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.
Summary
Definition
History and exam
Key diagnostic factors
- wheezing
- shortness of breath
- acute flaccid limb weakness
Other diagnostic factors
- rhinorrhea
- cough
- sneezing
- muscle aches
- fever
Risk factors
- <18 years of age
- history of asthma, wheezing
- history of chronic lung disease
- late summer or fall
Diagnostic investigations
1st investigations to order
- clinical diagnosis
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
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

Professor of Pediatrics
Medical Director of Pediatric Infection Prevention
Center for Pediatric Infectious Diseases
Cleveland Clinic Children’s
Cleveland Clinic
Cleveland
OH
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
LA
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
AZ
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
MD
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
CO
Disclosures
SRD declares that he has no competing interests.
Differentials
- Rhinovirus infection
- Seasonal influenza infection
- Respiratory syncytial virus infection
More DifferentialsGuidelines
- Acute flaccid myelitis (AFM): clinical guidance for the acute medical treatment of AFM
- Acute flaccid myelitis (AFM): initial evaluation and diagnostic studies
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