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PostPosted: Wed Oct 01, 2014 4:50 am 
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Media reports are citing increasing examples of limb weakness or paralysis in children who had recent EV-D68 symptoms or confirmation.

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PostPosted: Wed Oct 01, 2014 4:52 am 
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Paralysis in Kids With Enterovirus D68

By Brenda Goodman, MA
WebMD Health News Reviewed by Brunilda Nazario, MD
Editor’s note: This story was updated on Sept. 30 with additional cases in Colorado and Virginia and comments from the Children's Hospital Colorado media briefing.

Sept. 29, 2014 -- Some children hospitalized with breathing problems caused by enterovirus D68 in Colorado, Virginia, and Kansas City have also developed unexplained paralysis in their arms and legs, officials say.

Doctors have been watching for paralysis in enterovirus patients affected by the current outbreak, which the CDC says has spread to at least 40 states.

That’s because D68 is related to the virus that causes polio, which crippled thousands of children across the United States before a vaccine was created in the 1950s. And in 2012, researchers at Stanford University reported 25 childhood cases of paralysis of an unknown cause that shared features with polio, and in some cases also started as a respiratory illness.

When enteroviruses move beyond the gut or airways, they can attack nerve cells in the spine that control movement.


“The polio virus is a professional at doing this. All the other enteroviruses are amateurs. They do it very, very, very rarely,” says William Schaffner, MD. He's an infectious disease expert at Vanderbilt University in Nashville, TN. “But D68 is a new one. It’s a bit of a different enterovirus. The question is: Could it be doing this?”

He cautions that other germs, including West Nile virus, can also cause paralysis, and it could simply be a case of double infection in this cluster of children.

“This could be just coincidental, so we can’t leap to the conclusion that enterovirus D68 is the cause of this paralysis,” he says. “It’s right at the top of our list of suspects, but we haven’t nailed it yet.”

Investigation Details
Early in the outbreak, pediatricians said they hadn’t seen any signs that infected children were having trouble moving their limbs.

But that changed recently when Children’s Hospital Colorado reported they had a cluster of nine patients with paralysis and signs of nerve damage on MRIs.

Four of the nine children have had enterovirus D68 isolated from their airways. Tests are pending for two others. And now the CDC is also checking samples of the children’s spinal fluid for the virus.

Late Monday, in a press briefing, doctors from Children’s Hospital Colorado said they’d recently seen another case of paralysis, bringing their total to 10 patients. That child is also getting further testing to see if there’s any link to enterovirus.

In each case, the paralysis or weakness started about a week after the breathing problems. Some of the affected kids are also having trouble lifting their necks and trunks. They’re getting physical therapy to help them with daily living skills. The doctors said it’s too early to say how much movement they’ll recover.

Despite the scary symptoms, Chris Nyquist, MD, medical director of infection prevention and control at Children’s Hospital Colorado, said parents shouldn’t panic.

“Probably millions of children are being infected with enterovirus D68 across the nation and they are having simple cold symptoms,” Nyquist says. "If we find that this is an association, which we haven’t proven, this is very, very uncommon. "The CDC sent out an alert to doctors across the country on Friday telling them to report similar cases. On Monday, a spokesperson for the agency declined to say how many patients with paralysis officials are aware of across the country or when the CDC might have test results.

Mary Anne Jackson, MD, is chief of the pediatric infectious diseases section at Children’s Mercy Hospital in Kansas City, MO, one of the first hospitals to flag the surge in enterovirus D68 infections. She says they have three cases under investigation with symptoms similar to those seen in the Colorado patients.

The Virginia Department of Health is investigating one report of a child with unexplained paralysis.

Schaffner says that in many children, symptoms of paralysis will ease over time as inflammation and swelling of the tissues improves.


“But some of these illnesses can have a permanent residual paralysis, just like the old-timey polio did, because if those cells have been destroyed, there can be some residual paralysis,” he says.

There is no vaccine to prevent enterovirus D68. There are no effective treatments for the infection, either.

Hospitals rely on medications to open airways and supplemental oxygen to help kids get through the worst of the breathing problems.

So far, no deaths linked to enterovirus D68 have been confirmed, but the New Jersey Department of Health said Monday the CDC was testing samples taken from a 4-year-old with suspicious symptoms who died at home.

Right now the best way to protect kids from enteroviruses are to:

Practice good hand-washing habits.
Avoid close contact with people who are sick.
Disinfect frequently touched surfaces like toys and doorknobs.

http://www.webmd.com/cold-and-flu/news/ ... ovirus-d68

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PostPosted: Wed Oct 01, 2014 5:03 am 
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How often does enterovirus D68 cause paralysis?

By Bahar GholipourPublished September 30, 2014

Several children in Denver have developed limb weakness or paralysis after contracting respiratory illness, and four of the children have tested positive for enterovirus D68, the virus that has now sickened more than 400 people in 40 states, according to the Centers for Disease Control and Prevention.

