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Sunday, October 5, 2014

COLORADO: UNEXPLAINED ILLNESS CAUSES PARALYSIS IN CHILDREN

Unexplained Paralysis Hospitalizes Children

Young biy in a hospital gownCDC, with various state and local health departments, is alerting parents about an illness involving the brain and spinal cord identified in 10 children in Colorado. The children were hospitalized with muscle weakness or paralysis mostly in their arms or legs. Parents and children should always follow basic steps to stay healthy and avoid infections: wash hands frequently with soap and water, stay away from sick people, and disinfect objects that a sick person has touched.
Many parents are concerned to hear about these sick children in Colorado. This seems to be a rare sickness. Some of the children also have had cold-like symptoms. We don’t know yet what caused this illness or whether it spreads from one person to another. If a parent sees a child isn’t walking correctly or develops sudden weakness in an arm or leg, the parent should contact a doctor right away.
Who has been affected by this sickness?
Between August 9 and September 29, 2014, 10 children from 1 to 18 years of age in Colorado were hospitalized with this sickness. While we don’t yet know what caused this sickness, we do know the following things about the 10 children who’ve been hospitalized.
  • Most had a problem with their spinal cord that could be seen on a magnetic resonance image (MRI) scan, a special scan that can identify nervous system problems.
  • All had a fever, most with symptoms of respiratory illness, about one week before they felt muscle weakness.
  • None of the children had any kind of virus found in their spinal fluid. It is possible that the correct test has not been done yet, or that the specimen was collected too late to find a virus. But that does not mean that a virus or other agent did not cause the damage to their spinal cord.
  • About half of the children had EV-D68 in their nose secretions; the virus typically affects breathing. We do not yet know whether this respiratory infection is linked to their muscle weakness.
Doctor holding a patients hand.
Doctors and nurses who see patients in their offices, clinics or hospitals with unexplained muscle weakness or paralysis in the arms or legs are testing them to see if they might have this sickness. They also are reporting information to their state or local health department.
What can I do to protect my child?
Being up to date on all recommended vaccinations is the best way to protect you and your family from serious diseases including polio and acute respiratory illnesses including influenza, measles and whooping cough.
Although it is still unknown what’s causing this sickness and whether it can be spread from person to person, it is best for everyone in your house to follow basic steps to stay healthy and avoid infections: wash your hands frequently with soap and water, stay away from sick people, and disinfect objects that a sick person has touched.
Washing your hands the right way is one of the best things you and your children can do to protect against getting sick. Wash your hands
  • before you touch food;
  • after going to the bathroom, blowing your nose, changing a baby’s diaper, or touching an animal, an animal’s food, pee or poop;
  • and before and after taking care of a sick person or a cut or wound.
If your child is having problems walking or standing or develops sudden weakness in an arm or leg, you should contact a doctor right away.
What are CDC, health departments, doctors and nurses doing to find out why children are getting sick?
CDC is working closely with partners in Colorado and elsewhere to find out why the children hospitalized are sick.
Doctors and nurses who see patients in their offices, clinics or hospitals with unexplained muscle weakness or paralysis in the arms or legs are testing them to see if they might have this sickness. They also are reporting information to their state or local health department.

CLINICAL HISTORY / DATA:

On September 12, 2014, CDC was notified by the Colorado Department of Public Health and Environment of a cluster of nine children evaluated at Children's Hospital Colorado with acute neurologic illness characterized by extremity weakness, cranial nerve dysfunction (e.g., diplopia, facial droop, dysphagia, or dysarthria), or both. Neurologic illness onsets occurred during August 8–September 15, 2014. The median age of the children was 8 years (range = 1–18 years). Other than neck, back, or extremity pain in some patients, all had normal sensation. All had a preceding febrile illness, most with upper respiratory symptoms, occurring 3–16 days (median = 7 days) before onset of neurologic illness. Seven of eight patients with magnetic resonance imaging of the spinal cord had nonenhancing lesions of the gray matter of the spinal cord spanning multiple levels, and seven of nine with magnetic resonance imaging of the brain had nonenhancing brainstem lesions (most commonly the dorsal pons). Two of five with magnetic resonance imaging of the lumbosacral region had gadolinium enhancement of the ventral nerve roots of the cauda equina. Eight children were up to date on polio vaccination. Eight have not yet fully recovered neurologically.
Eight patients demonstrated a mild to moderate cerebrospinal fluid (CSF) pleocytosis (>5 white blood cells/ยตL), predominantly lymphocytic, consistent with an inflammatory or infectious process. CSF glucose was normal; CSF protein was normal or mildly elevated. Initial testing of CSF from eight patients showed no evidence of West Nile virus antibodies, although further testing is pending. CSF testing for enteroviruses, including enterovirus D68 (EV-D68), enterovirus 71, and poliovirus, by reverse transcription–polymerase chain reaction (RT-PCR) was negative in all patients. Other CSF tests for infectious causes were unrevealing. 
Initial nasopharyngeal specimens were available for eight children.Six were positive for rhinovirus/enterovirus by RT-PCR. These six positive nasopharyngeal specimens were subsequently typed: four were identified as EV-D68, one as rhinovirus A24, and one was not EV-D68 but has not been typed further.The specimen positive for rhinovirus A24 also was positive for adenovirus by RT-PCR. Single rectal swabs or stool samples from eight patients were negative for enterovirus (including poliovirus) by RT-PCR. 
This cluster of acute neurologic illnesses occurred against a backdrop of detection of EV-D68 causing severe respiratory disease in many parts of the United States, including Colorado (1,2). There are two case reports in the literature of EV-D68 causing neurologic illness (acute flaccid paralysis and encephalomyelitis) as evidenced by detection of EV-D68 in the CSF (3,4). However, given the current suspected widespread circulation of EV-D68 respiratory infections in Colorado, and the antecedent respiratory illness in most of these children, the detection of EV-D68 in nonsterile upper respiratory tract specimens in those with neurologic illness might be coincidental. Epidemiologic and laboratory investigations of these cases are ongoing.
On September 19, the Colorado Department of Public Health and Environment issued a Health Alert informing Colorado clinicians of this cluster and requesting reports of similar cases. One additional case with similar neurologic findings was reported as a result of this advisory and is currently under investigation. On September 26, CDC issued a national Health Advisory (available at http://www.bt.cdc.gov/han/han00370.asp), which provides guidance for identifying and reporting cases. Clinicians should report to their local and state health departments patients aged ≤21 years with 1) acute onset of focal limb weakness occurring on or after August 1, 2014, and 2) magnetic resonance imaging showing a spinal cord lesion largely restricted to gray matter. To prevent infections in general, persons should stay home if they are ill, wash their hands often with soap and water, avoid close contact (such as touching and shaking hands) with those who are ill, and clean and disinfect frequently touched surfaces.