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Previous Volume 341:936-942 September 23, 1999 Number 13 Next

	Full Text PDF Editorial by Dolin, R. Letters Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited PubMed Citation

ABSTRACT

Background Enterovirus 71 infection causes hand-foot-and-mouth disease in young children, which is characterized by several days of fever and vomiting, ulcerative lesions in the oral mucosa, and vesicles on the backs of the hands and feet. The initial illness resolves but is sometimes followed by aseptic meningitis, encephalomyelitis, or even acute flaccid paralysis similar to paralytic poliomyelitis.

Methods We describe the neurologic complications associated with the enterovirus 71 epidemic that occurred in Taiwan in 1998. At three major hospitals we identified 41 children with culture-confirmed enterovirus 71 infection and acute neurologic manifestations. Magnetic resonance imaging (MRI) was performed in 4 patients with acute flaccid paralysis and 24 with rhombencephalitis.

Results The mean age of the patients was 2.5 years (range, 3 months to 8.2 years). Twenty-eight patients had hand-foot-and-mouth disease (68 percent), and six had herpangina (15 percent). The other seven patients had no skin or mucosal lesions. Three neurologic syndromes were identified: aseptic meningitis (in 3 patients); brain-stem encephalitis, or rhombencephalitis (in 37); and acute flaccid paralysis (in 4), which followed rhombencephalitis in 3 patients. In 20 patients with rhombencephalitis, the syndrome was characterized by myoclonic jerks and tremor, ataxia, or both (grade I disease). Ten patients had myoclonus and cranial-nerve involvement (grade II disease). In seven patients the brain-stem infection produced transient myoclonus followed by the rapid onset of respiratory distress, cyanosis, poor peripheral perfusion, shock, coma, loss of the doll's eye reflex, and apnea (grade III disease); five of these patients died within 12 hours after admission. In 17 of the 24 patients with rhombencephalitis who underwent MRI, T₂-weighted scans showed high-intensity lesions in the brain stem, most commonly in the pontine tegmentum. At follow-up, two of the patients with acute flaccid paralysis had residual limb weakness, and five of the patients with rhombencephalitis had persistent neurologic deficits, including myoclonus (in one child), cranial-nerve deficits (in two), and ventilator-dependent apnea (in two).

Conclusions In the 1998 enterovirus 71 epidemic in Taiwan, the chief neurologic complication was rhombencephalitis, which had a fatality rate of 14 percent. The most common initial symptoms were myoclonic jerks, and MRI usually showed evidence of brain-stem involvement.

Source Information

From the Departments of Pediatrics (C.-C.H., C.-C.L., T.-F.Y.) and Public Health (S.-T.W.), College of Medicine, National Cheng Kung University, Tainan; the Department of Pediatrics, Chang Gung Children's Hospital, Kaohsiung (Y.-C.C.); and the Department of Radiology, Tri-Service General Hospital and National Defense Medical Center, Taipei (C.-Y.C.) — all in Taiwan.

Address reprint requests to Dr. Huang at the Department of Pediatrics, College of Medicine, National Cheng Kung University, 138 Sheng-Li Rd., Tainan, 704, Taiwan, or at huangped{at}mail.ncku.edu.tw.

Full Text of this Article

Related Letters:

Enterovirus 71 Infection and Neurologic Complications
Wong K. T., Lum L. C. S., Lam S. K., Huang C.-C., Liu C.-C., Chang Y.-C.
Extract | Full Text  
N Engl J Med 2000; 342:356-358, Feb 3, 2000. Correspondence

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