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An unusual cluster of cases of acute flaccid paralysis in Colorado coincided with a large outbreak of enterovirus D68 respiratory infections in children locally and throughout the U.S. Investigators now describe 12 children meeting their case definition: acute flaccid paralysis with spinal-cord lesions or acute cranial nerve dysfunction with brainstem lesions, with onset between August 1 and October 31, 2014.
Median age was 11.5 years; 75% were male. All had a febrile illness (11 with respiratory symptoms), with a median onset 7 days before neurologic-symptom development. Neurologic deficits included flaccid limb weakness in 10 (asymmetric in 7), bulbar weakness in 6, and cranial nerve VI or VII dysfunction in 5. On neuroimaging, 11 had spinal-cord lesions affecting the central gray matter; 9 had brainstem lesions. Cerebrospinal fluid (CSF) pleocytosis was found in all 10 whose CSF was examined ≤7 days after neurologic-symptom onset; all CSF specimens assessed tested negative for enteroviruses and other known pathogens. Nasopharyngeal specimens, obtained from 11 children, tested positive for rhinovirus or enterovirus in 8 (typed as enterovirus D68 in 5). As of December 1, 2014, all 10 children with limb weakness had neuromotor sequelae.
Messacar K et al. A cluster of acute flaccid paralysis and cranial nerve dysfunction temporally associated with an outbreak of enterovirus D68 in children in Colorado, USA. Lancet 2015 Jan 28; [e-pub ahead of print]. (http://dx.doi.org/10.1016/S0140-6736(14)62457-0)
Mirand A and Peigue-Lafeuille H.Acute flaccid myelitis and enteroviruses: An ongoing story. Lancet 2015 Jan 28; [e-pub ahead of print]. (http://dx.doi.org/10.1016/S0140-6736(15)60121-0)
Comment
With the elimination of poliomyelitis from most countries worldwide, other causes of acute flaccid paralysis have been identified, including neurotropic viruses such as enterovirus A71, Japanese encephalitis virus, and West Nile virus. Enterovirus D68 was detected in the CSF in two previously reported cases of neurologic disease. The current study does not establish a causative role for enterovirus D68 but provides strong supporting evidence. If the virus does cause severe neurologic disease as well as severe respiratory infections, the search for effective interventions should have high priority. Editorialists note that continued surveillance for flaccid paralysis is essential to detect the emergence of other potentially neurotropic viruses.