Eurosurveillance: Acute Flaccid Paralysis Following EV-D68 Infection – France

CDC EV-D68 Fact Sheet

 

# 9294

 

In August of 2014, a seldom seen in North America non-polio enterovirus D-68 (EV-D68) appeared in America’s Midwest and quickly spread across the nation, causing a wide spectrum of respiratory illness, predominantly in young children and adolescents (see Kansas City Outbreak Identified As HEV 68).

At roughly the same time, a coincident rise in cases of neurological illness with AFP (acute flaccid paralysis) or limb weakness – often associated with a recent respiratory illness – was reported across the country.

 

In September the CDC  issued a HAN: Acute Neurologic Illness with Focal Limb Weakness of Unknown Etiology in Children, alerting doctors around the country to be aware of this trend, and providing information on reporting cases.

While there is a high degree of suspicion that the recent EV-D68 outbreak and the rise in paralytic cases are related, a causal link has not been established.  

 

The CDC’s latest EV-D68 update reads:

 

From mid-August to November 5, 2014, CDC or state public health laboratories have confirmed a total of 1,112 people in 47 states and the District of Columbia with respiratory illness caused by EV-D68.

 

While the CDC’s latest UPDATE on the unexplained neurological cases reads:

As of October 29, CDC has verified reports of 64 cases in 28 states that meet our case definition below. We are working with healthcare professionals and state and local officials to investigate all of these cases.

We are also in the process of verifying about half a dozen additional reports. These investigations take time. Therefore, the number of cases will likely increase further as we update these numbers weekly on Thursday, but the increase will not necessarily reflect changes in occurrence of cases in real time.

 

While it doesn’t prove causality, today the ECDC’s Eurosurveillance Journal carries a report of France’s first  EV-D68 case with Acute Flaccid Paralysis (AFP).

 

Eurosurveillance, Volume 19, Issue 44, 06 November 2014

Rapid communications

Acute flaccid paralysis following enterovirus D68 associated pneumonia, France, 2014

M Lang, A Mirand, N Savy, C Henquell, S Maridet, R Perignon, A Labbé, H Peigue-Lafeuille

Human enterovirus D68 (EV-D68) is known to be associated with mild to severe respiratory infections. Recent reports in the United States and Canada of acute flaccid paralysis (AFP) in children with detection of EV-D68 in respiratory samples have raised concerns about the aetiological role of this EV type in severe neurological disease. This case study is the first report of AFP following EV-D68 infection in Europe.

---

We report the first case of acute flaccid paralysis (AFP) following enterovirus-D68 (EV-D68) infection in Europe. The United States (US) and Canada are currently experiencing nationwide outbreaks of EV-D68 infections associated with severe respiratory diseases especially in children with underlying respiratory disease that began in mid-August 2014 [1,2]. Concomitantly, clusters of neurological illness characterised by AFP with anterior myelitis have been reported in the US and Canada [3,4]. The detection of EV-D68 in nasopharyngeal specimens of some affected children raises the question of a possible link between EV-D68 infections and severe neurological disease.

<SNIP>

Discussion

While EV-D68 has to date been almost exclusively associated with respiratory diseases, investigations are currently underway to determine its role in the acute neurological illnesses that have been reported in children in the US [3] and in Canada [4] since August 2014. Nine EV-D68-associated deaths are currently being investigated at the US Centers for Disease Control and Prevention (CDC) to confirm or refute EV-D68 as the cause of death [15]; as of 5 November, no information has been released about the death’s preceding symptoms.

The case reported here meets the definition given by CDC to identify similar neurological manifestations characterised by acute onset of focal limb weakness occurring on or after 1 August 2014 and MRI showing a spinal cord lesion largely restricted to grey matter [16]. Common features with the cases reported in the US include (i) respiratory illness preceding development of neurological symptoms, (ii) a local epidemiological context of EV-D68 detection among children admitted to hospital for respiratory infections leading to asthma crisis (data not shown) and (iii) EV-D68 detection in respiratory samples. By contrast, to our knowledge, neither meningeal syndrome nor myocarditis and acute respiratory distress syndrome had been reported in the days preceding the onset of paralysis in the US patients.

