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Acute Flaccid Paralysis in a Child Infected with Enterovirus D68: a Case Report

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Acute Flaccid Paralysis in a Child Infected with Enterovirus D68: a Case Report Michelle D. Sherwood, MD, Soren Gantt, MD, PhD, MPH, Mary Connolly, MD, FRCPC, Simon Dobson, MD, MBBS Acute flaccid paralysis in a child infected with enterovirus D68: A case report A broad range of tests for viral, bacterial, and autoimmune causes was undertaken when a 9-year-old presented with polio-like symptoms. ABSTRACT: Enterovirus D68 is in- nterovirus D68 (EV-D68) is horn cells of the spinal cord.7 AFP creasingly being reported as a cause increasingly being reported is nearly always asymmetric, affects of severe respiratory illness across as a cause of severe respira- proximal more than distal muscle E 1 North America, with several children tory illness across North America. groups, progresses over 2 to 3 days, in Canada testing positive for this Members of the Picornaviridae fam- and is associated with neck or back virus and experiencing concurrent ily, enteroviruses (EVs) are non- pain.7 There is reduced muscle tone polio-like symptoms. In one recent enveloped, single-stranded RNA vi- and weakness, but typically sensation case in British Columbia, a 9-year- ruses that have traditionally been is unaffected. EV-D68, which pri- old patient presented with acute classified as polioviruses, coxsacki- marily causes respiratory infections, flaccid paralysis of his left arm fol- eviruses A, coxsackieviruses B, and is another serotype that may cause lowing a respiratory illness and fever. echoviruses E.2 Recently, human en- AFP.5,6,8 EV-D68 was first identified Enterovirus D68 was eventually iso- teroviruses have been subdivided into in California in 1962 and appears to lated in a nasopharyngeal specimen four species—enterovirus A, B, C, be relatively uncommon.9 However, and the patient was treated with in- and D—of which there are more than travenous immunoglobulin. To date 100 serotypes.3 Dr Sherwood is a third-year Child and Fam- the patient has experienced only Transmission of EVs is by the ily Research Institute (CFRI) resident in pe- slight improvement in his left arm fecal-oral route, respiratory secre- diatrics at BC Children’s Hospital. Dr Gantt function. This case illustrates the tions, or close contact with infected is a senior associate clinician scientist with importance of appropriate screen- people.4 Peak EV transmission oc- the CFRI, and an associate professor in the ing for polio and nonpolio enterovi- curs in the summer and fall in temper- Division of Infectious and Immunological ruses. Clinicians faced with a case of ate climates.4 Nonpolio EV infections Diseases, Department of Pediatrics, Uni- acute flaccid paralysis should con- are largely asymptomatic, but can re- versity of British Columbia. Dr Connolly is tact their regional health authority sult in a range of diseases, including a clinical investigator with the CFRI, and a or the BC Centre for Disease Control respiratory illnesses and central ner- clinical professor and division head in the for early guidance on how to collect vous system infections.5 Specifically, Division of Neurology, Department of Pedi- specimens for testing. While there nonpolio EVs have increasingly been atrics, University of British Columbia. She is no established treatment protocol reported in association with acute flac- is also director of the Epilepsy Surgery Pro- for enterovirus D68 infection, we do cid paralysis (AFP) in immunocompe- gram at BC Children’s Hospital. Dr Dobson know that hand washing and avoid- tent North American children.5,6 is a clinical investigator with the CFRI, and ing close contact with ill people can Like poliovirus, enterovirus A71 a clinical associate professor in the Division prevent transmission. (EV-A71) and others are known to of Infectious and Immunological Diseases, cause AFP, which results from inflam- Department of Pediatrics, University of mation and destruction of the anterior British Columbia. BC MEDICAL JOURNAL VOL. 56 NO. 10, DECEMBER 2014 bcmj.org 495 Acute flaccid paralysis in a child infected with enterovirus D68: A case report because EV-D68 is not reportable in There was no history of contact with (117 × 106/L) and mild pleocytosis North America, the incidence of in- sick individuals, insect bites, recent (88 × 106/L; neutrophils 41% and fection may be underestimated.5 Dur- vaccination, toxin exposures, animal lymphocytes 44%), normal glucose, ing an outbreak of EV-D68-related exposures, trauma, rash, visual distur- and elevated protein (0.5 g/L). respiratory illness between 2008 and bance, dysphagia, or bowel or blad- Intravenous vancomycin, cefota- 2010 in Asia, Europe, and the United der dysfunction. Earlier in childhood xime, and acyclovir were started. An States,9 a previously healthy 5-year- he had received four doses of inacti- MRI of the spine revealed asymmet- old presented with a fatal case of fe- vated poliovirus vaccine according