Enterovirus D-68

Last reviewed: 5 Jan 2023
Last updated: 17 Nov 2022
17 Nov 2022

Healthcare providers advised to consider enterovirus D-68 and acute flaccid myelitis

The Centers for Disease Control and Prevention’s (CDC) Health Alert Network (HAN) has published an advisory urging healthcare providers to consider enterovirus D-68 (EV-D68) as a possible cause of acute severe respiratory illness, with or without fever in children, and to advise of the potential for an increase in cases of acute flaccid myelitis in the coming weeks.

During August 2022, several US health systems reported increases in severe respiratory illness in children who tested positive for rhinovirus (RV) or enterovirus (EV), with a higher proportion of EV-D68 positivity than in previous years. EV-D68 primarily causes acute respiratory illness, but has been associated with acute flaccid myelitis (AFM), a rare but serious neurologic complication involving limb weakness.

Recommendations for healthcare providers in the HAN advisory include:

  • EV-D68 should be considered as a possible cause of acute, severe respiratory illness (with or without fever) in children. Adults may also become infected with EV-D68, but it is thought to be more commonly detected in adults with underlying conditions.

  • When the cause of respiratory infection in severely ill patients is unclear, testing of respiratory specimens for RV and EV should be considered.

  • AFM should be strongly considered in patients with acute flaccid limb weakness, especially after respiratory illness or fever, and between the months of August and November 2022.

  • Specimens from multiple sources (cerebrospinal fluid, serum, stool, and a nasopharyngeal or oropharyngeal swab) should be collected from patients presenting with possible AFM as early as possible and preferably on the day of onset of limb weakness.

See Epidemiology

See Diagnosis: approach

Original source of update



History and exam

Key diagnostic factors

  • wheezing
  • shortness of breath
  • acute flaccid limb weakness
More key diagnostic factors

Other diagnostic factors

  • rhinorrhea
  • cough
  • sneezing
  • muscle aches
  • fever
Other diagnostic factors

Risk factors

  • <18 years of age
  • history of asthma, wheezing
  • history of chronic lung disease
  • late summer or fall
More risk factors

Diagnostic investigations

1st investigations to order

  • clinical diagnosis
More 1st investigations to order

Investigations to consider

  • respiratory viral testing
  • real-time reverse transcription (rRT) PCR assay or molecular sequencing
  • pulse oximetry
  • contrast MRI of the spine and brain
  • lumbar puncture
  • electromyography
  • testing for poliovirus
More investigations to consider

Treatment algorithm


with mild upper respiratory symptoms

with asthma exacerbation or severe unexplained lower respiratory illness

with acute flaccid myelitis



Charles B. Foster, MD
Charles B. Foster

Professor of Pediatrics

Medical Director of Pediatric Infection Prevention

Center for Pediatric Infectious Diseases

Cleveland Clinic Children’s

Cleveland Clinic




CF declares that he has no competing interests.

Giovanni Piedimonte, MD, FAAP, FCCP
Giovanni Piedimonte

Vice-President for Research and Institutional Official

Office of Research; Departments of Pediatrics, Biochemistry & Molecular Biology

Tulane University

New Orleans



GP declares that he has no competing interests.

Neil R. Friedman, MD
Neil R. Friedman

Interim Director, Barrow Neurological Institute at Phoenix Children’s

Director of Clinical Transformation

Barrow Neurological Institute at Phoenix Children’s




NRF declares that he has no competing interests.

Peer reviewers

Feras Khan, MD

Clinical Assistant Professor

Emergency Medicine Physician

Department of Emergency Medicine

University of Maryland School of Medicine




FK declares that he has no competing interests.

Samuel R. Dominguez, MD, PhD

Associate Professor

Pediatric Infectious Disease

Children’s Hospital Colorado and University of Colorado School of Medicine




SRD declares that he has no competing interests.

  • Enterovirus D-68 images
  • Differentials

    • Rhinovirus infection
    • Seasonal influenza infection
    • Respiratory syncytial virus infection
    More Differentials
  • Guidelines

    • Acute flaccid myelitis (AFM): clinical guidance for the acute medical treatment of AFM
    • Acute flaccid myelitis (AFM): initial evaluation and diagnostic studies
    More Guidelines
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