The enterovirus genome was not detected in the CSF of this patient and we cannot assert that EV-D68 was associated with meningitis. There are two case reports in the literature of EV-D68 infection associated with severe neurological disease as evidenced by detection in the CSF [17,18]. As in recent reports, the significance of EV-D68 association with AFP is hampered by the fact that it was only detected in respiratory or stool samples, in which enteroviruses can be detected many weeks after infection. However, the absence of detection in CSF does not necessarily rule out this possibility since poliovirus and EV-A71, two recognised neurotropic EVs, are not frequently recovered [19]. Further physiopathological studies may be needed to assess the neurotropism of EV-D68.

There are increasingly numerous reports of polio-like illnesses in the US (64 cases as of 30 October 2014) [15].

Surveillance of AFP cases has already been implemented as a measure in the global initiative to eradicate poliomyelitis and should allow rapid identification of similar neurological manifestations in association with EV-D68 infection [20]. However, determination of AFP aetiologies can be challenging, because of the absence of pathogen detection in the CSF. Investigation of AFP cases should include both EV screening of two stool samples collected ≥ 24 hours apart and < 14 days after symptom onset [21] and early and quick testing of diverse samples, especially upper respiratory samples, for infectious agents including EVs, to increase the chance to identify a pathogen. In the case of EV-D68 infections, the detection capabilities of the EV-D68 genome of commercial and in-house molecular methods should be assessed.

 

 

While our experience with EV-D68 goes back 50 years, the number of outbreaks that have been studied has been small. Testing has been difficult and time consuming, and treatment for EV-D68 is no different than for any other viral respiratory illness.   Therefore, we don’t really know as much about this virus as we’d like.

Other non-polio enteroviruses have a better documented track record for causing neurological complications, such as EV-71.  In recent years, EV-71 has been linked to a number of clusters of AFP  around the globe, particularly in Asia, Australia, and the Pacific (see Australia: Acute Flaccid Paralysis & EV71).

For now, the investigation into this rash of unexplained paralysis remains unresolved.

COCA Call Friday: Neurologic Illness with Limb Weakness in Children

Credit CDC – Non Polio-Enteroviruses

 

 

# 9141

 

Although a causal link has not been established, the recent outbreak of EV-D68 which has rapidly spread across the nation has been tentatively associated with a number of children presenting with varying degrees of neurological illness, including limb weakness or paralysis.

 

Last Friday we saw a CDC HAN: Acute Neurologic Illness with Focal Limb Weakness of Unknown Etiology in Children issued, and tomorrow the CDC will hold a COCA (Clinician Outreach Communication Activity) call to ensure that practitioners have up-to-date information for their practices.

 

Neurologic Illness with Limb Weakness in Children

  = No Continuing Education

Date: Friday, October 3, 2014

Time:2:00 – 3:00 PM (Eastern Time)

Participate by Phone:

• 888-831-8979 (U.S. Callers)
• 415-228-4881 (International Callers)

Passcode:2142380

Presenter(s)

Daniel Feikin, MD
Chief
Epidemiology Branch
Division of Viral Diseases
National Center for Immunization and Respiratory Diseases - CDC

Steve Oberste, PhD
Chief
Polio and Picornavirus Laboratory Branch
Division of Viral Diseases
National Center for Immunization and Respiratory Diseases – CDC

Overview

CDC is working closely with partners in Colorado and other state and local health departments to investigate an acute neurologic illness of unknown etiology occurring in children. Characterized by focal limb weakness and abnormalities of the spinal cord gray matter on MRI, a cluster of these illnesses was first reported from Colorado in September, 2014. These neurological findings are coincident with an increase of respiratory illnesses among children. During this COCA Call, clinicians will learn about the latest situation, surveillance, and CDC clinical guidance for testing, patient evaluation and case reporting.

CDC HAN: Acute Neurologic Illness with Focal Limb Weakness of Unknown Etiology in Children

 

# 9117

 

There are a fair number of possible causes for a cluster of acute neurological illness in children, ranging from vector-borne encephalopathies like West Nile Virus, to a variety of polio and non-polio enteroviruses. In recent years, EV-71 has been linked to a number of clusters of AFP (acute flaccid paralysis) around the globe, particularly in Asia, Australia, and the Pacific (see Australia: Acute Flaccid Paralysis & EV71).

