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ABSTRACT Guillain-Barré syndrome (GBS) is the most frequent cause of acute flaccid paralysis and if not diagnosed and treated timely, a significant cause of long-term disability. Incidence in Latin America ranges from 0.71 to 7.63 cases/100,000 person-years. Historically, GBS has been linked to infections (mainly gastrointestinal by Campylobacter jejuni) and vaccines (including those against severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]); however, a trigger cannot be detected in most cases. Regarding SARS-CoV-2, epidemiological studies have found no association with its development. Acute motor axonal neuropathy is the most common electrophysiological variant in Mexico and Asian countries. Intravenous immunoglobulin or plasma exchanges are still the treatment cornerstones. Mortality in Mexico can be as high as 12%. Advances in understanding the drivers of nerve injury in GBS that may provide the basis for developing targeted therapies have been made during the past decade; despite them, accurate criteria for selecting patients requiring acute treatment, prognostic biomarkers, and novel therapies are still needed. The newly-developed vaccines against SARS-CoV-2 have raised concerns regarding the potential risk for developing GBS. In the midst of coronavirus disease 2019 and vaccination campaigns against SARS-CoV-2, this review discusses the epidemiology, clinical presentation, management, and outcomes of GBS in Mexico.

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BACKGROUND: Guillain-Barré syndrome is the most common cause of flaccid paralysis, with multiple known clinical variants. Autonomic dysfunction, although frequently reported in the clinical course, is often overlooked in the pediatric population and is usually not the initial presenting symptom in this age group CASE PRESENTATION: We present the case of a previously healthy 17-year-old who arrived at the Emergency Department complaining of gastrointestinal symptoms associated with lipothymia. An initial electrocardiogram (ECG) showed sustained sinus bradycardia subsequently associated with arterial hypertension. Structural and inflammatory cardiac pathology were ruled out, as well as auriculoventricular conduction block and posterior reversible encephalopathy syndrome. On the ninth day after initial symptoms, the patient presented sensory and motor nerve disturbances with the cerebrospinal fluid analysis showing a clear albumin-cytologic dissociation, consistent with an atypical presentation of GBS with autonomic dysfunction. Immunoglobulin therapy was administered, developing subsequent aseptic meningitis, that required discontinuation of previous therapy and treatment with plasmapheresis. Clinical improvement was achieved with full motor function recovery. CONCLUSION: This case illustrates a Guillain-Barré syndrome variant in which autonomic dysfunction preceded neurologic deficit, a finding uncommon in children, emphasizing this as an important differential diagnosis for severe bradycardia in pediatric patients.

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Guillain-Barré syndrome (GBS) is the most frequent cause of acute flaccid paralysis and if not diagnosed and treated timely, a significant cause of long-term disability. Incidence in Latin America ranges from 0.71 to 7.63 cases/100,000 person-years. Historically, GBS has been linked to infections (mainly gastrointestinal by Campylobacter jejuni) and vaccines (including those against severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]); however, a trigger cannot be detected in most cases. Regarding SARS-CoV-2, epidemiological studies have found no association with its development. Acute motor axonal neuropathy is the most common electrophysiological variant in Mexico and Asian countries. Intravenous immunoglobulin or plasma exchanges are still the treatment cornerstones. Mortality in Mexico can be as high as 12%. Avances in understanding the drivers of nerve injury in GBS that may provide the basis for developing targeted therapies have been made during the past decade; despite them, accurate criteria for selecting patients requiring acute treatment, prognostic biomarkers, and novel therapies are still needed. The newly-developed vaccines against SARS-CoV-2 have raised concerns regarding the potential risk for developing GBS. In the midst of coronavirus disease 2019 and vaccination campaigns against SARS-CoV-2, this review discusses the epidemiology, clinical presentation, management, and outcomes of GBS in Mexico.