It is not yet completely clear whether enterovirus D68 caused these children's neurological symptoms. Health officials at the Centers for Disease Control and Prevention (CDC) said on Friday (Sept. 26) that they are investigating the matter and searching for similar cases in other states that may have gone unreported.

"It's at the top of our list, but those investigations are still continuing, and I think we have not yet determined conclusively that D68 is the cause," said Dr. William Schaffner, an infectious disease expert at the Vanderbilt University School of Medicine in Nashville, Tennessee.[7 Devastating Infectious Diseases]

Enterovirus D68 is a rare virus and is in the same family of viruses as poliovirus; it can cause mild to severe respiratory illness. This year, outbreaks of infection with enterovirus D-68 have been reported in 40 states and the District of Columbia. The virus sickened at least 277 people between mid-August and Sept. 26, according to the CDC.

How enterovirus D68 could cause paralysis

Paralysis is not a common symptom of enteroviruses other than poliovirus, but is a possibility, according to the CDC. Enterovirus D68 generally targets the respiratory system and causes flulike symptoms, but it can get into the nervous system, and that's how it may cause muscle weakness or paralysis, Schaffner said.

"All the viruses in this enterovirus family can do this, but they do it very rarely," Schaffner said. To compare this virus to polio, he used an analogy: "The polio virus does this professionally. All the others are amateurs in creating paralytic illness."

Once in the nervous system, the enterovirus attacks certain cells that send signals to the muscles. The virus can cause inflammation, so that the cells don't work as well, or the virus can actually get into the cells and destroy them.

"Sometimes, as the inflammation recedes, you can get some restored function. But if those cells in the spinal cord have been actually killed, you're left with some permanent paralysis," Schaffner told Live Science.

It is not clear why in some cases the virus reaches the nervous system, while in others it doesn't, or what could be done to prevent a nervous system invasion if a person is infected, he said.

"Most of the children who are infected don't get this [paralysis]. Why the virus, on rare occasions, moves from the throat into the spinal cord, we don't know," Schaffner said.

How commonly can this happen?

This is not the first time that enterovirus D68 has been tied to paralysis. Last year, five children in California developed a poliolike illness that caused severe weakness or paralysis in their limbs. Two of those children tested positive for enterovirus D68. (In the other three children, the researchers were not able to find the cause of the paralysis.)

Still, doctors consider the risk of paralysis in someone infected with enterovirus D68 to be very low, Schaffner said. Even in the case of polio, paralysis occurs in only 1 in 200 cases of infection.

The nine children affected in Denver are between 1 and 18 years old, and all showed "spots or lesions in the grey matter of the spinal cord on MRI scans," Dr. Larry Wolk, the chief medical officer and executive director for the Colorado Department of Public Health and Environment, told ABC News.

Eight of the children in Denver were tested by the CDC, with four testing positive for enterovirus D68. Two others tested positive for different strains of another enterovirus, and the results for two children are not ready yet. The CDC could confirm that most of the children had previously been vaccinated against polio,so polio could be ruled out as the culprit.

But even the four children who tested positive for D68 have created a puzzle for the researchers, Schaffner said. The virus was found in these children's throats, and not their cerebrospinal fluid, which is found in the brain and the spine. "Often when an enterovirus causes paralytic illness, you can recover the virus from the cerebrospinal fluid," Schaffner said.

It's also unclear why there haven't been reports elsewhere of paralysis occurring in children infected with this virus, Schaffner said. A newly launched investigation and notices sent to children's hospitals across the country may help find some answers, he said.

http://www.foxnews.com/health/2014/09/3 ... paralysis/

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PostPosted: Wed Oct 01, 2014 5:06 am 
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Spread of enterovirus D68 takes an alarming turn with reports of paralysis: What we know and don’t know

By Ariana Eunjung Cha September 30 at 1:25 PM

Since doctors in Denver reported last week that several children who tested positive for the respiratory virus experienced limb weakness or paralysis, there’s been a lot of confusion about what that means. Here’s the latest on what we do and don’t know about the mystery symptom:

*Ten children at Children’s Hospital Colorado who were admitted between Aug. 9-Sept. 28 have experienced “paralysis-like symptoms,” according to the Denver Post. The affected children were ages 1 to 18 with the average age being 8.

*None of the children are completely unable to move but have “varying degrees of muscle weakness, difficulty swallowing, difficulty breathing, weakness in the neck and trunk, and difficulty walking,” Joyce Oleszek, a pediatric rehabilitation specialist, told the Denver Post.

*It’s too early to say whether the symptoms are permanent," hospital officials said.

*Four of the children in Colorado tested positive for enterovirus D68.

*Their symptoms are probably not related to polio. Eight of the 10 children affected were up to date on their polio vaccinations. (D68 is related to the virus that causes polio but D68 and other viruses in the enterovirus family typically do not cause these types of symptoms.)

*They don't seem to be due to West Nile either. Tests of the children’s spinal fluid came back negative for the mosquito-borne virus.

*Doctors at Children’s Mercy Hospital in Kansas City, Mo. are investigating three cases of children with similar symptoms, according to Bloomberg.

