Outcome of paediatric acute flaccid myelitis associated with enterovirus D68: a case series

Pediatric Patients With Acute Flaccid Myelitis: Long-term Respiratory and Neurologic Outcomes

BACKGROUND

Acute flaccid myelitis (AFM), an infection-mediated neurologic condition, may be accompanied by respiratory failure and subsequent variable recovery. This study assessed and provided prescriptive data on long-term respiratory and neurologic outcomes according to respiratory status at the time of presentation.

METHODS

This was a retrospective cohort study using a large, single-payer healthcare database to identify children 1-18 years old, diagnosed with AFM between January 1, 2011 and December 31, 2019. Descriptive statistics described the overall cohort and the cohort by respiratory failure status. Bivariate analyses evaluated incidence rate ratios of outcome data, comparing those with respiratory failure to those without.

RESULTS

A total of 37 patients met the study criteria for AFM; 28 were from a previously established cohort. Median follow-up time was 4.7 years [interquartile range (IQR): 2.39-6.06]. Overall incidence rate of AFM over the study period was 0.6 per 100,000 person-years. Eight patients (21.6%) had respiratory failure during the index hospitalization. Among children with respiratory failure, 6 patients (75%) required follow-up respiratory support. Those with respiratory failure had higher Modified Rankin Scores [mean difference 1.29, 95% confidence interval (CI): 0.34-2.23] and a higher rate of respiratory-related emergency and in-hospital visits (incidence rate ratios 1.94; 95% CI: 1.27-2.96) compared to those without respiratory failure.

CONCLUSIONS

Having respiratory failure at presentation was observed to have worse outcomes, including the need for long-term respiratory support, higher healthcare utilization, and prolonged neurologic deficits. This study contributes to the scant literature on pediatric patients with AFM.

Emerging Therapeutics in the Fight Against EV-D68: A Review of Current Strategies

Enterovirus-D68 (EV-D68) was first identified in 1962 in pediatric patients with acute respiratory conditions in California, USA (US). From the 1970s to 2005, EV-D68 was underestimated due to limited data and serotyping methods. In 2014, the United States experienced outbreaks of acute flaccid myelitis (AFM) in children EV-D68 positive. WIN-like compounds (pleconaril, pocapavir, and vapendavir) bind to the virus capsid and have been tested against various enteroviruses (EVs) in clinical trials. However, these compounds encountered issues with resistance and adverse effects, which impeded their approval by the Food and Drug Administration (FDA). Presently, the medical field lacks FDA-approved antiviral treatments or vaccines for EV-D68. Ongoing research efforts are dedicated to identifying viable therapeutics to address EV-D68 infections. This review explores the current advancements in antiviral therapies and potential therapeutics to mitigate the significant impact of EV-D68 infection control.

Acute Flaccid Myelitis: Mid-Term Clinical Course of Knee Extension Paralysis and Outcomes of Nerve Transfer

BACKGROUND

Acute flaccid myelitis (AFM) is a rare debilitating poliomyelitis-like illness characterized by the sudden onset of flaccid palsy in the extremities. The purpose of this study was to report the mid-term clinical course of knee extension in AFM and the effect of contralateral obturator nerve-to-femoral nerve transfer (CONFNT) for restoration of knee extension in AFM.

METHODS

Twenty-six patients with lower extremity palsy due to AFM were referred to our clinic for possible surgical reconstruction. Their median age was 4.0 years, and the first evaluation of the palsy was done at a mean of 6 months after paralysis onset. The paralysis ranged from lower limb monoplegia to quadriplegia. The clinical course of knee extension was assessed using the British Medical Research Council (MRC) grading scale and surface electromyography (EMG). Five patients with unilateral paralysis of knee extension underwent CONFNT.

RESULTS

The mean follow-up period for 19 limbs with complete paralysis of knee extension (MRC grade M0) in 13 patients who were evaluated for spontaneous recovery was 43 months. No patient who had complete paralysis of knee extension at >6 months and paralysis of the hip adductor muscle had improvement of knee extension to better than M2. Five of the original 26 patients were treated with CONFNT and followed for a mean of 61 months. Two of 5 patients had the CONFNT ≤8 months after paralysis onset and obtained M4 knee extension. Only 1 of the 3 patients with CONFNT performed approximately 12 months after paralysis onset obtained M3 knee extension; the other 2 obtained only M1 or M2 knee extension.

CONCLUSIONS

The paralysis of the lower extremity in our patients with AFM was similar to that in poliomyelitis. However, in AFM, spontaneous recovery of knee extension was possible if there were signs of recovery from hip adductor paralysis up to 6 months after paralysis onset. CONFNT may enhance the recovery of knee extension and seems to be a reliable reconstruction for restoring knee extension if performed no more than 8 months after paralysis onset.

LEVEL OF EVIDENCE

Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Midterm Outcomes of Surgical Reconstruction and Spontaneous Recovery of Upper-Extremity Paralysis Following Acute Flaccid Myelitis

Background

Acute flaccid myelitis (AFM) is a disabling, poliomyelitis-like illness that mainly affects children. Although various surgical interventions are performed for intractable paralysis due to AFM, the timing of surgery and its long-term outcomes have yet to be established, especially for shoulder reconstruction. This study aimed to analyze the midterm outcomes of nonsurgically and surgically treated upper-extremity AFM and the factors influencing shoulder functional outcomes after surgical reconstruction.

Methods

We retrospectively examined 39 patients with AFM in 50 upper extremities between 2011 and 2019. The degree of spontaneous recovery of completely paralyzed muscles was evaluated at a median of 3, 6, and 37 months after the onset of paralysis. Twenty-seven patients with 29 extremities underwent surgery involving nerve transfer, muscle-tendon transfer, or free muscle transfer for shoulder, elbow, and hand reconstruction.

