NH Clinicians Should Be Vigilant for Acute Flaccid Myelitis Cases

August 02, 2016

Key Points and Recommendations:

1. The Centers for Disease Control and Prevention (CDC) has received an increased number of acute flaccid myelitis (AFM) case reports for 2016 across the United States.

2. New Hampshire has one confirmed case of acute flaccid myelitis (AFM) so far in 2016.

3. Clinicians should remain vigilant for cases of AFM, and suspected cases of AFM should be promptly reported to NH Division of Public Health Services (DPHS) at 603-271-4496 (after hours, 603- 271-5300).

4. Patients suspected of having AFM should have specimens collected for testing as soon as possible according to CDC guidance.

Situation:

The CDC recently reported that from January through June 2016, there was an increased number of suspect AFM cases reported across the United States. Of these reported cases, 21 were classified as "confirmed" and three were classified as "probable" cases, according to current case definitions. These numbers are an increase nationally compared to what was observed in 2015. Further information about national AFM surveillance and AFM case definitions can be found on the CDC website.

In June 2016, the New Hampshire Department of Health and Human Services (DHHS), DPHS received a report of a child from New Hampshire with AFM. Given the CDC findings of increased AFM cases reported nationally, we are asking clinicians to remain vigilant for suspect AFM cases and report cases promptly to the DPHS. Reporting of cases will help the CDC to monitor this illness and better understand potential causes, risk factors, and preventive measures.

Background:

The CDC initially investigated reports of children across the United States with AFM from August to December 2014, which coincided with a national outbreak of severe respiratory illness among children caused by enterovirus D68 (EV-D68). Despite this association in timing, a cause for the 2014 AFM cases has not been determined, and cases of AFM are still being investigated. A number of different viruses have been associated with AFM. More information about AFM can be found on the CDC website.

Clinical Presentation and Reporting:

AFM is a neurological illness that affects the central nervous system and causes a sudden onset of limb weakness and loss of muscle tone and reflexes. Affected individuals may also have facial droop or weakness, difficulty with eye movements, ptosis, dysphagia, or dysarthria. An MRI typically shows a spinal cord lesion largely restricted to gray matter and spanning one or more spinal segments.

Clinicians should suspect AFM if a patient presents with acute onset of limb weakness and consider performing an MRI and obtaining additional laboratory testing as discussed below. Patients with consistent clinical and imaging findings should be reported to NH DPHS at 603-271-4496 (after hours, 603-271-5300). Patient summary forms should also be completed for suspect AFM cases and faxed to NH DPHS at 603-271-0545. A copy of the patient summary form and instructions for completing the form can be found on the CDC website.

Specimen Collection and Testing:

To investigate potential etiologies of AFM, the CDC has requested that patients with AFM have cerebrospinal fluid (CSF), upper respiratory tract, serum, whole blood, and stool specimens collected for analysis at the CDC. These specimens should be collected as early as possible in the course of illness because early specimen collection has the best chance to yield a diagnosis. Specimens should not be shipped to DPHS or CDC without first consulting with NH DPHS at 603-271-4496. Instructions regarding specimen collection, storage, and shipping can be found on the CDC website.

Clinicians treating patients with suspected AFM should also pursue local laboratory testing for known causes of AFM at their normal clinical laboratories and consider testing for enteroviruses (polio and non-polio viruses), West Nile virus, and other infectious causes of AFM.

Clinical Management:

Information to help clinicians manage patients suspected of having AFM can be found on the AFM section of the CDC website.

For any questions regarding the contents of this message, please contact NH DHHS, DPHS,

Bureau of Infectious Disease Control at 603-271-4496 (after hours, 800-852-3345, ext. 5300).

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