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Helfferich J, Fall A, Pardo CA, Jacobs BC, Messacar K. Acute flaccid myelitis in low- to middle-income countries: diagnosis and surveillance. Brain Commun 2024; 6:fcae167. [PMID: 39027410 PMCID: PMC11255474 DOI: 10.1093/braincomms/fcae167] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 01/25/2024] [Accepted: 05/09/2024] [Indexed: 07/20/2024] Open
Affiliation(s)
- Jelte Helfferich
- Department of Neurology, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Amary Fall
- Division of Medical Microbiology, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Carlos A Pardo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Bart C Jacobs
- Department of Neurology and Immunology, Erasmus MC, University Medical Center Rotterdam, 3015 CN Rotterdam, The Netherlands
| | - Kevin Messacar
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, CO 80045, USA
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Werner JM, Wlodarczyk J, Seruya M. Diagnostic Accuracy of Manual Muscle Testing to Identify Nerve Transfer Candidates in Children with Acute Flaccid Myelitis. Plast Reconstr Surg 2023; 152:1057-1067. [PMID: 36988635 DOI: 10.1097/prs.0000000000010457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
BACKGROUND Manual muscle testing is a mainstay of strength assessment despite not having been compared with intraoperative electrical stimulation of peripheral nerves. METHODS Intraoperative electrical stimulation served as the reference standard in evaluating predictive accuracy of the Active Movement Scale (AMS) and the Medical Research Council (MRC) scale. Retrospective consecutive sampling of all patients with AFM who underwent exploration or nerve transfer at a pediatric multidisciplinary brachial plexus and peripheral nerve center from March of 2016 to July of 2020 were included. The nonparametric area under the curve (AUC) was calculated. Optimal cutoff score (Youden J ) and diagnostic accuracy values were reported. The AMS and MRC scale were directly compared for predictive superiority. RESULTS A total of 181 upper extremity nerves (73 donor nerve candidates and 108 recipient nerve candidates) were tested intraoperatively from 40 children (mean age ± SD, 7.9 ± 4.9 years). The scales performed similarly ( P = 0.953) in classifying suitable donor nerves with satisfactory accuracy (AUC AMS , 71.5%; AUC MRC , 70.7%; optimal cutoff, AMS >5 and MRC >2). The scales performed similarly ( P = 0.688) in classifying suitable recipient nerves with good accuracy (AUC AMS , 92.1%; AUC MRC :, 94.9%; optimal cutoff, AMS ≤3 and MRC ≤1). CONCLUSIONS Manual muscle testing is an accurate, noninvasive means of identifying donor and recipient nerves for transfer in children with acute flaccid myelitis. The utility of these results is in minimizing unexpected findings in the operating room and aiding in the development of contingency plans. Further research may extend these findings to test the validity of manual muscle testing as an outcome measure of the success of nerve transfer. CLINICAL QUESTION/LEVEL OF EVIDENCE Diagnostic, I.
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Affiliation(s)
- Julie M Werner
- From the Division of Pediatric Rehabilitation Medicine, Children's Hospital Los Angeles
| | - Jordan Wlodarczyk
- Department of Surgery, Keck School of Medicine, University of Southern California
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Singh B, Arora S, Sandhu N. Emerging trends and insights in acute flaccid myelitis: a comprehensive review of neurologic manifestations. Infect Dis (Lond) 2023; 55:653-663. [PMID: 37368373 DOI: 10.1080/23744235.2023.2228407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 06/08/2023] [Accepted: 06/18/2023] [Indexed: 06/28/2023] Open
Abstract
Acute Flaccid Myelitis (AFM) is a neurological condition in the anterior portion of the spinal cord and can be characterised as paraplegia (paralysis of the lower limbs), and cranial nerve dysfunction. These lesions are caused by the infection due to Enterovirus 68 (EV-D68); a member of the Enterovirus (EV) family belongs to the Enterovirus species within the Picornavirus family and a Polio-like virus. In many cases, the facial, axial, bulbar, respiratory, and extraocular muscles were affected, hence reducing the overall quality of the patient's life. Moreover, severe pathological conditions demand hospitalisation and can cause mortality in a few cases. The data from previous case studies and literature suggest that the prevalence is high in paediatric patients, but careful clinical assessment and management can decrease the risk of mortality and paraplegia. Moreover, the clinical and laboratory diagnosis can be performed by Magnetic resonance imaging (MRI) of the spinal cord followed by Reverse transcription polymerase chain reaction (rRT-PCR) and VP1 seminested PCR assay of the cerebrospinal fluid (CSF), stool, and serum samples can reveal the disease condition to an extent. The primary measure to control the outbreak is social distancing as advised by public health administrations, but more effective ways are yet to discover. Nonetheless, vaccines in the form of the whole virus, live attenuated, sub-viral particles, and DNA vaccines can be an excellent choice to treat these conditions. The review discusses a variety of topics, such as epidemiology, pathophysiology, diagnosis/clinical features, hospitalisation/mortality, management/treatment, and potential future developments.
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Affiliation(s)
- Baljinder Singh
- Centre for Pharmaceutical Innovation, University of South Australia, North Terrace, Adelaide, SA, Australia
| | - Sanchit Arora
- Department of Pharmaceutics, Delhi Institute of Pharmaceutical Sciences and Research (DIPSAR), Delhi Pharmaceutical Sciences and Research University (DPSRU), New Delhi, India
| | - Navjot Sandhu
- Department of Quality Assurance, ISF College of Pharmacy, Moga, Affiliated to IK Gujral Punjab Technical University, Jalandhar, India
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Helfferich J, Neuteboom RF, de Lange MMA, Benschop KSM, Van Leer-Buter CC, Meijer A, Bakker DP, de Bie E, Braakman HMH, Brandsma R, Niks EH, Niermeijer JM, Roelfsema V, Schoenmaker N, Sie LT, Niesters HG, Te Wierik MJM, Jacobs BC, Brouwer OF. Pediatric acute flaccid myelitis: Evaluation of diagnostic criteria and differentiation from other causes of acute flaccid paralysis. Eur J Paediatr Neurol 2023; 44:28-36. [PMID: 36996587 DOI: 10.1016/j.ejpn.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/20/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND Acute flaccid paralysis (AFP) is characterized by rapidly progressive limb weakness with low muscle tone. It has a broad differential diagnosis, which includes acute flaccid myelitis (AFM), a rare polio-like condition that mainly affects young children. Differentiation between AFM and other causes of AFP may be difficult, particularly at onset of disease. Here, we evaluate the diagnostic criteria for AFM and compare AFM to other causes of acute weakness in children, aiming to identify differentiating clinical and diagnostic features. METHODS The diagnostic criteria for AFM were applied to a cohort of children with acute onset of limb weakness. An initial classification based on positive diagnostic criteria was compared to the final classification, based on application of features suggestive for an alternative diagnosis and discussion with expert neurologists. Cases classified as definite, probable, or possible AFM or uncertain, were compared to cases with an alternative diagnosis. RESULTS Of 141 patients, seven out of nine patients initially classified as definite AFM, retained this label after further classification. For probable AFM, this was 3/11, for possible AFM 3/14 and for uncertain 11/43. Patients initially classified as probable or possible AFM were most commonly diagnosed with transverse myelitis (16/25). If the initial classification was uncertain, Guillain-Barré syndrome was the most common diagnosis (31/43). Clinical and diagnostic features not included in the diagnostic criteria, were often used for the final classification. CONCLUSION The current diagnostic criteria for AFM usually perform well, but additional features are sometimes required to distinguish AFM from other conditions.
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Affiliation(s)
- Jelte Helfferich
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - Rinze F Neuteboom
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marit M A de Lange
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Kimberley S M Benschop
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Coretta C Van Leer-Buter
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Adam Meijer
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Dewi P Bakker
- Department of Paediatric Neurology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Eva de Bie
- Department of Paediatric Neurology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Hilde M H Braakman
- Department of Paediatric Neurology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Rick Brandsma
- Department of Paediatric Neurology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Erik H Niks
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Vincent Roelfsema
- Department of Paediatrics, Martini Hospital, Groningen, the Netherlands
| | | | - Lilian T Sie
- Department of Paediatric Neurology, Haga Hospital, the Hague, the Netherlands
| | - Hubert G Niesters
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Margreet J M Te Wierik
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Bart C Jacobs
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Oebele F Brouwer
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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5
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Acute Flaccid Myelitis: Review of Clinical Features, Diagnosis, and Management with Nerve Transfers. Plast Reconstr Surg 2023; 151:85e-98e. [PMID: 36219869 DOI: 10.1097/prs.0000000000009788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Acute flaccid myelitis (AFM) is a devastating neurologic condition in children, manifesting as acute limb weakness and/or paralysis. Despite increased awareness of AFM following initiation of U.S. surveillance in 2014, no treatment consensus exists. The purpose of this systematic review was to summarize the most current knowledge regarding AFM epidemiology, cause, clinical features, diagnosis, and supportive and operative management, including nerve transfer. METHODS The authors systematically reviewed the literature based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using multiple databases to search the keywords ("acute flaccid myelitis"), ('acute flaccid myelitis'/exp OR 'acute flaccid myelitis'), and (Acute AND flaccid AND myelitis). Included articles reported on (1) AFM diagnosis and (2) patient-specific data regarding epidemiology, cause, clinical features, diagnostic features, or management of AFM. RESULTS Ninety-nine articles were included in this review. The precise cause and pathophysiologic mechanism of AFM remain undetermined, but AFM is strongly associated with nonpolio enterovirus infections. Clinical presentation typically comprises preceding viral prodrome, pleocytosis, spinal cord lesions on T2-weighted magnetic resonance imaging, and acute onset of flaccid weakness/paralysis with hyporeflexia in at least one extremity. Supportive care includes medical therapy and rehabilitation. Early studies of nerve transfer for AFM have shown favorable outcomes for patients with persistent weakness. CONCLUSIONS Supportive care and physical therapy are the foundation of a multidisciplinary approach to managing AFM. For patients with persistent limb weakness, nerve transfer has shown promise for improving function in distal muscle groups. Surgeons must consider potential spontaneous recovery, patient selection, donor nerve availability, recipient nerve appropriateness, and procedure timing.
