantially less severe in children Gerna et al. found a high incidence of HCoV-229E, HCoV-
than in adults. In patients <12 years of age, the clinical OC43, and HCoV-NL63 infections in infants and children
course of SARS was generally milder and shorter than in with bronchitis, bronchiolitis, or pneumonia, but most of
those >12 years: no death was reported, only 5% of the the LRTIs were demonstrated in children co-infected with
infected children were admitted to an intensive care unit, HCoVs and other respiratory viruses (37). Furthermore,
and <1% required mechanical ventilation (28). Leung and the method used to collect respiratory samples can also
Chiu found that several children with SARS-CoV infection play a role in explaining the greater incidence of LRTIs
recovered without any sequelae after receiving supportive (11,14,16,22). In this regard, it is important to emphasize
therapy alone (36). The only pediatric patients with severe that when only hospitalized patients (with, consequently,
respiratory problems associated with SARS-CoV infection only the most severe cases) are enrolled, the incidence of
were >12 years (36). The clinical picture in persons <12 LRTIs seems greater (34,37).
years was similar to that caused by other respiratory virus- Unlike in healthy children, the development of severe
es, including infl uenza viruses. Moreover, the extrarespira- clinical features after infection with non-SARS HCoV is
tory manifestations of SARS-CoV infection described in relatively common among newborns, premature and low
adults (hepatitis and CNS dysfunction) have never been birthweight infants, and children at risk because of under-
reported in children. lying health problems. Gagneur et al. described 3 HCoV-
The clinical role of all non-SARS CoVs seems to be 229E–related outbreaks in a pediatric and neonatal inten-
similar: in most healthy children: they cause URTIs that sive care unit in France during 1998 (38), and 75% of the
spontaneously disappear in a few days. This fi nding is neonates and 92% of the extremely premature infants were
clearly shown by our data indicating no difference in the symptomatic. Kuypers et al. studied the contribution of
incidence and clinical severity of the diseases associated non-SARS HCoVs to acute RTIs and found that several
with HCoV-229E, HCoV-OC43, and HCoV-NL63. Re- children with isolated HCoV disease had an underlying
gardless of the HCoV causing the infection, >50% of the medical condition (21).
children had a common cold or pharyngitis, and laboratory Recently collected data concerning the individual vi-
and radiologic investigations were required in <15% (18). ruses indicate that HCoV-NL63 may be more frequently
Moreover, we also found that the socioeconomic effects of associated with croup than with HCoV-229E or HCoV-
these viruses on the families of the infected children was OC43. Van der Hoek et al. found that 9 (45%) of 20 chil-
marginal: the viruses spread signifi cantly less than infl u- dren infected by HCoV-NL63 alone, and 12 (25%) of 49
enza viruses among household members, caused only a HCoV-NL63–positive children as a whole, had croup,
limited number of similar infections in the family, and led compared with 54 (6%) of 900 HCoV-NL63–negative
to fewer lost working or school days (18). children (p<0.001) (16). Wu et al. (22) and Han et al. (35)
Although possible, the association of non-SARS also reported a high prevalence of croup in children infect-
HCoV infection and LRTI is uncommon in healthy chil- ed with HCoV-NL63. Furthermore, other reports indicate
dren. In most published studies, the incidence of pneumo- that both HCoV-NL63 (9,12,15,16,21) and HCoV-HKU1
nia or bronchiolitis was <5% (7–26,34). Differences in the (20,26) are associated with the development of bronchioli-
incidence of LRTIs among studies can at least partially tis and wheezing.
be attributed to the different prevalence of co-infections.
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 16, No. 2, February 2010 185
PERSPECTIVE
Extrarespiratory Problems they may represent specifi c neurologic damage induced by
As mentioned above, SARS-CoV does not seem to HCoV-HKU1 or that the virus may trigger a negative im-
cause extrarespiratory problems in children, but all of the mune response.
other HCoVs can be associated with signs and symptoms Finally, Esper et al. identifi ed HCoV-NL63 in respira-
involving organs and systems other than the respiratory tory specimens from 8 (72.7%) of 11 children with Kawa-
tract. Abdominal pain, emesis, and diarrhea can be the fi rst saki disease (KD) and in only 1 (4.5%) of 22 age-matched
signs and symptoms of an acute infection due to non-SARS controls, thus suggesting that KD may be triggered by a
CoVs. These manifestations have been reported, particu- response to HCoV-NL63 infection (40). However, the fi nd-
larly in the cases of HCoV-OC43 and HCoV-NL63, and ings of other studies do not support this observation, and
seem to be the direct consequences of viral invasion of the so the question of the causative role of HCoV-NL63 in the
intestinal mucosa, as suggested by the presence of HCoV- development of KD remains unanswered.