 

A month ago, when the EV-D68 virus was first identified in a cluster of sick kids in the Midwest (see Kansas City Outbreak Identified As HEV 68), I mentioned that this rarely reported non-polio enterovirus had been detected in two of five children who developed a rare polio-like syndrome last winter (see Acute Flaccid Paralysis Cases In California) .

 

While this may have simply been an incidental finding, due to the history of other non-polio enteroviruses to cause neurological illness, EV-D68 infection was considered at least plausible cause for these illnesses. The CDC has frequently stated that  `EV-D68 causes primarily respiratory illness, although the full spectrum of disease remains unclear.’

The EV-D68 virus has now spread to more than 40 states, and has likely sickened tens of thousands of children, but until now we’d not heard any credible reports of EV-D68 infected children developing neurological symptoms. Testing for the virus, however, is both difficult and time consuming – and the battery of tests required to rule out other causes of neurological illness can take considerable time – and so there are often lags in reporting.

 

Given the recent surge in enterovirus infections across the nation, and their history of occasionally producing neurological illness, it is not altogether surprising that health authorities in Denver, Colorado have now reported a cluster of children presenting with acute neurological symptoms following recent respiratory infections.

 

To date, four of nine have tested positive for the EV-D68 virus. 

With the caveat that the etiology remains unknown, the CDC is anxious to identify other recent cases or clusters, and to nail down the cause (or causes) of these illnesses. 

 

Last night the CDC issued the following HAN (Health Alert Network)  Advisory to clinicians, with instructions on reporting and recommendations for testing. 

 

Acute Neurologic Illness with Focal Limb Weakness of Unknown Etiology in Children

Summary

The Centers for Disease Control and Prevention (CDC) is working closely with the Colorado Department of Public Health and Environment (CDPHE) and Children’s Hospital Colorado to investigate a cluster of nine pediatric patients hospitalized with acute neurologic illness of undetermined etiology. The illness is characterized by focal limb weakness and abnormalities of the spinal cord gray matter on MRI. These illnesses have occurred since August 1, 2014 coincident with an increase of respiratory illnesses among children in Colorado. The purpose of this HAN Advisory is to provide awareness of this neurologic syndrome under investigation with the aim of determining if children with similar clinical and radiographic findings are being cared for in other geographic areas. Guidance about reporting cases to state and local health departments and CDC is provided. Please disseminate this information to infectious disease specialists, intensive care physicians, pediatricians, neurologists, radiologists/neuroradiologists, infection preventionists, and primary care providers, as well as to emergency departments and microbiology laboratories.

Background

The CDPHE, Children’s Hospital Colorado, and CDC are investigating nine cases of acute neurologic illness among pediatric patients. The cases were identified during August 9–September 17, 2014 among children aged 1–18 years (median age 10 years). Most of the children were from the Denver metropolitan area. All were hospitalized. Common features included acute focal limb weakness and specific findings on magnetic resonance imaging (MRI) of the spinal cord consisting of non-enhancing lesions largely restricted to the gray matter. In most cases, these lesions spanned more than one level of the spinal cord. Some also had acute cranial nerve dysfunction with correlating non-enhancing brainstem lesions on MRI. None of the children experienced altered mental status or seizures. None had any cortical, subcortical, basal ganglia, or thalamic lesions on MRI. Most children reported a febrile respiratory illness in the two weeks preceding development of neurologic symptoms. In most cases, cerebrospinal fluid (CSF) analyses demonstrated mild-moderate pleocytosis (increased cell count in the CSF) consistent with an inflammatory or infectious process. CSF testing to date has been negative for West Nile virus and enteroviruses, including poliovirus. Nasopharyngeal specimens were positive for rhinovirus/enterovirus in six out of eight patients that were tested. Of the six positive specimens, four were typed as EV-D68, and the other two are pending typing results. Testing of other specimens is still in process. Eight out of nine children have been confirmed to be up to date on polio vaccinations. Epidemiologic and laboratory investigations of these cases are ongoing.

