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Doi K, Hattori Y, Maruyama A, Marei AE, Sakamoto S, Sasaki J, Hayashi K, Fujita M. Acute Flaccid Myelitis: Mid-Term Clinical Course of Knee Extension Paralysis and Outcomes of Nerve Transfer. J Bone Joint Surg Am 2024:00004623-990000000-01117. [PMID: 38815052 DOI: 10.2106/jbjs.23.01268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
BACKGROUND Acute flaccid myelitis (AFM) is a rare debilitating poliomyelitis-like illness characterized by the sudden onset of flaccid palsy in the extremities. The purpose of this study was to report the mid-term clinical course of knee extension in AFM and the effect of contralateral obturator nerve-to-femoral nerve transfer (CONFNT) for restoration of knee extension in AFM. METHODS Twenty-six patients with lower extremity palsy due to AFM were referred to our clinic for possible surgical reconstruction. Their median age was 4.0 years, and the first evaluation of the palsy was done at a mean of 6 months after paralysis onset. The paralysis ranged from lower limb monoplegia to quadriplegia. The clinical course of knee extension was assessed using the British Medical Research Council (MRC) grading scale and surface electromyography (EMG). Five patients with unilateral paralysis of knee extension underwent CONFNT. RESULTS The mean follow-up period for 19 limbs with complete paralysis of knee extension (MRC grade M0) in 13 patients who were evaluated for spontaneous recovery was 43 months. No patient who had complete paralysis of knee extension at >6 months and paralysis of the hip adductor muscle had improvement of knee extension to better than M2. Five of the original 26 patients were treated with CONFNT and followed for a mean of 61 months. Two of 5 patients had the CONFNT ≤8 months after paralysis onset and obtained M4 knee extension. Only 1 of the 3 patients with CONFNT performed approximately 12 months after paralysis onset obtained M3 knee extension; the other 2 obtained only M1 or M2 knee extension. CONCLUSIONS The paralysis of the lower extremity in our patients with AFM was similar to that in poliomyelitis. However, in AFM, spontaneous recovery of knee extension was possible if there were signs of recovery from hip adductor paralysis up to 6 months after paralysis onset. CONFNT may enhance the recovery of knee extension and seems to be a reliable reconstruction for restoring knee extension if performed no more than 8 months after paralysis onset. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kazuteru Doi
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan
| | - Yasunori Hattori
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan
| | - Akio Maruyama
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan
| | - Abdelhakim Ezzat Marei
- Department of Orthopedics and Traumatology, Tanta University Hospital, Tanta, El- Gharbia Governorate, Egypt
| | - Sotetsu Sakamoto
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan
| | - Jun Sasaki
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan
| | - Kota Hayashi
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan
| | - Makimi Fujita
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan
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Doi K, Hattori Y, Sakamoto S, Yii Chia DS, Gour V, Sasaki J. Midterm Outcomes of Surgical Reconstruction and Spontaneous Recovery of Upper-Extremity Paralysis Following Acute Flaccid Myelitis. JB JS Open Access 2024; 9:e23.00143. [PMID: 38774108 PMCID: PMC11104719 DOI: 10.2106/jbjs.oa.23.00143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2024] Open
Abstract
Background Acute flaccid myelitis (AFM) is a disabling, poliomyelitis-like illness that mainly affects children. Although various surgical interventions are performed for intractable paralysis due to AFM, the timing of surgery and its long-term outcomes have yet to be established, especially for shoulder reconstruction. This study aimed to analyze the midterm outcomes of nonsurgically and surgically treated upper-extremity AFM and the factors influencing shoulder functional outcomes after surgical reconstruction. Methods We retrospectively examined 39 patients with AFM in 50 upper extremities between 2011 and 2019. The degree of spontaneous recovery of completely paralyzed muscles was evaluated at a median of 3, 6, and 37 months after the onset of paralysis. Twenty-seven patients with 29 extremities underwent surgery involving nerve transfer, muscle-tendon transfer, or free muscle transfer for shoulder, elbow, and hand reconstruction. Results Patients with complete paralysis of shoulder abduction at 6 months did not show later recovery. Twenty-two patients with 24 extremities underwent shoulder surgery, and all but 1 were followed for at least 24 months after surgery. Although postoperative shoulder abduction recovery was similar between transfer of the spinal accessory nerve and of the contralateral C7 nerve root to the suprascapular nerve, the outcomes obtained with spinal accessory nerve transfer had more variability, likely related to latent spinal accessory nerve paralysis, shoulder instability related to pectoralis major paralysis, and the type of paralysis. Shoulder abduction recovery was also greatly affected by scapulothoracic joint movement. In contrast, the outcomes of the elbow flexion and hand reconstructions were more consistent and acceptable. Conclusions All patients had loss of shoulder abduction, and restoration of shoulder function was less predictable and depended on the quality of the donor nerves and recovery of the synergistic muscles. Strict donor nerve selection and additional nerve transfer for shoulder reconstruction are imperative for satisfactory outcomes. Level of Evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kazuteru Doi
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan
| | - Yasunori Hattori
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan
| | - Sotetsu Sakamoto
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan
| | | | - Vijayendrasingh Gour
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan
| | - Jun Sasaki
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan
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Rivera GS, Stokum JA, Dean J, Sadowsky CL, Belzberg AJ, Elrick MJ. Nerve Transfer Surgery in Acute Flaccid Myelitis: Prognostic Factors, Long-Term Outcomes, Comparison With Natural History. Pediatr Neurol 2024; 150:74-81. [PMID: 37981447 PMCID: PMC10894453 DOI: 10.1016/j.pediatrneurol.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 10/13/2023] [Accepted: 10/26/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Nerve transfer surgery is sometimes offered to patients with acute flaccid myelitis (AFM). The objectives of this study were to evaluate surgical efficacy, assess which clinical and neurophysiological data are valuable for preoperative planning, and report long-term outcomes. METHODS This is a single-center, retrospective case series of patients with AFM who received nerve transfer surgery. All patients had preoperative electromyography and nerve conduction studies (EMG/NCS). Matched control muscles that did not receive nerve transfer surgery were defined in the same cohort. RESULTS Ten patients meeting inclusion criteria received a total of 23 nerve transfers (19 upper extremity, four lower extremity). The mean age at symptom onset was 3.8 years, surgery was 0.5 to 1.25 years after diagnosis, and mean follow-up was 2.3 years (range 1.3 to 4.5 years). Among muscles with preoperative strength Medical Research Council (MRC) grade 0, muscles receiving nerve transfers performed significantly better than those that did not (MRC grade 2.17 ± 0.42 vs 0 ± 0, respectively, P = 0.0001). Preoperative EMG/NCS predicted worse outcomes in recipient muscles with more abundant acute denervation potentials (P = 0.0098). Donor nerves found to be partially denervated performed equally well as unaffected nerves. Limited data suggested functional improvement accompanying strength recovery. CONCLUSIONS Nerve transfer surgery is an effective strategy to restore strength for patients with AFM with persistent, severe motor deficits. Postoperative outcomes in patients with complete paralysis are better than the natural history of disease. This study demonstrates the utility of preoperative clinical and electrophysiological data in guiding patient selection for nerve transfer surgery.
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Affiliation(s)
- Glenn S Rivera
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jesse A Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Janet Dean
- Department of Physical Medicine and Rehabilitation, Kennedy Krieger Institute, Baltimore, Maryland
| | - Cristina L Sadowsky
- Department of Physical Medicine and Rehabilitation, Kennedy Krieger Institute, Baltimore, Maryland
| | - Allan J Belzberg
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthew J Elrick
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, Maryland.
