Health

Advisory

ACUTE NEUROLOGIC ILLNESS WITH FOCAL LIMB WEAKNESS OF UNKNOWN ETIOLOGY IN CHILDREN

Forwarded by the Delaware Division of Public Health (DPH)

Summary:

The Centers for Disease Control and Prevention (CDC) is working closely with the Colorado Department of Public Health and Environment

(CDPHE) and Children’s Hospital Colorado to investigate a cluster of nine pediatric patients hospitalized with acute neurologic

illness of undetermined etiology. The illness is characterized by focal limb weakness and abnormalities of the spinal cord gray matter on

MRI.  These illnesses have occurred since August 1, 2014 coincident with an increase of respiratory illnesses among children in

Colorado. The purpose of this HAN Advisory is to provide awareness of this neurologic syndrome under investigation with the aim of

determining if children with similar clinical and radiographic findings are being cared for in other geographic areas.  Guidance

about reporting cases to state and local health departments and CDC is provided.  Please disseminate this information to infectious

disease specialists, intensive care physicians, pediatricians, neurologists, radiologists/neuroradiologists, infection preventionists,

and primary care providers, as well as to emergency departments and microbiology laboratories.

Background

The CDPHE, Children’s Hospital Colorado, and CDC are investigating nine cases of acute neurologic illness among pediatric patients.

The cases were identified during August 9–September 17, 2014 among children aged 1–18 years (median age 10 years). Most of

the children were from the Denver metropolitan area. All were hospitalized. Common features included acute focal limb weakness and

specific findings on magnetic resonance imaging (MRI) of the spinal cord consisting of non-enhancing lesions largely restricted to the

gray matter. In most cases, these lesions spanned more than one level of the spinal cord. Some also had acute cranial nerve dysfunction

with correlating non-enhancing brainstem lesions on MRI. None of the children experienced altered mental status or seizures. None had any

cortical, subcortical, basal ganglia, or thalamic lesions on MRI. Most children reported a febrile respiratory illness in the two weeks

preceding development of neurologic symptoms. In most cases, cerebrospinal fluid (CSF) analyses demonstrated mild-moderate pleocytosis

(increased cell count in the CSF) consistent with an inflammatory or infectious process. CSF testing to date has been negative for

enteroviruses, including poliovirus and West Nile virus. Nasopharyngeal specimens were positive for rhinovirus/enterovirus in six out of

eight patients that were tested. Of the six positive specimens, four were typed as EV-D68, and the other two are pending typing results.

Testing of other specimens is still in process. Eight out of nine children have been confirmed to be up to date on polio vaccinations.

Epidemiologic and laboratory investigations of these cases are ongoing.

The United States is currently experiencing a nationwide outbreak of EV-D68 associated with severe respiratory disease. The possible

linkage of this cluster of neurologic disease to this large EV-D68 outbreak is part of the current investigation. CDC is seeking

information about other similar neurologic illnesses in all states, especially cases clustered in time and place. CDC has particular

interest in characterizing the epidemiology and etiology of such cases.

Recommendations

• Patients who meet the following case definition should be reported to state and local health departments:Patients ≤21 years of age with
  1. Acute onset of focal limb weakness occurring on or after August 1, 2014;AND
  2. An MRI showing a spinal cord lesion largely restricted to gray matter.
• State and local health departments should report patients meeting the case definition to CDC using a brief patient summary form(www.cdc.gov/non-polio-enterovirus/investigation/).

  State health departments should send completed summary forms to CDC by email at limbweakness@cdc.gov.

• Providers treating patients meeting the above case definition should consult with their local and state health department forlaboratory testing of stool, respiratory, and cerebrospinal fluid specimens for enteroviruses, West Nile virus, and other known

  infectious etiologies.

• Health departments may contact CDC for further laboratory and epidemiologic support by phone through the CDC Emergency OperationsCenter (770-488-7100), or by email at limbweakness@cdc.gov. Confirmation of the

  presence of EV-D68 currently requires typing by molecular sequencing.

For More Information or to Report a Case

For more information regarding enterovirus, and/or to report an enterovirus D68 (EVD-68) case or an Acute Neurological Illness with Limb

Weakness in children case, contact the DPH Office of Infectious Disease Epidemiology at 888-295-5156 or 302-744-1033 or fax 302-223-1540

For Additional CDC Information

Please visit the CDC enterovirus website (http://www.cdc.gov/non-polio-enterovirus/) for general information about enterovirus infections, including EVD-68, and for

up-to-date guidance about infection control measures. For information about poliovirus, please visit the CDC poliovirus website (http://www.cdc.gov/vaccines/vpd-vac/polio/in-short-both.htm). For information about West Nile Virus, please visit the CDC

West Nile Virus website (http://www.cdc.gov/westnile/). State and local health

departments with questions should contact the CDC Emergency Operations Center (770-488-7100).

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