Acute onset of limb weakness and an MRI showing a spinal cord lesion largely restricted to the gray matter have been noted in several children who tested positive for enterovirus D68 infections, which have been spreading rapidly across the nation.
Federal health officials are urging that cases be reported to state and local health departments. The Centers for Disease Control and Prevention issued the alert on Sept. 26th in response to an ongoing investigation in Colorado involving a cluster of nine children who have been hospitalized with acute neurologic illness. A 10th case was added to the cluster on Monday, Sept. 29, according to the Colorado Department of Public Health & Environment.
Four of the children have tested positive for the virus and test results are pending in two other cases. Most cases had a febrile respiratory illness in the 2 weeks before they developed neurologic symptoms.
EV-D68, which has been historically rare, is a non–polio enterovirus causing mild to severe respiratory illness. Since initial reports in mid-August, more than 440 cases of EV-D68 have been confirmed in 40 states and the District of Columbia. The numbers are likely to increase as states process the backlog of specimens, according to the CDC. “As the scale of this year’s EV-D68 outbreak is much larger in comparison to the past, we will likely see rare complications of this infection, such as paralysis,” Dr. Jana Shaw, an infectious disease specialist at Upstate Golisano Children’s Hospital in Syracuse, N.Y., wrote in an e-mail. “In our experience, many patients with respiratory illness had uneventful hospitalizations and completely recovered. Hence, the frequency of paralysis with EV-D68 remains to be seen.”
The Colorado pediatric cases were identified between Aug. 9 and Sept. 17 this year among children aged 1-18 years old, with a median age of 10 years. All were hospitalized. Eight of the nine children are up to date with their polio vaccinations.
Most patients presented with acute focal limb weakness and their MRIs showed nonenhancing lesions that were largely restricted to the gray matter and spanned more than the level of the spinal cord in most cases. Some patients also had acute cranial nerve dysfunction with correlating nonenhancing brainstem lesions on MRI. There were no cases of altered mental status or seizure, nor any cortical, subcortical, basal ganglia, or thalamic lesions on MRI, according to the CDC report.
CDC is prioritizing testing of specimens from children with severe respiratory illness, according to its website.
Nearly half of the specimens tested for EV-D68 at the CDC have tested positive and about one-third have tested positive for an enterovirus or rhinovirus other than EV-D68, according to the agency.
“Not much is known about the spectrum and the severity of the disease [EV-D68] can cause,” Dr. Shaw said. “Recent reports of polio-like illness among children alert us to include EV-D68 virus in a differential diagnosis when evaluating a pediatric patient with acute focal limb weakness and prior respiratory illness. The current nationwide outbreak of EV-D68 gives us an opportunity to learn more about this virus, its epidemiology, and the etiology of recent polio-like illness reported in Colorado.”
In a recent commentary in JAMA Pediatrics, Dr. Shaw wrote that “rapid detection and media collaboration are crucial in limiting the effect of an outbreak in a community.”
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