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4
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Frost J, Rudy MJ, Leser JS, Tan H, Hu Y, Wang J, Clarke P, Tyler KL. Telaprevir Treatment Reduces Paralysis in a Mouse Model of Enterovirus D68 Acute Flaccid Myelitis. J Virol 2023; 97:e0015623. [PMID: 37154751 PMCID: PMC10231134 DOI: 10.1128/jvi.00156-23] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/09/2023] [Indexed: 05/10/2023] Open
Abstract
In 2014, 2016, and 2018, the United States experienced unprecedented spikes in pediatric cases of acute flaccid myelitis (AFM), which is a poliomyelitis-like paralytic illness. Accumulating clinical, immunological, and epidemiological evidence has identified enterovirus D68 (EV-D68) as a major causative agent of these biennial AFM outbreaks. There are currently no available FDA-approved antivirals that are effective against EV-D68, and the treatment for EV-D68-associated AFM is primarily supportive. Telaprevir is an food and drug administration (FDA)-approved protease inhibitor that irreversibly binds the EV-D68 2A protease and inhibits EV-D68 replication in vitro. Here, we utilize a murine model of EV-D68 associated AFM to show that early telaprevir treatment improves paralysis outcomes in Swiss Webster (SW) mice. Telaprevir reduces both viral titer and apoptotic activity in both muscles and spinal cords at early disease time points, which results in improved AFM outcomes in infected mice. Following intramuscular inoculation in mice, EV-D68 infection results in a stereotypic pattern of weakness that is reflected by the loss of the innervating motor neuron population, in sequential order, of the ipsilateral (injected) hindlimb, the contralateral hindlimb, and then the forelimbs. Telaprevir treatment preserved motor neuron populations and reduced weakness in limbs beyond the injected hindlimb. The effects of telaprevir were not seen when the treatment was delayed, and toxicity limited doses beyond 35 mg/kg. These studies are a proof of principle, provide the first evidence of benefit of an FDA-approved antiviral drug with which to treat AFM, and emphasize both the need to develop better tolerated therapies that remain efficacious when administered after viral infections and the development of clinical symptoms. IMPORTANCE Recent outbreaks of EV-D68 in 2014, 2016, and 2018 have resulted in over 600 cases of a paralytic illness that is known as AFM. AFM is a predominantly pediatric disease with no FDA-approved treatment, and many patients show minimal recovery from limb weakness. Telaprevir is an FDA-approved antiviral that has been shown to inhibit EV-D68 in vitro. Here, we demonstrate that a telaprevir treatment that is given concurrently with an EV-D68 infection improves AFM outcomes in mice by reducing apoptosis and viral titers at early time points. Telaprevir also protected motor neurons and improved paralysis outcomes in limbs beyond the site of viral inoculation. This study improves understanding of EV-D68 pathogenesis in the mouse model of AFM. This study serves as a proof of principle for the first FDA-approved drug that has been shown to improve AFM outcomes and have in vivo efficacy against EV-D68 as well as underlines the importance of the continued development of EV-D68 antivirals.
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Affiliation(s)
- Joshua Frost
- Department of Immunology & Microbiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michael J. Rudy
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - J. Smith Leser
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Haozhou Tan
- Department of Medicinal Chemistry, Ernest Mario School of Pharmacy, Rutgers, the State University of New Jersey, Piscataway, New Jersey, USA
| | - Yanmei Hu
- Department of Medicinal Chemistry, Ernest Mario School of Pharmacy, Rutgers, the State University of New Jersey, Piscataway, New Jersey, USA
| | - Jun Wang
- Department of Medicinal Chemistry, Ernest Mario School of Pharmacy, Rutgers, the State University of New Jersey, Piscataway, New Jersey, USA
| | - Penny Clarke
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kenneth L. Tyler
- Department of Immunology & Microbiology, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
- Division of Infectious Disease, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Neurology Service, Rocky Mountain VA Medical Center, Aurora, Colorado, USA
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5
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Lu E, Sinha A, Freeman MC. Clinical progress note: Enterovirus D68 and acute flaccid myelitis. J Hosp Med 2023; 18:435-438. [PMID: 36938975 DOI: 10.1002/jhm.13085] [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: 12/12/2022] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 03/21/2023]
Affiliation(s)
- Elise Lu
- Department of Pediatrics, Paul C. Gaffney Division of Pediatric Hospital Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Amit Sinha
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Megan Culler Freeman
- Department of Pediatrics, Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Halasa NB, Spieker AJ, Young CC, Olson SM, Newhams MM, Amarin JZ, Moffitt KL, Nakamura MM, Levy ER, Soma VL, Talj R, Weiss SL, Fitzgerald JC, Mack EH, Maddux AB, Schuster JE, Coates BM, Hall MW, Schwartz SP, Schwarz AJ, Kong M, Spinella PC, Loftis LL, McLaughlin GE, Hobbs CV, Rowan CM, Bembea MM, Nofziger RA, Babbitt CJ, Bowens C, Flori HR, Gertz SJ, Zinter MS, Giuliano JS, Hume JR, Cvijanovich NZ, Singh AR, Crandall HA, Thomas NJ, Cullimore ML, Patel MM, Randolph AG. Life-Threatening Complications of Influenza vs Coronavirus Disease 2019 (COVID-19) in US Children. Clin Infect Dis 2023; 76:e280-e290. [PMID: 35717646 PMCID: PMC9384330 DOI: 10.1093/cid/ciac477] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/06/2022] [Accepted: 06/08/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Clinical differences between critical illness from influenza infection vs coronavirus disease 2019 (COVID-19) have not been well characterized in pediatric patients. METHODS We compared demographics, clinical characteristics, and outcomes of US children (aged 8 months to 17 years) admitted to the intensive care or high-acuity unit with influenza or COVID-19. Using mixed-effects models, we assessed the odds of death or requiring life support for influenza vs COVID-19 after adjustment for age, sex, race and Hispanic origin, and underlying conditions including obesity. RESULTS Children with influenza (n = 179) were younger than those with COVID-19 (n = 381; median, 5.2 years vs 13.8 years), less likely to be non-Hispanic Black (14.5% vs 27.6%) or Hispanic (24.0% vs 36.2%), and less likely to have ≥1 underlying condition (66.4% vs 78.5%) or be obese (21.4% vs 42.2%), and a shorter hospital stay (median, 5 days vs 7 days). They were similarly likely to require invasive mechanical ventilation (both 30.2%), vasopressor support (19.6% and 19.9%), or extracorporeal membrane oxygenation (2.2% and 2.9%). Four children with influenza (2.2%) and 11 children with COVID-19 (2.9%) died. The odds of death or requiring life support in children with influenza vs COVID-19 were similar (adjusted odds ratio, 1.30; 95% confidence interval, .78-2.15; P = .32). CONCLUSIONS Despite differences in demographics and clinical characteristics of children with influenza or COVID-19, the frequency of life-threatening complications was similar. Our findings highlight the importance of implementing prevention measures to reduce transmission and disease severity of influenza and COVID-19.
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Affiliation(s)
- Natasha B Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andrew J Spieker
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cameron C Young
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Samantha M Olson
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Margaret M Newhams
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Justin Z Amarin
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kristin L Moffitt
- Division of Infectious Diseases, Boston Children’s Hospital, Boston, Massachusetts, USA,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Mari M Nakamura
- Division of Infectious Diseases, Boston Children’s Hospital, Boston, Massachusetts, USA,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA,Antimicrobial Stewardship Program, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Emily R Levy
- Divisions of Pediatric Infectious Diseases and Pediatric Critical Care Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vijaya L Soma
- Department of Pediatrics, Division of Infectious Diseases, New York University Grossman School of Medicine and Hassenfeld Children’s Hospital, New York, New York, USA
| | - Rana Talj
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott L Weiss
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Julie C Fitzgerald
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Elizabeth H Mack
- Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Aline B Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Jennifer E Schuster
- Division of Pediatric Infectious Disease, Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri, USA
| | - Bria M Coates
- Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Stephanie P Schwartz
- Department of Pediatrics, Division of Critical Care, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Adam J Schwarz
- Division of Critical Care Medicine, Children's Hospital Orange County (CHOC), Orange, California, USA
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Philip C Spinella
- Division of Critical Care, Department of Pediatrics, Washington University School of Medicine in St Louis, St. Louis, Missouri, USA
| | - Laura L Loftis
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children’s Hospital, Houston, Texas, USA
| | - Gwenn E McLaughlin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Charlotte V Hobbs
- Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Courtney M Rowan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana, USA
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ryan A Nofziger
- Division of Critical Care Medicine, Akron Children’s Hospital, Akron, Ohio, USA
| | | | - Cindy Bowens
- Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children’s Medical Center, Dallas, Texas, USA
| | - Heidi R Flori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mott Children’s Hospital and University of Michigan, Ann Arbor, Michigan, USA
| | - Shira J Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Cooperman Barnabas Medical Center, Livingston, New Jersey, USA
| | - Matt S Zinter
- Department of Pediatrics, Division of Critical Care, University of California–San Francisco, San Francisco, California, USA
| | - John S Giuliano
- Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Janet R Hume
- Division of Pediatric Critical Care, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota, USA
| | - Natalie Z Cvijanovich
- Division of Critical Care Medicine, University of California–San Francisco Benioff Children’s Hospital Oakland, Oakland, California, USA
| | - Aalok R Singh
- Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Hillary A Crandall
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Neal J Thomas
- Department of Pediatrics, Penn State Hershey Children’s Hospital, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Melissa L Cullimore
- Division of Pediatric Critical Care, Department of Pediatrics, Children’s Hospital and Medical Center, Omaha, Nebraska, USA
| | | | - Adrienne G Randolph
- Correspondence: Adrienne G. Randolph, Boston Children’s Hospital, 300 Longwood Avenue Bader 634, Boston, MA, USA 02115 ()
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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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Lopez AS, Kidd S, Yee E, Dooling K, Routh JA. Six- and 12-month functional outcomes among patients with confirmed acute flaccid myelitis (AFM) with onset in 2018, United States. J Pediatr Rehabil Med 2023; 16:391-400. [PMID: 37182848 PMCID: PMC11019776 DOI: 10.3233/prm-220054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023] Open
Abstract
PURPOSE Acute flaccid myelitis (AFM), an uncommon but serious neurologic condition, primarily affects children, and can progress quickly to paralysis and respiratory failure. Data on long-term outcomes of patients with AFM are limited. This study reports on functional status through 12 months for AFM patients who became ill in 2018 in the United States. METHODS Health departments collected information on outcomes at 6 and 12 months after onset of AFM using a standardized form that asked patients or their parents/guardians about functional status. Analyses were restricted to confirmed cases. RESULTS Of the 238 confirmed AFM cases reported to CDC in 2018, 90 (38%) had assessments at 6 months, 82 (34%) at 12 months, and 49 (21%) at both 6 and 12 months. Among the 49 patients with data at both time points, the proportion of patients reporting significant or severe impairment at 6 months ranged from 2% to 59% depending on the outcome. Although proportions decreased by 12 months and ranged from 2% to 51%, most patients had some impairment at 12 months. No deaths were reported. CONCLUSION Six- and 12-month outcomes in patients with onset of AFM in 2018 span a wide range of functionality, particularly of upper and lower extremities. Importantly, improvement appears to occur over time in some patients.