The United States is currently experiencing a nationwide outbreak of EV-D68 associated with severe respiratory disease. The possible linkage of this cluster of neurologic disease to this large EV-D68 outbreak is part of the current investigation. CDC is seeking information about other similar neurologic illnesses in all states, especially cases clustered in time and place. CDC has particular interest in characterizing the epidemiology and etiology of such cases.

Recommendations

• Patients who meet the following case definition should be reported to state and local health departments:

  Patients ≤21 years of age with

  1. Acute onset of focal limb weakness occurring on or after August 1, 2014;

  AND

  1. An MRI showing a spinal cord lesion largely restricted to gray matter.

• State and local health departments should report patients meeting the case definition to CDC using a brief patient summary form (www.cdc.gov/non-polio-enterovirus/investigation/). State health departments should send completed summary forms to CDC by email at limbweakness@cdc.gov.
• Providers treating patients meeting the above case definition should consult with their local and state health department for laboratory testing of stool, respiratory, and cerebrospinal fluid specimens for enteroviruses, West Nile virus, and other known infectious etiologies.
• Health departments may contact CDC for further laboratory and epidemiologic support by phone through the CDC Emergency Operations Center (770-488-7100), or by email at limbweakness@cdc.gov. Confirmation of the presence of EV-D68 currently requires typing by molecular sequencing.

Acute Flaccid Paralysis Cases In California

 

 

Credit CDC – Non Polio-Enteroviruses

 

 

# 8325

 

Overnight the news media has been filled with numerous reports of an – as yet, unidentified – polio-like paralytic illness that has stricken a small number of children in California over the past two years.  Crof already has a couple of media reports on his blog (see US: A polio-like illness in California children & US: More on the polio-like illness in California), and ProMed Mail released a summary this morning.

 

The basic facts are recounted in the following excerpt from the Los Angeles Times report, after which I’ll have more:

 

Mysterious polio-like illnesses reported in some California children

By Eryn Brown

February 23, 2014

(excerpt)

The afflicted kids suffer severe weakness or paralysis, which strikes rapidly -- sometimes after a mild respiratory illness. Scans of the patients' spinal cords show patterns of damage similar to that found in polio sufferers, Glaser said. Two of the affected children tested positive for enterovirus-68, a virus that is usually associated with respiratory illness but which has been linked to polio-like illnesses as well.

 

Dr. Keith Van Haren, a pediatric neurologist at Stanford University's Lucile Packard Children's Hospital who has worked with Glaser's team, will present the cases of five of the children at the American Academy of Neurology's upcoming annual meeting in Philadelphia.

 

All five patients had paralysis in one or more arms or legs that reached its full severity within two days, he said. None had recovered limb function after six months.

 

"We know definitively that it isn't polio," Van Haren added, noting that all had been vaccinated against that disease.

(Continue . . . )

 

This report, along with others, suggest that 20 to 25 children in California may have developed Acute Flaccid Paralysis (AFP) following a mild respiratory illness over the past couple of years, and investigators expect that once clinicians know to look for it, they may discover it beyond California.

 

Non-polio AFP is a complex and broad clinical syndrome that can be caused by a wide range of pathogens, including West Nile Virus (and other mosquito-borne encephalopathies), echoviruses, adenoviruses, Campylobacter jejuni (leading cause of Guillain-Barre syndrome), a large group of enteroviruses, along with a variety of toxins and poisons.

 

While the exact cause (or causes) of these California cases remains unknown, a viral infection is strongly suspected, and high on the list of suspects are members of the ubiquitous non-polio enterovirus family of viruses or NPEVs  (which includes Coxsackievirus A, Coxsackievirus B, Echoviruses & numerous other Enteroviruses).

 

According to the CDC, NPEVs cause 10 to 15 million – mostly mild and often asymptomatic – infections in the United States each year, primarily among infants, children, and teenagers. Fever, runny nose, sneezing, coughing, a skin rash or mouth blisters, and body and muscle aches are the most commonly reported symptoms. 

 

NPEV infection may also lead to viral conjunctivitis, hand, foot, and mouth disease (HFMD), or viral meningitis and less commonly, a person may develop myocarditis, pericarditis, encephalitis - or in rare cases - even paralysis.

