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1 ! 71!" 1 I= 2 Enterovirus!"#$%&'()*+,-./0123 8!"#$%&10!"#$%&'()*+343!!"#$%&'()*+,-./ :;<=>?!"#$%&'()*+,-."/ "89:;<=!"#$%&'()*+%,-.(/ !!"#$%&'()*+,!"#$!"#$%&'71!"#$%&'#()!*+,-./ /67!"# 71!"#$!"!"#$%&'!"#$%&71!"#$%&!'()*+,-./!0!"#$%&'()*+,-./0123)/4!536+78$9!"#$% Myoclonus!"#$%&'!()/!"#!"#$%&'()*+,-71!"#$%& '()*+!"#$%&'()*+,-./ ,78!"!"#$71!"#$%&'()*+,-./0123&'+4!"#$ %&'()*+,-.#/ :;!"#$%&'()*+,*-./ !"#!"#$%&'() *+,-./ (56789:!71!"#$%&'()*+,$-./$ !71!"#$%&'()*+1998!"#$%& '!"#$%&'()*+,-./ :+;<!"#$%&10!"#71!"#$%&'()*+,-!"#$%& '()*+,-./ :;<=!"#$%! 71!"#!!" 813!"#$ 386!"#$%&#'( ! kshsieh@isca.vghks.gov.tw!"#$%& 2 168

2 71 Enterovirus B Sepsis-like Myoclonus / Troponin A / B 169

3 seizure C Catacholamines A / 71 / D B E Rhombencephalitis A 71 B 1gm/kg/day glycerol ~ 1gm/kg/Hr Hyperventilation 25-35mmHg 25mmHg 2/

4 71 mmhg mg% >200mg% ICU C 3A 1 Nitropurside ug/kg/ min Ismolol ug/kg/min Midzolan Morphine D 3B A PEPP 6-8 cmh2o 15 cmh2o Oxygenation Index= 100/ >13 High Frequency Oscillation Dopamine 5-15 ug/kg/min Dobutamine 2-20 ug/kg/min Epinephrine ug/kg/min Milrinone ug/kg/min 60mmHg 70 mmhg 70+age 2 mmhg 10mmHg fluid Challenge 5-10 ml/kg mg% Extra Corporal Membrane Oxygenation ECMO E 3B

5 References: 01. Asano Y, Yoshikawa T. Enterovirus infections in children. Curr Opin Pediatr. 1995;7: Eggers HJ. Notes on the pathogenesis of enterovirus infections. Observations, experiments, and speculations. Med Microbiol Immunol. 1990;179: Brown EH. Enterovirus infections. Br Med J. 1973; 2: Bryant PA, Tingay D, Dargaville PA, Starr M, Curtis N. Neonatal coxsackie B virus infection-a treatable disease? Eur J Pediatr. 2004;163: Nelson Textbook of Pediatrics by Robert M. Kliegman (2007), Section 13. Viral Infections main/main.aspx 07. Modlin JF, Dagan R, Berlin LE, Virshup DM, Yolken RH, Menegus M. Focal encephalitis with enterovirus infections. Pediatrics. 1991;88: Pichichero ME, McLinn S, Rotbart HA, Menegus MA, Cascino M, Reidenberg BE. Clinical and economic impact of enterovirus illness in private pediatric practice. Pediatrics. 1998;102: Dierssen U, Rehren F, Henke-Gendo C, Harste G, Heim A. Rapid routine detection of enterovirus RNA in cerebrospinal fluid by a one-step real-time RT-PCR assay. J Clin Virol. 2008;42: Middleton J, Lee BE, Fox JD, Tilley PA, Robinson JL. Comparison between the clinical and laboratory features of enterovirus and West Nile virus infections. J Med Virol. 2008;80: Hsia SH, Wu CT, Chang JJ, Lin TY, Chung HT, Lin KL, Hwang MS, Chou ML, Chang LY. Predictors of unfavorable outcomes in enterovirus 71-related cardiopulmonary failure in children. Pediatr Infect Dis J. 2005; 24: Chang LY, Hsia SH, Wu CT, Huang YC, Lin KL, Fang TY, Lin TY. Outcome of enterovirus 71 infections with or without stage-based management: 1998 to Pediatr Infect Dis J. 2004;23: Huang CC, Liu CC, Chang YC, Chen CY, Wang ST, Yeh TF. Neurologic complications in children with enterovirus 71 infection. N Engl J Med. 1999;341:

6 71!" ENTEROVIRAL 71 INFECTION - A CRITICAL REVIEW Kai-Sheng Hsieh 1, Jia-Kan Chang 2 Abstract During the past 10 years, enteroviral 71 infection has caused significant psychosocial negative impact in Taiwan. Apparently this emerging infectious disease will alert pediatric health care professionals to take more effort to combat this serious illness. In Taiwan, traditionally the new illness caused by enteroviral 71 infection is called "Enterovirus Infection". The authors feel that it is a misnomer because there are many different types in enterovirus. For example, poliomyelitis is caused by poliovirus which is also an enterovirus but we never called poliomyelitis as enterovirus infection. Therefore the authors recommend a new term "Enterovirus 71 syndrome" or "Brainstem viral syndrome" instead of the traditional nonspecific "Enterovirus infection" to avoid misleading and confusion. Usually there are no specific laboratory findings for the laboratory diagnosis of enteroviral 71 syndrome except viral-targeted microbiology tests such as viral culture, serology or PCR-related tests. However, many of the drawbacks with these microbiological tests limited its application in the early diagnosis of enteroviral 71 syndrome. Therefore we must rely on the early clinical detection of enteroviral 71 syndrome. Although hand-foot-mouth disease or herpangina is often associated with enteroviral 71 syndrome, many patients with enteroviral 71 syndrome lack such presentations. The spectrum of enteroviral 71 syndrome is currently durided into 4 stages: 1. Hand- Foot-Mouth/ Herpangina or nonspecific viral syndrome stage. 2. Neurological stages with conscious change, seizure, myochonic jerks or motor palsy. 3(A) Sympathetic stimulation stages 3(B) Decompensated stage with extreme tachycardia/ hypertension and soon followed my cardiopulmonary decompensation. 4. Recovery stage. The management of enteroviral 71 syndrome depends on the clinical stages of patients. Careful monitoring is needed to close and precise recognition of different stages so that appropriate measures could be undertaken. In summary, enteroviral 71 syndrome is an emerging disease with possible serious complications. Every pediatrician should be alerted to this new syndrome and be familiar with its management to maximize clinical outcome! Key words: Enteroviral 71 Syndrome Correspondence: Dr. Kai-Sheng Hsieh Department of Pediatrics, Kaohsiung Veterans General Hospital; 386, Da-Chun 1 st Rd., Kaohsiung 813, Taiwan Phone: ; Fax: ; kshsieh@isca.vghks.gov.tw Department of Pediatrics, Cheng-Hsin General Hospital 2 173