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Immunoglobulin infusion (IVIG) is one of the first line therapy in Guillain Barre Syndrome (GBS). Several medical complications are associated with GBS (pneumonia, sepsis, deep vein thrombosis, dysautonomy). Acute kidney injury (AKI) is an uncommon complication during IVIG infusion. Several risk factors were associated with AKI during IVIG. These are an older age, previous renal disease, concomitant use of nephrotoxic agents, diabetes mellitus, hypovolemia, sepsis or using of IVIG that contained in its preparation sucrose or mannitol as stabilizers to avoid precipitation and aggregation. Infusion rate and total dose play a determinant role. The most important pathophysiological mechanism of AKI are the osmotic stress applied to the epithelium of proximal tubules and glomeruli. The osmotic overload is principally generated by IVIG stabilizers (sucrose). In general, AKI is reversible but approximately 30% hemodialysis is necessary. It is essential to respect doses, infusion rates and closely monitoring renal function parameters during IVIG infusion.

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Botulism is generally a fatal disease caused by ingestion of neurotoxins produced by Clostridium botulinum. The present study describes the epidemiological, clinical, and laboratory aspects of a type C botulism outbreak in free-living aquatic birds residing in an urban park in Quirinópolis, Goiás, Brazil. Among a population of approximately 80 waterfowl, a total of 30 birds, including ducks (Cairina moschata), teals (Anas platyrhynchos), and geese (Anser cygnoides), died within 10 days. Of these, six birds showed signs of flaccid paralysis of the pelvic limbs, eyelids, neck, and wings. To confirm the suspicion of botulism, four lake water samples, two samples of the feed consumed by the birds, and samples of serum, intestinal content, stomach content, and liver tissue from two teals that died after presenting clinical signs were analyzed. Using bioassay and neutralization with homologous antitoxin in mice, it was possible to detect the presence of botulinum toxin type C in a water sample and in the intestinal content of one of the necropsied teals. Additionally, the presence of C. botulinum type C was identified in the lake water using polymerase chain reaction. Based on the clinical signs and laboratory results, a diagnosis of botulism caused by botulinum toxin type C was confirmed with probable transmission by lake water.

O botulismo é uma doença geralmente fatal, causada pela ingestão de neurotoxinas produzidas pelo Clostridium botulinum. O presente estudo descreve os aspectos epidemiológicos, clínicos e laboratoriais de um surto de botulismo tipo C em aves aquáticas de vida livre habitantes de parque urbano em Quirinópolis, Goiás. De uma população de cerca de 80 aves aquáticas, um total de 30 aves, entre patos (Cairina moschata), marrecos (Anas platyrhynchos) e gansos (Anser cygnoides), morreram no intervalo de 10 dias. Destes, seis aves apresentaram sinais de paralisia flácida de membros pélvicos, pálpebras, pescoço e asas. Para confirmar a suspeita de botulismo, foram analisadas quatro amostras da água do lago, duas amostras da ração consumida pelas aves e amostras de soro, conteúdo intestinal, conteúdo estomacal e fígado de dois marrecos que morreram após apresentarem os sinais clínicos. Pelo bioensaio e neutralização com antitoxina homóloga em camundongos foi possível detectar a presença de toxina botulínica tipo C em uma amostra de água e no conteúdo intestinal de um dos marrecos necropsiados. Adicionalmente, pela reação em cadeia da polimerase identificou-se a presença de C. botulinum tipo C na água do lago. Com base nos sinais clínicos e resultados laboratoriais estabeleceu-se o diagnóstico de botulismo causado pela toxina botulínica tipo C e veiculada provavelmente pela água do lago.

