CDC update on children with Zika

As a result of a forum convened with the American academy of Pediatrics and the American Academy of Obstetricians and Gynecologists, the Centers for Diseases and Control (CDC) published new clinical management guidelines for Zika infants. Ever since the Zika infection was recognized as a public threat, physicians have been reporting post-natal complications like eye abnormalities, incident microcephaly in infants with a normal head circumference at birth and diaphragmatic paralysis. This update used clinical data collected up to September 2017 and will be revised again.

Infants born to mothers with possible Zika infection and who exhibit some of the above-mentioned symptoms should be tested with specific serum and urine tests; if they come out negative, they should have a CSF sample tested for Zika RNA and IgM Zika antibodies. At age one month, they should have a head ultrasound, a comprehensive ophthalmologic examination and auditory brainstem audiometry.

The ophthalmologic exam should pick up any of the following anomalies:

  1. Microphthalmia
  2. Coloboma
  3. Intraocular calcifications
  4. Optic nerve hypoplasia and atrophy
  5. Macular scarring with focal pigmentary retinal mottling

The ABR audiometry must be done at one month because the Zika virus infection can produce sensorineural hearing loss; its late onset has not been documented.

As epileptic activity can be part of the Zika syndrome, the infants at risk must have a complete neurological examination to detect some subclinical EEG abnormalities. An MRI of the brain can detect subtle brain abnormalities like the following;

  1. Cortical thinning
  2. Corpus Callosum abnormalities
  3. Calcifications at the junction of white and gray matter
  4. Ventricular enlargement

As they grow, these infants must be periodically examined for clinical signs of increased intracranial pressure, an ominous sign of a developing hydrocephalus.

There is a large group of infants without clinical signs of congenital Zika and who were born to mothers with possible exposure to the virus in their pregnancies but without laboratory evidence of an infection that pose a clinical challenge for the medical personnel. There are some socio-economic variables like the lack of proper testing or inadequate laboratory facilities that produce false-negative test results. The CDC does not approve of further testing in these infants unless worrisome clinical symptoms appear later and subject to discussion with the caring personnel.

Serial ultrasound examinations can be cumbersome and expensive; the use of amniocentesis carries the certain risk of fetal loss and/or damage. Any testing must be a shared-decision between the professionals, patients and their families.

What do you think? Please tell us.

Don’t leave me alone.


Need for a surveillance system

In order to address the generalized public anxiety that the arrival of Zyka provoked in the USA last year, some mendacious mandarins of the mass media quickly labelled it as just a microcephaly that affected mostly folks living in dire poverty. Even though microcephaly is common, infants may have a normal head size at birth, but develop postnatal microcephaly or other neurologic symptoms at six months. We should top calling it microcephaly as it is bigger than that.

The Zika virus is trophic—attracted—to the neural stem—precursor—cells; the first clinical reports of prenatal infection came form Brazil in January 2016. In the USA, the Aedes Agypti mosquito vector is present throughout the year in Texas and Florida but expands seasonally to many more states. We have limited ways to stop an emerging pathogen but we have the technical tools—like polymerase chain reaction and genome sequencing—to quickly identify it in order to set up the necessary Public Health measures.

Dr. Amilcar Tamauri et al, from the Federal University of Rio de Janeiro, observed 11 infants with congenital Zyka infection from gestation to six months in the state of Paraíba. Seven of the infants were female and the median maternal age of delivery was 25 years; three of the infants died. The virus was identified in the amniotic fluid, placenta, cord blood, and neonatal tissues collected post-mortem in the three babies that died after delivery. All the patients had signs of brain damage and severe neurologic impairments.

Dr. Dobins et al. studied 57 cases of the congenital Zyka syndrome and presumed or proven Zika exposure during pregnancy in Fortaleza. About half of the children had a bony protuberance of the occipital bone, dubbed as the occipital shell. When the fetal brain cannot grow, it shrinks. The frontal and parietal bones, but not the occipital bone, collapse. Fifty one children had diffuse subcortical or sub-cortical calcifications in CT Scan.All the patients had enlarged extra-axial space and ventriculomegaly.

Infants exposed to the Zika virus should receive a comprehensive medical and developmental evaluation, for which a surveillance system is mandatory.

What do you think? Please tell us.

Don’t leave me alone.


The D.C. duncehood

It finally landed. The Zika virus has arrived in the BRSF in earnest.

Wynwood, a trendy and touristy small section of Miami, has had 14 cases of infection in the past few days, most likely spread by an infected traveller from the Caribbean or South America. The one square gentrified quarter is full of upscale boutiques, innovative restaurants and expensive nightclubs. Scores of tourists and residents are daily wandering in its streets, usually in the evening, all year round.

As young people nowadays like to live near “ where the action is”, many new building developments have sprouted there to satisfy that big demand. A few of them were completed but several are still under construction with many places where standing water collects—a mosquito breeding ground.

The Centers for Disease Control and Prevention (CDC) put out a warning that pregnant women should avoid traveling to Miami and those that did after June 15 should be tested for the virus. It was prompted by the state’s request to activate a CDC emergency response as local efforts to eliminate the mosquito breeding grounds were failing.

In a blatant display of its irresponsible, shameful elitism that disdains the commoners’ plight, both chambers of the US Congress adjourned for its planned summer recess without approving a Zika emergency Funding bill. Millions of dollars that were already earmarked for municipalities to pay for critically needed human and material resources are being kept on hold until  our so-called “elected” representatives get their tan.

The White House initially requested 1.9 billion dollars but Congress reached a bipartisan compromise of 1.1 billions. However Senate democrats blocked it after House Republicans attached some unrelated provisions— the “poison pills.” One of them was about using Confederacy flags in military funerals.

As the “gerrymandering”—drawing an odd district to assure a persistent voting advantage to a party—has had the collateral effect of wiping the moderate candidates out and enthroning the extremists in both parties, there is political paralysis in Washington D.C.

The D.C. duncehood is enabling the Dead to dictate draconian conditions to the Living.

What do you think? Please tell us.

Don’t leave me alone.

The linkage with Guillain Barré syndrome

-“Nothing beats the sight of a young, white man lying prostrate in a hospital bed.”

That crude statement from an acquaintance that works in a Primary care facility in the French Polynesia expressed anger at the system’s racism. As long as Zika was in the news as something that would only threaten “poor pregnant women”, it was considered as too exotic. But when an unusually high number of patients with Guillain Barre—a viral infection that produces a momentary paralysis of the four limbs—appeared in the wards, all the sanitary alarms went off, prompting a serious investigation by health authorities.

Dr. Frédéric Ghawché, a neurologist working at the “Centre Hospitalier de Polynésie Francaise”; headed a team that found that 41 of 42 patients diagnosed with GBS had anti-Zika virus immunoglobulin M (IgM) or IgG, and all had neutralizing antibodies against Zika compared with 54 (56%) of 98 people in an age-matched control group admitted for a non-febrile illness.

Even though specialists noted that the study lacked proof that the Zika virus might cause the GBS, it suggested there might be a linkage between the two. Flavirus antibodies are cross- reactive across the species and there could be spurious early antibody responses when the patient had another infection. They concluded that it was “very likely” that the GBS patients were infected with Zika in the past and the virus was added to the list of causative culprits.

All 42 of the GBS patients in the Tahiti case-control study received the standard treatment—intravenous immunoglobulin—and one even received plasmapheresis. The median duration of their hospital stay was only 11 days (with a range of 7 to 20 days) for all patients and 51 days (range of 16 to 70) for the more serious cases that were admitted to the Intensive Care Unit. Three months after their discharge only 24 patients (57%) were able to walk without assistance, which proves that the illness is not self-limiting for all.

I wonder what will prod the authorities of the BRSF to act against the looming threat.

A rise of GBS diagnoses in the public Jackson Memorial Hospital’s wards? Mmm…

A small, yet noticeable surge, in the private Baptist Hospital’s wards? Probably.

What do you think? Please tell us.

Don’t leave me alone.

Is the BRSF prepared for Zika’s arrival?

Something funny happened to me on my way to work last week.

I passed by a garage and tire store in Calle Ocho where I saw that a small pile of old discarded tires were full of rainwater after a few stormy days.

I called one of the workers standing by and I pointed at the backwater. “Why don’t you clean it? It’s a breeding ground for dangerous mosquitoes.” “Oh, no…That water is clear…See? There’s no way any bugs are there.”

The female Aedes aegypti, the vector mosquito that transmits Zika, prefers to lay its eggs in clear water; when the water level rises to cover them, larvae emerge and begin their mutation from tumblers into adults in three days.

Public Health preventive measures—like dispatching workers to inform the residents how to take steps to limit the vector’s proliferation—might be too much asking for the authorities of the “Banana Republic of South Florida.” (BRSF) The web page of City of Miami’s Department of Risk Management has a generic discussion on Zika and does not mention preventive measures.

The explosive growth of downtown Miami during the past few years has not been accompanied by a sizable increase in its basic infrastructure like roads and sewer services. Just try to get in and out of Mary Brickell Village after a rainstorm without hitchhiking a ride in a patrolling US Navy’ s submarine. The city of Miami is dedicating limited resources to combat a potentially devastating Zika epidemic in a small. highly dense urban area.

The changing weather patterns, the incoming flux of travelers from abroad and the resilient poverty of some population segments could contribute to the outbreak of Zika virus infections in US cities. Using meteorologically-driven computer models for 2005-2015, researchers at the National Center for Atmospheric Research projected that the relatively warm winter weather in South Florida could sustain some low to moderate mosquito populations.

Just a few miles from the still-being-built sprawling complex of City Centre, dubbed as a wonderland of shopping and entertainment, a dinghy tire shop is a potential breeding place for dangerous bugs eager to swarm down on and bite all its unsuspecting visitors.

What do you think? Please tell us.

Don’t leave me alone.