By Stan Deresinski, MD, FACP, FIDSA
Clinical Professor of Medicine, Stanford University
SYNOPSIS: The Centers for Disease Control and Prevention is receiving increasing reports of pediatric infections with enterovirus-D68, which previously has been associated with the development of acute flaccid myelitis.
SOURCE: Centers for Disease Control and Prevention. Health Alert Network. Severe respiratory illnesses associated with rhinoviruses and/or enteroviruses including EV-D68 – multistate, 2022. Sept. 9, 2022. https://emergency.cdc.gov/han/2022/han00474.asp
During August 2022, the Centers for Disease Control and Prevention (CDC) received multiple reports from several regions in the United States of an increasing number of hospitalizations of children with severe respiratory illness who had positive tests for enterovirus (EV) and/or rhinovirus (RV). Further testing determined that some of the specimens contained enterovirus D68 (EV-D68). At the same time, examination of data from pediatric acute respiratory illness surveillance sites found that, among the specimens from children found to be RV/EV positive, the proportion that proved to be EV-D68 was higher than in previous years. Because EV-D68 has been associated with the development of acute flaccid myelitis (AFM), the CDC issued this health alert recommending enhanced vigilance for the occurrence of AFM.
CDC recommendations for clinicians include testing of respiratory specimens for RVs and EVs in children with severe respiratory infection of unknown cause and to report clusters of severe respiratory illness to local and state health departments. In addition, AFM should be strongly considered in patients with acute flaccid limb weakness, and to strongly consider AFM, particularly occurring after a febrile illness with or without respiratory symptoms and especially during August and November. In such patients, collect specimens for testing, including cerebrospinal fluid, serum, stool, and oropharyngeal or nasopharyngeal swabs, as early as possible and alert your public health laboratory to facilitate their transmittal of the specimens to the CDC for testing. The samples should be accompanied by a completed data collection form.1
There is no known effective treatment for EV-D68 infection. Infection control measures should include standard, contact, and droplet precautions.
COMMENTARY
Commonly used multiplex polymerase chain reaction testing systems cannot distinguish RV from EV and report them simply as RV/EV. EV-D68 is a non-polio enterovirus that causes respiratory infection, but evidence has implicated it as a cause of AFM, an illness similar to paralytic polio.
Other viruses have been associated with AFM, including EV-A71, herpesviruses, adenoviruses and flaviviruses, including Japanese encephalitis and West Nile viruses.2 The onset of weakness often is rapid, more proximal than distal, and associated with loss of reflexes in the affected limb. Other findings may include facial or eyelid droop, swallowing and/or speaking difficulties, and, in infants, weak or hoarse cry. Back or limb pain may be present. In some cases, progression of the illness may result in respiratory failure. In addition to virological studies, magnetic resonance imaging of the brain and spinal cord should be performed with the latter for investigation of the presence of brain stem and gray matter spinal cord lesions.
REFERENCES
- Centers for Disease Control and Prevention. Acute Flaccid Myelitis (AFM). Data Collection Form. https://www.cdc.gov/acute-flaccid-myelitis/hcp/data-collection.html
- Centers for Disease Control and Prevention. Acute Flaccid Myelitis (AFM). Clinicians & Health Departments. https://www.cdc.gov/acute-flaccid-myelitis/hcp/clinicians-health-departments.html
The Centers for Disease Control and Prevention is receiving increasing reports of pediatric infections with enterovirus-D68, which previously has been associated with the development of acute flaccid myelitis.
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