Acute Flaccid Myelitis Associated With Enterovirus D68 in Children, Argentina, 2016

Carolina M. Carballo; Marcela García Erro; Nora Sordelli; Gabriel Vazquez; Alicia S. Mistchenko; Claudia Cejas; Manlio Rodriguez; Daniel M. Cisterna; Maria Cecilia Freire; Maria M. Contrini; Eduardo L. Lopez


Emerging Infectious Diseases. 2019;25(3):573-576. 

In This Article

Abstract and Introduction


After a 2014 outbreak of severe respiratory illness caused by enterovirus D68 in the United States, sporadic cases of acute flaccid myelitis have been reported worldwide. We describe a cluster of acute flaccid myelitis cases in Argentina in 2016, adding data to the evidence of association between enterovirus D68 and this polio-like illness.


We report a cluster of acute flaccid myelitis (AFM) cases in Buenos Aires, Argentina, in 2016. AFM was defined as acute flaccid paralysis (AFP) with magnetic resonance imaging (MRI) showing lesions predominantly affecting the gray matter of the spinal cord.[1] We prospectively studied all patients with AFP who were admitted to Hospital de Niños "Ricardo Gutiérrez" in Buenos Aires during April 24–August 24, 2016, under the Argentine National Surveillance Acute Flaccid Paralysis Program for poliovirus as part of the World Health Organization AFP Program in the Americas. We obtained fecal samples or rectal swab specimens, serum samples, nasopharyngeal swab specimens, and cerebrospinal fluid (CSF) samples.

Fecal samples were tested at the National Reference Center for the Argentine National Surveillance Acute Flaccid Paralysis Program for enterovirus, including wild-type and vaccine-derived poliovirus. We screened clinical samples for enterovirus D68 (EV-D68) using a panrhinovirus and enterovirus nested PCR of enterovirus targeting the 5′ untranslated region.[2] We purified the amplified products and prepared them for Sanger sequencing. We performed BLAST searches ( of GenBank sequences to identify which picornavirus was present. We obtained viral protein 1 partial sequences as previously described.[3] In addition, we studied a wide panel of viruses (parainfluenza virus 1, 2, and 3; influenza A/B; respiratory syncytial virus; adenovirus; metapneumovirus; rhinovirus; varicella zoster virus; herpes simplex virus; cytomegalovirus) by reverse transcription PCR (RT-PCR) and studied bacteria by culture. We performed MRI and electromyography for all patients.

Fourteen children were admitted with AFP during April–August 2016. Six were confirmed to have AFM by case definition; the other 8 had alternative diagnoses, including Guillain-Barré syndrome,[3] influenza virus myositis,[2] encephalitis by echovirus (in 1 child with Down syndrome), acute transient hip synovitis,[1] and transverse myelitis.[1] Patients' clinical, demographic, and outcome findings are shown in Table 1, diagnostic findings in Table 2.

In 4 (66.7%) of 6 patients, we confirmed EV-D68 infection by nested RT-PCR. In 1 patient, enterovirus was detected but not typed; in 1 patient, no agent was detected. All patients had distinctive neuroimaging changes. We followed confirmed AFM cases for 6 months to assess clinical improvement.

The median age of patients with AFM was 3.9 (range 1–5) years; 4 (66.7%) of the 6 were female, and 3 (50%) had a history of asthma. All patients had prodromal signs or symptoms before onset of neurologic symptoms: 100% had upper respiratory tract infection (URTI); 4 (66.7%) had fever; and 1 (16.7%) had vomiting and abdominal pain. Neurologic symptoms appeared 1–11 (median 2) days after URTI symptoms.

Results of hematology and chemistry analysis were normal for 5 (83%) patients. Patient 1 had leukocytosis (leukocytes 18,000 cells/mm3, with 82% neutrophils) and elevated levels of alanine aminotransferase (103 IU/L [reference 10–43 IU/L]), aspartate aminotransferase (97 IU/L [reference 10–35 IU/L]), and creatine kinase (6,591 IU/L [reference 24–170 IU/L]). During follow-up, patient 1 showed an increased creatine kinase level that could not be related to enterovirus infection.

All confirmed AFM case-patients showed T2 gray matter hyperintensity within the spinal cord on MRI. Electromyography showed early signs of denervation and low motor neuron function in all 5 patients in whom the test could be done. Specimen collection was performed 9.5 (range 3–30) days after URTI symptoms started and 7.5 (range 1–18) days after onset of neurologic symptoms.

We identified enterovirus using nested RT-PCR of nasopharyngeal samples in 5 (83%) of 6 patients; 4 (80%) of 5 were typed as EV-D68, but in 1 patient (20%) the viral load was too low for typing. We identified EV-D68 in 2 (33%) of 6 fecal specimens. We performed molecular characterization of EV-D68 strains based on phylogenetic analyses of a partial VP1 genomic region (Figure).


Molecular characterization of enterovirus D68 strains from Argentina, 2016, compared with reference strains from GenBank. Tree based on phylogenetic analyses of partial viral protein 1 genomic region (nucleotide positions 2554–2799, corresponding to the Fermon strain). Bold indicates strains detected in this study (GenBank accession nos. MF445419–20). We generated trees using the neighbor-joining method, as implemented in MEGA 6 software ( Bootstrap values from 1,000 replicates are shown at the nodes. The trees were rooted with the prototype strain Fermon (GenBank accession no. AY426531). Scale bar indicates nucleotide substitutions per site.

Results of nested RT-PCR for enterovirus were negative for all CSF samples; results of the respiratory virus panel were negative for all patients. Neither bacteria nor fungus were isolated in blood or CSF samples. Serum PCR to identify herpes simplex virus, varicella zoster virus, and cytomegalovirus also yielded negative results.

Intravenous immunoglobulin was empirically infused in 5 (83%) patients; 2 (33%) received systemic corticosteroids. Three patients required intensive care unit admission. All patients had neurologic sequelae: persisting palsy in >1 limbs and atrophy of muscles with a shortening of limbs. Two patients required chronic noninvasive ventilatory support during 6 months of follow-up. No patients died.