Results

Patients with complete paralysis of shoulder abduction at 6 months did not show later recovery. Twenty-two patients with 24 extremities underwent shoulder surgery, and all but 1 were followed for at least 24 months after surgery. Although postoperative shoulder abduction recovery was similar between transfer of the spinal accessory nerve and of the contralateral C7 nerve root to the suprascapular nerve, the outcomes obtained with spinal accessory nerve transfer had more variability, likely related to latent spinal accessory nerve paralysis, shoulder instability related to pectoralis major paralysis, and the type of paralysis. Shoulder abduction recovery was also greatly affected by scapulothoracic joint movement. In contrast, the outcomes of the elbow flexion and hand reconstructions were more consistent and acceptable.

Conclusions

All patients had loss of shoulder abduction, and restoration of shoulder function was less predictable and depended on the quality of the donor nerves and recovery of the synergistic muscles. Strict donor nerve selection and additional nerve transfer for shoulder reconstruction are imperative for satisfactory outcomes.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Nerve Transfer Surgery in Acute Flaccid Myelitis: Prognostic Factors, Long-Term Outcomes, Comparison With Natural History

BACKGROUND

Nerve transfer surgery is sometimes offered to patients with acute flaccid myelitis (AFM). The objectives of this study were to evaluate surgical efficacy, assess which clinical and neurophysiological data are valuable for preoperative planning, and report long-term outcomes.

METHODS

This is a single-center, retrospective case series of patients with AFM who received nerve transfer surgery. All patients had preoperative electromyography and nerve conduction studies (EMG/NCS). Matched control muscles that did not receive nerve transfer surgery were defined in the same cohort.

RESULTS

Ten patients meeting inclusion criteria received a total of 23 nerve transfers (19 upper extremity, four lower extremity). The mean age at symptom onset was 3.8 years, surgery was 0.5 to 1.25 years after diagnosis, and mean follow-up was 2.3 years (range 1.3 to 4.5 years). Among muscles with preoperative strength Medical Research Council (MRC) grade 0, muscles receiving nerve transfers performed significantly better than those that did not (MRC grade 2.17 ± 0.42 vs 0 ± 0, respectively, P = 0.0001). Preoperative EMG/NCS predicted worse outcomes in recipient muscles with more abundant acute denervation potentials (P = 0.0098). Donor nerves found to be partially denervated performed equally well as unaffected nerves. Limited data suggested functional improvement accompanying strength recovery.

CONCLUSIONS

Nerve transfer surgery is an effective strategy to restore strength for patients with AFM with persistent, severe motor deficits. Postoperative outcomes in patients with complete paralysis are better than the natural history of disease. This study demonstrates the utility of preoperative clinical and electrophysiological data in guiding patient selection for nerve transfer surgery.

Pathogenesis of enterovirus infection in central nervous system

Enteroviruses (EVs) are classified into 15 species according to their sequence diversity. They include four human EV (A, B, C, and D) and three rhinoviruses (A, B, and C), and cause diseases in millions of people worldwide. Generally, individuals with enteroviral infections have mild clinical symptoms, including respiratory illness, vomiting, diarrhea, dizziness, and fever. More importantly, some members of the human EV family are neurotropic pathogens that may cause a wide range of clinical diseases, such as aseptic meningitis and encephalitis. Previously, the EV that caused the most severe neurotropic symptoms was poliovirus (PV), a member of the EV C group. Poliovirus has been eliminated in most countries through a global vaccination campaign. Non-PV EVs infect the central nervous system (CNS) and are the major EVs causing neurological diseases. These human non-PV EVs include EV A (e.g., EV-A71, CVA6, and CVA16), B (e.g., CVA9 and CVB3, CVB5, echovirus 11 [E11], E30, and E7), C (e.g., CVA24), and D (e.g., EV-D68). Here, we review the relationship between EV infection and CNS diseases and advance in the use of cellular receptors and host immune responses during viral infection.

Telaprevir Treatment Reduces Paralysis in a Mouse Model of Enterovirus D68 Acute Flaccid Myelitis

In 2014, 2016, and 2018, the United States experienced unprecedented spikes in pediatric cases of acute flaccid myelitis (AFM), which is a poliomyelitis-like paralytic illness. Accumulating clinical, immunological, and epidemiological evidence has identified enterovirus D68 (EV-D68) as a major causative agent of these biennial AFM outbreaks. There are currently no available FDA-approved antivirals that are effective against EV-D68, and the treatment for EV-D68-associated AFM is primarily supportive. Telaprevir is an food and drug administration (FDA)-approved protease inhibitor that irreversibly binds the EV-D68 2A protease and inhibits EV-D68 replication in vitro. Here, we utilize a murine model of EV-D68 associated AFM to show that early telaprevir treatment improves paralysis outcomes in Swiss Webster (SW) mice. Telaprevir reduces both viral titer and apoptotic activity in both muscles and spinal cords at early disease time points, which results in improved AFM outcomes in infected mice. Following intramuscular inoculation in mice, EV-D68 infection results in a stereotypic pattern of weakness that is reflected by the loss of the innervating motor neuron population, in sequential order, of the ipsilateral (injected) hindlimb, the contralateral hindlimb, and then the forelimbs. Telaprevir treatment preserved motor neuron populations and reduced weakness in limbs beyond the injected hindlimb. The effects of telaprevir were not seen when the treatment was delayed, and toxicity limited doses beyond 35 mg/kg. These studies are a proof of principle, provide the first evidence of benefit of an FDA-approved antiviral drug with which to treat AFM, and emphasize both the need to develop better tolerated therapies that remain efficacious when administered after viral infections and the development of clinical symptoms. IMPORTANCE Recent outbreaks of EV-D68 in 2014, 2016, and 2018 have resulted in over 600 cases of a paralytic illness that is known as AFM. AFM is a predominantly pediatric disease with no FDA-approved treatment, and many patients show minimal recovery from limb weakness. Telaprevir is an FDA-approved antiviral that has been shown to inhibit EV-D68 in vitro. Here, we demonstrate that a telaprevir treatment that is given concurrently with an EV-D68 infection improves AFM outcomes in mice by reducing apoptosis and viral titers at early time points. Telaprevir also protected motor neurons and improved paralysis outcomes in limbs beyond the site of viral inoculation. This study improves understanding of EV-D68 pathogenesis in the mouse model of AFM. This study serves as a proof of principle for the first FDA-approved drug that has been shown to improve AFM outcomes and have in vivo efficacy against EV-D68 as well as underlines the importance of the continued development of EV-D68 antivirals.

