Acute management of EV71 infection

Acute Management of EV71 Infection Dr. Ng Chi Hang Department of Paediatrics Queen Elizabeth Hospital 14 th May 2008

Enterorivuses Non-enveloped RNA virus 4 species Poliovirus Coxsackievirus Echoviruses Enteroviruses 4 serotypes, type 68-71

EV71 Associated with more severe complications Encephalitis Poliomyelitis-like paralysis Survive for days on fomites at room temperature Inactivated at temp. > 60 C

Epidemiology Transmission routes Faecal-oral Respiratory droplets Direct contact of contaminated objects Peak infection in May to July in HK Young children are main target

Infection Infectious period Starts several days before symptoms Peak within 1 week of disease onset Excrete in stool for 6-8 weeks Excrete in respiratory secretion for 1 week Incubation period of HFMD 3-7 days

Clinical Features of EV Mostly subclinical or non-specific febrile illness Fever with upper resp. & GI symptoms Herpangina Fever, painful oral vesicles on tonsils & posterior pharynx Hand-foot-mouth disease Fever, vesicles on buccal mucosa & tongue & interdigital surfaces of hands & feet Meningoencephalitis Fever, meningeal signs, change in mental state, seizure Acute flaccid paralysis Fever followed by sudden asymmetric flaccid paralysis

Special features of EV71 80% cases results in HFMD Majority are self-limiting Herpangina or non-specific febrile illness Severe complications Aseptic meningitis encephalitis (brainstem encephalitis or rhombencephalitis) Encephalomyelitis Acute flaccid paralysis (typical monoplegia) Acute respiratory failure (acute pulm. oedema, pulm. haemorrhage) Heart failure Classical features may not always present together Fever, papulovesicular rash at distal extremities, buttocks and extensor surfaces of knees, & oropharyngeal ulcers

Patient Management 1 Out-patients Most cases are mild and do not warrant hospitalization Only symptomatic treatment and attention to adequate hydration Should not attend school or day care

Patient Management 2 Out-patients Children (esp. </= 5yrs) with HFMD / herpangina, or close contacts of confirmed cases should be considered for hospitalization if warning signs are detected within 7 days of onset of illness

Patient Management 3 Out-patients Warning signs High fever, > 39 C Persistent fever, > 3 days Neurological features Irritability, sleepiness, frequent sleep interruption, drowsiness, difficulty to arouse, fluctuating consciousness, visual or auditory hallucinations, diplopia, photophobia, persistent headache, repeated vomiting, bulging anterior fontanelle in infants, neck pain or neck stiffness, abnormal posturing, generalised hypotonia or rigidity, myoclonic jerks, unsteady gait, ataxia, limb weakness, abnormal eye movements( sustained upward gaze, nystagmus, opsoclonus), squint, cranial nerve palsy

Patient Management 4 Out-patients Warning signs (cont d) Autonomic disturbance (increased sympathetic tone) Agitation, insomnia, increased startle reflex, panic attacks, pallor, cold sweating, tremor, tachycardia out of proportion to the degree of fever, hypertension, abdominal distension (paralytic ileus), urinary retention (atonic neurogenic bladder), hyperglycaemia, leukocytosis Cardiopulmonary features Pallor, cyanosis, tachypnoea, shortness of breath, hypotension, cold extremities, poor peripheral circulation, delayed capillary refill, tachycardia, bradycardia, irregular pulse rhythm Others Poor feeding, decreased urine output

Patient Management 3 Out-patients 3 most important warning signs of severe EV71 infection in Taiwan Persistent sleepiness / drowsiness Repeated vomiting Frequent myoclonic jerks (e.g. occurring several times or more in an hour)

Patient Management 4 Out-patients Advice upon discharge from OPD / A&E Seek early medical attention if warning signs are observed High fever Lethargy and weakness Refusing feeds and passing less urine Rapid breathing Vomiting Drowsiness or irritability Repeated jerky limb movement

腸病毒感染併發重症 臨床處理注意事項

腸病毒感染併發重症之前驅病徴 一 有嗜睡 意識不清 活力不佳 手腳無力應即早就醫, 上述一般神經併發症是在發疹二至四天後出現 二 肌躍型抽搐 ( 類似受到驚嚇的突發性全身肌肉收縮動作 ) 三 持續嘔吐 四 持續發燒 活動力降低 煩躁不安 意識變化 昏迷 頸部僵硬 肢體麻痺 抽搐 呼吸急促 全身無力 心跳加快或心律不整等