like particles in the stool samples of many patients with
acute disease (3,7–23). Assessment of the Importance of
Non-SARS CoV infections have also been associated Known HCoVs in Children
with acute and chronic CNS diseases (4,20), although no Superfi cial analysis of all of the available data con-
clear evidence has shown that the viruses played a direct cerning the effects of HCoVs in children suggests that
causative role. Nevertheless, some evidence exists of a pos- the assessment of the importance of HCoVs made before
sible relationship between HCoV infection and CNS dam- SARS-CoV was identifi ed can still be considered valid. In
age. HCoV-229E and HCoV-OC43 infections have been general, all of these viruses (including SARS-CoV) have
associated with the development of various chronic neuro- been confi rmed as mainly respiratory viruses with limited
logic disorders, including multiple sclerosis, because these clinical relevance in children. They cause mainly URTIs,
viruses have been found more frequently in the autopsied are not frequently isolated in hospitalized children (7–26),
brain tissue of patients with these diseases more frequently and, because they are rarely transmitted to other household
than in healthy patients (4). A possibly causative role of members, have a marginal socioeconomic effects on fami-
HCoV-OC43 in determining chronic brain damage is fur- lies (18). Even SARS-CoV infection, which had a dramatic
ther supported by the fact that chronic demyelinisation of effect on adults, was mainly associated with relatively mild
mouse CNS can be induced by infection with another CoV, disease in almost all patients <12 years of age (28,34).
mouse hepatitis virus (MHV), which belongs to the same Moreover, most children with a diagnosis of severe respi-
antigenic group as HCoV-OC43 and has structural similari- ratory syndrome in whom a HCoV was isolated were co-
ties with it (39). infected by other respiratory viruses (7–26). These fi nding
Because MHV induces the secretion of pro-infl am- suggest that the severity of the respiratory disease at least
matory molecules, such as interleukin-1β (IL-1β), tumor in some of these cases was attributable to the second virus.
necrosis factor, IL-6, and macrophage-infl ammatory 1β, Because only premature infants, neonates with a low
during the infection of neural cells, HCoV-OC43 may act birthweight, and children with an underlying severe chron-
similarly in the CNS of infected children and lead to se- ic disease are at risk of experiencing a severe respiratory
vere brain damage. Furthermore, SARS-CoV (which has problem associated with HCoV infection (21,37), we could
many genetic similarities to both viruses) seems to cause conclude that no further studies of the role of HCoVs in chil-
lung damage by activating the same pro-infl ammatory mol- dren are needed because what is already known is enough
ecules, because a particularly high level of circulating IL- to make such investigations superfl uous. Furthermore, on
1β has been found in children with SARS (34). the basis of the data regarding the natural outcome of re-
An association of acute neural disease with HCoV in- spiratory infections, developing vaccines or specifi c drugs
fection has been clearly demonstrated by the detection of appear to be unnecessary.
HCoV-OC43 in the cerebrospinal fl uid of a child presumed However, different conclusions can be drawn when the
to have acute disseminated encephalomyelitis, and the fre- global spectrum of the diseases caused by these viruses in
quent association between HCoV-HKU1 infection and the animals and humans is considered. It is now well known
development of febrile seizures seems to lead to the same that an enormous reservoir of CoVs exists among animals,
conclusion. Lau et al. studied 10 children infected by this particularly horseshoe bats, and that CoV isolates recovered
virus and found that half were affected by febrile seizures, from animals in China have up to 99.8% nucleotide iden-
the highest prevalence among all the HCoVs (20). Because tity with SARS-CoV (27). Because CoVs can easily mu-
the fever in all of these children was not particularly high tate, this means that (as in 2003) sustained exposure to the
and lasted for a shorter period than fever associated with infected animals can lead to a SARS-like CoV strain that
other viral respiratory infections, it was considered unlike- is newly adapted to infect humans and capable of causing
ly that all were simple febrile seizures, but possible that the reappearance of SARS. Moreover, it has been shown
186 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 16, No. 2, February 2010
Coronavirus Infections in Children
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