Life-Threatening Complications of Influenza vs Coronavirus Disease 2019 (COVID-19) in US Children

BACKGROUND

Clinical differences between critical illness from influenza infection vs coronavirus disease 2019 (COVID-19) have not been well characterized in pediatric patients.

METHODS

We compared demographics, clinical characteristics, and outcomes of US children (aged 8 months to 17 years) admitted to the intensive care or high-acuity unit with influenza or COVID-19. Using mixed-effects models, we assessed the odds of death or requiring life support for influenza vs COVID-19 after adjustment for age, sex, race and Hispanic origin, and underlying conditions including obesity.

RESULTS

Children with influenza (n = 179) were younger than those with COVID-19 (n = 381; median, 5.2 years vs 13.8 years), less likely to be non-Hispanic Black (14.5% vs 27.6%) or Hispanic (24.0% vs 36.2%), and less likely to have ≥1 underlying condition (66.4% vs 78.5%) or be obese (21.4% vs 42.2%), and a shorter hospital stay (median, 5 days vs 7 days). They were similarly likely to require invasive mechanical ventilation (both 30.2%), vasopressor support (19.6% and 19.9%), or extracorporeal membrane oxygenation (2.2% and 2.9%). Four children with influenza (2.2%) and 11 children with COVID-19 (2.9%) died. The odds of death or requiring life support in children with influenza vs COVID-19 were similar (adjusted odds ratio, 1.30; 95% confidence interval, .78-2.15; P = .32).

CONCLUSIONS

Despite differences in demographics and clinical characteristics of children with influenza or COVID-19, the frequency of life-threatening complications was similar. Our findings highlight the importance of implementing prevention measures to reduce transmission and disease severity of influenza and COVID-19.

Acute Flaccid Myelitis: Review of Clinical Features, Diagnosis, and Management with Nerve Transfers

BACKGROUND

Acute flaccid myelitis (AFM) is a devastating neurologic condition in children, manifesting as acute limb weakness and/or paralysis. Despite increased awareness of AFM following initiation of U.S. surveillance in 2014, no treatment consensus exists. The purpose of this systematic review was to summarize the most current knowledge regarding AFM epidemiology, cause, clinical features, diagnosis, and supportive and operative management, including nerve transfer.

METHODS

The authors systematically reviewed the literature based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using multiple databases to search the keywords ("acute flaccid myelitis"), ('acute flaccid myelitis'/exp OR 'acute flaccid myelitis'), and (Acute AND flaccid AND myelitis). Included articles reported on (1) AFM diagnosis and (2) patient-specific data regarding epidemiology, cause, clinical features, diagnostic features, or management of AFM.

RESULTS

Ninety-nine articles were included in this review. The precise cause and pathophysiologic mechanism of AFM remain undetermined, but AFM is strongly associated with nonpolio enterovirus infections. Clinical presentation typically comprises preceding viral prodrome, pleocytosis, spinal cord lesions on T2-weighted magnetic resonance imaging, and acute onset of flaccid weakness/paralysis with hyporeflexia in at least one extremity. Supportive care includes medical therapy and rehabilitation. Early studies of nerve transfer for AFM have shown favorable outcomes for patients with persistent weakness.

CONCLUSIONS

Supportive care and physical therapy are the foundation of a multidisciplinary approach to managing AFM. For patients with persistent limb weakness, nerve transfer has shown promise for improving function in distal muscle groups. Surgeons must consider potential spontaneous recovery, patient selection, donor nerve availability, recipient nerve appropriateness, and procedure timing.

Six- and 12-month functional outcomes among patients with confirmed acute flaccid myelitis (AFM) with onset in 2018, United States

PURPOSE

Acute flaccid myelitis (AFM), an uncommon but serious neurologic condition, primarily affects children, and can progress quickly to paralysis and respiratory failure. Data on long-term outcomes of patients with AFM are limited. This study reports on functional status through 12 months for AFM patients who became ill in 2018 in the United States.

METHODS

Health departments collected information on outcomes at 6 and 12 months after onset of AFM using a standardized form that asked patients or their parents/guardians about functional status. Analyses were restricted to confirmed cases.

RESULTS

Of the 238 confirmed AFM cases reported to CDC in 2018, 90 (38%) had assessments at 6 months, 82 (34%) at 12 months, and 49 (21%) at both 6 and 12 months. Among the 49 patients with data at both time points, the proportion of patients reporting significant or severe impairment at 6 months ranged from 2% to 59% depending on the outcome. Although proportions decreased by 12 months and ranged from 2% to 51%, most patients had some impairment at 12 months. No deaths were reported.

CONCLUSION

Six- and 12-month outcomes in patients with onset of AFM in 2018 span a wide range of functionality, particularly of upper and lower extremities. Importantly, improvement appears to occur over time in some patients.

Acute flaccid myelitis a review of the literature

Acute flaccid myelitis (AFM) is a rare neurological disorder that first rose to national attention in 2014. This neurological disorder has a biennial presentation with every other even year being a peak year. Most patients present in childhood 5 days after a prodromal infection. Patients usually present with muscle weakness and hypo or areflexia in the summer or fall months. Clinical outcomes are variable however most patients do not improve. Currently there are no definitive prognostic factors or etiologies found. However, it is thought that enterovirus-D68 (EV-D68) could be a potential component in the pathobiology of AFM. Treatment options are limited with variable options and no consensus. Supportive therapy has been shown to be the most effective thus far. With our review of the literature, we highlight the recent growing evidence of a possible relationship between EV-D68 and AFM. Additionally, we identify the knowledge gaps in AFM with treatment and prognostic factors.

