Thoughts on diagnoses for the mystery illness in Cambodia

[Giuseppe]

Re: Thoughts on diagnoses for the mystery illness in Cambodia

EV71 doesn't explain fully the age-restricted septic shock syndrome, reason behin the activation of IHR alerting system.

In Hong Kong, where ev-71 and coxsackievirus usually circulate during hot season, there are cluster of cases - spanning various classes of ages - especially in kindergarten, with children and teachers involved.

I have not seen cases only in one class of age.

For this reason, the case cannot be close here.

 

[alert]

Re: Thoughts on diagnoses for the mystery illness in Cambodia

EV71 is indeed highly contagious, but the vast majority of cases are mild. 60 EV71 deaths probably represents over 50,000 cases of mild infection.

We do need to know a little bit more about the respiratory failure that was reported. I'm not sure that septic shock is the cause of that. It could still have something to do with the treatment they were given. Dr. Richert would know more about the precise symptoms that almsot anyone else, and he still thinks the poor outcome has something to do with the prior treatment.

RoRo has posted a couple reports from years past in this thread reporting high apparent CFR outbreaks of EV71. It seems like something may trigger a more virulent form of the disease, but as that puzzle has been unsolved for a decade or more, I do not necessarily expect a solution to this in the next few weeks.

As far as lack of clustering, these kids were too young to go to kindergarten; 90% were under age 5, and more than half were under age 3. What does not usually happen in EV71 outbreaks is clusters of SEVERE cases, and it appears that to this point, only the severe cases were reported.

 

[alert]

Re: Thoughts on diagnoses for the mystery illness in Cambodia

The counts are getting very murky. Dr. Richner is reporting 66 cases, of whom he thinks 64 died. The WHO two days ago indicates 74 total cases, but said only 57 had the same symptoms, and then 56 of those 57 died. No indication if any of the other 17 died.

Now the WHO is saying it is adding two cases to the 57 to get 59, but now only 52 of them died. So did at least four (and maybe six if both new cases were fatal) of the 56 deaths reported two days ago actually survive? Or is this a net change (i.e. four deaths were discarded, and six survivors were added)? And what supposedly happened to the 12 deaths that Dr. Richner is counting that are not in the WHO count as of now? Were they in the other 17 cases?

I would think that if the number of survivors is small (even the most recent WHO update only lists 7, and Dr. Richner is reporting just 2), that shouldn't be that hard to keep track.

Could some of the extra cases be discarded due to dengue or S. suis diagnosis? Today also adds an 11-year-old to the list of victims. It would be interesting to know if she tested positive for something other than EV71 as that is beyond the usual age range for severe EV71 infection.

 

[Emily]

Re: Thoughts on diagnoses for the mystery illness in Cambodia

http://www.ncbi.nlm.nih.gov/pubmed/10568570

Lancet. 1999 Nov 13;354(9191):1682-6.
Clinical features and risk factors of pulmonary oedema after enterovirus-71-related hand, foot, and mouth disease.
Chang LY, Lin TY, Hsu KH, Huang YC, Lin KL, Hsueh C, Shih SR, Ning HC, Hwang MS, Wang HS, Lee CY.
Source

Department of Pediatrics, Chang Gung Children's Hospital, Kweishan, Taoyuan, Taiwan.
Abstract
BACKGROUND:

In Taiwan, from April to July, 1998, an epidemic of hand, foot, and mouth disease associated with enterovirus 71 (EV71) occurred with fatal complications. We did a clinical study of EV71-related diseases in Taiwan.
METHODS:

We studied 154 children with virus-culture confirmed EV71 infection. Children were divided into three groups: 11 patients with pulmonary oedema; 38 patients with central nervous system (CNS) involvement and no pulmonary oedema; and 105 children without complications. We compared the clinical features, laboratory findings, risk factors, and outcome among these three groups.
FINDINGS:

Nine children with pulmonary oedema had hand, foot, and mouth disease, one had herpangina, and one had febrile illness with eight children with limb weakness and one with limb hypesthesia. All children had had sudden onset of tachycardia, tachypnoea, and cyanosis 1-3 days after onset of the disease. Nine of 11 children died within 12 h of intubation; one child was braindead within 15 h and died 17 days after intubation; one child was in deep coma and died 3 months later. In children with CNS complication and no pulmonary oedema, one child died of pneumonia after 4 months of ventilator support and four children had sequelae. All 105 children without complications recovered. There was a significant association between CNS involvement and pulmonary oedema (odds ratio 12.4 [95% CI 2.6-60.1], p=0.001). Risk factors for pulmonary oedema after CNS involvement were hyperglycaemia, leucocytosis, and limb weakness. Hyperglycaemia was the most significant prognostic factor for pulmonary oedema (odds ratio 21.5 [3-159], p=0.003).
INTERPRETATION:

EV71 can cause hand, foot, and mouth disease, CNS involvement with severe sequelae, and fatal pulmonary oedema. Hyperglycaemia is the most important prognostic factor.