Background: Few states have published statewide epidemiology of abusive head trauma (AHT). Objective: To examine the statewide epidemiology of AHT in West Virginia (WV), with the primary objective of establishing AHT incidence for comparison to national data, and to use as a baseline for comparison to incidence post-implementation of a statewide AHT prevention program. Participants and setting: AHT cases in children less than 2 years old were identified from the 3 tertiary pediatric centers in WV. Methods: Cases were identified by using ICD-9 codes for initially identifying those with injuries which might be consistent with AHT, followed by medical record review to determine which of these met the criteria for inclusion as a case. Medical examiner data was used to find additional cases of AHT. Using the number of cases identified along with relevant census data, incidence of AHT was calculated. Results: There were 120 cases of AHT treated in WV hospitals from 2000 to 2010, 100 of which were WV residents. The incidence was 36.1/100,000 children < 1 year of age and was 21.9 cases per 100,000 children < 2 years of age. Incidence in infants increased during the latter years (2006-2010) of the study to 51.8/100,000 compared to the incidence during 2000-2005, which was 24.0/100,000 (p < .01). Conclusions: Compared to US national, state and regional figures, the WV incidence of AHT was among the highest. In addition, the incidence of AHT increased significantly over the study period. Possible factors contributing to the rise in incidence are discussed.

BACKGROUND:La Crosse viral encephalitis is well described in children, but to date, there are only 2 adult cases described in the literature. Despite the fact that pediatric infection can be life threatening and typically presents as a febrile meningoencephalitis often complicated by seizures and mental status changes, little is known about the presentation and course of adult infection. We report the largest case series of adult La Crosse encephalitis.METHODS:Inpatient data were reviewed between 2001 and 2012 to identify adults (≥18 years of age) with possible La Crosse encephalitis. Subsequent review of serologic testing was followed by a comprehensive chart review.RESULTS:Ten cases were identified, with ages ranging from 20 to 80 years. Fever, headache, and hyponatremia were seen in the majority, while mental status changes occurred in 5 patients and seizures in 2 patients. The mean length of stay was 8.4 days (± 8.4); 3 patients required intensive care unit admission, 2 of them were intubated, and 4 patients required discharge to a rehabilitation facility.CONCLUSIONS:La Crosse Virus produces a clinically significant encephalitis in adults, and a high level of suspicion should be maintained, particularly in endemic areas. There were no deaths, but La Crosse encephalitis in adults remained a morbid illness often associated with mental status changes, prolonged length of stay or intensive care unit admission, and frequent need for postdischarge rehabilitation.

Background: La Crosse viral encephalitis (LACVE) is associated with residual epilepsy and neurocognitive deficits in survivors. This report summarizes 3 phases of clinical studies of children treated with intravenous (IV) ribavirin (RBV), each one exploring a different phase (I, IIA, IIB) of clinical trial development. Methods: In phase I, 7 children with life-threatening LACVE were treated with emergency use RBV using a moderate IV dose (8.33 mg/kg/dose q 8 hours day 1, 5 mg/kg/dose q 8 hours days 2–10). In phase IIA, 12 children with severe LACVE were enrolled: 8 treated with RBV (same dose as phase I) and 4 with placebo. In phase IIB an escalated dose was used (33 mg/kg dose 1, then 16 mg/kg/dose q 6 hours for 4 days, and 8 mg/kg/dose q 8 hours for 3 days). Results: In a group of 15 children treated in phase I and phase IIA, RBV appeared safe at moderate dose, but based on steady-state RBV levels of 9.3 &mgr;M, estimated cerebrospinal fluid levels were less than 20% of the EC50 of RBV for LACVE. At the escalated dose used in phase IIB, adverse events occurred, likely related to RBV, and therefore the trial was discontinued. Nevertheless, valuable pharmacokinetic (PK) and safety data were obtained at moderate dose, with potential treatment implications for other indications. Conclusions: Although the results do not support the use of RBV for LACVE, this nevertheless is the largest study of antiviral treatment for LACVE to date and the largest pharmacokinetic analysis of IV RBV in children for any indication.

La Crosse virus encephalitis is the most common mosquito-borne virus in children in the United States. La Crosse virus encephalitis has emerged as a significant health concern due to its potential for acute morbidity, including seizures, alterations in mental status, and, in rare cases, death, as well as the potential for chronic morbidity, including, epilepsy and cognitive and behavioral disorders. The aim of this study is to provide a clinical description of the largest series of children reported with periodic lateralizing epileptiform discharges (PLEDS) associated with La Cross virus encephalitis with reference to their clinical course, seizure type, electroencephalogram (EEG) patterns, and 2- and 10-year long-term neurologic outcome. In addition, to evaluate whether this subset of children may indeed have more severe disease than children with La Crosse virus encephalitis without PLEDS, comparisons are made between the 2 groups on specific variables. All patients presented with fever and disorientation; 6 of the 9 (66%) presented with seizures. PLEDS localized to the temporal lobe in 7 patients (77%). The children with PLEDS had longer intensive care unit stays (6.5 ± 2.4 vs 3.2 ± 1.9; P < .0001), a higher rate of intubation (88% vs 20%; P < .001), and a higher rate of cerebral herniation (1%; P < .05) than children with La Crosse virus encephalitis without PLEDS. Follow-up data on the subset with PLEDS also suggest a relatively high rate of epilepsy and behavioral difficulties with hyperactivity symptoms, memory deficits, and school difficulties. The implications for recognition, management, and follow-up of this worrisome subset of patients with La Crosse virus encephalitis are discussed.