Animal Models of Enterovirus D68 Infection and Disease

Human enterovirus D68 (EV-D68) is a globally reemerging respiratory pathogen that is associated with the development of acute flaccid myelitis (AFM) in children. Currently, there are no approved vaccines or treatments for EV-D68 infection, and there is a paucity of data related to the virus and host-specific factors that predict disease severity and progression to the neurologic syndrome. EV-D68 infection of various animal models has served as an important platform for characterization and comparison of disease pathogenesis between historic and contemporary isolates. Still, there are significant gaps in our knowledge of EV-D68 pathogenesis that constrain the development and evaluation of targeted vaccines and antiviral therapies. Continued refinement and characterization of animal models that faithfully reproduce key elements of EV-D68 infection and disease is essential for ensuring public health preparedness for future EV-D68 outbreaks.

Circulation of enterovirus D68 (EV-D68) causing respiratory illness in New South Wales, Australia, between August 2018 and November 2019

The incidence of enterovirus D68 (EV-D68) in New South Wales, Australia, is unknown. As part of a state-wide surveillance program, enterovirus positive diagnostic specimens were assessed from patients presenting to hospitals with respiratory and meningitis syndromes from August 2018 to November 2019. Diagnostic enterovirus positive samples were collected from 339 patients and re-extracted followed by targeted PCR across the whole EV-D68 genome (7.4 kb). Obtained amplicons (n=208) were sequenced using Illumina sequencing technology and the phylogenetic relationships analysed relative to EV-D68 Fermon strain. We identified EV-D68 in 31 patients, both children (n=27) and adults (n=4). Phylogenetically, the majority (n=30) were from subclade B3, the same as that causing outbreaks of EV-D68 across the USA and Europe during 2018. These data strengthen the importance of having an active enterovirus surveillance network.

Enterovirus D68 epidemic, UK, 2018, was caused by subclades B3 and D1, predominantly in children and adults, respectively, with both subclades exhibiting extensive genetic diversity

Enterovirus D68 (EV-D68) has recently been identified in biennial epidemics coinciding with diagnoses of non-polio acute flaccid paralysis/myelitis (AFP/AFM). We investigated the prevalence, genetic relatedness and associated clinical features of EV-D68 in 193 EV-positive samples from 193 patients in late 2018, UK. EV-D68 was detected in 83 (58 %) of 143 confirmed EV-positive samples. Sequencing and phylogenetic analysis revealed extensive genetic diversity, split between subclades B3 (n=50) and D1 (n=33), suggesting epidemiologically unrelated infections. B3 predominated in children and younger adults, and D1 in older adults and the elderly (P=0.0009). Clinical presentation indicated causation or exacerbation of respiratory distress in 91.4 % of EV-D68-positive individuals, principally cough (75.3 %), shortness of breath (56.8 %), coryza (48.1 %), wheeze (46.9 %), supplemental oxygen required (46.9 %) and fever (38.9 %). Two cases of AFM were observed, one with EV-D68 detectable in the cerebrospinal fluid, but otherwise neurological symptoms were rarely reported (n=4). Both AFM cases and all additional instances of intensive care unit (ICU) admission (n=5) were seen in patients infected with EV-D68 subclade B3. However, due to the infrequency of severe infection in our cohort, statistical significance could not be assessed.

Upper extremity nerve transfers for acute flaccid myelitis: a systematic literature review

BACKGROUND

Acute flaccid myelitis (AFM) is a rare disease that commonly affects young children. AFM's pathophysiology involves loss of lower motor neurons following a viral infection and induces acute asymmetric flaccid paralysis most commonly in the upper extremities. Nerve transfers have emerged as a treatment option for these patients with permanent motor deficits.

OBJECTIVE

To summarize the literature and report safety and efficacy outcomes following nerve transfers for recovery of shoulder abduction and external rotation, and elbow flexion and extension in pediatric patients with AFM. Recovery of at least antigravity function was defined as a successful outcome. This systematic review was performed according to the PRISMA guidelines. The PubMed, Embase and Cochrane databases were utilized.

RESULTS

Five studies comprising 44 patients (median age 2.95 years; 71% male), and 93 upper extremity nerve transfers were included. Thirty-eight patients received 65 nerve transfer procedures aiming for recovery of shoulder abduction and/or external rotation with a transfer to the axillary and/or suprascapular nerve. The recovery of shoulder abduction and external rotation was achieved in 40.7% (n = 11/27) and 60% (n = 6/10) of patients, respectively. Time from injury to surgery showed an inverse relationship with the odds for successful recovery (OR: 0.81; 95% CI: 0.64-1.02; p = 0.07); however, statistical significance was not reached. Successful recovery of elbow flexion with a transfer to the musculocutaneous was reported at a rate of 92.3% (n = 12/13). Successful re-innervation of the radial nerve with recovery of elbow extension was found in 75% (n = 6/8) of patients. No complications were reported.

CONCLUSIONS

Upper extremity nerve transfers appear to be promising and safe for AFM patients. Shoulder abduction is the most challenging upper extremity function to recover. Further studies are warranted to identify whether nerve transfers are associated with superior outcomes when performed earlier.

Does acute flaccid myelitis cause respiratory failure in children?

INTRODUCTION

Acute flaccid myelitis (AFM) is a rare disease that affects spinal cord gray matter, results in acute flaccid weakness of one or more limbs and predominantly involves the cervical spinal cord, which places patients at higher risk for respiratory failure. Our study aims to describe respiratory failure in pediatric AFM patients with emphasis on the need for assisted ventilation and respiratory nerve involvement from an acute and long-term perspective.

MATERIALS AND METHODS

We reviewed the medical records of patients diagnosed with AFM seen in a multidisciplinary clinic for persistent limb weakness between 2016 and 2020.

RESULTS

We studied 54 patients, 35% were female. The median age of patients at illness onset was 5 years (range 7 months-19 years). The median age of patients at the time of study was 8.5 years (range 2-20 years). Eleven patients (20%) required assisted ventilation for acute respiratory failure. Of those that experienced acute respiratory failure, 81% developed chronic respiratory failure. Fifty-six percent of patients with chronic respiratory failure were able to wean off assisted ventilation by 1 year. All patients that experienced unilateral diaphragm impairment with AFM onset experienced acute and chronic respiratory failure.

