Cluster of Fatal Cardiopulmonary Failure among Children Caused by an Emerging Strain of Enterovirus 71, Nakhorn Ratchasima Province, Thailand, 2006
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Date
2010-06-02
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Outbreak, Surveillance and Investigation Reports
Abstract
Background: Fatal outcomes following enteroviral infection are rare in Thailand. In late June 2006, four deaths among children with fever and cardiopulmonary failure were reported from Nakhorn Ratchasima Province. We conducted an investigation to identify the etiology and to implement control measures. Methods: Medical records of the four fatal cases were reviewed. Active case finding was conducted in the affected district. A case was defined as a child aged 38oC) and/or Hand Foot and Mouth Disease (HFMD) during July5th-August 5th, 2006. Laboratory investigation included viral isolation from stool, throat and nasopharyngeal swabs. Paired sera were tested for Enterovirus 71 antibody by microneutralization technique. Nucleotide sequencing was done in virus isolated from a confirmed fatal case and electron microscopy was evaluated in autopsy case. Results: The four fatal cases ranged in age from 4 to 39 months; three were male. Illness onset occurred between June 22nd and 25th, 2006. Two cases resided in the same district and had a history of close contact - hugging and kissing. All cases exhibited abrupt onset of high (39-41oC) fever, tachycardia, acute dyspnea, respiratory failure and coma. Bilateral pulmonary edema without cardiomegaly was noted on all chest roentegrams. In a case that autopsy was performed, an infiltration with mononuclear cells was found in the brainstem and cardiac tissues. An enterovirus 71 isolated from the stool of one case was subsequently identified as serogroup C4, Shenzhen strain. Of 39 children surveyed, 20.5% (3 HFMD and 5 non-HFMD) exhibited positive antibodies to enterovirus 71. An electron microscopic study of formalin-fixed tissues in a fatal 4-month-old case revealed viral-like particle, average 20 nm in diameter with spherical structure in brain tissue but without any findings cardiac or lungs tissues. Conclusions: An emerging strain of enterovirus 71 (C4, Shenzhen) was likely the cause of this outbreak. Control measures including improved personal and environmental hygiene and isolation of sick children at home were implemented. Pediatricians were informed about atypical clinical characteristics of enterovirus 71. A surveillance has been established nationwide for fever and pulmonary edema cases among children below 15 years of age.
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Outbreak, Surveillance and Investigation Reports; Issue 1, Vol 1, 2008; 1-3