Enterovirus D68 in Children: How Serious Is It This Year?

There has been an increase in acute respiratory illnesses among children and adults associated with rhinoviruses and enteroviruses, including Enterovirus D68, in the United States this summer and fall.

Key takeaways:
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    Respiratory illnesses have different signs and symptoms. To identify the illness and provide supportive care, clinical evaluations should be conducted as soon as possible.
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    No vaccinations are available for Enterovirus E68.
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    Antiviral medications have no specific efficacy data.
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    The antiviral drugs pleconaril, pocapavir, and vapendavir have significant activity against a wide variety of rhinoviruses and enteroviruses; however, the CDC evaluated these drugs against current strains of EV-D68, and none showed significant activity.
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    Supportive care is usually all that is needed since severe infections, including acute flaccid paralysis, are rare.

The Centers for Disease Control has issued an advisory to healthcare providers regarding an uptick in severe respiratory illnesses requiring hospitalization in children, and often a type of enterovirus is the culprit.

Enterovirus D68 usually causes mild, cold-like symptoms, but it can lead to severe respiratory illnesses as well. Enterovirus D68 can also cause acute flaccid myelitis, a rare but serious neurologic complication that can lead to permanent paralysis and even death.

Enterovirus D68 respiratory infections prevalence

Enterovirus D68 was first identified in 1962 in California in 4 children with severe respiratory illnesses. There have been only 26 cases in the United States from 1970 to 2005. In the fall of 2009, there were multiple infections found in New York.

It has increased worldwide since then, but mostly due to the use of more sensitive testing methods during the COVID pandemic. The frequency of outbreaks appears to vary among different countries.

Enterovirus D68 circulates between summer and fall and appears to spread by close contact with infected people. Contact with respiratory and gastrointestinal secretions transmits EV-D68. It is spread by cough, saliva, mucus, or by touching objects or fomites.

Children with a history of asthma, wheezing, or other underlying respiratory diseases appear to be at greater risk of severe disease, particularly children between 1 month to 16 years of age.

What is Enterovirus D68?

Enterovirus D68 (EV-D68), also known as enterovirus 68 (EV-68 or EV68), is a non-poliovirus, nonenveloped, positive-sense single-stranded RNA virus that belongs to the Picornaviridae family.

While most of these types of viruses primarily affect the gastrointestinal tract, EV-D68 tends to involve the respiratory tract instead.

It causes acute respiratory disease ranging from mild upper respiratory tract symptoms to severe pneumonia and has been associated with central nervous system infections with poliovirus-like manifestations leading to acute flaccid myelitis.

Prognosis for children infected with Enterovirus D68

It varies. Most children suffer from mild, self-limited respiratory infections, but some suffer from severe respiratory disease, particularly those with asthma.

Neurological involvement or acute flaccid myelitis is rare, fortunately. There is no clear etiology. Most who are afflicted do not develop prolonged or permanent paralysis.

Those patients who have mental confusion initially do not have lasting complications affecting their cognition.

What is the best prevention to avoid infection with Enterovirus D68?

Preventive measures are as follows:

  • Stay home if ill
  • Wash hands with soap and water
  • Avoid close contact with those who are ill
  • Clean and disinfect frequently touched surfaces

What are the symptoms? How do I suspect an Enterovirus D68 infection in my child?

The symptoms can vary from mild to severe. Some are severe enough to warrant intensive care in the hospital.

Potential manifestations of EV-D68 infection are as follows:

  • Acute onset
  • Cough
  • Fever (although a considerable percentage of cases without fever were reported in the latest outbreaks)
  • Rhinorrhea (runny nose)
  • Sore throat
  • Fatigue
  • Headache
  • Myalgia (muscle aches)
  • Dyspnea (difficulty breathing)
  • Diarrhea
  • Bronchiolitis (a common lung infection in young children involving inflammation and congestion in the small airways or bronchioles)

How is Enterovirus D68 diagnosed?

Nasopharyngeal or oropharyngeal swabs and other respiratory specimens such as nasal wash or aspirates have a high yield for diagnosis.

In July 2015, a new assay test was developed by researchers at the Washington University School of Medicine in St Louis. This assay is an RRT-PCR that is more sensitive than commercially available assays for enterovirus and rhinovirus detection.

This new assay is also more specific for EV-D68, unlike the commercially available assays, which do not distinguish between the two. This newly developed assay was also able to detect divergent strains of EV-D68.

Chest X-ray should be obtained. It will show signs of infection and possible pneumonia.

In cases of acute flaccid paralysis, an MRI of the spine and brain can help distinguish possible neurological involvement.

In some cases, a spinal tap to obtain cerebrospinal fluid can aid in diagnosis and treatment.

Blood cultures are typically negative since the infection is from a virus, not a bacterium.

Treatment for Enterovirus D68

In outpatient settings, the patient should have an asthma action plan to control asthma long-term and understands how to manage worsening asthma or attacks. Parents are provided instructions concerning when to call the primary physician or to seek emergency treatment.

Patients with severe respiratory infections should be hospitalized for supportive treatment, as follows:

  • Oxygen if the patient is hypoxic (low oxygen levels).
  • If the patient presents with clinical evidence of bronchospasm. Severe difficulty breathing.
  • Endotracheal intubation and mechanical ventilation may be needed in patients with impending respiratory failure.

Please note there is no specific intervention that has been shown definitive efficacy in EV-D68 infections with acute flaccid myelitis with neurologic signs such as paralysis.

Beware of this illness

Although the long-term effects of this illness are often minimal, there is still a chance a patient, especially one aged between one month and 16 years, can have severe symptoms. It is important to recognize these symptoms and seek medical treatment immediately.

Those patients and individuals who stay on the lookout for the EV-D68 infection will have a higher chance of overcoming the infection and bouncing back to 100 percent.

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