DISCUSSION

Many patients with AFM may experience respiratory compromise and develop chronic respiratory failure. However, most of these patients can be weaned off ventilatory support by 1 year from illness onset. Most children with unilateral diaphragm impairment can sustain adequate ventilation without the need for long-term ventilatory support.

Nerve Transfers for Restoration of Elbow Flexion in Patients With Acute Flaccid Myelitis

PURPOSE

The purpose of this study was to evaluate short- to midterm outcomes of patients with acute flaccid myelitis who underwent nerve transfers for restoration of elbow flexion.

METHODS

Patients with a minimum of 10 months of follow up after undergoing nerve transfers to restore elbow flexion were clinically assessed using the Active Movement Scale (AMS). They were evaluated for any postoperative complications, particularly weakness in the distribution of the donor nerve(s). Fifteen of 25 consecutive patients who were treated using this surgical technique were included in the final analysis.

RESULTS

All patients exhibited poor elbow flexion preoperatively (AMS 0 to 3). At a mean follow up of 17.3 months, 80% (15/25) of patients achieved excellent elbow flexion (AMS 6 or 7); 9 of these 15 had full active range of motion. Two patients achieved good elbow flexion (AMS 5) with antigravity movement to less than 50% of the passive range of motion. No cases of superficial or deep infection were reported, and all patients maintained identical motor function, relative to preoperative status, of the muscles innervated by the donor nerves.

CONCLUSIONS

Nerve transfer surgery has shown promising short- to midterm results for recovery of nerve and muscle function, particularly for the restoration of elbow flexion. We recommend this treatment option for patients not demonstrating clinical improvement after 6 to 9 months of incomplete recovery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Retrospective Analysis of Six Years of Acute Flaccid Paralysis Surveillance and Polio Vaccine Coverage Reported by Italy, Serbia, Bosnia and Herzegovina, Montenegro, Bulgaria, Kosovo, Albania, North Macedonia, Malta, and Greece

Here we analyzed six years of acute flaccid paralysis (AFP) surveillance, from 2015 to 2020, of 10 countries linked to the WHO Regional Reference Laboratory, at the Istituto Superiore di Sanità, Italy. The analysis also comprises the polio vaccine coverage available (2015-2019) and enterovirus (EV) identification and typing data. Centralized Information System for Infectious Diseases and Laboratory Data Management System databases were used to obtain data on AFP indicators and laboratory performance and countries' vaccine coverage from 2015 to 2019. EV isolation, identification, and typing were performed by each country according to WHO protocols. Overall, a general AFP underreporting was observed. Non-Polio Enterovirus (NPEV) typing showed a high heterogeneity: over the years, several genotypes of coxsackievirus and echovirus have been identified. The polio vaccine coverage, for the data available, differs among countries. This evaluation allows for the collection, for the first time, of data from the countries of the Balkan area regarding AFP surveillance and polio vaccine coverage. The need, for some countries, to enhance the surveillance systems and to promote the polio vaccine uptake, in order to maintain the polio-free status, is evident.

Re-emergence of enterovirus D68 in Europe after easing the COVID-19 lockdown, September 2021

We report a rapid increase in enterovirus D68 (EV-D68) infections, with 139 cases reported from eight European countries between 31 July and 14 October 2021. This upsurge is in line with the seasonality of EV-D68 and was presumably stimulated by the widespread reopening after COVID-19 lockdown. Most cases were identified in September, but more are to be expected in the coming months. Reinforcement of clinical awareness, diagnostic capacities and surveillance of EV-D68 is urgently needed in Europe.

Acute flaccid myelitis and Guillain-Barré syndrome in children: A comparative study with evaluation of diagnostic criteria

BACKGROUND AND PURPOSE

Differentiation between acute flaccid myelitis (AFM) and Guillain-Barré syndrome (GBS) can be difficult, particularly in children. Our objective was to improve the diagnostic accuracy by giving recommendations based on a comparison of clinical features and diagnostic criteria in children with AFM or GBS.

METHODS

A cohort of 26 children with AFM associated with enterovirus D68 was compared to a cohort of 156 children with GBS. The specificity of the Brighton criteria, used for GBS diagnosis, was evaluated in the AFM cohort and the specificity of the Centers for Disease Control and Prevention (CDC) AFM diagnostic criteria in the GBS cohort.

RESULTS

Children with AFM compared to those with GBS had a shorter interval between onset of weakness and nadir (3 vs. 8 days, p < 0.001), more often had asymmetric limb weakness (58% vs. 0%, p < 0.001), and less frequently had sensory deficits (0% vs. 40%, p < 0.001). In AFM, cerebrospinal fluid leukocyte counts were higher, whereas protein concentrations were lower. Spinal cord lesions on magnetic resonance imaging were only found in AFM patients. No GBS case fulfilled CDC criteria for definite AFM. Of the AFM cases, 8% fulfilled the Brighton criteria for GBS, when omitting the criterion of excluding an alternate diagnosis.

CONCLUSIONS

Despite the overlap in clinical presentation, we found distinctive early clinical and diagnostic characteristics for differentiating AFM from GBS in children. Diagnostic criteria for AFM and GBS usually perform well, but some AFM cases may fulfill clinical diagnostic criteria for GBS. This underlines the need to perform diagnostic tests early to exclude AFM in children suspected of atypical GBS.

Acute Flaccid Myelitis

Acute flaccid myelitis (AFM) is an incompletely understood neurologic disorder occurring in epidemic fashion causing weakness ranging from mild paresis to devastating paralysis in children and some adults. This article reviews the case definition of AFM as well as its epidemiology and association with enteroviral infection. The clinical presentation, diagnostic investigation with particular attention to electrodiagnostics, acute management, and surgical options are described. Clinical outcomes and considerations for acute and long-term rehabilitation management are discussed extensively based on review of current literature, highlighting avenues for further study.

