Five Emerging Neuroinvasive Arboviral Diseases: Cache Valley, Eastern Equine Encephalitis, Jamestown Canyon, Powassan, and Usutu.

There are many arthropod-borne viruses (arboviruses) capable of neuroinvasion, with West Nile virus being one of the most well known. In this review, we highlight five rarer emerging or reemerging arboviruses capable of neuroinvasion: Cache Valley, eastern equine encephalitis, Jamestown Canyon, Powassan, and Usutu viruses. Cache Valley and Jamestown Canyon viruses likely circulate throughout most of North America, while eastern equine encephalitis and Powassan viruses typically circulate in the eastern half. Usutu virus is not currently circulating in North America, but has the potential to be introduced in the future given similar climate, vectors, and host species to Europe (where it has been circulating). Health care providers should contact their state or local health departments with any questions regarding arboviral disease surveillance, diagnosis, treatment, or prevention. To prevent neuroinvasive arboviral diseases, use of insect repellent and other mosquito and tick bite prevention strategies are key.

Antibody and Viral Nucleic Acid Testing of Serum and Cerebrospinal Fluid for Diagnosis of Eastern Equine Encephalitis.

Eastern equine encephalitis diagnostic serum antibody can appear 6 days after the onset of symptoms, and its numbers can increase 4-fold in 4 days, arguing for early and frequent serum testing. In populations where cerebrospinal fluid viral nucleic acid testing sensitivity and specificity remain undetermined, cerebrospinal antibody testing should also be performed.

Eastern equine encephalitis: a classical case.

We present the case of a 40-year-old man with rapidly deteriorating acute meningoencephalitis, finally diagnosed as eastern equine encephalitis (EEE). The course and timing in this patient are quite characteristic. EEE is an arthropod borneviral illness in which the mosquito serves as the vector. It is amongst the most severe of the arbovirus encephalitides and has a high mortality and morbidity. In nonfatal cases, residual neurological deficits are often severe and permanent. North American lineage of EEE is mainly found in the northeast especially along the coastal areas. EEE is primarily found in horses and other domestic mammals that remain outdoors nocturnally. In humans, symptoms range from nonspecific constitutional features to catastrophic neurological sequelae including death. Hyponatremia and increased cerebrospinal fluid (CSF) white blood cell count are independent predictors of poor outcomes. Diagnosis is suggestive by demonstrating IgM antibody in blood or CSF samples and can be confirmed by other serologic assay including immunohistochemistry and polymerase chain reaction (PCR). Measures recommended by the Center for Disease Control (CDC) for prevention include using repellents, protective clothing, screens, and eradication of mosquito breeding areas. EEE remains without cure and prevention is the best medicine.

Deadly Neuroinvasive Mosquito-Borne Virus: A Case of Eastern Equine Encephalitis.

None: Eastern equine encephalitis (EEE) is a rare and potentially fatal neuroinvasive disease with a high mortality rate of > 30%. It is an uncommon vector-borne illness, with an average of 8 cases reported in the United States annually. Alarmingly, in 2019 alone, the Centers for Disease Control and Prevention (CDC) confirmed 38 cases of EEE virus in the United States, reported from 10 states. In this report, we describe a 42-year-old man who worked primarily in wooded areas and presented to a hospital in southern New Jersey with an intractable headache and global facial paraesthesia. He reported multiple tick bites in the weeks prior to his presentation. Based on high clinical suspicion, cerebrospinal samples were sent to the CDC, which confirmed the diagnosis of EEE. The patient was treated with supportive care, and, after spending 9 days on mechanical ventilation in the intensive care unit, he was extubated and subsequently had some improvement of his symptoms with the implementation of an extensive physical therapy program. We hope this report will contribute to increasing awareness among the public health and medical communities regarding the increasing number of EEE cases and the importance of following prevention measures, especially in areas with high prevalence and early recognition of the disease for treatment.

Case report: Eastern equine encephalitis virus imported to the UK.

