Clinical Spectrum of Enterovirus 71 Infection in Children in Southern Taiwan, with an Emphasis on Neurological Complications

Abstract

An outbreak of enterovirus 71 (EV71) infection occurred in Taiwan in 1998. The clinical spectrums and laboratory findings for 97 patients with virus culture-proven EV71 infections were analyzed. Eighty-seven percent of the patients were younger than age 5 years. Hand-foot-and-mouth syndrome occurred in 79% of the children and central nervous system (CNS) involvement in 35%, including nine fatal cases. The predominant neurological presentations were myoclonus (68%), vomiting (53%), and ataxia (35%). Brain stem encephalitis was the cardinal feature of EV71 CNS involvement during this outbreak. Magnetic resonance imaging and pathological findings illustrated that the midbrain, pons, and medulla were the target areas. EV71 brain stem encephalitis can present either with cerebellar signs and an initially mild, reversible course or with overwhelming neurogenic shock and neurogenic pulmonary edema (NPE) resulting in a fatal outcome. Brain stem encephalitis that progressed abruptly to neurogenic shock and NPE was indicative of poor prognosis in this epidemic. Early aggressive treatment and close monitoring of the neurological signs are mandatory to improve the chance of survival.

MRI Findings in Children with Acute Flaccid Paralysis and Cranial Nerve Dysfunction Occurring during the 2014 Enterovirus D68 Outbreak

“…This pattern of clinical involvement in EV-71 neurologic disease has often been described as brain stem encephalitis or rhombencephalitis. 9,11,15,[20][21][22][23][24][25] Almost all patients presented with cervical spinal cord T2 hyperintensities, and 9 reported weakness of Ն1 extremity (Fig 3 and On-line Table). This clinical and imaging pattern has been described as AFP in prior case series of EV-71 neurologic disease.…”

“…EV-71 most commonly presents with nonneurologic manifestations but has been associated with multiple outbreaks of AFP and brain stem encephalitis throughout the world. [9][10][11][12][13][14][15] MR imaging in affected patients typically reveals a rhombencephalitis affecting the dorsal pons and medulla, and a radiculomyelitis with a predilection for the anterior horn cells of the spinal cord and ventral nerve roots, findings that have also been described in poliomyelitis. [16][17][18][19] Although EV-D68 has not been proved as the causative agent in this cluster, these cases demonstrate distinctive imaging features that are very similar to the neuroimaging presentation of both EV-71 and poliovirus.…”

Characterization of pharmacologically active compounds that inhibit poliovirus and enterovirus 71 infectivity

“…The case-severity rate of EV71 in an outbreak in Taiwan was ,0.3 % (Ho et al, 1999), suggesting a high neuropathogenicity of EV71 as well as PV, which causes poliomyelitis in 0.1-1.0 % of infected individuals (reviewed by Minor, 1992). EV71 causes fatal pulmonary oedema and/or pulmonary haemorrhage in young children by destruction of the vasomotor and respiratory centres in the brain stem Ho et al, 1999;Huang et al, 1999;Komatsu et al, 1999;Lum et al, 1998;Wang et al, 1999).…”

Hand, Foot and Mouth Disease: A case report

“…Brainstem encephalitis, a distinctive form of encephalitis with stereotypic neuropathological characteristics has become the hallmark of severe EV71-associated HFMD in the recent recurrent EV71 epidemics in Asia, which began in the late 1990s [16,17]. The most severely affected children can develop fulminant cardio-respiratory failure, which is often fatal and causes a high incidence of severe neurological and possible psycho-behavioral sequelae among survivors, despite intensive care support [18].…”