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

Enterovirus D-68 (EV-D68) is an important cause of viral lower respiratory tract illness in children. In 2014, the US experienced an outbreak of EV-D68, with numerous children requiring hospital admission due to severe lower respiratory illness and asthma.

Most people infected have mild symptoms such as runny nose, cough, sneezing, or muscle aches; some patients have fever. Often patients with more severe disease have a history of asthma or chronic lung disease.

A possible association exists between EV-D68 infection and polio-like acute flaccid myelitis.

Diagnosis is clinical. Most clinical tests for rhinovirus do not distinguish EV-D68 in the absence of specific testing.

Specific testing for EV-D68 should be considered in children with severe unexplained respiratory illness, even in the absence of fever. Although not routinely available, specific testing can be obtained on a case-by-case basis through state or local health departments, or the Centers for Disease Control and Prevention.

In patients with mild upper respiratory symptoms, the illness is typically self-limited and no specific therapy is indicated.

Patients with asthma exacerbation or severe unexplained respiratory illness should receive supportive care. Management should occur in a setting that can provide access to appropriate pediatric subspecialty and critical care support. Currently there is no specific antiviral therapy available for the treatment of any enterovirus.

Preventive measures to avoid transmission include avoiding close contact with sick persons, washing hands with soap and water, covering coughs and sneezes, staying home when sick, and cleaning and disinfecting contaminated surfaces. In the healthcare setting, healthcare providers should use standard, contact, and droplet precautions.

Definition

Enterovirus D-68 (EV-D68) is a member of the Picornaviridae family. It has emerged as an important cause of acute respiratory illness, especially in children.[1][2][3] In 2014, the US experienced an outbreak, with numerous children requiring hospital admission due to severe lower respiratory illness and asthma. Emerging data also support a role for EV-D68 in polio-like acute flaccid myelitis.[4][5][6][7] EV-D68 is closely related to rhinoviruses. Most clinical tests for rhinovirus do not distinguish EV-D68 in the absence of strain-specific typing.[8][Figure caption and citation for the preceding image starts]: MRI of the spine showing a T2/STIR hyperintensity restricted to the ventral gray matter of the cervical and thoracic spinal cord in a child with acute flaccid myelitis.From the collection of Neil Friedman, MBChB, Center for Pediatric Neurology, Cleveland Clinic, Cleveland, Ohio [Citation ends]. com.bmj.content.model.Caption@1fb5b33

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

ONGOING

with mild upper respiratory symptoms

with asthma exacerbation or severe unexplained lower respiratory illness

with acute flaccid myelitis

Contributors

Authors

Charles B. Foster, MD

Professor of Pediatrics

Medical Director of Pediatric Infection Prevention

Center for Pediatric Infectious Diseases

Cleveland Clinic Children’s

Cleveland Clinic

Cleveland

Disclosures

CF declares that he has no competing interests.

Giovanni Piedimonte, MD, FAAP, FCCP

Vice-President for Research and Institutional Official

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

Tulane University

New Orleans

Disclosures

GP declares that he has no competing interests.

Neil R. Friedman, MD

Interim Director, Barrow Neurological Institute at Phoenix Children’s

Director of Clinical Transformation

Barrow Neurological Institute at Phoenix Children’s

Phoenix

Disclosures

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

Baltimore

Disclosures

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

Aurora

Disclosures

SRD declares that he has no competing interests.

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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Enterovirus D-68

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

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

with mild upper respiratory symptoms

with asthma exacerbation or severe unexplained lower respiratory illness

with acute flaccid myelitis

Contributors

Authors

Charles B. Foster, MD

Disclosures

Giovanni Piedimonte, MD, FAAP, FCCP

Disclosures

Neil R. Friedman, MD

Disclosures

Peer reviewers

Feras Khan, MD

Disclosures

Samuel R. Dominguez, MD, PhD

Disclosures

Differentials

Guidelines

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