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Dinov D, Donowitz JR. Acute flaccid myelitis a review of the literature. Front Neurol 2022; 13:1034607. [PMID: 36605787 PMCID: PMC9807762 DOI: 10.3389/fneur.2022.1034607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
Acute flaccid myelitis (AFM) is a rare neurological disorder that first rose to national attention in 2014. This neurological disorder has a biennial presentation with every other even year being a peak year. Most patients present in childhood 5 days after a prodromal infection. Patients usually present with muscle weakness and hypo or areflexia in the summer or fall months. Clinical outcomes are variable however most patients do not improve. Currently there are no definitive prognostic factors or etiologies found. However, it is thought that enterovirus-D68 (EV-D68) could be a potential component in the pathobiology of AFM. Treatment options are limited with variable options and no consensus. Supportive therapy has been shown to be the most effective thus far. With our review of the literature, we highlight the recent growing evidence of a possible relationship between EV-D68 and AFM. Additionally, we identify the knowledge gaps in AFM with treatment and prognostic factors.
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Affiliation(s)
- Darina Dinov
- Department of Neurology, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, United States,*Correspondence: Darina Dinov ✉
| | - Jeffrey R. Donowitz
- Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, United States
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Lazzarini LM, Werner JM, Perez IA, Seruya M, Ramos-Platt L, Tiongson E, Keens TG. Does acute flaccid myelitis cause respiratory failure in children? Pediatr Pulmonol 2022; 57:682-685. [PMID: 34910378 DOI: 10.1002/ppul.25789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 10/15/2021] [Accepted: 11/23/2021] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Acute flaccid myelitis (AFM) is a rare disease that affects spinal cord gray matter, results in acute flaccid weakness of one or more limbs and predominantly involves the cervical spinal cord, which places patients at higher risk for respiratory failure. Our study aims to describe respiratory failure in pediatric AFM patients with emphasis on the need for assisted ventilation and respiratory nerve involvement from an acute and long-term perspective. MATERIALS AND METHODS We reviewed the medical records of patients diagnosed with AFM seen in a multidisciplinary clinic for persistent limb weakness between 2016 and 2020. RESULTS We studied 54 patients, 35% were female. The median age of patients at illness onset was 5 years (range 7 months-19 years). The median age of patients at the time of study was 8.5 years (range 2-20 years). Eleven patients (20%) required assisted ventilation for acute respiratory failure. Of those that experienced acute respiratory failure, 81% developed chronic respiratory failure. Fifty-six percent of patients with chronic respiratory failure were able to wean off assisted ventilation by 1 year. All patients that experienced unilateral diaphragm impairment with AFM onset experienced acute and chronic respiratory failure. DISCUSSION Many patients with AFM may experience respiratory compromise and develop chronic respiratory failure. However, most of these patients can be weaned off ventilatory support by 1 year from illness onset. Most children with unilateral diaphragm impairment can sustain adequate ventilation without the need for long-term ventilatory support.
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Affiliation(s)
- Laura M Lazzarini
- Division of Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Julie M Werner
- Division of Rehabilitation Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA.,Institute for Nursing and Interprofessional Research, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Iris A Perez
- Division of Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA.,Department of Pediatrics, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Mitchel Seruya
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, California, USA.,Plastic and Reconstructive Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Leigh Ramos-Platt
- Department of Pediatrics, Keck School of Medicine of University of Southern California, Los Angeles, California, USA.,Division of Neurology, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Emmanuelle Tiongson
- Department of Pediatrics, Keck School of Medicine of University of Southern California, Los Angeles, California, USA.,Division of Neurology, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Thomas G Keens
- Division of Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA.,Department of Pediatrics, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
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Daniels DK, Conners GP. A Review of the Diagnosis and Management of Acute Flaccid Myelitis in the Emergency Department. Pediatr Emerg Care 2022; 38:126-130. [PMID: 35226621 DOI: 10.1097/pec.0000000000002660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Since 2014, biennial rises in acute flaccid myelitis (AFM) have brought attention to this rare but debilitating condition. Children with AFM typically present with acute onset, flaccid weakness accompanied by longitudinally extensive gray matter injury demonstrated on magnetic resonance imaging. A clearer understanding of the epidemiology and suspected pathogenesis of AFM may result in increased recognition. The purpose of this review article is to guide emergency physicians in recognizing key clinical features, initiating diagnostic evaluation and providing appropriate interventions for children with suspected AFM.
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Affiliation(s)
| | - Gregory P Conners
- Stanley A. August Professor and Chair of Pediatrics, Executive Director, Upstate Golisano Children's Hospital, SUNY Upstate Medical University, Syracuse, NY
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9
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Setia A, Bhatia J, Bhattacharya S. An Overview of Acute Flaccid Myelitis. CNS & NEUROLOGICAL DISORDERS DRUG TARGETS 2022; 21:774-794. [PMID: 34823462 DOI: 10.2174/1871527320666211125101424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 04/19/2021] [Accepted: 06/20/2021] [Indexed: 06/13/2023]
Abstract
Acute Flaccid Myelitis is defined by the presence of Acute Flaccid Paralysis (AFP) and a spinal cord lesion on magnetic resonance imaging that is primarily limited to the grey matter. AFM is a difficult situation to deal with when you have a neurologic illness. According to the Centers for Disease Control and Prevention (CDC), a large number of cases were discovered in the United States in 2014, with 90% of cases occurring in children. Although the exact cause of AFM is unknown, mounting evidence suggests a link between AFM and enterovirus D68 (EV-D68). In 2014, an outbreak of AFM was discovered in the United States. The condition was initially linked to polioviruses; however, it was later found that the viruses were caused by non-polioviruses Enteroviruses D-68 (EV-D68). The number of cases has increased since 2014, and the disease has been declared pandemic in the United States. The sudden onset of muscle weakness, usually in an arm or leg, as well as pain throughout the body, the change in patient's facial expression (facial weakness), and shortness of breath, ingesting, and speaking are all common symptoms in patients suffering from neurologic disease. This article includes graphic and histogram representations of reported AFM incidents and criteria for causality, epidemiology, various diagnostic approaches, signs and symptoms, and various investigational guidelines. It also includes key statements about recent clinical findings related to AFM disease.
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Affiliation(s)
- Aseem Setia
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, Punjab-142001, India
| | - Jasween Bhatia
- Department of Masters in Public Health Science, Symbiosis Institute of Health Science, Pune-411042, India
| | - Sankha Bhattacharya
- Department of Pharmaceutics, School of Pharmacy & Technology Management Shirpur, SVKM\'S NMIMS Deemed-to-be University, Shirpur, Maharashtra 425405, India
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Walker LJ, Thorley BR, Morris A, Elliott EJ, Saul N, Britton PN. Using the Acute Flaccid Paralysis Surveillance System to Identify Cases of Acute Flaccid Myelitis, Australia, 2000‒2018. Emerg Infect Dis 2022; 28:20-28. [PMID: 34932461 PMCID: PMC8714202 DOI: 10.3201/eid2801.211690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Since 2012, the United States has reported a distinct syndrome of acute flaccid paralysis (AFP) with anterior myelitis, predominantly in children. This polio-like syndrome was termed acute flaccid myelitis (AFM). Australia routinely conducts AFP surveillance to exclude poliomyelitis. We reviewed 915 AFP cases in Australia for children <15 years of age during 2000‒2018 and reclassified a subset to AFM by using the US Council of State and Territorial Epidemiologists case definition. We confirmed 37 AFM cases by using magnetic resonance imaging findings and 4 probable AFM cases on the basis of cerebrospinal fluid pleocytosis. Nonpolio enteroviruses were detected in 33% of AFM cases from which stool samples were tested. Average annual AFM incidence was 0.07 cases/100,000 person-years in children <15 years of age. AFM occurred sporadically in Australia before 2010 but regularly since then, indicating sustained, albeit rare, clinical manifestation in children. The AFP surveillance system in Australia is well-positioned to identify future AFM cases.