 

The CDC lists the following common Outbreaks of Various Non-Polio Enteroviruses

• Coxsackievirus A16 is the most common cause of hand, foot, and mouth disease (HFMD) in the United States. However, in 2011 and 2012, coxsackievirus A6 was a common cause of HFMD in this country; some of the infected people became severely ill.
• Coxsackievirus A24 and enterovirus 70 have been associated with outbreaks of conjunctivitis.
• Echoviruses 13, 18, and 30 have caused outbreaks of viral meningitis in the United States.
• Enterovirus 71 has caused large outbreaks of HFMD worldwide, especially in children in Asia. Some infections from this virus have been associated with severe neurologic disease, such as brainstem encephalitis.

 

We’ve looked at HFMD outbreaks in the past, most often caused by the Coxsackie A16 virus (and more rarely by Coxsackie A10) here in the United States. In recent years, we’ve also seen the recent emergence of the Coxsackie A6 virus which has been linked to somewhat more severe HFMD cases (see MMWR: Coxsackievirus A6 Notes From The Field).

But it is the Enterovirus 71 that has been most often linked to severe cases of HFMD – particularly across Asia - with serious outbreaks recorded over the past 15 years in places like China, Taiwan, Malaysia, Hong Kong, and two years ago in both Vietnam and Cambodia (see Updating The Cambodian EV71 Story).

 

Last year, in Australia: Acute Flaccid Paralysis & EV71, we looked at a report from the National Enterovirus Reference Laboratory in Australia that described 5 recent cases of acute flaccid paralysis (AFP) in children who tested positive for the EV71 virus.

 

Concerns over the evolution and spread of EV71 have grown in recent years, as detailed in the following 2008 report from The Lancet: Enterovirus 71 infection: a new threat to global public health?  

 

While a potential cause, EV71 is just one of the possible suspects behind these California cases.  Indeed, AFP can be caused by a variety of viral infections, and so there may be more than one etiology involved

 

At least two of the children in California have tested positive for Enterovirus-68, which we looked at in some depth back in 2011 (see MMWR: Clusters Of HEV68 Respiratory Infections 2008-2010).  First detected in California in 1962, but rarely seen since that time, that report summarized six clusters of HEV68 from Asia, Europe, and the United States between 2008-2010.  Those clusters included severe illness, and three fatalities.

 

Although the full spectrum of illness that EV-68 infection can produce has not been well established, it has previously been more commonly associated with respiratory symptoms than with paralysis.

 

So whether EV-68 is actually the cause of these recent California paralysis cases, or simply an incidental finding, is something that will require more research to establish. Despite their outward similarity to NPEV infections, these AFP cases in California may be due to something altogether different.  New viral discoveries are made practically every year.

But most `mystery illnesses’  usually end up being due to previously identified diseases that have either evolved or mutated a bit, or have migrated to a new area.

 

While it is too soon to speculate on the exact cause of these AFP cases, the CDC’s recommendations to prevent NPEV transmission are universally good hygiene suggestions, and are worth following:

 

You can help protect yourself and others from non-polio enterovirus infections by—

• Washing your hands often with soap and water, especially after using the toilet and changing diapers,
• Avoiding close contact, such as touching and shaking hands, with people who are sick, and
• Cleaning and disinfecting frequently touched surfaces.

ECDC Risk Assessment : Suspected Polio In Syria

Syria - Credit Wikipedia

# 7993

 

The discovery last week of a cluster of Acute Flaccid Paralysis (AFP) in Syria (see WHO: Reports Of Suspected Polio In Syria) has set alarm bells ringing both inside, and outside of that civil war torn country.  While there are other, non-polio causes of AFP, preliminary testing has indicated that at least 2 of the 22 cases were positive for wild poliovirus. 

 

Final testing is awaited, but the assumption is that they are dealing with `hot’ AFP cases, and an appropriate response is being planned.

 

While 22 cases may not seem like a lot, the reality is that only about 1%-2% of those infected develop paralysis. This from the New York Health Dept.  Poliomyelitis FAQ

 

Up to 95 percent of people infected with polio have no symptoms. However, infected persons without symptoms can still spread the virus and cause others to develop polio. About four to five percent of infected people have minor symptoms such as fever, muscle weakness, headache, nausea and vomiting. One to two percent of infected persons develop severe muscle pain and stiffness in the neck and back. Less than one percent of polio cases result in paralysis.