Acute Flaccid Myelitis: A Multidisciplinary Protocol to Optimize Diagnosis and Evaluation

Acute flaccid myelitis is an emerging neurologic disease, first described in 2014 and predominantly affecting young children. Acute flaccid myelitis cases tend to spike every 2 years, in the late summer to fall, and the next peak is expected in 2020. The diagnosis of acute flaccid myelitis is often delayed, leading to suboptimal evaluation, including incomplete laboratory assessment. Acute and chronic morbidity are high, and a standardized, multidisciplinary approach to evaluation and treatment is essential to optimizing outcomes. In a review of acute flaccid myelitis patients treated in 2018 at our institution, we noted considerable variability in days to presentation, evaluation, and treatment. In response, the authors developed a protocol for the evaluation and management of pediatric patients suspected of having acute flaccid myelitis. The protocol was developed using local experience/case review, expert consensus, and the relevant literature. The protocol spans the spectrum of care, from initial evaluation in a primary care or emergency setting, to acute hospital management and evaluation and long-term inpatient and rehabilitation settings. The purpose of this report is both to share the findings from our 2018 case review and to disseminate our acute flaccid myelitis protocol. Our hope is that publication of our protocol will both inform the development of a standardized approach to acute flaccid myelitis and to encourage other centers to form a multidisciplinary acute flaccid myelitis team to provide expert care throughout the disease process, from presentation to recovery.

Survey of diagnostic and typing capacity for enterovirus infection in Italy and identification of two echovirus 30 outbreaks

BACKGROUND

Enterovirus infections can cause a variety of illnesses, ranging from asymptomatic infections to severe illness and death.

AIM

To support polio eradication activities, in February 2019, the WHO Regional Reference Laboratory for polio in Italy, at the National Institute of Public Health (Istituto Superiore di Sanità), promoted an investigation on non-polio enterovirus laboratory capacity, with the support of the Italian Ministry of Health. The aim was to collect data on the assays used routinely for diagnostic purposes and to characterize enterovirus outbreaks strains by sequence analysis of the Viral Protein 1 region.

METHODS

A questionnaire was administered to public health laboratories through all Italian Regions for 2018 and subsequently, an electronic form for lab-confirmed enterovirus infection reported from February 2019 to January 2020, including patients clinical characteristics, and laboratory data was distributed through 25 laboratories participating the survey.

RESULTS

Overall, a homogenous laboratory capacity for enterovirus infection diagnosis was found and 21,000 diagnostic tests were retrospectively reported in 2018. Then, in 2019, two outbreaks of Echovirus 30 were identified and confirmed by molecular analyses.

CONCLUSION

These results underline the need monitor the circulation of non-polio enterovirus to ascertain the real burden of the disease in the country.

Acute flaccid myelitis: cause, diagnosis, and management

Acute flaccid myelitis (AFM) is a disabling, polio-like illness mainly affecting children. Outbreaks of AFM have occurred across multiple global regions since 2012, and the disease appears to be caused by non-polio enterovirus infection, posing a major public health challenge. The clinical presentation of flaccid and often profound muscle weakness (which can invoke respiratory failure and other critical complications) can mimic several other acute neurological illnesses. There is no single sensitive and specific test for AFM, and the diagnosis relies on identification of several important clinical, neuroimaging, and cerebrospinal fluid characteristics. Following the acute phase of AFM, patients typically have substantial residual disability and unique long-term rehabilitation needs. In this Review we describe the epidemiology, clinical features, course, and outcomes of AFM to help to guide diagnosis, management, and rehabilitation. Future research directions include further studies evaluating host and pathogen factors, including investigations into genetic, viral, and immunological features of affected patients, host-virus interactions, and investigations of targeted therapeutic approaches to improve the long-term outcomes in this population.

Nerve transfers for acute flaccid myelitis: a case series

BACKGROUND

Acute flaccid myelitis (AFM) syndrome consists of loss of lower motor neurons following a viral infection, with preserved sensory function. It usually affects the upper limbs asymmetrically, with proximal more than distal muscle involvement.

METHODS

Five cases were surgically treated with nerve transfers: spinal accessory to suprascapular nerve transfer (4 patients), branch of radial nerve to axillary nerve transfer (Somsak's procedure) (2 patients), and transfer of a fascicle of the ulnar nerve to the motor branch to the biceps (Oberlin's procedure) (1 patient).

RESULTS

Motor improvement was seen in three cases. Widespread motor involvement was associated with poor outcome.

CONCLUSION

This small series of cases reinforces that nerve transfers are a reliable option for treatment of selected children with AFM.

The Utilization of Nerve Transfer for Reestablishing Shoulder Function in the Setting of Acute Flaccid Myelitis: A Single-Institution Review

BACKGROUND

Acute flaccid myelitis (AFM) is a rare disease of young children. The typical presentation involves acute-onset flaccid paralysis in one or more extremities with a nonspecific viral prodrome. Long-term outcomes demonstrate that functional recovery plateaus around six to nine months. The purpose of this study was to evaluate the efficacy of nerve transfers for restoring shoulder function in these patients.

METHODS

A retrospective review of all patients diagnosed with AFM at a single institution. Shoulder function was evaluated using the active movement scale (AMS). Children at a minimum of six months after diagnosis with plateaued shoulder AMS scores of 4 or less were indicated for surgery.

RESULTS

Eleven patients were identified with a mean time from symptom onset to surgery of 12 months. Average follow-up was 19 months. The mean AMS score at follow-up for shoulder external rotation and abduction was 4.6 and 2.8, respectively. A total of six different nerve transfers with five different donor nerves were used individually or in conjunction with each other. The most common transfers were from the spinal accessory nerve to the suprascapular nerve (n = 8) and from the intercostal nerves ×3 to the axillary nerve (n = 5). Patients who received a transfer from the radial nerve to the axillary nerve (n = 2) had the best functional returns, with the mean AMS score of 6.5 in both external rotation and abduction at follow-up.

CONCLUSION

Nerve transfer procedures may help restore shoulder function in the setting of AFM. Combination procedures that involve a transfer from the radial nerve to the axillary nerve may provide the best functional results.