*The Centers for Disease Control and Prevention labs are backlogged with samples, but so far at least 443 people in 40 states and the District of Columbia have been confirmed as having been infected with the virus. It’s unclear how many of the children in that group are experiencing muscle weakness or paralysis symptoms as the CDC is still in the process of collecting that data.


*There have been no deaths definitively linked to D68 although the New Jersey Department of Health on Monday said the CDC took samples from a four-year-old who died at home with suspicious symptoms.

*A cluster of five children in California who also experienced paralysis-like symptoms was identified last year, and two of those children tested positive for EV-D68, according to CNN.

*A similar cluster was reported in Victoria, Australia in 2013. The Age reported that the enterovirus they were infected with was EV71, which is different from D68 but related to it.

*Since 2012, Stanford University researchers have been tracking at least 20 cases of childhood paralysis that appears to be similar to polio and began with respiratory symptoms. In a news release earlier this year, pediatric neurologist Keith Van Haren warned of a possible new threat.

"In the past decade, newly identified strains of enterovirus have been linked to polio-like outbreaks among children in Asia and Australia. These five new cases highlight the possibility of an emerging infectious polio-like syndrome in California,” Van Haren said.




Ariana Eunjung Cha is a national reporter for the Post. She has previously served as the newspaper’s bureau chief in Beijing, Shanghai and San Francisco, a correspondent in Baghdad and as a tech reporter based in Washington.


http://www.washingtonpost.com/news/to-y ... dont-know/

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PostPosted: Wed Oct 01, 2014 5:23 am 
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CDC investigates kids' limb paralysis; is enterovirus to blame?
By Jacque Wilson, CNN
updated 10:13 AM EDT, Tue September 30, 2014
Image
Most of the children experienced a respiratory illness before being admitted to the hospital.
STORY HIGHLIGHTS
NEW: "It seems to be attacking the spinal cord and brain stem," doctor says
MRI tests spotted abnormalities in sick children's spinal gray matter
Health officials are looking for the cause; it may be enterovirus
Ten children in Colorado hospitalized with limb paralysis

(CNN) -- Health officials are looking for the cause of a neurologic illness that's affected 10 children in Colorado.
The children were hospitalized between August 9 and September 28 with muscle weakness in their limbs, according to the Centers for Disease Control and Prevention.
Something is affecting the children's motor nerves, causing weakness primarily in their shoulders, triceps, biceps and hips, says Dr. Joyce Oleszek, a pediatric rehabilitation specialist at Children's Hospital Colorado. Doctors are also seeing some weakness in the neck and facial muscles in these patients.
"It seems to be attacking the spinal cord and brain stem," Oleszek said at a press conference Monday.
MRI tests spotted abnormalities in the children's spinal gray matter. Most of the children experienced a respiratory illness before being admitted to the hospital, although only two had a history of asthma.
The latest case was a girl who arrived at Children's Hospital Colorado over the weekend. She and three of the other patients are still at the hospital. The rest have been discharged, said Dr. Sam Dominguez, a microbial epidemiologist at the hospital. Doctors do not know if the neurological damage will be permanent.
The CDC is investigating the cause of these symptoms. Health officials do not believe that the cases were caused by polio, as at least eight of the 10 children are up to date on their polio vaccinations.
"We don't know, at this point, if there is any association between the enterovirus EV-D68 that's circulating and the paralytic conditions some of the children in Colorado are experiencing," CDC spokesman Tom Skinner said.
Tests of the children's cerebrospinal fluid came back negative for enteroviruses and West Nile virus. But a test of their nasal passages found enterovirus in six out of eight patients who were tested.
Of those six, four tested positive for enterovirus D68, which has been sending children across North America to the hospital with severe respiratory illnesses. The other two test results are pending.
"It could be something else. That doesn't prove cause and effect, but it's circumstantial evidence," said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. The cause "still remains a puzzle."
Virus sends hundreds to hospital
Enterovirus: My son was 'like a goldfish gasping for breath'
A cluster of children with similar paralysis symptoms was identified in California last year. Samples from two of the children tested positive for enterovirus D68.
Enterovirus D68 is part of the Picornaviridae family, which also includes the poliovirus, other enteroviruses and rhinoviruses. Enteroviruses are very common, especially in late summer and early fall. The CDC estimates that 10 million to 15 million infections occur in the United States each year.
These viruses usually appear like the common cold; symptoms include sneezing, a runny nose and a cough. Most people recover without any treatment. But some types of enterovirus are more serious. These can cause hand, foot and mouth disease; viral meningitis; encephalitis (inflammation of the brain); an infection of the heart; and paralysis in some patients.
This year, enterovirus D68 seems to be exacerbating breathing problems in children who have asthma. The virus has infected at least 277 people in 40 states, according to the CDC. Cases have also been reported in Canada. Children's Hospital Colorado has treated over 4,000 children with severe respiratory illness since August 18, said Dr. Chris Nyquist, medical director for Infection Prevention and Control. About 10% were admitted.
CNN affiliate WCBS reported Friday that a New Jersey toddler died last week from a severe respiratory illness and that the CDC will be testing samples to see whether he had enterovirus D68.
The CDC is asking other hospitals across the country to be on the lookout for similar cases and to send in information on any patients with these symptoms.
"Parents shouldn't panic," Nyquist says. "This is very, very uncommon. "
Common-sense things, like frequent hand-washing and avoiding sick people, can help protect kids from becoming infected, she said.