Eastern equine encephalitis (EEE) is rare, but the most severe of the mosquito-borne encephalitides in the United States with a high case fatality rate of 30%. Here, we present a patient with EEE. EEE virus causes sporadic human disease in the Eastern parts of the United States, but the case we describe was a Scottish tourist who acquired the disease from mosquito bites while in holiday in the United States. This is a first report of an imported case to Europe.

Eastern equine encephalitis virus infection and hemophagocytic lymphohistiocytosis in a 5-month-old infant.

Eastern equine encephalitis virus infection is a rare sporadic central nervous system infection transmitted by a mosquito vector. Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening disease associated with the inability of an overactive immune system to effectively respond to infections. Many viruses are known to trigger primary, as well as secondary, HLH. We report a pediatric case of eastern equine encephalitis virus-associated HLH which caused severe neurologic injury and death.

Eastern equine encephalitis in a captive harbor seal (Phoca vitulina).

A 31-yr-old male, captive harbor seal (Phoca vitulina) was evaluated for a 48-hr period of anorexia followed by the onset of seizures. A prolonged seizure failed to respond to anticonvulsant therapy and the animal was euthanized. At necropsy, no significant gross lesions were identified. Reverse transcriptase-polymerase chain reaction testing of brain samples was positive for eastern equine encephalitis virus (EEEV) RNA, and serum was positive for anti-EEEV antibodies by plaque reduction neutralization. Histopathologic evaluation revealed severe and multifocal encephalitis with leptomeningitis, characterized by neutrophilic infiltrates in neuropil, neuronal necrosis, satellitosis, neuronophagia, and perivascular cuffs of lymphocytes, macrophages, and neutrophils. Additionally there was moderate, multifocal, adrenal cortical necrosis. Immunohistochemical staining for EEEV demonstrated viral antigen within necrotic neurons and glial cells. Virus was isolated from frozen brain tissue, sequenced for comparison to other strains, and determined to be a typical North American strain. EEEV should be included as a possible cause of neurologic disease in harbor seals with compatible signs located in geographic regions where vector transmission of EEEV is encountered.

Eastern equine encephalitis in 9 South American camelids.

BACKGROUND: Eastern equine encephalitis (EEE) virus is a mosquito-borne togavirus (alphavirus) that causes severe (often fatal) encephalitis in many mammalian species, but it has not been reported previously in South American camelids. HYPOTHESIS: South American camelids can become naturally infected with EEE virus and show encephalitic signs similar to those observed in other affected species. ANIMALS: Nine cases (8 alpacas and 1 llama, aged 3.5 weeks to 12 years) were identified; 4 of 9 were 510 weeks old. All cases were from the East Coast of the United States and presented in late summer and fall. METHODS: A retrospective study was performed to include confirmed cases of EEE in camelids in North America before 2006. RESULTS: Eight of nine (89%) camelids died or were euthanized in extremis, with the mean time to death of 2 days. Clinical signs were consistent with encephalitis and included fever, lethargy, ataxia, seizures, recumbency, torticollis, opisthotonus, and vestibular signs. No consistent hematologic abnormalities were identified, and cerebrospinal fluid contained an increased protein concentration in the single camelid analyzed. No successful therapy was identified. EEE was confirmed by alphavirus detection by using immunohistochemistry (IHC) and polymerase chain reaction (PCR) in the central nervous system (CNS) and by serology. Findings included polioencephalitis with lymphocytic perivascular cuffing; neutrophil infiltration; gliosis; neuron satellitosis; necrosis; and edema, with intracytoplasmic alphavirus within neurons and glial cells. No virus was detected in extraneural tissues. CONCLUSIONS AND CLINICAL IMPORTANCE: In endemic areas, EEE should be considered a differential diagnosis for young and adult camelids with CNS disease. Brain histopathology with indirect IHC or PCR is diagnostic.

Eastern equine encephalitis--New Hampshire and Massachusetts, August-September 2005.