Update on acute flaccid myelitis: recognition, reporting, aetiology and outcomes

Acute flaccid myelitis, defined by acute flaccid limb weakness in the setting of grey matter lesions of the spinal cord, became increasingly recognised in 2014 following outbreaks in Colorado and California, temporally associated with an outbreak of enterovirus D68 respiratory disease. Since then, there have been biennial increases in late summer/early fall. A viral infectious aetiology, most likely enteroviral, is strongly suspected, but a definitive connection has yet to be established. Patients typically present with asymmetric weakness, maximal proximally, in the setting of a febrile illness. MRI demonstrates T2/FLAIR abnormalities in the central grey matter of the spinal cord, and cerebrospinal fluid typically shows a lymphocytic pleocytosis with variable elevation in protein. The weakness may be progressive over several days and involve respiratory muscles, making early recognition and close monitoring essential. Other complications in the acute period may include autonomic instability and bowel/bladder involvement. There is no clear recommended treatment at this time, although intravenous immunoglobulin, steroids and plasma exchange have been used. Intensive therapies and rehab services have shown benefit in maximising function, and surgical interventions may be considered in cases without optimal response to therapies. Close attention should also be paid to psychosocial factors. Prognosis is generally guarded, and additional factors that predict final outcome, including host factors and treatment effects, have yet to be elucidated. Multicentre collaborative efforts will be required to provide answers about this rare but serious disorder.

Enterovirus infection and acute flaccid myelitis

Recent outbreaks of limb paralysis similar to poliomyelitis, termed acute flaccid myelitis (AFM), have prompted intense investigation into potential etiology. Peaks of AFM were seen in the United States in 2012, 2014, 2016 and 2018, coincident with peaks in enterovirus transmission, particularly EV-D68. Similar peaks of AFM and EV-D68 circulation were reported in other parts of the world. The causal relationship between EV-D68 is still not widely accepted as it is for poliovirus and EV-A71, the latter of which is endemic in the US. Recent in vitro and mouse model data as well as enhanced-sensitivity diagnostic assays have provided further evidence linking the causal relationship between EV-D68 and AFM. In addition, an outbreak of EV-A71-associated AFM was recently described, highlighting the possibility of an additional emerging non-polio enterovirus of public health concern. As AFM is a devastating disease with poor prognosis in many children, particularly those with EV-D68, recent studies call for increased surveillance, pursuit of novel therapeutics and strategies to prevent transmission before the next outbreak.

Severe Acute Flaccid Myelitis Associated With Enterovirus in Children: Two Phenotypes for Two Evolution Profiles?

Acute flaccid myelitis (AFM) is an acute paralysis syndrome defined by a specific inflammation of the anterior horn cells of the spinal cord. From 2014, worrying waves of life-threatening AFM consecutive to enterovirus infection (EV-D68 and EV-A71) have been reported. We describe 10 children displaying an AFM with an EV infection, the treatments performed and the 1 to 3-years follow-up. Two groups of patients were distinguished: 6 children (“polio-like group”) had severe motor disability whereas 4 other children (“brainstem group”) displayed severe brainstem weakness requiring ventilation support. Electrodiagnostic studies (n = 8) support the presence of a motor neuronopathy associated to myelitis. The best prognosis factor seems to be the motor recovery after the first 4 weeks of the disease.

Acute Flaccid Myelitis Among Hospitalized Children in Texas, 2016

BACKGROUND

Acute flaccid myelitis is characterized by acute-onset flaccid limb weakness with predominantly gray matter lesions in the spinal cord spanning one or more segments. Rates of full recovery are poor, and there is no standard treatment or definitive cause.

METHODS

This is a retrospective review of children diagnosed with acute flaccid myelitis in Texas during 2016. Patients were identified through a Texas collaborative of six hospitals in four major metropolitan areas. Data abstraction included health history, illness presentation, medical treatments, laboratory studies, imaging data, recovery, and ability to perform activities of daily living up to approximately two years from illness onset.

RESULTS

Among all sites, 21 patients met inclusion criteria. Treatments varied with the most common being intravenous immunoglobulin, high-dose methylprednisolone, and plasmapheresis. No differences were seen in response to medical treatments. A potential etiology was found in 12 (57%) cases, including four with enterovirus D68. Five cases recovered fully. Of the 16 patients without full recovery, abilities ranged from (1) able to perform all activities of daily living for age independently (n = 5), (2) mild deficits (n = 5), and (3) substantial reliance on caregivers for activities of daily living (n = 6).

CONCLUSION

Many reports describe symptoms and outcomes of acute flaccid myelitis, but limited data are available on long-term functional outcomes. We were unable to make a strong case for any single cause or treatment modality. Fortunately, the majority of patients (15, 71%) were able to perform activities of daily living with complete independence or only mild deficits.

Acute Flaccid Myelitis: Current Status and Diagnostic Challenges

Acute flaccid myelitis (AFM) is a sudden-onset polio-like neuromuscular disability found commonly in young children. There is an increasing incidence of confirmed AFM cases in the USA and other countries in recent years, and in association with nonpolio enterovirus infection. This represents a significant challenge to clinicians and causes significant concern to the general public. Acute flaccid paralysis (AFP) is the long-known limb paralytic syndrome caused by a viral pathogen. AFM is a subset of AFP that is also characterized by a limb paralytic condition, but it has certain distinct features such as lesions in magnetic resonance imaging of the spinal cord gray matter. AFM leads to spinal cord, brainstem, or motor neuron dysfunction. The clinical phenotypes, pathology, and patient presentation of AFM closely mimic AFP. This article provides a concise overview of our current understanding of AFM and the clinical features that distinguish AFM from AFP and similar other neurological infectious and autoimmune diseases or disorders. We also discuss the diagnosis, clinical pathology, possible pathogenetic mechanisms, and currently available therapies.

Circulation of non-polio enteroviruses in 24 EU and EEA countries between 2015 and 2017: a retrospective surveillance study

BACKGROUND

Enteroviruses can cause severe infections, especially in young children. Non-polio enterovirus infections are not notifiable in most countries in the EU and European Economic Area (EEA) region, and surveillance varies substantially between countries. We collected and analysed available enterovirus data across EU and EEA countries to assess the current epidemiological situation and need for standardising surveillance.