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Botulism is a disease usually fatal, caused by the ingestion of neurotoxins produced by Clostridium botulinum. In dogs, intoxication is caused by the ingestion of botulinum toxin type C, and animals often recover spontaneously. The present study describes the occurrence of type C botulism in two dogs domiciled on neighboring rural properties in the municipality of Goiânia, state of Goiás, Brazil, probably associated with ingestion of decomposing bovine carcass. Upon clinical evaluation, the dogs were alert in the lateral decubitus position with ascending flaccid paralysis, absence of eyelid reflexes, and reduced muscle tone. Due to their worsening clinical symptoms, the animals died within 12 h and 3 days after supportive treatment. Botulinum toxin type C was identified, in the serum and feces of both dogs, by seroneutralization in mice with homologous monovalent antitoxin. The results of the high-throughput gene sequencing showed that the abundance of C. botulinum in the fecal microbiota of one of the affected dogs was low (0.53%). In this way, the present study highlights the need of sanitary practices related to the appropriate collection and disposal of bovine carcasses in rural areas since they represent a risk factor for the occurrence of botulism in dogs domiciled on rural properties.

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Guillain-Barre syndrome (GBS) is an acute immune-mediated progressive predominantly motor symmetric polyradiculoneuropathy which causes demyelination and leads to weakness, ataxia and areflexia. There are a variety of forms of the syndrome; and despite being the most common cause of acute flaccid paralysis in children, it has a low incidence under 18 years old, and it is even rarer in children less than 2 years of age. Very few cases have been reported under 12 months of age. We describe a case of an 11-month-old male infant presenting with weakness and inability to ambulate who was diagnosed with GBS.

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Due to the advanced stage of polio eradication, the possible role of non-polio enteroviruses (NPEVs) associated to acute flaccid paralysis (AFP) cases has been highlighted. In this study, we described epidemiological aspects of NPEVs infections associated to AFP and explore the viral genetic diversity, information still scarce in Brazil. From 2005 to 2017, 6707 stool samples were collected in the scope of the Brazilian Poliomyelitis Surveillance Program. NPEVs were isolated in 359 samples (5.3%) and 341 (94.9%) were genotyped. About 46 different NPEV types were identified with the following detection pattern EV-B > EV-A > EV-C. The major EV-types were CVA2, CV4, EV-A71, CVB3, CVB5, E6, E7, E11, CVA13 and EV-C99, which corresponds to 51.6% of the total. Uncommon types, such as CVA12, EV-90 and CVA11, were also identified. Different E6 genogroups were observed, prevailing the GenIII, despite periods of co-circulation, and replacement of genogroups along time. CVA2 sequences were classified as genotype C and data suggested its dispersion in South-American countries. CVA13 viruses belonged to cluster B and Venezuelan viruses composed a new putative cluster. This study provides extensive information on enterovirus diversity associated with AFP, reinforcing the need of tailoring current surveillance strategies to timely monitor emergence/re-emergence of NPEVs.

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Outbreaks of Guillain-Barré syndrome (GBS) are uncommon. In May 2019, national surveillance in Peru detected an increase in GBS cases in excess of the expected incidence of 1.2 cases/100,000 population. Several clinical and epidemiologic findings call into question the suggested association between this GBS outbreak and Campylobacter.

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Cryptococcus is a cosmopolitan fungus with tropism for the nervous system and a higher prevalence of infection in immunosuppressed patients. Neurological compromise caused by this microorganism mainly debuts as a meningeal syndrome (headache, fever, neck stiffness) with predominant encephalic involvement. In this report we present the rare case of a non-HIV patient with flaccid paralysis and peripheral nerve involvement due to crytpococcal meningitis. This is a 53-years-old woman, with a past-medical history of diabetes, who presented with dysarthria, unilateral peripheral facial paralysis, asymmetric ascending quadriparesis, generalized hyporeflexia and urinary retention. Neuroimaging was initially reported as negative for vascular or demyelinating diseases. Electrophysiological studies were performed, and acute flaccid paralysis of undetermined etiology was defined as a temporal clinical diagnosis. Cerebrospinal fluid molecular analysis confirmed the presence of Cryptococcus neoformans var. gatti; posteriorly, antifungal treatment with amphotericin B and fluconazole was started. Polyneuroradiculopathy symptoms significantly improved over the in-hospital stay. In conclusion, spinal cord and peripheral nerve involvement by Cryptococcus is an infrequent cause of acute flaccid paralysis that should be considered in the differential diagnosis even in HIV-negative patients.

