Wednesday, December 12, 2018

Polio-Like Illness Returns to Texas in 2018

By Donald Murphey, MD
Pediatric Infectious Diseases, Dell Children’s Medical Center
Member, Texas Medical Association (TMA) Council on Science and Public Health; and consultant, TMA Committee on Child and Adolescent Health

Acute flaccid myelitis (AFM) is a newly recognized neurologic [nervous system] disorder that has appeared in patients in late summer and early fall in 2014, 2016, and 2018. The cause and the treatment are unknown. Many patients do not recover fully. 

If you’ve read the latest health headlines, you might have heard about a rare polio-like illness outbreak happening in the United States this year — and it’s making its presence known here in Texas. Acute flaccid myelitis is a rare neurological illness that leads to sudden paralysis, mainly among children. Children with AFM have sudden-onset profound weakness in their arms and/or legs, often with pain in those areas or the neck, and they often experience fever and signs of viral respiratory or gastrointestinal infection. AFM is similar to but different from polio.

We do not know the long-term outcomes, but many patients experience permanent paralysis from the disease. The cause of AFM is unknown, but it might be due to viral infection. Some physicians believe it is connected to infection with a virus called enterovirus D68. When AFM patients are tested, we often find a virus in the nose or throat, or in the intestines/stool, but not in the spinal fluid or blood. Magnetic resonance imaging of the nervous system shows inflammation in the center of the spinal cord where there are nerve cells that control movements. Testing of affected patients’ spinal fluid shows white cell inflammation but not a specific virus or germ causing the infection.

In addition to patients’ arm and leg weakness, they may also have weakness of their trunk and face. The weakness can happen quickly or increase over several days. They also might develop breathing difficulty. They usually have recent fever with cough, congestion, or vomiting and diarrhea, or have these when the weakness arises.

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We have seen AFM cases in the United States primarily in three waves — in 2014, 2016, and 2018 — all around the same time of year, in late summer and fall. Nationwide, the Centers for Disease Control and Prevention confirmed 120 AFM cases in 2014 and 149 in 2016. As of early December, there are 158 confirmed cases nationwide in 2018. AFM was rare prior to 2014. Doctors around the world have seen AFM cases as well.

The initial cases in 2014 were more common in Colorado and California. The same areas saw outbreaks of severe respiratory infection with the enterovirus D68 virus. Most patients with AFM in 2014 suffered poor outcomes; as many as 90 percent experienced permanent paralysis. Scientists are still gathering data on the cases from 2016, but the outcome seems to be better. In 2016 and in 2018, some children have had complete recovery or have had significant improvement in their paralysis.

Texas experienced AFM cases in the same three years — 2014, 2016, and 2018. The Texas Department of State Health Services confirmed three cases in 2014, 19 in 2016, and 21 in 2018 (so far).

Physicians are not required to report AFM cases to the health department. The Texas Medical Association and Texas Pediatric Society encourage physicians and health care providers to report possible AFM cases to their local and state health departments and to send testing to the state lab.

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