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Affiliation(s)
- Adriana S Lopez
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sarah Kidd
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Eileen Yee
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Janell A Routh
- Centers for Disease Control and Prevention, Atlanta, GA, USA
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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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Abstract
Human enterovirus D68 (EV-D68) is a globally reemerging respiratory pathogen that is associated with the development of acute flaccid myelitis (AFM) in children. Currently, there are no approved vaccines or treatments for EV-D68 infection, and there is a paucity of data related to the virus and host-specific factors that predict disease severity and progression to the neurologic syndrome. EV-D68 infection of various animal models has served as an important platform for characterization and comparison of disease pathogenesis between historic and contemporary isolates. Still, there are significant gaps in our knowledge of EV-D68 pathogenesis that constrain the development and evaluation of targeted vaccines and antiviral therapies. Continued refinement and characterization of animal models that faithfully reproduce key elements of EV-D68 infection and disease is essential for ensuring public health preparedness for future EV-D68 outbreaks.
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Circulation of enterovirus D68 (EV-D68) causing respiratory illness in New South Wales, Australia, between August 2018 and November 2019. Pathology 2022; 54:784-789. [PMID: 35717412 DOI: 10.1016/j.pathol.2022.03.007] [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: 09/29/2021] [Revised: 02/28/2022] [Accepted: 03/08/2022] [Indexed: 11/20/2022]
Abstract
The incidence of enterovirus D68 (EV-D68) in New South Wales, Australia, is unknown. As part of a state-wide surveillance program, enterovirus positive diagnostic specimens were assessed from patients presenting to hospitals with respiratory and meningitis syndromes from August 2018 to November 2019. Diagnostic enterovirus positive samples were collected from 339 patients and re-extracted followed by targeted PCR across the whole EV-D68 genome (7.4 kb). Obtained amplicons (n=208) were sequenced using Illumina sequencing technology and the phylogenetic relationships analysed relative to EV-D68 Fermon strain. We identified EV-D68 in 31 patients, both children (n=27) and adults (n=4). Phylogenetically, the majority (n=30) were from subclade B3, the same as that causing outbreaks of EV-D68 across the USA and Europe during 2018. These data strengthen the importance of having an active enterovirus surveillance network.
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Howson-Wells HC, Tsoleridis T, Zainuddin I, Tarr AW, Irving WL, Ball JK, Berry L, Clark G, McClure CP. Enterovirus D68 epidemic, UK, 2018, was caused by subclades B3 and D1, predominantly in children and adults, respectively, with both subclades exhibiting extensive genetic diversity. Microb Genom 2022; 8:mgen000825. [PMID: 35532121 PMCID: PMC9465064 DOI: 10.1099/mgen.0.000825] [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] [Indexed: 11/18/2022] Open
Abstract
Enterovirus D68 (EV-D68) has recently been identified in biennial epidemics coinciding with diagnoses of non-polio acute flaccid paralysis/myelitis (AFP/AFM). We investigated the prevalence, genetic relatedness and associated clinical features of EV-D68 in 193 EV-positive samples from 193 patients in late 2018, UK. EV-D68 was detected in 83 (58 %) of 143 confirmed EV-positive samples. Sequencing and phylogenetic analysis revealed extensive genetic diversity, split between subclades B3 (n=50) and D1 (n=33), suggesting epidemiologically unrelated infections. B3 predominated in children and younger adults, and D1 in older adults and the elderly (P=0.0009). Clinical presentation indicated causation or exacerbation of respiratory distress in 91.4 % of EV-D68-positive individuals, principally cough (75.3 %), shortness of breath (56.8 %), coryza (48.1 %), wheeze (46.9 %), supplemental oxygen required (46.9 %) and fever (38.9 %). Two cases of AFM were observed, one with EV-D68 detectable in the cerebrospinal fluid, but otherwise neurological symptoms were rarely reported (n=4). Both AFM cases and all additional instances of intensive care unit (ICU) admission (n=5) were seen in patients infected with EV-D68 subclade B3. However, due to the infrequency of severe infection in our cohort, statistical significance could not be assessed.
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Affiliation(s)
| | - Theocharis Tsoleridis
- School of Life Sciences, University of Nottingham, Nottingham, UK.,Wolfson Centre for Global Virus Research, University of Nottingham, Nottingham, UK
| | - Izzah Zainuddin
- Clinical Microbiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alexander W Tarr
- School of Life Sciences, University of Nottingham, Nottingham, UK.,Wolfson Centre for Global Virus Research, University of Nottingham, Nottingham, UK
| | - William L Irving
- Clinical Microbiology, Nottingham University Hospitals NHS Trust, Nottingham, UK.,School of Life Sciences, University of Nottingham, Nottingham, UK.,Wolfson Centre for Global Virus Research, University of Nottingham, Nottingham, UK
| | - Jonathan K Ball
- School of Life Sciences, University of Nottingham, Nottingham, UK.,Wolfson Centre for Global Virus Research, University of Nottingham, Nottingham, UK
| | - Louise Berry
- Clinical Microbiology, Nottingham University Hospitals NHS Trust, Nottingham, UK.,School of Life Sciences, University of Nottingham, Nottingham, UK
| | - Gemma Clark
- Clinical Microbiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - C Patrick McClure
- School of Life Sciences, University of Nottingham, Nottingham, UK.,Wolfson Centre for Global Virus Research, University of Nottingham, Nottingham, UK
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Texakalidis P, Xenos D, Murthy NK, Karras CL, Trybula SJ, Behbahani M, DeCuypere MG, Lam SK, Alden TD. Upper extremity nerve transfers for acute flaccid myelitis: a systematic literature review. Childs Nerv Syst 2022; 38:521-526. [PMID: 34982205 DOI: 10.1007/s00381-021-05419-x] [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: 11/12/2021] [Accepted: 11/18/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Acute flaccid myelitis (AFM) is a rare disease that commonly affects young children. AFM's pathophysiology involves loss of lower motor neurons following a viral infection and induces acute asymmetric flaccid paralysis most commonly in the upper extremities. Nerve transfers have emerged as a treatment option for these patients with permanent motor deficits. OBJECTIVE To summarize the literature and report safety and efficacy outcomes following nerve transfers for recovery of shoulder abduction and external rotation, and elbow flexion and extension in pediatric patients with AFM. Recovery of at least antigravity function was defined as a successful outcome. This systematic review was performed according to the PRISMA guidelines. The PubMed, Embase and Cochrane databases were utilized. RESULTS Five studies comprising 44 patients (median age 2.95 years; 71% male), and 93 upper extremity nerve transfers were included. Thirty-eight patients received 65 nerve transfer procedures aiming for recovery of shoulder abduction and/or external rotation with a transfer to the axillary and/or suprascapular nerve. The recovery of shoulder abduction and external rotation was achieved in 40.7% (n = 11/27) and 60% (n = 6/10) of patients, respectively. Time from injury to surgery showed an inverse relationship with the odds for successful recovery (OR: 0.81; 95% CI: 0.64-1.02; p = 0.07); however, statistical significance was not reached. Successful recovery of elbow flexion with a transfer to the musculocutaneous was reported at a rate of 92.3% (n = 12/13). Successful re-innervation of the radial nerve with recovery of elbow extension was found in 75% (n = 6/8) of patients. No complications were reported. CONCLUSIONS Upper extremity nerve transfers appear to be promising and safe for AFM patients. Shoulder abduction is the most challenging upper extremity function to recover. Further studies are warranted to identify whether nerve transfers are associated with superior outcomes when performed earlier.