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Desde la eliminación de la circulación del virus polio salvaje, disminuyeron los casos de parálisis fláccida aguda. Sin embargo, continúan ocurriendo casos asociados a otros enterovirus no polio y virus neurotropos. Se presenta el caso de una paciente de 9 años con diagnóstico de meningitis y mielitis con compromiso motor en los miembros inferiores y vejiga neurogénica asociado a enterovirus, con resolución completa del cuadro neurológico posterior a la administración de gammaglobulina hiperinmune.

Since the wild poliovirus no longer circulates, the number of cases of acute flaccid paralysis decreased. However, cases related to non-polio enteroviruses and neurotrope viruses continue to occur. We present a nine-year-old patient with meningitis and myelitis with motor involvement in the lower limbs and neurogenic bladder associated with enterovirus, with complete resolution of the neurological symptoms following the administration of hyperimmune gammaglobulin.

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Since the wild poliovirus no longer circulates, the number of cases of acute flaccid paralysis decreased. However, cases related to non-polio enteroviruses and neurotrope viruses continue to occur. We present a nine-year-old patient with meningitis and myelitis with motor involvement in the lower limbs and neurogenic bladder associated with enterovirus, with complete resolution of the neurological symptoms following the administration of hyperimmune gammaglobulin.

Desde la eliminación de la circulación del virus polio salvaje, disminuyeron los casos de parálisis fláccida aguda. Sin embargo, continúan ocurriendo casos asociados a otros enterovirus no polio y virus neurotropos. Se presenta el caso de una paciente de 9 años con diagnóstico de meningitis y mielitis con compromiso motor en los miembros inferiores y vejiga neurogénica asociado a enterovirus, con resolución completa del cuadro neurológico posterior a la administración de gammaglobulina hiperinmune.

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Hepatitis E virus is increasingly being associated with idiopathic neurological disease. We tested 325 stool samples from Brazilian children presenting acute flaccid paralysis or Guillain-Barré syndrome using a broadly reactive and sensitive Reverse-transcription Polymerase chain reaction. Hepatitis E genome was not detected in any of the samples tested. Our results suggest that hepatitis E virus does not seem to be associated as the etiologic agent of acute flaccid paralysis and Guillain-Barré syndrome cases occurred in Brazilian children during the period of investigation (2010-2012).

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BACKGROUND: Acute poliomyelitis (APM/polio) is a viral infection caused by the polio virus that continues to have a fascinating social and economic impact on countries throughout the world. Humans acquire the virus by close personal contact with transmission occurring through the fecal-oral route. The majority of poliovirus infections results in no illness or produces only self-limited symptoms, however in approximately 5% of infected patients flaccid paralysis of the limbs can occur and 1% can die. Although APM is no longer a feared disease mainly due to the development of effective vaccines, its eradication remains elusive. METHODS: The aim of this study is to review the historical impact of APM in Trinidad. A retrospective analysis of all cases occurring from 1939 to 1972 was undertaken. Data for the study were derived from two sources the Annual Statistical Reports of the Ministry of Health 1972-2000 and the epidemiological publications of the League of Nations Health Organization and the World Health Organization. RESULTS: There were four outbreaks of APM in Trinidad 1941, 1942, 1954, and 1972. After the final outbreak in 1972, APM was eradicated not only from Trinidad but also all the countries of the Americas mainly through the effective use of the oral polio vaccine. CONCLUSION: Polio has brought together international agencies, governments, and the people to build an effective public health system around a common vision for health and wellbeing. The polio eradication and endgame strategic plan represents a major milestone in polio eradication developed by global polio eradication initiative. The initiative would still benefit from adopting some of the best practices in governance from other organizations in the global health sector.