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Helfferich J, Roodbol J, de Wit MC, Brouwer OF, Jacobs BC. Acute flaccid myelitis and Guillain-Barré syndrome in children: A comparative study with evaluation of diagnostic criteria. Eur J Neurol 2021; 29:593-604. [PMID: 34747551 PMCID: PMC9299116 DOI: 10.1111/ene.15170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/03/2021] [Accepted: 11/01/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE Differentiation between acute flaccid myelitis (AFM) and Guillain-Barré syndrome (GBS) can be difficult, particularly in children. Our objective was to improve the diagnostic accuracy by giving recommendations based on a comparison of clinical features and diagnostic criteria in children with AFM or GBS. METHODS A cohort of 26 children with AFM associated with enterovirus D68 was compared to a cohort of 156 children with GBS. The specificity of the Brighton criteria, used for GBS diagnosis, was evaluated in the AFM cohort and the specificity of the Centers for Disease Control and Prevention (CDC) AFM diagnostic criteria in the GBS cohort. RESULTS Children with AFM compared to those with GBS had a shorter interval between onset of weakness and nadir (3 vs. 8 days, p < 0.001), more often had asymmetric limb weakness (58% vs. 0%, p < 0.001), and less frequently had sensory deficits (0% vs. 40%, p < 0.001). In AFM, cerebrospinal fluid leukocyte counts were higher, whereas protein concentrations were lower. Spinal cord lesions on magnetic resonance imaging were only found in AFM patients. No GBS case fulfilled CDC criteria for definite AFM. Of the AFM cases, 8% fulfilled the Brighton criteria for GBS, when omitting the criterion of excluding an alternate diagnosis. CONCLUSIONS Despite the overlap in clinical presentation, we found distinctive early clinical and diagnostic characteristics for differentiating AFM from GBS in children. Diagnostic criteria for AFM and GBS usually perform well, but some AFM cases may fulfill clinical diagnostic criteria for GBS. This underlines the need to perform diagnostic tests early to exclude AFM in children suspected of atypical GBS.
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Affiliation(s)
- Jelte Helfferich
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Joyce Roodbol
- Department of Neurology and Pediatric Neurology, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marie-Claire de Wit
- Department of Pediatric Neurology, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Oebele F Brouwer
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bart C Jacobs
- Department of Neurology and Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Florian IA, Lupan I, Sur L, Samasca G, Timiș TL. To be, or not to be… Guillain-Barré Syndrome. Autoimmun Rev 2021; 20:102983. [PMID: 34718164 DOI: 10.1016/j.autrev.2021.102983] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/02/2021] [Indexed: 02/06/2023]
Abstract
Guillain-Barré Syndrome (GBS) is currently the most frequent cause of acute flaccid paralysis on a global scale, being an autoimmune disorder wherein demyelination of the peripheral nerves occurs. Its main clinical features are a symmetrical ascending muscle weakness with reduced osteotendinous reflexes and variable sensory involvement. GBS most commonly occurs after an infection, especially viral (including COVID-19), but may also transpire after immunization with certain vaccines or in the development of specific malignancies. Immunoglobulins, plasmapheresis, and glucocorticoids represent the principal treatment modalities, however patients with severe disease progression may require supportive therapy in an intensive care unit. Due to its symptomology, which overlaps with numerous neurological and infectious illnesses, the diagnosis of GBS may often be misattributed to pathologies that are essentially different from this syndrome. Moreover, many of these require specific treatment methods distinct to those recommended for GBS, in lack of which the prognosis of the patient is drastically affected. Such diseases include exposure to toxins either environmental or foodborne, central nervous system infections, metabolic or serum ion alterations, demyelinating pathologies, or even conditions amenable to neurosurgical intervention. This extensive narrative review aims to systematically and comprehensively tackle the most notable and challenging differential diagnoses of GBS, emphasizing on the clinical discrepancies between the diseases, the appropriate paraclinical investigations, and suitable management indications.
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Affiliation(s)
- Ioan Alexandru Florian
- Department of Neurology, Cluj County Emergency Clinical Hospital, Cluj-Napoca, Romania, Department of Neurosurgery, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.
| | - Iulia Lupan
- Department of Molecular Biology, Babes Bolyai University, Cluj-Napoca, Romania.
| | - Lucia Sur
- Department of Pediatrics I, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.
| | - Gabriel Samasca
- Department of Immunology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.
| | - Teodora Larisa Timiș
- Department of Physiology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.
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Fadda G, Alves CA, O’Mahony J, Castro DA, Yeh EA, Marrie RA, Arnold DL, Waters P, Bar-Or A, Vossough A, Banwell B. Comparison of Spinal Cord Magnetic Resonance Imaging Features Among Children With Acquired Demyelinating Syndromes. JAMA Netw Open 2021; 4:e2128871. [PMID: 34643718 PMCID: PMC8515204 DOI: 10.1001/jamanetworkopen.2021.28871] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
IMPORTANCE The recognition of magnetic resonance imaging (MRI) features associated with distinct causes of myelitis in children is essential to guide investigations and support diagnostic categorization. OBJECTIVE To determine the clinical and MRI features and outcomes associated with spinal cord involvement in pediatric myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), multiple sclerosis (MS), and seronegative monophasic myelitis. DESIGN, SETTING, AND PARTICIPANTS In this cohort study, participants were recruited between 2004 and 2017 through the multicenter Canadian Pediatric Demyelinating Disease Study, which enrolled youth younger than 18 years presenting within 90 days of an acquired demyelinating syndrome. Of the 430 participants recruited, those with lesions on available spine MRI and anti-MOG testing performed on archived samples obtained close to clinical presentation were selected. Participants with poor-quality images and final diagnoses of nondemyelinating disease, anti-aquaporin 4 antibody positivity, and relapsing seronegative myelitis were excluded. Data analysis was performed from December 2019 to November 2020. MAIN OUTCOMES AND MEASURES Spinal cord involvement was evaluated on 324 MRI sequences, with reviewers blinded to clinical, serological, and brain MRI findings. Associated clinical features and disability scores at 5 years of follow-up were retrieved. Results were compared between groups. RESULTS A total of 107 participants (median [IQR] age at onset, 11.14 [5.59-13.39] years; 55 girls [51%]) were included in the analyses; 40 children had MOGAD, 21 had MS, and 46 had seronegative myelitis. Longitudinally extensive lesions were very common among children with MOGAD (30 of 40 children [75%]), less common among those with seronegative myelitis (20 of 46 children [43%]), and rare in children with MS (1 of 21 children [5%]). Axial gray matter T2-hyperintensity (ie, the H-sign) was observed in 22 of 35 children (63%) with MOGAD, in 14 of 42 children (33%) with seronegative myelitis, and in none of those with MS. The presence of leptomeningeal enhancement was highly suggestive for MOGAD (22 of 32 children [69%] with MOGAD vs 10 of 38 children [26%] with seronegative myelitis and 1 of 15 children [7%] with MS). Children with MOGAD were more likely to have complete lesion resolution on serial images (14 of 21 children [67%]) compared with those with MS (0 of 13 children). CONCLUSIONS AND RELEVANCE These findings suggest that several features may help identify children at presentation who are more likely to have myelitis associated with MOGAD. Prominent involvement of gray matter and leptomeningeal enhancement are common in pediatric MOGAD, although the pathological underpinning of these observations requires further study.
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Affiliation(s)
- Giulia Fadda
- Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Cesar A. Alves
- Division of Neuroradiology, Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Julia O’Mahony
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Denise A. Castro
- Department of Diagnostic Radiology, Queen’s University, Kingston, Ontario, Canada
| | - E. Ann Yeh
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Ruth Ann Marrie
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Douglas L. Arnold
- Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Patrick Waters
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Amit Bar-Or
- Center for Neuroinflammation and Neurotherapeutics, Multiple Sclerosis Division, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Arastoo Vossough
- Division of Neuroradiology, Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brenda Banwell
- Division of Child Neurology, Department of Neurology, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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14
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Abstract
Spinal cord diseases in pediatric patients are highly variable in terms of presentation, pathology, and prognosis. Not only do they differ with respect to each other but so too with their adult equivalents. Some of the most common diseases are autoimmune (ie, multiple sclerosis, acute disseminated encephalomyelitis, and acute transverse myelitis), congenital (ie, dysraphism with spina bifida, split cord malformation, and tethered cord syndrome), tumor (ie, juvenile pilocytic astrocytoma, ependymoma, and hem-angioblastoma), and vascular (ie, cavernous malformations, arteriovenous malformations, and dural arteriovenous fistulas) in nature. These each require their own niche treatment paradigm and prognosis. Furthermore, presentation of different spinal cord diseases in children can be difficult to discern without epidemiologic and imaging data. Interpretation of these data is crucial to facilitating a timely and accurate diagnosis. Correspondingly, the aim of this review was to highlight the most pertinent features of the most common spinal cord diseases in the pediatric population.
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Affiliation(s)
- Victor M Lu
- Department of Neurological Surgery, Nicklaus Children's Hospital, Miami, FL.,Department of Neurological Surgery, University of Miami, Miami, FL
| | - Toba N Niazi
- Department of Neurological Surgery, Nicklaus Children's Hospital, Miami, FL.,Department of Neurological Surgery, University of Miami, Miami, FL
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15
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Chong PF, Torisu H, Yasumoto S, Okumura A, Mori H, Sato T, Kimura J, Ohga S, Tanaka-Taya K, Kira R. Clinical and electrophysiological features of acute flaccid myelitis: A national cohort study. Clin Neurophysiol 2021; 132:2456-2463. [PMID: 34454273 DOI: 10.1016/j.clinph.2021.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 07/06/2021] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To summarize the neurophysiological properties of acute flaccid myelitis (AFM) and evaluate limb-based motor outcomes. METHODS Nerve conduction studies (NCS) in 49 patients (21 females, 28 males; median age = 52 m) with AFM (median = 7 d after onset; range 1-122 d) were reviewed. Neurophysiological findings, together with treatment and prognosis, and neurophysiology-neuroimaging correlations were analyzed. RESULTS The findings indicated that 64% of paralytic limbs during the acute stage (≤14 d after onset) showed diminished or absent compound muscle action potentials (CMAPs), 79% showed normal motor nerve conduction velocities, 55% showed decreased persistence or absent F-waves, and 95% showed normal sensory nerve conduction velocities. The rate of CMAP abnormalities increased from 41% on days 1-2 to 83% on days 13-14. The reduction in CMAP amplitude was correlated with weaker muscle strength at both the peak neurological deficit and the last follow-up. The baseline limb-based muscle strength at nadir and anterior horn-localized magnetic resonance imaging lesions at recovery stage (>14 d) were strong predictors of outcome at the last follow-up. CONCLUSIONS AFM typically shows neurophysiological features of neuronopathy. SIGNIFICANCE NCS is probably useful in the diagnosis and evaluation of AFM.