 

Meaning that 22 AFP cases are simply the tip of the viral iceberg, and could represent more than 2,000 additional infections.

 

Although Polio is believed to be endemic now in only 3 countries (Afghanistan, Nigeria and Pakistan), already this year we’ve seen reports of polio virus detection in the Middle East (see WHO: WPV1 (Polio) Risks In Israel Remain Moderate to High)  and in Africa (see WHO: Polio Outbreak In Horn Of Africa).  An wider outbreak in Syria would greatly complicate global eradication efforts.

 

The World Health Organization has warned that a `failure to eradicate polio from these last remaining strongholds could result in as many as 200 000 new cases every year, within 10 years, all over the world’. 

 

The ECDC released a 5-page Rapid Risk Assessment of the situation, and the threat it may pose to EU countries, this morning.   First the link to the report, followed by some excerpts:

 

 

Suspected outbreak of poliomyelitis in Syria: Risk of importation and spread of poliovirus in the EU

24 Oct 2013

Available as PDF in the following languages

ENGLISH

This document is free of charge.

Abstract

Following the announcement by WHO of a cluster of cases of acute flaccid paralysis in Syria, ECDC conducted a risk assessment and concludes that this does pose a risk that polio might be imported to the EU. The Risk Assessment includes number of recommendations for EU Member States.

EXCERPTS

Main conclusions and recommendations

 
This cluster of cases of acute flaccid paralysis among Syrian citizens increases the risk for the importation of
wild polio virus to the EU/EEA and further re-establishment and transmission in the Member States.

 
Recommendations:

• Countries hosting Syrian citizens in designated areas (camps) should assess the level of transmission of wild poliovirus among them. Such assessments can be carried out through enhanced clinical surveillance, environmental surveillance, and systematic collection of stool samples from symptomatic and asymptomatic persons.
• EU Member States receiving refugees and asylum seekers from Syria should assess their vaccination status on arrival and provide polio vaccination and other vaccinations as needed.
• Regional and international efforts to assess the risk and provide vaccination and other public health services in Syria and to Syrian refugees hosted by neighbouring countries should be supported.
• This situation stresses the need for Member States to consider implementing the recommendations made in the ECDC risk assessment of wild-type poliovirus transmission in Israel [2] (see Annex).
• Countries should review their national preparedness plans, and ensure that items such as framework and responsibilities for outbreak response, enhanced activities and reporting timelines vaccine of choice for outbreak response, and are appropriately addressed.

 

ECDC threat assessment for the EU

 
The probability is very high that the cluster of cases of AFP in Deir Al Zour province in Syria is caused by wild-type poliovirus, and this risk assessment is based on the assumption that wild poliovirus will be confirmed. Confirmation of the polio outbreak in Deir Al Zour province would signal widespread transmission of poliovirus in Syria and possibly in the areas bordering Syria.

 
The likelihood of poliovirus spreading from Syria to neighbouring countries hosting Syrian refugees is high.

 

Large numbers of people are leaving Syria and it is expected that the number of asylum seekers, refugees and undocumented migrants entering the EU will probably continue to increase as the conflict evolves. If poliovirus is indeed circulating in Syria, it should be assumed that a proportion of Syrian refugees are also carrying the virus.

The risk will be highest among children born in Syria since 2011 because of the interruptions to vaccination
services. Further, refugees from Syria are more likely to mix with under-vaccinated populations living in poor
sanitary conditions. 

Chikungunya & Reports Of Flaccid Paralysis In India

 

 

# 5329

 

 

An interesting (although possibly misleading) report appears in today’s Deccan Chronicle on Chikungunya (CHKV) infections and reports of new `polio-like’ acute flaccid paralysis (AFP) complications occurring in Tamil Nadu (southern India) and Andaman & Nicobar Islands (bay of Bengal) during 2010.

 

First the story, which openly suggests that CHKV has `gone rogue’ (presumably meaning: mutated to a more virulent form) – but in actuality provides very little evidence to support the notion.

