Neurologic complications in children with enterovirus 71 infection

Chao Ching Huang, Ching Chuan Liu, Ying Chao Chang, Cheng Yu Chen, Shan Tair Wang, Tsu Fuh Yeh

Research output: Contribution to journalArticle

522 Citations (Scopus)

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 brainstem involvement.

Original languageEnglish
Pages (from-to)936-942
Number of pages7
JournalNew England Journal of Medicine
Volume341
Issue number13
DOIs
Publication statusPublished - Sep 23 1999
Externally publishedYes

Fingerprint

Enterovirus Infections
Nervous System
Myoclonus
Paralysis
Brain Stem
Hand, Foot and Mouth Disease
Aseptic Meningitis
Cranial Nerves
Enterovirus
Magnetic Resonance Imaging
Apnea
Neurologic Manifestations
Taiwan
Herpangina
Encephalomyelitis
Cyanosis
Mouth Mucosa
Poliomyelitis
Tremor
Encephalitis

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Neurologic complications in children with enterovirus 71 infection. / Huang, Chao Ching; Liu, Ching Chuan; Chang, Ying Chao; Chen, Cheng Yu; Wang, Shan Tair; Yeh, Tsu Fuh.

In: New England Journal of Medicine, Vol. 341, No. 13, 23.09.1999, p. 936-942.

Research output: Contribution to journalArticle

Huang, Chao Ching ; Liu, Ching Chuan ; Chang, Ying Chao ; Chen, Cheng Yu ; Wang, Shan Tair ; Yeh, Tsu Fuh. / Neurologic complications in children with enterovirus 71 infection. In: New England Journal of Medicine. 1999 ; Vol. 341, No. 13. pp. 936-942.
@article{92dd8135c6e34b8fb3634c3ef0bdf6ee,
title = "Neurologic complications in children with enterovirus 71 infection",
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 brainstem involvement.",
author = "Huang, {Chao Ching} and Liu, {Ching Chuan} and Chang, {Ying Chao} and Chen, {Cheng Yu} and Wang, {Shan Tair} and Yeh, {Tsu Fuh}",
year = "1999",
month = "9",
day = "23",
doi = "10.1056/NEJM199909233411302",
language = "English",
volume = "341",
pages = "936--942",
journal = "New England Journal of Medicine",
issn = "0028-4793",
publisher = "Massachussetts Medical Society",
number = "13",

}

TY - JOUR

T1 - Neurologic complications in children with enterovirus 71 infection

AU - Huang, Chao Ching

AU - Liu, Ching Chuan

AU - Chang, Ying Chao

AU - Chen, Cheng Yu

AU - Wang, Shan Tair

AU - Yeh, Tsu Fuh

PY - 1999/9/23

Y1 - 1999/9/23

N2 - 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 brainstem involvement.

AB - 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 brainstem involvement.

UR - http://www.scopus.com/inward/record.url?scp=0033598405&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=0033598405&partnerID=8YFLogxK

U2 - 10.1056/NEJM199909233411302

DO - 10.1056/NEJM199909233411302

M3 - Article

C2 - 10498488

AN - SCOPUS:0033598405

VL - 341

SP - 936

EP - 942

JO - New England Journal of Medicine

JF - New England Journal of Medicine

SN - 0028-4793

IS - 13

ER -