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Affiliation(s)
- Pin Fee Chong
- Department of Pediatric Neurology, Fukuoka Children's Hospital, Fukuoka, Japan; Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroyuki Torisu
- Section of Pediatrics, Department of Medicine, Fukuoka Dental College, Fukuoka, Japan
| | - Sawa Yasumoto
- Medical Education Center, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Akihisa Okumura
- Department of Pediatrics, Aichi Medical University, Nagakute, Aichi, Japan
| | - Harushi Mori
- Department of Radiology, Jichi Medical University, Tochigi, Japan
| | - Tatsuharu Sato
- Department of Pediatrics, Nagasaki University Hospital, Nagasaki, Japan
| | - Jun Kimura
- Division of Clinical Electrophysiology, Department of Neurology, University of Iowa Health Care, Iowa City, IA, USA
| | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keiko Tanaka-Taya
- Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - Ryutaro Kira
- Department of Pediatric Neurology, Fukuoka Children's Hospital, Fukuoka, Japan.
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16
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Weber EL, Werner JM, Johnson MB, Kim G, Tiongson E, Ramos-Platt L, Seruya M. Characteristics of Upper Extremity Recovery in Acute Flaccid Myelitis: A Case Series. Plast Reconstr Surg 2021; 147:645-655. [PMID: 33009334 DOI: 10.1097/prs.0000000000007583] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Clinical characteristics and timing associated with nonsurgical recovery of upper extremity function in acute flaccid myelitis are unknown. METHODS A single-institution retrospective case series was analyzed to describe clinical features of acute flaccid myelitis diagnosed between October of 2013 and December of 2016. Patients were consecutively sampled children with a diagnosis of acute flaccid myelitis who were referred to a hand surgeon. Patient factors and initial severity of paralysis were compared with upper extremity muscle strength outcomes using the Medical Research Council scale every 3 months up to 18 months after onset. RESULTS Twenty-two patients with acute flaccid myelitis (aged 2 to 16 years) were studied. Proximal upper extremity musculature was more frequently and severely affected, with 56 percent of patients affected bilaterally. Functional recovery of all muscle groups (≥M3) in an individual limb was observed in 43 percent of upper extremities within 3 months. Additional complete limb recovery to greater than or equal to M3 after 3 months was rarely observed. Extraplexal paralysis, including spinal accessory (72 percent), glossopharyngeal/hypoglossal (28 percent), lower extremity (28 percent), facial (22 percent), and phrenic nerves (17 percent), was correlated with greater severity of upper extremity paralysis and decreased spontaneous recovery. There was no correlation between severity of paralysis or recovery and patient characteristics, including age, sex, comorbidities, prodromal symptoms, or time to paralysis. CONCLUSIONS Spontaneous functional limb recovery, if present, occurred early, within 3 months of the onset of paralysis. The authors recommend that patients without signs of early recovery warrant consideration for early surgical intervention and referral to a hand surgeon or other specialist in peripheral nerve injury. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
- Erin L Weber
- From the Keck School of Medicine, University of Southern California; and the Children's Hospital Los Angeles
| | - Julie M Werner
- From the Keck School of Medicine, University of Southern California; and the Children's Hospital Los Angeles
| | - Maxwell B Johnson
- From the Keck School of Medicine, University of Southern California; and the Children's Hospital Los Angeles
| | - Gina Kim
- From the Keck School of Medicine, University of Southern California; and the Children's Hospital Los Angeles
| | - Emmanuelle Tiongson
- From the Keck School of Medicine, University of Southern California; and the Children's Hospital Los Angeles
| | - Leigh Ramos-Platt
- From the Keck School of Medicine, University of Southern California; and the Children's Hospital Los Angeles
| | - Mitchel Seruya
- From the Keck School of Medicine, University of Southern California; and the Children's Hospital Los Angeles
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17
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McEntire CR, Dowd RS, Orru' E, David C, Small JE, Cervantes-Arslanian A, Lerner DP. Acute Myelopathy: Vascular and Infectious Diseases. Neurol Clin 2021; 39:489-512. [PMID: 33896530 DOI: 10.1016/j.ncl.2021.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Vascular and infectious causes are rare but important causes of spinal cord injury. High suspicion for these processes is necessary, as symptoms may progress over hours to days, resulting in delayed presentation and diagnosis and worse outcomes. History and clinical examination findings can assist with localization of the affected vascular territory and spinal level, which will assist with focusing spinal imaging. Open and/or endovascular surgical management depends on the associated vascular abnormality. Infectious myelopathy treatment consists of targeted antimicrobial therapy when possible, infectious source control, and again, close monitoring for systemic complications.
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Affiliation(s)
- Caleb R McEntire
- Department of Neurology, Massachusetts General Hospital and Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard S Dowd
- Department of Neurosurgery, Tufts University School of Medicine, Boston, MA 02111, USA
| | - Emanuele Orru'
- Department of Radiology, Neurointerventional Radiology Division, Lahey Hospital and Medical Center, Burlington, MA 01805, USA
| | - Carlos David
- Department of Neurosurgery, Tufts University School of Medicine, Boston, MA 02111, USA; Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington, MA 01805, USA
| | - Juan E Small
- Department of Radiology, Neuroradiology Section, Lahey Hospital and Medical Center, Burlington, MA 01805, USA
| | | | - David P Lerner
- Division of Neurology, Lahey Hospital and Medical Center, Burlington, MA 01805, USA; Department of Neurology, Tufts University School of Medicine, Boston, MA 02111, USA.
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18
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Abstract
Acute flaccid myelitis (AFM) is an incompletely understood neurologic disorder occurring in epidemic fashion causing weakness ranging from mild paresis to devastating paralysis in children and some adults. This article reviews the case definition of AFM as well as its epidemiology and association with enteroviral infection. The clinical presentation, diagnostic investigation with particular attention to electrodiagnostics, acute management, and surgical options are described. Clinical outcomes and considerations for acute and long-term rehabilitation management are discussed extensively based on review of current literature, highlighting avenues for further study.
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Affiliation(s)
- William Ide
- Department of Pediatric Rehabilitation, Kennedy Krieger Institute, 707 North Broadway, Ste. 232, Baltimore, MD 21205, USA; Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine
| | - Michelle Melicosta
- Department of Pediatric Rehabilitation, Kennedy Krieger Institute, 707 North Broadway, Ste. 232, Baltimore, MD 21205, USA; Department of Pediatrics, Johns Hopkins University School of Medicine
| | - Melissa K Trovato
- Department of Pediatric Rehabilitation, Kennedy Krieger Institute, 707 North Broadway, Ste. 232, Baltimore, MD 21205, USA; Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine.
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19
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Vawter-Lee M, Peariso K, Frey M, Bolikal P, Schaffzin JK, Schwentker A, O'Brien WT, Zamor R, Kerrey BT. Acute Flaccid Myelitis: A Multidisciplinary Protocol to Optimize Diagnosis and Evaluation. J Child Neurol 2021; 36:421-431. [PMID: 33258719 DOI: 10.1177/0883073820975230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Acute flaccid myelitis is an emerging neurologic disease, first described in 2014 and predominantly affecting young children. Acute flaccid myelitis cases tend to spike every 2 years, in the late summer to fall, and the next peak is expected in 2020. The diagnosis of acute flaccid myelitis is often delayed, leading to suboptimal evaluation, including incomplete laboratory assessment. Acute and chronic morbidity are high, and a standardized, multidisciplinary approach to evaluation and treatment is essential to optimizing outcomes. In a review of acute flaccid myelitis patients treated in 2018 at our institution, we noted considerable variability in days to presentation, evaluation, and treatment. In response, the authors developed a protocol for the evaluation and management of pediatric patients suspected of having acute flaccid myelitis. The protocol was developed using local experience/case review, expert consensus, and the relevant literature. The protocol spans the spectrum of care, from initial evaluation in a primary care or emergency setting, to acute hospital management and evaluation and long-term inpatient and rehabilitation settings. The purpose of this report is both to share the findings from our 2018 case review and to disseminate our acute flaccid myelitis protocol. Our hope is that publication of our protocol will both inform the development of a standardized approach to acute flaccid myelitis and to encourage other centers to form a multidisciplinary acute flaccid myelitis team to provide expert care throughout the disease process, from presentation to recovery.