METHODS

Aggregated data on any enterovirus detected between Jan 1, 2015, and Dec 31, 2017, through national enterovirus reference laboratories were requested from representatives in all 31 EU and EEA countries. Information collected included enterovirus types detected by month, patient age group, symptom, and specimen type. We also collected sequence data on viral capsid sequences for the three most clinically relevant enterovirus types, as identified from the data.

FINDINGS

Aggregated data were provided by representatives from 24 (77%) of 31 countries. 9914 (66%) of 14 999 enterovirus infections with information about age were in children younger than 5 years, and 3197 (45%) of 7139 individuals for whom symptoms were reported had neurological symptoms. Other symptoms were non-specific fever (in 1607 [23%] patients), respiratory symptoms (in 1197 [17%] patients), hand, foot, and mouth disease (in 528 [7% patients), and myocarditis (in 39 [1%] patients). 68 deaths were temporally associated with enterovirus infection. Typing for 11 559 (67%) of 17 136 specimens revealed 66 enterovirus types. Coxsackievirus A6 was the most frequently detected enterovirus type (in 1556 [13%] of 11 559 typed enteroviruses), and 292 (65%) of 448 patients with coxsackievirus A6 infection with available clinical data presented with hand, foot, and mouth disease. Echovirus 30 was the second most frequently detected enterovirus type, representing 1412 (12%) of 11 559 typed enteroviruses, and 384 (82%) of 467 individuals with echovirus 30 infection with available clinical data had neurological symptoms. Sequences available from 18 countries showed circulation of newly emerging strains of enterovirus A71 and enterovirus D68.

INTERPRETATION

To our knowledge, this study is the largest investigation of enterovirus circulation in EU and EEA countries and confirms the availability of non-polio enterovirus data in the region. Our study highlights the wide circulation of non-polio enteroviruses in Europe, mostly affecting young children and leading to neurological symptoms. Collecting data on morbidity and mortality related to enterovirus infections, as well as harmonising case definition for surveillance, should be encouraged.

FUNDING

None.

Understanding Enterovirus D68-Induced Neurologic Disease: A Basic Science Review

In 2014, the United States (US) experienced an unprecedented epidemic of enterovirus D68 (EV-D68)-induced respiratory disease that was temporally associated with the emergence of acute flaccid myelitis (AFM), a paralytic disease occurring predominantly in children, that has a striking resemblance to poliomyelitis. Although a definitive causal link between EV-D68 infection and AFM has not been unequivocally established, rapidly accumulating clinical, immunological, and epidemiological evidence points to EV-D68 as the major causative agent of recent seasonal childhood AFM outbreaks in the US. This review summarizes evidence, gained from in vivo and in vitro models of EV-D68-induced disease, which demonstrates that contemporary EV-D68 strains isolated during and since the 2014 outbreak differ from historical EV-D68 in several factors influencing neurovirulence, including their genomic sequence, their receptor utilization, their ability to infect neurons, and their neuropathogenicity in mice. These findings provide biological plausibility that EV-D68 is a causal agent of AFM and provide important experimental models for studies of pathogenesis and treatment that are likely to be difficult or impossible in humans.

Acute flaccid myelitis caused by enterovirus D68: Case definitions for use in clinical practice

Acute flaccid myelitis (AFM) was increasingly detected in recent years, coinciding with upsurges of enterovirus D68 (EV-D68) infections. We reviewed the evidence for a causal relationship between both. Based on reported cases, we provide case definitions for AFM caused by EV-D68 infections to enable a standard procedure for affected patients. Current case definitions are focussing on epidemiological aspects but clinical case definitions are still missing. We propose the following case definitions to be used in clinical practice in order to mirror clinical realities and facilitate a common systematic approach in case management: A possible case is defined as a person presenting with either acute myelitis/paralysis or Guillain-Barré Syndrome (GBS), particularly during periods of EV-D68 circulation. A probable case is defined as a person presenting with symptoms of either acute myelitis/paralysis or GBS and at least one of the following criteria: i) MRI abnormality representing with T2 hyperintensity in spinal cord grey matter with or without hyperintensity at dorsal brain stem, ii) investigations showing an axonal neuropathy including reduced compound motor action potentials with normal conduction velocities and absence of conduction blocks compatible with anterior horn cell disease or iii) detection of enteroviruses in a respiratory specimen obtained from the lower respiratory tract during periods of EV-D68 circulation. A confirmed case is defined as a person presenting with acute flaccid myelitis/paralysis, MRI abnormality and detection of enterovirus-D68-specific nucleic acids in a respiratory specimen using a validated PCR assay targeting the VP1 gene with subsequent sequencing and typing.

Acute flaccid myelitis and enterovirus D68: lessons from the past and present

Acute flaccid myelitis is characterized by the combination of acute flaccid paralysis and a spinal cord lesion largely restricted to the gray matter on magnetic resonance imaging. The term acute flaccid myelitis was introduced in 2014 after the upsurge of pediatric cases in the USA with enterovirus D68 infection. Since then, an increasing number of cases have been reported worldwide. Whereas the terminology is new, the clinical syndrome has been recognized in the past in association with several other neurotropic viruses such as poliovirus.Conclusion: This review presents the current knowledge on acute flaccid myelitis with respect to the clinical presentation and its differential diagnosis with Guillain-Barré syndrome and acute transverse myelitis. We also discuss the association with enterovirus D68 and the presumed pathophysiological mechanism of this infection causing anterior horn cell damage. Sharing clinical knowledge and insights from basic research is needed to make progress in diagnosis, treatment, and prevention of this new polio-like disease. What is Known: • Acute flaccid myelitis (AFM) is a polio-like condition characterized by rapid progressive asymmetric weakness, together with specific findings on MRI • AFM has been related to different viral agents, but recent outbreaks are predominantly associated with enterovirus D68. What is New: • Improving knowledge on AFM must increase early recognition and adequate diagnostic procedures by clinicians. • The increasing incidence of AFM urges cooperation between pediatricians, neurologists, and microbiologists for the development of treatment and preventive options.