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Abstract A 68 year-old male patient was hospitalized for radical prostatectomy. He had no abnormal medical history including neurological deficit before the operation. Prior to general anesthesia, an epidural catheter was inserted in the L3-4 interspace for intraoperative and postoperative analgesia. After surgery for nine hours, he developed confusion and flaccid paralysis of bilateral lower extremities occurred. No pathology was detected from cranial computed tomography and diffusion magnetic resonance imaging no pathology was detected. His thoracic/lumbar magnetic resonance imaging. Intraabdominal pressure was shown to be 25 mmHg, and abdominal ultrasonography revealed progression in the inflammation/edema/hematoma in the perirenal region. The Bromage score was back to 1 in the right foot on the 24th hour and in the left foot on the 26th hour. Paraplegia developed in patients after epidural infusion might be caused by potentiated local anesthetic effect due to retroperitoneal hematoma and/or elevated intra-abdominal pressure.

Resumo Paciente do sexo masculino, 68 anos, hospitalizado para prostatectomia radical. O paciente não tinha história médica anormal, inclusive nem déficit neurológico, antes da operação. Antes da anestesia geral, um cateter peridural foi inserido no espaço intermédio L3-4 para analgesia no intra e pós-operatório. Após a cirurgia, que durou nove horas, o paciente desenvolveu confusão e paralisia flácida bilateral dos membros inferiores. Tomografia computadorizada de crânio e imagem de difusão por ressonância magnética não detectaram lesão. Os achados nas imagens de ressonância magnética torácica/lombar eram normais. A pressão intra-abdominal era de 25 mmHg e o ultrassom abdominal revelou progressão de inflamação/edema/hematoma na região perirrenal. O escore de Bromage voltou a 1 no pé direito na 24a hora e no pé esquerdo na 26a hora. A paraplegia desenvolvida nos pacientes após a infusão epidural pode ter sido causada por um efeito potencializado do anestésico local devido a hematoma retroperitoneal e/ou pressão intra-abdominal elevada.

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Botulism commonly affects water birds and it has recently been observed to be emerging in poultry production. In the present work, outbreaks of botulism in wild native species, such as the black-fronted Piping-guan (Aburria jacutinga), wild duck (Cairina moschata) and its crosses with mallard (Anas platyrhynchos), and domestic chickens (Gallus gallus domesticus) are described. Following treatments with a commercial botulism antitoxin CD, 28 (96.5%) out of 29 animals fully recovered after 24-72 h. The antitoxin therapy was shown to be a useful option for the treatment of affected birds, including those that were severely affected.

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Resumen Objetivo Reportar un brote de 10 casos de mielopatías ácida aguda asimétrica por compromiso de la motoneurona espinal. Material y métodos: Relación V/M: 6/4 media de edad de 3 años, todos con parálisis ácida aguda, analizamos sus aspectos clínicos, etiológicos, neurorradiológicos, terapéuticos y evolutivos. Resultados: 8 presentaron parálisis áccida de miembros superiores asimétrica, 1 monoplejía de miembro inferior izquierdo, 1 hemiparesia, 5 sumaron compromiso de pares craneanos y 4 requirieron asistencia respiratoria mecánica. Todos coincidieron con catarro de vía aérea superior y/o ebre. La resonancia magnética medular fue anormal en todos, identi cando dos patrones de imágenes: uno lineal relacionado al compromiso del asta anterior y otro más heterogéneo con médula espinal engrosada, sin refuerzo con contraste, 5/10 presentaron además compromiso bulbo-protuberancial. Ninguno presento lesiones supratentoriales. En 4/10 identi camos enterovirus humano subtipo D68 HEV-D68) en secreciones de vía aérea y en 1/10 de ellos también en LCR. En el resto se detectaron otros enterovirus A, B y C, en uno rinovirus y otro In uenza. Nueve pacientes recibieron como tratamiento gammaglobulina y corticoides y 4 además recambio plasmático terapéutico sin mejoría clínica. Conclusiones: Ante una parálisis ácida aguda es importante descartar el HEV-D68. Consideramos los casos no detectados como "falsos negativos" dado que las muestras fueron tomadas tardíamente. Los otros virus identi cados no se han relacionado a mielopatías. Si bien la siopatología no es clara la ausencia de respuesta a tratamiento antin amatorio e inmunomodulador orienta a un mecanismo de agresión directa del virus. Se trata del primer reporte por HEV-D68 en Latinoamérica.

