Viral Sepsis in Children

Gupta, Neha; Richter, Robert; Robert, Stephen; Kong, Michele

Several limitations to the current diagnostic testing for causative viruses are worth noting, and results of viral testing always need to be interpreted with caution. For instance, although a type of enterovirus, HPeV cannot be detected on routine enterovirus PCR assay. HPeV-specific PCR is required to detect this virus in respiratory, CSF and stool samples of infected children and should be considered as a part of workup for neonates and young children presenting with sepsis (113) . The clinical utility of viral respiratory PCR panels is also limited by their high rates of positive detections without clinical correlates. Detection of a virus in a patient with sepsis does not necessarily indicate causation. Some studies have shown that a respiratory virus can be detected in about one third of asymptomatic children (114, 115) . Viral PCR testing is particularly difficult to interpret due to its high sensitivity for viral nucleic acids, making it challenging for the clinician to distinguish between active viral disease and viral nucleic acid or live viral carriage (112, 116, 117) . A positive test could be a result of asymptomatic colonization, prolonged viral shedding or viral coinfection. In a study by Rhedin et al. comparing PCR results between symptomatic and asymptomatic patients, RSV, metapneumovirus and parainfluenza viruses had a significantly higher detection rate in children with acute respiratory infection, suggesting causation; however, other viruses (enterovirus, coronavirus, bocavirus, rhinovirus, and adenovirus) had an equally high detection rates in asymptomatic children (101) . Because of these positive viral detections in asymptomatic children, it is important that clinicians consider the big picture, and factor in other pertinent information that may indicate an active ongoing bacterial infection before discontinuing antibacterial agents based on a viral assay. The use of serum biomarkers (see section below) and whole blood gene expression analysis (118) may serve a crucial role in this setting to discern viral from bacterial sepsis. When faced with a septic child who has an unusual sepsis presentation, does not respond to usual therapies, or has persistently negative diagnostic evaluations, a viral etiology must be considered and consultation with an infectious disease expert is recommended.