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Affiliation(s)
- P Texakalidis
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Division of Neurosurgery, Ann & Robert H Lurie Children's Hospital of Chicago, IL, 60611, Chicago, USA
| | - D Xenos
- Hippokrates General Hospital, Athens, Greece
| | - N K Murthy
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Division of Neurosurgery, Ann & Robert H Lurie Children's Hospital of Chicago, IL, 60611, Chicago, USA
| | - C L Karras
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Division of Neurosurgery, Ann & Robert H Lurie Children's Hospital of Chicago, IL, 60611, Chicago, USA
| | - S J Trybula
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Division of Neurosurgery, Ann & Robert H Lurie Children's Hospital of Chicago, IL, 60611, Chicago, USA
| | - M Behbahani
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Division of Neurosurgery, Ann & Robert H Lurie Children's Hospital of Chicago, IL, 60611, Chicago, USA
| | - M G DeCuypere
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Division of Neurosurgery, Ann & Robert H Lurie Children's Hospital of Chicago, IL, 60611, Chicago, USA
| | - S K Lam
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Division of Neurosurgery, Ann & Robert H Lurie Children's Hospital of Chicago, IL, 60611, Chicago, USA
| | - T D Alden
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Division of Neurosurgery, Ann & Robert H Lurie Children's Hospital of Chicago, IL, 60611, Chicago, USA.
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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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15
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Rabinovich RV, Pino PA, Aversano M, Kozin SH, Zlotolow DA. Nerve Transfers for Restoration of Elbow Flexion in Patients With Acute Flaccid Myelitis. J Hand Surg Am 2022; 47:91.e1-91.e8. [PMID: 34020841 DOI: 10.1016/j.jhsa.2021.02.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 12/06/2020] [Accepted: 02/18/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to evaluate short- to midterm outcomes of patients with acute flaccid myelitis who underwent nerve transfers for restoration of elbow flexion. METHODS Patients with a minimum of 10 months of follow up after undergoing nerve transfers to restore elbow flexion were clinically assessed using the Active Movement Scale (AMS). They were evaluated for any postoperative complications, particularly weakness in the distribution of the donor nerve(s). Fifteen of 25 consecutive patients who were treated using this surgical technique were included in the final analysis. RESULTS All patients exhibited poor elbow flexion preoperatively (AMS 0 to 3). At a mean follow up of 17.3 months, 80% (15/25) of patients achieved excellent elbow flexion (AMS 6 or 7); 9 of these 15 had full active range of motion. Two patients achieved good elbow flexion (AMS 5) with antigravity movement to less than 50% of the passive range of motion. No cases of superficial or deep infection were reported, and all patients maintained identical motor function, relative to preoperative status, of the muscles innervated by the donor nerves. CONCLUSIONS Nerve transfer surgery has shown promising short- to midterm results for recovery of nerve and muscle function, particularly for the restoration of elbow flexion. We recommend this treatment option for patients not demonstrating clinical improvement after 6 to 9 months of incomplete recovery. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Remy V Rabinovich
- Department of Orthopaedic Surgery, Philadelphia Hand to Shoulder Center and Thomas Jefferson University Hospitals, Philadelphia, PA.
| | - Paula A Pino
- Department of Orthopaedic Surgery, Pontefical Catholic University of Chile, Santiago, Chile
| | - Michael Aversano
- Department of Orthopaedic Surgery, Shriners Hospital for Children - Philadelphia, PA
| | - Scott H Kozin
- Department of Orthopaedic Surgery, Shriners Hospital for Children - Philadelphia, PA
| | - Dan A Zlotolow
- Department of Orthopaedic Surgery, Shriners Hospital for Children - Philadelphia, PA
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Fontana S, Buttinelli G, Fiore S, Amato C, Pataracchia M, Kota M, Aćimović J, Blažević M, Mulaomerović M, Nikolaeva-Glomb L, Mentis A, Voulgari-Kokota A, Gashi L, Kaçaniku-Gunga P, Barbara C, Melillo J, Protic J, Filipović-Vignjevic S, O’Connor PM, D’Alberto A, Orioli R, Siddu A, Saxentoff E, Stefanelli P. Retrospective Analysis of Six Years of Acute Flaccid Paralysis Surveillance and Polio Vaccine Coverage Reported by Italy, Serbia, Bosnia and Herzegovina, Montenegro, Bulgaria, Kosovo, Albania, North Macedonia, Malta, and Greece. Vaccines (Basel) 2021; 10:44. [PMID: 35062705 PMCID: PMC8779529 DOI: 10.3390/vaccines10010044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/23/2021] [Accepted: 12/24/2021] [Indexed: 11/16/2022] Open
Abstract
Here we analyzed six years of acute flaccid paralysis (AFP) surveillance, from 2015 to 2020, of 10 countries linked to the WHO Regional Reference Laboratory, at the Istituto Superiore di Sanità, Italy. The analysis also comprises the polio vaccine coverage available (2015-2019) and enterovirus (EV) identification and typing data. Centralized Information System for Infectious Diseases and Laboratory Data Management System databases were used to obtain data on AFP indicators and laboratory performance and countries' vaccine coverage from 2015 to 2019. EV isolation, identification, and typing were performed by each country according to WHO protocols. Overall, a general AFP underreporting was observed. Non-Polio Enterovirus (NPEV) typing showed a high heterogeneity: over the years, several genotypes of coxsackievirus and echovirus have been identified. The polio vaccine coverage, for the data available, differs among countries. This evaluation allows for the collection, for the first time, of data from the countries of the Balkan area regarding AFP surveillance and polio vaccine coverage. The need, for some countries, to enhance the surveillance systems and to promote the polio vaccine uptake, in order to maintain the polio-free status, is evident.
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Affiliation(s)
- Stefano Fontana
- Department of Infectious Disease, Istituto Superiore di Sanità, 00161 Rome, Italy; (S.F.); (G.B.); (S.F.); (C.A.); (M.P.)
| | - Gabriele Buttinelli
- Department of Infectious Disease, Istituto Superiore di Sanità, 00161 Rome, Italy; (S.F.); (G.B.); (S.F.); (C.A.); (M.P.)
| | - Stefano Fiore
- Department of Infectious Disease, Istituto Superiore di Sanità, 00161 Rome, Italy; (S.F.); (G.B.); (S.F.); (C.A.); (M.P.)
| | - Concetta Amato
- Department of Infectious Disease, Istituto Superiore di Sanità, 00161 Rome, Italy; (S.F.); (G.B.); (S.F.); (C.A.); (M.P.)
| | - Marco Pataracchia
- Department of Infectious Disease, Istituto Superiore di Sanità, 00161 Rome, Italy; (S.F.); (G.B.); (S.F.); (C.A.); (M.P.)
| | - Majlinda Kota
- Laboratory of Virology, Department of Control of Infectious Diseases, Institute of Public Health, 1001 Tirana, Albania;
| | - Jela Aćimović
- Department of Epidemiology, Public Health Institute of the Republic of Srpska, 78000 Banja Luka, Bosnia and Herzegovina;
| | - Mia Blažević
- Institute for Public Health of Federation Bosnia and Herzegovina, 71000 Sarajevo, Bosnia and Herzegovina; (M.B.); (M.M.)
| | - Mirsada Mulaomerović
- Institute for Public Health of Federation Bosnia and Herzegovina, 71000 Sarajevo, Bosnia and Herzegovina; (M.B.); (M.M.)
| | - Lubomira Nikolaeva-Glomb
- Department of Virology, National Centre of Infectious and Parasitic Diseases, 1504 Sofia, Bulgaria;
| | - Andreas Mentis
- National Poliovirus/Enterovirus Reference Laboratory, Diagnostic Department, Hellenic Pasteur Institute, 11521 Athens, Greece; (A.M.); (A.V.-K.)
| | - Androniki Voulgari-Kokota
- National Poliovirus/Enterovirus Reference Laboratory, Diagnostic Department, Hellenic Pasteur Institute, 11521 Athens, Greece; (A.M.); (A.V.-K.)
| | - Luljeta Gashi
- Department of Epidemiology, National Institute of Public Health, 10000 Pristina, Kosovo; (L.G.); (P.K.-G.)
| | - Pranvera Kaçaniku-Gunga
- Department of Epidemiology, National Institute of Public Health, 10000 Pristina, Kosovo; (L.G.); (P.K.-G.)
| | | | - Jackie Melillo
- Department for Health Regulation, Health Promotion and Disease Prevention, MSD2090 Msida, Malta;
| | - Jelena Protic
- National Reference Laboratory for ARBO Viruses and Hemorrhagic Fever, Institute of Virology, Vaccines and Sera “Torlak”, 11152 Belgrade, Serbia;
| | - Svetlana Filipović-Vignjevic
- Diagnostics and Research and Development, Institute of Virology, Vaccines and Sera “Torlak”, 11152 Belgrade, Serbia;
| | - Patrick M. O’Connor
- Global Immunization Division US Centers for Disease Control and Prevention, Atlanta, GA 30333, USA;
| | - Alessandra D’Alberto
- Prevention of Communicable Diseases and International Prophylaxis, Directorate General of Health Prevention, Ministry of Health, 00144 Rome, Italy; (A.D.); (R.O.); (A.S.)
| | - Riccardo Orioli
- Prevention of Communicable Diseases and International Prophylaxis, Directorate General of Health Prevention, Ministry of Health, 00144 Rome, Italy; (A.D.); (R.O.); (A.S.)
| | - Andrea Siddu
- Prevention of Communicable Diseases and International Prophylaxis, Directorate General of Health Prevention, Ministry of Health, 00144 Rome, Italy; (A.D.); (R.O.); (A.S.)
| | - Eugene Saxentoff
- Division of Health Emergencies and Communicable Diseases (DEC), Regional Office for Europe World Health Organization, DK-2100 Copenhagen, Denmark;
| | - Paola Stefanelli
- Department of Infectious Disease, Istituto Superiore di Sanità, 00161 Rome, Italy; (S.F.); (G.B.); (S.F.); (C.A.); (M.P.)