ric, fusiform swelling of the cervi- ver, pneumonia, and AFP.10 In that to the schedule recommended in BC cal cord between the second cervical case, examination of the cerebrospi- and had not traveled outside of North vertebra (C2) and the upper border of nal fluid (CSF) revealed aseptic men- America, making poliovirus infection the first thoracic vertebra (T1), with ingitis, and EV-D68 was detected by unlikely. His family history was neg- left-sided predominance Figure 1 . PCR.10 A second case of EV-D68 as- ative for childhood cancer, immuno- There was T2/FLAIR hyperintensity sociated with AFP was then identified deficiency, or vascular disease. in the C2 to T1 region Figure 2 . There through nationwide surveillance.11 Physical examination of the was no distal intraspinal abnormality Between 2012 and 2014, 23 cases patient revealed a temperature of noted, and the brain appeared normal, of AFP were identified in California 38.3°C with a heart rate of 131, a other than for a single subtle hyperin- with no definitive cause identified, al- respiratory rate of 12, oxygen satu- tense focus in the left posterior pons though respiratory specimens for two ration of 98%, and blood pressure of uncertain significance. of the children tested positive for EV- of 128 mm Hg over 82 mm Hg. He Nucleic acid testing of a nasopha- D68.5 In September 2014, EV-D68 appeared anxious but alert. While he ryngeal swab was positive for entero- was detected in the respiratory speci- had a full range of motion in his neck virus, which was subsequently typed as mens of several children with con- and back, and no evidence of menin- EV-D68 by sequencing . The specimen current AFP in Canada and the US.5,6 gmus, he did have tenderness along was negative for rhinovirus, influenza, While the full spectrum of EV-D68 the cervical vertebrae. The results of parainfluenza, respiratory syncytial vi- infections and any causal relationship a cranial nerve examination, includ- rus, human metapneumovirus, adeno- with AFP have not been fully estab- ing fundoscopy, were normal. He had virus, coronavirus, and mycoplasma. lished, the medical community needs normal right arm and bilateral leg CSF cultures were also negative and to be aware that acute flaccid paraly- strength. Other than slight left thumb all antimicrobials were discontinued sis can be associated with this entero- abduction, he had no strength (0/5) in after 48 hours. Serology results were virus infection, as illustrated by a case his left arm (deltoid, biceps, triceps, negative for herpes simplex virus of AFP in a child with EV-D68 infec- wrist, and intrinsic muscles). The (HSV) 1 and 2, syphilis, cytomegalo- tion in British Columbia. left arm was hypotonic and areflexic. virus (CMV), and Epstein-Barr virus Sensation was difficult to assess, but (EBV). Results were negative for My- Case data was judged to be grossly normal to all coplasma pneumoniae IgG antibodies, A previously healthy, fully immu- modalities. The patient was slightly but positive for M. pneumoniae IgM nized 9-year-old boy presented to unsteady during the tandem gait test. antibodies. PCR testing of CSF was BC Children’s Hospital with sudden- The results from the remainder of his negative for enterovirus, HSV, CMV, onset left arm weakness and inability physical examination were normal, EBV, and human herpes virus 6. There to move his left arm in the morning. with no significant respiratory, car- were no oligoclonal bands in the CSF He had an upper respiratory illness diovascular, or skin findings. and antibodies for neuromyelitis op- that had begun 5 days earlier with Results from a complete blood tica were negative. fever, cough, rhinorrhea, and post- count were normal, with the excep- One day after admission, the child tussive emesis. He had had headaches tion of a slightly elevated neutrophil developed mild weakness in his right for 2 days accompanied by neck and count. Serum electrolytes, coagula- shoulder and neck flexors (–4/5). left shoulder pain. His history was sig- tion factors, liver enzymes, C-reac- Nerve conduction tests in the right nificant for travel to the south Atlan- tive protein, chest X-ray, and CT of arm and neck found no abnormalities, tic region of the US 1 month earlier. the head without contrast revealed in contrast to studies of the left arm, Family members had similar cold- no abnormalities. CSF examination which showed motor nerve conduc- like symptoms around the same time. showed red blood cells in the CSF tion was absent despite normal sen- 496 BC MEDICAL JOURNAL VOL. 56 NO. 10, DECEMBER 2014 bcmj.org Acute fl accid paralysis in a child infected with enterovirus D68: A case report sory nerve function. The child defer- symptom onset and before administra- vesced by day 2 of admission and his tion of IVIG.5 Specimens include two headaches decreased in intensity. He stool samples collected more than 24 received two courses of intravenous hours apart, CSF, acute-phase serum, immunoglobulin (IVIG) at 1 g/kg/d and nasopharyngeal and throat swabs.
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