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Features of enterovirus 71 infection characterized
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As enterovirus 71 continues to gain significance as an important public health problem causing serious clinical illness, death and long-term neurologic and psychiatric disorders in children, researchers explored the clinical features, pathogenesis and transmission of the disease as well as management strategies.
Reports of enterovirus 71 (EV71) outbreaks in Australia, Canada, Hong Kong, Japan, Malaysia and Taiwan reviewed by the researchers revealed that although patients often present with dermatologic symptoms such as hand-foot-and-mouth disease and herpangina, central nervous system involvement can lead to symptoms as severe as brain stem encephalitis, aseptic meningitis, acute flaccid paralysis and pulmonary edema. Acute respiratory diseases may also occur.
Epidemiologic data gathered from March 1998 to December 2007 via a sentinel surveillance system established by the Taiwan CDC indicated that most severe cases of hand-foot-and-mouth disease and herpangina occurred in children younger than 4 years, with the majority (75%) occurring in children 2 years or younger.
Lack of EV71–specific antibodies in children likely plays a role in the prevalence of the disease, according to the researchers, as data from a 1998 Taiwan epidemic showed that antibody levels among infants and children dropped from 7% to 11% down to 3% to 4% from 1994 to 1997.
Additional viral surveillance from the Taiwan CDC showed that a variety of enteroviruses accounted for severe infections in the country from 1998 to 2007, including EV71 (17%), coxsackievirus A6 (5%), A10 (5%), A16 (24%) and B3 (10%) as well as echovirus 6 (6%) and 4 (5%). However, EV71 was most commonly isolated from patients with encephalitis and pulmonary edema/hemorrhage (93%) between 1998 and 2005 compared with patients who had aseptic meningitis.
"The data indicate that large numbers of other enteroviruses, especially coxsackievirus A16, cocirculated and that their infections were a major contributor to hand-foot-and-mouth disease/herpangina during EV71 epidemics in Taiwan," the researchers wrote. "However, EV71 was responsible for almost all of the complications of hospitalized patients, particularly those that led to death."
Long-term neurologic and psychiatric disorders have also been linked to EV71 infections with CNS involvement, according to the researchers. Patients who experienced poliomyelitis-like syndrome, encephalomyelitis and cardiopulmonary failure as a result of EV71 infection often experienced limb weakness, atrophy and neurodevelopmental disorders, data from a long-term follow-up study involving 142 children indicated. Researchers from a separate study also found higher rates of attention-deficit/hyperactivity disorder–related symptoms among 86 children with EV71 CNS involvement (20%) than among a control group of 172 children (3%).
Although no specific therapies are currently approved for treating enteroviral infections, a variety of antiviral, steroidal and IV immunoglobulin therapies including pyridyl imidazolidinone, milrinone and ribavirin have been used to treat these infections but have not been studied in randomized, placebo-controlled trials.
Lee TC. Pediatr Infect Dis J. 2009;28:904-910.