During August-September 2005, the New Hampshire Department of Health and Human Services reported seven cases of human eastern equine encephalitis virus (EEEV) disease, the first laboratory-confirmed, locally acquired cases of human EEEV disease reported from New Hampshire in 41 years of national surveillance. Also during August--September 2005, the Massachusetts Department of Public Health reported four cases of human EEEV disease, five times the annual average of 0.8 cases reported from Massachusetts during the preceding 10 years. Four of the 11 patients from New Hampshire and Massachusetts died. EEEV is transmitted in marshes and swamps in an enzootic bird-mosquito-bird cycle primarily by the mosquito Culiseta melanura. Bridge mosquito vectors (e.g., Coquillettidia perturbans, Aedes vexans, or Aedes sollicitans) transmit EEEV to humans and other mammals. This report summarizes the investigations of cases in New Hampshire and Massachusetts conducted by the two state health departments and CDC. The findings underscore the importance of surveillance for, and diagnostic consideration of, arboviral encephalitis in the United States and promotion of preventive measures such as local mosquito control and use of insect repellent.

Eastern equine encephalomyelitis virus infection in six captive southern cassowaries (Casuarius casuarius).

CASE DESCRIPTION Within a 2-week period, 4 southern cassowaries (Casuarius casuarius) at an exhibit at a Virginia zoo died acutely subsequent to eastern equine encephalitis virus (EEEV) infection. This prompted a search for other EEEV outbreaks in cassowaries, which resulted in the identification of 2 additional cassowaries that died of EEEV infection at a conservation center in Florida. CLINICAL FINDINGS Both juvenile and adult birds were affected. Three of the 6 birds died acutely with no premonitory signs. Clinical disease in the other 3 birds was characterized by lethargy and ataxia. Clinicopathologic findings typically included leukocytosis, hyperuricemia, abnormally high liver enzyme activities, and hyper-ß globulinemia, which was indicative of acute inflammation. TREATMENT AND OUTCOME The 3 birds with clinical disease died despite supportive treatment. Gross abnormalities commonly observed during necropsy included coelomitis and evidence of diarrhea. Frequently observed histologic abnormalities were encephalitis, vasculitis, hepatitis, nephritis, and splenitis. The diagnosis of EEEV infection was confirmed by detection of serum anti-EEEV antibodies or detection of viral RNA in brain tissue by use of a reverse-transcriptase PCR assay. CLINICAL RELEVANCE Findings suggested that EEEV can cause high morbidity and mortality rates in southern cassowaries. Clinical disease might be reduced or prevented by vaccination, isolation of ill birds, and mosquito control strategies.

MRI findings in eastern equine encephalitis: the "parenthesis" sign.

Two patients with eastern equine encephalitis (EEE) presented to a tertiary referral center. Both subjects' brain magnetic resonance imaging showed T2/FLAIR (fluid-attenuated inversion recovery) hyperintensities including linear areas of hyperintensity in the external and internal capsules with sparing of the lentiform nuclei. Single case reports of imaging findings in EEE exist with nonspecific patterns of abnormality. We propose that this "( ) parentheses sign" on T2 or FLAIR imaging may distinguish EEE from other processes.

Rabies direct fluorescent antibody test does not inactivate rabies or eastern equine encephalitis viruses.

An examination using the routine rabies direct fluorescent antibody test was performed on rabies or Eastern equine encephalitis positive mammalian brain tissue to assess inactivation of the virus. Neither virus was inactivated with acetone fixation nor the routine test, thus laboratory employees should treat all samples as rabies and when appropriate Eastern equine encephalitis positive throughout the whole procedure.

Eastern equine encephalitis in a free-ranging white-tailed deer (Odocoileus virginianus).

