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Be alert for unusual presentations that may indicate EV-D68
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SAN DIEGO — The AAP’s Committee on Infectious Diseases encourages all pediatricians to be alert for any unusual presentations when treating children this season, particularly regarding the central nervous system, as it may indicate enterovirus D68.
During a seminar, Mark H. Sawyer, MD, of University of California, San Diego School of Medicine and Rady Children’s Hospital in San Diego, discussed the recent outbreak of enterovirus D68 (EV-D68) and how pediatricians should handle the outbreak.
“The first 30 cases of EV-D68 that were identified had an age range of 6 weeks to 16 years,” Sawyer said. “Twenty-one of those had a prior history of asthma or wheezing, they all presented with respiratory distress but only seven of them were febrile. So that’s one clue to picking enterovirus out of the pack as opposed to influenza, which usually causes fever, as does adenovirus and so do the other respiratory viruses. Many of these children are nonfebrile, their chest X-ray appearance is nonspecific, bilateral infiltrates have likeness to some hyperinflation and others to go along with their wheezing symptoms.”
As of Oct. 15, there are 780 cases of EV-D68 across 46 states and the District of Columbia in the United States, and there have been at least seven deaths in patients who tested positive for EV-D68.
Sawyer noted that many of those with EV-D68 and flaccid paralysis had preceding respiratory or gastrointestinal illness.
“Yes, EV-D68 is part of the flaccid paralysis story, it’s not clear whether it is the whole story though. There may be other things mixed in there. I should point out that these cases [with EV-D68 and flaccid paralysis] are distinguishable from polio. So when you are seeing a patient whom you suspect has this, it’s very important to obtain a travel history. If they have recently travelled from a country with circulating poliovirus, you need to look for EV-D68 and polio and coordinate that evaluation with your health department,” Sawyer said.
There is no specific treatment for EV-D68, according to Sawyer. He recommended supportive care via fluids and ventilation when necessary and bronchodilators for children with wheezing.
“There are antivirals that have activity with other members of the enterovirus family and so far those have been looked at in vitro and they do not look promising for the treatment of EV-D68, including neurologic symptoms,” Sawyer said. “CDC is preparing management guidelines about whether other adjunctive therapy like steroids or IVIG will play a role in this illness, which is why we need more case ascertainment so we can see how people have been treating them and whether we can tease out strategies.”
Pediatricians should encourage parents to educate their children about hand washing, instruct parents to keep children out of school or daycare when ill, provide asthma action plans to patients with a history of wheezing and administer influenza vaccine to reduce risk of another respiratory infection. — by Amanda Oldt
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Presented at: 2014 AAP National Conference and Exhibition; Oct. 11-14; San Diego.
Disclosure: Sawyer reports no relevant financial disclosures.