 

Following that, I’ve some cites that indicate that these sorts of complications aren’t exactly new.

 

 

Rogue chikungunya attacks Chennai, docs for caution

February 21st, 2011

The government may have vehemently denied the presence of chikungunya in the state last year, but studies have found that the viral disease has begun to exhibit rogue symptoms. The ICMR's Regional Medical Resource Centre has analysed over 1,000 cases of the disease from Tamil Nadu and Andaman & Nicobar Islands, and found that patients with chikungunya suffered from polio-like symptoms of ‘flaccid paralysis.’

 

<SNIP>

 

“However, the disease seems to have taken on an unusual turn in 2010. Patients suffered neurological symptoms of short-term paralytic attacks. Once the spasm passed, they found that their limbs were left weakened. They were not able to use their limp arms and legs,” explained Dr Elango.

(Continue . . . )

 

This report goes on to state that the ICMR was studying the virus strain looking for mutations or genetic changes that might explain these new symptoms.

 

Admittedly, declarations of feared or suspected `viral mutations’ are nothing new to the Indian press (see here, here, and here) and so I tend to take these stories with a very large grain of salt.

 

Nevertheless, given the explosion in Chikungunya cases around the world since 2004, the emergence of a new, more virulent `rogue’ strain of CHKV capable of causing a `polio-like’ illness would be pretty big news.

 

And with viruses, mutations are always possible.

 

A hasty search turns up a number of references to flaccid paralysis as a symptom of Chikungunya, however, going back to at least 2006. 

 

 

Epidemiol Infect. 2008 Sep;136(9):1277-80.

Four cases of acute flaccid paralysis associated with chikungunya virus infection.

Singh SS, Manimunda SP, Sugunan AP, Sahina, Vijayachari P.

GB Pant General Hospital, Port Blair, Andaman and Nicobar Islands, Port Blair-744101, India.

Abstract

The recent epidemic of chikungunya fever (2005-2006) in India has affected millions of people. The Andaman and Nicobar Islands, an archipelago situated in the Bay of Bengal 1200 km from peninsular India, also witnessed an outbreak of chikungunya fever starting in July 2006 which affected thousands of people.

 

Chikungunya fever classically manifests as high fever, myalgia, arthralgia and arthritis and in a certain percentage of cases with maculopapular rashes. However, deviation from the classical clinical features of chikungunya fever was reported in the earlier and recent epidemics.

 

During the recent epidemic in the Andaman and Nicobar Islands we came across ten cases of flaccid limb weakness following symptoms and signs suggestive of chikungunya fever. In four subjects we confirmed the diagnosis of chikungunya virus infection by serological method (IgM ELISA method). This is the case report of those four subjects.

 

 

In Chikungunya Fever: An Epidemiological Review of a Re-Emerging Infectious Disease (J. Erin Staples, Robert F. Breiman, and Ann M. Powers) which was published in the Journal Clinical Infectious Diseases  in September of 2009, we learn:

 

During early epidemics, rare but serious complications of the disease were noted, including myocarditis, meningoencephalitis, and mild hemorrhage [8, 39, 42, 43]. From recent epidemics, further neuroinvasive complications have been recognized, including Guillan-Barré Syndrome, acute flaccid paralysis, and palsies [44–48].

(Citations below)

44. Chikungunya in paediatrics: epidemic of 2005–2006 in Saint-Denis, Reunion Island. Arch Pediatr 2008;15:253-62.

45. Guillain-Barré syndrome complicating a chikungunya virus infection. Neurology 2007;69:2105-7.

46. Neurological complications in chikungunya fever. J Assoc Physicians India 2007;55:765-9.

47. Chikungunya virus induced sudden sensorineural hearing loss. Int J Pediatr Otorhinolaryngol 2008;72:257-9.

48. Four cases of acute flaccid paralysis associated with chikungunya virus infection. Epidemiol Infect 2008;136:1277-80.

 

 

Convincing evidence that flaccid paralysis has been – on rare occasions - associated with CHKV infection prior to the past year.

 

While primarily associated with fever, rash, and arthralgias, the finding that CHKV should produce occasional neurological symptoms (including AFP) isn’t completely surprising.