腸病毒 71 型相關病徵 一 一般病徵 :0 至 5 歲要特別注意 腸病毒 71 型感染的病例中, 有 80% 為手足口病, 許多病例的手腳皮疹十分細小且不明顯, 故應仔細觀察 併發重症者以五歲以下最多, 所以對罹患手足口病之五歲以下兒童必須特別注意觀察

腸病毒 71 型相關病徵 二 重症出現時機 :3 至 7 天 腸病毒 71 型感染併發重症主要有腦幹腦炎 心臟衰竭 肺水腫與肺出血等表現,, 這些嚴重病症均於發病後 7 天內出現, 平均為發病後 3 天左右, 所以發病後 7 天內應特別注意觀察嚴重併發症的各種可能病徵

腸病毒 71 型相關病徵 三 三大重症前兆 : 持續昏睡 持續嘔吐與肌躍型抽搐 為重症三大前兆, 對於腸病毒感染病患, 應該囑咐家屬特別注意觀察這三種重症前兆, 一有懷疑即 應立刻轉送醫院 肌躍型抽搐為全身肢體突發式顫抖而有點類似受到驚嚇的動作, 於睡覺時發作特別頻繁, 這種動作於正常兒童時偶而可見, 但若每小時發作數次則為異常

四 腸病毒 71 型侵犯中樞神經系統之症狀 : ( 一 ) 交感神經系統症狀 : 腦幹受犯引起進一步休克之前常見交感神經興奮症狀, 包括臉色蒼白 血壓上升 體溫正常時心跳過快 全身冒冷汗 神情緊張 肢體顫抖 (tremor) 等 ( 二 ) 神經系統症狀 : 除了肌躍型抽搐之外, 還可能出現意識障礙 ( 木僵 譫妄 呆滯 昏睡 昏迷 ) 抽搐 肢體麻痺 非自主性眼球動作 ( 眼球往上看 眼球固定偏向一側 眼球亂轉 眼球震顫 鬥雞眼 ) 神經失調 (ataxia) 腦神經功能異常等 ( 三 ) 心肺系統症狀 : 常見症狀包括呼吸急促 心跳過速或過慢 輕微運動導致呼吸急促 臉色蒼白 皮膚發紺 手腳冰冷等

疑似腸病毒重症轉診時機 病童罹患疱疹性咽峽炎或手足口病, 或病童之親密接觸者有疱疹性咽峽炎或手足口病時, 如果出現下列情形, 應儘速轉診治療 : 一 神經系統病徵 : 包括持續昏睡 持續嘔吐 肌躍型抽搐 意識障礙 ( 包括木僵 譫妄 呆滯 昏睡 昏迷 ) 急性肢體麻痺 抽搐 腦神經功能異常等神經學異常 二 交感神經病徵 : 包括臉色蒼白 血壓上升 體溫正常時心跳過快 全身冒冷汗 肢體顫抖 (tremor) 高血糖等 三 心肺系統病徵 : 包括呼吸急促 心跳過速或過慢 血壓上升或下降 脈搏微弱 輕微運動導致呼吸急促 臉色蒼白 皮膚發紺 手腳冰冷等

腸病毒腦炎重症患者臨床處理綱要 本綱要主要針對嚴重腸病毒腦炎患者制定, 此類病人在病程中需密切注意是否出現心肺衰竭及肺水腫 除例行診療外, 應特別注意下列事項 : 一 個人簡史 (brief history) 最近用藥及就醫情況 家族史 ( 含家族最近一個月所罹患之急性病症 ) 是否經常性活動於托兒所 幼稚園及學校等場所, 其場所是否有類似病例 有無餵哺母乳

二 現病史 (present illness) 1. 一般性症狀與徵候 (general symptoms and signs) 發燒 活力狀態 流涎 喉嚨紅腫發炎 牙齦紅腫發炎 口腔潰瘍 : 位置 皮疹 : 是否有水泡, 特別注意手 腳與臀部 其它皮膚狀態 胃腸症狀