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17
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Benschop KS, Albert J, Anton A, Andrés C, Aranzamendi M, Armannsdóttir B, Bailly JL, Baldanti F, Baldvinsdóttir GE, Beard S, Berginc N, Böttcher S, Blomqvist S, Bubba L, Calvo C, Cabrerizo M, Cavallero A, Celma C, Ceriotti F, Costa I, Cottrell S, Del Cuerpo M, Dean J, Dembinski JL, Diedrich S, Diez-Domingo J, Dorenberg D, Duizer E, Dyrdak R, Fanti D, Farkas A, Feeney S, Flipse J, De Gascun C, Galli C, Georgieva I, Gifford L, Guiomar R, Hönemann M, Ikonen N, Jeannoël M, Josset L, Keeren K, López-Labrador FX, Maier M, McKenna J, Meijer A, Mengual-Chuliá B, Midgley SE, Mirand A, Montes M, Moore C, Morley U, Murk JL, Nikolaeva-Glomb L, Numanovic S, Oggioni M, Palminha P, Pariani E, Pellegrinelli L, Piralla A, Pietsch C, Piñeiro L, Rabella N, Rainetova P, Uceda Renteria SC, Romero MP, Reynders M, Roorda L, Savolainen-Kopra C, Schuffenecker I, Soynova A, Swanink CM, Ursic T, Verweij JJ, Vila J, Vuorinen T, Simmonds P, Fischer TK, Harvala H. Re-emergence of enterovirus D68 in Europe after easing the COVID-19 lockdown, September 2021. ACTA ACUST UNITED AC 2021; 26. [PMID: 34763750 PMCID: PMC8646978 DOI: 10.2807/1560-7917.es.2021.26.45.2100998] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
We report a rapid increase in enterovirus D68 (EV-D68) infections, with 139 cases reported from eight European countries between 31 July and 14 October 2021. This upsurge is in line with the seasonality of EV-D68 and was presumably stimulated by the widespread reopening after COVID-19 lockdown. Most cases were identified in September, but more are to be expected in the coming months. Reinforcement of clinical awareness, diagnostic capacities and surveillance of EV-D68 is urgently needed in Europe.
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Affiliation(s)
- Kimberley Sm Benschop
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - Jan Albert
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Andres Anton
- Respiratory Virus Unit, Microbiology Department, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Cristina Andrés
- Respiratory Virus Unit, Microbiology Department, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Maitane Aranzamendi
- Microbiology Department, Donostia University Hospital and Biodonostia Health Research Institute, San Sebastián, Spain
| | | | - Jean-Luc Bailly
- Université d'Auvergne, LMGE UMR CNRS 6023, Equipe EPIE - Epidémiologie et physiopathologie des infections à entérovirus, Faculté de Médecine, Clermont-Ferrand, France.,CHU Clermont-Ferrand, National Reference Centre for enteroviruses and parechoviruses - Associated laboratory, Clermont-Ferrand, France
| | - Fausto Baldanti
- Department of Clinical Surgical Diagnostic and Pediatric Sciences, Università degli Studi di Pavia, Pavia, Italy.,Microbiology and Virology Department, Fondazione IRCCS Policlinico San Matteo, Italy
| | | | - Stuart Beard
- UK Health Security Agency, Colindale, United Kingdom
| | - Natasa Berginc
- National laboratory of health, environment and food, Laboratory for public health virology, Ljubljana, Slovenia
| | - Sindy Böttcher
- National Reference Center for Poliomyelitis and Enteroviruses, Robert-Koch Institute, Berlin, Germany
| | - Soile Blomqvist
- National Institute for Health and Welfare, Helsinki, Finland
| | - Laura Bubba
- Department of Biomedical Sciences of Health, University of Milan, Milan, Italy
| | | | - Maria Cabrerizo
- National Centre for Microbiology, Instituto de Salud Carlos III, Enterovirus and Viral Gastroenteritis Unit/Polio National Lab, Madrid, Spain
| | - Annalisa Cavallero
- Laboratory of Microbiology, ASST Monza, San Gerardo Hospital, Monza (MB), Italy
| | | | - Ferruccio Ceriotti
- Virology Unit, Division of Clinical Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Inês Costa
- National Institute of Health (INSA), Lisbon, Portugal
| | | | - Margarita Del Cuerpo
- Microbiology Department Hospital Universitari de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jonathan Dean
- National Virus Reference Laboratory, University College Dublin, Dublin, Ireland
| | | | - Sabine Diedrich
- National Reference Center for Poliomyelitis and Enteroviruses, Robert-Koch Institute, Berlin, Germany
| | - Javier Diez-Domingo
- Center for Public Health Research (FISABIO-Public Health), Generalitat Valenciana, Valencia, Spain
| | | | - Erwin Duizer
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - Robert Dyrdak
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Diana Fanti
- Chemical-clinical and Microbiological Analyses, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Agnes Farkas
- National Public Health Center, Budapest, Hungary
| | - Susan Feeney
- Regional Virus Laboratory, Belfast Health and Social Care Trust (BHSCT, Royal Victoria Hospital, Belfast, United Kingdom
| | - Jacky Flipse
- Laboratory for Medical Microbiology and Immunology, Rijnstate, Velp, the Netherlands
| | - Cillian De Gascun
- National Virus Reference Laboratory, University College Dublin, Dublin, Ireland
| | - Cristina Galli
- Department of Biomedical Sciences of Health, University of Milan, Milan, Italy
| | - Irina Georgieva
- National Reference Laboratory for Enteroviruses, National Center of Infectious and Parasitic Diseases, Sofia, Bulgaria
| | | | | | - Mario Hönemann
- Institute of Medical Microbiology and Virology, University of Leipzig, Leipzig, Germany
| | - Niina Ikonen
- National Institute for Health and Welfare, Helsinki, Finland
| | - Marion Jeannoël
- National Reference Center for Enteroviruses and Parechoviruses, Institut des Agents Infectieux, Hospices Civils de Lyon, Lyon, France
| | - Laurence Josset
- National Reference Center for Enteroviruses and Parechoviruses, Institut des Agents Infectieux, Hospices Civils de Lyon, Lyon, France
| | - Kathrin Keeren
- Secretary of the commission for Polio Eradication in Germany, Robert-Koch Institute, Berlin, Germany
| | - F Xavier López-Labrador
- CIBERESP, Instituto de Salud Carlos III, Madrid, Spain.,Center for Public Health Research (FISABIO-Public Health), Generalitat Valenciana, Valencia, Spain
| | - Melanie Maier
- Institute of Medical Microbiology and Virology, University of Leipzig, Leipzig, Germany
| | - James McKenna
- Regional Virus Laboratory, Belfast Health and Social Care Trust (BHSCT, Royal Victoria Hospital, Belfast, United Kingdom
| | - Adam Meijer
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - Beatriz Mengual-Chuliá
- Center for Public Health Research (FISABIO-Public Health), Generalitat Valenciana, Valencia, Spain
| | - Sofie E Midgley
- The Danish WHO National Reference Laboratory for Poliovirus, Statens Serum Institut, Copenhagen, Denmark
| | - Audrey Mirand
- Université d'Auvergne, LMGE UMR CNRS 6023, Equipe EPIE - Epidémiologie et physiopathologie des infections à entérovirus, Faculté de Médecine, Clermont-Ferrand, France.,CHU Clermont-Ferrand, National Reference Centre for enteroviruses and parechoviruses - Associated laboratory, Clermont-Ferrand, France
| | - Milagrosa Montes
- Microbiology Department, Donostia University Hospital and Biodonostia Health Research Institute, San Sebastián, Spain
| | | | - Ursula Morley
- National Virus Reference Laboratory, University College Dublin, Dublin, Ireland
| | - Jean-Luc Murk
- Elisabeth Tweesteden Hospital, Tilburg, the Netherlands
| | - Lubomira Nikolaeva-Glomb
- National Reference Laboratory for Enteroviruses, National Center of Infectious and Parasitic Diseases, Sofia, Bulgaria
| | - Sanela Numanovic
- Department of Virology, Norwegian Institute of Public Health, Oslo, Norway
| | - Massimo Oggioni
- Virology Unit, Division of Clinical Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Elena Pariani
- Department of Biomedical Sciences of Health, University of Milan, Milan, Italy
| | - Laura Pellegrinelli
- Department of Biomedical Sciences of Health, University of Milan, Milan, Italy
| | - Antonio Piralla
- Microbiology and Virology Department, Fondazione IRCCS Policlinico San Matteo, Italy
| | - Corinna Pietsch
- Institute of Medical Microbiology and Virology, University of Leipzig, Leipzig, Germany
| | - Luis Piñeiro
- Microbiology Department, Donostia University Hospital and Biodonostia Health Research Institute, San Sebastián, Spain
| | - Núria Rabella
- Microbiology Department Hospital Universitari de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Sara Colonia Uceda Renteria
- Virology Unit, Division of Clinical Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - María P Romero
- Department of Biomedical Sciences of Health, University of Milan, Milan, Italy
| | | | | | | | - Isabelle Schuffenecker
- National Reference Center for Enteroviruses and Parechoviruses, Institut des Agents Infectieux, Hospices Civils de Lyon, Lyon, France
| | - Aysa Soynova
- National Reference Laboratory for Enteroviruses, National Center of Infectious and Parasitic Diseases, Sofia, Bulgaria
| | - Caroline Ma Swanink
- Laboratory for Medical Microbiology and Immunology, Rijnstate, Velp, the Netherlands
| | - Tina Ursic
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Jorgina Vila
- Pediatric Hospitalization Unit, Department of Pediatrics, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Tytti Vuorinen
- Clinical Microbiology, Turku University Hospital and Institute of Biomedicine, University of Turku, Turku, Finland
| | | | - Thea K Fischer
- Nordsjaellands Hospital, Hillerod, Denmark.,University of Sothern Denmark, Odense, Denmark
| | - Heli Harvala
- University College London (UCL), Department of infection and Immunity, London, United Kingdom.,NHS Blood and Transplant, Microbiology Services, Colindale, United Kingdom
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18
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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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19