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Affiliation(s)
- Marissa Vawter-Lee
- 2518University of Cincinnati, College of Medicine, Cincinnati, OH, USA.,Division of Neurology, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Katrina Peariso
- 2518University of Cincinnati, College of Medicine, Cincinnati, OH, USA.,Division of Neurology, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mary Frey
- Division of Emergency Medicine, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Priya Bolikal
- 2518University of Cincinnati, College of Medicine, Cincinnati, OH, USA.,Division of Physical Medicine and Rehabilitation, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Joshua K Schaffzin
- 2518University of Cincinnati, College of Medicine, Cincinnati, OH, USA.,Division of Infectious Diseases, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ann Schwentker
- 2518University of Cincinnati, College of Medicine, Cincinnati, OH, USA.,Division of Pediatric Plastic and Craniofacial Surgery, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - William T O'Brien
- 2518University of Cincinnati, College of Medicine, Cincinnati, OH, USA.,Division of Neuroradiology, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ronine Zamor
- 2518University of Cincinnati, College of Medicine, Cincinnati, OH, USA.,Division of Emergency Medicine, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Benjamin T Kerrey
- 2518University of Cincinnati, College of Medicine, Cincinnati, OH, USA.,Division of Emergency Medicine, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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20
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Haddad AF, Hofmann JW, Oh T, Jacques L, Yu G, Chiu C, Nolan A, Strober J, Gupta N. Pathologic Findings Associated With a Case of Acute Flaccid Myelitis. J Neuropathol Exp Neurol 2021; 80:484-487. [PMID: 33870421 DOI: 10.1093/jnen/nlab031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Alexander F Haddad
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Jeffrey W Hofmann
- Department of Pathology, University of California, San Francisco, California, USA
| | - Taemin Oh
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Line Jacques
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Guixia Yu
- Department of Laboratory Medicine, University of California, San Francisco, California, USA
| | - Charles Chiu
- Department of Laboratory Medicine, University of California, San Francisco, California, USA
| | - Amber Nolan
- Department of Pathology, Univeristy of Washington, Seattle, Washington, USA
| | - Jonathan Strober
- Department of Neurology, University of California, San Francisco, California, USA.,Division of Pediatric Neurology, UCSF Benioff Children's Hospital, San Francisco, California, USA
| | - Nalin Gupta
- Department of Neurological Surgery, University of California, San Francisco, California, USA.,Division of Pediatric Neurosurgery, UCSF Benioff Children's Hospital, San Francisco, California, USA
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21
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Chong PF, Kira R, Torisu H, Yasumoto S, Okumura A, Mori H, Tanaka-Taya K. Three-Year Longitudinal Motor Function and Disability Level of Acute Flaccid Myelitis. Pediatr Neurol 2021; 116:14-19. [PMID: 33388543 DOI: 10.1016/j.pediatrneurol.2020.11.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/23/2020] [Accepted: 11/27/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND We summarize the long-term motor outcome and disability level in a cluster of pediatric patients with acute flaccid myelitis (AFM) associated with the enterovirus D68 outbreak in 2015. METHODS This is a nationwide follow-up questionnaire analysis study. Clinical data including the motor function (manual muscle strength test) and other neurological symptoms were collected at the acute (nadir), recovery (six months), and chronic (three years) stages. We use the Barthel index, which measures 10 variables describing activity of daily living and mobility to assess the disability level. RESULTS Clinical data of 33 patients with AFM (13 females, 20 males; median age = 4.1 years) were available. Among patients with tetraplegia or triplegia, paraplegia, and monoplegia at the acute stage, two of seven, four of thirteen, and two of thirteen exhibited complete recovery without paralysis; of those five of seven, eight of thirteen, and two of thirteen showed improvement with lesser limb involvement at the chronic stage, respectively. Nine patients (27%) demonstrated improvement at the recovery-to-chronic period. All six patients with positive isolation of enterovirus D68 from biological samples at the acute stage showed persistent motor deficits. Other neurological findings had better prognosis than motor weakness. Better Barthel index score at the chronic stage was observed (P < 0.001; median difference [95% confidence interval], 53 [40 to 63]), implying an improved disability level even in patients with persistent motor deficits. CONCLUSIONS AFM has a high rate of persistent motor deficits showing one- to two-limb paralysis. Disability level of patients with AFM, however, generally improved at the three-year time point.
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Affiliation(s)
- Pin Fee Chong
- Department of Pediatric Neurology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Ryutaro Kira
- Department of Pediatric Neurology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Hiroyuki Torisu
- Department of Pediatrics, Fukuoka Dental College Medical and Dental Hospital, Fukuoka, Japan
| | - Sawa Yasumoto
- Medical Education Center, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Akihisa Okumura
- Department of Pediatrics, Aichi Medical University, Nagakute, Aichi, Japan
| | - Harushi Mori
- Department of Radiology, Graduate School and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Keiko Tanaka-Taya
- Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo, Japan.
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22
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Murphy OC, Messacar K, Benson L, Bove R, Carpenter JL, Crawford T, Dean J, DeBiasi R, Desai J, Elrick MJ, Farias-Moeller R, Gombolay GY, Greenberg B, Harmelink M, Hong S, Hopkins SE, Oleszek J, Otten C, Sadowsky CL, Schreiner TL, Thakur KT, Van Haren K, Carballo CM, Chong PF, Fall A, Gowda VK, Helfferich J, Kira R, Lim M, Lopez EL, Wells EM, Yeh EA, Pardo CA. Acute flaccid myelitis: cause, diagnosis, and management. Lancet 2021; 397:334-346. [PMID: 33357469 PMCID: PMC7909727 DOI: 10.1016/s0140-6736(20)32723-9] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 09/15/2020] [Accepted: 09/17/2020] [Indexed: 12/20/2022]
Abstract
Acute flaccid myelitis (AFM) is a disabling, polio-like illness mainly affecting children. Outbreaks of AFM have occurred across multiple global regions since 2012, and the disease appears to be caused by non-polio enterovirus infection, posing a major public health challenge. The clinical presentation of flaccid and often profound muscle weakness (which can invoke respiratory failure and other critical complications) can mimic several other acute neurological illnesses. There is no single sensitive and specific test for AFM, and the diagnosis relies on identification of several important clinical, neuroimaging, and cerebrospinal fluid characteristics. Following the acute phase of AFM, patients typically have substantial residual disability and unique long-term rehabilitation needs. In this Review we describe the epidemiology, clinical features, course, and outcomes of AFM to help to guide diagnosis, management, and rehabilitation. Future research directions include further studies evaluating host and pathogen factors, including investigations into genetic, viral, and immunological features of affected patients, host-virus interactions, and investigations of targeted therapeutic approaches to improve the long-term outcomes in this population.
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Affiliation(s)
- Olwen C Murphy
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kevin Messacar
- Department of Pediatric Infectious Diseases, Children's Hospital Colorado, Aurora, CO, USA
| | - Leslie Benson
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Riley Bove
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Jessica L Carpenter
- Department of Neurology, Children's National Health System, Washington, DC, USA
| | - Thomas Crawford
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Janet Dean
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Roberta DeBiasi
- Department of Pediatric Infectious Diseases, Children's National Health System, Washington, DC, USA
| | - Jay Desai
- Division of Neurology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Matthew J Elrick
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Raquel Farias-Moeller
- Department of Neurology, Children's Hospital of Wisconsin and the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Grace Y Gombolay
- Department of Neurology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Benjamin Greenberg
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Matthew Harmelink
- Department of Neurology, Children's Hospital of Wisconsin and the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sue Hong
- Division of Pediatric Critical Care, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sarah E Hopkins
- Division of Neurology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joyce Oleszek
- Department of Physical Medicine and Rehabilitation, Children's Hospital Colorado, Aurora, CO, USA
| | - Catherine Otten
- Department of Pediatric Neurology, Seattle Children's Hospital, Seattle, WA, USA
| | - Cristina L Sadowsky
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA; International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Teri L Schreiner
- Department of Child Neurology, Children's Hospital Colorado, Aurora, CO, USA
| | - Kiran T Thakur
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Keith Van Haren
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Carolina M Carballo
- Department of Infectious Diseases, Hospital de Niños "Ricardo Gutiérrez", Buenos Aires, Argentina
| | - Pin Fee Chong
- Department of Pediatric Neurology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Amary Fall
- Institut Pasteur de Dakar, Département de Virologie, Dakar, Senegal
| | - Vykuntaraju K Gowda
- Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India
| | - Jelte Helfferich
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Ryutaro Kira
- Department of Pediatric Neurology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Ming Lim
- Children's Neuroscience Center, Evelina London Children's Hospital, Guy's and St Thomas' NHS Trust, and Faculty of Life Sciences, King's College, London, UK
| | - Eduardo L Lopez
- Department of Infectious Diseases, Hospital de Niños "Ricardo Gutiérrez", Buenos Aires, Argentina
| | - Elizabeth M Wells
- Department of Neurology, Children's National Health System, Washington, DC, USA
| | - E Ann Yeh
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada
| | - Carlos A Pardo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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23
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Ünver O, Türkdoğan D, Güler S, Kipoğlu O, Güngör M, Paketçi C, Çarman KB, Öztürk G, Genç HM, Özkan M, Dündar NO, Işık U, Karatoprak E, Kılıç B, Özkale M, Bayram E, Yarar C, Sözen HG, Sağer G, Güneş AS, Kahraman Koytak P, Karadağ Saygı E, Ekinci G, Saltık S, Çalışkan M, Kara B, Yiş U, Aydınlı N. Acute flaccid myelitis outbreak through 2016-2018: A multicenter experience from Turkey. Eur J Paediatr Neurol 2021; 30:113-120. [PMID: 33218883 DOI: 10.1016/j.ejpn.2020.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/04/2020] [Accepted: 10/30/2020] [Indexed: 10/23/2022]
Abstract
AIM We aim to describe the demographic characteristics, etiology, neurophysiology, imaging findings, treatment, prognosis, and prognostic factors of acute flaccid myelitis. METHODS The clinical data, laboratory test and, magnetic resonance imaging (MRI) results of pediatric patients diagnosed with acute flaccid myelitis according to the Centers for Disease Control criteria between August 1, 2016, and December 31, 2018, from 13 centers in Turkey were reviewed. RESULTS Of the 34 cases identified, 31 were confirmed (91.2%). Eighteen patients (55.9%) were boys. The median patient age was 4 years (interquartile range 2.5-6.9 years). Most of the patients were admitted in 2018 (n = 27). A preceding history of a febrile illness was reported in all patients, with a median of 4 days (interquartile range 3-7 days) before symptom onset. Thirty-one patients had T2 hyperintensity on spinal MRI, and 18 patients had cerebrospinal fluid pleocytosis. The most common infectious agents were entero/rhinoviruses (n = 5) in respiratory specimens. All patients except one received immunotherapy either alone or in combination. Among 27 patients with follow-up data 24 had persistent weakness. Involvement of four limbs together with an abnormal brain MRI at onset were associated with a poor prognosis. CONCLUSION The number of patients with acute flaccid myelitis increased since 2012, spiking with every 2-year interval, largely in the pediatric population. The median age decreases with every outbreak. Clinicians should be aware of the clinical picture for early collection of specimens and early start of rehabilitation programs. Further studies are needed to better characterize the etiology, pathogenesis, risk factors, and treatment of this rare condition.