Patients with Rocky Mountain spotted fever (RMSF), a tickborne infection caused by Rickettsia rickettsii, respond quickly to tetracycline-class antibiotics (e.g., doxycycline) when therapy is started within the first few days of illness; however, untreated RMSF may result in severe illness and death. Persons aged <10 years have the highest age-specific incidence of RMSF. This report summarizes the clinical course and outcome of RMSF in four children from four regions of the United States and underscores the need for clinicians throughout the United States to consider RMSF in children with rash and fever, particularly those with a history of tick bite or who present during April-September when approximately 90% of RMSF cases occur.

La Crosse encephalitis, a mosquito-borne viral disease that can be mistaken for herpes simplex encephalitis, is under-recognized in the United States, despite case reports from 28 states and an incidence in endemic areas (20-30/100,000) exceeding that of bacterial meningitis. The disease recurs every summer in endemic foci in the midwestern and mid-Atlantic United States in areas forested with hardwood trees, which provide breeding sites for the treehole-dwelling mosquito vector, Aedes triseriatus. La Crosse encephalitis should be considered in the child presenting with meningoencephalitis in summer and early fall, particularly for children living in (or recent travel to) endemic areas in mid-Atlantic and midwestern states.

La Crosse encephalitis (LE), a mosquito-borne viral disease which can be mistaken for herpes simplex encephalitis, is under-recognized in the US, despite case reports from 28 states and an incidence in endemic areas(20-30/100,000) exceeding that of bacterial meningitis. The following is our 10-year experience (1987-1996) with 128 LE admissions, which is the largest single series reported and the first including experience with intracranial pressure (ICP) monitoring and specific antiviral therapy. Diagnosis was by La Crosse IgM and IgG serum titers. Typical cases occurred in school-age children(mean = 7.81, range 0.5-16 years), presenting between early July and late October. Symptoms usually involved headache and fever (83%) for 3-4 days and vomiting (71%) for 1-2 days, with progression to seizures (46%) and/or disorientation (44%). Only 24.5% had nuchal rigidity. Of those presenting with seizures, 1 in 4 occurred abruptly, and 1 in 4 evolved to status epilepticus(SE). Cerebrospinal fluid yielded: 1) white blood cells (WBC) modestly elevated (mean = 129, range 2-867), with 10% of patients having 210 WBC's; 2) negative viral cultures. Peripheral WBC's were elevated (mean = 15.7K, s.d. = 5.9K) with left shift. One in four children required intubation for seizures and/or coma and more than one-half (57.1%) required intensive care. Notably, 3 patients developed acute uncal herniation within 48 hours of admission and received IV ribavirin per FDA approval for emergency use. Those who had significant in-hospital deterioration (e.g., herniation, SE) tended to have decline in sodium (p <0.025) concurrent with the event. Except for the sentinel case in 1987, all patients have survived. LE should be considered in the the child presenting with meningoencephalitis in summer/early fall, particularly for children living in (or recent travel to) endemic areas in midatlantic and midwestern states. Early diagnosis can be made via IgM and IgG serology using indirect immunoflourescence. We are conducting a randomized clinical trial of IV ribavirin for severe cases.

In a retrospective study, 33 achalasia patients were treated with dilation therapy using large diameter mercury bougienage (mean, 56 French) and/or pneumatic balloon dilation. Mean follow-up time was 35 months. Mercury bougienage, performed in 20 patients, was successful in 10 (50%) with no complications. Pneumatic dilation was performed as initial therapy or in those having failed previous pharmacologic therapy and/or bougienage. A successful response was achieved in 19 of 23 patients (83%), with a 3.2% complication rate. In addition, in four patients with eventual recurrence of symptoms after initial pneumatic dilation, bougienage was used as a successful alternative to repeat pneumatic treatment. The combined efficacy of both forms of dilation was 88% with a complication rate of 1.4%. These data indicate that mercury bougienage should be considered initial therapy for achalasia in view of its simplicity, safety, and acceptable efficacy, followed by pneumatic dilation if bougienage is unsuccessful. Bougienage also may be considered if eventual recurrent symptoms develop after initially successful pneumatic dilation. Surgery should be utilized only if dilation therapy fails to achieve a satisfactory response.