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Jan W, Jones B, Jeelani NUO, Jacques TS, Lyall H, Randell P, Mewasingh L, Whittaker E. Acute flaccid myelitis caused by enterovirus D68 unmasking primary intracranial tumour in a previously healthy child. J Paediatr Child Health 2021; 57:1713-1716. [PMID: 33577116 DOI: 10.1111/jpc.15374] [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: 11/26/2019] [Revised: 11/17/2020] [Accepted: 01/21/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Wajanat Jan
- Department of Imaging, Imperial College Healthcare NHS Trust, London, UK
| | - Brynmor Jones
- Department of Imaging, Imperial College Healthcare NHS Trust, London, UK
| | | | - Thomas S Jacques
- Developmental Biology and Cancer Department, University College London, London, UK
| | - Hermione Lyall
- Paediatric Infectious Diseases, Imperial College Healthcare NHS Trust, London, UK
| | - Paul Randell
- Virology, Imperial College Healthcare NHS Trust, London, UK
| | - Leena Mewasingh
- Paediatric Neurology, Imperial College Healthcare NHS Trust, London, UK
| | - Elizabeth Whittaker
- Paediatric Infectious Diseases, Imperial College Healthcare NHS Trust, London, UK
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20
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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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21
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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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22
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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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23
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Survey of diagnostic and typing capacity for enterovirus infection in Italy and identification of two echovirus 30 outbreaks. J Clin Virol 2021; 137:104763. [PMID: 33711692 DOI: 10.1016/j.jcv.2021.104763] [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: 08/28/2020] [Revised: 02/12/2021] [Accepted: 02/14/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Enterovirus infections can cause a variety of illnesses, ranging from asymptomatic infections to severe illness and death. AIM To support polio eradication activities, in February 2019, the WHO Regional Reference Laboratory for polio in Italy, at the National Institute of Public Health (Istituto Superiore di Sanità), promoted an investigation on non-polio enterovirus laboratory capacity, with the support of the Italian Ministry of Health. The aim was to collect data on the assays used routinely for diagnostic purposes and to characterize enterovirus outbreaks strains by sequence analysis of the Viral Protein 1 region. METHODS A questionnaire was administered to public health laboratories through all Italian Regions for 2018 and subsequently, an electronic form for lab-confirmed enterovirus infection reported from February 2019 to January 2020, including patients clinical characteristics, and laboratory data was distributed through 25 laboratories participating the survey. RESULTS Overall, a homogenous laboratory capacity for enterovirus infection diagnosis was found and 21,000 diagnostic tests were retrospectively reported in 2018. Then, in 2019, two outbreaks of Echovirus 30 were identified and confirmed by molecular analyses. CONCLUSION These results underline the need monitor the circulation of non-polio enterovirus to ascertain the real burden of the disease in the country.
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24
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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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25
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Abstract
BACKGROUND Acute flaccid myelitis (AFM) syndrome consists of loss of lower motor neurons following a viral infection, with preserved sensory function. It usually affects the upper limbs asymmetrically, with proximal more than distal muscle involvement. METHODS Five cases were surgically treated with nerve transfers: spinal accessory to suprascapular nerve transfer (4 patients), branch of radial nerve to axillary nerve transfer (Somsak's procedure) (2 patients), and transfer of a fascicle of the ulnar nerve to the motor branch to the biceps (Oberlin's procedure) (1 patient). RESULTS Motor improvement was seen in three cases. Widespread motor involvement was associated with poor outcome. CONCLUSION This small series of cases reinforces that nerve transfers are a reliable option for treatment of selected children with AFM.
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26
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Paziuk TM, Tadley M, Aversano M, Kozin SH, Zlotolow DA. The Utilization of Nerve Transfer for Reestablishing Shoulder Function in the Setting of Acute Flaccid Myelitis: A Single-Institution Review. Pediatr Neurol 2020; 111:17-22. [PMID: 32951650 DOI: 10.1016/j.pediatrneurol.2020.06.016] [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] [Received: 04/02/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Acute flaccid myelitis (AFM) is a rare disease of young children. The typical presentation involves acute-onset flaccid paralysis in one or more extremities with a nonspecific viral prodrome. Long-term outcomes demonstrate that functional recovery plateaus around six to nine months. The purpose of this study was to evaluate the efficacy of nerve transfers for restoring shoulder function in these patients. METHODS A retrospective review of all patients diagnosed with AFM at a single institution. Shoulder function was evaluated using the active movement scale (AMS). Children at a minimum of six months after diagnosis with plateaued shoulder AMS scores of 4 or less were indicated for surgery. RESULTS Eleven patients were identified with a mean time from symptom onset to surgery of 12 months. Average follow-up was 19 months. The mean AMS score at follow-up for shoulder external rotation and abduction was 4.6 and 2.8, respectively. A total of six different nerve transfers with five different donor nerves were used individually or in conjunction with each other. The most common transfers were from the spinal accessory nerve to the suprascapular nerve (n = 8) and from the intercostal nerves ×3 to the axillary nerve (n = 5). Patients who received a transfer from the radial nerve to the axillary nerve (n = 2) had the best functional returns, with the mean AMS score of 6.5 in both external rotation and abduction at follow-up. CONCLUSION Nerve transfer procedures may help restore shoulder function in the setting of AFM. Combination procedures that involve a transfer from the radial nerve to the axillary nerve may provide the best functional results.
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Affiliation(s)
| | | | | | - Scott H Kozin
- Shriners Hospital for Children, Philadelphia, Pennsylvania
| | - Dan A Zlotolow
- Shriners Hospital for Children, Philadelphia, Pennsylvania
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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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Enterovirus infection and acute flaccid myelitis. Curr Opin Virol 2020; 40:55-60. [PMID: 32711392 DOI: 10.1016/j.coviro.2020.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 06/12/2020] [Accepted: 06/17/2020] [Indexed: 12/16/2022]
Abstract
Recent outbreaks of limb paralysis similar to poliomyelitis, termed acute flaccid myelitis (AFM), have prompted intense investigation into potential etiology. Peaks of AFM were seen in the United States in 2012, 2014, 2016 and 2018, coincident with peaks in enterovirus transmission, particularly EV-D68. Similar peaks of AFM and EV-D68 circulation were reported in other parts of the world. The causal relationship between EV-D68 is still not widely accepted as it is for poliovirus and EV-A71, the latter of which is endemic in the US. Recent in vitro and mouse model data as well as enhanced-sensitivity diagnostic assays have provided further evidence linking the causal relationship between EV-D68 and AFM. In addition, an outbreak of EV-A71-associated AFM was recently described, highlighting the possibility of an additional emerging non-polio enterovirus of public health concern. As AFM is a devastating disease with poor prognosis in many children, particularly those with EV-D68, recent studies call for increased surveillance, pursuit of novel therapeutics and strategies to prevent transmission before the next outbreak.
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29
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Aubart M, Gitiaux C, Roux CJ, Levy R, Schuffenecker I, Mirand A, Bach N, Moulin F, Bergounioux J, Leruez-Ville M, Rozenberg F, Sterlin D, Musset L, Antona D, Boddaert N, Zhang SY, Kossorotoff M, Desguerre I. Severe Acute Flaccid Myelitis Associated With Enterovirus in Children: Two Phenotypes for Two Evolution Profiles? Front Neurol 2020; 11:343. [PMID: 32411086 PMCID: PMC7198806 DOI: 10.3389/fneur.2020.00343] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/07/2020] [Indexed: 12/19/2022] Open
Abstract
Acute flaccid myelitis (AFM) is an acute paralysis syndrome defined by a specific inflammation of the anterior horn cells of the spinal cord. From 2014, worrying waves of life-threatening AFM consecutive to enterovirus infection (EV-D68 and EV-A71) have been reported. We describe 10 children displaying an AFM with an EV infection, the treatments performed and the 1 to 3-years follow-up. Two groups of patients were distinguished: 6 children (“polio-like group”) had severe motor disability whereas 4 other children (“brainstem group”) displayed severe brainstem weakness requiring ventilation support. Electrodiagnostic studies (n = 8) support the presence of a motor neuronopathy associated to myelitis. The best prognosis factor seems to be the motor recovery after the first 4 weeks of the disease.