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Affiliation(s)
- Olcay Ünver
- Division of Pediatric Neurology, Department of Pediatrics, Marmara University School of Medicine, İstanbul, Turkey.
| | - Dilşad Türkdoğan
- Division of Pediatric Neurology, Department of Pediatrics, Marmara University School of Medicine, İstanbul, Turkey
| | - Serhat Güler
- Division of Pediatric Neurology, Department of Pediatrics, İstanbul University Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Osman Kipoğlu
- Division of Pediatric Neurology, Department of Pediatrics, İstanbul University Faculty of Medicine, İstanbul, Turkey
| | - Mesut Güngör
- Division of Pediatric Neurology, Department of Pediatrics, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Cem Paketçi
- Division of Pediatric Neurology, Department of Pediatrics, Dokuz Eylül University Medical Faculty, İzmir, Turkey
| | - Kürşat Bora Çarman
- Division of Pediatric Neurology, Department of Pediatrics, Eskişehir Osmangazi University Medical Faculty, Eskişehir, Turkey
| | - Gülten Öztürk
- Division of Pediatric Neurology, Department of Pediatrics, Marmara University School of Medicine, İstanbul, Turkey
| | - Hülya Maraş Genç
- Division of Pediatric Neurology, Department of Pediatrics, Ümraniye Training and Research Hospital, İstanbul, Turkey
| | - Mehpare Özkan
- Division of Pediatric Neurology, Department of Pediatrics, Bahçeşehir University Medical Faculty, İstanbul, Turkey
| | - Nihal Olgaç Dündar
- Division of Pediatric Neurology, Department of Pediatrics, Izmir Katip Çelebi University Medical Faculty, İzmir, Turkey
| | - Uğur Işık
- Division of Pediatric Neurology, Department of Pediatrics, Acıbadem University School of Medicine, İstanbul, Turkey
| | - Elif Karatoprak
- Division of Pediatric Neurology, Department of Pediatrics, Medeniyet University School of Medicine, İstanbul, Turkey
| | - Betül Kılıç
- Division of Pediatric Neurology, Department of Pediatrics, Medipol University School of Medicine, İstanbul, Turkey
| | - Murat Özkale
- Division of Pediatric Intensive Care Unit, Department of Pediatrics, Başkent University School of Medicine, Adana, Turkey
| | - Erhan Bayram
- Division of Pediatric Neurology, Department of Pediatrics, Dokuz Eylül University Medical Faculty, İzmir, Turkey
| | - Coşkun Yarar
- Division of Pediatric Neurology, Department of Pediatrics, Eskişehir Osmangazi University Medical Faculty, Eskişehir, Turkey
| | - Hatice Gülhan Sözen
- Division of Pediatric Neurology, Department of Pediatrics, Ümraniye Training and Research Hospital, İstanbul, Turkey
| | - Güneş Sağer
- Division of Pediatric Neurology, Department of Pediatrics, Marmara University School of Medicine, İstanbul, Turkey
| | - Ayfer Sakarya Güneş
- Division of Pediatric Neurology, Department of Pediatrics, Kocaeli University School of Medicine, Kocaeli, Turkey
| | | | - Evrim Karadağ Saygı
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, İstanbul, Turkey
| | - Gazanfer Ekinci
- Department of Radiology, Yeditepe University School of Medicine, İstanbul, Turkey
| | - Sema Saltık
- Division of Pediatric Neurology, Department of Pediatrics, İstanbul University Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Mine Çalışkan
- Division of Pediatric Neurology, Department of Pediatrics, İstanbul University Faculty of Medicine, İstanbul, Turkey; İstanbul University Institute of Child Health, İstanbul, Turkey
| | - Bülent Kara
- Division of Pediatric Neurology, Department of Pediatrics, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Uluç Yiş
- Division of Pediatric Neurology, Department of Pediatrics, Dokuz Eylül University Medical Faculty, İzmir, Turkey
| | - Nur Aydınlı
- Division of Pediatric Neurology, Department of Pediatrics, İstanbul University Faculty of Medicine, İstanbul, Turkey
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24
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Werner JM, Berggren J, Kim G, Loffredo K, Pascual M, Tiongson E, Seruya M. Recommendations for Therapy following Nerve Transfer for Children with Acute Flaccid Myelitis. Phys Occup Ther Pediatr 2021; 41:209-226. [PMID: 33016189 DOI: 10.1080/01942638.2020.1822981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AIM To provide recommendations for pre- and post-operative occupational and physical therapy for children with acute flaccid myelitis (AFM). METHODS Writing panel members consisted of an interdisciplinary team of seven healthcare professionals specializing in the care of children with AFM. The panel reviewed background material on AFM, nerve transfer, and rehabilitation principles applied to pediatrics. Recommendations were prioritized if evidence was available. Where there was no known evidence to support a recommendation, this was noted. RECOMMENDATIONS Communication and coordination among interprofessional team members are vital to a comprehensive family-centered rehabilitation program. Surgical planning should include team preparation accounting for frequency, duration, and timing of treatment, as well as individual characteristics and developmental status of the child. Recommendations for pre-operative and six phases of post-operative therapy address assessment, strengthening, range of motion, orthoses, performance of functional activity, and support of the family. CONCLUSION Rehabilitation following nerve transfer in children with AFM requires interdisciplinary collaboration and a multisystem approach to assessment and treatment. As new evidence becomes available, recommendations may be revised or replaced accordingly.
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Affiliation(s)
- Julie M Werner
- Institute for Nursing and Interprofessional Research, Children's Hospital Los Angeles, Los Angeles, CA, USA.,Division of Pediatric Rehabilitation Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jamie Berggren
- Division of Pediatric Rehabilitation Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Gina Kim
- Division of Pediatric Rehabilitation Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Kimberly Loffredo
- Division of Pediatric Rehabilitation Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Marielle Pascual
- Division of Pediatric Rehabilitation Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Emmanuelle Tiongson
- Division of Neurology, Children's Hospital Los Angeles, Los Angeles, CA, USA.,Department of Pediatrics, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Mitchel Seruya
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA.,Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
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25
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Elrick MJ, Pekosz A, Duggal P. Enterovirus D68 molecular and cellular biology and pathogenesis. J Biol Chem 2021; 296:100317. [PMID: 33484714 PMCID: PMC7949111 DOI: 10.1016/j.jbc.2021.100317] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 12/13/2022] Open
Abstract
In recent years, enterovirus D68 (EV-D68) has advanced from a rarely detected respiratory virus to a widespread pathogen responsible for increasing rates of severe respiratory illness and acute flaccid myelitis (AFM) in children worldwide. In this review, we discuss the accumulating data on the molecular features of EV-D68 and place these into the context of enterovirus biology in general. We highlight similarities and differences with other enteroviruses and genetic divergence from own historical prototype strains of EV-D68. These include changes in capsid antigens, host cell receptor usage, and viral RNA metabolism collectively leading to increased virulence. Furthermore, we discuss the impact of EV-D68 infection on the biology of its host cells, and how these changes are hypothesized to contribute to motor neuron toxicity in AFM. We highlight areas in need of further research, including the identification of its primary receptor and an understanding of the pathogenic cascade leading to motor neuron injury in AFM. Finally, we discuss the epidemiology of the EV-D68 and potential therapeutic approaches.
