New Emerging Viruses Causing Acute Gastroenteritis in Children With Hematopoietic Cell Transplant

Young girl with tummy ache.
The epidemiology of acute gastroenteritis pathogens identified from pediatric patients who have undergone allogenic hematopoietic cell transplant may be changing.

The epidemiology of acute gastroenteritis pathogens identified from pediatric patients who have undergone allogenic hematopoietic cell transplant may be changing, according to a study published in the Journal of the Pediatric Infectious Diseases Society.

Symptoms of acute gastroenteritis, including vomiting and/or diarrhea, are common among children who undergo hematopoietic cell transplant and can be caused by chemotherapy, infection, and/or mucosal breakdown. The recognition of infectious acute gastroenteritis and identification of the causal pathogen are needed to provide treatment and institute appropriate infection control measures to prevent outbreaks, but determining the etiology of acute gastroenteritis can be difficult. The most common cause of acute gastroenteritis in children in the United States who were immunocompetent was rotavirus, before the rotavirus vaccination program was implemented. In the post-rotavirus vaccine era,norovirus is one of the most frequent causes of infectious acute gastroenteritis, along with Clostridioides difficile.

Rapid molecular diagnostic testing increases the recognition of viral pathogens. However, there are limited data regarding the longitudinal assessment of infectious pathogens during both symptomatic periods of acute gastroenteritis and asymptomatic periods in children, and a better understanding of the epidemiology and etiologies of acute gastroenteritis in pediatric patients who undergo hematopoietic cell transplant is needed. Therefore, this longitudinal, prospective, multicenter study investigated the prevalence of acute gastroenteritis-associated infectious pathogens in children undergoing allogeneic hematopoietic cell transplant.

In total, 31 pediatric patients from 4 children’s hospitals in the United States were included and enrolled from 2015 to 2016. Stool was collected weekly from pre-hematopoietic cell transplant and through 100 days post-transplant and tested for infectious acute gastroenteritis pathogens by molecular testing. Researchers obtained information from each participants’ medical record, including demographics, clinical symptoms, vaccination history, antimicrobial medications, and outcomes, which were abstracted and recorded in a standardized case report form.

Results suggested that previously reported etiologic viruses (rotavirus and norovirus) may be less common and emerging viruses may be increasingly recognized as a result of the use of molecular diagnostics. Of 208 samples, a pathogen was identified in 18%; many of these detections occurred during asymptomatic periods. The most frequently detected pathogen was C difficile in 29.0% patients, followed by sapovirus, adenovirus, and rotavirus, each of which was detected in 9.7% of patients. Salmonella spp and E histolytica were each detected from the samples of 3.2% of patients. However, 20% of positive samples were collected from children with diarrhea.

Norovirus was not detected in the samples and rotavirus was detected infrequently, which may be related to the use of the rotavirus vaccination availability in the general population. Sapovirus was detected in 21% (n=8) of pathogen-infected samples and was commonly associated with acute gastroenteritis; 87.5% of the sapovirus-positive samples were collected during symptomatic periods. . Of the 23 patients who were eligible to receive the rotavirus vaccine pre-hematopoietic cell transplant, 55% (n=11) had received it. Bacterial and parasitic pathogens were not frequently detected.

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Results further demonstrated that gut graft-vs-host disease developed in 43.7% of patients with detected pathogens compared with 60.0% of patients without detected pathogens (odds ratio, 0.52; 95% CI, 0.12-2.17; P =.37). Graft-vs-host disease of any kind was found in 68.8% patients with detected pathogens, compared with 80.0% of those without detected pathogens (odds ratio, 0.55; 95% CI, 0.11-0.87; P =.48).

Overall, the study authors concluded that, “Despite the small nature of this pilot study, these data will inform further design and direction of [acute gastroenteritis] studies that can more precisely assess the etiology of [acute gastroenteritis] in this vulnerable population.”


Schuster JE, Johnston SH, Piya B, et al. Infectious causes of acute gastroenteritis in US children undergoing allogenic hematopoietic cell transplant: a longitudinal, multicenter study [published online September 24, 2019]. J Pediatric Infect Dis Soc. doi:10.1093/jpids/piz063