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Twenty-Nine Cases of Enterovirus-D68 Associated Acute Flaccid Myelitis in Europe 2016; A Case Series and Epidemiologic Overview

Knoester, Marjolein, MD, PhD1; Helfferich, Jelte, MD2; Poelman, Randy, MSc1; Van Leer-Buter, Coretta, MD, PhD1; Brouwer, Oebele F., MD, PhD2; Niesters, Hubert G.M., MD, PhD1 on behalf of the 2016 EV-D68 AFM Working Group

The Pediatric Infectious Disease Journal: September 18, 2018 - Volume Publish Ahead of Print - Issue - p
doi: 10.1097/INF.0000000000002188
Original Studies: PDF Only

BACKGROUND: Enterovirus D68 (EV-D68) is a respiratory virus within the genus Enterovirus and the family of Picornaviridae. Genetically, it is closely related to rhinovirus that replicates in the respiratory tract and causes respiratory disease. Since 2014, EV-D68 has been associated with the neurologic syndrome of acute flaccid myelitis (AFM).

METHODS: In October 2016, questionnaires were sent out to a European network including 66 virologists and clinicians, to develop an inventory of EV-D68 associated AFM cases in Europe. Clinical and virologic information of case patients was requested. In addition, epidemiologic information on EV-testing was collected for the period between March and October 2016.

RESULTS: Twenty-nine cases of EV-D68 associated AFM were identified, from 12 different European countries. Five originated from France, 5 from Scotland and 3 each from Sweden, Norway and Spain. Twenty-six were children (median age 3.8 years), 3 were adults. EV-D68 was detected in respiratory materials (n=27), feces (n=8) and/or cerebrospinal fluid (n=2).

Common clinical features were asymmetric flaccid limb weakness, cranial nerve deficits and bulbar symptoms. On magnetic resonance imaging, typical findings were hyperintensity of the central cord and/or brainstem; low motor amplitudes with normal conduction velocities were seen on electromyography. Full clinical recovery was rare (n=3), and 2 patients died.

The epidemiologic data from 16 European laboratories showed that of all EV-D68 positive samples, 99% was detected in a respiratory specimen.

CONCLUSIONS: For 2016, 29 EV-D68 related AFM cases were identified in mostly Western Europe. This is likely an underestimation, since case identification is dependent on awareness among clinicians, adequate viral diagnostics on respiratory samples, and the capability of laboratories to type EVs.

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

1Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

2Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

32016 EV-D68 AFM Working Group (Supplemental Digital Content 1)

Conflicts of interest and sources of funding: The authors have no conflicts of interest or funding to disclose.

Corresponding author: M. Knoester, University Medical Center Groningen, Department of Medical Microbiology and Infection Prevention (Postal zone EB86), Hanzeplein 1, 9713 GZ Groningen. The Netherlands. Email:, Tel: +31-50-3610223;Fax: +31-50-3619105

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