G394(P) A Cluster of acute flaccid paralysis attributable to enterovirus d68 – the beginning of a new epidemic?

Aim We report our experience of diagnosis, management and clinical progress of five children who presented to a single tertiary children’s hospital over couple of months with acute flaccid paralysis. Enterovirus D68 (EV D68) has been isolated from all these children. Public health concerns have been raised that this may indicate the onset of an epidemic following similar situations in Wales in 2015/6 and the USA in 2014. Methods The clinical features, investigations and management of five children with flaccid paralysis is described. We will update the clinical recovery and also add any additional cases presenting to our hospital with EV D68 infection. Results All children (3 boys and 2 girls; age 2–6 years) presented with acute flaccid paralysis following a 2–7 day history of non-specific viral symptoms. The pattern of paralysis was asymmetrical(proximal weakness worse than distal) with upper limb involvement more than lower limb. Additional features include facial weakness, bulbar involvement and respiratory weakness. Two children are ventilated and have autonomic dysfunction requiring anti-hypertensive treatment. CSF results show normal protein, lymphocytosis and are negative for bacteria and viruses. One child deteriorated significantly following general anaesthesia. Neurophysiology indicated axonal neuropathy. MRI showed high T2 signal within the cervical spinal cord and brainstem. EV D68 was isolated in NPA of all children. IVIG was given to all except one who was making good recovery. We will update on disease progression and further cases. A total of 60 cases of EV D68 isolated on retrospective analysis of all NPA taken over preceding 3 months and the majority of the children had only respiratory symptoms. Conclusions In children presenting with acute flaccid paralysis, investigation for EV D68 should be considered. There were previous cases of Guillain Barre Syndrome like phenotype has been described but our cases have similar clinical presentation as polio. NPA aspirates are key to diagnosis. Enterovirus may not be identified within the CSF. Neuroimaging and neurophysiology are of additional benefit. Public health should be informed as this presentation seems to occur in clusters or as an epidemic. We will report neurological outcome as these children have presented recently.