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Affiliation(s)
- Melodie Aubart
- Department of Paediatric Neurology, Necker-Enfants malades Hospital, University of Paris, AP-HP, Paris, France.,INSERM 1163, Imagine Institute, Paris, France
| | - Cyril Gitiaux
- Department of Paediatric Neurophysiology, Necker-Enfants malades Hospital, University of Paris, AP-HP, Paris, France.,INSERM U955-Team 10, Department of Neurosciences, Mondor Biomedical Research Institute, Paris-Est University, Créteil, France
| | - Charles Joris Roux
- Department of Paediatric Radiology, Necker-Enfants malades Hospital, University of Paris, AP-HP, Paris, France
| | - Raphael Levy
- Department of Paediatric Radiology, Necker-Enfants malades Hospital, University of Paris, AP-HP, Paris, France
| | - Isabelle Schuffenecker
- Laboratory of Virology, National Reference Center for Enterovirus, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Audrey Mirand
- Laboratory of Virology, National Reference Center for Enterovirus Associated Laboratory, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Nathalie Bach
- Paediatric Department, CHU Caen-Normandie, Caen, France
| | - Florence Moulin
- Intensive Care Unit, Necker-Enfants malades Hospital, University of Paris, AP-HP, Paris, France
| | - Jean Bergounioux
- Intensive Care Unit, CHU Raymond Poincaré, Paris Saclay University, AP-HP, Garches, France
| | - Marianne Leruez-Ville
- Laboratory of Virology, Necker-Enfants malades Hospital, University of Paris, AP-HP, Paris, France
| | - Flore Rozenberg
- Laboratory of Virology, Cochin Hospital, University of Paris, AP-HP, Paris, France
| | - Delphine Sterlin
- Laboratory of Immunology, Pitié-Salpétrière Hospital, Sorbonne University, AP-HP, Paris, France
| | - Lucile Musset
- Laboratory of Immunology, Pitié-Salpétrière Hospital, Sorbonne University, AP-HP, Paris, France
| | - Denise Antona
- Direction des maladies infectieuses, Santé publique France, Saint-Maurice, France
| | - Nathalie Boddaert
- INSERM U955-Team 10, Department of Neurosciences, Mondor Biomedical Research Institute, Paris-Est University, Créteil, France.,Department of Paediatric Radiology, Necker-Enfants malades Hospital, University of Paris, AP-HP, Paris, France
| | | | - Manoelle Kossorotoff
- Department of Paediatric Neurology, Necker-Enfants malades Hospital, University of Paris, AP-HP, Paris, France
| | - Isabelle Desguerre
- Department of Paediatric Neurology, Necker-Enfants malades Hospital, University of Paris, AP-HP, Paris, France
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Downey R, McElvain D, Murphey DK, Bailey A, Patel B, Fernandez M, Loftis L, Carreno CG, Eger L, Aguilera EA, Wootton S, Castagnini LA, Hauger SB. Acute Flaccid Myelitis Among Hospitalized Children in Texas, 2016. Pediatr Neurol 2020; 106:50-55. [PMID: 32192819 DOI: 10.1016/j.pediatrneurol.2020.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 01/13/2020] [Accepted: 01/21/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Acute flaccid myelitis is characterized by acute-onset flaccid limb weakness with predominantly gray matter lesions in the spinal cord spanning one or more segments. Rates of full recovery are poor, and there is no standard treatment or definitive cause. METHODS This is a retrospective review of children diagnosed with acute flaccid myelitis in Texas during 2016. Patients were identified through a Texas collaborative of six hospitals in four major metropolitan areas. Data abstraction included health history, illness presentation, medical treatments, laboratory studies, imaging data, recovery, and ability to perform activities of daily living up to approximately two years from illness onset. RESULTS Among all sites, 21 patients met inclusion criteria. Treatments varied with the most common being intravenous immunoglobulin, high-dose methylprednisolone, and plasmapheresis. No differences were seen in response to medical treatments. A potential etiology was found in 12 (57%) cases, including four with enterovirus D68. Five cases recovered fully. Of the 16 patients without full recovery, abilities ranged from (1) able to perform all activities of daily living for age independently (n = 5), (2) mild deficits (n = 5), and (3) substantial reliance on caregivers for activities of daily living (n = 6). CONCLUSION Many reports describe symptoms and outcomes of acute flaccid myelitis, but limited data are available on long-term functional outcomes. We were unable to make a strong case for any single cause or treatment modality. Fortunately, the majority of patients (15, 71%) were able to perform activities of daily living with complete independence or only mild deficits.
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Affiliation(s)
- Rachel Downey
- Pediatric Infectious Diseases, Dell Children's Medical Group, Austin, Texas; Dell Children's Medical Center of Central Texas, Austin, Texas.
| | - Dawn McElvain
- Dell Children's Medical Center of Central Texas, Austin, Texas; Pediatric Neurology, Child Neurology Consultants of Austin, Austin Texas
| | - Donald K Murphey
- Pediatric Infectious Diseases, Dell Children's Medical Group, Austin, Texas; Dell Children's Medical Center of Central Texas, Austin, Texas; The University of Texas at Austin Dell Medical School, Austin, Texas
| | - Ann Bailey
- Infection Prevention, Dell Children's Medical Center of Central Texas, Austin, Texas
| | - Bhairav Patel
- Dell Children's Medical Center of Central Texas, Austin, Texas; Neuroradiology, Austin Radiological Association, Austin Texas
| | - Marisol Fernandez
- Pediatric Infectious Diseases, Dell Children's Medical Group, Austin, Texas; Dell Children's Medical Center of Central Texas, Austin, Texas; The University of Texas at Austin Dell Medical School, Austin, Texas
| | - Laura Loftis
- Pediatrics and Medical Ethics, Baylor College of Medicine, Section of Pediatric Critical Care, Texas Children's Hospital, Houston, Texas
| | | | - Lynne Eger
- Infectious Diseases, Cook Children's Medical Center, Fort Worth, Texas
| | - Elizabeth A Aguilera
- Pediatrics, Infectious Diseases, The University of Texas, McGovern Medical School, Houston Texas
| | - Susan Wootton
- Pediatrics, Infectious Diseases, The University of Texas, McGovern Medical School, Houston Texas
| | - Luis A Castagnini
- Pediatrics, Baylor College of Medicine, Section Chief of Pediatric Infectious Diseases, San Antonio, Texas; Children's Hospital of San Antonio, San Antonio, Texas
| | - Sarmistha B Hauger
- Pediatric Infectious Diseases, Dell Children's Medical Group, Austin, Texas; Dell Children's Medical Center of Central Texas, Austin, Texas; The University of Texas at Austin Dell Medical School, Austin, Texas
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31
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Fang X, Huda R. Acute Flaccid Myelitis: Current Status and Diagnostic Challenges. J Clin Neurol 2020; 16:376-382. [PMID: 32657057 PMCID: PMC7354978 DOI: 10.3988/jcn.2020.16.3.376] [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: 10/31/2019] [Revised: 01/15/2020] [Accepted: 01/17/2020] [Indexed: 01/07/2023] Open
Abstract
Acute flaccid myelitis (AFM) is a sudden-onset polio-like neuromuscular disability found commonly in young children. There is an increasing incidence of confirmed AFM cases in the USA and other countries in recent years, and in association with nonpolio enterovirus infection. This represents a significant challenge to clinicians and causes significant concern to the general public. Acute flaccid paralysis (AFP) is the long-known limb paralytic syndrome caused by a viral pathogen. AFM is a subset of AFP that is also characterized by a limb paralytic condition, but it has certain distinct features such as lesions in magnetic resonance imaging of the spinal cord gray matter. AFM leads to spinal cord, brainstem, or motor neuron dysfunction. The clinical phenotypes, pathology, and patient presentation of AFM closely mimic AFP. This article provides a concise overview of our current understanding of AFM and the clinical features that distinguish AFM from AFP and similar other neurological infectious and autoimmune diseases or disorders. We also discuss the diagnosis, clinical pathology, possible pathogenetic mechanisms, and currently available therapies.
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Affiliation(s)
- Xiang Fang
- Department of Neurology, University of Texas Medical Branch, Galveston, TX, USA.
| | - Ruksana Huda
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, USA.