http://www.cnn.com/2014/09/29/health/co ... terovirus/

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PostPosted: Wed Oct 01, 2014 8:55 am 
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Published Date: 2014-09-30 21:39:47
Subject: PRO/EDR> Polio-like illness - North America: Canada (BC)
Archive Number: 20140930.2819618
POLIO-LIKE ILLNESS - NORTH AMERICA: CANADA (BRITISH COLUMBIA)
*************************************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
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Date: 30 Sep 2014
From: Dr. Danuta Skowronski <danuta.skowronski@bccdc.ca>


In response to the [27 Sep 2014] ProMED request for information about possible neurological manifestations of enterovirus D68 [EV-D68] (Archive number 20140927.2809908), we would like to share the following information from the province of British Columbia (BC), Canada.

Among the 8 laboratory-confirmed cases of EV-D68 detected as of [30 Sep 2014] in BC, there were 2 individuals reported to the BC Centre for Disease Control (BCCDC) with paralytic symptoms, including a child aged 5-10 years and a young adult aged 15-20 years. Both are male, previously healthy and had symptom onset in late August 2014. They reside several hundred kilometres apart and are not epidemiologically linked. Unlike other areas affected by EV-D68, a general increase in severe respiratory illness visits to emergency rooms or hospitals has not yet been observed in BC. However, all public primary and secondary schools had been closed in BC due to a teacher's strike that recently ended and with school only having resumed from summer recess on [22 Sep 2014].

The younger child presented with a 5-day history of fever, cough, rhinorrhea and congestion. Household members, both adult and pediatric, had similar cold-like symptoms. Two days prior to admission, the child experienced headache and neck pain radiating to the left shoulder, worsened by coughing. The child developed sudden onset of left arm weakness. Examination at admission identified left arm flaccid paralysis and areflexia without any sensory findings. CSF examination showed elevated leukocytes consisting of a mix of neutrophils and lymphocytes with slight predominance of the latter, normal glucose and elevated protein (0.5 g/L). MRI identified asymmetric swelling from C2 to T1. Nerve conduction and EMG examination confirmed findings consistent with anterior horn cell involvement but normal sensory findings. CSF was negative for enterovirus RNA but the nasopharyngeal swab was PCR-positive for enterovirus/rhinovirus, subsequently confirmed to be EV-D68 by sequencing of the 5' UTR at the BCCDC. Serology was IgM positive for Mycoplasma pneumoniae but nasopharyngeal swab was PCR-negative. There was no improvement in neurological symptoms during the 9-day course in hospital and the child was discharged with outpatient follow-up. There remains no neurological improvement nearly one-month post-admission.

The young adult had a prior history of shingles in the late spring and respiratory symptoms over the past 2-3 months. For the current episode, the patient awoke with right arm weakness and presented to hospital with one-day history of flu-like symptoms including mild fever, general aches and fatigue. No other family members had cold-like symptoms. The patient rapidly deteriorated over the ensuing 24 hours with difficulty breathing requiring intubation and mechanical ventilation. CSF specimen showed elevated leukocytes consisting of a mix of neutrophils and lymphocytes with slight predominance of the former, normal glucose and elevated protein (0.63 g/L). CSF was negative for enterovirus and VZV, but tracheal aspirate was positive for enterovirus/rhinovirus, determined by sequencing to be EV-D68 at the BCCDC. MRI showed longitudinal high signal within the cervical cord. Nearly one month post-admission, the patient still requires assistance with ventilation.

The detection of EV-D68 from respiratory specimens in association with neurological findings does not prove causality particularly in the absence of virus detection in the CSF. It is possible that other etiologies were present and that the detection of EV-D68 was the result of contemporaneous viral shedding. In the current outbreak, EV-D68 has more often been reported in association with severe respiratory illness but neurologic findings in association with EV-D68 have also been reported previously elsewhere [1-3]. Most laboratories do not currently have the capacity to diagnose or characterize EV-D68 in order to systematically assess the extent of its circulation or the spectrum of its clinical involvement. Given the seriousness and prolonged duration of paralytic findings in these 2 recent cases of laboratory-confirmed EV-D68 in BC, we thought it was pertinent that we share this information. A comparison of EV-D68 gene sequences collected from patients across the 2014 outbreak in North America is also warranted and may help identify unique virus features associated with more severe complications, including possible neurologic manifestations.