二 現病史 (present illness) 2. 神經症狀與徵候 (neurological symptoms and signs) 煩燥不安, 清醒時有無故驚嚇 頭痛 嘔吐 頸部僵硬與疼痛 複視 睡眠狀態改變 : 嗜睡, 睡眠中斷, 無法入睡 意識狀態異常 : 說話不清, 視聽幻覺, 胡亂說話 肢體運動異常 : 肌肉張力減低或增強 步態不穩 肢體麻痺 運動失調 (ataxia) 變換體位會有驚惶失措狀抽搐, 肌抽躍 (myoclonic jerks)

二 現病史 (present illness) 3. 心肺系統症狀與徵候 (cardiopulmonary symptoms and signs) 呼吸狀況 心跳異常情形 膚色, 唇色 手腳冰冷, 冒冷汗

Patient management 1 In-patients Prompt recognition of deterioration and supportive treatment Monitor HR, RR, BP, SaO2, fluid balance Early detection of signs of CNS involvement Accurate assessment of LV function CT or MRI if persistent or progressive neurological signs +/- cardiopulmonary collapse or pulmonary oedema When deterioration of consciousness, early intubation with mechanical ventilation + neurointensive care Risk factors for neurogenic pulmonary oedema Hyperglycaemia (>150mg/dl,~8.3mmol/L), leukocytosis (>17,500/cu.mm) and limb weakness

Patient management 2 In-patients Defer lumbar puncture Rapid deteriorating conscious level Status epilepticus Unstable cardiorespiratory status Evidence of significant raised ICP Presence of focal neurological signs

Patient management 3 In-patients Left ventricular failure Shock or cardiopulmonary collapse fails to respond to initial fluid resuscitation Early echocardiogram Inotropic support Vigorous fluid resuscitation with volume overload may be detrimental by aggravating pulmonary oedema

Patient management 4 In-patients No specific antiviral therapy IVIG efficacy remains to be proven CDC of Taiwan Not recommended for children > 5 years of age Children with HFMD / herpangina or children with close contacts of confirmed HFMD / herpangina And Severe complications 1gm/kg infused over 12hrs for once only

腸病毒感染嚴重患者靜脈注射免疫球蛋白之適應症 一 靜脈注射免疫球蛋白對於腸病毒感染併發重症病人的治療效果, 目前仍有待確認 二 不鼓勵使用於 5 歲以上患者 三 適應症 : 出現手足口病或疱疹性咽峽炎臨床症狀, 或雖無以上症狀, 但與其他確定病例有流行病學上相關 ( 註 1) 的腸病毒感染個案, 並且符合下列條件之一 : ( 一 ) 肌抽躍合併無明顯誘發因素之心率過速 ( 心跳每分鐘超過 150 次 ) ( 註 2) ( 二 ) 急性肢體麻痺 ( 三 ) 急性腦炎, 尤其是供伴隨局部特異性腦幹神經症狀 : 失調 (ataxia) 對側偏癱 (cross hemiplegia) 特定腦神經損害 ( specific cranial Ns lesion ) 或腦幹自主神經機能障礙 (brainstem dysautonomia) ( 註 3) ( 四 ) 肺功能衰竭, 如急性肺水腫 肺出血 成人型呼吸窘迫症 ( 五 ) 心臟功能衰竭 ( 六 ) 敗血症候群 (Sepsis syndrome) ( 註 4) 註 1: 指個案發病前與確定病例有親密接觸可能性者, 包括家庭或學校中的腸病毒感染的確定病例 註 2: 只有肌抽躍症狀者不符合使用條件 註 3: 只有腦膜炎而無腦炎或類小兒麻痺症候群者, 及非腸病毒引起的腦炎患者不符合使用條件 註 4: 併發多發性器官衰竭之患者因使用效果不佳, 故不建議使用 四 建議劑量為 1 gm/kg 靜脈滴注 12 小時, 共一次

Infection control measures 1 Cohort in isolation room, HFMD or herpangina A9, B2G Standard precautions / contact precautions Wash hands Immediately & thoroughly Wear gloves and gown Remove them upon leaving the patient environment Personal protection equipments Mask, face shield Procedures generate splashes to mucous membranes

Infection control measures 2 Disinfect patient items properly 1:49 diluted household bleach Not inactivated by <80% alcohol Advice to patients or parents / caretakers Hand hygiene Restrict from nurseries/kindergartens/schools/activities with other children for 2 weeks Inform ICT & report the severe cases

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