 

Chikungunya is an alphavirus, after all; a genus that includes a number of mosquito borne encephalitis-producing viruses (e.g. Eastern Equine Encephalitis, Western Equine Encephalitis, Venezuelan Equine Encephalitis).

 

Acute Flaccid Paralysis (AFP) has also been observed on rare occasions in association with a number of other encephalitic infections, including West Nile Virus, St. Louis Encephalitis, Japanese Encephalitis, and enterovirus 71.

 

The article that appears in today’s Deccan Chronicle provides us with precious few details.

 

We are not told how many cases of AFP have been  detected recently among confirmed CHKV cases in Tamil Nadu, or whether the ICMR has actually found any molecular changes to the virus they’ve been looking for.

 

All of which leaves us little with which to gauge the actual significance of today’s news report. 

 

But changes to the virus or not, Chikungunya is a serious and growing concern around the world, and it even has the potential to spread to the Southern United States and parts of Europe.

 

 

 

Until more information is forthcoming on today’s story, for more on the Chikungunya virus and other arboviral threats, you may wish to revisit the following blogs:

 

India: Chikungunya & Eye Infections

Pathological Flyers

India: Deep In The Miasma

ASTMH: Dengue and Insect-Borne EIDs In The US

A Message Of Import

More On the Veracruz Paralysis Outbreak

 

 

# 5157

 

 

Two days ago in Guillain-Barre Syndrome in Mexico, I wrote about a mysterious outbreak of acute flaccid paralysis in Mexico that at first was attributed to GBS, or Guillain-Barre Syndrome.

 

Since that time we’ve seen numerous news stories in the Mexican media, often with conflicting information.   FluTrackers has a thread with more than 50 posts on this outbreak, which has numerous translated news articles.

 

Early suggestions that this might in some way be connected to flu vaccinations (a common kneejerk reaction whenever GBS appears), are being dismissed by the Health Secretariat who announced that `of the 35 cases of acute flaccid paralysis, only two received the vaccine against seasonal influenza’.

 

Tonka, senior moderator on FluTrackers, posted a translation from an article from excelsior.com this morning.

 

SSA denies link with vaccine and H1N1 outbreak

The deputy director of epidemiology says there is no evidence that flaccid paralysis is caused by the vaccine and Guillain-Barré syndrome

Georgina Olson

• Strange outbreak sparks alert at Veracruz, and there are two dead

• Suman 33 patients with syndrome 'Guillain-Barre'

MEXICO CITY, Dec. 18 .- Of the 42 cases of acute flaccid paralysis have been presented in Veracruz and Nayarit none have been caused by the application of the vaccine against influenza A H1N1 or which is used to attack the influenza Seasonal also still have no evidence to prove that the disease is Guillain-Barré syndrome, said in an interview with Excelsior Dr. Hugo López-Gatell, deputy general director of epidemiology at the Health Secretariat (SSA).

"No, there is no evidence linking the vaccine against influenza A virus H1N1 or other influenza season, with the occurrence of these cases of acute flaccid paralysis," the official said.

(Continue . . . )

 

 

While all of this tells us what this outbreak isn’t, right now no one seems to know what this outbreak is.

 

According to media reports, of the (and the numbers here seem to vary a bit) 3 dozen or so cases reported so far, only 10 remain hospitalized.  

 

GBS-like symptoms (acute flaccid paralysis) can be caused by a variety of factors, including as sequelae from viral and bacterial infections, and even from environmental toxins.

 

According to another report on El Mundo, also posted by Tonka, health authorities are taking water, food,  and environmental samples from areas where these cases have been reported.

 

Performed first water sample

Staff of the Department of Health investigates the factors that can trigger paralysis, to make them known to the public and can be prevented.

Friday, December 17, 2010 Juliet H. Zambrano

 

 

All of these tests will likely take weeks.

 

The good news is that the number of cases does not seem to be expanding very rapidly, and that most of these cases are resolving fairly quickly.

 

For now, however, the cause of this outbreak remains unknown.

 

I’ll update this story from time to time, but you can follow this thread on Flutrackers to keep up with the latest news reports.