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Affiliation(s)
- Matthew J Elrick
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
| | - Andrew Pekosz
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Priya Duggal
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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26
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Patel R, Gombolay GY, Peljovich AE, Conklin J, Blackwell LS, Howarth R, Wolf DS, Upadhyayula SR, Verma S. Acute Flaccid Myelitis: A Single Pediatric Center Experience From 2014 to 2019. J Child Neurol 2020; 35:912-917. [PMID: 32677590 DOI: 10.1177/0883073820939392] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Acute flaccid myelitis has emerged as the leading cause of acute flaccid paralysis in children. Acute flaccid myelitis leads to significant physical disability; hence, objective outcome measures to study disease severity and progression are desirable. In addition, nerve transfer to improve motor function in affected children needs further study. METHODS Retrospective study of acute flaccid myelitis subjects managed at Children's Healthcare of Atlanta from August 2014 to December 2019. Clinical, electromyography and nerve conduction study, neuropsychological functional independence (WeeFIM), and nerve transfer data were reviewed. RESULTS Fifteen children (11 boys and 4 girls) mean age 5.1±3.2 years (range 14 months to 12 years) were included. All subjects (n = 15) presented with severe asymmetric motor weakness and absent tendon reflexes. Motor nerve conduction study of the affected limbs in 93% (n = 14) showed absent or markedly reduced amplitude. Ten patients received comprehensive inpatient rehabilitation and neuropsychological evaluation. Admission and discharge WeeFIM scores showed deficits most consistent and pronounced in the domains of self-care and mobility. Multiple nerve transfer surgery was performed on 13 limbs (9 upper and 4 lower extremities) in 6 children. Postsurgery (mean duration of 10.4 ± 5.7 months) follow-up demonstrated improvement on active movement scale (AMS) in 4 subjects. CONCLUSION Acute flaccid myelitis affects school-age children with asymmetric motor weakness, absent tendon reflexes, and reduced or absent motor amplitude on nerve conduction study. Comprehensive rehabilitation and nerve transfer led to improvement in motor function on neuropsychology WeeFIM and AMS scores.
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Affiliation(s)
- Rifali Patel
- Pediatric Neurology, MercyOne, Des Moines, IA, USA
| | - Grace Y Gombolay
- Division of Pediatric Neurology, Department of Pediatrics and Neurology, 1371Emory University School of Medicine, Atlanta, GA, USA
| | - Allan E Peljovich
- The Hand and Upper Extremity Center of Georgia, Department of Orthopaedic Surgery, 1367Children's Healthcare of Atlanta, Atlanta Medical Center Orthopaedic Residency Program, Atlanta, GA, USA
| | - Jessica Conklin
- Division of Neuropsychology, 1367Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Laura S Blackwell
- Division of Neuropsychology, 1367Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Robyn Howarth
- Division of Neuropsychology, 1367Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - David S Wolf
- Division of Pediatric Neurology, Department of Pediatrics and Neurology, 1371Emory University School of Medicine, Atlanta, GA, USA
| | - Saila R Upadhyayula
- Division of Pediatric Neurology, Department of Pediatrics and Neurology, 1371Emory University School of Medicine, Atlanta, GA, USA
| | - Sumit Verma
- Division of Pediatric Neurology, Department of Pediatrics and Neurology, 1371Emory University School of Medicine, Atlanta, GA, USA
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27
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Hardy D, Hopkins S. Update on acute flaccid myelitis: recognition, reporting, aetiology and outcomes. Arch Dis Child 2020; 105:842-847. [PMID: 32041735 DOI: 10.1136/archdischild-2019-316817] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 01/08/2020] [Accepted: 01/17/2020] [Indexed: 12/31/2022]
Abstract
Acute flaccid myelitis, defined by acute flaccid limb weakness in the setting of grey matter lesions of the spinal cord, became increasingly recognised in 2014 following outbreaks in Colorado and California, temporally associated with an outbreak of enterovirus D68 respiratory disease. Since then, there have been biennial increases in late summer/early fall. A viral infectious aetiology, most likely enteroviral, is strongly suspected, but a definitive connection has yet to be established. Patients typically present with asymmetric weakness, maximal proximally, in the setting of a febrile illness. MRI demonstrates T2/FLAIR abnormalities in the central grey matter of the spinal cord, and cerebrospinal fluid typically shows a lymphocytic pleocytosis with variable elevation in protein. The weakness may be progressive over several days and involve respiratory muscles, making early recognition and close monitoring essential. Other complications in the acute period may include autonomic instability and bowel/bladder involvement. There is no clear recommended treatment at this time, although intravenous immunoglobulin, steroids and plasma exchange have been used. Intensive therapies and rehab services have shown benefit in maximising function, and surgical interventions may be considered in cases without optimal response to therapies. Close attention should also be paid to psychosocial factors. Prognosis is generally guarded, and additional factors that predict final outcome, including host factors and treatment effects, have yet to be elucidated. Multicentre collaborative efforts will be required to provide answers about this rare but serious disorder.
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Affiliation(s)
- Duriel Hardy
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sarah Hopkins
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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28
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Kidd S, Lopez AS, Konopka-Anstadt JL, Nix WA, Routh JA, Oberste MS. Enterovirus D68-Associated Acute Flaccid Myelitis, United States, 2020. Emerg Infect Dis 2020; 26. [PMID: 32833616 PMCID: PMC7510737 DOI: 10.3201/eid2610.201630] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Acute flaccid myelitis (AFM) is a serious neurologic condition that causes limb weakness or paralysis in previously healthy children. Since clusters of cases were first reported in 2014, nationwide surveillance has demonstrated sharp increases in AFM cases in the United States every 2 years, most occurring during late summer and early fall. Given this current biennial pattern, another peak AFM season is expected during fall 2020 in the United States. Scientific understanding of the etiology and the factors driving the biennial increases in AFM has advanced rapidly in the past few years, although areas of uncertainty remain. The Centers for Disease Control and Prevention and AFM partners are focused on answering key questions about AFM epidemiology and mechanisms of disease. This article summarizes the current understanding of AFM etiology and outlines priorities for surveillance and research as we prepare for a likely surge in cases in 2020.
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29
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Gong L, Wang Y, Zhang W, Chen C, Yang X, Xu L, Zhao C, Jiang L, Yuan Z, Xia Z, Jiang P, Ge Q, Yan J, Sun Y, Chen Y, Zhao Z, Zhang Y, Gao F. Acute Flaccid Myelitis in Children in Zhejiang Province, China. Front Neurol 2020; 11:360. [PMID: 32528396 PMCID: PMC7256184 DOI: 10.3389/fneur.2020.00360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/14/2020] [Indexed: 01/16/2023] Open
Abstract
In July-December 2018, an outbreak of polio-like acute flaccid myelitis (AFM) occurred in Zhejiang province, China. Enterovirus (EV)-D68 infection has been reported to be associated with AFM. This study aimed to investigate the clinical presentation, laboratory findings, and outcomes of AFM patients. We investigated the clinical and virologic information regarding the AFM patients, and real-time PCR, sequencing, and phylogenetic analysis were used to investigate the cause of AFM. Eighteen cases met the definition of AFM, with a median age of 4.05 years (range, 0.9-9 years), and nine (50%) were EV-D68 positive. Symptoms included acute flaccid limb weakness and cranial nerve dysfunction. On magnetic resonance imaging, 11 (61.1%) patients had spinal gray matter abnormalities. Electromyography results of 16 out of 17 patients (94.1%) were abnormal. Cerebrospinal fluid (CSF) pleocytosis was common (94.4%), while CSF protein concentration was normal in all patients. There was little improvement after early aggressive therapy. Phylogenetic analysis revealed that EV-D68 subclade B3 was the predominant lineage circulating in Zhejiang province in 2018.
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Affiliation(s)
- Liming Gong
- Zhejiang Provincial Centre for Disease Control and Prevention, Hangzhou, China
| | - Yilong Wang
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China.,Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Weiqing Zhang
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China.,Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Chen Chen
- Zhejiang Provincial Centre for Disease Control and Prevention, Hangzhou, China
| | - Xinghui Yang
- Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China.,Department of Radiology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Lu Xu
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China.,Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Congying Zhao
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China.,Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Lihua Jiang
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China.,Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Zhefeng Yuan
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China.,Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Zhezhi Xia
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China.,Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Peifang Jiang
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China.,Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Qiong Ge
- Zhejiang Provincial Centre for Disease Control and Prevention, Hangzhou, China
| | - Juying Yan
- Zhejiang Provincial Centre for Disease Control and Prevention, Hangzhou, China
| | - Yi Sun
- Zhejiang Provincial Centre for Disease Control and Prevention, Hangzhou, China
| | - Yin Chen
- Zhejiang Provincial Centre for Disease Control and Prevention, Hangzhou, China
| | - Zhengyan Zhao
- Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Yanjun Zhang
- Zhejiang Provincial Centre for Disease Control and Prevention, Hangzhou, China
| | - Feng Gao
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China.,Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
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30
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Bove R, Rowles W, Carleton M, Olivera E, Sheehan M, Werdal HP, Scott R, Axton L, Benson L. Unmet Needs in the Evaluation, Treatment, and Recovery for 167 Children Affected by Acute Flaccid Myelitis Reported by Parents Through Social Media. Pediatr Neurol 2020; 102:20-27. [PMID: 31630913 DOI: 10.1016/j.pediatrneurol.2019.08.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/13/2019] [Accepted: 08/17/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND We aimed to characterize the outcomes of 167 children affected by acute flaccid myelitis by leveraging the power of social media. METHODS Members of a closed social media (Facebook) group were invited to participate in an anonymous online survey. Descriptive statistics were applied to quantitative responses, and free-text responses were grouped into themes using a grounded theory approach. RESULTS Caregivers provided information about 167 affected children; 77% were at least 6 months since onset. Clinical features matched those of larger published case series (e.g., walking impairment in 76.7%, intravenous immunoglobulin treatment in 80.8%; 28.2% tested positive for Enterovirus D68; 17% children had asthma before acute flaccid myelitis onset). Mean duration of initial hospitalization was 49.1 (S.D., 74.0) days, and of initial inpatient rehabilitation was 42.3 (S.D., 67.6) days. Among challenges, parents frequently reported delays in diagnosis, including lack of neurological examination at initial medical evaluation for weakness. Other challenges included familial and professional impact of protracted hospitalizations, uncertainty about cause or prognosis of acute flaccid myelitis, and the dynamic nature of care needs in growing children. The social media group played a critical role not only for social support but also for dissemination of rehabilitation approaches and of networks of expert clinicians. CONCLUSIONS Children with acute flaccid myelitis have persistent and dynamic deficits, but many continue to show ongoing functional improvements beyond the initial expected window of recovery. In an emerging disease paralyzing young children, social media can strengthen knowledge networks and focus on rehabilitation.
