December 3, 2022

​The Centers for Disease Control and Prevention (CDC) has recently issued a health alert for clinicians regarding a common respiratory illnesses including one that can cause an uncommon type of paralysis in children called acute flaccid myelitis (AFM.)
In July and August, there was an increase in cases of rhinovirus and enterovirus – two viruses that cause common upper respiratory infections in children. This increase in cases comes after the last wave of these viruses in the summer and fall of 2018, before the start of the COVID-19 pandemic.
Rhinovirus is typically associated with upper respiratory infections and although this virus tends to spread year-round, there are usually peaks in the spring and the fall of each year. Enterovirus can very similar symptoms to rhinovirus but can also lead to fever, rash, and neurologic illness. A type of enterovirus called enterovirus D-68 has in rare cases led to AFM.
Dr. Lydia Marcus, assistant professor in the Division of Pediatric Neurology at the UAB Marnix E. Heersink School of Medicine and Children’s of Alabama, explained that enterovirus-D68 is one of many non-polio enteroviruses and typically causes respiratory and occasional gastrointestinal symptoms.
“Symptoms are often mild but sometimes can be more severe, and can include difficulty breathing, coughing, congestion, body aches, fever, diarrhea, or vomiting,” explained Marcus.
Although enterovirus is found year-round, it peaks during the late summer and early fall.
Most children with these viruses will only have symptoms of the common cold such as a runny nose, body and muscle aches, sneezing, and some a fever. However, with recent hospitalizations increasing with these viruses, clinicians are starting to see an increase in cases of acute flaccid myelitis [AFM] which can result in paralysis.
“The symptoms of acute flaccid myelitis can include neck, back, arm or leg pain, weakness in the neck, arms or legs, difficulty swallowing, slurred speech, facial weakness or double vision,” Marcus told Healthline.
These symptoms come after the traditional upper respiratory symptoms that children experience with enteroviruses.
“On rare occasions, the EV-D68 virus can cause a paralytic illness that resembles polio,” says Dr. William Schaffner, an infectious disease expert at Vanderbilt University Medical Center in Tennessee.
“The paralysis occurs an average of 5 days after the onset of the respiratory illness and is of rapid onset – hours to days – and frequently is asymmetrical and may involve any combination of limbs, commonly including the arms,” Schaffner explained to Healthline.
As many of the symptoms between rhinovirus and enterovirus are similar, it’s sometimes difficult to determine which virus a patient has without doing specialized testing. Because of the similarities, traditional testing makes these two viruses indistinguishable, however, through specialized PCR analysis, clinicians were able to determine that enterovirus-D68 is the likely culprit for acute flaccid myelitis.
Many children overcome enterovirus with over-the-counter medications and not requiring hospitalization or invasive treatment, however, a small percentage of children may develop paralysis from this virus.
It was estimated of the over 1,100 cases of enterovirus D-68 in the U.S. and Canada in 2014 approximately 10.4% of people developed AFM.
Marcus says that “infants, children, and young adults are more likely to get enterovirus infections and become ill compared to adults as children’s immune systems are still developing immunity to these very common viruses.”
Since August 2014, the CDC reports that there have been 693 confirmed cases of acute flaccid myelitis in the United States with outbreaks occurring in 2014, 2016, and 2018.
Schaffner explains the every-other-year pattern “was interrupted by the social distancing and virtual schooling during the COVID pandemic and now that relatively normal behavior has been restored, this could have permitted a resurgence of D68 transmission once again.”
As of mid-September, there are only 14 confirmed cases of acute flaccid myelitis, but experts warn that as enterovirus cases increase, the number of myelitis cases will increase as well.
Although the neurologic complications of this virus have been documented since 1962, enterovirus-D68 started to be surveyed closely by the CDC in 2014 after hospitals in Missouri and Illinois notified health officials of an increase in admissions of children with severe respiratory illnesses. Resultingly, with the increase in rhinovirus and enterovirus cases in the United States this year, the CDC Health Alert Network issued a warning for clinicians to be vigilant for this virus.
Health experts say that parents should not be overly concerned about the rare outcomes of enterovirus-D68.
Marcus reminds parents that “AFM is a very rare neurologic disorder whereas enterovirus and other viral infections are quite common, so being aware of and not brushing off any concerning symptoms is the most important thing.”
Like any other illness, it’s important to keep a watchful eye on your children and their illnesses, including the common cold, but with the rarity of acute flaccid myelitis, over-the-counter medications and a watchful eye are important for treatment success in most children.
Experts stress that prevention is key. They advise that washing hands with soap and warm water for at least 20 seconds, avoiding touching eyes, noses, and mouth with unwashed hands, avoiding close contact with others who are sick, and cleaning and disinfecting frequently are all steps that people can take to help prevent the spread of not only this virus.
If your child starts to experience symptoms that appear more severe than an average upper respiratory infection, early diagnosis and detection are important. You can follow up with a primary care or pediatric physician, your local health department, or an emergency room physician can make for an early diagnosis.

Dr. Rajiv Bahl, is an emergency medicine physician, board member of the Florida College of Emergency Physicians, and health writer. You can find him at RajivBahlMD.com.









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