Michelle Murti MD, FRCPC
Fraser Health Authority

Sue Pollock MD, FRCPC
Interior Health Authority

Mel Krajden MD, FRCPC
Patrick Tang MD, PhD, FRCPC
Catharine Chambers MSc
Danuta M Skowronski MD, FRCPC
BC Centre for Disease Control
British Columbia, Canada

References
1. Polio-like illness - USA: (California) Enterovirus 68 Suspected, Request for Information. ProMED 2014-02-24. Archive Number: 20140224.2296126.
2. Kuehn BM. Poliolike cases probed in California: CDC says rare cases not cause for widespread alarm. JAMA 2014;311:1280-81.
3. Kreuter JD, Barnes A, McCarthy JE, et al. A fatal central nervous system enterovirus 68 infection. Arch Pathol Lab Med 2011;135:793-96.

--
Communicated by:
Danuta M Skowronski MD, FRCPC
BC Centre for Disease Control
<danuta.skowronski@bccdc.ca>

[ProMED-mail would like to thank Dr. Danuta Skowronski and colleagues for their rapid response to our RFI (request for information) on the reports of a polio-like illness possibly associated with infection with enterovirus D68 (EV-D68) and for sharing the details of these 2 patients. The above report submitted by them is the 1st official report describing clinical history, physical examination, supportive laboratory and MRI studies and epidemiologic studies conducted on cases matching the case definition provided by CDC: Patients less than or equal to 21 years of age with acute onset of focal limb weakness occurring on or after [1 Aug 2014]; and an MRI showing a spinal cord lesion largely restricted to grey matter. The absence of identification of the EV-D68 in cerebrospinal fluid (CSF) does not necessarily rule out etiology as recovery of poliovirus (another member of the enterovirus family) from CSF is not a frequent occurrence.

A disturbing mention in the above report is that primary and secondary schools opened late following the summer recess (on 22 Sep 2014), so that these early cases of neurologic disease were identified before the expected surge in cases of EV-D68 seen when children who may be shedding the virus are congregated in the school setting.

For the HealthMap/ProMED map of British Columbia, Canada, see http://healthmap.org/promed/p/264. - Mod.MPP]
See Also
Polio-like illness - USA (03): (MA, CO, MO) EV-D68 suspected, RFI ARCHIVE PENDING
Polio-like illness - USA (02): (CO) enterovirus 68 susp, alert, RFI 20140927.2809908
Polio-like illness - USA: (CA) enterovirus 68 susp, RFI 20140224.2296126
Human enterovirus D68 - North America (03) CDC update 20140925.2805500
Human enterovirus D68 - North America (02): more cases 20140924.2802168
Human enterovirus D68 - North America, update 20140923.2798679
Human enterovirus 68 - Canada: (AB), correction 20140919.2788704
Human enterovirus 68 - USA (07): update 20140919.2788495
Human enterovirus 68 - Canada (02): (ON) susp. 20140916.2778719
Human enterovirus 68 - Canada: (Alberta) 20140916.2775534
Human enterovirus 68 - USA (06): (NY) conf. 20140914.2773026
Human enterovirus 68 USA (05): (CT) susp 20140913.2771924
Human enterovirus 68 - USA (04): update, RFI 20140910.2763945
Human enterovirus 68 - USA (03): midwest, CDC 20140908.2758285
Human enterovirus 68 - USA (02): children, susp across Midwest 20140908.2757391
Human enterovirus 68 - USA: (Kansas City, MO) 20140830.2737051
2013
----
Human enterovirus 71 - Australia: sub-genogroup C4a, acute flaccid paralysis 20130526.1738087
2011
----
Human enterovirus 68 (02): comment 20111005.2994
Human enterovirus 68 - novel pathogen, worldwide 20110929.2945
.................................................mpp/

http://www.promedmail.org/direct.php?id=2819618

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PostPosted: Wed Oct 01, 2014 8:58 am 
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Published Date: 2014-09-30 22:49:31
Subject: PRO/EDR> Polio-like illness - USA (03): (MA, CO, MO) enterovirus 68 susp. RFI
Archive Number: 20140930.2818951
POLIO-LIKE ILLNESS - USA (03): (MASSACHUSETTS, COLORADO, MISSOURI), ENTEROVIRUS 68 SUSPECTED, REQUEST FOR INFORMATION
*********************************************************************************************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

In this update:
[1] Massachusetts, 4 cases
[2] Colorado, 1 new case
[3] Colorado 10 cases, Missouri 3 cases RFI

******
[1] Massachusetts, 4 cases
Date: 30 Sep 2014
Source: CBS Boston [edited]
http://boston.cbslocal.com/2014/09/30/b ... -symptoms/


Boston Children's Hospital said on Tue [30 Sep 2014] that it is monitoring patients who have developed polio-like symptoms, possibly related to enterovirus D68.

The Centers for Disease Control and Prevention [CDC] is currently investigating 9 cases in Colorado where symptoms consisted of weakness in one or more limbs and an MRI showed distinctive findings in the central portion of the spinal cord causing weakness.

Dr. Mark Gorman of Boston Children's Hospital said at a Tuesday [30 Sep 2014] press conference that patients who meet 3 sets of criteria will have additional samples sent to be tested by the CDC.

Patients who are under 21 years old, have experienced limb weakness on or after [1 Aug 2014] and have an MRI that show lesions near the spinal cord will be tested for enterovirus D68.

Gorman said Children's Hospital has seen 4 patients who met the criteria set by the CDC. Of the 4, one had a nasal sample that was negative for enterovirus D68, and the other results have not yet come in.

The patients admitted to Children's Hospital range from 4 to 15 years old. None of the 4 had enterovirus D68 detected in their spinal fluid. One of the 4 children has since been discharged from the hospital.

There is not a clear relationship between enterovirus and the polio-like symptoms, doctors said. Gorman added that it is a 2-part illness where patients develop respiratory symptoms followed by neurological symptoms about 2 weeks later.

"I should be clear that these patients do not have polio," said Gorman.

Gorman added that Children's Hospital doctors are working with medical centers nationally to gather more information and determine how to help children and families impacted by the symptoms.

CBS Denver reported that 9 children were recently taken to an Aurora, Colorado hospital with muscle weakness and some with loss of feeling in their arms or legs. Colorado doctors ran additional tests, and 4 of the patients tested positive for enterovirus D68.

Families are reminded to take preventative steps to help avoid illness in themselves and their children.

Gorman said good hand washing is the 1st step to avoiding illness. He also said that if parents or children have an active illness, they should stay home, adding that anyone with unusual symptoms should seek immediate medical attention.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

******
[2] Colorado, 1 new case
Date: 30 Sep 2014
Source: Brush Tribune News [edited]
http://www.brushnewstribune.com/ci_2663 ... -weakening


State health authorities have confirmed a 10th case of paralysis-like symptoms in a Colorado child, an outbreak that state and federal officials say might be linked to concurrent viral outbreaks.

The 10th child is at Children's Hospital Colorado, where the other 9 children were diagnosed, said Dr. Larry Wolk, director of the Colorado Department of Public Health and Environment and a pediatrician.

At a news conference at the hospital Monday [29 Sep 2014], Children's Hospital doctors said it is too soon to know whether the afflicted kids will recover from the paralysis or how long that recovery might take. And they're no closer to understanding why Colorado appears to be the focus of the ailment.

Dr. Chris Nyquist, medical director of infection prevention and control at Children's Hospital, said the affected group -- kids averaging 8 years old -- provides fertile ground for the spread of viruses, especially at this time of year.

"You have a new strain of virus circulating in a susceptible population that likes to spread things back and forth to each other. It's really a perfect storm for spreading viral illness through school settings, day care settings and really from the middle of the nation throughout the rest of the nation," Nyquist said. "We really can't say this is something specific to Colorado's environment."

Doctors emphasized that it remains uncertain whether the muscle weakness is connected to the viral outbreak.

The Colorado cases were identified between [8 Aug and 17 Sep 2014] among children ages 1-18, most from the Denver area.

8 of the 9 children originally diagnosed with what Wolk called myelitis, an infection or inflammation of the gray matter of the spinal cord, were tested for viral outbreaks. 4 children tested positive for enterovirus 68, and the other 4 were positive for rhinovirus or another enterovirus. There was no information given for the 10th child.

Dr. Joyce Oleszek, who specializes in pediatric rehabilitation medicine, said there are no cases where the children are completely unable to move, just varying degrees of muscle weakness, difficulty swallowing, difficulty breathing, weakness in the neck and trunk, and difficulty walking. She said it was too early to know whether the paralysis is permanent. "Only time will tell," she said.

The parents of one of the 10 Colorado children affected by the illness said their daughter came down with respiratory symptoms 7 weeks ago, but they didn't take her complaints very seriously. By the end of August [2014], though, a fever surfaced, and then got worse until "she was sicker than I've ever seen her," said the girl's mother, who agreed to talk on condition her daughter's identity would be protected.

The girl's left arm weakened. She couldn't cross the monkey bars anymore or steer her bicycle. When she played the piano, her left hand suddenly struggled to touch the keys. When she wasn't better by Labor Day, her parents took her to see a doctor and learned of the similar symptoms that had struck other Colorado children.

The girl, a Denver grade-schooler, still suffers from the illness. And though she never was paralyzed, the prognosis for her left arm is unclear. She is undergoing physical therapy now and is stable. Despite her daughter's hospitalization in mid-September 2014, her mother said, "we also count our blessings. It could have been a lot worse."

Doctors still don't understand how the illness is attacking the body, said Dr. Sam Dominguez, a microbial epidemiologist at Children's. And they remain concerned that they may see more cases emerge.

It will probably take weeks to determine whether enterovirus was the cause of the paralysis, Dominguez added, but doctors may never know.

On Friday [26 Sep 2014], the Centers for Disease Control and Prevention issued a national alert for doctors in other states to watch for patients suffering from limb weakness accompanied by lesions on the spine.

"Parents shouldn't panic," Nyquist said. She pointed out that millions of children are being infected with enterovirus 68 across the nation and have nothing more than simple cold symptoms. "Doing those things you can do for your children in the beginning is really the most important thing for parents to focus on, and when to go get health care," Nyquist said.

Difficulty breathing or walking or weakness in a limb are all warning signs that parents should seek medical care, regardless of whether there are respiratory symptoms.

Nyquist noted that Children's Hospital had seen 4021 kids with severe respiratory illness in the emergency room or in urgent care between [18 Aug 2014] and the past weekend [27-28 Sep 2014]. Of those, about 10 percent were admitted to the hospital, a higher than usual number for this time of year.

[Byline: Elizabeth Hernandez, Kevin Simpson, David Olinger]

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

******
[3] Colorado 10 cases, Missouri 3 cases RFI
Date: 29 Sep 2014
Source: The Examiner [edited]
http://www.examiner.com/article/cdc-inv ... s-children


What started out as a typical enterovirus D68 (EV-D68) outbreak has changed into something more serious. The Centers for Disease Control (CDC) is looking into a link between the recent enterovirus D68 outbreak and paralysis in children. Bloomberg Businessweek reported on [29 Sep 2014] at least 10 cases of children with paralysis in Colorado and 3 in Missouri. All 13 children had EV-D68.

40 states have reported cases of EV-D68 with only 277 confirmed cases. Hospitals in Colorado have reported thousands of suspected cases. In New York, they are only testing children with the most severe symptoms due to the high number of pediatric emergency room events. Missouri hospitals have reported many cases, 3 of which included paralysis symptoms.

It is known that EV-D68 can cause muscle weakness and paralysis in the limbs. It was thought to be a very rare symptom of the disease. Out of the thousands of suspected cases of the virus this year [2014], only a few have developed muscle weakness or paralysis. The Huffington Post says the symptoms are not polio related. Most of the children with paralysis symptoms or severe muscle weakness are current on their polio vaccinations.

WCVB5 in Boston quoted Dr. Joyce Oleszek of Children's Hospital Colorado as saying: "It seems to be attacking the spinal cord and brain stem." Oleszek elaborated that at least 10 children admitted to the hospital between [9 Aug 2014 and 28 Sep 2014] have some form of paralysis. It can range from severe muscle weakness to the ability to use a limb or hand. It does not appear to have the full body paralysis associated with polio. She said the type of paralysis they are seeing at Children's Hospital seems to affect the shoulders, biceps, triceps, and hips.

Some of the children with paralysis symptoms underwent an MRI. The results showed abnormalities in the spinal grey matter. The children's spinal fluid was tested for traces of EV-D68. All tests came back negative. It is unknown whether the paralysis is permanent. Three children in Missouri had similar symptoms. The CDC is investigating whether there is a link between the virus and the symptoms they are seeing.

Experts say that the spread of the virus is controllable. It is important to wash your hands frequently. Sneeze or cough into your elbow, not your hands. Watch your children carefully if they start to develop flu-like symptoms, especially if they have respiratory problems.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[According to the above media reports, there are now cases of paralytic disease reported in children in Colorado (10), Massachusetts (4) and Missouri, in addition to the cases reported in California earlier this year (2014, see Polio-like illness - USA: (CA) enterovirus 68 susp, RFI 20140224.2296126). Enterovirus D-68 (EV-D68) infection has been identified in a number of these cases, leading to the current theory that these paralytic cases may well be related to infection with EV-D68.

The clinical descriptions mention in most cases a history of a respiratory infection approximately 2 weeks preceding the onset of paralysis and or weakness, and MRI studies of the spinal cords have demonstrated disease in the grey matter, consistent with lesions in the anterior horn cells, similar to what is seen with poliovirus infection. All studies to date have ruled out the possibility that the paralyses are due to infection with poliovirus. While there is increasing circumstantial evidence that EV-D68 may be the etiologic agent, definitive studies demonstrating this have not been done as yet.

As a reminder, poliovirus is a member of the enterovirus family. There has not been a case of poliovirus associated paralysis acquired in the USA since 1979, and the last case of wild poliovirus associated disease diagnosed in the USA was an imported case in 1993 (http://www.cdc.gov/vaccines/pubs/surv-m ... polio.html. Other non-polio enteroviruses have been implicated in polio-like illnesses, such as EV-D68 and EV71 (see references below and prior ProMED-mail posts listed below for more information). This moderator is curious as to whether laboratory studies have included stool and throat swabs for virus isolation as well as paired sera (acute and convalescent) for evidence of recent EV-D68. In the case of poliovirus, the highest virus identification came from stool specimens followed by oropharyngeal (throat), and the lowest yield was from blood or spinal fluid.

Since the CDC announced an alert for states to report cases of acute onset of focal limb weakness occurring on or after 1 Aug 2014 and an MRI showing a spinal cord lesion largely restricted to grey matter (see Polio-like illness - USA (02): (CO) enterovirus 68 susp, alert, RFI 20140927.2809908), it is not surprising to learn of cases in other states as we are now in a "seek and ye shall find" mode of active surveillance. It is curious that the date of active surveillance begins on 1 Aug 2014, so that the initial reported series of cases in California will not be included as part of this current "outbreak."

