Risk Factors,treatment,and Gene Polymorphisms In Enterovirus 71-induced Hand-foot-mouth Disease Associated With Neurogenic Pulmonary Edema

Part I Risk factors for neurogenic pulmonary edema in the patients with EV71-induced hand-foot-mouth diseaseBackgroundHand-foot-mouth disease(HFMD)is an acute infectious disease caused by a variety of enteroviruses in children.It is characterized by fever and rashes on the hands,feet,mouth,buttocks,and other surfaces.The nervous system may be severely affected,including aseptic meningitis,brainstem encephalitis,encephalomyelitis,or acute flaccid paralysis.Most cases of severe brainstem encephalitis are caused by enterovirus 71(EV71).EV71 can progress rapidly in a short period of time,and severe life-threatening complications such as neurogenic pulmonary edema(NPE)or even heart-lung failure may occur.At present,there is no specific therapeutic agent to prevent or treat HFMD.The treatment is supportive and symptomatic.For these reasons,in patients with severe HFMD,early identification of major risk factors and timely implementation of corresponding treatment measures are important.Recently,a study examined the relationship between cellular immune responses and abnormal activation of a large number of cytokines causing brainstem damage after EV71 infection.In severe cases,systemic inflammatory reactions and increased pulmonary vascular permeability can induce neurogenic pulmonary edema.Further clinical studies are needed to determine whether cytokines are risk factors that can predict EV71 infection in patients with severe HFMD and NPE.ObjectiveThe clinical manifestations and laboratory examinations of patients with NPE were analyzed,with a focus on cytokine indicators.Risk factors of NPE of EV71-induced HFMD were evaluated.MethodsA total of 113 children diagnosed with severe EV71 infection at Linyi People's Hospital of Shandong Province from April 2016 to October 2018 were included for analysis.Patients were divided into two groups depending on the presence or absence of neurogenic pulmonary edema.There were 65 patients without neurogenic pulmonary edema(the non-NPE group),including 36 males and 29 females,with an average age of 1.89 ± 1.20 years;There were 48 patients with pulmonary edema(the NPE group),including 26 males and 22 females,with an average age of 1.58±1.13 years.Clinical data from the groups were analyzed,including general information(age,gender,and weight),clinical characteristics,laboratory tests(complete blood counts,biochemistries,and cytokine tests),auxiliary tests(imaging,electrocardiograms,and electroencephalography).The clinical data obtained were analyzed statistically.Results1.Univariate analysis of clinical manifestations and laboratory tests showed that:(1)There were statistically significant differences in peak body temperature and fever duration between children with NPE and those without NPE(P<0.05);(2)The incidences of signs and symptoms including drowsiness,fretting,eye regulation disorders,limb tremor,limb weakness,tachycardia,shallow breathing,prolonged CRT,cold limbs,flowery skin,and exudative patterns on chest radiographs were significantly more common in the NPE group than in the non-NPE group(P<0.05);(3)White blood cell counts and levels of blood glucose,lactic acid,IL-6,and IL-13 in the NPE group were significantly higher than those in the non-NPE group(P<0.05).2.Logistic regression equation found that drowsiness,limb tremor,eye regulation disorder,high lactic acid level,and elevated IL-6 levels were risk factors neurogenic pulmonary edema.ConclusionDrowsiness,limb tremor,eye regulation disorder,high lactic acid level,and elevated IL-6 were risk factors for enterovirus 71-induced pulmonary edema.Part ? Therapeutic efficacy of milrinone in the management of enterovirus 71-induced neurogenic pulmonary edemaBackgroundEV71-induced hand-foot-mouth disease complicated by brainstem encephalitis and neurogenic pulmonary edema has attracted widespread attention because of its rapid progression,difficult treatment,and high mortality rate.There are no effective treatments for neurogenic pulmonary edema caused by EV71 infection.Milrinone is a phosphodiesterase inhibitor that improves positive muscle strength and has vasodilator effects.Milrinone regulates immune cell activity by increasing intracellular cAMP levels,and has a variety of anti-inflammatory effects.It is possible that milrinone may improve survival in EV71-induced neurogenic pulmonary edema.Nevertheless,because of differences in the study population,the ability to identify early cases,and the quality of clinical intensive care,the efficacy of milrinone in the treatment of EV71-induced neurogenic pulmonary edema needs further study.ObjectiveTo evaluate the therapeutic efficacy of milrinone in the management of enterovirus 71-induced neurogenic pulmonary edema.MethodsA total of 43 children with enterovirus 71-induced neurogenic pulmonary edema who were admitted to Linyi People's Hospital in Shandong Province from April 2016 to October 2018 were included for analysis.Patients were divided into the Milrinone and Non-milrinone(control)groups depending on their treatment.Based on the clinical baseline characteristics and comprehensive treatment,the treatment group was given intravenous milrinone therapy in the early stage of cardiopulmonary failure in the third stage of HFMD,when the children had increased heart rate and respiration,cold sweating,cooling of the extremities and skin flowering.Changes in vital signs such as blood pressure and heart rate,laboratory values(hematology and cytokine examinations),cardiac function,and discharge outcome were compared between the groups,and the obtained data were statistically analyzed.Results1.The mean body temperatures were 38.95±0.40 0C and 38.60 ± 0.45? and the mean heart rates were 143.89± 18.95 and 188.06± 25.85 beats/minute in the treatment and control groups,respectively.There was a statistically significant difference between the groups(P<0.05).2.The white blood cell counts were 7.19 ± 2.95 × 109/L and 13.39± 3.80 ×109/L,the neutrophil ratios were 46.84±18.73%and 47.89 ± 16.79%,hemoglobin concentrations were 96.11 ± 14.77 g/L and 96.62± 14.48 g/L,and platelet counts 217.00 ± 73.87 × 109/L and 387.81 ± 99.34× 109/L in the treatment and control groups,respectively.The differences in white blood cell and platelet counts were statistically significant(P<0.05);however,the neutrophil ratios and hemoglobin concentrations were not significantly different between the groups(P>0.05).3.IL-6 levels were 55.89 ±19.22 pg/ml and 67.93 ± 27.53 pg/ml,IL-10 were 64.76 ± 20.45 pg/ml and 76.11 ± 15.07 pg/ml,and IL-13 were 107.09±25.42 pg/ml and 144.49±30.63 pg/ml in the treatment group and the control group,respectively.Compared with the control group,the results of IL-6,IL-10 and IL-13 levels were significantly different between groups.4.The LVEFs were 59.48±3.67%and 46.00 ±3.07%and the FSs were 31.67 ±2.39%and 28.42±3.87%in the treatment and control groups,respectively.Compared with the control group,the results of LVEF and FS were significantly different after treatment.Conclusion1.Milrinone increases cardiac output and improves cardiac function.2.Milrinone reduces levels of Il-6,11-10 and 11-13 in the blood and reduce the inflammatory response.3.Milrinone can improve the cure rate and reduce the mortality rate,and can be used to treat enterovirus 71-induced neurogenic pulmonary edema.Part III The correlation of the IL-13-1112 C/T gene polymorphism with enterovirus 71-induced HFMDBackgroundSymptoms of EV71-induced HFMD vary,and the same subtype of virus produces different clinical symptoms among different hosts.These differences are related to differences in the virulence of virus itself and depend on the individual host responses to the virus.It is speculated that host genetic factors may control the expression of some cytokines or regulate host immunity in various states with different reactivities to cytokines.The effect of gene polymorphism of cytokines,especially single nucleotide polymorphisms,on the risk and severity of HFMD has become a hot topic in recent years.Recent studies have found that the IL-13-1112 C/T(rs1800925)site polymorphism was associated with infectious diseases such as chronic periodontitis and enteritis.There is a correlation between the IL-13-1112 C/T site polymorphism and the susceptibility to several inflammatory diseases.Currently,there are few studies on the correlation between the IL-13-1112 C/T polymorphism and EV71-induced hand-foot-mouth disease.ObjectivePCR product sequencing and enzyme-linked immunosorbent assay(ELISA)were used to detect the IL-13-1112 C/T site gene polymorphism and IL-13 expression levels in children in EV71-infected hand-foot-mouth disease and normal children and to explore the correlation between IL-13-1112 C/T polymorphisms with EV71_induced hand-foot-mouth disease.MethodA total of 145 patients with HFMD admitted to Linyi People's Hospital in Shandong Province from April 2016 to December 2016 were analyzed,as well as 55 normal children recruited during physical examinations as the control group.There were two groups:the common group(78 cases)and the severe group(67 cases)according to the disease stage.Blood from the all HFMD children on the first day of admission were collected in EDTA-anticoagulant tubes and stored at-20? for genomic DNA extraction.Specimens of the control group were collected at the outpatient examination center.DNA first-generation PCR product sequencing technology was used to detect single nucleotide polymorphisms of IL-13-1112 C/T locus in children infected with HFMD and in normal control children.At the same time,serum levels of IL-13 ware measured using enzyme-linked immunosorbent assay(ELISA)in 91 HFMD children.The data obtained were analyzed statistically.Result1.The frequencies of CC,CT,and TT genotypes of the IL-13-1112 C/T locus were significantly different between the EV71 infection group and the control group.Compared with the normal controls,the frequencies of the CC genotype and the C allele were significantly higher in the EV71 infection group.2.The frequencies of CC,CT,and TT genotypes at the IL-13-1112 C/T locus were significantly different between the severe and general groups.Compared with the general group,the frequencies of CC genotype and C allele were significantly higher in the severe group.3.The frequencies of CC,CT,and TT genotypes at the IL-13-1112 C/T locus were significantly different between the general and control groups.Compared with the control group,the frequencies of CC genotype and C allele were significantly higher in the general group.4.There was a statistically significant difference in serum IL-13 level for each genotype(P<0.05).Children with the CC genotype had higher levels of IL-13 gene transcription and greater serum IL-13 protein expression.Conclusions1.The C allele of the IL-13-1112 C/T locus may be related to the susceptibility to EV71 infection,and the C allele confers a higher risk of severe EV71 infection.2.The IL-13 C/T gene polymorphism and the expression of IL-13 were associated with the severity of EV71-related HFMD.