A 3-year-old male came to clinic with fever, runny nose and cough for 36 hours. His parents had treated him with ibuprofen which helped but they felt he was now wheezing. He had no history of asthma or other respiratory problems. He did attend day care and there had been several other children with similar illnesses, and enteroviruses were circulating in the community. He was drinking and urinating well. The past medical history showed upper respiratory tract infections and some otitis media. The family history was negative for asthma, but there was an elderly uncle with chronic obstructive pulmonary disease. The review of systems was negative including for rashes.
The pertinent physical exam showed he was mildly ill-appearing with a fever of 38.2°C., respiratory rate of 28/minute, pulse of 104 beats/minute and growth parameters that were 75-90% for age. HEENT showed clear rhinorrhea, mildly erythematous pharynx, and clear tympanic membranes. His lungs had some transmitted upper airway sounds, but also some mild end-expiratory wheezing at both bases. Skin examination showed no rashes. The diagnosis of a viral infection, that was triggering mild bronchospasm was made. The patient’s clinical course in the clinic showed him to have resolution of the bronchospasm after treatment with albuterol. The family was instructed to provide supportive care and was shown how to use an albuterol metered-dose inhaler with a spacer device. They were also instructed on how to look for respiratory distress and to call if he was having more problems. At an appointment a few weeks later, his mother says that he used the albuterol for about another 2 days and then the symptoms had resolved.
Enteroviral infections are RNA viruses including Coxsackieviruses A and B, Echoviruses and Enteroviruses. They are common and spread by respiratory secretions, fecal-oral contamination and fomites. They commonly occur in summer and fall in temperate climates but are less seasonally seen in the tropics. Hand hygiene is especially important to prevent infection. The incubation period is usually 3-6 days. The viruses are best isolated from the throat, stool and rectal swab specimens but other infectious sites can also be used for viral isolation. Treatment is supportive. Infants, children and teens are more likely to be infected but all ages can be infected as these are very common viral illnesses.
Common symptoms of enteroviral infections include fever, upper respiratory symptoms such as rhinorrhea, cough and sneezing, rashes and mouth ulcerations, body and muscle aches and conjunctivitis. Other less common problems include viral meningitis and encephalitis possibly with paralysis, and myocarditis and pericarditis.
Enterovirus D68 (EV-D68) is a non-polio enterovirus that usually causes fever, rhinorrhea, cough, sneezing, and body and muscle aches.
In the summer of 2014 the United States has had an outbreak of EV-D68 and it appeared early in the Midwest where this patient was seen. Although the patient was not tested, in retrospect this patient was probably an early case of EV-D68.
EV-D68 is not a new virus but was originally isolated in 1962 in California and has rarely been reported in the US, except for small clusters. In 2014, the outbreak has caused many children to have severe respiratory illnesses. It affected children with and without a previous history of asthma, and many needed admission to intensive care for aggressive respiratory support.
Questions for Further Discussion
1. What diagnostic tests are available to detect EV-D68?
2. What epidemiological surveillance systems does your country have for monitoring enteroviral infections?
- Disease: Enterovirus D68 | Viral Infections
- Age: Preschooler
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Centers for Disease Control. Symptoms.
Available from the Internet at http://www.cdc.gov/non-polio-enterovirus/about/symptoms.html (rev. 5/10/14, cited 9/26/14).
MMWR. Severe Respiratory Illness Associated with Enterovirus D68 – Missouri and Illinois, 2014
September 12, 2014 / 63(36);798-799.
Available from the Internet at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6336a4.htm?s_cid=mm6336a4_w (rev. 9/12/14, cited 9/26/14).
Centers for Disease Control. Enterovirus D68.
Available from the Internet at http://www.cdc.gov/non-polio-enterovirus/about/EV-D68.html (rev. 9/25/14, cited 9/26/14).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital