Acute Flaccid Myelitis Among Hospitalized Children in Texas, 2016
Rachel Quick, MSN, RN, CNS, Dawn McElvain, MSN, RN, CPNP, Bhairav Patel, MD, Donald Murphey, MD, Ann Bailey, MBA, BSN, RNC-NIC, CIC, Marisol Fernandez, MD, Laura Loftis, MD, Carla Garcia, MD6, Lynne Eger, MD, Elizabeth Aguilera, MD, CCRP
Pediatric Infectious Diseases
Abstract
Background: Background: This is a multisite study of pediatric patients with acute flaccid myelitis (AFM) in Texas during the year 2016 among 6 children's hospitals. AFM is a poorly understood disease. Data describing pathogenesis, treatment, and recovery are limited. AFM is a central nervous system/spinal cord disease, characterized by limb paralysis, CSF pleocytosis and MRI findings with gray matter edema of spinal cord in previously healthy children, often with preceding or concurrent viral illness. Outbreaks occurred in the U.S. in 2014 and 2016. Prognosis in 2014 was poor; 80-90% with permanent paralysis. There is no known cause, but it is believed infectious or post-infectious; linked to enterovirus D68 in 2014 cases Anti-inflammatory treatment during 2014 did not appear effective and the CDC later advised against use. There is no recommended medical treatment. AFM is not a nationally notifiable condition and therefore, many cases are not reported Study Objective: Form a collaborative database of Texas cases of AFM that occurred during the 2016 outbreak, creating the largest cohort of regional 2016 case data. Research goals included describing disease presentation, treatments used, response to medical intervention, pathogens identified, long-term outcome data, and any variables associated with prognosis.
Methods: Study Design & Setting: Retrospective chart review of hospitalized patients meeting inclusion criteria among 6 Texas children's hospitals in 4 major metropolitan areas. (Austin, Dallas/Ft. Worth, Houston, San Antonio). This study was IRB approved for all participating hospitals. Inclusion Criteria: Patients age 0-18 years hospitalized between January 1- December 31, 2016 identified by each participating hospital according to the following Texas Department of Health and Human Services and definition of confirmed AFM: An illness with onset of acute focal limb weakness AND a magnetic resonance image (MRI) showing spinal cord lesion largely restricted to gray matter and spanning one or more spinal segments. Variables: Detailed chart review included the following: demographics, patient medical history, prodromal illness, vaccine history, neurologic exam at nadir of illness, imaging of brain and spine, laboratory data, medical treatments, physical therapy, degree of improvement following treatments, and outpatient visits up to 18 months.
Results: 22 cases of AFM were seen in children in Texas in the midst of a second nationwide epidemic of AFM in the US in 2016. Characteristics described in Table 1. A plausible pathogen was identified in 50% of cases (Table 2). 95% (21) showed some degree of improvement as of the last follow up (94% (17) with and 100% (4) without treatment) (fig 3). 45% had recovery of function (ability to perform activities of daily living); 32% had full recovery of strength and function (fig 1) Among the 8 patients with all extremities involved, 6 had significant residual weakness, ranging from flaccidity in one extremity to complete caregiver dependence. One was lost to follow up after discharge. None of the three patients with Enterovirus D-68 made a full recovery, and all three remain completely or largely dependent on caregivers.
Discussion: Our cases were similar to those described across the U.S. in 2014 Clinical outcomes were markedly better than those seen in 2014 Associated viral infections were varied, but included cases of enterovirus D68. We were unable to find a consistent correlation between a specific treatment and improvement or recovery, therefore it is unclear if the use of anti-inflammatory treatment like IV methylprednisolone and IVIG is beneficial. We did not see complications overall due to anti-inflammatory therapy. Patients with all extremities involved or enterovirus D68 identified appear to have poorer outcomes.