Eastern equine encephalitis (EEE) was diagnosed in a free-ranging, adult, male white-tailed deer (Odocoileus virginianus) from Houston County, Georgia, USA, in July 2001. The yearling buck had neurologic disease and died during transport to our diagnostic facility. Eastern equine encephalitis virus (EEEV) was isolated in Vero cell culture and identified by reverse-transcriptase polymerase chain reaction; as well, EEEV antigen was detected in brain by immunohistochemistry. This is the first report of fatal EEEV infection in a white-tailed deer. Antibodies to EEEV were demonstrated by microtiter neutralization in 14 of 99 (14%) of the white-tailed deer from Georgia sampled in fall 2001. Most antibody-positive deer originated from the Coastal Plain physiographic region. Eastern equine encephalitis virus should be considered a possible cause of neurologic disease in white-tailed deer where it may occur.

Detection of eastern equine encephalitis virus in infected mosquitoes using a monoclonal antibody-based antigen-capture enzyme-linked immunosorbent assay.

Surveillance of mosquito populations for virus activity is not often performed by small, vector-control districts because they do not have the financial resources to use virus isolation, or newer methods such as the polymerase chain reaction. Consequently, development and refinements of rapid, sensitive, and simple enzyme-linked immunosorbent assays (ELISAs) applicable to a wide variety of public health settings are justified. We have developed an antigen-capture ELISA for the detection of eastern equine encephalitis (EEE) virus in mosquitoes that uses both monoclonal capture and detector antibodies. The sensitivity of this assay is 4.0-5.0 log10 plaque-forming units/ml, which is comparable to previously published EEE antigen-capture assays developed with polyclonal antibody reagents. This test identifies only North American strains of EEE virus and does not react with either western equine encephalitis or Highlands J viruses. Test sensitivity was enhanced by sonicating mosquito pools, treating them with Triton X-100, and increasing the time and temperature of antigen incubation. The conversion of this ELISA to a monoclonal antibody-based format should result in a readily standardizable and transferable assay that will permit laboratories lacking virus isolation facilities to conduct EEE virus surveillance.

Nested multiplex RT-PCR for detection and differentiation of West Nile virus and eastern equine encephalomyelitis virus in brain tissues.

A traditional nested reverse transcription-polymerase chain reaction (RT-PCR) assay specific for eastern equine encephalomyelitis (EEE) virus was designed to multiplex with a previously described West Nile (WN) virus nested RT-PCR assay. Differentiation of EEE and WN was based on base pair size of the amplified product. One hundred fifty-seven mammalian and avian brain tissues were tested by EEE/WN nested multiplex RT-PCR, EEE nested RT-PCR, and WN nested RT-PCR, and results were compared with other diagnostic test results from the same animals. Serological and virus isolation testing confirmed the results of the multiplex PCR assay. When compared with cell culture virus isolation, the multiplex assay was shown to be more sensitive in detecting the presence of EEE or WN virus in brain tissues. The multiplex assay was shown to be sensitive and specific for North American EEE and WN and provided a rapid means of identifying both viruses in brain tissues. No apparent sacrifice in sensitivity was observed in the multiplex procedure compared with the individual EEE and WN nested RT-PCR assays. Data collected from an additional 485 multiplex RT-PCR tests conducted during the summer and fall of 2002 further support the validity of the procedure.

Diagnosis of eastern equine encephalitis by immunohistochemistry in two flocks of Michigan ring-neck pheasants.

The diagnosis of eastern equine encephalitis (EEE) virus infection in avian species is relatively difficult when compared with other species. There are no characteristic histologic lesions in the avian brain that would serve to distinguish EEE from infections with, for example, Newcastle disease or highly pathogenic avian influenza virus. Traditionally, virus isolation (VI) and/or hemagglutination inhibition (HI) has been used for a definitive diagnosis of EEE in birds. Recently, we developed an immunohistochemistry (IHC) technique for confirmatory diagnosis of EEE infection in equine brain. This test also detected EEE virus in formalin-fixed avian brain. VI confirmed IHC finding in two cases of EEE in ring-neck pheasants. IHC is a rapid, sensitive test for confirming and differentiating a histopathologic diagnosis of EEE in avian species and should be considered as an alternative test to VI or HI.