Carita Savolainen-Kopra

Haider Al-Hello

Soile Blomqvist

Frontiers in Pediatrics

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TYPE General CommentaryPUBLISHED 25 March 2024| DOI 10.3389/fped.2024.1338097EDITED BYDavid Warburton,Saban Research Institute, United StatesREVIEWED BYShubhada Bopegamage,Slovak Medical University, SlovakiaKatja Wolthers,University of Amsterdam, Netherlands*CORRESPONDENCEHaider Al-Hellohaider.al-hello@thl.fiRECEIVED 17 January 2024ACCEPTED 15 March 2024PUBLISHED 25 March 2024CITATIONAl-Hello H, Blomqvist S and Savolainen-Kopra C (2024) Commentary: Risk factors andearly markers for echovirus type 11 associatedhaemorrhage-hepatitis syndrome in neonates,a retrospective cohort study.Front. Pediatr. 12:1338097.doi: 10.3389/fped.2024.1338097COPYRIGHT© 2024 Al-Hello, Blomqvist and Savolainen-Kopra. This is an open-access articledistributed under the terms of the CreativeCommons Attribution License (CC BY). Theuse, distribution or reproduction in otherforums is permitted, provided the originalauthor(s) and the copyright owner(s) arecredited and that the original publication inthis journal is cited, in accordance withaccepted academic practice. No use,distribution or reproduction is permittedwhich does not comply with these terms.Frontiers in PediatricsCommentary: Risk factors andearly markers for echovirus type11 associated haemorrhage-hepatitis syndrome in neonates, aretrospective cohort studyHaider Al-Hello*, Soile Blomqvist and Carita Savolainen-KopraExpert Microbiology Unit, Department of Health Security, National Institute for Health and Welfare,Helsinki, FinlandKEYWORDSmutations, RNA-dependant RNA polymerase, echovirus 11, enterovirus, fidelityA Commentary onRisk factors and early markers for echovirus type 11 associatedhaemorrhage-hepatitis syndrome in neonates, a retrospective cohortstudyBy Wang P, Xu Y, Liu M, Li H, Wang H, Liu Y, Wang B, Xia S, Su H, Wei M, Tao L, Chen X, Lu B,Gu X, Lyu H, Zhou W, Zhang H, Gong S (2023). Front. Pediatr. 11:1063558. doi: 10.3389/fped.2023.1063558Dear EditorsWe have read with great interest the publication by Wang et al. (1), which reports onhaemorrage-hepatitis syndrome in neonates caused by Echovirus 11 (E-11). We appreciatethe article’s suggestions on the diagnosis and treatment of haemorrage-hepatitis syndromebut wonder if the data and conclusions regarding the similarity of the E-11 strain isolatedin 2019 GWCMC01/GZ/CHN/2019 and E-11 D207 (GenBank accession EF634316),isolated in 2002 and not in 2007, as stated in the publication above, should needfurther study. The reasons are as follows:Firstly, the RNA-dependent RNA polymerase of the picornavirus family has lowreplication fidelity, and the absence of proofreading mechanism leads to geneticmutations. The mutation rate for RNA viruses is 10−3 to 10−5 per 10 kb of the RNAgenome, which is equivalent to 0.1–10 mutations (for example, the echovirus 11 mayhave a mutation for each transcript). The mutation rate of polioviruses, based onseveral studies, is approximately 3 × 10−2 mutations/synonymous site/year in the geneencoding viral protein 1 (VP1) (2). As a result of this high error rate, each time thegenome is replicated, new variants arise that produce heterogeneous virus progenyreferred to as “quasispecies” (3–5). High mutation frequencies allow these viruses torapidly adapt to changing environments. According to information obtained fromGenBank, the two strains carry only four nucleotide changes throughout the genome.These mutations are located in the 5′ untranslated region (5′UTR) of the genome andthus the entire capsid coding region as well as non-structural proteins coding region areidentical. The high similarity between the two virus strains is challenging to01 frontiersin.orgAl-Hello et al. 10.3389/fped.2024.1338097understand, considering that the time between the first and thesecond isolations was 18 years, and the geographical area wascompletely different.Secondly, according to our article published in 2007, the E-11D207 (EF634316) is pancreatropic. This means that E-11 D207tends to replicate in the pancreatic islets of Langerhans, whichwas documented in association with diabetes in a Slovakianchild. To gain new phenotypic features, the virus is supposed toacquire a new genetic characteristic represented by nucleotidemutations and amino acid substitutions. In the case of thepublication Al-Hello et al. (6), the pancreatropic E-11/D207 wasfound to be closely related to a specific subgroup B of E-11strains known to cause uveitis. The strains are E-11/Kust/86, E-11/Kar/87 and E11/Kh3/97 published by Lukashev et al. (7, 8).The first two strains were causative agents of uveitis