Outbreak of Neurologic Enterovirus Type 71 Disease: A Diagnostic Challenge

Abstract

Background. Similar to poliovirus, enterovirus type 71 (EV71) causes severe disease, including aseptic meningitis, encephalitis, acute flaccid paralysis, and acute cardiopulmonary dysfunction. Large epidemics of EV71 infection have been reported worldwide.Methods. After recognition of a cluster of cases of EV71 disease, we reviewed records of patients with EV71 disease who required hospitalization at The Children's Hospital in Denver, Colorado, from 2003 through 2005. The presence of enterovirus was detected by reverse-transcriptase polymerase chain reaction (PCR) and/or viral culture of specimens from multiple sources, and the virus was typed as EV71 using genetic sequencing.Results. Eight cases of EV71 disease were identified in both 2003 and 2005. Fifty-six percent of patients with EV71 disease were р6 months of age (range, 4 weeks to 9 years). All 16 patients had EV71 central nervous system infection. Enterovirus PCR (EV-PCR) of cerebrospinal fluid specimens yielded positive results for only 5 (31.2%) of the 16 patients; all of these patients were !4 months of age and had less severe disease. However, EV-PCR of upper respiratory tract specimens yielded positive results for 8 (100%) of 8 patients, and EV-PCR of lower gastrointestinal tract specimens yielded positive results for 7 (87.5%) of 8 patients.Conclusions. An outbreak of neurologic EV71 disease occurred in Denver, Colorado, during 2003 and 2005. Likely, EV71 disease remains unrecognized in other parts of the United States, because EV-PCR of cerebrospinal fluid frequently yields negative results. EV-PCR of specimens from the respiratory and gastrointestinal tracts had higher diagnostic yields than did EV-PCR of cerebrospinal fluid. EV71 infection should be considered in young children presenting with aseptic meningitis, encephalitis, acute flaccid paralysis, or acute cardiopulmonary collapse. EV71 infection may be an underrecognized emerging disease in the United States.

MRI Findings in Children with Acute Flaccid Paralysis and Cranial Nerve Dysfunction Occurring during the 2014 Enterovirus D68 Outbreak

“…EV-71 most commonly presents with nonneurologic manifestations but has been associated with multiple outbreaks of AFP and brain stem encephalitis throughout the world. [9][10][11][12][13][14][15] MR imaging in affected patients typically reveals a rhombencephalitis affecting the dorsal pons and medulla, and a radiculomyelitis with a predilection for the anterior horn cells of the spinal cord and ventral nerve roots, findings that have also been described in poliomyelitis. [16][17][18][19] Although EV-D68 has not been proved as the causative agent in this cluster, these cases demonstrate distinctive imaging features that are very similar to the neuroimaging presentation of both EV-71 and poliovirus.…”

Dominant CD4‐dependent RNA‐dependent RNA polymerase‐specific T‐cell responses in children acutely infected with human enterovirus 71 and healthy adult controls

“…3,4 EV71 has recently emerged as an increasingly important neurotrophic enterovirus in the postpoliomyelitis eradication era. 5,6 In a previous study, we demonstrated that EV71 accounted for approximately 94Á4% of the fatal cases of HFMD. 7 At present, there are no effective antiviral medications 8 and no prophylactic vaccine against EV71 infection.…”

“…Previously identified human CD4 + T-cell epitope highlights in bold. 5 ND, not determined. 6 Number of participants recognized corresponding peptides.…”

Prolonged Symptoms in Solid Organ Transplant Recipients with Enteroviral Meningitis

“…PCR based identification had a sensitivity 94.7% vs. 66.7% for detection of enteroviruses in CSF by viral culture alone [19,20], and rapid availability of the result makes testing much more clinically useful. Among patients with likely enteroviral meningitis and a negative CSF PCR, upper respiratory tract and gastrointestinal tract specimens for enterovirus PCR further increase the ability of a clinician to establish a diagnosis of enterovirus infection [21]. Enteroviral meningoencephalitis has been reported in a case series of children after bone marrow transplantation, 2 of the patients were not known to have enteroviral infection, prior to transplant.…”