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Bubba L, Broberg EK, Jasir A, Simmonds P, Harvala H. Circulation of non-polio enteroviruses in 24 EU and EEA countries between 2015 and 2017: a retrospective surveillance study. THE LANCET. INFECTIOUS DISEASES 2019; 20:350-361. [PMID: 31870905 DOI: 10.1016/s1473-3099(19)30566-3] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/10/2019] [Accepted: 09/11/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Enteroviruses can cause severe infections, especially in young children. Non-polio enterovirus infections are not notifiable in most countries in the EU and European Economic Area (EEA) region, and surveillance varies substantially between countries. We collected and analysed available enterovirus data across EU and EEA countries to assess the current epidemiological situation and need for standardising surveillance. METHODS Aggregated data on any enterovirus detected between Jan 1, 2015, and Dec 31, 2017, through national enterovirus reference laboratories were requested from representatives in all 31 EU and EEA countries. Information collected included enterovirus types detected by month, patient age group, symptom, and specimen type. We also collected sequence data on viral capsid sequences for the three most clinically relevant enterovirus types, as identified from the data. FINDINGS Aggregated data were provided by representatives from 24 (77%) of 31 countries. 9914 (66%) of 14 999 enterovirus infections with information about age were in children younger than 5 years, and 3197 (45%) of 7139 individuals for whom symptoms were reported had neurological symptoms. Other symptoms were non-specific fever (in 1607 [23%] patients), respiratory symptoms (in 1197 [17%] patients), hand, foot, and mouth disease (in 528 [7% patients), and myocarditis (in 39 [1%] patients). 68 deaths were temporally associated with enterovirus infection. Typing for 11 559 (67%) of 17 136 specimens revealed 66 enterovirus types. Coxsackievirus A6 was the most frequently detected enterovirus type (in 1556 [13%] of 11 559 typed enteroviruses), and 292 (65%) of 448 patients with coxsackievirus A6 infection with available clinical data presented with hand, foot, and mouth disease. Echovirus 30 was the second most frequently detected enterovirus type, representing 1412 (12%) of 11 559 typed enteroviruses, and 384 (82%) of 467 individuals with echovirus 30 infection with available clinical data had neurological symptoms. Sequences available from 18 countries showed circulation of newly emerging strains of enterovirus A71 and enterovirus D68. INTERPRETATION To our knowledge, this study is the largest investigation of enterovirus circulation in EU and EEA countries and confirms the availability of non-polio enterovirus data in the region. Our study highlights the wide circulation of non-polio enteroviruses in Europe, mostly affecting young children and leading to neurological symptoms. Collecting data on morbidity and mortality related to enterovirus infections, as well as harmonising case definition for surveillance, should be encouraged. FUNDING None.
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Affiliation(s)
- Laura Bubba
- Bacteriology Reference Department, Public Health England, London, UK; European Programme for Public Health Microbiology Training, Solna, Sweden
| | - Eeva K Broberg
- European Centre for Disease Prevention and Control, Solna, Sweden
| | - Aftab Jasir
- European Centre for Disease Prevention and Control, Solna, Sweden
| | - Peter Simmonds
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Heli Harvala
- Microbiology Services, National Health Service (NHS) Blood and Transplant, London, UK; Division of Infection and Immunity, University College London, London, UK.
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33
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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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Hixon AM, Frost J, Rudy MJ, Messacar K, Clarke P, Tyler KL. Understanding Enterovirus D68-Induced Neurologic Disease: A Basic Science Review. Viruses 2019; 11:E821. [PMID: 31487952 PMCID: PMC6783995 DOI: 10.3390/v11090821] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 08/28/2019] [Accepted: 08/29/2019] [Indexed: 12/28/2022] Open
Abstract
In 2014, the United States (US) experienced an unprecedented epidemic of enterovirus D68 (EV-D68)-induced respiratory disease that was temporally associated with the emergence of acute flaccid myelitis (AFM), a paralytic disease occurring predominantly in children, that has a striking resemblance to poliomyelitis. Although a definitive causal link between EV-D68 infection and AFM has not been unequivocally established, rapidly accumulating clinical, immunological, and epidemiological evidence points to EV-D68 as the major causative agent of recent seasonal childhood AFM outbreaks in the US. This review summarizes evidence, gained from in vivo and in vitro models of EV-D68-induced disease, which demonstrates that contemporary EV-D68 strains isolated during and since the 2014 outbreak differ from historical EV-D68 in several factors influencing neurovirulence, including their genomic sequence, their receptor utilization, their ability to infect neurons, and their neuropathogenicity in mice. These findings provide biological plausibility that EV-D68 is a causal agent of AFM and provide important experimental models for studies of pathogenesis and treatment that are likely to be difficult or impossible in humans.
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Affiliation(s)
- Alison M Hixon
- Medical Scientist Training Program, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Joshua Frost
- Department of Immunology & Microbiology, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Michael J Rudy
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Kevin Messacar
- Hospital Medicine and Pediatric Infectious Disease Sections, Department of Pediatrics, University of Colorado, Aurora, CO 80045, USA.
- Children's Hospital Colorado, Aurora, CO 80045, USA.
| | - Penny Clarke
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO 80045, USA.
| | - Kenneth L Tyler
- Department of Immunology & Microbiology, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Division of Infectious Disease, Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Neurology Service, Rocky Mountain VA Medical Center, Aurora, CO 80045, USA
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35
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Pino PA, Intravia J, Kozin SH, Zlotolow DA. Early results of nerve transfers for restoring function in severe cases of acute flaccid myelitis. Ann Neurol 2019; 86:607-615. [DOI: 10.1002/ana.25558] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 06/14/2019] [Accepted: 07/21/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Paula A. Pino
- Department of Orthopedic SurgeryPontifical Catholic University of Chile Santiago Chile
| | | | - Scott H. Kozin
- Department of Orthopedic SurgeryShriners Hospital for Children–Philadelphia Philadelphia PA
| | - Dan A. Zlotolow
- Department of Orthopedic SurgeryShriners Hospital for Children–Philadelphia Philadelphia PA
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36
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Kramer R, Lina B, Shetty J. Acute flaccid myelitis caused by enterovirus D68: Case definitions for use in clinical practice. Eur J Paediatr Neurol 2019; 23:235-239. [PMID: 30670331 DOI: 10.1016/j.ejpn.2019.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 12/17/2018] [Accepted: 01/04/2019] [Indexed: 01/05/2023]
Abstract
Acute flaccid myelitis (AFM) was increasingly detected in recent years, coinciding with upsurges of enterovirus D68 (EV-D68) infections. We reviewed the evidence for a causal relationship between both. Based on reported cases, we provide case definitions for AFM caused by EV-D68 infections to enable a standard procedure for affected patients. Current case definitions are focussing on epidemiological aspects but clinical case definitions are still missing. We propose the following case definitions to be used in clinical practice in order to mirror clinical realities and facilitate a common systematic approach in case management: A possible case is defined as a person presenting with either acute myelitis/paralysis or Guillain-Barré Syndrome (GBS), particularly during periods of EV-D68 circulation. A probable case is defined as a person presenting with symptoms of either acute myelitis/paralysis or GBS and at least one of the following criteria: i) MRI abnormality representing with T2 hyperintensity in spinal cord grey matter with or without hyperintensity at dorsal brain stem, ii) investigations showing an axonal neuropathy including reduced compound motor action potentials with normal conduction velocities and absence of conduction blocks compatible with anterior horn cell disease or iii) detection of enteroviruses in a respiratory specimen obtained from the lower respiratory tract during periods of EV-D68 circulation. A confirmed case is defined as a person presenting with acute flaccid myelitis/paralysis, MRI abnormality and detection of enterovirus-D68-specific nucleic acids in a respiratory specimen using a validated PCR assay targeting the VP1 gene with subsequent sequencing and typing.
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Affiliation(s)
- Rolf Kramer
- European Public Health Microbiology Training Programme (EUPHEM); Centre National de Référence des Enterovirus et Parechovirus, Laboratoire de Virologie, Institut des Agent Infectieux, HCL, Hôpital de la Croix-Rousse, Lyon, France.
| | - Bruno Lina
- Centre National de Référence des Enterovirus et Parechovirus, Laboratoire de Virologie, Institut des Agent Infectieux, HCL, Hôpital de la Croix-Rousse, Lyon, France; Virpath, CIRI, Université de Lyon, INSERM U1111, CNRS 5308, ENS de Lyon, UCBL, Lyon, France
| | - Jay Shetty
- Paediatric Neurosciences, Royal Hospital for Sick Children, Edinburgh, UK; Child Life and Health, University of Edinburgh, Edinburgh, UK
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Affiliation(s)
- 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
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38
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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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39
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Affiliation(s)
- Sacha Stelzer-Braid
- Virology Research Laboratory, Prince of Wales Hospital, Sydney, NSW 2031, Australia
- School of Medical Sciences, and School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - William Rawlinson
- Virology Research Laboratory, Prince of Wales Hospital, Sydney, NSW 2031, Australia
- School of Medical Sciences, and School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- Serology and Virology Division (SAViD), Microbiology NSW Health Pathology Randwick, NSW 2031, Australia
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