outbreaks inSiberia in 1986 and 1987, while the third virus was an occasionalisolate in the Russian Far East in 1997. The genetic similaritybetween uveitis strains and E-11 D207 (EF634316) ranges from90% to 91%. Although they were isolated in Russia and Siberiaover a similar or shorter period of time as compared to theperiod of time between E-11 D207 (EF634316) and GWCMC01/GZ/CHN/2019, the genetic similarity is much less.Thirdly, in enterovirus species B (EV-B) recombination andmutations caused by the error-prone polymerase lackingproofreading machinery have been recognized as the mainmechanisms of evolution (2, 4). EV-B, to which echovirus 11belongs, is the most abundant species of enterovirus.Recombination events have been detected mostly in species B (9).Comparison of phylogenetic trees from different genomic regionshas revealed recombination events in several types, such as E-7,E-30, E-11, E-9, and CV-B (10–14). In addition, interspeciesrecombination has also been observed, such as what occurs inthe 5′UTR in EV-A and EV-B (15, 16). This indicates that theprocess of recombination among enteroviruses is abundant innature, and for this reason, the high similarity between the twostrains with long time period between them is difficult, if notimpossible, to understand.For the above mentioned reasons, we would like to draw yourattention to the fact that this high similarity between the twostrains is highly unlikely. Also, we would like to inform you thatGWCMC01/GZ/CHN/2019 virus strain has been used in severalFrontiers in Pediatrics 02studies (17–19), which raises a concern about the results of thoseand potential new studies, if genomic data is used to drawconclusions. It is critical to note that we approached this issuefrom a virological perspective, and we do not take a stance onthe other clinical aspects and patient care described in the paper.However, for E-11 inducing diabetes or hemorrhage-hepatitis, itis necessary to improve prevention, facilitate treatment and avoidfurther spread.Sincerely,Haider Al-Hello, Soile Blomqvist and Carita Savolainen-KopraAuthor contributionsHA-H: Supervision, Writing – original draft, Writing – review& editing. SB: Writing – review & editing, Supervision. CS-K:Writing – review & editing, Supervision.FundingThe author(s) declare that no financial support was received forthe research, authorship, and/or publication of this article.Conflict of interestThe authors declare that the research was conducted in theabsence of any commercial or financial relationships that couldbe construed as a potential conflict of interest.Publisher’s noteAll claims expressed in this article are solely those of theauthors and do not necessarily represent those of their affiliatedorganizations, or those of the publisher, the editors and thereviewers. Any product that may be evaluated in this article, orclaim that may be made by its manufacturer, is not guaranteedor endorsed by the publisher.References1. Wang P, Xu Y, Liu M, Li H, Wang H, Liu Y, et al. Risk factors and early markersfor echovirus type 11 associated haemorrhage-hepatitis syndrome in neonates, aretrospective cohort study. Front Pediatr. (2023) 11:1063558. doi: 10.3389/fped.2023.10635582. 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Phylogenetic andserological characterization of echovirus 11 and echovirus 19 strains causing uveitis.Arch Virol. (2002) 147(1):131–42. doi: 10.1007/s705-002-8307-28. Lukashev AN, Lashkevich VA, Koroleva GA, Ilonen J, Karganova GG, Reznik VI,et al. Molecular epidemiology of enteroviruses causing uveitis and multisystemhemorrhagic disease of infants. Virology. (2003) 307(1):45–53. doi: 10.1016/s0042-6822(02)00058-29. Simmonds P, Welch J. Frequency and dynamics of recombination within differentspecies of human enteroviruses. J Virol. (2006) 80(1):483–93. doi: 10.1128/JVI.80.1.483-493.2006frontiersin.orgAl-Hello et al. 10.3389/fped.2024.133809710. Oprisan G, Combiescu M, Guillot S, Caro V, Combiescu A, Delpeyroux F, et al.Natural genetic recombination between co-circulating heterotypic enteroviruses. J GenVirol. (2002) 83(Pt 9):2193–200. doi: 10.1099/0022-1317-83-9-219311. Lukashev AN, Lashkevich VA, Ivanova OE, Koroleva GA, Hinkkanen AE,Ilonen J. 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Commentary: Risk factors and early markers for echovirus type 11 associated haemorrhage-hepatitis syndrome in neonates, a retrospective cohort study

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Commentary: Risk factors and early markers for echovirus type 11 associated haemorrhage-hepatitis syndrome in neonates, a retrospective cohort study

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