More information on the demographics and results of investigations in the recently reported cases in Colorado, Missouri and Massachusetts would be greatly appreciated.

For a map showing the states in the USA, see http://healthmap.org/promed/p/106.

Selected references
-------------------
1. The National Committee for the Certification of Wild Poliovirus Eradication in Hong Kong (NCC). Fifteen years of acute flaccid paralysis surveillance in Hong Kong: Findings from 1997 to 2011. J Paediatr Child Health. 2014; 50(7): 545-52. doi: 10.1111/jpc.12492; abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24528511.
2. Kim H, Kang B, Hwang S, et al: Clinical and enterovirus findings associated with acute flaccid paralysis in the republic of Korea during the recent decade. J Med Virol. 2014; 86(9): 1584-9. doi: 10.1002/jmv.23763; abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24114945.
3. Peacey M, Hall RJ, Wang J, et al: Enterovirus 74 infection in children. PLoS One. 2013; 8(10): e76492; full article available at http://www.plosone.org/article/info%3Ad ... ne.0076492.
4. Laxmivandana R, Yergolkar P, Gopalkrishna V, Chitambar SD: Characterization of the non-polio enterovirus infections associated with acute flaccid paralysis in South-Western India. PLoS One. 2013; 8(4): e61650; full article available at http://www.plosone.org/article/info%3Ad ... ne.0061650.
5. Rao CD, Yergolkar P, Shankarappa KS: Antigenic diversity of enteroviruses associated with nonpolio acute flaccid paralysis, India, 2007-2009. Emerg Infect Dis. 2012; 18(11): 1833-40; full article available at http://wwwnc.cdc.gov/eid/article/18/11/ ... rticle.htm.
6. Shaukat S, Angez M, Alam MM, et al: Characterization of non-polio enterovirus isolates from acute flaccid paralysis children in Pakistan reflects a new genotype of EV-107. Virus Res. 2012; 170(1-2): 164-8; abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23041515.
7. Shahmahmoodi S, Mehrabi Z, Eshraghian MR, et al: First detection of enterovirus 71 from an acute flaccid paralysis case with residual paralysis in Iran. J Clin Virol. 2008; 42(4): 409-11; abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18403258.
8. Junttila N, Leveque N, Kabue JP, et al: New enteroviruses, EV-93 and EV-94, associated with acute flaccid paralysis in the Democratic Republic of the Congo. J Med Virol. 2007; 79(4): 393-400; abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17311342.
9. Huang CC, Liu CC, Chang YC, et al: Neurologic complications in children with enterovirus 71 infection. N Engl J Med. 1999; 341(13): 936-42; full article available at http://www.nejm.org/doi/full/10.1056/NE ... 9233411302.
10. Dietz V, Andrus J, Olive JM, et al: Epidemiology and clinical characteristics of acute flaccid paralysis associated with non-polio enterovirus isolation: the experience in the Americas. Bull World Health Organ. 1995; 73(5): 597-603; full article available at http://whqlibdoc.who.int/bulletin/1995/ ... 97-603.pdf.
11. Hayward JC, Gillespie SM, Kaplan KM, et al: Outbreak of poliomyelitis-like paralysis associated with enterovirus 71. Pediatr Infect Dis J. 1989; 8(9): 611-6; abstract available at http://www.ncbi.nlm.nih.gov/pubmed/2797956.
- Mod.MPP]
See Also
Polio-like illness - North America: Canada (BC) 20140930.2819618
Polio-like illness - USA (02): (CO) enterovirus 68 susp, alert, RFI 20140927.2809908
Polio-like illness - USA: (CA) enterovirus 68 susp, RFI 20140224.2296126
Human enterovirus D68 - North America (03) CDC update 20140925.2805500
Human enterovirus D68 - North America (02): more cases 20140924.2802168
Human enterovirus D68 - North America, update 20140923.2798679
Human enterovirus 68 - Canada: (AB), correction 20140919.2788704
Human enterovirus 68 - USA (07): update 20140919.2788495
Human enterovirus 68 - Canada (02): (ON) susp. 20140916.2778719
Human enterovirus 68 - Canada: (Alberta) 20140916.2775534
Human enterovirus 68 - USA (06): (NY) conf. 20140914.2773026
Human enterovirus 68 USA (05): (CT) susp 20140913.2771924
Human enterovirus 68 - USA (04): update, RFI 20140910.2763945
Human enterovirus 68 - USA (03): midwest, CDC 20140908.2758285
Human enterovirus 68 - USA (02): children, susp across Midwest 20140908.2757391
Human enterovirus 68 - USA: (Kansas City, MO) 20140830.2737051
2013
----
Human enterovirus 71 - Australia: sub-genogroup C4a, acute flaccid paralysis 20130526.1738087
2011
----
Human enterovirus 68 (02): comment 20111005.2994
Human enterovirus 68 - novel pathogen, worldwide 20110929.2945
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PostPosted: Mon Nov 10, 2014 12:13 pm 
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Thread on polio-like D68

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