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Affiliation(s)
- Riley Bove
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California.
| | - William Rowles
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California
| | - Mia Carleton
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California
| | - Erin Olivera
- Ventura County Medical Center, Simi Valley, California
| | | | | | | | | | - Leslie Benson
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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32
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Leonhard SE, Mandarakas MR, Gondim FAA, Bateman K, Ferreira MLB, Cornblath DR, van Doorn PA, Dourado ME, Hughes RAC, Islam B, Kusunoki S, Pardo CA, Reisin R, Sejvar JJ, Shahrizaila N, Soares C, Umapathi T, Wang Y, Yiu EM, Willison HJ, Jacobs BC. Diagnosis and management of Guillain-Barré syndrome in ten steps. Nat Rev Neurol 2019; 15:671-683. [PMID: 31541214 PMCID: PMC6821638 DOI: 10.1038/s41582-019-0250-9] [Citation(s) in RCA: 401] [Impact Index Per Article: 80.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2019] [Indexed: 12/20/2022]
Abstract
Guillain-Barré syndrome (GBS) is a rare, but potentially fatal, immune-mediated disease of the peripheral nerves and nerve roots that is usually triggered by infections. The incidence of GBS can therefore increase during outbreaks of infectious diseases, as was seen during the Zika virus epidemics in 2013 in French Polynesia and 2015 in Latin America. Diagnosis and management of GBS can be complicated as its clinical presentation and disease course are heterogeneous, and no international clinical guidelines are currently available. To support clinicians, especially in the context of an outbreak, we have developed a globally applicable guideline for the diagnosis and management of GBS. The guideline is based on current literature and expert consensus, and has a ten-step structure to facilitate its use in clinical practice. We first provide an introduction to the diagnostic criteria, clinical variants and differential diagnoses of GBS. The ten steps then cover early recognition and diagnosis of GBS, admission to the intensive care unit, treatment indication and selection, monitoring and treatment of disease progression, prediction of clinical course and outcome, and management of complications and sequelae.
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Affiliation(s)
- Sonja E Leonhard
- Department of Neurology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Melissa R Mandarakas
- Department of Neurology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Francisco A A Gondim
- Hospital Universitário Walter Cantidio, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil
| | - Kathleen Bateman
- Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Maria L B Ferreira
- Department of Neurology, Hospital da Restauração, Recife, Pernambuco, Brazil
| | - David R Cornblath
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pieter A van Doorn
- Department of Neurology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Mario E Dourado
- Department of Integrative Medicine, Hospital Universitário Onofre Lopes, Universidade Federal do Rio Grande do Norte, Natal, Brazil
| | - Richard A C Hughes
- UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Badrul Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | - Carlos A Pardo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - James J Sejvar
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Cristiane Soares
- Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil
| | | | - Yuzhong Wang
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining, Shandong, China
| | - Eppie M Yiu
- Department of Neurology, The Royal Children's Hospital Melbourne, Melbourne, VIC, Australia
- Neurosciences Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Hugh J Willison
- College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Bart C Jacobs
- Department of Neurology, Erasmus University Medical Center, Rotterdam, Netherlands.
- Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.
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Blackburn J, Le Saux N. Acute flaccid myelitis associated with enterovirus D68: An emerging infectious disease. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2019; 4:131-135. [PMID: 36340649 PMCID: PMC9603033 DOI: 10.3138/jammi.2019-03-28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 03/28/2019] [Indexed: 06/16/2023]
Affiliation(s)
- Julie Blackburn
- University of Ottawa, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Université de Montréal, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Nicole Le Saux
- University of Ottawa, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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Matsuo K, Koga M, Shiraishi M, Hasegawa M, Kanda T, Fukusako T. [A case of severe acute flaccid myelitis requiring continuous mechanical ventilation]. Rinsho Shinkeigaku 2019; 59:579-583. [PMID: 31474644 DOI: 10.5692/clinicalneurol.cn-001319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Many cases of acute flaccid paralysis occurred during an enterovirus D68 (EV-D68) outbreak in North America in the fall of 2014, and this epidemic has been newly defined as a distinct disease entity named acute flaccid myelitis (AFM). This disease entity is relatively popular among pediatricians, whereas it remains little-known among neurologists in Japan. We reported a 7-year-old girl with AFM, in whom severe limb weakness and respiratory failure developed five days after appearance of respiratory symptoms. Clinical features of our case were mimicked by those of acute axonal motor neuropathy at early stage of the disease, and this resulted in delayed diagnosis of AFM. DNA of EV-D68 was not detected. There are few reported cases of severe AFM, in which artificial ventilation is needed for a long time including both acute and recovery phases of the illness, and functional prognosis of AFM is discussed by literature.
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Affiliation(s)
- Kinya Matsuo
- Department of Neurology, Yamaguchi Prefectural Grand Medical Center.,Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine
| | - Michiaki Koga
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine
| | | | - Masanari Hasegawa
- Department of Pediatrics, Yamaguchi Prefectural Grand Medical Center
| | - Takashi Kanda
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine
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Reply to "Poor clinico-radiological correlation: A hallmark of acute flaccid myelitis". Brain Dev 2019; 41:482. [PMID: 30871736 DOI: 10.1016/j.braindev.2019.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 02/20/2019] [Indexed: 11/20/2022]
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Cramer N, Munjal N, Ware D, Ramgopal S, Simon D, Freeman MC, Michaels MG, Stem C, Thakkar K, Williams JV, Panigrahy A, Neville DNW, Owusu-Ansah S. New Cluster of Acute Flaccid Myelitis in Western Pennsylvania. Ann Emerg Med 2019; 74:503-508. [PMID: 30826069 DOI: 10.1016/j.annemergmed.2019.01.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Indexed: 01/17/2023]
Abstract
Acute flaccid myelitis is a debilitating illness characterized by acute onset of limb weakness, with one or more spinal segments displaying magnetic resonance imaging-confirmed gray matter lesions. Since the first outbreak in 2014, tracking by the Centers for Disease Control and Prevention has demonstrated biennial epidemics in the United States, with a current outbreak occurring in 2018. The cases of 3 children with acute flaccid myelitis who were initially thought to have common nonneurologic diagnoses are presented. Emergency physicians need to be vigilant to recognize the subtleties of acute flaccid myelitis because the illness progression is rapid and therapy is nuanced.
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Affiliation(s)
- Natan Cramer
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Neil Munjal
- Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Sriram Ramgopal
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Dennis Simon
- Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Megan C Freeman
- Department of Pediatrics, Division of Pediatric Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Marian G Michaels
- Department of Pediatrics, Division of Pediatric Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Christopher Stem
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Kavita Thakkar
- Department of Pediatrics, Division of Child Neurology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - John V Williams
- Department of Pediatrics, Division of Pediatric Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Ashok Panigrahy
- Department of Pediatric Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Desiree N W Neville
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Sylvia Owusu-Ansah
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.
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Acute flaccid myelitis and enterovirus D68: lessons from the past and present. Eur J Pediatr 2019; 178:1305-1315. [PMID: 31338675 PMCID: PMC6694036 DOI: 10.1007/s00431-019-03435-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/11/2019] [Accepted: 07/16/2019] [Indexed: 12/20/2022]
Abstract
Acute flaccid myelitis is characterized by the combination of acute flaccid paralysis and a spinal cord lesion largely restricted to the gray matter on magnetic resonance imaging. The term acute flaccid myelitis was introduced in 2014 after the upsurge of pediatric cases in the USA with enterovirus D68 infection. Since then, an increasing number of cases have been reported worldwide. Whereas the terminology is new, the clinical syndrome has been recognized in the past in association with several other neurotropic viruses such as poliovirus.Conclusion: This review presents the current knowledge on acute flaccid myelitis with respect to the clinical presentation and its differential diagnosis with Guillain-Barré syndrome and acute transverse myelitis. We also discuss the association with enterovirus D68 and the presumed pathophysiological mechanism of this infection causing anterior horn cell damage. Sharing clinical knowledge and insights from basic research is needed to make progress in diagnosis, treatment, and prevention of this new polio-like disease. What is Known: • Acute flaccid myelitis (AFM) is a polio-like condition characterized by rapid progressive asymmetric weakness, together with specific findings on MRI • AFM has been related to different viral agents, but recent outbreaks are predominantly associated with enterovirus D68. What is New: • Improving knowledge on AFM must increase early recognition and adequate diagnostic procedures by clinicians. • The increasing incidence of AFM urges cooperation between pediatricians, neurologists, and microbiologists for the development of treatment and preventive options.
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