Abstract Objective: To report an outbreak of 10 cases of acute asymmetric accid myelopathy due to spinal motor neuron injury. Material and methods: Ten children, six male, with a mean age of 3 years presented with acute accid myelitis. We analyzed clinical features, etiology, neuroradiological images, treatment, and outcome. Results: Eight children had bilateral and asymmetric accid myelitis of the upper limbs, 1 had upper limb monoplegia, and 1 presented with hemiparesis. The cranial nerves were involved in 5 patients and 4 required mechanical ventilation. In all cases acute accid myelitis co-occurred with upper airway infection and/or fever. Spinal cord magnetic resonance imaging was abnormal in all, showing 2 di erent patterns: A linear pattern involving the anterior horns and another that was more heterogeneous showing spinal cord expansion. The lesions were non-enhancing in all. In 5/10 patients involvement of the medulla oblongata and pons was also observed. None of the patients presented with supratentorial lesions. In 4/10 children, the human enterovirus subtype D68 (HEV-D68) was identi ed in the airway and in 1/10 in the cerebrospinal uid as well. In the remaining patients di erent enterovirus species A, B, and C variants were detected, as well as rhinovirus in 1 and in uenza in another. Nine children received treatment with intravenous immunoglobulin and steroids and 4 of these children also underwent plasma exchange. Treatment did not lead to clinical improvement. Conclusions: In a patient with acute accid myelitis, HEV-D68 infection should be ruled out. Cases in which the virus was not detected were considered as "false negatives" as samples were collected late in course of the disease. The lack of response to anti-in ammatory and immunomodulatory treatment suggests a direct viral mechanism. This study is to our knowledge the rst on an HEV-D68-infection-related report in Latin America.

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A 68 year-old male patient was hospitalized for radical prostatectomy. He had no abnormal medical history including neurological deficit before the operation. Prior to general anesthesia, an epidural catheter was inserted in the L3-4 interspace for intraoperative and postoperative analgesia. After surgery for nine hours, he developed confusion and flaccid paralysis of bilateral lower extremities occurred. No pathology was detected from cranial computed tomography and diffusion magnetic resonance imaging no pathology was detected. His thoracic/lumbar magnetic resonance imaging. Intraabdominal pressure was shown to be 25mmHg, and abdominal ultrasonography revealed progression in the inflammation/edema/hematoma in the perirenal region. The Bromage score was back to 1 in the right foot on the 24th hour and in the left foot on the 26th hour. Paraplegia developed in patients after epidural infusion might be caused by potentiated local anesthetic effect due to retroperitoneal hematoma and/or elevated intra-abdominal pressure.

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Introducción: Los reportes de infecciones por enterovirus D68 (EV-D68) han aumentado en los últimos años. Material y métodos: Cohorte prospectiva. Se realizó la búsqueda de EV-D68 en niños internados en el Hospital de Pediatría Juan P. Garrahan entre 1-5-2016 y 30-9-2016 con: infección respiratoria aguda baja (IRAB) que requirieran cuidados intensivos, parálisis aguda fláccida (PAF) asimétrica con compromiso de sustancia gris en resonancia magnética nuclear (RMN) o identificación de cualquier enterovirus con cuadro clínico compatible. La identificación de EV-D68 se realizó en el Servicio de Neurovirus, Instituto Nacional de Enfermedades Infecciosas INEI-ANLIS "Dr. CG. Malbrán". Resultados: n: 6. PAF: cuatro niños presentaron PAF asimétrica, con arreflexia y RMN compatible con mielitis. Requirieron ventilación mecánica en unidades de cuidados intensivos (UCI) dos de los 4 niños. Todos presentaron parálisis residual. Se identificó EV-D68 en secreciones nasofaríngeas (SNF) de todos ellos. En líquido cefalorraquídeo sólo en uno. Miocarditis: Una niña sana de 5 años se internó en UCI por disfunción miocárdica y fiebre. Presentaba además derrame pericárdico moderado. Recibió gamaglobulina e.v. con buena evolución. En SNF se identificaron virus sincicial respiratorio (VSR) y EV-D68. IRAB grave: se identificó EV-D68 en un paciente de 14 meses que permaneció en UCI por IRAB grave con requerimientos de ventilación no invasiva por 72 hs, con buena evolución posterior. Se constató coinfección VSR y EV-D68 en SNF. Conclusiones: Se reportan 6 pacientes internados con infección por EV-D68. La vigilancia epidemiológica activa es esencial para identificar la circulación, las características clínicas y el pronostico de las infecciones por virus emergentes (AU)

Introduction: Reports on enterovirus D68 (EV-D68) infections have increased over the past years. Material and methods: A prospective cohort study. A search for EV-D68 infection was conducted in children hospitalized at Hospital de Pediatría Juan P. Garrahan between 1-5-2016 and 30-9-2016 with: acute lower respiratory infection (ALRI) requiring intensive care unit (UCI) admission, acute flaccid paralysis (AFP), asymmetry with grey matter involvement on magnetic resonance imaging (MRI), or identification of any enterovirus associated with compatible features. The identification of EV-D68 was performed at the Department of Neuroviruses of the InstitutoNacional de EnfermedadesInfecciosas INEI-ANLIS "Dr. CG. Malbrán". Results: n: 6. AFP: four children had asymmetric AFP with areflexia and MRI compatible with myelitis. Two of four required mechanical ventilation in the ICU. All of them presented with residual paralysis. EV-D68 was identified in the nasopharyngeal swab (NPS) in all of them and in the cerebrospinal fluid in only one. Myocarditis: A 5-year-old healthy girl was admitted to the ICU because of myocardial dysfunction and fever associated with moderate pericardial effusion. She was put on IV gamma globulin with a good response. In the NPS respiratory syncytial virus (RSV) and EV-D68 were identified. Severe ALRI: EV-D68 was identified in a 14-month-old patient who was admitted to the UCU because of severe ALRI requiring non-invasive ventilation for 72 hours with a good outcome. A RSV and EV-D68 coinfection was found in the NPS. Conclusions: We report six inpatients with a EV-D68 infection. Active epidemiological surveillance is crucial to identify circulation of the virus, clinical features, and prognosis of emerging viruses (AU)

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The last case of paralytic poliomyelitis caused by wild poliovirus in Brazil occurred in 1989. The interruption of the indigenous poliovirus transmission was obtained through mass immunization campaigns to eligible children and an active epidemiological and laboratorial surveillance of all cases of acute flaccid paralysis (AFP) among children under 15 y of age. This paper describes and evaluates the performance of the AFP surveillance system in different geographic areas of Brazil between 2005 and 2014, using indicators recommended by WHO. AFP surveillance indicators as well as virological investigation of polio and non-polio enteroviruses in stool samples received in the laboratory were assessed from 2005-2014. During the period, 5463 cases of AFP were investigated. Of these, 55% were males and 45% were females. Those under 5 y of age represented 48% of all cases reported and investigated. AFP notification rate was within the acceptable values with mean value of 1.3 (North), 1.4 (Northeast), 1.1 (Southern), 1.0 (Southeast) and 1.4 (Midwest) cases of AFP per 100.000 population aged 15 y as well as the adequacy of fecal specimens received in the laboratory. Sabin- related polioviruses accounted for 1.7% of the isolates while, 6.7% were non-polio enterovirus with the values ranging from 5.0% to 8.9 %. No wild-type polio was found. The AFP epidemiological and laboratorial surveillance activities have been kept at appropriate levels in Brazil. These data are a very strong indication, which supports the status of country free of polio.

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